Q: What kinds of treatment are available?

A: The following treatment methods have all been shown to have some effectiveness in treating avoidant paruresis (AP). We define “shown” as meaning that people with paruresis who have tried these techniques have reported benefit. The current state of research does not yet include a true double-blind clinical trial for any method below. The chances of success for any method will depend on a number of factors, both known and unknown, and there may be risks associated with each approach.

1. Cognitive-Behavioral Therapy (CBT)

Method: A process of work with a psychotherapist that includes graduated-exposure therapy, where a person is gradually introduced to the feared situation and over time becomes more comfortable (“desensitized”) to the fear. Work also involves examining the person’s thought processes and learning to counter irrational thinking with more healthy patterns of thought.

Benefits: The process can be short-term, usually six to ten office visits followed by a period of independent work and one or two follow-up visits.  This method can produce permanent changes in behavior that do not require long-term use of medication for many individuals. With a competent therapist and a dedicated patient it can be very successful.

Risks/Shortcomings: Cost of treatment, approximately $125 per session. The relationship between patient and doctor is crucial to success, so a person may need to switch therapists if the method is not working out. Mental health therapy can have an impact on a person’s insurability, so a person needs to look at the risks in their particular situation. Paying cash for treatment is one way to prevent an impact on one’s medical record from undergoing psychotherapy. CBT may not provide complete relief from symptoms; some patients may need additional sessions or other kinds of treatment to achieve the level of anxiety reduction required for long-term recovery.

2. Support Groups

Method: Regular participation in a group of people with paruresis to practice graduated exposure exercises, provide support and encouragement, and discuss the person’s experiences and thoughts during the recovery process.

Benefits: Support groups are usually free. The process can produce permanent changes in behavior that do not require long-term use of medication. It is a valuable adjunct to people undergoing medication and/or CBT because group participation happens outside a doctor’s office in a real-life setting, and serves as a way of increasing the frequency and intensity of work on graduated exposure practice. Supportive partnerships develop in a well-run group that can aid in addressing setbacks and other problems that may crop up in the recovery process.  Groups also provide the benefit of working with people who have personal experience in recovering.

Risks/Shortcomings: There are differences in support groups, so the quality and atmosphere is not guaranteed or controlled. The size of the group, frequency of meetings, and relationships between participants will vary from group to group. Because of these risks, using a support group as the only method of working on recovery may not work out unless it happens to be an excellent group.  Because there is no professional assistance, a support group is unlikely to address other psychological issues that may accompany paruresis.

3. Medication

Method: Use of prescription drugs under a doctor’s supervision that reduce anxiety and depression allowing a person to develop more healthy thinking patterns over time. Medication is usually combined with a program of CBT and/or support group work. The preferred class of drugs prescribed for social anxiety is the Selective Serotonin Reuptake Inhibitor, or SSRI, because it provides benefits with the fewest risks. Other drugs that have been proven clinically effective to reduce social anxiety may be effective for paruresis treatment depending on your particular situation. Monoamine Oxidase (MAO) inhibitors are a class of drugs that has high effectiveness for social anxiety, but carries greater risks and strict dietary restrictions. There are several other classes of antidepressants that are sometimes used to treat anxiety and social phobia. It is best to seek assistance from a psychiatrist (M.D. or D. O. degree with appropriate advanced training and board certification). Note, a psychologist (typically someone with a Ph.D. or Psy. D. degree) cannot prescribe medicine. 

There are also large number of medicines known as minor tranquilizers that may be used to treat anxiety and social phobia. Some, but not all, are controlled substances because they may over time cause a physical dependence on the medicine. Usually, though, it is fairly easy to gradually reduce the dose if your doctor agrees that you should no longer take the medicine.

Other drugs, notably D-cycloserine and gabapentin, are being investigated for possible treatment but are prescribed “off-label.”  A licensed physician may prescribe medicines to treat a condition as s/he thinks appropriate. Many if not most medicines are routinely prescribed for “off-label” treatment.

