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Paruresis (IPA [paɹ jə 'ɹi: sɪs]), also known as pee shy, shy kidney, bashful bladder, or shy bladder syndrome, is a type of social anxiety disorder, that can affect both men and women, in which the sufferer is unable to urinate in the (real or imaginary) presence of others, such as in a public restroom.
Many people experience isolated transient manifestations of urinary difficulty in particularly undesirable situations, and this is sometimes described as stage fright. However, that is to be distinguished from paruresis.
Paruresis goes beyond simple shyness, embarrassment or desire for privacy in that it is much more severe and may cause unnecessary inconvenience, because the inability to urinate, although psychological in origin, is physical in its effect, and not under the control of the sufferer.
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 Psychology 51:19-29. They surveyed 1,419 college students and found 14.4% had experienced paruresis, either incidentally or continuously.
There is growing recognition of the condition by the UK's 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 (see link below). It is now reported to have been accepted as a valid reason for jury service excusal. From 1st 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, to which there is a link below.
Severe cases of this disorder can have highly restricting effects on a person's life. Severe sufferers may not be willing to travel far from their home. Others cannot urinate even in their own home if someone else can be heard to be there.
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.
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 drugs test.
There is growing evidence to suggest that some drugs 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.
The codes and procedures for drugs testing in sport are set by WADA, the World Anti-Doping Agency. Enquiries to WADA reveal that their doping codes do not cater for the condition at all, and they say they have never had any reports of problems with it. It is thought to be remarkable that such a widespread common condition is not experienced by any world class atheletes, and there is some suspicion that inability to comply with observed urine tests by sufferers of Paruresis has eliminated them from competitive sport long before they get anywhere near the Olympics.
Various strategies to cope with paruresis include:
- drinking less fluid and emptying out whenever 'safe'
- avoidance or use of less-busy public restrooms,
- using a stall instead of a urinal, or
- running the tap or flushing to mask the urination sounds.
Still, the above are merely "work-arounds" that address the symptom and not the problem.
Actual treatments for the condition include:
- cognitive behavior therapy,
- training with biofeedback,
- anti-anxiety medications,
- using a catheter, although this is alleviating the symptoms rather than effecting a cure, and
- reducing the level of privacy at which the condition triggers by indulging in graduated exposure therapy. This last can be achieved by sufferers working together at organised events known as workshops.
- Soifer, S., Zgourides, G. D., Himle, J., & Pickering, N. L. (2001). Shy bladder syndrome: Your step-by-step guide to overcoming paruresis. Oakland, CA: New Harbinger Publications.
- Gruber, D. L., & Shupe, D. R. (1982). Personality correlates of urinary hesitancy (paruresis) and body shyness in male college students: Journal of College Student Personnel Vol 23(4) Jul 1982, 308-313.
- Hammelstein, P., Pietrowsky, R., Merbach, M., & Brahler, E. (2005). Psychogenic urinary retention ('Paruresis'): Diagnosis and epidemiology in a representative male sample: Psychotherapy and Psychosomatics Vol 74(5) Aug 2005, 308-314.
- Hatterer, J. A., Gorman, J. M., Fyer, A. J., Campeas, R. B., & et al. (1990). Pharmacotherapy of four men with paruresis: American Journal of Psychiatry Vol 147(1) Jan 1990, 109-111.
- Jaspers, J. P. C. (1998). Cognitive-behavioral therapy for paruresis: A case report: Psychological Reports Vol 83(1) Aug 1998, 187-196.
- Kaufman, K. R. (2005). Monotherapy treatment of paruresis with gabapentin: International Clinical Psychopharmacology Vol 20(1) Jan 2005, 53-55.
- McCracken, L. M., & Larkin, K. T. (1991). Treatment of paruresis with in vivo desensitization: A case report: Journal of Behavior Therapy and Experimental Psychiatry Vol 22(1) Mar 1991, 57-62.
- Rogers, G. M. (2003). Treatment of paruresis in the context of benign prostatic hyperplasia: A case report: Cognitive and Behavioral Practice Vol 10(2) Spr 2003, 168-177.
- Ruben, D. H. (2001). Beyond obvious contingencies: When paruresis competes with concurrent avoidance responses: the Behavior Therapist Vol 24(9) Oct 2001, 194.
- Watson, T. S., & Freeland, J. T. (2000). Treating paruresis using respondent conditioning: Journal of Behavior Therapy and Experimental Psychiatry Vol 31(2) Jun 2000, 155-162.
- Zgourides, G. (1991). Atenolol treatment of paruresis: Psychological Reports Vol 68(3, Pt 1) Jun 1991, 766.
- Zgourides, G., Warren, R., & Englert, M. (1990). Use of a portable radio-headset as an adjunct to exposure therapy in treating paruresis: Phobia Practice & Research Journal Vol 3(1) Spr-Sum 1990, 43-44.
- Zgourides, G. D. (1987). Paruresis: Overview and implications for treatment: Psychological Reports Vol 60(3, Pt 2) Jun 1987, 1171-1176.
- Zgourides, G. D. (1988). Bethanechol chloride as a suggested adjunct to prolonged in vivo exposure therapy in the treatment of paruresis: Perceptual and Motor Skills Vol 66(1) Feb 1988, 319-322.
- Zgourides, G. D., & Warren, R. (1990). Propranolol treatment of paruresis (psychogenic urinary retention): A brief case report: Perceptual and Motor Skills Vol 71(3, Pt 1) Dec 1990, 885-886.
- International Paruresis Association
- European Paruresis Association
- United Kingdom Paruresis Trust
- NHSDirect Site - reference to paruresis
- American Urological Association - Paruresis
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