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An unusual case of a wasp phobic
ARTICLE IN PRESS
Journal of Behavior Therapy and Experimental Psychiatry 34 (2003) 219–224
An unusual case of a wasp phobic June S.L. Browna,*, Sharon Abrahamsa, Matthew Helbertb a
Psychology Department, Institute of Psychiatry, University of London, De Crespigny Park, London SE5 8AF, UK b St. Bartholomew’s Hospital, London, UK
Received 18 September 2000; received in revised form 14 August 2001; accepted 21 September 2001
Abstract This study concerns a woman with a very specific phobia of free-flying wasps. Her underlying and disabling belief was that she was allergic to wasp venom and, if stung, would certainly die. A behavioural approach, such as systematic desensitization and exposure, was not thought suitable because of the patient’s pattern of fear. Instead, the treatment of choice was an allergy test to directly challenge her belief. The allergy test was negative and led to a dramatic improvement which was maintained 1 year after treatment. r 2003 Elsevier Ltd. All rights reserved.
1. Introduction It has been thought that the processes underlying phobias and their treatment were largely non-cognitive and behavioural treatment should be the treatment of choice. In particular, exposure in vivo has been seen to be the most efficient and effective method of treating specific phobias (Emmelkamp, 1994). In addition, imaginal systematic desensitisation has also been found to be effective (Bedell, Archer, & Rosmann, 1979). However, the cognitionless view of phobias has come to be questioned. McNally and Steketee (1985) found that their animal phobics seemed to fear their own reactions to the feared object (self-related) more than the object itself (objectrelated). Similarly, Arntz, Lavy, van den Berg, and van Rijsoort (1993) found selfrelated (e.g. I will lose control) and spider related (e.g. the spider jumps onto me) fears among their spider phobics. Additionally, Thorpe and Salkovskis (1995) *Corresponding author. Tel.: +44-207-8485004. E-mail address: [email protected] (J.S.L. Brown). 0005-7916/$ - see front matter r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbtep.2001.09.001
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proposed that beliefs about coping (e.g. I would be unable to cope) were also relevant and asserted that a combination of beliefs about the phobic object itself, the amount of harm experienced by the phobic and a sense of helplessness explained the fear of phobics. Cognitive changes have also resulted from behavioural interventions. Arntz et al. (1993) found that among a group of spider phobics, a one-session exposure treatment (Ost, 1989) led to a significant reduction in negative beliefs about spiders. Similarly, Thorpe and Salkovskis (1997) reported cognitive change after a similar one-session treatment for spider phobics although some cognitive elements were included in their treatment package. Little has been written about the treatment of wasp phobics. In the only previously published treatment study about wasp phobia (Brough, Yorkston, & Stafford-Clark, 1965), treatment of a patient required 46 sessions of systematic desensitization under light hypnosis. In the present case study with a woman with a phobia of free-flying wasps, a purely cognitive intervention was attempted since a behavioural approach was felt to be inappropriate.
2. Presenting problem The patient, C, referred by her GP was described as having longstanding ‘‘phobias of bees and wasps’’, which had recently worsened.
3. Assessment At the initial interview, C, a 35 year old woman living with her partner and two pre-school children, identified that her main problem was with wasps. She was terrified that, if stung, she would die because she believed that she was allergic to their stings. She had, however, never actually been stung and had no evidence of being allergic. She also believed that she was allergic to bees but that they would only sting if severely provoked. She reported frequent dreams, up to 5 times a week, of being stung. C’s phobia appeared to be quite specific to live wasps. Even then, she could tolerate seeing one in a glass cage if she knew it could not escape. She reported no fear of pictures or television programmes in which wasps were shown. She reported feelings of nausea, panic and behavioural avoidance whenever she felt at risk of being stung. Dangerous situations had sometimes resulted; she had pushed people over in the street, as well as clambered over other passengers on a bus when trying to escape wasps. Even if with her children, she would run away, only returning when she felt safe and/or only if there was no chance of them being brought to her. In the summer months, C wore long-sleeved tops and trousers to protect herself from being stung since she felt there were likely to be more wasps. She avoided anything likely to attract wasps such as picnics, and did not allow her children to eat
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anything sweet outdoors. She also reported that she would avoid leaving the house if she spotted a wasp outside. However, she had managed not to allow her fear to affect her work at a factory, by leaving early in the morning before wasps would normally be active and maintaining constant vigilance on the way home. 3.1. Pre-treatment reports C rated the severity of her problem to be 95%. She held three beliefs which seemed to underlie her phobia, and which she was totally convinced were true. The belief ‘‘I am allergic to wasps and will die if I am stung’’ was the one most frequently mentioned. The other beliefs were ‘‘I am going to be stung’’ and ‘‘I am not going to be able to cope with a wasp’’ (see Table 1). C’s levels of anxiety in several imagined situations involving wasps and bees were measured using the subjective units of distress (SUDS) with ratings of 0 (no disturbance) to 100 (intense disturbance). These ratings are presented in Table 1, together with her ratings on the fear survey schedule (FSS) (Wolpe & Lang, 1977) and a list of situations C avoided.
