Paruresis

Last updated

Paruresis
Other namesBashful bladder, bashful kidneys, stage fright, pee-shyness, shy bladder syndrome
Charles Marville, Urinoir en ardoise a 3 stalles, Chaussee du Maine, ca. 1865.jpg
Outdoor urinal in Paris (1865). Paruresis is a type of phobia in which one is unable to urinate in the presence of others, as in a public toilet.
Pronunciation
Specialty Psychiatry

Paruresis, also known as shy bladder syndrome, is a type of phobia in which a person is unable to urinate in the real or imaginary presence of others, such as in a public restroom. The analogous condition that affects bowel movement is called parcopresis or shy bowel.

Contents

Signs and symptoms

Some people have brief, isolated episodes of urinary difficulty in situations where other people are in close proximity. Paruresis, however, goes beyond simple shyness, embarrassment, fear of exposure, or fear of being judged for not being able to urinate. Other people may find that they are unable to urinate while in moving vehicles, or are fixated on the sounds of their urination in quiet restrooms or residential settings. In severe cases, a person with paruresis can urinate only when alone at home or through the process of catheterization. [1]

Causes

Paruresis is considered a symptom of social anxiety and is correlated with other social anxiety symptoms. When the patient is under the effect of anxiolytics or otherwise disinhibited, paruresis tends to disappear.

Pathophysiology

It appears that paruresis involves a tightening of the sphincter or bladder neck due to a sympathetic nervous system response. The adrenaline rush that produces the involuntary nervous system response probably has peripheral and central nervous system involvement. The internal urethral sphincter (smooth muscle tissue) or the external urethral sphincter (striated muscle), levator ani (especially the pubococcygeus) muscle area, or some combination of the above, may be involved. It is possible that there is an inhibition of the detrusor command through a reflex pathway as well. The pontine micturition center (Barrington's nucleus) also may be involved, as its inhibition results in relaxation of the detrusor and prevents the relaxation of the internal sphincter. [2]

Diagnosis

The condition is catered for in the rules for mandatory urine testing for drugs in UK prisons, and UK Incapacity Benefit tribunals also recognise it. It is listed in the NHS approved Healthinote Directory. [3] It is now reported to have been accepted as a valid reason for jury service excusal. [4] From 1 August 2005, the guidance on the rules relating to the testing of those on probation in the UK cites paruresis as a valid reason for inability to produce a sample which is not to be construed as a refusal. [5]

The condition is recognised by the American Urological Association, who include it in their on-line directory of conditions. [6]

Paruresis was described in section 300.23 of the DSM-IV-TR as "performance fears ... using a public restroom" but it was not mentioned by name. [7] The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) mentions paruresis by name. [8] [9]

Kaplan & Sadock's Synopsis of Psychiatry states, "Persons with social phobias (also called social anxiety disorder) have excessive fears of humiliation or embarrassment in various social settings, such as in speaking in public, urinating in a public rest room (also called shy bladder), and speaking to a date." [10] The Synopsis describes shy bladder as "inability to void in a public bathroom" and notes that relaxation exercises are an application of behavior therapy for dealing with this disorder. [11] Some paruretics experience delayed urination and must wait for their need to void to overcome their anxiety, while others are unable to urinate at all. [12]

Treatment

In terms of treating the mental aspect of paruresis, such treatment can be achieved by graduated exposure therapy and cognitive behavioral therapy. In graduated exposure therapy, the subject has a trusted person stand outside the restroom at first, and once the fear is overcome the observer is brought closer in, until step by step the phobia is vanquished. [13] The International Paruresis Association provides a detailed discussion of this method on its website. [14] In addition to gradual exposure therapy, cognitive behavioral therapy is used to change a patient's mental approach to the condition, from one of a person who cannot urinate, to a person who can urinate or is not overly fearful when they can't publicly urinate. [15]

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classifies paruresis as a social anxiety disorder (SAD). In the UK NICE (National Institute for Health and Social Care Excellence) Guidelines set out Recognition, Assessment and Treatment for Social Anxiety Disorders. [16]

