Psychological Approaches to Understanding

1
Psychological Approaches to Understanding
Promoting Continence
2
An Overview

• Behavioural Models
• Behavioural Interventions
• Effectiveness of Behaviour Therapy
• References and resources

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A psychological perspective can help

• Understanding the psychological consequences of
  incontinence
• Explain continence / incontinence
• Identify strategies for developing and promoting
  continence
• e.g. Behaviour Therapy

4
The Behavioural Perspective

• Based on theories of learning
• Views continence as appropriate response to
  stimuli and / or
• A set of skilled behaviours that need to be
  learned (and can be taught)
• Assumes behaviours can be objectively observed
  measured (unlike some other models)
• Various treatments can be seen to be derived from
  one or more approaches to learning

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3 Behavioural Models

• Classical Conditioning
• Focus on conditioned stimuli, antecedents
• Operant Conditioning
• Focus on consequences of behaviours
• Stimulus-Response (S-R) Models
• Focus on stimulus-response connections - chains

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Classical Conditioning

• Pavlov

US
UR
US
UR
CS
CS
CR
U unconditioned C conditioned S stimulus
R response
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Classical Conditioning

• 3 features of classical conditioning
• Extinction
• Discrimination
• Generalisation
• Alarms

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Operant Conditioning

• Positive Reinforcement
• Primary
• Social
• Secondary
• Stimulatory
• Rewards for appropriate toileting
• Developing toileting skills
• Dry pants training

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Stimulus - Response

• Toileting behaviour is made up of a series of
  stimulus-response connections a chain
• Problems
• Lack of training opportunity to establish chain
• Decreased learning ability less strength
  between links
• CNS damage, weaker perception of stimuli
• CNS damage resulting in reduced control of
  eliminatory responses

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The S-R model

• 3 primary components
• Stimulus of full bladder
• Remaining dry
• Continent passing of urine
• S-R model underpins forward and backward chaining

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Bettisons (1979) S-R Model
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Some treatment approaches

• Training for pre-requisite skills
• Token Systems / Dry Pants training
• Alarms
• Biofeedback
• Timed v Individualised
• Intensive training

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Pre-requisite skills

• Assessment may indicate that the person lacks
  skills in finding the toilet, dressing /
  undressing, appropriate voiding, hygiene, etc
• Following functional analysis these skills can be
  developed
• Techniques could include task analysis, backward
  chaining, positive reinforcement, fading
  generalisation

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Dry Pants Training

• Based on operant conditioning and token economy
• Assumes that learner is physically able to
  achieve continence
• Assumes that the token is reinforcer
• Whole day may be too big a target
• May focus on failures
• Stress anxiety may lead to failure
• May inadvertently encourage punishment

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Smiling Faces awarded for dry days
A recipe for failure?
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Alarms

• May be used in pants or in bed
• Aim to pair sphincter contraction and waking with
  full bladder sensation
• May be linked with Dry Bed or Dry Pants
  training
• Assumes learner has physical potential to achieve
• Various problems reported with alarms, and their
  use in practice

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Alarms Classical Conditioning

• Developed by Mowrer Mowrer (1938)

US
UR
micturition
Bladder distension
US
UR
Sphincter contraction / waking
CS
alarm
CS
CR
Sphincter contraction / waking
Bladder distension
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• Alarm interventions for nocturnal enuresis in
  children
• Glazener Evans (2002). 22 trials / 1125
  subjects
• Alarm interventions are an effective treatment
  for nocturnal bedwetting in children.
• Desmopressin and tricyclics appeared as effective
  while on treatment, but this effect was not
  sustained after treatment stopped,
• and alarms may be more effective in the long
  term. (see Prodigy guidelines)

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Bladder Training

• Involves the gradual postponing of voiding at
  first desire, and enforced voiding at set times,
  gradually prolonging interval, and hopefully
  bladder capacity
• May use overlearning
• Retention control training using shaping
• Requires baseline measurement
• May be implemented with pelvic floor muscle
  training, biofeedback / or medication

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Timed Waking in Nocturnal Enuresis

• Best to use a staggered schedule to avoid
  limiting bladder capacity
• Eg 1hr, 3hr, 1.5 hrs, 4hrs
• May cause voiding on approach, rather than waking
• May be tiring or too difficult for carers to
  implement
• Can be implemented with overlearning

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Timed v Regular toileting

• Timed toileting involves individualised toileting
  regimes to reflect usual frequencies
• Regular toileting is a pre-determined schedule
• Both approaches may have some value in preventing
  continence, though may also limit independence
• Training effect may be more limited

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Timed v Regular in elderly care

• Southern Henderson (1990) developed
  individualised timed schedules for 180 elderly
  hospital patients
• Of the average of 8 toilet visits daily, only
  about 2 were successful
• 1 week of baseline data was collected using pants
  alarms / or checking, to identify clusters
• Intervention greatly reduced unsuccessful
  toileting and incontinence episodes
• They claimed in addition to save a great deal of
  nursing time that could be used on activities
  other than toileting

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Systematic Reviews (Cochrane Database)

• Prompted voiding for the management of urinary
  incontinence in adults
• 5 studies / 355 subjects, Eustice, Roe Paterson
  (2000)
• prompted voiding increased self-initiated voiding
  decreased incontinent episodes in short-termno
  evidence re long-term effects.
• A single small trial suggested that adding the
  muscle relaxant, Oxybutinin, reduced the number
  of incontinent episodes in the short-term
• insufficient evidence to reach firm conclusions
  for practice

