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Journal ArticleDOI

Paruresis (psychogenic inhibition of micturition): cognitive behavioral formulation and treatment.

01 Nov 2008-Depression and Anxiety (Wiley Subscription Services, Inc., A Wiley Company)-Vol. 25, Iss: 11, pp 903-912
TL;DR: A revised cognitive and behavioral conceptualization of paruresis is presented, drawing on empirical evidence from other anxiety disorders, and a cognitive‐behavioral intervention strategy is outlined, with clear targets for Cognitive and behavioral strategies.
Abstract: Paruresis is a condition characterized by difficulty or inability to urinate in situations where others are present, or may soon be present. Despite knowledge that paruresis can significantly impact on occupational functioning, social functioning, and quality of life, there exists a paucity of research into effective treatments. Although cognitive conceptualizations have been advanced for other anxiety disorders, there has not been a comprehensive cognitive behavioral model of paruresis. This article presents a revised cognitive and behavioral conceptualization of paruresis, drawing on empirical evidence from other anxiety disorders. Using this conceptualization, a cognitive-behavioral intervention strategy is outlined, with clear targets for cognitive and behavioral strategies.

Summary (2 min read)

Introduction

  • Social functioning, and quality of life, there exists a paucity of research into effective treatments.
  • Clinical Presentation of Paruresis General Presentation Individuals with paruresis report significant difficulty in initiating and/or sustaining urination in situations where they perceive scrutiny of their actions (e.g. being seen or heard to urinate) or the consequences of their actions (e.g. another person entering a lavatory that they have just used).
  • Over one third reported an impact of their symptoms on their social activity, while over half reported that it had led to adverse consequences for their work and career (e.g. turning down jobs).
  • Paruresis is commonly comorbid with other psychological conditions.

Gender Differences

  • Many studies examining the prevalence and nature of paruresis have used male samples (e.g. Malouff and Lanyon, 1985; Hammelstein et al., 2005).
  • There is limited information about differences in presentation between males and females with paruresis.
  • On standard measures of social anxiety symptoms women outscore men on most symptoms, whereas urinating in a public restroom is one of very few symptoms scored higher by men than women (Turk et al., 1998).
  • Two general hypotheses have been forwarded in the literature:.
  • The second of these, and the formulation that is promoted herein, is that paruresis shares common symptoms with anxiety conditions such as social phobia, but is a distinct condition.

Paruresis as Social Anxiety Disorder

  • This view has considerable intuitive appeal, with paruresis triggered in social situations where other people are present, or soon to be present.
  • Comorbidity between social anxiety disorder and paruresis has been reported to be approximately 28.6% (Vythilingum et al., 2002).
  • Individuals with paruresis are known to show elevated levels of anxiety and avoidance symptoms (Malouff and Lanyon, 1985), social anxiety symptoms (Hammelstein et al., 2005), body shyness (Gruber and Schupe, 1982), and fear of negative evaluation (Hammelstein and Soifer, 2006).
  • This view is supported by empirical work by Malouff and Lanyon (1985) who found paruretics and non-paruretics to differ on performance anxiety and interpersonal anxiety, but not a host of other demographic and psychological variables.

Paruresis as an Independent Psychological Disorder

  • The classification of paruresis as a variant, subtype or symptom of social anxiety disorder has recently been questioned by Hammelstein and Soifer (2006).
  • Further support for the independence of paruresis from social anxiety disorder can be obtained by examining the relationship between symptoms of the two conditions.
  • The limited amount of research into pharmacotherapeutic interventions from different classes make it difficult to draw firm conclusions, with further research needed to clarify the efficacy of these treatments.
  • Approximately 43% of individuals with paruresis report trying either medication or behavioural intervention, while around 44% report receiving other forms of psychotherapy (Vythilingum et al., 2002).
  • Repeated attempts at urination, with the associated anxious arousal may lead to the development of significant avoidance behaviour.

