Panic Disorder has been described as perhaps the most terrifying of
all psychiatric symptoms (Maxmen, 1986). Suddenly and devoid of any logical
reason, panic attacks inundate the unsuspecting victim with overwhelming
ominous thoughts. Moreover, these episodes are accompanied by a
constellation of horrific sensations that create fears of going mad or of actively
dying. Complicating the picture is the slippage of controls that the individual
has always taken for granted. The loss of control at times escalates into a
sense that one is losing consciousness (Beck & Emery, 1985). The striking
characteristic of a panic attack is the overwhelming and paralyzing experience of being engulfed by anxiety (Barlow, 1993). The individual’s reasoning powers are categorically suppressed by the anxiety and the accompanying cognitive ideations of doom, destruction, and imminent death (Burns & Beck, 1978). A host of physiological correlates are present during an episode and they conspire to convince the victim that
he must fight for his own life. Profuse sweating, peculiar sensations in the extremities,
hyperventilation, chest pains, nausea, paresthesias, chills or hot flashes, and feeling
dizzy or faint constitute the constellation of physiological symptomatology that make
panic attacks such a devastating experience (American Psychiatric Association, 1994).
Most episodes have duration of 3 to 10 minutes and rarely more than 30 minutes.
Panic attacks can present in a host of Anxiety Disorders including Panic
Disorder, Social Phobia, Simple Phobia, and Posttraumatic Stress Disorder. The DSM
IV (American Psychiatric Association, 1994) further classified Panic Disorder to be with
or without Agoraphobia and adds that for Agoraphobia to be present, the individual
has to report anxiety in places or situations from which escape might be difficult or in
which help may not be available in the event of having unexpected panic attack symptoms
(American Psychiatric Association, 1994).
Hypnotherapy of Anxiety Disorders
Because hypnosis exploits the intimate connection between mind and body
(Rossi & Cheek, 1988) and provides relief through improved self-regulation (Kirsch,
Capafons, Cardeña, & Amigó, 1999), it holds utility in the treatment of the anxiety
disorders. Moreover, as it beneficially affects the control of cognitions (Zarren &
Eimer, 2001) and enhances the experience of self-mastery (Dowd, 2002), hypnosis has
been deemed an efficacious treatment for the management of Anxiety Disorders (Smith,
1990).
Hypnosis has been employed in the treatment of Panic Disorder in different
ways, depending on the theoretical orientation of the hypnotherapist. The combination
of hypnosis and behavioristic principles and strategies was documented in a study of
the efficacy of biofeedback-aided hypnotherapy for intractable phobic anxiety (Somer,
1995). McNeal (2001) reported on the role of hypnosis aided with EMDR in the efficacious
treatment of phobias. A dynamically oriented hypnotic approach for the therapy of
anxiety reactions was developed by Spiegel and Spiegel (1978). Their approach stressed
the importance of helping the patient understand the historical origin of the anxiety
condition.
Hypnosis is recognized as a potent anti-anxiety intervention, which can be
incorporated into a variety of theoretical systems and models of therapy. Its efficacy
and role in enhancing the successful treatment of anxiety disorders has been endorsed
for a variety of orientations including the psychodynamic, interpersonal, cognitive, or
behavioral (Gilbertson & Kemp, 1992; Miller, 1986). Additionally, the role of hypnosis
in treating anxiety conditions from a co-morbid pharmacological/hypnosis perspective
was investigated in a study of the efficacy of alprazolam (Xanax) and hypnosis with a
college-aged population (Nishith, Barabasz, Barabasz, & Warner, 1999). Their findings
supported the use of hypnosis as a substitute for sedative drug use. Awake-Alert Hypnosis
Despite the fact that relaxation-oriented inductions hold the greatest popularity
and are the most widely used form of trance induction, hypnosis is not equivalent to relaxation nor is relaxation a required characteristic (Alarcon, Capafons, Bayot, &
Cardeña, 1999). The notion that a relaxation-based induction could be counterproductive
in conditions where cognitive alertness was desirable was suggested by Oeting (1964).
