Unwrapping paruresis From what is known to what we still need to know Alex Gardner.

Unwrapping paruresis

From what is known to

what we still need to know

Alex Gardner

Personal

position

Known to others Not known to others

Known to self OPEN AREA HIDDEN AREA

Not known to self

INFORM OTHERS

BLIND AREA

LISTENTO

OTHERS

RESEARCH

You can pee ifYou are on your own

But not in the presence of others..Or imagined others

Very likelyPARURESIS

Paruresis can range from

Slight and transientthrough to

Extreme andvery debilitating

It can cause considerable bladder problems if not treated

I keep six honest serving-men(They taught me all I knew);Their names are WhatWhat and WhyWhy and WhenWhenAnd HowHow and WhereWhere and WhoWho.

Rudyard Kipling

At the outset it is important to clarifyThe difference betweenFailure to Pee due to:

Organic factorsMarked by a difficultyto urinate on demandeven at Home when alone

Psychogenic factorsMarked by the inabilityto pee in the presence of others…..But OK at home

The Secret Phobia?

DSM IV 300.23 classified this as a social phobia and because of the excessive secrecy,

it was also known as the secret phobia. 7% *of the population are believed to be affected.

That is about 4 million paruretics4 million paruretics in the UK It affects both men and women and prevents them

using public toilets or urinating in theirown home when others are present.

Now considered to be a Social Anxiety DisorderSocial Anxiety Disorder this change has implications for treatment

A 1997 social phobia sub-analysis done at Harvard Medical School from the 1994

National Co-Morbidity Study indicates that 6.7% of a RANDOM sample of people( U.S.)

said that they have difficulty using a public toiletaway from home.

A Canadian study of Social Phobia in community surveys in Winnipeg, Manitoba, and Alberta showed that

of (N= 1956) respondents, 9.1% (N=178) said yes to fears of "using toilet away from home.”

(Archives of General Psychiatry, Nov. 2000)

McCullough (2000) usefully makes the distinction between

Primary paruresis the inability to urinate around others,

Secondary paruresis

the importance and meaning we assign to our primary paruresis.

Guilt Anxiety ShameLow Self Esteem Helplessness

these result in avoidant behaviours with fears ofmisfires, humiliation, ridicule

and overall secrecy

Stage 1The inability to urinate due to unknown factors …but most likely to be a combination of psychological /neurological ones

giving rise to the PRIMARY PARURESIS

This is the shutdown of the sphincters thus blocking of the Urine Flow

It is involuntary and outwith persons control

Chocking or Shutdown

Self-consciousness has been shown to be a contributing factor of choking in athletes.

Situationally self-relevant performance cues had greater influence on highly self-conscious individuals

than those with low self-consciousness. For the paruretic individuals, this would apply to For the paruretic individuals, this would apply to

perceived scrutiny by others in the restroomperceived scrutiny by others in the restroom Social anxiety research shows that for some people

the primary arousal factors are psychological manifestations of self-consciousness and fear

(Heckelman & Schneier, 1995).

Stage 2

Development of profound emotional psychological components such as guiltshame anxiety etc

Thus giving rise to the SECONDARY paruresis.

Any hesitancy in urination is not seen as normal but as a confirmation of ones own inadequacy

Stage 3These deep seated psychological factors, perhaps as a result of a learning curve similar to the development of known accepted phobic states, produces an avoidant reaction with greater anxiety. I would call this TERTIARYTERTIARY paruresis characterised by avoidant behaviours reinforcing the primary and secondary events

It is different from other phobic states in that the avoidance does bring feelings of security by withdrawal

FEAR

HopeRELIEF

Disappointment

Perception of threat

ONON OFFOFF

OFFOFF ONON

Avoidance of threat is reinforcingAvoidance of threat is reinforcing

People with AP would believe that in the toilet setting and in proximity to other people (or belief that others might be present) the best way to cope with the pressures

was to avoidavoid: a) busy restroomsrestrooms,, b) urinalsurinals. Taking a choice of stalls if there is a real pressing need, even then there may be problemsc) standingstanding in the stall and hence sitting down to urinate etc These and other strategies could be seen as avoidant behavioursavoidant behaviours

This avoidant response gave rise to the early belief that AP was a phobia, and the belief that it must be treated like other phobic states.

This error in thinking is perhaps why certain therapeutic approaches did not work well. (eg hypnosis) Reviewing the evidence confirms that this is more likely to be a Social Anxiety DisorderSocial Anxiety Disorder

Failure to speak about it gave the term the Secret Phobia

Stage 4

as a result of all of the above it can give rise to feelings of being abnormal and the further shame/guilt makes them fail to communicate the problem or seek help.

the excessive hiding away of the issues is again a well recognised component of AP.

Parurectics

• will not tell partners or friends• will not attend social functions• may avoid certain work situations• will not go on holiday• attend theatre• become secretive about their actions• become skilled at keeping their secret

Deception Secrecy

Act of commission Act of omission

Sets upFalse beliefs

Evades True beliefs

SECRECY

Thought suppression

Thought Intrusion

After WegnerIronic processes

Thoughtshyper accessible

Therapy

enhances

releases

Reflection

Rumination processes

Private self-consciousness is a primary factor in urination breakdown and provides a stronger argument than the anxiety model does. The self-consciousness ‘freezing’ model is based on the choking under pressure model of behaviour breakdown. It centres on attentional shifts from pressure inducing environmental cues (judgement/fear at the urinal) to the self, creating increased levels of private consciousness and self-ruminating thoughts. The pressure to micturate rapidly increases and attention is directed to its complex processes. However, the harder an individual tries the less chance there is of success

