Revision date: March 13, 2005
This document is provided for free, but wouldn't be possible without
the help of many volunteers and contributing members of IPA. If
you find the material helpful, please consider making a donation
to IPA so we can further our efforts in helping those with paruresis.
The information given in this document is not intended as a substitute
for therapy or medical advice from a professional. IPA recommends
that anyone seeking help for paruresis obtain professional advice
before and during a treatment program.
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Q: How do you pronounce �paruresis?�
Q: Is this condition mental, physical,
or something else?
Q: What kinds of treatment are available?
Q: I�m facing a urine drug test
for employment, what can I do?
Q: I�m facing a urine
drug test in prison, for probation, or related to a criminal/civil
judgment. What can I do?
Q: How important is it to know how
this condition originated?
Q: How long does it take to recover?
Q: What are my chances of recovering
fully?
Q: What can I do to maximize my
chances of recovering?
Q: Are there other disorders
that may be present with paruresis that I need to know about?
Q: I�m a woman, is there anything
different about paruresis for women to know?
Q: I�m gay, is there anything
different about paruresis for me to know about?
Q: Should I tell others about my paruresis?
Q: I am a parent of a school-age
child with paruresis, what can I do for my child?
Q: I am thinking of joining
the military, what kind of barrier will paruresis be for me?
Q: I am a student in high school
or college, how can I recover?
Q: I have limited income, what
can I do to get treatment?
Q: What books do you recommend
for learning about paruresis and recovery?
Q: Is my diet a factor in paruresis?
Can I help my recovery by changing it?
Q: I am taking an airline trip,
how can I get through it?
Q: How does alcohol affect paruresis?
Q: I�ve lost my job (or
employment offer) due to being unable to provide a urine sample.
What can I do?
Q: Is it important to let my doctor
know about my paruresis?
Q: What percentage of the population
has paruresis?
Q: What causes paruresis?
Q: Does paruresis put me at risk
for other problems?
Q: What does a "medical screen"
mean?
Q: What is the breath-holding technique?
Does it work for everyone?
Q: How do you pronounce �paruresis?�
A: It�s pronounced: �par-YOU-ree-sis.� The origin of the
word is from the Latin language, and means abnormal urination. It
is the technical medical term for the condition.
Q: Is this condition mental, physical, or
something else?
A: For diagnostic purposes, paruresis is classified as a
social phobia in the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV 300.23). However, this classification does not
mean the cause of paruresis is purely mental, or that a person with
paruresis is �mentally ill.� We don�t understand enough about paruresis
at this point to state that it only has one origin. The description
given in the DSM currently classifies it as a Social Anxiety Disorder
with contributing genetic, physiological, and environmental factors.
Indeed, there is growing evidence that anxiety has a genetic and
physiological origin, not a mental one.[i]
Until we know more, it can be helpful to think about paruresis
as a disease that can be treated with a variety of approaches,
including psychotherapy, medication, and support group work. Having
paruresis does not mean you are crazy, suffer serious psychological
problems, or that you might end up in a mental hospital. It simply
means you experience anxiety that affects your ability to urinate.
When a person learns proven techniques to manage the anxiety, recovery
becomes possible. Many people are recovering successfully from this
disease. You might also wish to think of paruresis in terms
of having a skill (peeing in public) that needs some improvement
work in order to live the life you want. Thinking you are
inferior or blaming yourself has been shown to make recovery more
difficult, so start off on the right foot by realizing you are not
responsible for your paruresis (just like you aren't responsible
for getting a cold.) What you are responsible for is your
recovery.
Anxiety is a very powerful feeling. When a person experiences anxiety,
their mind will try to figure out a solution to reduce it.
Often, people adopt a strategy of avoiding the situation where they
felt the anxiety. Unfortunately, avoiding the situation has a strange
effect, and the anxiety can increase in intensity after a period
of staying away from the fear-inducing situation.
Confronting the anxiety can also be dangerous, as a person can
develop a panic response to the situation. Once a panic response
develops, even the thought of visiting a restroom can trigger intense
anxiety and desire to avoid. These are logical consequences
to the brain�s instinctive reaction to reduce unpleasant feelings.
They don�t mean a person is necessarily mentally ill. What they
do mean is that a person needs to learn other ways to manage the
anxiety that don�t have these unhealthy consequences. Learning these
techniques is part of the treatment and recovery process.
Defeating avoidance is in many ways a form of jujitsu. It is using
a weak position to defeat a stronger enemy through learning the
vulnerabilities of the enemy and using gentle, carefully applied
force in the right places and at the right times.
Q: What kinds of treatment are available?
A: The following treatment methods have all been shown to
have some effectiveness in treating avoidant paruresis (AP). We
define �shown� as meaning that people with paruresis who have tried
these techniques have reported benefit. The current state of research
does not yet include a true double-blind clinical trial for any
method below. The chances of success for any method will depend
on a number of factors, both known and unknown, and there may be
risks associated with each approach.
- Cognitive-Behavioral Therapy (CBT)
Method: A process of work with a psychotherapist that
includes graduated-exposure therapy, where a person is gradually
introduced to the feared situation and over time becomes more
comfortable (�desensitized�) to the fear. Work also involves examining
the person�s thought processes and learning to counter irrational
thinking with more healthy patterns of thought.
Benefits: The process can be short-term, usually six to
ten office visits followed by a period of independent work and
one or two follow-up visits. This method can produce permanent
changes in behavior that do not require long-term use of medication
for many individuals. With a competent therapist and a dedicated
patient it can be very successful.
Risks/Shortcomings: Cost of treatment, approximately $125
per session. The relationship between patient and doctor is crucial
to success, so a person may need to switch therapists if the method
is not working out. Mental health therapy can have an impact on
a person�s insurability, so a person needs to look at the risks
in their particular situation. Paying cash for treatment is one
way to prevent an impact on one�s medical record from undergoing
psychotherapy. CBT may not provide complete relief from symptoms;
some patients may need additional sessions or other kinds of treatment
to achieve the level of anxiety reduction required for long-term
recovery.
- Support Groups
Method: Regular participation in a group of people with
paruresis to practice graduated exposure exercises, provide support
and encouragement, and discuss the person�s experiences and thoughts
during the recovery process.
Benefits: Support groups are usually free. The process
can produce permanent changes in behavior that do not require
long-term use of medication. It is a valuable adjunct to people
undergoing medication and/or CBT because group participation happens
outside a doctor�s office in a real-life setting, and serves as
a way of increasing the frequency and intensity of work on graduated
exposure practice. Supportive partnerships develop in a well-run
group that can aid in addressing setbacks and other problems that
may crop up in the recovery process. Groups also provide
the benefit of working with people who have personal experience
in recovering.
Risks/Shortcomings: There are differences in support groups,
so the quality and atmosphere is not guaranteed or controlled.
The size of the group, frequency of meetings, and relationships
between participants will vary from group to group. Because of
these risks, using a support group as the only method of working
on recovery may not work out unless it happens to be an excellent
group. Because there is no professional assistance, a support
group is unlikely to address other psychological issues that may
accompany paruresis.
- Medication
Method: Use of prescription drugs under a doctor�s supervision
that reduce anxiety and depression allowing a person to develop
more healthy thinking patterns over time. Medication is usually
combined with a program of CBT and/or support group work. The
preferred class of drugs prescribed for social anxiety is the
Selective Serotonin Reuptake Inhibitor, or SSRI, because it provides
benefits with the fewest risks. Other drugs that have been proven
clinically effective to reduce social anxiety may be effective
for paruresis treatment depending on your particular situation.
Monoamine Oxidase (MAO) inhibitors are a class of drugs that has
high effectiveness for social anxiety, but carries greater risks
and strict dietary restrictions. There are several other classes
of antidepressants that are sometimes used to treat anxiety and
social phobia. It is best to seek assistance from a psychiatrist
(M.D. or D. O. degree with appropriate advanced training and board
certification). Note, a psychologist (typically someone with a
Ph.D. or Psy. D. degree) cannot prescribe medicine.
There are also large number of medicines known as minor tranquilizers
that may be used to treat anxiety and social phobia. Some, but
not all, are controlled substances because they may over time
cause a physical dependence on the medicine. Usually, though,
it is fairly easy to gradually reduce the dose if your doctor
agrees that you should no longer take the medicine.
Other drugs, notably D-cycloserine and gabapentin, are being investigated
for possible treatment but are prescribed �off-label.� A
licensed physician may prescribe medicines to treat a condition
as s/he thinks appropriate. Many if not most medicines are routinely
prescribed for �off-label� treatment.
Benefits: These medications can make the difference between
success and failure in recovery for some people. Medication can
improve the ability of a person to make lasting changes in personality
that reduce or eliminate the need for medication after a period
of about a year. General reductions in anxiety with medication
use may transfer to other situations and improve a person�s overall
functioning and well being.
Risks/Shortcomings: Cost may be substantial since medications
are a long-term prospect. There may be dependency issues to work
out when stopping the medication or changing to a different one.
Insurance is often used to reduce cost, but a history of psychiatric
care might result in stigmatization in employment or insurability.
We urge young people to get the treatment they need, but to be
especially aware of these potential difficulties. Those in stable
careers and older individuals don�t usually need to be too concerned
about stigmatization. If your medical history includes a use of
anxiety medications you run the risk of being uninsurable if you
apply in the future for individual coverage instead of a group
coverage policy from an employer. Paying cash for medical care
and medications is a way to reduce this risk if a person can afford
it. IPA believes that medication alone is not an effective
treatment for paruresis, it must be combined with CBT and/or support
group work.
Many medications have side effects that a person will need to
deal with. Several classes of antidepressant medications tend
to have sexual side effects, weight gain, dry mouth, and effects
on digestion. Recent research is revealing that genetic differences
can reduce or eliminate the effectiveness of SSRIs in some people.[ii]
So if a medication or class of medications isn�t working, changing
to a different one may be needed.
There is now a required FDA warning for many SSRIs regarding increased
suicide risk for young people. Adults may have some suicide risk,
but it appears to be greatly reduced and possibly nonexistent.
Any thoughts of suicide, especially if they are coupled with
some intent to actually do it, are a medical crisis. Go to an
emergency room or to your personal physician immediately.
Anyone on a medication program needs to be monitored for changes
in personality that could be dangerous, but such changes are rare
and unlikely for most people.
While many report they can reduce or eliminate the medication
after a period of time, some patients have entered a cycle of
increased dosages, multiple medications, and/or changes in medications
that has decreased their quality of life. Each person needs to
be aware of these risks and work closely with a trusted doctor
to manage them properly and prevent problems.
The three main approaches outlined above can be combined together
to increase a person�s chance of success. The decision to
do this will depend on a person�s situation, and it is best to consult
a treatment professional on which options to combine. At different
stages in treatment, different options may be appropriate.