History

The term paruresis was coined by Williams and Degenhart (1954) in their paper "Paruresis: a survey of a disorder of micturition" in the Journal of General Psychology 51:19–29. They surveyed 1,419 college students and found 14.4% had experienced paruresis, either incidentally or continuously. [17]

Other names

Paruresis is also known by many colloquial terms, including bashful bladder, bashful kidneys, stage fright, pee-shyness, and shy bladder syndrome. [18]

Society and culture

Drug testing

Observed urine tests can be problematic for those with paruresis. Mandatory drug testing, Guantanamo.png
Observed urine tests can be problematic for those with paruresis.

Some drug testing authorities find paruresis a nuisance, and some implement "shy bladder procedures" which pay no more than lip service to the condition, and where there is no evidence that they have conducted any real research into the matter. In the U.S. Bureau of Prisons, the Code of Federal Regulations provides that "An inmate is presumed to be unwilling if the inmate fails to provide a urine sample within the allotted time period. An inmate may rebut this presumption during the disciplinary process." [19] Although U.S. courts have ruled that failure to treat properly diagnosed paruresis might violate prisoner's constitutional rights, the courts have also "routinely rejected suspicious or unsubstantiated attempts to invoke it in defense of failure to complete drug testing," [20] particularly when there were no medical record or physician testimony to back up the claim of paruresis. [21]

The International Paruresis Association stresses the importance of medical documentation of one's condition since "[t]he person who is unable to produce a urine sample is presumed guilty in the absence of any evidence." [22] Some prisons have offered the use of a "dry cell"—i.e., a cell with no toilet facilities, but only a container for the prisoner's waste—as an accommodation to inmates who are hindered by paruresis from providing an observed urine sample. [23]

FBOP Program Statement 6060.08 states, "Ordinarily, an inmate is expected to provide a urine sample within two hours of the request, but the Captain (or Lieutenant) may extend the time if warranted by specific situations (for example, the inmate has a documented medical or psychological problem, is dehydrated, etc.). Staff may consider supervising indirectly an inmate who claims to be willing but unable to provide a urine sample under direct visual supervision. For example, this might be accomplished by allowing the inmate to provide the sample in a secure, dry room after a thorough search has been made of both the inmate and the room." [24] At least six state prison systems—Florida, [25] Massachusetts, Maryland, Michigan, New York [26] and Tennessee [27] —have modified their drug testing regulations to provide accommodations for prisoners with paruresis. [28]

Per the Handbook of Correctional Mental Health, "No definitive or objective test is available to confirm or refute the presence of paruresis. The absence of prior treatment or the ability to void in some social situations but not in others does not rule it out. Although modalities associated with the treatment of social phobias help some individuals, no universally effective medication or other treatment exists. Coercive interventions, such as forcing fluids while observing a person with paruresis, are ineffective and can cause serious medical complications. Alternatives to observed urine specimen collection for individuals who self-report paruresis include unobserved collections in a dry room, testing of hair specimens, sweat testing with a patch, and blood testing ('Test for Drugs of Abuse' 2002). These alternatives preclude the need for futile attempts to differentiate inmates with true paruresis from those who fabricate complaints." [29]

The condition has been occasionally portrayed in popular culture, sometimes for comedic effect or parody. Examples of this include:

See also

Related Research Articles

<span class="mw-page-title-main">Interstitial cystitis</span> Medical condition of the bladder and pelvic floor

Interstitial cystitis (IC), a type of bladder pain syndrome (BPS), is chronic pain in the bladder and pelvic floor of unknown cause. Symptoms include feeling the need to urinate right away, needing to urinate often, and pain with sex. IC/BPS is associated with depression and lower quality of life. Many of those affected also have irritable bowel syndrome and fibromyalgia.

