Some aspects of personality in persistent enuresis as determined by responses to psychological tests and to drug therapy

The purpose of this study was to investigate the personality patterns of a group of boys who had a lifelong history of nocturnal enuresis. This particular group was chosen because of the frequency of enuresis beyond age 5 is in excess of 10% and of these enuretics 80% are of the 'persistent' (lifelong) type. Thus, the group chosen appears to make up the majority of enuretic male children. Precautions were tdken to ensure that the enuresis was without demonstrable physiologic basis and was therefore of a psychogenic origin. The techniques of evaluation were the following: (1) non- projective psychological tests, which included the Wechsler Intelligence Scale for Children, the High School Personality Questionnaire and the Childrens Personality Questionnaire; (2) projective psychological tests, which included the Rorschach Technique, the Michigan Picture Stories and the Thematic Apperception Test; and (3) response to a drug, which was Tofranil (the trade name of imipramine hydrochloride by Geigy Pharmaceuticals). The experimental group consisted of 30 boys from local institutions for dependent, delinquent and neglected children. They were examined by a physician for evidence of organic problems that might produce enuresis. The test battery was then administered and each subject randomly assigned to a drug treatment group. Drug and placebo administration were randomly assigned, drug and placebo administration were counterbalanced, and the 'double-blind' technique was employed. The experimental subjects were compared with a control group who were similar in all respects except they were not enuretic past age 5- All subjects were between the ages 5 and 16. The specific points under investigation were that persistent enuresis in boys is accompanied by features on psychological test material indicating difficulties in impulse regulations and relative preoccupation with ideas based in the phallic stage of psychosexual development. Secondly, the experimental group's response to drug therapy was investigated in order to determine whether the drug, Tofranil, was effective and, if so, to determine whether the obliteration of the enuretic act was followed by other 'symptoms' substituted for the enuretic act. Statistical treatment of the data revealed the following results. The experimental subjects showed no difference from the controls in terms of their preoccupation with ideas based in the phallic stage of psychosexual fixation, nor did the experimental group show difficulty with impulse regulation. There was, however, a difference between the groups in terms of their general level of responsiveness in projective test material. The scores for the Rorschach categories of small detail, human detail, animal detail, pure form and inanimate movement were all significantly lower in the experimental group. This finding was also reflected in a statistically non-significant but comparable trend in other Rorschach categories of large detail, color-naming, popular responses, animal responses, white space responses and number of responses. These differences were interpreted as reflecting a non-responsive tendency on the part of the experimental group and that it could be seen as one aspect of a relatively 'depressed' state due presumably to early affectional deprivation. The experimental group showed a positive response to the drug under study, Tofranil, in that there were significantly fewer wet nights when subjects took the drug than when they took placebo capsules or when they did not take any capsules. It was speculated that this positive response could be due to the anti-depressant effect of the drug or possibly to its inhibition of abnormal bladder muscle contractions. There were no reported side-effects of the drug and there were no cases in which other behaviors which could be labelled 'substitute symptoms' appeared when the frequency of enuresis declined during drug treatment. This latter point was considered in two aspects: (1) that no other symptoms emerged upon obliteration of the enuresis; and (2) that new symptoms did emerge but they were not observable in the group living situation from which most subjects were drawn. From the data of this study, it was concluded that the acquired- persistent dichotomy of enuresis is useful and meaningful; that it corresponds roughly to the neurotic and character disorder classifications; that persistent enuresis is not associated with the personality features found in the neurotic enuretic children; that the children included in this study are not the expected representation of the typical 'delinquent psychopathic character' whose enuresis is an aspect of 'sphincter morality'; and that the drug, Tofranil, is useful in controlling this particular kind of enuresis. Future investigations into the personality dynamics of enuretic children were seen as useful only to the extent that future investigators specifically select enuretic subjects according to age^ socio-economic status^ history of the symptom, sex, and whether the enuresis presents a problem to the subject and his family.