Anxiety and Depression in Chronic Obstructive Pulmonary Disease: Perspectives on the Use of Hypnosis

Abstract

Chronic Obstructive Pulmonary Disease (COPD) is a highly prevalent and debilitating respiratory condition, characterized by chronic airflow limitation, breathlessness, and other persistent respiratory symptoms. Critically, patients suffering from COPD often find themselves trapped in a vicious comorbidity cycle: while breathlessness and increased respiratory rate are known inducers of anxiety, the latter have been shown in turn to exacerbate breathlessness and chest discomfort. Hypnosis holds great potential for the simultaneous complementary management of anxiety and breathlessness in COPD. It is an inexpensive psychological intervention tailored to the patient’s own experience, convenient in terms of logistics and implementation. In this short qualitative review, we present hypnosis’ structural, cognitive, and neural fundamentals, and assess existing instances of hypnosis use in the treatment of anxiety, depression, and respiratory disease. We then discuss its potential as a tool for improving health-related quality of life and the self-management of COPD within (and beyond) pulmonary rehabilitation.

Full text

Frontiers in Psychology | www.frontiersin.org 1 May 2022 | Volume 13 | Article 913406
MINI REVIEW
published: 19 May 2022
doi: 10.3389/fpsyg.2022.913406
Edited by:
Eleonora Volpato,
Fondazione Don Carlo Gnocchi Onlus
(IRCCS), Italy
Reviewed by:
Zuhrah Beevi,
Heriot-Watt University Malaysia,
Malaysia
*Correspondence:
Hernán Anlló
hernan.anllo@cri-paris.org
Specialty section:
This article was submitted to
Health Psychology,
a section of the journal
Frontiers in Psychology
Received: 05 April 2022
Accepted: 22 April 2022
Published: 19 May 2022
Citation:
Anlló H, Larue F and Herer B (2022)
Anxiety and Depression in Chronic
Obstructive Pulmonary Disease:
Perspectives on the Use of Hypnosis.
Front. Psychol. 13:913406.
doi: 10.3389/fpsyg.2022.913406
Anxiety and Depression in Chronic
Obstructive Pulmonary Disease:
Perspectives on the Use of Hypnosis
HernánAnlló
1,2*, FrançoisLarue
2,3 and BertrandHerer
2,4
1 Laboratory of Cognitive and Computational Neuroscience, Department of Cognitive Studies, École Normale Supérieure de
Paris, PSL University, Paris, France, 2 Complementary Care and Behavior Research Team, Bligny Hospital Center, Briis-sous-
Forges, France, 3 Palliative Care Unit, Bligny Hospital Center, Briis-sous-Forges, France, 4 Pneumology Unit, Bligny Hospital
Center, Briis-sous-Forges, France
Chronic Obstructive Pulmonary Disease (COPD) is a highly prevalent and debilitating
respiratory condition, characterized by chronic airow limitation, breathlessness, and other
persistent respiratory symptoms. Critically, patients suffering from COPD often nd
themselves trapped in a vicious comorbidity cycle: while breathlessness and increased
respiratory rate are known inducers of anxiety, the latter have been shown in turn to
exacerbate breathlessness and chest discomfort. Hypnosis holds great potential for the
simultaneous complementary management of anxiety and breathlessness in COPD. It is
an inexpensive psychological intervention tailored to the patient’s own experience,
convenient in terms of logistics and implementation. In this short qualitative review,
wepresent hypnosis’ structural, cognitive, and neural fundamentals, and assess existing
instances of hypnosis use in the treatment of anxiety, depression, and respiratory disease.
Wethen discuss its potential as a tool for improving health-related quality of life and the
self-management of COPD within (and beyond) pulmonary rehabilitation.
Keywords: COPD, anxiety, depression, hypnosis, breathlessness, comorbidity, self-management, complementary
care
INTRODUCTION
Chronic Obstructive Pulmonary Disease (COPD) causes persistent and progressive respiratory
symptoms, including breathlessness, sputum, and suboptimal oxygenation (GOLD Report, 2022).
