INCONTINENCE ANXIETY

Most people do not put much thought into the act of remaining continent. It is generally regarded as an automated process not requiring thought or conscious effort. Unfortunately, individuals with incontinence anxiety experience significant distress over the fear of being incontinent in public. This page will discuss the bladder and bowel anxiety conditions known as incontinence anxiety (bladder and bowel incontinence anxiety).

WHAT IS INCONTINENCE ANXIETY?

Incontinence anxiety (also known as bladder and bowel incontinence anxiety, bladder and bowel obsession, bladder/bowel control anxiety, urinary obsession, and bowel obsession) are psychological conditions characterised by an overwhelming fear of incontinence in public. The prevalence and age of onset of incontinence anxiety is currently unknown due to lack of research. However, it is expected that these conditions may be more prevalent in older age groups due to continence being a greater concern for older adults.

WHAT ARE THE SYMPTOMS OF INCONTINENCE ANXIETY?

Individuals affected by incontinence anxiety experience a range of physical and psychological symptoms. Sufferers of incontinence anxiety experience anxious thoughts about losing control of their bladder and/or bowel in public (e.g., being judged and criticised by others around them, and feeling embarrassed and humiliated as a result). Incontinence anxiety symptoms typically occur in public settings and tend to be worse in non-private situations (e.g., busy shopping centres, sporting stadiums, restaurants).

Symptoms of incontinence anxiety range in severity and can include:

An overwhelming fear of urinary and/or faecal incontinence in public situations.
Constantly feeling like your bladder and/or bowel is not completely empty.
Spending an excessive amount of time in the restroom making sure that your bladder and/or bowel is completely empty.
Avoidance behaviours such as avoiding being out in public due to the fear of incontinence.
Avoiding or limiting travel/use of public transport to decrease the perceived risk of public incontinence.
Planning your routine so that you are always in close vicinity to a restroom, to the point where daily life is substantially disrupted.
Avoiding social activities (e.g., dating, going to sporting events, parties) due to the fear of incontinence in public.
Forcing yourself to use the restroom before leaving the house.
Safety behaviours such as limiting fluid and/or food intake to reduce the perceived likelihood of incontinence.
Anxiety related physical symptoms such as excessive sweating, a racing heartbeat, nausea, muscle tension, trembling, and blushing.

Individuals with incontinence anxiety tend to experience more severe symptoms when in busy, public situations. As the amount of people and proximity to others increase (e.g., in a crowded sporting stadium), anxiety surrounding incontinence also increases. The difficulties associated with incontinence anxiety can have a significant impact on quality of life. Not only do sufferers notice that it negatively impacts their social activities, but it also has consequences for their work. An overwhelming fear of incontinence can influence the type of work environment that an individual is comfortable in and can affect whether they are willing to travel for work (e.g., travel by public transport). While incontinence anxiety can adversely impact on quality of life, due to embarrassment many individuals do not seek treatment.

MODELS AND CAUSES OF INCONTINENCE ANXIETY

Current research on incontinence anxiety has identified that it shares similar features with social anxiety disorder. Like social anxiety disorder, individuals with incontinence anxiety experience fear of being negatively evaluated by people around them (e.g., if I lose control of my bladder in public, people with laugh and make fun of me), and use avoidance behaviours (e.g., avoiding being out in public) to reduce feelings of anxiety and distress.

Recently, Kuoch, Meyer, Austin, and Knowles (2019) conducted a study where they applied the extended bivalent fear of evaluation model of social anxiety (for more information about this model, click here) to incontinence anxiety symptoms. Their model identified that socio-cognitive processes such as fear of negative and positive evaluation, along with dysfunctional attitudes, concerns of social reprisals, and disqualification of positive social outcomes contributed to incontinence anxiety symptoms (see below for diagram and summary of factors predicting incontinence anxiety symptoms).

Dysfunctional attitudes: Pervasive negative attitudes that are held towards oneself, the outside world, and the future (e.g., people will probably think less of me if I make a mistake.)

Fear of negative evaluation: Distress from being unfavourably evaluated by others (e.g., I am afraid that people will criticise me for taking too long to urinate).

