Flooding and response prevention as a treatment for bowel obsessions

Jovrnd ofAtu& Dirorden. Vd. 4. pp. 241.2J6. Prind in the USA. All rights rcsaved.

caa76tas/w s3.c~+ co Cop+ght0 1990 Pngamm Press plc

1990

Flooding and Response Prevention as a Treatment for Bowel Obsessions DEBORAH C. BEIDEL, PH.D.

AND CYNTHIAM. Bmm, PH.D.

Department of Psychiarty. Western Psychiafric Inslifute and Clinic University of Piasburgh School of Medicine

Abstract - Behavioral interventions encompassing imaginal flooding. response prevention, graduated exposure and relaxation were used to treat two patients with persistent, disabling bowel obsessions. The cases illustrate the successful treatment of this condition and provides data bearing on the phenomenology of the syndrome, including its relationship to panic and obsessional disorders.

INTRODUCTION Individuals who feel fearful in public places or who avoid such places entirely are assumed to suffer from panic disorder with agoraphobia. While most patients who seek treatment at an anxiety disorders clinic report that their avoidance stems from the fear of a panic attack (Barlow, 198.Q there are those who also avoid public places but who deny experiencing panic. Rather, they worry excessively about the sudden development of a symptom(s) which could be incapacitating or extremely embarrassing, such as dizziness or falling, depersonalization or derealization, loss of bladder or bowel control, vomiting, or cardiac distress (APA, 1987, p. 241). These individuals endorse the presence of senseless and intrusive thoughts and ritualistic behaviors, symptoms which are more characteristic of obsessive-compulsive disorder than agoraphobia. In the psychiatric literature, the term “bowel obsession” has been used to describe the fears of these individuals. A recent report described the successful treatment of four such patients with tricyclic antidepressants (Jenike, Vitagliano, Rabinowitz, Goff, & Baer, 1987). In each case, the patient had an overwhelming fear of fecal incontinence when in a public situation, engaged This study was supported in part by NIMH Grants #41852. #43252, and #18269. Correspondence concerning this article should be addresses to D.C.Beidel. 3811 O’Hara Street, Pittsburgh, PA 15213.

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in ritualistic behaviors to prevent the occurrence of these events, and increasingly restricted daily activities. In only one case was there an actual instance of loss of bowel control. All patients experienced remission of their obsessional symptoms when treated with either imipramine or doxepin, although two patients required behavior therapy to address their avoidance of public situations. All were reported to be free of obsessions at follow-up, which ranged from 10 to 24 months posttreatment. Another case report (Caballero, 1988) described a patient with similar obsessional thoughts and ritualistic behaviors who had an equally positive response when treated with clomipramine. Despite these positive reports, there are indications that when the medication is withdrawn, the symptomatology returns. Jenike et al. (1987) reported that one patient’s symptoms returned when the imipramine dosage was reduced from 100 mg. to 50 mg., while a second patient resisted any attempt to reduce her medication. The follow-up medication status of the other two patients was not reported. Thus, treatment with antidepressants may be only partially effective and the results may persist only as long as the patient continues the medication. Alternative treatments are necessary for patients who cannot tolerate the medication or who prefer a non-pharmacological approach. In this report, behavior therapy consisting of imaginal flooding and response prevention, followed by graduated exposure and relaxation were used to treat two patients with severe and disabling fears of nausea and/or fecal incontinence when in public situations. Furthermore, additional clinical information which became available during the course of assessment and treatment may be useful in refining the conceptualization of this anxiety state.

METHOD Case I Ms. A was a 30 year old white single female who presented at the Western Psychiatric Institute and Clinic’s Anxiety Disorders Program with a fear of losing control of her bowels when in public. The onset occurred two years prior to presentation, when she was prescribed an antibiotic medication for treatment of flu symptoms. The medication created extreme bowel distress and precipitated several instances of mild fecal incontinence. The medication was discontinued, but the gastrointestinal distress remained, most notably diarrhea, gastrointestinal pain, and borborygmi (intestinal rumblings). She had numerous diagnostic and laboratory procedures, all resulting in negative findings. She was prescribed Librax 8 mg. and imipramine 100 mg., but experienced side effects from both medications, necessitating their discontinuation. Four months prior to her admission at the Anxiety Disorders Clinic at Western Psychiatric Institute and Clinic, she had been diagnosed by a gastroenterologist as having “Bowel Syndrome.” She was placed on a restrictive diet, given biofeedback therapy to strengthen her sphincter muscles, and at the time of referral had been prescribed several medications including Lomotil, Belladenal. and Equalactin. Although the patient had not suffered incontinence for almost one year, the

