آیا "سندرم مثانه خجالتی" (paruresis) به درستی به عنوان هراس اجتماعی طبقه بندی شده است؟

Paruresis manifests in an inability to urinate in public restrooms followed by a considerable avoidance behavior. According to DSM-IV TR this disorder is classified as social phobia. A sample of N = 226 subjects completed different questionnaires concerning paruresis, social phobic symptoms, lower urinary tract symptoms and depressive symptoms. These individuals were divided into four groups: no symptoms, suffering primarily from paruresis, non-generalized social phobia and generalized social phobia. The paruretic group differs significantly in all symptom variables from both the non-generalized and the generalized social phobia groups. Regression analysis separated by groups shows that the interference with everyday life can be mainly explained by paruretic symptoms (in the paruretic group) or by social anxiety and depressive symptoms, respectively (in the social phobic groups). These results question the classification of paruresis as simply being a form of social phobia.

Paruresis manifests in a fear and inability to urinate in public restrooms when other persons are present or may enter the room (Hammelstein, 2002 and Soifer et al., 2001; Zgourides, 1987). This disorder was first labeled as “paruresis” and described as a “disorder of micturition” by Williams and Degenhardt (1954). According to DSM-IV-TR (American Psychiatric Association, 2003) this disorder falls under the category of a social phobia. However, most descriptions, books and articles concerning social phobias do not refer to paruresis (Hofmann & DiBartolo, 2001). Fifty years after the first systematic description, there is still little knowledge about the origin and specific features of this disorder. Unfortunately, most literature is based on treatment case reports (Hatterer, Gorman, Fyer, & Campeas, 1990; Jaspers, 1998 and Lamontagne and Marks, 1973; McCracken & Larkin, 1991; Nicolau, Toro, & Perez Prado, 1991; Rogers, 2003 and Sagar and Ahuja, 1988; Zgourides, 1991 and Zgourides and Warren, 1990; Zgourides, Warren, & Englert, 1990), while other studies examine voiding dysfunction in sub-clinical samples such as college students (Gruber & Shupe, 1982; Rees & Leach, 1975). Based on these descriptions of paruresis, two primary classifications can be identified (even though the existing literature did not consider these classifications). On the one hand, the functional nature of paruresis was emphasized and the syndrome was consequently described as a “functional disorder of micturition” (Williams & Degenhardt, 1954; Zgourides, 1987) or as “psychogenic urinary retention” (Allen, 1972 and Christmas et al., 1991; Khan, 1971 and Lamontagne and Marks, 1973; Margolis, 1965, Nesbitt et al., 1965, Nicolau et al., 1991, Tu, 1992 and Wheeler and Renshaw, 1995). On the other hand, presence of anxiety and avoidance were pointed out, and paruresis was described as a social anxiety disorder (Hammelstein, 2002, Jaspers, 1998 and Malouff and Lanyon, 1985; Soifer et al., 2001). Supporting evidence exists for both views. In the case of paruresis as a functional disorder, the patients’ subjective complaints are the substantiation: patients emphasize their inability to urinate and often negate the experience of fear (Hammelstein, Jäntsch, & Barnett, 2003; Hammelstein, Pietrowsky, Merbach, & Brähler, in press). Yet, analysis of social phobia subtypes raise concerns about classification of paruresis solely as a social anxiety disorder. In analyzing the items on the “Liebowitz Social Anxiety Scale” (LSAS; Liebowitz, 1987), Heimberg et al. found that the item “urinating in (use of) a public restroom” was shown to be the most different from other items on the LSAS (Heimberg, Holt, Schneier, Spitzer, & Liebowitz, 1993). Based on this result Heimberg et al. postulated that paruresis should be eliminated as an example of social phobia in the text of DSM-IV. Furthermore, medical treatments which are effective for some forms of social anxiety (like beta-blockers or MAO-inhibitors) do not improve paruretic symptomatology (Hatterer et al., 1990, Zgourides, 1988 and Zgourides, 1991; Zgourides & Warren, 1990). Classification of paruresis as social anxiety is a good match to the features of the disorder itself: the pronounced avoidance behavior and the fear of negative evaluation (people recognizing and ridiculing the paruretic's voiding dysfunction). Studies in sub-clinical samples have found higher values of self-reported interpersonal anxiety and performance anxiety in subjects suffering from paruretic symptoms in contrast to control subjects (Malouff & Lanyon, 1985). When examining male college students (n = 90), Gruber and Shupe (1982) found a strong relationship between paruretic symptoms and body shyness and found that more paruretic symptoms are associated with increased feelings of fear and self-centeredness. According to the affect model of depression and anxiety ( Clark, Watson, & Mineka, 1994; Watson, Clark, & Carey, 1988), Hammelstein and Meyer (submitted for publication) found a higher negative affect but no differences in positive affect when comparing subjects suffering from paruresis with controls which further support the classification of paruresis as a form of anxiety. Vythilingum, Stein, and Soifer (2002) reported a high comorbidity between paruresis and other forms of social anxiety and took that as a symbol of the association between paruresis and social anxiety. However, according to DSM-IV-TR (American Psychiatric Association, 2003) this disorder is designated as a social phobia and—as far as we know—no study exists that compares subjects suffering from paruresis with subjects suffering from other forms of social phobia. The authors’ study tries to fill this gap by comparing paruresis with different forms of social phobia symptomatology (paruretic symptoms, social anxiety symptoms, depressive symptoms, lower urinary tract symptoms) and their interference with everyday life. Examining possible similarities and differences between paruresis and social phobias, not only mean differences of self-reported complaints, are of interest to see the level of interference with everyday life within these groups. The authors assume that paruresis is a form of social phobia. That means we hypothesize that paruretic subjects differ from pure social phobic subjects only in the severity of paruretic symptoms, not in the severity of social anxiety symptoms or lower urinary tract symptoms. We assume that in contrast to pure social phobic subjects, the level of interference with everyday life in paruretic subjects can be predicted mainly by the severity of paruretic symptoms. 1. Methods 1.1. Subjects To ensure a maximal variance of paruretic and social phobic symptoms, subjects were recruited through different Internet self-help forums. This online-recruiting seems appropriate because subjects suffering from paruresis rarely visit general practitioners or therapists. The questionnaire was placed on nine German self-help forums (three forums for social phobia, three forums for anxiety disorders, two forums for paruresis and one forum for male-specific problems). These self-help forums which are dedicated to specific clinical problems (social phobia, anxiety disorders, paruresis) have similar compositions. On all these forums the web user can gather information about the etiology of the disorder and about different treatment possibilities. On every forum there is a kind of virtual message board to leave notes or questions for other web users. The male-specific forum is an informational service that is non-profit and provides information about different male-specific themes (intimate relationships, sexuality, education, alimony, child custody, etc.). On this forum there is no virtual message board. Our sample consisted of 226 subjects (female subjects: n = 82, 36.3%) between the ages of 15 and 55 (M = 29.2, S.D. = 8.2). Level of education was quite high; with the average amount of education ranging from 8 to 18 years (M = 11.6 (S.D. = 1.7). Male subjects were older than female subjects (F(1, 221) = 7.23, P < .01, Cohen's d = .38), but they did not differ in years of education (F(1, 179) = .36, P = .55, Cohen's d = .09).