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In this chapter, we offer a comprehensive review of the literature regarding the use of hypnosis in the treatment of anxiety disorders. We will present evidence.
Table of contents

In this relaxed state, they can discuss their feelings and emotions without raising stress and anxiety levels. A hypnotherapy session usually lasts about an hour. A trained therapist uses various relaxation techniques to guide you into a hypnotic state. In this state, you are still conscious and aware.

Your body becomes more relaxed and the mind more responsive to suggestions from the therapist. Hypnotherapy can help target unwanted or unhealthy habits and possibly replace them with healthier behaviors. Examples include being able to better control pain or anxiety or adjusting negative thought patterns that could be worsening depression symptoms. Hypnotherapy offers the potential to help treat your medical conditions without the need for invasive therapies or additional medications.

Therapists consider hypnotherapy a safe treatment option, with minimal side effects. A person can use hypnotherapy in addition to other treatments for depression to enhance an overall sense of well-being, lift mood, and boost feelings of hopefulness. Hypnotherapists use it to treat a number of conditions, including:. A person with depression experiences a wide variety of emotions. These behaviors may include smoking and poor eating and sleeping habits. Hypnotherapy does have some risks. The most dangerous is the potential to create false memories called confabulations.

Some other potential side effects are headache, dizziness, and anxiety. However, these usually fade shortly after the hypnotherapy session. People considering hypnotherapy should first consult their doctor or psychiatrist. It is possible that hypnotherapy could worsen symptoms. People suffering from delusions, hallucinations, or other psychotic symptoms might not be the best candidates for hypnotherapy.

The therapy requires a person to focus and enter a trance state of hypnosis. For some people, this is very difficult. Hypnotherapy appears to work best when used with other forms of treatment, says Steve G. Kopp, a licensed mental health counselor and marriage and family therapist. Depression is more than just feeling sad or having negative thoughts. Kopp also warns that hypnotherapist quality varies widely. Anyone considering hypnotherapy should make sure the therapist is not only certified to perform hypnosis, but is also a trained mental health professional. Several professional organizations and licensing agencies exist for hypnotherapy practitioners.

To be an ASCH member, practitioners must attend at least 40 hours of workshop training, 20 hours of individual training, and have completed at least two years of clinical practice as a hypnotherapist. For those interested in hypnotherapy, contacting these organizations to find a local chapter and licensed professionals is a good start. Although a clear definition of dissociation is lacking, the first proponent of the dissociation theory described it as a split in the subunits of mental life, resulting in one or more parts left out from conscious awareness and voluntary control [ 39 ].

Additionally, these subsystems are coordinated by a higher-order executive system, the 'executive ego' [ 39 ]. According to this theory, hypnosis alters the functioning of the executive ego, which tricks the mind about what is really going on. For example, when someone is asked to raise their arm under hypnosis, the executive ego might be responsible for the movement; however, because the awareness component of this has been separated into another part, this appears as an involuntary act to the hypnotised person [ 28 ]. Akin to dissociative theories, sociocognitive theories reject the idea that hypnosis requires an altered state of consciousness [ 41 ].

In fact, the same individualized social and cognitive variables that shape complex social behaviours are thought to determine hypnotic responses and experiences [ 41 ]. These variables are a a positive experience attitudes, expectations, beliefs with hypnosis in general, b good motivation to respond to suggestions, c clear indications that signal how to respond to hypnotic suggestions, and d implicit or explicit instructions in which to become absorbed or to imagine suggestions provided by the hypnotist.

It is thought that when all of these variables are working together in a given individual, the person is under hypnosis [ 25 ]. Moreover, sociocognitive theories state that responses under hypnosis are goal-directed and that hypnotised people continue to act according to their aims and values, just as they ordinarily behave according to a socialized role [ 42 ]. Finally, rather than being attributed to an altered state of mind, the enhanced responses seen in people under hypnosis are merely a reflection of increased motivation and expectations [ 42 ].

Beyond differences and resulting controversy steaming from the dissociative and sociocognitive theory perspectives, new findings from psychophysiological and brain imaging studies have allowed the scientific community to support the hypothesis that experiences under hypnosis are "genuine" [ 24 ]. Indeed, studies demonstrated that there are distinctive patterns of activation anterior cingulate cortex and frontal cortical areas attributable to hypnosis and that these patterns comprise mechanisms used in other familiar cognitive tasks focused attention, imagination, absorption [ 24 , 31 ].