Aside from a daunting mortality rate [3.23 million deaths in 2019 according to the WHO
(2020) report on noncommunicable diseases], COPD hinders patients’ health-related quality
of life (HRQoL) by reducing mobility, increasing fatigue levels, and propitiating psychological
comorbidities such as anxiety, depression, and suicidality (Kellner et al., 1992; Hegerl and
Mergl, 2014; Pumar et al., 2014). e 2022 edition of the Global Initiative for Obstructive
Lung Disease report (GOLD) observes that treating psychological comorbidities is critical in
COPD, as evidence shows that the alleviation of anxiety and depression symptoms also improves
respiratory disease prognosis. In particular, the complementary use of cognitive behavioral
therapy and mind–body interventions such as mindfulness-based therapy have been found to
reliably reduce anxiety and depression in COPD, diminish fatigue, and improve lung function
and exercise capacity (Farver-Vestergaard et al., 2015).

Anlló et al. Hypnosis for COPD Anxiety and Depression
Frontiers in Psychology | www.frontiersin.org 2 May 2022 | Volume 13 | Article 913406
Evidence shows that hypnosis is a fast, cost-eective
intervention for the treatment of anxiety and depression, both
as stand-alone therapy and as a part of larger therapeutic
strategies (Hammond, 2010; Cafarella etal., 2012; Milling etal.,
2019; Valentine et al., 2019). On the grounds of its
implementational and therapeutic advantages, it is worth
discussing its incorporation to the treatment of breathlessness-
related anxiety and depression in COPD. In the present work,
wesuccinctly introduce hypnosis’ structure, its cognitive building
blocks, and its basic neural correlates. We then reect upon
how hypnosis could contribute to the treatment of transient
and chronic anxiety and depression in COPD, and its compatibility
with pulmonary rehabilitation and self-management strategies.
COPD, PSYCHOLOGICAL
COMORBIDITIES, AND QUALITY OF
LIFE
At the current juncture, COPD is a chronic, incurable condition.
is makes improving patients’ symptoms and HRQoL a chief
priority in the management of the disease (Engström et al.,
2001). Because of its handicapping nature, COPD progression
aects all subjective and objective dimensions of HRQoL in
an incremental fashion (Afroz et al., 2020). On the physical
level, it restricts general physical function and breathing
mechanics, leading to increased levels of fatigue and reduced
autonomy. On the psychological level, it fosters negative aects,
increases emotional burden and negative coping. On the social
level, it restricts the patient’s capability to work and generally
impacts interpersonal relations and autonomy.
While multiple comorbidities are associated with COPD,
anxiety and depression have been reliably identied as some
of the most important predictors of poor HRQoL and treatment
adherence (Dalal et al., 2011; Willgoss and Yohannes, 2013;
Yohannes and Alexopoulos, 2014). Timely diagnosing anxiety
and depression in COPD have proven particularly challenging
due to symptom overlapping and an unclear etiological association
between conditions (Pumar etal., 2014). However, identication
and treatment of these psychological comorbidities are
paramount: evidence shows that anxiety, depression, and
suicidality are not only highly prevalent among the COPD
population (Kunik et al., 2005; Stage et al., 2006; Sampaio
et al., 2019), but also are accurate predictors of poorer health
status, of increased risk of exacerbation, and of higher emergency
admissions (Blakemore etal., 2019). Studies exploring HRQoL
in stable and severe COPD cohorts have found clear associations
between anxiety and depression levels, and poorer quality of
life (Cully etal., 2006; Eisner et al., 2010). is is unsurprising,
given the vicious bidirectional nature of the relationship between
COPD and these psychological comorbidities (Atlantis et al.,
2013). On the one hand, breathlessness, chest tightness, and
increased respiratory rate are known inducers of anxiety (Kellner
etal., 1992; Tselebis etal., 2016), and the psychosocial adversity
caused by COPD can easily lead to depression (Alexopoulos,
2005). On the other hand, anxiety and depression are common
culprits for the acute worsening of chronic breathlessness, chest
pain, fatigue, and other prominent COPD symptoms (Atlantis
et al., 2013; Simon et al., 2013).
