Anxiety and anxiety-related conditions are the most common psychological afflictions of man and account for a major percentage of initial complaints to psychiatrists as well as to general practitioners. Although it is estimated that some 5% of the population may suffer from acute or chronic anxiety, with women outnumbering men two to one (Cohen and White, 1950), the numbers are probably significantly higher.

As a symptom, anxiety is a final common pathway for many conditions, physical as well as psychological. As syndromes, anxiety disorders are under intensive study to define more precisely their etiologies and clinical outcomes. Recent studies, showing disturbances of lactate metabolism in certain anxious individuals, point to the possibility that some anxiety states, like some depressive states, have strong biological and genetic determinants.

Hypnosis finds its most common clinical utilization in the treatment of anxiety and its related states, not only because of anxiety's prevalence, but because hypnosis has such a clear role as a potent anti-anxiety agent. In this chapter, we will examine hypnotic behavioral approaches to anxiety, while hypnopsychotherapeutic approaches will be discussed in Chapter 14.

The first task of the hypnotherapist is to evaluate the anxiety condition. At the end of the initial interview, several questions must be asked. Is the anxiety organically determined? Is there a medical, physiological, or otherwise somatic basis for its existence? The list of medical conditions which, as a by-product, contain anxiety is long: hypertension, cardiac arrhythmias, anemia, hypoglycemia, withdrawal from sedative hypnotics (including alcohol), and caffeinism, cocaine, and psychostimulant abuse, among others. Anxiety is also sometimes confused with medical conditions which, in their presentation, share its expressions. Coronary artery disease, with chest pain, respiratory distress, and cardiac symptoms can mimic anxiety states; so can hyperthyroidism, pheochromocytomas and Meniere's disease. The treatment, while not obviating adjunctive psychotherapeutic or hypnotherapeutic intervention, will of course be mainly aimed at treating the primary medical condition.

Is the anxiety an aggravating component of a chronic medical syndrome? Most psychosomatic conditions are intimately connected to anxiety and stress. Flare-ups of such diseases as peptic ulcer, ulcerative colitis, or hypertension produce anxiety. Conversely, difficulties with psychosocial adjustment bring exacerbations in these conditions. Anxiety control is important to ease the interactive play of psyche and soma.

Is the anxiety a part of another psychiatric syndrome? Anxiety weaves into most psychiatric syndromes. Major depression is rarely seen without it, and so is mania. Schizophrenia, especially in the decompensation phase, as the individual experiences ego fragmentation, can be marked by fright--as can organic brain syndromes with their cognitive disruptions. Treatment of anxiety in these conditions is centered on correcting the global psychiatric syndrome.

When medical conditions and major psychiatric syndromes are eliminated as reasons for anxiety, we are left with more functional causes. It is useful, in our therapeutic approach, to see patients' experiences of anxiety as falling into three general categories: (1) individuals reporting chronic, free-floating feelings of fear (generalized anxiety disorder); (2) individuals manifesting discreet episodes of panic, but who, in between attacks, are relatively anxiety free (panic disorders); and (3) mixed syndromes.

There are other syndromes which contain anxiety as a core experiential manifestation.

Phobias are differentiated by the fact that they happen in the context of identifiable situations. They are marked by anxiety and avoidance. Thus agoraphobia is manifested in environments where the individual feels trapped and unable to return to safety, ie, common places include elevators, subways, planes, tunnels and bridges. Social phobias appear in interpersonal situations; and simple phobias are persistent, irrational fears of specific objects or animals. Phobias may be mildly bothersome or severely incapacitating. There are individuals who stay imprisoned in their homes because they fear the anxiety they may experience if they venture outside.

Posttraumatic stress disorders, acute or chronic, have generalized anxiety as a major component of a constellation of somatic and psychological disturbances following an accident, a loss, or any other disaster.

Obsessive compulsive disorders are characterized by tension stemming from the conscious emergence of thoughts, desires, and wishes to perform certain actions, and attempts to deny, ignore, undo, or suppress them. When severe, the anxiety becomes generalized, chronic, and incapacitating.

Adjustment disorders represent maladaptive responses to identifiable psychological stressors. Predominant symptoms in adjustment disorders with anxious mood, are nervousness, worry, and jitteriness.

Generalized anxiety disorder (DSM-III, 300.02) is characterized by pervasive, persistent anxiety, manifested by motor tension--strained facies, fidgeting, restlessness, fatigueability; autonomic hyperactivity-sweating, palpitations, light-headedness, paresthesias, upset stomach, lump in the throat, high resting pulse and respiratory rate; apprehensive expectation--worry, rumination, anticipation of misfortune to self or others; hyperattentiveness resulting in distractibility, difficulty in concentrating, insomnia, irritability, and impatience. To meet diagnostic criteria, the anxious mood has to have lasted at least a month.

