Phobiaand Post-Traumatic Stress Disorder
Definition of Phobia
Marked and persistent fear that is excessive and unreasonable, and is often recognized by the patient as such.
(not always so in children)
Anxiety disorder
Learned
Simple (very rare)
Complex (social phobia, agoraphobia): meaning: feel bad about self
Features:
Highly “hypnotisable”
Consistent: anxiety is circumstantial (trigger), and oftenanticipatory
Arousal (CASE)
Avoidance
Hypervigilance
Disturbance of function
Not part of another disorder
>6/12
Rationale for using hypnosis
Based on assumptions:
The phobia is a learned response to an earlier perceived threat that can be resolved by re-exposure in controlled circumstances
Hypnosis provides a safe environment for imaginal exposure to the feared trigger/stimulus
Intervention can resolve the hypnotically reproduced fear
Resolution can be then transferred to the original trigger in vivo
Techniques
Preparation work
Psycho-education
Explanation
Permission
Resourcing
Set-uphypnosis ( yourstate, rapport, space, concordance,
compliance)
Direct symptom control
Anchors for relaxation.
Abdominal respiration
Self-control techniques:
Breathing
Self-talk
Special Place
Correcting attentional biases
Attention-switching strategies :
Normalisation of attention (vshypervigilance),
Distraction
Amnesia
Imagery (in vitro to replace in vivo:
covert (=imaginal) modeling
covert reinforcement)
Paradoxical injunction anchors for relaxation, analgesia, anaesthesia
Ego-strengthening
Ego-shrinking
Future rehearsal
Post–hypnotic suggestion.
Correcting interpretive biases
Cognitive restructuring. Help patient gain a more rational and realistic appraisal of their situation, thus reducing the perceived threat.
Explanation
Reframing
Imaginal rehearsal and cognitive restructuring
Systematic Desensitization
Flooding
Modelling
Psycho-dynamic issues
Regression techniques (e.g. Alden’s Bubble, Affect Bridge) can be helpful in addressing traumatic memories.
If the patient’s symptomatology includes a description of a feeling of emptiness inside, and simple outcome-based approaches have not helped, an exploration of psychodynamic issues and their resolution may often produce the shift required to help them move on. This emptiness echoes Freud’s primitive wound; often the result of a failure of secure attachment relationships in childhood.
Group work
Mutual support: good with phobias
Good evidence base for use of hypnosis with agoraphobia, social phobia, driving needles, hospitals, vomiting, dentist.
On the spot
Dissociative Strategies
Useful for “procedures”
Anticipatory anxiety and related phobic responses can be dealt with in advance with the techniques above.
When the patient is about to undergo the procedure, some patients find it helpful to separate themselves from the site of, for example, an injection at the point at which the insertion of the needle takes place.
“That arm no longer belongs to me”.
Invite the patient to go to their special place and leave their arm behind, mouth behind etc. for the clinician to work on while they are away.
An alternative is to use hypnosis to create an area of anaesthesia.
These techniques do not have much impact on the phobia, and do not reduce the avoidance behaviours and anticipatory anxiety, but are helpful when the patient has reached the point of being able to commit to the procedure.
Conscious/Unconscious Split
It is important that any exposure-based intervention carried out for an anxiety disorder keeps the patient in contact with the feared or anxiety-provoking situation and does not serve simply as another form of escape or avoidance. There is a risk of this when using “special place” as it may remove the patient from reality-testing. This can be avoided by using anchors to achieve the relaxation response.
A useful strategy is to suggest the patient engage in an unconscious/conscious split. Suggest that the wide-awake, front, conscious part of their mind remains completely in touch with the current, anxiety–provoking experience, while the deeper (or ‘back’ or ‘unconscious’) part of their mind, the part that ‘controls all the things they do automatically without thinking, such as controlling breathing, tension in their muscles, their heart rate etc. etc.’ can ‘take some time out’ (or whatever phrase you prefer) to go to their Special Place and find calm, relaxed and comfortable feelings.
Suggest their anchors can enable them to access the deeper parts of their mind to assist in this process, and that they can use the breathing pattern they use for their self-hypnosis to deepen the relaxation that part of their mind is experiencing.
Use an anxiety scale (SUD) to take self-reports throughout the procedure to calibrate, monitor and identify when an appropriate point to proceed has been reached.
Once the scale is calibrated do not use the word “anxious” or similar anymore. Say “What is the number (for how that feels) now?”
Reinforce the process by saying something along the lines of: “as the deeper part of your mind finds the relaxed and calm feelings the alert part can be even more focused and efficient at dealing with the situation you find yourself in, especially now that it is no longer distracted by the unwanted feelings’.
Specific situations
Scanner
safe place
hallucinateprotective,pleasant bubble: dimensions acceptable to the patient.
Lack of control: Mental rehearsal of success
Phlebotomy (hypotension)
Clenchedfist
Complex phobias
cognitive component : patient has attached (negative) meaning to experience: feel bad about self.
