While anxiety is a normal emotion experienced at some time by virtually all humans, 'pathological' anxiety, excessive or inappropriate to the situation, may appear in the form of an anxiety disorder. The distinction between normal and 'pathological' anxiety needs to be established for each. Normal anxiety has a protective function in threatening situations and may enhance motivation to resolve the threat. On the other hand, pathological anxiety serves no useful purpose and is associated with an inability to function at a satisfactory level. It has been estimated that perhaps as many as 10% of the population may experience an anxiety disorder.
An association between hypnotic susceptibility and several anxiety disorders has been suggested. Frankel (1976) first presented evidence that phobic patients show greater hypnotic susceptibility than other patient groups and that a disproportionate number of his 24 phobic patients were in the highly hypnotizable range, when assessed using standardized assessments of susceptibility. There is some additional evidence supporting this observation (Frankel & Orne, 1976; Gerschman, Burrows, Reade & Foenander, 1979; Foenander, Burrows, Gerschman & Horne, 1980; Frischolz, Spiegel et al. 1982; Robney, Hollander & Campbell, 1983; John, Hollander & Perry, 1983; Kelly, 1984) but two studies, using different assessment techniques, have failed to find greater hypnotic susceptibility in phobic patients (Gerschman, Burrows & Reade, 1987; Owens, Bliss, Koester & Jeppsen, 1989). Frankel (1974) has also speculated that the heightened hypnotic susceptibility may be implicated aetiologically in the development and maintenance of phobic conditions.
Management of the anxiety disorders may include psychotherapy, pharmacotherapy or both. The primary goals of psychological and hypnotically based therapies for the treatment of anxiety disorders are: the exposure of the patient (via imagery or reality) to the situation provoking the anxiety (thereby allowing deconditioning, habituation or desensitization); cognitive re-evaluations of the situation to alter the perception of threat; determining the personal significance (symbolic) of the stress or anxiety provocation; increasing the sense of self-efficacy in the patient's ability to deal with the stress-eliciting situation and the stress or anxiety symptoms; and the rehearsal of coping strategies. Despite the applicability and efficacy of hypnosis-based behavioral, cognitive and other psychotherapy interventions, there is a need to understand patient differences and to individualize treatment interventions (Jackson & Stanley, 1987). There is a need to bear this in mind when deciding on clinical interventions appropriate for individual patients. Insight-oriented psychotherapy attempts to assist the patient in finding, understanding and thereby changing the cause of the anxiety. In this approach anxiety is assumed to be symbolic of some other issue, which the patient is not facing or is not aware of. In contemporary therapy, insight-oriented therapy approach is less common, as cognitive-behavioral psychotherapies have demonstrated their effectiveness, particularly in treating anxiety disorders. The principal components of cognitive-behavioral therapy are applied differently in the different anxiety disorders.
With appropriate training the majority of patients can learn control of their anxiety response. This leaves them free to focus on problem-solving, or unlearning the connection between the anxiety and the anxiety-provoking situation. The anxiety-management techniques can have either or both of two purposes, the lowering of average—that is basal—anxiety levels, or the control of the acute anxiety response in the anxiety-provoking situation. Meditation, yoga and the many other forms of meditation can be of great assistance, particularly in lowering the average or basal levels of anxiety and arousal. These techniques may be of less use in treating situational anxieties.
There are numerous other approaches to training patients in the control of anxiety responses. All require the patient to practise the skill being acquired for a significant time, in order to have the degree of control over the anxiety necessary to deal with the anxiety disorder. The use of relaxation techniques to assist patients in learning to control their anxiety responses has a long history. Jacobson (1929) first introduced Progressive Relaxation which involved the patient learning discrimination of the muscle tension and control over it via a process of systematically tensing and relaxing the muscle groups of the body. An alternative, briefer and effective approach to training patients in anxiety control was introduced by Benson (1975).
Hypnosis, and in particular self-hypnosis, plays a very useful part in the treatment of anxiety disorders. Principally hypnosis is used to train the patient in cued rapid relaxation to be applied in the anxiety-provoking situation, as well as assisting in changes in perception about the nature of the perceived threat and the patient's confidence in their ability to cope with that situation. A detailed review of the various uses of hypnosis appears in Stanley, Judd & Burrows (1990), Stanley (1994), and Stanley, Norman & Burrows (1999).
When patients use self-hypnotic arousal reduction and relaxation it adds to their confidence in coping and their sense of self-control. They are able to influence what they previously thought unalterable. This shifts their locus of control beliefs and increases their sense of self-efficacy.
Cognitive therapy is based on the belief that it is the interpretation of the situation as threatening that is involved in the maintenance of the anxiety disorder (Beck & Emery, 1985). A three-stage schema-based information-processing model of anxiety has been proposed (Beck & Clark, 1997). Anxiety may result from the symptoms of the anxiety being interpreted as threatening, as in panic disorder.
