Phobia and Post-Traumatic Stress Disorder

Definition of Phobia

Marked and persistent fear that is excessive and unreasonable, and is often recognized by the patient as such.(not always so in children)

Anxiety disorderLearnedSimple (very rare)Complex (social phobia, agoraphobia): meaning: feel bad about self

Features:

Highly “hypnotisable”Consistent: anxiety is circumstantial (trigger), and often anticipatoryArousal (CASE)AvoidanceHypervigilanceDisturbance of functionNot part of another disorder>6/12

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Rationale for using hypnosis

Based on assumptions:

The phobia is a learned response to an earlier perceived threat that can be resolved by re-exposure in controlled circumstances Hypnosis provides a safe environment for imaginal exposure to the feared trigger/stimulus

Intervention can resolve the hypnotically reproduced fear

Resolution can be then transferred to the original trigger in vivo

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Techniques

Preparation work

Psycho-educationExplanationPermissionResourcingSet-up hypnosis ( your state, rapport, space, concordance,

compliance)

Direct symptom control

Anchors for relaxation.Abdominal respiration Self-control techniques: Breathing Self-talk Special Place

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Correcting attentional biases

Attention-switching strategies :

Normalisation of attention (vs hypervigilance), DistractionAmnesiaImagery (in vitro to replace in vivo:

covert (=imaginal) modelingcovert reinforcement)

Paradoxical injunction anchors for relaxation, analgesia, anaesthesiaEgo-strengtheningEgo-shrinking Future rehearsal Post–hypnotic suggestion.

Correcting interpretive biases

Cognitive restructuring. Help patient gain a more rational and realistic appraisal of their situation, thus reducing the perceived threat.

ExplanationReframingImaginal rehearsal and cognitive restructuringSystematic DesensitizationFloodingModelling

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Psycho-dynamic issues

Regression techniques (e.g. Alden’s Bubble, Affect Bridge) can be helpful in addressing traumatic memories.

If the patient’s symptomatology includes a description of a feeling of emptiness inside, and simple outcome-based approaches have not helped, an exploration of psychodynamic issues and their resolution may often produce the shift required to help them move on. This emptiness echoes Freud’s primitive wound; often the result of a failure of secure attachment relationships in childhood.

Group work

Mutual support: good with phobias

Good evidence base for use of hypnosis with agoraphobia, social phobia, driving needles, hospitals, vomiting, dentist.

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On the spot

Dissociative Strategies

Useful for “procedures”

Anticipatory anxiety and related phobic responses can be dealt with in advance with the techniques above.

When the patient is about to undergo the procedure, some patients find it helpful to separate themselves from the site of, for example, an injection at the point at which the insertion of the needle takes place.

“That arm no longer belongs to me”.

Invite the patient to go to their special place and leave their arm behind, mouth behind etc. for the clinician to work on while they are away.

An alternative is to use hypnosis to create an area of anaesthesia.

These techniques do not have much impact on the phobia, and do not reduce the avoidance behaviours and anticipatory anxiety, but are helpful when the patient has reached the point of being able to commit to the procedure.

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Conscious/Unconscious Split

It is important that any exposure-based intervention carried out for an anxiety disorder keeps the patient in contact with the feared or anxiety-provoking situation and does not serve simply as another form of escape or avoidance. There is a risk of this when using “special place” as it may remove the patient from reality-testing. This can be avoided by using anchors to achieve the relaxation response.

A useful strategy is to suggest the patient engage in an unconscious/conscious split. Suggest that the wide-awake, front, conscious part of their mind remains completely in touch with the current, anxiety–provoking experience, while the deeper (or ‘back’ or ‘unconscious’) part of their mind, the part that ‘controls all the things they do automatically without thinking, such as controlling breathing, tension in their muscles, their heart rate etc. etc.’ can ‘take some time out’ (or whatever phrase you prefer) to go to their Special Place and find calm, relaxed and comfortable feelings.

Suggest their anchors can enable them to access the deeper parts of their mind to assist in this process, and that they can use the breathing pattern they use for their self-hypnosis to deepen the relaxation that part of their mind is experiencing.

Use an anxiety scale (SUD) to take self-reports throughout the procedure to calibrate, monitor and identify when an appropriate point to proceed has been reached.

Once the scale is calibrated do not use the word “anxious” or similar anymore. Say “What is the number (for how that feels) now?”

Reinforce the process by saying something along the lines of: “as the deeper part of your mind finds the relaxed and calm feelings the alert part can be even more focused and efficient at dealing with the situation you find yourself in, especially now that it is no longer distracted by the unwanted feelings’.

