Toilet phobia
Toilet phobia
Definition
Toilet phobia is an often debilitating psychological condition that affects an individual’s ability to urinate or defecate in public facilities. It is an umbrella term that encompasses two different phobias—paruresis, the fear of urinating in public places, which is also referred to as “bashful bladder syndrome,” “shy bladder syndrome,” or “pee-phobia”; and parcopresis, the fear of having a bowel movement in a public place or when other people are in their vicinity. Many psychologists consider toilet phobias to be a form of social anxiety disorder.
Description
Many people occasionally experience difficulty urinating or having a bowel movement. Often, these difficulties stem from an underlying medical condition, such as a blockage in the urinary system, constipation, illness, or a side effect of medication. However, when an individual is able to urinate or defecate at home but not in public, the cause is likely the psychological conditions paruresis or parcopresis. Individuals with these conditions will feel embarrassed at the thought that they might be heard or criticized while using the toilet, and their anxiety can gradually worsen as the inability to use public bathrooms persists.
Different degrees of toilet phobias exist. People who have the most severe form are unable to use a public restroom entirely, and may even be unable to
use the bathroom at the home of a friend or family member. Other people with toilet phobias can only use a public restroom if it is empty, and still others can go in a public facility if they are enclosed in a private stall (rather than standing at a urinal).
To prevent the urge to urinate when away from home, individuals with toilet phobia may restrict fluids or take medications that prevent them from going to the bathroom. They may refuse to attend social functions and avoid traveling, for fear that they will be unable to find an empty restroom.
Young children may experience phobias during toilet training. The primary causes of toilet phobias in children are the fears of passing a painful bowel movement or being punished for making a mess. In most people with paruresis, the condition develops during the adolescent or teenage years, although it can arise at any time.
Demographics
An estimated 7%, or 17 million Americans, experience paruresis. Although paruresis can occur in both men and women, approximately 90% of those who seek treatment for the condition are male. This may be because public men’s restrooms are much more open (urinals, rather than closed stalls) than women’s restrooms.
Causes and symptoms
Causes
Toilet phobias are believed to have genetic, physical, and psychological components. Paruresis and parcopresis tend run in families, as do social anxiety disorder and depression, which are also common among those who have toilet phobias.
The physical component of the disorder occurs when an individual experiences anxiety using a public restroom. That anxiety awakens the sympathetic nervous system, which causes smooth muscles in the urinary tract to close down, shutting off the flow of urine. The level of anxiety the person feels may grow with each subsequent attempt to use a public restroom.
There are a number of theories regarding the psychological triggers for toilet phobias, including:
- Being harassed, bullied, or made fun of during a childhood or adolescent bathroom experience
- Sexual abuse
- A subconscious association between using the bathroom and sexuality
- Obsessive-compulsive disorder connected to a fear of contamination
- Having critical parents, or having been raised to be ashamed of the toileting process
Because of the embarrassment involved with toilet phobias, most people who experience them do not seek professional help for their condition.
Symptoms
The following are symptoms of toilet phobias:
- Limiting or avoiding fluids
- Taking medication to prevent urination or a bowel movement
- Avoiding travel, social situations, and jobs that require the use of a public restroom
- Having a distended bladder from holding in urine for long periods of time or having other bladder or kidney problems
- Feeling sweaty, dizzy, faint, or shaky when attempting to use a public restroom
- Being embarrassed or ashamed of using the toilet and of the phobia itself
Diagnosis
Individuals with toilet phobias are often referred to a urologist for an initial evaluation. The urologist will do a series of tests to identify whether the problem stems from a condition such as diabetes or an enlarged prostate gland, or whether it is the side effect of a medication. The doctor may do a urodynamic evaluation, which measures urine flow rate, bladder pressure, and residual urine volume to see how well the bladder is filling and emptying. If the urological assessment is negative, the patient may be referred to a psychologist or psychiatrist. For a diagnosis of toilet phobia to be made, the phobia must be significant enough to affect the individual’s daily life. For example, the person must be going out of his or her way to avoid public restrooms.