Approaches to chronic generalized anxiety, which may incorporate hypnotic intervention, may be roughly grouped into analytic or behavioral types. Hypnoanalytic methods will be explored in a later chapter. Behavioral techniques do not necessarily exclude the importance of psychodynamic factors but rather, as in the case of anxiety, treat them as incidental to the illness itself, ie, anxiety is not a reflection of an underlying disorder, it is the illness; as a learned maladaptive response it needs to be unlearned. In this model, anxiety, once removed, is not replaced by other symptoms. In clinical practice, however, it is observed that some symptoms occur in a learned maladaptive model, others in a conflict-generated model, and the rest as admixtures of the two. Hypnosis may be woven into most behavioral techniques. In this way, the therapeutic potential of both disciplines may act additively, if not synergistically.

The following methods can be applied to the treatment of the generalized anxiety syndrome.

While neutral hypnosis already assumes generalized relaxation, special hypnotic procedures can allow for its amplification.

The therapist will want to know the anxiety's signature in his particular patient. Where is the anxiety in the body? With what words can it best be described? Does it restrict breathing, speaking clearly, thought, motor performance, or coordination? These notions are important because, during the course of relaxation training, the therapist may choose wording and imagery accordingly. The subject who feels, for example, a burning sensation in the abdomen as an anxiety equivalent, may be asked to imagine sensations of coolness to counteract it; to someone whose anxiety comes out as tightness in the neck muscles, sensations of warmth in these areas may be suggested.

It may be explained to the patient before the induction that relaxation is both a physical and a mental state. It is pointed out that the body, in relaxation, feels slowed down and reluctant to move, the visceral spaces are experienced as comfortably rested, and breathing and heart rate attain natural baseline rhythms. Psychologically, the mind progressively feels detached from concerns, worries, and current stressful emotions.

Asking the subject, "What would you feel like if you were totally and deeply relaxed?" is a useful avenue to explore. In addition to misconceptions in need of modification, the responses may point to useful avenues for tailoring the hypnotic process to powerful preconceived notions.

Knowing that the purpose of hypnotherapy for our patient is relaxation training, the induction is geared to maximizing it. Suggestions are given for feelings which regularly accompany relaxation, ie, restful heaviness of the body. Similarities are drawn to states of mind the subject is already familiar with, which in themselves contain relaxed feelings, ie, daydreaming, reveries, or sleep. At the end of the induction, when the subject has already achieved significant tension reduction, appropriate deepening procedures are used.

The therapist should have at his disposal several procedures for the amplification of relaxation. Some may turn out to be much more effective than others; however, since there is no reliable way to predict beforehand which deepening technique will be most efficient, a trial-and-error approach often has to be attempted. The following techniques are commonly used to dissolve anxiety in the context of the hypnotic trance.

Direct suggestion. Direct suggestions for generalized relaxation in the subject who achieves a light to medium trance is often sufficient to attain desired results. Suggestions for total body relaxation, for letting go of tensions, physical and mental, are most effective when rhythmically timed with respiration.

In the same way that anxiety is experienced differently by each individual, so is relaxation. It is important, at the end of the first session, to ask how relaxation manifested itself. If, for example, feelings of floating or drifting were elicited, these same feelings can be directly searched for, brought forth, and expanded in the following sessions for faster induction and further deepening.

Counting method.Some individuals respond best to a counting technique. Many variations of this technique exist. It is explained, for example, that as slow counting progresses from 1 to 20, relaxation will become more and more profound, 20 representing the deepest level of relaxation the subject can attain during the session.

Counting with imagery. Counting may be combined with imagery. For example: "As I count from 1 to 20, you can see yourself walking down 20 steps into the garden of your subconscious mind. In your garden, you will find wonderful feelings of total relaxation flowing throughout your body."

Progressive relaxation. Some subjects are most responsive to a stepwise and methodical method. Individual muscle groups are focused on, starting from the lower extremities or from the head and neck, until all muscle groups are relaxed.

Autogenic training. The production of relaxation in many individuals is facilitated by suggestions or feelings of heaviness and sensations of warmth in the body (see autogenic training, below).

