Psychological treatments for bladder and bowel anxieties

Cognitive behavioural therapy (also commonly referred to as CBT) has a strong evidence base for the effective treatment of many common psychological conditions including Major Depression (MD), Generalised Anxiety Disorder (GAD), Panic Disorder (PD), Obsessive Compulsive Disorder (OCD), and social Anxiety Disorder (SAD). Currently, cognitive behavioural therapyoffers the most consistent evidence for the reduction of bladder and bowel anxieties and is therefore one of the most accepted treatment options.

Cognitive behavioural therapy is a short-term focused approach to changing unhelpful thinking patterns*(also known as cognitive distortions, thinking errors, or distorted automatic negative thoughts) using cognitive flexibility strategies that help to reappraise unhelpful thoughts with healthier ones. Another key component of cognitive behavioural therapy is exposure work, that is engaging in strategies that help individuals to face their anxieties in order to build confidence, reduce avoidance, and in turn redoing anxiety. Other strategies used in cognitive behavioural therapy include psychoeducation, problem solving, stress management/relaxation training, and mindfulness. This type of therapy involves homework tasks in between sessions. Currently, there is evidence supporting the efficacy of cognitive behavioural therapy in the treatment of bladder and bowel anxieties.

*Example of unhelpful thinking is engaging in catastrophizing: You expect disaster. You notice or hear about a problem and start “what if’s:” What if tragedy strikes? What if it happens to you?)

Evidence of treatment approaches for paruresis:

Soifer, Himle and Walsh (2010) identifiedsubstantial improvements in paruresis symptoms using a cognitive behavioural treatment approach. In their intervention, Soifer and colleagues targeted fears experienced by paruresis sufferers along with dysfunctional behavioural processes (e.g., avoidance behaviours).Soifer and colleagues noted alleviation in symptoms after the intervention and at one-year follow-up.

In 2011, Maia Barros documented the use of cognitive behavioural treatment of a 23-year-old male with paruresis. During treatment, Maia Barros identified that the individual displayed key features of anxiety including prominent fear of negative evaluation in addition to avoidance behaviours. Cognitive behavioural therapy delivered alongside anti-anxiety medication was noted to reduce paruresis symptoms.

Similarly, Hambrook, Taylor, and Bream (2017) employed techniques such as cognitive flexibility (e.g., reappraising unhelpful thoughts regarding urination), behavioural experiments (e.g., graduated exposure of paruresis sufferer to increasingly busy restrooms), andpsychoeducation (e.g., informing the paruresis sufferer about how anxiety influences bladder function) in the treatment of a male in his 40s with paruresis. Hambrook and colleagues noted that a cognitive-behavioural treatment approach was successful in alleviating paruresis symptoms.

Evidence of treatment approaches for parcopresis:

Maia Barros (2011) documented the use of cognitive behavioural treatment of a 23-year-old male with parcopresis. During treatment, Maia Barros identified that the individual displayed key features of anxiety including prominent fear of negative evaluation in addition to avoidance behaviours. Cognitive behavioural therapy delivered alongside anti-anxiety medication was noted to reduce parcopresis symptoms.

Evidence of treatment approaches for incontinence anxiety:

Jenike, Vitagliano, Rabinowitz, Goff, and Baer (1987) explored the use of cognitive-behavioural therapy in treatment of bowel incontinence anxiety. Jenike and colleagues used techniques such as cognitive restructuring, relaxation, and exposure therapy. Treatment was noted to be successful as individuals were free of symptoms after treatment, and at 15-24 months follow-up.

Likewise, Beidel and Bulik (1990) utilised behavioural interventions, exposure therapy, and relaxation in the treatment of two individuals (30 and 24-year-old female) with bowel incontinence anxiety. From their findings, Beidel and Bulik reported that incontinence anxiety symptoms were ameliorated after the intervention and at 6-months follow-up. Beidel and Bulik argued that the behavioural interventions in their intervention targeted fear and avoidance displayed byindividuals with incontinence anxiety.

Eisen and Silverman (1991) also reported on the successful treatment of a 15-year-old male with bowel incontinence anxiety, using cognitive behavioural therapy and exposure therapy. In particular, Eisen and Silverman utilized cognitive activities which addressed dysfunctional thinking, homework, and exposure therapy based on a fear hierarchy (i.e., developing a list of increasingly anxiety-provoking situations).Eisen and Silverman reported substantial improvement after treatment and at 3- and 6-months follow-up.

Graduated exposure therapy is a common treatment for anxiety disorders and involves exposure to the feared object or situation within a safe context. Exposure is graduated, so that the individual confronts their fear through a series of increasingly difficult challenges, until they reach the goal of a non-phobic response to their feared situation.

Evidence for graded exposure interventions to treat paruresis:

Soifer, Himle, and Walsh (2010) identified substantial improvements in paruresis symptoms using a graduated exposure and cognitive behavioural treatment approach. In their intervention, Soifer and colleagues instructed paruresis sufferers to develop a fear hierarchy (i.e., a list of increasingly anxiety-provoking situations), drink enough liquids so that their bladder was full, and practice urinating in increasingly anxiety-provoking situations based on their fear hierarchy (e.g., increasingly busy restrooms). Soifer and colleagues noted alleviation in symptoms after the intervention along with one-year follow-up.

