First Name

Date

Shy Bladder Syndrome Questionnaire

First of all, thank you for your interest so far in this initiative. This series of questionnaires is part of a research project addressing possible underlying issues that may generate paruresis. It seeks to develop new thinking about the condition and so widen the range of treatment and intervention offered to those suffering from this condition. It is also an opportunity for you to self-assess your own situation. If you are interested in taking this work forward, I would be most grateful you would complete the four pages of statements. Feel free to add any personal stories of your own to support your answers. Would you like to be kept informed of the results of this research? Would you be happy if I contacted you further? No No Yes Yes email address _________________________

Please be assured that your answers will be kept confidential and that your responses cannot be identified beyond your first name. Thank you very much in advance for your active support. I hope you find it useful yourself just in the completion of it. Please post your completed copy to Fran Burgess Paruresis Research Station House Training Centre Station Road Whalley, Clitheroe BB7 9RT Regards Fran Burgess Fran Burgess has been a Psychotherapist specialising in the application of Neuro Linguistic Programming for ten years. She is a founding Director of The Northern School of NLP in Lancashire, and is on the Professional Standards Committee of NLPtCA, the UK based Neurolingistic Psychotherapy and Counselling Association. And she also has suffered with paruresis.

Shy Bladder Syndrome Research Project

Fran Burgess November 2007 fran@nlpand.co.uk

First Name Levels of Comfort

Date

Please complete this questionnaire as instinctively as possible. If in doubt score nearer to Never than Always. Your responses will be taken as your Starting Point and we will return to this profile a review points during/after any therapeutic intervention.
Occasionally Occasionally Frequently Always Rarely

Never

Someone

There is

Those nearby are

In my own home

In others homes when I am

is within earshot. can see me is beside me knows I am there sees me enter the loo knows that I have gone to the loo is running water or dryers is waiting for me is talking to me is likely to come in a queue conversation going on a lot of people and general activity strangers friends family members work colleagues of equal status work colleagues of lesser status work colleagues of higher status same sex opposite sex when Im alone family members are nearby family members are in the house non family members are nearby non family members are in the house the lavatory is away from living areas the lavatory is near to living areas the lavatory is beside living areas the lavatory is en suite in the open air under the influence of drugs or alcohol am distracted by a particular problem or situation outside of the peeing in a hurry

In public facilities which are located in a

Public conveniences store/ supermarket Motorway service station garage pub restaurant trains planes portoloos hospital Police station prison Communal living the Forces, In public It is a self contained WC on its own lavatories It is the Disabled persons loo when there are 2-6 cubicles 6-10 cubicles 1020 cubicles Over 20 cubicles the cubicles have no door are partially partitioned have walls from floor to ceiling have no gap under the door have fulty or non existent locks have messy and wet floors have and wet seats the urinals are a stainless steel trough are a porcelain trough have individual stalls have dividers between stalls there are 2-6 stalls 6-10 stalls 1020 stalls I would consider having a poo outside of my own home

Shy Bladder Syndrome Research Project

Fran Burgess November 2007 fran@nlpand.co.uk

Always

Rarely

Never

I am able to pee when

I am able to pee when

Frequently

First Name

Date

Background Information
1. 2. I am aware of being a problem when I was aged The effects on my Social activities Work choices Friendships Intimate relationships 3. less than 5 5-10 significant significant significant significant 10-15 considerable considerable considerable considerable 15-20 insignificant insignificant insignificant insignificant after 20 not at all not at all not at all not at all severe severe severe severe

Please include an extreme example of how this problem has affected your life.

4.

Its impact in my childhood was teens 20s 30s 40s 50s 60s

severe severe severe severe severe severe severe

significant significant significant significant significant significant significant

considerable considerable considerable considerable considerable considerable considerable

insignificant insignificant insignificant insignificant insignificant insignificant insignificant

not at all not at all not at all not at all not at all not at all not at all

5.

Please include significant events in your life which may have influenced the impact, positively (eg getting married) or negatively (eg bullying).

6. 7. 8. 9.

I have told I have consulted Generally those that know have been I have felt

no-one my GP supportive ashamed every time nil

only close friends a urinary Specialist understanding embarrassed 80% of the time 10-30% married Agree

specialists a therapist exasperated isolated 70% 40-60% divorced Disagree

been totally open a counsellor unbelieving guilty 60% 60-80% separated Please give details a self help group mocking fearful 50% 80-90% heterosexual 40% 100% homosexual bisexual 30%

10. I would like to be able to pee freely in public

11. My chances of fully overcoming this problem are 12. I am male female

single

13. Medically I have no physical problems with my urinary track.

Shy Bladder Syndrome Research Project

Fran Burgess November 2007 fran@nlpand.co.uk

First Name

Date

Your Level of Social Anxiety

Adapted from Overcoming Social Anxiety and Shyness : Dr Gillian Butler
Not applicable Strongly disagree Strongly disagree Strongly agree Strongly agree Agree Agree

Please record your response to these statements.

Please record your response to these statements.