Performance anxiety an example
Approach: as above
Preparation/resourcing
Learning: ?“Causal event”. Trigger desensitisation
Plus: ego-strengthening
self-confidence
Address wider psycho-social issues
Ego-shrinking: dissassociaton, noticing no-one taking any notice
Outline of Method
Preparation, explanation
Permission
Induction
Deepening
Anchors :Safe Place, calmness , relaxation, confidence , resources
Permissionrevisited: ideo-motor signals, calibration
Identify and dissociate from target
Resolve (what did they need to know? What did they need to learn)
Gratitude to protective part
Desensitise (Wolpe)
Distress reduces with repeated, increasingly challenging, imaginal exposure
Future rehearsal
Post-hypnotic suggestions
Parts integration (catatonic arm)
Reorientation
Post-Traumatic Stress Disorder
First described by Ancient Greeks
Pierre Janet (1839-1947) 5000 patient study of psychological impact of trauma
Traumatic memories have “all or nothing” character
Trauma is often decontextualized and mis-labeled in its historical context
Freud: (1856-1939) “This man is suffering from memories”
Features
History of serious traumatic event
Distressing flashbacks: visual, emotional, nightmares
Hyperarousal/hypervigilance/generalized anxiety disorder/insomnia
Numbing of emotions (dissociation)
Avoidance
Anger
Fear, forgetfulness, depression, alcohol/substance abuse
Significant functional disturbance (social, occupational etc.)
Duration:
>1/12 (<1/12: acute stress disorder, adjustment disorder)
Acute: <3/12
Chronic<3/12
Response:
CASE Cognitive, autonomic,somato-sensory, emotional
Reduced cortisol levels
Aetiology
75% traumatised people de-traumatise without intervention
Dream it out, talk it out, contextualise it
25% develop PTSD
EMLI
Traumatic event
Freud (1839-1947) “An experience which within a short period of time presents the mind with an increase of stimulus too powerful to be dealt with or worked off in the normal way”
Meaning
There is nothing either good or bad, but thinking makes it so. (Shakespeare)
Landscape
Co-existing psychiatric issues: anxiety, panic disorder, depression, increased hypnotisability (? cause?effect))
Inescapability
Perceived inescapability
3 factors particularly pre-dispose:
Anxious already
Significant trauma
More hypnotisable (phobias the same)
Pathology
Dysfunctional storage of memory
Trauma dissociates cognition from soma: the patient knows they are safe but do not feel it.
The body keeps the score. The Unconscious always wins.
Amygdala hyper-active (implicit (autonomic )memory) and dominates cortical activity.
Medial pre-frontal cortex (conscious awareness, explicit memory) smaller and less responsive, also reduced volume of hippocampus and reduced neuro-transmitter levels (memory storage)
Structural changes: post-traumatic stress injury
Patient selection: who needs help?
1.Can they talk about it?
Critical incident debriefing: getting people to talk about the trauma: 75% will recover anyway. For the 25% who get PTSD: talking about it re-activates it and embeds it deeper.
If victim debriefed in a state of high emotion, the process can increase the arousal to the point of overload, trapping the sensory impressions in the amygdala.
2. Does it still feel recent?
3.Do even nebulous reminders set off "flashbacks"?
i.e. Does even the vaguest reminder set off a huge panic response
Simpler: Doesthepatientexperiencerecurrent, suddenunpleasantimages, feelingsoremotions, oftnefornoapparentreason?
If so, tidyingupthedebrisfromsomepasttraumaoften
helps
Rationale for hypnosis
Modified complex phobia: address response to triggers: desensitize, reintegrate dissociated parts.
Dysfunctionalstorage of traumaticmemories:
psycho-dynamic, regressive techniques
What to do?
Targets
Past: dysfunctional storage of memory
Present: defence mechanisms, dissociation
Future: reintegration of dissociated parts of personality
Hypnotic Intervention
Preparation
Permission
Stabilisation and resourcing
Set up “Stop” sign
Special place
Self-hypnosis
Humour
Induction (beware of imagery techniques in induction if visual flashbacks)
Imagery techniques: for resourcing and for addressing flashbacks (alter sub-modalities), nightmares, anxiety, depression.
Anger: silent abreaction
Modify internal dialogue
Double-dissociation
Psycho-dynamic: regression: use a dissociation method, older, wiser self.
N.B. do not associate with a negative state.
Amnesia
Ego-strengthen
Ego-shrink
Future Pace
Post-hypnotic suggestions: relaxation, resilience, confidence, motivation, energy, drive, humour
Re-orientation
Excessive dissociation
CIPOS (Jim Knipe)
Constant installation of present orientation and safety.
