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Paruresis: what counselors need to know about assessment and treatment of shy bladder syndrome.

Paruresis, considered a category of social phobia, is the fear of being unable to initiate or sustain urination in the presence of others or in situations where others may become present. Many clients who struggle with paruresis present with symptoms commonly associated with other types of social phobia, which makes assessment, diagnosis, and treatment difficult. Although paruresis is relatively common, many counselors know little about it. This article focuses on the prevalence, etiology, course, assessment, diagnosis, and treatment of paruresis. Case scenarios are presented to guide counselors in assessing and diagnosing paruresis. Implications for counselors are discussed.

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Paruresis, also known as shy bladder syndrome, is defined as the fear of being unable to initiate or sustain urination because of the subconscious perception of a threat, such as the fear of being scrutinized by others (Boschen, 2008; Soifer, Zgourides, Himle, & Pickering, 2001). Paruresis can create significant social, interpersonal, and occupational distress because it impacts the individual's ability to engage in activities of daily living. It also affects interpersonal relationships because many individuals with paruresis are unable to urinate even in their own homes when other people are present (Vythilingum, Stein, & Soifer, 2002). The purpose of this article is to provide an overview of paruresis, including its prevalence, etiology, course, assessment, and diagnostic criteria. Empirically supported assessment measures and treatments will be presented, as well as implications for mental health counselors.

PREVALENCE, ETIOLOGY, AND COURSE

It is estimated that 7% of the United States population (20 million) experience paruresis to some degree when using public restrooms (Kessler, Stein, & Berglund 1998; Malouff & Lanyon, 1985), with 1 to 2 million suffering from severe paruresis (Soifer et al., 2001; Soifer & Ziprin, 2000). Even though the estimate of 7% is often cited (Ginandes 2002; Kaufman, 2005; Rogers, 2003; Soifer, Himle, & Walsh, 2010; Soifer et al., 2001; Soifer & Ziprin, 2000), reported prevalence rates vary considerably, with estimates ranging from 2.8% to 32% (Gruber & Shupe, 1982; Hammelstein, Pietrowsky, Merbach, & Brahler, 2005; Kessler et al., 1998; Malouff & Lanyon, 1985; Rees & Leach, 1975; Williams & Degenhardt, 1954). According to Hammelstein et al. (2005), the variation in prevalence rate estimates is largely due to the lack of valid screening measures and defined clinical diagnostic criteria for paruresis. For example, studies that estimated higher prevalence rates of 20-32% (Gruber & Shupe, 1982; Rees & Leach, 1975) used questionnaires that focused on whether individuals had some difficulty with urinating in public restrooms but did not ask about the degree of impairment the individuals experienced. However, using the Paruresis Checklist (PCL; Soifer et al., 2001) with a large sample (N = 1,105), Hammelstein et al. (2005) found that only 2.8% of the population experienced paruresis symptoms that significantly affect daily life. It is also important to note that even though approximately 90% of individuals who seek treatment for paruresis are male (Soifer et al., 2001) and most studies conducted of prevalence rates have only sampled males, it is thought that the incidence is more evenly distributed between males and females (Rees & Leach, 1975; Soifer et al., 2001).

Because of the lack of valid screening measures and defined clinical diagnostic criteria, health care professionals may not properly identify symptoms or diagnose the disorder. Vythilingum et al. (2002) suggested that healthcare professionals recognized only one-third of those with paruretic symptoms. Yet it is important that healthcare professionals be able to identify these symptoms because paruresis often causes significant disruptions in daily activities. Such disruptions may be limiting or avoiding travel, sporting and social events, and dating (Vythilingum et al., 2002). Paruresis may also condition occupational and career decisions. In a survey of those with paruresis, Vythilingum et al. (2002) found that 56% limited their occupational choices and 51% declined to take a job due to the disorder.