1 I find it difficult to concentrate or remember what people say 2 I focus attention on myself, very aware of what I am saying. 3 I think about what might go wrong ahead of time 4 I dwell on things I think I did wrong, after the event. 5 My mind goes blank and I am unable to think what to say. 6 I speak quickly/quietly, mumble or get words mixed up. 7 I avoid catching anothers eye. 8 I do things to make sure that I do not attract attention. 9 I keep safe, by sticking to familiar places, people, topics. 10 I avoid difficult social occasions or situations. 11 I blush, sweat, tremble, stammer which others can notice. 12 I feel tense with aches and pains that go with feeling tense. 13 I have panicky feelings, palpitations, sweating, dizziness or nausea. 14 I feel frequently nervous, anxious, fearful or self conscious. 15 I feel frustration and anger, with myself and/or with others. 16 I feel unconfident and have feelings of inferiority. 17 I feel sad, depressed or hopeless about being able to change. 18 I am never the first to arrive if I can help it. 19 I find jobs to do in social situations. 20 I put off meeting people or crowded places. 21 I avoid talking to people I know, in shops or in the street. 22 I avoid talking about anything too personal. 23 I avoid using my hands when others might be watching. 24 I never eat in a public place on my own. 25 I never go to the cinema or theatre on my own. 26 I rehearse what I am going to say, checking my wording. Sub Total

27 I cover my face partially with my hair, my hands, makeup, glasses, facial hair. 28 I wear loose fitting clothes which hide parts of my body. 29 I tell lots of jokes, or never tell jokes. 30 I keep my opinions to myself. 31 I avoid saying anything challenging or controversial. 32 I keep an eye on the escape route, never getting fully involved. 33 I am most comfortable when my role is clear. 34 I assume others will judge me negatively. 35 I believe my shortcomings outweigh my good qualities. 36 I fear my performance will fall short of requirements. 37 People are likely to ignore or reject me. 38 People will quickly discover my shortcomings. 39 My anxiety is expressed in particular compulsive, unconscious behaviours. 40 I dread creating an embarrassing situation. 41 I imagine disasters happening when people are around. 42 I feel I am an odd one out. 43 I avoid any stressful social situation. 44 I endure stressful social situations. 45 I have strategies for reducing anticipated stress. 46 My distress interferes with my day to day life. 47 My distress affects only one or two aspects of my life. 48 My distress affects all aspects of my life. 49 I know my fears are unreasonable and unfounded. 50 People find my behaviours unacceptable. Sub Total Total

Shy Bladder Syndrome Research Project

Fran Burgess November 2007 fran@nlpand.co.uk

Not applicable

Disagree

Disagree

First Name

Date

Disagree

Strongly disagree

1 Members of my family frequently walked around naked. 2 The bathroom or loo door was usually kept open when in use. 3 It would be common to be on the loo and members of the family would come into the bathroom. 4 It would be common to be in the bath and a member of the family would come in to use the loo. 5 We were encouraged to use family names for urination and defecation. 6 Sounds and smells arising from going to the loo were taken as fact and not something to feel embarrassed or ashamed about. 7 Personal hygiene and cleanliness was an accepted natural practice. 8 My mother appeared comfortable about bodily functions. 9 My father appeared comfortable about bodily functions. 10 I have no shameful memories of potty training. 11 I have no strong associations of anxiety and bodily functions during my childhood 12 I have no strong recollection of being forced to pee at certain times. 13 I have no strong recollection of being made to pee in public, as a child. 14 I was never made to feel bad if I had an accident. 15 We were encouraged to believe that there was nothing shameful about our bodies. 16 I grew up feeling comfortable about my body. 17 I felt comfortable with my familys attitudes to bodies and bodily functions. 18 I profoundly believe that bodily functions are something acceptable. 19 As an adult, I fully accept that my body shape may not fit the body image portrayed in the media. 20 I dont fantasise about improvements in my shape and size. 21 I wouldnt seriously consider surgery to enhance any part of my body. 22 I have felt comfortable being undressed in communal changing rooms. 23 I have felt comfortable sunbathing in public view. 24 I find obesity/skinniness very unattractive, and something to be kept hidden. 25 Discussing bodily functions publicly is distasteful. Total Shy Bladder Syndrome Research Project

1 I have a strong need to be in control of my life and events in it. 2 I can only let go under the influence of drugs or alcohol. 3 I fear I will make a fool of myself with alcohol or drugs. 4 I fear I will be taken advantage of if I am not on guard. 5 I have been bullied. 6 I have bullied others. 7 I dislike and avoid critical feedback. 8 I dislike being teased about my failings. 9 I dont attain full sexual arousal and orgasm with a partner. 10 I dont attain full sexual arousal and orgasm with myself. 11 I have to double check what other people say they have done. 12 I find it hard to trust the intentions of 13 14 15 16 17 I find it hard to be a passenger in a 18 19 20 I dont trust myself to get things right. 21 Getting things wrong is something to be avoided at all cost. 22 I become concerned that I will be left on my own. 23 My shortcomings outweigh my good qualities. 24 Nobody else will look out for me, so I have to do it all the time. 25 I like being the one that makes the decisions. 26 I fear that others have the power to damage my life. 27 I frequently brace myself against the possibility of bad things happening. 28 I am quickly defensive of my behaviours. 29 I seek to blame others when things go wrong. 30 My own potential power alarms me. Total Fran Burgess November 2007 fran@nlpand.co.uk family members friends of same sex friends of opposite sex intimate partners work associates car plane boat

Strongly disagree

Strongly agree

Strongly agree

Agree

Agree

Please record your response to these statements. Leave blank any statement that is not applicable.

Please record your response to these statements. Leave blank any statement that is not applicable.

Disagree

First Name

Date

Shy Bladder Syndrome Research Project

Fran Burgess November 2007 fran@nlpand.co.uk