4. History of problem The phobia began when C was a teenager but had become worse in the past 4 years, since having her children. She had also recently seen people dying of an allergic reaction on television and feared this would happen to her. In terms of family history, C reported that her mother had a similar albeit less intense fear of wasps, based on a dislike of being stung but which had ceased when her mother had survived being stung. She denied any family history of allergy to wasp stings. She describes her family as being close and her childhood as happy.
5. Formulation C appeared to have a specific fear of free-flying wasps, which did not seem to be symptomatic of other underlying fears. She was highly anxious if she saw a wasp and, as a result, avoided a number of situations. C’s fear seemed to be based on the belief she might be allergic to wasp venom, get stung, and then die. This will be referred to as her allergy/death belief. For most of her life, she appears to have coped with the problem by avoidance. However, with the arrival of her children, this strategy was not always possible and she had consequently sought help for her problem. An imaginal systematic desensitisation approach was not thought to be appropriate as C only experienced anxiety in the presence of a live wasp. Equally, in vivo exposure to wasps was not indicated as C reported she was able to control her anxiety with a trapped live wasp and the alternative of working with a free flying wasp would not have led to controlled and useful exposure to wasps, a key
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component of exposure. In addition, there was some risk that C might drop out of treatment should she feel too anxious. Finally, there was also the possibility that C may actually have been allergic to wasp venom. Similar considerations applied to cognitive challenging, since fully challenging C’s allergy/death belief, necessarily involved behavioural experimentation and the risk of her being stung. Given all the contra-indications, and since C’s fear was considered to be mainly based on the belief that she might be allergic to wasp venom and die if stung, a logical, albeit unconventional, decision was made to directly and safely confront her belief by arranging a specific allergy test. Although initially somewhat sceptical when this was proposed to her, C nevertheless agreed to undergo the test. 5.1. Treatment This consisted of an allergy test by an immunologist at a general hospital. In the unlikely event of a positive result, C would have been offered treatment in the form of venom desensitisation, involving the administration of progressively higher doses of venom over several months until the equivalent of an insect sting was given. Injections would then have continued for a period of approximately 2 years. However, the result of the allergy test was negative.
6. Results 6.1. Post-treatment reports Two weeks after the allergy test, C reported that the test result had ‘‘helped immensely.’’ She had not panicked since, had been able to walk past wasps, and now felt she could ‘‘walk normally’’ down the street, despite it being August, her most feared month for wasps. From believing totally (100%) she would die as a result of being stung, C now did not hold that belief at all (0%). C’s perception of the severity of the problem had dropped from 95% to 45%. C also reported that she no longer dreamt about wasps. Her FSS ratings for fear of flying insects had reduced substantially. Her SUDS ratings had also dropped to 10%, reflecting her diminished anxiety when seeing a wasp outside (see Table 1). While she was still a little anxious of wasps in the house (30%), she coped with them more actively. For example, when she saw a wasp on a curtain, she opened the window and turned the curtain to let it out. Her avoidance had also diminished so that she ceased to avoid four out of the previously reported five situations (see Table 1). 6.2. Reports at 1 year C seemed to have largely maintained her progress between the post-treatment point and 1 year follow-up.