Interestingly, clinical and biological markers of COPD appear
to be less important determinants of depression than actual
feelings of breathlessness and subjective appreciation of HRQoL
(Hanania etal., 2011). At the same time, the impact of anxiety
and depression on HRQoL in COPD appears to bedecorrelated
from bronchiectasis and objective lung function (Engström
et al., 2001; Ekici et al., 2015). Overall, these ndings suggest
that improvements of HRQoL in COPD may depend on
therapeutic strategies that concentrate on patients’ subjective
and experiential correlates of the disease, or at the very least
takes them seriously into account.
HYPNOSIS FUNDAMENTALS
To the eects of the present review, it is more convenient to
privilege a procedural denition of hypnosis rather than to
navigate the long-standing theoretical debates on the nature of
the phenomenon (Terhune, 2014; Terhune etal., 2017). During
a standard hypnotic intervention, customarily a trained
professional (e.g., a researcher, a medical doctor, and a therapist)
delivers a suggestion (e.g., motor, cognitive, and aective) to
a receptor (e.g., the participant of a research protocol and a
patient). Usually, this suggestion is preceded by an induction
phase composed of relaxation and attention exercises, aimed
at producing experiential and motivational changes that serve
the purpose of enhancing the receptor’s permeability to suggestion
(Woody and Sadler, 2016). Much like placebo interventions,
hypnotic interventions work best when practiced within a socio-
cultural context that increases the receptor’s motivation and
compliance (e.g., a lab and a hospital; Lynn and Sherman, 2000).
When performed under these conditions, hypnosis elicits a
hypnotic response, which consists of the inhibition/facilitation
of all sorts of motor, sensory, cognitive, or aective responses.
For example, an inhibitory motor suggestion can successfully
induce paralysis and set o neurophysiological patterns dierent
from simulated paralysis (Cojan et al., 2009). On the other
hand, a facilitatory perceptual suggestion can eectively trigger
hallucinatory content for susceptible individuals (Woody and
Szechtman, 2011) or the onset of positive feelings (Gaunitz etal.,
1975). Figure 1 below presents a short summary with examples
of tested hypnotic suggestions, sorted by type, the function they
target, and the hypnotic response they are known to produce.
While there is no denitive answer on what are the cognitive
mechanisms behind hypnotic responses, reasonable consensus
has been reached that they rely primarily on cognitive control
and the top-down modulation of perception (Terhune et al.,
2017). Perception is built simultaneously by bottom-up sensory
information, and top-down conceptual information stemming
from prior world-knowledge and expectations (De Lange etal.,
2018). Crucially, it has been shown that, when purposefully
managed, top-down inuences can drastically shape perception
(Carrasco et al., 2004; Balcetis and Dunning, 2006, 2010).
Hypnosis would thus be a particularly powerful technique for

Anlló et al. Hypnosis for COPD Anxiety and Depression
Frontiers in Psychology | www.frontiersin.org 3 May 2022 | Volume 13 | Article 913406
the maximization of the top-down inuence in the building
of perceptual experience: instead of accessing the usual perceptual
priors triggered by standard contextual information, hypnotized
individuals rely on the hypnotic mental representations and
expectations conveyed to them through hypnotic suggestion
and use them to consolidate an alternate perceptual experience
instead (Brown and Oakley, 2004).
Concerning hypnosis’ neural substrates, much remains to
be uncovered. Yet, several studies coincide in pointing out
common brain correlates to hypnotic responding, such as (1)
reduced activity in the dorsal Anterior Cingulate Cortex, (2)
increased functional connectivity between the dorsolateral
prefrontal cortex and the insula in the Salience Network (Jiang
etal., 2017), and (3) reduced connectivity between the Executive
Control Network and the Default-Mode Network (Jiang et al.,
2017; Landry et al., 2017). At the neurophysiological level,
Jensen et al. (2015) have proposed that the changes detected
in theta oscillations during hypnosis may act as facilitators of
hypnotic responding.
