MANAGEMENT OF AQUAPHOBIA BY DIVING BOTTLES (Article published in Subaqua No. 230, pages 84-87)

I. HOW PHOBIA CAN HUNT LIFE:

"The symptoms of fear - whatever the origin - I know them well: tremors, increased heart rate, cold sweats, suffocation… Up to the paralysis that fear panics can cause. In a situation of fear, we find ourselves totally vulnerable, we no longer control any of our emotions. We no longer recognize ourselves. Often, it happens that we make our own fears suffer from our loved ones. Subsequently, when the fear situation disappears and
we become “normal” again, we no longer know how to talk to them again, because a great feeling of shame has set in.

The fears that affect us on a daily basis can ruin certain moments in our lives. We are focused on it, and everything else goes to the background. Some people - like me - can even see their life organized according to a whole system of irrepressible fears, caused by phobias.

Phobias, the word is dropped!

This method of functioning, based on fear, ruins existence. When we climb the ranks of this fear that grips us, we hardly dare to leave our home because of the anguish of being confronted with a situation of panic. When the phobia takes over, the pleasures of life hardly exist.

All these fears directly affect everyday life. They have the power to make pleasant moments in life such as holidays difficult (unknown place, fear of being afraid…). The gaze of others is also painful to bear, because the excessive attitude of the phobic often makes them laugh. They tease him and they play with his weakness.

We can see that these obsessive anxieties are mainly linked to the fear of dying [Perhaps this is also the way to feel that we are indeed alive?].

Phobia is a common ailment that affects millions of people, but which fortunately is healed. However, the feeling of fear does not disappear totally! ... In short, does the feeling of fear
Phobia would not be simply related to the pain of living? "

When we ask Martine to tell us about her phobia of water (aquaphobia), it is in these terms that she describes it. We all have phobias. Do we all need to consider drug therapy or treatment? Of course not. Where there is a need to take charge is when the phobia has an impact on our mode of functioning, on our behavior; in short, when it ruins our lives! And within this framework, could diving - a leisure activity par excellence - not turn into a therapeutic tool? ...

According to the DSM IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition), a phobia is a "Persistent and intense fear of unreasonable or excessive character, triggered by the presence or anticipation of confrontation with a specific object or situation.

Exposure to the phobogenic stimulus almost systematically triggers an immediate anxiety reaction that may take the form of a panic attack that is situation-related or facilitated by the situation.

The subject recognizes the excessive nature of his fear.

The phobogenic situation is avoided or experienced with intense anxiety or distress.

Avoidance, anxious anticipation or suffering in the dreaded situation significantly disrupt the individual's habits, professional activities or social activities or relationships with others, or having this phobia. 'accompanied by a feeling of great suffering'.

In practice, the mere fact of making Martine imagine being in the water is enough to make her anxious. She recognizes that this fear is excessive, but she can not control herself. The patient is aware of the abnormal nature of her disorder, which forces her to reorganize certain situations she has to face in her daily life.

Let's see now how to help Martine overcome her phobia of water, thanks to diving.

II. MANAGEMENT:

In the case of a simple phobia, CBT (behavioral and cognitive therapies) are the most effective. In fact, TBIs today represent the most widely recognized method of psychological care by all scientific approaches. CBTs are based on techniques that evolve regularly over time based on research that evaluates their effectiveness.

These therapies act, as their name suggests, on behaviors not adapted to everyday life (example: Martine lives on the Côte d'Azur, accompanies her children to the beach in the summer but forbids them to go to school. water because if any problem occurred she could not
not immerse yourself in helping them. If she finds herself even splashed, her throat is knotted, her heart is accelerating, she finds herself in sweat with the impression that she will die. She is therefore forced to stay away from the water, take quick showers, taking care not to wet her face). CBTs also act on the thoughts (cognitions) associated with these unsuitable behaviors (in the case of Martine: "If I'm in the water, I'm going to drown," "If I have water on my face, I'll inhale and choke", etc.).

It is then a question of modifying an inappropriate behavior so that the person improves as quickly as possible (the unsuitable actions are fought and eliminated, the adapted actions are favored and reinforced).

1. Martine's story:

Martine, aged 43 years, is executive assistant in Cannes. Widow since 3 years, she lives in Nice, and no longer manages to immerse herself in the water: the mere idea of ​​being splashed anxiety at the highest point, resulting in avoidance behavior (she never goes at the beach, no longer manages to accompany his children to the pool) which complicates his existence.

The beginning of the disorders presented Martine goes back to March 2004, date when her husband died suddenly of a myocardial infarction while it takes a bath of sea. This last one presented, according to the patient, disorders of the alimentary behaviors, with frequent bulimic attacks; however, no psychological care had ever been requested.

The day of his death, he telephones his wife, informing him of the occurrence of a bulimic access and proposing to join her at the beach at the exit of his work because he feels anguished.
A heart attack takes Martine's husband while he was swimming in his
direction.

