‘Soctal Work in Health Caro, 4494-507, 2010 Copyright © Taylor & Francis Group, LLC ISSN: 0098-1389 print/1541-034X online ‘DOF: 10.1080/00981381003684898 Routledge Fora ep Paruresis (Shy Bladder Syndrome): A Cognitive-Behavioral Treatment Approach ‘STEVEN SOIFER, PhD, MSW ‘School of Socal Work, Universi of Maryland, Baltimore, Maryland, USA JOSEPH HIMLE, PhD, MSW School ef Social Work and Department of Pschiaiy, University of Aicbigan, Ann Arbor, ‘Michigan, USA KATHLEEN WALSH, PhD, MSW ‘Millersille University, atillersile, Pennsylvania, USA Paruresis is a social anxtety disorder characterized by a fear of being unable to urinate in the presence of others. This condition bas not been covered in the social work literature, yet 1s a perfect ‘example of a person-in-enyironment problem. This article explores the use of graduated exposure therapy during weekend-long work. shops for the treatment of parurests. One bundred one participants participated in workshops and were administered pretreatment, posttreatment, and I-year follow-up treatment scales. Repeated measures analysis of variance indicated significant improvement in shy bladder symptoms, Significant improvement in global sever- ity 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. KEYWORDS shy bladder, bashful bladder, paruresis, social ant ely, public restrooms, graduated exposure therapy Received September 10, 2008; accepted November 19, 2009. ‘We express our immense appreciation to Cathy Costa, Research Assistant, for editing this anti, Address correspondence to Steven Soifer, PhD, MSW, Associate Professor, Universi Of Maryland Schoo! of Soctal Work, 525 W. Redwood Street, Baltimore, MD 21201. E-mail ssoifer@ssw.umaryland edaPanurests (Shy Bladder Syndrome) 495 PARURESIS: SHY BLADDER SYNDROME—THE LATEST SOCIAL PHOBIA? | Paruresis, more commonly known as shy or bashful bladder syndrome, is _the fear of being unable to urinate (and often actually not being able to | trinate) in the presence of other people, While paruresis usually manifests self in public restroom facilities, itis not uncommon for many people with Paruresis to be unable to urinate in even their own homes when guests _-me present, People with parutesis may experience significant hardships in s many areas of their lives such as interpersonal relationships, travel, and work, including problems with workplace drug testing (Soifer, Zgourides, Himle, & Pickering, 2001). Approximately 17 million people in the United States, roughly 79% of the population, report that they have trouble using the restroom away from home (Kessler, Stein, & Berglund, 1998). Although all of these reposted problems using the restroom cannot be attributed to paruresis, it is likely that many of these people suffer from this synelrome, ‘The precise preva- lence of paruresis in the general population is unknown. However, the prevalence is estimated to range from 2% to 50%, suggesting that it is a common problem, and it appears to affect men and women equally and _ seems to be present in different areas of the world (Furmark, 2000; Gruber & , Shupe, 1982; Hammelstein, Pietrosky, Merbach, & Braehler, 2005; Palmtag & Feidasch, 1980; Rees & Leach, 1975; Stein, Torgrud, & Walker, 2000; Williams & Degenhardlt, 1954). Although the Diagnostic and Statistical Manual of Mental Disorders (2000) does not specifically mention paruresis, it does refer to the difficulty _ of using public restrooms as an example of a social phobia (social anxiety disorder). For some, the difficulty is very mild and presents itself as a “once ina blue moon” phenomenon, such as when in line for the restroom clu ing the seventh-inning stretch at a baseball game, For others, though, this Social anxiety disorcler may become so severe that they essentially become homebound, limiting their outings to occasional shoxt tips because the only “safe” bathrooms are in their houses (Soifer et al., 2001). White clearly a “private trouble,” paruresis is also a “public issue” that fn be addressed through environmental interventions (Mills, 1959), ancl as such it offers social workers a perfect example of how a person-in- favironment perspective (PIE) can be useful in understanding social anxiety Jind developing effective interventions, People with paruresis most com- [monly identify three triggers that are associated with difficulty urinating in public restrooms (Soifer et al., 2001). For the typical person with parure- }%, these triggers must be managed for urination to occur (Soifer et al, 2001), The first of these triggers, familiarity with other people present in the ‘esitoom, can