Hypnosis has long been used with diverse therapeutic
purposes, such as introducing and reinforcing better adaptive
behavioral patterns (e.g., to diminish compulsory acting),
thinking patterns (e.g., to counteract depressive ruminations),
and emotional response (e.g., to induce calmness in the aermath
of trauma; Barabasz et al., 2010). Furthermore, hypnosis is of
great use for re-orienting attention away from aversive stimuli,
which has warranted it a particularly popular place in acute,
chronic, and perioperative pain management therapies (Patterson
and Jensen, 2003; Patterson et al., 2006; Patterson, 2010). It
can yield positive results when utilized as stand-alone therapy
but is most eective when implemented as a therapeutic
complement to an already established psychological treatment
or medical procedure (Ramondo et al., 2021). Oentimes,
practitioners wonder whether a hypnotic intervention’s ecacy
will be conditioned to the patients’ hypnotic suggestibility.
While, indeed, hypnotizability is the main predictor of successful
hypnotic responding in experimental hypnosis (Barnier et al.,
2021), suggestions posed in the context of medical treatments
are generally easy to follow and do not demand a particularly
high susceptibility (e.g., relaxation, searching for positive
memories, and evoking mental imagery). Further, existing
evidence has indicated that the success of hypnosis in the
clinical milieu depends primarily on patient motivation and
expectation (Barber, 1980), even when treating psychological
conditions as complex as anxiety and depression (Yapko, 2001).
Finally, evidence shows that the technique is safe, and the
risks associated with it (e.g., evoking bad memories and emotional
abreactions) are negligible (Lynn et al., 1996). Peer-reviewed
research on hypnosis safety suggests that the occurrence of
“negative” sensations following hypnosis is rare, and decorrelated
from suggestibility, which indicates hypnosis may not be at
the source of these feelings to begin with (Brentar etal., 1992;
Lynn et al., 1996).
HYPNOSIS AND THE COMPLEMENTARY
MANAGEMENT OF MOOD AND
RESPIRATORY DISORDERS
Over the past 30 years, eorts to assess the ecacy of hypnosis
as a therapeutic tool for the treatment of anxiety and depression
in a controlled manner have progressively mounted, with
favorable results. While less numerous, promising studies on
the use of hypnosis in respiratory medicine have also shown
that the technique can exibly target key respiratory symptoms
present in COPD.
A recent comprehensive meta-analysis including 13 randomly
controlled trials (RCT) has assessed the ecacy of hypnosis
for treating depression symptoms (Milling etal., 2019). Results
show that hypnosis samples presented a mean signicant
improvement superior to controls, both at treatment end (eect
size of improvement d = 0.71) and follow-up (d = 0.52). Such
an impact places hypnosis within the same range of ecacy
of other forms of treatment such as cognitive behavioral therapy
(d = 0.67) and short-term psychodynamic therapy (d = 0.69;
Cuijpers et al., 2011). Studies posterior to this meta-analysis
continued to conrm this trend. For example, Fuhr etal. (2021)
have shown no dierence in mean reduction of depressive
symptoms between hypnosis and cognitive behavioral therapy
aer 16–20 sessions, nor at the 6-month and 12-month follow-ups.
In a study comparing hypnosis to meditation and progressive
muscle relaxation in children with primary headaches, all three
methods were shown to reliably reduce depression symptoms
aer 9 months of treatment (Jong et al., 2019). Aravena et al.
(2020) also showed a signicant decrease of depressive
symptomatology aer audio-recorded hypnosis sessions in
patients with bromyalgia.
e evaluation of evidence concerning the use of hypnosis
for the management of anxiety is also positive overall. In a
novel meta-analysis, Valentine et al. (2019) analyzed 17 RCT
and found a mean signicant improvement of anxiety against
controls at treatment end (d = 0.79; d = 1.12 when contrasted
against no-contact controls) and during follow-up (d = 0.99).
