Proactive Phobia Management With Hypnosis

By Iain B. McIntosh BA (Hons), MBChB, DGMRCP, DRCOG, FTTMRCPS(Glas)

Fears and phobias are common. Fear and anxiety can be the psychological stimuli to drive personal behaviour. Phobias however may prove an annoying inconvenience or a major disability. Fear is a normal condition of life and a response to a real or imagined threat. Minor fears are within the cultural norm, with a continuum of fear between mild and intense phobia- a morbid response disproportionate to causative stimulus. Phobias can be simple and specific, or be associated with panic reaction and wider ranging agoraphobia.

Phobia
• A degree of anxiety and fear out of all proportion to the evoking situation.
• Cannot be explained or reasoned away.
• Beyond voluntary control.
• Can lead to incapacitating avoidance behaviour.

Despite surveys, [1-3] there remains a lack of data on prevalence of specific phobias in adults. The majority appear to occur in women, Travel associated phobia represents 2.8 per cent of phobias reported by women. [3,4]In a survey of 7,074 patients, listing 13 common fear-provoking objects or situations, 16 per cent admitted to a phobia and 13 per cent of these reported fear of flying, with a female to male ratio of 2:1. [5]

The mechanism of phobia
The phobic reaction has cognitive, physiological and behavioural components. The psychic element appears as overt anxiety and an exaggerated arousal response on exposure to the feared situation, or even thought of exposure (eg, the approach of a dreaded flight).

The physiological response results in a sweating, tremulous, palpitating and breathless patient complaining of assorted pains from muscle tension.

Avoidance behaviour, eg.in air travelling executive, or a mother's refusal to contemplate air travel, depriving family of holiday, introduces a social element that often forces the patient to seek professional help. Understanding the underlying problem encourages a practical approach to therapy.

Components of the phobic state
• Cognitive element: subjective fear.
• Behavioural response: avoidance.
• Physiological manifestation: tachycardia; hyperventilation; this often lead to:
• A social component: disruption of normal living.
The phobic cycle is open to curative intervention at three levels through different components. Relaxation can be taught to control physical symptoms; cognitive therapy helps control and change fear-provoking thoughts; and exposure and desensitisation treatment can overcome restrictions in lifestyle.

Usually it is not known how a phobia develops. Sometimes there is a trigger (eg, an unhappy incident occurring on a flight); some are simply conditioned fear reactions. Given time, therapy usually alleviates symptoms and cures the phobia. Prescription of tranquilisers does nothing to cure the underlying condition and merely treats symptoms, with the risk of initiating dependence upon the anxiolytic drug.

Modifying behaviour and hypnotherapy
Proactive management
The majority respond to a few highly effective behavioural management techniques including hypnotherapy. Behaviour modification is widely used to treat phobics. [2] The principal is to expose the patient to the situation causing distress until he/she gets used to it. Attempts are then made to extinguish the fear by relating it to a pattern of response that provokes no anxiety. Desensitisation consists of muscle relaxation and reduction of anxiety, and construction of a graded hierarchy of aversive stimuli from information provided by the patient. [7] Such a hierarchy, for example in a flying phobia, would consist of arrival at the airport, proceeding to the departure lounge, boarding the plane, take-off and landing. The hierarchy can be presented to the patient in imagery or reality.

Desensitisation works well with social and specific phobias, but is time-consuming and often requires many sessions.

The use of hypnosis for phobia borrows from behaviour modification and desensitisation, with therapy facilitated by a trance state. [9] Teaching autohypnosis, whereby at a coded signal the patient can recreate the relaxed state, decreases risk of dependence and diminishes time required for therapy. Graded desensitisation is practicable within the trance state and visual imagery and vicarious modelling can also be used.

With good management, disabling fear, disturbed conditioned responses and avoidance behaviour can be replaced by rational activity and normal, socially acceptable reactions.

Case
A patient, who had built up a UK business, had a unique opportunity to expand her firm in South Africa, but had long had a phobia for air travel. Unable to resist the opportunity for expansion, plans were made, tickets bought, but the day before departure she succumbed to panic and terror at the thought of flying.

