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  #1  
Unread July 20th, 2004, 08:09 AM
Joop Meijers Joop Meijers is offline
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Question Fear of cockroaches in 12 yr old girl

I am treating a bright 12 year old who gets panicky seeing cockroaches or being in places where she thinks they will be. She does not avoid situations but gets extremely upset ( she labels her feelings more as terrible disgust than fear).
Since she is 'fed up' with feeling this way she wants to become less afraid or disgusted.
I wonder what the therapy goal ought to be. Through classical gradual exposure see if she can reduce her extreme arousal vis a vis cockroach stimuli? To help her accept her feelings as quite normal ? Her mother is as afraid of cockroaches as the girl is but mother copes by being able to kill a cockroache if she sees one.
The girl's fear began 4 years ago when she stepped on one while putting on her shoes ( he was in her shoe). So far she copes by screaming and yelling and phoning her parents to come home, wherever they are.
She is vry motivated to get rid of the fear.
Any suggestions?
Thanks
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  #2  
Unread July 20th, 2004, 11:59 AM
JustBen JustBen is offline
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Default Re: Fear of cockroaches in 12 yr old girl

I don't think that helping her to accept her feelings as "normal" would be helpful here. After all, while being disgusted by cockroaches is typical, that level of intensity certainly is not. Also, even if she learns to accept her feelings, she's still stuck with insufficient coping skills to deal with those feelings.

Given that the patient is highly motivated to extinguish or reduce this fear, why not offer this as the therapy goal and move forward with some exposure techniques? I'm sure you know the drill -- work with the patient to develop a hierarchy of situations that cause the undesirable reactions, and work through them. Start with mental imagery, and work your way into the "real thing". Maybe you could contact a local exterminator to get hold of some specimens.

It's always tough to offer advice based on (necessarily) limited information available in a forum post, but I'm curious as to why you'd even consider the "help her accept her feelings as quite normal" option the first place? Am I missing some important information? Perhaps I'm just inexperienced and am not seeing something that would be immediately obvious to a seasoned therapist.
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  #3  
Unread July 21st, 2004, 02:45 AM
Joop Meijers Joop Meijers is offline
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Thumbs up Re: Fear of cockroaches in 12 yr old girl

Thanks for your comment. I think you rightfully picked up on some confusion on my part. Lately I became interested in mindfulness training in relation to CBt. One of the main ideas of mindfulness training- as I understand it (or not) is that an alternative way cope with strong feelings is to learn to accept them, that is to attend to them, be curious of them, not to get attached to them etc. As I understand it this would be an opposite approach of exposure. So I guess my confusion played a role in asking the question. Still, I have decided to go on with regular gradual exposure since this -I think- is a sfer bet. Thanks!
Joop
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  #4  
Unread July 21st, 2004, 03:17 AM
Carl Robbins Carl Robbins is offline
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Default Re: Fear of cockroaches in 12 yr old girl

I don't understand how you see mindfulness and exposure as incompatible.

Moving through a graduated hierarchy while allowing oneself to experience the arousal, forgoing attempts at self-regulation, can be seen as the OPTIMAL way to "talk to the amygdala."

Certainly, mindfulness and acceptance-based coping can be understood as different from systematic desensitization in which the feared stimuli (presented imaginally) are paired with relaxation.
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  #5  
Unread July 21st, 2004, 06:59 AM
loftus75 loftus75 is offline
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Default Re: Fear of cockroaches in 12 yr old girl

I suspect you'll find that it isn't the insect that's the problem here, though I'm assuming that this part of your clients experience hasn't been addressed, forgive me if this is not correct. But from the description it is the contents of the insect rather than the insect itself. Many people have a 'yuk' phobia, some people do this with eggs for instance. To test for this you might try using a toy insect to see how she reacts, of course you'll have to tell her, and show her it's a toy, if she responds positively to this then that might indicate she is reacting to the contents, knowing there is no content to this toy might put her at ease, illustrating there is something more to her disgust. If it's the contents, as it would appear from your description, then I suspect you could say this is a normal feeling, though her reaction would then need to addressed.

If you can get to the specific issue it makes the CB process a lot easy. BTW, the term 'yuk' isn't exactly a scientific term however it conveys the idea in common terms.