Though the disorder now known as paruresis was first identified in the 1920s, it was considered a physiological condition. Williams and Degenhardt (1954) coined the term paruresis and classified it as a psychological disorder. Since then, about 75 articles have explored the disorder's etiology, prevalence, contributing factors, assessment measures, and treatment approaches. Recently, six quantitative studies (Ginades, 2002; Jaspers, 1998; Kaufman, 2005; Rogers, 2003; Soifer et al., 2010; and Watson & Freeland, 2000) have examined behavioral, cognitive-behavioral, psychopharmacological, and integrative approaches to treat severe cases. Since 2000, six instruments (Deacon, Lickel, Abramowitz, & McGrath, 2012; Gibbs, 2004; Hammelstein & Pietrowsky, 2005; Soifer et al., 2001; Soifer et al., 2010) have been developed to better understand and assess paruresis. These studies and instruments suggest that though paruresis has been problematic, efforts to assess and treat it are gaining recognition and acceptance.

The etiology of paruresis varies. For some individuals there is no apparent cause for the symptoms; however, onset is normally the result of an interpersonal conflict related to urination or body shyness in adolescence (Boschen, 2008; Gruber & Shupe, 1982; Soifer et al., 2010). Soifer et al. (2010) noted several situations that often lead to difficulty urinating with others present. Among them are being teased or rushed by others while urinating or being unable to produce a urine sample upon request for medical purposes. Following the stressful experience, individuals become anxious about the next time they will need to urinate when others are nearby. As the anxiety worsens, individuals with paruresis begin unconsciously to perceive public restrooms or urinating near others as a "threat," which activates the sympathetic nervous system (Soifer et al., 2001). Because the sympathetic nervous system is designed to prepare humans to react to a threat, its activation results in increased heart rate, respiration, and release of epinephrine by the adrenal glands. At the same time, the detrusor muscle of the bladder is relaxed and the internal and external urethral sphincters are contracted. These physiological changes make urination difficult or impossible. Since the changes are due to the sympathetic nervous system, they are involuntary--they cannot be "willed" away (Soifer et al., 2001). With each unsuccessful attempt at urinating in the presence of others, the fear of urinating in public facilities increases and becomes more generalized (Soifer et al., 2010).

Contributing Factors

Several psychological and environmental factors also appear to contribute to the disorder. Soifer et al. (2010) discussed such triggers as the sufferer's familiarity with the individuals in the restroom. For some, it is easier to urinate when family and friends are present, yet for others it is easier when surrounded by strangers. Other triggers are the proximity of individuals within the restroom and the amount of privacy experienced (Soifer et al., 2010).

Additional extenuating environmental factors may compound paruretic symptoms, including the number of people in the restroom, if there is a line to use the facilities, the lack of visual obstructions (e.g., stalls), if the restroom is small, and whether the restroom is quiet (Anderson, 1977; Malouff & Lanyon, 1985; Vythilingum et al., 2002). Paruresis also presents differently for males and females. Males tend to be more concerned with being seen while urinating, females more concerned with being heard (Rees & Leach, 1975).

About 50% of individuals with paruresis have at least one other comorbid diagnosis (Vythilingum et al., 2002). From most to least common, comorbid diagnoses include social anxiety, major depression, alcohol abuse, alcohol dependence, and obsessive-compulsive disorder (Vythiligum et al., 2002). Finally, because in a small number of cases medical issues (e.g., prostatism, urethral obstructions, and diabetes mellitus) can contribute to paruresis, these problems should be ruled out before diagnosing paruresis (Blaivas, 1998; Vythilingum et al., 2002).

ASSESSMENT AND DIAGNOSIS

Assessment

Paruresis is often not the primary focus of treatment for many counseling clients. Rather, they may present with related concerns, such as employment and career issues, depression, substance abuse problems, avoidance of social situations, avoidance of or concerns with travel, concerns about leaving the house for extended periods of time, restriction of social activities, maintaining a specific regimen for social activities, and issues with partners or friends related to engaging in social activities. Because counselors may not recognize these presenting symptoms as indicating paruresis, screening is a critical first step in assessment and diagnosis.

