Emetophobia and the Biopsychosocial Model of Low Back, Neck Pain

Exposure therapy for emetophobia: a case study with three-year follow-up. J Anxiety Disord. 2013 Jun;27(5):527-34. Maack DJ, Deacon BJ, Zhao M.

Emetophobia, also referred to as a specific phobia of vomiting, is a largely under-researched and poorly understood disorder with prevalence estimates of ranging between 1.7 and 3.1% for men and 6 and 7% for women (Hunter & Antony, 2009; Philips, 1985). The current case study, therefore, sought to methodically apply exposure-based behavioral treatment to the treatment of a 26 year-old, Hispanic, female suffering from emetophobia. Although not as powerful as a randomized design, this description may still add to the existing emetophobia literature through the illustration of adaptation of published behavioral treatments for other specific phobias. The case presented was successful in terms of outcome, and includes a three-year follow up wherein treatment gains were measurably maintained.

My comments:

So what does an case study from the Journal of Anxiety regarding emetophobia (fear of vomiting, either doing it or witnessing it) have to do with physical therapy, back and neck pain? Well let me summarize the treatment, how it worked and I’ll get to that.

First some background: In community college I took General Psychology and Developmental Psychology and that’s the extent of my professional training in psychology. Since then I have done a fair amount of reading psychology books and individual studies such as to make me a better than average dabbler. However what I think I excel at is searching pubmed (the world’s largest medical database) for papers and studies regarding any number ailments/treatments, reading and evaluating the quality of the findings, and linking those findings to one another and integrate them with my own ideas and experiences. The use of case studies, clinical trials, randomized controlled trials, meta-analysis and review papers is a universal practice in good medicine and is largely similar between medical professions for which the subject matter is different.

I recently learned the considerable stress that emetophobia has on a friend of mine, with research showing other emetophobics will go so far as to avoid social gathering for fear that someone there will become intoxicated and vomit and that 44% of all female emetophobics will avoid pregnancy out of the fear of morning sickness. I looked up and read several peer-reviewed papers (of which only a few exist) so since yesterday I have probably become one of the world’s experts on emetophobia. The condition is understudied, and as such there are no randomized controlled trials on emetophobia so treatment effects are still speculative. There are a few case studies (reports on a single patient describing treatment and effect), and the most frequent method of treatment I came across with beneficial effect included some kind of “exposure therapy” for which randomized controlled trials have found effective in the treatment of a number of related psychological conditions including anxiety and phobias. All of this makes sense to me as I will often get a patient I have to treat for an ailment for which the effects of exercise or electric stimulation has not been well studied, so you do your best following proven principles on as similar conditions as possible and more often than not it works.

The above cited case report was the newest and most descriptive and the treatment appeared to work very well. In order for the patient to get over her fear required 5 treatments (1-3 hours in length) spaced 1-2 weeks apart, in which the patient was started off giving her history and taking a few standardized anxiety tests to objectify her level of impairment and a treatment plan was developed for which the patient agreed to. Treatment than began immediately by watching relatively benign videos of people vomiting on the computer and the patient was given a home program to watch 30 minutes of such videos daily gradually increasing graphic nature of sounds and images in youtube videos over time. As she did so anxiety was shown to quickly decrease and over the course of her 5 visits she was given increasingly difficult tasks including pretending to vomit, watching two of her treating psychologists actually vomit (which is more than I do for my patients) and culminating in her making herself throw up, at which point she didn’t like it (who does) but no longer thought it was such a big deal that it negatively impacted her life. Three years later her improvements remained. The results of this paper sound very reasonable to me and as such I have no reason to doubt the positive treatment effect.

