Paruresis, also known as shy bladder syndrome, describes a form of social anxiety in which a person experiences distress and/or difficulty urinating in the presence of others. Specifically, a worry regarding being judged by others or “exposed” as having difficulty or not being able to pee “normally” is often at the core of great apprehension and avoidance of trying to urinate in public.
A 2017 review article revealed that as many as 1 out of every 5 individuals with paruresis also struggle with other forms of social anxiety, and that paruresis alone significantly impacts quality of life (Kuoch et al, 2017). As noted in NSAC’s very helpful past article you can find here, a lot of hope can be found if you are struggling with shy bladder through cognitive-behavioral therapy (CBT). As noted there, CBT will help through graduated exposures to be able to reduce anxiety and create a learning process that enables one to urinate in public more freely over time. Additionally, through my experience working with many people living with shy bladder (you are not alone), I have found the below steps to be vital in creating an effective exposure plan and overcoming shy bladder syndrome.
1. Spend Time to Identify Your Safety Behaviors
All too often when I meet with individuals living with paruresis, they are eagerly and courageously wanting to make progress and jump into an exposure. Or perhaps one has already attempted graduated exposures with great effort, but progress stalled without knowing why.
One of the most important aspects of effective exposures is to spend time to become aware of all of the habits used to feel less anxious in the moment when attempting to urinate in public…these habits are also known as safety behaviors. While wanting to avoid the fear of not being able to void or being judged by others, safety behaviors unfortunately can reinforce the anxious thoughts and feelings, and get in the way of long-term progress. A few very common examples of safety behaviors with shy bladder include:
- Restricting liquid intake while out in public
- Only attempting to urinate in “safe” feeling restrooms
- Researching restroom environments before visiting a place
- Checking in and around the restroom for others present before trying to go
- Checking internally for signs of anxiety or urgency before trying to go
- Scanning for noise or checking others behavior for threat before trying to go
These are just a few examples of the habits that people with paruresis develop to try to avoid a negative outcome and get through a challenging situation, but which wind up building apprehension and can get in the way of making progress. A vital step is to become aware of all the nuances of safety behaviors present so that strategies can be developed to practice graduated exposures without them getting in the way.
2. Frame a New Goal
A lot of times the worry regarding being able to void or not builds up into a pressure-packed goal of being able to pee or not…as if an audience were there waiting to throw tomatoes or cheer if you “pass” or “fail.” When starting graduated exposures, it is very helpful to reappraise the goal to focus on something else.
For example, many people I’ve worked with find an initial goal of just attempting to go and waiting for two minutes no matter what as a much more helpful starting place. This allows one to take the focus off of the pressure to pee or not, have the opportunity to become aware of and get better at tolerating the thoughts and feelings that arise in the two minutes, and test out any predictions present of what will happen if they wait the two minutes even if voiding doesn’t happen.
3. Slow Down
The habitual focus on performance and the feared / expected outcome of not being able to pee can often lead to a rushed process attempting to void that is cut short at the peak of anxiety. With a new goal in mind of just being there for a time, allowing oneself to slow down, breathe deeply, and let it be…accepting uncertainty as part of the process…this will help create new mental associations with the process of voiding, and might just might lead to positive surprises along the way.
4. Make Space and Carry On
Finally, another common barrier to progress I’ve noticed is the tendency to scan for any anxiety present before trying to pee, and to automatically see that as a threat or problem in and of itself that needs to be solved first. Instead of trying to combat or push away the anxiety, or avoid trying to pee in response to feeling anxious, shift your response to just acknowledging that anxiety is present. Remember that it is just a feeling that can be there (not a threat or predictor of outcome), and carry on with your goal of giving yourself the deserved opportunity to try to void. This can be a more helpful way through the process.
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I hope the steps described above can be helpful in making progress and providing hope that effective help is available. Clinicians well-trained in CBT and with experience working with paruresis can help provide the structure and support needed to help overcome shy bladder. Additionally, the International Paruresis Association provides a wealth of resources and workshops to help those afflicted by shy bladder.
References
Kuoch KLJ, Meyer D, Austin DW, Knowles SR. A systematic review of paruresis: Clinical implications and future directions. Journal of Psychosomatic Research. July 2017, 98: 122-129.