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Biofeedback

• Useful for urge or stress incontinence
• May be based on feedback on detrusor pressure, or
  more general measures of relaxation through
  galvanic skin response (GSR) or electromyography
  (EMG)
• Use of appropriate sensors illustrate effect of
  effort in contracting pelvic floor muscles

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Biofeedback equipment with perineometer probes
and LCD monitor
Biofeedback session monitor output patient has
to follow the white line with pelvic floor
contractions
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Evaluation of Biofeedback

• Burgio et al (1998) evaluated Biofeedback against
  Drug treatment and controls in a 6 year study of
  197 women in a RCT
• Biofeedback was significantly more effective, and
  was significantly more satisfactory to patients
  (however there are some limitations to the study)

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• Behavioural and cognitive interventions with or
  without other treatments for defaecation
  disorders in children - Brazzelli Griffiths
  (2001)
• A review of 16 randomised trials with a total of
  843
• no evidence that biofeedback training adds any
  benefit to conventional treatment in the
  management of encopresis and constipation in
  children.
• some evidence that behavioural intervention plus
  laxative therapy, rather than behavioural
  intervention or laxative therapy alone, improves
  continence in children with encopresis

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Figure 3.-Proportions of subjects by group who
reduced frequency of incontinence by 100, 75,
and 50. From   Burgio JAMA, Volume
280(23).December 16, 1998.1995-2000
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Intensive Training

• A variation of Dry Pants
• Developed by Azrin Foxx (1971)
• Claimed great success (in 4 hours!)
• Involves intensive practice throughout the day,
  with increased fluids, positive reinforcement,
  and pants toilet alarms
• Very labour intensive
• May be impractical at home
• May pose ethical problems
• See abstract here

? Richard Ingram / UWE Bristol 2001
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Summary

• There are a wide range of psychological models of
  continence, and associated treatments
• Behavioural interventions are based on learning
  theories
• They must be preceded by full assessment
• Often they can be combined successfully with
  other approaches
• Often they may achieve greatest success with
  fewer side-effects

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References

• Azrin, N. H., Foxx, R. M. (1971). A rapid
  method of toilet training the institutionalized
  retarded. Journal of Applied Behavior Analysis,
  4, 89-99
• Blackwell, C. (1989). A guide to the treatment of
  enuresis for professionals. Bristol Enuresis
  Resource and Information Centre (ERIC).
• Brazzelli M, Griffiths P. (2002). Behavioural and
  cognitive interventions with or without other
  treatments for defaecation disorders in children
  (Cochrane Review). In The Cochrane Library,
  Issue 1, 2002. Oxford Update Software.
• Burgio KL, Locher JL. Goode PS. Hardin JM.
  McDowell BJ. Dombrowski M. Candib D. (1998).
  Behavioral vs. drug treatment for urge urinary
  incontinence in older women. A randomized
  controlled trial. JAMA December 16,
  19982801995-2000,
• Butler, R.J. (1987). Nocturnal Enuresis
  Psychological Perspectives. Bristol Wright.
• Butler, R.J. (1993). Enuresis Resource Pack
  charts, questionnaires and information to assist
  professionals. Bristol Enuresis Resource and
  Information Centre (ERIC).
• Eustice S, Roe B, Paterson J. (2002). Prompted
  voiding for the management of urinary
  incontinence in adults (Cochrane Review). In The
  Cochrane Library, Issue 1, 2002. Oxford Update
  Software.

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References

• Getliffe, K., Dolman, M. (1997). (Editors).
  Promoting continence A clinical and research
  resource. London Bailliere Tindall.
• Glazener CMA, Evans JHC. (2002). Alarm
  interventions for nocturnal enuresis in children
  (Cochrane Review). In The Cochrane Library,
  Issue 1, 2002. Oxford Update Software.
• Lucas, M., Emery, S., Beynon, J. (Editors)
  (1999). Incontinence. Oxford Blackwell Science.
• Morgan, R. (1984). Behavioural Treatments with
  Children. London Heinemann
• Morgan, R. (1993). Guidelines on minimum
  standards of practice in the treatment of
  enuresis. Bristol Enuresis Resource and
  Information Centre (ERIC).
• Resnick NM. (1998) Improving treatment of urinary
  incontinence Editorial. JAMA December
  16,2802034-5.

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References

• Smith, P.S., Smith, L.J. (1987). Continence and
  incontinence Psychological approaches to
  development and treatment. London Croom Helm.
• Southern, D., Henderson, P. (1990). Setting
  standards tackling incontinence. Nursing Times,
  86(10)36-8, Mar 7-13
• White, H. (1997). Incontinence in perspective.
  Chapter 1 IN Getliffe, K Dolman, M (Editors).
  Promoting continence A clinical and research
  resource. London Bailliere Tindall.
• Yule, W., Carr, J. (1987). Behaviour
  modification for people with mental handicaps.
  London Croom Helm.

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Useful Links

• Prodigy guidelines on nocturnal enuresis
• http//www.prodigy.nhs.uk/guidance.asp?gtEnuresis
  20-20nocturnal
• EMG / biofeedback
• http//www.veritymedical.co.uk/modes/EMG.htm
• The Continence Foundation
• http//www.continence-foundation.org.uk/
• Writing a project
• http//www.continence-foundation.org.uk/in-depth/p
  roject-work-in-continence-care.php
• ERIC
• http//www.eric.org.uk/
• CINAHL Search
• http//dialspace.dial.pipex.com/town/nhspeople/d/a
  dag86/student/files/continence.pdf