Socio-cognitive processes associated with bladder and bowel incontinence anxiety: A proposed bivalent model

  • Kenley L. J. Kuoch
  • Denny Meyer
  • David W. Austin
  • Simon R. KnowlesEmail author


The aim of this study was to examine whether the extended bivalent fear of evaluation model (extended BFOE) of Social Anxiety Disorder (SAD) could be used to explain bladder and bowel incontinence anxiety (BBIA). It was hypothesised that the relationship between dysfunctional attitudes (DAs) and BBIA would be mediated by fear of negative evaluation (FNE), fear of positive evaluation (FPE), concerns of social reprisal (CSR), and disqualification of positive social outcomes (DPSO). Three-hundred-and-seventeen undergraduate students (76.7% female; mean age = 31.07 years) completed a cross-sectional online study. A structural equation model (SEM) supported the proposed model (χ2p value = .131, CMIN/df = 1.560, CFI = .996, TLI = .990, RMSEA = .042, SRMR = .0245) with significant relationships found between DAs and FNE (p < .001), DAs and FPE (p = .002), DAs and CSR (p = .007), FNE and CSR (p < .001), FNE and DPSO (p < .001), FPE and CSR (p < .001), FPE and DPSO (p < .001), CSR and DPSO (p < .001), BBIPSS bladder and bowel with incontinence anxiety (p < .001). These results suggest that DAs, FNE, and DPSO are important contributory factors in BBIA. Given that FNE was the strongest mediator in the model, clinicians may find it advantageous to target FNE in treatment of incontinence-anxiety.


Bladder and bowel incontinence anxiety Socio-cognitive Psychosomatic Extended bivalent fear of evaluation model 



The authors would like to thank all the individuals who participated in our research.


This research was conducted through the support of the Australian Government Research Training Program Scholarship.

Compliance with Ethical Standards

Competing Interests


Provenance and Peer Review

Not commissioned, externally peer reviewed.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.


