Paruresis

Paruresis

A person with paruresis finds it difficult or impossible to urinate when other people are around. Paruresis is believed to be a common type of social phobia, ranking second only to the fear of public speaking. The condition is also known as ‘avoidant paruresis’, ‘shy bladder syndrome’, ‘psychogenic urinary retention’ and ‘pee-phobia’. Research into these conditions is limited, despite the anecdotal evidence that they are quite common. The United Kingdom National Phobic Society suggests that around four million people in the UK (around six percent) are unable to urinate in public toilets due to anxiety.

Paruresis affects men and women of all races. In mild cases, paruresis is an occasional event, like a form of performance anxiety. For example, a man at a public urinal may find that he is unable to urinate when flanked by other men. In severe cases, a person with paruresis can only urinate when alone at home. Without treatment, it can affect your personal, social, and professional life. You might find it hard to be away from home for more than a short time. You could end up avoiding parties, sporting events, and dates. It might even limit your choice of jobs.

Some statements that those with toilet anxiety may identify with include:

I worry about going to the toilet around others
I worry about being seen in the toilet
I can’t urinate when around others in a bathroom/restroom
I can’t have a bowel movement when around others in a bathroom/restroom
I worry about what others will think when I go to the toilet
I worry about what others will smell when I go to the toilet
I worry about being heard in the toilet
I avoid going in a toilet with others
I worry about hearing others when I go to the toilet
I worry about other individuals urinating close to me
I worry about other individuals having a bowel motion close to me

Our sphincter muscles are what keep us dry. Almost always tense, they allow the bladder to work like a reservoir, keeping the urine in while we’re typing on our computers at work, playing with our children, chatting on the phone or reading the newspaper. Six or eight times a day, we ask it to relax on command — a command so natural for most of us that there’s no hesitation, no second-guessing in it, says Dr. Michael Chancellor, director of Beaumont Hospital-Royal Oak’s neurourology program. But for some, a momentary hesitation can lead to panic and finally to a frightened paralysis as muscles of the pelvic floor refuse to relax. The fear is not in peeing, it’s not being able to — and having others notice, says Carl Robbins, director of training at the Anxiety and Stress Disorders Institute of Maryland and cofounder of IPA. Much like the performance anxiety associated with stuttering, insomnia or sexual performance, “the anxiety or fear of the event makes it more likely to occur,” he says.

After it happens the first time, you worry about it happening again. In other words, you have performance anxiety. It snowballs from there. The more you try to force nature to take its course, the more your body refuses to cooperate. The anxiety fills a part of your nervous system with adrenaline, and the muscles that let you empty your bladder just freeze up.

Paruresis relates to two conditions: paruresis, the fear to urinate, and parcopresis, the fear of having a bowel movement in public (e.g., worry about smells, noises). What are some of the triggers for paruretics? Paruretics most commonly refer to three triggers that influence them when in public restrooms. For the typical paruretic, these triggers must be removed or the person must try another toilet for urination to occur on a particular occasion. First, familiarity with other people present in the restroom can trigger BBS, with strangers usually (but certainly not always) leading to greater inhibition than friends or relatives. Because of the personal nature of elimination, the degree of familiarity and perceived acceptance often determine whether or not the paruretic will successfully void.

Second, proximity plays a role in the problem. Proximity for the paruretic is both physical, involving the relative closeness of others in or near the restroom, and psychological, involving the need for privacy–essentially the desire to hide one’s urination and any perceived faults in it– from others. The most frequent complaint about physical stimuli in public facilities is the absence of suitable partitions and doors on stalls. Many paruretics remark that they cannot urinate (or defecate) in a stall toilet if the door is missing. They feel embarrassed about their personal space being invaded visually. Discomfort with lack of partitioning is central to the issue of perceived lack of privacy in public restrooms. Of course, the perception and need for privacy differ considerably across people. One individual is comfortable only at home with the bathroom door locked, while another is comfortable using a urinal in a crowded restroom.

Third, temporary psychological states, especially anxiety, anger, and fear can interfere with urination. Social phobics who are overly sensitive about the sounds and smells they make while urinating are usually fearful of being criticized for such, which in turn arouses their nervous system. Also, excessive emotional arousal may explain why attempts to urinate under favorable conditions are often unsuccessful if the individual is overly excited or feels pressured to hurry.

Paruresis is not a physical condition because nothing is wrong with the person’s urinary tract. The urinary sphincter must be relaxed in order for urine to flow from the bladder down the urethra. Anxiety about urinating overstimulates the person’s nervous system and ‘clamps’ the sphincter shut. Failure to urinate heightens the person’s anxiety, particularly if the bladder is uncomfortably full.

For some people, an embarrassing incident starts the social phobia: for example, the inability to urinate into a cup in front of a doctor or nurse. Worrying about the embarrassing incident makes the person feel anxious about urinating in the presence of others.

So what are the options for treating paruresis? It may be helpful to see a mental health professional. Treatment may include:

Relaxation techniques– to learn a range of strategies to help reduce anxiety.
Psychotherapy– a type of counselling that helps you deal with the here and now, and teaches problem solving.
Cognitive behaviour therapy– changing the way you think and behave.
Graduated exposure therapy– a step-by-step program that involves deliberately trying to urinate in increasingly more difficult places. About eight people out of every 10 with paruresis are helped by graduated exposure therapy. With the help of your mental health professional you might be asked to do the following:

Make a ranked list of urination locations from easiest to most difficult. For example, most people with paruresis find it easiest to urinate at home alone. The hardest location is usually a crowded and noisy public toilet. The idea is to start with the easiest locations and work your way up in degrees to the most difficult.
Have a ‘bathroom partner’ to support you. This could be a family member or trusted friend.
Ask your bathroom partner to stand as close to your home toilet as you feel comfortable while you are trying to urinate. Urinate for a few seconds then stop for a few minutes.
Have your bathroom partner stand a little closer to the toilet. Go back into the toilet and urinate again for a few seconds, then stop.
Keep practicing, with your bathroom partner getting closer and closer to the toilet. This may take several sessions over a period of time.
Try to make as much noise as possible while urinating. Deliberately splash your urine into the toilet water. Do this with your pee partner nearby.
Pick a quiet public rest room (once you are comfortable with urinating at home) and then, with your bathroom partner standing outside the toilet door, practice the same way you did at home.
Use your bathroom partner and work your way up the ranked scale of difficult locations until you can successfully urinate in a crowded and noisy public toilet.
Graduated exposure therapy is more successful if it is practiced often, perhaps three or four times per week.
Drink plenty of water before your practice session to make sure that your bladder is full.
Avoid any negative self-talk while trying to urinate. Remember that paruresis is a common social phobia. You are not abnormal or ‘the only one’.
Take it slowly, step by step. Don’t pressure yourself. You should see considerable improvement after about 12 sessions or so.

With support and encouragement paruresis can be helped. Seek out a professional that you are comfortable with and work hand in hand with them to help work through your paruresis.

References

http://www.chicagotribune.com/lifestyles/health/sc-health-0707-bladder-20100707-story.html

https://paruresis.org/about-avoidant-paruresis/

https://www.webmd.com/urinary-incontinence-oab/shy-bladder#1

https://www.betterhealth.vic.gov.au/health/ConditionsAndTreatments/shy-bladder-syndrome

https://www.anxiety.org/toilet-anxiety-public-restrooms-your-worst-nightmare