"I know it sounds crazy, but when I am in the rest room and someone comes in, I feel like that person’s focus is on me and what I am doing, even though they obviously came into the rest room to tend to their own physical needs. It feels like they are thinking about what I am doing, how long I am taking, how much I am going, and whether or not what I am doing is ‘normal.’ It makes me very self-conscious, and I can feel myself freeze up. Then, I just can’t go, because I’m worrying about whether or not I measure up to what they think is okay, even though the truth is, they probably never even noticed I was there" (Soifer, Zgourides, Himle & Pickering, 2001, p. 12).

This is a quote from my journal, dated June 6, 2002. I am currently a junior in college, and I suffer from the social phobia known as paruresis (informally called bashful bladder syndrome), or the inability to urinate in certain social situations. Although I have suffered from a mild form of this phobia for many years, it did not become apparent to me that it was exerting control over such a large part of my life until I left for college. At that point, the anxiety continued to increase in severity and I sought help in the middle of my sophomore year. This was the first time that I had been treated by a mental health professional. Since then, I have learned more about the disorder and the treatment possibilities and have worked hard at finding ways to both cope with and improve my condition.

At the point that I began my therapy last year, I was given the following DSM-IV diagnosis:

Axis I: Social Phobia

Axis II: none

Axis III: none

Axis IV: separation from family and home, sexual development, family stressors

Axis V: GAF at present: 65; highest level past year: 80

Currently, the DSM-IV diagnosis remains the same, except for the global assessment of functioning, which has been raised to approximately 70 at this point. Due to the nature of the disorder, however, this measurement is only indicative of very specific patterns of functioning in my life, as it affects some aspects tremendously while not influencing other aspects in any way.

The DSM-IV separates the social phobias into three different categories: performance type, limited interactional type, and generalized type (Schwartz, 2000, p. 153). Paruresis falls into the performance type of social anxiety, in which the "phobic stimulus involves public performance of activities that can be engaged in comfortably if the individual is doing them while alone" (Schwartz, 2000, p. 153).

I have experienced many symptoms as a result of my social anxiety, some which are common to many paruretics and others that are unique to my own life experience. My symptoms match the DSM-IV criteria for a social phobia; specifically, for paruresis. These symptoms can be best understood through the work of Soifer et al. (2001), who has written the most comprehensive book on paruresis to date. In general, I suffer from the inability to urinate in the presence of others. The types of people who cause the most anxiety have changed throughout the years. Currently, I am able to void most easily in situations where I am surrounded by strangers or close family members. The most difficult circumstances are those in which close friends or mild acquaintances are present. I also experience anxiety and problems urinating when I feel rushed, pressured or judged by others or when loud noise is present. Additionally, if I am experiencing other excessive psychological states, such as sadness, frustration, agitation, arousal or apprehension, I am often unable to void.

In my mind, I am able to determine how ‘safe’ I feel in a situation by the types of boundaries that are present. These include both physical and mental boundaries. For example, stalls that are missing doors lack visual boundaries and thus cause extreme anxiety, while stalls with thick, wooden doors make me feel more protected and safe. If the bathroom is set up with the sinks in front of the stalls, there is an increased chance of a person standing directly in front of my stall, another source of anxiety. I prefer to use stalls in the corners or backs of restrooms, as far away from other individuals as possible. My anxiety is often reduced if there is a soft, continuous noise in the bathroom, such as music, water from the sink, or a dryer, because this creates a sound boundary and it is less likely that others will hear me urinating. I also like to keep mental and emotional boundaries from people. If I speak to another person in the bathroom, make direct eye contact, or experience another type of interaction, the anonymity between us decreases, and I have more difficulty subsequently urinating. I prefer in this situation not to let other people into my world, and to take care of what I am doing without any external influences.