  1. Al-Osail, A. M., Al-Sheikh, M. H., Al-Osail, E. M., Al-Ghamdi, M. A., Al-Hawas, A. M., Al-Bahussain, A. S., & Al-Dajani, A. A. (2015). Is Cronbach's alpha sufficient for assessing the reliability of the OSCE for an internal medicine course? BMC Research Notes, 8, 582. Scholar
  2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington D.C.Google Scholar
  3. Barrett, P. (2007). Structural equation modelling: Adjudging model fit. Personality and Individual Differences, 42(5), 815–824. Scholar
  4. Beevers, C. G., Strong, D. R., Meyer, B., Pilkonis, P. A., & Miller, I. W. (2007). Efficiently assessing negative cognition in depression: An item response theory analysis of the dysfunctional attitude scale. Psychological Assessment, 19(2), 199–209.Google Scholar
  5. Beidel, D. C., & Bulik, C. M. (1990). Flooding and response prevention as a treatment for bowel obsessions. Journal of Anxiety Disorders, 4, 247–256.CrossRefGoogle Scholar
  6. Bentler, P. M. (1990). Fit indexes, Lagrange multipliers, constraint changes and incomplete data in structural models. Multivariate Behavioral Research, 25(2), 163–172.CrossRefGoogle Scholar
  7. Boschen, M. J. (2008). Paruresis (psychogenic inhibition of micturition): Cognitive behavioral formulation and treatment. Depression and Anxiety, 25(11), 903–912. Scholar
  8. Byrne, M. B. (2009). Structural equation modelling with AMOS: Basic concepts, applications and programming (2nd ed.) Routledge.Google Scholar
  9. Carleton, R. N., Collimore, K. C., & Asmundson, G. J. (2007). Social anxiety and fear of negative evaluation: construct validity of the BFNE-II. Journal of Anxiety Disorders, 21(1), 131–141. Scholar
  10. Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment, and treatment (pp. 63–93). New York: Guilford Press.Google Scholar
  11. Cook, S. I., Meyer, D., & Knowles, S. R. (2018). Relationships between psychoevolutionary fear of evaluation, cognitive distortions, and social anxiety symptoms: A preliminary structural equation model. Australian Journal of Psychology. Scholar
  12. Cosci, F. (2013). "Bowel obsession syndrome" in a patient with chronic constipation. General Hospital Psychiatry, 35(4), e451–e453. Scholar
  13. Epstein, S., & Jenike, M. A. (1990). Disabling urinary obsessions. Psychosomatics, 31(4), 450–452. Scholar
  14. Field, A. (2014). Discovering statistics using IBM SPSS statistics (t. Edition Ed.). London: Sage Publications.Google Scholar
  15. Gilbert, N., & Meyer, C. (2005). Fear of negative evaluation and eating attitudes: A replication and extension study. The International Journal of Eating Disorders, 37(4), 360–363. Scholar
  16. Hammelstein, P., & Soifer, S. (2006). Is "shy bladder syndrome" (paruresis) correctly classified as social phobia? Journal of Anxiety Disorders, 20(3), 296–311. Scholar
  17. Heimberg, R. G., & Becker, R. E. (2002). Cognitive-behavioral group therapy for social phobia: Basic mechanisms and clinical strategies. New York: Guilford Press.Google Scholar
  18. Kamboj, S. K., Langhoff, C., Pajak, R., Zhu, A., Chevalier, A., & Watson, S. (2015). Bowel and bladder-control anxiety: A preliminary description of a viscerally-centred phobic syndrome. Behavioural and Cognitive Psychotherapy, 43(2), 142–157. Scholar
  19. Khan, S. R., & Naqvi, I. (2016). Self-criticism and fear of negative evaluation among university students with and without obesity. Pakistan Journal of Psychological Research, 31(2), 509–530.Google Scholar
  20. Kocijan, L., & Harris, L. M. (2016). Fear of positive evaluation and social anxiety. Behaviour Change, 33(01), 15–26. Scholar
  21. Kuoch, K. L. J., Meyer, D., Austin, D. W., & Knowles, S. R. (2017). A systematic review of paruresis: Clinical implications and future directions. Journal of Psychosomatic Research, 98, 122–129. Scholar
  22. Kuoch, K. L. J., Cook, S., Austin, D. W., Meyer, D., & Knowles, S. R. (2019a). Exploration of the socio-cognitive processes underlying paruresis and parcopresis. Current Psychology.
  23. Kuoch, K. L. J., Meyer, D., Austin, D. W., & Knowles, S. R. (2019b). Socio-cognitive processes associated with paruresis and parcopresis symptoms: A proposed bivalent model. Current Psychology.
  24. Kuoch, K. L. J., Meyer, D., Austin, D. W., & Knowles, S. R. (2019c). Development and validation of the bladder and bowel incontinence phobia severity scale (BBIPSS). Journal of Cognitive Psychotherapy, 33(4), 271-285. Scholar
  25. Lipton, M. F., Weeks, J. W., & De Los Reyes, A. (2016). Individual differences in fears of negative versus positive evaluation: Frequencies and clinical correlates. Personality and Individual Differences, 98, 193–198. Scholar
  26. Maia Barros, R. E. (2011). Paruresis and parcopresis in social phobia: A case report. Revista Brasileira de Psiquiatria, 33, 416–417.CrossRefGoogle Scholar
  27. Malouff, J. M., & Lanyon, R. I. (1985). Avoidant paruresis: An exploratory study. Behavior Modification, 9(2), 225–234. Scholar