Gibbons (1974) created an approach that emphasized suggestions of alertness which
he coined “hyperempiria” and which he described as a “new altered state of
consciousness.” The evidence which clearly demonstrated that relaxation based
techniques are not essential to hypnosis is summarized by Cardeña, Alarcón, Capafons,
and Bayot (1998) and by Wark (1998).
The field of alert-hypnosis is predominantly represented by studies that
establish an operational distinction between two strategies or different approaches:
Awake-alert hypnotic techniques and active-alert hypnotic techniques. The research
and applications of the awake-alert strategies are synonymous with the work of Cardeña
et al., (1998). Capafons (1999) is also a major contributor to the awake-alert literature.
Representatives of the awake-alert school of non-relaxation-based hypnosis (Cardeña
et al., 1998) recognize that their approach is based on the contributions of three
conceptual systems. Gibbons (1974) is credited for his hyperemperic procedure; Bányai
and Hilgard (1976) are recognized for their general approach; and the contribution of
emotional self-regulation therapy (Capafons & Amigó, 1995) is also acknowledged.
Basically, the hypnotic induction in this system is presented to the individual as a
method to achieve mental activation, with simultaneous activation and calm but free of
anxiety (Alarcón et al., 1999). A transcription of a representative induction, in its
entirety, can be found in Cardeña, et al. (1998).
The active-alert techniques also enjoy substantive representation (Bányai &
Hilgard, 1976; Bányai, Zseni & Túry, 1993). This procedure entails the use of controlled
and steady resistance while pedaling a bicycle. As the individual pedals, suggestions
are provided to enhance the active-alert induction of hypnosis. Bányai, et al. (1993)
provided an example, described in detail, of the active-alert induction.
Methods of alert trance or active hypnosis, rather than relaxation and drowsy
hypnosis, have been employed and documented in clinical situations. Alert-trance
methods have been adapted to athletic performance enhancement with weight lifters
(Howard & Reardon, 1986).
Case Report
The patient was a 72-year-old widowed heiress who lived in Florida during the
winter months. Her raison d’etre revolved around the exclusive social life of her
affluent community: dinner engagements, the philanthropic balls, and the various and
sundry social engagements attended by the celebrities and aristocrats. During her
youth this patient abused alcohol and barbiturates, medically prescribed, to manage
social and public speaking phobias. This abusive pattern of relying on alcohol and
barbiturates damaged the lining of this patient’s intestinal tract and created a chronic
case of diverticulitis. This presented an obstacle whenever this patient required
medications as most medications triggered acute episodes of diverticulitis.
At the present time, she was not particularly bothered by thoughts of ridicule
and public failure. She enjoyed the spotlight and the adulation and attention that her
role created. She could recognize the role that her physical attributes played in her
social success. A radiantly attractive lady all of her life, she had become noticeably
aged by the passage of time. She was cognizant of her narcissistic features and knew that loss of appeal was a significant blow to her vanity and ego.
The panic episodes were characterized by an accelerated heart rate, shortness
of breath, chest pain, fears of losing control and being detected, and sweating; they fit
the criteria for Panic Disorder as described in the DSM IV (American Psychiatric
Association, 1994).
She was tried on several SSRIs plus a benzodiazepine but the medications had
to be discontinued because they irritated her intestinal lining and exacerbated the
patient’s diverticulitis. At this point the patient accepted her psychiatrist’s referral for
hypnosis.
First phase of treatment
The first step in her hypnotherapy was to inform this patient that this modality
was most efficacious in aborting incipient panic attacks when employed at the earliest
phase of the episode. This task was facilitated by introducing the “intensity
thermometer,” a 0-10 subjective intensity scale where 0 symbolizes the absence of
panic and 10 is the worst imaginable. She was then instructed to break down a typical
panic attack and give a detailed description of every level on the intensity thermometer.
She was asked to define and describe, phenomenologically, each level in terms of the
three following inquiries: 1) Describe how you react physiologically at each level; 2)
Describe your behaviors or what you are doing at each level; and 3) Describe the
dialogue and ideas that go through your mind at each level.
