A CASE STUDY
Synopsis Knowledge of hypnosis is useful in clinical practice and hypnotherapy plays an important role as an adjunctive/alternative therapy, especially when dealing with allergies and anxiety related ailments. Allergies to dust, various food items, synthetic fibre, dry and cold air developing into asthmatic attack and acute itching due to atopic dermatitis can be really stressful for a child. This generates lot of distress and discomfort and subsequently, develops into extreme anxiety levels. Associated behavioural issues create additional problem for family members and people around the child. A comprehensive treatment approach becomes essential in these circumstances. An illustrative case study is presented here in which hypnotherapy played a big role along with counselling, family involvement and medical treatment. All this led to symptomatic relief and improved behaviour and hence expedited and enhanced the response to pharmacological treatment. This also improved the family atmosphere. Introduction Conceptualising anxiety and anxiety disorders in children poses a set of problems unique in psychodiagnostic endeavours. There is no universally accepted definition of anxiety. But all the definitions are around the apprehension about a person’s own well-being or that of someone or something significant to the person. Anxiety is common experience in lives of adults and children alike and most of the time, anxiety is often an appropriate response to events. It can also result in positive effects under certain circumstances especially when they face some sort of challenge to perform. Many times, terms “fear” and “anxiety” are used almost indistinguishably. As per revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R),[American Psychiatric Association 1987] fear is used as subset of anxiety. Some theorists[Clarke and Jackson 1983] distinguish between the two on the basis of the presence or absence of objective danger signs. Distinguishing anxiety, fear and phobias is particularly difficult in paediatric cases as children do not necessarily share same information as adults and their perception about a situation. In most of the cases, is very different from adults. But in children, these perceptions visibly and significantly disrupt their lives and those of the family members. Since fear and anxiety are integral part of human experience, sometimes it becomes difficult to establish when they become a problem. This is where professional help is required. This becomes even more problematic when the secondary role anxiety plays in other psychological or physiological disorders. Anxiety has also been implicated in aetiology maintenance of certain paediatric psychophysiological disorders, such as asthma, headaches and hives, tics, ulcers, sleep disorders, irritable bowel syndrome (IBS), enuresis and other autoimmune diseases. Anxiety disorders represent one of the most common categories of psychopathology in children and adolescents. In children, anxiety is not only common, but a statistically normal occurrence. A recent study of children aged eight to 13 years, having a primary diagnosis of anxiety disorder revealed that 79% of the sample also had another co-morbid anxiety disorder, mood disorder or behaviour disorder.[Kendall et al. 2001] Prevalence rates for having at least one childhood anxiety disorder vary from six per cent to 20% over several large epidemiological studies.[Costello et al. 2004] Anxiety disorders impair emotional, cognitive, physical and behavioural functioning in multiple areas and are usually chronic in nature. Hence, the child needs to be evaluated in context of his family, school, community and culture. Important areas of assessment include history of onset and development of anxiety symptoms, associated stressors, medical history, school history, family history and mental status examination. Anxiety and hypnosis in children In general, children respond more readily to hypnosis than adults.[Gardner 1974, Milling and Costantino 2000] Children’s greater overall hypnotic hypnotisability may be a result of a natural unbiased observation of the world, free of the mind–body split that adults apply to perception.[Cowles 1998] Although children may a times manifest marked anxiety and resistance to hypnotic induction, this occurs less frequently than in adults and is usually overcome more easily.[Kaffman 1968] Hypnotherapy can be combined with family therapy,[Haley 1973, Lind 1990] psychotherapy[Iglesias 2004, Peebles-Kleiger 2001, Williams and Singh 1976] and cognitive-behavioural therapy (CBT),[Hutchinson-Phillips et al. 2005, Kirsch et al. 1995] and used within inpatient multidisciplinary treatment programmes.