The following text is a pre-publication version of the paper in The Journal of Integrative Research, Counselling and Psychotherapy’
Psychotherapist, Psychologist and Hypnotherapist
The following case study reports the successful treatment of a 24 year old female student with a 6 month history of panic disorder without agoraphobia. On presentation, she reported that she had had panic attacks on the underground and that this was associated with a constant fear that she would embarrass herself by losing control and by unexpectedly micturating in public. This produced a huge amount of avoidance behaviour, and she was beginning to reduce her liquid intake before and during journeys to college. Her mother suggested to her that she should wear nappies and that this would give her the confidence to travel freely. Both therapist and client agreed that this was not a desirable course of action, and formulated a treatment programme which consisted of systematic desensitization (both in vitro and in vivo), the gradual reduction of wearing nappies and specifically-designed homework tasks. She was also given the post hypnotic suggestion to use the anchoring word ?calm? in stressful situations (Bandler & Grindler, 1979; Williamson, 2004). The student made a remarkable recovery in six sessions: she reported that she was no longer wearing nappies, she was able freely to travel on public transport, she no longer anticipated embarrassing herself and was able to drink freely throughout the day. With the complex nature of panic disorder, this case study reiterates the importance of helping patients to come to terms with the family dynamics responsible for the condition (Kraft, 2011a). However, it emphasizes that solution-focussed techniques and principles (De Shazer, 1988; Lankton, 2004) can be used to enhance the treatment, in that it helps clients, in a relatively short space of time, to begin to reduce their anxiety outside the comfort of the home, to focus on the present and to construct a new, preferred future for themselves (Iverson, Gergen & Fairbanks II, 2005).
The author conducted a worldwide search of the literature using Medline, PubMed and PsycINFO focussing on the following key words and phrases: ?hypnosis panic disorder?, ?hypnotherapy panic disorder, ?hypnosis panic?, ?hypnotherapy panic? and ?panic disorder without agoraphobia?. Initially, papers, especially meta-analyses and case studies, were consulted within the period 2000-2011 before a second, wider search was implemented. This second search included articles from 1975 to the present day.
Panic disorder is a chronic condition and an ongoing health problem (Milrod, Leon, Busch, Rudden, Schwalberg et al, 2007), affecting up to 5% of the population (Bienvenu, 2006; Roy-Byrne, Craske & Stein, 2006). Patients suffering from this condition frequently use emergency departments in hospitals and, in a variety of settings, have presented with a number of unexplained symptoms including chest pains and palpitations (Beitman, Thomas & Kushner, 1992), IBS (Walker, Roy-Byrne, Katon, Li & Amos, 1990), dyspnea (Katon, 1996), difficulty breathing (Norton, Harrison, Hauch & Rhodes, 1985), hyperhidrosis (Wilhelm, Trabert & Roth, 2001), and insomnia (Ohayon & Roth, 2003; Torpy, Burke & Golub 2011). Panic disorder significantly reduces quality of life (Keller, Yonkers, Warshaw, Meredith & Pratt et al,1994; Schmidt & Telch, 1997), and is often associated with alcohol and substance abuse (Katon, 1996).
Barlow, Chorpita and Turovsky (1996) proposed a theory which clearly delineates a distinction between panic and anxiety: they observed that unexpected panic attacks were a common feature in modern-day society (Norton, Cox & Malan, 1992; Bouton, Mineka & Barlow, 2001) and that these occurrences rarely develop into panic disorder. Further, they pointed out that individuals who do not suffer from panic disorder tend to disregard these situations as ?one-off events?. By contrast, patients suffering from panic disorder develop an uncontrollable fear and become hypersensitive to any slight physiological change which might precipitate panic (Goldstein & Chambless, 1978; Kraft & Kraft, 2006). As the disorder develops, patients tend to construct various elaborate avoidance behaviours or ?safety behaviours? (Bouton, Mineka & Barlow, 2001) in order to reduce the risk of panic. Many patients, according to DSM IV (American Psychiatric Association, 1994) also fear the possible implications of having a panic attack; in order to be diagnosed with panic disorder without agoraphobia, patients must have had recurrent attacks for a period of one month (American Psychiatric Association, 1994).