Paruresis may often be screened for during the intake assessment, particularly when presenting issues suggest other types of disorders that may need to be ruled out (e.g., panic disorder with or without agoraphobia, avoidant personality disorder, major depressive disorder, or dysthymic disorder). Referring clients for a medical evaluation in order to rule out any physiological causes is also critical (Blaivas, 1998; Vythilingum et al., 2002). Once the counselor finds evidence to further evaluate the presence of paruresis, it is necessary to establish whether or not the client's fear of urinating in public restrooms is excessive and persistent (Soifer et al., 2001). Counselors must also determine if the client's difficulties with urination are limited to public restrooms and do not occur when the client is alone in a private restroom. It is also necessary to confirm that the symptoms of the disorder are causing the client significant distress and impairment in daily life (Soifer et al., 2001). Counselors may notice that clients with paruresis tend to avoid dating, avoid socializing or attending social events, feel shame and embarrassment when bodily functions are discussed, have regrets about missed opportunities in life, or experience resistance or reluctance when discussing symptoms.

The following case scenarios illustrate examples of instances when counselors should assess for paruresis.

Case Scenario 1. Bob has been working as an inside sales representative for a major manufacturing company for the past 10 years; he has been an outstanding performer and the number one sales representative for the past four years. Because Bob conducts a majority of his work by telephone, online video chat, and other technologies, he has been able to work mainly from home. Bob reported he enjoyed the freedom and independence of working from home where he can be by himself. Recently, Bob was offered a promotion to regional sales manager and associate vice president of sales. Initially he was very excited about the opportunity to advance his career; however, when he learned the job would require national and international air travel and he would have to work in the corporate office rather than at home, he became anxious and worried. During the intake, Bob denied having a fear of flying and mentioned how much he enjoys socializing and meeting new people. He reported being diagnosed with dysthymic disorder years ago; he came to counseling because this promotion is causing heightened stress, worry, fear, and feelings of depression. He mentioned that it is not the administrative responsibilities that concern him but having to "be away from home." He was also warned that if he does not take the position he will lose out on future opportunities. Bob stated that he has turned down similar jobs at other companies because of travel requirements and being away from home.

Responding to the conflict Bob has presented, and aware of possible paruresis, the counselor would

1. Examine Bob's concern about taking the new position and why working from home is important to him and critical to this decision. Listen for concerns about leaving the house or any issues related to using restrooms outside the home or concerns with urination while others are present.

2. Explore Bob's history, including his reasons for turning down similar opportunities and his history of dysthymia. It is important to rule out dysthymic disorder as a factor in his hesitance to accept this position. Furthermore, major depressive disorder frequently co-occurs with paruresis, so it is important to assess Bob's current level of depression (Vythilingum et al., 2002).

3. Discuss Bob's reluctance and the anxiety associated with this opportunity, since there is no evidence of fear of flying or socializing. Listen for any additional concerns about being away from the house for extended periods of time, using public restrooms, urinating with others present, receiving negative evaluations about his ability to urinate, or experiencing body shyness.

4. Explore symptoms of paruresis if Bob reported any concerns that signal paruresis as a possible issue, such as anxiety about leaving his home for extended periods of time, any concerns about urinating or using a restroom with another person around, or any issues related to body shyness. These symptoms include (a) displeasure or problems using restrooms outside the home, (b) difficulty urinating while others are present, (c) difficulty initiating urination at home or in a private restroom, (d) avoiding urinating in public restrooms, and (e) medical problems that may be creating difficulty with urination.

