Latest Thinking on Paruresis and Parcopresis

CLINICAL

Latest thinking on paruresis and parcopresis

A new distinct diagnostic entity?

Kenley LJ Kuoch, David W Austin, PARURESIS refers to the difficulty or history of paruresis),1 and helping patients Simon R Knowles inability to initiate or sustain micturition to discuss and identify options to address where individuals are present (eg a public these conditions. restroom) because of overwhelming fear Background 1 Paruresis and parcopresis are of perceived scrutiny. Paruresis reportedly psychogenic conditions that involve affects between 2.8% and 16.4% of Associated psychopathology a difficulty or inability to void or the population.2 Paruresis tends to be and comorbidity defecate, respectively, in a public setting more prevalent in males (75–92%) than Paruresis and parcopresis are (eg public restroom). Both conditions females (8.1–44.6%), which may be due to psychologically distressing as these are associated with significant anatomical differences between male and conditions result in interpersonal, psychological distress. As a result of 2 shame, embarrassment and stigma, female genitourinary systems. occupational and social impairment, and 1,4 individuals with these conditions may A closely related condition is reduction in quality of life. Symptoms not actively identify behaviours or parcopresis, which refers to the difficulty can range from very mild and inconsistent5 symptoms or seek treatment in or inability to defecate in public restrooms to severe and sustained where individuals general practitioner (GP) consultations. because of overwhelming fear of perceived with paruresis refrain from socialising or 3 6 Objective scrutiny. Little is known about parcopresis travel, and avoid leaving their homes. 4 The objective of this article is to and prevalence of this condition has yet A study by Vythilingum et al involving provide a summary of the associated to be confirmed.2 In the one case study 63 individuals with paruresis found that psychopathology and comorbidity, and that has been published on this condition, 38.1% limited or avoided travel, 33.5% diagnostic challenges associated with parcopresis has been noted to share similar avoided dating and 15.9% reduced or paruresis and parcopresis. Treatment characteristics with paruresis whereby avoided drinking fluids. Patients with recommendations relating to paruresis there is overlap in symptomology.3 paruresis were also reported to turn down and parcopresis are also provided. Key clinical features that paruresis job offers (50.8%), limit their occupation Discussion and parcopresis patients may present (55.6%), and hide their condition from Paruresis and parcopresis can have a with include the complaint of significant partners (25.4%), friends (58.7%) and significant impact on an individual’s difficulty or inability to urinate or defecate family (44.4%). Similarly, parcopresis has psychological health and overall quality 1 of life. GPs play a part in identifying in public facilities. Consistent with been associated with avoidance of public 3 these conditions, defusing feelings of anxiety, patients may also report avoidance and social situations. shame and embarrassment, and behaviours and psychosomatic symptoms The inability to initiate or sustain enabling access to psychological such as diaphoresis, tachypnea, heart micturition or defecation is underpinned interventions, which are likely to provide palpitations, muscle tension, blushing, by an overwhelming fear of scrutiny2 – significant benefits to individuals living nausea and trembling, which occur during a fear commonly associated with social with paruresis and/or parcopresis. moments of heightened arousal (eg being anxiety disorder (SAD). Past research has inside a busy restroom).1,3,4 argued that paruresis should be classified As a result of feelings of shame, as a subtype of SAD because of overlap embarrassment and a perceived stigma in symptoms1,4 and the primarily socially associated with paruresis and parcopresis, anxious disposition of those with paruresis patients may be reluctant to identify (eg avoidance strategies, overwhelming and seek treatment for these conditions. fear of negative evaluation).3,7,8 General practitioners (GPs) play a Nevertheless, paruresis and SAD are critical part in identifying risk factors likely to be two distinct conditions, (eg psychological comorbidity, and family as patients with paruresis do not

