The treatment of hysterical spasm and agoraphobia by behaviour therapy

THE TREATMENT AGORAPHOBIA

OF HYSTERICAL BY REHAVlOUR

SPASM AND THERAPY

D. F. CLARK" (Received 19 June 1963)

Summary-A case of muscular spasm and agoraphobia is described and the techniques of treatment by behaviour therapy outlined. A particular plea is made for the accommodation within the conceptual framework of learning theory, of practices more akin to traditional psychotherapy and it is shown how this may support more specific symptom orientated approaches, such as reciprocal inhibition and systematic desensitization.

INTRODUCTION THE publication

of a recent article by Cooper (19631, in which he compares the effects of behaviour therapy and other types of therapy in 30 experimental patients and 16 controIs marks the beginning of some rapprochement between the learning theory and conditioning protagonists and other more traditionally inclined therapists. In his paper he proposes that no one answer to the cure of neurotic disorders, be it in Freudian or Hullian terms, need necessarily reign supreme, but that the most effective of the currently available tecIlniques should be utilized in the case of those patients whose di~cu~ties match the ones best treated by any of these given techniques. This seems a sensible working solution, although if the canon of parsimony is to be upheld it may well be that so-called “other” treatments should be conceptualized within the framework of the theory of learning and conditioning. Even so, the phenomena of placebo effect in whichever setting they occur and whether or not they are a function of the patiellt~t~~erapist relationship, remain worthy of further detailed study before the balance be tipped in one direction or another. The following case is quoted. however. in an attempt to show how techniques both of a typical learning theory sort and also of the type more often associated with traditional psychotherapy can be combined and conceptualized within the mnt" theoretical schema. Behaviour theorists should not be blind to the possibilities afforded by the traditional psychotherapeutic situation, even if they describe it in different terms. A 30-year-old married woman, whose case is discussed here, had previously been seen by the psychologist some years ago, when it was suggested to the psychiatrist in charge that she was an hysteric personality, who seemed likely to develop symptoms involving her intra-familial adjustment and heterosexual adjustment in particular, Subsequent events confirmed this prediction and the patient had been referred in this instance in the hope that the psyc~~ologist could devise some form of bellaviour therapy aimed at the relief of her symptoms. One main difhcufty was that such treatment would have to be effective within the course of 7 or 8 weeks, before the patient undertook a journey to Kenya where she and her husband had necessarily to move because of the latter’s employment. The patient’s main symptom was that she was troubled by a spasm of the jaw muscles or by the anxiety that a spasm was impending. The anxiety about this was considerable and the symptoms appeared to be the focus of what would otherwise have been free-floating * Towers Hospital, Humberstone,

L&ester.