Furthermore, there are specific psychophysiological correlates for suggested experiences [ 24 , 31 ]. Some studies demonstrated that there is a qualitative distinction between neurocognitive activations that occur when people are asked to imagine certain images under hypnosis and in ordinary conditions [ 31 ]. Also, the hypnotic experiences appear to create brain states closer to the real experience, a phenomenon corroborated by the subjective reports of individuals [ 31 ].

Finally, brain imaging and psychophysiological studies might also enrich our understanding of the respective contribution of the social context, the subject's aptitudes, expectations, and intrasubjective experience of hypnotic phenomena. Thus far, the value of hypnosis has already been recognized for many physical and medical conditions.

Using Hypnosis in the Treatment of Anxiety Disorders: Pros and Cons

Indeed, in , the National Institute of Health Technology Assessment Panel Report considered hypnosis as a viable and effective solution to treat pain associated with cancer and many other chronic pain conditions [ 43 ]. It was even found that in certain conditions, the degree of analgesia resulting from hypnosis matched or even exceeded that provided by morphine [ 43 ]. In their review of the literature, Neron and Stephenson [ 45 ] also present evidence on the effectiveness of hypnotherapy for emesis, analgesia, and anxiolysis in acute pain.

In addition to reducing the pain associated with cancer, hypnosis was also found to effectively reduce the affective morbidities anxiety, discomfort, and emotional upset associated with the medical procedures [ 46 - 48 ], as well as reduce fatigue [ 46 , 49 ], sleep problems [ 49 ], nausea [ 46 ] and the quantity of medication needed [ 46 ].

Similar results reduction in pain, anxiety and medication and better satisfaction were found for plastic surgery patients [ 50 ], severe burn care patients [ 51 ], women giving birth [ 52 ], breast biopsy patients [ 53 ] and patients undergoing dental procedures [ 54 ]. Hypnosis also served as a sole anaesthetic ingredient for thousands of surgeries [ 43 ]. Of note is that in the medical environment, clinical hypnosis is provided as an adjunct to medical treatment.

There is usually no time for multiple sessions based on skills acquisition and homework. Intervention is often provided at bedside, or in preparation and during medical procedures away from the usual office-based psychotherapy setting. The goal of care is often symptom relief and comfort during the medical procedure and not psychological therapeutic change, which is typically the end point of psychotherapy.

Hypnosis is used because it is efficacious but most importantly it is practical short: More specifically, it was found to be particularly effective for the treatment of obesity [ 15 , 56 ]. Indeed, long-term weight loss was maintained at follow-ups, which is an issue for most people who gain their weight back soon after losing it [ 15 ].

In their review of the literature, Chambless and Ollendick [ 57 ] even identified hypnosis in conjunction with CBT as an empirically supported therapy for obesity, along with headaches and irritable bowel syndrome [ 57 ]. A study done with women suffering from chronic breast cancer pain revealed that cognitive hypnotherapy or CBH was effective not only in reducing pain, but also in decreasing pain over time as the cancer progressed [ 58 ]. However, these results should be interpreted with caution, as some research demonstrated considerable limitations such as the exclusive use of self-reports, small sample sizes, a lack of differentiation between hypnosis and relaxation techniques and no clear definition of cigarette smoking [ 56 ].

More recently, some studies using more reliable approaches showed promising results in the use of hypnosis for cigarette smoking. Indeed, results indicate that after treatment, at three month, six month and 12 month follow-ups, more participants in the hypnosis group were abstinent [ 60 , 61 ]. Rather than using CBH, these studies either compared hypnosis to behavioural treatment or to a waiting-list control group.

Hypnosis appears to be a promising avenue for many physiological and psychological problems but most importantly, hypnosis is a cost-effective alternative procedure [ 43 ]. However, as Schoenberger's review [ 62 ] indicates, more rigorous methodologies as well as more studies comparing specifically the added benefit of hypnosis to CBT are needed to determine its real effects. The essential feature of social anxiety disorder SAD or social phobia is an important and persistent fear or worry about social and performance situations [ 63 ].