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fear that she would lose bowel control remained. She described a high degree of bodily vigilance, where any gastrointestinal sound or perceived movement triggered fears of fecal incontinence. She reported high anticipatory anxiety prior to leaving her home, and extreme distress when in public places such as shopping malls, grocery stores, airplanes, driving on limited access roads, and waiting in long lines. Furthermore, her fears prevented her from eating in restaurants for the past two years. She was extremely distressed about an upcoming family vacation (occurring approximately one month from the date of admission to the clinic) which would require extensive driving on a limited access road. There was no evidence of past or current symptoms of panic disorder, depression, specific phobias, or generalized anxiety disorder. Case 2 MS. B was a 24 year old white single female. Fifteen months prior to her admission to the anxiety disorders clinic, she had taken a vacation aboard a cruise ship and had become ill when the ship encountered a storm at sea. Since that time, she reported daily intrusive thoughts of becoming nauseous, vomiting or losing bowel control at work or in other public places, particularly in crowds. Her fears became so intense that they led to occasional mild nausea, which precipitated escape or avoidance of many public places. She missed an average of 3 112 work days per week, and accrued six weeks of absences during a nine week period, culminating in the termination of her employment. Similar to Ms. A, she sought treatment from various physicians including gastroenterologists and internists. In addition, she had sought treatment from a psychologist who had used a graduated desensitization hierarchy to treat her “agoraphobia.” This intervention had been unsuccessful. Her fear of vomiting led to a restricted food intake which resulted in a 30 pound weight loss. She developed several ritualistic behaviors, including carrying a brown paper bag at all times, refusing to eat in public places or at home if she had to go out, eating several pieces of peppermint candy per day and always carrying more “in case” she felt ill, and always wearing flat shoes so that if she became ill it would be less likely that she would lose her balance. In addition, Ms. B reported the recent onset of more “typical” obsessivecompulsive rituals such as washing her hands frequently (lo-15 times per day) and avoiding individuals who had recently recovered from the flu. Ms. B noted that, in retrospect, her family had always been excessively concerned about “germs” and contracting the flu, although prior to the incident described above, this concern had not affected her daily functioning. RESULTS

Assessment Following instruments,

the initial evaluation, the patients completed several self- report including the Symptom Checklist 90-R (Derogatis, 1983), Social

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Phobia and Anxiety Inventory (Turner. Beidel, Dancu. & Stanley, 1989). the Maudsley Obsessional-Compulsive Inventory (Rachman & Hodgeson, 1980), and the Chambless Scales: The Mobility Inventory, Body Sensations Questionnaire, and Agoraphobic Cognitions Questionnaire (Chambless, Caputo, Bright, & Gallagher, 1984; Chambless, Caputo, Jasin, Gracely, & Williams, 1985). Pretreatment scores are presented in Table 1. In addition, the patients completed daily self-monitoring designed to assess overall daily distress, degree of distress in anxiety producing situations, and frequency of entry into distressing situations. Baseline monitoring was limited to approximately ten days (Ms. A) or two weeks (Ms. B). Self-monitoring occurred daily through the treatment phase, although Ms. A did not comply with the monitoring instructions during her vacation. Self-monitoring data are presented in Figures 1 through 3. Imaginal Flooding Treatment was conducted across two phases. Both patients underwent ten sessions of imaginal flooding. Flooding scenes were directed at the patients’ TABLE 1. Pw ANDPosr TREATME.VT SCORESONASSESSMENT BATIFRY Ms. A Inventory

Pre-Tx

Ms. B Post-TX

Symptom Checklist go-Revised Somatization 54 47 Obsessive -Compulsive 56 50 Depression 51 47 Anxiety 67 50 Phobia 67 49 Maudsley Obsessional-Compulsive Inventory 2 2 Social Phobia and Anxiety Inventory Social Phobia 37 31 Agoraphobia 29 7 Mobility Inventory Alone Act. Alone Act. Places 2.6 2.6 2.0 1.3 Qpen Spaces 1.0 1.0 2.0 1.0 Riding 1.0 4.7 1.0 1.0 Situations 1.0 1.3 1.0 1.0 Agoraphobia Cognitions Questionnaire 4.3 1.0 Body Sensations Questionnaire

5.0

2.0

Pre-Tx.