Case Scenario 2. Kim is an engaging, outgoing female who presented for therapy due to conflicts with her boyfriend. She reported that he is unhappy and frustrated with her because she refuses to "try new things" socially and will only go to a few places of her choosing. Kim explained that she likes certain restaurants and social venues that she is familiar with and will not deviate from these locations; however, she reported sometimes thinking that she is "too regimented." Also, she participates in few social activities outside her home. Kim denied having an eating disorder currently or in the past. She did not present with any other mental health issues. She denied any history of depression and no evidence was presented to suggest obsessive compulsive disorder. Kim enjoys socializing and meeting new people and never feels shy around others. As a matter of fact, she reported having a large circle of friends, many of whom she invites to her home for dinner parties and social activities. Kim was concerned about her relationship and expressed sadness that it will end like so many previous relationships. The counselor who is sensitive to issues of paruresis would

1. Examine the discrepancies between Kim's desire to socialize and her need to control social settings. What is it about these particular social activities and venues that Kim likes and does not like? The counselor should note whether Kim makes reference to noise levels in these public settings, due to the fact that many women with paruresis prefer to urinate where they cannot be heard, either because the location is extremely loud and busy or because it is extremely quiet and secluded.

2. Discuss Kim's concerns about going to social venues or establishments that deviate from those she feels comfortable with. Attempt to isolate her fears and concerns by exploring issues with new social settings. Listen for any concerns related to leaving the house, using a busy or quiet restroom, or urinating outside of the home.

3. If there is evidence of paruresis, explore the symptoms. (The symptoms are detailed in item 4 in case scenario 1.)

Case Scenario 3. Mario, 23, is a male college student who is an avid sports fan. He spends a lot of time watching his favorite teams with his friends. He also is active in organized sporting activities throughout the year. Mario mentioned that his interest and passion for sports started when he was a child when his father took him to a couple of professional football games. Even though he really enjoyed watching his teams live, during adolescence he became less and less interested in attending live events. In college, he said, he would constantly decline requests to attend games and would often make up excuses for not attending. Noticing his reluctance to attend, his friends would question Mario about his apparent lack of interest. Mario's friends also noticed his reluctance to attend other events, such as concerts. Recently, Mario's favorite football team advanced to the Superbowl and his friends were able to secure tickets. Mario has come to counseling because he is feeling anxious and worried about going to the game. He is also concerned that his friends will stop wanting to hang out with him because of his behaviors.

During the intake, he denied any concerns about socializing and being around people. He reported enjoying the excitement and energy of the crowds. No evidence gathered suggested panic attacks with or without agoraphobia or major depressive episodes. He did report an increase in alcohol consumption over the past several years. When asked about his reluctance to attend, the counselor noticed that he seemed uncomfortable with the discussion and avoided the subject. As the discussion continued, the counselor noticed Mario's eyes looking down and his body language indicating shame, humiliation, and embarrassment. Based on this scenario, the counselor would

1. Address and explore nonverbal responses related to Mario's reluctance to attend the event, specifically using immediacy to examine his shame response and feelings of embarrassment. Explore what is not comfortable about going to events now versus previously. Listen for any concerns about using public restrooms, urinating with others present, experiencing negative evaluations or body shyness, being away from home, and waiting in long restroom lines at the events.

2. Discuss with the client factors and circumstances that led to this change in behavior, paying special attention to events or circumstances that occurred in adolescence, because paruresis often emerges after an interpersonal conflict related to urination or body shyness during this period (Boschen, 2008; Gruber & Shupe, 1982; Soifer et al., 2010).

3. Examine the impact avoidance of attending social events is having on his relationships with friends. If paruresis is an issue for Mario, this information will help determine if it is persistent and causing him significant distress.

4. Explore issues that contribute to his substance use, because alcohol abuse and alcohol dependence often co-occur with paruresis (Vythilingum et al., 2002).

5. If it appears that paruresis may be an issue, explore the symptoms. (See the symptoms listed in item 4 from case scenario 1.)

Assessment Measures

There are numerous psychometric instruments to assess paruresis, including the Gruber and Shupe (1982) questionnaire, the Malouff and Lanyon (1985) questionnaire, the Urinary Anxiety Questionnaire (UAQ; Gay, 1991), the Paruresis Severity Scale (PSQ; Gibbs, 2004), the Bashful Bladder Scale (Soifer et al., 2010), and the Patient-Rated Global Paruresis Severity Scale (Soifer et al., 2010). However, few studies have utilized these instruments or tested their psychometric properties. Three instruments for which there is evidence of psychometric properties are the PCL (Soifer et al., 2001), the Paruresis-Scale (PARS; Hammelstein & Pietrowsky, 2005), and the Shy Bladder Scale (SBS; Deacon et al., 2012). Although the three measures have yet to be applied in clinical settings, their psychometric properties suggest that they would be useful for counselors during assessment and diagnosis.