For instance, at the early stages when anxiety levels can be quite
high and difficult to control medication may be appropriate, but
as a person makes progress, support group participation may be a
better option because it reduces reliance on a drug and increases
emphasis on changing one�s thinking through the process of helping
others and accepting others� help.
IPA workshops are a short-term form of treatment that address cognitive-behavioral
approaches of graduated exposure therapy, and introduce a person
to an environment they will experience in a support group. A workshop
is a good place to begin a treatment program, but one or more of
the three approaches above are critical to adopt on a long-term
basis for a person with paruresis to make a full recovery.
A very few people have reported benefits from �alternative� forms
of treatment such as hypnosis, meditation, herbal remedies such
as Kava or St. John�s Wort, etc. IPA does not endorse these methods
as being effective for most people. If a person wants to experiment
with alternative forms of treatment, we recommend that the exploration
be conducted under the guidance of a treatment professional.
Generally, alternative forms of treatment may have a greater benefit
when pursued in combination with the more traditional approaches
above. We are not aware of cases where they alone produced a complete
recovery.
Some people have learned to practice Clean Intermittent Self-Catheterization
(CIC) as a means of coping with paruresis in difficult situations.
While using a catheter is not a method of treating paruresis, it
does provide a measure of security, help the person lead a more
normal life, and be able to give a urine sample for mandatory drug
testing if there is no alternative test available. A sympathetic
urologist can instruct you on how to do this procedure. More information
can be found at IPA�s Catheters
page. Catheter use is a survival technique, not a recovery technique.
Everyone recovering from AP needs to know when to practice survival
and when to be working on recovery. Both are valuable skills, but
the latter is the only way to reduce the need for practicing survival.
Q: I�m facing a urine drug test for employment,
what can I do?
A: It depends on how much time you have. Because a recovery
program can take several weeks or months to produce significant
progress, your options are more limited if the test is in a few
days. If you know the test isn�t likely for quite a while, get into
a recovery program immediately. You may be able to provide
a sample without any additional measures.
Every person with paruresis needs to document their condition with
a doctor before taking a drug test. This step helps establish
that you have a medical condition that makes providing urine difficult.
Unfortunately, regulations for drug testing currently in force (which
IPA is working to change) state that inability to provide a urine
sample is the same as refusal to provide one. Essentially, a person
with paruresis is assumed guilty of drug use without any evidence
of drug use. If your drug test is in a few days, get to your doctor
immediately. Have the doctor write a letter that documents your
paruresis and provide that letter to the drug-testing monitor when
the test is done. If possible, also have your doctor perform a blood,
saliva, or hair test as close as possible to the date of your urine
test so there is an independent verification of your drug-free status.
While this will cost you some money, it may protect you from loss
of your job, or help you in getting one if you are unemployed. A
hair test is considered to be the best one for establishing drug-free
status, as it can detect use for up to three months prior to the
date of the test. Blood tests are more expensive and considered
less useful because most chemical traces of drug use are cleared
quickly from the bloodstream.
The way urine-based drug testing programs work, having an alternative
test before the urine test is not considered hard evidence of a
person being �clean.� The purpose of taking this test is to help
protect you legally if you decide to take court action against the
employer, or file a complaint with your state�s employment rights
protection board.
Anyone who is asked to take a drug test should probably take his
or her own test immediately afterward. This protects you from false
allegations resulting from errors or inaccuracies; they do happen.
The most certain way of being able to provide a urine sample is
to learn to use a urinary catheter. A urologist can teach you how
to use one in advance of the test. It will likely take at least
a week to schedule an appointment, learn to use a catheter, and
practice with it in advance of the drug test. When scheduling the
appointment, get an assurance from the urologist or nurse that you
will be instructed in the use of the catheter. Explain the
reason you are seeking help is to pass a drug test. Do not allow
a urologist to delay, ask for more tests, or prescribe drugs as
a solution. Your job is on the line. Under no circumstances should
you try to use a catheter without instruction, as there are risks
associated with improper use, and you may have a physical problem
that can only be discovered through a doctor�s examination. See
IPA�s Catheters
page for more details.
If you are seeking Federal employment, an important regulation
to be aware of is that SAMHSA regulations apply to you. Under these
regulations, ONLY a Medical Review Officer (MRO) can make the determination
that a failure to provide a sample is a refusal to test. The MRO
is a person who reviews drug test results, and usually is not present
at the time of the test. If you bring documentation of your paruresis
with you to the test site and can�t provide a sample, the MRO could
be your best friend. Make sure that person gets your documentation.
If the drug test is several weeks away, you have time to desensitize
to the drug test situation by working on some simulated drug testing
with a pee buddy acting as the drug-test monitor. Try to arrange
most of the day to spend with the person, drink a fair amount of
water throughout the day, and ask the person to choose random times
(unknown to you) to whip out a cup and say "time for a sample."
If possible, use a restroom that closely simulates the one you'd
find at the lab. Have your buddy simulate as closely as possible
what the monitor would do, stand the same distance away, give you
a time limit, etc. If you do this exercise several times a week
for a few weeks, giving a sample will get a lot easier. It�s important
to remember that your rate of progress may differ, so do not depend
on this practice to get you through the test. Do all the other things
listed in the summary below to increase your chances of having a
good experience at the test.
In summary:
If you have a few days before the test, do the following:
- Document your condition with a doctor (see sample letter below)
- Familiarize yourself with the DOT (Department of Transportation)
or SAMHSA (Substance Abuse and Mental Health Services Administration)
regulations so you can demand your rights if necessary.
- Be aware that the DOT and SAMHSA rules do not apply in most
testing situations, particularly in the private sector.
Private employers have a great deal of freedom to do as they wish
consistent with the laws of their own state.
- Ask your doctor for instruction on how to use a catheter
- Get an independent test of hair, oral fluid, or blood to establish
you are not a drug user.
If you have a few weeks or months, do this:
- Document your condition with a doctor (see sample letter below)
- Get into a recovery program immediately
- Stay absolutely clean as far as drug use so that you can pass
a hair test if needed
- Begin practicing simulated drug tests with a trusted person
so you can reduce anxiety in the test situation.
- As the time for the test approaches, you will know from your
rate of progress if you�ll need to learn to use a catheter in
order to be sure you can provide a sample.
Once your doctor establishes a diagnosis of paruresis, here is
a sample letter the doctor can provide that may help in persuading
drug test labs to provide reasonable accommodation for you:
"Re: Drug Testing (via urinalysis)
This is to document the fact that NAME has been a patient of mine
since YEAR, and from the time of his first office visit, was unable
to produce urine samples on demand, necessitating the need for him
to bring urine samples from home. The inability to urinate on demand
or under time pressure (and also frequently in the presence of others
in a public setting) is called paruresis (more commonly known as
"shy bladder") and is a bona fide social anxiety disorder
listed in the Diagnostic Statistical Manual of Mental Disorders
IV with Code 300.23.
NAME has shared with me that he is quite willing to be drug-tested
at work, as frequently as he is selected to do so, but given his
paruresis condition which in the past he has attempted to over-come
by drinking un-healthy and potentially-dangerous amounts of water,
I suggest an alternate form of testing (such as saliva, sweat, hair
or blood analysis) be employed."
Q: I�m facing a urine drug test
in prison, for probation, or related to a criminal/civil judgment.
What can I do?
A: You should provide your attorney with a heads-up on
this situation so there is someone who can defend you at the probation
hearing, and further advise you about legal issues and your rights
after conviction.
You need three things to make your case: (1) Medical documentation
of your condition, (2) a lawyer willing to work hard for you, and
(3) the information and assistance that we can provide�which could
include expert testimony about paruresis in general and arguments
to help establish your rights to alternative testing to prove your
drug-free status.
Show your lawyer this document. If your lawyer has any questions,
please contact IPA at our 800 number for further clarification.
IPA can help you get in touch with a lawyer with a history of successful
legal challenges so yours can establish precedent in court.
The key vulnerability in current drug testing policy where your
lawyer can make a persuasive argument is that a policy of calling
an inability to provide a sample �a refusal to test� and presuming
drug use based on the inability to provide a sample is a discriminatory
practice, especially for a person with paruresis. A person with
shy bladder or paruresis wants to give a sample, but is unable to
do it.
The United States justice system is based on the fundamental concept
of �innocent until proven guilty,� but drug-testing policy turns
this concept on its head. The person who is unable to produce a
urine sample is presumed guilty in the absence of any evidence.
Drug use must be established by testing, and without a test or a
witness testifying you were under the influence of drugs at the
time of the test there is no evidence of drug use, nor is there
reasonable suspicion of it. You can offer to provide the evidence
by any other means that's convenient for you, such as a hair test,
using a catheter to obtain the urine sample, a saliva test, or a
sweat patch. You or your lawyer will need to prevail upon the judge
to use common sense in your case, not a policy based on invalid
assumptions that people can urinate in front of someone watching
them.
Equating a refusal to test with guilt is erroneously based on laws
for driving under the influence of alcohol, where a person�s refusal
to submit to a breathalyzer test given at the police station is
legal evidence of guilt in most states. However, there are key differences.
In the case of drunk driving, there is an arresting officer who
gives a field sobriety test to the driver and observes through the
driver�s behavior suspicion of intoxication. There is also an �implied
consent law� where a licensed driver agrees to submit to testing
for intoxication in order to be granted the privilege to drive.
There is no such implied consent governing you in this situation.
Staying off of drugs may be a condition of probation or a requirement
if you are serving a jail sentence, but proving you are drug free
can be accomplished through a variety of means other than urine
testing.
From a medical point of view, the alcohol breath test is quite
different from a urine test. We all must breathe; there is no such
thing as an inability to breathe for a living person. Urination,
however, is quite different. A person with paruresis won�t
be able to urinate with others present. Contrary to widespread public
belief, the muscles that control urination are not under the person�s
voluntary control.[iii] Someone
with paruresis won�t be able to urinate until their anxiety disappears,
which will not happen in a drug testing facility. The person may
experience bodily harm in terms of bladder or kidney damage before
being able to urinate. A doctor serving as an expert witness can
explain to the court that once a person�s bladder fills beyond a
certain point, it may be impossible to drain it without medical
intervention. There will be horrific pain, and only insertion of
a catheter will empty the urine from the person�s bladder. This
amounts to cruel and unusual punishment without any evidence of
guilt. It�s the legal equivalent of torture.
If these arguments are made successfully, your lawyer should be
able to prove that there is no solid legal basis for presuming drug
use if a person with paruresis is unable to provide a urine sample.
If you have an alternative test showing you are drug free, the court
should find in your favor. IPA wants to hear from anyone with either
a positive or negative court decision regarding drug testing so
we can continue to strengthen our arguments.