Similarly, Hambrook, Taylor, and Bream (2017) implemented exposure therapy, and behavioural experiments (i.e., graduated exposure of the individual to their feared stimulus) in the treatment of a male in his 40’s suffering from paruresis. Hambrook and colleagues found that this reduced paruresis symptoms post-intervention.

Evidence for graded exposure interventions to treat parcopresis:

To date, the efficacy of graduated exposure therapy for parcopresisis unknown. However, given that parcopresis shares close similarities with paruresis, and that graduated exposure therapy has been employed for the treatment of paruresis, graduated exposure therapy may be effective for some individuals with parcopresis.

Evidence for graded exposure interventions to treat incontinence anxiety:

Jenike, Vitagliano, Rabinowitz, Goff, and Baer (1987) explored the use of exposure therapy, cognitive restructuring, and relaxation in the treatment of bowel incontinence anxiety. Treatment was noted to be successful as individuals were free of symptoms after treatment, and at 15-24 months follow-up.

Likewise, Beidel and Bulik (1990) utilised exposure therapy, behavioural interventions, and relaxation in the treatment of two individuals (30 and 24-year-old female) with bowel incontinence anxiety. From their findings, Beidel and Bulik reported that incontinence anxiety symptoms were ameliorated after the intervention and at 6-months follow-up.

Eisen and Silverman (1991) also reported on the successful treatment of a 15-year-old male with bowel incontinence anxiety, using exposure theraptand cognitive behavioural therapy. In particular, Eisen and Silverman utilized exposure therapy based on a fear hierarchy (i.e., developing a list of increasingly anxiety-provoking situations) in addition tocognitive activities which addressed dysfunctional thinking, and homework.Eisen and Silverman reported substantial improvement after treatment and at 3- and 6-months follow-up.

Relaxation training involves learning a technique that increases feelings of relaxation and calmness, while reducing negative feelings of stress and anxiety. A variety of relaxation techniques exist, with some of the most well know including deep breathing, mindfulness meditation, progressive muscle relaxation, tai chi, yoga, and other forms of exercise. Given that stress has a significant impact on anxiety, it is likely that stress management in the form of relaxation training will be an important part of helping to address bladder and bowel anxieties. Further, the effectiveness of relaxation training may be enhanced by adding it to a cognitivebehavioural therapy approach.

Evidence for relaxation training to treatparuresis and parcopresis:

To date, the efficacy of relaxation training for paruresis and parcopresis is unknown. However, given that relaxation training has been employed for the treatment of anxiety conditions, relaxation training may be effective for some individuals with paruresis and/or parcopresis. Further research into the use of relaxation training for this purpose is required.

Evidence for relaxation training to treat incontinence anxiety:

Research by Jenike, Vitagliano, Rabinowitz, Goff, and Baer (1987) explored the use of relaxation in addition to cognitive-behavioural therapy in treatment of bowel incontinence anxiety. Jenike and colleagues used techniques such as cognitive restructuring, relaxation, and exposure therapy. Treatment was noted to be successful as individuals were free of symptoms after treatment, and at 15-24 months follow-up.

Likewise, Beidel and Bulik (1990) utilised relaxation in the treatment of two individuals (30 and 24-year-old female) with bowel incontinence anxietyin addition to exposure therapy and behavioural interventions. From their findings, Beidel and Bulik reported that incontinence anxiety symptoms were ameliorated after the intervention and at 6-months follow-up.

In a hypnotherapy session, the therapist induces a state of deep relaxation in the patient. In this relaxed state, the brain can more readily challenge or alter unwanted thoughts and habits replacing themwith those that are healthier and more useful.

Evidence for hypnosis to treat bladder and bowel anxieties:

To date, the efficacy of hypnotherapy for paruresis, parcopresis, and incontinence anxiety is unknown. However, given that hypnotherapy has been employed for the treatment of anxiety disorders, it may be effective for some individuals with bladder and bowel anxieties.

Mindfulness-based stress reduction

Mindfulness-based stress reduction (often referred to as MBSR) is an eight-week program that involves intensive mindfulness (the process of directing attention to experiences occurring in the present moment) training. It was developed to support individuals afflicted with anxiety, stress, depression, chronic pain, and stress related to medical conditions. Mindfulness-based stress reduction helps individuals become aware of stressful or unpleasant feelings and stress reactions they may have. It allows individuals to recognize their feelings and enables them to react in a positive manner. While mindfulness-based stress reduction has not been evaluated for the treatment of bladder and bowel anxieties, it may be effective for some individuals. 

Acceptance and commitment therapy

Acceptance and commitment therapy (often referred to as ACT) is a psychological intervention that employs acceptance (the ability to recognize and accept a negative or uncomfortable situation, without trying to change it) and mindfulness (the process of directing attention to experiences occurring in the present moment) strategies, in addition tocommitting to activities which are underpinned by ones’ values. The aim of acceptance and commitment therapy is to recognize, understand, and accept difficult feelings or situations rather than actively try to eliminate or change them. While ACT has not been evaluated for the treatment of bladder and bowel anxieties, it may be effective for some individuals.