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Bowel and bladder anxiety: An obsession or a variant of agoraphobia?

It has long been debated whether bowel and bladder anxiety are a part of obsessive compulsive spectrum disorder or a variant of agoraphobia with no consensus view yet. Tricyclic antidepressants are reportedly efficacious in such cases and lead to complete resolution of symptoms. Here, we report a 36-year-old male having urges to visit toilet when in public places or where toilets are not easily available and a resulting avoidance of such spaces fearing an episode of incontinence. Symptoms originated 16 years ago when he was in university which compelled him to drop out. We treated him with paroxetine and relaxation therapy to which he responded satisfactorily.


INTRODUCTION
Bowel and bladder anxiety has found mention in literatures as early as the 80s. It has been viewed differently by different authors. Furthermore, it is not a homogenous entity and symptomatology and underlying cognitive phenomenon is varied in the cases reported till date. Some view it as an obsessive spectrum disorder where the patient is preoccupied with thoughts and imageries of bowel motion and fear or embarrassment of experiencing an episode of incontinence in public and exhibits ritualistic behaviors of visiting toilets in certain circumstances. [1,2] Whereas, it has been given a different perspective by others, who conceptualize it as a variant of agoraphobia where the person fears going to places from where escape seems difficult. [3] Escape, in this context, would refer to finding a toilet in such places. Furthermore, because of hypersensitivity and overactivity of viscera which overlaps with functional bowel diseases, they are sometimes labeled as irritable bowel syndrome. [4] Irrespective of the theoretical constructs, these patients experience considerable distress and impairment of functioning. Underreporting also remains a barrier in the diagnosis and treatment of this disorder.
Most of the reported cases show a satisfactory response to tricyclic antidepressants [2] including clomipramine. [5] One patient of bowel obsession responding to trazodone has also been reported. [6] Here, we report a case which shows both agoraphobic and obsessive compulsive properties.

CASE REPORT
A 36-year-old male presented with complaints of increased frequency of bowel motions in specific situations. It started at the age of 20 after his mother passed away. At that time, he was pursuing his postgraduation. Despite having defecated and cleared his bowels routinely in the morning, he would experience bowel urges during lecture sessions and he had to compulsorily visit toilet multiple times in the middle of the sessions. However, he would pass very small quantity of formed stools and there was no history of loose or watery stools during such episodes. Furthermore, these midday urges would be absent during holidays or when he was at home and there was easy accessibility to toilets. No duration of constipation was reported. It had become so troubling that he eventually stopped going to college.
Thereafter, he secured a job, got married, and fathered two children. However, he still avoided going to places where toilets were not within reach, fearing that he may have to defecate in public. If at all he had to go to market places, he would start being apprehensive on the way followed by somatic symptoms such as palpitations and diaphoresis and abdominal discomfort. This heightened anxiety, however, never precipitated into a panic attack. On such journeys, he would ritualistically visit petrol stations to use the toilet. He had a few other designated places where he would visit toilet before reaching the marketplaces. He had no other obsessive thoughts and did not exhibit any other compulsive behavior and scored only 6 on the Yale-Brown Obsessive Compulsive Scale. Furthermore, there was no family history of anxiety disorder.
He was put on paroxetine controlled-release preparation (12.5 mg) and also advised on relaxation techniques to which he responded well and his untimely bowel urges and unwarranted fears of incontinence in public dissipated.

DISCUSSION
In our case, we tried to avoid a diagnosis of obsessive compulsive disorder (OCD) because the patient had no repetitive thought or imagery. It was mostly a fear related to catastrophe in the form of incontinence in public. Furthermore, these fears were situation specific and would be completely absent if he avoided those places. This was unlike in obsession where the ego-dystonic thoughts prevail during most of the time.
His ritualistic behavior also was situation specific and was not mimicking compulsive behaviors of OCD.
If we draw a comparison with previous case reports, in some of them, we find a similarity with our patient, where the basic fear is loss of bowel control in public places, avoidance of such places, and sometimes ritualistic visit of toilets. Perusal of such literature makes us believe that they could be categorized as agoraphobia or a variant of it. Furthermore, in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, in the description of agoraphobia without panic, fear of losing bladder/bowel control is mentioned as a symptom if not as diagnostic criteria. [7] However, there are other reports where the cognitive component of OCD in the form of imageries was indeed present. These imageries were repetitive, intrusive, and difficult to fight and could be resolved only by going to the toilet repeatedly. [4] Conceptualizing these cases as a variant of OCD seem reasonable.
One literature supports the label of obsessive compulsive spectrum disorder based on the response of these cases to tricyclics. [1] However, we have to bear in mind these reports dates back to a time when serotonin-specific reuptake inhibitor (SSRI) were either not marketed or not used as a first line in anxiety disorder, and most of the case reports do not mention a trial with SSRIs. Hence, a retrospective diagnosis of bowel obsession based on the response to tricyclics could well be misleading in bowel/bladder anxiety. In our case, we chose paroxetine which apart from being effective in anxiety disorder and panic attacks also has considerable anticholinergic property [8] which could tackle the increased gut motility.

CONCLUSION
Trying to box these varied symptoms and label them as either bowel obsessions or agoraphobia may not be wise. Bowel/bladder anxieties may not be a unitary concept; rather it may be two separate disorders which can be distinguished only by a careful perusal of the symptoms and understanding of the phenomenology. Furthermore, increasing public awareness regarding the disorder for early diagnosis and treatment and thereby reducing their functional impairment is suggested so that patients do not have to compromise with their academic career, jobs, or social life.

Financial support and sponsorship
Nil.
There are no conflicts of interest.