Post-TX. 6 MO. Follow-Up

65

60

57

57 62 85 78

54

57 67 63

52 57 64 58

15

7

6

170 46

118 30

95 22

Alone Act. 2.6 2.7 1.5 1 .5 3.1 3.0 2.1 2.7

Alone Act. 2.0 2.1 1.0 1.0 2.4 2.4 1.8 1.8

3.5

1.8

1.4

3.9

2.6

1.8

Alone 4.0 1.5 3.1 3.1

Act. 3.8 1.5 2.0 3.8

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core fear of fecal incontinence and included attention to somatic sensations and distressing cognitions as well as the expected social consequences. For Ms. B, fear of vomiting in public was coupled with the fear of fecal incontinence. Wtthin session and between session extinction was achieved based on both physiological variables (blood pressure and heart rate), and subjective distress. While Ms. B’s self-monitoring data showed some decrease in distress as a result of the imaginal flooding, Ms. A’s data indicated an increase in overall distress and continued concern associated with the onset of gastric or abdominal disturbance.

Relaxation Training Ms. A’s continued high overall distress may have resulted from the intensive flooding procedure or the upcoming vacation, since continued concern over the impending travel could have served to maintain or further increase the gastrointestinal symptomatology (Jacob & Rapport, 1985). Relaxation training was introduced to address this issue. Ms. A was instructed in progressive muscle relaxation and practiced twice per day, and to use feelings of gastrointestinal distress as a cue to institute relaxation. This procedure was similar to cue-controlled relaxation, although specific conditioning trials were not conducted. The initiation of relaxation at the onset of somatic cues was intended to break the cycle of somatic distress leading to cognitive distress followed by further exacerbation of somatic symptomatology.

In Vivo Exposure Following

the imaginal

flooding, graduated in vivo exposure programs were

Overall Degree of Distress r

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Exposure

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DAILY RATING OF OVERALL

DEGREE OF SUBJECTIVE

DISTRESS.

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D.C.BEIDEL

AND C.M. BULIK

Degree of Distress in Situations Usually Provoke Anxiety

that

9Baseline lmaglnal 2

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introduced. For Ms. A, the behavioral interview used to develop the exposure hierarchy revealed the existence of several ritualistic behaviors associated with urinary and fecal incontinence, including rigid voiding schedules, inability to leave the house until toileting was completed, and a rigid belief in the necessity of daily bowel movements. Failure to successfully complete these

Frequency of Entry Into Situations Typically Create Distress

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FIG.3. FREQUENCY OFENTRY 1xroD1s~RFisSlNG SITUATIONS.