As a result of this painful episode, Martine consults her general practitioner and benefits from a tranquilizing treatment and a one-month work stoppage for nervous breakdown. At this time, she suffers from a very debilitating insomnia, a constant tiredness and black thoughts (she thinks of death all day long).

Over the months, while she has returned to work, Martine is suffering from acute attacks of anxiety (called panic attacks) that combine rapid breathing, chest tightness, palpitations, cold sweats, muscle contractures and vertigo. The fear of dying is the strongest feeling in these moments; it is accompanied by agitation both psychic and motor, in search of a person who can help him.

Martine then avoids bathing, fearing that the anxiety felt in contact with water does trigger a new panic attack. This is the eldest son of the patient, aged 20 and living with her, who takes care of accompanying his two sisters 10 years to the pool and the beach when necessary. When Martine gets a shower, she avoids wetting her face and washes as quickly as possible.

2. The analysis of the disorder:

Martine presents a phobia of water (aquaphobia) quite typical. It is interesting for the therapist to understand what makes her suffer. This is called functional analysis trouble.

3. Psychotherapeutic intervention:

We start by giving Martine information about her phobia, by dramatizing it as much as possible, and showing her that it corresponds to a known illness that can be cured in fifteen sessions thanks to a cognitive-behavioral management.

We inform Martine of the basic principles of CBT and practical modalities, in particular systematic desensitization techniques:

Focus: systematic desensitization

This is a technique that aims to change inappropriate behavior (here avoiding water). At first, we list with Martine a series of scary situations for her. In a second step, we suggest to the patient, relaxed, a calm image ("You are in the mountains, by the fireside, reading a good book. Your cat is purring next to you. Outside, the snow is falling with big flakes but you are very warm »). Martine's eyes are closed, she is relaxed. Then we ask him to imagine the least distressing situation on the list. After approximately 5 seconds of clear image, the patient is asked to leave her and express her level of anxiety. Then she relaxes for about 20 seconds. A second presentation of the same situation is made for about 20 seconds, alternating with relaxation. And so on… Once the anxiety diminishes by at least half, we go back in the list. Little by little, we are thus able to face the most distressing situation. It is a little the same principle that is used in allergology during pollen desensitization (we inject doses of increasingly strong substance to which the patient is allergic, so that it is there Gradually, it is the dose of anxiety that is made to vary). Once Martine manages to confront in imagination scenes that are more and more distressing for her, we ask her to put herself in real life. She will then go to the first step of her list. She has "tasks" to do outside.

We explain to Martine step by step what the therapy will consist of, and ask her to begin to observe each of the situations that pose a problem and lead to avoidance.
We also propose to "rate" his anxiety of 0 10 in these situations.

● Objective:

Martine would like to "become as before", that is to say, go to the beach with her children, be able to swim and especially be able to put the head under water.

So the goal of the therapy is to be able to swim and put your head under water.

In agreement with the patient, we envisage about fifteen sessions, at the rate of a weekly maintenance of 30 at 45 minutes. An agenda is set at the beginning of the session, and a feedback is done at the end of each interview (we ask Martine what she thought of the meeting of the day).

● Conduct of the sessions:

The therapy runs from May 4 to 9 July 2008. It requires 13 sessions. Here below, in a nutshell, are some of the key sessions:

¨ 1 sessions to 3:

The first three sessions focus on:

- the biography and the story of Martine's illness;

- the diagnosis;

- disorder analysis;

- the establishment of a "therapeutic contract", which defines the objectives of the
therapy and the overall course of the sessions;

- the review of problematic situations leading to avoidance, with
prioritization of situations (from the most distressing to the least distressing,
listed from 100 to 0):

Goal : To be able to swim and put your head under water.

In 100: take a scuba diving lesson (accompanied by a dive instructor therapist);

In 90: to bathe by getting into the water from a boat, immersing the head;

In 80: to bathe by getting into the water from a boat anchored in the open sea, without submerging the
head;

In 70: to bathe by getting into the water from a boat anchored a few meters from the edge, without
immerse the head;

In 60: take a boat ride;

In 50: plunge your head into a basin filled with water;

In 40: spray your face with water

In 30: take a course on drowning hazards in scuba diving;

In 20: board a boat that stays at the dock;

In 10: to walk on the port of Nice.

¨ 4 session:

This session is intended for information concerning phobias, as well as for the psychophysiological explanation of the anxiety phenomenon using diagrams.

Once these elements are acquired, we go on to learn the control of panic attacks, with explanation and practice of rapid relaxation techniques.

Martine appears very receptive, considering for the first time a simple way to intervene on her symptoms.

Task for the next session:

Perform daily fast relaxation exercises in a non-distressing situation.

¨ 5 session:

The session starts with a review of the tasks performed at home.

Martine appreciates this way of working, and she is very motivated by the use of quantified results.

She talks about her willingness to better control her persistent fear of panic attack, and now thinks she no longer has to "suffer" this unbearable internal suffering.

Throughout this session, we are working on fast relaxation techniques.

Task for the next session:

Perform daily fast relaxation exercises in a non-distressing situation.

