Phenomenology of bowel/bladder-control anxiety Christine Langhoff D.Clin.Psy. Thesis (Volume 1), 2013 University College London 2 Overview Volume 1 of this thesis is presented in three parts. Part 1 is a systematic review of Internet-based cognitive behavioural therapy for social anxiety disorder, which includes an objective assessment of study quality. Part 2 describes two studies exploring bowel/bladder-control anxiety (BBCA). Study 1 is an Internet-based survey to obtain initial clinical and demographic details about BBCA and study 2 uses postal questionnaires to explore the relationship of BBCA with panic attacks. This is a joint thesis as it forms part of a larger project and was conducted alongside that of another Trainee Clinical Psychologist. Part 3 is a critical appraisal of the research process, which considers implications of the conceptualisation of BBCA for the research project as well as multiple testing and advertising. It further discusses issues of conducting research and delivering psychological therapy via the Internet. 3 Contents Acknowledgements ......................................................................................................7 Part 1: Literature Review. A systematic review of Internet-based cognitive behavioural therapy for the treatment of social anxiety disorder. ........................8 Abstract ........................................................................................................................9 Introduction ................................................................................................................11 Method .......................................................................................................................17 Results.........................................................................................................................22 Discussion ..................................................................................................................49 References ..................................................................................................................57 Part 2: Empirical Paper. Phenomenology of bowel/bladder-control anxiety….71 Abstract ......................................................................................................................72 Introduction ................................................................................................................74 Method .......................................................................................................................81 Results.........................................................................................................................97 Discussion ................................................................................................................117 References ................................................................................................................130 Part 3: Critical Appraisal ......................................................................................140 Critical Appraisal .....................................................................................................141 References ................................................................................................................155 Appendices...............................................................................................................158 Appendix A: UCL Ethical Approval………………………………………………159 Appendix B: Consent Form for Study 1….……………………………………….161 Appendix C: Study 1: BBCA Online Questionnaire …..…………………...….….163 Appendix D: Study 1: Panic Online Questionnaire...………………………...…....173 Appendix E: Study 1: Participant Information Sheet and Consent Form ….……...181 4 Appendix F: Study 2 Questionnaires………………………….…………………...184 Appendix G: Information on Joint Theses ……………………………....………...196 List of Figures – Literature Review Figure 1: Flowchart of Literature Search Process……………………..…………….20 List of Figures – Empirical Paper Figure 1: Adverts used for Study……………………………………………………84 Figure 2: Locations of Online Advertisements…………………………………..….85 Figure 3: Participant Flow through the Study……………………………………….88 List of Tables - Literature Review Table 1: Characteristics of the 19 Included Studies…………………………………23 Table 2: Effect Sizes for primary outcome measures……………………………….35 Table 3: Consensus Cochrane Handbook Ratings…………………………………..48 List of Tables - Empirical Paper Table 1: Demographics of the three groups of respondents………………………...99 Table 2: Description of the problem history of the respondents…………………...101 Table 3: Avoidance and Impairment scores for the three groups of respondents….103 Table 4: Bowel and bladder control specific questions (modal values) and percentage values of the proportion of participants in each group scoring the modal value…..105 Table 5: Factor Loadings and communality of the FOIS………………………….108 Table 6: FOIS group differences…………………………………………………..109 Table 7: Demographics of participants with panic attacks………………………...111 Table 8: Mean Scores and Standard Deviations for Questionnaire Measures……..112 Table 9: Mean Scores and Standard Deviations for UPS and BSSS………………113 Table 10: Scores and independent samples t-tests for disgust, shame, body vigilance, anxiety control and fear of incontinence…………………………………......……115 5 Table 11: Outcome of the Logistic Regression Analysis for the main predictors…116 6 Acknowledgements Firstly, I would like to acknowledge the hundreds of participants who gave their time to take part in the research study. Without their participation, this research would not have been possible. I am immensely grateful for the continuous support and guidance I have received from my supervisor, Dr Sunjeev Kamboj at UCL. His passion for the research, eye for detail and highly responsive style of supervision were invaluable and his advice helped me avoid getting lost in the large amounts of data I collected for the project. My sincere thanks also go to Dr Sue Watson, Ravi Das and Dr Nancy Pistrang for their additional guidance. I would also like to acknowledge the hard work of Lan Rachel Bagott, Alex Zhu and Agnes Chevalier, who gave up their own time to assist with various stages of the research during my maternity leave. I am most thankful for the support of Rosanna Pajak, my thesis partner, whose dedication to our joint project was inspiring. Her patience with the research process helped me tremendously especially in the early stages of planning this complex project. I am deeply indebted to my partner, Emmanuel Ngwengi, without whom I would not have realised my dream of becoming a clinical psychologist. His encouragement and support have never faltered and I will be forever grateful. Finally, I am thankful to my daughter, Saffron Ngwengi, who has kept be grounded and balanced during the final year of my thesis. 7 Part 1: Literature Review A systematic review of Internet-based cognitive behavioural therapy for the treatment of social anxiety disorder 8 Abstract Background: Internet-based cognitive behavioural therapy (ICBT) for social anxiety disorder (SAD) has been proposed to be effective both in terms of outcomes and cost. The need to develop this form of treatment has arisen from the fact that among those with anxiety disorders, SAD patients continue to have the lowest rates of treatment-seeking despite the availability of effective face-to-face therapies such as CBT. Aims: To summarise and evaluate evidence for the effectiveness of both guided and unguided ICBT for SAD. Method: Extensive literature searches of literature published before 2013 identified randomised controlled trials (RCTs) of ICBT interventions for SAD. Treatment studies are examined by comparison group (waitlist or active) as well as by the level of guidance provided (guided or unguided). Results: Nineteen studies were identified which reported a total of twenty RCTs, with five reporting more than one comparison group. Sixteen trials reported outcomes of guided ICBT and seven that of unguided ICBT. Twelve trials included a waitlist control group. The majority of ICBT for SAD showed statistically significant improvements relative to waitlist and equivalent outcomes relative to active control interventions. The overall effect size across studies was large. Guided and unguided ICBT had similar outcomes. The quality of the studies was generally good but detection bias was a consistent problem. Conclusions: ICBT for SAD appears to be superior to waitlist and equivalent to active control interventions. Guided and unguided ICBT have similar outcomes but the evidence base for unguided ICBT remains limited. In future research, 9 independent assessment of outcomes should be conducted as well as longer-term follow-ups and trials in clinical settings to establish effectiveness. 10 Introduction Social anxiety disorder (SAD), also known as social phobia (SP), was officially recognised in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980 (APA, 1980). Since then it has become clear that SAD is associated with high levels of social and occupational impairment (Bruch, Fallon & Heimberg, 2003) and finding effective treatments has become imperative. SAD is the most common anxiety disorder in the general population (e.g. Wittchen & Fehm, 2001), with lifetime prevalence rates in western countries of up to 13% (Kessler et al., 2005) and a twelve month rate of up to 7.4% (Kessler, Petukhova, Sampson, Zaslavsky & Wittchen, 2012).