Threat may be attributed to an animal, germs or blood, as in a specific phobia and some obsessive-compulsive disorders. The perceived threat may result from some aspect of a particular situation, as in social phobia, agoraphobia, or from reminders of past traumatic events, as in post-traumatic stress disorders. The cognitive approach has the patient challenge the beliefs about threat through helping the patient to examine the irrational thought processes and self-statements.
As a form of persuasive communication, hypnotically based treatments offer a powerful addition to the cognitive-behavioral strategies. The suspension of critical thinking in the hypnotic state may make the patient more susceptible to accepting the persuasive communications of cognitive-behavioral therapy.
Clients, who typically make critical and negative comments towards therapeutic communications, are essentially required by the hypnotic context to listen to persuasive messages from the therapist, in a way that they may not ordinarily do so; this process of attending and listening, without commenting, may make the clients more accessible to the content of the therapist's message. (McConkey, 1984, p. 80)
Additionally, alterations in cognitive processes may help patients accept alternative interpretations of events, their significance, their own coping abilities, and the expected outcome.
When anxiety is situation-specific, exposure-based treatments take a prominent role in cognitive-behavioral treatment. While the patient manages the anxiety by techniques detailed above, therapist-guided, or more commonly patient-guided stepwise exposure to the situation, is the basis of unlearning of the anxiety response. While there is no evidence that the exposure-based treatments need to be carried out in stepwise fashion, the gradual exposure of the stepwise approach maintains patients in treatment and prevents the therapy experience itself becoming traumatic.
Many psychotherapies use imagery and fantasy to facilitate the process of change. For some patients hypnotically assisted therapies may result in them being able to respond to imagery and fantasy as reality. Specifically, hypnosis may enhance a variety of interventions applied to the treatment of anxiety.
(i) Systematic desensitization remains one of the most common treatments for specific phobic disorders. Lang (1979) showed that patients who benefit from systematic desensitization have a greater ability to generate emotional responses to the imagined items from a hierarchy. The more realistic the experience of the imagined situation, the more likely are such responses to be generated. Hypnosis offers an adjunct to desensitization that is potentially extremely powerful, since the attribution of realism to imagined events is a characteristic of the hypnotic state.
(ii) The effectiveness of coping rehearsal may similarly be aided by the reality attributions effected through hypnosis. With the increased realism of fantasy rehearsal, and the uncritical acceptance of the implied message that this will occur, patients' expectations and motivations to expose themselves to the anxiety-provoking situation may be heightened. In the absence of self-defeating thoughts that maintain anxiety (Beck & Emery, 1985) successful coping may become a viable outcome.
Patients with anxiety disorders frequently become over-absorbed in their anxiety. Their anxiety responses result in thoughts concerning the danger posed by the symptoms and their inability to cope. Dissociation from the symptoms via hypnosis can provide an adaptive and useful method of reducing this reactivity to the anxiety-producing situation and to the symptoms that may follow.
The anxiety disorders have been variously subdivided. One widely accepted classification, the Diagnostic and Statistical Manual of Mental Disorders (4th edition) (American Psychiatric Association, 1994), subdivides the anxiety disorders into panic disorders with/without agoraphobia, social phobia, simple phobia, generalized anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder. Management may include pharmacotherapy and/or a wide variety of psychological treatments.
The cardinal clinical characteristic of panic disorder is the rapid onset of anxiety symptoms, without apparent or clearly defined precipitating events.
With panic disorder the three priorities are firstly, the teaching of skills to lower average or basic anxiety level and to give specific control of the acute anxiety episodes. Often this may involve the relaxation techniques or self-hypnosis. Additionally, appropriate breathing techniques may be used to control the physiological signs of the panic disorder. The second component of the treatment of panic disorder involves realistic patient education and techniques of patient self-talk about the nature of their symptoms, as signs of the panic disorder rather than signs of threat to the patient's life, survival or well-being. That is, they are something unpleasant to be managed rather than something to be panicked about. Fears of embarrassment are dealt with in the same way that they would be dealt with in social phobia. The third component of treatment involves therapist-guided graded exposure to the situation the patient is most afraid of, be that situations that trigger the panic attacks, social situations where the fear may focus on what others will think, but more commonly the anxiety symptoms themselves. Exposure to the symptoms may be brought about through the patient hyperventilating on instruction, and then managing the symptoms by means of the relaxation technique or breathing techniques previously taught to them.
Suggested strategies for dealing with the frequently present agoraphobic symptoms are detailed below. With sufficient practice, self-hypnosis techniques may assist in reducing the panic state and gaining control over symptoms. Rapid reduction in anxiety, and dissociation from fears of the panic state, may be used to truncate the secondary anxiety response (anticipatory anxiety) about having a panic attack.