Pure imagery. Imagery techniques for relaxation are the most idiosyncratic of all methods. While, for example, the image of a beach may be attractively soothing for one person, it may leave another indifferent. Preliminary discussions will give the hypnotherapist some idea of what constitutes positive imagery for his patient. During hypnosis, the art of giving imagery suggestions resides in good part on the utilization of multiple sensory modalities--in a beach image, for example, a more engrossing effect can be created by talking about the sights, sounds, smells, and sensations one is likely to experience in such a setting.

Use of touch Touch, properly used and timed, is a powerful focusing modality for the patient. In the same way that touch may be used to induce analgesia in parts of the body, it may also be applied to suggest deep feelings of relaxation. For example: "As I touch your shoulder, your entire arm becomes deeply relaxed, all the way down to your fingertips. I'll touch your other shoulder and now your forehead; as I do, feelings of deep relaxation begin to drift throughout your body."

Autogenic training is a method of psychophysiological selfeducation containing elements of both hypnosis and meditation. The first of many editions of Autogenic Training appeared in 1932. Its author, J.H. Schultz, a German psychiatrist and neurologist, was influenced by research on sleep and hypnosis performed by Oskar Voght at the Berlin Institute some 30 years before. Voght observed that some subjects could produce in themselves states of mind similar or identical to hypnosis by performing certain exercises; and that these self-induced states had therapeutic value--subjects reported improvements in well-being, disappearance of headaches, lowering of anxiety level, and reduction of fatigue and tension. Voght called these exercise "prophylactic rest--autohypnosis."

Schultz streamlined the exercises. He found that most deeply hypnotized subjects invariably experienced sensations of heaviness and warmth in various parts of their bodies and postulated that the creation of these sensations, in a reverse psychophysiological process, could bring about the experience of the trance state.

A series of exercises was designed, in a format of increasing difficulty, and their practice gathered many followers throughout the world. The first of these are physiologically oriented, focusing on the neuromuscular and visceral systems. Subjects are asked, in exercises of introspective creative imagination, to produce sensations of heaviness and pleasant warmth in the limbs--it is easiest initially to produce them in these areas--then in the chest and the abdominal regions. Once mastered, usually after six to 12 months of training, subjects graduate to meditative exercises, which focus on the development of certain higher mental functions.

Preliminary instructions are for the use of a quiet dimly illuminated room, free of disturbances. The subject, in loose clothing, may adopt a fully reclined, semireclined, or a simple sitting posture.

First stage--eyes are gently closed. A gentle bodily introspection eliminates obvious internal muscular tension. The sensations of heaviness of the dominant arm, as it lies on its support, is brought to awareness. Some people find it helpful to repeat silently "my arm feels heavier and heavier." When heaviness is experienced throughout the arm, the same feeling is extended into the other arm through, as Schultz described, a process of generalization; the legs come next, the back, and the regions of the head and neck. When the whole body is experienced as being heavy, the second stage is attempted.

Second stage--warmth. For most people, feelings of heaviness are more easily conjured than those of warmth. The same process used to create feelings of heaviness is applied to feelings of warmth, first starting on one extremity, then progressing to the whole body, except for the forehead and temples which are imbued with sensations of coolness. Autosuggestions may help, ie, "my arm feels warmer, pleasantly warm," and imagery may be used, "my body feels like it is resting on the warm sands of the beach."

Third stage--regularization of cardiac rhythm and respiration. The object of this stage is not to seek control of cardiac rhythm, as is the aim of some yoga exercises, but to effect a slowdown and regularity of heart function which is congruent with total relaxation. Deep hypnotic and meditative states are accompanied by lowered metabolic work, decreased oxygen consumption, a slow (50 to 60 beats per minute) heart rate, and slower, more abdominal respiration. In the practice of the third stage, awareness is centered on the internal sensations of cardiac pulsations--a hand may be placed over the precordium--and self-instructions are given to help these desired results.

Fourth stage--centering on the upper abdominal region. Borrowing from ancient meditative exercises, the subject, having mastered the previous steps, is guided to center a relaxed attentiveness on the upper abdominal regions.

Reported effects of autogenic training. Effects of autogenic training are subjective as well as objective. Veteran practitioners talk about a generalized sense of well-being, feelings of energy and stamina, and relative freedom from symptoms commonly associated with stress. Objectively, during autogenically induced states as in meditative states, there is evidence of autonomic and metabolic slowdown.

While Schultz elaborated his method in Berlin, Germany, Jacobson in the United States worked towards similar goals but through different routes. His method is based on observations that the mere thought of a muscular action brings on electromyographic changes. This, he pointed out, bespeaks of a direct relationship between muscular tonus and psychological tension. For the purpose of achieving relaxation at cortical levels, Jacobson developed a methodical technique involving the progressive relaxation of all muscular groups in the body. Jacobson's method, for proper execution, requires a minimum of six months of training.