Social phobia can be divided into two types: In their review of five meta-analyses that looked specifically at the treatment of SAD, Rodebaugh, Holaway, and Heimberg [ 64 ] found that CBT appears to provide benefits for adults diagnosed with SAD, with modest to large effect sizes when compared to waiting-list control, as well as moderate to large effect sizes from pre to post-treatment.

Hypnosis as a sole treatment. To our knowledge, there is only one randomized controlled trial testing the use of hypnosis as a sole treatment for social phobia. In early attempts to view the potential of hypnosis to treat social anxiety, Stanton [ 65 ] randomized 60 adults seeking help for handling their anxiety. Anxiety levels were assessed by the Willoughby Questionnaire. The author compared a hypnotic procedure consisting of positive suggestions and mental imagery to another group that listened to quiet music movements from Mozart symphonies and to a control group.

1. Introduction

Both experimental groups met in their respective groups for 30 minutes for three weeks. At the end of treatment, both experimental groups experienced a significant reduction in their anxiety, whereas the control group saw minor changes in their anxiety levels. Moreover, the reduction for the hypnosis group was larger.

Finally, the therapeutic gains were maintained for the hypnosis group only at six month follow-ups. Although these results were encouraging, this study presented many limitations such as the fact that there was no statistical calculation of the difference between the hypnosis and music groups and that the validity of the instrument was not presented. One case report also indicated that hypnosis was useful in treating social phobia [ 66 ]. Although hypnosis was used as a sole treatment, the author pointed out that the patient had experience with typical phobia treatments such as systematic imaginal and in-vivo exposure and that this familiarity might have contributed to the successful outcome.

Schoenberger, Kirsch, Gearan, Montgomery, and Pastyrnak [ 67 ] conducted a randomized controlled study on public speaking anxiety in which they compared the efficacy of CBT to the same therapy combined with hypnosis and a waiting-list control group. The experimental treatments included cognitive restructuring and in-vivo exposure.

The hypnosis component consisted of replacing relaxation training by hypnotic inductions and suggestions [ 67 ]. In terms of self-report measures of public speaking anxiety, both experimental treatments produced a reduction in anxiety compared to the control group. As for the subjective and behavioural measures of fear, only the hypnotic group differed significantly from the control group.

These measures were taken by a blind observer during a impromptu speech that participants gave in front of two observers. Finally, the mean effect sizes calculated across the dependant measures revealed a significant difference between the two experimental groups in favor of the hypnotic treatment mean effect for the nonhypnotic treatment is 0. A phobia is characterized by a marked and persistent fear prompted by the presence or anticipation of an encounter with a specific object or situation [ 63 ].

This situation can create a sensation of panic, somatic manifestations of anxiety, fainting or even trigger a panic attack in the phobic person. The lifetime prevalence rate varies from 7. CBT procedures including in vivo-exposure and systematic desensitization are considered the treatments of choice for specific phobias [ 68 ]. Even though these techniques apply to most phobias, certain ones require specific adaptation such as the applied tension technique for blood-injury-injection phobias [ 68 ]. We found two randomized controlled studies that utilized hypnosis as a stand-alone treatment for specific phobias.

In the first one, Hammarstrand, Berggren, and Hakeberg [ 69 ] compared a group of women with dental phobias using two types of experimental treatments: The psychophysiological treatment consisted of progressive relaxation, videos of dental scenes and biofeedback training. As for the hypnotherapy, the participants were told to imagine different dental scenes, which corresponded to the videos of the psychophysiological group, and received suggestions. In addition, a control group who received general anaesthesia was added. Unlike the rest of the participants, this group was not randomized.

The results showed that only the psychophysiological group experienced a significant reduction in anxiety. However, no significant difference between the two experimental and control groups was found. It should be noted that out of the 22 participants in this study, only 13 completed the treatments eight in the psychophysiological treatment, five in hypnotherapy and thus the sample was too small to draw real conclusions.