tigger problems initiating urine. Conversely, some individu- als with paruresis might find it easier to urinate around friends or relatives496 S.Sofferet al as opposed to strangers. Because of the personal natute of elimination, the degree of familiarity with and perceived acceptance of others in the room often determine whether the person with paruresis will successfully void Goifer et al., 2001). Second, proximity plays a role in the ability to initiate urine. Proximity for the person with paruresis is both physical, relating to the relative close- ness of others in or near the restroom, and psychological, relating to the need for privacy. Many people with paruresis report significant distress and difficulty initiating urine when others are nearby (Soifer et al., 2001). TI problem is especially challenging when suitable partitions between urinals, and stall doors are not in place. When people with paruresis feel that their personal space has been invaded, they often report that they cannot initiate urine Golfer et al, 2001). Better designed restrooms, especially for men, would go a long way toward alleviating the problem for many who suffer from this disorder, ‘Third, temporary psychological states, especially anxiety, anger, and feat, can interfere with urination, Many people with paruresis are very con- cerned about the sounds and smells they make while urinating (Soifer et al,, 2001). They also often worry that others will notice that they are or are }ot urinating and will criticize them for it. The influence of emotional states ‘on the ability to urinate may in part explain why people with paruresis sometimes report difficulty urinating when they are overly excited or under pressure to hurry even when they ate at home or using an isolated public restroom (Soifer et al., 2001). In addition to common triggers experienced by people with paruresis, certain behavioral patterns typily paruresis. For some people with parure- sis, difficulty urinating in the presence of others appears to begin out of nowhere, but for most, the onset of the problem is associated with an ‘unpleasant event(s), Common situations associated with the onset of parure- sis include being harassed or teased by peers in a public restroom, being rushed to urinate by another person, and being unable to produce urine for a medical or drug test. Once individuals experience difficulty urinating, they often begin to worry about whether they will be able to urinate when next confronted with needing to use a public restroom, The combined impact of, the initial failure to urinate and the subsequent worry about failing again often produces increased sympathet This activity can create a level of anxiety that is incompatible with urinating (Zgourides, 1987). As each forcible attempt to control the process fails, greater increases in sympathetic nervous system activity further reduce the chances of success- fully voiding, in many cases, this performance anxiety eventually generalizes to all or most public restrooms so that the only “safe” toilet the person can reliably use is at home (Zgourides, 1987). Generally, people with paruresis try 10 adjust to the problem by uri- nating as often as possible when at home, restricting the intake of fluids,Parurests (Shy Bladder Syndrome) -and-refusing extended social invitations. Most people with paruresis also engage in a series of protective behaviors stich as locating vacant restrooms F when away from home, thinking of water when trying to wrinate, and run- ning the tap to optimize the chanees of urinating under adverse conditions. Most commonly, however, people with paruresis cope by avoiding public restrooms at all costs (Soifer et al., 2001). LITERATURE REVIEW ot surprisingly, there is no discussion of paruresi erature: Most of what has been written appears either in the urological or psychological literature. As this social anxiety disorder becomes more widely known, and given the large number of people it affects, the authors expect that more will be written about shy bladder syndrome in the social work and Lhe general health care literature. Moreover, because this issue is an excel- ent example of how a PIE perspective can illuminate a complex problem, ‘Lis ripe for social workers to address. "Urological literature reveals that early attempts to treat paruresis focused ‘on surgical interventions. One favorite method of treatment was bladder neck ‘surgery CVinsbury-White, 1936). Surgery of the urethral sphincters sas reported as late as the 1950s (Emmett, Hutchins, & McDonald, 1950). Freudian interpretations and psychoanalysis