Ask David

I will answer a question on obsessive compulsive disorder, body dysmorphic disorder, vomit phobia, cognitive behaviour therapy or sometimes on depression and other anxiety disorders. I cannot answer all the questions I receive but will answer those from individuals with these disorders or their relatives, carersor or professional . I cannot give specific advice without assessing you - I can only discuss the issue in general terms. Please submit your question by email and state it is for teh "Ask David" section and whether you are happy for your email to be published in your question (as others might also want to contact you).

Question on BDD 2/11/05: "My son has BDD. He has now booked in for cosmetic surgery and I am about to part with a lot of money. I wouldn't mind this if I thought it would end his problems but in my heart I know it won't. He has been taking citalopram 60mg for months and it is having no effect. I can't describe what we are all going through. The next drug the doctors are going to try is an antipsychotic."

Answer: Thank you. This is very tough- I have seen several families completely torn by the incessant demands by their son or daughter for cosmetic surgery when the family think it is a waste of money. I am not against cosmetic procedures per se but the effect in BDD is unpredictable. Both I and Katherine Phillips have published surveys of cosmetic surgery in BDD patients seen in our clinics. Overall, the effect is unpredictable in any given individual. Some people may be satisfied by surgery but it usually then transfers to a different area. Surgery is very unlikely to help symptoms of BDD. Your son is likely to remain preoccupied, distressed or handicapped by some aspect of appearance. It could be that I like others in the field are biased because I see people with BDD who have failed cosmetic surgery. It may be that some people with mild BDD without much handicap may benefit if they do not have too many expectations about any change occurring in their life. Also some operations such as breast augmentation or reduction may do better than say an operation to the nose (a rhinoplasty) which is common in BDD.

I wouldn't financially support surgery (at least not until he gets over his BDD). You should certainly discuss his problems with the surgeon and make him or her aware of your son's history and symptoms.

Anti-psychotics are generally unhelpful and not recommended for most people unless the person is very agitated (See NICE guidelines for the treatment of OCD and BDD). A doctor may want to check his blood level of citalopram to determine he had taken a reasonable dose for at least 12 weeks. If the level is low and he is taking the medication, he might need a higher dose. If that that was OK I would recommend trying a different SSRI such as fluoxetine, again up to the maximum dose for at least 12 weeks.

We have an NHS out-patient clinic at the Maudsley Hospital or a residential unit at the Bethlem Hospital or at the Priory Hospital if your son is willing to attend. The best psychological treatment is cognitive behaviour therapy. The key issue is trying to engage your son in a psychological understanding of what is keeping his problem going and how his solutions have become the problem. There are many factors such as checking, ruminating, comparing, camouflaging, avoiding, and being excessively self-focussed that are likely to maintain his preoccupation and fears and each of these are targeted in therapy. However he needs to be committed to not having surgery and testing out whether what he is doing "works" for him or whether is makes it worse.

Question - helping someone with OCD who will not seek help 15/10/05

I act as a Social Care Worker in a residential unit. My client's compulsions, from what I can see, are excessive hand washing - I would say this takes about 10- 30minutes depending on how he feels, on each hand washing session. He will hand wash when he has been to the toilet, when he needs to go out to the shop, pre-showering, if he touches his used clothes, if he needs to change bedding (although he also says he needs to shower if he touches old bedding). He seems to be unable to say why he needs to hand wash. He will now avoid showering and washing his hair. If he DOES shower, it will take him anywhere between 1-3 hours, including time to actually get into the shower room. He has voiced being afraid of being alone in the shower and on many occasions has asked for us to be in with him - however this has not been appropriate for our line of work and therefore has been declined. He now also avoids cooking as he feels it may be contaminated. He will refuse to buy foods from supermarkets as he has previously been followed by security guards and on one occasion escorted out of the supermarket, due to what they perceive as "abnormal behaviour" (taking copious amounts of time to check food packaging. Neither will he allow me to food shop for him, as he feels that the food may get contamination from the time I pick it from the shelf, to the time it reaches the project. However, he will purchase numerous bars of soap from the local shop and pre packed sandwiches, which he appears to live on. At the project where my client lives, we have a number of toilets which he will "check", usually on getting up in the morning. He appears to switch the light on and off a certain amount of times, although he will not tell me why or what his "number" is. He will check the angle of the door, he will also move his feet to a rhythm back and forth (this is especially visible whilst he washes his hands). He will check that lids are on foods, butters, jams etc. He feels unable to leave the site, unless he showers - however, as showering causes him extreme anxiety, he now practically stays on site. He has had no previous CBT of any kind, or indeed does not appear to have had any other therapy for his OCD. He says he does want to change and appears to be in a state of depression, anxiety and frustration everyday however, is not very open to support at the project - although I feel his self esteem is very low. My client asks that we encourage him through his hand washing rituals by standing with him and talking to him "about anything". Just making conversation appears to help in through. He says that he seems to react to an "authoritarian" voice and appears to get things done when a male supports him. He explains that he needs to be told what to do. Currently we are supporting him this way and sticking to a time limit - for example, 5 minutes for hand-washing. So far he has not disclosed to me or others, what his feared consequences are if he does not do the rituals. Is it fair to attempt to distract my client from his rituals? When he states that "It takes as long as it takes" (usually hand washing or checking) I am reluctant to pull him away and am unsure whether distracting him does more damage than good. If I was qualified in this area, I would be using distraction techniques, suggesting he keeps a diary of thoughts, actions, anxiety levels, to challenge his fears (as I myself have previously had CBT).