We suggest to your PO or correctional health administrator that
they use a hair test, sweat patch, or oral fluid test on you. These
are inexpensive, and the hair test is especially good for detecting
use of drugs during the past 90 days. In other words, if you have
been staying off the stuff for 3 months, the hair test will prove
it. Another option is to see a doctor or urologist and learn to
use a catheter to provide the urine sample. See IPA�s Catheters
page for more details. Tell your probation officer or other authority
involved in the drug testing program about these options and try
to work with them to find one that is acceptable to both of you
and involves the minimum cost.
Alternative tests are less expensive for the government than a
hearing to revoke probation, and far less expensive than putting
you in jail. These are important and practical arguments to make
with the authorities. Depending on how the negotiations go, you
may need to pay all or part of the extra cost for an alternative
test. If you need to use a catheter you�ll likely need to bear the
cost of a doctor�s visit and buying the catheter, which typically
costs under $12. IPA hopes someday to change the law so that the
government will pay for these tests, but until that point the responsibility
may be yours. Please support the IPA, as we can�t achieve these
things without the help of your donations.
If you need to pay for a hair test, and it might not be a bad idea
to have one done so the evidence that you are clean is available
to your attorney and the court, they cost around $70-100. It takes
about a week to get the results back.
Call the IPA 800 number at www.paruresis.org for information on
how to get a hair test.
Q:
How important is it to know how this condition originated?
A: Paruresis is one of those problems that takes on a life
of its own. Knowing or working on the "original cause"
will do little to help you recover. Rather, reducing avoidance,
working on changing your thinking and attitudes about peeing/not
peeing, and developing survival techniques will be a far more fruitful
way to spend your time, money, and energy.
Here's an analogy: If I started smoking when I was 17 because of
peer pressure, I will not get over my current cigarette addiction
at age 52 by figuring out why I succumbed to the pressure or even
learning how to stand up to my peers.
Q: How long does it take to recover?
A: Recovery time varies depending on the individual. While
in the best case a month of graduated exposure work can produce
good results, most people report that several months of work are
required. Many of us have worked on aspects of our recovery for
a year or more. Some rare cases of recovery in a few days have been
reported as a result of attending a workshop or working with a therapist,
but there is skepticism as to whether the recovery will be lasting,
or if the person had a case of paruresis to begin with. While some
people with a long-term history of paruresis or a severe case report
that dramatic improvements are possible, even those with the most
successful recoveries have found it necessary to continue graduated
exposure work as part of one�s lifestyle. Otherwise, there may be
a relapse. Sometimes a person who has made excellent progress at
and immediately after a workshop will suddenly relapse. In these
situations attendance at a second workshop, or even a third workshop,
may be useful. Similarly, joining a support group may be helpful.
Looking at the prospect of working on recovery for a year or more
may sound daunting, but it is not. What happens is that a person
makes small changes in lifestyle over time that build more opportunities
to work on practicing in public restrooms. As we make these changes,
recovery work becomes part of life, and life becomes more enjoyable.
The result is that a person isn�t putting the kind of intense effort
into recovery that it feels like during the first month or two of
work. Expect the initial stages to feel a bit difficult, but take
heart in the notion that this will get easier over time and the
rewards will provide additional motivation to continue working on
more challenging situations. It isn�t work to go out in the
evening with some good friends, enjoy dinner, drinks, or a movie,
and to visit the restroom a couple of times. That�s a normal life!
In general, your recovery time will depend on how long and how
serious your case of paruresis is. People who have had it for a
short time or have milder symptoms can expect to recover sooner.
Younger people can also expect to recover sooner than those of us
who are older and �more set in our ways� as they say. That said,
we do have a number of people who have attended workshops who are
retired and in their 60�s or older and have reported great success
in making improvement. So it is never too late to start on a recovery
program.
While these general statements reflect what we have heard from
people, IPA does not have firm statistics on the time required to
recover. Please do not view the above with any discouragement, or
over-optimism. We have seen many exceptions to the above very rough
estimates. A person may need to vary several factors in order to
find the best combination of things that work for their particular
situation. See the question below on maximizing one�s chances of
recovering for more information.
Q: What are my chances of recovering fully?
A: Your chances of recovering to any degree are negligible
if you have a physiological cause to your urinating difficulty and
you choose to treat it as a psychological disorder (paruresis).
You must first get a medical screen (see medical
screen FAQ below) to rule out any physiological causes.
Having ruled out physical causes to urination difficulties, the
majority of IPA workshop attendees will see a marked reduction of
their symptoms after a series of CBT treatments and diligent practice
several times daily over a period of several weeks to several months.
This post-workshop program is essential for recovery. The
vast majority of people who attend workshops won�t make long-term
progress without it. The degree of your improvement is very dependent
on the amount of work you invest in recovering from both the primary
and secondary aspects of paruresis. It also depends on your willingness
to voluntarily expose yourself to feelings of dread and embarrassment
during recovery. It isn't easy, but it is very feasible to recover
markedly from this disorder.
Peer-reviewed studies of various treatments for social anxiety
(but not paruresis itself, since we do not have specific studies
on large populations) indicate an approximate rate of long-term
improvement (reduction of symptoms) for somewhere between 40 and
65 percent of the study participants, depending on the study. Higher
rates were reported for people who combined therapy techniques,
such as CBT plus a support group, medication plus a support group,
or all three in combination. While these are not stellar recovery
rates, they are significant.
Recent studies on cognitive-behavioral therapy[iv],[v]
for social anxiety indicate that the highest recovery rates happen
when treatment includes exposure therapy and cognitive restructuring,
which consists of learning to question one�s flawed thinking and
substitute healthy patterns of thinking.
Q: What can I do to maximize my chances
of recovering?
A: What does this really mean? The key question is whether
or not people who recover are doing anything differently from those
who don�t � in other words, �Can I control whether or not I recover?�
What we know is that it takes hard work to get better for most people.
So being willing to work hard appears to be a major component of
increasing the chance of success. There is a problem with quoting
numbers from studies, which is that a study was done under a particular
set of circumstances: a given therapist perhaps, or one kind of
medication, or a certain population of individuals. Each person
is different, doctors vary in their competency and relationship
with patients, and in one�s process of recovery different ideas
will be tried. Another important thing to realize in working
on recovery is that there are many options out there, and trying
as many as possible increases the chances of finding something that
works.
A critical element to recovering is having a supportive �pee buddy�
or sponsor. This person commits to helping you recover. If both
of you are working on recovery as part of a support group, you can
also commit to helping the other person recover. The sponsor is
not responsible for your recovery (only you can do that), but is
there to help provide support, answer questions, give encouragement,
and help deal with setbacks. This support extends to accompanying
you to restrooms for graduated exposure work. A good sponsor is
someone who is non-judgmental and a good listener. The sponsor makes
a long-term commitment to support the new member. This commitment
is truly heartfelt and a gift on the part of the sponsor.
Most who have made great strides in recovery had a pee buddy or
sponsor of some sort. Your sponsor doesn�t need to be close to where
you live; some people have had one in another city a distance away.
As long as the two of you meet periodically and are able to talk
by phone whenever you need to, a longer distance relationship can
still be helpful. Many report that their pee buddy has become a
lifelong friend and strong, mutually beneficial relationships have
developed.
Our culture emphasizes self-reliance, and it tends to view asking
for another person's help as a sign of weakness, especially among
men. We would do well to reject this notion. Don't let a culture's
mistaken beliefs get in the way of your recovery. Do what we know
works. In athletics, it is well known that a workout partner can
improve one�s fitness. We are just beginning to catch on to the
idea that the same thing applies to recovery, which is a form of
brain and bodywork.
Persistence pays off. Making up one�s mind to get better, and then
doing what it takes to get there is a good way to improve the chance
of recovering. Those who give up after seeing one therapist or going
to one workshop are not going to improve. Be willing to change therapists
or medications, attend more workshops, get involved in a support
group, or become the leader of a support group. The people
who do these things report that they make progress. Studies indicate
that people who take an active role in helping others recover from
a number of psychological disorders have higher recovery rates themselves
and spend less money on treatment.[vi]
Q: Are there other disorders
that may be present with paruresis that I need to know about?
A: Some with paruresis have reported other problems that
seem to �go with it.� But it�s important to realize that paruresis
does not appear to be caused by any one thing. If a particular problem
seems to be preventing your ability to recover, then get treatment
for it. We have a number of members with Obsessive-Compulsive Disorder
(OCD), some with panic attacks or other forms of anxiety in situations
outside the restroom, and some with a history of dependency on legal
or illegal drugs. While these kinds of disorders may contribute
to, or reinforce a person�s paruresis, it is wrong to assume that
having paruresis means you are obsessive-compulsive, a drug addict,
etc.
Some men have reported chronic prostatitis; both men and women
have reported interstitial cystitis, and a few people have reported
stones in the kidney, bladder, gall bladder, or salivary glands.
There is some evidence to suggest that chronic or acute prostatitis
in men may be related to excessive tension in the pelvic floor muscles,
as well as infection risk from infrequent urination and/or concentrated
urine. The same may be true for interstitial cystitis. Stones can
be the result of limiting fluid intake in order to reduce the need
to urinate. Once beginning a treatment program, people with paruresis
should drink plenty of fluids and use restrooms more, not less often.
This will improve overall health and reduce the risk of stones and
other urinary tract problems.
Q: I�m a woman, is there anything different
about paruresis for women to know?
A: In general, the similarities between women and men in
terms of etiology, triggers, privacy issues, and treatment methods
far outweigh the differences between the genders.
Your urologist, gynecologist, or urogynecologist will often be
the person to talk with about your paruresis. This can be
a positive thing. Many men report that urologists have limited or
no experience outside of treating prostate trouble, bladder infections,
and sexually transmitted disease, so the doctor is not very interested
in something they are not familiar with. Gynecological practice
is more general in nature and your doctor may be more accepting
and helpful.
Both men and women find discussing paruresis with their doctors
extremely difficult and embarrassing. Young people are generally
shy about their bodies and typically have not experienced intimate
medical exams (especially the men). They should try to pick a doctor
with whom they are likely to feel most comfortable. Consider both
the age and gender in selecting your doctor. For a variety of reasons,
women are often more comfortable with a male physician, whereas
some men are more comfortable with a woman. Some young people are
more comfortable with a doctor who is elderly. Choose someone you
will be comfortable with.
The main distinction is that while private stalls may be the back-up
option for some men, they are the only option available for women,
unless they have learned to pee in the wilds! A woman who cannot
urinate in private stalls in public restrooms only has self-catheterization
as the last resort. This will need to be your reliable fallback
strategy, which is essential to developing a successful recovery
plan.
