by Gérard V. Sunnen, M.D.
"Anxiety and anxiety-related conditions are the most common psychological afflictions of man and account for a major percentage of initial complaints to psychiatrists as well as to general practitioners. Although it is estimated that some 5% of the population may suffer from acute or chronic anxiety, with women outnumbering men two to one (Cohen and White, 1950), the numbers are probably significantly higher.
As a symptom, anxiety is a final common pathway for many conditions, physical as well as psychological. As syndromes, anxiety disorders are under intensive study to define more precisely their etiologies and clinical outcomes. Recent studies, showing disturbances of lactate metabolism in certain anxious individuals, point to the possibility that some anxiety states, like some depressive states, have strong biological and genetic determinants.
Hypnosis finds its most common clinical utilization in the treatment of anxiety and its related states, not only because of anxiety's prevalence, but because hypnosis has such a clear role as a potent anti-anxiety agent. In this chapter, we will examine hypnotic behavioral approaches to anxiety, while hypnopsychotherapeutic approaches will be discussed in Chapter 14.
EVALUATION OF ANXIETY
The first task of the hypnotherapist is to evaluate the anxiety condition. At the end of the initial interview, several questions must be asked. Is the anxiety organically determined? Is there a medical, physiological, or otherwise somatic basis for its existence? The list of medical conditions which, as a by-product, contain anxiety is long: hypertension, cardiac arrhythmias, anemia, hypoglycemia, withdrawal from sedative hypnotics (including alcohol), and caffeinism, cocaine, and psychostimulant abuse, among others. Anxiety is also sometimes confused with medical conditions which, in their presentation, share its expressions. Coronary artery disease, with chest pain, respiratory distress, and cardiac symptoms can mimic anxiety states; so can hyperthyroidism, pheochromocytomas and Meniere's disease. The treatment, while not obviating adjunctive psychotherapeutic or hypnotherapeutic intervention, will of course be mainly aimed at treating the primary medical condition.
Is the anxiety an aggravating component of a chronic medical syndrome? Most psychosomatic conditions are intimately connected to anxiety and stress. Flare-ups of such diseases as peptic ulcer, ulcerative colitis, or hypertension produce anxiety. Conversely, difficulties with psychosocial adjustment bring exacerbations in these conditions. Anxiety control is important to ease the interactive play of psyche and soma.
Is the anxiety a part of another psychiatric syndrome? Anxiety weaves into most psychiatric syndromes. Major depression is rarely seen without it, and so is mania. Schizophrenia, especially in the decompensation phase, as the individual experiences ego fragmentation, can be marked by fright--as can organic brain syndromes with their cognitive disruptions. Treatment of anxiety in these conditions is centered on correcting the global psychiatric syndrome.
When medical conditions and major psychiatric syndromes are eliminated as reasons for anxiety, we are left with more functional causes. It is useful, in our therapeutic approach, to see patients' experiences of anxiety as falling into three general categories: (1) individuals reporting chronic, free-floating feelings of fear (generalized anxiety disorder); (2) individuals manifesting discreet episodes of panic, but who, in between attacks, are relatively anxiety free (panic disorders); and (3) mixed syndromes.
There are other syndromes which contain anxiety as a core experiential manifestation.
Phobias are differentiated by the fact that they happen in the context of identifiable situations. They are marked by anxiety and avoidance. Thus agoraphobia is manifested in environments where the individual feels trapped and unable to return to safety, ie, common places include elevators, subways, planes, tunnels and bridges. Social phobias appear in interpersonal situations; and simple phobias are persistent, irrational fears of specific objects or animals. Phobias may be mildly bothersome or severely incapacitating. There are individuals who stay imprisoned in their homes because they fear the anxiety they may experience if they venture outside.
Posttraumatic stress disorders, acute or chronic, have generalized anxiety as a major component of a constellation of somatic and psychological disturbances following an accident, a loss, or any other disaster.
Obsessive compulsive disorders are characterized by tension stemming from the conscious emergence of thoughts, desires, and wishes to perform certain actions, and attempts to deny, ignore, undo, or suppress them. When severe, the anxiety becomes generalized, chronic, and incapacitating.
Adjustment disorders represent maladaptive responses to identifiable psychological stressors. Predominant symptoms in adjustment disorders with anxious mood, are nervousness, worry, and jitteriness.
HYPNOTIC TREATMENT OF SYNDROMES MANIFESTING GENERALIZED ANXIETY
Generalized anxiety disorder (DSM-III, 300.02) is characterized by pervasive, persistent anxiety, manifested by motor tension--strained facies, fidgeting, restlessness, fatigueability; autonomic hyperactivity-sweating, palpitations, light-headedness, paresthesias, upset stomach, lump in the throat, high resting pulse and respiratory rate; apprehensive expectation--worry, rumination, anticipation of misfortune to self or others; hyperattentiveness resulting in distractibility, difficulty in concentrating, insomnia, irritability, and impatience. To meet diagnostic criteria, the anxious mood has to have lasted at least a month.
