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Paruresis (// PAR-ə-REE-sis) is a type of phobia in which the sufferer is unable to urinate in the (real or imaginary) presence of others, such as in a public restroom. The analogous condition that affects bowel movement is called parcopresis.
Some people have brief, isolated episodes of urinary difficulty in situations where other people are in close proximity. Paruresis, however, goes beyond simple shyness, embarrassment, fear of exposure, or fear of being judged for not being able to urinate. Other people may find that they are unable to urinate while in moving vehicles, or are fixated on the sounds of their urination in quiet restrooms or residential settings. In severe cases, a person with paruresis can urinate only when alone at home or through the process of catheterization.
Although most sufferers report that they developed the condition in their teenage years, it can strike at any age. Also, because of the differing levels of severity from one person to another, some people's first experience of the problem is when, for the first time, they "lock up" attempting to produce a sample for a drug test. Many women are unaware that they, too, are subject to paruresis; articles about women and urination emphasize other female urinary dysfunctions, such as urinary incontinence or frequent urination.
Some people cope by deliberately holding in their urine, by refraining from drinking liquids, or locating unoccupied or single-occupancy public bathrooms.
Severe cases of this disorder can have highly restricting effects on a person's life. In moderate to severe cases, overcoming paruresis can be extremely difficult without the help of a psychologist, therapist or support groups. Severe sufferers may not be willing to travel far from their home or be able to form intimate relationships. Others cannot urinate even in their own home if someone else can be heard to be there.
The term paruresis was coined by Williams and Degenhart (1954) in their paper "Paruresis: a survey of a disorder of micturition" in the Journal of General Psychology 51:19-29. They surveyed 1,419 college students and found 14.4% had experienced paruresis, either incidentally or continuously.
Paruresis is also known by many colloquial terms, including bashful bladder, bashful kidneys, mental cloggery, stage fright, pee fright, urophobia, pee-shyness, the slow dribbles, creeping pee-pee, public piss syndrome, shy bladder syndrome.
There is growing recognition of the condition by the UK's National Health Service (NHS) and government. The condition is catered for in the rules for mandatory urine testing for drugs in UK prisons, and UK Incapacity Benefit tribunals also recognise it. It is listed in the NHS on-line encyclopaedia of conditions and disorders. It is now reported to have been accepted as a valid reason for jury service excusal. From 1 August 2005, the guidance on the rules relating to the testing of those on probation in the UK explicitly cites paruresis as a valid reason for inability to produce a sample which is not to be construed as a refusal.
It has, from time to time been the topic of advice columns such as Ann Landers, to which sufferers have written in and been counselled on their problem.
In the US Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), it is classified as a form of social phobia also known as being a type of chronic social anxiety, but that is disputed by some clinicians.
There can be serious difficulties with workplace drug testing where observed urine samples are insisted upon, if the testing regime does not recognise and cater for the condition. In the UK, employees have a general right not to be unfairly dismissed, and so have an arguable defence if this arises, but this is not the case everywhere.
There is growing evidence to suggest that some drug testing authorities find paruresis a nuisance, and some implement "shy bladder procedures" which pay no more than lip service to the condition, and where there is no evidence that they have conducted any real research into the matter. In the U.S. Bureau of Prisons, the Code of Federal Regulations provides that "An inmate is presumed to be unwilling if the inmate fails to provide a urine sample within the allotted time period. An inmate may rebut this presumption during the disciplinary process." Although U.S. courts have ruled that failure to treat properly diagnosed paruresis might violate prisoner's constitutional rights, the courts have also "routinely rejected suspicious or unsubstantiated attempts to invoke it in defense of failure to complete drug testing," particularly when there were no medical record or physician testimony to back up the claim of paruresis. The International Paruresis Association stresses the importance of medical documentation of one's condition since "[t]he person who is unable to produce a urine sample is presumed guilty in the absence of any evidence." Some prisons have offered the use of a "dry cell" — i.e., a cell with no toilet facilities, but only a container for the prisoner's waste — as an accommodation to inmates who are hindered by paruresis from providing an observed urine sample.
The codes and procedures for drug testing in sports are set by the World Anti-Doping Agency (WADA). Enquiries to WADA reveal that their doping codes do not cater for the condition at all, and they say they have never had any reports of problems with it.
Monroe Weil, Ph.D., a psychologist, has described a method he developed for treating paruresis by the use of breath holding combined with in vivo desensitization. The International Paruresis Association provides a detailed discussion of this method on its website. Also, many videos have been posted to YouTube by various individuals demonstrating their approaches to this method. Medication is also an option, SSRI drugs like Prozac, Zoloft, Paxil, etc. can be beneficial, and benzodiazepines such as Xanax, Valium, or Klonopin can be used before the drug test or while in public to relax the muscles and bring the anxiety level down enough to where you can produce a sample.
The condition has been occasionally portrayed in popular culture, sometimes for comedic effect or parody. Examples of this include: