a case study of successful treatment
psychological treatment for bashfull bladder*
Baruch Elitzur, Ph.D. Psychiatric Clinic, Ichilov Hospital, Tel Aviv Medical Center
Translated by Judith Barrett, M.A.
Judy Barrett, IPA staffer, has translated this article (in the Jewish Journal Harefuah) from the original Hebrew, and we have permission from the author to post it.
"Bashful bladder" syndrome, or paruresis, is diagnosed as a psychogenic disturbance which results from a social phobia.
In two separate studies conducted among college students, the incidence rate was found to be 7% and 32%. Despite the high frequency of the disorder, published studies on the subject are few. A majority of those published deal with the situation of a patient treated from a single theoretical model. The present study details treatment of paruresis with three patients. In the course of treatment, there was adopted a multidimensional approach which employed a wide range of short-term techniques: relaxation, guided imagery, paradox, gestalt, metaphor, cognitive-behavioural and psychodynamic. Treatment concluded after six sessions. Two younger patients (age 18 and 24) reported total improvement in their condition. A third, much older patient (age 50), reported partial improvement.
"Bashful bladder" syndrome refers to the retention of urine against a psychogenic background, without any organic finding. Under stress, sympathetic nervous system activity can affect bladder output in one of two extreme ways: urinary frequency, and urinary retention. Many who seek treatment for anxieties complain of urinary frequency. This year, for the first time, there came under my treatment three men who suffered from urinary retention when at a public urinal or in proximity to others. The disorder is known in the literature as "bashful bladder" or paruresis. Although the disorder is not [sic] currently in the DSM-IV (American Psychiatric Association, 1994), it is commonly included under the syndrome of social phobias (Scholing & Emmerkamp, 1993).
In a sample of 381 college students, Malouff and Lanyon (1985) found that 7% suffered from bashful bladder and that their anxiety level was higher than the norm. In contrast, Gruber and Shupe (1982) found bashful bladder among 32% of the college students surveyed. In personal conversation with a considerable number of physicians, psychiatrists and psychologists, I found that despite the high statistical incidence of the disorder, the number of those who seek professional treatment is miniscule. A significant proportion of professionals were not aware of this disorder at all.
Zgourides (1987), in his review of publications on bashful bladder, details etiology of the disorder according to the literature: difficulty in expressing hostility, a subconscious relation between urination and sexual drives, past urological disease, prior trauma, heightened sensitivity to penetration of personal space, and a compelling desire to be punished. Elitzur (1988b) proposed three additional explanations for the disorder. Two are based on psychoanalytic theory: a subconscious castration anxiety, and latent homosexual tendencies. A third explanation, based on evolutionary theory, is detailed infra.
The literature on treatment for bashful bladder is quite small, and most concern a single patient who is invariably treated in accordance with the principles of one theoretical school. Hatterer et al. (1990) found that pharmacological treatment for bashful bladder by means of phenelzine, a drug from the class of MAO inhibitors, was not effective. However, treatment with atenolol, from the class of beta-blockers, helped one patient and in two of the others caused troublesome side-effects involving prolonged erection.
Psychoanalytic treatment for bashful bladder was presented by Bird (1980).
Treatment with a biofeedback technique yielded only partial results (Christmas, Noble, Watson and Turner-Warwick, 1991). The majority of those reporting on psychological treatment methods employed the cognitive-behavioural alone (Zgourides, 1987). A cognitive-behavioural approach was valued for psychological treatment with a short-term focus (a limited number of weeks or months), whereas a psychoanalytic approach was valued for long-term treatment (a number of years).
The present study demonstrates a short-term treatment for bashful bladder, using a multidimensional model which employs an assortment of psychological techniques: relaxation (Elitzur, 1988a), guided imagery (Shorr, 1974), paradox
(Weeks & L'Abate, 1982), gestalt (Perls, 1969), metaphor (Gindhart, 1981)
cognitive-behavioral (Meichenbaum, 1977) and psychodynamic.
