Erica Russell, LMFT, LPCC, of the OCD Center of Los Angeles discusses the often unacknowledged topic of incontinence anxiety, bringing this under the radar condition out from behind closed doors and describing how it can be successfully treated using Cognitive Behavioral Therapy.
A friend invites you to join her for a relaxing day at the beach. She offers to drive and bring snacks—all you need to do is pack a towel and be ready when she picks you up. Sounds great, right? But you are immediately filled with dread and your stomach begins to churn. How long is the drive? What if your stomach starts to hurt along the way? What if you get diarrhea and you’re trapped in her car? Or what if you need to poop while you’re at the beach? Would you be able to find a bathroom and make it there on time? Or what if you have an accident… while wearing a bathing suit? This is starting to sound like a nightmare. So you politely decline the invite, making an excuse about having to catch up on work.
If you can relate to this scenario, you might be struggling with fear of loss of bowel or bladder control, an anxiety disorder that is more common and more treatable than you might think! Anxiety about loss of bowel or bladder control actually falls under the diagnostic umbrella of Agoraphobia, an anxiety disorder that is often very misunderstood.
What is Agoraphobia?
There are many misconceptions about Agoraphobia. Most people associate this term with a person who is housebound or afraid of being in crowds, and while sometimes that may be true, Agoraphobia is actually broader than those descriptions depict. In the DSM V, Agoraphobia is defined as marked fear or anxiety about two or more of the following five situations: using public transportation, being in open spaces, being in enclosed places, standing in line or being in a crowd, or being outside of the home alone. The individual fears or avoids these situations because of thoughts that escape might be difficult or that help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms, including fear of incontinence. Put more simply, Agoraphobia is a fear of symptom attacks and an associated pattern of maladaptive avoidance behavior. While a symptom attack can mean many things (a panic attack, fainting, getting a severe headache), here we’ll be focusing on incontinence.
Triggers for Agoraphobic Fear
Anxiety about loss of bowel or bladder control involves fear associated with specific situations/places in which it might be difficult to quickly access a bathroom or in which it would be embarrassing if an incontinence-related accident were to occur. Due to this fear, it is very common for individuals to avoid these situations. Examples include:
-Being away from home
-Walking in an area that is far from home
-Visiting a more remote location where bathroom access could be limited (like camping or going for a hike)
-Taking a long drive, especially when you are a passenger
-Using public transportation
-Waiting in line at a drive-through
-Driving in traffic
-Going somewhere new (where you don’t know where the bathrooms will be)
-Sitting in a classroom
-Waiting in a long line
-Attending a show at a theater
Anxiety about incontinence also involves a fear of experiencing certain internal sensations associated with loss of bowel or bladder control, and when these sensations are present, the individual may be more likely to either avoid the above mentioned situations or to engage in safety behaviors, which I’ll come back to soon. The tricky thing about our body is that the more we focus on a sensation, the more hyperaware and fearful we are, the stronger that sensation is likely to feel. Imagine worrying that there is something wrong with your heart, focusing on your heartbeat, and noticing as your heart literally begins to speed up in response. The same thing can happen as we focus on bathroom-related sensations—as we focus our attention on our stomach and experience more anxious thoughts, those sensations get louder. Let’s look at some internal sensations that might be triggering for anxiety:
-Urge to urinate
-Urge to defecate
-Stomach pain or cramping
-Nausea/ indigestion
-Gas
-Feeling full
-Feeling hot
-Feeling cold
The Role of Safety Behaviors:
Because it would be impossible to avoid ALL of those feared situations and places or to eliminate the above-described sensations, it is also common that Agoraphobic fear is paired with a tendency to engage in safety behaviors aimed at preventing a symptom attack. When the feared symptom attack is a loss of bowel or bladder control, safety behaviors may include:
-Preventative or overuse of anti-diarrheal medications
-Researching bathroom locations before leaving the house
-Booking aisle seats in theaters or on airplanes
-Wearing diapers
-Packing a change of clothes, “just in case”
-Avoiding eating until full
-Avoiding drinking water
-Restricting the kind of things you eat or drink
-Keeping a travel potty seat in the car
-Wearing clothes you think would be more likely to conceal an accident
How is Agoraphobic Fear Maintained?
If you have related to much of what I’ve discussed so far, you might be wondering “But where did this fear come from? And why won’t it go away??” Catastrophic thinking is a powerful element in anxiety. Many people who struggle with anxiety about loss of bowel or bladder control have had 1 or 2 accidents in the past (as most humans have!) while sick or in an odd circumstance, but some have never had an accident before. Similar to fears of fainting or throwing up, anxiety about incontinence is usually less about trauma and more about catastrophic fears taking over. We imagine how embarrassing it would be to have an accident at the beach—playing out a nightmare scenario of humiliation. And because it’s POSSIBLE, we find that scenario too hard to dismiss.
When catastrophic fears are running through our minds, we begin to misinterpret certain situations and sensations as dangerous. And to manage that fear, we begin to avoid or rely on safety behaviors in an effort to prevent that fear from coming true. While this avoidance and control might seem helpful or reasonable in the short term by relieving our anxiety, long term, it backfires, reinforcing the belief that we SHOULD be afraid and that we CAN’T handle dealing with those situations or sensations. With time, this cycle of fear and avoidance can spiral to the point that your world starts to feel smaller and smaller as the places you can go and what you can do begins to become more limited. This is the cycle of anxiety, and this is what maintains Agoraphobic fear.
Reason to Hope: Treatment for Agoraphobia
The good news is that there are awesome, evidence-based treatments available for Agoraphobia! Using Cognitive Behavioral Therapy, we can work with clients to identify external and internal anxiety triggers, identify safety behaviors, and explore catastrophic thoughts, creating a personalized plan to overcome the cycle of misinterpreting danger and relying on avoidance. Using cognitive restructuring, we teach clients to challenge catastrophic thinking with a more realistic, compassionate voice. Using mindfulness based skills, we help clients learn to shift focus off of bodily sensations and back to what matters in the present moment. Most importantly, exposure therapy to feared situations and sensations helps clients to build confidence in their ability to tolerate these triggers and to begin reclaiming freedom in their actions. Exposure therapy is typically a gradual, collaborative process, and while the idea of confronting your fears and ditching the safety behaviors may sound intimidating, having this experiential learning is key in overcoming Agoraphobic fear. Imagine this in comparison to a fear of flying— looking at statistics about air travel safety and keeping more logical thoughts in mind might be somewhat helpful, but for most people, getting real practice with flying is a game changer in overcoming their fear.
If you are interested in learning more about treatment for anxiety about loss of bowel and bladder control, or other Agoraphobic fears, there is help available! The OCD Center of Los Angeles offers individual therapy for Agoraphobia and other anxiety disorders, and we would love to assist you on the road to recovering from your fears. Life is too short to revolve around the bathroom— let’s work together to stop anxiety from running the show, and get back to doing the things that matter most!
•Erica Russell, LMFT, LPCC, is a psychotherapist at the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related anxiety based conditions. In addition to individual therapy, the center offers nine weekly therapy groups, as well as online therapy, telephone therapy, and intensive outpatient treatment. To contact the OCD Center of Los Angeles, click here.
One Comment
Thank you for sharing this post. I have learned a lot about the feeliings of dread in certain situations that is attached to Agoraphobia. I always thought this condition as being housebound or afraid of being in crowds too. But there is more a broader range of symptoms. The fear of urinary or bowel of incontinence is understandable especially if you are not able to be near a washroom. But there may be ways to treat those fears as you said in this article, using CBT.