This Discussion Board is for men who
find it difficult or impossible to urinate in a public or social situation. Women should use the women's Board.
The Board is maintained and moderated by the
U.K. Paruresis Trust. Registered Charity no: 1109541.
For
further information, visit our website, or contact us at
From www.dsm5.org: "Publication of the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in May 2013 will mark one the most anticipated events in the mental health field. As part of the development process, the preliminary draft revisions to the current diagnostic criteria for psychiatric diagnoses are now available for public review and comment."
This manual, though American, is used globably as a reference for diagnosis, and it is important to get paruresis mentioned in it.
As a result of the invitation to submit comments, I have submitted the following. Please accepot that the submission is not perfect, nor comprehensive. It is an attempt to get the condition recognised for explicit mention in the revised edition of the DSM.
The social anxiety Avoidant Paruresis should be included in the revised version of the DSM.
Paruresis (aka Shy Bladder Syndrome) was first researched and defined by the American psychologists Williams and Degenhardt in their paper “Paruresis: a survey of a disorder of micturition” in the Journal of General Psychology, 1954, 51, 19-29.
It is listed on the UK’s National Health Service’s NHS Direct website: see Complex Phobias in the section on Phobias.
The UK Home Office Prison Service has procedures to cater for paruresis in prison. The Home Office has provided a letter detailing these procedures.
The condition is recognised by the Maudsley Hospital in London UK. The hospital is · A provider of mental health and substance misuse services in Croydon, Lambeth, Lewisham and Southwark; substance misuse services in Bexley, Greenwich and Bromley; and specialist services for people from across the U.K. · A cross between a large local mental health trust and a teaching hospital, linked to a major international research institute · A provider of the most extensive portfolio of mental health services in the United Kingdom · A world leader in research, working in partnership with the Institute of Psychiatry, King’s College London · The largest mental health training institution in the country. The Clinical Psychology Department of Liverpool University, UK approved a research proposal into the condition.
A Member of Parliament tabled an Early Day Motion calling for more research into this condition.
The UK Paruresis Trust
The UK Paruresis Trust is a UK registered charity. The registration required that the proposed aims of the charity be supported by a professional recommendation.
The Trust runs a support service and has also run therapeutic residential weekend workshops for the last six years; these workshops are always well subscribed. It is notable that participants are being referred by the medical profession.
SBS is a specific social anxiety, meaning the individual is usually anxious about being scrutinised or criticised by others when “performing in public” - in this case, urinating in the presence of others. The psychological conflict that generates this particular form of social anxiety is expressed through the physical symptom of being unable to urinate whenever the person desires.
This is due to the body’s autonomous nervous system (over which the individual has no control) reacting to a perceived threat by shutting down the urinary process. However much the individual wants to relieve him or herself, the tap is turned off.
The experience of SBS varies from person to person; however, certain general patterns are evident. First, SBS occurs mostly in public toilets, but it can also occur in the homes of friends and relatives, or even at home if visitors are nearby or a family member is “waiting”. Typically, though, she or he finds the home bathroom to be the only truly “safe” toilet - the only place where the she is consistently able to void.
Second, SBS ranges in intensity from “mild,” in which the person can urinate in public facilities under certain circumstances, to “severe,” in which the person can only urinate when alone at home. Thus the degree of SBS hesitancy ranges from a momentary delay in initiating the process to chronic and acute retention. Most people occasionally experience at least some hesitancy in public toilets, but this differs from SBS in the matter of degree and context. A person who every now and then must wait a few seconds before being able to urinate does not have avoidant paruresis. Rather, SBS is often a life-long condition characterised by excessive hesitancy or a total inability to urinate. The problem also causes distress in relationships, and in everyday activities like travel, social engagements, long business meetings, and interferes in a significant way with the person’s ability to carry on with these normal activities.
Third, most sufferer’s describe a personal “comfort threshold” required for urinating, whether in public facilities or at home. When this comfort threshold is eclipsed by too many “negatives” in a particular situation - such as noise, odours, lack of visual privacy, other people in the toilet talking, people waiting for the person, stress, tiredness - SBS “kicks in” and prevents the person from urinating at that time.