Treatments
Several treatments have been proposed for toilet phobias, including cognitive-behavioral therapy, hypnotherapy, biofeedback, medication, and self-catheterization. The most commonly used treatment for paruresis is graduated behavior therapy, in which patients learn to overcome their phobia by progressing through increasingly public bathroom scenarios. For example, someone may first urinate in a public bathroom while someone is standing outside the rest-room, and work their way up to voiding while someone is right outside the stall.
Toilet phobias also can be treated with medication, although no clinical evidence exists to prove its effectiveness. Sometimes the drug diazepam can relax the pelvic floor muscles to relieve urinary retention. Selective serotonin reuptake inhibitors (SSRIs) may be used to treat the underlying anxiety that is causing the toilet phobia.
For children who are experiencing toilet phobias, several possible interventions can be used. If the child fears having a painful bowel movement, stool softeners can help ensure that the bowel movement is not uncomfortable. Parents can reassure their child about using the toilet by using sweets or other rewards as incentives. If the phobia stems from anxiety or depression, the child may require counseling from a psychiatrist or psychologist.
Prognosis
Although cognitive-behavioral therapy, psychotherapy, and other treatments are not effective in each case, these techniques help some people overcome toilet phobias. Thus far, no randomized, controlled
KEY TERMS
Biofeedback —A treatment that uses a special machine to help the patient learn how to control involuntary body processes, including heart rate and blood pressure.
Catheterization —The use of a hollow, flexible tube to drain urine from the body.
Cognitive-behavioral therapy —A therapeutic approach that teaches patients how to identify the thoughts and beliefs that are causing their behaviors to learn how to change those behaviors.
Hypnotherapy —A type of therapy that puts a patient into a deep state of relaxation, making him or her more suggestive to the therapist’s instructions.
Obsessive-compulsive disorder —A type of anxiety disorder characterized by repeated uncontrollable thoughts and repetitive actions.
Parcopresis —A type of social anxiety disorder in which a person is unable to have a bowel movement in a public place.
Paruresis (also referred to as bashful bladder syndrome, shy bladder syndrome, or pee-phobia) —A type of social anxiety disorder in which a person is unable to urinate in a public place.
Selective serotonin reuptake inhibitors (SSRIs) —A class of antidepressant medications used to treat depression and anxiety.
Social anxiety disorder —A condition in which a person feels intense anxiety during normal social situations.
Urodynamic evaluation —A series of tests that assess urinary tract function.
Urologist —A doctor who specializes in treating diseases related to the urinary tract.
studies have been done to evaluate toilet phobia treatments; however, surveys and case studies suggest that behavioral therapies can have either minimal or complete success in at least half of the patients who try them.
Prevention
There is no way to prevent toilet phobias. However, treatments such as graduated behavior therapy may be effective in reducing the anxiety associated with using public restrooms.
Resources
BOOKS
Bandelow, Borwin, and Dan J. Stein, eds. Social Anxiety Disorder. New York: Marcel Dekker, 2004.
Heimberg, Richard G., Michael R. Liebowitz, Debra A. Hope, and Franklin R. Schneier, eds. Social Phobia: Diagnosis, Assessment, and Treatment. New York: The Guilford Press, 2006.
Soifer, Steven, MSW, PhD, George D. Zgourides, PsyD, Joseph Himle, MSW, PhD, and Nancy L. Pickering. Shy Bladder Syndrome: Your Step-By-Step Guide to Overcoming Paruresis Oakland, CA: New Harbinger Publications, 2001.
ORGANIZATIONS
Anxiety Disorders Association of America, 8730 Georgia Avenue, Suite 600, Silver Spring, MD 20910. Telephone: (240) 485-1001. http://www.adaa.org
International Paruresis Association, P.O. Box 65111, Baltimore, MD 21209. Telephone: (800) 247-3864. http://www.paruresis.org
National Institute of Mental Health, 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. Telephone: (866) 615-6464. http://www.nimh.nih.gov
Stephanie N. Watson