A Revised Cognitive Behavioural Model

  • Earlier behavioural models of psychopathology neglect the significant developments in cognitive science, cognitive psychology, and cognitive psychotherapy over the last 40 years.
  • The consequences of this self-focused attention may include an obliviousness to the fact that others are not attending to them, as well as heightened awareness of the inability to relax the urethral sphincter and commence micturition.
  • Paruresis – ein bisher vernachlässigtes psychotherapeutisches problem.

Behavioural (Classical)

  • Conditioned association of social cues such as presence of others, public urinals, etc. with anxiety and inhibition of urination.
  • Aim to weaken existing associations, also known as In vivo exposure.
  • Narrow range of stimuli associated with micturition.
  • Aim to establish associations between public facilities and urination, also known as In vivo exposure.
  • Excessive generalization of conditioned association between social context and inhibition of micturition.

Behavioural (Operant)

  • Positive punishment of attempts at urination through unpleasant physiological symptoms (e.g. hot flushes), embarrassment, shame, etc. Arousal management: Aim to reduce physiological arousal symptoms.
  • Aim to encourage approach behaviour, and not use reinforcing avoidance behaviours, also known as In vivo exposure.
  • Use of safety behaviours Relinquishing safety behaviours:.
  • Aim to encourage surrender of safety behaviours/signals.

Cognitive (Content)

  • Beliefs about the meaning, probability and severity of negative evaluation Cognitive restructuring: Aim to rationally reassess meaning, probability and severity of negative evaluation.
  • Aim to empirically test meaning, probability and severity of negative evaluation.
  • Aim to rationally reassess beliefs about body appearance, also known as Cognitive restructuring.
  • Aim to improve self-efficacy through successful exposure tasks, also reducing anticipatory anxiety, also known as In vivo exposure.

Cognitive (Process)

  • Allocation of attentional resources to self-monitoring Attention training: Aim to assist patient in redeploying attention away from the self.
  • Attentional bias to stimuli which may indicate negative evaluation Attention training: Aim to address imbalance in bias to negative stimuli.
  • Aim to encourage unbiased, rational reappraisal of attempts, also known as Cognitive restructuring.
  • Figure Captions Figure 1. Visual formulation model of paruresis.

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Paruresis (Psychogenic inhibition of micturition): Cognitive
Behavioral Formulation and Treatment
Author
Boschen, Mark J
Published
2008
Journal Title
Depression and Anxiety
DOI
https://doi.org/10.1002/da.20367
Copyright Statement
© 2008 Wiley Periodicals, Inc. This is the pre-peer reviewed version of the following article:
Paruresis (Psychogenic inhibition of micturition): Cognitive Behavioral Formulation and
Treatment, Depression and Anxiety, Vol. 25, 2008, pp. 903-912, which has been published in
final form at http://dx.doi.org/10.1002/da.20367.
Downloaded from
http://hdl.handle.net/10072/22369
Griffith Research Online
https://research-repository.griffith.edu.au

Paruresis
1
Running head: Paruresis
Paruresis (psychogenic inhibition of micturition): Cognitive behavioural formulation
and treatment
Mark J. Boschen
School of Psychology, Griffith University
PMB 50 Gold Coast Mail Centre, Queensland 9726, Australia. Email:
m.boschen@griffith.edu.au, Phone: +61 7 5552-8283, Fax +61 7 5552-8291
SHORT TITLE: Paruresis Formulation and Treatment
KEYWORDS: Cognitive Therapy, Behavior Therapy, Formulation

Paruresis
2
Abstract
Paruresis is a condition characterised by difficulty or inability to urinate in
situations where others are present, or may soon be present. Despite knowledge that
paruresis can significantly impact on occupational functioning, social functioning, and
quality of life, there exists a paucity of research into effective treatments. Although
cognitive conceptualisations have been advanced for other anxiety disorders, there has
not been a comprehensive cognitive behavioural model of paruresis. This paper
presents a revised cognitive and behavioural conceptualisation of paruresis, drawing
on empirical evidence from other anxiety disorders. Using this conceptualisation, a
cognitive-behavioural intervention strategy is outlined, with clear targets for cognitive
and behavioural strategies.