Fear of positive evaluation: Distress from being favourably evaluated by others (e.g., I generally feel uncomfortable when people give me compliments).

Concerns of social reprisals: Fear of being evaluated too positively by others, and the resulting reprisal that may ensue (e.g., I do everything I can to avoid envy from others who “out-rank” me, even in casual social situations).

Disqualification of positive social outcomes: Attributing positive experiences and success to external factors as opposed to one’s own ability or effort (e.g., When people tell me that they find what I’m saying to be interesting, I usually assume that they are just humouring me).

The extended bivalent fear of evaluation model of incontinence anxiety

Kuoch, K. L. J., Meyer, D., Austin, D. W., & Knowles, S. R. (2019). Socio-cognitive processes associated with bladder and bowel incontinence anxiety: A proposed bivalent model.

Current Psychology

Causes of incontinence anxiety

Very little research has been conducted into the causes of incontinence anxiety. Of the available research, previous experience with incontinence has been reported to be a key feature in individuals who have developed incontinence anxiety. In particular, past trauma regarding incontinence, and co-morbid medical conditions are noted as being potential causes of incontinence anxiety.

Past trauma or experience

For some individuals with incontinence anxiety, traumatic or stressful events related to public incontinence (e.g., losing control of one’s bladder in busy train) have been reported to be a contributing factor. After being incontinent in public, the individual may become stressed and nervous about losing control of their bladder and/or bowel which then leads to further anxiety and difficulties being in public. A study by Pajak and colleagues (2013) reported that some individuals with incontinence anxiety believed their condition was due to a previous episode of incontinence in public.

Co-morbid medical conditions

It is probable that many individuals with incontinence anxiety are also afflicted with an underlying medical condition. Individuals may experience urinary incontinence due to old age, recurrent urinary tract infections (UTIs), lower urinary tract symptoms (LUTS), neurological disorders or cognitive impairment (e.g., Multiple sclerosis, brain or spinal damage, Parkinson’s disease, dementia). Conversely, faecal incontinence may result from sphincter damage and rapid colonic transit.

DIAGNOSIS OF INCONTINENCE ANXIETY

In the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; a manual used by mental health professionals to diagnose mental disorders), there is no valid diagnostic criteria for incontinence anxiety. As a result, incontinence anxiety is currently diagnosed by excluding possible medical reasons and confirming that symptoms are due to a psychological cause.

If you are experiencing continence concerns, it is a good idea to see a General Practitioner (GP) to rule out potential medical issues. Your treating doctor may conduct a series of examinations to screen for physical abnormalities. Examination may include collection of a thorough medical history, physical examination, and use of appropriate diagnostic and investigative assessments (see below for further details).

Physical examination: During a physical examination, your doctor will press against your abdomen to feel for signs of abnormalities.

Blood test: A blood test may be ordered to assess overall health and help identify signs of infection that may causing symptoms.

Radiological investigation: Your doctor may refer you for urinary and/or gastrointestinal imaging (e.g., x-ray, ultrasonography, magnetic resonance imaging, computed tomography) to check for irregularities that may be causing incontinence symptoms.

Colonoscopy or Sigmoidoscopy: A colonoscopy and sigmoidoscopy involves inserting a cystoscope (a small, flexible telescope with a camera) through the anus to examine the inside lining of the bowel. This examination will allow the doctor check for physical abnormalities within the large intestine, and sigmoid colon respectively.

Neurological investigation: Your doctor may refer you to neurological investigation (e.g., electromyography) to identify whether incontinence anxiety symptoms are due to a neurological cause.

TREATMENT OF INCONTINENCE ANXIETY

Psychological treatments

Once potential medical causes have been eliminated, the treating doctor can arrange for a referral for psychological treatment. While there is a paucity of research into psychological treatments for incontinence anxiety, Cognitive Behavioural Therapy is likely to be beneficial due to its efficacy in treating social anxiety disorder. Some of the most common treatment approaches for incontinence anxiety are listed below:

Cognitive Behavioural Therapy

Cognitive Behavioural Therapy (CBT) offers the most consistent evidence for the reduction of social anxiety. Given the presence of anxiety-related symptoms in incontinence anxiety and previous use of CBT to treat incontinence anxiety, CBT is one of the most accepted treatment options. CBT is a short-term focused approach to changing unhelpful thoughts, habits, and behaviours, and replacing them with healthier ones.

