treatment of a situational phobia

7/28/2019 Treatment of a Situational Phobia

1/5

10.1192/bjp.125.1.95Access the most recent version at doi:1974, 125:95-98.BJP

ARNOLD ORWINA Case for RunningTreatment of a Situational Phobia

permissionsReprints/

[email protected] obtain reprints or permission to reproduce material from this paper, please write

to this article atYou can respond http://bjp.rcpsych.org/cgi/eletter-submit/125/584/95

fromDownloaded

The Royal College of PsychiatristsPublished byon December 19, 2011http://bjp.rcpsych.org/

http://bjp.rcpsych.org/site/subscriptions/go to:The British Journal of PsychiatryTo subscribe to
http://bjp.rcpsych.org/http://bjp.rcpsych.org/


2/5

Brit . J . Psych ia t. ( i@7i@),25 , 95 -8

Treatment of a Situational PhobiaA Case for RunningBy ARNOLD ORWIN

Systematic desensitization using bodily respouses other than relaxation as the specificanxiety inhibitor has produced positive resultsin phobic states. Jones (1924) used feeding,W olpe (ig6g) advocated motor activity usinga conditioned motor response, Ventis ( z973)described a case where induced laughter waseffective and Orwin (i@yp) paired the respiratory relief obtained after maximum voluntaryrespiratory arrest with the anxiety evokingstimuli. A derivation of this latter techniqueutilized the autonom ic excitation caused by thevigorous physical exertion of running, to compete w ith the anxiety response in the agoraphobic syndrome (Orwin, 1973). This briefreport describes an unusual situational phobiatreated by this latter m ethod (therunningtreatm ent'), follow ing previous experience w iths imple claustrophobia.

CA5E H IS TORYA young unmarried woman aged years, wasreferred by her general practitioner with a phobiaof h ig h lev el lav ato ry c iste rn s. A pp aren tly th is fearh ad sta rted a t a bo ut 2 ye ars o f a ge w hen h er m oth ertook her to a public lavatory while on holiday. She

recalled that this lavatory w as frightening because itwas dark and there was the sound of continuousrunning water above her head. She became veryanxious and w anted to leave, but despite her scream sh er mo th er fo rc ed h er to sta y and m ic tu ra te .From then she developed a general fear of suchlavatories an d at first h ad som e con cern on u sin g th elavatory at home. This anxiety gradually recededbut was always exacerbated by redecoration oralter atio ns to th e la va to ry , e.g . w he n o n on e oc ca sio na new cistern had to be fitted. H er fear of publiclavatories rem ained although subdued and shemana ged to co pe w ith sc hoo l la va tories.Aged g years she was taken by an aunt into ap ub lic la va to ry in th e cen tr e o f a city an d a lth ou ghurgen tly needing t o m ic tura te she r ef us ed to use t hef ac il it ie s. She was f or cib ly p la ced on the s ea t, bu t she

started screaming and had to be removed, havingcaused a considerab le commotion . Th ereafter,anxiety in school lavatories increased but wastolerated, for at this time she became aware thatshe w ould be extrem ely em barrassed if her phobia.w as revealed to h er sch oolfrien ds. T he fear of p ub lic.l avator ie s was aggravated and genera li zed so that bylate adolescence she could not enter an unfam iliarlavatory with a high level cistern. Finally, shearrived at the stage where she could not go into anystrange toilet suite until it had been surveyed by a.friend in advance so as to be assured that cisterns@were ofth elo wle velva rie ty . T his n atu ra lly h am pere d.h er so cia l a ctiv itie s, fo r in n ew situ atio ns sh e h ad to b eaccom panied by at least one of the few friends w hoknew of her predicam ent. She had learnt that byimbibing enough whisky to make her carefree shecould partially overcome her reluctance to approach.an unknow n lavatory alone, but if there w as a highlevel cistern sh e w ou ld immed iately leave in a p an ic.Specifically, the m ost feared situation was ofsitting below a cistern 6o-ioo cm . above her headw here th ere w ere exp osed p ip es cu rved to overh an gthe persons i tt ing be low . She mainta ined that she was.f right ened o f t he c is te rn f all ing on to her head .