It is difficult to pinpoint precisely what thoughts I have that cause the anxiety, although I have worked hard over the last year to understand this. I have determined that I experience the highest level of anxiety when I think that people can hear me urinating. Again, the reality of the situation is irrelevant; only my perception influences my anxiety level. I am concerned that others are negatively evaluating me or the way that I am "performing." I experience a type of egocentric paranoia, in which I am certain that other people are having thoughts about the way I am urinating, regardless of who they are or what they are doing. This leads to anxiety, often marked by slight trembling or shaking, an increased heart rate and perspiration, and freezing up, which result in an inability to urinate. I am often almost scared to get "caught," "mess up" or be "discovered," as if the activity I am doing is somehow wrong. While I recognize that this fear is irrational, that knowledge is not enough at this point to help me urinate. The anxiety and inability to void lead to a pattern of avoidance and panic that has affected my life significantly.

I am often forced to try several different bathrooms before finding one that is suitable. I look for bathrooms that are far away from other people and from noise. Many times, I walk into bathrooms and walk right back out if there are people present. Other times I wait by the sink or in the stall until they leave and then urinate. When I travel with friends or sports teams, I often go for long periods of time without urinating and usually dehydrate myself to make this easier. The longest I have waited was approximately 13 hours. Occurrences such as these can lead to headaches and stomach pains, and I sometimes have symptoms of a bladder infection for the next few days, but I have never suffered from an actual urinary track infection or other diagnosable medical condition. I search out private restrooms in public places and, after having been to a bathroom once, will forever remember where it is and what it looks like. I know which restaurants and gas stations have ‘safe’ bathrooms on long drives that I make repeatedly, and can often keep track of which bathrooms will be empty at certain times of the day in places that I attend frequently. I have had to change plans with friends, decline social invitations or not eat and drink when I wanted to in order to cater to the needs of my anxiety. It has affected where I live on campus and the types of summer plans I have been able to make, in addition to daily life decisions. Bashful bladder syndrome affects every second of my day. It influences my decisions on which direction I walk in to class, what times I meet people, the order of my daily activities, and what social gatherings I attend. I often compare the feeling I have when drinking fluids to the experience of an individual suffering from anorexia eating food. With each sip, I think about the consequences of my action. Every sip of liquid that I take will make the rest of my day more difficult and will significantly increase my suffering later on; I often berate myself for drinking too much. I obsess about these consequences and my willpower in being able to not drink for long periods of time. These feelings are intensified in situations in which it will be hard for me to find a restroom. Soifer et al. (2001) writes, "The truth is, living with BBS [bashful bladder syndrome] is nothing short of a nightmare from which you never wake up. It is impossible to avoid the problem, simply as a function of the physical necessity of daily voiding" (p. 85).

There is currently no consensus about the etiology of paruresis (Soifer et al., 2001). Most researchers have concluded that the biopsychosocial approach is the most appropriate, yet this encompasses many different theories within each of the three factors (biological, psychological and social). In terms of biology, researchers may take either a neural or genetic perspective. The neural perspective attributes bashful bladder syndrome to nervous system activity, while the genetic perspective argues that there may be a genetic predisposition to developing paruresis (Soifer et al.).

Psychological influences also play a role, yet there are many different theories as to why and how this occurs. As argued by Soifer et al. (2001), these differences are, for the most part, based on traditional theoretical orientations. For example, the psychodynamic perspective maintains that anxiety is due to repressed conflicts and motivations. The cognitive approach argues that faulty cognitions such as embarrassment or tension can inhibit relaxation and lead to hesitancy in urinating. From an existential-humanistic perspective, paruretics have a damaged sense of self-acceptance that needs to be reworked and understood in a new light.

The approach that has gained the most support and has had the most success in therapy has been the cognitive-behavioral perspective. Cognitive-behavioral theorists maintain that a combination of faulty cognitions and learned experiences result in the development of paruresis. The learned experiences may be a single traumatic event or repeated patterns of behavior. Through classical conditioning, operant conditioning and observational learning, the patterns of behavior in which an individual is initially afraid and then avoidant become cemented (Soifer et al., 2001).

The social aspect of the biopsychosocial model is concerned with the way that different cultural norms and standards interact to produce certain environments. Researchers may address cross-cultural differences in the way restrooms, urinating, defecating and other bodily functions are viewed. Additionally, the social perspective examines how animals, specifically other mammals, approach the process of voiding and how this may relate to human voiding (Soifer et al., 2001).