Additionally hypnosis may be used with panic disorder patients to reinforce their belief that they can deal with intense anxiety states. Such improved self-efficacy (Frankel, 1974) and a shift to an internal locus of control may come about via hypnotic demonstrations of control (behavioral control) or through attitudinal shifts toward confidence in coping (cognitive control) encouraged by persuasive communications of exploring the precipitants of panic states, should any exist.
As avoidance and escape from anxiety are the key features of agoraphobia, whether with panic disorder or without, the priority is therapist-guided graded exposure to the situation the patient is anxious about. The patient, in a step-by-step way, approaches the situations that trigger anxiety and which they have been avoiding. Exposure to the anxiety symptoms themselves is also of importance, especially where panic disorder is involved with the agoraphobia. The acquisition of anxiety-management skills, while not essential, is helpful in facilitating the graded exposure and making treatment less threatening, by establishing specific control over acute anxiety. The anxiety-management skills may involve the patient in regular practice of either relaxation techniques or self-hypnosis, with or without imagery-based rehearsal of exposure to the anxiety-producing situations. Alternatively, breathing techniques may be taught to assist in the control of the physiological signs, if the agoraphobia is a secondary development of panic disorder. The third component of the treatment of agoraphobia involves the patient in realistic self-talk about the nature of their anxiety, the absence of real threat, and their acceptance of the anxiety symptoms as unpleasant experiences to be faced and coped with, not run away from.
Hypnotic interventions may assist the treatment of agoraphobia by re-establishing a sense of security and coping through a supportive therapist relationship, enhanced by hypnosis, establishing a sense of 'control' over physical symptoms and cognitive anxiety, thereby permitting exposure and changing self-efficacy perceptions, imaginal rehearsal of coping as a prelude to in vivo exposure, enhancing motivation and determination through the exploration of what freedom from the symptoms means to lifestyle ('Doing what they have always wanted to do'), changing general self-image, and enhancing dissociation from the anxiety and self- or symptoms focus (a healthy dissociative mechanism).
Social phobias present in a variety of forms with different aetiological implications: fears of public speaking, fainting, losing control of bladder or bowels, vomiting, or embarrassing oneself by inappropriate action or speech. Jackson & Stanley (1987) noted the variety of aetiological explanations which have been offered to account for social phobias, ranging from inadequately developed social skills to fears of incurring the displeasure or rejection of others and catastrophic assumptions concerning the outcome of such displeasure, and even to a general intolerance of discomfort. In addition, some cases of social phobia may occur as a secondary complication of panic disorder (Liebowitz, 1987).
With social phobias the main feature to be addressed is the patient's fear of the evaluation of others in the social situation. Their cognitive processes result in them turning embarrassments into disasters and their normal preference for the approval of others into almost a requirement for their survival. Cognitive therapy actively encourages them to explore and challenge their beliefs that the situation is any more than embarrassing. The three-stage schema-based cognitive model of anxiety proposed by Beck & Clark (1997) is a useful starting point for conceptualizing social phobias. The cognitive approach has the patient challenge the beliefs about threat through helping the patient to examine the irrational thought processes and self-statements, particularly in the social situation. Homework-based exposure to the feared social situations is mandatory in the treatment of the socially phobic. Exaggerated confronting of social anxiety by 'shame-attacking exercises' may also greatly assist the socially phobic patient if they can be encouraged to do them.
Apart from general anxiety reduction, hypnotic techniques may be applied to establish a sense of self-worth and self-esteem. For example, cognitive restructuring within the hypnotic state may sensitize patients to their positive characteristics and successes, while emphasizing that projected disasters do not occur, and that those problems which do can be coped with. Additionally, through the use of rapidly induced self-hypnosis, patients may develop control over bodily processes where they fear loss of control (Jackson & Stanley, 1987). Dissociation into a tranquil and relaxed state on a cue specific to social situations may be achieved, as may realistic coping through fantasy rehearsal.
With specific phobias, systematic desensitization, in vivo or in imagination, remains the mainstay of treatment. Treatment by exposure in reality is more effective than imagery-based treatment, but imagery-based treatments are of considerable importance where the situation of which the patient is fearful cannot easily be produced (e.g. storms, earthquakes, injury, etc.). The therapist guides and encourages the patient through graded exposure to the phobic stimuli or situation. It is an advantage if the patient understands the ways in which phobias are acquired and the process of deconditioning. Phobic anxiety is learned as a result of one of four processes: traumatic experiences of the phobic situation (classical conditioning); observing role models acting with fear (observational learning); informational learning coming about through either a lack of reality-based information about the situation or being encouraged to believe the situation is threatening (cognitive learning); or the consequences of accidental anxiety reduction on leaving a situation, resulting in threat and anxiety being attributed to the situation (operant learning). This new insight results in the patient recognizing the phobic response as an adaptive anxiety response inappropriately attached to the phobic situation, and assists the patient not only in understanding the process of unlearning, but also in ceasing self-blame or criticism. While the graded exposure is not vital to unlearning phobic responses the approach is more acceptable to the patient and assists in their therapy commitment. Group support and treatment of a variety of phobias with a group of phobic patients also assists in normalizing the process of the acquisition and unlearning of specific phobias. The acquisition of the anxiety-management skills based on either relaxation techniques or self-hypnosis, and with or without imagery-based rehearsal of exposure to the anxiety-producing situations, while not essential, may facilitate the in vivo graded exposure.