Second phase of treatment
An eye-fixation induction was employed for the induction of orthodox hypnosis
and direct suggestions under hypnosis were provided that she will become immediately
cognizant of incipient panic episodes at the earliest onset or level. It was reiterated
under hypnosis that to the degree that she employed hypnosis at the earliest level of
the panic episode, to that degree she would be successful in aborting the episode.
Third phase of treatment
Training in awake-alert hypnosis was approached from an eye-fixation, eyeclosure, orthodox induction. After inducing hypnosis by employing an eye-fixation
and eye-closure induction, the patient was gradually conditioned to open her eyes,
while remaining in a hypnotic state. The fractionation method (Kroger, 1963) was
adapted and successfully employed to teach this patient to enter into an awake-alert
hypnotic state with eyes open and devoid of body relaxation; instead the patient was
conditioned to engender a disconnected and “woodsy” feeling all over her body.
The fractionation method involved the following steps: a) induction of orthodox
hypnosis using eye fixation and eye closure; b) suggestions that from the neck up her
hypnotic state would evolve into an awake-alert trance allowing her eyes to be open
and to be able to speak while the rest of her body remained in traditional relaxed
hypnosis; c) broadening the area of the body, from the head to her waist, which was to
enter awake-alert hypnosis. Suggestions were provided that instead of being in a state
of relaxation, her body was becoming “woodsy” and would feel as if an anesthetic
agent had been injected yet it could be active and move about as necessary; and d) the
final step instructed the patient to be able to induce awake-alert hypnosis over her
entire body. From this point on, hypnosis was induced in the awake-alert fashion. Fourth phase of treatment
Starting at this phase of treatment, awake-alert hypnosis was induced at all
sessions using the alert-awake method. The following step involved conditioning the
patient under awake-alert hypnosis to the suggestions in the following “Waterford
script” for aborting panic attacks.
You are now in a state of hypnosis with your eyes open. You are
familiar with this experience, as you have practiced its induction many
times. You know that it is a unique type of hypnosis that allows your
eyes to remain open, for you to be alert and be able to converse and to
move about freely. You also know that it makes your body numb, as if
you had taken an injection of an anesthetic. It makes your body feel
numb and “woodsy,” yet you are free to move about unimpeded. As
you continue staring at the Waterford, a sense of security comes over
you. Somehow it feels like you and the Waterford are blending, joining
forces. The Waterford is the finest of its kind and this element of
grandeur makes it a symbol of success, power, elegance and impeccable
taste. Without a doubt, only the most socially upward mobile, the
intellectually elite and the aristocratic are entitled to enjoy the splendor
and beauty of such a treasure. These individuals do indeed possess
certain qualities that distinguish them from the general public: They
are individuals that understand duress and know how to overcome it;
this is why they belong to the ranks of the successful. They are
endowed with a self-corrective mechanism in their personalities that
make them impervious to defeat. They are resilient and momentary
pain and duress makes them stronger. These realizations make you
feel safe and offer you comfort. They offer you strength, confidence
and security.
As you already know, at the slightest hint of discomfort, you
are to immerse yourself in the splendor of the Waterford and transport
yourself within the safe heaven that it is prepared to offer you. The
intricate labyrinths perceived within the deepness and richness of the
glass offer the perfect haven and sanctuary for you to feel protected.
It is indeed an impenetrable fortress all around you. The greater the
discomfort, the deeper within the Waterford that you retreat. The
numbness and “woodsy” feeling that you have throughout your body
serve as a reminder that you won’t feel any pain. As the Waterford
transmits peace, serenity and safety to you, your entire being registers
the benefits. Your heart rate accordingly normalizes…your respirations
slow down…your stomach unwinds and feels comfortable again…at
this point, you consult your intensity thermometer to determine when
its acceptable to disengage from the Waterford.