TREATMENTAfter the history had been taken she was.

asked to leave the consulting room for a physicalexam ination in another part of the building and@when recalled was made to sit in a chair by awindow with a curtain partially drawn. Thecurtain concealed a detached lavatory cisteraon the window sill level with her head, whichhad been placed there while she was out of theroom. She was engaged in conversation forsome minutes and then, to assess the intensity ofanxiety, was told of the position of the cistern.She did not believe this at first but graduallyb ecam e m ore anxious as realization d aw ned an dfled in panic from the room when on beingasked to draw back th e cu rtains sh e discoverecYthe feared object. After som e encouragem ent abe

95


3/5

96 TREATMENT OF A S ITUATIONAL PHOBIA A CASE FOR RUNN INGcomposed herself and came back into the roomto sit in a second chair about 4 metres from thecistern. She would move no closer to it and stillportrayed and described considerable anxietyover her previous ordeal. She could not beprevailed upon to go back to the chair by thecistern and stated that if this was demanded ofher she would have to leave.She was then told she would be required torun until she was breathless and that on herreturn to the room she should endeavour to sitin this chair. She was also told that the effects

of vigorous physical activity might preventthe detection of anxiety. Although dubiousabout this she left the building and ran threetimes along a measured 50 metres at her bestspeed. She then ran back into the consultingroom and w ithout difficulty and gasping forair reached for and fell gratefully into the firstchair view ing the cistern w ithout overt concern.A s she recovered her b reath she d iscovered th atit no longer produced anxiety only a slightfeeling of uneasew hich w as quite endurable.She returned one week later w hen the cisternwas placed on a shelf so that it would be levelwith her head if she sat on an adjacent chair.After I 00 metres sprint she again sat withoutanx ie ty . T he c is te rn was th en r aise d su cc es siv ely5 cm. at a time for three more trials using thesame technique and no anxiety was evoked.The following week the cistern was no longersupported on a fixed shelf but suspended bywire from an intravenous drip stand so that itwas initially 15 cm . above her head. Therunning procedure was repeated and the cisterngradually raised till at the end of the sixth trialshe could tolerate it 6o cm . above her for anindefinite period. This treatm ent session andthose follow ing w ere carried out by nursing staff.On her fourth visit, a fortnight later, she was

taken by a nurse to the vicinity of a publiclavatory which she was told contained a highlevel suite and made to run towards it. Shem an ag ed to r eac h th e d oo r, itself a con sid era bleach ievem ent, b ut then exhibited great anxietypossibly because she had not run as freely asbefore. However, the next week, after appropriate running she entered a hospital lavatoryof a sim ilar typ e and sat on the seat, first w ith thedoor open (2 trials) then with the door closed.

During the fourth trial she stayed and micturated but developed slight anxiety when sheflu sh ed the bow l. In th e final session, follow in gthe same procedure, she entered the lavatoryon five successive trials and on each occasionshe sat for one m inute and was able to tolerateflu shing the bow l w ithou t anxiety. T hereaftershe could use the lavatory w ithout concern.Progress : One month later she reported nodifficulty in strange clubs, public houses orhotels. On follow-up after five months shere ta in ed h er imp ro veme nt.

DIscussIoNThere is evidence to suggest that physicalactivity can be used to inhibit both realitybased and neurotic anxiety. Control of the

form er is probably best seen on the battlefieldor in prim itive religious ceremonies. In bothcircumstances psychological factors are involvedand it would be difficult to dissociate thephysical response from its particular em otionalco ntext b ut p ossib ly th e im po rtan ce of muscu la ractivity has been overlooked. In the soldier,fe ar m ay b e con tain ed b y, fo r ex ample, in vok in gpatriotism , enthusiasm for the cause, theinspiration of the leader, and the confidencewhich emanates from the disciplined cohesionof an army, as well as the use of alcohol. Butmilitary history does seem to indicate that theraw m ilitiam an, less able to control his em otionsthan the hardened soldier, had a better tastefor a vigorous charge against the enemy thanstanding on the defensive awaiting attack. Asexamples we have the impetuous rush of theEnglish fyrd against the veteran Dane (Oman,1953) and the rapidly executed assault incolumn of the relatively untrained revolutionary French conscrip ts against w ell trainedprofessional armies (Fuller, 1957). A parallelprocess appears to occur during the ritesof many primitive religions. Sargant (1959)analysed the p hysio lo gyo f co nver sio n' to areligious faith, and described the effect ofrhythm ic drumming, the developm ent of em otional excitement often aided by varioussuggestive techniques and the use of alcoholan d other dru gs. In addition th ere w as dancingto the p oint of physical exh austion w ith feelin gs


4/5

97Y ARNOLD ORWINof th e first session , it w as confined to m on itoringprogress and advising the nUrse in charge on theh ie ra rc hy o f situ atio ns .Running as a form of treatment may have

application in specific situational phobias as inagoraphobia. It is attractive because of itsbasic simplicity and the m inimal demand ontherapist tim e, but further research is necessaryto determ ine its true value.

SUMMARYThe treatm en t o f a sp ecific situ atio nal p ho bia(of high level lavatory cisterns) is described.The method used was to utilize the autonom ic

excitation caused by vigorous m uscular activityas an inhibitor of the situational anxiety.T he p atien t w as m ade to enter feared situ ation simmediately after running close to the lim it oftoleration. The near lifelong phobia was removed in five short sessions with little psychiatric involvement. The method is attractivebecause of its basic sim plicity, the rapidity of theresponse and the m inimal demand on therapisttime.