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Table 1 Assessments indicating change from pre- , post-treatment to followup Before
Post-treatment
1 year fu
Self-reported anxiety ratings (or SUD) Wasp anywhere in visual field-outdoors Wasp in house Bee in visual field (flying) Bee on a flower Wasp under glass Wasp on TV Wasp in photo
99 99 90 30 30 0 0
10 30 5 0 10 0 0
20 40 0 0 0 0 0
Avoidance Full clothing, covering arms and legs Picnics Buses Sticky sweets and drinks for children Wasp in garden, avoids going out
Yes Yes Yes Yes Yes
No No No Yes No
No No Sometimes Yes Occasionally
Fear survey schedule Fear of flying insects
Very much
Very little
Very little
Beliefs and perceived strength of belief I am allergic to wasps and will die if I am stung I am going to get stung I am not going to be able to cope with a wasp
100% 100% 100%
0% 60% 70%
0% 30% 20%
The strength of her allergy/death belief remained at 0%. Her own ratings of the severity of the problem had fallen to 15% at follow-up; she explained that she had not been able to fully recognise how much the problem had diminished until her second summer. The strength of her beliefs that she was going to get stung and would not be able to cope also diminished further. Her low anxiety ratings about flying insects on the FSS were maintained but her fear of seeing wasps outdoors and indoors had each increased a little. Her avoidance of situations had also increased a little. However, she said that her avoidance was no longer due to her belief she might die, merely that she did not want to be stung. She said she was better able to cope and was more actively dealing with wasps (Tabel 1).
7. Discussion The dramatic changes in C’s allergy/death belief, following the test results, were clearly fundamental to her dramatic improvement. It seems safe to assume that this cognitive change led directly to a significant reduction in her perceived severity of the problem, the observed reduction in her anxiety levels in feared situations, and a
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decrease in avoidance behaviour. It is of significance that these changes occurred even though no exposure or breaking down of avoidance was carried out. However, it is not yet clear how generalisable this treatment is to other wasp phobics. This phobic had a very specific phobia of live wasps and her key beliefs were focused around the allergic properties of wasp venom. In addition, her phobia had a relatively late onset compared to most phobics whose fears usually start in childhood (Marks & Gelder, 1996). If generalisation can be shown, then this method may prove to be another treatment choice for therapists dealing with wasp phobics. In summary, this study has shown the use of a somewhat unconventional and brief response to an unusual presenting problem. As only a cognitive intervention was used in this case study, it has also demonstrated the pivotal role cognitive processes can have in the actual treatment of a wasp phobic, and so complements other work showing the importance of cognitive beliefs in the maintenance of animal phobias.
References Arntz, A., Lavy, E., van den Berg, G., & van Rijsoort, S. (1993). Negative beliefs of spider phobics: A psychometric evaluation of the spider phobia beliefs questionnaire. Advances in Behaviour Research and Therapy, 15, 257–277. Bedell, J. R., Archer, R. P., & Rosmann, M. (1979). Relaxation therapy, desensitization, and the treatment of anxiety-based disorders. Journal of Clinical Psychology, 35, 840–843. Brough, D. I., Yorkston, N., & Stafford-Clark, D. (1965). A case of a wasp phobia treated by systematic desensitization under light hypnosis. Guys Hospital Reports, 114(3), 319–325. Emmelkamp, P. M. G. (1994). Behaviour therapy with adults. In A. E. Bergin, & S. L. Garfield (Eds.), Handbook of psychotherapy and behaviour change (4th ed.). New York: Wiley. Marks, I. M., & Gelder, M. (1996). Different ages of onset in varieties of phobia. American Journal of Psychiatry, 123, 218–1221. McNally, R. J., & Steketee, G. S. (1985). The etiology and maintenance of severe animal phobias. Behaviour Research and Therapy, 23, 431–435. Ost, L. G. (1989). One session treatment for specific phobias. Behaviour Research and Therapy, 27, 1–7. Thorpe, S. J., & Salkovskis, P. M. (1995). Phobic beliefs: Do cognitive factors play a role in specific phobias? Behaviour Research and Therapy, 33(7), 805–816. Thorpe, S. J., & Salkovskis, P. M. (1997). The effect of one-session treatment for spider phobia on attentional bias and beliefs. British Journal of Clinical Psychology, 36, 225–241. Wolpe, J., & Lang, P. (1977). A fear schedule for use in behaviour therapy. Behaviour Research and Therapy, 2, 27–30.
