How To Practice Exposure Therapy for Paruresis

Public restrooms can cause fear among those with social anxiety.
Paruresis refers to the fear of using public restrooms. Joey Boylan / Getty Images

Paruresis, also known as shy bladder, refers to fear and avoidance of using public restrooms. It is related to social anxiety disorder (SAD) in that it is a type of performance phobia that is specific to this setting.

Impact of Paruresis

A survey of 63 patients affiliated with the International Paruresis Association (IPA) showed that paruesis had on average been a problem for a couple of decades and significantly affected their lives, such that one third avoided parties, sporting events, and dating, while half were limited in their choice of job.

Patients were more likely to indicate impairment in performance than social interaction settings with respect to social anxiety.

Treatment of Paruresis

The most common treatment for paruresis is graduated exposure therapy. Data collected by the IPA  indicates that 80% of people receiving this form of treatment show improvement. 

Graduated exposure therapy involves gradually using restrooms in increasingly difficult circumstances and is usually performed under the supervision of a trained behavioral therapist.

However, if you have a willing partner, there are steps you can take to attempt graduated exposure on your own.

This process is not overly difficult; however, you will need the following: 

  • A trusted friend or relative to help you with exposures
  • At least one hour twice per week to practice
  • Paper and pen to write out a hierarchy
  • Access to locations to practice exposures

Steps to Overcoming Paruresis On Your Own

1. Enlist the help of a trusted friend or relative.

This person will be present during early exposures to mimic the situations that you would experience in public.

If you are unable to find a partner, it is possible to follow the steps by utilizing naturally occurring public locations.

2. Learn whether urgency to urinate makes it more or less difficult for you to perform.

If having to urinate urgently makes the process easier, be sure to drink lots of fluids prior to each exposure session.

If the need becomes very urgent and you are still unable to urinate, consult a doctor or urologist.

3. Construct a behavioral hierarchy scale.

Make a list of locations or situations in which you find it difficult to use restrooms. For each item on the list, assign it a value from 0 to 10, with 0 being very easy (e.g., your home) and 10 being the most difficult (e.g., a busy public restroom).

4. Begin with an item rated 0, such as urinating at home while a guest is present.

Have your partner remain in your home in another room while you attempt to urinate. If possible, allow urine to flow for 3 seconds before stopping.

5. Meet your partner for a 3-minute break.

6. Once again, attempt to urinate.

Do not use coping strategies such as running a faucet or trying not to make noise. This will only extend the time needed for exposure as you will later need to learn how to perform without coping techniques.

7. Continue in this fashion alternating exposures and breaks for up to an hour.

8. If the session has been successful, move on to the next easiest item on your hierarchy and practice this exposure in your next session.

Have a goal of working on exposures at least twice per week—several times per week being even better.

9. After 8 to 12 sessions, you should find your ability to urinate freely greatly improved.

Completing 15 to 20 sessions is the ideal goal.

Tips 

1. Do not spend more than 4 minutes trying to urinate.

If it is not working, take a short break and try again. Sometimes moving back a step in your hierarchy can also help.

2. If paruresis is just one of many social fears that affect you, exposure therapy alone is unlikely to improve the broad scope of your anxiety.

In these types of cases, it is important to meet with a psychologist or psychiatrist to determine the best course of action for your social anxiety.

3. Before starting exposure therapy, have a doctor rule out medical causes.

Sources:

International Paruresis Association. Paruresis Fact Sheet.

Vythilingum B, Stein DJ, Soifer S. Is “Shy Bladder Syndrome” a Subtype of Social Anxiety Disorder? A Survey of People with Paruresis. Depress Anxiety. 2002;16(2):84-87. doi:10.1002/da.10061.

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