Results from meta-analyses, looking at both panic disorder with an without agoraphobia, have shown that cognitive approaches (particularly CBT), in vivo exposure and a combination of these techniques have been significantly efficacious when compared to control groups (Trull, Nietzel & Main, 1988; Mattick, Andrews, Hadzi-Pavlovic & Christensen, 1990; Bakker, van Balkom, Spinhoven, Blaauw & van Dyck, 1998; Oei, Llamas & Devilly, 1999; Westen & Morrison, 2001; Mitte, 2005). Evidence from these studies points to the fact that in vivo exposure is the main component in the treatment of panic disorder with an effect size ranging from d= 0.78 to d=1.34 in respect of the standardized mean difference (Sanchez-Meca, Rosa-Alcazar, Marin-Martinez, Gomez-Conesa, 2010); importantly, both CBT and in vivo studies have consistently shown lasting effects of treatment gains (American Psychiatric Association, 1998). Successful treatments have also been reported using psychoanalytic psychotherapy, ?panic-focused psychodynamic intervention? (Milrod & Shear, 1991) as well as virtual reality exposure therapy (VRE) (Botella, Garcia-Palacios, Villa, Banos, Quero, Alcaniz & Riva, 2007), although the latter approach is expensive to implement.
Evidence to show that hypnosis, as an adjunct, has been used successfully in the treatment of panic disorder is scant: this implies that, certainly with regard to the use of hypnosis in therapy, many cases of individuals suffering from ?panic? have fallen under the remit of general anxiety disorder or more specific disorders including situational phobias (Kraft & Kraft, 2004), social phobia (Lipsett, 1998), OCD (Moore & Burrows, 1991), PTSD (Spiegel, 1992; Degun-Mather, 2001) or separation anxiety disorder (Miller, 1986). In order to fulfil the criteria for diagnosis, individuals must not suffer from attacks which are associated with any of the other mental disorders listed above. Hypnosis has been extremely effective in the treatment of panic disorder with or without agoraphobia, as defined by DSM IV (American Psychiatric Association, 1994), in specific case studies (Wild, 1994; Stafrace, 1994; Iglesias & Iglesias, 2005). But, more generally, it has been well-documented that hypnosis has been used effectively to reduce anxiety, providing patients with more control and the ability to cope during potentially stressful situations, (Hobbs, 1982; Saap, 1992; O?Neill & Barnier, 1999; Kraft & Kraft, 2006; Kraft 2011a; Kraft 2011b). Indeed, one of the most particular aspects of panic, be it associated with panic disorder, agoraphobia or another specific disorder, is that individuals tend to overestimate the risks that they are facing and under-estimate the inner resources that they have in these situations (Barlow, 2000). But hypnosis can be used by the therapist to build patients? coping skills and sense of control; and, with the additional use of self hypnosis, can help them first to manage and then to significantly reduce or even eliminate anxiety (Yapko, 2003).
The present study focuses on the treatment of a young female student who had been developing all the hallmarks of panic disorder without agoraphobia. She pinpointed her initial trigger situation at an airport over a year before treatment, and it was here that she first felt trapped; subsequently, she began to experience panic attacks on public transport and feared that she would micturate and publicly embarrass herself. She had begun to develop avoidance behaviours?that is to say, she had significantly reduced her use of public transport?and this resulted in a marked reduction in mobility. The author felt that it was important to break these cycles of behaviour because of the risk that they might develop into agoraphobia?indeed, it has been reported that approximately one in three individuals suffering from panic disorder, at least, to some extent, become agoraphobic (Bienvenu, 2006; Sanchez-Meca, Rosa-Alcazar, Marin-Martinez & Gomez-Conesa, 2010). Furthermore, it has been reported that the number of panic symptoms?including hyperhidrosis, nausea, abdominal pain, fear of losing control, chills or hot flushes?during an attack are significantly more extreme in individuals suffering from panic disorder with agoraphobia when compared to those with panic disorder alone (Lee, Hahn, Lim & Oh, 2007). The treatment used here was a multi-modal approach which combined psychodynamically-orientated psychotherapy with hypnosis and systematic desensitization; in addition, some further interventions?for example, coping questions and visualizing a preferred future?were used and these techniques fall under the remit of solution-focussed brief therapy.
The patient in this study had been suffering from panic disorder without agoraphobia for 6 months. During this period, she had begun to avoid public transport and had had a constant fear that she would embarrass herself by micturating in public. As a result, she had begun to wear black clothes and nappies in order to provide her with some security in the eventuality of losing control in public.
Limitations of the study
Although the client in this paper signed the declaration, giving permission for the author to publish the following case study, she was unavailable for follow up.
