Case Reports
hook of Medicine. Edited by Wyngaarden J. Smith L. Philadelphia. WB Saunders. 1985 8. Johns DR. Teimey M. Felsenstein 0: Alteration in the natural history of neurosyphilis by concurrent infection with Ihe human immunodeficiency virus. N Engl 1 Med 316:1569-1572.1987 9. Tramonl EC: Syphilis in the AIDS era. N Engl 1 Med
316:1600-1601.1987 10. Hamer R. Smith J. Israel C: The ITA-ABS test in lale syphilis. lAMA 203:545-548. 1968 II. Tramonl EC: Treponema pallidum (syphilis). in Pri",·i· pies and Practice of Infectious Diseases. Edited by Mandell G. Douglas G. Bennen J. New York. John Wiley and Sons. 1985
Disabling Urinary Obsessions: An Uncommon Variant of Obsessive-Compulsive Disorder STEVE EpSTEIN, M.D. MICHAEL
A.
e recently treated two patients who presented with debilitating fear of urinary incontinence and excessive preoccupation with their urinary tracts to such an extent that there was major interference with work and social functioning. Both patients had similar symptoms. which included fear of urinary incontinence. urinary frequency without organic etiology. temporary relief of distress by bladder evacuation. and extreme efforts to be near a bathroom. Neither patient had other symptoms of obsessive-compulsive disorder (OCD). such as washing or checking rituals. Since bowel obsessions. a possible subtype of OCD. have been shown to be responsive to antidepressant medication. I we gave imipramine to one patient. who had almost complete resolution of symptoms. The other patient left treatment prior to such a triaL
W
Received August 18. 1989: accepted OclOber 31. 1989. From the Departmenl of Psychiatry. Tufts University School of Medicine: and the Depanment of Psychiatry. Harvard Medical School. Address reprinl requests to Dr. Jenike. OCD Clinic and Research Unit. Bulfinch 3. Massachusens General Hospital. Fruit Street Boston. MA 02114. Copyright © 1990 The Academy of Psychosomatic Medicine.
450
JENIKE. M.D.
Case Reports Case I. Mr. A. a 25-year-old student. reported 5 months of "feeling like I have to urinate every time I'm stressed." He feared that he would become incontinent when in classes. cars. or subways. After these bladder concerns began. he experienced bladder pressure. nausea. tachycardia. weakness. and sweaty palms. which were completely relieved by urination. Occurring seven to nine times daily. these symptoms were so debilitating that he quit school and avoided public transportation. Mr. A's symptoms began at age 24 with a gradually increasing need to leave classes to urinate: he was never incontinent. Symptoms became so intense that he sought urological consultation; examination. urine culture. and intravenous pyelogram were reportedly normal. He denied bed-wetting as a child. substance abuse or caffeine use. medication use. and symptoms of depression or thought disorder. His family was without psychopathology. Imipramine was prescribed and increased to 100 mg at bedtime over 2 weeks. Within 5 days of starting medication. tachycardia and sweatiness resolved. and within 6 weeks urinary obsessions were largely relieved. At 6-month follow-up he did not mention urinary symptoms and wanted to reduce his medication. Two months later he discontinued imipPSYCHOSOMATICS
Case Reports
ramine and remained symptom free. He plans to take imipramine in the future should his symptoms recur. Case 2. Mr. B. a 37-year-old clerk. presented with concerns that he had to urinate an average of 10 times a day and. at worst. every half hour. Although never incontinent. he persistently feared that he would lose urine in public. He planned his life around bathrooms to the extent that it interfered with work and social activities. When urinating. he spent al leasl .5 minutes straining to rid himself of every drop of urine. Mr. B's symptoms began al age 16: he received I year of psychotherapy but no further psychiatric treatment despite persistent symptoms until age 29. when he was diagnosed as having compulsive and borderline personality disorders and again lreated wilh psychotherapy and low doses of lhioridazine. Because of increasing depressive symptoms and suicidal ideation. he was admitted to an inpatient psychialric unit and treated with thiothixene and chlorpromazine. Over the subsequent 2 weeks. he became less preoccupied. On physical exam. he was noted to have a midsystolic click. At the time of presentation to our clinic. at age 36. Mr. B denied substance abuse. symptoms of depression. panic. and anxiety. and he had no evidence of a lhought disorder. He denied family psychopathology. except for his father. who had engaged in some checking of doors and windows. He was given an 8-week trial of buspirone. up to 60 mg/day. without positive effect. Diazepam. 8 mg/day. relieved some anxiety. but urinary symploms persisted. He was given a prescription for fluoxetine but stopped treatment prior to taking it.
