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Helping unlock the bathroom 'stall'

Research, seminars can cure shy-bladder phobia

The urinals at Fenway Park may beckon during the seventh-inning stretch, but it's a sure thing that some people won't be able to answer nature's call when beer- and soda-satiated fans line up behind them. Others freeze up at mall bathrooms or highway rest stops. Or, for those like Nancy K., perhaps urinating in restrooms on airplanes, at work, or even when visiting friends' homes seems impossible.

Nancy, who asked that her last name not be used, has paruresis, or fear of urinating in public, also called shy bladder syndrome. Paruretics worry someone will see them, hear them, or is waiting for them to urinate.

"Almost every person has a problem going for some reason, at some time," says Dr. Steven Soifer, an associate professor at the University of Maryland School of Social Work, who has written a book on the subject and leads seminars to treat the condition.

Based on a 1997 Harvard Medical School study, 17 million people have difficulty using the bathroom away from home. Soifer estimates that perhaps a million of those people have full-blown paruresis, a social phobia that interferes with their travel, work, and relationships.

Social phobias are a medical condition. "Most individuals with social phobia start off as shy children and some develop social anxiety disorders, like paruresis," says Dr. Eric Hollander, professor of psychiatry at Mount Sinai School of Medicine in New York, and director of the Compulsive, Impulsive, and Anxiety Disorders Program there.

Paruresis's cause isn't exactly clear, adds Dr. Michael Chancellor, a urologist at the University of Pittsburgh School of Medicine. "It's probably a combination of physical factors such as tight pelvic muscles, and psychological ones, like a traumatic incident."

Regardless, Chancellor says, "once the inability to relax the sphincter valve becomes hardwired into the brain circuitry, it has to be unlearned."

For Nancy, who is 47, shy bladder began when she was 16. She and a friend went to the movies and drank alcohol. When they went to the restroom, Nancy couldn't urinate.

"I remember my friend's curiosity about my trouble," says Nancy. "I was mortified." Afterward she avoided any situation where she could be embarrassed again.

"The bad news is that social phobias like paruresis are common. The good news is that they're very treatable. If people have generalized social anxiety the standard treatment often includes antidepressant medication," says Hollander. In addition, "facing your fears" strategies learned through cognitive behavioral therapy help people confront the feared situation and change their negative thoughts. "They see nothing terrible is going to happen," Hollander says.

Several weeks ago, Nancy, who is married and has three children, signed up online for a $395 weekend seminar that Soifer taught in Boston. She took a day off from the animal hospital where she works and traveled from Long Island, N.Y., hoping for a breakthrough for a condition that kept her from attending college away from home (dorm bathrooms were too intimidating) and that she kept secret, even from her husband, for many years.

At Soifer's workshops, participants share common stories, and then take action. They "fluid load" by drinking lots of water, coffee, or soda to nurture the urge. They then team up with a "pee buddy," who starts a comfortable distance away and gradually moves closer while the participant tries to urinate.

"At first, I was in the bathroom in my hotel room with the door locked, and my buddy was downstairs in the lobby," says Nancy. Nancy tried to go. Then her buddy moved into the room, closer to the bathroom door. Nancy was able to urinate a little bit, but didn't make as much progress as she hoped. "I'm planning to try medications and another seminar," she says.

Paruresis may be worse for men because urinals are so very public. At the workshop, male buddies eventually stand directly behind their partners, maybe even harrumphing or pacing impatiently to replicate real-life circumstances. If this sounds intimidating, it is. Most make progress, but need to reinforce lessons learned by continuing to practice at public restrooms or with a support group. Soifer estimates that there are about 40 support groups in the United States.

Reinforcement is the key, says Hollander. "People have to face their fears on a regular basis. When they're uncomfortable about something, rather than avoid it, they should seek it out over and over again until they've mastered it," he says.

For rare severe cases, Chancellor teaches patients who absolutely cannot go in public how to use a catheter. "Four times a day they push the catheter past the tight sphincter to let all the urine out," says Chancellor. "It puts paruretics at more risk of infection, but if they can't go, their urine is stagnant and their risk of infection goes up even more," he says.

Nancy recently told a coworker at the animal hospital about her problem. The other day, she helped restrain a frightened dog, which urinated all over her. The co-worker looked at Nancy. "Jealous?" she asked. They both laughed. "It felt good to confide in someone," Nancy says.

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