Daphne, aged 24, was a very pleasant and intelligent student in her first year at university. Her mother insisted that she come for the first session and it was here that they both described her condition in detail. Daphne reported that she first experienced difficulties on an aeroplane over a year ago: she said that she felt trapped and feared that, because she didn?t have immediate access to a lavatory, that she would ?wet herself?. She said that the thought of being caught urinating in public and being out of control would be incredibly embarrassing and this filled her with dread. She stressed to me that she didn?t have a ?medical problem? and that this episode was related to a great deal of stress; further, following this initial episode, she went for several weeks without any problems. However, on a recent trip on the underground, she was reminded of this unpleasant event and said that she, once again, felt trapped and feared that she be unable to control herself; in addition, she felt that she had an almost uncontrollable urge to urinate throughout the journey and she was constantly aware of her bladder. Her mother commented that she had also had a panic attack in which she experienced hypercardia and hyperventiliation. The author explained to her that it was impossible to ?over breathe? with her mouth shut and her eyes closed, and said that this technique would have the immediate effect of helping her to control her breathing. It was also pointed out to her that, in these stressful situations her mind seemed to focus on her bladder, and had somehow ?elected this part of her body to express [her] emotion?. Daphne understood this point and confirmed that this was a reasonable assessment of her situation.
At this point, her mother wanted to know whether she could come to the next session. It was stressed to her that it was important that Daphne deal with her problems on her own, but that she could be involved with her recovery by supporting her at home. I also said that she was right to ask me this question because she was obviously concerned about her daughter. Both mother and daughter were very tearful at this point and expressed how worrying it was that she had developed so much avoidance behaviour. Alarmingly, her mother had also suggested that her daughter wear nappies so that she could get to college. The implications of this were numerous; however, rather than challenge both mother and daughter at this point, the author decided to encourage them both to find some solutions together. I asked Daphne what her goal was for the therapy and encouraged her to envision what her preferred future might be like. She replied that she wanted to be able to go to college on her own and to be able to do this without having to wear nappies. At this point, her mother talked about her past and her own fears of public transport; realizing very quickly that this was, indeed, the source of Daphne?s problem, I ignored the mother?s attention-seeking behaviour and pointed out that we were all here to sort out one problem at a time. It was very important at this point to keep the conversation on track and to focus on moving forward. Indeed, I said that I would support Daphne in her personal goals for the future. At the end of the discussion, Daphne agreed that she should go to college as much as possible during the week, and that she should systematically develop her ability to travel longer distances on public transport.
At the second session, Daphne reported that she had made significant improvement. She smiled throughout the session and said that she had been able to travel on the underground although she still needed to wear nappies. She also said that she would stop wearing them when she was ready. When I asked whether she had ever had an accident in public, she commented that it had happened once and that this may well have been the course of her fears. The wearing of nappies, put Daphne back in the position of being a baby again; however, at this point, the author (DK) did not mention this because it was important to celebrate the fact that she was making significant progress. Indeed, throughout the session, Daphne?s successes were acknowledged; and, whenever she spoke negatively about her situation, coping suggestions (Greene, Lee, Trask & Rheinscheld, 2000; De Jong & Miller, 1995) were used in order to remind her of her inner resources. For example, whenever she talked about her fear of travelling, I challenged this perception by saying, ?And yet, with all this going on, you are still thriving at university as a student and have a loving relationship with your boyfriend. How do you do it??. During the discussion, Daphne also pointed out that she was now able to adjust her clothing: she wasn?t wearing a sash which normally covered her groin area and was wearing blue jeans rather than the usual black pair. In addition, she said that she felt comfortable enough to drink two cups of coffee at breakfast which is something she had not done since her panic attacks started. Her own personal motivation was at a high and this was encouraged throughout the session; indeed, at one point she said, ?I have had this [problem] for a year now, and it is time that it went?.
At the end of the session which, again, did not involve any hypnosis, Daphne said that there was a birthday party this weekend that she wanted to go to, and that she would not let anything get in her way to stop her going. She explained that, if she had something to read on the underground, it would take her mind off her fears of being trapped and embarrassing herself. Daphne said that she would bring a book or a magazine with her and that she would see travelling on public transport as a ?challenge?. She said that her friends irritated her by asking her constantly how she was doing: further, they travelled to see her, and this had the effect of perpetuating her condition. She said that this week she had asked her friends to stop interfering. Finally, in this important session, she said that she wanted to be ?back to normal? by Christmas so that she could visit her friends and family by train, and wear the clothes that she wanted to wear.