Also, women face the possibility of encountering long lines in
crowded bathrooms. This may exacerbate time pressure, which many
report already feeling when they enter a restroom. Some women have
heightened concerns about easily being visible to others when they�re
using a stall, unless they�re fortunate to encounter a fully enclosed,
ceiling-to-floor one; others seem ultra-sensitive to noise.
Other noticeable differences between the sexes pertain to bathroom
behavior. Women often enter public restrooms in packs, enjoying
the social aspect when they congregate. Some talk between stalls;
others linger in restrooms while they apply make-up or perhaps change
a baby�s diaper. Little children, who can be disruptive, more frequently
accompany their mother to the restroom than their father.
Given anatomical differences, the self-catheterization process
is not the same for women as it is for men. It is highly recommended
that a knowledgeable female health care practitioner teach women
before attempting the process. There are different methods, but
for practical purposes, it is useful to learn to sit on a toilet,
identify the opening to the urethra by �feel�, insert a short catheter,
and allow the urine to drain into the toilet bowl.
Also, all catheters are not created equal, and women may require
one whose diameter is smaller, e.g., a 10 FR vs. a 14 FR. Catheters
are available in a number of different styles, sizes, and materials.
Anyone who decides to try them will need to do some experimenting
to find which kind works best. Follow this link to specific instructions
and tips on catheter use for women: www.umm.edu/ency/article/003972.htm.
The IPA web site also maintains a page with women�s
catheter tips.
Women are more susceptible to urinary tract infections (UTIs or
cystitis) following catheterization. Antibiotics (e.g., Bactrim,
Septra) can be prescribed for use as a preventative or treatment
to alleviate the symptoms. There are other things that can be done
to reduce the risk of infection, such as drinking plenty of fluids�especially
cranberry juice�at the first opportunity after using a catheter.
Besides self-catheterization, women can avail themselves of a few
other tools that may be of some help. One is the use of a female
urinary pouch that connects to a leg bag system (worn on the inner
calf) and can be completely hidden beneath loose fitting jeans or
pants and allows users to enjoy events. The other is a device, like
a funnel or medical-grade tubing, which facilitates urinating while
standing up and could be beneficial in outdoor situations.
Lastly, while it may appear that paruresis affects men in greater
proportion than women, no hard-core evidence actually supports that
theory. Some women may simply be more inhibited about participating
in open forums where they fear violation of their privacy.
Others prefer communicating directly with other women, either in
person, by telephone, or private e-mail exchange.
In the meantime, until the IPA membership base expands to include
more of them, women will have to expend extra energy to reach out
to other women. They can plan on traveling further to attend an
all-women�s IPA workshop, participate in a regular IPA workshop
in which the presence of at least one other female (though not necessarily
one who has paruresis) is guaranteed, join a support group which
may consist largely of men, start a female-only support group in
their area, or consider asking a non-paruretic female friend for
help with the practice of desensitization exercises. If you know
another woman with paruresis, please encourage her to join IPA!
Q: I�m gay, is there anything different
about paruresis for me to know about?
A: We have no evidence at this time that one�s sexuality
indicates any need for changes in treatment. The primary thing to
consider is cultural differences related to sex segregation in restrooms,
and how they affect one�s perceptions of urination and sexual behavior
among adults. The healthiest way to view our culture�s desire to
segregate restrooms by sex is that urination and sexual activity
are completely separate things, and that whether one is straight
or gay a restroom isn�t an appropriate place to be thinking about
sex. It�s a place for elimination of body wastes. Unfortunately,
this ideal view becomes complicated because the genitals are used
for two purposes. Dr. Christopher McCullough remarked that if humans
were designed to pee from the index finger, there would be no such
confusion between sex and urination. Being stuck with genitals designed
for two purposes, both straight and gay people need to come to terms
with how to deal with this reality.
For people with paruresis, the notion of imagining another person�s
sexuality in a restroom without knowing it for a fact is the same
kind of irrational thinking that leads to anxiety when we think
others are paying attention to sounds we make while urinating, or
to how long it is taking. These are all irrational thoughts where
we attempt to read another person�s mind (that�s impossible!) For
both gay and straight people, it isn�t healthy to be thinking about
other people�s views of us, their intentions, or judgments of us
in a restroom. We are there to use the restroom, not our imaginations.
There is one specific difference for gay people to consider, and
that is at some gay clubs the restrooms blur the lines between places
for elimination and places for sex. Those situations are far beyond
our culture�s unwritten rules for restroom use. Anyone with paruresis
needs to concentrate on using restrooms where the normal cultural
rules apply, and to learn how to separate the body�s dual functions
for the genitals. Once that is achieved, moving on to more
challenging and confusing situations is one�s own decision.
Gay people may need to deal with society�s mistaken prejudices
regarding sexual orientation and sexual abuse. Many erroneously
believe that sexual predators, particularly pedophiles, frequent
restrooms and that those people are predominantly gay.
Being gay does not equate to being a sexual predator or molester.
Statistically there are many more heterosexual predators and molesters
in the world.[vii], [viii]
Noted sexual abuse authority Dr. A. Nicholas Groth wrote:
The research to date all points to there being no significant
relationship between a homosexual lifestyle and child molestation.
There appears to be practically no reportage of sexual molestation
of girls by lesbian adults, and the adult male who sexually molests
young boys is not likely to be homosexual (Groth & Gary, 1982,
p. 147).
A person should never bring sexual orientation into mind when dealing
with the idea of sexual abuse or molestation in restrooms. They
are two different and unrelated things. Getting them straight will
help in thinking more clearly about your paruresis and its treatment.
Q: Should I tell others about my paruresis?
A: Paruresis thrives on secrecy and shame. It�s an essential
part of recovery to let others know about your paruresis and to
observe that most people are supportive and don�t view it in the
same catastrophic or shameful way that you do. This will help you
begin to see that a lot of the shame and guilt you feel don�t exist
in others; it is self generated as a consequence of the phobia.
Once you tell friends about your paruresis, you�ll find that they
will be more understanding, and you�ll be less nervous around them
when the need arises to use a restroom. That alone will reduce anxiety
and make it easier to urinate.
Use good sense when choosing whom you share your paruresis with.
Telling trusted individuals, close friends, and family members is
a good way to begin. People you don�t feel would be likely to support
you are not good allies in helping you with your recovery. People
in the workplace may not be a good choice if you feel sharing the
information might be used against you in any way (such as a malicious
employee suggesting you are a drug user in order to force you to
undergo a drug test and put your job in danger.)
If you encounter a negative or insensitive response from a person,
try not to let it affect you. People who are ignorant or condescending
toward those with paruresis are the ones who have an illness: A
lack of empathy and inability to help and support others.
There are a small number of people like that we will encounter,
and the best course is to avoid them. But don�t let a few people
stand in the way of your recovery by preventing you from taking
a chance on sharing your paruresis in order to find supportive help
from people you trust. The benefits we gain from reaching out to
the good people in our lives far outweigh the risks.
Q: I am a parent of a school-age
child with paruresis, what can I do for my child?
A: If you are reading this because your child showed you
this web site, the first thing to do is tell your child you are
glad they were courageous enough to share that they have paruresis,
and that you are there to help. Children are very concerned
about how their parents, peers, and teachers view them and often
worry that paruresis could reduce their stature in the eyes of the
people they care about the most. Reassure your child that
there is nothing seriously wrong. Your child isn�t crazy. Paruresis
tends to affect very bright, caring, and capable people for reasons
we don�t fully understand yet. Recovery is very likely, especially
for younger individuals.
If your child is encountering teasing or bullying from peers or
family members, take steps to give your child the tools to deal
with it. This topic is too broad to address here, but there are
many excellent resources to deal with teasing and bullying online
and in most communities. The better a child is able to defend against
attacks from others, the more secure they will feel when beginning
to work on recovering from paruresis. Many older people with paruresis
have remarked that if they had taken a good self-defense course
in their school years, they would have been able to put bullies
in their place, and could have had a much happier childhood.
Your child may need some special arrangements at school in order
to use restrooms that are more private. Work with the school nurse
or a counselor to get permission for your child to use restrooms
during class or at times outside of recess or lunch hour if this
is needed. This step will reduce the stress on your child. It will
be less needed after work on a recovery program begins.
Encourage children with paruresis to participate in school activities
so that they are regularly involved in social situations and don�t
become isolated because of their paruresis. If these activities
require urine drug testing, teach children to use a catheter to
provide the sample, or work with your school authorities on accepting
an alternative drug test method, such as hair, oral fluid, or sweat
patch. As of this writing, there are no federal or state laws requiring
schools to use any particular testing method. Don�t accept excuses,
such as �We are required to do it this way.� Too frequently school
systems contract their drug testing to companies that try to do
things as quickly and inexpensively as possible. The testing companies
care nothing at all about your child or his or her welfare. If necessary
discuss things with the Principal and Superintendent. If they won�t
help, protest to the school board and seek out legal counsel. Also
contact IPA so we know what is happening and can send letters to
school officials. In some special situations we may be able to find
you legal assistance or pay a small portion of the expenses.
Find a good child psychologist specializing in cognitive-behavioral
therapy and anxiety disorders and have this person work with your
child on a graduated-exposure therapy program for recovering from
paruresis. This kind of program will generally be short, a few weeks
or months in length, and will produce excellent results if your
child is motivated and works on recovering. In some cases, medication
may be needed in combination with exposure therapy. Be sure your
physician selects a medication appropriate for young people, as
some anxiety medications for adults produce different and sometimes
dangerous effects when used by children. Your psychologist�usually
a Ph.D. or Psy. D. or psychiatrist (M.D. or D.O.)�can contact IPA
for more specific treatment information if this is necessary; we
are happy to educate professionals on the details of treatment.
IPA workshops accept young adults (usually 17 years or older) and
attending a workshop is a good way for a young adult to learn about
paruresis and meet others with it, and discover that there are many
normal adults working on recovery. Parents often accompany their
children to a workshop. Young adults should also consider working
in a support group if one is available in your community. The Shy Bladder Center (the branch of IPA responsible for running workshops)
may be able to work with younger children on an individual basis,
but workshop formats are not appropriate for children.
Finally, if your child is involved in athletics or you live in
a hot climate, talk about the importance of drinking plenty of water
throughout the day. Students often restrict fluid intake as a way
of managing their paruresis to reduce the need to visit restrooms.
The combination of low fluid intake, physical exertion, and heat
can put a young person with paruresis at risk of heatstroke or dehydration,
and most children aren�t aware of how serious the danger can be.
Once a student starts a recovery program, drinking lots of fluids
is recommended so that they have lots of opportunities to practice
using restrooms.
Q: I am thinking of joining
the military, what kind of barrier will paruresis be for me?