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necessarily present with comorbid SAD abnormalities prior to a diagnosis of difficulty with initiating and sustaining (approximately 5.1–22.2% of individuals paruresis and/or parcopresis being made. micturition and defecation. His symptoms with paruresis also had comorbid SAD).2 Given the complexities of urinary and included difficulty voiding and defecating Similarly, parcopresis is likely to be a gastrointestinal functioning, collection of in public restrooms, along with rapid distinct condition rather than a form a thorough history, physical examination heartbeat, excessive sweating, muscle of SAD. Proposed criteria for paruresis and use of appropriate investigative tension and trembling when trying to and parcopresis, based on the work of and diagnostic assessment should be void or defecate. The patient reported Deacon et al9 and Knowles and Skues,10 conducted to rule out disorders of organic that symptoms did not occur in his own is published in Kuoch et al.2 aetiology and allow for accurate diagnosis home, except when friends or family Psychological comorbidity in patients and initial management.12 members were close by when he was in with paruresis is common, with 22.2% Clinicians should also be cognisant of the restroom. As a result of his anxiety, identified as having major depressive potential differential diagnoses whereby the patient reported avoiding work, social episodes, 14.3% alcohol abuse disorder, other urinary and/or gastrointestinal and public situations (eg shopping centres) 7.9% alcohol dependence disorder, conditions share similar signs or when he believed that there was a potential and 4.8% with obsessive compulsive symptoms with paruresis or parcopresis. to need to use a restroom. As a result of disorder.4 Rates of psychopathology For instance, dysfunctional voiding (DV) his anxiety, the patient restricted fluid are currently unknown in patients has been noted to share similar symptoms intake and altered his dietary habits to with parcopresis, but individuals with with paruresis as both conditions involve decrease the likelihood of needing to use parcopresis have been reported to have urinary retention in the absence of the restroom in public. The patient also similar psychological comorbidities to anatomic, obstructive, infectious or engaged in significant avoidance strategies, those afflicted with paruresis.3 neurologic pathology.5 However, unlike which has led to an increasingly isolated Although research in this area is limited, DV, paruresis is isolated to unfamiliar and debilitating existence. The primary the psychogenic nature of paruresis and or busy public restrooms.2 Likewise, concern reported by the patient was a fear parcopresis has been explored. In a recent inability to defecate in gastrointestinal that people would see/hear him urinate study involving 254 respondents (74% conditions, such as constipation, is or defecate. The patient reported no other female; mean age = 31.67 years), it was differentiated from parcopresis by not psychological worries or concerns. identified that greater paruresis and being restricted to only occurring in Upon excluding organic causes for parcopresis symptoms were associated unfamiliar or busy public restrooms. his difficulty to void and defecate, and with a propensity towards dysfunctional At the current time, the Diagnostic ruling out other mental health disorders attitudes, where there is a tendency to think and statistical manual of mental disorders (eg SAD, post-traumatic stress disorder negativity of oneself or be seen negatively (DSM-5) identifies paruresis as an example [PTSD]), the GP diagnosed the patient by others (eg ‘If I fail at my work, then I of SAD.13 However, a recent systematic with simple phobia (paruresis and am a failure as a person’).11 Further, it was review found that paruresis and SAD are parcopresis). While not a diagnostic test, found that a fear of evaluation mediated likely to be two distinct conditions as the patient’s scores from the Shy Bladder the relationship between dysfunctional individuals who present with paruresis do and Bowel Scale (SBBS) were 3 and 3.5 attitudes and symptoms of paruresis and not necessarily present with comorbid SAD out of 4 on the paruresis and parcopresis parcopresis. These findings are consistent (approximately 5.1–22.2% of individuals subscales, respectively. These scores are with past research identifying the central with paruresis also had comorbid SAD).2 consistent with those of individuals who role of fear in paruresis and parcopresis.1,4,8 Parcopresis is yet to be classified in the have been diagnosed with paruresis and Like other anxiety-based conditions, DSM; however, like paruresis, it is likely parcopresis. paruresis and parcopresis are associated to be a distinct condition rather than The patient was referred to a with avoidance behaviours,3 which are likely a form of SAD. Based on the current psychologist who provided 20 sessions of to reinforce dysfunctional attributes and research, while it is likely that a minority of cognitive behavioural therapy. The focus of fears of future evaluations, and exacerbate individuals presenting with either or both these sessions included psychoeducation distress. Further, given that paruresis and of these conditions will meet criteria for (educating the patient about how anxiety parcopresis have been exhibited to be highly mental health disorders such as SAD, the influences bladder and bowel function), correlated with each other,11 this suggests majority are likely to better meet criteria stress/anxiety management (breathing that patients with one condition may also for a specific phobia. A case presentation retraining) and cognitive restructuring be afflicted with the other. of paruresis and parcopresis follows. (reappraising unhelpful thoughts the patient may have regarding voiding and defecation). A key focus of the Diagnostic challenges CASE: PRESENTATION OF PARURESIS intervention was engaging in gradual Patients presenting with suspected AND PARCOPRESIS exposure activities (exposing the patient to paruresis or parcopresis should be A man aged 31 years presented to his increasingly anxiety-provoking situations examined for anatomic or physiologic GP with a 10-year history of increasing to allow for a habituation or extinction