Specific phobias, whether single or multiple in nature, may respond well to hypnotic interventions. As observed by Frankel (1974), phobic patients tend to be more hypnotizable than other patients or the general population. As well as facilitating imaginal desensitization via enhancement of the imagined stimuli and coping strategies (covert modelling), hypnotic techniques may be used to produce cognitive changes concerning feared situations. Enhancement of the sense of self-control, increased self-confidence and a reinterpretation of the phobic circumstances may also be achieved (Liebowitz, 1987). In addition, therapeutic dissociation from the fear-inducing situation may be developed via hypnosis to facilitate the exposure component of therapeutic interventions. This approach controls patients' tendency to become absorbed in their symptoms, a tendency which may accelerate their phobia response. The hypnotic technique of age regression may assist in exploring the symbolism of the feared object/situation, or in uncovering trauma where this is aetiologically involved (Clarke & Jackson, 1983).
With post-traumatic stress disorder two issues require resolution. The first issue is dealing with the memories and affect of the traumatic experience. The patient with post-traumatic stress disorder attempts to avoid the memories and affect and may voluntarily or involuntarily use full or partial dissociation, as a coping mechanism. The dissociated affects and/or memories are then responded to as though they are reoccurring when they intrude into consciousness. As well there is often a continuous level of anxiety associated with the impending intrusion into consciousness of the affects and memories. Hypnotic techniques and eye movement desensitization are used in dealing with this dissociative partial coping, with cognitive restructuring of the thoughts of the trauma being a primary goal (Spiegel, Hunt & Dondershine, 1988; Shapiro, 1989).
Secondly, the avoidance of stimuli associated with the traumatic events needs to be dealt with as a form of phobic avoidance with progressive exposure. Systematic desensitization, in vivo or in imagination, remains an important part of treatment. Treatment by exposure in reality is more effective than imagery-based treatment, but imagery-based treatments are of considerable importance where the traumatic associations cannot easily be produced. The therapist guides and encourages the patient through the graded exposure to the traumatic stimuli or situation. The acquisition of anxiety-management skills based on either relaxation techniques or self-hypnosis, and with or without imagery-based rehearsal of exposure to the anxiety-producing situations, while not essential, may facilitate the in vivo graded exposure.
Brett & Ostroff (1985) have argued that images play a central role in the maintenance of post-traumatic stress disorder. Stutman & Bliss (1985) noted that, amongst Vietnam veterans, victims of this disorder demonstrated higher hypnotic susceptibility and imagery vividness than those without the disorder. Kingsbury (1988) detailed the application of hypnosis to the treatment of post-traumatic stress disorder, including cognitive reframing of events, dissociation to distance the sufferer from the event and alterations of memories of the events. Similar applications of hypnosis to achieve both abreactive reactions and cognitive restructuring are often the treatment of choice (MacHovec, 1985).
The psychoanalytically oriented use of hypnosis in post-traumatic stress disorder has been described (Peebles, 1989). The use of age-regression and abreactive techniques permits therapeutic changes to occur.
With generalized anxiety disorder there are two specific goals of treatment; firstly the lowering of the average level of anxiety and secondly the changes in thoughts, perceptions and attitudes that reactivate the anxiety response. With appropriate training the majority of patients can learn to control their basal level of anxiety. There are numerous approaches to training patients in the control of anxiety responses. All require the patient to practise the skill being acquired for a significant time in order to have sufficient control over the anxiety necessary to deal with the anxiety disorder. The use of relaxation techniques to assist patients in learning to control their anxiety responses has a long history. Apart from the relaxation techniques commonly used (Jacobson, 1929; Benson, 1975), hypnosis and in particular self-hypnosis, play a useful part in the treatment of generalized anxiety disorder (Stanley & Burrows, 1998).
Generalized anxiety may be reduced through the use of frequent brief self-hypnosis to decrease physiological arousal and to alter the absorption in anxiety symptoms. Through enhancement of a sense of self-control with hypnosis and cognitive restructuring, those with generalized anxiety can be assisted. Combined with age regression, cognitive restructuring may be useful in re-establishing a sense of 'safety in one's own company'.
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