for the problem were reported inthe psychologic literature during the 1940s, 1950s, and early 1960s. In par- | icular, case reports from Menninger (1941), Williams and Johnson (1956), Chapman (1959), and Wahl and Golden (1963) stand out (the last of which ‘nentioned men having this condition for the first time in the literature), ‘While these case reports were often successful, psychoanalytic treatment len required several years before improvement was realized. It is also Finportant to note that successful case reports do not indicate how many people with paruresis failed to improve with psychoanalysis. In their seminal article, Williams and Degenhardt (1954) coined the term hirurests, an important development given that as many as 36 other different J erms for the disorder have been used over the yeats in the wrologic literature (Golfer, Nicaise, Chancellor, & Gordon, 2009), Williams and Degenharclt also found through 2 survey an incidence rate of paruresis of 14% among students ‘one college, and they attributed the causes of the difficulties the stucents faperienced with urination t© anxiety in social situations. Starting in the mid 1960s and through the 1970s, clinician began to use Fore behavioral approaches in treating paruresis beginning with counter ‘nditioning (Cooper, 1965; Wilson, 1973). Others followed suit in utilizing ‘whole range of behavioral therapy techniques, such as in vivo dlesensitiza- ion (Anderson, 1977, Eliott, 1967), flooding (Lamontagne & Marks, 1973), ditioned relaxation (Ray & Morphy, 1975), systematic desensitization in498 S$. Soffer et a combination with relaxation training (Glasgow, 1975), paradoxical inten- tion (Ascher, 1979), and multi-modal behavioral therapy (Montague & Jones, 1979). ‘These studies laid the groundwork for more sophisticated behavioral treatments implemented in the 1980s and 1990s, including the continued use of paradoxical intention Gacob & Moore, 1984) anc multi-modal behay- ioral therapies (Markway, Carmin, Pollard, & Flynn, 1992; Nicolau, ‘Toro, & Prado, 1991), in vivo desensitization in combination with furosemide G diuretic) to increase urgency (Thyer & Curtis, 1984), in vivo therapy with a portable radio headset to block out sounds Zgourides, Warren, & Englert, 1990), in vivo desensitization in combination with relaxation train: ing (McCracken & Larkin, 1991), cognitive restructuring in combination with graduated in vivo exposure Gaspers, 1998), and respondent conditioning, (Watson & Freeland, 2000). It should be noted that there are also two case reports of the successful treatment of paruresis with hypnosis (Mozdzierz, 1985; Seif, 1982). As clinicians began to use behavioral approaches to teating paruresis in the 1970s, medication began to be prescribed for paruresis, either as a stand: alone or an adjunct to therapy. Montague and Jones (1979); Stams, Martin, and Tan (1982); Kawabe and Nijima (1987); Haiterer et al. (1990); Zgourides, and Warren (1990); and Bohn and Sternbach (1997) used or reported on a variety of drugs, including alpha blockers, beta blockers, benzodiazepines, and selective serotonin reuptake inhibitors (SSRIs) with mixed results. To date, there is no medication known that will “cure” paruresis, Beginning in the 2000s, more sophisticated analyses and studies of panuresis have appeared in the literature. A survey by Vythilingum, Stein, and Solfer (2002) indicated that only about 50% of those with paruresis have co-morbid symptoms. Hammelstein and Soifer (2006) collected data that indicates paruresis may be more than just a social phobia and may actu- ally be more a functional urination disorder. It is possible that there may be different forms of paruresis, some that may be forms of social phobia and some that may be more physical, Most recently, Boschen (2008) has pre- sented a cognitive and behavioral model for understanding paruresis, This ‘model incorporates an intervention strategy based on empirical evidence from treatment of other anxiety disorders, CURRENT TREATMENT APPROACH ‘The formation of the International Paruresis Association (IPA) in 1996 took the treatment of paruresis to a new level. Building on the work of Joseph Himle, Ph.D., at the University of Michigan's Anxiety Disorders Program, where the individual treatment of people with paruresis from a behavioral perspective had been occurring since the early 1990s, the co-founders ofParuresis (Shy Bladder Syndrome) Hlobbins is more of a cognitive therapist; consequently, they decided to ‘se 2 cognitive-behavioral therapy (CBT) approach to the workshops that Tnciuded graduated exposure. CBT