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D. P. CLARK

anxiety, generated from a number of sources. For example, she stated that she was consciously anxious only that she would have a facial spasm or if she had to go out, but in fact showed several signs of anxiety clinically and on the G.S.R., when domestic and sexual topics were discussed. The association of anxiety/spasm may well have been learned at the age of 9 or 10 when the patient saw a t%m in which a person with whom she tended to identify strongly had lockjaw and died in a rather frightening scene in the film. It was also noticed that the patient had been prrticularty anxious when her children had had antitetanus injections. There appeared also to be a large depressive component in the clinical picture, which related to the fact that she was strongly ambivalent about a termination of pregnancy carried out on psychiatric advice some time previously. At the first session, exploration of the nature of the symptom and what it meant to the patient was carried out in detail, and it appeared that the spasm occurred more frequently when the patient was out of doors. Under these circumstances it was constant on both sides, but mostly occurred on the right side. The frequency and intensity of the spasm was always greater when outside the house and less when indoors. It was less again, and almost non-existent when the p&tit was lying in bed. Lying down elsewhere also helped to dissipate the symptom and the patient also found that sleeping tablets, sodium amylobarbitone, tended to help the spasm and to relax her. Otherwise she felt continually pent-up, tense and anxious. Overtly she was fretful, nervous and edgy and during the first session or two was close to tears, actually crying on a number of occasions. However, the spasm was also repeatable on voluntary effort. It was noticeable that this particular symptom became most marked only after the 2 children were born and the patient and her husband began to use contraceptives for the tlrst time. The patient showed subsidiary symptoms, such as the fact that hard foods worried her and she tended consequently to senw soft mashes and so forth for meals, because of the fear that her jaw would lock when tackling the former. Similarly, the patient had a fear of going out and about, even to do shopping or to go to the nearby town. The patient’s M.P.I. scores were Neuroticism 36, Extraversion 32; she being, therefore, a rather severely neurotic extravert. This result was, in fact, adumbrated by the provisional diagnosis of hysteria following the previous psychological investigation. She had an I.Q. of 107 and was, because of the impending immigration, strongly motivated to improve. TREATMENT The patient was counselled at some length regarding her sexual problems and detailed discussion of the patient’s difficulties in this area, together with some advice about experimentation in her sex life and information about adequate contraception was given. This counselling was carried out on most of the 7 sessions of treatment. Secondly, reciprocal inhibition of the muscular spasm was induced by training the patient in progressive relaxation along the lines suggested both by Wolpe (1958) and Jacobson (1938). She was trained in relaxation by a technique closely related to hypnosis and when she had induced a good muscular relaxation and was in a semi-drowsy state, subjects which might increase her anxiety level were progressively intensively discussed. As soon as the patient felt a spasm about to come on or felt the anxiety associated with this she was instructed to smile broadly whether she felt like it or not. She had to put her face in the set of a smile. As she smiled the progressive relaxation was again instituted and strong suggestions of relaxation and frwdom from anxiety were given. Because of a great

THE TREATMENT

OF HYSTERICAL

SPASM AND AGORAPHOBIA

BY BEHAVIOUR

THERAPY

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deal of contra-suggestibility, which was most apparent at the first 3 sessions, a straightforward hypnotic-type of relaxation procedure was not considered particularly useful. Later, this regime was amended so that, as well as the smiling response, the patient was asked to open her jaw widely, again to inhibit this tension of the jaw muscles, as long as she could. The period during which she kept her jaw open was gradually shortened, as relaxation became more adequate. The patient’s subsidiary symptoms were tackled in the following way-she was put on a regime whereby she was asked to buy “Opal fruits”, a well-known sweet which has a chewy texture and to cut them into small sections of approximately + the size of a normal sweet. At first she should take only a small piece and perhaps chew it once before swallowing, but on successive days she took more chews and large pieces of sweet until eventually she could work up to eating the whole sweet with a good deal of chewing. Equally a stimulus gradient of the same sort was used to deal with the patient’s fear of going out. On the first day she was instructed to go into the garden and then return straight into the house before apprehensiveness supervened. On the following occasion she had to go to the foot of the garden and progressively until she was going down the street 100 yards, 200 yards, 400 yards and eventually to the nearest shop briefly and returning home. This was increased to the degree whereby the patient was eventually able to visit chain stores in the town of Loughborough and eventually Leicester, travelling on her husband’s motor cycle to and from these places. The latter point in the stimulus gradient was one which did give the patient some anxiety, not because of her husband’s driving but because of the distance from home, but she was prepared to tackle this again. Ideally it would have been wise to continue this regime rather longer than has been done but the time was limited because of the patient’s departure for Kenya after the seventh session. However, at that stage both the patient and her husband, who was also present, commented that she was sufficiently well not to require further treatment and there can be no doubt that she certainly looked very much better, with no observable jaw spasm, very little startle, a new hairdo, a much better and neater personal appearance, and more positive attitudes and controlled body movements. She still found that there were exacerbations of her illness at her menstrual periods, when her frustration tolerance dropped somewhat but she was encouraged to continue with her regime of reciprocal inhibition and to discuss with her husband as much as she could her psychosexual attitudes and the relationship with each other in general. In many ways the complete move to a new environment was likely to facilitate this revaluation of her personal relationships. The patient was instructed at the final session that if she should have further difficulties when she went to Kenya she should correspond with the psychologist, who would give her further guidance on treatment procedures, should she require them. However, if things were to go quite well and improvement to continue she should not trouble to write. Nearly a year has elapsed since the end of treatment and presumably the patient remains well, since no correspondence has reached the psychologist, who, in spite of all efforts, has been unable to find out the patient’s current address. DISCUSSION A brief digression on learning theory will clarify what was aimed at in treatment. Hull’s fundamental formula, linking performance, habit and drive, is, of course, sE, = ,H,x D. In other words, any given performance results from the multiplicative function of habit and drive. If no drive strength is present, then no performance will result,

