Paruresis

Paruresis (/ˌpɑrəˈriːsɪs/ PAR-ə-REE-sis) is a type of phobia in which the sufferer 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.

Impact

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]

Although most sufferers report that they developed the condition in their teenage years, it can strike at any age. Also, because of the differing levels of severity from one person to another, some people's first experience of the problem is when, for the first time, they "lock up" attempting to produce a sample for a drug test. Many women are unaware that they, too, are subject to paruresis; articles about women and urination emphasize other female urinary dysfunctions, such as urinary incontinence or frequent urination.

Some people cope by deliberately holding in their urine, by refraining from drinking liquids, or locating unoccupied or single-occupancy public bathrooms.

Severe cases of this disorder can have highly restricting effects on a person's life. In moderate to severe cases, overcoming paruresis can be extremely difficult without the help of a psychologist, therapist or support groups. Severe sufferers may not be willing to travel far from their home or be able to form intimate relationships. Others cannot urinate even in their own home if someone else can be heard to be there.

Origin of the term

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.

Other names

Paruresis is also known by many colloquial terms, including bashful bladder, bashful kidneys, mental cloggery, stage fright, pee fright, urophobia, pee-shyness, problem public pissing (ppp), the slow dribbles, creeping pee-pee, public piss syndrome, shy bladder syndrome.

General recognition

There is growing recognition of the condition by the UK's National Health Service (NHS) and government. 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 on-line encyclopaedia of conditions and disorders.[2] It is now reported to have been accepted as a valid reason for jury service excusal.[3] From 1 August 2005, the guidance on the rules relating to the testing of those on probation in the UK explicitly cites paruresis as a valid reason for inability to produce a sample which is not to be construed as a refusal.

The condition is recognised by the American Urological Association, who include it in their on-line directory of conditions.[4]

It has, from time to time been the topic of advice columns such as Ann Landers, to which sufferers have written in and been counselled on their problem.

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.[5] The current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) mentions paruresis by name.[6][7]

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."[8] 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.[9] 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.[10]

Context and urine samples

Observed urine tests can be problematic for those with paruresis.

There can be serious difficulties with workplace drug testing where observed urine samples are insisted upon, if the testing regime does not recognise and cater for the condition. In the UK, employees have a general right not to be unfairly dismissed, and so have an arguable defence if this arises, but this is not the case everywhere.

There is growing evidence to suggest that 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."[11] 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,"[12] particularly when there were no medical record or physician testimony to back up the claim of paruresis.[13] 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."[14] 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.[15]

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."[16] At least six state prison systems — Florida,[17] Massachusetts, Maryland, Michigan, New York[18] and Tennessee[19] — have modified their drug testing regulations to provide accommodations for prisoners with paruresis.[20]

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."[21]

Treatment

A proven method of physically treating paruresis is through breath holding. The paruretic person takes a normal breath in, exhales about three-quarters of it, and then holds their breath for a given length of time, usually 60 seconds or less, and in doing so, the internal sphincter muscle of the urethra relaxes enough so that the person can urinate freely.[22][23][24] It is thought to work because either the high levels of carbon dioxide or the low levels of oxygen from breath holding relax the aforementioned muscle. Another method of physically treating paruresis is through Intermittent catheterisation. A urinary catheter is inserted into the urethra whenever manual voiding cannot be achieved, and this enables the paruretic to urinate. 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.[25] The International Paruresis Association provides a detailed discussion of this method on its website.[26] In addition to gradual exposure therapy, cognitive behavioral therapy is used to change a sufferer's mental approach to the disease, 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.

In popular culture

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

See also

References

  1. ↑ Paruresis - shy bladder syndrome - Better Health Channel
  2. ↑ NHSDirect Site - reference to paruresis
  3. ↑ - UKPT page re: jury service and incapacity benefit cases.
  4. ↑ American Urological Association - Paruresis
  5. ↑ "300.23, Social Phobia (Social Anxiety Disorder". Diagnostic and Statistical Manual of Mental Disorders (4th (Text Revised) ed.). American Psychiatric Association. 2000. p. 453.
  6. ↑ Riv Psichiatr. 48 (4): 345–53. Jul–Aug 2013. doi:10.1708/1319.14632. Missing or empty |title= (help)
  7. ↑ "300.23, Social Anxiety Disorder (Social Phobia)". Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Association. 2013. p. 203. Some individuals fear and avoid urinating in public restrooms when other individuals are present (i.e., paruresis, or 'shy bladder syndrome'.)
  8. ↑ Benjamin J. Sadock, Harold I. Kaplan, Virginia A. Sadock. "16.3 Specific Phobia and Social Phobia". Kaplan & Sadock's Synopsis of Psychiatry. p. 597.
  9. ↑ 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.
  10. ↑ Marshall, John R. (1994). "The Drama of Social Phobia". Social Phobia: From Shyness to Stage Fright. Perseus Books. p. 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.
  11. ↑ Code of Federal Regulations, Title 28: Judicial Administration, Part 550—Drug Programs, Subpart D—Urine Surveillance, § 550.31 Procedures
  12. ↑ Medard v. Doherty, 2007 NY Slip Op 32130 - NY: Supreme Court, New York 2007
  13. ↑ In the matter of Becker v. Goord, 13 AD 3d 947 - NY: Supreme Court, Appellate Div., 3rd Dept. 2004
  14. ↑ http://www.paruresis.org/FAQ/faq_page_4.htm
  15. ↑ Meeks v. Tennessee Department of Correction, Tenn: Court of Appeals, Nashville 2008
  16. ↑ Federal Bureau of Prisons (1999-11-24). "Urine Surveillance and Narcotic Identification" (PDF).
  17. ↑ Florida Department of Corrections Procedure 602.010, mentioned in footnote 12 of Pate v. Peel, 256 F.Supp.2d 1326 (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.”).
  18. ↑ "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.
  19. ↑ "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 (June 1, 2011). "Policy #506.21(VI)(B)(9), Inmate Drug/Alcohol Testing and Sanctions" (PDF).
  20. ↑ Soifer, Steven (2001). "Evolving Legal Ramifications". Shy Bladder Syndrome. New Harbinger. p. 98. ISBN 1-57224-227-2.
  21. ↑ Scott, Charles L. (15 October 2009). Handbook of Correctional Mental Health (2nd ed.). American Psychiatric Publishing. ISBN 978-1585623891.
  22. ↑ Weil, Monroe (May 2001). "A treatment for paruresis or shy bladder syndrome". The Behavior Therapist (New York, NY: Association for Advancement of Behavior Therapy) 24 (5): 108. Lay summary. PsycINFO record 2002-13573-001.
  23. ↑ http://www.paruresis.org/breath_hold.html
  24. ↑ http://zenandtheartofreality.wordpress.com/2012/10/11/breath-hold-instructions/
  25. ↑ Weil, Monroe (May 2001). "A treatment for paruresis or shy bladder syndrome". The Behavior Therapist (New York, NY: Association for Advancement of Behavior Therapy) 24 (5): 108. Lay summary. PsycINFO record 2002-13573-001.
  26. ↑ http://www.paruresis.org/breath-hold
  27. ↑ Strauss, Neil (2005). The game: penetrating the secret society of pickup artists (1st ed. ed.). New York: HC. ISBN 0060554738.
  28. ↑ Scott, Adams. "Dilbert". Universal Uclick. Retrieved Oct 21, 2011.

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