Insights into Psychology

What Is… Paruresis (Shy Bladder Syndrome)

Insights into psychology: Paruresis - toilet sign male/female with legs crossed

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?


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32 thoughts on “What Is… Paruresis (Shy Bladder Syndrome)”

  1. I think I basically have this. I haven’t been able to use urinals in public toilets if other people are around since childhood. I’m OK with cubicles (although it can be hard if the lock is broken), and I’m slowly becoming OK with urinals if no one else is around. It’s not a huge problem unless the cubicles are all taken, although I do wonder sometimes what I would do if I was supervising a young child and needed to go. Also, as well as a shy bladder, I think I have a fairly small bladder, as I need to pee quite regularly, which can also bring problems that interact with this.

  2. I’ve always thought of this as a guy’s problem and not a major one at that – unsympathetic me! I avoid public restrooms because the germy aspect also – talk about paranoia – I don’t feel safe in them, I’m always thinking I’m gonna get mugged. I think all public restrooms should be single use – one person at a time, lock the door!

  3. Huh. Interesting!! I’ve never thought about it, but I get a little shy if I’m at someone’s house and I fear they can overhear me. And I’m usually okay with most public facilities, but there are some exceptions. If there’s too much space to see between the slats, then I’m an unhappy camper. I think things should be better designed than that. It makes a difference if I’m among strangers versus being social with people I know, although that whole trope of girls going to the bathroom in groups seems hilarious to me. Like, “Let’s all go to the bathroom together!” I dislike single bathroom stalls where it’s one room. My issue is that if someone accidentally walks in on you (although I’d definitely lock the door), then the whole freakin’ restaurant can see in. To me that would be the worst. On the other hand, I do think the single rooms are beneficial for gender identity issues as being a gender neutral space. One thing that weirds me out is the restrooms at the local mall. They’re far down a long dimly lit corridor, which to me seems dangerous and poorly thought out. I’ve heard that in Japan they have super toilets that block out any sound. Nice!

  4. I can see how this could happen. Anxiety can make it difficult, and if compounded by the almost unavoidable fear that someone might be about to observe the activity, one might well freeze. In fact, it’s vaguely in my memory of something like that happening to me — though many many years ago, and no doubt under the influence of some ungodly chemical.

  5. I had a female cousin with this disorder. Luckily, her husband was wealthy enough to literally rent a motel room anytime she had to go when they were out. I like to be alone in a public bathroom, but it’s not the hugest deal if someone walks in. I’m mostly thinking about germs, not them hearing me…

  6. I am generally ok with public toilets, unless I am in a bit of a situation with the number two and I am aware someone decided to use the cubicle next to me, when they came in. Then I get a little uncomfortable.

      1. Yes it feels like that doesn’t it. Makes that feeling worse knowing that when you went in, there were plenty of cubicles for the next person to pick from, but they chose the next one to you.
        I always pick a cubicle, where I miss one at least from the occupied one.

  7. It doesn’t approach the level of disorder for me, but I do have trouble peeing if some bitch is out there doing a makeup touch-up. Its not a problem if a bunch of girls are talking or whatever, but when its quiet and it’s one person. I have literally flushed without going and found a bathroom elsewhere in some cases. That was primarily the reason I ditched res treatment. Someone sat at the door, waited for you to go and then went and LOOKED at your toilet production to make sure you didn’t puke. All of that was horrifying for me. So like it’s not a full on disorder but I am kind of somewhere in that neighborhood for sure.

    1. Yeah, a lot of the things they do as “treatment” for eating disorders approach torture. I never had that one, and I’m grateful. ❤️️

      1. The best part is that I have ARFID so it’s wholly unnecessary. But as I think about it, I think it would bother me no matter what I had because they are saying “we don’t trust you”. How about just kick out the bitches who can’t be trusted and let the others go to the bathroom in peace.

          1. That would be nice, but since ARFID is less common than the others, they can’t justify a whole program for it. At least not yet. It’s also an insurance coverage matter. I complained and the lady told me that they could move me to a “higher level” which involves less monitoring and no bathroom checks, but if they moved me up too fast the insurance company would refuse to cover my stay and say that higher level care isn’t necessarily. To which I replied, “well maybe they know something and I don’t belong here” to which she smiled and said that they know a little more about eating disorders than the insurance company does. That was the other thing that pissed me off enough to pack my shit and go. They have to game the insurance like that to get ARFID covered. So they lie for at least 2 weeks just to get it covered.

        1. Yup. They wholly underestimate the ability of the ED sufferer to get around the restrictions if they want.

  8. It’s so interesting to see a post done on this as I literally just heard of it for the first time in the current book that I’m reading. Definitely fascinating!

  9. I’ve never heard either of paruresis or shy bladder syndrome, but I can see how such a thing may develop in people because public restrooms are so awkward, weird and stressful. I think I may have something like this myself although to a very small degree which is not disabling or impacting my quality of life or anything, definitely wouldn’t make to the top of my mental health-related difficulties list and I don’t even think about it a lot, probably largely because I can quite easily avoid situations involving this most of the time. My Mum – who does not have social anxiety or any other mental illness at all but is and has always been rather self-conscious – hates public restrooms and will always avoid them even more desperately than me, and not go into someone else’s toilet unless she really really can’t do otherwise, which is her main reason for why she thinks she’s very odd.
    What makes me avoid public restrooms or at other people’s houses is both the pee aspect, that someone would hear it and because it feels very awkward in general; as well as the germ/emetophobic aspect. I sometimes even have a bit of a problem going to my own loo when we have guests and I believe they could hear me doing my thing or want to go to the loo while I’d be in there, not because they’d be able to get in as of course I’d lock it but just because it would feel weird, even though we have two toilets so it’s not like it would be a real problem. When I had tutors who would come to my house regularly at a set time, I would avoid going to the loo directly before our lessons because I’d be afraid that they would come while I would still be in there, not to mention that I’d never go in the middle of a lesson, so I had to do it in advance at least half an hour before the start. And when I was at school, I would avoid peeing there for all cost too, even if it meant I had to hold it in and couldn’t focus. I did however of course have to get used to doing it in the boarding school and most of the time it wasn’t a big problem unless someone else other than my roommates were in our room.

    1. It’s strange how we humans have issues around toileting when our furry friends couldn’t care less. My girls have a mild preference to pee/poop in the their cage rather than on me, but pretty much as soon as I take Butternut out of his cage he starts pooping.

      1. Hahahaha! I think not even furry friends are always free from weird toileting problems, because my Mishmish is very used to his toileting routine. He always has to have the same litter or else he will hold it in, supposedly until the end of time. It’s actually quite problematic because he was about to have a urine sample collected some time ago and that was simply impossible because he wouldn’t pee in that pseudo-litter thing wwhich is used to collect the sample more easily. Apparently most cats are easy to cheat that it’s actual litter, but not Misha the Tsar! He was very nervous and erratic but wouldn’t relieve himself until Mum replaced it with his litter. And if for some reason he is unable to pee in his proper toilet or doesn’t feel safe doing so (like when we had another little kitten – Sasha – for a while) or something, he just won’t as long as he can. Now that I think of it, my late horse was the same. He would never just poop wherever, during work time, he either needed a poo break and always took his time with it very freely, or only did his thing after we were finished. 😀

  10. Its so interesting to read this! Never heard about this before, although i see people experiencing this due fo their OCD but never really knew it hab a term! Thank you for shining a light on this interesting topic😄. It was a good read👍🏻

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