Use of short-term memory (20 seconds) and dual attention
Back of head scale
Play catch, simple maths, phone number, walk around
Alsohelpful:
Psycho-sensory therapies:
Thought Field Therapy, Emotional Freedom Technique,
EMDR Eye Movement Desensitisation and Reprocessing)
Havening
Mindfulness
M.E.W.C. 19/2/2017
mctraining.org.uk
08968 046315
References
Bandler R.(2008)Richard Bandler’s Guide to Transformation Health Communication Inc P.193
Brann,Owens,and Williamson The Handbook of Contemporary Clinical Hypnosis 2012 Wiley-Blackwell
Crawford, H.J. & Barabasz, A.F. (1993) Phobias and intense fears: Facilitating their treatment with hypnosis. In Rhue, J.H., Lynn, S.J. & Kirsch, I. (eds) Handbook of Clinical Hypnosis, American Psychological Association, Washington, DC. Pp. 311-337.
Croyell et al (1982) Excessive mortality in panic disorder: comparison with primary unipolar depression. Archives of General Psychiatry 39 701-3
Derbyshire, S.W.G., Whalley, M.G., Stenger, V.A. & Oakley, D.A. (2004) Cerebral activation during hypnotically induced and imagined pain.NeuroImage, 23, 392-401.
De Silva, P., Rachman, S. & Seligman, M.E. P. (1977) Prepared phobias and obsessions: Therapeutic outcome. Behaviour Research and Therapy, 15, 65-77.
Eysenck M.W. (1997) Anxiety and Cognition: a unified theory. Psychology Press Hove
Gow, M.A. (2002) Treating dental needle phobia using hypnosis. Australian Journal of Clinical and Experimental Hypnosis, 30, 198-202. (Handout)
Heap and Avarind (2002) Hartland’s Medical and Dental Hypnosis (4th Edition) Churchill Livingstone
Knipe J. (2015) EMDR Toolbox Springer Ch 13 P.195 The CIPOS Procedure
Kraft, D.; Street, H. (2011)."The place of hypnosis in psychiatry Part 4: Its application to the treatment of agoraphobia and social phobia". Retrieved 4 February 2013.
Marks I.M. (1969) Fears and Phobias, Heinemann, London
Robins et al (1984) Lifetime prevalence of specific psychiatric disorder in three sites. Archives of General Psychiatry 41 949-58
Weissmann and Merikangas (1986) The epidemiology of anxiety and panic disorders. Journal of Clinical Psychiatry 47 (suppl.),11-17
Rogers, Janet (May 2008). "Hypnosis in the treatment of social phobia".Australian Journal of Clinical & Experimental Hypnosis36 (1): 64–68.
Schoenberger, Nancy E. (1996). "Cognitive-Behavioral Hypnotherapy for phobic anxiety".Casebook of clinical hypnosis429. Washington: American Psychological Association. pp.33–49. doi:10.1037/11090-002.
Hill, R.; Bannon-Ryder, G. (June 2005)."The use of hypnosis in the treatment of driving phobia".Contemporary Hypnosis22 (2): 99–103.
Waxman, D. (May 1978). "Hospital phobia: a rapid desensitization technique". Postgraduate Medical Journal54: 328–330.
Morse, D. R.; Cohen, B. B. (May/June 1983)."Desensitization using meditation-hypnosis to control "needle" phobia in two dental patients".AnesthProg.30 (3): 83–85.
Cyna, A.M.; Tomkins, D.; Maddock, T.; Barker, D. (August 2007). "Brief hypnosis for severe needle phobia using switch-wire imagery in a 5-year old=". Department of PaediatricAnaesthesia, Women's and Children's Hospital, Adelaide, SA, Australia.
Gow, M. A. (2006)."Hypnosis with a 31-year-old female with dental phobia requiring emergency extraction".Contemporary Hypnosis23 (2). pp.83–91.
Wijesnghe, B. (1974). "A vomiting phobia overcome by one session of flooding with hypnosis". Journal of behavioural therapy and experimental psychiatry5: 169–170.
Watson, J.P.; Marks (2). "Prolonged Exposure: A Rapid Treatment For Phobias". British Medical Journal. 5739 1 (1): 13–15. JSTOR25413031.
Ost, L. G., Sterner, U. & Fellinius, J. (1989) Applied tension, applied relaxation and the combination in the treatment of blood phobia. Behaviour Research and Therapy, 27, 109- 121.
Seligman, M.E.P., & Rosenhahn, D.L. (1998) Abnormality. Norton: New York.
Szechtman, H., Woody, E., Bowers, K.S. & Nahmias, C. (1998) Where the imaginal appears real: a positron emission tomography study of auditory hallucinations. Proceedings of the National Academy of Sciences of the USA, 95, 1956-1960
Walters, V.J. & Oakley, D.A. (2003) Does hypnosis make in vitro, in vivo?Hypnosis as a possible virtual reality context in cognitive behavioural therapy for an environmental phobia.Clinical Case Studies, 2, 295-305.
Watkins, J. G., and WatkinsH. H. (1997). Ego States: Theory and Therapy. New York: Norton.
Wolpe J. (1969) Basic principles and practice of behaviour therapy of neuroses.American Journal of Psychiatry.125, 1242-47.
John Grinder You Tube NLP Double Disassociation with John Grinder
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