Moreover, since the control group was not randomized, there is the possibility that these participants were different from the other two groups. In an exploratory study of four people suffering from specific phobias i. The hypnotherapy consisted of imaginary exposure with the use of the "magic bubble technique " [1] - , as well as the age regression technique [1] - [ 21 ]. The author stated that behavioural techniques expose patients to the avoided stimuli in a "here and now" context [ 21 ]. Although these techniques have been proven efficacious, therapy should employ self-exploration in order for patients to understand their unique conscious and unconscious processes [ 21 ].

Age regression hypnotherapy can thus solve this problem [ 21 ]. Results of this study indicated that all participants saw their anxiety reduced in a significant way. Even though the participants' anxiety increased slightly at the two-week follow-up, participants still experienced on average a The benefits of the group therapy might have been enhanced if it was combined with other well-recognized methods for treating phobias — a focus for future research. As for the integration of hypnosis with CBT or behavioural protocols for specific phobias, we found several case reports and case studies and only one randomized controlled trial.

Recently, Forbes [ 71 ] compared the relative effectiveness of systematic desensitization with hypnosis to the same treatment with relaxation in the management of animal phobias.

How hypnosis helped me tackle my crippling anxiety

His results showed that patients in the hypnosis group enjoyed greater anxiety reduction than the other group. Finally, case studies also corroborated the effectiveness of CBH for driving phobia [ 72 ], animal phobia [ 73 ], and airplane phobia [ 74 ]. This evidence tends to support the use of CBH as an effective therapy for different types of phobias. As for panic attacks, they are discrete periods of intense fear or discomfort that are accompanied by both physical and cognitive symptoms such as heart palpitations, hyperventilation, dizziness, a fear of losing control or going crazy, depersonalization and so on.

People who suffer from PD sometimes develop agoraphobia, which is an anxiety related to being in places or situations in which escape might be difficult or impossible and help difficult to receive. In community samples, rates vary between one and two percent, although higher rates [3. Indeed, efficacious and robust treatment effects of this therapy have been verified across a variety of treatment settings for extended follow-up periods. Hypnosis as a sole treatment or in conjunction with other non- cognitive and behavioural techniques.

Hypnotic techniques such as age regression, hypnoanalysis [1] - [ 77 ], ego-strengthening suggestions [ 78 ], and the use of medication in conjunction in one case [ 79 ] led most patients to become panic free. However, no controlled trial studies could be found on hypnosis alone. In the only controlled trial study on the efficacy of CBH in treating PDA, Dyck and Spinhoven [ 80 ] demonstrated that a combined therapy self-hypnosis and exposure was not superior to exposure alone in terms of time spent by agoraphobics walking on a prescribed route.

In this case, the hypnotic technique employed was imaginary exposure plus suggestions from the therapist consisting of successful encounters with the feared situation prescribed route. Thus, reservations must be kept in mind with regard to these latter results. Interestingly, the authors also found that preference for treatment shifted toward the combined treatment as the study went on [ 80 ].

Positive results for CBH were demonstrated in many case reports [ 18 , 81 , 82 ]. Indeed, hypnosis was found to enhance CBT protocols by facilitating exposures to both the symptoms of panic and situational anxiety. Moreover, it also was found to be successful in conjunction with Rational Emotive therapy RE. People who suffer from Generalized Anxiety Disorder GAD experience excessive and hardly controllable worry and anxiety most of the time.

Contrary to some other anxiety disorders where the anxiety is focused on a specific event or thing e. Many individuals also develop somatic symptoms such as muscle tension, nausea, and sweating. In community samples, approximately three percent of the population will develop GAD [ 63 ]. As for the treatment of GAD, traditional narrative reviews and meta-analyses have consistently found that CBT and applied relaxation are the most efficacious treatments [ 83 ].

The hypnosis component was comprised of suggestions involving the lessening of anxiety. Although these results are positive, the patients were not randomized to the treatments but rather assigned to treatment based on their own desire to receive hypnotherapy or CBT. It is thus safer to say that hypnosis was as effective as CBT for patients who believed in and wished to be treated with hypnotherapy.

Also, since this was a retrospective study, many aspects such as the number of sessions, and the integrity of therapy could not be controlled for. In a pilot randomized controlled study of 10 patients, Allen [ 84 ] assessed the comparable efficacy of a treatment incorporating CBT, hypnosis, and biofeedback to a waiting-list control group. All patients in the experimental group demonstrated a reduction in both trait and state anxiety. Most of them four out of five even obtained post-test state anxiety scores below the normative range.

