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About Avoidant Paruresis Written by: Steven Soifer, MSW, Ph.D.,
George Zgourides, Psy.D., and Joe Himle, MSW,
Ph.D. Note: Here is another paper on Paruresis.
What is Bashful
Bladder? WARNING AND DISCLAIMER: This discussion is NOT
a substitute for medical advice and does not constitute the practice
of medicine, psychiatry, clinical psychology, clinical social work or
any other mental health profession. If you are having trouble urinating,
you should always contact a physician since difficulty with voiding
can be a symptom of a serious medical condition. We are a group of professional
people, people who suffer from paruresis, and
some who have recovered. We have assembled a board of directors and
an advisory board to help people cope with urinary dysfunction that
has a psychological or social origin. In this discussion, we are NOT
practicing medicine, psychiatry, clinical psychology, clinical social
work or any other mental health profession. You should have your doctor
evaluate your condition before diagnosing yourself, and seek the appropriate
necessary mental health counseling if warranted. IPA, Inc. disclaims
any and all legal liability whatsoever. Whenever I try to use a public restroom, everything freezes up! In contrast to physiological conditions like prostatitis (inflammation
of the prostate) that block the flow of urine, BBS is a psychological
disorder that involves the urinary system. More precisely, BBS is a
type of social phobia, meaning the paruretic is usually shy and
fears being scrutinized or criticized by others when performing in public—in
this case, urinating in a public restroom. The psychological conflict
that generates this particular form of social phobia is expressed through
the physical symptom of being unable to urinate whenever the person
desires. One of the first steps in the process of recovery is to change
one’s thinking to no longer view urination in public as a performance.
It is simply a necessary body function we all need to do, and
there is no reflection on an individual’s worth that comes from the
manner in how we do it. There is no requirement that it be fast enough,
loud enough, or “perfect” enough. The experience of BBS varies somewhat from person to person; however, certain
general patterns are evident. First, BBS occurs mostly in public restrooms,
but it can also occur in the homes of friends and relatives, or even
at home if visitors are nearby or a family member is waiting for the
paruretic. Typically, though, she or he finds the home bathroom to be
the only truly safe toilet, the only place where the paruretic is consistently
able to void. Most cases of BBS tend to be progressive in nature, where
the fear of using public facilities grows over time and increasingly
limits the sufferer’s options for activities outside the home. Second, BBS ranges in intensity from mild, in which the person can urinate
in public facilities under certain circumstances, to severe, in which
the person can only urinate when alone at home. Thus the degree of BBS
hesitancy ranges from a momentary delay in initiating the process to
chronic and acute retention. Most people occasionally experience at
least some hesitancy in public restrooms, but this differs from BBS
in the matter of degree and context. A person who every now and then
must wait an extra second or two before being able to urinate is not
a paruretic. Rather, BBS is often a life-long condition characterized
by excessive hesitancy or a total inability to urinate. The problem
also causes distress over everyday activities like travel, social engagements,
long business meetings, and interferes in a significant way with the
paruretic’s ability to carry on with these normal activities. Third, most paruretics describe a personal comfort threshold required for
urinating, whether in public facilities or at home. In a particular
situation where too many negatives such as noise, odors, lack of visual
privacy, and other people in the restroom talking eclipse this comfort
threshold, BBS kicks in and prevents the person from urinating. Typical Characteristics of BBS What are some of the triggers for BBS? 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. Paruretics tend toward the former.
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. For some individuals BBS appears to start out of nowhere, but for most
an unpleasant experience or group of experiences appear to precipitate
the onset of the problem. In the case of the latter, after some negative
event such as being unable to urinate in front of a nurse during a medical
test, the individual begins to catastrophize; that is, he or
she worries about being able to urinate next time he or she is in some
type of public restroom. In this way performance anxiety, the key feature
of social phobias, develops and becomes associated with urinating in
the presence of others. The individual enters public restrooms with
aroused sympathetic nervous system activity, which creates a level of
anxiety that is incompatible with urinating. As each forcible attempt
to control the process fails, increased performance anxiety due to mounting
levels of sympathetic activity decreases the individual’s chances of
voiding at that time. In many cases this performance anxiety eventually
generalizes to all or most public restrooms, so that the only safe toilet
the person can reliably use is at home. Generally, paruretics try to adjust to the problem by urinating as much
as possible when at home and before leaving their home toilet, restricting
the intake of fluids, and refusing extended social invitations. Most
paruretics also perform a series of rituals such as locating vacant
restrooms whenever away from home, thinking of water when trying to
urinate, and running the tap to optimize the chances of urinating under
adverse conditions. Most commonly, though, paruretics cope by avoiding
public restrooms at all costs. Seek a medical evaluation before attempting to treat a bashful bladder
problem. Rule out a medical condition before diagnosing paruresis. A
general rule of thumb is that if you have no medical reason for difficult
urination and can go at home when alone without a problem but have difficulties
in most, or all, social situations, then you probably suffer from paruresis. The most commonly used treatment for bashful bladder involves the individual
gradually attempting to urinate in more and more difficult locations.