A: People in military service face three major barriers
from paruresis: Urine drug testing, the difficulties of dealing
with restrooms that have very little privacy, and unpredictable
combat situations. While we have heard stories of people with paruresis
who served in the military and managed to get through it, you need
to carefully weigh the impact paruresis has on your life and whether
it is worth dealing with the problem in a military environment.
Generally, it�s not a good idea to join the military in order to
get over paruresis. Working on a recovery program is a much better
way to go about it. In a combat situation, you need to be in peak
condition and able to think clearly and give every ounce of energy
and strength. A full bladder in pain will prevent that. As a result,
your paruresis could become life threatening for yourself and the
others on your squad. Don�t put others� lives in danger for the
purpose of working on your own problems.
That said, for economic or other reasons there are going to be
people who have few options but to consider military service. If
you have any time at all, please get into a recovery program, go
to a workshop, attend a support group, and schedule a few sessions
with a civilian psychologist skilled in cognitive-behavior therapy
before enlisting so that you can begin a program of graduated exposure
therapy before going to boot camp. Those skills will give you the
ability to cope better once in the service.
Regarding urine drug testing in the services, you can work on simulated
drug testing drills to reduce the anxiety in that situation. Find
a person you are willing to work with who can help you practice.
Drink enough water so that your kidneys are working, but don't overdo
it. Ask your partner to choose random times when he will take out
a cup, and say "it's time, give me a sample". Then go
to a private location and do it. If the military test is witnessed,
have your partner do exactly the same thing the monitor would do,
stand in the same place, say the same things, do any searches they
do, strip clothes to the same degree, etc. Try to use a restroom
layout that looks like the one where the tests are performed. That
way you are simulating as closely as possible the conditions of
the real test. Go through this drill LOTS of times. Do it until
you notice you are quite relaxed in the situation.
If you practice this routine a good number of times, the test should
become a lot easier. There's no difference between this and any
other aspect of the military. Training and practice makes perfect.
Be sure to get a physical that rules out any other reasons
for paruresis. Get the physical from a civilian doctor so
there's nothing on your military record.
Q: I am a student in high school or
college, how can I recover?
A: Many libraries have Steve Soifer�s book on AP. See your
nurse or school clinic about on-campus options for cognitive/behavioral
therapy and other anxiety treatment options or support groups. Talk
to your parents about your paruresis. Show them information from
this web site (see the question above on information
for parents of children with paruresis) and try to get them
to help find a doctor to get you started on a recovery program.
If you don�t get support from your parents, find another trusted
person to help out such as a grandparent, aunt, uncle, older trusted
sibling, special teacher, school nurse, and even your clergy person
if they have had counseling training. Don�t give up if your parents
aren�t supportive or are unable to support you due to financial
or other concerns. Try to find help through other means. Your life
is important, and paruresis does not have to get in the way.
It is common for younger people to feel very concerned about sharing
something like paruresis with an adult because of the desire to
fit in with the crowd. It is not a sign of weakness or craziness
to ask for help. The earlier you get help, the quicker recovery
tends to be, so get started now. Most of us who are older have grown
to realize that in the scheme of things paruresis is a minor problem
compared to the things many �normal� people are hiding. The less
you worry about how others will view you when asking for help, the
less power you give the paruresis and that will start the process
of weakening it and giving you the upper hand in getting better.
Q: I have limited income, what can I do
to get treatment?
A: Many doctors and psychologists have a sliding scale fee
for patients on a limited income. Talk to your doctor, or use a
referral service such as Anxiety Referral Online (https://webarchive.library.unt.edu/eot2008/20090508194835/http://www.anxietyreferralonline.com)
to find therapists that offer this option. If you currently have
a physician, he or she may be able to prescribe some of the medications
used to treat paruresis so you don�t need to see another doctor
for this purpose. It is still preferable to work with a therapist
specializing in cognitive-behavioral therapy (CBT) if you can afford
one.
Support groups can be a valuable option for those on limited income
since they are free. You can set up your own support group if one
is not available in your area. Participation in a support group
without any other medical or psychological assistance is not something
IPA recommends, but it may be the only option for some people of
limited means.
The cost of CBT therapy can run around $125 per session, but most
therapists will only need to treat you for six to ten sessions.
That means it may be possible for you to find the money for these
sessions by saving for them, taking on another job if you can find
it, or working on other creative ideas. If a sliding scale
is applied, these costs will be lower. Consider volunteering for
a mental health services agency in your community. Some of these
agencies may have ways of offering treatment for free or at reduced
rates in exchange for volunteer work.
Check with your state�s health services agency to find out if they
offer options for treatment for people of limited economic means.
Many states offer assistance of this type, but the amount of assistance,
forms of treatment covered, and requirements for qualifying for
benefits vary from state to state.
Q: What books do you recommend for learning
about paruresis and recovery?
A: Below is a partial list of books that people have found
helpful in recovering from paruresis. As for any kind of book, reading
is a form of self-help and this kind of work should be undertaken
with consultation from other sources such as your doctor or a treatment
professional because each person�s case may be different. Some of
these materials can be purchased directly from IPA online at the
IPA Store
page. Your local library may have them available as well. Steve
Soifer�s book is the only book that specifically covers paruresis.
The other books deal with possible underlying mechanisms that may
contribute to paruresis. Not every person will find relevant help
in every book. Because of the current state of understanding about
paruresis, those seeking treatment through self-help reading will
need to do personal research and find avenues that work for your
individual situation. Mark Twain made a funny quote that applies:
"Be careful about reading health books. You may die of a misprint."
What this illustrates is that we all need to use our common sense
about advice from books. Everyone's recovery process is different,
while similarities are also involved. No one who writes a book is
right all the time, or for all people.
Soifer, Steven M.S.W. Ph.D., George D. Zgourides, Psy.D., Joseph
Himle, M.S.W., Ph.D., Nancy L. Pickering. Shy Bladder Syndrome.
Oakland, California: New Harbinger Publications, 2001. ISBN:
1572242272. This is the groundbreaking book that first brought
paruresis and its treatment to the public.
Dr. Howard Liebgold maintains a site for his "Phobease"
materials at:
https://webarchive.library.unt.edu/eot2008/20090508194835/http://www.angelnet.com/fear.html
or from the IPA
Store.
His materials cost $75-125 and you get a book along with cassettes
or videotapes. His materials take a humorous and startlingly clear
look at the psychology and physiology of fear and explain complicated
ideas in simple, powerful ways. Many people have reported excellent
results from Dr. Liebgold�s course.
Markway, Barbara G., Alec Pollard, Cheryl N. Carmin, Teresa Flynn,
and C. Alec Pollard. Dying of Embarrassment. Oakland,
California: New Harbinger Publications, 1992. ISBN: 1879237237.
Recommended by Dr. Liebgold in his �Phobease� course, this book
covers social phobia and ways to recover.
Beattie, Melody. Codependent No More. New York: HarperCollins,
1987. ISBN: 0-06-255446-8.
Beattie, Melody. Beyond Codependency. New York: HarperCollins,
1989. ISBN: 0894865838. Both of Beattie�s books have very useful
information on the recovery movement�s perspective of personal growth
and change. There are some excellent chapters on dealing with relapse,
understanding the contributions of family history and upbringing
to our situation, identifying unhealthy thinking and replacing it
with healthy thinking, and breaking through resistance.
Ratey, John J. and Catherine Johnson. Shadow Syndromes: The
Mild Forms of Major Mental Disorders That Sabotage Us. New York:
Bantam Books, 1998. ISBN: 0553379593. This book takes the
view that many problems such as depression, anger, anxiety, inability
to complete tasks, and others are mild forms of more serious mental
disorders that can affect the very course of our lives. The authors
describe methods for recognizing and learning to deal with each
individual�s unique biological makeup.
Twerski, Abraham M.D. Addictive Thinking. Center City, Minnesota:
Hazelden Publishing, 1997. ISBN: 1-56838-138-7. This is a
short book that is very easy to understand and is packed with good
information. It can help with learning to think rationally, understand
the tricks that anxiety can play, how to recognize the tricks, and
cope with them in healthy ways. While paruresis is different from
a chemical dependency, it has some similarities to addictive behavior
that make this book a useful reference.
Nakken, Craig M.S.W., L.I.C.S.W., L.M.F.T. Addictive Personality:
Understanding the Addictive Process and Compulsive Behavior.
Center City, Minnesota: Hazelden Publishing, 1996. ISBN:
1568381298. This book explains many personality characteristics
that contribute to addictive forms of behavior. Packed with
valuable insights that can help the reader apply successful techniques
from the recovery movement to paruresis recovery.
Bemis, Judith and Amr Barrada. Embracing the Fear. Center
City, Minnesota: Hazelden Publishing, 1994. ISBN: 0-89486-971-X.
This book is highly consistent with Twerski and others who view
reducing anxiety through avoidant behavior as a form of dependency.
Weekes, Claire M.B., D.Sc., M.R.A.C.P. Peace from Nervous Suffering.
New York: Penguin Books, 1972. ISBN: 0801558026.
Weekes, Claire M.B., D.Sc., M.R.A.C.P. Hope and Help for Your
Nerves. New York: Signet, 1990. ISBN: 0-451-16722-8. Weekes�
books deal with the trauma of anxiety and how it affects our daily
living. They are not paruresis recovery books. However, if your
paruresis has contributed to depression, panic attacks, chronic
pain, and/or impacted other parts of your life to the point where
your mood is not what you want it to be, these can be helpful references.
Schwartz, Jeffrey M. M.D. Brain Lock. New York: ReganBooks,
1996. ISBN: 0060987111. This book covers Obsessive-Compulsive Disorder
(OCD) and can be helpful in breaking down some of the thinking patterns
we focus on that distract us from recovery work.
McCullough, Christopher Ph.D. Free 2 P: A Self-Help Guide for
Men with Paruresis. Self-published work, 2000. Dr. Christopher
McCullough is an IPA Advisory Board member. His book is available
at the IPA
Store. While much of the book is written for men, his
concept of primary and secondary paruresis does apply equally to
women. Primary paruresis is the inability to urinate around others,
secondary paruresis is the importance and meaning we assign to our
primary paruresis.
Aron, Elaine Ph.D. The Highly Sensitive Person. New York:
Random House, 1997. ISBN 0-553 06218-2. This book identifies and
defines a new personality type, the highly sensitive person -- and
gives readers many tips on how to overcome its limitations and maximize
its strengths.
Ellis, Albert Ph.D. A Guide To Rational Living. North Hollywood,
California: Wilshire Book Company, 1976. ISBN: 0879800429.
It�s the original self-help instruction book in cognitive behavior
therapy technique. Other books from the same author are also recommended.
Ellis, Albert Ph.D. Overcoming Destructive Beliefs, Feelings,
and Behaviors: New Directions for Rational Emotive Behavior Therapy.