When Daphne arrived for her third session, she said that she had some good and bad news. She said that she had managed to go out on both Friday and Saturday without wearing a nappy; she was very pleased with this achievement, but she had a slight panic because the journey was delayed. She felt that she wanted to micturate throughout the journey; but when she arrived, she was able to enjoy herself for two hours before passing urine.
In the hypnotherapy, Daphne was encouraged to choose a special place where she felt comfortable and relaxed, and this consisted of her being at home alone in her bedroom. I said that this special place was a place in which her confidence would grow inside of her. I then encouraged Daphne to imagine her confidence and abilities as a symbol in front of her, and to describe it. She said that she thought of a plus sign, and we both agreed that this was a very positive symbol. She was then invited to bring this symbol towards her solar plexus and, once her hands touch her chest, the symbol, with its inherent confidence and inner strength, would grow inside of her. Following more ego strengthening, using age progression, Daphne was able to experience?using all the sensory modalities?being able to travel freely on public transport without panic. It was intimated to her that this achievement would be realized sooner than she might think. Following this, Daphne was given post hypnotic suggestions that she would practise going on the underground as much as possible and that, on each occasion, she would become more and more confident and relaxed, and that she would think about more important things during future journeys. Next, Daphne spent five minutes with an imaginary remote control in which, using the play, fast forward and rewind buttons, she was able to explore practising going on journeys in her own time. This technique provided her with an immense amount of control. Finally, Daphne was given post hypnotic suggestions that she could reduce her anxiety at any time she wished by visualizing her special place, and using the anchoring word ?calm? (Bandler & Grindler, 1979; Williamson, 2004).
Daphne cancelled her next session and so there was a gap in her treatment. When she did arrive for her fourth session, she told me that she felt that she had gone backwards. She had returned to wearing a nappy to go to college and said that it represented a source of comfort for her. She let it slip that she blamed her mother and that it was her idea in the first place that she should wear a nappy, but she quickly retracted this point. I picked her up on this comment, but she said that she didn?t blame her mother. Not convinced by this, it was explained to her that, by wearing nappies, she was, in some respects, returning to being a baby and that her mother was partly responsible for this. At this point, Daphne began to fear that this was now a ?physical problem?, but I reminded her that a physician had already established that there was no organic cause. A discussion then ensued in which we explored the reason why she needed to be comforted by wearing a nappy. She was unable to identify the exact source of this need but intimated that she felt that she did not have adequate boundaries at home. In light of this, I said that it would it would perhaps be a good idea for her to be able to comfort herself in a more appropriate way, and she volunteered the information that reading a book on the train would help her not to focus on her panic and would also help her to be more relaxed at the same time. By the end of the session, I felt that her mother was manipulating her progress still further when Daphne pointed out that she said that she was unable to pay the fees every week, and that she would have to see me in two weeks? time. So, in order to encourage her and move her forward, I suggested to her, using her own terminology, that her challenges for the next two weeks should be to continue travelling on public transport, to wear normal underwear at college and only to change into nappies on the return home. She agreed to these challenges.
As promised, Daphne came for her fifth session, without wearing a nappy. She was proud about this and said that her aim for next week was to wear normal underwear throughout the day, including on the underground. Her panic attacks had ceased and she felt comfortable and relaxed on train journeys using visualization techniques and the anchor word ?calm?. We then discussed what she wanted to do in the hypnosis, and Daphne concluded that she wanted to have a psychotherapy session today and that she would use hypnosis again after she had achieved the ?next challenge?. Daphne asked me whether she should be doing any more behavioural work during the course of the next week; as a result, we discussed the importance of actually getting rid of the nappies so that she would not have them there to use. Daphne said that she had one left and that she would throw it away in two days? time?that is to say, she would bring it with her to college the next day, but she would throw it away at the end of the evening. I pointed out that this ritual would be very positive for her. At the end of the session, Daphne confirmed that her mother, in some way, was finding her growing up extremely difficult, and that she was struggling to build her independence as a young woman, at which point we agreed that being able to travel without panic and wearing appropriate underwear were the first steps to gaining this independence as a young woman. Throughout the dialogue, we focussed on the near future and on moving her life forward rather than on the past. In addition, a form of ?problem free talk? (George, Iveson & Ratner, 1999; Iverson, 2002; Lethem, 2002) was utilized in order to help her to transfer her skills to other aspects of her life. For example, whenever Daphne became negative, the therapist reinforced and reminded her of her abilities to achieve excellent grades at university, and pointed out that these skills were transferable. We explored together that fact that she was confident at university and Daphne visualized being that confident self in different, more challenging scenarios. Daphne said that she was looking forward to two trips, both of which were approximately two hours? duration; she said that she would wear normal underwear on both trips. Incidentally, the ?problem free talk? in this instance, unlike the examples in the literature (for example Iverson, 2002) was one-way, and lasted for a relatively short space of time (3/4 minutes); however, it was a useful technique at this point in the therapy.