Discussion Mr. A had marked alleviation of urinary symptoms with imipramine while Mr. B had no relief with buspirone and refused antidepressant medication. In a recent open trial, buspirone was ineffective for typical OCD.~ Mr. A's symptoms included autonomic features suggestive of panic disorder; his cognitions. however, were not typical of these patients, and autonomic symptoms occurred only subsequent to the predominant fear of incontinence. Both patients had symptoms which were characteristic of agoraphobia. Mr. B, although not having a panic disorder, was found to have a midsystolic VOLUME.ll·NUMBER4·FALL 1990
click. which often is reported in this disorder.'·~ Mellman and Uhde.~ in evaluating panic disorder patients for the presence of obsessive-compulsive disorder. have highlighted the difficulty in distinguishing panic-phobic from obsessivecompulsive symptoms in some patients. However. our patients clearly presented with urinary obsessions as their most disabling symptom; Mr. B had no panic symptoms. Neither patient had evidence of a social phobia. and both were able to urinate comfortably in public facilities. When over 300 psychiatrists were queried at a recent conference. over half had treated at least one similar patient, often successfully with antidepressant medication. As with bowel obsessions. 1 this disorder may not be rare. These patients may constitute a small subgroup of OCD patients. comparable to patients who wash. check. or only have obsessional thoughts. Urinary obsessions might be a manifestation ofOCD, and these patients may respond to the same treatments.' Antidepressant medications have been shown to be useful for a number of anxiety disorders,7 including panic disorder or agoraphobia with panic attacks. x classical OCD,' post-traumatic stress disorder.~ and social pho1O bia. It is possible that urinary obsessions could be added to this list. Whether or not these disorders are related in some fundamental way to OCD must await our understanding of their underlying pathophysiology. Until definitive answers are available, when patients with urinary obsessions present to clinicians. antidepressant medications should be considered. even when clinical depression is not present.
References I. Jenike MA. Vitagliano HL. Rabinowitz J. el al: Bowel
obsessions responsive to tricyclic antidepressants in four patients. Am J Psychiatry 144: 1347-13411. 19117 2. Jenike MA. Baer L: Buspirone in obsessive-compulsive disorder: an open lrial. Am J PsychitJIry 145: 12115-12116. 19811
3. Dager SR. Comess KA. Dunner DL: Differentialion of anxious patients by two dimensional echocardiographic evaluation of the mitral valve. Am J PSl"chiatrl" 143:533536. 19116 4. Libenhson R. Sheehan DV. King ME. el al: The preva-
451
Case Reports
len,.: of mitral valv.: prolaps.: in pali.:nts with pani, disoHIer. tlm./ P,'."chia/lT 143:511-515. 19Xb 5, M.:llman TA. Uhd.: TW: Ohs.:ssiv.:-,ompulsiv.: symptoms in panic' disoHIer. tlm./ P,n'chialrr 144: 1573-157b. 19X7 b, knik.: MA. Baa L. Minidlidlo WE (.:ditors): O!>.H'ssi"£,('(1mI'll/sir.. Ois(lrdcr,\: Th"(Irr al/d Mal/ag£'m,'III, 2nd Edilion, Chi,ago. Y.:arhook M.:dkal Puhlishing. 1990 7, Li.:howill. MR: Th.: dfi,ac'y of anlid.:pr.:ssants in DSMIII anxi':ly disord.:rs. in Psrchialrr U/'t!al": Th .. Amcricall Psrchialric .-\.\,\(Iciali(ll/ tll/l/lla/ R,'ri.."" Vol .t Edil.:d hy
Grinspoon L. Washington. DC. Am.:ri'an Psy,hiatri, Pr.:ss. 19X4 X, Go)g.:r S. Grunhaus L. Binna'h.:r B. .:t al: Tr.:atm.:nl of spontan.:ous panic' alla,ks with domipramin.:. tlm./ Psrchialrr 13X:1215-1217. 19XI 9, Hogh.:n GL. Cornlkld RB: Tr.:atm.:nl of lraumatk war n.:urosis with ph.:n.:ll.in.:, Al'
hook of Medicine. Edited by Wyngaarden J. Smith L. Philadelphia. WB Saunders. 1985 8. Johns DR. Teimey M. Felsenstein 0: Alteration in the natural history of neurosyphilis by concurrent infection with Ihe human immunodeficiency virus. N Engl 1 Med 316:1569-1572.1987 9. Tramonl EC: Syphilis in the AIDS era. N Engl 1 Med
316:1600-1601.1987 10. Hamer R. Smith J. Israel C: The ITA-ABS test in lale syphilis. lAMA 203:545-548. 1968 II. Tramonl EC: Treponema pallidum (syphilis). in Pri",·i· pies and Practice of Infectious Diseases. Edited by Mandell G. Douglas G. Bennen J. New York. John Wiley and Sons. 1985
Disabling Urinary Obsessions: An Uncommon Variant of Obsessive-Compulsive Disorder STEVE EpSTEIN, M.D. MICHAEL
A.
