Fear of losing control of your bowels

The following was my reply to postings on the BABCP "CBT Cafe" discussing possible applications of a cognitive model for the treatment of the fear of losing control of bowels that seemed to be lacking in attention to the behavioural and physiological component of the disorder.

Re: Fear of losing control of bowels - Panic Disorder or Specific Phobiaa
« Reply #6 on: September 26, 2013, 10:35:58 pm »
Quote
Hi
Back in the old days (pre CBT) just about the only training in Behavioural Psychotherapy was for nurses, bowel and bladder habits were regarded as our bread and butter. So you could try an alternative to Clarkes formulation from 1986 with a greater emphasis on the A and B than the C and always informed by the ABC. Lots of conditioning stuff and negative reinforcement going on. Based on stuff that Rob Newell and Pete Henderson taught me as a trainee.
Fear of soiling self – often following traumatic brown pants experience.
Aversive consequences, of shame and humiliation leading to avoidance behaviour.
Increased fear of soiling leads to increased self-focus on bowel or bladder fullness.
Increased awareness of bowel or bladder fullness follows and the client responds by urinating or defecating with the slightest stimuli.
In other words they stop holding and retaining and as a consequence of not squeezing and holding the muscles get weaker. Awareness of reduced capacity to hold and retain increases fear and acts as confirmatory evidence
Increased use of the toilet as a “precaution” and other safety behaviours (eg; dietary restraint, use of Imodium) maintain fear.
Treatment might include:-
Education on normal effects of anxiety on the G.I tract and impact on anticipatory anxiety leading to safety behaviours and or avoidance.
Baseline recording including bowel/ bladder movements, diet and medication use
Bowel/ bladder retraining exercises, monitoring and recording times from urge to voiding, holding both before going to toilet and after sitting on the seat, establishing regular bowel habit.
All this with exposure in imagination to feared consequence (soiling self).
By this time you have a real good idea of how long the person can retain on best and worst days.
Hopefully you have reduced anxiety response through exposure in imagination, stimulated awareness of ability to hold and retain, improved muscle tone.
Now push the exposure in real life, not just going out further from safety zones but including exposure in imagination to soiling yourself.
A good exposure exercise is to encourage the client to cack themselves in a controlled way. The idea is that they stand in the bath until they cack themselves. Many will find that the turds retreat and if not they can start to actually discriminate when the turtle is about to touch the cotton. Realising perhaps that they were not on the edge of soiling themselves they were several yards or maybe miles from the edge of brown pant gorge. Include imagining they are at a formal dinner party.
Some adaptations with IBS but too little time to go into this. But, similar principals apply with a greater focus on arousal reduction, mindfulness meditation exercises (also introduced to us at the Institute of Psychiatry by Padmal De Silva in 1986).
I am available for weddings and Bar Mitzvahs





Happy days Dave!!!!!!!!!!!!!!!!!!!!!!!!!!!!! It still works a charm.

Obviously 'it still works a charm' is less than empirical. That said I'd love to see a presentation on a BE involving testing a hypothesis regarding faecal incontinence being tested by cacking into a bath being presented by any profession other than nursing at BABCP conference. Obviously, that would have to get past the Scientific Committee and they are never going to let anything past that is anything less than 'compliant.

Mick

Great stuff! Brings me right back....Fionnula

Hi David,
Your behavioural programme brought back inspiring memories of work at the Psychological Unit at the Maudsley Hospital in 1990 when l did the Adult Behavioural Psychotherapy nursing course.
Our director was of course Professor Isaac Marks who would demand that the treatment of choice for this specific fear of incontinence would be the exposure programme you outlined and he would not have countenanced a cognitive approach.
Great days and times and l believe as do other therapists that the behavioural aspect of CBT has been superseded by the cognitive therapy acolytes.
Alan