Under the tip of the iceberg: psychological factors in incontinence.

AIMS: To highlight two main psychological factors (cognitive barriers and safety-behaviors) involved in the development and maintenance of emotional distress in patients with urinary incontinence (UI) and thus facilitate a better understanding of this condition and contribute to a more comprehensive treatment.
MATERIALS AND METHODS: Articles and books were reviewed up to December 2010 using a non-systematic research in MEDLINE and PsycINFO, focusing on the situations more frequently seen in our clinical experience.
RESULTS: Several emotional symptoms that hinder a person's ability to benefit from urological treatment were found. An "accident" places a person at risk of developing a constant state of heightened worry and increased vigilance that predisposes the individual to develop significant anxiety and depression. Cognitive barriers such as dysfunctional beliefs, automatic negative thoughts, and cognitive biases are frequent. They affect patients' behavior and influence the development of coping strategies (safety-seeking behaviors) to manage symptoms and prevent feared consequences. Cognitions may act as barriers that lead to a misperception of one's health and maintain emotional distress. Safety behaviors are negatively reinforced and prevent disconfirmation of dysfunctional cognitions, thus maintaining the trouble and distress. Clinical examples are outlined.
CONCLUSIONS: Cognitive barriers and safety behaviors explain some of the atypical psychological patterns seen in patients with UI. Future research should be oriented to design multimodal interventions and assess their impact on health outcomes. Whenever possible, the assessment of emotional, cognitive, and behavioral responses in individuals with UI could improve the management of this condition. Cognitive-behavioral therapy should be recommended to certain patients.