approaches that use graduated exposure have become the teat- ment of choice for phobias since the late 1970s (Dobson, 2001), CBT “sssumels) that patterns of cognition shape the emotional and behavioral ronsequences of that cognition” (Dobson, 2001, p. ix). Given the vati- ty of both cognitive and behavioral techniques involved in this treatment 8pproach in this system and the nature of Pparuresis, CBT allows for some exiblity in approach for dealing with different symptoms among clients but most importantly provides a consistent treatment framework for this anxiety disorder, | Outcome studies for CBT in the treatment of phobias are quite good. Jn particular, the recent meta-study by Butler Chapman, Forman, and Beck anxiety disorders but also iccess rate is about 80% or ‘er. form of CBT, graduated exposure, has demonstrated efficacy in the steatmient of phobie clients. Based on the principles of operant conditioning, eguduated exposure techniques instruct phobic clients to gradually to stay longer in the phobic situations (Emmelkamp, Bouman, & Scholing, 1992). here is no other treatment approach with as extensive an evidence base lety disorder and social phobia, and that is why CBT, including finduated exposure, has been used since the founding of IPA in its efforts fo teat paruresis, i IPA began to offer weekend workshops for the treatment of paruresis in 1997. With the advent of the Intemet, people with this “secret” phobi tould now anonymously access the World Wide Web and with increasing ease find an organization and program for dealing with paruresis, From the pery beginning, IPA has never needed to adverti workshops other than pon its website; rarely are workshops cancelled for lack of enrollment. Often, those who enroll have seen several health and mental health professionals ‘ono avail. They report that finding people knowledgeable about paruresis Isvery difficult, especially professionals who could actually help them, The professionals the workshop attendees saw often learned about this anxiety ber of the workshop ipants were local to the hosting cities, often people would travel, sor even great distances, to attend these workshops. Ironically, sometimes People would choose to travel to workshops far away from home (e.g,, a00 8. Soler etal ‘man from England who attended a workshop in Texas) to make sure they ‘would not run into someone they knew. After each workshop, the workshop facilitator encourages the formation of @ support group in the area in which the workshop was held. Often, support groups formed and thrived, but in some cases, the support groups never got off the ground or faltered. Nonetheless, support groups helped to provide a supportive environment in which many workshop attendees and others from the general public could come to practice techniques and recover from this sometimes debilitating disorder, Finally, sufferers of paturesis who attended the workshops were encouraged to tell others, especially significant others, family members, rel- atives, and friends about their problem in order to lessen the feelings of isolation many people with paruresis expetience and to help create a more supportive environment following the workshop. Feelings of shame and ‘embarrassment often interfere with sufferers’ ability (0 tell others, but the act of doing so is frequently an important part of recovery. METHOD Overview From 1997 through 2003, the investigators offered weekend workshops throughout the United States to people with paruresis in several major cities. ‘These workshops included group sharing techniques (Friday night) andl the latest in cognitive-behavioral therapy methods (Saturday and Sunday), and ‘were meant to help people begin to recover from paruresis. Participants typ- ically paid $300 to attend the workshop; in a few cases, the payment was less or more because participants could choose to pay cither the $300 flat fee or 196 of their gross income. A description of the participants and how they were recruited, measures, and a description of the workshops follow. Participants ‘The participants were 101 people (89 male and 12 female) seeking treatment for paruresis who responded to website postings or were referred by pro- fessionals to attend a 3-day paruresis workshop held at a local hotel in one of five major U.S, cities, The size of the groups (n = 5) ranged from 5 to 35 Participants with a mean of 20.2 participants. The two larger groups @5 and 28 participants) were led by two, rather than one, clinicians. The mean age of the participants was 39.4 years (SD = 10.6). Participants reported experi