History of paruresis
The term “paruresis” was first coined in 1954 by Williams and Degenhardt. Before this time, research into urinary dysfunction tended to focus on possible failures of the bladder and associated structures. While some references were made to a psychological influence on urinary function, Williams and Degenhardt were the first to describe a disorder of micturition (urination) in which the inability to pass urine was associated with social conditions.
Since then, a lack of clarity around definitions has become apparent. While some authors use terms such as paruresis and psychogenic urinary retention interchangeably, others argue that there is a distinction to be made. Specifically, that paruresis refers to an inability to pass urine in the presence of others, while psychogenic urinary retention refers to a chronic inability to pass urine that is not alleviated by a change in social conditions. Additionally, in 2002, Vythilingum, Stein, and Soifer altered the definition of paruresis from being a difficulty initiating the flow of urine in the presence of others, to the fear of not being able to urinate in the presence of others.
Reflecting the limited research on paruresis, there has been an ongoing debate over the classification of paruresis as a social anxiety disorder (also called social phobia). In the DSM-5 (the diagnostic manual classifying mental health disorders), paruresis is considered to be a subtype of social anxiety disorder. Paruresis has also been described as a type of performance anxiety, which is often seen in social anxiety disorder.
There has also been a paucity of research into the underlying physiological processes associated with paruresis.While several physiological pathways have been proposed, the most recent proposals have involved an interplay between anxiety and physical processes.In 2009,Soifer, Nicaise, Chancellor, and Gordon suggested that high levels of anxiety produced diffuse orthosympathetic stimulation (activation of the “fight-or-flight response” where heart rate and breathing increases, and the body becomes tense), which in turn resulted in detrusor inhibition at vesical and ganglionic levels. This then leads to increased muscle tone of the external urinary sphincter producing urinary inhibition and a reported “locking up” or “freezing” sensation.
More recently in 2017, Gordon and Nicaise theorised that paruresis symptoms were due to increased epinephrine (a hormone and neurotransmitter that increases heart rate, blood pressure, and muscle strength) release and activation of the sympathetic nervous system.This release of epinephrine involuntarily increases muscle tone of the external urinary sphincter and pelvic floor, which inhibits bladder contraction and produces urinary retention.
Regarding assessment of paruresis, research in this area has been limited. Previous assessment measures for paruresis include the Paruresis Checklist by Soifer, Zgourides, Himle, and Pickering (2001), the Paruresis Scale by Hammelstein, Pietrowsky, Merbach, and Braehler (2005), the Bashful Bladder Scale by Soifer, Himle, and Walsh (2010), and the Shy Bladder Scale by Deacon, Lickel, Abramowitz, and McGrath (2012).
To date, the most recent, validated assessment tool for paruresis is the Shy Bladder and Bowel Scale by Knowles and Skues (2016). The Shy Bladder and Bowel Scale is differentiated from other measures as it was the first to assess both paruresis and parcopresis (difficulty to inability to defecate in restrooms). The Shy Bladder and Bowel Scale is short and easy to complete, andhas strong psychometric properties. Recently, the Shy Bladder and Bowel Scale has been found to accurately predict individuals who self-report having paruresis and/or parcopresis versus those that don’t. Click HERE for further information about the Shy Bladder and Bowel Scale.
To date there is limited research exploring the efficacy of psychological treatments for paruresis. In 2010, Soifer, Himle, and Walsh investigated the use of graduated exposure treatment (gradually exposing the individual to their feared situation/scenario until they no longer display a fear response) for paruresis. Soifer and colleagues noted that by gradually exposing paruresis sufferers to increasingly busy, public restrooms, a reduction in paruresis symptoms occurred.
In 2017, the first systematic review (a type of scientific review that systematically collects and critically assesses all research conducted to date on a certain topic with the aim to provide evidence-based conclusions) of paruresis was conducted by Kuoch, Meyer, Austin, and Knowles. In this systematic review, Kuoch and colleagues aimed to investigate four key questions concerning paruresis: (1) What is the prevalence of paruresis? (2) What is the prevalence of psychopathology in paruresis cohorts and what percentage of individuals with paruresis report having social anxiety disorder? (3) What is the quality of life and levels of anxiety and depression in individuals with paruresis? (4) Do psychological interventions for individuals with paruresis reduce paruresis symptoms?
Based on the available literature, Kuoch and colleagues found that the prevalence of paruresis ranged between 2.8-16.4%, and that males are more likely to be afflicted than females. Psychopathology (anxiety and depression in particular) was noted to be positively related to paruresis severity and was suggested to range from 5.1-70.3%. Moreover, the percentage of individuals with paruresis and social anxiety disorder ranged between 5.1-22.2%.Quality of life was found to be significantly impaired for those with paruresis with social and occupational challenges being the most commonly reported issues. Lastly, paruresis symptoms were reported to be ameliorated by psychological treatment.
Following the systematic review, Kuoch, Meyer, Austin, and Knowles were the first to apply the extended bivalent fear of evaluation model of social anxiety to paruresis symptoms in 2019. Through their research, Kuoch and colleagues empirically identified that processes involved in social anxietycould also be used to explain paruresis symptoms. These findings will help to assist researchers and clinicians with their investigation and treatment of paruresis (see paruresis and social anxiety disorder section for further details).