<span class="mw-page-title-main">Phobia</span> Anxiety disorder classified by a persistent and excessive fear of an object or situation

A phobia is an anxiety disorder, defined by an irrational, unrealistic, persistent and excessive fear of an object or situation. Phobias typically result in a rapid onset of fear and are usually present for more than six months. Those affected go to great lengths to avoid the situation or object, to a degree greater than the actual danger posed. If the object or situation cannot be avoided, they experience significant distress. Other symptoms can include fainting, which may occur in blood or injury phobia, and panic attacks, often found in agoraphobia and emetophobia. Around 75% of those with phobias have multiple phobias.

<span class="mw-page-title-main">Urology</span> Medical specialty on the urinary and reproductive systems

Urology, also known as genitourinary surgery, is the branch of medicine that focuses on surgical and medical diseases of the urinary system and the reproductive organs. Organs under the domain of urology include the kidneys, adrenal glands, ureters, urinary bladder, urethra, and the male reproductive organs.

Specific phobia is an anxiety disorder, characterized by an extreme, unreasonable, and irrational fear associated with a specific object, situation, or concept which poses little or no actual danger. Specific phobia can lead to avoidance of the object or situation, persistence of the fear, and significant distress or problems functioning associated with the fear. A phobia can be the fear of anything.

<span class="mw-page-title-main">Urination</span> Release of urine from the urinary bladder

Urination is the release of urine from the bladder to the outside of the body. Urine is released through the urethra and exits the penis or vulva through the urinary meatus in placental mammals, but is released through the cloaca in other vertebrates. It is the urinary system's form of excretion. It is also known medically as micturition, voiding, uresis, or, rarely, emiction, and known colloquially by various names including peeing, weeing, pissing, and euphemistically number one. The process of urination is under voluntary control in healthy humans and other animals, but may occur as a reflex in infants, some elderly individuals, and those with neurological injury. It is normal for adult humans to urinate up to seven times during the day.

<span class="mw-page-title-main">Urinary incontinence</span> Uncontrolled leakage of urine

Urinary incontinence (UI), also known as involuntary urination, is any uncontrolled leakage of urine. It is a common and distressing problem, which may have a large impact on quality of life. Urinary incontinence is common in older women and has been identified as an important issue in geriatric health care. The term enuresis is often used to refer to urinary incontinence primarily in children, such as nocturnal enuresis. UI is an example of a stigmatized medical condition, which creates barriers to successful management and makes the problem worse. People may be too embarrassed to seek medical help, and attempt to self-manage the symptom in secrecy from others.

Psychology is an academic and applied discipline involving the scientific study of human mental functions and behavior. Occasionally, in addition or opposition to employing the scientific method, it also relies on symbolic interpretation and critical analysis, although these traditions have tended to be less pronounced than in other social sciences, such as sociology. Psychologists study phenomena such as perception, cognition, emotion, personality, behavior, and interpersonal relationships. Some, especially depth psychologists, also study the unconscious mind.

<span class="mw-page-title-main">Enuresis</span> Involuntary urination in an older child or adult

Enuresis is a repeated inability to control urination. Use of the term is usually limited to describing people old enough to be expected to exercise such control. Involuntary urination is also known as urinary incontinence. The term "enuresis" comes from the Ancient Greek: ἐνούρησις, romanized: enoúrēsis.

<span class="mw-page-title-main">Urinary retention</span> Inability to completely empty the bladder

Urinary retention is an inability to completely empty the bladder. Onset can be sudden or gradual. When of sudden onset, symptoms include an inability to urinate and lower abdominal pain. When of gradual onset, symptoms may include loss of bladder control, mild lower abdominal pain, and a weak urine stream. Those with long-term problems are at risk of urinary tract infections.

Nocturia is defined by the International Continence Society (ICS) as "the complaint that the individual has to wake at night one or more times for voiding ". The term is derived from Latin nox – "night", and Greek [τα] ούρα – "urine". Causes are varied and can be difficult to discern. Although not every patient needs treatment, most people seek treatment for severe nocturia, waking up to void more than 2 or 3 times per night.