[Aronson 1986] Furthermore, hypnotherapy is goal-oriented in focusing on the child’s resources. A review of a literature search from PubMed, PsychINFO and the Cochrane databases revealed many publications, mostly case reports based on a large number of cases, addressing the use of hypnotherapy in various child psychiatric conditions. Findings indicate that hypnotherapy may be useful for a wide range of disorders and problems, and may be particularly valuable in the treatment of anxiety disorders and trauma-related conditions. Hypnosis has been used both primarily and adjunctively to treat anxiety disorders and issues developed due to this in children with one of the earliest published account being Mason’s 1897 treatment of a child who was too frightened to receive medical treatment. The anxiety- related psycho physiological disorders have been addressed directly by hypnosis, usually with suggestions and invoking the imagination and fantasies of children for relaxation, comfort and confidence. During hypnotherapy, reduction of anxiety and removal or prevention of symptoms is not treated differently and direct suggestions are given for removal of symptoms, related anxiety and prevention of recurrence. Many issues can be resolved with hypnotherapy. Asthma and many such autoimmune disorders are very prominent. In treatment of these issues, special focus is also on anxiety component. Kohen et al.[1984] reported that 90% of their 40 paediatric asthmatic patients had reduced attacks, fewer emergency hospital visits and fewer consultations with physicians following the use of relaxation and mental imagery. Hackman et al.[2000] also showed similar results. Hypnosis has also helped with anxiety related to sleep diorders/disruptions. Jacobs[1962] reported treating the fear of dark in a six years old who could not fall asleep without mother being present. Gardner[1978] reported successfully reducing recurrent nightmares in children. Gold et al.[2007] also examined the benefit of using hypnosis in various paediatric disorders and some psychological conditions like Tourette’s syndrome and sleep-terror disorder. Anxiety is also associated with the diagnosis and treatment of medical conditions. Olness and Gardner[1978] treated a seven years old needle phobic boy who required repeated intravenous infusions of plasma by teaching himself hypnosis for relaxation and “switch off techniques.” Hilgard and LeBaron[1984] used suggestions for turning the smell of alcohol swab into “pleasant perfume” and putting a hand “to sleep” to eliminate needle fear in seven years old cancer patient. The dental literature addresses both prevention of anxiety and its treatment. Shaw,[1975] Erickson et al.[1961] and Bernick[1972] all emphasised the importance of helping children perceive dental experiences in positive light, even before treatment begins. Crasilneck and Hall[1975] and Lawlor[1976] reported their successful treatment of school phobia in young children. Hypnosis was used to determine the underlying concerns which were then resolved with positive suggestions and subsequently by discussions and environmental manipulation. Klauber[1984] recommended the use of hypnosis for children afraid of making errors. Gardner and Olness[1981] helped a five years old boy who refused to go out because of his fear of probability of meeting a dog. Hypnosis and hypnotherapy The hypnotic state is achieved using an induction procedure. Clinical hypnosis starts by introducing relaxation. Total relaxation is considered to be a simple form of hypnosis.[Hackman et al. 2000] However, hypnotherapists also use guided imagery, both in the induction part and in subsequent planting of suggestions. Owing to the patient’s concrete way of thinking and increased suggestibility when in a trance, the therapist will be very attentive to their choice of words and metaphors.[Evans 2000] Suggestions are verbal communications and differ from everyday instructions in that they imply a ‘successful’ response and are experienced by the subject as having a quality of effortlessness.[Evans 2000] Suggestions may be concrete, imaginative, regressive or ego strengthening.[Gardner 1974, McNeal and Frederick 1993] They can be seen as ‘therapeutic key messages.’ The specific hypnotherapeutic techniques used depend on a dynamic understanding of the presenting problem, the patient’s goals and characteristics (age, interests and medical conditions), the therapist’s theoretical orientation. A case study Case history A 12 years old girl’s parents approached to get the help for their daughter. They had read about the probable benefits of hypnotherapy in similar circumstances through their research on internet. Presenting problem Girl was facing the problem of atopic dermatitis for almost two years. Her face, arms, legs, neck and back were completely covered by angry rashes and she was continuously scratching herself. She was also bleeding at few spots due to furious scratching. She also had signs of breathlessness. She was allergic to dust, synthetic fibre, dry and cold air, nuts, casein, soya, wheat etc. Taking bath was a torture for her as she complained that water increased the irritation and burnt her skin. She was already taking the regular medical treatment which was primarily the use of steroids and antihisthamines. But it helped her temporarily which made the patient feel even more angry and helpless. Another major problem was the insomnia which she was facing due to constant itching and scratching that aggravated at night. Her mother or elder sister needed to soothe her up at all odd hours. She could hardly sleep and got up with sore rashes everywhere on her body and in very irritable mood. Because of unpleasant appearance of skin, other children in school and neighbourhood teased her and were not