Benefits: These medications can make the difference between success and failure in recovery for some people. Medication can improve the ability of a person to make lasting changes in personality that reduce or eliminate the need for medication after a period of about a year. General reductions in anxiety with medication use may transfer to other situations and improve a person’s overall functioning and well being.

Risks/Shortcomings: Cost may be substantial since medications are a long-term prospect. There may be dependency issues to work out when stopping the medication or changing to a different one. Insurance is often used to reduce cost, but a history of psychiatric care might result in stigmatization in employment or insurability. We urge young people to get the treatment they need, but to be especially aware of these potential difficulties. Those in stable careers and older individuals don’t usually need to be too concerned about stigmatization. If your medical history includes a use of anxiety medications you run the risk of being uninsurable if you apply in the future for individual coverage instead of a group coverage policy from an employer. Paying cash for medical care and medications is a way to reduce this risk if a person can afford it. IPA believes that medication alone is not an effective treatment for paruresis, it must be combined with CBT and/or support group work. 

Many medications have side effects that a person will need to deal with. Several classes of antidepressant medications tend to have sexual side effects, weight gain, dry mouth, and effects on digestion. Recent research is revealing that genetic differences can reduce or eliminate the effectiveness of SSRIs in some people.[ii] So if a medication or class of medications isn’t working, changing to a different one may be needed.

There is now a required FDA warning for many SSRIs regarding increased suicide risk for young people. Adults may have some suicide risk, but it appears to be greatly reduced and possibly nonexistent. Any thoughts of suicide, especially if they are coupled with some intent to actually do it, are a medical crisis. Go to an emergency room or to your personal physician immediately.  Anyone on a medication program needs to be monitored for changes in personality that could be dangerous, but such changes are rare and unlikely for most people.

While many report they can reduce or eliminate the medication after a period of time, some patients have entered a cycle of increased dosages, multiple medications, and/or changes in medications that has decreased their quality of life. Each person needs to be aware of these risks and work closely with a trusted doctor to manage them properly and prevent problems.

The three main approaches outlined above can be combined together to increase a person’s chance of success.  The decision to do this will depend on a person’s situation, and it is best to consult a treatment professional on which options to combine. At different stages in treatment, different options may be appropriate.  For instance, at the early stages when anxiety levels can be quite high and difficult to control medication may be appropriate, but as a person makes progress, support group participation may be a better option because it reduces reliance on a drug and increases emphasis on changing one’s thinking through the process of helping others and accepting others’ help.

IPA workshops are a short-term form of treatment that address cognitive-behavioral approaches of graduated exposure therapy, and introduce a person to an environment they will experience in a support group. A workshop is a good place to begin a treatment program, but one or more of the three approaches above are critical to adopt on a long-term basis for a person with paruresis to make a full recovery.

A very few people have reported benefits from “alternative” forms of treatment such as hypnosis, meditation, herbal remedies such as Kava or St. John’s Wort, etc. IPA does not endorse these methods as being effective for most people. If a person wants to experiment with alternative forms of treatment, we recommend that the exploration be conducted under the guidance of a treatment professional.  Generally, alternative forms of treatment may have a greater benefit when pursued in combination with the more traditional approaches above. We are not aware of cases where they alone produced a complete recovery.

Some people have learned to practice Clean Intermittent Self-Catheterization (CIC) as a means of coping with paruresis in difficult situations. While using a catheter is not a method of treating paruresis, it does provide a measure of security, help the person lead a more normal life, and be able to give a urine sample for mandatory drug testing if there is no alternative test available. A sympathetic urologist can instruct you on how to do this procedure. More information can be found at IPA’s Catheters page. Catheter use is a survival technique, not a recovery technique. Everyone recovering from AP needs to know when to practice survival and when to be working on recovery. Both are valuable skills, but the latter is the only way to reduce the need for practicing survival.