PARCOPRESIS

Using the restroom is considered one of the twelve basic activities of daily living. For most people, going to the restroom to defecate is a normal activity that occurs without hinderance or concern. However, for individuals with parcopresis defecating in public restrooms is distressing and anxiety provoking. This page will discuss the bowel anxiety condition known as parcopresis (shy bowel syndrome).

WHAT IS PARCOPRESIS?

Parcopresis (also known as shy bowel syndrome) is a psychological condition characterised by a difficulty or inability to defecate (e.g., in a public restroom) due to an overwhelming fear of perceived scrutiny. Parcopresis typically occurs in busy public restrooms (e.g., within shopping centres and sporting stadiums). However, in severe cases parcopresis can occur in private restrooms such as within one’s own home. The prevalence and age of onset of parcopresis is currently unknown due to lack of research on this condition. However, given that parcopresis shares similar features to paruresis (for more information on paruresis, click here), it is possible that parcopresis occurs in adolescence.

WHAT ARE THE SYMPTOMS OF PARCOPRESIS?

Individuals with parcopresis experience a variety of symptoms ranging from physical to psychological. People afflicted with parcopresis experience anxiety around defecating and use of restrooms. The severity of symptoms tends to worsen when in public situations (e.g., in a crowded restroom), where parcopresis sufferers perceive that they are being judged or criticised by others within the restroom.

Symptoms of parcopresis range in severity and can include:

A noticeable difficulty or inability to defecate in public restrooms. In severe cases, parcopresis sufferers will be unable to defecate when family and/or friends are present in the home.
Avoidance behaviours such as avoiding using public restrooms.
Only using public restrooms that are secluded and offer greater privacy.
Avoiding or limiting travel/use of public transport to decrease the need to use a restroom in public.
Avoiding social activities (e.g., dating, going to sporting events, parties) that may require the use of a public restroom.
Safety behaviours such as avoiding certain foods (e.g., spicy food) to reduce the likelihood of using restrooms in public.
Anxiety related physical symptoms such as excessive sweating, a racing heartbeat, nausea, muscle tension, trembling, and blushing.

Individuals with parcopresis tend to experience greater symptoms when there are more people present and in close proximity (e.g., a busy public bathroom with a queue of people waiting in line). Anxiety levels may also depend on the privacy of the restroom, whereby parcopresis sufferers may only be able to defecate if the restroom is completely empty. Some individuals even report difficulty using the restroom in their own home, especially if they have guests over.

The difficulties associated with parcopresis can have a significant impact on quality of life. Not only do sufferers notice that it impacts on their social activity, but it also has consequences for their work. Anxiety regarding restroom use can influence the type of work environment that an individual is comfortable in and may affect whether they are willing to travel for work (e.g., airplane travel). Parcopresis can also cause considerable embarrassment and shame among sufferers, with most individuals not seeking assessment or treatment.

MODELS AND CAUSES OF PARCOPRESIS

Current research on parcopresis has identified that it shares similar features with social anxiety disorder. Like social anxiety disorder, individuals with parcopresis experience fear of being negatively evaluated by people around them (e.g., being negatively judged by other restroom occupants for the smell of my stool), and use avoidance behaviours (e.g., avoiding using restrooms in public) to reduce feelings of anxiety and distress.

Recently, Kuoch, Meyer, Austin, and Knowles (2019) conducted a study where they applied the extended bivalent fear of evaluation model of social anxiety (for more information about this model, click here) to parcopresis symptoms. Their model identified that socio-cognitive processes such as fear of negative and positive evaluation, along with dysfunctional attitudes and concerns of social reprisals contributed to parcopresis symptoms (see below for diagram and summary of factors predicting parcopresis symptoms).

Dysfunctional attitudes: Pervasive negative attitudes that are held towards oneself, the outside world, and the future (e.g., people will probably think less of me if I make a mistake.)

Fear of negative evaluation: Distress from being unfavourably evaluated by others (e.g., I am afraid that people will criticise me for taking too long to defecate).

Fear of positive evaluation: Distress from being favourably evaluated by others (e.g., I generally feel uncomfortable when people give me compliments).

Concerns of social reprisals: Fear of being evaluated too positively by others, and the resulting reprisal that may ensue (e.g., I do everything I can to avoid envy from others who “out-rank” me, even in casual social situations).

The extended bivalent fear of evaluation model of parcopresis

Kuoch, K. L. J., Meyer, D., Austin, D.W., & Knowles, S.R. (2019). Socio-cognitive processes associated with paruresis and parcopresis symptoms: A proposed bivalent model.
Current Psychology

Causes of parcopresis

Regarding potential causes of parcopresis, traumatic or stressful events related to restroom use have been argued to be contributing influences. For instance, individuals with parcopresis may have experienced traumatic or stressful events in public restrooms during childhood or adolescence, such as being bullied or teased. After this traumatic experience, the individual may become stressed and nervous about using public restrooms which then leads to further anxiety and difficulties surrounding defecation.

DIAGNOSIS OF PARCOPRESIS

In the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; a manual used by mental health professionals to diagnose mental disorders), validated diagnostic criteria for parcopresis has yet to be published. As a result, parcopresis is currently diagnosed by excluding possible medical reasons and confirming that symptoms are due to a psychological cause.

If you are experiencing problems defecating, it is a good idea to see a General Practitioner (GP) to rule out potential medical issues. Your treating doctor may conduct a series of examinations to screen for physical abnormalities. It is essential that a medical examination is conducted as faecal retention symptoms can be a sign of physical illness (e.g., obstruction within the gastrointestinal tract leading to defecatory difficulties).

