Treatment of a Situational PhobiaA Case for Running

ARNOLD ORWIN BJP 1974, 125:95-98. Access the most recent version at doi: 10.1192/bjp.125.1.95

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Brit. J. Psychiat. (i@7i@), 125, 95-8

Treatment

of a Situational PhobiaA Case for Running

By ARNOLD ORWIN

Systematic spouses other in phobic

desensitization using bodily re than relaxation as the specific

started

screaming

and had to be removed,

having was that

caused a considerable commotion.

Thereafter,

anxiety inhibitor
states.

has produced
Jones (1924)

positive results
used feeding,

anxiety in school lavatories increased but tolerated, for at this time she became aware

Wolpe

(ig6g)

advocated

motor activity

using

she would be extremely embarrassed if her phobia.

was revealed to her schoolfriends. The fear of public.

a conditioned motor response, Ventis ( z973) described a case where induced laughter was effective and Orwin (i@yp) paired the respira tory relief obtained after maximum voluntary respiratory arrest with the anxiety evoking stimuli. A derivation of this latter technique utilized the autonomic excitation caused by the vigorous physical exertion of running, to com pete with the anxiety response in the agora phobic syndrome (Orwin, 1973). This brief report describes an unusual situational phobia

lavatories was aggravated and generalized so that by late adolescence she could not enter an unfamiliar
lavatory with a high level cistern. Finally, she arrived at the stage where she could not go into any
strange toilet suite until it had been surveyed by a.

friend in advance so as to be assured that cisterns@

were ofthelowlevelvariety. This naturally hampered. her social activities, for in new situations she had to be

accompanied by at least one of the few friends who knew of her predicament. She had learnt that by
imbibing
could

enough

whisky to make her carefree she

her reluctance to approach.

treated by this latter method (therunning treatment'), following previous experience with simple claustrophobia.
CA5E HISTORY
@ A young unmarried woman aged years, was

partially

overcome

an unknown lavatory alone, but if there was a high

level cistern she would immediately leave in a panic.

Specifically, the most feared situation was of sitting below a cistern 6o-ioo cm. above her head
where there were exposed pipes curved to overhang

the person sitting below. She maintained that she was. frightened of the cistern falling onto her head.
TREATMENT

referred by her general

practitioner

with a phobia

of high level lavatory cisterns. Apparently this fear had started at about 2 years of age when her mother
took her to a public lavatory while on holiday. She recalled that this lavatory was frightening because it

After the history examination

when recalled window with on the window

had been taken

she was.

was dark and there was the sound of continuous

running water above her head. She became very anxious and wanted to leave, but despite her screams

asked to leave the consulting

room for a physical

in another part of the building and@

was made to sit in a chair by a a curtain partially drawn. The

her mother forced her to stay and micturate.

From then she developed a general fear of such lavatories and at first had some concern on using the lavatory at home. This anxiety gradually receded but was always exacerbated by redecoration or alterations to the lavatory, e.g. when on one occasion

curtain concealed a detached

lavatory cistera

sill level with her head, which

had been placed there while she was out of the

room. She was engaged in conversation for some minutes and then, to assess the intensity of anxiety, was told of the position of the cistern.

a new cistern had to be fitted. Her fear of public lavatories remained although subdued and she
managed to cope with school lavatories.

Aged g years she was taken by an aunt into a public lavatory in the centre of a city and although urgently needing to micturate she refused to use the facilities. She was forcibly placed on the seat, but she
95

She did not believe this at first but gradually became more anxious as realization dawned and fled in panic from the room when on being asked to draw back the curtains she discoverecY
the feared object. After some encouragement abe

96

TREATMENT OF A SITUATIONAL PHOBIAA CASE FOR RUNNING

composed herself and came back into the room to sit in a second chair about 4 metres from the cistern. She would move no closer to it and still

portrayed

and described

considerable

anxiety

over her previous ordeal. prevailed upon to go back her she would have to leave.