As for the control group, their anxiety remained at a clinically significant level [ 84 ]. Obsessions may be persistent ideas, thoughts, impulses or images that can be related to many different topics such as contamination, religion, symmetry and repeated doubts. As for compulsions, they are repetitive behaviours or mental acts that people perform in order to diminish the anxiety associated with their obsessions.

The estimated lifetime prevalence of OCD is 2. In a recent review of the literature, Podea, Suciu, Suciu, and Ardelean [ 86 ] concluded that CBT is an effective treatment for OCD, that it is at least as effective as medication and that it demonstrates good benefits at follow-ups. So far, hypnosis has occupied a relatively restricted role in the treatment of OCD [ 87 ] and this is reflected in the few numbers of studies on this topic.

Indeed, no well controlled studies on the efficacy of CBH have been completed so far to see the additive effect of hypnosis to CBT [ 88 ]. Rather, the hypnosis literature only contains descriptions of clinical work done with a minimal number of patients and a series of case studies usually unaccompanied by measurable data. Still, as a combination to CBT, hypnosis was found to be efficacious in many case reports and one case study [ 88 - 92 ].

For example, because his patient did not respond to CBT and medication, Frederick [ 88 ] developed an intervention in which CBT and hypnoanalysis were incorporated. The hypnosis part was mainly aimed at the resolution of the dissociative symptoms. Other authors used hypnosis during exposures e. Very recently, Meyerson and Konichezky [ 87 ] presented three single-case reports in which hypnotically-induced dissociation HID combined with CBT protocols was successfully used in order to treat patients with OCD. According to Yapko [ 93 ], HID is the ability to split a fully and unified experience into many different components, while amplifying awareness of one part and diminishing awareness of the others.

For example, some patients report that they cannot recognize themselves without their disorder. HID can thus be used to help the person dissociate him or herself from the disorder and amplify their feeling of experiencing life without the disorder. The traumatic event must put at risk the physical integrity of the individual or others and the person's response must involve intense fear, helplessness, or horror A2. The characteristic symptoms of PTSD include B stress and hyperarousal, C persistent avoidance of situations or reminders of the trauma and D vivid experiences of being back in the midst of the traumatic event, which are often referred to as a flashback.

Finally, E these symptoms must last for at least one month. PTSD lifetime prevalence rates are approximately eight percent. This interest has been triggered by factors such as the evidence that PTSD patients seem to be more highly hypnotisable when compared to the general population and other patient populations [ 96 - 98 ]. Butler, Duran, Jasiukaitis, Koopman et al.

Evidence in support of this model are the fact that higher scores on hypnotisability scales are associated with avoidance symptoms, which is a core aspect of PTSD [ 96 ] as well as with better therapeutic success [ ]. However, research is needed to exclude the possibility that it is the development and maintenance of PTSD that create a state of high hypnotisability. Moreover, clinical findings seem to suggest that there is a similarity in phenomenology between PTSD symptoms and the experience of hypnosis [ ].

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For example, during hypnosis, the person is entirely focused and absorbed into the suggestions and this absorption is also evidenced in PTSD sufferers, who sometimes focus so intensely on their traumatic memories that they are able to create physical and emotional responses.

Another common factor is the phenomenon of dissociation, which can occur both during and after the trauma. Finally, both PTSD and hypnosis are experiences in which the person is hyper-responsive to both their environment social, physical cues and internal cues [ ]. Because traditional interventions are mostly aimed at targeting the core symptoms of PTSD, the interest in hypnosis was also prompted by the fact that as a flexible form of treatment, it might be able to target important symptoms such as sleep and dream disturbance, pain, and emotional and anxiety withdrawal problems associated with traumas [ , ].

Hypnosis as a sole treatment or in conjunction with relaxation training. A recent randomized controlled study tested the hypothesis that hypnosis could help relieve the cluster of hyperarousal symptoms in PTSD, in a group of women who had experienced sexual trauma [ ]. This study compared the use of a hypnotic induction Elkins Hypnotisability Scale to a standard care intervention, which was a combination of supportive counselling, CBT, interpersonal therapy, and solution-focused technique [ ].