Examination may include collection of a thorough medical history, physical examination, and use of appropriate diagnostic and investigative assessments (see below for further details).

Physical examination: During a physical examination, your doctor will press against your abdomen to feel for signs of abnormalities.

Blood test: A blood test may be ordered to help identify signs of infection that may causing symptoms. It can also be used to examine inflammation markers.

Radiological investigation: Your doctor may refer you for gastrointestinal imaging (e.g., x-ray, ultrasonography, barium enema, magnetic resonance imaging, computed tomography) to check for obstructions in the gastrointestinal system.

Colonoscopy or Sigmoidoscopy: A colonoscopy and sigmoidoscopy involves inserting a cystoscope (a small, flexible telescope with a camera) through the anus to examine the inside lining of the bowel. This examination will allow the doctor check for physical abnormalities within the large intestine, and sigmoid colon respectively (e.g., scar tissue or tumours causing obstruction).

Neurological investigation: Your doctor may refer you to neurological investigation (e.g., electromyography) to identify whether faecal retention symptoms are due to neurological dysfunction.

TREATMENT OF PARCOPRESIS

Psychological treatments

Once potential medical causes have been eliminated, the treating doctor can arrange for a referral for psychological treatment. There is a paucity of research into psychological treatments for parcopresis. However, Cognitive Behavioural Therapy is likely to be beneficial in treating parcopresis due to its efficacy intreating social anxiety disorder. Some of the most common treatment approaches for parcopresis are listed below:

Cognitive Behavioural Therapy

Cognitive Behavioural Therapy (CBT) offers the most consistent evidence for the reduction of social anxiety. Given the presence of anxiety-related symptoms in parcopresis and previous use of CBT to treat parcopresis, CBT is one of the most accepted treatment options. CBT is a short-term focused approach to changing unhelpful thoughts, habits, and behaviours, and replacing them with healthier ones.

Graduated Exposure Therapy

Graduated exposure therapy is a common treatment for anxiety conditions and involves individuals being gradually exposed to their feared object or situation within a safe context. Exposure to the feared stimulus is gradual, so that the individual gradually confronts their fear until they no longer experience distress to their feared object situation. Given the effectiveness of graduated exposure therapy in social anxiety disorder and paruresis, it may be a feasible intervention for parcopresis.

Relaxation training

Relaxation training involves learning techniques that increases calmness and relaxation and decrease feelings of anxiety and stress. Several relaxation techniques are available, with some of the most popular including deep breathing, mindfulness meditation, progressive muscle relaxation, tai chi, yoga, and other forms of exercise.

Other potential psychological approaches to treating parcopresis

Mindfulness-Based Stress Reduction (MBSR)

Mindfulness-based stress reduction is an eight-week program that involves intensive mindfulness (directing attention to experiences occurring in the present moment) training. This program was developed to support individuals experiencing anxiety, depression, stress, chronic pain, and stress related to medical conditions. Mindfulness-based stress reduction assists individuals to become aware of stressful or unpleasant feelings and stress reactions they may be experiencing. It allows individuals with anxiety, depression, or other afflictions to recognise their feelings in the current moment and enables them to react in a positive way.

Acceptance and Commitment Therapy (ACT)

Acceptance and commitment therapy is a psychological treatment program that uses acceptance (the process of recognising and accepting negative or uncomfortable situations without trying to change them) and mindfulness (focusing ones attention to experiences that are occurring within the present moment) strategies, with behaviour-change and commitment strategies. The aim of acceptance and commitment therapy is to recognise, understand, and accept challenging feelings and situations as opposed to actively trying to eliminate or change them. Acceptance and commitment therapy allow individuals to open-up to unpleasant feelings they may be experiencing, learn to not avoid situations or circumstances that may elicit these feelings, and to learn not to overreact to them.

Medical treatments

Medical health professionals (e.g., General Practitioners) may prescribe an anxiolytic (anti-anxiety medication) to help treat the anxiety symptoms related to parcopresis. The use of anxiolytic medication alongside psychological therapy is best discussed with your treating doctor (see below for further information).

Selective serotonin reuptake inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are a type of medication prescribed to address anxiety symptoms. SSRIs work by reducing the reabsorption of serotonin by nerve cells, which in turn leads to increased levels of serotonin within the brain. Serotonin is a naturally occurring neurotransmitter/chemical within the brain that is involved in the regulation of a variety of functions such as mood. In anxiety disorders, serotonin is in a state of imbalance. Through the stabilisation of serotonin levels, SSRIs may assist in decreasing anxiety symptoms associated with parcopresis. Your treating doctor may prescribe SSRIs under a variety of names such as paroxetine, fluoxetine, escitalopram, citalopram, and sertraline.

SUMMARY OF PARCOPRESIS

Parcopresis is a psychological condition characterised by a difficulty or inability to defecate due to overwhelming fear of perceived scrutiny. Parcopresis typically occurs in busy public restrooms but can occur in private restrooms in severe cases. The prevalence of parcopresis is currently unknown due to the lack of research on this condition. Parcopresis is classified as a form of social anxiety disorder as both conditions share similar features. The most recent model of parcopresis argues that psychological processes such as fear of negative and positive evaluation, along with dysfunctional attitudes and concerns of social reprisals contribute to parcopresis symptoms. Individuals with suspected parcopresis should be examined by a medical doctor to ensure that their symptoms are not due to a medical cause. A range of psychological and medical treatments are available for individuals with parcopresis.