Methodology. Starting from the tip of one extremity--the right hand, for example--the individual is guided to move his awareness to the wrist, the forearm, in deliberate succession, to cover eventually the totality of the musculature. To help in focusing awareness and to enhance the experience of relaxation, each muscle group is sometimes tensed, then relaxed.

Hypnosis may be used with Jacobson's or modified Jacobson's techniques to stimulate progress. Conversely, and much more frequently practiced, are modified Jacobson techniques used in the context of the hypnotic trance to achieve progressively deeper states of relaxation.

Through modern biotechnology, many methods of selfmonitoring have been developed and applied to the treatment of conditions such as tension headaches, anxiety, neuromuscular rehabilitation, enuresis, hypertension, Raynaud's disease, migraine, asthma, cardiac arrhythmias, bruxism, and epilepsy, among many others.

Applications to anxiety control and to the learning of relaxation states include electromyographic (EMG), galvanic skin response (GSR), thermal, and EEG biofeedback. Due to the fact that anxiety has different manifestations in different individuals, one physiological parameter may be much more useful for anxiety control than another. In some subjects, for "ample, whose surface expressions of anxiety are translated into muscle activity, EMG training will have greater applicability than, let us say, thermal feedback.

While some individuals do well with biofeedback for anxiety control, others have difficulty generalizing the effects of training to the totality of their experience. Some investigators point out that certain subjects may be able to learn deep muscle relaxation, yet continue to report significant anxiety. Orne and Paskewitz (1974), in studying EEG feedback showed, similarly, that patients could generate high alpha rhythm and still experience debilitating anxiety. These results contradicted the idea that low EMG or high alpha were always incompatible with anxiety.

Some investigators, for purposes of increasing the efficacy of biofeedback treatment, have combined it with hypnosis (hypnobiofeedback). Since hypnosis can facilitate restriction of the field of awareness and promote introspective centering, it is theorize that biofeedback learning can be enhanced and accelerated in the context of a hypnotic state. While this turns out to be true for some subjects, it is not so for all. More sophistication is awaited in this potentially fruitful field, since there is still a paucity of studies using these treatment combinations.

In the past three decades, systems of self-training adapted from Eastern cultures, have been practiced on an increasingly large scale in the Western world. The process of meditative training can be seen from different perspectives. From the viewpoint of state theorists, meditation can be understood as a body of methods designed to guide the individual into special conditions of consciousness. Seen from a behavioral perspective, meditation can be conceptualized as a physiological learning process, designed to bring about autonomic slowdown and anxiety control.

In 1935, Dr. Therése Brosse, a Frenchwoman, traveled to India with a portable ECG machine. She hooked up her machine to a veteran meditator and demonstrated that cardiac rhythm could be influenced by willfulness. The ECG showed a complete volitional stoppage of the heart for a few seconds. Modern experiments have not only replicated the above effects, but have shown wide-ranging bodily manifestations of meditative training: a toning down of all physiological functions (decrease in heart rate and respiratory rate among others), and of metabolism itself (decrease in oxygen consumption and lactate production) (Wallace 1970).

In spite of considerable interest in meditative training, there remains some confusion in the face of the number of techniques available; there have also been difficulties applying methods meant to be practiced in a sociocultural context so different from our own. In the United States, most of the experimental work has been done with transcendental meditation (TM).

In the technique of transcendental meditation, the subject sits comfortably, eyes closed, for 20 minutes twice a day and maintains persistent awareness of a rhythmically repetitive--usually unspoken--mantra or sound. A universally used sound is "Om," but the word one, which has a similar symbolic meaning, may be substituted.

Studies of TM demonstrate that it stabilizes autonomic functioning and lowers physiological arousal. In addition to its somatic effects, TM is reported to produce ongoing psychological changes such as the positive restructuring of self-concepts, the attainment of feelings of inner peace, and the stabilizing of mood. In addition, veteran meditators describe experiencing poorly definable or describable feelings of mood states, which may be termed states of transcendence.

To be effective, this meditative technique needs to be practiced on a long-term basis. Studies have shown that short-term meditation is no more effective than placebo.