Amherst, New York: Prometheus Books, 2001. ISBN: 1573928798
Bourne, Edmund J. Ph.D. Beyond Anxiety and Phobia: A Step-By-Step
Guide to Lifetime Recovery. Oakland, California: New Harbinger
Publications, 2001. ISBN: 1572242299. Takes the position that true
recovery from anxiety requires more than a short-term intervention.
Explores the meaning of anxiety symptoms and long-term healing through
alternative modalities. Discusses how certain personality
issues such as perfectionism can sabotage the healing process. Other
books from the same author are also recommended.
Q: Is my diet a factor in paruresis?
Can I help my recovery by changing it?
A: Drinking more fluids helps to improve the health of the
urinary system, so that can be helpful for recovery. People dealing
with urinary tract infections find that cranberry juice is effective
in reducing or eliminating infection. Substances that increase anxiety,
especially caffeine, should be avoided or used with care. Caffeine
does stimulate urine production and some people have noticed that
drinking tea, which contains low to moderate amounts of caffeine,
can be helpful in graduated exposure practice. Caffeine does have
the useful characteristic that dosage is relatively easy to control
by drinking a certain amount of coffee or tea. Alcohol has effects
that are more difficult to predict. Because alcohol can relax muscles
in the body, it may improve the ability to relax the urinary sphincter.
However, in many people it relaxes the bladder muscle as well, which
reduces the urge and ability to urinate. People tend to control
their alcohol intake less reliably, especially if they drink more
heavily. For this reason IPA does not recommend use of alcohol
during graduated exposure therapy, or as a method of making the
work easier. See the more detailed discussion on Alcohol
below for more information.
Q: I am taking an airline trip, how can
I get through it?
A: We know of two prescription drugs that may be helpful.
Desmopressin slows urine production. It�s available in spray form
under the names Concentraid, DDAVP, or Stimate, or generically as
Desmopressin Acetate Nasal Solution. Desmopressin is a chemical
that is similar to a hormone found naturally in your body. It decreases
urine production and increases urine concentration. Its main use
is to help treat kids with bedwetting problems.
We have also heard a report that the drug Detrol reduces urinary
urgency and frequency if the person experiences frequent urges to
urinate. If you are facing an airline trip, one of these drugs may
be useful depending on your situation. Consult your physician and
try the drug out before the trip to learn if it will provide temporary
relief. For short-term use on an airline flight, your doctor may
even be able to provide a free sample of the drug.
IPA is not medically qualified to make any judgments about the
medical implications of using either of these medications and common
sense would indicate that one should not take these drugs for extended
periods. However, they may be of use for occasional trips and short
periods of difficulty for the paruresis patient.
Learning to use a catheter will allow you to take an airline trip
with total certainty of being able to empty your bladder. Many of
our members carry catheters on airline flights. They feel much more
at ease and can enjoy travel again. It is strongly recommended that
if you use catheters to help get through a flight, bring several
on board with you. When lubricated, they are slippery and sometimes
slip out of your hands. Or, you might accidentally let one touch
the lavatory table or wall. Always bring extras, since planes get
diverted for long periods due to weather and other unpredictable
events. Sometimes, short flights can last many hours. See IPA�s
Catheters page
for more details.
A number of people report success with holding their breath (described
below) to initiate urination. This technique does not work for everyone,
so you will need to test it and likely practice it a number of times
before relying on it dependably.
More details on the use of Desmopressin can be found in the Best
of Boards article.
Some people have reported that they are able to urinate freely
using an external catheter. These are available without prescription
in medical supply stores, and there is a product available through
the web called the Stadium Pal. For those who can use these devices,
they may be very helpful. If considering this option, remember that
airline security personnel might give you a pat-down search for
hidden objects and you may need to explain about the external catheter.
This will be very likely if there are any metal parts in the catheter
or collection bag.
Q: How does alcohol affect paruresis?
A: Alcohol has two major effects. These can operate in opposing
ways, making it difficult to predict how alcohol will affect your
paruresis. First, it can reduce inhibitions. Because many who drink
experience a reduction in social fear and inhibitions while under
its influence, they report it is easier to urinate after drinking.
However, for many people the amount of alcohol required is significant
and carries major health risks, including addiction, liver damage,
and impairment of ability to drive, operate machinery, or do work.
Regularly using alcohol in this way amounts to �self-medication�
of the anxiety associated with paruresis. Because alcohol does not
treat the underlying causes of paruresis, it can create unwanted
complications and over time may increase one�s symptoms because
a person is treating the symptoms and not the underlying irrational
thinking. IPA does not recommend alcohol use as a means of treatment.
The second effect alcohol has is to relax muscles in the body.
Because of the way the urinary system operates this can have confusing,
unpredictable results. Specifically, it may improve the ability
to relax the urinary sphincter while one is under its influence.
However, in many people it relaxes the bladder muscle as well, which
reduces the urge and ability to urinate even with the sphincter
relaxed. The relative relaxation of the bladder and sphincter will
vary so that there is no way of knowing if it will be easier or
harder to urinate. Attempting to control the dosage of alcohol
to find a �sweet spot� is also fraught with risk and uncertainty
because as people drink more, they tend to control their alcohol
intake less reliably. Finally, these effects disappear once a person
is sober. So even if they work for you, you�ll need to be intoxicated
all the time in order to say you�ve recovered from paruresis. Trading
paruresis for alcoholism isn�t a good idea.
Q: I�ve lost my job (or
employment offer) due to being unable to provide a urine sample.
What can I do?
A:
1) Find a lawyer experienced in Equal Employment Opportunity law,
disabilities, and employee law. If you live in a small city, travel
to a nearby larger city if necessary to find someone qualified.
Ask about their experience in these matters and their willingness
to represent you as a disabled person, before you sign a contract
or retainer agreement. If the lawyer lacks past experience
in defending disabled clients, look for someone else. It is IPA�s
position that anyone with paruresis has a disability if they experience
difficulty providing urine specimens for employment. These
days, 60% of companies do urine testing, and if you can't provide
a urine specimen, then you have an employment disability. Note that
currently, IPA�s position of paruresis being a disability has not
been established in court in all states. IPA is trying to establish
legal protection for paruretics. This that will take time until
we are successful. Your assistance, both financial and in notifying
us of test cases, can help.
The Americans With Disabilities Act (ADA) has a three-part definition
of "disability." The definition is based on the one given
in the Rehabilitation Act, and reflects the specific types of discrimination
experienced by people with disabilities. Therefore, it is not the
same as the definition of disability in other laws, such as state
workers' compensation laws or other federal or state laws that provide
similar benefits for people with disabilities and disabled veterans.
Based on experience, your lawyer will know the best way to pursue
a claim given the different laws involved where you live.
Under the ADA, an individual with a disability is a person who:
- Has a physical or mental impairment that substantially limits
one or more major life activities;
- Has a record of such impairment; or
- Is regarded as having such impairment.
A physical impairment is defined by the ADA as:
"Any physiological disorder or condition, cosmetic disfigurement,
or anatomical loss affecting one or more of the following body systems:
neurological, musculoskeletal, special sense organs, respiratory
(including speech organs), cardiovascular, reproductive, digestive,
genitourinary, hemic and lymphatic, skin, and endocrine."
(Emphasis added.)
Because paruresis affects the genitourinary system and employment
is a major life activity, denial of employment due to paruresis
in the opinion of IPA is discrimination, and a violation of the
ADA.
Under the terms of the ADA, any employer with 15 or more employees
is a "covered employer." A qualified individual with a
disability is protected by the ADA. Both an applicant and an employee
are subject to the ADA's protections. Covered employers are required
to provide reasonable accommodation for qualified individuals unless
doing so would cause undue hardship. According to the US Equal Employment
Opportunity Commission,[ix]
a reasonable accommodation is any change in the work environment
or in the way a job is performed that enables a person with a disability
to enjoy equal employment opportunities. The EEOC lists three categories
of "reasonable accommodations":
i. changes to a job application process
ii. changes to the work environment,
or to the way a job is usually done
iii. changes that enable an employee
with a disability to enjoy equal benefits and privileges of employment
(such as access to training).
IPA�s position is that any employer who does not provide an alternative
(non-urine) means to provide a drug test for a person with paruresis
violates category (i) if an applicant is applying for a job, and
violates category (iii) if an employee is subject to drug testing
as a condition of continued employment.
2) Have an independent drug test done. The purpose of this test
is to show that at the time of your original drug test, you were
clean of drugs. Once you have that unassailable fact established
by documentation from a doctor's office, then a judge and jury are
likely to find in your favor. Don't put this step off, as it�s critical
to establish your legal case. Don�t go to any small drug testing
office to get this done; go with an industrial medicine practice
or other large medical practice that will have a doctor with sufficient
credibility. IPA recommends that you get a hair drug test because
hair tests look back 90 days which is more than sufficient to cover
your event period, thus proving you were clean of drugs at that
point. Alternatively saliva, urine or even a blood test could be
used to establish your innocence on drug use. Blood tests carry
less weight because most drugs are cleared from the blood more quickly
than with any other popular testing method. Therefore, IPA recommends
not using them unless you have specific reasons why a blood test
would bolster your case. It will likely cost you somewhere around
$100 to obtain the test. It is well worth the money because
of the legal weight the test results will provide in court.
3) Write down the details of what happened to you during the drug
test. What were the comments made to you regarding test procedures,
were you intimidated in some way, was there a lack of privacy, etc.
We have found in numerous cases that urine collectors have violated
the Federal or non-Federal (DOT) standards for drug testing in such
areas as:
- Not referring the candidate to a doctor's office for shy bladder
diagnosis where appropriate (required by DOT standards in specific
circumstances)
- Requiring or implying that donors must drink more water
(this is optional, not a requirement under SAMHSA rules, but not
under DOT rules)
- Keeping donors longer than the currently allowable 3 hours
- Where public restrooms are used with a collector positioned
in the restroom, the collector must be of the same gender as the
donor
- Timing the person giving the urine sample. The person has three
hours to provide a sample, but there is no regulation stating
how long a person needs to take at any given try during the three-hour
period. Collectors often confuse a rule requiring them to test
the temperature of urine within four minutes after its production
with a non-existent rule that donors have only four minutes to
try to produce a sample.
Whatever details you can remember about how you were treated might
strengthen a legal case, so please write them down. Try to obtain
the name of the urine collector, the name of the collector�s supervisor,
the name of the testing company, the name and business address of
the Medical Review Officer associated with the testing company.