Using the biopsychosocial approach, it is possible to draw conclusions about the etiology of my anxiety. Biologically, I may have a genetic predisposition to developing anxiety disorders. My mother has suffered from agoraphobia with panic attacks for many years, and has recently been prescribed an anti-depressant medication. Psychologically, my therapist and I have taken the cognitive-behavioral perspective to understand the causes of my anxiety. First, I have a fear of negative evaluation by others and am very sensitive to criticism and embarrassment, especially by people who are close to me or who may have some influence on my life. I am afraid of negative judgment by others, primarily people who are important to me. Subsequently, I am less concerned about the judgments passed by strangers (and do not worry that close family members pass any judgment at all). Often, certain friends will seem less threatening if they do not appear to be as judgmental. Second, I can remember a traumatic experience that occurred when I was eight years old that I believe was the origin of my anxiety in restrooms. I was with my father at a Broadway show and was forced to use the restroom alone during intermission. I can very vividly remember the bathroom. There was a long line of people waiting to use a single stall, which was elevated on a type of platform. After waiting in line, each person climbed the stairs, used the toilet, and the next person was able to go. There was a sense of urgency and pressure because of the amount of people who were waiting, and also a sense of performing in which one could be negatively evaluated, because of the way people were watching and waiting as you ascended the stairs, used the bathroom, and descended again. I remember being apprehensive about being alone and nervous about everyone waiting for me. I was unable to go and was forced to sit through the second act of the show having to urinate. I believe that this started a pattern of fearing the bathroom when there were other people present and also being concerned about the implications of not being able to go in certain situations. These symptoms and feelings grew progressively worse throughout middle school, high school and college, until I sought help for the anxiety. My therapist and I have concluded that the symptoms grew worse when I left for college because of my changing psychosocial environmental factors, coded on Axis IV. For example, I was experiencing slight adjustment and separation anxiety, exploring my sexuality, and facing tension with my parents as I struggled through the process of individualization. These stressors perpetuated and increased my anxiety. In terms of social causes, the negative stigmas attached to urinating, defecating and other bodily functions in our society may have attributed to or perpetuated my fears and symptoms.

Based on the support for cognitive behavioral theories on the causes of paruresis, the most appropriate treatment plan subsequently stems out of this orientation. Initially, it is crucial for the patient to recognize that he or she is suffering from a type of social phobia. Part of this acceptance may include telling other people, perhaps family members, significant others or close friends. The paruretic must relinquish personal responsibility for the etiology of the disorder, but also claim responsibility for treatment. The next step taken by the paruretic should be the creation of an anxiety hierarchy, in which the client identifies the situations that cause anxiety and rates them in terms of difficulty. After the hierarchy has been created, the paruretic is able to begin graduated exposure therapy, which has been the most successful treatment for bashful bladder syndrome (Soifer et al., 2001). The paruretic uses the anxiety hierarchy to construct practice situations, in which she or he slowly increases the level of difficulty, focusing on achieving a high rate of success. In addition to exposure therapy, cognitive restructuring therapy, in which the client identifies faulty cognitions and works to adjust these, has proven to be useful (Soifer et al.). Relaxation training and support groups are also often used to help paruretics.

I have been in treatment for approximately one year and have applied many of these techniques, with the help of my therapist, to combat the paruresis. One of the first steps I took was to create my anxiety hierarchy, which I continually reassess and reform, based on my current status. After making the hierarchy, I identified situations that could serve as potential practices. I began by practicing in my own house with my mother, the least ‘threatening’ person. We scheduled practice sessions each day in which we slowly increased the difficulty level. This was done in a variety of ways; for example, she gradually moved closer to the bathroom, we progressively opened the door more, and she would talk or make loud noise. Eventually, I was ready to practice with other members of my family, and then move out of the house to situations in the local malls or restaurants. Additionally, I spend time with my therapist discussing the traumatic experience I had when I was younger, which may or may not have contributed to my paruresis. We also work in-depth on my cognitions, such as my attitude towards urination, bodily functions, negative evaluations by others, and the way I approach the practices. I have spent time learning relaxation methods from my therapist as well as meditation and relaxation groups. In addition to this combination of therapeutic techniques, I have worked at being mindful of what I am doing. This includes focusing on the present moment and not drifting away into another time or place. I try to listen to and observe the sounds, sights and smells around me to truly exist in that moment. As Soifer et al. (2001) has argued, distraction has proven to hinder the progress of a paruretic in the long run (though it may be helpful and enticing in the moment), and so being mindful forces me to limit the distraction techniques that I often like to use.

