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Hypnotherapy Research in Anxiety Disorders
Aile Trumm, BSc (Hons), C.Hyp
Adapted from master’s thesis in Health Research Methods, “Effectiveness of
Hypnotherapy in Anxiety Disorders: a Systematic Review”, which was submitted to
the University of Birmingham in September 2018. Thesis is available on request, free
of charge.
A Brief History and Definition of Hypnotherapy.
Since the times of ancient civilizations, hypnotherapy has been known and
documented under different names, the ways of conducting the therapy have also
differed. In 18th century Austria, hypnosis was known as “animal magnetism” or
“mesmerism”, named after Franz Anton Mesmer. The word hypnosis comes from the
Ancient Greek after “Hypnos” who was the God of sleep and was first coined in
relation to treatment by the Scottish doctor James Braid (1795 – 1860) who is
regarded by many as a first genuine hypnotherapist.
According to Clarke (2013), hypnotherapy is still not easily or consistently defined.
National Health Service UK defines hypnotherapy as: “a type of complementary
therapy that uses hypnosis, which is an altered state of consciousness”. American
Psychological Association (2017) defines hypnotherapy as a “state of
consciousness involving focused attention and reduced peripheral awareness
characterised by an enhanced capacity for response to suggestion“. Giffiths (2017)
argues that the latter definition is so vague that it could be applied to anyone
watching advertisements on TV.
There are many different types of hypnotherapy. To name a few: traditional
hypnotherapy, hypnoanalysis, Ericksonian hypnotherapy, cognitive-behavioural
hypnotherapy, clinical hypnotherapy, solution focused hypnotherapy and Lesserian
curative hypnotherapy. Neuro-Linguistic Programming, Past Life Regression, Time
Line Therapy and many more are considered to be part of hypnotherapy according
to Hypnotherapy Directory (2018).
The term “hypnosis” is used in research interchangeably for both hypnotic state
and the procedure used to induce the state. Hypnosis usually involves suggestions
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for relaxation, calmness, tranquillity and imagery experiences, contrary to the
stigma of mind control or mental submission. The hypnotic state may be
distinguished from other states of consciousness, such as sleep, wakefulness,
relaxation and meditation. Neuroimaging techniques have confirmed that
distinction by demonstrating the role of divisions in the anterior cingulate and
prefrontal cortices during the hypnotic state. There is evidence that hypnotic
suggestions arouse changes in respective brain regions. Furthermore, recoding
techniques such as biofeedback show that during the hypnotic state, the
parasympathetic nervous system is activated. Therefore, the breathing slows
down, the heart beats slower, the muscles in the body become relaxed and the
rapid eye movements (REMS) are observed. Although the hypnotic state shares
some similarities with sleep state (as hypnosis has been proven to be an alpha-
wave state), it has been argued that it is not a sleep state, as the attention of the
subject has been concentrated and he or she is aware of the sounds (therapists’
voice) and suggestions. Bass (1931) suggests that the hypnotic state only shares
superficial resemblance to sleep, after discovering that the patellar reflex (the knee-
jerk reaction) of patients in hypnosis was the same as if they were in the waking
state, whereas during sleep there is no response. Therefore, major
electroencephalographic (EEG) findings appear to support the altered state of
consciousness view, validating participants’ subjective responses to hypnosis.
There is growing interest in providing hypnotherapy in healthcare settings, including
the provision of hypnotherapy training to healthcare workers in the UK (Abudarham,
1991) as hypnotherapy may also be relatively quick and inexpensive, compared to
more expensive and time consuming Cognitive Behavioural Therapy (CBT). In fact,
Huston (2010) conducted a retrospective pre-post intervention looking into the
effectiveness of hypnotherapy in treating generalised anxiety disorder (GAD),
comparing hypnotherapy with CBT. No difference between these two treatments was
found, therefore suggesting hypnotherapy was equally effective. Roy-Byrne (2015)
mentioned that psychiatrists struggle to offer the instantaneous relief that is
expected of them from anxious patients. On the other hand, the sensation of a
hypnotic state may provide a feeling of relaxation rather quickly.
NICE’s (2011) decision to include hypnotherapy as a complimentary intervention for
the treatment of anxiety disorders, based on one paper by Zhao et al. (2005). In the
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aforementioned paper, benzodiazepine treatment was compared to application of
hypnotherapy and no significant difference was found, possibly suggesting an
alternative to the medication (Zhao et al., 2005). There remains controversy over
NICE’S decision. On the contrary, Nisith et al. (1999) argue in their trial that
hypnotherapy may be considered as a possible alternative to medication when
comparing hypnotherapy to alprazolam prescription. Hypnotherapy has no side
effects, whereas there are known problems and side effects associated with most
prescribed anxiety medications. Patients have reported feeling dazed and
unfocused, even when prescribed low doses. People who are prescribed medication
often experience medication hangovers as some of the tranquillisers are highly
addictive. Taking commonly prescribed anxiety medication (benzodiazepines, beta
blockers, SSRI antidepressants, Buspirone) may disrupt work, school and everyday
functioning for the patient due to side effects, which may cause problems later due to
withdrawal.
Nowdays, In addition, NICE (2014) recognises alternative complementary therapies
for the treatment of anxiety disorders, hypnotherapy included, but discourages the
use of hypnotherapy without utilising medication first or at the same time.
Anxiety Disorders
Anxiety disorders were recognised and distinguished from other mental health
disorders causing a negative effect (for example depression), as early as Biblical
times. They were even recognised by ancient Greek and Latin physicians and
philosophers. Treatments comparable with modern day cognitive psychology were
known to be utilised at the time. However, in the early years A.D. anxiety disorders
were not recognised as separate disorders and only achieved differential
classification status again in the late 19th century. Now, anxiety disorders are defined
by The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
as: “disorders that share features of excessive fear, anxiety and related behavioural
disturbances.” (p. 189). American Psychiatric Association (APA) defines anxiety
disorders as: “differing from normal feelings of nervousness or anxiousness and
involve excessive fear or anxiety”. Furthermore, there is an additional note about the
diagnosis of anxiety disorders, which requires the fear or anxiety to be out of
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proportion to the situation or age inappropriate and hinders a person’s ability to
function normally.
Classification of the types of anxiety disorder did not change significantly until 2013.
DSM-V re-classified obsessive-compulsive (OCD) and post-traumatic stress
disorders (PTSD) separately from anxiety disorders, whilst still maintaining emphasis
on a close relationship between previous and current classification, placing them
close in the manual and drawing links between them. At the same time, separation
anxiety disorder and selective mutism were included as anxiety disorder
subheadings. Therefore, anxiety disorders according to the new classification are as
follows: separation anxiety disorder, selective mutism, specific phobia, social anxiety
disorder (social phobia), panic disorder, panic attack specifier, agoraphobia,
generalized anxiety disorder (GAD), substance/medication-induced anxiety disorder,
anxiety disorder due to another medical condition, other specified anxiety disorder
and unspecified anxiety disorder (DSM-V, 2013; p. 189). Although PTSD has been
removed from DSM-V as aforementioned, it is still an anxiety disorder according to
NHS and Anxiety UK.
Anxiety disorders represent one of the major groups of disorders seen in psychiatry
and in medicine generally. In several countries, anxiety disorders are more prevalent
than mood disorders (e.g. depression, bipolar disorder), substance use disorders
and impulse control disorders. There are various estimates of current global
prevalence of anxiety disorders ranging from 7.3% up to 33.7%. The National
Institute for Health and Care Excellence (NICE) reports that in Europe 22% of
patients in primary care present with some anxiety disorder per year, GAD being
most prevalent. Women appear to be almost twice as likely to be affected than men,
regardless of age and geographical location.
Anxiety disorders pose a significant morbidity burden as they may be associated with
increased impairments in psychosocial functioning in daily activities, work
productivity, health-related quality of life (e.g. fatigue, somatic diagnoses) and suicide
attempts. A significant burden on patient functioning and well-being often leads to
increased health care utilization and high economic burden.