Presenting for consultation she was in a state of agitation, intent on cancelling flights, and requested a letter to confirm inability to fly on health grounds. She refused to consider anxiolytic medication, but reluctantly accepted the offer of hypnotherapy.

She quickly entered a trance state and relaxed; she created a visual image of boarding and sitting in the aeroplane with continuing calmness, muscle and mind relaxation and freedom from tension.

She was able to visualise herself in and proceeding through prolonged exposure to the feared situation. Given post-hypnotic suggestions that she would remain calm throughout the flight, and that the standard pre-take off and recorded music would relax her, she ventured on a successful return flight the next day.

Now after the passage of years and many air trips she remains undisturbed by a once disabling phobia

BRIEF SELECTIVE HYPNOTHERAPY
Brief selective hypnotherapy is effective in treatment of flying phobias. Flying phobias are common. Many travellers are apprehensive and fearful of flying, a condition which most overcome by rationalisation and thought blocking, others develop a phobia for flying, This condition responds well to hypnotherapy which can be time consuming. Limited session brief, focused, selective hypnotherapy can however cure disabling fear, disturbed conditioned responses and avoidance behaviour.

Research
A study of treatment effects of conventional hypnotherapeutic (CH)sessions with limited contact brief, selective hypnotherapy (LCBSH) for flying phobias.An opportunistic between group study of consecutive patients with flying phobias presenting for treatment Patients were given alternatively given open session long duration hypnotherapeutic deconditioning therapy (treated to successful outcome) or standardised tape recording assisted,15 minute duration sessions limited to three.

Measure. A branched questionnaire identifying demography, and details of phobic state, with linear analogue scale recording of severity and avoidance behaviour, Duration of patient /therapist contact was recorded. Telephone follow-up of outcome after 6 months.

Results
33 patients .30 participants. Compliance:86% 20 (77%)women and 6(23)% men. All admitted to only phobia(flying)which created problems for them.6 (23%) rated it severe and 11(42%) scored avoidance of flying as a response to the phobia.21(80%) were greatly improved or cured with treatment .Avoidance scores were markedly reduced or nullified in 20 (77%)/

3 were lost to long term follow up but of the remaining 23 people, 18(78%) successfully undertook a flight without panic in the 6 months after treatment. There was no gender or age difference in response to treatment. In the LCBSH) group only 10 were available for follow up 9 (90%)of whom were improved and had flown recently .In the CH group 9 had also flown successfully,.One in each group still exhibited phobic symptoms and avoidance and the remainder. were objectively and subjectively improved. LCBSTH patients had 5 times less therapist contact than those treated conventionally.

The majority of patients either lost their fear of flying or had phobic symptoms greatly improved .There were no between group difference in outcome but LCBSTH was a time efficient and therapeutically effective and potentially a viable means of treating flying phobias.(9)

References
1. Agras S, et al. The epidemiology of common fears and phobias. Compr Psychiatry 1969; 10: 151-6. 2. Marks I. Progress in behaviour therapy. New York: New York Academic Press; 1975. 3. Burns LE, Thorpe GL. Fears and clinical phobias: epidemiological aspects and the national survey of agoraphobics. J Int Med Res 1977; 5(1 Suppl): 132-9. 4. Wilson GD. Social desirability and sex differences in expressed fear. Behav Res Ther 1967; 5: 136-7. 5. McIntosh I. Incidence, management and treatment of phobias in a group medical practice. Pharmaceutical Medicine 1980; 1: 77-82. 6. McIntosh I, et al. A survey of UK health professionals' attitudes to severe travel phobic anxiety and therapeutic interventions. Presented at: British Travel Health Association 2nd annual conference, London; 1999. 7. France R, Robson M. Behaviour therapy in primary care: a practical guide. London: Croom Helm; 1986. 8. McIntosh I. Hypnotherapy: the case for the GP. Psychiatry in Practice 1981; November. 9. McIntosh I. Brief selective hypnotherapy is effective in treatment of flying phobias Brit trav health assoc j. 2007 42-47