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even if the habit is strong. This sijnple equation is etll~lplicat~d, however, by the fact that repetition of a performance results in the growth of ti\;o types of inhibitory potential, I, and S1,. G\+y~~ne-Jones‘ revision of Hiull’s original equation can be taken to model the effects of the behavioural approach to symptom reduction. Thus. when $, = (D-I,)x(,~H, --,,I,) and ,t, is taken as the symptom. it was decided to tackle this patient’s problem from tuo angles, an attempt being made to reduce the value of two of the ternis on the right of the ~qll~ltiol~, so bringing about a reduction of that on the left. i.e. the symptoms. Both drive and habit strength would be reriucecl by lowering anxiety levels by discussion, counsellil:g and reciprocal inhibitioll. Continued exploration of the symptom pattern suggested that a large amount of the drive, i.e. genera1 level of anxiety, derived from the patient’s heterosexunl adjustment and This was confirmed by the congicts she experienced at the time psychosexual attitudes. of the preiil~~ture tcrl~~ili~lti~~n of pregnancy. ~Lirtllerll~~~rc, she claimed never to have experienced adequate orgasm during her marriage, mainly because her husband apparently had difficulty in performing adequately when wearing 21condom and the patient f’ound that a cervical cap seemed to her messy and for this reason not desirable. She also had ;L history of having heard her parents quarrelling a great deal about scs uhcn she WIS a child 01 12 and fllrtllertl~ore her own menarchc had been sonicthing of a surprise and shock to her. since she had never been \*arned that it was impending. SIX had heard little about sex at school and had a rather biased view of it when she \sent into the W.R.N.S. The all.xiet\ associated with these areas of her adaptation LLits so grc:kt that she even hoped the maladaptive behaviour of a~mpto1~1 formation bhe had adopted to cope with it would not be disrupted by therapy, and she nekcr failed to express a persistent hope for H miraculous hypnotic type of cure which ~~ouid not inuolve c~i~~or~lti~~tl t>!‘thcsc faulty ~~~i~li)t~i~iolls. The counselling, thercforc, MM an attempt to r&we dri;,c strut:$h. :il:d the patient was finally much more happy about using a cervical cap and :llthough she had not then experienced ndcquatc orgasm in ifitercourse she had. by the lil‘th \esbion of trcutlnent, experienced it following pettin?. I fcr Itusbnnd \~,;Is ;~lso seen and ~~~unselled on this matter and suggestions \\eerc made ti> cnah!e him to reach a better scuu:tl pcrforntnncc Icwl. It was found that after some \ quiwcal but. of course, socially the smiling technique v.?;s more acceptable. One of the difticulties of this type of treatment has been p~~inied out by Solomon 2nd W! nnl: (I 954). who remark that the actual degree of anxiety should bc known as ~\ell as lhc strength in relation to the incompatible res’ponse and this shwld really bc known for each step in the hicl:trchy of response situations devised. Techniyuc~ ~.rortgly applied in the absence of such knowledge might result in the anxiety respo~lsc being attached to parts of lhc Gtuations which \vcrc For example, presentatirrn of a piece of Opal fruit previously neutral or even attractive. to the patient ~vhen she was in a situation of anxiety might result in the anxiety being associated with the Opal fruit and the patient refusing to touch it. Ho\\ever, this diniculty does not appear to have been m~:ch discussed by previous writers on the sub.ject and on the

