IS “SHY BLADDER SYNDROME” A SUBTYPE OF SOCIAL ANXIETY DISORDER?A SURVEY OF PEOPLE WITH PARURESIS

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Keywords: paruresis; social anxiety disorder; comorbid,

INTRODUCTION

Paruresis, or “shy bladder syndrome,” is characterized by fear of not being able to urinate in public bathrooms or in situations in which others may be aware that the subject is urinating. There have been few empirical studies of paruresis; those that have been done suggest that it may be far more common than assumed. Paruresis appears more in males, and it may be associated with significant comorbid psychopathology [Soifer et al., 2001; Himle, 1997, Zgourides, 1987, Malouf, 1985]. Anecdotal reports suggest the efficacy of cognitive-behavioral techniques but not of phenelzine [Hatterer et al, 1990]. However, other medications such as SSRIs may be helpful as an adjunct to therapy [Soifer et al, 2001].

Some authors have suggested that paruresis is a subtype of social anxiety disorder (social phobia) [Soifer et al, 2001; Kessler et al., 1998]. Certainly, urinating in front of others can be conceptualized as an anxiety-evoking performance situation, Thus, the Liebowitz Social Anxiety Scale (LSAS) [Liebowitz, 1987], a scale commonly used in social anxiety disorder research includes an item to assess fear and avoidance of urinating in front of others.

1. MRC Unit on Anxiety Disorders, University of Stellenbosch, Tygerberg, Cape Town, South Africa
2. School of Social Work, University of Maryland, Baltimore, Maryland

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Received for publication 2 May 2002; Accepted 29 May 2002
© 2002 WILEY-LISS, INC.

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 | Brief Report: Pururesis Survey |

The potential clinical importance of paruresis is reinforced by the existence of the “International Paruresis Association,” founded in 1996 by Professor Steven Soifer and therapist Carl Robbins, The Association has conducted weekend workshops for people with paruresis in order to promote awareness of the condition and encouraged appropriate treatment. In this paper, we report the results of a survey of people affiliated with the TPA.

METHODS

People affiliated with the IPA were surveyed with a self-report questionnaire, The questionnaire included items addressing demographic variables, the phenomenology of paruresis, and comorbid diagnoses, Items from the Liebowitz Social Anxiety Scale (ISAS) were included. Distribution of the questionnaire was done over the Internet, After 2 reminders, 63 questionnaires were received, which was equivalent to a response rate of 10%.

RESULTS

SUBJECTS

The mean age of subjects was 38.1 + 12 years. Symptoms were chronic, with a mean onset of 13,2 +4.9 years, and a mean duration of 24.5+13 years.

SYMPTOMS

Consistent with earlier literature, we found that most sufferers experienced difficulty urinating in situations where others were present. The most difficult situations for people were urinating in I) a public restroom where there was a line of 84.1%), 2) a busy public restroom (58.7%), and 3) a quiet public restroom (39.7%). Most subjects (68.7%) did not have problem urinating at a friend’s home, A minority of subjects (15%) indicated that even urinating at home could be
problematic.

In anxiety-provoking situations, subjects experienced many symptoms of panic attacks, including trembling (44.4%), sweating (38.0%), shortness of breath (34.9%), blushing (34.9%), and nausea (17.5%).

Our data shows that contamination concerns are not significant for most sufferers, with only about 6% reporting fears about the cleanliness of bathrooms, However, current comorbid disorders were common among subjects, the most common being social anxiety disorder (social phobia) 28.6%, major depressive episode (MDE) 22.2%, alcohol dependence 7.9%, alcohol abuse 14.3%, and obsessive-compulsive disorder (OCD) 4,8%. Nineteen (19) percent of subjects had a history of a past MDE, In total 49.2% of all subjects surveyed had at least one comorbid diagnosis.

Parvresis appears to be unrelated to medical problems in the majority of patients, However, in 9% of the patients, medical problems, particularly prostatism, were mentioned as a contributing factor to their symptoms.

Almost sixteen percent of subjects reported a family history of paruresis. Other psychiatric conditions were also common in the subjects’ families, most notably social anxiety disorder (15.9%) and depression BL7%). Only 1.6% of subjects had a family history of OCD.

CONSEQUENCES

Paruresis was reported to have a significant impact on sufferers’ lives, Self-report indicated that 15.9% limit/avoid fluids, 38.1% limit or avoid traveling, 25.4% limit or avoid Sports events or parties, 36.5% limit or avoid invitations, and 33.5% limit or avoid dating.

Symptoms have also had adverse implications for occupational choice in 30.2% of the respondents, paruresis had an impact on their chances of promotion, in 55.6% it Limited the type of job they chose to do, and 50.8% had turned down jobs because of their paresis.

Paruresis is also associated with significant feelings of shame; 27.0% were moderately land 39.7% were markedly embarrassed by their paruresis, A significant number of sufferers hid their symptoms, with 25.4% not telling their partners, 44.4% not telling their family, and 58.7% hiding their disorder from friends.

Paruresis also has medical implications. For over half of our sample (57.1%), it is impossible to produce a urine specimen on demand, Of these respondents the majority (91.7%) have found this to be a problem. Furthermore, 9.5% of the sample reported bladder or kidney problems secondary to paruresis.

Unfortunately, there was also a significant lag of 13.8+11 years until the diagnosis of symptoms, with a mean age at that time of 27.2 +11 years. In most cases (58.5%), this was a self-diagnosis, with fewer subjects (37.7%) reporting being diagnosed by a health professional, Indeed, most patients (51.8%) had never had their symptoms medically evaluated.