Flooding, sometimes referred to as in vivo exposure therapy, is a form of behavior therapy and desensitization – or exposure therapy – based on the principles of respondent conditioning. As a psychotherapeutic technique, it is used to treat phobia and anxiety disorders including post-traumatic stress disorder. It works by exposing the patient to their painful memories, with the goal of reintegrating their repressed emotions with their current awareness. Flooding was invented by psychologist Thomas Stampfl in 1967. It is still used in behavior therapy today.

<span class="mw-page-title-main">Neurogenic bladder dysfunction</span> Bladder disorder due to disease or injury of the nervous system

Neurogenic bladder dysfunction, often called by the shortened term neurogenic bladder, refers to urinary bladder problems due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination. There are multiple types of neurogenic bladder depending on the underlying cause and the symptoms. Symptoms include overactive bladder, urinary urgency, frequency, incontinence or difficulty passing urine. A range of diseases or conditions can cause neurogenic bladder including spinal cord injury, multiple sclerosis, stroke, brain injury, spina bifida, peripheral nerve damage, Parkinson's disease, multiple system atrophy or other neurodegenerative diseases. Neurogenic bladder can be diagnosed through a history and physical as well as imaging and more specialized testing. In addition to symptomatic treatment, treatment depends on the nature of the underlying disease and can be managed with behavioral changes, medications, surgeries, or other procedures. The symptoms of neurogenic bladder, especially incontinence, can severely degrade a person's quality of life.

<span class="mw-page-title-main">Overactive bladder</span> Condition where a person has a frequent need to urinate

Overactive bladder (OAB) is a common condition where there is a frequent feeling of needing to urinate to a degree that it negatively affects a person's life. The frequent need to urinate may occur during the day, at night, or both. Loss of bladder control may occur with this condition. This condition is also sometimes characterized by a sudden and involuntary contraction of the bladder muscles, in response to excitement or anticipation. This in turn leads to a frequent and urgent need to urinate.

Parcopresis, also termed psychogenic fecal retention or shy bowel, and known colloquially as poop shy, is the inability to defecate without a certain level of privacy. It can be either a difficulty or inability to defecate due to significant psychological distress, and is associated with avoidance in public and social situations. It is typically researched alongside and has comorbidity with paruresis, which is an inability or difficulty to urinate in the presence of others.

Mental health professionals often distinguish between generalized social phobia and specific social phobia. People with generalized social phobia have great distress in a wide range of social situations. Those with specific social phobia may experience anxiety only in a few situations. The term "specific social phobia" may also refer to specific forms of non-clinical social anxiety.

Social anxiety is the anxiety and fear specifically linked to being in social settings. Some categories of disorders associated with social anxiety include anxiety disorders, mood disorders, autism spectrum disorders, eating disorders, and substance use disorders. Individuals with higher levels of social anxiety often avert their gazes, show fewer facial expressions, and show difficulty with initiating and maintaining a conversation. Social anxiety commonly manifests itself in the teenage years and can be persistent throughout life; however, people who experience problems in their daily functioning for an extended period of time can develop social anxiety disorder. Trait social anxiety, the stable tendency to experience this anxiety, can be distinguished from state anxiety, the momentary response to a particular social stimulus. Half of the individuals with any social fears meet the criteria for social anxiety disorder. Age, culture, and gender impact the severity of this disorder. The function of social anxiety is to increase arousal and attention to social interactions, inhibit unwanted social behavior, and motivate preparation for future social situations.

<span class="mw-page-title-main">Social anxiety disorder</span> Anxiety disorder associated with social situations

Social anxiety disorder (SAD), also known as social phobia, is an anxiety disorder characterized by sentiments of fear and anxiety in social situations, causing considerable distress and impairing ability to function in at least some aspects of daily life. These fears can be triggered by perceived or actual scrutiny from others. Individuals with social anxiety disorder fear negative evaluations from other people.