e recently treated two patients who presented with debilitating fear of urinary incontinence and excessive preoccupation with their urinary tracts to such an extent that there was major interference with work and social functioning. Both patients had similar symptoms. which included fear of urinary incontinence. urinary frequency without organic etiology. temporary relief of distress by bladder evacuation. and extreme efforts to be near a bathroom. Neither patient had other symptoms of obsessive-compulsive disorder (OCD). such as washing or checking rituals. Since bowel obsessions. a possible subtype of OCD. have been shown to be responsive to antidepressant medication. I we gave imipramine to one patient. who had almost complete resolution of symptoms. The other patient left treatment prior to such a triaL
W
Received August 18. 1989: accepted OclOber 31. 1989. From the Departmenl of Psychiatry. Tufts University School of Medicine: and the Depanment of Psychiatry. Harvard Medical School. Address reprinl requests to Dr. Jenike. OCD Clinic and Research Unit. Bulfinch 3. Massachusens General Hospital. Fruit Street Boston. MA 02114. Copyright © 1990 The Academy of Psychosomatic Medicine.
450
JENIKE. M.D.
Case Reports Case I. Mr. A. a 25-year-old student. reported 5 months of "feeling like I have to urinate every time I'm stressed." He feared that he would become incontinent when in classes. cars. or subways. After these bladder concerns began. he experienced bladder pressure. nausea. tachycardia. weakness. and sweaty palms. which were completely relieved by urination. Occurring seven to nine times daily. these symptoms were so debilitating that he quit school and avoided public transportation. Mr. A's symptoms began at age 24 with a gradually increasing need to leave classes to urinate: he was never incontinent. Symptoms became so intense that he sought urological consultation; examination. urine culture. and intravenous pyelogram were reportedly normal. He denied bed-wetting as a child. substance abuse or caffeine use. medication use. and symptoms of depression or thought disorder. His family was without psychopathology. Imipramine was prescribed and increased to 100 mg at bedtime over 2 weeks. Within 5 days of starting medication. tachycardia and sweatiness resolved. and within 6 weeks urinary obsessions were largely relieved. At 6-month follow-up he did not mention urinary symptoms and wanted to reduce his medication. Two months later he discontinued imipPSYCHOSOMATICS
Case Reports
ramine and remained symptom free. He plans to take imipramine in the future should his symptoms recur. Case 2. Mr. B. a 37-year-old clerk. presented with concerns that he had to urinate an average of 10 times a day and. at worst. every half hour. Although never incontinent. he persistently feared that he would lose urine in public. He planned his life around bathrooms to the extent that it interfered with work and social activities. When urinating. he spent al leasl .5 minutes straining to rid himself of every drop of urine. Mr. B's symptoms began al age 16: he received I year of psychotherapy but no further psychiatric treatment despite persistent symptoms until age 29. when he was diagnosed as having compulsive and borderline personality disorders and again lreated wilh psychotherapy and low doses of lhioridazine. Because of increasing depressive symptoms and suicidal ideation. he was admitted to an inpatient psychialric unit and treated with thiothixene and chlorpromazine. Over the subsequent 2 weeks. he became less preoccupied. On physical exam. he was noted to have a midsystolic click. At the time of presentation to our clinic. at age 36. Mr. B denied substance abuse. symptoms of depression. panic. and anxiety. and he had no evidence of a lhought disorder. He denied family psychopathology. except for his father. who had engaged in some checking of doors and windows. He was given an 8-week trial of buspirone. up to 60 mg/day. without positive effect. Diazepam. 8 mg/day. relieved some anxiety. but urinary symploms persisted. He was given a prescription for fluoxetine but stopped treatment prior to taking it.
