You Could Have This Anxiety Disorder If You Can't Pee in Public
Paruresis is a social phobia that can make it impossible to pee in front of others.
I can’t talk to you while I pee. One of my least favorite office interactions is when a coworker (or worse yet, a manager) happens to be in the restroom at the same time as me and wants to keep chatting while we’re in separate stalls. My very good friends know if we duck into a public bathroom together, chitchat will resume once we’re washing our hands.
I’ve never known if it’s stage fright, embarrassment, anxiety, or some unfortunate combo of all three–but it turns out I don’t even have it that bad. In some people, anxiety about peeing in front of others can be so severe, it’s a legitimate phobia.
Listed under social phobias in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is paruresis, otherwise known as shy bladder or shy bladder syndrome–a.k.a. the inability to urinate in the presence of others.
Just about everyone can remember a time when, for whatever reason, they haven’t been able to go, says Steven Soifer, PhD, CEO of the International Paruresis Association. Estimates suggest some 7% of Americans–around 20 million people–have paruresis, and these people “just can’t, literally,” he says. As many as 22% of people who have shy bladder syndrome also have social anxiety disorder.
Here's what to know if you think you might be one of them.
What is paruresis?
Paruresis is sort of like performance anxiety for your bladder, says Soifer, also the incoming chair of the social work department at the University of Mississippi. “In social situations, people have difficulty or even impossibility of being able to urinate in the presence of others. Someone could put a gun to your head and say, ‘Pee or die,’ and it’s not clear what would happen,” he says. “People don’t get that unless you know someone who has it or have it yourself.”
That lack of understanding even extends to doctors, he adds, who might unhelpfully suggest remedies like “Just drink a lot of water and you’ll pee.” People with paruresis won’t, he stresses. Some hold their bladders for so long, they’ll end up in the hospital.
Obviously, this is extremely disruptive to public life. Soifer has worked with people who couldn’t pee during overnight work trips or ended relationships because a partner didn't understand why they couldn't travel. He himself once held his bladder throughout a 16-hour train tip from Paris to Madrid. “The bathroom doors wouldn’t lock on the train, and people were sitting outside the bathroom door. There’s no way I could go! I was almost doubled over in such pain until I found a bathroom I could use.” (He's been in recovery from paruresis for about 20 years, he says.)
That discomfort distinguishes paruresis from other social phobias, he adds. “You may have physical symptoms of anxiety with a phobia of planes or elevators, but not pain.”
Another major symptom is constant worry over where you'll be able to pee next. The thoughts tend to be obsessive: “Where am I going to be able to go, is someone going to hear me, is someone going to see me,” Soifer says.
Only about half of the people Soifer treats remember any specific incident that caused their inability to pee in front of others, he says. It’s rarely a consequence of sexual abuse or violent trauma, but may be the result of bullying in school or “vicarious learning,” like watching a parent berate a brother or sister in the bathroom, he says. Some people develop paruresis after a surgery, when a recovery nurse needs them to pee before they can be discharged to go home. “That can be very intimidating if a nurse is taking you to the bathroom and standing outside the door,” Soifer says.
It’s thought that men and women develop paruresis in equal numbers, but Soifer says 90% of people who sign up for his treatment workshops are men. “Women have a whole lot more options for privacy,” he explains. “You don’t have to go up to a urinal and take the goods out and then urinate with other people there, potentially watching you.”
So what do you do about a shy bladder?
During weekend CBT workshops, Soifer helps people gradually become desensitized to their paruresis triggers. Participants practice peeing in a hotel room bathroom with a person standing in the hallway, for example. Then that person will enter the hotel room. Then they'll get closer to the bathroom door, until they're close enough to hear a pee stream. Once a participant has successfully completed that phase, the group might travel to a less private space, like an empty public bathroom, before ultimately attempting to pee in a busier public bathroom, Soifer explains. The process is called graduated exposure; exposure therapy is used to help people confront fears and phobias of all sorts.
Acceptance and commitment therapy, another type of psychotherapy, may also hold some benefits, Soifer says. “One principle is being able to accept the problem,” he says. “That’s the starting point: When you fight [paruresis], you just don’t make any progress.”
Anti-anxiety medications may play a role, too. They won’t suddenly make a person with paruresis pee, Soifer says, but they can curtail feelings of embarrassment and shame enough to participate in exposure therapy.
As awareness of paruresis grows–Soifer says it took a decade just to get shy bladder syndrome into the DSM–the stigma surrounding it lessens, which is leading more people to treatment at a younger age, he says. But stigma and misunderstanding have kept plenty of others from speaking up. “I had a guy at a workshop who was 83. He broke out in tears at the end of the workshop, saying, ‘My whole life passed me by. I could have dealt with this had I only known,’” Soifer says.
If you’re ready to get help for paruresis, you can find support groups and workshops through the IPA’s website, and you can search for therapists who specialize in CBT using the Find a Therapist Directory at the Anxiety and Depression Association of America.
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