52

C H A p T E R

of disorder as well as those with a low education

. are the most common form of
tietY d ordersith a prevalence rate of 18% in and/or income (Kessler, et al., 2005; Kessler, iu,
}Jl"ral 15¡Uness, wand 15% in Europe (GBE, Demler, Merikangas, & Walters, 2005;
2004;
¡11e,, . d States Lep1.ne, 2002). A high leve!of comorbidity with
·•e vn1te d et al., 2005). In Germany, depresion (up to 60%) has been observed, and
· Berg un ' . d '
almost i Iessler, h the rapy pau ents are 1
d . many pat1nts also suffer from other Axis I
agnose w1 th
disorders (Hofme1¡er Sevink et al., 2012).
40% of_psyc/order (GBE, 2004 ). Sorne Symptoms can be described on different le
studies 30 al1X1 cy che "economic burden" of els. Anxious or phobic patients feel psychophysi
anxiety have esomat e worth more than € 74.40
billion per disorders co e (Gustavsson et al.,
2011). in Europ·fication th1' s menta1 d1'
year ological symptoms, such as sweating, palpitations,
of sorder
The c1as51 .
che followmg: tachycardia, hypertension, and muscle spasms,
includes which, in sorne cases, lead to fatigue or
lized anxiety disorder is characterized exhaus tion. In terms of cognition, they have
by ' Genera· cent and ongom. g fear and worry unrealis tic and dysfunctional thoughts about
.thout
w1a pers1 s d I J'f . the phobic
preva 'f ic cause or antece ent. Its et1 me objects. A significant problem is that most of these
ª spec1
lence is close to 3%. . . patients behaviorally avoid objects and situations
•
A
ecific phobia 1s a fear of an ob¡ect or of which they are anxious or phobic. This might be
s1tua-
· sp is
not . 1 ¡·
actua the only reason why exposure-based therapies are
. to
n chat proport10na 1ts poten- .
;, danger, such as a fear of a harmless 1 s about 3%.
animal orspecific location (e.g., airplane). Its
prevalence is 5% to 12% of the population. With the e .
are iw· xception of social phobias, women
, Social phobia or social anxiety disorder is
char acterized by an exaggerated fear of
becom ing humiliated or embarrassed by
others. This affects 11% to 16% of the
population.
• Agoraphobia is the fear of being unable to
escape
&om a public place or situation, especially if
one expects having a panic attack by being
there. Approximately 2% to 11% of the
population are believed to have it.
' Panic disorder is defined as a fear or
discomfort tht abruptly arises and peaks in
less than 10 minutes but can last for
severa! hours in most
cases w'th '
out apparent cause. Its prev alence
 so effective. This, however, can become
a problem in hypnotherapeutic
approaches with sorne anxiety patients:
They choose hypnosis because they
hope that they can continue their
avoidance behavior. There are many
case examples of Erickson abstain ing
from hypnosis, confronting his patients
directly with their phobias, and also
utilizing other people at hand-like his
l'k 1
an anlc'ice rnor e than men to be affected
by
i ety Ys ·
ºWed p e m gle, divorced, and
disorder.
wid-
1
op e are more likely to develop this
kind
spouse-to deter them from avoiding or
escaping. In sorne cases, a "systemic view"
might also be necessary when patients seem to
use other people to serve their anxious purposes.
A complex systemic problem arises within
partner ships or families, for example, when a
patient with a social phobia cannot leave the
home alone or cannot meet other people.
EVIDENCE
Unlike cogmuve behavioral psychotherapy, for
which exposure is the empirically validated treat
ment of choice, there is, to date, insufficient
470 1 111: PSYCHOLOGICAL APPLICATIONS

scientific evidence for the effectiveness of hypno attacks. She had no explanat'
sis/hypnotherapy for anxiety disorders. Reenstorf toms, which plagued her for ion severfor¡ her8Yt¡1
(2006) described seven older scientifi_c tud1es, five h a d occurred more frequentl ª Yea p.
of which were conducted with nonchmcal popula She could not 1·dent1.fy any Y. in. recent rs. anq
tions (i.e., students) and two were flawed in f or w h . the symptoms woSltUati n or rtttt¡
their 0 es.
h b
1ch uld o
design. Flammer (2006) conducted a more thor t e su way or public spaces ur. Be¡ n 0