Answer: Thank you. It sounds as if your client has quite severe OCD and is significantly handicapped. It sounds as if his feared consequences is of contamination although we don't know what this means to him (for example, losing control). He responds by various compulsions to wash and probably finishes a compulsion when he feels comfortable or right. Your position is similar to many families or carers who struggle in caring for their son or daughter with OCD as you feel helpless and frustrated. You and they know that your client is suffering badly and that he could potentially benefit greatly from Cognitive Behaviour Therapy (CBT) and yet he say he doesn't want help. The key issue at this stage is just getting him to seek help.

I would keep telling him that he has recognized condition, OCD, which is treatable and he can choose to change once he knows more about how to solve the problem. I would try to find out about some of the obstacles he has for getting help such as shame or fears about what therapy would involve.

I would focus him on the consequences of not getting help as it's fairly certain that his OCD will not get better and more likely to get worse. Use metaphors such as man trying to dig his way out of hole (see our book on Overcoming OCD by myself and Rob Willson published by Robinson). It's his agenda which is unworkable orhopeless and it's his solutions that are the problem. If for example he fears being contaminated and for example being out of control or too anxious, I would focus him on how his life is out of control and anxiety provoking now because of his OCD.

I would like to know more his real values in life and what he wants to be remembered for when he dies, because it is very unlikely that he is moving in his valued directions in life at present. How does he think he is going to achieve them in his present condition? If he wants to achieve them, he will have to commit himself to feeling some discomfort and being uncertain or out of control in the short term. However this will improve quickly once he starts to engage in the negotiated homework and treats it as a worry problem. It looks as he is becoming increasingly isolated from society and his family and his nutrition is deteriorating (which might also make it worse). I don't think there is a right or wrong answer about distracting him during his hand washing rituals by standing with him and talking to him or telling him what to do. It depends on what the goals are. It may help him function in the short term but it doesn't solve his OCD. The danger is that you end up making life just comfortable enough for him not to want to change. It is such a difficult tight rope to follow. I think you need to be emotionally supportive in focussing him on change. (For other carers, this might mean not accommodating or engaging in a person's avoidance or rituals or asking a sufferer to live elsewhere so they can look after their own mental health) .i.e. a carers role is to be emotionally supportive and assit them in seeking help (for example get them to appointments on time and getting them as muich information about OCD.Later ith their permission you may become a co-therapist and monitor their homework and model exposure tasks or do behavioural experiments (here it'simportant tomake sure your role doesn't function as a ritual of reassurance). Other roles as a carer run the risk of accommodating the OCD and being a disincentive to change.

CBT for OCD is different to what hat you might have personally experienced as in OCD there is more focus on the cognitive processes (e.g. fusion between thoughts and reality; the excessive responsibility in being able to prevent harm from occurring; the problematic criteria used to terminate a wash) and on the function of the avoidance and compulsions rather than challenging the content of the thoughts as in traditional CBT. The first step in therapy for OCD is to gain a good psychological understanding of what the problem is - for example your client may assume that he has a problem of contamination. The alternative theory in therapy is that he has a problem with worrying about contamination and that this has become fused with reality to make him think the problem is of contamination. Furthermore his solutions of avoidance and compulsions and selective attention to anything that is regarded as contaminating makes his worrying worse. If he is to truly treat this as a worry problem, he will learn to turn his behaviours upside down through various behavioural experiments and graded exposure to contaminants. If he were to see a cognitive behaviour therapist, you may be asked to be a co-therapist and be the cheerleader on the side and modelling exposure by later putting your hand down the toilet and on the floor and touching your face.