Paruresis
3
Paruresis (psychogenic inhibition of micturition): Cognitive behavioural formulation
and treatment.
Introduction
Paruresis refers to the inability to initiate or sustain effective urination
(micturition) in situations where there is a perception of scrutiny, or potential scrutiny,
by others. It is associated with significant distress, impairment of social and
occupational functioning, and reduced quality of life (Vythilingumet al., 2002;
Soiferet al., 2001; Brandt et al., 1994). The condition was first described by Williams
and Degenhardt (1954) who conducted a survey of paruresis symptoms in over 1400
university students. Paruresis is distinct from conditions such as Hinman syndrome,
hysterical urinary retention, psychogenic urinary retention, and other conditions in
which the individual presents with a chronic inability to pass urine, unrelated to the
presence or attention of others (Malouff and Lanyon, 1985).
A slightly different definition of paruresis was offered by Vythilingum et al.
(2002). These authors described paruresis as “…fear of not being able to urinate in
public bathrooms or in situations in which others may be aware that the subject is
urinating” (p84). This re-definition is noteworthy for two reasons: Firstly, it shifts
the focus from the inability to micturate to the fear that one may be unable to pass
urine. Secondly, it emphasises the role of the attention or awareness of others. This
revised definition of paruresis has been considered in development of the
conceptualisation offered in this review.
Research interest into psychological problems of micturition has grown
steadily until the end of the 20
th
century. Although there has been some decline in
research into chronic forms such as psychogenic urinary retention, research in

Paruresis
4
paruresis has remained relatively constant since the mid-1980s. Despite this research
interest, there is no comprehensive theoretical model of paruresis that can be used to
inform treatment. While other anxiety disorders have benefited from a cognitive-
behavioural reconceptualisation (e.g. Rapee and Heimberg, 1997; Clark, 1986; Clum
and Knowles, 1991; Boschen, 2007; Boschen and Oei, in press), such a reformulation
has not been reported for paruresis.
The aim of this paper is to present a synthesis of previous research into
paruresis, and to utilise this information to devise a comprehensive re-formulation of
the disorder. This cognitive-behavioural conceptualisation of paruresis is then used to
propose a cognitive-behavioural intervention program that is founded on evidence-
based treatment principles.
Clinical Presentation of Paruresis
General Presentation
Individuals with paruresis report significant difficulty in initiating and/or
sustaining urination in situations where they perceive scrutiny of their actions (e.g.
being seen or heard to urinate) or the consequences of their actions (e.g. another
person entering a lavatory that they have just used). Significant subjective anxiety
may or may not be present during attempts at micturition (Hammelstein et al., 2003).
Paruresis is not directly related to contamination concerns as seen in OCD and
although medical complications may be present, these are an etiological factor in less
than 10% of individuals (Vythilingum et al., 2002)
The stimuli associated with inhibition of micturition in paruresis are varied,
but include increased numbers of people present, closer physical proximity to others,
and the type of urinal being used (Malouff and Lanyon, 1985; Ascher, 1979). Most

Citations
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Journal ArticleDOI
TL;DR: Little is known about the prevalence of parURESis and more rigorous studies of paruresis are required, and Recommendations in terms of clinical implications, diagnostic criteria and future research relating to parureis are discussed.

21 citations


Cites background from "Paruresis (psychogenic inhibition o..."

  • ...Nevertheless, there is strong evidence that paruresis is not a subtype of SAD despite both conditions sharing common cognitive-behavioural symptomology as the majority of individuals with paruresis do not have SAD [8]....

    [...]

  • ...Unsuccessful attempts at voiding in public may lead to feelings of anxiety and embarrassment, which are then exacerbated with further unsuccessful attempts and avoidance strategies [8]....

    [...]

  • ...In particular, individuals with paruresis may be inclined to perceive others as being critically evaluative, have inflated concerns of their body image, overestimate severity of negative evaluation, and be predisposed to interpreting ambiguous cues as being indicative of negative evaluation [8,37]....