ough meta-analysis of 18 randomized . b Were ty . ng

controlled clinical trials (N = 732) covering
phobias, general
ized anxiety disorders, and unspecified anxiety
t1o.ns, ut even then she di'd not k Pica\ s·ttuªt
tamty whether or when it actual!no With
Why she had panic attacks ev Y d1d happ r.
et
dis s,
f h en at en
orders. For pre and post comparisons, a d
a ter er ay housework she rne Wh ·
moderare h0
effect size (d = .72) was found, and a large effect her l. . room or on the, sat comf0 en
(d
= 1.02) was found when compared with a
waiting 1vmg terrace rtab\y ¡'
sh
understand. ' e cou\d ne..n
control group. Hypnosis is particularly effective After two sessions of rather f . •er
for
. ru1t1ess
phobias ( d = 1.23) and in the treatment of expl orat1on, as we could not find genera\
children/
adolescents ( d = 1.35). For patients treated with · · · any mea ·
contm gent stt muh preceding her p . nt ngfu¡
hypnosis, 74% experienced symptom improvement . an1c attack
in contrast to 26% of patients in a waiting ma de a new w1th hypnosis. s,_ l
control
atempt
While b
condition. Hypnotherapy also proved to be supe trance followmg a, careful induction' S he SU eing ddtn \
remem b d havm g these symptoms e
rior to attention-placebo ( d = .66). A direct ha d a .ere surgery about 3 years ver s1nce he
. en Y
com
smus earli S .1 s
. . . 11 '
er. t1 l sh
parison with behavior therapy, however, showed couId not m1t1a y specify further .
any
no significant difference. Unfortunately, 10 out c1. es, b. ut rat h er th ought of an uncle to conhe tingen ·
of fo11 h dh W O IU the
owmg a appened: After a relativ el h
the 18 studies examined in the meta-analysis
were
A
conducted with children, adolescents, and 1ess operatt.on the hosp1.tal, he had foundY arm.
students .
m
h k' f a small
with examination anxieties. The proven scar t e s m rom a stitch above his he
effective .
m
ness of hypnosis, therefore, cannot be applied when there is nothing to expose. Such is the case
to patients of a general psychotherapeutic for many panic disorder patients, who
practice. That is, its practica! efficiency has cannot identify any cues in the outside world
over
not yet been demonstrated.
There are sorne significant problems with behav
iorally based exposure therapies . One is the
accep tance of and adherence to the exposure,
which, in most cases, must be continued at home.
Choy, Fyer, and Lipsitz (2007), for example,
showed that in vivo exposure has the highest
dropout rate. Park et al. (2001) found that the
degree of adherence to self-exposure at home
predicted the stability of the improvement after
two years. Another problem with exposure arises
km. d of v1·s1·on had occurred to him, in whiacrht.
he
dreamt, either during surgery or shortly thereah
seeing himself from a position above lying on 1 ;
operating table while doctors worked hectically
around him. Upon questioning where the scar
on bis chest carne from, a doctor told him that
there had been an incident during the operation,
another attempt to explore her symptoms on ª suhb·
which they panic. These situations call for a
treat
ment approach other than behavioral exposure.
The
following case is an example for this latter
problem.
CASE EXAMPLE: PANIC ATTACKS AFTER AN
"OPERATION ACCIDENT"
A 29-year-old housewife and mother of two
young children carne to therapy because of
panic
that bis heart stopped and that he had to be
resuscitated . As my female patient told this
story, she still could not find any connections
between herself and the panic attacks. She was
easily hypnotizable
and could develop an arm levitation without tac·
tile support (Peter, Piesbergen, Lucic, Staudacher,
& Hagl, 2013). 1 took advantage of ideomotor
signaling (Ewin & Eimer, 2006; Peter, 2009a) for
. " whet
conscious leve!. 1asked her er "unconscious d
he
there was a link between the sinus surgery : t
t
. Th "Y han we n
subsequ ent panic attacks. e es- . m i n d
d
nconscio us
up and so Isuggested t h at her u h d
' ·¡ h Id the Yes-
rise wo uld provide more deta1 s ou
an
tim e the further. This happene d , and after
sorneregress'ion,
patient reported, in a spontaneo ª e ht befare
a being in a hospital room alone t 'bel ne)
{plicable
surgery
1
wh1·le expen·encm· g a tern sked
de, her ro
fear. 1 intervened immediately ahn erody and
. d from
to carefully detach her mm
 471
52: ANXIETIES IN ADULTS •