The PCL (Soifer et al., 2001) is a self-diagnostic tool. It consists of 10 dichotomous (yes, no) items based on the criteria for social phobia detailed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, 4th ed., text rev., American Psychiatric Association [APA], 2000). The items are related to signs of paruresis (e.g., fear of urinating in the presence of others; Hammelstein & Soifer, 2006). Severity of symptoms is determined by adding up the scores on the first eight items of the PCL (Soifer et al., 2001; yes = 1, no = 0); a cut-off score of 5 indicates the disorder. The last two PCL items are used as additional diagnostic criteria but do not determine severity of symptoms (e.g., whether or not the symptoms stem from a physical cause; Hammelstein & Soifer, 2006). Although the original version of the PCL has no formal reliability or validity, using a modified German-language version of the scale Hammelstein et al. (2005) found evidence of reliability (Cronbach's [alpha] = .75) and validity.

The PARS (Hammelstein & Pietrowsky, 2005) is another Germanlanguage measure that assists in diagnosis of paruresis and assessment of symptom severity. The PARS contains 13 items related to symptoms of paruresis and the avoidant behaviors related to those symptoms (Hammelstein & Soifer, 2006). Items of the PARS are answered using a five-point Likert scale (1 = not at all, 5 = extremely). The instrument was found to be reliable (Cronbach's a = .94) and possessed a higher discriminative power than the PCL (Soifer et al., 2001) when used only with participants with paruresis. The PCL and the PARS (Hammelstein & Pietrowsky, 2005) were also found to have a high correlation (r = .84), indicating high convergent validity (Hammelstein & Soifer, 2006).

The SBS (Deacon et al., 2012), created because of the lack of psychometric instruments for paruresis, is based on both the researchers' clinical experiences and the literature. It asks about common experiences and symptoms associated with paruresis. The 19 items are divided into three subscales: (a) difficulty urinating in public (e.g., "The only way I can urinate is if I am alone"); (b) interference and distress (e.g., "I avoid going to crowded places because of my fear of urinating in public"); and (c) fear of negative evaluations (e.g., "I worry that other people will be disgusted by the sound of my urine"). Responses use a five-point Likert scale (0 = very little, 4 = very much). Deacon et al. (2012) found evidence that the SBS had high internal consistency ([alpha] = .93) and evidence of discriminative validity.

Once the initial screening is completed, counselors could utilize the PCL (Soifer et al., 2001), the PARS (Hammelstein & Pietrowsky, 2005), or the SBS (Deacon et al., 2012) to assess clients for paruresis. These assessments could assist counselors in diagnosing paruresis and determining the severity of the disorder for any of the clients in the case scenarios. For example, after the screening a counselor could ask Kim (scenario 2), to complete the PCL (Soifer et al., 2001). This assessment would help confirm a diagnosis of paruresis by revealing that concerns related to urination outside of the house are persistent, excessive, and distressing. The last question of the PCL can also help confirm that the client's issues are not due to a medical problem. If the client has not ruled out a medical cause, this question can also lead the counselor to refer the client to a doctor for a medical examination.