Summary of criteria Criteria for a specific social phobia
A. Marked fear or anxiety about performing i.e. urinating in front of others. This extends to difficulties in urinating when alone, when aware that others are supposedly aware of his/her trying to urinate i.e. having been seen going into the toilet, friend waiting etc.
B. The individual fears that he or she will be unable to urinate, and that this will be negatively evaluated (i.e., be humiliating, embarrassing, lead to rejection, or offend others) as being unacceptable behaviour.
C. The social situations almost invariably provoke immediate fear or anxiety.
D. The social situations are avoided or endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the danger posed by the social situation. Obviously others are usually not interested in the subject’s performance, or lack of it. However if with friends or colleagues, it could be commented on negatively, which enhances the fear.
F. The duration is from onset for life. There is a strong element of negative reinforcement. Known onset times range from infancy to adulthood. The oldest subject encountered so far was 85. Onset in infancy, childhood and puberty usually associated with a specific event e.g. bullying in school toilet.
G. The fear, anxiety, and avoidance cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. A common factor is the substantial reduction in socialization, with concomitant negative affect on relationships, both with friends and with partners: viz “this condition is so isolating”. Case studies exist of refusing job promotion, turning down a new job, avoiding family holidays pleading work pressures.
H. The fear, anxiety, and avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
I. The fear, anxiety, and avoidance are not restricted to the symptoms of another mental disorder. Research on potential correlation with generalised social phobia and with depression showed a low correlation. Instead the subjects scored above average for public self-consciousness and for rumination.
J. The fear and/or avoidance is clearly unrelated to any general medical condition (e.g., stuttering, Parkinson’s disease, obesity, disfigurement from burns or injury).
Treatment
The recommended treatment is Cognitive Behaviour Therapy (CBT). This is used to address the individual’s illogical perception of reality, and to enable the individual to start on a process of graduated exposure. The aim is to reduce the level of anxiety to such a level that the autonomic nervous system’s threat response is not triggered.
Affected population
This is difficult to ascertain, because the condition is associated with such a level of shame and embarrassment that the individual goes to great lengths to hide it; this can go as far as refusing a job promotion, or an offer of a new job; to avoiding social situations including holidays.
Williams & Degenhardt’s research gave a figure of 14%; a US Co morbidity study suggested 7%. A survey by a men’s magazine found that 1 in 5 men reported frequent difficulty in public toilets.
Conclusion
Avoidant Paruresis (aka Shy Bladder Syndrome) is a Specific Social Anxiety with the unique component that it is linked to the autonomic nervous system’s ability to shut down the process of urination, leaving the individual with no conscious facility to override this. The condition severely affects quality of life in a negative way, but is amenable to improvement using standard techniques of Cognitive Behaviour Therapy, albeit full success requires regular graduated exposure over a significant period of time e.g. up to two years.
Re: DSM 5 revision
Posted by Simon on 28/5/2010, 9:35 pm, in reply to "DSM 5 revision"
Hi Andrew,
Have scanned the document - great work. The W.H.O.'s International Classification of Diseases is also currently being revised - not sure how to go about it but would be worth submitting this to them if possible as well.
All the best, Simon
PS. Although I only have a "mild" form I have often wondered if I have done my bladder damage by holding in too long and over-stretching it. Are you aware of any evidence about this?
Re: DSM 5 revision
Posted by Andrew on 29/5/2010, 9:44 am, in reply to "Re: DSM 5 revision"
Hi Simon
If you could find out how to submit to the WHOICD I would be very grateful.
You ask about over-stretching the bladder; I am not sure about this. I think I once heard that it is possible to lose "tone" i.e. to lose muscle strength resulting in lower pressure, but dont take it as gospel.
Another thing that may happen is that the sphincter becomes over developed, and so (a) can be difficult to fully relax and (b) may reduce the urethal diameter. But again I cannot be sure.