Abstract
Parcopresis is a condition where individuals have trouble (or inability) defecating in restrooms due to the perceived scrutiny of others. The aim of the current research was to identify the prevalence of public toilet avoidance and explore if an extended socio-cognitive model of parcopresis predicts toilet avoidance. Seven-hundred and fourteen university students (73.2% female; mean age = 28.79 years) met criteria to participate and completed a series of questionnaires and ten restroom vignettes. On average 80.00% (gender adjusted 82.54%) of the participants chose to use an available toilet, while 16.78% (gender adjusted 14.44%) avoided a toilet for non-contamination fears. A further 3.22% (gender adjusted 3.01%) participants on average avoided using a toilet due to fears of contamination. Males were significantly more likely to use and not avoid toilets than females across all vignettes. A structural equation model (SEM) indicated the data supported the proposed model well (χ2 p value = .185, CMIN/df = 1.359, CFI = .998, TLI = .995, RMSEA = .023, SRMR = .0207) with significant direct relationships being found between: dysfunctional attitudes influencing fear of positive and negative evaluation and fear of social reprisal, and fear of positive and negative evaluation influencing fear of social reprisal and social anxiety symptoms. Social anxiety symptoms had a direct significant influence on parcopresis symptoms, while in turn parcopresis symptoms had a direct significant influence on toilet avoidance. The current study provides evidence that toilet avoidance is underpinned by social anxiety processes and affects at least 14.44% of university students.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Data Availability
The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request and after relevant ethical approval.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Arlington: American Psychiatric Publishing, Inc.
Ascher, L. M. (1978). Paradoxical intention in the treatment of urinary retention. Behav. Res. & Therapy, 17(3), 267–270
Asher, M., & Aderka, I. M. (2018). Gender differences in social anxiety disorder. Journal of Clinical Psychology, 74(10), 1730–1741. https://doi.org/10.1002/jclp.22624.
Asher, M., Asnaani, A., & Aderka, I. M. (2017). Gender differences in social anxiety disorder: A review. Clinical Psychology Review, 56, 1–12. https://doi.org/10.1016/j.cpr.2017.05.004.
Beevers, C. G., Strong, D. R., Meyer, B., Pilkonis, P. A., & Miller, I. W. (2007). Efficiently assessing negative cognition in depression: An item response theory analysis of the dysfunctional attitude scale. Psychological Assessment, 19(2), 199–209
Boschen, M. J. (2008). Paruresis (psychogenic inhibition of micturition): Cognitive behavioral formulation and treatment. Depression and Anxiety, 25(11), 903–912. https://doi.org/10.1002/da.20367.
Boyce, P., Gilchrist, J., Talley, N. J., & Rose, D. (2000). Cognitive-behaviour therapy as a treatment for irritable bowel syndrome: A pilot study. The Australian and New Zealand Journal of Psychiatry, 34(2), 300–309. https://doi.org/10.1080/j.1440-1614.2000.00731.x.
Brown, T. A., & Naragon-Gainey, K. (2013). Evaluation of the unique and specific contributions of dimensions of the triple vulnerability model to the prediction of DSM-IV anxiety and mood disorder constructs. Behavior Therapy, 44(2), 277–292. https://doi.org/10.1016/j.beth.2012.11.002.
Carleton, R. N., Collimore, K. C., & Asmundson, G. J. (2007). Social anxiety and fear of negative evaluation: Construct validity of the BFNE-II. Journal of Anxiety Disorders, 21(1), 131–141. https://doi.org/10.1016/j.janxdis.2006.03.010.
Cook, S. I., Meyer, D., & Knowles, S. R. (2018). Relationships between psychoevolutionary fear of evaluation, cognitive distortions, and social anxiety symptoms: A preliminary structural equation model. Australian Journal of Psychology, 71, 92–99. https://doi.org/10.1111/ajpy.12215.
Evans, S. C., Roberts, M. C., Keeley, J. W., Blossom, J. B., Amaro, C. M., Garcia, A. M., Stough, C. O., Canter, K. S., Robles, R., & Reed, G. M. (2015). Vignette methodologies for studying clinicians' decision-making: Validity, utility, and application in ICD-11 field studies. International Journal of Clinical and Health Psychology, 15(2), 160–170. https://doi.org/10.1016/j.ijchp.2014.12.001.
Hammelstein, P., & Soifer, S. (2006). Is "shy bladder syndrome" (paruresis) correctly classified as social phobia? Journal of Anxiety Disorders, 20(3), 296–311. https://doi.org/10.1016/j.janxdis.2005.02.008.
