1. Paul Salkovskis p.salkovskis@iop.kcl.ac.uk Institute of Psychiatry Centre for Anxiety Disorders and Trauma, Maudsley Hospital What is toilet phobia? History, research and the present status of toilet phobia

2. TABOO STIGMA

3. Toilet phobia: is it a distinct diagnosis?  What is the purpose of diagnosis?  Does it tell us what the problem is?  No, the person does that!  Although it does not tell us what the diagnosis is, it tells us where to begin to look  So…..should toilet phobia be a distinct diagnosis??

4. Toilet phobia:  Phobia: a clinical condition characterised by avoidance or by the person consistently experiencing fear when confronted by the feared object.  Other toilet fear: not being able to reach one in time (sometimes linked to Irritable bowel syndrome)  Use of toilet: unavoidable.  Avoidance therefore tends to be of going out of easy reach of a familiar “safe” toilet.

5. Psychological problems linked to toilet phobia  Specific phobia –toilet related stimuli –Claustrophobia Trapped Suffocated –Fear of being alone  Agoraphobia, with and without panic  Generalised Anxiety Disorder (GAD)  Specific social phobia (“Social anxiety disorder”)  Obsessive compulsive disorder (especially, but not only, contamination fears)  Paruresis  Parcopresis

6. Special features  Stigma and taboos  Link to primary bodily functions

7. Research  Epidemiology: very little  Fundamental processess: social psychology of paruresis. Little else.  Treatment: patchy reports  Natural history: –Some early onset, linked to childhood fears –Paruresis onset looks like social phobia  Physical findings: nothing consistent

8. What is toilet phobia?  A mixture of problems, with fears of toilets being the “final common pathway”  Anxiety and anxiety motivated safety seeking behaviour are the common features  Final common pathway of what?

9. What do we know about anxiety?  Normal emotion  Can become a problem when it is severe and persistent

10. perceived likelihood it will happen Anxiety is proportional to the perception of danger; that is Anxiety and threat: understanding the severity of anxiety X + perceived “awfulness” if it did perceived rescue factors perceived coping ability when it does ___________________________

11. negative interpretations Events and situations Reactions to perceived threat Simplified Cognitive model of the persistence of anxiety

12. Anxiety: summary of cognitive- behavioural theory  Anxiety is a result of perceived threat  Factors which maintain exaggerated threat beliefs will maintain anxiety  Research supports the hypothesis that these factors include selective attention and other cognitive changes, mood changes, physiological reactions and safety seeking behaviours

13. Cognitive specificity in anxiety disorders  Phobias: imminent danger from an identifiable situation  Panic: imminent catastrophic danger indicated by bodily sensations  Hypochondriasis (health anxiety): less imminent catastrophic danger indicated by medically relevant stimuli including bodily sensations  Social phobia: imminent negative social judgement  Obsessive-compulsive disorder: responsibility for harm, focussed on intrusive cognitions  Generalised Anxiety Disorder: overestimation of threat, intolerance of uncertainty, worry about worry

14. Beliefs in toilet phobia  I will be contaminated –That will be dangerous to me –That will be dangerous to others  I will panic and….(lose control, etc)  I won’t be able to pee

15. negative interpretations Events and situations Automatic reactions Simplified Cognitive model of the persistence of anxiety Strategic reactions

16. Safety seeking behaviours in toilet phobia  Avoidance –General –Not going out –Choice of toilet, time of day, use of cubicles  Specific (subtle) –“In toilet behaviours”  Washing  Precautions to ensure proximity

17. Toilet phobia: is it a distinct diagnosis?  “Toilet phobia” is the manifestation of a range of different concerns focussed on toilets and the need to use the toilet.  Situation, not diagnosis  Why focus on it then?  Psychological problems tend to be stigmatised  In fears related to toilets and excretion, stigma is complicated by taboos

18. Paul Salkovskis p.salkovskis@iop.kcl.ac.uk Institute of Psychiatry Centre for Anxiety Disorders and Trauma, Maudsley Hospital Obsessive compulsive disorder and toilet phobia

19. The Diagnostic phenomenology of OCD  Intrusive thoughts, images and impulses  Obsessions and/or compulsions  Compulsions are meaningfully related to fears  By definition, the person seeks to ignore or suppress intrusions  Key to diagnosis is distress/disability

20. Cognitive phenomenology of obsessions and compulsions  Obsession: A recurrent thought, image, impulse or doubt which creates awareness of the potential for danger which the person can cause or prevent  Compulsion: An action or reaction that is intended to both to prevent the danger of which the obsession has created awareness and to diminish responsibility for its ocurrence.

21. OCD and toilet fears  Fear of contamination of –Self –Others  Fear of losing control in public places

22. CBT for obsessional problems  Engagement in assessment: helping the patient to feel understood  Formulation: reaching a shared understanding  Discussion of alternative explanations  Engagement in treatment: helping the patient to choose to change  Helping the patient to actively test the alternative account and explore its implications  Generalising changes  Relapse prevention

23. Treatment of OCD is highly successful  Cognitive behavioural therapy  But; availability still a problem  For some, engagement is an issue  Solutions range from telephone therapy (increased accessibility) to intensive treatment (for treatment refractory cases)

24. Paul Salkovskis p.salkovskis@iop.kcl.ac.uk Institute of Psychiatry Centre for Anxiety Disorders and Trauma, Maudsley Hospital Cognitive Behavioural Therapy and the treatment of toilet-related fears

25. “There is nothing as practical as a good theory” Why do well validated theories result in better psychological treatments?

26. How psychological treatments work  People suffer from anxiety because they think situations as more dangerous than they really are.  Treatment helps the person to consider alternative, less threatening explanations of their problem If the alternative explanation is to be helpful:  It has to fit with your past experience  It has to work when you test it out Good therapy is about two (or more) people working together to find out how the world really works

27. What the patient usually wants and needs to know  Why is my anxiety so severe?  Why does my anxiety persist?  Why me, why now?

28. perceived likelihood it will happen Anxiety is proportional to the perception of danger; that is Anxiety and threat: understanding the severity of anxiety X + perceived “awfulness” if it did perceived rescue factors perceived coping ability when it does ___________________________

29. negative interpretations Events and situations Reactions to perceived threat Simplified Cognitive model of the persistence of anxiety

30. negative interpretations Events and situations Reactions to perceived threat Persistence and origins of anxiety Pre-existing assumptions

31. Anxiety: summary of cognitive- behavioural theory  Anxiety is a result of perceived threat  Factors which maintain exaggerated threat beliefs will maintain anxiety  Research supports the hypothesis that these factors include selective attention and other cognitive changes, mood changes, physiological reactions and safety seeking behaviours

32. Cognitive behavioural treatment  Engagement in assessment: helping the person to feel understood  Engagement in treatment: helping the person to commit themselves to the process of change  Formulation: reaching a shared understanding  Discussion of alternative explanations  Engagement in treatment: helping the patient to choose to change  Helping the patient to actively test the alternative account and explore its implications  Generalising changes  Relapse prevention