Of note, hypnosis was at least as eective as cognitive behavioral
therapy (d = 0.82) and better than mindfulness meditation
(d = 0.39; Mitte, 2005; Blanck etal., 2018). Here as well, newer
studies on the ecacy of hypnosis for treating anxiety symptoms
as either stand-alone or complementary therapy indicate
intervention eectiveness. To name a few, Roberts etal. (2021)
FIGURE1 | Examples of hypnotic suggestions. Hypnotic and posthypnotic
suggestions can either inhibit or facilitate a vast array of motor, perceptual,
cognitive, and affective responses. Examples are provided together with
studies evaluating their implementation and phenomenology.

Anlló et al. Hypnosis for COPD Anxiety and Depression
Frontiers in Psychology | www.frontiersin.org 4 May 2022 | Volume 13 | Article 913406
have shown support for the use of hypnosis to reduce symptoms
of anxiety among postmenopausal women. Roberts etal. (2021)
indicate that hypnosis is a suitable adjunct in Crohn’s disease
and may improve general psychosocial QoL, including anxiety.
Concerning the use of hypnosis specically targeted at
respiratory diseases, evidence has been somewhat scarce, but
equally promising. Hypnosis-based psychodynamic treatments
were proven eective for reducing anxiety and depression in
amyotrophic lateral sclerosis patients with impaired respiratory
function (Kleinbub et al., 2015). Further examples include
hypnosis for improving breathlessness in pediatric medicine
(McBride et al., 2014), asthma (Brown, 2007), and palliative
care (Brugnoli, 2016; Montgomery et al., 2017). While no
meta-analysis has been conducted to date, the observed main
benets of incorporating hypnosis to the management of
respiratory conditions include relief of anxiety related to
ventilation problems, alleviation of discomfort, and improvements
in breathing regulation (Anbar, 2012).
In the specic case of COPD, hypnosis has been used almost
exclusively as a relaxation technique (Cafarella et al., 2012).
To our knowledge, there is only one RCT evaluating the use
of hypnosis to manage anxiety and breathlessness in COPD
that implements a relaxation control (Anlló et al., 2020). is
crossover study has shown that a 15-min scripted hypnotic
intervention positively impacted respiratory rate, pulsated oxygen
saturation, Borg scores, and anxiety (as assessed by State–Trait
Anxiety Inventory – 6 items version).
Interestingly, as of 2022, many new trials assessing the
impact of hypnotic interventions on depression and anxiety
symptoms are currently in progress, which shows that the
technique continues to accrue interest in the medical community
(e.g., Anlló etal., 2021a; Grégoire etal., 2022; Fernandes etal.,
ongoing NCT04010825). In particular, at least two of these
ongoing trials are targeting the use of hypnosis specically
for the psychological and emotional correlates of COPD (Anlló
et al., 2021b; Fernandes et al., ongoing NCT04010825).
DISCUSSION
While hard to disentangle, it is important to understand the
separate roles of each of the building blocks of hypnosis as
an intervention. Treating the technique as a monolithic
interventional battery hinders our understanding of its real
potential in respiratory medicine. For example, when
implemented in respiratory medicine, and particularly in COPD,
hypnosis has been mostly used as a form of “relaxation therapy”
(Cafarella etal., 2012; Tselebis etal., 2016). Certainly, hypnotic
inductions oen include relaxation exercises (Batty etal., 2006),
and of course, the implementation of hypnosis and other forms
of guided mental imagery as a form of relaxation is benecial
in and of itself (Hammond, 2010; Volpato et al., 2015, 2022).
However, as explained above, hypnotic eects depend primarily
on the contents of suggestions (Figure 1), which are
fundamentally independent from hypnosis’ relaxation component
(Cardeña etal., 2012). us, a dierent use of hypnosis, where
the emphasis is shied toward tailoring suggestions to generate
sensory and experiential changes that modify the subjective
experience of patients (Elkins, 2017), could represent signicant
progress in the complementary management of the physical
and psychological symptoms of respiratory disease. For instance,
Anlló etal. (2020) hypothesized that these perceptual modulations
could be implemented to optimize breathing mechanics and
reduce anxiety by suggesting a feeling of “air eortlessly entering
the lungs.” ere, a 15-min scripted hypnotic intervention
positively impacted transient anxiety in mild and severe COPD
patients (23.8% aer hypnosis versus only 3% aer the “relaxation
and attention” control). Crucially, it also improved respiratory
rate, arterial oxygen saturation, and Borg scores. We think it
is plausible that this across-the-board eect may respond to
the endogenously generated sensory feedback produced by the
hypnotic suggestion. While promising, more evidence is needed
to support this conclusion.