The treatment course of anxiety disorders is generally the following: a doctor may
suggest trying an individual self-help course for a month or two, to assess whether it
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is effective in helping the patient learn to cope with anxiety. This usually involves
working from a book or computer programme individually, with only occasional
contact with the doctor. Alternatively, a patient may prefer to attend a group course
where people with similar problems meet with a therapist every week to learn ways
to tackle the anxiety. If these initial treatments don't help, the patient is usually
offered either a more intensive psychological treatment or medication, or
combination of both.
Research in Hypnotherapy.
Hypnotherapy research for anxiety and depressive disorders has enjoyed
considerable growth until the early 1990’s but has since seen a decline. Various
possible explanations are offered for this trend. The change may be due to the loss
of many influential prolific researchers who have retired. These senior academics,
linked to their institutions, attracted funding and institutional support which many
believe has not been equalled. Following the loss of leading research centres in
hypnotherapy, research has become an individual pursuit.
There have been two eminent approaches to research in hypnotherapy. The first of
these is hypnosis research, where the nature of hypnosis itself is researched. There
have been significant research gains made regarding the nature of hypnosis, due to
the development of cognitive neuroscience and the application of neuroimaging
methods.
Hypnotherapy treatments have demonstrated efficacy for a number of conditions.
There is indication from the existing systematic reviews that the strongest empirical
support is for use of hypnosis treatments: in pain management, irritable bowel
syndrome, insomnia, several stress-related medical conditions and PTSD symptoms.
Limited and sometimes inconclusive evidence from literature reviews suggests that
hypnotic treatments may also be effective for a wide variety of other problems and
conditions such as depression and anxiety.
To further confuse matters, there are other perceived obstacles surrounding
hypnotherapy research. Namely, that there are various misconceptions and fears
surrounding hypnotherapy, most likely stemming from the historical background
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and misuse of hypnosis by those commonly referred as “showmen and
charlatans”. Not all people who call themselves hypnotherapists are equally qualified
in hypnotherapy training. There are issues surrounding practice regulations. For
example, in the United Kingdom there are currently no laws to regulate the level of
training and experience required to practice hypnotherapy. In the United States,
most states exert little or no direct regulation over the practice of hypnotherapy.
Therefore, it is necessary to include the hypnotherapy qualifications/experience of
therapists in the research papers. Unfortunately, it is rarely done. In the light of the
differences between therapies, it is necessary to point out which type of
hypnotherapy has been utilised when researching the effectiveness in hypnotherapy.
Unfortunately, also a rarely occurring practice in research.
An additional challenge may be that hypnotherapy research continues to be labelled
“unscientific” in the broader research community (Polito, Barinier and Cox, 2016;
Raz, 2011).
However, there is some indication that the misconceptions about hypnosis may be
softening due to general research progress. For example, the National Institutes of
Health in the United States of America has recognised hypnosis as a topic of interest
and has begun to fund large-scale studies evaluating the efficacy and mechanisms
of hypnosis treatments.
Dissertation
The objective of the dissertation was to systematically evaluate the relevant
evidence for the effectiveness of hypnotherapy interventions used for treatment of
anxiety disorders. Although the history of hypnotherapy is extensive and there are
some good quality studies and systematic reviews* which investigate the
effectiveness of hypnotherapy in pain relief, IBS and many other domains, it was
unclear whether there will be enough good quality research regarding hypnotherapy
and anxiety since the publication and recommendations by Coelho, Canter and Ernst
were published (2007).
*Systematic review is a research method designed to sum up the best available research on a specific
question. This is done by synthesizing the results of several studies.
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There is only one previous systematic review known to the author about the efficacy
of hypnotherapy in anxiety. A systematic review published in 2007 by Coelho, Canter
and Ernst identified 14 Randomised Controlled Trials (RCT’s)* which explored the
efficacy of hypnosis for the treatment of any type of anxiety. The overall quality of
included research papers was low.