encing symptoms for an average of 25.9 years (SD = 10,6) prior to attending the workshop.Parurests (Shy Bladder Syndrome) Measures I primary outcome measures included the Bashful Bladder Scale (available from senior author), a 12-jtem inventory that measures the ability to urinate F in several common phobic situations. The Bashful Bladder Scale yields a total raw score from 0-48 with scores of 0-10 considered to be s and scores of 11-20, 21-30, and 31-48 indicating mild, moderate, and severe | bashful bladder, respectively. This scale was administered at the very begin- ning of the workshop, at the very end of the workshop, and sent by e-mail to participants 1 year after the workshop. At the 1-year follow-up point, the scale was completed by more than 95% of the participants, that is, 96 of 101 participants responded. This high respondent rate was achieved through several reminder e-mails and phone calls to participants. ‘The second primary outcome measure was a patient-rated global paruresis severity scale, which ranges from 0 (no sympioms) to 10 (extreme ‘paruresis). This scale was also administered at the beginning of the work- shop, at the end of the workshop, and to participants 1 year after the workshop. Workshop satisfaction was rated on a 0 (none) to 4 (enormously) scale of general satisfaction with the workshop, No formal reliability or validity data is available for these measures. Workshop Descript Workshops were led by one to two mental health professionals who were trained in the cognitive-behavioral treatment of paruresis. These profession- als were either licensed social workers or psychologists, Workshops were held on weekends from Friday through Sunday in hotels with a conference room for group meetings and several different restroom opportunities for practice. The following is a typical weekend workshop schedule: Friday, 7:00 p.m, to 10:00 p.m. Thwoductions Sharing our stories Workshop overview Constructing behavioral hierarchies Saturday, 9:00 a.m, to 5:00 p.m Historical overview of paruresis Behavioral (graduated exposure) approach to treating paruresis Setting up the Buddy System Graduated exposure exercises: Rounds 1-4 Debriefing Questions andl answers ‘The International Paruresis Association Seer502 S.Sogfer etal. Sunday, 9:00 a.m. to 3:00 p.m. Questions a Graduated exposure exercises: Rounds 5-7 ‘Where do you go from here? Wrap up and evaluation On the fist day (Friday from 7:00 pan. to 10:00 p.m.), Workshop participants Share their personal stories about paruresis and how it has impacted their fives, Participants develop and discuss their personal behavioral exposure hierarchies, which include their continuum of fears ranging from the worst possible scenario (e.g, for men, this may be standing in front of kage trough-like urinal where people are shoulder to shoulder with one another) to situations in which they are the most comfortable (e.g,, alone in one’s ‘own home). During this session, participants start ‘buddying up" to develop practice dyads and wads so that they can begin the graduated exposure process. Typically, participants select partners with similar hierarchies ‘On the second day of the workshop (Saturday from 9:00 a.m. to 5:00 pam), the workshop facilitator opens with a historical overview of parure- Sis, including information about its medical and psychological origins as yell as various teatment modalities. The facilitator provides a detailed description of the graduated exposure process and asks the participants to begin working on the least anxiety producing scenarios in their behavioral hierarchies. Exposure partners then begin their practice sessions. Throughout the course of the workshop, participants drink fluids so that they have enough tirine available for repetitive exposure practice, During the morning portion Of the workshop, there are 1-2 practice sessions of about 45 minutes each in duration, wherein participants and their respective “buddies” practice the graduated exposure technique and attempt to void in various settings, mov- ing up their own behavioral hierarchies. Participants typically start with the least difficult level of their hierarchies and work upward under their own control and at their own pace. The afternoon hours are reserved for addi- tional practice opportunities and exposure 10 restroom in the community outside the hotel if participants have progressed sufficiently. ‘On the final day of the workshop (Sunday from 9:00 a.m. to 3:00 p.m), participants convene and participate in another 2-4 graduated expo- Sure sessions, Participants are then given the opportunity