Acxwowi.wos@wrsThe autho r g ra te fu ll y a cknow ledg es the suppor t o f thenurs ing s ta ff a t the Regiona l Behaviour Re se ar ch Unit inthe t re atment o f thi s c as e.

REFERENCESFU LLER,J. F . C . (ig@ 7) The Decisive Battler oft/ic W orld andt he ir I nfl ue nc eo n H is to ry . Cha pt er 1 3. L oti do n: E yr eand Spott iswoode .J on as, M . C . (1 92 4) L ab ora to ry s tu dy o f f ea r: T he c aseo f Pe ter . Pedagogica lSeminaryand Journa l o f Genetic

Psycho logy , 31 , 30815 .OMAN, C. W . C. (953) The Art of War. Chapter ti.U.S.A. : Cornel l Universi ty Press .O aw @, A . ( I9 7@ ) Re sp ir at or yr el ie f: n ew a nd r ap idmeth od for th e tre atm en t o f p ho bic sta te s. B ritishJournalof Psychiatry,119,6357. (,973) The running treatment': a prelim inarycommunication on a new use for an old therapy

( phys ic al a ct iv it y) i n t he ago ra phob ic s yndrome .BritishJournalof Psychiatry,122, 175-79.SARo@u@r,W . (i9@@)Battle for The M ind, Chapter 5.London: Pan Books Ltd.VA IIN5, S. & R@ x, A. A. (1967) Effects of cognitivedesensitizationn avoidanc ebehavio r.ournalefPers onal it y a nd Soc ia l P sychol og y, 7 , 3 45 -50.

of relief from sin and evil and presumablyfreedom from associated an xieties. S im ilarly itis generally agreed that for the tensions ofeveryday life, energetic activity, whether asexercise or sport, is beneficial, and follow ingfrom this it has often been prescribed nonspecifically as an adjunct in the treatment ofn eu ro tic a nx ie ty .From the behavioural point of view it is notdifficult to see w hy m uscular action m ay relieve

anxiety, as normally it completes the fundamental biological pattern ofarousal and anxietym ediated behaviour leading to avoidance w hichis dependent upon motor activity. One assumesthat the autonomic nervous system runs synchronously with this reaction, there being abuild up o fin te rn al d riv e in te rp re te d c ognitiv elyas development of anxiety until successfulavoidance occurs. At that tim e the discharge ofmuscular response leads to concomitant autonom ic changes which are associated with andd etected a s freed om from a nxiety , i.e . m uscu laractivity is equated with an autonomic nervoussystem in a post anxiety or elief'tate.In the runn ingr ea tment ' t his aut onomicrelief'tate is proceeding at the tim e of thepresentation of the anxiety stimulus. Theanxiety response normally evoked is nowp robably inhib ite d a t tw o le ve ls : phy sio lo gic allyby com petition from the m etabolic dem ands ofo ngo in g moto r a ctiv ity , an d c og nitiv ely b eca usedespite the provocation anxiety cannot bedetected in th e p rev ailin g au to nomic ex citatio n.O nce this is experienced expectation of a sim ilaranxiety-free response may arise in the future asshown by the work of Valins and Ray (1967)who indicated that avoidance behaviour canbe altered by in form ation concern ing intern alreactions.Apart from the need to ensure that thepatient was physically fit, no other problemem erged in treatm ent. The m ethod was easy touse and im posed no u ndu e strain on th e p atien t,

while the basic hypothesis as put to her wassoon confirm ed by her own responses. Consequently, m otivation w as high, as w as expectationof a successful outcome, and she responded infive treatm ent visits. Th e in vestm en t of psychiatric tim e was sm all, for apart from the initialh is to ry , phy sic al in ve stig atio n, a nd supe rv isio n


5/5

98 TREATMENT OF A SITUATIONAL PHOBIAA CASE FOR RUNNINGVaw r,s ,W . L . (i@ 7@)Case h is to ry : The use o f l aught er Woua ,J . ( 969)hePr ac ti ceo fBehavi ou rTher apy ,Chapas an alternative response in system atic desensitiza- ter 8. London: Pergam on Press.

t io n. B eh av io r T he ra py , 4 ,1 20 -2 2.

A synopsis of this paper w as published in the M ay 1974 Journal.

A rn old O rw in , M .R .C .P sych ., C on su ltan t in C harge, R egion al B eh aviou r R esearch U nit, H ollym oor C lin ic,Hollymo or H os pita l, X or th fie ld , B irmin gh am , B 3i 5EX a nd Hon ora ry R es ea rc hF e llow, D ep artm en t o fP .@ych ia tt y, Un iv er si ty o f B irm ingham

( Re ce iv ed ,@ Xovembe r 1973)

treatment of a situational phobia

Documents