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Specific situations

Scanner

safe place hallucinate protective, pleasant bubble:

dimensions acceptable to the patient. Lack of control: Mental rehearsal of success

Phlebotomy (hypotension)

Clenched fist

Complex phobias

cognitive component : patient has attached (negative) meaning to experience: feel bad about self. Performance anxiety an example

Approach: as above

Preparation/resourcingLearning: ? “Causal event”. Trigger desensitisation

Plus: ego-strengthening self-confidenceAddress wider psycho-social issues Ego-shrinking: dissassociaton, noticing no-one taking any notice

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Outline of Method

Preparation, explanationPermission InductionDeepeningAnchors : Safe Place, calmness , relaxation, confidence ,

resourcesPermission revisited: ideo-motor signals, calibration

Identify and dissociate from target

Resolve (what did they need to know? What did they need to learn)

Gratitude to protective part

Desensitise (Wolpe)

Distress reduces with repeated, increasingly challenging, imaginal exposure

Future rehearsal

Post-hypnotic suggestions

Parts integration (catatonic arm)

Reorientation

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Post-Traumatic Stress Disorder

First described by Ancient Greeks

Pierre Janet (1839-1947) 5000 patient study of psychological impact of traumaTraumatic memories have “all or nothing” characterTrauma is often decontextualized and mis-labeled in its historical context

Freud: (1856-1939) “This man is suffering from memories”

Features

History of serious traumatic event

Distressing flashbacks: visual, emotional, nightmaresHyperarousal/hypervigilance/generalized anxiety disorder/insomniaNumbing of emotions (dissociation)AvoidanceAngerFear, forgetfulness, depression, alcohol/substance abuseSignificant functional disturbance (social, occupational etc.)

Duration:

>1/12 (<1/12: acute stress disorder, adjustment disorder)Acute: <3/12Chronic<3/12

Response: CASE Cognitive, autonomic,somato-sensory, emotionalReduced cortisol levels

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Aetiology

75% traumatised people de-traumatise without interventionDream it out, talk it out, contextualise it

25% develop PTSD

EMLI

Traumatic event

Freud (1839-1947) “An experience which within a short period of time presents the mind with an increase of stimulus too powerful to be dealt with or worked off in the normal way”

Meaning

There is nothing either good or bad, but thinking makes it so. (Shakespeare)

Landscape

Co-existing psychiatric issues: anxiety, panic disorder, depression, increased hypnotisability (? cause?effect))

Inescapability

Perceived inescapability

3 factors particularly pre-dispose:

Anxious alreadySignificant traumaMore hypnotisable (phobias the same)

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Pathology

Dysfunctional storage of memory

Trauma dissociates cognition from soma: the patient knows they are safe but do not feel it.

The body keeps the score. The Unconscious always wins.

Amygdala hyper-active (implicit (autonomic )memory) and dominates cortical activity.

Medial pre-frontal cortex (conscious awareness, explicit memory) smaller and less responsive, also reduced volume of hippocampus and reduced neuro-transmitter levels (memory storage)

Structural changes: post-traumatic stress injury

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Patient selection: who needs help?

1.Can they talk about it?

Critical incident debriefing: getting people to talk about the trauma: 75% will recover anyway. For the 25% who get PTSD: talking about it re-activates it and embeds it deeper.

If victim debriefed in a state of high emotion, the process can increase the arousal to the point of overload, trapping the sensory impressions in the amygdala.

2. Does it still feel recent?

3.Do even nebulous reminders set off "flashbacks"?

i.e. Does even the vaguest reminder set off a huge panic response

Simpler: Does the patient experience recurrent, sudden unpleasant images, feelings or emotions, oftne for no apparent reason?

If so, tidying up the debris from some past trauma oftenhelps

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Rationale for hypnosis

Modified complex phobia: address response to triggers: desensitize, reintegrate dissociated parts.

Dysfunctional storage of traumatic memories :psycho-dynamic, regressive techniques

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What to do?

Targets

Past: dysfunctional storage of memoryPresent: defence mechanisms, dissociationFuture: reintegration of dissociated parts of personality

Hypnotic Intervention

PreparationPermissionStabilisation and resourcingSet up “Stop” signSpecial placeSelf-hypnosisHumour

Induction (beware of imagery techniques in induction if visual flashbacks)

Imagery techniques: for resourcing and for addressing flashbacks (alter sub-modalities), nightmares, anxiety, depression.

Anger: silent abreaction

Modify internal dialogue

Double-dissociation

Psycho-dynamic: regression: use a dissociation method, older, wiser self.N.B. do not associate with a negative state.

Amnesia

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Ego-strengthenEgo-shrink

Future PacePost-hypnotic suggestions: relaxation, resilience, confidence, motivation, energy, drive, humour

Re-orientation

Excessive dissociation

CIPOS (Jim Knipe)Constant installation of present orientation and safety.

Use of short-term memory (20 seconds) and dual attentionBack of head scale

Play catch, simple maths, phone number, walk around

Also helpful: Psycho-sensory therapies: Thought Field Therapy, Emotional Freedom Technique, EMDR Eye Movement Desensitisation and Reprocessing)HaveningMindfulness

M.E.W.C. 19/2/2017

mctraining.org.ukmewchambers@icloud.com08968 046315

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John Grinder You Tube NLP Double Disassociation with John Grinder ▶ 12:35https://www.youtube.com/watch?v=G4vgZmEBC2k

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