Paruresis (// 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 or shy bowel.
It appears that paruresis involves a tightening of the sphincter and/or bladder neck due to a sympathetic nervous system response. The adrenaline rush that produces the involuntary nervous system response probably has peripheral and central nervous system involvement. The internal urethral sphincter (smooth muscle tissue) or the external urethral sphincter (striated muscle), levator ani (especially the pubococcygeus) muscle area, or some combination of the above, may be involved. It is possible that there is an inhibition of the detrusor command through a reflex pathway as well. The pontine micturition center (Barrington's nucleus) also may be involved, as its inhibition results in relaxation of the detrusor and prevents the relaxation of the internal sphincter.
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.
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 first experience the problem when they "lock up" for the first time attempting to produce a sample for a drug test or alcohol 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.[example needed]
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.
Sometimes paruresis can be overcome by someone nearby turning a water tap/faucet on and letting the water run noisily.
A possible cause of paruresis is undergoing a voiding cystourethrography (VCUG) in the past. "Complications that can occur in both sexes include UTI, hematuria, cystitis as well as urinary dysfunction following a catheterization, phobia of urination, nocturia, and stopping urination. In the literature, psychological trauma resulting from VCUG was considered the same as from a violent rape, especially in girls."
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.
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. The current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) mentions paruresis by name.
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." 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. 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.
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. 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.
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." At least six state prison systems — Florida, Massachusetts, Maryland, Michigan, New York and Tennessee — have modified their drug testing regulations to provide accommodations for prisoners with paruresis.
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."
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. The International Paruresis Association provides a detailed discussion of this method on its website. In addition to gradual exposure therapy, cognitive behavioral therapy is used to change a sufferer's mental approach to the condition, 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.
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.
Paruresis is also known by many colloquial terms, including bashful bladder, bashful kidneys, stage fright, pee-shyness, and shy bladder syndrome.
In popular culture
The condition has been occasionally portrayed in popular culture, sometimes for comedic effect or parody. Examples of this include:
- In the 1978 Cheech & Chong film Up in Smoke, Cheech's character, Pedro, tells a police officer in a public restroom that he has "stage fright". He is then able to urinate after the police officer turns on a water faucet.
- In a 1995 episode of the first season of Friends, Chandler pesters Joey, while the latter tries to urinate. Joey begs Chandler to cease the disturbance, claiming that he needs to concentrate in order to urinate. In another episode, Monica is stung on the foot by a jellyfish, and Joey is unable to urinate on it to soothe the pain, so Chandler comes to the rescue.
- In a 1999 episode of The Tom Green Show, Glenn Humplik, Green's co-host, is unable to urinate because Green insists on filming him while he does so. The camera follows Glenn as he tries to get away until he manages to sneak into an office at a gas station and urinate inside.
- In the 1999 film Fight Club, Tyler Durden says to the narrator "do not watch, I cannot go when you watch" in a scene where he is a waiter, attempting to urinate into the food he will be serving.
- Throughout the 2001 - 2010 comedy series Scrubs, the central character, Dr. John "J.D." Dorian, suffers paruresis whenever he is in the presence of his mentor's ex-wife, Jordan Sullivan. In addition, one episode focuses on characters Perry Cox and Christopher Turk, and the former's inability to urinate when he is around the latter.
- In Neil Strauss' 2005 book The Game a pick-up artist under the alias "Extramask" confides in Strauss about his inability to urinate in public. Later, he overcomes the phobia by regaining confidence in his ability to urinate.
- In the 2005 comedy Waiting..., Calvin's paruresis is depicted as a major problem in his social life. The 2009 sequel, Still Waiting..., shows how once the problem is overcome, Calvin's life changes completely.
- In a 2006 comic strip Dilbert, the namesake of the strip is required to give a urine sample at work and he says that he is unable due to "shy bladder". His pointy-haired boss asks if his paruresis is a side effect of the "nose candy".