Graduated Exposure Therapy

Graduated exposure therapy is a common treatment for anxiety conditions and involves individuals being gradually exposed to their feared object or situation within a safe context. Exposure to the feared stimulus is gradual, so that the individual gradually confronts their fear until they no longer experience distress to their feared object or situation. Given the effectiveness of graduated exposure therapy in social anxiety disorder and incontinence anxiety, it is an intervention worth considering.

Relaxation training

Relaxation training involves learning techniques that increases calmness and relaxation and decrease feelings of anxiety and stress. Several relaxation techniques are available, with some of the most popular including deep breathing, mindfulness meditation, progressive muscle relaxation, tai chi, yoga, and other forms of exercise.

Other potential psychological approaches to treating incontinence anxiety

Mindfulness-Based Stress Reduction (MBSR)

Mindfulness-based stress reduction is an eight-week program that involves intensive mindfulness (directing attention to experiences occurring in the present moment) training. This program was developed to support individuals experiencing anxiety, depression, stress, chronic pain, and stress related to medical conditions. Mindfulness-based stress reduction assists individuals to become aware of stressful or unpleasant feelings and stress reactions they may be experiencing. It allows individuals with anxiety, depression, or other afflictions to recognise their feelings in the current moment and enables them to react in a positive way.

Acceptance and Commitment Therapy (ACT)

Acceptance and commitment therapy is a psychological treatment program that uses acceptance (the process of recognising and accepting negative or uncomfortable situations without trying to change them) and mindfulness (focusing ones attention to experiences that are occurring within the present moment) strategies, with behaviour-change and commitment strategies. The aim of acceptance and commitment therapy is to recognise, understand, and accept challenging feelings and situations as opposed to actively trying to eliminate or change them. Acceptance and commitment therapy allow individuals to open-up to unpleasant feelings they may be experiencing, learn to not avoid situations or circumstances that may elicit these feelings, and to learn not to overreact to them.

Medical treatments

Medical health professionals (e.g., General Practitioners) may prescribe an anxiolytic (anti-anxiety medication) to help treat the anxiety symptoms related to incontinence anxiety. The use of anxiolytic medication alongside psychological therapy is best discussed with your treating doctor (see below for further information).

Selective serotonin reuptake inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are a type of medication prescribed to address anxiety symptoms. SSRIs work by reducing the reabsorption of serotonin by nerve cells, which in turn leads to increased levels of serotonin within the brain. Serotonin is a naturally occurring neurotransmitter/chemical within the brain that is involved in the regulation of a variety of functions such as mood. In anxiety disorders, serotonin is in a state of imbalance. Through the stabilisation of serotonin levels, SSRIs may assist in decreasing anxiety symptoms associated with incontinence anxiety. Your treating doctor may prescribe SSRIs under a variety of names such as paroxetine, fluoxetine, escitalopram, citalopram, and sertraline.

SUMMARY OF INCONTINENCE ANXIETY

Incontinence anxiety refers to psychological conditions characterised by an overwhelming fear of incontinence in public. Incontinence anxiety typically occurs in public settings and in situations where there are many people in close proximity. The prevalence and age of onset of incontinence anxiety is currently unknown due to the lack of available research. Incontinence anxiety shares similarities with social anxiety disorder as both conditions contain overlapping features. The most recent model of incontinence anxiety argues that psychological processes such as fear of negative and positive evaluation, along with dysfunctional attitudes, concerns of social reprisals, and disqualification of positive social outcomes contribute to incontinence anxiety symptoms. Individuals with suspected incontinence anxiety should be examined by a medical doctor to ensure that their symptoms are not due to a medical cause. A range of psychological and medical treatments are available for individuals with incontinence anxiety.