Paruresis, also known as shy bladder or pee shyness, is a form of social anxiety disorder. A person fears being unable to urinate in the presence of others, typically in public restrooms. About 21 million Americans or roughly 7% of the general population suffer from this disorder. It affects both men and women; however, given the set up of public restrooms, men tend to have a higher prevalence.
Primary paruresis is the physical act of being unable to urinate when needed. The inability to urinate could be the result of physical abnormalities, the side effect of medication (such as opioids and antihistamines), or the body’s response to extreme fear, i.e. the fight-or-flight response. Secondary paruresis is the meaning that one gives to their inability to start the flow of urine. Specifically, the paruretic experiences significant anxiety over the possibility of being judged by others. The fear is centered on what others’ would think if the paruretic were unable to initiate the flow of urine. The judgments include: “They’ll think there’s something wrong with me if they don’t hear peeing.” “I’ll be judged as less of a man if I can’t urinate where others can.” Also, the anticipation of not knowing if one will be able to urinate can exacerbate anxiety and self-consciousness; hence making the act of urination difficult if not impossible.
As with all mental health concerns, the severity of paruresis varies from person-to-person. Some paruetics are mildly inconvenienced by the occasional inability to urinate in specific settings, i.e. sports arena restrooms with long lines of impatient fans waiting for the urinal. Others experience significant impairment in most settings when faced with the need to urinate. These individuals can become housebound as they fear needing to void without having a “safe” bathroom within close reach. People who undergo urine testing for employment are also greatly impacted. Others may avoid long airline flights for fear of enduring the painful experience of not being able to urinate.
Cognitive Behavioral Therapy (CBT) is helpful in reducing the impact of paruresis. Graduated exposure (GE), one of the powerful ingredients of CBT, helps paruretics learn new associations between the feared stimulus (restrooms or situations that previously elicited extreme anxiety) and the ability to successfully void. When anxiety is heightened due to either the inability to urinate in the presences of others (primary paruresis) or the false meaning assigned to not being able to urinate, i.e. “I’m less of a man,” etc. (secondary paruresis), the brain triggers a physiological reaction that constricts the bladder’s ability to void. Through repetition, the paruretic learns to manage anxiety and to retrain the brain-bladder connection by learning that the feared stimulus is not something to be feared.
Those concerned with paruresis should first visit their primary care provider or urologist to rule out medical causes. Well-trained CBT therapists at Pacific CBT have expertise treating paruresis. Both individual and group therapy could be helpful in addressing this issue.
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