Paruresis (Shy Bladder) Survey Results - updated
Russell Gibbs’ Paruresis (Shy Bladder) Survey Results: A Summary from the Australian-based, global Internet Research, conducted in 2004. (This review updated December 2007 by the researcher, Psychologist Russell Gibbs)
Paruresis (Shy Bladder Syndrome, Bashful Bladder, Pee Shy) and what I have termed Public Toilet Anxiety (PTA), is the inability to urinate with others present, a very common (compared to other disorders) but poorly researched and little understood, specific social phobia. In the largest study about Paruresis performed to date, 264 adult males aged 18 –80 who identified with having urination hesitancy problems, completed a global, anonymous Internet survey over a 4-month period in 2004.
The sample was well distributed demographically, representing diverse social strata and geographical location. Seventy percent were university educated, comprising 44% undergraduate and 26% post-graduate, the remaining 30% having trade qualifications and a variety of educational and training backgrounds. Approximately half the sample (44%) was either married or de-facto, a small proportion (6%) were divorced, separated, or widowed, and the remainder (49%) were single. Fifty-one percent were employed full time, 5% part-time, 13% self-employed, 7% unemployed, and 17% were students. Country of residence representations comprised 50 from Australia and New Zealand , 120 from North America , 8 from Europe , 55 from the United Kingdom , 12 from Canada , and 19 from other nations. The diverse population from over 20 countries also included Finland, Switzerland, China, Malaysia, India, British Columbia, Brazil, and Iceland .
As no established scale or questionnaire to measure Paruresis had been developed, I constructed the Paruresis Severity Scale (PSQ) specifically for this research. The PSQ Scale contains 11 items and proved to be a statistically reliable measure suitable for use in future research. The PSQ Individual Items comprised additional questions about Paruresis history, personal experience, and related issues. The highest scores recorded among the 11 PSQ questions (answering mostly or always) were: experiencing anxiety when using restrooms (94%), experiencing urination failure which caused stress (88%), feeling judged when voiding (75%), and searching for vacant restrooms (86%) also clearly affected most men surveyed. Only 2.7% of those surveyed never used cubicles (stalls) and 74% mostly or always did.
Those people who indicated that some aspects of Paruresis did not affect their lives related to job opportunities (41.7%), urinating at home (19.3%), and restricting liquid intake (14.0%). All remaining percentage scores where the question related to not having a problem were much lower, meaning that most men had problems relating to all 11 questions.
Over half those surveyed were unable to urinate successfully at public urinals, they avoided using public toilets, and they believed Paruresis affected the personal, social, and/or employment aspects of their lives.
PSQ History revealed that Paruresis was first experienced at age 12 and below for 45% of respondents, 13 - 18 for 44%, over 19 years for 11%, with 43% reporting having the problem for over 30 years. Only 25% reported any improvement with age, of whom 51% attributed the reason for change to their increased coping skills and having used relaxation techniques. Interestingly, 14% reported familial history of Paruresis; however, a large percentage (61%) of the participants were unsure of any family history.
Although 44% sought treatment the majority of those waited 20 - 30 years before seeking help. The most common treatment methods were psychotherapy (47%), graduated exposure therapy (36%), attending self-help groups (32%), medication (28%), and cognitive behaviour therapy (24%). Success rates for these treatments were overall very low: no improvement 44%, some improvement 38%, great improvement 15%, and problem overcome only 2% of survey participants.
PSQ Related Issues revealed that the most commonly reported situation of first experiencing Paruresis was at school (58%). Perceived causes of developing Pauresis placed anxiety, shyness, and embarrassment as prominent. A related issue gaining publicity, particularly due to its growing incidence in North America, is compulsory urine sampling under observation, such as in employment related drug screening. Results in this survey revealed that 13% of participants had given a sample, while 93% indicated they would, “...feel stress/anxiety if having to do so”. The last question of the PSQ, participants’ comments, attracted substantial interest from 181 men who provided personal experiential information about living with Paruresis, amounting to over 15,000 words. This valuable information will be the subject of another paper.
The psychological tests included in the survey revealed that the men scored significantly higher than the general population on Private Self-Consciousness (meaning they dwell on negative aspects of the self as well as having an interest in self-awareness), Neuroticism (tending to worry a lot), and Conscientiousness (being reliable and able to complete tasks to a high standard). An important result, which contributed to this development of a personality profile of Paruresis, was that the sample tended to be Introverted (shy, withdrawn) and aligns with them also being highly self-consciousness.
In summary, the results mentioned combined with other findings from the survey, suggest that Paruresis was the primary social anxiety experienced by most of the sample, and that Self-Conscious attention to urination performance (more so than physiological anxiety symptoms) may be the main factor in urination breakdown. The study presented a Self-Consciousness Model of Urination ‘freezing’ as an alternative to the existing ‘fight or flight’ model based solely on high levels of anxiety, and results provided initial support for this model.
Future treatment programs could therefore benefit from exploring the cognitive aspects (thoughts and self-talk) involved in the anticipatory fear and consequential failure to successfully urinate when in the presence of others. Cognitive Behaviour Therapy (CBT) combined with graduated exposure therapy (systematic desensitisation), as currently promoted by Professor Steven Soifer of the International Paruresis Association (IPA) and myself as co-ordinator of workshops in Australia for the Paruresis Association of Australia (PAA), should ensure greater success in workshop outcomes and future relapse prevention (misfires) for participants. Established CBT methods used to change irrational beliefs (e.g., I’m abnormal because I cannot pee in public facilities), negative self-talk (e.g., I’m hopeless and will always have trouble urinating), and unfounded beliefs (e.g., no one would understand – I’ll have to suffer alone), are therefore strongly recommended based on the results of this comprehensive study on Paruresis.
Australian people experiencing Paruresis (Shy Bladder Syndrome) are welcome to contact me for professional advice and treatment guidelines. Paruresis need not be a lifetime burden, as has been demonstrated in testimonies from those who have overcome it (see Paruresis Association of Australia website: www.paruresis.org.au/ ).
Russell E Gibbs
Registered Psychologist
Email: gibbs.psychology@bigpond.com
Phone 02 65856311