THE TREATMENT

OF HYSTERICAL

SPASM AND

AGORAPHOBIA

R\’ REHAVIOLJR THERAPY

249

occasions when this writer has used it, it would appear to be largely a theoretical point. One can aluays play safe in practice by making early items of the stimulus hierarchy as innocuous as possible and making steps in the gradient as tiny as practicable. The key to some apparently contradictory features of this case seems to lie in the patient’s high neuroticism. On testing she was found to be an hysteric, a neurotic extravert. Her extroversion should have suggested poor conditionability. Yet she looked asthenic, showed obvious anxiety, though psychically it was converted into symptoms, and was prone to reactive depressions, all dysthymic-type features. On the other hand, she certainly conditioned poorly; the induction of relaxation was almost as difficult at the last session as at the first, but again, a check using the P.G.R. confirmed clearly defined anxiety gradients. In view of this it seems not unlikely that the main aspect of therapy was the discursive attempt at reduction of drive and the subsidiary attempt to block the habit strength by reciprocal inhibition. Finally, the patient not infrequently facilitated the reciprocal inhibition not by practising the relaxation ritual but by taking a tablet of sodium amylobarb. (prescribed by her G.P. for sleeplessness) during the day. This. of course, is legitimate and such procedure often occurs in the course of eclectic psychotherapy. In the latter instance, however, the significance of the inhibition of the anxiety is often lost because the patient then has had no instructions on how to associate her anxiety inhibited state with progressively greater items in the stimulus gradient. One wonders too, since this patient was already an extravert, how conditioning was affected at all, since the effect of barbiturates would be to increase cortical inhibition and thereby to induce more extraverted behaviour patterns. Apparently this extraverting effect and the reduction of anxiety it brought with it were more therapeutically important than the reduction in conditionability it induced. One of the most useful illustrative features of this case is the way it demonstrates how different approaches to symptom reduction can be made within the conceptual framework of behaviour theory. Discursive exploration of sexual and interpersonal problems and counselling was carried out, but this was done not with a view to releasing repressed material in the analytic sense but with the aim of drive reduction, in the sense that learned anxiety had accumulated about certain topics and discussion of these dissipated it. Verbal behaviour of an acceptable sort replaced symptom production. Since no special techniques were used to release genuinely repressed material and since the discussion was direct and very early in the treatment programme it would seem most unlikely that the patent reduction of anxiety, as measured by P.G.R. response, was due to de-repression. Indeed, it is very probable that much of the benefit to patients accruing from psychotherapy of a more traditional sort can be conceptualized better in terms of the reduction of acquired or secondary drives. Secondly, the direct assault on the symptoms, made through the reciprocal inhibition of muscular set and through the systematic desensitization programme, constitutes a further attempt to stamp out maladaptive patterns of behaviour. It has the advantage over traditional analytic type psychotherapy of not being confined to the clinic room and to the patient/therapist relationship. It can be practised regularly at home or at work and is, therefore, more economic of time for all concerned. It has the added advantage of appearing to the patient to be directly relevant to her illness. Behaviour therapy techniques, therefore, are not in any way mutually exclusive, although there are theoretical grounds for preference being given to certain procedures in certain patients. They differ from analytic type therapies, however, in that they follow from an experimentally validated theoretical framework, that they allow of specific predictions being made, and more important. of being tested, and that they make the

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F. CLARK

demand on the therapist only that he be an experimental& rather than an authoritarian and that he be reasonably well versed in the neurophysiology and general psychology of conditioning and learning. Acknowledgement-The writer is much indebted to Dr. D. F. Narborough, Leicestershire, for permission to treat this patient.

MACGREGOR

of Carlton Hayes Hospital,

REFERENCES COOPERJ. E. (1963) A study of behaviour therapy in thirty psychiatric patients. Lancer 1, 41 l-415. JACOBSONE. (1938) Progressive Relaxation. University of Chicago Press, Chicago. SOLOMONR. L. and WYNNE L. C. (1954) Traumatic avoidance learning: The principle of anxiety

servation and partial irreversibility. WOLPE E. (1958)

Psychotherapy

Psychol. Rev. 61, 353-385. by Reciprocal Inhibition. Stanford University Press, California.

con-