In describing the subjective experience of the hypnotic trance, mention was made of alterations in the sense of time flow and of sensations of relative removal from the bonds of the external reality situation. Usually, there is less or no perceived need to move physically, attention is withdrawn from concerns with bodily motion and balance, and there is less or no need to interact socially. Yet, in hypnosis the individual still feels a presence and has awareness of the rapport with another person--that being the hypnotist. In hypnosis, the elements of this relationship are intertwined with the experience of the trance. In hypnosis, part of the patient's psyche is linked to the hypnotist's psyche, in a process of dynamic communication. The hypnotist may communicate with one part of the subject's self, then with another, but there is always a bridge. In the subjective experience of the subject, he or she is not "free." Although the hypnotist may be very permissive, very choice-giving, the confines of the relationship remain.

Self hypnosis brings more autonomy. The link of rapport is broken and a more conscious part of the psyche gives suggestions to another more unconscious part. Usually, self-instructions are fairly specific and invite or reinforce personal change.

Sometimes the individual enters a hypnotic state and does not give himself or herself specific suggestions or directions. This is called neutral hypnosis, a state marked by relaxation, free-floating imagery, and dream fragments or sequences. In neutral hypnosis, the sense of control floats, undirected. The subject may observe and remember or not observe and not remember. It is an unstructured trance state.

If we add one ingredient to this trance state, we have meditation. That ingredient is directed watchfulness.

The meditative trance is similar in quality to the self-hypnotic trance. In meditation, however, the individual starts out with no overt trance-inducing signal, but rather, the resolve to begin, and focuses the observing ego on a part of the body (eg, the solar plexus), a sound (mantra), a symbolic image (mandala), a spiritual feeling, or a universal idea.

Indications for meditative training. Although, like most therapies, meditative training has been claimed to relieve many somatic and psychological disorders, its clearest and best documented indication is in the treatment of generalized anxiety.

Demands of meditative training. Meditative training takes dedication, motivation, daily practice, patience, and requires a certain soundness of mind from the practitioner. It is not for everyone because it demands an ability to develop a certain mind set of internal relaxed watchfulness, an ability to learn to deal with thought intrusions, and a capacity to accept intermittent progress.

The following case history illustrates the use of clinical meditation.

A 48-year-old businessman came for treatment of anxiety. He mentioned distressing tightness in his chest and an uncomfortable feeling of heat in the upper abdomen. He described a clinical picture typical of a generalized chronic anxiety disorder which he had tried to live with for over a year. He could not recount any significant antecedent changes in his life. A complete medical check had shown no abnormality--even his blood pressure was normal. Surprisingly early during the course of the evaluation, he wanted to talk about treatment options; he had done some thinking and reading on his own and had already come to some decisions about what he did not want. He would refuse medications and was not prepared to spend much time with analytical methods. When hypnotic relaxation training was mentioned, he replied that he did not like the idea of it either. Options were dwindling. He had heard of meditation, and he felt interested and comfortable with this suggestion. The fact that during training he would be "in control" especially appealed to him.

After a preliminary relaxation exercise--a shortened Jacobson technique--he was asked, as he sat calmly, eyes closed, to send his awareness into his upper abdominal region and simply to leave it there for a few minutes. Thought intrusions, he was told, were frequent and were best dealt with by noticing them, letting them pass, and returning to the focus of meditation. He was asked to terminate the experience himself, at his discretion, by simply deciding to do so. Five minutes later, he opened his eyes. The gnawing burning feeling in his abdomen had decreased "by at least half," and his chest cavity felt considerably "lighter." Home. practice consisted of two 10-minute sessions a day (this form of meditation is more demanding than TM because more thought intrusions are usually experienced). Six weeks later, he reported a very satisfactory diminution of anxiety symptoms with frequent periods of total clearing.

The most frequently treated phobic disorder is reported to be agoraphobia. The first episode typically occurs in the teens or early 20s. It is so dramatically frightening that all the details of the experience as well as the exact date of occurrence are clearly remembered. A second episode usually occurs several weeks or months thereafter, and increasing anticipatory anxiety, avoidance, and progressive withdrawal develop to the point where, several years later, it is not unusual for the patient to have assumed psychological invalidism. The patient may remain confined, chronically fearful, and depressed. In such patients, there is reported a much higher incidence of alcoholism, hypertension, cardiac illness, and suicide.

Treatment of this disorder has been shown to be most successful if it is multimodal. Pharmacotherapy may include tricyclic antidepressants, monoamine oxidase inhibitors, or alprazolam for the panic attacks; and benzodiazepines for anticipatory anxiety. In addition, beta blockers may be used. Psychotherapy and family therapy address themselves to support, insight and working through. Finally, behavior therapy and hypnosis round out the overall treatment process. Hypnosis is used to decrease anticipatory anxiety, improve self-esteem, raise motivation, and teach the patient that he may regain control over the relaxation process.