¨ 6 session:

Martine has done the homework, and we do not fail to congratulate her.

Fast relaxation is now acquired.

The session is devoted to explaining the links between cognitions (thoughts), emotions, behaviors and consequences.

Martine seems pleased to better understand the mechanisms of her troubles.

Task for the next session:

The patient should continue the daily exercises of rapid relaxation.

¨ 7 session:

We perform with Martine what is called a cognitive restructuring. For this, we proceed as follows:

- Martine: "If I find myself in the water and I make a panic attack, I will lose my self-control, gesticulate in all directions"

- Therapist: "And what will be the consequence of this?"

- Martine: "People are going to crowd around me, I'm going to be ridiculous"

- Therapist: "Result ?"

- Martine: "They'll think I'm crazy"

- Therapist: "Result ?"

- Martine: "I'm going to be locked up in a psychiatric hospital"

- Therapist: "Result ?"

- Martine: "I'm going to die in the psychiatric hospital."

A postulate is then highlighted here, postulate that can be summarized as follows: "I must avoid getting into the water and avoid any situation that could trigger a panic attack, otherwise I will be interned and die in the psychiatric hospital."

Martine believes in this postulate to 80%.

We then ask Martine to list the arguments in favor of this postulate, and the arguments against:

To	Against
- I will look completely crazy if I gesture for no reason. - People who do crazy things find themselves interned in psychiatry against their will. - Psychiatry is a world apart, and some patients are locked up there all their lives.	- Not all people with bizarre behavior end up interned. - My health is good. - Patients don't die in the psychiatric hospital.

After this contradictory examination, Martine side his belief in this postulate to 20%.

Feedback:

Very proud to have been able to evoke this problem, the patient thanks "Help him to finally see it more clearly".

Tasks for the next session:

Stroll on the port of Nice and get on a boat that stays at the dock. Use rapid relaxation to reduce anxiety.

¨ 8 session:

Martine was busy performing the tasks we asked her to do, despite an anxiety listed on 8 (on a scale from 0 to 8) at the initiation of the action, and which went down to 4 after a few minutes.

We then bring to the patient's imagination the scenes that are painful to her (by choosing on her list the least distressing to begin), according to the principle of systematic desensitization. Martine gradually learns to reduce and manage her anxiety. She appears very receptive to this type of technique, and expresses her satisfaction once the session is over: "I never thought I would see my anguish diminish so much" (anxiety listed at 8 at the beginning and 3 at the end of the test).

Task for the next session:

Take a course on the risks of drowning in scuba diving.

¨ 9 sessions to 12:

These sessions are intended to continue the systematic desensitization, taking for example situations more and more distressing.

At the same time, progress is also being made at the level of the tasks to be performed at home. Previously avoided situations are confronted in reality, the levels being crossed without any real difficulty.

At the 12^rd session, Martine can now swim by getting into the water from a boat anchored in the open sea, without immersing her head.

At the different feedbackshe shares her impression of "relearning to live".

¨ 13 session:

This session is devoted to evaluating the therapy. Martine said she was very satisfied, the contract having been completed and the therapeutic objectives fulfilled: she managed to make a baptism of diving, and even took immense pleasure!

We agree to meet again in two months to evaluate the results and conduct recall sessions if necessary.

¨ Two months after the end of the therapy:

Martine reports on maintaining the autonomy achieved through therapy, and points out that in just two months, only two panic attacks have occurred, which she has managed to control. She even signed up for a scuba diving course to pass her 1 level.

III. PHOBIA, A VERY DISTURBED DISORDER:

Many people are affected by this condition that plagues their lives and those around them. In the United States alone, it is estimated that more than 13 million patients are consulting for panic and phobia problems! In the general population, nearly one individual on 10 would suffer from severe phobia.

In most cases, the person does not fully understand what is happening to him: one fine day he found himself struggling with this pathology that came out of nowhere, which has since only increased without being able to explain why .

The phobia, when it does not represent a real handicap for the subject, is not a serious problem in itself. It becomes worrying from the moment it prevents the person from living normally, from the moment it spoils his existence. Our objective here has been to give the reader some leads, leads which will hopefully allow him to better understand what a phobia is, and above all to know that there are suitable and very effective therapeutic means to combat it. And in the context of aquaphobia, scuba diving can be a very effective tool, the practice of which will allow the subject to apprehend the big blue from a reassuring perspective.

REFERENCES :

André C, Muzo: Small anxieties and big phobias. Threshold, Paris, 2002

Cottraux J: Behavioral and cognitive therapies. Fourth Edition, Masson, Paris, 2004

Palazzolo J: Behavioral and Cognitive Therapies - A Practical Manual. Editions In Press, Paris, 2007

Palazzolo J:Clinical cases in behavioral and cognitive therapies. 2^rd edition. Masson, Practical Collection in Psychotherapy, Paris, 2006

Palazzolo J:Heal quickly - Treat anxieties, depression, phobias by TBI. Hachette Practice, Paris, 2005