You will also need to find out exactly which regulations apply
to your situation. Remember, DOT and SAMHSA rules do not apply in
most testing situations, particularly for the private sector. Private
employers have a great deal of freedom to do as they wish consistent
with the laws of their own state. What this means is that you may
have few legal rights or remedies. However, you always have a right
to sue if you are harmed (physically or emotionally) by mistreatment
at the urine collection site. You may need to discuss these sorts
of issues with your own attorney. It seems that typically they don�t
like to take these types of cases, but you should at least talk
with a personal injury or employment discrimination attorney.
4) Go talk to your state's Equal Employment Office. An IPA member,
who was rejected on a pre-employment drug test for not being able
to provide a urine sample, went to the Nevada office. He was subsequently
offered the job after he had accomplished Step (2) above and after
the Nevada office appealed on his behalf. At IPA, we are yet unsure
what this resource can do for us but they have offices in each state
and should not be overlooked. See the �Advocacy� section of our
site�s Links
page for information on locating your state�s office.
5) If you are a union member, talk to your union�s grievance representative.
The union may be able to help you in defending your case. IPA has
heard of unions being very supportive of employee rights in botched
drug testing incidents. This is a situation where your dues payments
may be worth every penny.
6) Obtain a document signed by a medical doctor that expresses
the diagnosis of shy-bladder or paruresis for you. A drug testing
Medical Review Officer (MRO) has previously sent a letter to IPA
emphasizing the importance of this pre-drug test documentation.
His opinion was that anyone with paruresis is going to know about
it and have documentation prior to any drug test. Without this documentation,
his judgment, of 14 years experience, was to disallow any claim
of paruresis. Ideally you should have this documentation before
taking the test, but if you don�t have it you will need it in court
to argue your case. It will also carry weight in any employee/agency
negotiations.
7) Meet with your agency or company employee representatives. You
may want to do this with legal and/or union representation. In that
meeting, communicate the following:
- You have a urination disability.
- You have documentation of your disability diagnosis (shy-bladder,
paruresis) by a medical doctor.
- You have had an independent drug test done and it proves you
are clean of illegal drug usage.
- You request "reasonable accommodation" under the Americans
With Disabilities Act. The Reasonable Accommodation you request
is one of the Alternative Tests now being considered by the US
Department of Health and Human Services (HHS) and Department of
Transportation (DOT). That includes Hair Testing, Oral Fluids
(saliva), or Patch (Sweat) testing. Even blood testing is acceptable
if necessary to prove your innocence.
Note (1): Please do not get emotional, excessively angry, or threaten
bodily harm to employer representatives, drug testing personnel,
or any other people involved in this negotiation. Such actions may
only convince the employer to fight harder to deny you employment
and could limit any settlement. Should you need to pursue the claim
in court, maintaining a professional demeanor will deny the employer
an opportunity to use evidence of your emotional actions against
you in their testimony. Try to be calm, cool, and confident in the
reasonableness of your case. If you have any doubts in being able
to stay cool, let a lawyer do the talking.
Note (2): Depending on your individual situation, the sequence
of the above steps may vary.
Note (3): If you are a Federal worker, you have avenues available
to you that should not be ignored, such as an Agency EEO office,
grievance procedures, appeals to the Merit System Protection Board
and the courts, etc. But the basic steps listed above should still
be relevant except that in Step 3), you would deal with the Agency
or Federal EEO office instead of your state's equal employment office.
Q: Is it important to let my doctor know
about my paruresis?
A: Yes. But be prepared to educate your doctor when you
visit, as many are unfamiliar with this condition. First off, your
doctor needs to make sure there is no physical cause of your paruresis.
If one exists, resolving it might be the only treatment you need.
IPA recommends that everyone seeking paruresis treatment first rule
out any physical cause with his or her doctor. Older men can experience
a common problem called benign prostatic hyperplasia that is easily
treatable. There are many other physical conditions that have some
of the symptoms of paruresis. Urinary retention is a side effect
of some medications. Your doctor will likely ask questions about
family history, any symptoms you are experiencing, and may run some
tests. Depending on your individual situation, several possible
tests may be performed, including:
- Ultrasound
- Draining your bladder with a catheter
- Performing an X-ray of the bladder (cystogram)
- Voiding cysto-urethrography, a process of imaging the bladder
and urethra during urination
- Urodynamic evaluation, which may include urinating into a special
toilet that will measure the volume of urine voided, the speed
it was excreted, and how long the process took.
- Cystoscopy, a procedure that lets a urologist look at the urethra
and bladder from the inside.
Some of these tests may not be possible if you are unable to void
in the medical test facility. Be sure to talk to your doctor about
your ability to void in different situations. There is no reason
to go through unnecessary grief unless there is a clear medical
reason that one of these tests will help with your diagnosis.
Talking to your doctor will also establish a diagnosis of paruresis
once any required tests have been performed. Your doctor can then
provide you with a letter establishing your paruresis diagnosis.
This letter could be very important in helping you request reasonable
accommodation for an alternative employment drug test. By showing
you had a condition that was established long before the drug test,
it may reduce suspicion that you are a drug user trying to avoid
a test.
All of the above information assumes you have an understanding
doctor or urologist who is informed about paruresis or is willing
to listen to you and read any information you bring to your doctor
from this website. Unfortunately, there are wide differences in
the level of awareness in the medical community about paruresis,
its diagnosis, and treatment. Most of our members have needed to
bring information from the IPA to educate their doctors. Pay close
attention to how your doctor reacts. If your doctor is unwilling
to consider the information from IPA that you provide, tries to
make light of your situation, or suggests to a man that simply using
a stall is a solution, you�re seeing the wrong person. Find someone
else immediately.
If you don�t feel your doctor is the right one, it will be well
worth your time and effort to locate a specialist in urology or
a different doctor who has experience and compassion for patients
with paruresis. Your local IPA support group may be able to provide
a doctor�s name whose services have helped other group members.
See chapter six of Steve Soifer�s book, �Shy Bladder Syndrome� for
an excellent discussion on how to deal with the medical community.
For many people, the doctor will be the first person they�ve ever
told about their paruresis. It can be a very uncomfortable and bothersome
experience to open up to another person about this condition, especially
when the likely next steps include poking, prodding, and various
medical procedures involving discomfort. There are a few things
you can do to make the experience less traumatic. First, tell other
supportive family and friends about your paruresis in advance of
going to the doctor if you can. Perhaps one of these people will
be willing to accompany you for the appointment. The experience
of doing this will put you more at ease at your appointment. Talk
to your doctor by phone in advance of the appointment. If he or
she is reassuring, you will likely have a more pleasant office visit.
If the telephone call isn�t to your satisfaction, finding a different
doctor might be in order. Finally, take heart in knowing that paruresis
isn�t a life-threatening situation. Your life may be unpleasant,
but this isn�t a condition like cancer. Nearly all people who seek
medical help end up going in for one or two tests and then working
with a psychologist for a few visits. Treatment won�t involve an
endless series of hospital visits or a lot of physical pain.
Most of us reach a low point before finally deciding we need to
see a doctor. That may be an upcoming drug test, failing a drug
test because of inability to provide a urine sample, an embarrassing
social situation with friends, or feeling isolated from others after
severe paruresis cuts off our contact with the outside world. If
you�ve reached this point, seeing a doctor and getting control of
your treatment and recovery is the next logical step. You are taking
a very positive action for your own health.
Young people, teenagers, and younger adults often avoid medical
visits out of a sense of modesty, privacy, and fear of embarrassment.
Keep in mind that your doctor has examined thousands of people,
and heard about far more embarrassing situations than yours. Courage
and a good sense of humor will get you through.
Q: What percentage of the population has paruresis?
A: Until IPA has funding to do a verifiable study,
our best data come from a document called the National Comorbidity
Survey[x], a survey of 8,098
people on the prevalence and types of various psychiatric disorders.
In this survey, 6.6 percent of respondents noted that they experienced
a fear of using a toilet away from home. IPA regards this number
as an approximate figure on the prevalence of paruresis, because
it does not take into account the severity or duration of symptoms.
One of our objectives is to undertake a more specific study on paruresis
to gain more information on how many are affected by the disease
and to what extent.
We have another piece of anecdotal
evidence, an account from a person in the US Navy that reported
when mass drug testing of the 300 shipboard personnel was conducted,
ten to fifteen people were unable to provide a urine sample. The
person giving the account was placed in a room with the others who
failed and all were required to stay until they could provide one,
so that is how he knew the number. This works out to between three
and five percent. The incident happened between 1986 and 1988, so
these were enlisted personnel. Since it is likely that people with
paruresis would be less inclined to join the military, we believe
the figure of three to five percent to be a lower bound of the incidence
of paruresis in the US adult male population. This person's account
is in our Best of Board compilation.
Q: What causes
paruresis?
A: Paruresis appears to
be a complex condition, with multiple factors that contribute to
it. One piece of evidence supporting this observation is that standard
treatment methods for many well-known disorders do not produce high
recovery rates when applied to people with paruresis. If the cause
of paruresis were simple, we would expect recovery to also be simple
and effective for nearly everyone. As medical science advances,
we are learning that individual genetics can play an important role
in why treatments that work for some people don�t work for others.
We know that paruresis is classified
as an anxiety disorder, owing to the fact that those with paruresis
experience symptoms in common with other anxiety disorders. Many
with paruresis reported experiencing teasing or other kinds of physical
or emotional abuse from family, classmates, or others, particularly
if the abusive behavior was in a restroom or related to toilet training.
Currently there is some evidence, most of it anecdotal, that paruresis
has characteristics of other kinds of conditions. The most frequently
reported ones are forms of depression, Obsessive-Compulsive disorder
(OCD), panic disorder, and behavioral addiction. IPA has learned
that a large percentage of people suffering from a rare childhood
condition known as selective mutism also have paruresis. Recent
research also indicates that a drug used for treating epilepsy may
be useful in treating paruresis. Just because links to other disorders
are suspected doesn�t mean you�re going to become severely depressed,
jump off a cliff, develop epilepsy, or end up an addict. But these
links are tantalizing and someday will lead to understanding the
underlying causes of paruresis. It also helps to be aware of these
related conditions so you can take steps to get early treatment
if you or your children experience any of them.
The complexity of paruresis� origin
means that a person seeking treatment may wish to look at the disease
from many different perspectives, and find a method of treatment
that works for you. A great many have been helped by cognitive-behavioral
therapy. Some of us have had success using treatments recommended
for recovering from OCD. Others have had success with techniques
from the recovery movement more often applied to behavioral addictions.
Some have used medications originally intended to reduce depression.
Some who have had difficulty finding an approach that works have
simply accepted this and learned to use a catheter when faced with
a difficult restroom situation. But even those people go on to lead
normal lives once they have a means of coping with their paruresis.
Q: Does
paruresis put me at risk for other problems?
A: In general, the
risk of significant health problems for those with paruresis is
not believed to be high. However, there are important risks
to be aware of. Some men have reported having chronic prostatitis.