Formulation
The panic attacks symbolized the terror behind the prospect of losing her
social position, standing and the coveted role of chairwoman at various philanthropic
functions. This patient was able to recognize that in reality her social life was all she had. This explained the recalcitrance and intensity of the panic attacks. The decision to
employ an intervention that strengthened the patient’s fantasy of entitlement and
specialness, the apparent source of the presenting problem, was based on one
conclusion. This individual’s personality organization indeed presented characteristics
typically associated with adjustment difficulties including self-admiration, a sense of
entitlement, and self-centeredness. However, upon further examination, her history
indicated that it was not necessarily maladaptive. This conclusion, in turn, was based
on two pivotal circumstances. The first concerns individuals engaged in occupations
or avocations in which chasing the spotlight and thriving on the adulation of others are
not only appropriate and adaptive but a sine qua non for success (Weiner, 1998). This
lady’s accomplishment in her avocation depends on attracting the attention of others;
thereby being noticed is essential for success. The second circumstance that limits
the maladaptive effect of this patient’s narcissistic orientation involves the fact that
she is best described by Weiner’s (1998) definition of a “nice narcissist.” Weiner (1998)
noted that despite their self-centeredness these people are able to show considerable
genuine interest in others. In most cases their primary concerns lie with their own
priorities, but they are able to enjoy being around others, can be entertaining and
ingratiating even though it is mostly as a means of ensuring an appreciative audience
that will gratify their needs for attention and admiration (Weiner, 1998). Millon & Davis
(1996) described this personality type as “healthy narcissist” and, in addition to the
usual characteristics of the personality type, these writers indicated, that these
individuals can demonstrate “interpersonal empathy, interest in the ideas and feelings
of others, and willingness to acknowledge one’s personal role in problematic
interpersonal relationships” (p. 408). These writers deem this personality organization
as not maladaptive.
Results
Data collected at the start of therapy demonstrated the panic episodes to
present with a frequency of approximately three times a week. The patient was having
the episodes equally during lunch engagements as well as during dinner parties. The
level of intensity was typically reaching levels 6-7 (as measured by the intensity
thermometer); at this point she was forced to leave with the excuse that “she wasn’t
feeling well.” After four weeks of three-times-a- week 30-minute visits, the following
results were documented: a) the frequency of the episodes was unchanged; she
continued to have approximately three episodes a week; and b) the intensity level of
the episodes was markedly suppressed. The patient became able to thwart the
development of incipient episodes by applying the hypnotic procedure in the early
phases (levels 1-3) of the panic process. She was followed up with weekly 30- minute
visits, for reinforcement, for 2 additional months. She was seen the following “season”
for follow-up and the picture was virtually the same. She continued to manage incipient
episodes with the same hypnotic technique.
Discussion
The Waterford technique is an anecdotal example of the efficacy and importance
of utilization and individualization of ego-strengthening suggestions (Frederick &
McNeal, 1999; Phillips & Frederick, 1992; McNeal & Frederick, 1993). The Waterford technique was designed to address the idiosyncratic psychodynamics underlying the
panic attacks: The decline of physical attributes and the inherent threat that this
represented to this patient’s healthy narcissistic personality. The Waterford technique
relied on indirect means to imbue this patient’s fragile ego with individualized egostrengthening suggestions that incorporated the same grandiose attributes that the
patient ascribed to Waterford glassware. The Waterford technique transfused her ego
with indirect suggestions of being elegant, refined, and of possessing discriminating
taste, sophistication, prestige, and elitist status. Suggestions of resilience, strength,
comfort, and security were also included. These ego-strengthening efforts were intended
to improve the patient’s self esteem by helping to get in touch with inner resources and
to develop “Inner Strength” (Frederick & McNeal, 1993; McNeal & Frederick, 1993).
The Waterford technique also provided this patient a place of refuge or
sanctuary where she could retreat and find safety (Finkelstein, 1990). The suggestions
of anesthetic-like sensations or a “woodsy” feeling all over her body offered the patient
contradictory and mutually exclusive physical sensations to those that accompanied
her subjective experience of panic.
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