Diagnosis

The DSM-IV-TR (APA, 2000) does not refer to paruresis as a specific disorder. Rather, it describes fear of using public restrooms as a performance fear within the category of social phobia (social anxiety disorder), like the fear of public speaking. Based on this classification, individuals with paruresis experience many of the same anxieties (e.g., fear of negative judgment by others) and behaviors (e.g., avoidance of fear-provoking situations) as individuals with social phobia, but the symptoms are specifically associated with urination in public restrooms (Soifer et al., 2001). Several studies support this classification (Malouff & Lanyon, 1985; Vythilingum et al., 2002); however, Marks (1987) suggested that paruresis be classified as a specific phobia (sphincteric phobia). A study by Hammelstein and Soifer (2006) comparing individuals with no paruresis symptoms, paruresis symptoms, nongeneralized social phobia, and generalized social phobia found that those with both generalized and nongeneralized social phobia presented significantly different symptoms from individuals with paruresis, suggesting that social phobia and paruresis are distinct, because the fear of being unable to urinate is a primary focus of paruresis. While the conclusions of that study support the Marks (1987) classification of paruresis, no other support for these findings has been found, and the accepted classification of paruresis continues to be as social phobia in the DSM-5 (APA, 2013). Because the DSM-5 does not give a separate diagnosis for paruresis, counselors would continue to use the social phobia diagnosis for it (APA, 2013).

Although the DSM-IV-TR (APA, 2000) and the DSM-5 (APA, 2013) do not specify diagnostic criteria for paruresis, valid and reliable assessment measures established by Soifer et al. (2001), Hammelstein and Pietrowsky (2005), and Deacon et al. (2012) seem to focus on the same clusters of symptoms and behaviors (e.g., fear of urinating in public restrooms, avoidance of public restrooms). Based on these measures, the following criteria could be used to diagnose paruresis as a form of social anxiety disorder (Deacon et al., 2012; Hammelstein & Pietrowsky, 2005; Soifer et al., 2001):

1. Noticeable, excessive, and persistent fear associated with urinating in public restrooms while others are present. These fears may include concerns about what other people think when the client attempts to urinate and a fear of being humiliated due to problems urinating.

2. Difficulty initiating urination in public restrooms when others are present.

3. Lack of difficulty initiating urination while at home or in a private restroom.

4. Avoidance of urinating in public restrooms.

5. Distress and difficulties associated with using public restrooms interfere significantly with the client's daily life.

6. No apparent medical cause for the client's symptoms.

TREATMENT

The earliest reports of treatment date to the early 1920s. The treatments then involved surgical procedures and psychoanalysis and were focused primarily on female clients (Soifer et al., 2001). The surgical procedures proved largely ineffective because doctors noted that the symptoms had no physiological cause (Soifer et al., 2001). Soifer et al. (2010) reported that psychoanalytic treatments for paruresis appeared to be effective, but it often took several years before clients gained any improvements. Since then, researchers have found more effective and efficient forms of treatment that address the psychological causes of paruresis, so that clients find that symptoms are relieved within weeks and months rather than years.

Behavioral Interventions

In the mid-1960s, traditional psychodynamic approaches were supplanted by behavioral interventions. One of the most effective and common behavioral treatments for paruresis is systematic desensitization (Anderson, 1977; Jaspers, 1998; Ray & Morphy, 1975; Rogers, 2003). This often begins with creation of an anxiety hierarchy in which the client describes the types of situations in which it is difficult to urinate, listing them in order from those that provoke the most anxiety to those that provoke the least (Day, 2008). When creating the hierarchy, it is helpful to ask the client to consider various anxiety-provoking cues, such as the proximity of others, whether they feel rushed, and whether or not their urination can be seen or heard (Jaspers, 1998). It is helpful to have the client use a Subjective Units of Distress (SUDs) rating (1-10) to help rank each item on the hierarchy according to the degree of anxiety the client experiences in each situation (Day, 2008).

After formulating the anxiety hierarchy, clients are taught relaxation techniques, such as progressive muscle relaxation (e.g., Day, 2008; Jaspers, 1998; Olmert, 2008; Soifer et al., 2001) or a breathing technique (e.g., Olmert, 2008; Soifer et al., 2001; Weil, 2001), which they practice often during the session and at home. The final stage of systematic desensitization involves gradually exposing clients to situations on their anxiety hierarchy. In each situation clients use the relaxation technique to reduce stress and facilitate urination; they do not move up to the more difficult situations on their hierarchy until they have successfully urinated several times in the less difficult situation. Clients who are unsuccessful in a given situation (i.e., urination does not occur within two minutes) should return to the previous situation on the hierarchy where they were successful, and urinate in that situation two more times before again attempting the more difficult situation (Soifer et al., 2001).