to reflect on their experiences, identify successes anc challenges, and develop strategies for how they will continue their progress after completion of the workshop. Participants are asked to identify practice buddies in their home area and are strongly encouraged to participate in support groups, online chats spon sored by IPA, and other methods of support. A more detailed description of workshop activities can be found in chapter 1 of Soifer et al. (2001)‘Parurests (Shy Bladder Syndrome) RESULTS: epeated measures analysis of variance indicated significant improvement in Bashful Bladder Scale ‘Total Scores from pretreatment fo posttreatment to ‘year follow-up (df = 2, f = 45.62, p < 0001; see Figure 1). Participants | improved from the middle of the “moderate” to the low end of the “moder- se” range of the Bashful Bladder Scale from the beginning of the workshop F to 1-year follow-up. F Significant improvement in global severity of bashful bladder was also cbserved from pretreatment to 1-year follow-up (df = 97, 1 = 6.856, p< 0001; see Figure 2). Finally, high levels of participant satisfaction with the weekend work- shop were observed (mean = 3.18 [SD = .67}; see Figure 3). DISCUSSION ‘the central finding of this study is that graduated exposure therapy improves F self-reported global severity of paruresis. Furthermore, the gains reported by participants were maintained at the 1-year follow-up point. Clinical impres Hons suggest that continued practice with graduated exposure techniques after the initial treatment intervention during the follow-up period was crit- ical to maintaining and extending positive outcomes that were observed posttreatment, However, the authors clo not have data to support the benefits of farther exposure. Although the improvement in bashful bladder symp- toms was modest, this study suggests that brief graduated exposure therapy provided over a weekend can decrease the severity of paruresis. Pro-Treatmert Post-Teatmert one-Yeae Fallon FIGURE 1 Bashful Blacker Scale Total Score changes from pretreatment to posttreatment to year follow-up.5, Soffer etal. Pre-treatment Post-reatment Cone-YosrFatiow-up FIGURE 2 Global sever of paresis changes from pretreatment to posteatment 9 1-Y63t follow-up. 4 38 3 25 2 15 1 os. ° we Satlatectton 20re FIGURES Average satisfaction with workshop Iminediatly postreatment Participants also reported high levels of satisfaction with (he work shops, Anecdotal reports indicate that the participants Tet reduced feelings sree Anand enjoyed the support of their peers and benefited from the cease that they were not alone in coping with shy bladder. Many partic pants repoited at the end of the workshop that they were able to urinate in the presence of others for the first time in years or, in some cases, EYEE ae the use of graduated exposure therapy in the treatment of persons with shy bladder syndrome is exploratory and that res eh sup- porting its value is scarce, Further studies are needed vo examine long-term eotnomes and ils effectiveness when coupled with psychotropic medications a aeroith other types of medical and psychological interventions, Continued a Wah selated to graduated exposure therapy anc shy bladder syndiome se necessary to determine what client variables and intervention/group facilitator characteristics are associated with improvement in symplon's, seeditionally, clinical impressions suggest that extending the length of the ‘workshop and/or encouraging participants to join support or practice BrOMPS lafter initial treatment may also improve outcomes,Paruresis (Shy Bladder Syndrome) ‘The results of this study need to be viewed with some caution. Fitst, ‘an important limitation of this study is the absence of a control group. ‘Additional research in order to determine whether the exposure therapy intervention was responsible for the observed improvement or whether the gains were due (6 non-specific effects associated with the therapeutic milieu needed, Second, the Bashful Bladder Scale may not be sensitive enough to detect the level of improvement observed after completion of the work- shop. Finally, the self-report method utilized by the Bashful Bladder Scale licates only what participants say about their improvements and may not ‘accurately reflect their true feelings and/or actual improvement in the ability to urinate. “The implications of this study for social work are important, There is a large population of people suffering from a newly identified social anxiety disorder, paruresis, who need treatment. 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