Paruresis

Template:Search infobox Steven C. Campbell, M.D., Ph.D.

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Overview

Paruresis (IPA Template:IPA), also known as pee shyness, shy kidney, bashful bladder, stage fright, urinophobia 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. The analogous condition that affects bowel movement is called parcopresis.

Impact

Many people have brief, isolated episodes of urinary difficulty in situations where other people are in close proximity, 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. Paruresis can be mild, moderate or severe. In mild cases, paruresis is an occasional event, like a form of subconscious performance anxiety. For example, a man at a public urinal may be surprised to find it difficult to urinate when flanked by other men, possibly because he may be worried about them seeing his penis, while others may find that they are unable to urinate while in moving vehicles. In severe cases, a person with paruresis can urinate only when alone at home.

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.

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.

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 Psychology 51:19-29. They surveyed 1,419 college students and found 14.4% had experienced paruresis, either incidentally or continuously.

General recognition

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. 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.

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.

In DSM-IV TR, it is classified as a social phobia.

Context and urine samples

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.

The codes and procedures for drug testing in sport are set by the World Anti-Doping Agency ("WADA"). 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 athletes, and it is believed by some that this is because sufferers avoid activities where they know they will be required to submit to such testing without the right to choose an alternative testing method. If that is correct, then there might well be a vicious circle which would be of the nature of potential world class athletes who are sufferers being deterred by the testing regime, whilst the testing regime does not cater for the condition because it has not encountered sufferers.

Treatments and strategies

There are a number of "work-arounds" that address the symptom and not the problem:

• drinking less fluid and emptying out whenever 'safe' (although this can be dangerous and lead to dehydration)
• avoidance of large or busy public restrooms
• finding less-busy or single-occupancy restrooms
• returning to a specific bathroom or stall which is familiar and feels safer
• using bathrooms on other floors or in other buildings to avoid familiar persons
• timing bathroom visits to avoid the presence of others (solitude)
• timing bathroom visits to correspond to heavy usage by others (masking effect from noise, greater anonimity)
• tickling the buttocks
• running the tap or flushing to mask urination sounds
• thinking about water flowing
• using a catheter
• using a stall instead of a urinal
• closing ones eyes and imagining no one is there
• focusing on a single point or thought (with or without eyes open)
• holding one's breath, forcing urination to begin before the next breath is taken
• combination of two or more of the preceding techniques

Actual treatments for the condition include:

• cognitive behavior therapy,
• training with biofeedback,
• anti-anxiety medications, 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.

Cultural references

• (1966) In the 1966 spaghetti Western The Good, the Bad and the Ugly, the character played by Eli Wallach pretends that he can't urinate while the man holding him captive is watching. (They are handcuffed together.) When the captor averts his eyes, the Wallach character slugs him.
• (1968) In the 1968 Gore Vidal novel Myra Breckinridge, Rusty has difficulty giving a urine sample, saying he is 'pee-shy'.
• (c. 1981) In the 1980's television series Hill Street Blues, the shyness of the character Officer Joe Coffee (played by Ed Marinaro) is in part developed by his admission that he can't pee in public.
• (1988) In "The Mezzanine" by Nicholson Baker, the character experiences paruresis and explains that vizualising himself peeing on his neighbour's shoes helps a lot in these situations.
• (c. 1993) In the television series Frasier, Dr. Niles Crane admits to having "shy kidneys".
• (c. 1993) In The Simpsons episode Homer Goes to College Benjamin admits "Someone knocked on the door and I couldn't go!" after Lisa asks why he "needs to go to the bathroom" again, even though they "just stopped five minutes ago".
• (1994) In an episode of Beavis and Butt-Head, the title characters ask David Van Driessen how to urinate. They are sent to see Principal McVicker, who tries to explain, but stutters and cannot finish the explanation. The boys are then forced into the bathroom with Coach Buzzcut, who commands them to "unzip your pants, pull out your penises, and leak!" When the dimwiitted duo cannot expel the urine, they are left standing at the urinal. The boys are sent to a urologist, and when soothing music is played, they begin to wet their pants.
• (1996) In the movie Big Bully, one of the children states that he has a shy bladder and can't go when "everyone is standing around him like its a barnyard trough."
• (c. 1996) The band Pansy Division recorded a song entitled "Pee Shy" on their album Wish I'd Taken Pictures.
• (1997) In the 1997 novel "Empire State" by Colin Bateman, the character Nathan Jones is having problems urinating at a Woody Allen gig because of another man in the room, who Nathan realises is also not urinating. It turns out to be Woody himself, also (fictionally) a 'drier', having the same problem.
• (c. 1997) In an episode of Buffy The Vampire Slayer, the character Jonathan cannot urinate because another character is talking in the other room. As a result, Jonathan asks the person in the other room to stop talking.
• (c. 1998) In an episode of Suddenly Susan, Susan Keane (portrayed by Brooke Shields) alleges that Jack Richmond (portrayed by Judd Nelson) cannot use a urinal (with other people present) because he gets stagefright. Richmond counters that he often wears expensive suits and he is just trying to avoid backsplash.
• (1999) In the 1999 film Trick, Christian Campbell's character Gabriel, is unable to urinate at a restroom urinal in the presence of a drag queen (played by Miss Coco Peru). This prompts her to mention that he is "pee-shy" and turns away so that he can proceed to urinate.
• (1999) In the 1999 film Fight Club, the character Tyler Durden states he cannot urinate with someone watching as he attempts to contaminate some soup.
• (c. 2000) In episode 306 of Coupling, Jeff admits that he has problems 'declenching' and is wary of 'secret listeners'.
• (c. 2001) In the television series Scrubs, the character of Elliot cannot use the bathroom while someone is talking to her.
• (2005) In the 2005 film Waiting..., Robert Patrick Benedict portrays Calvin, who suffers from paruresis.
• (2006) In the 2006 movie "Clerks 2", Jay says he has "Public Piss Syndrome," and cannot urinate in public.
• (2006) In the 2006 short film Shanks, Jack Wright portrays Rusty, who suffers from paruresis.
• (2006) The comic strip Dilbert portrayed shy bladder in a story arc that began 6 June
• (2007) Comedienne and Progressive Talk Show host Stephanie Miller commented to her listeners that she needs to "tickle her butt" to be able to urinate.

External links

• International Paruresis Association
• European Paruresis Association
• Paruresis Advice & Community Site
• United Kingdom Paruresis Trust (UKPT)
• Looks easy enough... but not for everyone
• Paruresis - A Bladder Problem