She could not be to the chair by the

During the fourth trial she stayed and mic turated but developed slight anxiety when she flushed the bowl. In the final session, following the same procedure, she entered the lavatory on five successive trials and on each occasion
she sat for one minute and was able to tolerate

cistern and stated that if this was demanded

of

She was then told she would be required to run until she was breathless and that on her return to the room she should endeavour to sit in this chair. She was also told that the effects
of vigorous physical activity might prevent the detection of anxiety. Although dubious about this she left the building and ran three

flushing the bowl without anxiety. Thereafter she could use the lavatory without concern. Progress : One month later she reported no difficulty in strange clubs, public houses or hotels. On follow-up after five months she retained her improvement.
DIscussIoN There is evidence to suggest that physical

times along a measured 50 metres at her best speed. She then ran back into the consulting
room and without difficulty and gasping for

air reached for and fell gratefully into the first chair viewing the cistern without overt concern. As she recovered her breath she discovered that it no longer produced anxiety only a slight
feeling of uneasewhich was placed was quite endurable. be level

activity can be used to inhibit both reality based and neurotic anxiety. Control of the former is probably best seen on the battlefield
or in primitive
circumstances

religious
psychological

ceremonies.
factors are

In both
involved

She returned one week later when the cistern

on a shelf so that it would

with her head if she sat on an adjacent chair. After I00 metres sprint she again sat without anxiety. The cistern was then raised successively 5 cm. at a time for three more trials using the same technique and no anxiety was evoked. The following week the cistern was no longer supported on a fixed shelf but suspended by wire from an intravenous drip stand so that it
was initially 15 cm. above her head. The running procedure was repeated and the cistern

and it would be difficult to dissociate the physical response from its particular emotional context but possibly the importance of muscular activity has been overlooked. In the soldier, fear may be contained by, for example, invoking
patriotism, enthusiasm for the cause, the inspiration of the leader, and the confidence which emanates from the disciplined cohesion

of an army, as well as the use of alcohol. But

military history does seem to indicate that the raw militiaman, less able to control his emotions

than the hardened soldier, had a better taste for a vigorous charge against the enemy than
standing on the defensive awaiting attack. As examples we have the impetuous rush of the English fyrd against the veteran Dane (Oman,
1953) and the rapidly executed assault in

gradually raised till at the end of the sixth trial

she could tolerate it 6o cm. above her for an

indefinite period. This treatment session and those following were carried out by nursing staff.
On her fourth visit, a fortnight later, she was taken by a nurse to the vicinity of a public lavatory which she was told contained a high

column of the relatively untrained revolu tionary French conscripts against well trained
professional armies (Fuller, 1957). A parallel

level suite and made to run towards it. She managed to reach the door, itself a considerable achievement, but then exhibited great anxiety possibly because she had not run as freely as before. However, the next week, after appro priate running she entered a hospital lavatory of a similar type and sat on the seat, first with the door open (2 trials) then with the door closed.

process appears to occur during the rites of many primitive religions. Sargant (1959) analysed the physiology of conversion' to a religious faith, and described the effect of rhythmic drumming, the development of emo tional excitement often aided by various suggestive techniques and the use of alcohol and other drugs. In addition there was dancing to the point of physical exhaustion with feelings

BY ARNOLD

ORWIN

97

of relief

from

sin and

evil

and

presumably

freedom from associated anxieties. Similarly it is generally agreed that for the tensions of everyday life, energetic activity, whether as
exercise or sport, from this it has is beneficial, and following often been prescribed non

of the first session, it was confined to monitoring progress and advising the nUrse in charge on the

hierarchy
Running application

of situations.
as a form of treatment may in specific situational phobias have as in

agoraphobia.

It is attractive

because

of its

specifically as an adjunct in the treatment of neurotic anxiety.