Urinary tract infections related to retaining urine for too long
a time are possible in both men and women. Some people try to cope
by limiting fluid intake, and that can carry a risk of stones in
the kidney, gall bladder, or salivary glands. Limiting fluid intake
increases the possibility of heatstroke for people who live in hot
climates or do a lot of physical exertion. If the bladder is allowed
to fill beyond its normal capacity, it can become stretched and
incapable of contracting fully. An overextended bladder produces
higher risk of bladder infection because it can�t flush out all
the urine. In severe cases, overfilling the bladder can lead to
urinary reflux (where urine backs up into the kidneys) and even
kidney failure.
Infrequent voiding and overfilling
the bladder can also lead to neurological problems that are difficult
to resolve. Possible consequences are urinary frequency, where a
person fails to empty the bladder completely and instead experiences
frequent urges to urinate. The signals to and from the brain and
bladder can become weakened, making it difficult to sense urgency
and to coordinate the bladder contraction and opening of the urinary
sphincter.
There is a tendency for some individuals
with high levels of anxiety to attempt to self medicate the symptoms
through the use of legal or illegal drugs. Many of these drugs �
alcohol, tobacco, marijuana, tranquilizers, and sedative-hypnotics
� can create either physical or psychological dependency, leading
to addiction. IPA hears reports from people on our web forum who
have dealt with this kind of dependency or are currently doing so.
These drugs do nothing to reduce the underlying cause of anxiety.
They can make a person feel better temporarily, but as the body
becomes accustomed to the drug ever-increasing amounts will be required
to bring the same level of relief, resulting in an addictive spiral.
The only solution is to treat the underlying anxiety, not the symptoms
of it.
For all these reasons, IPA recommends
people with paruresis drink plenty of water, use restrooms several
times a day, and avoid overindulging in legal or illegal drugs.
Besides the health benefits, repeated restroom use is a part of
a graduated exposure therapy program which will help greatly with
recovery. From a practical standpoint, using restrooms several times
a day may seem daunting if you experience great fear while in them.
It will be important to do the process gradually and choose restroom
situations that provoke the least anxiety possible at the start
of the process. Guidance from a competent therapist is often needed
to begin this process. You can find out more about the process of
graduated exposure by reading Steve Soifer�s book "Shy Bladder
Syndrome: Your Step-by-Step Guide to Overcoming Paruresis."
Q: What does
a "medical screen" mean?
A: Difficult urination is
a symptom similar to a high temperature reading. There are several
potential physiological causes. The excellent book: Conquering
Bladder and Prostate Problems, The Authoritative Guide for Men and
Women by Jerry G. Blaivas, MD, lists several causes of difficulty
urinating, such as spinal cord injury, multiple sclerosis, diabetes
mellitus, urethral obstruction, stroke, too little urine in the
bladder, or a weak bladder. Under the category urethral obstruction,
the author lists vesical neck obstruction, prostatic obstruction,
urethral stricture (scar), or learned voiding dysfunction (paruresis
falls into this category).
We recommend that all IPA members
and posters to our Discussion Board get a medical screen to rule
out physical causes of urinating difficulty before assuming that
the cause is psychological (paruresis). We have had one poster who
participated for several months on our Discussion Board before his
doctor diagnosed a mild case of multiple sclerosis.
We know of no definitive test for
paruresis as insufficient research has been done in this area. From
the anecdotal information we receive on our Discussion Board, many
cases are first identified through an onset of symptoms between
10 - 25 years of age, although there are cases where symptoms appear
outside this age range. The classic symptom of paruresis is normal
urination when in the privacy of one's home, with much greater difficulty
being able to urinate in a public restroom with others present.
One should always get a medical screen from a qualified doctor for
sudden onset of urination difficulty or for a sudden worsening of
what is thought to be paruresis. People with paruresis commonly
think of any urinary symptoms as paruresis related, not considering
that they are also subject to urinary tract infections, prostate
enlargement, and any number of other physical causes which will
benefit from a doctor�s immediate attention.
Q: What
is the breath-holding technique? Does it work for everyone?
A: This technique is thought
to work because an increase in carbon dioxide in the bloodstream
has been reported to reduce anxiety and induce relaxation in some
patients. This technique is well suited for people who can usually
urinate around others once they get a stream started, but have difficulty
starting the stream. Monroe Weil, Ph.D. reported using it
successfully in three patients.[xi]
A brief description of the technique follows.
- Discuss this technique with
your physician first before using it. Even after getting
an OK from your doctor, if you experience any kind of abnormal
reaction be sure to let your doctor know before proceeding any
further with this technique. Before attempting to use
breath holding in a restroom, practice holding your breath. Start
out holding for 10 seconds, then 15, increasing the time in gradual
increments. Practice often in different settings. Pay attention
to your body�s response to holding your breath. If you are feeling
anxiety or panic while not in a restroom, you�ll need to do more
practice. Since the issue we�re dealing with is anxiety while
urinating, it won�t be productive to do something in a restroom
that is increasing your fear. When you can hold your breath for
45 seconds and feel calm during the process, you are ready.
- Your first attempt should be
in a place where you can feel comfortable, such as at home or
an empty public restroom, so that you can be free of distractions
or anxiety triggers. If the technique is working you will experience
it in a variety of ways. Some describe it as the "pelvic
floor dropping", or an unstoppable relaxation of the urinary
sphincter muscle; others say it will make you feel temporarily
incontinent. Your level of urgency should be moderate to strong,
but not extreme.
Take your position either in the stall or urinal, breathe normally,
and then exhale about 75% of your breath. Do not take in a big
gasp of air before exhaling. You�ll have too much oxygen in your
lungs and it will blunt the effect. It�s also important to not
exhale completely. There needs to be some air left in the lungs.
When holding your breath, pinch your nose if you have to. After
about 45 seconds you should experience the pelvic floor "drop"
and your stream will start. Once the stream starts if you
start clamping up just exhale again and your stream will return.
If your lungs are empty, you may need to take in a small breath
and then resume holding it.
- If you find the technique helps
you start urinating, with practice it will work at any level of
urgency, in every place. Continue practicing and eventually
it should be possible to reduce the time required to start urinating.
Some people start holding their breath as they approach the restroom
so the time required at a urinal or stall is reduced accordingly.
- Some people using the technique
report that it works best if a person has a low level of anxiety
in the restroom. A period of graduated exposure and support group
work may be needed to reduce the level of fear in a public restroom
to the point where the technique begins to work. So if you are
trying it and not getting any results, continue with your recovery
program and try it again a few months down the road. The amount
of reduction of the tension in the bladder neck and sphincter
provided by breath holding may only be enough to offset a certain
level of anxious tension in those areas. If a person is freaking
out in the restroom, no amount of breath holding might work.
Some additional notes on breath
holding:
If you find the technique useful,
after practice it will work even with a low level of urgency or
none at all. At this point if it is necessary to empty the
bladder in a crowded situation, before a trip, or to avoid waking
up at night, breath holding works every time.
During the practice period, some
people who reported a great deal of fear holding the breath for
a long time have persisted and found that the desired effect on
easing urination happens once they overcome the fear. If this applies
to you, try to stay with the practice and get past the fear. Many
believe they will faint if they hold their breath for too long,
but that is not a serious danger. If you have the level of control
to starve yourself of air to the point of fainting, once you faint
you�ll start breathing again. If you�re very concerned, then try
holding your breath at a doctor�s office where emergency help is
available. Most people report they can urinate after around 45 to
60 seconds of breath holding. That�s a long time, but if you are
healthy it�s not dangerously long.
There is one side effect of the
technique, which is that it can also relax the anal sphincter. So
if a person needs to deal with that, visit a stall and take care
of #2 before practicing at urinals.
Below is a personal account from
someone who has tried this technique and uses it successfully:
This would not be complete
w/o a sports analogy. When I first started skiing really steep
slopes, almost extreme terrain, I was with a group of very good
skiers. I'm a good black diamond, mogul skier and these folks
were way above that. Our ski instructor/guide told me that the
only way I could get down the slope was to have courage. I had
to trust my ability to slow my skis with all the techniques [I]
had previously learned. You must have the courage to see this
through. It is worth it, trust us! You will not faint or pass
out but you probably will gasp for air, at that point you are
close. Very close, stay with it. If you do gasp for air, just
suck in a little and hold your breath again.
For those of us doing it properly
it works every time in every condition. For me troughs at
Steeler games, planes, bars, everywhere. As a matter of fact sometimes
I'm very tense just from holding my breath and being stiff or
whatever, but I know if I see it through it works. Once the stream
starts if you start clamping up just exhale again and your stream
will return. For those of us practicing for years, usually once
our stream starts we can keep it going.
Over time a lot more people
will become comfortable with the technique. Again, it does not
improve your primary AP, although my secondary AP is almost non-existent.
I find myself making plans and doing things with people and places
that I would have avoided. I'm not thinking about AP. Then later
it dawns on me "oh my gosh, I just decided to go to such
and such with so and so w/o thinking about where I'm going to
pee. Pretty Cool.
One warning about using this technique:
In some individuals with panic disorder, it has been reported that
elevated levels of carbon dioxide can cause symptoms of increased
anxiety and panic. If you notice this happening and the symptoms
do not improve with practice, then the technique may not be useful
for you, or won�t become useful unless the panic disorder is treated.
Endnotes:
Clicking on an endnote number
will return you to the place in the document referring to the
endnote.
[i]
Enoch, Mary-Anne M.D. and David Goldman, M.D. �Genetic origins
of anxiety in women: a role for a functional catechol-O-methyltransferase
polymorphism,� Psychiatric Genetics 13.1(2003): 33-41.
[ii]
Zhang, Xiaodong, Raul R. Gainetdinov, Jean-Martin Beaulieu,
Tatyana D. Sotnikova, Lauranell H. Burch, Redford B. Williams,
David A. Schwartz, K. Ranga R. Krishnan, and Marc G. Caron.
�Loss-of-Function Mutation in Tryptophan Hydroxylase-2 Identified
in Unipolar Major Depression.� Neuron 45 (2005): 11-16.
[iii]
Allen, T.D. �Psychogenic Urinary Retention.� Southern Medical
Journal 65.3(1972): 302-304.
[viii]
Groth, A. N., & Gary, T. S. �Heterosexuality, homosexuality,
and pedophilia: Sexual offenses against children and adult sexual
orientation.� In A.M. Scacco (Ed.), Male rape: A casebook
of sexual aggressions (1982) pp. 143-152. New York: AMS
Press.
[xi]
Weil, Monroe Ph.D. �A Treatment for Paruresis or Shy Bladder
Syndrome.� The Behavior Therapist 24.5(2001): 108.
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