Following the initial induction, a hypnotic induction recording for subjects in the treatment group was given to use at home over a period of one week. The author reported a statistically significant decrease in hyperarousal symptoms, general anxiety, and difficulty concentrating for the hypnotic group [ ]. However, participants did not fall under the clinically significant line, and on many measures there was no significant difference between the control and treatment group.

Some noticeable limitations of this study were that even though the groups were randomized, some of the baseline symptoms of the hypnosis group were more severe than that of the control group, which might explain the small differences between the two groups on some measures at the end of treatment. Even though it was the study's goal to create a short treatment, it came out that one week was probably too short of an interval to see the real effects of hypnosis and reach clinically significant results. It would have been interesting to see the added benefit of hypnosis to the standard treatment over a longer period of time.

Moreover, in this study, there was minimal use of hypnosis. Indeed, the hypnotic induction did not include any suggestions to treat aspects of PTSD. As part of their symptoms, PTSD sufferers often complain about sleep problems [ 17 ]. Some studies indicated that hypnosis can be helpful in reducing time to sleep onset in a group of individuals with chronic insomnia [ , ].

A meta-analysis of 59 outcome studies also demonstrated that the short-term effects of hypnosis one-two months and relaxation training were comparable to the effects of short-term drug therapy and that the long-term outcomes even surpassed the drug therapy in certain instances [ ]. Abramowitz, Barak, Ben-Avi, and Knobler [ ] studied a group of chronic combat-related PTSD sufferers who experienced sleep problems even though they received supportive therapy and serotonin reuptake inhibitors SSRIs. The participants had difficulty falling asleep as well as maintaining sleep and reported night terrors.

The authors compared the efficacy of two weeks of one-and-a-half hour hypnotherapy sessions with the drug therapy Zolpidem to see the effects on PTSD symptoms and sleep problems. They found that in addition to see a reduction in the major PTSD symptoms, the hypnotic group reported better sleep quality, fewer awakenings, and less morning sleepiness.

chapter and author info

There are many recent instances of case studies and reports that describe the success of hypnosis in conjunction with CBT for traumas associated with industrial accidents [ - ], motor-vehicle accident [ ], sexual abuse and rape trauma [ - ], spouse abuse-related trauma [ , - ] and assault-related trauma [ ]. For example, Degun-Mather [ ] [ ] reported the success of hypnosis in conjunction with CBT in two cases of patients suffering from different traumas childhood and war.

Hypnotherapy was used in order to activate and reconstruct the traumatic memories. On a larger scale, Brom, Kleber, and Defares [ ] compared the effectiveness of four psychotherapeutic methods for the treatment of PTSD in patients: However, the authors of the original study reported that there was still a lot of similarity between the three treatment conditions which could be due to similarities in the behaviours of the therapists, which they did not measure directly.

No statistical measures were presented to compare the active treatment groups.

How hypnosis helped me tackle my crippling anxiety -

The rationale behind their study was that hypnotic techniques might be able to breach dissociative symptoms of ASD [ ]. A hypnotic induction was thus given right before imaginal exposure, in an attempt to ease the emotional processing of the traumatic memories [ ]. Their results indicated that at post-treatment and follow-ups six months, three years , fewer patients in the CBT 2. Also, hypnosis with CBT resulted in fewer re-experiencing symptoms than CBT alone at post-treatment, but this difference was not found at follow-up [ ].

Even though these results are positive, the authors used hypnosis in only one aspect of their therapy imaginary exposure. Hypnosis has many functions and is exploitable in many parts of therapy which will be described in details below and thus a broader application of it might have generated more additive gains and yielded clearer results.

Moreover, the literature on hypnosis and PTSD is filled with examples of how hypnosis can be used specifically in the treatment of PTSD, so that its benefits can be enhanced. For further reading, see Lynn et al. Recently, a new hypnotic technique called hypnotherapeutic olfactory conditioning HOC showed promising potential in the treatment of PTSD.