Journal of Behavior Therapy and Experimental Psychiatry 34 (2003) 219–224
An unusual case of a wasp phobic June S.L. Browna,*, Sharon Abrahamsa, Matthew Helbertb a
Psychology Department, Institute of Psychiatry, University of London, De Crespigny Park, London SE5 8AF, UK b St. Bartholomew’s Hospital, London, UK
Received 18 September 2000; received in revised form 14 August 2001; accepted 21 September 2001
Abstract This study concerns a woman with a very specific phobia of free-flying wasps. Her underlying and disabling belief was that she was allergic to wasp venom and, if stung, would certainly die. A behavioural approach, such as systematic desensitization and exposure, was not thought suitable because of the patient’s pattern of fear. Instead, the treatment of choice was an allergy test to directly challenge her belief. The allergy test was negative and led to a dramatic improvement which was maintained 1 year after treatment. r 2003 Elsevier Ltd. All rights reserved.
1. Introduction It has been thought that the processes underlying phobias and their treatment were largely non-cognitive and behavioural treatment should be the treatment of choice. In particular, exposure in vivo has been seen to be the most efficient and effective method of treating specific phobias (Emmelkamp, 1994). In addition, imaginal systematic desensitisation has also been found to be effective (Bedell, Archer, & Rosmann, 1979). However, the cognitionless view of phobias has come to be questioned. McNally and Steketee (1985) found that their animal phobics seemed to fear their own reactions to the feared object (self-related) more than the object itself (objectrelated). Similarly, Arntz, Lavy, van den Berg, and van Rijsoort (1993) found selfrelated (e.g. I will lose control) and spider related (e.g. the spider jumps onto me) fears among their spider phobics. Additionally, Thorpe and Salkovskis (1995) *Corresponding author. Tel.: +44-207-8485004. E-mail address: [email protected] (J.S.L. Brown). 0005-7916/$ - see front matter r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbtep.2001.09.001
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proposed that beliefs about coping (e.g. I would be unable to cope) were also relevant and asserted that a combination of beliefs about the phobic object itself, the amount of harm experienced by the phobic and a sense of helplessness explained the fear of phobics. Cognitive changes have also resulted from behavioural interventions. Arntz et al. (1993) found that among a group of spider phobics, a one-session exposure treatment (Ost, 1989) led to a significant reduction in negative beliefs about spiders. Similarly, Thorpe and Salkovskis (1997) reported cognitive change after a similar one-session treatment for spider phobics although some cognitive elements were included in their treatment package. Little has been written about the treatment of wasp phobics. In the only previously published treatment study about wasp phobia (Brough, Yorkston, & Stafford-Clark, 1965), treatment of a patient required 46 sessions of systematic desensitization under light hypnosis. In the present case study with a woman with a phobia of free-flying wasps, a purely cognitive intervention was attempted since a behavioural approach was felt to be inappropriate.
2. Presenting problem The patient, C, referred by her GP was described as having longstanding ‘‘phobias of bees and wasps’’, which had recently worsened.
3. Assessment At the initial interview, C, a 35 year old woman living with her partner and two pre-school children, identified that her main problem was with wasps. She was terrified that, if stung, she would die because she believed that she was allergic to their stings. She had, however, never actually been stung and had no evidence of being allergic. She also believed that she was allergic to bees but that they would only sting if severely provoked. She reported frequent dreams, up to 5 times a week, of being stung. C’s phobia appeared to be quite specific to live wasps. Even then, she could tolerate seeing one in a glass cage if she knew it could not escape. She reported no fear of pictures or television programmes in which wasps were shown. She reported feelings of nausea, panic and behavioural avoidance whenever she felt at risk of being stung. Dangerous situations had sometimes resulted; she had pushed people over in the street, as well as clambered over other passengers on a bus when trying to escape wasps. Even if with her children, she would run away, only returning when she felt safe and/or only if there was no chance of them being brought to her. In the summer months, C wore long-sleeved tops and trousers to protect herself from being stung since she felt there were likely to be more wasps. She avoided anything likely to attract wasps such as picnics, and did not allow her children to eat
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anything sweet outdoors. She also reported that she would avoid leaving the house if she spotted a wasp outside. However, she had managed not to allow her fear to affect her work at a factory, by leaving early in the morning before wasps would normally be active and maintaining constant vigilance on the way home. 3.1. Pre-treatment reports C rated the severity of her problem to be 95%. She held three beliefs which seemed to underlie her phobia, and which she was totally convinced were true. The belief ‘‘I am allergic to wasps and will die if I am stung’’ was the one most frequently mentioned. The other beliefs were ‘‘I am going to be stung’’ and ‘‘I am not going to be able to cope with a wasp’’ (see Table 1). C’s levels of anxiety in several imagined situations involving wasps and bees were measured using the subjective units of distress (SUDS) with ratings of 0 (no disturbance) to 100 (intense disturbance). These ratings are presented in Table 1, together with her ratings on the fear survey schedule (FSS) (Wolpe & Lang, 1977) and a list of situations C avoided.