Approaches to chronic generalized anxiety, which may incorporate hypnotic intervention, may be roughly grouped into analytic or behavioral types. Hypnoanalytic methods will be explored in a later chapter. Behavioral techniques do not necessarily exclude the importance of psychodynamic factors but rather, as in the case of anxiety, treat them as incidental to the illness itself, ie, anxiety is not a reflection of an underlying disorder, it is the illness; as a learned maladaptive response it needs to be unlearned. In this model, anxiety, once removed, is not replaced by other symptoms. In clinical practice, however, it is observed that some symptoms occur in a learned maladaptive model, others in a conflict-generated model, and the rest as admixtures of the two. Hypnosis may be woven into most behavioral techniques. In this way, the therapeutic potential of both disciplines may act additively, if not synergistically.
The following methods can be applied to the treatment of the generalized anxiety syndrome.
Hypnotically Induced Relaxation
While neutral hypnosis already assumes generalized relaxation, special hypnotic procedures can allow for its amplification.
The therapist will want to know the anxiety's signature in his particular patient. Where is the anxiety in the body? With what words can it best be described? Does it restrict breathing, speaking clearly, thought, motor performance, or coordination? These notions are important because, during the course of relaxation training, the therapist may choose wording and imagery accordingly. The subject who feels, for example, a burning sensation in the abdomen as an anxiety equivalent, may be asked to imagine sensations of coolness to counteract it; to someone whose anxiety comes out as tightness in the neck muscles, sensations of warmth in these areas may be suggested.
It may be explained to the patient before the induction that relaxation is both a physical and a mental state. It is pointed out that the body, in relaxation, feels slowed down and reluctant to move, the visceral spaces are experienced as comfortably rested, and breathing and heart rate attain natural baseline rhythms. Psychologically, the mind progressively feels detached from concerns, worries, and current stressful emotions.
Asking the subject, "What would you feel like if you were totally and deeply relaxed?" is a useful avenue to explore. In addition to misconceptions in need of modification, the responses may point to useful avenues for tailoring the hypnotic process to powerful preconceived notions.
Knowing that the purpose of hypnotherapy for our patient is relaxation training, the induction is geared to maximizing it. Suggestions are given for feelings which regularly accompany relaxation, ie, restful heaviness of the body. Similarities are drawn to states of mind the subject is already familiar with, which in themselves contain relaxed feelings, ie, daydreaming, reveries, or sleep. At the end of the induction, when the subject has already achieved significant tension reduction, appropriate deepening procedures are used.
The therapist should have at his disposal several procedures for the amplification of relaxation. Some may turn out to be much more effective than others; however, since there is no reliable way to predict beforehand which deepening technique will be most efficient, a trial-and-error approach often has to be attempted. The following techniques are commonly used to dissolve anxiety in the context of the hypnotic trance.
Direct suggestion. Direct suggestions for generalized relaxation in the subject who achieves a light to medium trance is often sufficient to attain desired results. Suggestions for total body relaxation, for letting go of tensions, physical and mental, are most effective when rhythmically timed with respiration.
In the same way that anxiety is experienced differently by each individual, so is relaxation. It is important, at the end of the first session, to ask how relaxation manifested itself. If, for example, feelings of floating or drifting were elicited, these same feelings can be directly searched for, brought forth, and expanded in the following sessions for faster induction and further deepening.
Counting method.Some individuals respond best to a counting technique. Many variations of this technique exist. It is explained, for example, that as slow counting progresses from 1 to 20, relaxation will become more and more profound, 20 representing the deepest level of relaxation the subject can attain during the session.
Counting with imagery. Counting may be combined with imagery. For example: "As I count from 1 to 20, you can see yourself walking down 20 steps into the garden of your subconscious mind. In your garden, you will find wonderful feelings of total relaxation flowing throughout your body."
Progressive relaxation. Some subjects are most responsive to a stepwise and methodical method. Individual muscle groups are focused on, starting from the lower extremities or from the head and neck, until all muscle groups are relaxed.
Autogenic training. The production of relaxation in many individuals is facilitated by suggestions or feelings of heaviness and sensations of warmth in the body (see autogenic training, below).
Pure imagery. Imagery techniques for relaxation are the most idiosyncratic of all methods. While, for example, the image of a beach may be attractively soothing for one person, it may leave another indifferent. Preliminary discussions will give the hypnotherapist some idea of what constitutes positive imagery for his patient. During hypnosis, the art of giving imagery suggestions resides in good part on the utilization of multiple sensory modalities--in a beach image, for example, a more engrossing effect can be created by talking about the sights, sounds, smells, and sensations one is likely to experience in such a setting.
