In this series, I dig a little deeper into the meaning of psychology-related terms. This week’s term is shy bladder syndrome, also known as paruresis.
Shy bladder syndrome, or paruresis, involves difficulty urinating in public settings due to fear of perceived scrutiny when others are present or anticipated to be present soon. It actually falls under the diagnostic umbrella of social phobia, or social anxiety disorder, in the DSM-5, although some experts argue that it’s a distinct condition. There’s a similar condition called parcopresis, which involves difficulty defecating for fear of public scrutiny.
While there are assorted physical conditions and medication side effects that can impact urination, those effects would still be apparent while at home alone, while the effects of shy bladder syndrome would not. It’s common to have co-occurring mental disorders, including more typical presentations of social anxiety disorder and major depressive disorder.
It’s not clear how often this actually happens, because people tend to feel embarrassed or ashamed to bring it up to their health care provider. Estimates vary from around 3-16%, but 7% was the figure that I saw pop up the most. It may be more common in males, but the difference in public washroom setups seems like it could account for that. Onset is usually in adolescence, but, on average, it takes 14 years to get diagnosed.
Contributing factors include trauma, over-controlling parents, bullying, learned associations between going to the bathroom and anxiety, and unrealistic beliefs, including distorted body image. It’s unrelated to OCD contamination fears.
Paruresis is often accompanied by other physical symptoms of anxiety. Fear of evaluation by others is a major psychological element. Other common thought patterns include concern of social reprisals and disqualification of positive outcomes, meaning positive outcomes are attributed to luck while negative outcomes attributed to one’s own actions.
Like other types of anxiety, people with paruresis tend to use avoidance strategies, which can significantly impact overall functioning, to the point of barely leaving the house. Avoidance also reinforces the anxiety in a vicious circle.
Cognitive behavioural therapy (CBT) is the main form of treatment, addressing both dysfunctional beliefs and avoidance behaviours. Self-catheterization is an option that does nothing to treat the underlying problem, but it provides a work-around that can improve overall functioning for people who are highly disabled by the condition. There’s even an International Paruresis Association, which can help hook you up with a Pee Partner (their term, not mine).
This fascinates me, because public toileting is a weird phenomenon. Or maybe I’m just on the weird side as an uptight Westerner. Urinals seem like a high-pressure situation, but that’s nothing compared to places like India where you might find an open-air public urinal at the side of the street. I like privacy to do my business. And it’s not fun when you’ve got to have explosive diarrhea and some woman is taking her sweet time touching up her makeup. Or maybe that’s TMI.
Anyway, I can see how social anxiety combined with “normal” levels of toilet weirdness could morph into something highly disordered. What are you thoughts?
- Kuoch, K. L., Austin, D. W., & Knowles, S. R. (2019). Latest thinking on paruresis and parcopresis: A new distinct diagnostic entity?. Australian Journal of General Practice, 48(4), 212-215.
- Kuoch, K. L., Meyer, D., Austin, D. W., & Knowles, S. R. (2019). Socio-cognitive processes associated with paruresis and parcopresis symptoms: A proposed bivalent model. Current Psychology, 1-7.
- The Shy Bladder Syndrome: What Is It, Why Should You Care, and How Can You Be Helpful?: A Guide for All Professionals Who Work with Children