J. B&m. Ther. & Exp. Psychiat. Vol. 7, pp. 277-278. Pergamon Press, 1976. Printed in Great Britain.

THE TREATMENT OF ENURESIS BY PROGRESSIVELY EARLIER WAKING

RATAN SINGH, DEBORA PHILLIPS and STEVEN C. FISCHER*

Temple University School of Medicine

and

Eastern Pennsylvania Psychiatric Institute

Summary-A 13-yr-old girl with a 7-yr history of enuresis had obtained only limited success using a daytime instrumental conditioning program. A new program involving waking 2 hr after failing asleep, and then progressively earlier, resulted in elimination of the enuresis. An S-month follow-up indicated that the recovery had been maintained.

AMONG behavioral treatments for enuresis, the alarm method (Mowrer and Mowrer, 1938), token reinforcement using start charts (Kanner, 1972, p. 429) and the daytime instrumental conditioning method (Kimmel and Kimmel, 1970; Paschalis, Kimmel and Kimmel, 1972; Stedman, 1972) are frequently reported in recent literature.

An advantage of the Kimmel procedure is that it requires no apparatus; but it depends on generalization of effects from daytime to night- time. The child is asked to report his need to urinate and is then asked to hold it for a further specified period of a few minutes. When the time demand is easily met by the child, it is increased. Positive reinforcement is delivered contingent upon holding urine the specified time. The procedure is continued until the child can retain bladder tension for 30 to 45 min. Generalization to nighttime bladder retention usually takes place at this stage. Paschalis et al.

(1972), using Kimmel’s procedure, obtained good but mixed results. Of the 31 subjects treated, 15 (48.4 %) were cured, 8 (25.8 %) were significantly improved, and 8 (25.8 %) showed no change. Thus, a significant number of cases remain unaltered by Kimmel’s procedure.

The following case obtained only limited control of bed wetting using Kimmel’s pro- cedure; but shifting to nighttime retention resulted in complete and lasting control.

CASE HISTORY

Joan, 13, had stopped wetting at the age of three but had started again at six, bed-wetting intermittently, from two to six nights per week. Only once in the past 7 yr did she remain dry for 3 weeks. The behavior analysis revealed only one constancy-that the wetting always occurred two or more hours after going to bed. Although there were quarrels with an older sister, these were not correlated with the wetting.

Prior treatment included four years of in- effectual family therapy. Joan was not very concerned about the bed-wetting because she believed that most girls were bed-wetters at her age and that the problem would auto- matically stop.

METHOD

The total duration of behavior therapy was 15 months. Joan did not attend sessions regularly, often did not follow instructions, and was not even available by telephone.

*Reprints may be obtained from Debora Phillips, Temple University School of Medicine, Department of Psychiatry, Behavior Therapy Unit, EPPI, Henry Avenue, Philadelphia, Pennsylvania 19129.

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278 RATAN SINGH, DEBORA PHILLIPS and STEVEN C. FISCHER

Kimmel’s daytime method was applied for 7 months with only limited success. Joan came to be able to hold the bladder tension in the daytime for 30 min before going to the toilet. Unfortunately, she refused to follow instructions for the procedure during school hours, so that the procedure was not in continuous effect. During this period she had 60 dry nights, including a run of 19 consecutive nights. Otherwise, she continued to wet at her original rate.

A nocturnal training procedure was then substituted. Since Joan always wet herself two or more hours after going to bed, she was instructed to set the alarm to go off 2 hr after her bedtime. She was to go to the toilet when the alarm rang, return to sleep and not go to the toilet again until morning (approximately 6 a.m.). After seven consecutive dry nights she was to set the alarm at 90 min after bedtime. Seven consecutive dry nights were the criterion for each further reduction in time-to 60 min after bedtime, 45 min and finally 30 min. She was then to go to the toilet without the alarm clock every other night in an effort to fade out its use.

Joan did not wet the bed for 7 days when the alarm clock was set at two hours after bed time. She wet it three times when it was set at 90 min. At 60 min, after one wetting accident in the first week, she completed seven consecutive nights without an accident. At 45 min there was also one wetting accident during the first week followed by one full week without an accident. At 30 min she had no accidents. She was thus now holding the bladder tension for almost the whole night.

At this point sessions were interrupted for two months while she was at summer camp. She was instructed to resume using the clock every night at camp with the alarm set for 30 min after her bedtime. During the first month of camp she had two occasions of bed-wetting, on each of which her clock was not operating. She remained dry during the last month of camp.

On her return, the following agreements were reached between the therapist, Joan, and her parents before resuming the treatment: (1) Joan herself would clean the bed sheets when wet, not her mother; (2) she would get a new bed if she remained free of bed-wetting for 6 months.

Nocturnal training was then continued for two months. She informed the therapist at the end of each successful week (having refused to do so more frequently) and was praised for not wetting. Her parents also praised her for dry nights. She was to call the therapist the morning after a wetting accident. After 1 week of dry nights the use of the alarm was faded. During this entire time Joan remained dry.

At 8-month follow-up no instance of bed-wetting had occurred.

DISCUSSION

In view of the long treatment period (15 months), recovery might be said to have been spontaneous. Although this cannot be dis- counted in any case study it should be noted

that the enuresis had been chronic, having lasted for 7 yr, four of which included family therapy. Assertive training had relieved the quarrels with her sister but had no effect on the enuresis. The best result using Kimmel’s method for seven months was 19 consecutive dry nights. The patient was completely dry, however, for the last three months of the nocturnal procedure and for an additional 8 months follow-up.

The present treatment differs both from Mowrer and Mowrer (1938) and Kimmel and Kimmel (1970). The Mowrer procedure at- tempts to classically condition waking by pairing it with the full bladder. Kimmel and Kimmel instrumentally condition daytime urine retention for increasingly longer periods of time. In the present case study the subject was wakened prior to the expected occurrence of urination. As treatment progressed the subject was wakened earlier.

A major point of importance emerging from this work is that generalization of daytime im- provement to nighttime may have to be planned rather than expected to occur automatically. The present work utilizing a nocturnal program and new contingencies specified the concrete steps involved in night time improvement. The nocturnal program may be effective when: (1) there is not full cooperation for Kimmel’s procedure, or (2) in those cases where Kimmel’s procedure produces no changes.

REFERENCES

KANNER L. (1972) C/ti/d Psyckiatry, Thomas, Springfield, 111.

KIMMEL H. D. and KIMMEL E. (1970) An instrumental conditioning method for the treatment of enuresis, J. Bekav. Thu. & Exp. Psychiat. 1, 121-123.

MOWRER 0. H. and MOWRER W. M. (1938) Enuresis: A method for its study and treatment, A/n. J. Ortha- psychiat. 8, 436-469.

PASCHALIS, A. Ph., KIMMEL H. D. and KIMMEL E. (1972) Further study of diurnal instrumental conditioning in the treatment of enuresis nocturna. _I. B&r. T/rep. & Exp. Psychiat. 3, 253-256.

STEDMAN J. M. (1972) An extension of the Kimmel treatment method for enuresis to an adolescent: a case report, J. Behav. Ther. & Esp. Psychiat. 3,307-309.