Soifer et al. (2001) recommended that graduated exposure sessions should be conducted for about one hour, multiple times a week. To prepare for exposure sessions, it is important that clients significantly increase their fluid intake before each session (a process called "fluid loading"), though making sure not to overload on fluids. Clients will then begin recording their urinary hesitancy on an urgency scale, where zero represents no urgency and ten represents extreme urgency. This urgency scale will help clients keep track of successes they have with various urgency levels, and it will help increase the probability of success during initial exposure sessions because such sessions should not begin until they have reached a seven or higher on the urgency scale. Because each session should last for an hour, it is helpful to have a partner for some of the initial exposure sessions, such as a therapist or trusted friend or family member, who can stand at various distances from the client in different bathroom environments to ensure that the client does not need to wait for a stranger. Then, when clients reach situations that are higher on their anxiety hierarchy that may involve much busier restroom environments, a partner will no longer be needed. The final stage of graduated exposure is the maintenance phase, when daily for 30 days clients practice urinating in situations highest on their anxiety hierarchies, and then as often as possible after that 30-day period (Soifer et al., 2001).

Cognitive Behavioral Therapies

Cognitive behavioral therapy (CBT) was first used to treat paruresis in the late 1990s. Most studies addressing CBT treatments for paruresis found CBT to be highly effective (Jaspers, 1998; Rogers, 2003; Soifer et al., 2010). CBT approaches target the physical, cognitive, and emotional components of paruresis by using behavioral techniques as well as cognitive restructuring techniques to treat the client's symptoms (Olmert, 2008; Soifer et al., 2001). Cognitive restructuring is a valuable part of paruresis treatment particularly for clients who are struggling with negative and unrealistic messages about urinating (Soifer et al., 2001).

According to Soifer et al. (2001), the first step in cognitive restructuring is to ask clients to identify the automatic thoughts, underlying assumptions or schemas, and cognitive distortions that produce their paruresis symptoms (e.g., "Everyone is looking at me," or "I know I am not going to be able to urinate."). If clients have difficulty identifying these automatic thoughts, ask them to visit a public restroom and record what they are thinking. The next step in cognitive restructuring is to replace distorted thoughts with more accurate and truthful thoughts and self-statements. To facilitate this, therapists can encourage clients to find evidence against their distorted thoughts in order to help them dispel such thoughts as they pop up. For example, therapists can ask clients to identify instances when other individuals in a public restroom were not looking at them and did not notice that they were unable to urinate. If clients are unable to cite that kind of evidence, encourage them to conduct a behavioral experiment during which they enter a restroom and pretend that they are going to urinate (without actually doing so) and then observe the others around them to see if anyone notices (Soifer et al., 2001).

Integrative and Multimodal Approaches and Adjunct Therapies

Integrative treatment models for paruresis were first presented by Montague and Jones (1979), who used a variety of different approaches, from self-catheterization to group psychotherapy, to treat clients. More recent integrative approaches have combined CBT with a variety of adjunct therapies, such as hypnosis, distraction techniques, family therapy, and support groups (Ginandes, 2002; Nicolau, Toro, & Prado, 1991; Soifer et al., 2001; Soifer et al., 2010). The rationale behind using these integrative approaches to treat paruresis stems from the theory that paruresis is a complex disorder, involving conscious and unconscious cognitions, emotional factors, physical symptoms, and environmental stressors.

Integrative approaches have considerable potential for treating clients with paruresis; however, because most of the research on paruresis treatments has consisted of case studies, it is often unclear whether the adjunct therapies are truly effective. For example, some case studies reported that distraction techniques, such as breath-holding, which activates the parasympathetic nervous system response (Weil, 2001) or listening to a radio headset (Zgourides, Warren, & Englert, 1990), were effective and were gradually decreased as a distraction technique. These studies reported that at a 12-month follow-up, the clients reported being almost symptom-free and needed to use the distraction

technique only rarely. However, the efficacy of these treatments has not been extensively tested, and Soifer et al. (2001) argued that distraction techniques interfere with client progress through graduated exposure.

