پدیدارشناسی و محتوای موضوعی تصاویر توده های نفوذی در روده و مثانه وسواسی
|کد مقاله||سال انتشار||مقاله انگلیسی||ترجمه فارسی||تعداد کلمات|
|29652||2013||8 صفحه PDF||سفارش دهید||7245 کلمه|
Publisher : Elsevier - Science Direct (الزویر - ساینس دایرکت)
Journal : Journal of Obsessive-Compulsive and Related Disorders, Volume 2, Issue 3, July 2013, Pages 233–240
Case reports and clinical experience suggest some individuals with anxiety-disorders experience an overwhelming fear of losing control of basic bodily functions in public. However, many features of bowel- and/or bladder-obsession, such as the accompanying cognitive processes or content, have not been described. Given the role of intrusive imagery in maintaining psychological disorders, this study examines mental imagery as a specific form of cognitive content in bowel/bladder obsession. Twenty participants reporting intrusive imagery linked to a fear of losing control of bowel or bladder function in public completed semi-structured interviews on the nature and characteristics of their mental imagery and its relationship to past events. Imagery was characterised by a predominance of physically-based and visual, ‘flash-forward’ mental events. This future-oriented imagery tended to end with the feared catastrophe (public incontinence) occurring, or was truncated, ending before the catastrophic event. Distressing past events significantly influenced the content of such imagery. Qualitative analysis of imagery interviews enabled a thorough thematic characterisation of imagery content and identification of seven coherent themes: visceral urgency, total exposure, self-as-inferior, absence-of-control, contamination/disgust, rejection-of-failing-self and judgemental-others. This first description of intrusive mental imagery in bowel/bladder obsession reveals thematic and phenomenological characteristics that may represent foci for novel imagery-based interventions.
Psychological therapists occasionally encounter patients who experience an overwhelming fear of losing control of basic bodily functions in a public place. The small number of existing studies of bowel and/or bladder obsession suggest shared features with social anxiety (Lelliott, McNamee, & Marks, 1991), obsessive compulsive disorder (OCD; Beidel and Bulik, 1990, Cosci, 2012, Hatch, 1997, Jenike et al., 1987 and Porcelli and Leandro, 2007) and panic (Eldridge, Walker, & Holborn, 1993; Lelliot et al., 1991). These shared features include repetitive checking for visceral sensations and frequent and repeated use of the toilet to check for complete evacuation of the bowel/bladder (c.f. OCD), fear of negative social evaluation (c.f. social anxiety disorder), ‘catastrophic’ cognitions about bodily dysfunction (c.f. panic disorder). Other features of this syndrome include experiences of visceral urgency, vigilance to the location of toilets, and high levels of role impairment (Beidel and Bulik, 1990, Hatch, 1997, Jenike et al., 1987 and Porcelli and Leandro, 2007). Despite an absence of diagnostic criteria, advances in cognitive behavioural treatment of bowel/bladder obsession is likely to proceed from a more detailed understanding of cognitive content (including imagery) and processes involved in problem-maintenance. There is also an increasing recognition of the importance of applying a symptom-focused, rather than a formal diagnostic understanding to psychological difficulties (Harvey, Watkins, Mansell, & Shafran, 2004) and this seems especially relevant to investigating a ‘disorder’ which has hitherto eluded categorisation. One transdiagnostic phenomenon implicated in a variety of mood and anxiety disorders is the occurrence of intrusive mental imagery related to the individual’s current concern (Brewin, Gregory, Lipton, Burgess, & Chris 2010). Our (SKK and SW) clinical observations in the course of treating people with bowel/bladder obsession suggests that intrusive imagery has special relevance to this presentation. Drawing on our clinical experience as well as the recent work on intrusive mental imagery in psychopathology (Brewin et al., 2010) our aim in this study is to characterise mental imagery in bowel/bladder obsession as an initial step to developing a more comprehensive cognitive behavioural conceptualization of this problem. The characteristics of intrusive mental imagery have been described across a range of anxiety and mood disorders (Brewin et al., 2010) and also in conditions where physical symptoms predominate (e.g. Berna et al. 2011). For example the occurrence of intrusive imagery is involuntary, repetitive and associated with high levels of distress. Furthermore, these repetitive images are often thematically linked to distressing past experiences (Hackmann et al., 2000, Price et al., 2012, Wheatley et al., 2007, Wild et al., 2007 and Wild et al., 2008). The content of mental imagery also has implications for self-concept and self-worth (Conway and Pleydell-Pearce, 2000, Hackmann et al., 2000, Wild et al., 2007 and Wild et al., 2008). For instance, a central aspect of the cognitive behavioural model of social anxiety is ‘processing of the self as a social object’ (Clark & Wells, 1995). The outcome of this processing is the generation of a negative mental representation of the self, contributed