Based on CBT protocols, HOC is a technique that helps patients create new olfactory associations in order to surmount anxieties and dissociative states [ ]. More precisely, it is the "development, under hypnosis, of a positive olfactory association which allows the patient to regain control of their symptoms, especially when they were created by olfactory stimuli" p. This technique is based on the notion that the sense of smell has the ability to create vivid memories due to the particular position of the olfactory bulb in the brain [ ]. In an exploratory study of three individuals suffering from needle phobia, panic disorder and PTSD respectively, Abramowitz and Lichtenberg [ ] found a marked reduction in the symptoms, as attested by the rating scales and reduction in the use of medication.

The gains were maintained at six month and one year follow-ups. In this study, the authors did not compare the direct added benefits of HOC to standard protocols. However, the fact that most patients had already been in therapy for a mean time of more than two years and that baseline symptoms presented significant psychopathology indicates that HOC was able to provide additional benefits to the therapy. Still, replication studies are needed for HOC. The two treatments were either a meditational relaxation technique comprised of muscle relaxation and concentration on inner breathing and stillness, or a self-hypnosis treatment, also comprised of muscle relaxation and suggestions to send tingling feelings and light to the parts of the body where anxiety symptoms were manifested [ ].

The participants were tested on levels of hypnotisability and were then separated into two groups: Then, the participants in each group were randomized to one of the two experimental treatments. Although more participants in the hypnotic group improved according to the Hamilton Anxiety Rating Scale, the results indicated that there was essentially no difference between the two techniques in terms of therapeutic efficacy [ ].

However, participants in the medium-high group, independently of the type of treatment, significantly improved on the psychiatric assessment and demonstrated a decrease in their average systolic blood pressure [ ]. One major limitation of this study is that at the beginning, the authors randomized 69 people to the four treatment conditions, however, 37 of them did not complete the protocol. Thus, in addition to providing no results on the drop-outs, the benefits of randomization cannot be assumed in this study.

Moreover, the hypnosis treatment was very similar in content to the meditational group, which can explain the minute difference between the two. Stanton [ ] randomly assigned a group of 40 students to either a self-hypnosis training group or a control group, which consisted of discussions on ways to reduce test anxiety. The participants were matched on sex and anxiety scores. After two sessions and at a six month follow-up, anxiety scores were significantly reduced for the hypnotic group only.

More recently, O'Neill, Barnier, and McConkey [ ] compared self-hypnosis training with progressive relaxation in a group of stressed, anxious, and worried patients. However, the hypnosis group surpassed the relaxation group on cognitive changes and perceptions of treatment efficacy [ ]. Indeed, the hypnosis patients reported superior expectations of the success of therapy [ ].

A closer look at the procedures revealed that the content of the instructions given to both groups were very similar. These results seem to indicate that the simple fact of defining certain aspects of therapy hypnosis provided confidence and better expectation in patients [ 16 ]. Finally, in an attempt to determine the effectiveness of hypnosis on test anxiety, Hyman [ ] randomized 21 participants to a hypnotic-induction only group, a post-suggestion hypnotic group or a control group.

The participants received only one session of hypnosis and the post-hypnotic suggestions consisted of suggestions for reduction of test anxiety [ ]. The results showed that directly after the inductions, there was no significant difference between the three groups, as evidenced by the Test Anxiety Inventory TAI. At one month follow-up though, a significant difference was observed between the post-hypnotic group and the control group in terms of anxiety. The post-hypnotic suggestion group was also the only group who experienced a significant decrease in test anxiety over time between post and follow-up assessments.

Although the sample size of this study was very small, this seems to indicate that post-hypnotic suggestions might be one of the active ingredients of hypnosis CBH. A study comparing the effects of two hypnotic procedures imagery and cognitive restructuring under hypnosis versus hypnotic induction only with two control groups attention placebo and no treatment on the treatment of test anxiety supports the idea that the combination of hypnosis and CBT offers more therapeutic gains [ ]. Indeed, results indicate that while the induction-only group had more improvements than the two control groups, only the group receiving imagery and cognitive restructuring under hypnosis obtained significant results on anxiety and academic performance [ ].

To date, except for PTSD, there is a very small number of randomized controlled studies assessing the impact of CBH for the treatment of anxiety disorders, which limits the conclusions that can be drawn about its external validity. However, the results presented above still indicate that CBH is a promising treatment modality. Indeed, in addition to demonstrating its efficacy as a complete intervention to reduce anxiety symptoms, all studies that compared the additive effect of hypnosis found positive results, except for one.