IDENTIFICATIONIDENTIFICATION

ORIENTATIONORIENTATION

ANTICIPATIONANTICIPATION

Physical/SensoryCognitiveAffective

NeedsAttitudesBeliefs

PersonalSocial

Interactional

(Past)

(Future)

(Present)

Real Worlds1 Prof A.Gardner

REALREALWORLDSWORLDS

APPROACH

AVOIDANCE

APPROACH

AVOIDANCE AVOIDANCE

APPROACH

Real Worlds1 Prof A.Gardner

Hesitancy is notunexpected

FailureFailureisis

expectedexpected

The more there isThe more there is

FAILUREFAILURE

The more is itThe more is it

EXPECTEDEXPECTED

Because of the secrecy surrounding paruresis little is formally known and research is very difficult to undertake

So “ evidence” is from anecdotal sources and one internet research (Gibbs 2001)

Of the 4 million people affected Males/females Are in the ration 9/1

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Axe 2 (11%)

Three reported times for onset;Three reported times for onset;

a.a.Infant age 3 – 5Infant age 3 – 5

b.b.Early teens age 11-15Early teens age 11-15

c.c.adultadult

Gibbs (2004) study of Avoidant Paruresis (AP) is the first one ever carried out on this condition and the perceptions of people with AP.

N=264 adult paruretic males aged 18 –80 completed a global, anonymous Internet survey over a 4 month period in 2004.Participants were invited to complete the survey on line accessing the questionnaire on paruresis advice web sites. These were mainly in the USA Europe and Australia. Men’s health and university web sites were also used. Gibbs constructed the Paruresis Severity Questionnaire (PSQ) specifically for this research

The six self-report measures were used

Paruresis (PSQ)Specific Social fears (SPSQ)

Private self-consciousness, (RRQ)Specific social anxiety, (SCS

Generalised social anxiety, (SIAS)and the Big Five personality traits. (BFI)

1. Compared to community norms

(A) men were significantly higher on:

•INTROVERSION Introspection/ socially withdrawn•NEUROTICISM Nervous and anxious•CONSCIENTIOUSNESS Reliable; attention to detail•PRIVATE SELF CONSCIOUNESS

a) Rumination Negative self evaluationb) Reflection Positive self interest & awareness

(B) Men scored within normal range on;

•OPENESS Pleasant, kind, trustworthy•AGREEABLENESS Public self consciousness-

concern over other’s scrutiny

Personality profile of paruresis (Gibbs 2004)

2. Paruresis and Social PhobiaParuresis outcomes are consistent with social phobia diagnosis as follows

Personality profile of paruresis (Gibbs 2004)

4. Onset in adolescence

5. Tendency to worry, be oversensitive, easily embarrassed

3. Concern over scrutiny of others (fear of restrooms)

2. Avoidance behaviour is present (fear of restrooms)

1. Anticipatory fears of needing to pee in public

Personality profile of paruresis (Gibbs 2004)

6. Often related to a specific evente.g Bullying teasing at school urinals etc.

NOT consistent with social phobias

A) Normal levels of trait like scrutiny of others (PubSC)

B) Excessive tendency to self-focus

C) Introversion

Personality profile of paruresis

The results suggests that Paruresis is an unique form of Social Anxiety Disorder consistent with men who are articulate, sensitive, functional, talented and not excessively anxious

However the inability to undertake the natural process of peeing, when in the presence of another, can be an extremely debilitating phenomena. Stresses can build up

The consequential personal, family, social and vocationaldeficits render living with paruresis very difficult

PSQ Individual Items: Frequencies for Psychosocial and Psychosomatic Issues, and Perceived Etiology of Paruresis

Personal experience % YES _____________________ ______ 1. Do you fear other’s negative judgement if you can’t begin urination? 91.7

2. Do you ever feel embarrassed when having urination problems? 95.8

3. Do you tend to blush when having urination difficulty? 46.2

4. If others are close by, do you become self-conscious and self critical

when having problems urinating? 96.2

5. Do you sweat, tremble, have a dry mouth or heart palpitations when

you fail to begin or complete urination? 50.8

_____________________________________________________________________

What do you believe was the cause(s)?

(l) Anxiety 52.3

(h) Shyness 51.2

(j) Embarrassment from failing to urinate successfully 48.0

(k) Low self esteem 36.7

(b) Teasing 16.0

(d) Strict parenting 15.6

(c) Harassed at urinal 15.2

(a) Bullying 11.3

(g) Verbal abuse 8.6

(i) General blushing problem 3.1

(f) Physical abuse 2.7

(e) Sexual abuse 1.6

This can affect

Mental health

Employment

Holidays

Physical health

Social Activities

Relationships

Leading to

self imposed Social isolationself imposed Social isolation

Gardner’s (2000) epilepsy study (N=4,500) findings suggested two processes that may be involved in this kind of withdrawal from social interactions

IMPOSITION

LIMITATION

Just so you got the message!Just so you got the message!

Paruresis stops people peeing

It breaks up relationships

It limits social behaviour

Social Phobia ???but now perhaps a

Social anxiety disorder

There is much we do not know…not know…hencehence…

We must rely on developing communications

Informing front line professionals

Establishing TRANSDISCIPLINARITY meetings

Developing research

Pre-disposing factorsPre-disposing factorsGenetics organic psychological

Precipitating factorsPrecipitating factorsTrauma conditioning experiences

Perpetuating factorsPerpetuating factorsPersonality avoidance strategies

3 P’s

http://www.inter-disciplinary.net/publishing/idp/eBooks/shhindex.html

We aim to peeAlex Gardner

in

Suffering the slings and arrows of outrageous fortune( Ed Bernie Warren)

Rudolphi press