she could look at this her throat. She saw nothing and heard only vague
ay fearful that dº ..
ar aW bed from a 1stant pos1t1on,
0f ·n he r h er, and ta lkmº voices without understanding anything. Before she
¡11o"es h ' king panicked, 1 intervened and explained to her that
Jt1iJ1g about g
..,art ' et t in . . h' ..
1vº"' erY qui ' With her bemg m t 1s this really was an unfortunate and absurd coinci
posmon
¡,eillg "bout her.h was by now so far away that dence, because this happens so extremely seldom.
(lle a w o
co observer, h room in the hallway, we then Unfortunately, there was again no proper explana
aJI ·de t e
as was otsi s the following: . tion for this incident.
.
she co discus very irrational s1tuat10n: Ithen told her:
The
O
¡,e¡ga
t
was noª ·n her bed terrified of that next-
" 'ªº 1 •
se she feared that the same thmg ccconcentrate and listen very carefully to my words,
was
1vo••· beca u . ad
a very· e was fortunate not to feel pain but
daY surgerY en to her as it d1d to her uncle. Thus
vould haPP r now had to go to her, soothe her,
'she,che Observe
. ' that the pro ba b·1·
her 11ty o f such an
a11d e"plalfl too srnall that she could easily forget
'd t was s
j¡!Cl e d fall asleep. 1 asked her whether she
1
about anble to do so, and upon her agreeing we
would e ªback into the room. She sat beside the
bo
th went .
cook her hand, and sa1d, partly supported
woinan,that what had happened to her uncle was
by ine,ely unlikely, and that it was therefore com
cxl cre"\mprobable something like that could
also
pete 1Y •
happen to her. Therefore, she could be qwte sure
that she will be safe, and so on.
As it mrned out, 1was wrong with these assump
rions.In the next age regression during the following
session, she relived how she responded paradoxically
to the sedatives the next morning. Instead of
being relaxed and detached, she was brought into
the oper ating room with panic anxieties but also
with flaccid muscles. Shewent again into an observer
position and, with my support, we explained to the
poor woman that chis was a totally unusual and
unfortunate situ ation. She had obviously
responded unexpectedly
1
?the anesthetic, which had no proper explanation,
ce it happens so rarely. Unfortunately, she was
still affected by this awkward incident. However,
she was told she could remain relaxed because this
s;only a physical" reaction, artificially provoked
si eFdrug. lt felt like fear because of the physical
a ws. urther, she should detach from her body in
ay and g f
hermind º. ar enough away that she could feel
everych· nung down. Then she would understand
Fina: crrctly and become very relaxed again.
"traurna"' unng several therapy meetings,
the Jcplanatio: gradually "reconstructed," and
an lllgly unexpl . as found for the previously
seem
torns: She ainable (i.e., "irrational") panic symp-
con . Woke up d ·
 and follow ali my inst,uctions -precisely,
becau.se you know well that this woman on
the operating table could othenuise develop
a pan ic disorder.Ask her to /et her body f
all deeply asleep and become very calm so
that she can leave her body completely now
with her mind and jo in with you. Make
sure that you together are so far detached
fr om it that you can float high enough in
order to look down and see her body lying
on the operating table. Notice the doctors
around it doing their job with no one
realizing that she woke up, because ali of
them are so engrossed in their work that
they cannot see anything else. Only you
yoursel f or her mind, respectively, know
that she is awake and probably will
develop fear if we da not intervene and do
the right things. Therefore, go back now
and move closer to the woman on the
aperating table, talk to her,and soothe
her.The best thingf would
rno unple . be to take her '
ve or . asam eelm g of not g ab le
b bem
reathe to
autonomously yet felt the tube
in
111......._
hand at her bedside like the night befare, and talk
with the woman on the operating table in a very
tender and quiet manner. Tell her that everything
is in order, that she feels no pain, j ust an unneeded
f eeling, and that everything would be over right
soon. Whileyou caress the hand of this woman,
insbuct her that she still should be a bit patient.
The doctors will do theirjob perfectly .If it takes too
long, she should reflect on things about which she
nonnally never had time to think, that you and I
are with her...."
Isuggested that if the woman on the