My treatment has been slow, but increasingly steady. I believe that this is the best treatment plan for me because its development has been based on the research and has been an interactive process between my therapist and myself which, in my mind, is the only way for therapy to truly be successful. The most difficult part was motivating myself to do my practices everyday. It took a long time for me to accept my illness and to understand that the only way I would see improvement was when I put time in each day to practice. With the support of my therapist and my family, I have been able to reach out to friends and other resources around me to help aid the process. It has been a challenge to ask for help, but I have learned that it is the only way to be successful. Also, the relaxation techniques that I have practiced have been extremely effective. In order to increase my willingness to do practices everyday, I instituted a system of self-reward, which works through positive reinforcement. Similar to the Alcoholics Anonymous approach, I keep track of subsequent days that I have done my practices. I wanted to encourage myself to be satisfied with the fact that I did the practice, instead of focusing on the actual success of each practice. I add up subsequent practice days, returning to zero if I miss a day. I am rewarded as I go along, at 30 days and again at 50, for my ongoing dedication. I currently have 42 days and am continuing to work hard. I believe that the only thing missing from my treatment plan is involvement in a support group or development of a relationship with another individual struggling with paruresis.

Research by Soifer et al. (2001) has shown that graduated exposure therapy is successful in 75-80 percent of cases (p. 51). There has been little empirical research, but studies to date indicate that relapse is likely, especially during times of high stress (related or unrelated), and so follow-up therapy and support groups are recommended. To reduce the rate and severity of relapses, paruretics are encouraged to continue doing practices in what Soifer et al. labels the "maintenance phase" (p. 47).

When initially beginning therapy last year, I was confident that I would be able to "solve" my problem quickly and move on with my life. I soon realized that this was my life, and that progress would be slow and often move backwards. It is important that I continue looking at the big picture, because otherwise my motivation disappears. I have worked for over a week in order to open the door just one more centimeter or have another person move one centimeter closer. If I stay too focused on the particular practice, I can get discouraged at my apparent lack of progress. When I look back two or three months, however, I can see significant improvements in the levels I can be successful at and the way I now handle my anxiety. I know that I will probably never enter a bathroom without thinking about my anxiety, but I am confident that I can work towards a level of comfort that enables me to live my day-to-day life in a way that is not centered on this debilitating disorder. Relapse is highly likely, and so maintenance and continual practice are crucial to continued success.

The past year has been the hardest year of my life. For the first time, I have been presented with a challenge that cannot be easily solved, understood or explained. I have struggled to find motivation, determination and dedication, all new experiences for me. My paruresis has forced me to devalue analysis and understanding, because confusion and frustration are significant aspects of treating anxiety. I have learned to take personal control over my treatment, but have also surrendered personal responsibility over its development, a difficult step to take. I understand that my experience with bashful bladder syndrome is not a radical departure from the rest of my "normal" life; it is a large part of the life I am living right now. With the strength and courage that I have received from my family and friends, I have been able to work everyday at fighting against the most powerful force I have encountered in the nineteen years I have lived: my own mind.

REFERENCES

Schwartz, Steven (2000). Abnormal psychology. Mountain View, California: Mayfield Publishing Company.

Soifer, S., Zgourides, G.D., Himle, J., & Pickering, N. (2001). Shy bladder syndrome: Your step-by-step guide to overcoming paruresis. United States of America: New Harbinger Publications, Inc.

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