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. It most commonly affects males, though there are female sufferers too.^{[citation needed]} 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 well 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.

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.

Some drugs can cause difficulty in urination, opiates such as heroin, hydrocodone, or synthetic opioids such as methadone in particular. It varies in severity and from person to person, but many users and abusers of these substances find themselves suffering from paruresis. Partly this is a physical side effect of these substances, but it is often seemingly a psychological symptom, directly related with "shyness", etc., like paruresis. While drugs such as heroin can make it more or less impossible to urinate, the effect can vary, and very often has a direct resemblance to "ordinary" paruresis, i.e. the user may find it impossible to urinate at all, or he/she may only be able to urinate when alone. Buprenorphine (such as in the opiate substitute Suboxone) seems to be slightly different than "normal" opiates, in that it causes symptoms more or less matching paruresis, with the difficulty directly related to psychological factors. In comparison, opiates can simply cause great difficulty regardless of things such as the presence (real or imaginary) of others. Many Suboxone users find themselves having a great deal of difficulty if they know or feel that others can see or hear them urinating. This can cause difficulties, as Suboxone (being used in substance abuse prevention programs) often requires patients to submit urine samples, which can be very difficult for many patients. Some Suboxone users never experience this, while others do only sporadically. It can affect patients even if they never had any problems with paruresis before beginning treatment. It is unclear by what mechanisms this is caused. It is certainly psychological in nature, as a person can experience it when alone, or unexpectedly have no difficulty even when others are close. Many users have found running water or other sound to "cover up" the sound of their urination is necessary, but once urine flow is finally started it will usually flow normally until completion. It is unclear as to how these chemical substances cause the psychophysical reaction described. The listing of this in the "side effects" of the medication is sporadic, with some pharmacies including it in the list of possible symptoms, while others neglect it.

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, stage fright, pee fright, urophobia, pee-shyness, public piss syndrome, shy bladder syndrome, air-blockage and psychogenic urinary retention.

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. It is now reported to have been accepted as a valid reason for jury service excusal. 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.

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 the US Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), it is classified as a form of social phobia also known as being a type of chronic social anxiety, but that is disputed by some clinicians.

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." 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," particularly when there were no medical record or physician testimony to back up the claim of paruresis. 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." 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.

The codes and procedures for drug testing in sports 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.^{[citation needed]}

Treatment

Monroe Weil, Ph.D., a psychologist, has described a method he developed for treating paruresis by the use of breath holding combined with in vivo desensitization. The International Paruresis Association, an important resource for paruretics, has information about this method on their website. Also, many videos have been posted to YouTube by various individuals demonstrating their approaches to this method. Medication is also an option, SSRI drugs like Prozac, Zoloft, Paxil, etc. can be beneficial, and benzodiazepines such as Xanax, Valium, or Klonopin can be used before the drug test or while in public to relax the muscles and bring the anxiety level down enough to where you can produce a sample.

In popular culture

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

• An series 5 episode of the TV show Screenwipe presented by Charlie Brooker uses paruresis as a subject in a parody of 'mission-documentaries' fronted by Konnie Huq. Although the concept of mission-docs is being lampooned, it appears that information about and interviews with sufferers of the condition are genuine.

• In the children's TV cartoon Chowder in the episode "The Vacation", the titular character is shown to have severe paruresis when he becomes locked in a bathroom with Mung Daal and Schnitzel while having to urinate, but can't do it because of the lack of privacy. In a comedic scene, Chowder makes the other two turn around, cover their eyes, and even sing out loud to drown out the noises of the urination, but it doesn't work, causing Chowder to then inflate to a huge size with urine. They then all fear that Chowder will "explode" and the other two characters will drown in urine, and the rest of the episode focuses on this fictional crisis.

• In the 2011 comedy movie The Change-Up, the protagonists Mitch and Dave, who have switched bodies paranormally after urinating in a fountain and wishing they had each others' lives, have to urinate in the same fountain again to revert back to their original bodies. They find the fountain has been moved to the inside of a shopping mall, where they have to expose themselves and do this in full public view with security guards in pursuit. Mitch in Dave's body has trouble urinating claiming to be completely "locked up" because of all the horrified onlookers. Once the two characters resolve their conflicts, Mitch in Dave's body is then released from the paruretic symptoms and they complete the wish to change back. After this, the lights all go out, giving them an escape. (It remains unclear whether the paruresis was associated with Mitch's consciousness or Dave's body.)

See also

• The Sound Princess

External links

• International Paruresis Association
• United Kingdom Paruresis Trust (UKPT)
• Can Shy Bladder Be Cured?