The three males who came under my care in the course of one year all complained of an almost identical disorder: an inability to urinate at a public urinal whenever another male was in proximity. When urinating in an enclosed stall in a public urinal, as soon as someone else entered the restroom their flow would stop. When urinating in their bathroom at home or at any other house, as soon as they heard noise from nearby – such as footsteps or the turning of a faucet – their flow would stop. These patients would struggle to urinate even in a place as "open" as a forest. Two of them developed methods for avoiding urination when in close proximity to others, but the need for isolation when urinating caused them distress. All three of the men noted that the problem began at a very young age. They could not recall any traumatic factor in the onset of the disorder. All three claimed that, apart from the problem of bashful bladder, they had adapted to daily living and enjoyed a sense of satisfaction – despite the fact that they considered themselves overly sensitive and lacking in assertiveness.
The first male, age 18, came to me for treatment because he feared the disorder would interfere with his adjustment to military reserve duty. The second male, age 24, came under pressure from his girlfriend because the disorder hindered them on outings with other couples. The third male, age 50, came for treatment because his hospitalisation had forced him to need a catheter when he was unable to urinate using a bedside container. Faced with the prospect of a second hospitalisation, he wished to avoid another catheter.
In the framework of short-term psychological treatment, one is aware of the great importance of explaining to the sufferer the root of their disorder. The assumption is that "knowledge is power". When a patient understands the cause of a disorder, he is less angry and less disappointed with himself: in this way, there lessens the chance of negative reinforcement. Similarly, when anger and disappointment diminish, it is easier to contend with setbacks. In accordance with the treatment technique of paradox, one is aware of the priority of establishing a positive meaning for this disorder (Weeks & L'Abte, 1982). For example, an accepted explanation for frequent urination when in a pressured situation relates it to an evolutionary advantage. During an emergency in the wild which stimulates the sympathetic response of "fight or flight", urination reduces body weight. In addition, in the event of a wound in the region of the bladder, premature voiding tends to prevent its rupture (Elitzur, 1988b). Since I was unable to find in the professional literature any explanation of an evolutionary advantage for urinary retention during an emergency, I am forced to postulate such an advantage.
The first four sessions were conducted with less than a week between each one. The fifth was conducted with a spacing of two weeks, and the sixth – which was designated for feedback – was spaced at almost a month.
first and second sessions
After receiving information about the disorder and a psychological assessment of personality, each patient was given a cognitive-paradoxical directive using the technique of metaphor. The directive concerned the positive evolutionary aspect of the disorder. Below is a reconstructed text of the directive:
"When God or Nature created humans and living creatures, there was planted in the brain a strong message which aimed to improve the chances of survival. We'll use as an example a deer standing in a forest and urinating. As soon as a lion appears opposite it, the deer is faced with three possible responses:
- To politely ask the lion to wait until it is done urinating, and after that flee;
- To continue urinating even while fleeing;
- To stop the flow of urine and quickly flee. With disappearance of the danger, the flow of urine will return.
I assume you'll agree with me that the third possibility is the most logical. This is exactly what happens to you when you are urinating at a public urinal. Since it is your character to be somewhat sensitive, in the subconscious you feel like a creature exposed to attack. When a strange person enters the restroom, or when you hear a noise nearby, the survival impulse causes the bladder to instantly close and your body moves to act in a state of stress.
The problem is that the survival instinct was implanted millions of years ago when human life in the wild was established, and it hasn't been revised since we came down from the trees. The situation is like that of a computer built at the beginning of the computer age, on whose hard drive was inserted a specific program. Today the computer still processes well, but sometimes the old program appears on the screen and interferes. It is very difficult to delete an old program. I am a psychologist who specializes in human computers. I will attempt to teach you, in a limited number of sessions, to delete the old program whenever you want to urinate in the presence of strangers."
Employing the techniques of metaphor, relaxation, guided imagery and behaviourism.
By means of metaphor, it was explained to each patient that their body is like a car that works in two gears: a tranquil gear and a stress gear. While in tranquil gear, each mechanism of the body works leisurely and muscle tension is low. When in stress gear, each mechanism of the body is alert, muscle tension increases and the bladder shuts down. They are forced to learn which muscle closes the bladder, and also to transfer their body from a stress gear in which muscle tension is greater than in a tranquil gear, to one in which muscle tension is low.
