Is health anxiety harming you?

Do you worry that you have a serious, undiagnosed medical condition?  The number of people in the UK suffering from health anxiety is rising.  Many of us are guilty of Googling a symptom when we have a cold or worrying that a sore throat may be something worse; but health anxiety is more than that. People affected by health anxiety have repeated, obsessive thoughts that they have (or will have) a physical illness.  The most common health anxieties tend to centre on conditions such as cancer, HIV, AIDs, etc. However, the person experiencing health anxiety may fixate on any type of illness.

According to the NHS, people with health anxiety have obsessively anxious thoughts about their health. They frequently check their body for signs of illness and are always asking people for reassurance that they’re not ill.  Often the physical symptoms of anxiety become signs of an impending and life-threatening health problem.

The distress and negative impact upon lives that health anxiety can cause is real, with sufferer’s worrying that their GP may have misdiagnosed them.  This preoccupation impacts negatively upon their lives, affecting work, study and relationships because of the constant need to seek reassurance about their health.

The National Council for Hypnotherapy notes that our society is one where great demands and responsibilities are placed on us and while some people manage, more and more people are showing signs of stress and anxiety which can make a significant impact on the quality of life and wellbeing.  Last year a report was released which found that mental health issues were the most common reason for people to take time off workAnxiety can also manifest itself in different worries, explains the NCH. “It may be fear of being around other people; it may be anxiety in specific social situations, anxiety in your relationships with particular people at home, at school or at work.

Working with a hypnotherapist may help you feel more confident and more at ease about things which have previously been challenging for you says the NCH.

“Hypnotherapy unlocks the potential you have to break free of negative thought patterns, and to react more positively and more confidently to situations in your life that may have previously made you anxious.”

To contact your nearest NCH-registered therapist and start the process of shedding your anxieties, simply click here.

Hypnotherapy versus CBT: October Research Snippet

Hypnotherapy versus CBT: October Research Snippet

Donald Robertson, NCH Research Director

This month’s research snippet is about a very important treatment outcome study on public-speaking anxiety, a clinical trial comparing an established (evidence-based) CBT protocol for social phobia (social anxiety disorder) against the same protocol augmented by hypnosis, and a third (waiting list) control group.  The study was published in 1997 and has been frequently-cited since as providing evidence of the “additive” value of hypnosis as an adjunct to CBT and potentially other evidence-based treatments.  I’ve decided to summarise it this month because it’s probably one of the most important treatment outcome studies available in relation to hypnotherapy, and so NCH members should be familiar with its findings, and because the study was based on the doctoral dissertation of Nancy Schoenberger, the main author, who was supervised by Prof. Irving Kirsch, one of the speakers at this year’s NCH Extravaganza.  So if you’re lucky you may have the opportunity to ask Prof. Kirsch about this study yourselves!  In a nutshell, the authors conclude: “the addition of hypnosis to cognitive behavioural treatment enhanced the effects of treatment.”

The study involved 62 participants with severe public-speaking anxiety.  They were divided into three groups,

  1. Standard CBT (based on Heimberg’s protocol for social phobia)
  2. CBT+Hypnosis (Cognitive-behavioural hypnotherapy, CBH)
  3. Waiting list control, i.e., a group who received no treatment to control for the effect of spontaneous remission, etc.

The researchers emphasise the established finding that relaxation is not a necessary component of hypnosis (hypnosis is not a “state of relaxation”), although it featured as a treatment component in this study.  (This key misconception is virtually extinct among modern researchers but is still fairly widespread among hypnotherapists.) 

In sum, the hypnotic treatment included all components of the cognitive behavioural treatment.  It differed from the nonhypnotic treatment only in the following ways: (a) relaxation training was termed “hypnosis” and contained reference to entering hypnosis, (b) relaxation practice at home was termed “self-hypnosis”, (c) automatic thoughts were termed self-suggestions, and (d) suggestions for improvement were given following the hypnotic induction.

Participants in both treatment groups received five sessions, two-hours long, of CBT or CBH, based on Heimberg’s established protocol for the generalised subtype of social phobia.  This has already been applied to public-speaking, the most common fear among social phobics, and the authors adapted it to include relaxation skills training and tailored it for application to a specific fear (public speaking).

42 of the 62 participants completed the whole programme of treatment and assessment (= 68% completers).  Essentially, the study found that CBH subjects improved to a greater extent, because of the apparent additive value of hypnosis, across a battery of outcome measures, although the initial credibility rating of both treatments was virtually identical.  The mean effect size across all measures, calculated using a standard formula called Cohen’s d, was 0.80 for CBT, which increased to 1.25 in the group where hypnosis as incorporated.  This shows a substantial increase on average, apparently due to the inclusion of hypnosis in the standard CBT protocol.

The researchers also attempted to identify “moderators” of treatment, i.e., other factors which determined the response to therapy.  They measured hypnotic susceptibility and attitudes toward hypnosis for this purpose.  Suggestibility did not seem to correlate well with outcome measures except for pulse rate (which may have been problematic in this study anyway).  Positive attitudes to hypnosis appear to have moderated the benefits of hypnosis, and correlated with greater reduction in anxious behaviours.