Use of touch Touch, properly used and timed, is a powerful focusing modality for the patient. In the same way that touch may be used to induce analgesia in parts of the body, it may also be applied to suggest deep feelings of relaxation. For example: "As I touch your shoulder, your entire arm becomes deeply relaxed, all the way down to your fingertips. I'll touch your other shoulder and now your forehead; as I do, feelings of deep relaxation begin to drift throughout your body."
Autogenic Training
Autogenic training is a method of psychophysiological selfeducation containing elements of both hypnosis and meditation. The first of many editions of Autogenic Training appeared in 1932. Its author, J.H. Schultz, a German psychiatrist and neurologist, was influenced by research on sleep and hypnosis performed by Oskar Voght at the Berlin Institute some 30 years before. Voght observed that some subjects could produce in themselves states of mind similar or identical to hypnosis by performing certain exercises; and that these self-induced states had therapeutic value--subjects reported improvements in well-being, disappearance of headaches, lowering of anxiety level, and reduction of fatigue and tension. Voght called these exercise "prophylactic rest--autohypnosis."
Schultz streamlined the exercises. He found that most deeply hypnotized subjects invariably experienced sensations of heaviness and warmth in various parts of their bodies and postulated that the creation of these sensations, in a reverse psychophysiological process, could bring about the experience of the trance state.
A series of exercises was designed, in a format of increasing difficulty, and their practice gathered many followers throughout the world. The first of these are physiologically oriented, focusing on the neuromuscular and visceral systems. Subjects are asked, in exercises of introspective creative imagination, to produce sensations of heaviness and pleasant warmth in the limbs--it is easiest initially to produce them in these areas--then in the chest and the abdominal regions. Once mastered, usually after six to 12 months of training, subjects graduate to meditative exercises, which focus on the development of certain higher mental functions.
Preliminary instructions are for the use of a quiet dimly illuminated room, free of disturbances. The subject, in loose clothing, may adopt a fully reclined, semireclined, or a simple sitting posture.
First stage--eyes are gently closed. A gentle bodily introspection eliminates obvious internal muscular tension. The sensations of heaviness of the dominant arm, as it lies on its support, is brought to awareness. Some people find it helpful to repeat silently "my arm feels heavier and heavier." When heaviness is experienced throughout the arm, the same feeling is extended into the other arm through, as Schultz described, a process of generalization; the legs come next, the back, and the regions of the head and neck. When the whole body is experienced as being heavy, the second stage is attempted.
Second stage--warmth. For most people, feelings of heaviness are more easily conjured than those of warmth. The same process used to create feelings of heaviness is applied to feelings of warmth, first starting on one extremity, then progressing to the whole body, except for the forehead and temples which are imbued with sensations of coolness. Autosuggestions may help, ie, "my arm feels warmer, pleasantly warm," and imagery may be used, "my body feels like it is resting on the warm sands of the beach."
Third stage--regularization of cardiac rhythm and respiration. The object of this stage is not to seek control of cardiac rhythm, as is the aim of some yoga exercises, but to effect a slowdown and regularity of heart function which is congruent with total relaxation. Deep hypnotic and meditative states are accompanied by lowered metabolic work, decreased oxygen consumption, a slow (50 to 60 beats per minute) heart rate, and slower, more abdominal respiration. In the practice of the third stage, awareness is centered on the internal sensations of cardiac pulsations--a hand may be placed over the precordium--and self-instructions are given to help these desired results.
Fourth stage--centering on the upper abdominal region. Borrowing from ancient meditative exercises, the subject, having mastered the previous steps, is guided to center a relaxed attentiveness on the upper abdominal regions.
Reported effects of autogenic training. Effects of autogenic training are subjective as well as objective. Veteran practitioners talk about a generalized sense of well-being, feelings of energy and stamina, and relative freedom from symptoms commonly associated with stress. Objectively, during autogenically induced states as in meditative states, there is evidence of autonomic and metabolic slowdown.
Jacobson's Method Of Relaxation
While Schultz elaborated his method in Berlin, Germany, Jacobson in the United States worked towards similar goals but through different routes. His method is based on observations that the mere thought of a muscular action brings on electromyographic changes. This, he pointed out, bespeaks of a direct relationship between muscular tonus and psychological tension. For the purpose of achieving relaxation at cortical levels, Jacobson developed a methodical technique involving the progressive relaxation of all muscular groups in the body. Jacobson's method, for proper execution, requires a minimum of six months of training.