You may also be interested to know it is my experience that clients presenting with this particular type of problem can also suffer, either at the time of presenting or at some later stage, Obsessive Compulsive Disorder. You might find the child is overly fastidious, or may even have ritualistic behaviours such as organising items in a certain way. She may say she does this because it keeps out the insects, it can be a precursor to the full blown version of OCD.
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  #6  
Unread July 22nd, 2004, 09:28 AM
James Pretzer James Pretzer is offline
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Default Re: Fear of cockroaches in 12 yr old girl

As far as treatment goals, I'd start by asking her how she would like to be able to react when she sees a cockroach. Does she see any need to react to a cockroach differently than she would respond to a grasshopper or butterfly?

Does she see cockroaches as being dangerous in some way? If so, it would be important to address those fears cognitively in order to lay a foundation for exposure-based treatment.

Yes, graduated exposure to decrease her intense response to cockroaches makes a lot of sense. There certainly is no need for her to develop a fondness for cockroaches, but it sounds like it would be quite useful if she could calmly deal with the cockroaches she encounters. My bet is that is that exposure would work fine if it is framed as a way to tone down the intensity of her reaction but that it would also work fine if framed in terms of mindfulness where the goal is to be mindful of her thoughts and emotions then respond skilfully anyway.

If there are other signs of OCD, it could be quite useful to address them. Likewise, if there are any signs that her primary fear is of her parents being gone and that this is a way to get them to come home, this would be important to address.

It may well be possible to treat her fear effectively without addressing her mother's fear of cockroaches. However, it would be quite helpful if the mother could model a calm but effective response to cockroaches (i.e. clamly squashing the cockroach) rather than modeling a fearful response. It might be quite useful to involve the mother in treatment as well.
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  #7  
Unread July 28th, 2004, 08:29 AM
James D James D is offline
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Smile Re: Fear of cockroaches in 12 yr old girl

Hi,
The reply by loftus reminds me of a documentary program I saw on tv a few years ago. It involved a woman who appeared to fear birds to the point of panic. She saw a hypnotherapist amongst other people (it didn't help her) about her phobia until she finally ended up in the office of Paul Salkovskis! He soon discovered that the woman was not so much afraid of the bird, but its feathers! He proceeded to do graded exposure using a single white feather to excellent effect. Paul had a wonderful tray of feathers too if my memory serves me correctly!

So, as loftus suggests, the girl may not be so much afraid of the cockroach as something strongly associated with it such as dirt and disease or that it can fly or something like that. Whats the worse that could happen to her??? It climbs up her leg and contaminates her? Her mother becomes frantic and would clean her incessently? If there is anything else to pinpoint you would be able to tailor your intervention more closely to the content of her fear. She may not even be aware of the exact nature of the fear until it is pointed out, as with the woman afraid of feathers.
As James P points out, the role of her mother is an important one. As she is just as fearful of cockroaches she may reinforce the fear, and the childs beliefs around cockroaches may have been formed by the mother too. Its a possibility. The way the mother describes her own fear of cockroaches may give insights into the psychological workings of her offspring. As James P also points out, involving the mother could be useful therapeutically and may help break the cycle panic (just as a child with conduct problems needs consistent reinforcement at home as well as at school).
Interesting if she has any rituals around putting her shoes on, checking for cockroaches, or situations she now avoids.
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  #8  
Unread August 1st, 2004, 09:31 AM
Joop Meijers Joop Meijers is offline
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Default Re: Fear of cockroaches in 12 yr old girl