very keen to play with her. She hated when she could not eat many things. Her parents were equally distressed by her appearance, teasing and taunting by other children, behaviour and questioning of relatives and family friends about the daughter’s condition. All this was too much stress for the young girl and developed lot of anxiety about her symptoms, other people’s reaction, and fear of night and expected itching. She was experiencing severe mood swings. She had stopped meeting people and was on her own in school. She was always on lookout for a reason to skip the school. She had lost faith on medical treatment. She had also developed severe hatred for her mother, as she perceived her to be too ‘bossy and dominating’ because she insisted her for medical treatment, bath and going to school. Family history Mother was prone to mild allergy to dust. Father and elder sister (18 years) had no major medical history. Both parents were working. Girl also hated her mother for not being around her all the time and for nagging her to stop scratching, to take bath etc. Girl was otherwise healthy, intelligent, inquisitive and friendly. There was widespread rashes on almost all her body but much more severe along the flexures of elbows, knees and neck. Expectation from hypnotherapy Parents expected their daughter to be able to control her itching, release her anger and be stress free. Girl wanted to get rid of her ‘ugly skin’ and get ‘soft skin’ so that she can go to school and play with other kids. She wanted her itching to just disappear so that she could sleep properly. She also wanted me to tell her mother to stop forcing her to have bath and medicines. Parents and daughter simply wanted to have normal life. Line of therapy Session one Detailed discussion was done with the child and parents to understand the problem, its development, expected outcome, present treatment and the motivation to choose hypnotherapy. Child was assessed for susceptibility to hypnosis and her favourite activities, places, food etc. The patient and her mother were given an outline of the nature and purpose of the therapy and were prepared to cooperate. It was also emphasised that the therapy would move in step by step manner. Child will be taught various ‘magic tricks’ (most children have a love of magic and fantasy and they easily intertwine fantasy and reality) which she will need to practice every day to be an expert to handle and solve her problems to get beautiful skin, without itching. It was also emphasised that therapy will work toward reducing/stopping the itching in stage one. Once the itching reduced, in stage two, focus will be on getting new and nicer looking skin and itching and scratching will stop completely. As the itching will reduce, she will be able to sleep more peacefully and with healthier skin, other kids will not tease her and she will get lots of friends. It was also made clear to parents that itching may reduce very soon but it would take time for skin to heal. During that time, they would have to keep motivating the daughter, not to talk to her about scratching. Sessions were planned twice a week. Main idea of this session was to make child comfortable, build rapport with her, remove any misconceptions about hypnosis so that parents had much more clear and reasonable expectations from therapy sessions. Session two A light hypnotic state was easily induced using the relaxation through visit to favourite place. In her favourite place, through mental imagery she received magical oil in her favourite colour which soothed her skin instantly. She was told to notice the redness from her skin to leave immediately after applying the oil while standing in front of mirror. Suggestions were made to get the access to this magical oil anytime, anywhere whenever she felt irritation on body and notice her skin improving in mirror. Outcome: She applied oil four to five times a day and could sleep more peacefully. Session three Child was very upset with her mother as she forced her to take bath, which according to her, was very painful for her. After some talk, she was ready to learn another ‘trick.’ In hypnotic state, in a safe room she invited her mother and friends one by one, with whom she was upset and had dialogue with them and released her related anger. She was taught breathing technique to release the anger on day to day basis. Outcome: She went for bath on her own and had fewer arguments with her mother and tried to remain unmoved by her mother’s bad behaviour (as perceived by daughter). Itching had reduced but got aggravated whenever she was angry or upset. Session four Guided imagery was used to release further resentment and anger against her mother. She was given affirmations which she was told to write every day 20-25 times. Her magic tricks were revised and modified as per her feedback and liking. Outcome: She was much calmer and started having dialogue with her mother without shouting, crying and getting upset. This further helped her to control the itching. Session five Under hypnosis, using guided imagery, she was taken for diving where she changed her skin and wore new skin which was much smoother and clearer. Outcome: Her belief in getting rid of irritable grew which helped her to heal faster and motivated her to practice her magic tricks with lot more energy and regularity. Session six She was taught another trick to change her skin as she was not very happy with ‘going for diving every day.’ She was also taught a trick to talk to heart and belly to check what she really wanted (mostly to remain happy for the whole day) and what she needed to do to achieve that. Outcome: Her relationship with her mother improved tremendously. Her skin started healing and looked less ‘furious.’ According to child, 40% of her skin changed in one month. Follow up Talk to parents and child every fortnight. Recording was given to assist her to perform and practice her ‘magic tricks’ which she was to do at least once a day. After three months, itching has stopped completely, skin has healed. Her relationship with her mother has improved a lot. She does not react to hot/cold air and allergy reaction to dust has reduced a lot. She has been recommended to use cotton clothes as far as possible. She is still allergic to nuts because, according to her, ‘she hates the taste of nuts.’ She has started taking bath without any fuss. Conclusion Hypnosis can be used both primarily and adjunctively to other therapies (psychotherapies and pharmacotherapy) to treat anxiety disorders and related issues. Clinical experience reveals that hypnotherapy can be cost-effective and have fewer side effects than other treatment methods. There are specific reasons to assume that hypnosis would be valuable in the treatment of various child psychiatric and physiological conditions, but it seems to be particularly valuable in anxiety disorders and trauma-related conditions. Suggested reading Ambrose G (1961) Hypnotherapy with children. London: Staples Press Anbar RD (2003) Self-hypnosis for anxiety associated with severe asthma: a case report. BMC Pediatr 3:7 Huynh ME, Vandvik IH, Diseth TH (2008) Hypnotherapy in child psychiatry: the state of the art. Clin Child Psychol Psychiatry 13:377-93 Kramer RL (1989) The treatment of childhood night terrors through the use of hypnosis--a case study: a brief communication. Int J Clin Exp Hypn 37:283-4 Kuttner L (1988) Favorite stories: a hypnotic pain-reduction technique for children in acute pain. Am J Clin Hypn 30:289-95 Olness K, Kohen DP (1996) Hypnosis and hypnotherapy with children. 3rd ed. New York: Guilford Press Reznick C (2009) The power of your child’s imagination. New York: Perigee Scott MJ (1960) Hypnosis in skin and allergic diseases. Springfield, Ill: Charles C. Thomas Wester WC II, O’Grady DJ (1991) Clinical hypnosis with children. New York: Brunner/Mazel References American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorder. 3rd ed. Revised. Washington, DC: American Psychiatric Association Aronson DM (1986) The adolescent as hypnotist: hypnosis and self-hypnosis with adolescent psychiatric inpatients. Am J Clin Hypn 28:163-9 Bernick SM (1972) Relaxation, suggestion and hypnosis in dentistry. What the pediatrician should know about children's dentistry. Clin Pediatr (Phila) 11:72-5 Clarke JC, Jackson JA (1983) Hypnosis and behavior therapy: the treatment of anxiety and phobias. New York: Springer Costello EJ, Egger HL, Angold (2004) Developmental epidemiology of anxiety disorders. In: Ollendick TH, March JS, editors. Phobic and anxiety disorders in children and adolescents. New York: Oxford University Press Cowles RS (1998) The magic of hypnosis: is it child’s play? J Psychol 132:357-66 Crasilneck HB, Hall JA (1975) Clinical hypnosis: principles and applications. New York: Grune & Stratton Erickson MH, Hershman S, Secter I (1961) The practical application of medical and dental hypnosis. New York: Julian Press Evans FJ (2000) The domain of hypnosis: a multifactorial model. Am J Clin Hypn 43:1-16 Gardner GG (1974) Hypnosis with children. Int J Clin Exp Hypn 22:20-38 Gardner GG, Olness K (1981) Hypnosis and hypnotherapy with children. New York: Grune Gold JI, Kant AJ, Belmont KA, Butler LD (2007) Practitioner review: clinical applications of pediatric hypnosis. J Child Psychol Psychiatry 48:744-54 Hackman RM, Stern JS, Gershwin ME (2000) Hypnosis and asthma: a critical review. J Asthma 37:1-15. Haley J (1973) Uncommon therapy: the psychiatric techniques of Milton H. Erickson. New York: Norton Hilgard JR, LeBaron S (1984) Hypnotherapy of pain in children with cancer. Los Altos, CA: William Kaufmann Hutchinson-Phillips S, Gow KE-MA, Gow K, Lumsden A (2005) Hypnosis as an adjunct to CBT: treating self-defeating eaters. J Cogn Behav Psychother 5:113-38 Jacobs L (1964) Sleep problems of children, treatment by hypnosis. N Y State J Med 64:629-34 Kaffman M (1968) Hypnosis as an adjunct to psychotherapy in child psychiatry. 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CitationMurdeshwar R. Hypnotherapy for children with anxiety related to allergies, asthma and atopic dermatitis: a case study. In: Das S, editor. Souvenir-cum-Scientific Update for the 22nd Annual Conference of Indian Psychiatric Society, Assam State Branch. Guwahati: ABSCON; 2012. p. 38-43. Available from: https://sites.google.com/site/mindtheyoungminds/souvenir-cum-scientific-update/hypnotherapy-for-children-with-anxiety-related-to-allergies-asthma-and-atopic-dermatitis-a-case-study