ENURESIS (Bed-wetting)

Persistent involuntary discharge of urine, usually during sleep, after the age of three. Bed-wetting may occur every night, several times a week, or only in reaction to stress.An estimated two million children and a large but unknown number of adults are afflicted with enuresis in the United States. It is more common among males than females and was one of the most frequent causes of neuro- psychiatric discharge from recruitment training during the last war. The incidence declines sharply with age and is relatively low among persons over thirty.Many causal factors and combinations of factors appear to be responsible for enuresis. Some cases are clearly due to organic conditions. Slight anatomical defects and persistent low-grade infections of the genitourinary system are most frequent; brain pathology and damage to the nerves in the spinal cord that control bladder function are infrequent and usually occur only in adults. A recent study by Muellner (1960) suggests that restricted bladder capacity may have greater significance than is now recognized, since he found that this condition was particularly common among enuretic children.Today the great majority of cases are believed to be psychogenic, although psychological and physical factors may collaborate in some instances. Most psychologists and psychiatrists emphasize emotional tension and disturbances in family relationships, particularly when these lead to repressed resentments and persistent feelings of anxiety. A neglected child may wet his bed not only to attract his parents’ attention but to force them to take care of him. An angry child may unconsciously use this indirect means of getting even with his parents, since he realizes that bedwetting will irritate them. A child who has had his parents to himself may regress to bed-wetting when a new baby appears on the scene, both to express his anger and to recapture his parents’ attention. Even the normal stresses of life may make an anxious,insecure child so tense that he will lose control over his bladder during the day as well as at night. In many cases, then, enuresis seems to be related to emotional difficulties. Yet there are other cases where no special problems of adjustment can be detected. It may well be that some children are born with sensitive urinary systems that are thrown out of gear even by ordinary, everyday frustrations and tensions. The relationship between enuretics, because structural defects or infections tend to be outgrown or corrected before maturity is reached. Several American investigations, and also an extensive study carried out in Sweden (Hallgren, 1956), indicate that emotional disorders can be found in over 80 per cent of adult cases. These disorders are primarily neurotic in character and often involve emotional immaturity. Enuresis also tends to occur among mental retardates, in proportion to the severity of the defect. About 4 per cent of mild retardates have been found to be enuretic as compared to 13 per cent of moderate and 84 per cent of severe cases. Many techniques are used in treating enuresis. Different forms of punishment have been tried, among them an electrical device which shocks the child when he urinates in bed. This technique has been found more effective than forcing the child to wash his own sheets since the punishment immediately follows the bed-wetting—and, more important, it conditions the child to wake up and go to the bathroom whenever his bladder is full. However, several studies have shown that this technique may bring on other problems in children who are easily upset or who have a restricted bladder capacity. A more humane device rings an alarm instead of shocking the child, and has been found to correct or greatly improve the condition in at least 75 per cent of cases. Relapses occur rather frequently, but the treatment can be successfully repeated. The common practice of restricting fluids during the latter part of the day is effective only in a minority of cases. The opposite technique of having the bed wetter take extra fluids for a time in order to increase bladder capacity seems to be far more successful, especially when it is accompanied with practice in holding urine during the day as a means of achieving better control at night. Tranquilizers and other drugs which inhibit the bladder reflex are sometimes used as auxiliary measures, particularly when childhood enuresis has been reactivated by special stresses in adult life. Psychotherapy designed to relieve the child’s tensions and anxieties, and sociotherapy directed to reducing the pressures and stresses in the family life, are considered essential by many therapists. Adults who have regressed to enuresis as a result of recruitment or combat stress usually respond to briefer psychotherapy. The prognosis is less favorable for chronic adult enuretics who have been clearly maladjusted since childhood or adolescence.Illustrative Case:Vivian was a six-year-old child referred to the psychiatric clinic from the pediatric clinic, where her mother had brought her with the chief complaint of bed-wetting. Physical studies had been entirely negative. Her mother stated initially that her only complaint about the child was the fact that she had wet the bed ever since infancy. Upon further questioning, it developed that the youngster had various other neurotic traits. However, these had not been particularly bothersome to the mother, and, therefore, she had paid little attention to them. The child suffered from frequent nightmares, bit her nails badly, and was a fearful and timid child who played poorly with other youngsters. She was reported by the teacher to be somewhat slow in her work, although her intelligence was found to be above average.Vivian was an only child. Her mother was a dominating, authoritative person who ran the family. The father was a hard-working, sincere, conscientious, but quite passive individual who bowed to all of his wife’s demands. He was extremely fond of his daughter, but played little part in her upbringing. All the rules and regulations in the house were made by the mother. As the psychiatric interview progressed, it developed that the mother had begun toilet-training her child at four months. She was proud of the fact that she had accomplished toilet training, with the exception of enuresis, by the time the child was ten months of age. Wetting had continued in spite of all her punitive attempts to suppress it. The mother was particularly disturbed by the messiness involved and by the fact that she herself had to change the sheets as well as wash them. The child adopted a passive attitude about her wetting, as if there was nothing she could do about it. She was an obedient if timid child who obeyed all the commands given to her by her parents and as far as the mother was concerned, measured up adequately with the one exception of her wetting. The child, according to the mother, had been particularly stubborn in this area.It was obvious that this child resented her mother’s strict approach and, although submitting to it, had allowed herself the one passive outlet of wetting the bed, which she knew was extremely disturbing to her mother, although she was not conscious of its rebellious nature.This child had struggled with a problem common to so many children in her particular situation. She was extremely attached to her mother in a dependent and immature way and yet was resentful of her mother’s dominating, authoritative attitude. Her rigid upbringing prevented the release of hostile impulses toward her mother—originally by her mother’s prohibition and then by her own developing conscience. The result was that she had to express her unconscious infantile wishes in terms of a passive-regressive type of behavior which, while not overtly aggressive, represented hostile feelings toward the mother. As therapy proceeded, a more flexible atmosphere was provided in which Vivian could live out, without guilt or criticism, her dependent childish wishes, which allowed her to feel sufficiently secure to attain more emotional maturity.The cessation of the enuresis was in a way the by-product of the intrapsychic changes which took place. There was no longer any reason for the girl to express her hostility and her infantilism by means of this regressive symptom. She subsequently became able to express resentment toward her mother in situations where she felt it and yet developed a much healthier positive relationship toward the mother. Her own conscience was made less severe and her mother’s restrictions made equally less severe. Eventually when the youngster had worked out a more satisfactory relationship with her mother, the enuresis began to diminish, and finally after approximately a year of treatment during which she was seen once a week, the symptom disappeared.