As stated before, this study used a cross-over design which might explain the lack of superiority for the combined group exposure and hypnosis. Also, Mellinger [ ] and Scrignar [ 91 ] reported the success of hypnosis as a valuable adjunct to render exposure practices more viable. Finally, using non-leading methods, Degun-Mather [ ] reported the successful use of hypnosis to transform the fragmented memories of a war veteran who suffered from chronic PTSD and dissociative fugues into a complete narrative, leading to re-appraisal and re-structuring of the trauma.

As for the evidence supporting hypnosis as a stand-alone treatment, results are mixed. Indeed, some of the case reports and studies presented above found positive results [ 21 , 27 ]. On the other hand, in , the STEER [ ] looked at four randomized controlled trials of hypnotherapy as a sole therapy for anxiety, coming to the conclusion that there was insufficient evidence regarding the efficacy of hypnotherapy and that it did not appear to be more effective than other treatments.

In their conclusion, the authors of the STEER report also mentioned that the general quality of all studies was unsatisfactory. All of them presented major methodological flaws, such as a lack of established questionnaires, no use of imagery or suggestions during hypnosis, small sample sizes and no clear indications of qualification of competence of the therapists. This again renders it difficult to draw firm conclusions. More recently, a systematic review of controlled trial studies revealed that hypnosis as a sole treatment for anxiety was not superior than control conditions waiting list controls, contact controls, or other non-standard treatments [ 14 ], and though it is a powerful supportive tool, using it as a therapy by itself is an error [ ].

Research on clinical hypnosis should reflect the clinical practice in psychotherapy, [ 56 ] and thus hypnosis should be viewed and studied as an adjunct to commonly used and recognized techniques. In fact, hypnotic technique can directly reinforce CBT strategies by helping patients to control and regulate the anxiety as well as the cognitive and attentional processes characteristic of many anxiety disorders [ 87 ]. One point to note, however, is that the boundaries between hypnosis as a stand-alone treatment and as an adjunct are sometimes unclear, as some people view a hypnotic induction followed by suggestions as CBT in itself [ 14 ].

For a summary table of the data presented above, see table 1. As a psychosocial treatment, CBT has roots in both the cognitive and behavioural traditions and is based on the idea that our thoughts influence our feelings and behaviours [ ]. Important components of CBT include relaxation training, exposure both imaginal and in-vivo , cognitive restructuring, the building of coping skills, ego-strengthening, and self-efficacy. In the following, based on what several authors described William, Bryant, Lynn and colleagues, Alladin, Degun-Mather , we will report a summary of how hypnosis can enhance each of these components [ 6 , 16 , 17 , 23 , ].

Developing a good therapeutic alliance and motivation toward the therapy. The benefits of adding hypnosis to standard treatments of anxiety are manifold.

The basis of therapy is the development of a good therapeutic alliance. The goal-directed and generally positive environment surrounding hypnosis may promote a better rapport with the therapist, as well as enhance treatment adherence [ 17 ]. For example, successful experiences of facing fears under hypnosis can foster trust in the hypnotherapist [ 23 ]. Moreover, positive views toward hypnosis might increase confidence in the effectiveness of therapy for certain patients [ 17 ]. Developing a sense of self-efficacy and heightened ego strengthening. Hypnotic techniques such as Ego strengthening are used to foster self-efficacy, self-esteem and self-assurance in patients.

Self-efficacy provides a better quality of life, self-regulation and control and is one of the essential components in the successful treatment of anxiety disorders [ 23 ]. Similarly, a great advantage of hypnosis is that it creates a feeling in the patients that they are in control of their difficulties, instead of being at the mercy of their symptoms [ ].

Indeed, people learn to surmount their fears in trance and obtain cognitive reinforcement of their ability to cope [ 18 ]. Relaxation techniques are an integral part of CBT as they help patients control their feelings of anxiety and tension [ ]. For example, with the high level of arousal that PTSD patients tend to display, it can become difficult for them to fully participate in their therapy [ 17 ].

Many hypnotic techniques can serve to soothe patients and help them build personal resources [ 17 ].