Wide consensus exists concerning the fundamental importance
of Pulmonary Rehabilitation Programs (PRPs) for improving
the clinical outcomes and behavioral patterns of COPD patients
(GOLD Report, 2022). Comprehensive PRPs frequently supplement
physical activity with short psychological therapy plans and self-
management strategies. ese have been shown to improve the
psychological symptoms associated with COPD and decrease
the risk of exacerbation regardless of disease severity (Coventry
et al., 2013; Gordon et al., 2019). Beyond its proven clinical
impact, hypnosis could greatly help with the logistic and
implementational limitations that encumber PRPs (Ranjan etal.,
2021). Hypnosis does not need hey material or technological
investments, its implementation is fast, and patients can obtain
clinically signicant relief even aer short sessions (Anlló et al.,
2020). Further, recent eorts assessing the feasibility of online
PRPs have produced encouraging results (Beatty and Lambert,
2013; Ranjan et al., 2021). Given how hypnosis is also eective
when administered through recordings and online, this renders
it a suitable complement to this approach (Flynn, 2019).
Additionally, most implementations of hypnosis eventually
transition into self-hypnosis (Barabasz etal., 2010), which makes
it a potentially useful technique for the self-management of
COPD symptoms (Lenferink et al., 2017).
Given this array of advantages, we propose that an
understanding of how the eects of hypnosis and self-hypnosis
interact with COPD-related breathlessness, anxiety, and
depression is worth considering. In particular, in patients
who manifest a strong preference for drug-free approaches
or have a mitigated response to pharmacological strategies.
It could also be advantageous for patients who present an
inability to exercise or to relax by their own means. Of course,
further research in the form of new RTCs is needed before
hypnosis can beendorsed conclusively for the complementary
management of anxiety and depression in COPD: we still
know little about hypnosis’ eectiveness across levels of disease
severity, its interaction with lung function, its interaction
with antidepressants, and patients’ willingness to adhere to
a hypnosis-based treatment. However, given the existing
evidence and current challenges in the treatment of COPD,
we conclude that the eort of answering these questions is
clearly justied.

Anlló et al. Hypnosis for COPD Anxiety and Depression
Frontiers in Psychology | www.frontiersin.org 5 May 2022 | Volume 13 | Article 913406
AUTHOR CONTRIBUTIONS
HA, FL, and BH conceived the outline of the article and
determined which were the important aspects to be covered
in this mini-review. HA wrote the manuscript under the
supervision of BH. HA and BH conducted the qualitative
literature search. FL provided additional feedback and evaluated
the feasibility of the review. All authors reviewed the manuscript,
contributed with hands-on amendments and critical feedback,
and validated the nal dra.
FUNDING
is study was funded by the Bligny Hospital Center (CHB)
and a standard support grant from Helebor Foundation (Paris,
France). HA’s contribution to this work was supported in part
by the Department of Cognitive Studies at Ecole Normale
Superieure de Paris, PSL University (ANR-10-LABX-0087 IEC
and ANR-10-IDEX-0001-02 PSL).
ACKNOWLEDGMENTS
e investigators thank the invaluable material contributions
of the Helebor Foundation (Paris, France). ey would also
like to thank Dr. Caroline Dupont, Mr. Jean-Louis Di Tommaso,
and all the personnel of the Centre Hospitalier de Bligny for
their help in making this prospective trial possible. We would
like to specially thank Agathe Delignières, Yolaine Bocahu,
Isabelle Segundo, and Dr. Adelina Ghergan for their continuous
support. Wealso extend our sincere gratitude to all the patients
who will in time participate in this trial and enrich its protocol
with their input and feedback.
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