Methodology. Starting from the tip of one extremity--the right hand, for example--the individual is guided to move his awareness to the wrist, the forearm, in deliberate succession, to cover eventually the totality of the musculature. To help in focusing awareness and to enhance the experience of relaxation, each muscle group is sometimes tensed, then relaxed.
Hypnosis may be used with Jacobson's or modified Jacobson's techniques to stimulate progress. Conversely, and much more frequently practiced, are modified Jacobson techniques used in the context of the hypnotic trance to achieve progressively deeper states of relaxation.
RELATIONSHIP OF HYPNOSIS TO MEDITATION, SELF-HYPNOSIS, AND NEUTRAL HYPNOSIS
In describing the subjective experience of the hypnotic trance, mention was made of alterations in the sense of time flow and of sensations of relative removal from the bonds of the external reality situation. Usually, there is less or no perceived need to move physically, attention is withdrawn from concerns with bodily motion and balance, and there is less or no need to interact socially. Yet, in hypnosis the individual still feels a presence and has awareness of the rapport with another person--that being the hypnotist. In hypnosis, the elements of this relationship are intertwined with the experience of the trance. In hypnosis, part of the patient's psyche is linked to the hypnotist's psyche, in a process of dynamic communication. The hypnotist may communicate with one part of the subject's self, then with another, but there is always a bridge. In the subjective experience of the subject, he or she is not "free." Although the hypnotist may be very permissive, very choice-giving, the confines of the relationship remain.
Self hypnosis brings more autonomy. The link of rapport is broken and a more conscious part of the psyche gives suggestions to another more unconscious part. Usually, self-instructions are fairly specific and invite or reinforce personal change.
Sometimes the individual enters a hypnotic state and does not give himself or herself specific suggestions or directions. This is called neutral hypnosis, a state marked by relaxation, free-floating imagery, and dream fragments or sequences. In neutral hypnosis, the sense of control floats, undirected. The subject may observe and remember or not observe and not remember. It is an unstructured trance state.
If we add one ingredient to this trance state, we have meditation. That ingredient is directed watchfulness.
The meditative trance is similar in quality to the self-hypnotic trance. In meditation, however, the individual starts out with no overt trance-inducing signal, but rather, the resolve to begin, and focuses the observing ego on a part of the body (eg, the solar plexus), a sound (mantra), a symbolic image (mandala), a spiritual feeling, or a universal idea.
Indications for meditative training. Although, like most therapies, meditative training has been claimed to relieve many somatic and psychological disorders, its clearest and best documented indication is in the treatment of generalized anxiety."
SUGGESTED READING AND REFERENCES
Benson H: The Relaxation Response. New York, Avon Books, 1975. Brosse T: A psychophysiological study of yoga. Main Currents in Modern Thought July 1946:77-84.
Cohen ME, White PD: Life situations, emotions, and neurocirculatory asthenia. Assoc Res Nerv Dis Proc 1950;29:832.
Deikman A: Experimental meditation, in Tart C(ed): Altered States of Consciousness. New York, Doubleday, 1972, pp 203-223,
Diagnostic and Statistical Manual of Mental Disorders, ed 3. American Psychiatric Association, 1980.
Goldfried M, Davidson GE: Clinical Behavior Therapy. New York, Holt, Rhinehart & Winston, 1976.
Jacobson E: Progressive Relaxation. Chicago, University of Chicago Press, 1938.
Luder M: Behavior and anxiety: Physiologic mechanisms. J Clin Psychiatry 1983;44(11, Sec 2): 5-10.
Langen D: Autogenic training and psychosomatic medicine, in Burrows G, Dennerstein L (eds): Handbook of Hypnosis and Psychosomatic Medicine. Amsterdam, Elsevier/North Holland Biomedical Press, 1980.
Morse DR, Morton S, Furst ML, et al: A physiological and subjective evaluation of meditation, hypnosis, and relaxation. Psychosomat Med 1977;39:304-324.
Orne MT, Paskewitz DA: Aversive situational effects on alpha feedback training. Science 1974;186:458.
Schultz JH, Luthe W: Autogenic Training. A Psychophysiologic Approach in Psychotherapy. New York, Grune and Stratton, 1959.
Seyle H: The Stress of Life, ed 2. New York, McGraw-Hill, 1976.
Schuchit M: Anxiety related to medical disease. J Clin Psychiatry 1983;44(11, Sec 2):31-36.
Voght 0: Zur Kenntnis des Wesens und der pscyhologischen Bedeutung des Hypnotismus. Zeitschift fur Hypnotismus 1894-95:3,227;1896:4,32,122,229.
Wallace R: Physiological effects of transcendental meditation. Science 1970;167:1751-1754.
Walsh R: Meditation practice and research. J Hum Psychol 1983;23(l):18-50.
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