operating table feels that her hand is being
touched, it would go up ali by itself, for then she
knows that every thing is in order, that she can
wait, be quiet, learn new things, and wait quietly
until it's ali over. The left hand of my real female
patient went up slightly and she remained visibly
calm. She confirmed after the trance session that it
was hard but very satisfy ing work.
In subsequent hypnotic sessions, we went
through this scene several times to deepen and
anchor the result. Before and after each sess1·
.
0 n,
r 474 • 111: PSYCHOLOGICAL APPLICATIONS
out the right distance from which you can
easily look at and understand what your
symptom!your symptom-figure tells you...."
Usually the patient feels very confident if an
uncov ered meaning is inherently consistent. If
not, it is
necessary to go on with further explorations.
Step 5: Solutions
In sorne cases, possible solutions follow resulting
from uncovered materials, for which sorne simple
reframing may suffice. In other cases, patients need
more help by the therapist in order to, for instance,
equalize confusions if a currently ambivalent situ
ation is masked by old anxious feelings, of which
the origin is not conscious at the moment. Yet, in
other cases, there may not have been a proper solu
tion possible in the situation when the anxiety first
manifested, so life simply continued and the trau
matic event fell into oblivion. Cues of the present
trigger the old anxious experience as long as there
is no meaningful solution for the original context.
This has to be created collaboratively by the thera
pist, the patient, and the unconscious knowledge
of the latter. Old business needs to be settled and
old wounds have to be healed. Feelings of guilt and
shame can also play a role in sorne anxiety disor
ders if they fit with similar feelings from the past.
These are usually forgotten or repressed and oper
ate now as a kind of permanent trigger for remorse
and physiological excitement. The therapist should
help the patient address directly hs .ºr her con
science in order to find ways of rem1ss10n. Because
these feelings are the most difficult and problematic
for people, the state of a hypnotic trance in adi
tion to ideomotor techniques are most appropnate
to deal with them.
Step 6: "Ecological Validation"
If a solution has been found or sufficiently
created, each part or "ego state" (Frederick,
2007) of the patient needs to be asked whether
it can accept it. A simple and good test involves
the patient establish ing the state of solution
imaginatively and physi ologically and
associating himself or herself with the formerly
anxíous sítuatíon. That is, he or she enters
imaginatively into it in order to experience
the newly developed reactíons of staying
calrn relaxed. and
Step 7: Posthypnotic Suggestion
and Amnesia
In order to continue all the processes that h
been started to s?lve the probles and soothe
: patient, appropnat posthypnot 1c
suggestions at the end of each sess1on are
needed:
''Your unconscious/your conscience will continue
to work on these matters so long as a good and
durable solution is found. It will find the right
time to do this, even at night and inyour
dreams or during the day when your conscious
mind not fully absorbed by other business.
And your conscious mind can forget it as it is
important that you know that your anxious
reactions are now over and you can confr ont
yourself easily with what you f eared in the
past. "
CONCLUSION
Though behaviorally based exposure therapies
are currently the empirically validated treatments
of choice for anxiety disorders, hypnotherapeu
tic approaches are also useful. They are necessary
at least when exposure fails because unconscious
processes still trigger the symptoms. In these
cases, a thorough and detailed hypnotherape
tic strategy (a la Paul Janouch) can be appie in
order to find a meaningful and satisfying solut10n
for the patient. At least moderate hypnotizability
and sorne capability for imaginative involvemnt
are prerequisites for this approach. Otherwise,
behavíorally based techniques are recommended.
Thís is also true if the patient searches for ?yp·
nosis as an inherent part of h1.s or her habrt
ro
constantly avoid exposure. Further research to
validate this hypnotherapeut1.c approach, hoW·
ever, is needed.
REFERENCES
Alladin A. (2014). The wounded self:New
 , . . . d .sorders,
apProach to un derstandm g and treatm g anx1 ety 1