RELATIONSHIP TO SOCIAL ANXIETY DISORDER

We subdivided our sample into 2 groups: those with paruresis who self-rated positive on the Mini International Neuropsychiatric Interview for DSM IV (MINT) [Sheehan et a), 1998) module for social anxiety disorder (SAD group) and those who had paruresis only (PO group). We then examined the differences in scores between the two groups on the Liebowitz Social Anxiety Scale (LSAS). The SAD group had 18 subjects and the PO group 45, No significant differences in age or gender were found between the two groups.

The SAD group had significantly higher scores on both performance and social interaction subscales of the LSAS (Table 1 as well as a significantly higher total L5AS score. When the individual items of the LSAS were compared, no difference between the groups was

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found on item 13 (urinating in a public bathroom). For the remaining items, the SAD group scored significantly higher on most items, except items 3 (eating in public places), 4 (drinking in public places), 6 (acting performing or giving a talk in front of an audience, 8 (working while being observed), 21 (trying to pick up someone), 22 (returning goods to a store), 23 (giving a party), and 24 (resisting a high-pressure salesman) (Table 1).

We also compared the mean score on the performance subscale of the LSAS to the social interaction subscale in the SAD subgroup, the PO subgroup, and the sample as a whole, For each group the mean scores on the performance subscale were significantly higher than the mean scores on the social interaction subscale (Table 2).

TREATMENT

Treatments used for paruresis included medication (42.9%), behavior therapy (42.9%), other forms of psychotherapy (44.4%), and other forms of psychotherapy (44.4%). In 28.6% of the subjects, the course of the disorder had remained stable; it had improved in 27.0%, and worsened in 7.9%, and has remained intermittent in 36.5%. We did not systematically attempt to assess the value of different treatments.

CONCLUSIONS

The main findings of this study were 1) that paruresis (which appears more commonly in men) is a chronic and disabling symptom, 2) that social anxiety disorder and depression are the most comorbid disorders and the most common disorders in family members, and 3) that there seems to be an association between paruresis and other performance anxieties.

These findings are consistent with previous work (Soifer et al, 2001; Himle, 1997; Zgourides, 1987; Malouf, 1985), which has indicated that paruresis can be problematic for many and that it may be associated with significant comorbid psychopathology. In addition, there is a significant lag time between symptom onset and a diagnosis of paruresis. We find it to be of particular concern that only a third of the sample have had their symptoms recognized by a healthcare professional. As a consequence, it is important to increase awareness of paruresis among healthcare professionals as well as the lay public. Increased recognition with consequent earlier onset of treatment would help alleviate the morbidity associated with paruresis.

Given the high incidence of comorbid disorders with pararesis, particularly social anxiety disorder and depression, it is important to rigorously evaluate all patients that present with paruresis for comorbid disorders and to treat both, Conversely, it would be worthwhile to specifically ask patients that present with symptoms of social anxiety disorder if they also have paruresis.

Arguably there is sufficient data for a heuristic strategy of conceptualizing paruresis as performance anxiety. Our data shows that patients with paruresis, whether or not they have a social anxiety disorder, score

TABLE 1. Mean scores on the LSAS: differences between SAD and PO group

	SAD group (n=:18) mean	PO group (n=45) mean	t	p
Total score	96.06	69.71	3.83	<.001
Performance subscale	51.78	39.44	3.27	<.003
Social interaction subscale	44.67	30.47	3.76	<.001
Items 3 (eating in public places)	2.04	2.44	1.61	ns
4 (drinking in public places)	2.61	2.11	1.17	ns
6 (acting, performing, or giving a talk in front of an audience)	4.89	3.96	1.84	ns
8 (working while being observed)	3.44	2.67	1.86	ns
21 (trying to pick up someone)	4.89	3.47	2.00	ns
22 (returning goods to a store)	3.39	2.56	1.82	ns
23 (giving a party)	4.17	3.35	1.19	ns
24 (resisting a high-pressure salesman)	3.17	2.60	1.15	ns

ns=not significant.

TABLE 2. Performance subscale vs, social interaction subscale scores on the LSAS

	Performance subscale mean score	subscale Social interaction subscale mean score	t	p
Total sample ((N=63)	42.97	34.52	8.753	<0.001
PO group (N=45)	39.44	30.47	9.698	<0.001
SAD group (N=18)	51.78	44.67	2.858	0.011

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 | Brief Report: Purusesis Survey |

significantly higher on the performance subscale of the LSAS than on the social interaction subscale. Of further interest is that many patients experienced blushing, 2 symptoms typically associated with the panic attacks of social anxiety disorder rather than with those of panic disorder, Furthermore, many patients have individual and family histories of other social anxiety symptoms. Finally, cognitive-behavioral techniques used for the treatment of public-speaking fears appear useful for people with paruresis [Soifer et al., 2001; Himle, 1997].

The reliability of our data is limited by the small sample size and low response rate, as well as the self-report format of the survey. However, the data reinforce the importance of paruresis as a form of social anxiety and underline the high morbidity and comorbidity associated with these symptoms, Additional empirical data would be helpful to determine its formal relationship to SAD, Also, additional work to develop and test ‘treatments for paruresis is necessary.

Acknowledgments

Dr. B. Vythilingum and DJ. Stein is supported by the Medical Research Council (MRC) of South Africa.

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