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activities resulted in significant distress. Thus, these elements were incorporated into the in vivo program. Each session was designed to expose Ms. A to the sensations of urinary and fecal urgency while preventing immediate access to a lavatory. This was accomplished in the following manner: Each day upon awakening, and prior to voiding or defecating, the patient drove her car for a specified period of time. The time limit for the first day was fifteen minutes, with daily five minute increases upon successful completion of the previous assignment. Initially, the patient drove on city streets. Limited access highways were added to the course as driving time increased. Driving was chosen inasmuch as it was one of the activities that the patient most feared, and the behavior that was of utmost concern to her with respect to her upcoming vacation. In all, fourteen exposure sessions were conducted, and there were no instances of fecal incontinence. The patient reported that she experienced no difficulty with the travel to and from her vacation site, and only had one instance of bowel distress during that time. Ms. A’s self-monitoring data showed a significant decrease in distress following the vacation. It is likely that this event served as an extended exposure session and consolidated the patient’s treatment gains. The patient continued to conduct exposure sessions on a twice per week basis for five additional weeks. At discharge, there was substantial improvement based on self-monitoring and inventory scores (see Table 1 and Figures l-3). A telephone call three months later indicated that all treatment gains had been maintained. Treatment for Ms. B also involved in vivo exposure to somatic sensations of gastrointestinal “fullness” while preventing immediate access to a lavoratory. She was required to eat a 400-500 calorie meal and then immediately leave the house and remain in a public place, such as a shopping mall, for at least two hours. Furthermore, the patient had to wear shoes with at least a one inch heel, and had to refrain from using peppermint candy to prevent the onset of nausea. Finally, she was not to use a restroom until the exposure session was completed. In vivo exposure occurred at least three times per week and proceeded along a hierarchy from situations creating only minimal distress until the final item, eating a full course meal then taking a one hour boat ride, was accomplished with only minimal distress. Eighteen exposure sessions were conducted, and there were no instances of nausea or fecal incontinence. Coinciding with the fourth week of in vivo exposure (Week #6 on Figures l-3), Ms. B returned to work, which created additional stress, and also brought her into contact with more individuals. For example, daily contact and conversation with co-workers increased the likelihood that she would be in contact with others who either had recently been ill or knew another individual who had been ill. In addition, Ms. B was faced with the necessity of eating lunch and remaining at work for several additional hours. The additional exposure opportunities initially produced an increase in distress, which may have extended the length of treatment, but was nonetheless important to incorporate into the overall treatment plan. In addition to her return to work, the patient resumed other social activities such as dining in restaurants which had heretofore been avoided, and she continued to enter situations on a regular basis. Data collected at the six month

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D. C. BEIDEL AND C. M. BlJLIK

follow-up indicated that Ms. B continued to make improvement during the follow-up period, as evidenced by self-report inventories and daily diary ratings. In addition, she recorded only one sick day during the six month period.

DISCUSSION These case presentations highlight the use of behavior therapy to treat avoidance behavior and general anxiety resulting from disabling fears of fecal incontinence and nausea. While the avoidance of public places is similar to that found in Agoraphobia, other features suggest a closer relationship to obsessional disorders. Based on the findings from this investigation and other studies, there is evidence that individuals with these types of fears might fit best within the obsessional dimension. There are several factors which support this interpretation. First, the topography of the behaviors is similar to other types of OCD patients. For example, both of our patients and those of Jenike et al. (1987) reported intrusive repetitive thoughts that they would become incontinent when in public. Only one of the patients presented by Jenike et al. (1987) had experienced actual incontinence, making this an isolated event. Similarly, Ms. B had never vomited or lost bowel control in public, although initially Ms. A had some reason for concern. Yet her thoughts continued long after the cessation of the fearful events, and long after the causal agent had been removed. Thus, the fear became senseless and intrusive. One of the characteristic features of obsessive-compulsive disorder is the engagement in repetitive acts designed to prevent the occurrence of feared events. Jenike’s patients conducted elaborate rituals prior to entry into public situations. Ms. A. engaged in similar behaviors including locating bathrooms immediateIy upon entry to a novel place, and locating gas stations along the highway as potential rest stops. In addition, there were ritualistic aspects to her medication regimen, which she used daily, although it had been prescribed “p.r.n.” Ms. B used peppermint candy ritualistically, had rigid schedules surrounding eating activities, as well as her more characteristic washing rituals. Finally, there were the premorbid obsessional and compulsive-like behaviors evident in both of these cases including rigid toileting schedules and belief in the necessity of daily bowel movements for Ms. A and the excessive concern about germs and illnesses for Ms. B. Thus, in both cases, there were predisposing factors which possibly contributed to the onset and maintenance of the anxiety state. The triggering of several instances of fecal incontinence or nausea, in combination with the longstanding history of cognitive and behavioral rigidity may have served to maintain the pattern of fear and avoidance. In individuals without these premorbid characteristics, it is likely that the fears would have dissipated once the causal agents had been removed. Further evidence for conceptualizing this category of fear as within the obsessional dimension comes from the positive response to interventions normally associated with treatment for obsessive-compulsive disorder. Although diagnoses should not be made solely on the basis of treatment response, the patients described by Jenike et al. (1987) had a positive response to tricyclic medications, often used to treat obsessive-compulsive disorder. Both of our

