Review articleA systematic review of paruresis: Clinical implications and future directions
Introduction
Paruresis commonly refers to the inability to initiate or sustain urination (micturition) where individuals are present (e.g., in a public toilet) due to the fear of perceived scrutiny from others [8]. Considerable interpersonal, occupational and social impairment, psychological distress, and reduction in life quality have been associated with this disorder [8], [39]. For some, their experience of paruresis can be very mild and occur inconsistently [35] however, in severe cases, paruresis sufferers may refrain from travel and social activities, leave their occupations, and avoid leaving their house due to their symptoms [24].
Paruresis is a phenomenon associated with a plethora of clinical nomenclature. For example, Malouff and Lanyon [22] employed the term “avoidant paruresis” while other researchers have used the terms “shy bladder syndrome” [14], [24] and “psychogenic urinary retention” [4], [5], [6]. There has been debate as to whether paruresis and psychogenic urinary retention are synonymous and the issue is further compounded by researchers alternating between the terms (e.g., [19], [36], [41]).
Although both paruresis and psychogenic urinary retention are classified as forms of urinary retention, paruresis differs from psychogenic urinary retention as, in the latter disorder, the individual experiences long-standing inability to urinate under any environment or circumstance which resultantly requires the patient to be catheterized [8], [22], [26]. Indeed, there is a difference between paruresis and other forms of more chronic, emotionally or physiologically influenced urinary retention [7]. In particular, such forms of urinary retention (e.g., vesical sphincter dyssynergia and non-neurogenic, neurogenic bladder) are mostly seen in children and result in incontinence and structural damage [7].
In terms of theoretical models of paruresis, early conceptualisations were predominately psychoanalytic. For example, Freudian interpretations explained paruretic symptomology in the context of psychosexual influences (e.g., unconscious ego-dystonic sexuality; [41]). Modern understandings of paruresis have moved away from psychoanalysis towards a cognitive-behavioural framework whereby paruretic symptoms are thought to result from an association between anxious arousal and urination in public restrooms [8]. Unsuccessful attempts at voiding in public may lead to feelings of anxiety and embarrassment, which are then exacerbated with further unsuccessful attempts and avoidance strategies [8]. Furthermore, dysfunctional thoughts and cognitive fallacies have been suggested to contribute to paruresis pathogenesis. In particular, individuals with paruresis may be inclined to perceive others as being critically evaluative, have inflated concerns of their body image, overestimate severity of negative evaluation, and be predisposed to interpreting ambiguous cues as being indicative of negative evaluation [8], [37]. These cognitive fallacies serve to exacerbate and reinforce paruretic symptomology and have also been noted in other psychopathologies [18].
Mental health conditions that have been reported to be commonly comorbid in paruresis presentations include, social anxiety disorder (SAD), depression, and obsessive compulsive disorder (OCD; [39]). Contention remains in regards to rates of psychopathology in paruresis presentations, and to date a systematic review identifying rates of psychopathology in paruresis has yet to be conducted. In the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the diagnostic classification of paruresis falls under the category of social anxiety disorder (SAD; [1]). The reason behind this classification stems from the argument that paruresis and SAD share common features (e.g., [8], [39]). In contrast, other researchers have argued that paruresis is distinct from SAD (e.g., [14]) as it is a functional disorder (a condition where normal function of the body is impaired in the absence of a physical cause; [23]).
While there have been several studies in the area of paruresis, no systematic review has been conducted to date. Four review questions were chosen because of their underlying connection to the psychosomatic nature of paruresis. The systematic review of these questions will both clarify current knowledge relating to paruresis and help direct future research in this area (Table 1).
The aim of the current systematic review was to explore four key questions relating to the paruresis literature:
- Question 1:
What is the prevalence of paruresis and its associated demographic features (i.e., age, gender, socioeconomic status, ethnicity)?
- Question 2:
What is the prevalence of psychopathology in paruresis cohorts, how does it compare to other chronic-health conditions, and what percentage of paruresis patients also have social anxiety disorder?
- Question 3:
How does quality of life, and levels of anxiety and depression compare between those with and without paruresis?
- Question 4:
Do psychological interventions for paruresis patients reduce paruresis symptoms, or, anxiety, or depression, and/or improve QoL?
Section snippets
Methods
This systematic review was registered in the International Prospective Register of systematic reviews PROSPERO (CRD42016049498).
Results
Of the 1535 studies identified during the initial searches, 117 were removed as duplicates. Of the 1418 articles that were screened on the basis of titles and abstracts, 1358 were excluded based on title and abstract (Fig. 1), leaving 60 articles for full review to determine each articles relevance to each question. As for the number of articles applicable to each question, eight articles were applicable to Question 1, six articles were applicable to Question 2, one article was applicable to
Discussion
This systematic review examined four questions which addressed: (1) prevalence of paruresis and its associated demographic features; (2) prevalence of psychopathology in paruresis cohorts, how it compares to other chronic-health conditions, and the percentage of paruresis patients that have social anxiety disorder; (3) how quality of life, anxiety and depression compares between those with and without paruresis; and (4) whether psychological interventions for paruresis reduce paruresis
Competing interests statement
The authors have no competing interests to report.
Funding
This research was conducted through the support of the Australian Government Research Training Program Scholarship.
Acknowledgments
The lead author would like to thank Ryan Veal for his assistance in proofreading this paper.
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