Hammelstein, P., Pietrowsky, R., Merbach, M., & Brahler, E. (2005). Psychogenic urinary retention ('paruresis'): Diagnosis and epidemiology in a representative male sample. Psychotherapy and Psychosomatics, 74(5), 308–314. https://doi.org/10.1159/000086322.
Heimberg, R. G., & Becker, R. E. (2002). Cognitive-behavioral group therapy for social phobia: Basic mechanisms and clinical strategies. New York: Guilford Press
Heimberg, R. G., Mueller, G. P., Holt, C. S., Hope, D. A., & Liebowitz, M. R. (1992). Assessment of anxiety in social interaction and being observed by others: The social interaction anxiety scale and the social phobia scale. Behavior Therapy, 23(1), 53–73. https://doi.org/10.1016/S0005-7894(05)80308-9.
Hu, L., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling: A Multidisciplinary Journal, 6(1), 1–55. https://doi.org/10.1080/10705519909540118.
Knowles, S. R., & Skues, J. (2016). Development and validation of the shy bladder and bowel scale (SBBS). Cognitive Behaviour Therapy, 45(4), 324–338. https://doi.org/10.1080/16506073.2016.1178800.
Kumari, R. S., Sudhir, P. M., & Mariamma, P. (2012). Perfectionism and interpersonal sensitivity in social phobia: The interpersonal aspects of perfectionism. Psychological Studies, 57(4), 357–368. https://doi.org/10.1007/s12646-012-0157-7.
Kuoch, K. L. J., Meyer, D., Austin, D. W., & Knowles, S. R. (2017). A systematic review of paruresis: Clinical implications and future directions. Journal of Psychosomatic Research, 98, 122–129. https://doi.org/10.1016/j.jpsychores.2017.05.015.
Kuoch, K. L., Austin, D. W., & Knowles, S. R. (2019a). Latest thinking on paruresis and parcopresis: A new distinct diagnostic entity? Aust J Gen Pract, 48(4), 212-215, https://doi.org/10.31128/AJGP-09-18-4700.
Kuoch, K. L. J., Cook, S., Austin, D. W., Meyer, D., & Knowles, S. R. (2019b). Exploration of the socio-cognitive processes underlying paruresis and parcopresis. Current Psychology. https://doi.org/10.1007/s12144-019-0125-7
Kuoch, K. L. J., Meyer, D., Austin, D. W., & Knowles, S. R. (2019c). Classification and differentiation of bladder and bowel related anxieties: A sociocognitive exploration. Current Psychology. https://doi.org/10.1007/s12144-019-00364-0
Kuoch, K. L. J., Meyer, D., Austin, D. W., & Knowles, S. R. (2019d). Socio-cognitive processes associated with paruresis and parcopresis symptoms: A proposed bivalent model. Current Psychology. https://doi.org/10.1007/s12144-019-00376-w
Maia Barros, R. E. (2011). Paruresis and parcopresis in social phobia: A case report. Revista Brasileira de Psiquiatria, 33, 416–417
Malouff, J. M., & Lanyon, R. I. (1985). Avoidant Paruresis: An exploratory study. Behavior Modification, 9(2), 225–234. https://doi.org/10.1177/01454455850092006.
Mattick, R. P., & Clarke, J. C. (1998). Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behaviour Research and Therapy, 36(4), 455–470. https://doi.org/10.1016/S0005-7967(97)10031-6.
McCambridge, J., Witton, J., & Elbourne, D. R. (2014). Systematic review of the Hawthorne effect: New concepts are needed to study research participation effects. Journal of Clinical Epidemiology, 67(3), 267–277. https://doi.org/10.1016/j.jclinepi.2013.08.015.
Mogg, K., & Bradley, B. P. (1998). A cognitive-motivational analysis of anxiety. Behaviour Research and Therapy, 36(9):809–48. https://doi.org/10.1016/s0005-7967(98)00063-1.
Reiter, S. R., Otto, M. W., Pollack, M. H., & Rosenbaum, J. F. (1991). Major depression in panic disorder patients with comorbid social phobia. Journal of Affective Disorders, 22, 171–177
Rogers, G. M. (2003). Treatment of paruresis in the context of benign prostatic hyperplasia: A case report. Cognitive and Behavioral Practice, 10(2), 168–177
Seres, G., Kovacs, Z., Kovacs, A., Kerekgyarto, O., Sardi, K., Demeter, P., et al. (2008). Different associations of health related quality of life with pain, psychological distress and coping strategies in patients with irritable bowel syndrome and inflammatory bowel disorder. Journal of Clinical Psychology in Medical Settings, 15(4), 287–295. https://doi.org/10.1007/s10880-008-9132-9.