9

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OBSESSIONS

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patients also demonstrated significant improvement utilizing imaginal flooding, response prevention, and graduated exposure, behavioral procedures commonly used to treat obsessive-compulsive disorder. Most of the data indicate that Ms. B’s case was more severe than that of Ms. A. Ms. B was more depressed, as indicated by her SCL-90-R depression score, and had been fired from her job as a result of her symptoms. Thus, the disorder had a more pervasive impact upon her life functioning, and may in part, explain why although demonstrating substantial improvement, she continued to report distress levels higher than Ms. A. In addition, her avoidance pattern was more pervasive than Ms. A (who only avoided eating in restaurants), which accounts for Ms. B’s higher frequencies of entry into formerly distressing situations (Figure 3). Of interest is Ms. A’s low score on the Maudsley Obsessive-Compulsive Inventory (MOC), despite the existence of obsessional and compulsive characteristics. The MOC was developed for the specific purpose of differentiating “traditional” OCD patients from other patients previously called “anxiety neurotics” (Turner & Beidel, 1988). Therefore, questions on the MOC relate specifically to cleaning, checking, and doubting. Given the purpose and content of the scale items, the patient’s low score is consistent with the MOC’s specificity and Ms. A’s non-traditional symptom picture. Prior conceptualization of bowel fears as falling within the agoraphobia realm may have been due to the severe behavioral restrictions characteristic of the individual’s functioning. Although these patients often exhibit extensive avoidance, the results presented here, as well as those of Jenike et al. (1987) suggest that the core of the disorder is obsessionality. Avoidance behavior is frequently seen in OCD patients who often go to great lengths to avoid being in contact with a feared situation, and are also sometimes “housebound.”

CONCLUSIONS This report highlights the similarities between individuals who fear losing control of their bowels in public and the more typical concerns of obsessional patients. Inasmuch as the patients had never had any type of panic attack (limited or otherwise), continued to experience intrusive thoughts long after the fearful stimulus had been completely eliminated, and engaged in ritualistic cleansing behaviors, the evidence appears to favor conceptualizing these cases as within the obsessional realm. Finally, the successful remediation of the disorder with behavior therapy suggests that behavioral interventions show promise as treatment modalities.

REFERENCES American Psychiatric Association (1987). Diagnostic and slatistical manual of mental disordersIII (Revised). Washington, DC.: American Psychiatric Association. Barlow, D.H. (1985). The dimensions of anxiety disorders In: A.H. Tuma and J.D. Maser (Ms.), Anxiety and the anxiety disorders (pp 479-500). Hillsdale, N.J.: Lawrence Erlbaum Associates. Caballero, R. (1988). Bowel obsession responsive to clomipramine. American Journal of

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Psychiatry, 145,650-651. Chambless. D.L., Caputo, C., Bright, P.. & Gallagher, R. (1984). Assessment of fear in agoraphobits: The Body Sensations Questionnaire and the Agoraphobics Cognitions Questionnaire. Behaviour Research and Therapy, 63. 1090-1097.

Chambless, D.L.. Caputo, C.. Jasin, S.E.. Gracely. E.J., & Williams, C. (1985). The mobility inventory for agoraphobia. Behaviour Research and Therapy, 23,35-M Derogatis. L.R. (1983). XL-90-R: Adminisfrafion. scoring and procedure manual. Baltimore: Clinical Psychometric Research. Jacob, R.G.,& Rapport, M.D. (1984). Panic disorder. In S.M. Turner (Ed). Behavioral theories and treatment ofanxiety @p.187-237). New York: Plenum Press. Jenike, M.A.. Vitagliano, H.L., Rabinowitz, J.. Goff, DC. & Baer, L. (1987). Bowel obsessions responsive to tricyclic antidepressants in four patients. American Journal of Psychiafry. 144.1347-1348. Rachman, S.. & Hodgeson, R.. (1980). Obsessions and compulsions. New Jersey: Prentice Hall. Turner, S.M.. & Beidel, D.C. (1988). Trealing obsessive-compulsive disorder. New York: Pergamon Press. Turner, S.M.. Beidel, D.C.. Dancu, C.V., & Stanley, M.A. (1989). An empirically derived inventory to measure social fears and anxiety: The social phobia and anxiety inventory. Psychological Assessment: A Journal of Consulling and Clinical Psychology, 1.3540.