From the behavioural point of view it is not the funda and anxiety One assumes

basic simplicity and the minimal demand on therapist time, but further research is necessary to determine its true value.

difficult to see why muscular action may relieve

anxiety, as normally it completes mental biological pattern ofarousal SUMMARY

mediated

behaviour

leading to avoidance which

is dependent

upon motor activity.

that the autonomic nervous system runs syn chronously with this reaction, there being a build up ofinternal drive interpreted cognitively
as development of anxiety until successful

The treatment of a specific situational phobia (of high level lavatory cisterns) is described. The method used was to utilize the autonomic excitation caused by vigorous muscular activity
as an inhibitor of the situational anxiety.

avoidance occurs. At that time the discharge of muscular response leads to concomitant auto
nomic
activity

changes
is equated

which
with

are associated
an autonomic

with and
nervous

The patient was made to enter feared situations immediately after running close to the limit of toleration. The near lifelong phobia was re
moved in five short sessions with little psych iatric involvement. The method is attractive because of its basic simplicity, the rapidity of the response and the minimal demand on therapist time. Acxwowi.wos@wrs The author gratefully acknowledges the support of the nursing staff at the Regional Behaviour Research Unit in the treatment of this case.
REFERENCES FULLER,J. F. C. (ig@7) The Decisive Battler oft/ic World and

detected as freedom from anxiety, i.e. muscular system in a post anxiety or relief' state. In the running treatment' this autonomic relief' state is proceeding at the time of the presentation of the anxiety stimulus. The
anxiety response normally evoked is now

probably inhibited at two levels : physiologically by competition from the metabolic demands of ongoing motor activity, and cognitively because despite the provocation anxiety cannot be detected in the prevailing autonomic excitation.
Once this is experienced expectation of a similar anxiety-free response may arise in the future as

shown by the work of Valins and Ray (1967)

who indicated that avoidance behaviour can

their Influenceon History. Chapter 13. Lotidon: Eyre and Spottiswoode.

Jonas, M. C. (1924) Laboratory study of fear: The case

of Peter. PedagogicalSeminaryand Journal of Genetic
Psychology, 31, 30815. OMAN, C. W. C. (953) The Art of War. Chapter ti.

be altered by information concerning internal

reactions. Apart from the need to ensure that the

patient was physically fit, no other problem emerged in treatment. The method was easy to use and imposed no undue strain on the patient,
while the basic hypothesis as put to her was

U.S.A.: Cornell University Press.

Oaw@, A. (I97@)Respiratory relief: A new and rapid

method for the treatment of phobic states. British

Journalof Psychiatry, 119,6357.

(,973) The running treatment': a preliminary

soon confirmed by her own responses. Conse

quently, motivation was high, as was expectation of a successful outcome, and she responded in

communication on a new use for an old therapy

(physical activity) in the agoraphobic syndrome.

BritishJournalof Psychiatry, 122, 175-79.

SARo@u@r, W. (i9@@)Battle for The Mind, Chapter 5.
London: Pan Books Ltd.

five treatment visits. The investment of psych iatric time was small, for apart from the initial history, physical investigation, and supervision

VAIIN5, S. & R@x, A. A. (1967) Effects of cognitive desensitization on avoidance behavior. Journal ef
Personality and Social Psychology, 7, 345-50.

98

TREATMENT

OF

A SITUATIONAL

PHOBIAA

CASE

FOR

RUNNING

Vawr,s, W. L. (i@7@) Case history: The use of laughter

as an alternative response in systematic desensitization. Behavior Therapy, 4,120-22.

Woua,J.

(969) ThePracticeof Behaviour Therapy,Chap

ter 8. London: Pergamon Press.

A synopsis of this paper was published in the May 1974 Journal.

Arnold

Orwin,

M.R.C.Psych., Consultant in Charge, Regional Behaviour Research Unit, Hollymoor Clinic,

Hollymoor Hospital, Xorthfield, Birmingham, B3i 5EX and Honorary Research Fellow, Department of
P.@ychiatty, University of Birmingham

(Received ,@ Xovember 1973)