The systematic review by Coelho, Canter and Ernst (2007) investigated adjunctive
therapy to hypnotherapy, without mentioning the type of hypnotherapy utilised. The
author of the current review has identified a lack of systematic reviews investigating
hypnotherapy as a standalone treatment when conducting scoping searches. As
different types of hypnotherapy operate slightly differently, psychological treatments
(such as CBT) in conjunction with hypnotherapy will be inappropriate with some
types of hypnotherapy, such as Lesserian Curative Hypnotherapy which is a
standalone treatment.
As it has been a decade since the last known systematic review and in light of
claimed advances in hypnotherapy research, it was found to be beneficial to conduct
an update as it might be beneficial to explore advances in anxiety treatment with
hypnotherapy, especially including children, as anxiety disorders.
It was discovered that there were only three articles investigating the effectiveness of
hypnotherapy in anxiety disorders despite a rather broad search strategy. Studies in
this review were collated from a variety of settings. Participants were from psychiatric
and general populations; the age range was from 6 to 66 years old. One study had
only male participants and three had more females than males. The results of these
studies all reported a significant difference in the measured outcomes favouring
hypnotherapy compared to control groups. The results overall are inconclusive due
to the methodological quality of the studies. Similar aspects of rigorous research
were often not reported or conducted.
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*RCT’s are considered a “gold standard” in research due to rigorous research methodology, part of it
being the randomisation of participants to different research conditions and then measuring the effect
of the treatment or intervention.
Although research in utilising hypnotherapy generally is promising, research
regarding the use of hypnotherapy for treating anxiety disorders is insufficient to
draw definitive inferences. Therefore, the current dissertation concluded that the
evidence is insufficient to support the effectiveness of hypnotherapy in treating
anxiety disorders and more research using more rigorous methodology is
recommended as a result. The main issue appears to be the quality of RCT’s in
hypnotherapy. Better quality research in the effectiveness of hypnotherapy appears
still be one of the most pressing matters.
Implications for Clinical Practice and Future Research
Furthermore, the low volume of RCTs included in the review would indicate that in
the past ten years, despite vast amount of case studies, there was few quantitative
studies conducted regards anxiety treatment with hypnotherapy. A useful future
research suggestion may be to also explore other research designs that outcome the
effect of hypnotherapy for anxiety disorders and PTSD.
Clinical hypnotherapy appears to be the most popular due to its meshing with
psychology. As clinicians are more likely to be trained in research methodology than
hypnotherapists and conduct research and publish articles, there might be an
additional bias towards the type of hypnotherapy that has been researched. To
overcome these biases, it may be useful to utilise hypnotherapists from different
types of hypnotherapy interventions to administer treatment as part of research
design. Additional insight may include the effectiveness of different types of
hypnotherapy in anxiety disorders. Furthermore, it may reduce the reporting bias and
benefit research methodologically. It would appear that the experience or level of
hypnotherapy training of person/people conducting hypnotherapy is rarely mentioned
in the research papers and it appears to be acceptable that a qualified psychologist
or psychiatrist may practice hypnotherapy without mentioning any formal training in
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hypnotherapy. It would be beneficial to integrate interdisciplinary collaboration in this
research area, having well-designed studies, experienced researchers and
experienced hypnotherapists working together. Alternatively, hypnotherapists may be
trained in research methodology and conduct rigorous research in hypnotherapy or
be aware of ongoing research and contribute with their knowledge and expertise in
all stages of research design.
Despite concerns about effectiveness and regulation, hypnotherapy is becoming
increasingly recognised as a potential method for reducing feelings of anxiety. In the
past decade, there has been a vast increase in research interest regarding anxiety
disorders due to the recognition of the prevalence, implications and morbidity burden
of the illness. Hypnotherapy may have potential to provide a fast, cost-effective
alternative to medication in the treatment of anxiety disorders, especially in children
and young adults. It would be beneficial to scientifically research hypnotherapy in the
treatment of children and young people as anxiety disorders usually have an early
onset.
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