<span class="mw-page-title-main">Separation anxiety in dogs</span>

Separation anxiety in dogs describes a condition in which a dog exhibits distress and behavior problems when separated from its handler. Separation anxiety typically manifests within minutes of departure of the handler. It is not fully understood why some dogs suffer from separation anxiety and others do not. The diagnosis process often leads to a misdiagnosis as it is difficult to differentiate from other medical and behavioral problems. The behavior may be secondary to an underlying medical condition. With chronic stress, impairments to physiological health can manifest. Increased stress in the dog alters hormone levels, thus decreasing natural immunity to various health problems. Separation anxiety can be treated with systematic desensitization and, if necessary, medication. Ignoring or punishing the dog, leaving them to "cry it out" does not solve separation anxiety and can damage the mental health of dogs.

<span class="mw-page-title-main">Overflow incontinence</span> Medical condition

Overflow incontinence is a concept of urinary incontinence, characterized by the involuntary release of urine from an overfull urinary bladder, often in the absence of any urge to urinate. This condition occurs in people who have a blockage of the bladder outlet, or when the muscle that expels urine from the bladder is too weak to empty the bladder normally. Overflow incontinence may also be a side effect of certain medications.

Fowler's syndrome is a rare disorder in which the urethral sphincter fails to relax to allow urine to be passed normally in younger women with abnormal electromyographic activity detected.