So what does this have to do with physical therapy, back and neck pain? One of the “schools of thought” in the treatment of back and neck pain is the “biopsychosocial model”. Followers of that model want to treat these painful conditions by emphasising the psychological aspects and all but ignoring the biological and environmental aspects. They will suggest patients continue to work and ignore their pain, consider their pain a normal part of life, and even do exercises that cause pain, apparently such that they become habituated to their “exposure” and used to it. This habituation is apparently in theory similar to the exposure therapy in the above psychological case. However, the problem is that activities that expose you to neck and back pain very often do cause further injury such that patients don’t get used to the pain, they just get worse. Neck and back pain generally have a large, large environmental component and are usually not an irrational phobia but a real injury. Sustained awkward postures, particularly in lumbar and cervical flexion and or repeated flexion and extension, does in fact damage spinal discs, causing disc bulging and herniation and over stretches stabilizing ligaments and muscles of the spine. Painful habituation exercises to the spine generally rely on various painful stretches to the spine, and by any rationality further damage painful tissues of the spine. Telling a patient with back and neck pain that it is normal and to return to work as usual, especially if that work includes excessive prolonged and repeated spine flexion, extension and twisting will only further damage the spine, increase pain, and cause more disability. Telling a patient that exercise is beneficial “but is all the same” will only lead to further spine damage and pain if that exercise consists of repeated and prolonged spine flexion/extension and twisting. Come to think of that, trusting this model might be why a spine surgeon performed not one, but two spine fusions on a road cyclist who later became my patient, and the surgeon said he should have no problem returning to cycling. I guess he figured all exercise is the same even if the spine is kept in full flexion, and he didn’t do the math and figure if two segments were fused, the remaining 3 would then be further stressed as the patient leaned forward to tuck into the bars. Incidentally my patient still wanted to ride and worked hard on core, LE strength, and neutral spine awareness. He continues to perform a lot of hamstring stretches while maintaining a neutral spine and is now able to ride his bike safely keeping spine neutral, though isn’t able crouch fully into his triathlon aero bars. He gave up some aerodynamics but is still on the road and won’t be a cripple so I think was a good compromise.

So does psychology have anything to add to physical therapy treatment for neck, back and other disorders. The research thus far would indicate no for both low back and neck pain, but I think the research thus far has been based on utilization of poor psychological methods that don’t understand the causes of spine injury. With neck pain in particular I often notice that anxiety has a significant effect on correlation with pain. It also tends to make patients very apprehensive with regards to beneficial strength-based exercise programs, which research shows are very effective. I notice this tendency much less so with back pain but I don’t doubt some effect. Active exercise programs that increase strength, ability and confidence as the patients sees themselves get stronger is psychologically empowering. Proper lifting techniques (using a neutral spine) teaches the neck or back pain sufferer that they can complete difficult tasks without pain and injury, resulting in lessening anxiety with such activities. Lessening anxiety also helps to reduce pain, the improved fitness of the exercise program contributes to improved feelings of well being. Such that a negative spiral of damage, pain, and disability is turned around. Psychological principles of adopting optimistic as opposed to pessimistic attitudes also increases hope, decreases discomfort, and all that is a lot easier to achieve when you teach the patient how they can lessen or eliminate pain, rather than tell them that pain is normal. So I don’t think the biopsychosocial model of low back and neck pain in physical therapy needs to be thrown out but it certainly needs a complete overhaul, needs to take into account environmental factors contributing to low back pain, it needs to understand that some activities and exercises are more damaging than others, and needs to stay up to date with new psychological techniques including much coming out in the new field of positive psychology.

So that’s my talk on emetophobia and physical therapy. The psychology paper helped me to better understand how psychologists treat some of mental disorders and thus where those methods might fall short, and where they might still be of benefit to physical injuries I treat as a physical therapist. It’s all very interesting and a bit of a new frontier for me so I expect this won’t be my last foray into the world of psychology and how it relates to physical therapy. I particularly think there is a lot to be learned and applied to my patients’ benefit, which off the top of my head I think will most help those with histories of chronic neck pain and headaches.

As always, if you have any further questions or need for clarifications, please don’t hesitate to ask. Being aware that some of my blog ideas are contentious and occasionally a bit out of the field of my expertise, I encourage my readers to come forth with any questions/comments that are of interest or concern. Your comments are valued and welcomed.

Chad Reilly is a licensed physical therapist, located in North Phoenix, practicing science based medicine with treatment protocols unique and effective enough to proudly serve patients from Phoenix, Scottsdale, Mesa, Chandler, Tempe, Peoria, and Glendale.

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