  28. Marsh, H. W., & Hocevar, D. (1985). Application of confirmatory factor analysis to the study of self-concept: First- and higher order factor models and their invariance across groups. Psychological Bulletin, 97(3), 562–582.CrossRefGoogle Scholar
  29. Pajak, R., & Kamboj, S. K. (2014). Experimental single-session imagery rescripting of distressing memories in bowel/bladder-control anxiety: A case series. Frontiers in Psychiatry, 5, 182. Scholar
  30. Pajak, R., Langhoff, C., Watson, S., & Kamboj, S. K. (2013). Phenomenology and thematic content of intrusive imagery in bowel and bladder obsession. Journal of Obsessive-Compulsive and Related Disorders, 2(3), 233–240. Scholar
  31. Park, H. K., Chang, S., Palmer, M. H., Kim, I., & Choi, H. (2015). Assessment of the impact of male urinary incontinence on health-related quality of life: A population based study. Lower Urinary Tract Symptoms, 7(1), 22–26. Scholar
  32. Porcelli, P., & Leandro, G. (2007). Bowel obsession syndrome in a patient with ulcerative colitis. Psychosomatics, 48(5), 448–450. Scholar
  33. Rapee, R. M., & Heimberg, R. G. (1997). A cognitive behavioral model of anxiety in social phobia. Behaviour Research and Therapy, 35(8), 741–756. Scholar
  34. Segedi, L. M., Segedi, D., & Llic, K. P. (2011). Quality of life in women with urinary incontinence. Med Glas Ljek komore Zenicko-doboj kantona, 8(2), 237–242.Google Scholar
  35. Seres, G., Kovacs, Z., Kovacs, A., Kerekgyarto, O., Sardi, K., Demeter, P., et al. (2008). Different associations of health related quality of life with pain, psychological distress and coping strategies in patients with irritable bowel syndrome and inflammatory bowel disorder. Journal of Clinical Psychology in Medical Settings, 15(4), 287–295. Scholar
  36. Soifer, S., Zgourides, G. D., Himle, J., & Pickering, N. L. (2001). Shy bladder syndrome: Your step-by-step guide to overcoming paruresis: New Harbinger Publications.Google Scholar
  37. Steiger, J. H. (1990). Structural model evaluation and modification an interval estimation approach. Multivariate Behavioral Research, 25(2), 173–180.CrossRefGoogle Scholar
  38. Weeks, J. W. (2010). The disqualification of positive social outcomes scale: A novel assessment of a long-recognized cognitive tendency in social anxiety disorder. Journal of Anxiety Disorders, 24(8), 856–865. Scholar
  39. Weeks, J. W., & Howell, A. N. (2012). The bivalent fear of evaluation model of social anxiety: Further integrating findings on fears of positive and negative evaluation. Cognitive Behaviour Therapy, 41(2), 83–95. Scholar
  40. Weeks, J. W., & Howell, A. N. (2014). Fear of positive evaluation: The neglected fear domain in social anxiety. Chichester: John Wiley & Sons, Ltd..Google Scholar
  41. Weeks, J. W., Heimberg, R. G., Fresco, D. M., Hart, T. A., Turk, C. L., Schneier, F. R., & Liebowitz, M. R. (2005). Empirical validation and psychometric evaluation of the brief fear of negative evaluation scale in patients with social anxiety disorder. Psychological Assessment, 17(2), 179–190. Scholar
  42. Weeks, J. W., Heimberg, R. G., & Rodebaugh, T. L. (2008a). The fear of positive evaluation scale: Assessing a proposed cognitive component of social anxiety. Journal of Anxiety Disorders, 22(1), 44–55. Scholar
  43. Weeks, J. W., Heimberg, R. G., Rodebaugh, T. L., & Norton, P. J. (2008b). Exploring the relationship between fear of positive evaluation and social anxiety. Journal of Anxiety Disorders, 22(3), 386–400. Scholar
  44. Weeks, J. W., Menatti, A. R., & Howell, A. N. (2015). Psychometric evaluation of the concerns of social reprisal scale: Further explicating the roots of fear of positive evaluation. Journal of Anxiety Disorders, 36, 33–43. Scholar
  45. Werner, K. H., Jazaieri, H., Goldin, P. R., Ziv, M., Heimberg, R. G., & Gross, J. J. (2012). Self-compassion and social anxiety disorder. Anxiety, Stress, and Coping, 25(5), 543–558. Scholar
  46. Wong, S. S. (2008). The relations of cognitive tirad, dysfunctional attitudes, automatic thoughts, and irrational beliefs with test anxiety. Current Psychology, 27, 177–191.CrossRefGoogle Scholar
  47. Yap, K., Gibbs, A. L., Francis, A. J., & Schuster, S. E. (2016). Testing the bivalent fear of evaluation model of social anxiety: The relationship between fear of positive evaluation, social anxiety, and perfectionism. Cognitive Behaviour Therapy, 45(2), 136–149. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Psychological SciencesSwinburne University of TechnologyMelbourneAustralia
  2. 2.Department of Statistics, Data Science and EpidemiologySwinburne University of TechnologyMelbourneAustralia
  3. 3.Centre for Mental HealthSwinburne University of TechnologyMelbourneAustralia
  4. 4.School of PsychologyDeakin UniversityGeelongAustralia
  5. 5.Department of PsychiatrySt Vincent’s HospitalMelbourneAustralia
  6. 6.Department of MedicineThe University of MelbourneMelbourneAustralia
  7. 7.Department of Gastroenterology and HepatologyRoyal Melbourne HospitalMelbourneAustralia
  8. 8.Swinburne University of Technology, John St, HawthornMelbourneAustralia

Personalised recommendations