Distraction is not an elegant solution during a ritual - in therapy you would want to encourage exposure to a contaminant after a ritual to undo the effect of the ritual. When he says his compulsion "takes as long as it takes", it usually means a person is using problematic criteria to terminate a compulsion - for example when he feels comfortable or right. This is the internal subjective criteria of his mind. Most people do this for only very important decisions like where who we are going to marry. He is not going by his reality- for example whether he can see he can see that his hands are clean. Ultimately he needs a referral to a professional (usually a psychologist or nurse therapist) trained in CBT. In this regard you may to ask about their training and experience in OCD. A GP can refer him to his local community mental health team. Unfortunately there is often a long waiting list in the UK. If treatment is unsuccessful then he can be referred to a specialist unit such as the Maudsley Hospital where I am based. If he is too far way then we also have a residential unit at the Bethlem Hospital. He may also like to attend the Anxiety Disorders conference in London on Saturday November 26th for individuals with OCD . He may like to meet another person with OCD in a local support group (details from OCD Action). He might want to read our book and the public version of the NICE guidelines for treating OCD (available end of November 2005). If he is not yet ready for CBT, then he might be willing to consider medication. There are a number of SSRI mediations that can on average lead to a 50% reduction in symptoms if he takes a trial of at least 12 weeks at the maximum tolerated dose. The main problem is the high rate of relapse on discontinuation and so medication should normally be combined with CBT. They can be prescribed by a GP (who can also do a home visit). If the GP find his health and OCD is deteriorating, he can ask the local community mental health team to a do a home visit. Just keep pushing for him to get help and explore the obstacles to change.

David Veale

Vomit phobia (29/08/05)

I have had a phobia of vomiting - both myself and others - since around the age of 13, and the obsessive and avoidance parts of the behaviour increased over the following 10 years. I’am now 32, am unable to work, and have also had various other ‘labels’ at different times including social phobia, agoraphobia, anxiety disorder with panic attacks, and M.E. The M.E is still ongoing but I am accepting of the fact that this could well be fed by, and possibly rooted in my general anxiety difficulties.
Over the years I have gained a lot of self-insight into my past as well as present patterns of response through long-term counselling. This has been very helpful and, amongst other things, I would link the emetophobia primarily to issues around emotional control or losing control etc. However it would appear that whilst understanding the roots of a fear does help, it does not cure the phobia! I have therefore also had several courses of CBT and have made some progress over the years in terms of functional life e.g. with difficulty, I can now go on short bus rides, sit in a doctors waiting room, eat in public, cope with shops etc but there are many more things that are still impossible, or that I avoid. In particular I would like to have children but fear both morning sickness and, perhaps most of all, whether I would be able to look after my child if they were sick. My question to you is whether, in your experience, graded exposure programmes (that is exposure to specific 'face to face risks', say, to hospital wards, vomit bowls, videos) are of benefit to this type of phobia? I have read somewhere that emetophobia is more difficult to treat than simple phobias and that graded exposure is not always the best choice of treatment. Could you comment on whether this is true - and why - or whether, having benefited from other therapies such as CBT, counselling and medication, graded exposure may be another useful piece of the jigsaw especially in relation to preparing for having children? Also, if this is a ‘difficult to treat phobia’ how easy is it to find a practitioner who has specific experience of, and expertise in, treating this particular phobia? "

Answer.
Thank you. There is very little research into vomit phobia and so it is difficult to give any hard facts. Most therapists would agree that vomit phobia can be difficult to treat (and more difficult than treating other specific phobias such as insect or heights). The symptoms are often long-standing and significantly handicapping.

Vomit phobics frequently experience nausea in anticipation of vomiting as a symptom of anxiety. This leads to excessive vigilance for sensations of nausea which intensifies the sensations in a vicious circle. The sensation of nausea becomes misinterpreted as evidence of impending vomit and being paralysed with fear. Vomiting is associated with the feared consequences of losing control, and to a lesser extent of becoming very ill or choking. Vomit phobics tend to avoid situations which are associated with an increased risk of vomiting (e.g. pregnancy) or of others vomiting (e.g. being near a drunk). However many of the situations avoided would be associated with an extremely low risk of vomiting (e.g. using a public toilet). In common with other anxiety disorders, safety seeking behaviours” are likely to prevent individuals from testing out their fears of vomiting or may intensify the sensations (for example looking for an escape route; trying to keep tight control of their behaviour; taking medication; reading; sucking antacids; checking the sell by date and the freshness of the food; washing hands & teeth excessively; checking the health of themselves and of others; behaviour and magical thinking, such as ‘not stepping on a 13th stair’ or repeating a word or action a certain number of times’ so as not to vomit.