Simon, H. B. (2007). On Call: Shy bladder syndrome. Harvard Men's Health Watch, 12(5), 8
Soifer, S. (2012). Shy bladder syndrome (paruresis). An update. Catonsville: International Paruresis Association Inc.
Soifer, S., Zgourides, G. D., Himle, J., & Pickering, N. L. (2001). Shy bladder syndrome: Your step-by-step guide to overcoming paruresis. Oakland: New Harbinger Publications
Soifer, S., Himle, J., & Walsh, K. (2010). Paruresis (shy bladder syndrome): A cognitive-behavioral treatment approach. Social Work in Health Care, 49(5), 494–507. https://doi.org/10.1080/00981381003684898.
Stein, D. J., Lim, C. C. W., Roest, A. M., de Jonge, P., Aguilar-Gaxiola, S., Al-Hamzawi, A., et al. (2017). The cross-national epidemiology of social anxiety disorder: Data from the world mental health survey initiative. BMC Medicine, 15(1), 143. https://doi.org/10.1186/s12916-017-0889-2.
Tierney, A. J. (1998). Nursing models: Extant or extinct? Journal of Advanced Nursing, 28(1), 77–85
Vythilingum, B., Stein, D. J., & Soifer, S. (2002). Is "shy bladder syndrome" a subtype of social anxiety disorder? A survey of people with paruresis. Depression and Anxiety, 16(2), 84–87. https://doi.org/10.1002/da.10061.
Weeks, J. W. (2010). The disqualification of positive social outcomes scale: A novel assessment of a long-recognized cognitive tendency in social anxiety disorder. Journal of Anxiety Disorders, 24(8), 856–865. https://doi.org/10.1016/j.janxdis.2010.06.008.
Weeks, J. W., Heimberg, R. G., & Rodebaugh, T. L. (2008). The fear of positive evaluation scale: Assessing a proposed cognitive component of social anxiety. Journal of Anxiety Disorders, 22(1), 44–55. https://doi.org/10.1016/j.janxdis.2007.08.002.
Weeks, J. W., Menatti, A. R., & Howell, A. N. (2015). Psychometric evaluation of the concerns of social reprisal scale: Further explicating the roots of fear of positive evaluation. Journal of Anxiety Disorders, 36, 33–43. https://doi.org/10.1016/j.janxdis.2015.06.008.
Weinstock, L. S. (1999). Gender differences in the presentation and management of social anxiety disorder. The Journal of Clinical Psychiatry, 60(Suppl 9), 9–13
Wong, S. S. (2008). The relations of cognitive triad, dysfunctional attitudes, automatic thoughts, and irrational beliefs with test anxiety. Current Psychology, 27, 177–191
Wong, D. F. K., & Sun, S. Y. K. (2006). A preliminary study of the efficacy of group CBT for people with social anxiety in Hong Kong. Hong Kong Journal of Psychiatry, 16, 50–56
Acknowledgments
The author would like to thank all the individuals who participated in this research, Mr. Toby Knowles for his support, Mr. Stephan Moller for had administrative and editorial assistance, and Dr. Kenley Kuoch for his review and feedback of the final manuscript.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Ethical Approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Consent to Participate
Informed consent was obtained from all individual participants included in the study.
Consent to Publish
Informed consent to publish the study findings was obtained from all individual participants included in the study.
Conflict of Interest
Author is an: invited speaker at IBD-related conferences co-organised by Crohn’s & Colitis Australia (a charity); Invited speaker at Coeliac-related conferences co-organised by Coeliac Australia (a charity); Member of the Medical Advisory Committee for Glutagen Pty Ltd.; Received consultancy fees from AbbVie Pty Ltd.; Received consultancy fees from Janssen-Cilag Pty Ltd.
Provenance and Peer Review
Not commissioned, externally peer reviewed.
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Knowles, S.R. Socio-cognitive processes are associated with parcopresis symptoms and public toilet avoidance in university students. Curr Psychol 42, 1762–1772 (2023). https://doi.org/10.1007/s12144-021-01586-x
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12144-021-01586-x