This treatment is usually called graduated exposure therapy. Each session
of exposure therapy involves several attempts at briefly urinating.
However, in order to use exposure therapy in this way, a substantial amount
of urine is needed. This need can be accomplished by drinking plenty
of fluids prior to the practice session. Usually drinking about one
quart of water one hour prior to the practice session is best. Some
people may require more water or more time to pass before they feel
the strong need to urinate. Most people with bashful bladder are more
successful if their need to urinate is high at the time of the practice
session. Occasionally, some people have more trouble when they are very
urgent, so experimentation may be necessary. Some find it helpful to
use a scale to record how strongly one feels the need to urinate. A
0-10 point scale works well starting with zero indicating no urgency
and ending with ten, which equals extreme urgency. It will probably
work out best to start practice sessions only after your urgency level
is rated at seven or above. Always have a safe backup plan in mind, too! For example, a significant minority of paruretics
find either temporary or permanent relief from symptoms by learning
self-catheterization. While this sounds difficult and painful, it really
isn’t when properly taught. Finding a sympathetic urologist who is willing
to teach you how to do it is the best approach.
For those whose symptoms are severe or who travel a lot, this may be
a good interim step while also seeking other treatment, such as graduated
exposure therapy. Since men can often use a stall as a backup
if they can’t use a urinal successfully but women don’t have this option,
catheter use is more important as a backup strategy for women working
on graduated exposure. You should also construct a behavioral hierarchy scale. Again, using a
0-10 scale, come up with those scenarios in which you have an easy time
using the bathroom (for example, 0 being at home alone), and those scenarios
in which you have a difficult time urinating (for example, 10 using
a public restroom at a major sports event during half-time or seventh
inning stretch). For most people, initial practice sessions should take place in an isolated
private restroom. It is very helpful to have a partner to work with
at this point. This partner can be a trained behavioral therapist, someone
from an IPA support group, a buddy, a close friend, or family member.
Practice should begin by having your partner stand outside in the restroom
with the door closed. Usually it is best to have your partner move some
distance from the door so they cannot hear you urinate. (Some people
even need to have their partner be outside their apartment or
home when first starting!) Once you and your partner are in place, you
should attempt to urinate. If you are successful, allow urine to flow
for approximately three seconds. After successfully completing the urination
trial, meet up with your partner and take a short break of approximately
three minutes, after which you should try again. It is best to aim your
urine stream to make as much noise as possible, since making sound while
urinating is of concern for many people with bashful bladder syndrome.
It is also best to avoid deliberate use of background noise, such as
running a water faucet; since much of the exposure treatment will likely
have to be repeated once the background noise is eliminated. In our
experience, using background noise often extends the length of the treatment
program. If you have trouble initiating urination, wait at the toilet for two minutes
before giving up and taking a break. If you feel that you are just about
to urinate after two minutes, wait up to two minutes more at the toilet
before giving up. Usually waiting beyond four minutes is not helpful.
If the trial is unsuccessful, take a short three-minute break before
trying again. Also, have your partner move back to where you were last
successful, and then once you succeed again, move incrementally toward
the point where you last failed. If you do not have a partner practice
urinating in restrooms that are empty at first, then move on to situations
where one person is present. Once you are successful in starting your urine, have your partner slowly
move closer to you until you are able to urinate with him directly behind
you. (Note: women do not have to do this step.) This could take several
sessions. If you are practicing without a partner, move to a slightly
more crowded restroom after you are successful with one person present.
For males, it is probably best to use the urinal for all your practice
sessions. If this is impossible, your self-treatment may take longer,
since you will have to practice first in the stall and then move on
to the urinal. Once you are consistently successful with a few people
present in the restroom then move on to more crowded restrooms. Useful
restrooms for this practice include those at interstate rest areas,
busy airports, sporting events, concerts, or theaters. Some general guidelines are important to review here. It is best to practice
often, preferably several times per week. Longer sessions are generally
more helpful than shorter sessions. About one hour is best, with the
goal of getting 15-20 practice trials in each of these one-hour sessions.
You may also need to continually fluid load during your session or drink
coffee or a caffeinated soft drink to have enough pressure and urine
for your session. If you have trouble initiating one day and then have
success the next, do not be overly concerned, since many people experience
inconsistency in their progress. It’s normal and nothing to worry about.