Kirsch’s cognitive “response set” theory holds that the effects of hypnosis are largely mediated by changes in the client’s expectations of improvement.  (It’s generally been found by researchers that treatment expectations correlate with outcome, across the board.)  Although some hypnotists seem to dispute this, it was also central to Braid’s definition of hypnotism that it worked partly by means of expectation.  Statistical analysis in this study showed that hypnosis generated greated expectation for improvement in symptoms of public speaking anxiety than did CBT alone.

In sum, the addition of hypnosis to a cognitive behavioural treatment of anxiety enhances clients’ therapeutic outcome expectancies.  It also appears to promote greater improvement in both expected and experienced anxiety.  Behavioural improvement in hypnotic treatment is associated with positive initial attitudes toward hypnosis, and change in anxiety expectancy appears to be the central unifying characteristic among otherwise uncorrelated measures of change.  These data are consistent with [Kirsch’s] hypothesis that the benefits of adding hypnosis to treatment are mediated by expectancy.

This study followed on from an important meta-analysis by Kirsch and his colleagues which pooled data from different studies comparing different forms of CBT for different problems to the same treatment plus hypnosis and found that for between 70-90% of subjects, on average, hypnosis added to the effects of CBT.  This type of evidence is of particular importance to hypnotherapists as the future of hypnosis and hypnotherapy are likely to be bound up with the integration of hypnosis as a method with other empirically-supported treatments (ESTs).  Dr. Assen Alladin’s recent book Cognitive Hypnotherapy contains numerous integrative protocols which are carefully designed to enhance the effects of established evidence-based treatments for a range of conditions by the incorporation of hypnosis and we should hope that developments like this will continue to add to our understanding of how hypnosis interacts with other nonhypnotic treatments, as this will surely continue to define its role in the future. 


Schoenberger, N. E., Kirsch, I., Gearan, P., Montgomery, G., & Pastyrnak, S. L. (1997). Hypnotic Enhancement of a Cognitive Behavioral Treatment for Public Speaking Anxiety. Behavior Therapy (28), 127-140.

Mindfulness, Metacognition and Hypnosis: August Research Snippet

Mindfulness, Metacognition and Hypnosis

August Research Snippet

Donald Robertson, NCH Research Director

Apologies for the absence of a July Snippet but here’s August’s a bit early as compensation.  Following our previous snippets on meta-analyses, finding research online, and treatment outcome studies, etc., we’ve recently looked at attempts to combine mindfulness research and hypnosis in the treatment of depression.  This is a popular area so I thought I’d continue in the same theme by looking at, arguably, the most important recent article on this subject.  In 2006, Steven Jay Lynn collaborated with the Buddhist teacher Lama Surya Das, and two other researchers, in an attempt to explore the possibility of combining elements of Buddhist mindfulness meditation practice, cognitive therapy, and hypnosis, drawing on recent research in cognitive psychology.

Mindfulness versus Thought Suppression

Over the past couple of decades, enthusiasm for mindfulness meditation techniques derived from Buddhism has flourished among cognitive-behavioural therapists, inspired by the early success of Jon Kabat-Zinn’s meditation programme for stress management.  Meditation and acceptance strategies have been used to counteract the tendency of many clients to try to suppress, control, or “fight” distressing thoughts.  Lynn et al. refer to the recent study by Wegner and his colleagues, which found that when people tried to deliberately suppress a thought there was evidence of a “rebound effect” in which they subsequently experienced more intrusions of the thought than a control group who were simply asked to think freely about the same thing.  Other studies have found evidence that emotional suppression can inhibit memory and problem-solving and increase physiological signs of nervous arousal.  Lynn and his colleagues report that of nearly a hundred subjects who were asked to keep their minds blank while listening to hypnotic suggestions, only one reported any success. 

Where thought-control strategies backfire, mindfulness and acceptance have been seen as offering an alternative way of responding to distressing experiences.  Lynn et al. follow other contemporary cognitive-behavioural therapists in contrasting non-judgemental mindfulness and acceptance with the unhealthy suppression of thoughts and feelings.  (However, they fail to mention that experimental studies on this “rebound” effect in thought suppression have produced some mixed results – q.v. Clark & Beck, 2010, for a more detailed review.)  Lynn et al. also cite a 2003 meta-analysis of mindfulness-based cognitive therapy and stress reduction approaches by Baer, which found a mean effect size of 0.59 (a medium-sized treatment effect) for this approach across various emotional problems and medical conditions.  In other words, it probably works, but the effects are comparable to those of other therapies and not dramatically superior to them.