- In a December 2008 episode of the satirical BBC Four review show Charlie Brooker's Screenwipe Konnie Huq hosts a mock version of a "mission documentary" entitled Konnie's Great British Wee, in which she claims to be on a mission to combat paruresis in males.
- In 2015, the International Paruresis Association protested a DirecTV ad starring Rob Lowe that portrayed a paruretic as goofy, wearing a fanny pack, and having his hair parted in the middle.
- Soifer, Steven; Nicaise, Greg; Chancellor, Michael; Gordon, David (2009). "Paruresis or Shy Bladder Syndrome: An Unknown Urologic Malady?". Urological Nursing. 29 (2): 87–94. PMID 19507406.
- Paruresis - shy bladder syndrome - Better Health Channel Archived 2 September 2006 at the Wayback Machine
- Azarfar A, Esmaeeili M, Farrokh A, Alamdaran A, Keykhosravi A, Neamatshahi M, Hebrani A, Ravanshad Y (May 2014). "Oral midazolam for voiding dysfunction in children undergoing voiding cystourethrography: a controlled randomized clinical trial". Nephro-Urology Monthly. 6 (3): e17168. doi:10.5812/numonthly.17168. PMC 4090665. PMID 25032141.
- "NHSDirect Site - reference to paruresis". Retrieved 5 August 2018.
- "Projects". UKPT - United Kingdom Paruresis Trust - Shy Bladder Syndrome Support. Retrieved 5 August 2018.
- American Urological Association - Paruresis Archived 28 July 2009 at the Wayback Machine
- "300.23, Social Phobia (Social Anxiety Disorder". Diagnostic and Statistical Manual of Mental Disorders (4th (Text Revised) ed.). American Psychiatric Association. 2000. p. 453.
- Antonio Prunas (July–August 2013). "La sindrome della vescica timida". Riv Psichiatr. 48 (4): 345–53. doi:10.1708/1319.14632. PMID 24056834.
- "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'.)
- Benjamin J. Sadock; Harold I. Kaplan; Virginia A. Sadock. "16.3 Specific Phobia and Social Phobia". Kaplan & Sadock's Synopsis of Psychiatry. p. 597.
- 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.
- 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.
- Code of Federal Regulations, Title 28: Judicial Administration, Part 550—Drug Programs, Subpart D—Urine Surveillance, § 550.31 Procedures
- Medard v. Doherty, 2007 NY Slip Op 32130 - NY: Supreme Court, New York 2007
- In the matter of Becker v. Goord, 13 AD 3d 947 - NY: Supreme Court, Appellate Div., 3rd Dept. 2004
- "FAQ - International Paruresis Association (IPA)". International Paruresis Association (IPA).
- Meeks v. Tennessee Department of Correction, Tenn: Court of Appeals, Nashville 2008
- Federal Bureau of Prisons (24 November 1999). "Urine Surveillance and Narcotic Identification" (PDF).
- 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.").
- "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.
- "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 (1 June 2011). "Policy #506.21(VI)(B)(9), Inmate Drug/Alcohol Testing and Sanctions" (PDF).
- Soifer, Steven (2001). "Evolving Legal Ramifications". Shy Bladder Syndrome. New Harbinger. p. 98. ISBN 978-1-57224-227-2.
- Scott, Charles L. (15 October 2009). Handbook of Correctional Mental Health (2nd ed.). American Psychiatric Publishing. ISBN 978-1585623891.
- 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.
- "Breath-Hold Technique - International Paruresis Association (IPA)". International Paruresis Association (IPA).
- "The Tom Green Show". YouTube. Retrieved 9 October 2015.
- Strauss, Neil (2005). The game: penetrating the secret society of pickup artists (1st ed.). New York: HC. ISBN 978-0060554736.
- Scott, Adams. "Dilbert". Universal Uclick. Retrieved 21 October 2011.
- "Screenwipe, episode 4, series 5 – British Comedy Guide". The British Comedy Guide. 9 December 2008. Retrieved 4 December 2011.
- "Shy bladder group protests DirecTV ad starring Rob Lowe". www.usatoday.com. Retrieved 19 January 2016.