The patients were inducted into a state of relaxation via multi-varied techniques (Elitzur, 1988a). While in this state, they are at ease to imagine that they are at a public urinal urinating next to a stranger. In addition, each patient is instructed to evoke images concerning his individual problem. The first patient was instructed to imagine that he was urinating in an open field, alongside his buddy from reserve duty. The second patient was directed to imagine that he was urinating while on an outing with his friend, and the third was instructed to imagine that he was urinating into a container while laying in his bed at the hospital.
Toward the end of the third session, an individual program was established which was scaled from the perspective of the problem. The patients were instructed to practice it throughout the week. The goal of the program was to prevail over the avoidant response in situations that stimulate urinary retention. With the objective of diminishing expectations and preventing disappointments, it was emphasized to each patient that the purpose was not to urinate in public restrooms, but to practice "as if". For example:
To enter a public restroom and stand before a urinal with his fly zipped. When a male enters to urinate, he should act as if he has just finished and then exit the room.
- to perform a similar exercise with the fly open
- to perform a similar exercise with his penis visible
- to enter an enclosed stall in a public restroom and practice relaxation
- to perform a similar exercise with his trousers unfastened.
- to enter a bathroom at home and have housemates make noise in an adjacent room
Both of the younger patients reported that they practiced "as if" a number of times and, though not required to urinate, succeeded in doing so after repeated attempts. The older patient successfully practiced "as if", but not with actual urination. Since all three of the patients rated themselves as overly sensitive persons who from an early age had difficulty with aggression, they were given a psychodynamic explanation that the disorder was tied to their psychological sensitivity (Bird, 1980). It was suggested to them that they could reinforce the psychological "defence mechanism" through practice expressing anger in an imaginary exercise.
Each patient was asked to close their eyes and describe experiences during which they felt helpless or powerless. The patient was instructed to imagine that this time he would defend himself from attack using various means, one of which even utilized streams of urine. At the end of the imaginary aggressiveness, each was instructed in a basic gestalt technique (Perls, 1969): to dramatically act out shouting at someone who had harmed him, even employing coarse street language which included specific words from the harmful incident. It is of note that all three patients greatly enjoyed this session.
The patients reported on their individual attempts, with varying degrees of success, to urinate at a public urinal. Each patient was instructed to continue practicing until he was satisfied with the results. In the technique of paradox, a clinician encourages the patient to "strive" repeatedly, and to understand that the lesson of failure is to teach him to contend with it and to avoid anger and disappointment with oneself.
The sixth session, which was conducted about a month later, was used for follow-up and support for continuing the exercise.
The two youngest patients were eager to practice both relaxation and the imagery between sessions. At the fourth session, both reported their success at urinating in various places under various conditions. They described this as an intense experience such as they had not felt in years. At the sixth session, they reported that they no longer felt a need to continue the exercise.
The third patient reported more modest results. According to him, he felt more comfortable urinating in public places, but avoided entering restrooms if others were there. The sixth session was conducted after his release from the second hospitalisation. He reported feeling dependent on a catheter only for the first day in the hospital, when he was confined to bed; but when he was free to walk around the department, he was able to urinate in the restroom after practicing relaxation. Although he was not completely free of the disorder, he asked to discontinue treatment.
Most articles which consider treatment for bashful bladder view the patient according to the tenets of a single theoretical model. This study adopts a multidimensional model which demonstrates a broad spectrum of short-term techniques. Its purpose is to broaden the perspective of clinicians who specialize in short-term treatment (Lazarus, 1981). A multidimensional approach enables the fitting of treatment techniques to an individual, and not the fitting of an individual to one exclusive technique.
The techniques described above met with complete success for the two younger patients, age 18 and 24; however the third patient, age 50, was diagnosed with only partial relief. It may be assumed that the third patient had more difficulty freeing himself because he had suffered from it for so many years that it became second nature.
Since the three patients discussed in this article did not suffer from abnormal psychological disturbances, it was feasible to employ short-term psychological treatment. For situations in which a patient suffers from deep mental disturbances, long-term mental health treatment is required. Experience indicates that it is possible to combine long-term treatment with short-term techniques, similar to those discussed in this article. In this way, it is possible to free the patient from an oppressive disorder and continue with long-term treatment even for grave mental health problems.
*Elitzur, B. (6-15-00). Tipul Psikologi be-Shalpuhit Bayyshanit. Harefuah
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