Here is the quite surprising follow-up of my treatment of the girl who was afraid of cockroaches. At the third session, after having read all your useful comments and being well prepared with a tentative hierarchy for exposure, the parents came in in stead of the girl. The girl had announced she did not want to continue therapy since she did not need it anymore so urgently. She claimed that she had understood what the problem was and how to deal with it. She had given proof of this- according to the parents- by approaching a cockroach in the swimmingpool, standing nearby the insect and looking at if for some time without feeling a strong need to escape. The parents also said they assumed that- the daughter being the ' queen of her class' she might have felt embarassed being in therapy and therefore- assumingly- had decided she wanted to overcome her fears by herself. Why had not she come with the parents to say so? ,, she did not want to hurt you. she thought you would take it as a kind of criticism if she quit, so she thought it better not to come" . I got some interesting diagnostic information from the parents: their daughter is indeed disgusted by a variety of stimuli ( like touching a dirty dish-washer, dirty water, etc). she has no rituals ( yet?) but tries to avoid situations involving stimuli perceived as dirty. She only has this problem at home, not outside the home! ( like some OCD patients!).
The mother told me something I did not know: after the birth the girl had a life threatening ilness (septicity) that left her very weak and severely hypotonic for a couple of years. Th first 4 years of her life she grew up very very protected by the mother who did her utmost to prevent her daughter from being in touch with anything that might cause an infection or sepsis ( the illness after birth had been caused by a bacterial infection that led to almost death) .
I gave some advice to the parents and we ended therapy. One of the questions I am struggling with right now: what do we know about prevention of OCD! Is there justification to predict OCD? I can make two mistakes: one, alarming the parents while maybe the chance of the daughter getting OCD is small; not warning them about this while maybe they should be warned. Do we know anything about predictive factors in childhood onset OCD?
Any ideas?
Joop Meijers
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  #9  
Unread August 2nd, 2004, 08:25 AM
loftus75 loftus75 is offline
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Default Re: Fear of cockroaches in 12 yr old girl

Unlike physiological illnesses OCD is a dysfunctional behaviour and many future events could change the outcome. Though I should add there might be a genetic factor, although I say this tentatively because many behaviours are simply passed on through family role modelling, beyond this to the best of my knowledge no OCD gene has been identified.

It is most interesting that the parents should choose to come rather than bring their daughter as well. Here lays one of the problems with self reporting. If we are to accept what clients and relatives say at face value then the matter is closed if they report they are no longer in need of assistance. However I would be very interested in the parents at this stage, children going through puberty can create a variety of manipulative situations and this may be the case here. I have had a few emails from Joop, and the geographical location and circumstances may involve cultural differences which may have to be taken into account. Here certain behaviours may be seen as the norm, where in other parts of the world they be seen as problematic, Joop would be best judge of this. However if the circumstances and culture are not an issue, Joop will have to judge whether any further action can or needs to be taken.

Experience tells me that OCD is closely related to an underlying anxiety that the client cannot identify the cause of. At the age of 12 and considering the circumstances Joop has outlined, I would suggest, if at all possible, one last meeting with the young girl, followed by another with her parents without the child. I would not question the child's recovery or her choice to stop the therapy. But I would satisfy one of two theories. 1/ that this is a manipulation, that is a use of her antecedents to produce some kind of gain. Or, 2/ She is dealing with heightened levels of anxiety related to puberty.

In the first theory her parents may need some help in parenting methods. In theory 2, her parents will still need some parenting help, as their daughter needs to have the changes she is going through explained to her. If her parents are as compliant as the story suggests, they would find talking to their child about 'adult' issues, very difficult.

Of course both theories may be wrong, however they do seem to be the most likely based on the story so far.
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  #10  
Unread October 31st, 2004, 09:46 PM
James Pretzer James Pretzer is offline
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Default Re: Fear of cockroaches in 12 yr old girl

Your client's sudden recovery isn't necessarily surprising. My experience has been that children sometimes respond to treatment much more quickly than adults typically do, in part because their problems are less ingrained and in part because pre-adolescents often are less skeptical about my explanations that adolescents and adults are. It may be that, once she understood that it was not necessary for her to avoid cockroaches, she was able to handle the exposure on her own.

Why didn't she want to meet with her therapist for an appointment that she saw as unnecessary. It could be simply because she's a kid who didn't see any reason to meet with a therapist if the problem is gone.

As far as whether there is a need to try to do something to prevent OCD, from the information that's been presented I'm not sure we're dealing with OCD. It sounds as though the client was taught explicitly by her mother to avoid anything "dirty" for fear that she would contract another infection and it does not sound as though she has developed any obsessions or compulsions. It certainly could be useful for the therapist (or her parents) to help her realize that she no longer needs to avoid items that seem dirty and to help her understand the value of facing one's fears rather than avoiding. However, I'm not sure she's particularly at risk for developing OCD.
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