IMPLICATIONS FOR COUNSELORS AND RESEARCHERS

Over the past two decades, our knowledge of paruresis has increased, but there are still no universally established diagnostic criteria. While this paper has presented diagnostic criteria, the items were culled from instruments with psychometric properties designed to diagnose paruresis rather than from clinical trials. The lack of standard diagnostic criteria has several implications for the disorder, including issues with accurate diagnosis, creating reliable and valid measures, and identifying a prevalence rate. Since so little research has been conducted on paruresis, counselors may not be aware of its many facets, the presentation or masking of symptoms, and the impact and implications it has for clients. Counselors suspecting paruresis should gather information on possible causes, inquire about medical issues (e.g., prostatism), and assess symptom presentation and other psychogenic issues.

Due to possible embarrassment related to the disorder, clients may be initially reluctant to discuss symptoms. Counselors must properly assess and rule out possible differential diagnoses. Establishing a strong therapeutic relationship and demonstrating sensitivity may help minimize any stigma, shame, and embarrassment accompanying this disorder. Educating clients about the fact that the disorder is fairly common and symptom presentation is best viewed along a continuum may also normalize client experiences and cognitions and reduce anxiety or depression associated with the disorder. In addition, when drawing up treatment plans, counselors should factor in the necessity of long-term follow-up, because in the short term many clients may experience symptom improvement that does not last. After completion of therapy, clients may regress or relapse, especially those with severe cases of paruresis, so counselors should factor in long-term evaluation and a plan for reinforcing treatment approaches.

One area that is almost nonexistent in the literature is experimental research to test the effectiveness of various treatment modalities. Although CBT and behavioral approaches seem to be most effective in treating paruresis, research using experimental methods is needed to demonstrate the efficacy of these and adjunctive therapies. Future studies should also draw from larger samples; the vast majority of the present research on paruresis is in the form of case studies. Long-term follow-up studies are needed to validate treatment efficacy.

CONCLUSION

Even though paruresis is an underdiagnosed disorder, prevalence rates imply that it is common and can be distressing to those who suffer from it (Hammelstein et al., 2005). Although there are no universally accepted diagnostic criteria for the disorder, an increasing number of instruments with established psychometric properties are available to help counselors diagnose paruresis. The etiology may vary from client to client; it appears that stressful or traumatic interpersonal experiences involving urinating in public restrooms are the most common cause (Soifer et al., 2010). After a stressful experience, individuals become nervous about urinating in public restrooms, and this anxiety creates a self-fulfilling prophecy (Soifer et al., 2010).

Because of the nature and course of paruresis, behavioral and CBT approaches with exposure and cognitive restructuring components seem to be most effective in treating it. For clients with severe paruresis or other psychological issues contributing to the disorder, integrating approaches such as systematic desensitization, cognitive restructuring, support groups, and family therapy may be necessary and valuable for the client. Established and accepted diagnostic criteria must be identified to ensure that treatment properly targets paruresis symptoms while effectively differentiating it from other types of disorders. In addition, because long-term follow-up is rare in the literature, it is unclear whether symptom reduction related to the approaches chosen is temporary or permanent. Further, if underlying causes of the disorder were not properly assessed or addressed during treatment, symptoms may reappear.

REFERENCES

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

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Michael S. McGraw, Gina L. Rothbaum, and William R. Sterner are affiliated with Marymount University. Correspondence should be addressed to William R. Sterner, Counseling Department, Marymount University. 2807 N. Glebe Road. Arlington. VA, 22207. E-mail: wsterner@marymount.edu.
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Author:McGraw, Michael S.; Rothbaum, Gina L.; Sterner, William R.
Publication:Journal of Mental Health Counseling
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Date:Jul 1, 2014
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