If you do have trouble with a given step in the exposure process, try and
find the halfway point between your previous success and the step that
is giving you difficulty. One of the most frequent mistakes people make
in doing the graduated exposure work is to move too quickly up their
behavioral hierarchy. In fact, just a few inches can make the difference,
since our boundaries around unsafe and safe situations are so clearly
delineated in our own minds! You should expect the self-treatment to require 8-12 sessions before you
are able to urinate freely. Of course, this is an average; you could
require fewer or more. It is important to know that this treatment has
been helpful to many people, but there is no guarantee that it will
help you. Our data indicate that about 80 percent of paruretics using
these techniques are helped to a significant degree. On very rare occasions,
people with bashful bladder find themselves unable to initiate urination during their practice
session and then are unable to urinate when they return home. If this
happens to you, seek medical attention. If untreated, this could constitute
a medical emergency, so seek out a urologist
immediately to gain relief. Finally, if your self-treatment fails, consult
a trained behavioral therapist for help. You may also wish to consult
your physician again to be sure nothing is physically wrong with your
urinary system. What Can You Do About Paruresis? Concrete Steps For those suffering from paruresis or who know of someone who suffers from
this social phobia, there are things one can do: Visit our website at http://www.paruresis.org
and get the latest information about this anxiety disorder. There is
a moderated discussion group accessible through the website, as well
as a place to ask questions. If you already haven’t done so, start talking to your loved ones, friends,
relatives, and co-workers about paruresis. A very typical response is:
“Oh, I know someone who suffers from that”, or even, “You know, I have
that problem too!” Join the International Paruresis Association (IPA), a tax-exempt, non-profit
organization, to keep informed about the latest developments on the
topic. The IPA, Inc. acts to educate the public, gather and disseminate
useful information, and seek effective treatments for paruresis. Also,
IPA can refer you to a cognitive-behavioral therapist to help you with
your paruresis. This link will take you to our signup
form. Find yourself a buddy in order to practice the graduated behavioral exposure
techniques outlined earlier in this pamphlet. The website allows you
to access a buddy
list for you to put your name onto or find someone else near you
who is seeking a buddy. The IPA, Inc. may also be able to help find
someone to work with in your area. Attend one of the IPA’s weekend workshops and practice with others to begin
recovering from paruresis. Workshops are held several times a year in
different parts of the Either join an existing support group or start one yourself. Regular participation
in a support group is one of the best ways to conquer your fear of urinating
in public. Support group members practice together at malls, movie theaters,
rest areas, and other places to overcome their paruresis. IPA can let
you know if there is a support group in your area, and if not, how you
can start one. This link will take you to our list
of support groups.
More than anything else, ongoing practice on a daily basis will allow you
to overcome or recover from your paruresis in a timely manner. Persistent,
consistent practice is essential for improvement. These days, many people face drug testing in their workplace, school, or
in some cases, prisons. There is no clear answer to the question: Can
I get around giving a urine sample under scrutiny at my workplace or
in prison? For those working in publicly funded jobs, the Americans
with Disabilities Act (ADA) may protect you from random urine
drug testing. This may also be true in the private sector. The way to approach the problem is by being straightforward with your employer.
Let the employer know that you suffer from an anxiety disorder named
paruresis, which is a bona fide social anxiety disorder listed in the
Diagnostic Statistical Manual of Mental Disorders (DSM) IV with code
300.23, and that under the Social Action: Getting Involved in Changing
Conditions Concerning Paruresis One important component in recovery is being public about your condition.
But beyond that, it is important that you take action in changing
the conditions that contribute to paruresis in the first place. One thing you can do is to be aware of how easy it is for someone to develop
paruresis. Education is crucial here. Talking about this condition,
especially in school and medical settings, is very important. If you
have children, make sure that they never feel pressured around
bodily functions (Will you PLEASE hurry up and go already? YUK!) Second, let your children’s teachers know about paruresis. In this way,
they will hopefully prevent conditions that could allow it to develop
in the school setting. Third, at your work place, health clubs, and other public facilities, if
you find a particular restroom design objectionable (for instance, no
dividers between urinals or low-bowl urinals), let the management know
and ask them to do something about it. Fourth, place an IPA public service announcement in your local paper to
tell people to contact us if they want information about paruresis and/or
a contact person for a buddy or support group in their area. Finally,
write letters to newspaper columnists (Dear Abby, Ann Landers), government
officials, or to the editor of your local newspaper to help get the
word out. All of these steps will help you feel empowered in relation to paruresis.
Revised
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