4. History of problem The phobia began when C was a teenager but had become worse in the past 4 years, since having her children. She had also recently seen people dying of an allergic reaction on television and feared this would happen to her. In terms of family history, C reported that her mother had a similar albeit less intense fear of wasps, based on a dislike of being stung but which had ceased when her mother had survived being stung. She denied any family history of allergy to wasp stings. She describes her family as being close and her childhood as happy.
5. Formulation C appeared to have a specific fear of free-flying wasps, which did not seem to be symptomatic of other underlying fears. She was highly anxious if she saw a wasp and, as a result, avoided a number of situations. C’s fear seemed to be based on the belief she might be allergic to wasp venom, get stung, and then die. This will be referred to as her allergy/death belief. For most of her life, she appears to have coped with the problem by avoidance. However, with the arrival of her children, this strategy was not always possible and she had consequently sought help for her problem. An imaginal systematic desensitisation approach was not thought to be appropriate as C only experienced anxiety in the presence of a live wasp. Equally, in vivo exposure to wasps was not indicated as C reported she was able to control her anxiety with a trapped live wasp and the alternative of working with a free flying wasp would not have led to controlled and useful exposure to wasps, a key
ARTICLE IN PRESS 222
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component of exposure. In addition, there was some risk that C might drop out of treatment should she feel too anxious. Finally, there was also the possibility that C may actually have been allergic to wasp venom. Similar considerations applied to cognitive challenging, since fully challenging C’s allergy/death belief, necessarily involved behavioural experimentation and the risk of her being stung. Given all the contra-indications, and since C’s fear was considered to be mainly based on the belief that she might be allergic to wasp venom and die if stung, a logical, albeit unconventional, decision was made to directly and safely confront her belief by arranging a specific allergy test. Although initially somewhat sceptical when this was proposed to her, C nevertheless agreed to undergo the test. 5.1. Treatment This consisted of an allergy test by an immunologist at a general hospital. In the unlikely event of a positive result, C would have been offered treatment in the form of venom desensitisation, involving the administration of progressively higher doses of venom over several months until the equivalent of an insect sting was given. Injections would then have continued for a period of approximately 2 years. However, the result of the allergy test was negative.
6. Results 6.1. Post-treatment reports Two weeks after the allergy test, C reported that the test result had ‘‘helped immensely.’’ She had not panicked since, had been able to walk past wasps, and now felt she could ‘‘walk normally’’ down the street, despite it being August, her most feared month for wasps. From believing totally (100%) she would die as a result of being stung, C now did not hold that belief at all (0%). C’s perception of the severity of the problem had dropped from 95% to 45%. C also reported that she no longer dreamt about wasps. Her FSS ratings for fear of flying insects had reduced substantially. Her SUDS ratings had also dropped to 10%, reflecting her diminished anxiety when seeing a wasp outside (see Table 1). While she was still a little anxious of wasps in the house (30%), she coped with them more actively. For example, when she saw a wasp on a curtain, she opened the window and turned the curtain to let it out. Her avoidance had also diminished so that she ceased to avoid four out of the previously reported five situations (see Table 1). 6.2. Reports at 1 year C seemed to have largely maintained her progress between the post-treatment point and 1 year follow-up.