    [...]

  • ...Although both paruresis and psychogenic urinary retention are classified as forms of urinary retention, paruresis differs from psychogenic urinary retention as, in the latter disorder, the individual experiences long-standing inability to urinate under any environment or circumstance which resultantly requires the patient to be catheterized [8,22,26]....

    [...]

  • ...Modern understandings of paruresis have moved away from psychoanalysis towards a cognitive-behavioural framework whereby paruretic symptoms are thought to result from an association between anxious arousal and urination in public restrooms [8]....

    [...]

Journal ArticleDOI
TL;DR: This article explored the use of graduated exposure therapy during weekend-long workshops for the treatment of paruresis, which is a social anxiety disorder characterized by a fear of being unable to urinate in the presence of others.
Abstract: Paruresis is a social anxiety disorder characterized by a fear of being unable to urinate in the presence of others. This condition has not been covered in the social work literature, yet is a perfect example of a person-in-environment problem. This article explores the use of graduated exposure therapy during weekend-long workshops for the treatment of paruresis. One hundred one participants participated in workshops and were administered pretreatment, posttreatment, and 1-year follow-up treatment scales. Repeated measures analysis of variance indicated significant improvement in shy bladder symptoms. Significant improvement in global severity of shy bladder was observed posttreatment and at the 1-year follow-up point. Findings suggest that graduated exposure therapy improves self-reported global severity of shy bladder symptoms and that these gains were maintained at 1-year follow up.

21 citations

Journal ArticleDOI
TL;DR: This article summarizes the key points to performing a quality UDS study that can evaluate and diagnose disorders of the lower urinary tract.

16 citations


Cites background from "Paruresis (psychogenic inhibition o..."

  • ...Other patients may have a long-standing history of “bashful bladder” or psychogenic inhibition, which is a condition characterized by the inability to initiate or maintain micturition in situations where there is a perception of scrutiny by others.(16) Reducing the number of personnel in the UDS laboratory during the study, the use of privacy screens, and the use of a “white noise” generator or playing relaxing...

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Book ChapterDOI
TL;DR: There may be a relationship and overlap between functional urologic disorders which involve disorders of the urethral sphincter and other functional disorders (e.g., irritable-bowel syndrome, fibromyalgia) as well as specifically functional neurologic disorders.
Abstract: The term functional urologic disorders covers a wide range of conditions related broadly to altered function rather than structure of the lower urinary tract, mainly of impaired urine voiding or storage. Confusingly, for a neurologic readership, these disorders of function may often be due to a urologic, gynecologic, or neurologic cause. However, there is a subset of functional urologic disorders where the cause remains uncertain and, in this chapter, we describe the clinical features of these disorders in turn: psychogenic urinary retention; Fowler's syndrome; paruresis (shy-bladder syndrome); dysfunctional voiding; idiopathic overactive bladder, and interstitial cystitis/bladder pain syndrome. Some of these overlap in terms of symptoms, but have become historically separated. Psychogenic urinary retention in particular has now largely been abandoned as a concept, in part because of the finding of specific urethral electromyogram findings in patients with this symptom now described as having Fowler's syndrome, and their successful treatment with sacral neurostimulation. In this chapter we review the poorly researched interface between these "idiopathic" functional urologic disorders and other functional disorders (e.g., irritable-bowel syndrome, fibromyalgia) as well as specifically functional neurologic disorders. We conclude that there may be a relationship and overlap between them and that this requires further research, especially in those idiopathic functional urologic disorders which involve disorders of the urethral sphincter (i.e., voluntary muscle).

11 citations


Cites methods from "Paruresis (psychogenic inhibition o..."

  • ...Cognitive behavioral therapy with graded exposure techniques and biofeedback is the treatment offered for this condition (Rogers, 2003; Boschen, 2008; Soifer et al., 2010)....

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This paper presents a revised cognitive and behavioural conceptualisation of paruresis, drawing on empirical evidence from other anxiety disorders.