For Cognitive Behaviour Therapy (CBT), you need a good psychological understanding of your vomit phobia and to identify the factors that are maintaining the problem (especially your beliefs about vomiting, the safety seeking and avoidance behaviours). It is striking that for vomit phobics despite a career of preventing themselves from vomiting; the frequency of vomiting is no less than anyone else (unless the person is getting regularly drunk etc). Thus you are trying too hard to stop yourself from vomiting but it has virtually no effect on whether you are going to vomit. You may think you are in control but like the rest of us, there is limit to your influence and if in the very unlikely event that you do catch something that makes you vomit there is very little you can do about it! Vomiting is highly adaptive for getting rid of toxins in the gut - you'd be far iller if you couldn't vomit.

A person with vomit phobia may recognise the very low probability of vomiting but believes that the awfulness of vomiting is so high or that the consequences of vomiting are too dangerous and awful. As a result their solution of avoidance, safety seeking behaviours and excessive vigilance for vomiting are now their problems. The problem however is of being excessively worried about vomiting and therfore believing that they may be paralysed with fear.They rate vomiting as being 100% awful and are therefore trying too hard to prevent themselves from vomiting. Thus for effective CBT it is crucial to act as if it is a worry problem and to enter situations and activities associated with nausea (caused by anticipatory anxiety) without excessive vigilance and safety seeking behaviours. The aim would be to refocus attention away from the nausea in avoided situations and to do this repeatedly to disconfirm the prediction of vomiting and to therfore improve the quality of your life. Here the emphasis is on being functional as the strategy of trying never to vomit has a significant cost and yet has no effect on the frequency of vomiting. In other words we would encourage you to act in your valued directions in life (such as wanting to be a mother) despite the sensations of nausea and fear of vomiting as this will subside over time. The aim of therapy would be to help you drop your safety seeking behaviours and all the situations you avoid associated with the fear of vomiting. However, it has to be done consistently and regularly (preferably daily) without trying to control or escape from your feelings and sensations of nausea.

Graded exposure has also been described –for example in imagination to vomiting, simulated vomit, joke vomit, or videos of others vomiting. We don’t know how effective these strategies are as we just don’t have the research data. Videos of another person vomiting may have limited benefit since the main fear is usually of the self vomiting. Watching simulated vomiting or others vomit may also not be sufficiently realistic. Inducing vomiting by a prescribed emetic such as ipecachuana is sometimes described. It could theoretically be justified for a single behavioural experiment to test the “awfulness” of vomiting but it cannot be done repeatedly for ethical and practical reasons. Another obstacle to exposure to simulated or real vomit is that it may not alter the rating of the “awfulness” of vomiting or the beliefs about the consequences of vomiting. Exposure to vomiting can sometimes be counter-productive – for example one person I saw with vomit phobia described repeated exposure to vomiting by a prescribed emetic as confirming for her the awfulness of vomiting and making her even more determined to avoid vomiting. However, another patient with vomit phobia who had had emergency surgery vomited repeatedly post-operatively which she described as having benefit in reducing her fear.

One can also use exposure in imagination to vomiting and role plays of the self vomiting (since this seems to be more important than others vomiting). The aim here would be to reduce the “awfulness” of vomiting to enable you to drop your avoidance, excessive vigilance and safety seeking behaviours. A therapist might also attempt to decrease the rating of the awfulness of vomiting and to develop more adaptive beliefs (for example “Being sick is very unpleasant, but not awful since there are much worse things that could happen”) and helping you to re-rate the awfulness of vomiting on a continuum (for example 0% being “unpleasant” up to 100% being “awful”). Another obstacle for vomit phobics is the fear of losing control if they did vomit. Lastly, it may be important to explore the meaning or imagery associated with “losing control” and to practice“losing control”.

In general I would advise you try to overcome vomit phobia before you get pregnant. You may have difficulty in looking after your child if they were sick and it would be best to practice on other children – unfortunately other children are not sick to order!

You need to ask a practitioner whether they have experience of treating this vomit phobia – it sounds as you are already quite knowledgeable. A good start would we www.babcp.com under “Find a Therapist” (which at present only covers private therapists. If you cannot get expertise locally on the NHS, then you could ask your local psychiatrist to refer you to our unit at the Centre for Anxiety Disorders at the Maudsley Hospital.

There is self help support group on the web “Gut Reaction” . I also have a FAQ on vomit phobia on this website.

ME or chronic fatigue can also be treated by CBT. I would recommend the book "Overcoming Chronic Fatigue" for you by Mary Burgess and Trudie Chalder published by Robinson.

David Veale