Report Author Paul Howard
Report Date: 28 June 2025
Table of Contents
Overview
This interim report presents findings from a randomly selected sample of 100 patients presenting with toilet-related anxiety disorders at The Surrey Institute of Clinical Hypnotherapy. All patients identified toilet anxiety as their primary presenting issue. The sample reflects a demographically representative subset of the wider clinical population and includes individuals presenting with anxiety related to urination, defaecation, or both.
Toilet anxiety, as defined by The Surrey Institute of Clinical Hypnotherapy, refers to a persistent fear or preoccupation with the availability, proximity, or access to toilets, typically accompanied by behavioural safety mechanisms and anticipatory anxiety. Crucially, toilet anxiety is not synonymous with toilet phobia (which involves active avoidance of toilets themselves), nor is it necessarily linked to medically diagnosed gastrointestinal or urological disorders. Rather, it constitutes a functional anxiety disorder maintained by maladaptive cognitive-behavioural and affective processes.
Important Notice: This report is intended solely for medical professionals. It is designed to share emerging clinical data and assist in the understanding and treatment of toilet anxiety. It should not be shared with individuals experiencing toilet anxiety themselves, as certain elements, particularly those relating to Functional Neurological Disorder (FND), may exacerbate anxiety or reinforce maladaptive beliefs. Inappropriate exposure to clinical framing or diagnostic language can be unhelpful, especially for patients who are sensitive to suggestion or whose symptoms include features of functional somatic syndromes.
The role of FND in toilet anxiety presentation is an area of growing clinical interest. Many patients show symptom profiles consistent with functional dysregulation of the brain-body axis, including heightened interoceptive sensitivity, altered motor inhibition, and maladaptive expectancy conditioning. In such cases, symptoms may persist not because of actual physiological necessity but due to a disruption in how the brain interprets and responds to bodily signals. This perspective aligns with contemporary understandings of FND and supports the need for treatment approaches that target neural patterning and subconscious belief structures, rather than focusing exclusively on conscious coping strategies.
Demographic Profile and Symptom Duration
- 61.00% of patients were female
- Mean age at presentation: 38.90 years
- Mean reported symptom duration: 16.05 years prior to receiving effective treatment
These data suggest that toilet anxiety is a chronic and often undiagnosed condition, with patients frequently enduring symptoms for over a decade before appropriate intervention. The age distribution further suggests that this disorder spans across adult developmental stages, and is not confined to early adulthood or adolescence.
Clinical Typology
Patients were categorised based on symptom focus:
- Type 1: Urination-related anxiety
- Type 2: Defaecation-related anxiety
- Type B: Combined urination and defaecation anxiety
A combined 77.27% of cases involved either Type 2 or Type B presentations, indicating a significant prevalence of defaecation-related fears. This subtype is frequently associated with higher levels of shame, disgust sensitivity, and anticipatory distress. Such patients often present with more rigid safety behaviours and heightened emotional reactivity.
Treatment History and Therapeutic Outcomes
- 65.25% of patients had previously accessed treatment modalities including CBT, psychotherapy, pharmacotherapy, or self-directed interventions
- Mean number of clinical hypnotherapy sessions required to achieve either resolution or functional remission: approximately 5.79 sessions
This substantial discrepancy between symptom duration and speed of therapeutic response highlights a key clinical implication: traditional interventions may fail to address the subconscious drivers of toilet anxiety. Hypnotherapeutic interventions appear to facilitate relatively rapid improvement by directly targeting maladaptive schemas and somatic stress conditioning.
Behavioural and Cognitive Phenotypes
High-prevalence patterns observed across the cohort include:
- 100.00% reported compulsive pre-emptive voiding behaviours
- 90.32% engaged in environmental toileting research (“toilet mapping”)
- 87.09% practiced fluid or dietary restriction
- 86.20% engaged in avoidance of social or logistical situations with uncertain toilet access
- 86.15% reported the ability to delay micturition or defaecation, indicating the absence of true urgency
- 80.00% used distraction techniques to mitigate anticipatory anxiety
These behaviours reflect a complex constellation of compulsive safety strategies that functionally reinforce the conditioned fear response. They represent a learned behavioural repertoire developed in response to perceived threat, maintained via negative reinforcement and cognitive bias.
Cognitive Distortions and Near Misses
A notable clinical feature is the centrality of “near miss” experiences in the development and perpetuation of toilet anxiety. These are episodes in which individuals feel they narrowly avoided a toileting accident. While common in the general population, individuals with toilet anxiety disproportionately encode such events with heightened emotional salience.
Although 75.38% of patients report never having experienced an actual adult toileting accident, they frequently replay near misses with catastrophic interpretation. Internal dialogues often include counterfactual ruminations such as, “What if this had happened in public?” or “What if I hadn’t made it?” These cognitions sustain the disorder in the absence of objective threat, consistent with theoretical models of cognitive-affective maintenance in anxiety disorders.
Comorbidities and Organic Diagnoses
- 15.87% of patients presented with a medical diagnosis such as Irritable Bowel Syndrome (IBS) or other functional urological/gastrointestinal disorders
This finding suggests that the majority of toilet anxiety cases are not driven by organic dysfunction. While medical comorbidity can compound symptom burden, the core psychopathology is more accurately characterised as a functional anxiety condition requiring psychological, not biomedical, intervention.
Clinical Conclusions
The data support several core clinical assertions:
- Toilet anxiety is a chronic, under-recognised anxiety disorder with significant functional impairment
- Subtypes involving defaecation are especially prevalent and debilitating
- Patients often develop complex behavioural adaptations that reinforce anticipatory anxiety
- Most patients do not have a history of toileting accidents, underscoring the role of imagined rather than actual threat
- Hypnotherapy, particularly when targeting subconscious belief structures and behavioural reinforcement cycles, offers rapid and sustainable symptom improvement
Implications for Practice
Toilet anxiety remains a poorly understood and under-discussed clinical issue. Its presentation can mimic features of IBS, agoraphobia, and social anxiety, but its distinct maintenance mechanisms require specific therapeutic strategies. Importantly, interventions must move beyond reassurance and conscious reframing, and instead target the deeper associative patterns and conditioned responses that underpin the disorder.
Specialised toilet anxiety treatment at The Surrey Institute of Clinical Hypnotherapy focuses on restructuring maladaptive cognitive-emotional frameworks, normalising bodily trust, and reducing compulsive safety behaviours. As this research progresses, we anticipate further refinement of typologies and treatment protocols, contributing to improved outcomes for this neglected patient population.
Paul Howard is the founder and Clinical Director of The Surrey Institute of Clinical Hypnotherapy, where he has worked with anxiety disorders for over 25 years. He holds a special interest in the treatment of toilet anxiety, having helped thousands of patients globally to overcome this complex and often misunderstood condition. His approach integrates clinical hypnotherapy with a deep understanding of functional anxiety presentations, and he continues to lead research and training in this field.
Further updates will follow upon completion of longitudinal outcome data and larger sample integration.