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Table 1 Assessments indicating change from pre- , post-treatment to followup Before
Post-treatment
1 year fu
Self-reported anxiety ratings (or SUD) Wasp anywhere in visual field-outdoors Wasp in house Bee in visual field (flying) Bee on a flower Wasp under glass Wasp on TV Wasp in photo
99 99 90 30 30 0 0
10 30 5 0 10 0 0
20 40 0 0 0 0 0
Avoidance Full clothing, covering arms and legs Picnics Buses Sticky sweets and drinks for children Wasp in garden, avoids going out
Yes Yes Yes Yes Yes
No No No Yes No
No No Sometimes Yes Occasionally
Fear survey schedule Fear of flying insects
Very much
Very little
Very little
Beliefs and perceived strength of belief I am allergic to wasps and will die if I am stung I am going to get stung I am not going to be able to cope with a wasp
100% 100% 100%
0% 60% 70%
0% 30% 20%
The strength of her allergy/death belief remained at 0%. Her own ratings of the severity of the problem had fallen to 15% at follow-up; she explained that she had not been able to fully recognise how much the problem had diminished until her second summer. The strength of her beliefs that she was going to get stung and would not be able to cope also diminished further. Her low anxiety ratings about flying insects on the FSS were maintained but her fear of seeing wasps outdoors and indoors had each increased a little. Her avoidance of situations had also increased a little. However, she said that her avoidance was no longer due to her belief she might die, merely that she did not want to be stung. She said she was better able to cope and was more actively dealing with wasps (Tabel 1).
7. Discussion The dramatic changes in C’s allergy/death belief, following the test results, were clearly fundamental to her dramatic improvement. It seems safe to assume that this cognitive change led directly to a significant reduction in her perceived severity of the problem, the observed reduction in her anxiety levels in feared situations, and a
ARTICLE IN PRESS 224
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decrease in avoidance behaviour. It is of significance that these changes occurred even though no exposure or breaking down of avoidance was carried out. However, it is not yet clear how generalisable this treatment is to other wasp phobics. This phobic had a very specific phobia of live wasps and her key beliefs were focused around the allergic properties of wasp venom. In addition, her phobia had a relatively late onset compared to most phobics whose fears usually start in childhood (Marks & Gelder, 1996). If generalisation can be shown, then this method may prove to be another treatment choice for therapists dealing with wasp phobics. In summary, this study has shown the use of a somewhat unconventional and brief response to an unusual presenting problem. As only a cognitive intervention was used in this case study, it has also demonstrated the pivotal role cognitive processes can have in the actual treatment of a wasp phobic, and so complements other work showing the importance of cognitive beliefs in the maintenance of animal phobias.
References Arntz, A., Lavy, E., van den Berg, G., & van Rijsoort, S. (1993). Negative beliefs of spider phobics: A psychometric evaluation of the spider phobia beliefs questionnaire. Advances in Behaviour Research and Therapy, 15, 257–277. Bedell, J. R., Archer, R. P., & Rosmann, M. (1979). Relaxation therapy, desensitization, and the treatment of anxiety-based disorders. Journal of Clinical Psychology, 35, 840–843. Brough, D. I., Yorkston, N., & Stafford-Clark, D. (1965). A case of a wasp phobia treated by systematic desensitization under light hypnosis. Guys Hospital Reports, 114(3), 319–325. Emmelkamp, P. M. G. (1994). Behaviour therapy with adults. In A. E. Bergin, & S. L. Garfield (Eds.), Handbook of psychotherapy and behaviour change (4th ed.). New York: Wiley. Marks, I. M., & Gelder, M. (1996). Different ages of onset in varieties of phobia. American Journal of Psychiatry, 123, 218–1221. McNally, R. J., & Steketee, G. S. (1985). The etiology and maintenance of severe animal phobias. Behaviour Research and Therapy, 23, 431–435. Ost, L. G. (1989). One session treatment for specific phobias. Behaviour Research and Therapy, 27, 1–7. Thorpe, S. J., & Salkovskis, P. M. (1995). Phobic beliefs: Do cognitive factors play a role in specific phobias? Behaviour Research and Therapy, 33(7), 805–816. Thorpe, S. J., & Salkovskis, P. M. (1997). The effect of one-session treatment for spider phobia on attentional bias and beliefs. British Journal of Clinical Psychology, 36, 225–241. Wolpe, J., & Lang, P. (1977). A fear schedule for use in behaviour therapy. Behaviour Research and Therapy, 2, 27–30.