Discussion Mr. A had marked alleviation of urinary symptoms with imipramine while Mr. B had no relief with buspirone and refused antidepressant medication. In a recent open trial, buspirone was ineffective for typical OCD.~ Mr. A's symptoms included autonomic features suggestive of panic disorder; his cognitions. however, were not typical of these patients, and autonomic symptoms occurred only subsequent to the predominant fear of incontinence. Both patients had symptoms which were characteristic of agoraphobia. Mr. B, although not having a panic disorder, was found to have a midsystolic VOLUME.ll·NUMBER4·FALL 1990
click. which often is reported in this disorder.'·~ Mellman and Uhde.~ in evaluating panic disorder patients for the presence of obsessive-compulsive disorder. have highlighted the difficulty in distinguishing panic-phobic from obsessivecompulsive symptoms in some patients. However. our patients clearly presented with urinary obsessions as their most disabling symptom; Mr. B had no panic symptoms. Neither patient had evidence of a social phobia. and both were able to urinate comfortably in public facilities. When over 300 psychiatrists were queried at a recent conference. over half had treated at least one similar patient, often successfully with antidepressant medication. As with bowel obsessions. 1 this disorder may not be rare. These patients may constitute a small subgroup of OCD patients. comparable to patients who wash. check. or only have obsessional thoughts. Urinary obsessions might be a manifestation ofOCD, and these patients may respond to the same treatments.' Antidepressant medications have been shown to be useful for a number of anxiety disorders,7 including panic disorder or agoraphobia with panic attacks. x classical OCD,' post-traumatic stress disorder.~ and social pho1O bia. It is possible that urinary obsessions could be added to this list. Whether or not these disorders are related in some fundamental way to OCD must await our understanding of their underlying pathophysiology. Until definitive answers are available, when patients with urinary obsessions present to clinicians. antidepressant medications should be considered. even when clinical depression is not present.
References I. Jenike MA. Vitagliano HL. Rabinowitz J. el al: Bowel
obsessions responsive to tricyclic antidepressants in four patients. Am J Psychiatry 144: 1347-13411. 19117 2. Jenike MA. Baer L: Buspirone in obsessive-compulsive disorder: an open lrial. Am J PsychitJIry 145: 12115-12116. 19811
3. Dager SR. Comess KA. Dunner DL: Differentialion of anxious patients by two dimensional echocardiographic evaluation of the mitral valve. Am J PSl"chiatrl" 143:533536. 19116 4. Libenhson R. Sheehan DV. King ME. el al: The preva-
451
Case Reports
len,.: of mitral valv.: prolaps.: in pali.:nts with pani, disoHIer. tlm./ P,'."chia/lT 143:511-515. 19Xb 5, M.:llman TA. Uhd.: TW: Ohs.:ssiv.:-,ompulsiv.: symptoms in panic' disoHIer. tlm./ P,n'chialrr 144: 1573-157b. 19X7 b, knik.: MA. Baa L. Minidlidlo WE (.:ditors): O!>.H'ssi"£,('(1mI'll/sir.. Ois(lrdcr,\: Th"(Irr al/d Mal/ag£'m,'III, 2nd Edilion, Chi,ago. Y.:arhook M.:dkal Puhlishing. 1990 7, Li.:howill. MR: Th.: dfi,ac'y of anlid.:pr.:ssants in DSMIII anxi':ly disord.:rs. in Psrchialrr U/'t!al": Th .. Amcricall Psrchialric .-\.\,\(Iciali(ll/ tll/l/lla/ R,'ri.."" Vol .t Edil.:d hy
Grinspoon L. Washington. DC. Am.:ri'an Psy,hiatri, Pr.:ss. 19X4 X, Go)g.:r S. Grunhaus L. Binna'h.:r B. .:t al: Tr.:atm.:nl of spontan.:ous panic' alla,ks with domipramin.:. tlm./ Psrchialrr 13X:1215-1217. 19XI 9, Hogh.:n GL. Cornlkld RB: Tr.:atm.:nl of lraumatk war n.:urosis with ph.:n.:ll.in.:, Al'