References

  1. ↑ Paruresis – shy bladder syndrome – Better Health Channel Archived 2 September 2006 at the Wayback Machine
  2. ↑ Soifer, Steven; Nicaise, Greg; Chancellor, Michael; Gordon, David (2009). "Paruresis or Shy Bladder Syndrome: An Unknown Urologic Malady?". Urological Nursing. 29 (2): 87–94. PMID   19507406.
  3. ↑ "Healthinote - Terms Acceptance". Healthinote. Retrieved 13 January 2025.
  4. ↑ "Projects". UKPT – United Kingdom Paruresis Trust – Shy Bladder Syndrome Support. Retrieved 5 August 2018.
  5. ↑ "Paruresis and Drug Testing". UKPT - United Kingdom Paruresis Trust - Shy Bladder Syndrome Support. Retrieved 13 January 2025.
  6. ↑ American Urological Association – Paruresis Archived 28 July 2009 at the Wayback Machine
  7. ↑ "300.23, Social Phobia (Social Anxiety Disorder". Diagnostic and Statistical Manual of Mental Disorders (4th (Text Revised) ed.). American Psychiatric Association. 2000. pp.  453.
  8. ↑ Antonio Prunas (July–August 2013). "La sindrome della vescica timida". Rivista di Psichiatria. 48 (4): 345–53. doi:10.1708/1319.14632. PMID   24056834.
  9. ↑ "300.23, Social Anxiety Disorder (Social Phobia)". Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Association. 2013. pp.  203. Some individuals fear and avoid urinating in public restrooms when other individuals are present (i.e., paruresis, or 'shy bladder syndrome'.)
  10. ↑ Benjamin J. Sadock; Harold I. Kaplan; Virginia A. Sadock. "16.3 Specific Phobia and Social Phobia". Kaplan & Sadock's Synopsis of Psychiatry. p. 597.
  11. ↑ Benjamin J. Sadock; Harold I. Kaplan; Virginia A. Sadock. "35.8 Behavior Therapy. Table 35.8–2: Some Common Clinical Applications of Behavior Therapy". Kaplan & Sadock's Synopsis of Psychiatry. p. 957.
  12. ↑ Marshall, John R. (1994). "The Drama of Social Phobia". Social Phobia: From Shyness to Stage Fright. Perseus Books. pp.  32. ISBN   978-0465078967. Nurses and others who work in medical offices have long been aware that some individuals are unable to produce urine samples. This phenomenon, sometimes called "bashful bladder," paruresis, is the inability to urinate in public restrooms.
  13. ↑ Weil, Monroe (May 2001). "A treatment for paruresis or shy bladder syndrome". The Behavior Therapist. 24 (5). New York, NY: Association for Advancement of Behavior Therapy: 108. PsycINFO record 2002-13573-001.
  14. ↑ "Breath-Hold Technique – International Paruresis Association (IPA)". International Paruresis Association (IPA).
  15. ↑ "CBT & Paruresis". UKPT - United Kingdom Paruresis Trust - Shy Bladder Syndrome Support. Retrieved 13 January 2025.
  16. ↑ "Recommendations | Social anxiety disorder: recognition, assessment and treatment | Guidance | NICE". www.nice.org.uk. 22 May 2013. Retrieved 13 January 2025.
  17. ↑ Williams, Griffith W.; Degenhardt, Elizabeth T. (1 July 1954). "Paruresis: A Survey of a Disorder of Micturition". The Journal of General Psychology. 51 (1): 19–29. doi:10.1080/00221309.1954.9920203. ISSN   0022-1309.
  18. ↑ "The UKPT - UK Paruresis Trust". UKPT - United Kingdom Paruresis Trust - Shy Bladder Syndrome Support. Retrieved 13 January 2025.
  19. ↑ Code of Federal Regulations, Title 28: Judicial Administration, Part 550—Drug Programs, Subpart D—Urine Surveillance, § 550.31 Procedures
  20. ↑ Medard v. Doherty, 2007 NY Slip Op 32130 – NY: Supreme Court, New York 2007
  21. ↑ In the matter of Becker v. Goord, 13 AD 3d 947 – NY: Supreme Court, Appellate Div., 3rd Dept. 2004
  22. ↑ "FAQ – International Paruresis Association (IPA)". International Paruresis Association (IPA).
  23. ↑ Meeks v. Tennessee Department of Correction, Tenn: Court of Appeals, Nashville 2008
  24. ↑ Federal Bureau of Prisons (24 November 1999). "Urine Surveillance and Narcotic Identification" (PDF).
  25. ↑ Florida Department of Corrections Procedure 602.010, mentioned in footnote 12 of Pate v. Peel, 256F.Supp.2d1326 (N.D. Florida, Panama City Division)("DOC's Procedure 602.010, Bashful Bladder Procedure, which outlines the steps to be taken to obtain a urine specimen from an inmate who claims that he suffers from BBS.").
  26. ↑ "Procedure for Inmates Claiming to be Unable to Urinate in Presence of Others: The following procedures shall be employed when the watch commander reasonably believes that the inmate is unable to provide a urine specimen due to an alleged inability to urinate in the presence of others (shy bladder). Reasonable belief is based upon the following criteria, including, but not limited to: Medical or mental health records supporting the inmate's claim (to be evaluated by health services or OMH staff), prior disciplinary and/or computerized urinalysis testing data indicating a history of urinalysis testing violations, if applicable, and the inmate's behavior and demeanor at the time of request for the urine sample . . . . Staff shall not witness the inmate urinate into the specimen container." "7 NYCRR 1020.4(e)". New York Department of Correctional Services.
  27. ↑ "There may be extenuating medical (e.g., dehydration, kidney problems, medication, etc.) and psychological (e.g., social phobias) conditions that may preclude the giving of a sample. In such cases, the inmate must provide written evidence from the health care staff indicating such a condition. The Warden shall, in extreme cases, authorize the use of an alternative drug testing method for those inmates who have a documented medical condition that would prohibit the use of urinalysis testing. Approval of the commissioner or his designee is required prior to the use of any alternate drug testing method or instrument." Tennessee Department of Correction (1 June 2011). "Policy #506.21(VI)(B)(9), Inmate Drug/Alcohol Testing and Sanctions" (PDF).
  28. ↑ Soifer, Steven (2001). "Evolving Legal Ramifications". Shy Bladder Syndrome. New Harbinger. p. 98. ISBN   978-1-57224-227-2.
  29. ↑ Scott, Charles L. (15 October 2009). Handbook of Correctional Mental Health (2nd ed.). American Psychiatric Publishing. ISBN   978-1585623891.
  30. ↑ Holden, Stephen (7 October 2005), "Film in review; Waiting", New York Times, retrieved 9 June 2020
  31. ↑ "Shy bladder group protests DirecTV ad starring Rob Lowe". usatoday.com. Retrieved 19 January 2016.
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.