Mindfulness & Metacognition

Lynn et al. appeal to a cognitive model combining elements of Adrian Wells’ influential metacognitive theory and Lynn and Kirsch’s own “response set” theory to explain the mechanism underlying mindfulness meditation and its relationship with hypnosis.  Contrary to Beck’s earlier cognitive therapy model, Wells introduced a focus on the notion of “metacognition”, thinking about thinking, or beliefs about beliefs.  According to this model, negative automatic thoughts aren’t particularly unhealthy in themselves, but rather they become so because of our attitude toward them.  In plain English, whereas Beck’s original cognitive therapy assumed that negative thoughts play a central role in the development of emotional disturbance, Wells points to the fact that many people experience lots of negative thoughts without becoming upset by them, whereas patients with severe emotional disorders appear to be unusually disturbed by individual negative thoughts and worries.  Mindfulness meditation, likewise, can be seen as an attempt to adopt a more detached attitude toward our stream of consciousness, and thereby to modify our thinking about thinking, i.e., to see automatic (spontaneous) thoughts as relatively transient and harmless, rather than important and dangerous.  Indeed, Beck has recently assimilated many aspects of Wells’ metacognitive approach into his revised cognitive therapy for anxiety (Clark & Beck, 2010).

Curiously, Lynn et al. don’t mention the fact that Wells’ metacognitive model raises serious problems for hypnotherapy because it suggests that the assumptions often made by hypnotherapists about the “power of thought” risk reinforcing maladaptive (metacognitive) assumptions held by many clients, i.e., the assumption that thoughts (including suggestions) are inherently powerful, whereas Wells teaches his clients that ideas are only as powerful as we believe them to be and we can learn to dismiss them as “mere thoughts”, lacking any real power or significance.  Likewise, Lynn et al. cite the recent research by Twohig (2004), which found that by repeating a negative thought to oneself one hundred times, like a mantra or autosuggestion, subjects made it seem less believable rather than more so, as some hypnotists might assume.  To borrow Wells’ terminology, hypnotism itself can be seen as a set of metacognitive beliefs rather than an altered state of consciousness or “hypnotic trance”.  The belief that autosuggestions are powerful when phrased in certain ways and the strategy of attending to their meaning for a prolonged period, to the exclusion of distractions, are ways of “thinking about thinking” (metacognition), which it’s the aim of most “hypnotic inductions” to instantiate.  In a sense, mindfulness meditation can be seen as a kind of “de-hypnosis” or “counter-hypnosis”, which aims to develop a metacognitive mind-set that weakens the hold of certain thoughts or suggestions, e.g., “Imagine that you are transparent, and disturbing thoughts and emotions cannot penetrate you or have any power to control your actions” (Lynn et al.), which contrasts sharply with typical preliminary hypnotic suggestions to experience certain ideas (suggestions) as powerful, controlling, and deeply penetrating into the mind, etc. 

Combining Hypnosis & Meditation

Lynn et al. summarise the relevance of hypnosis to mindfulness training as follows,

  1. Suggestions can be used to motivate clients to persevere with meditation practice on a regular basis.
  2. Suggestions can be used to generate a patient mind-set, so that when the attention naturally wanders this is seen as normal and accepted.
  3. Suggestions can be given about acceptance of things that cannot be changed.
  4. Hypnosis can be used to help people avoid identification with thoughts and feelings.
  5. Hypnosis can help clients to become more tolerant of unpleasant feelings.
  6. Clients can be hypnotised to perceive negative thoughts as transient and unimportant.

They specifically recommend the use of the following hypnotherapy techniques in conjunction with mindfulness meditation, which generally involves exposure to aversive feelings and events in CBT,

  1. Mental (“covert behavioural”) rehearsal of previously avoided situations.
  2. Cue-controlled relaxation to help facilitate exposure to feared situations.
  3. The use of hypnotic desensitisation to facilitate mental (“imaginal”) exposure .
  4. The use of hypnotic regression or reliving as a form of imaginal exposure to traumatic memories (as in PTSD treatment).
  5. The use of suggestion to help clients tolerate the discomfort and repetition of exposure therapy.

They add that the most basic use of hypnosis in combination with mindfulness-based CBT would be in the use of suggestion to directly develop an ongoing state of mindfulness.  As Lynn et al. emphasise, virtually all modern researchers now take it for granted (following several well-known studies) that hypnosis does not necessarily entail any form of relaxation, although it is frequently accompanied by it.  The same applies to meditation and Lynn et al. refer to a recent EEG brain imaging study in which subjects trained in relaxation showed markedly different brain activity from those trained in mindfulness meditation.

Negative Reactions

As an aside, Lynn et al. also note that a considerable body of research demonstrates the existence of transient, relatively superficial, negative reactions following standard hypnosis, i.e., things like headaches, feelings of nausea, anxiety, etc., in up to 29% of subjects.  This is comparable to the rates of negative responses reported by control groups who are simply asked to sit with their eyes shut, without being hypnotised, for the same amount of time.  However, similar negative reactions are also reported following meditation training, and may even be more frequent, being reported in up to 63% of subjects.  Hence, we might say that although negative reactions can occur following hypnosis it may be as harmless (generally speaking) as common meditation or relaxation techniques.



Lynn, Steven Jay; Das, Lama Surya; Hallquist, Michael N.; Williams John C.             (2006).  Mindfulness, acceptance and hypnosis: cognitive and clinical perspectives.  IJCEH, 54(2), 143-166.

Clark, David A.; Beck, Aaron T.    (2010).  Cognitive Therapy of Anxiety Disorders: Science and Practice.