response to occur). The engagement of symptoms.3 Other psychologically focused Key points these tasks led to significant changes in strategies such as stress management, • Paruresis and parcopresis are both confidence and ability to urinate and including mindfulness, may also promote psychogenic conditions (ie phobias) that defecate in public restrooms. In addition, more adaptive emotion regulation and involve a difficulty or inability to void or safety behaviours were also identified in turn a lessening of anxious arousal. defecate in a public setting. (eg avoid water and food intake >12 hours Pharmacotherapy may also be appropriate • While clinical trials are lacking, prior to a social event) and gradually as an adjunct. In one case study, gabapentin psychological-focused intervention, eliminated based on a collaborative was reported to improve paruresis symptom such as CBT, is likely to provide the approach. The sessions ended with the severity.18 Similarly, adjunctive treatment most benefit. patient reporting feeling more able to with selective serotonin reuptake inhibitors use public restrooms and SBBS scores of (SSRIs; paroxetine 40 mg) was noted to Authors Kenley LJ Kuoch BA (Psych & Forensic Sc), BSc (Hons), 1 and 1.5 out of 4 on the paruresis and reduce paruresis and parcopresis symptom Assoc MAPS, PhD (Psychology) candidate, Department parcopresis subscales, respectively. severity when delivered alongside CBT of Psychological Sciences, Swinburne University of Technology, Melbourne, Vic 3 intervention. Despite the reported efficacy David W Austin PhD, Professor of Psychology and of medication, psychotherapy is considered Associate Dean, School of Psychology, Deakin University, Geelong, Vic the best intervention for paruresis and Simon R Knowles MPsyc (Clinical), PhD, MAPS, Treatment recommendations parcopresis until further clinical trials Senior Lecturer, Department of Psychological 1 Sciences, Swinburne University of Technology, Given the psychogenic nature of are investigated. Melbourne, Vic; Clinical Psychologist, Department paruresis and parcopresis, psychological of Psychiatry, St Vincent’s Hospital, Melbourne, Vic; Department of Medicine, University of Melbourne, interventions are likely to be the first Melbourne, Vic; Department of Gastroenterology and line of treatment. Although clinical trials Summary Hepatology, Royal Melbourne Hospital, Melbourne, Vic. [email protected] have yet to be undertaken, cognitive Paruresis and parcopresis are anxiety- Competing interests: None. behavioural therapy (CBT) is likely to be based conditions that cause significant Funding: This research was conducted through the helpful given its known efficacy in treating psychological, interpersonal, occupational support of the Australian Government Research Training Program Scholarship. other anxiety-based conditions (eg SAD, and social impairment. Although the Provenance and peer review: Not commissioned, specific phobias).14 As identified above, prevalence of paruresis has been reported externally peer reviewed. paruresis and parcopresis are associated to range between 2.8% and 16.4%, the Acknowledgments with dysfunctional attitudes and thinking prevalence of parcopresis is presently The authors would like to thank Professor Denny Meyer patterns (eg fear of perceived scrutiny unknown. It should also be noted that for proofreading this manuscript and Professor Geoffrey Hebbard for advice regarding direction of this manuscript. from others).15 CBT has been shown to be paruresis is likely to be comorbid with efficacious at identifying and attenuating parcopresis as these conditions have been References 1. Boschen MJ. Paruresis (psychogenic inhibition of 16 these negative thinking patterns, leading observed to be highly interrelated. As micturition): Cognitive behavioral formulation and to reductions in anxiety symptomology. a result of stigma and a perception that treatment. Depress Anxiety 2008;25(11):903–12. doi: 10.1002/da.20367. Further, the use of graded exposure work symptoms are embarrassing, patients 2. Kuoch KLJ, Meyer D, Austin DW, Knowles SR. associated with CBT is also likely to be hesitate to raise paruresis and parcopresis A systematic review of paruresis: Clinical implications and future directions. 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