In the final session, the sixth, Daphne was delighted to report that she was able to go anywhere by public transport and no longer anticipated worrying about the possibility of embarrassing herself. She was wearing proper underwear at all times, she no longer had to make long preparations before journeys, and was able to drink normally throughout the day. Daphne concluded that she was delighted with her recovery and said that she was now ready to move on with her life which included studying at university and being more independent outside the home.
It was very clear in the first interview that Daphne?s mother was having difficulty coming to terms with the fact that her daughter was going to university and was building an independent life for herself as a young woman. In a desperate attempt to reduce her daughter?s mobility, thus delaying her growing up, she suggested to her that she wear nappies, and projected onto her feelings of fear associated with travelling on public transport. However, there seemed to be an unconscious desire that Daphne would eventually, when she had come to terms with this shift, ignore this behaviour and continue her studies without any problems. Daphne had learnt to be anxious on the underground from her mother: indeed, learning to be fearful from parents is a common feature in panic attacks, agoraphobia and phobic anxiety (Moore & Andrews, 1985; Rosenbaum, Biederman, Gersten, Hirshfeld, Meminger et al, 1988; King, Clowes-Hollins & Ollendick, 1997). On one level, she wanted to please her mother by being avoidant and by putting herself back in the position of being a helpless infant, constantly needing the attention and care of her mother; however, it was evident that her mother wanted her daughter to succeed and to be able to travel freely to university, and that, further, by the time they had arrived for the first consultation session, they were both ready for this transition.
There is often the tendency to feel that it is necessary to try to reveal the source of these unconscious desires right at the beginning of therapy; however, in this instance, particularly as they were both agreed that wearing nappies was not helpful and actually contra-indicated, the therapist, in the first instance, used a solution-based approach which identified the following, short-term goals:
1 to be able to travel freely on public transport
2 to be able to drink normally throughout the day, even before journeys
3 to wear normal clothes
This solution-based approach also had a long term goal which essentially consisted of her being independent and freer on public transport which would have the result that she would be able to continue her studies and develop her career at university.
Further, she was encouraged to succeed in various behavioural tasks as follows:
1 to practise going to college as much as possible and gradually to stop wearing nappies
2 to wear nappies on public transport and normal underwear at college
3 to wear normal underwear to college, taking nappies in a bag
4 wearing normal underwear when visiting friends for parties at the weekend
5 wearing normal underwear and throwing the nappies away
A modified version of ?Problem free talk? (George, Iverson & Ratner, 1999) was also used in order to identify her inner strength and to help her to transfer these skills to the travelling on the underground. Daphne was extremely confident at university and she was encouraged to harness these qualities during journeys on the train. Most importantly, the hypnosis served the purpose of increasing her confidence and her inherent ability to cope on the underground, and, using systematic desensitization (in vitro), she practised going on public transport over and over again, thus becoming more proficient and confident in this task. She was also able to reduce her anxiety during the homework tasks using the anchor word ?calm?.
A turning point in the therapy occurred when Daphne, in her own time, discovered that she was not given adequate boundaries at home and that, by having limited mobility, her mother was making a desperate attempt to create a boundary which stopped her going to university and being an independent woman. It was in this important session that Daphne realized that she had also not been given the comfort and support that she had needed at various points in her childhood, and that the nappies served the purpose of giving her comfort on the train?that is to say, when she was separated from her mother. Her coping strategy was to read a book on the train; we discussed this together and came to the conclusion that this was a more appropriate way of providing her with comfort, and that this, in turn, reduced her anxiety, her feelings of impending doom and constant fear of embarrassment. Daphne made significant progress when she realized the source of her anxiety; at the same time, she began to treat the process as ?a challenge?.
In six sessions, Daphne made significant improvement and no longer anticipated going on public transport, nor did she fear that she would have an accident in public. This study has shown that solution-focussed techniques and principles?focussing on the present and near future, use of coping questions and ?problem free talk?, and clearly defining goals?can be combined successfully with psychodynamic psychotherapy and hypnosis, and that this multi-modal approach is highly effective in the treatment of panic disorder without agoraphobia.
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