to by the occurrence of spontaneous, distorted images of the self. These spontaneous images are characteristically experienced from an observer’s perspective and their content often involves themes of failure, incompetence or the appearance of some undesirable physical characteristic (e.g. shaking uncontrollably, appearing very sweaty or possibly, an exaggerated facial expression or bodily posture denoting the urgent need to use the toilet; Clark, 2001). In addition, as with verbal thoughts, catastrophic imagery is generally a distorted representation of past or future events, playing a key role in disorder maintenance (Hackmann et al., 2000 and Pratt et al., 2004) while being maintained in turn through behavioural and cognitive avoidance (Hackmann, Bennett-Levy, & Holmes, 2011). In addition to potentially providing a metaphorical window into the mind of clients with bowel/bladder obsession, imagery represents a therapeutic target through rescripting (Hackmann et al., 2011). A more complete understanding of the characteristics of intrusive imagery in psychological disorders (e.g. their predominant sensory modality, view-point, vividness) is therefore relevant to development of such rescripting strategies. The aim of the current study is to provide the first detailed phenomenological description of anxiety-related imagery in people with bowel/bladder obsession. The inspiration for this study comes from similar recent description of mental imagery in anxiety and mood disorders (e.g. Day et al., 2004, Muse et al., 2010, Patel et al., 2007, Price et al., 2012 and Speckens et al., 2007). These descriptions have led to novel, theory-based imagery rescripting interventions (e.g. Wild et al., 2007 and Wild et al., 2008), which in some cases circumvent the traditional verbal reappraisal strategies use in cognitive therapy (e.g. Wheatley et al., 2007). Consistent with the literature on mental imagery in mood and anxiety disorders, our primary aim was to elicit and describe the content and phenomenological features of mental imagery, using an adapted version of an established semi-structured interview (Hackmann et al., 2000). Since this interview schedule has been used in the majority of studies examining intrusive mental imagery in psychopathology (Brewin et al., 2010) we retained its main components to allow easy comparison between our study and previous ones. However, in contrast to most previous studies, we also employed a detailed thematic analysis of imagery content. An inductive approach to determine coherent themes within the intrusive imagery is especially important for bowel/bladder obsession given an absence of studies focusing on beliefs and meaning-making in people with these difficulties. As the extent of distress and impairment associated with bowel/bladder obsession is also unclear, a number of measures of general psychopathology were used to supplement the qualitative and other descriptive features of bowel/bladder obsession outlined here.
نتیجه گیری انگلیسی
Of the 20 participants who were included in the analysis, 18 were female. The age was M=31.6 years (SD=12.8). Seven were in full time employment and seven were students, with the remaining six either unemployed (n=3), retired (n=1) or full-time homemakers (n=2). The majority (n=12) described themselves as single, six as married/cohabiting and two as separated/divorced. Table 1 presents sample characteristics specifically related to bowel/bladder obsession, as well as basic details related to psychopathology. Table 1. Sample characteristics (n=20). N M SD Focus of concern Bladder concern 11 Bowel concern 7 Both 2 Past experience of public incontinence a 11 Disclosed fear to another person 9 Treatment received 5 Experience panic attacks 17 IAPT Phobia Scale—panic symptom avoidance (0–8) b 4.1 2.8 IAPT Phobia Scale—Social avoidance (0–8) b 3.1 2.9 IAPT Phobia Scale—specific phobia avoidance (0–8) b 3.3 2.9 Impairment (W&SAS) 12.0 10.6 PHQ9 c 8.5 4.4 GAD7 c 10.2 5.8 a Since school age. b The following anchors are used: would not avoid=0; definitely avoid=4; always avoid=8. c n=16. Table options These data suggest marked avoidance of situations where panic-related symptoms might be evoked. Mean PHQ-9 scores indicating mild levels of depression within the sample (Kroenke et al., 2001) while GAD-7 scores are indicative of moderate anxiety (Kroenke et al., 2007 and Spitzer et al., 2006). Of the 17 participants reporting panic attacks, 11 had experienced at least one panic attack in the last fortnight and six experiencing more than one panic attack per week. Seven participants reported that their main concern was that they would be incontinent during a panic attack. A total of 15 participants indicated a belief that their fear was directly linked to a past experience of being incontinent, a ‘near miss,’ or both. Eleven participants had actually been incontinent in a public place since school age. Of these, six had been incontinent only once and five on two occasions. The (last) episode of incontinence occurred M=7.5±7.4 years ago. Approximately half the participants (n=11) had never discussed their fear with anyone. Six participants had received some form of treatment: five a psychological or psychiatric intervention, and one, a pharmacological treatment.