Mindfulness An Alternative Perspective for the Management of Anxiety Symptoms [Team-IRA] 9798886977974

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Psychology of Emotions, Motivations and Actions

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Fleura Shkëmbi, Ph.D.

Mindfulness

Copyright © 2023 by Nova Science Publishers, Inc. DOI: https://doi.org/10.52305/ZNNV1973. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. We have partnered with Copyright Clearance Center to make it easy for you to obtain permissions to reuse content from this publication. Please visit copyright.com and search by Title, ISBN, or ISSN. For further questions about using the service on copyright.com, please contact:

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Published by Nova Science Publishers, Inc. † New York

Dedicated to everyone who will read this book.

Contents

Preface

............................................................................................ ix

Acknowledgements ...................................................................................... xi Acronyms

.......................................................................................... xiii

Chapter 1

Introduction ....................................................................... 1

Chapter 2

Consciousness and Its Altered States ............................... 5

Chapter 3

A General Overview of Anxiety Disorders .................... 29

Chapter 4

Empirical Study ............................................................... 69

Chapter 5

Results............................................................................... 75

Chapter 6

A New Paradigm on Beneficial Effects of Mindfulness Intervention on the Anxiety .................. 81

Chapter 7

Limitations and Recommendations for Future Research......................................................... 91

Chapter 8

Implications ...................................................................... 95

Chapter 9

Conclusion ........................................................................ 97

Disclosure Statement .................................................................................. 99 Compliance with Ethical Standards, Informed Consent and Study Data .............................................................. 101 References

......................................................................................... 103

Index

......................................................................................... 127

Author’s Contact Information ................................................................. 135

Preface

Mindfulness: An Alternative Perspective for the Management of Anxiety Symptoms provides a comprehensive examination of the literature on altered states of consciousness, followed by a detailed analysis of hypnosis, neardeath experiences, and meditation, their scientific status as trance states, and their empirically supported benefits in treating anxiety disorders and enhancing well-being. The goal of this study is to see if meditation and relaxation practices may significantly relieve stress and anxiety symptoms in young people. A randomized experimental design was used to compare the efficacy of guided meditation and deep breathing as mindfulness techniques on anxiety levels (i.e., cognitive anxiety, somatic anxiety, systolic and diastolic blood pressure, heart rate, and self-esteem) among thirty-three university students in Albania. The intervention lasted four days, and the results revealed that all groups (experimental and control) reduced their anxiety symptoms, with guided meditation and deep breathing helping the majority of them (systolic and diastolic blood pressure, heart rate, and cognitive anxiety). Overall, this study presented much scientific evidence for the beneficial effects of mindfulness practices on anxiety. The efficacy of a four-day intervention consisting of two experimental groups (guided meditation alone; guided meditation and deep breathing) and a control group (music relaxation) on cognitive and somatic anxiety, self-esteem, systolic and diastolic blood pressure, and heart rate was evaluated using a randomized experimental design. This book makes an essential contribution to the literature by distinguishing between symptoms of cognitive and physical anxiety. Music relaxation, as a control condition, reduced systolic blood pressure, heart rate, and somatic anxiety. Most research has only investigated the effect of music therapies on patient anxiety or test and performance anxiety, therefore empirical information on music relaxation and its association with anxiety is

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likewise sparse. This is the first book to present evidence for the effect of music relaxation on somatic anxiety in this situation.

Acknowledgements

I want to thank the publisher, editors, and support team at Nova Science Publishers for their assistance throughout the book’s development and production. Thanks to everyone on my publishing team. I would also like to extend my sincere thanks to all my friends and my colleagues that were part of my journey until the publishing of this book. Finally, I would like to acknowledge with gratitude the support and love of my family. They all kept me going, and this book would not have been possible without them.

Acronyms

Near-Death Experiences (NDEs) Cognitive Behavior Therapy (CBT) Before the Christ Era (BCE) Diagnostic and Statistical Manual of Mental Disorders (DSM) Functional magnetic resonance imaging or functional MRI (fMRI) Obsessive-compulsive disorder (OCD) The American Psychological Association (APA) post-traumatic stress disorder (PTSD) serotonin-norepinephrine reuptake inhibitors (SNRI) The State-Trait Inventory for Cognitive and Somatic Anxiety (STICSA) Hypoactive sexual desire (HSD) Analysis of Variance (ANOVA) Mindfulness-Based Stress Reduction (MBSR)

Chapter 1

Introduction The concept of anxiety has been among the most persistent and popular topics of psychology. Anxiety had been identified as a sign of unwellness since ancient times, mentioned in Greek and Latin literature. However, it became a widely known phenomenon only after the 19th century, when Freud made the distinction between “real anxiety” (a natural reaction to threatening stimuli) and “neurotic anxiety” (maladaptive anxiety arising from unconscious conflict) (Crosby, 1976). The development of psychology, particularly in the 19th and 20tcenturiesry, saw the emergence of different approaches which held different perspectives for explaining human cognition and behavior. Contemporary psychology recognizes that neither approach is right or wrong and they often complement each other, with behavioral, cognitive, psychodynamic, evolutionary, biological, humanistic, and cross-cultural psychology being the main pillars of psychology. A less known and researched field is transpersonal psychology, which was first introduced as a psychological approach almost a century ago. Transpersonal psychology is closely related to humanistic psychology as it is concerned with exploring the highest human potential, but it further aims to access developmental stages that go beyond those of the adult ego (hence trans-personal). Transpersonal frameworks have been often used in other approaches, and some of them have gained large recognition, such as the works of Maslow, Jung, Grof’s holotropic breath work, guided imagery, and psycholytic psychotherapy (Kasprow & Scotton, 1999). Transpersonal research and literature are mostly focused on nonduality, intrinsic health, altered states of consciousness, and inclusivity. Altered states of consciousness (often referred to as “trance”) have gained particularly considerable attention, with different perspectives debating their nature and differentiation between normal states of consciousness. Recent neurocognitive findings support the idea that altered states of consciousness are characterized by a change in subjective experience, lack of reflective awareness, and lower perceptual boundaries (Glicksohn & Ohana, 2011; Hartman & Zimberoff, 2002).

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This book will provide a detailed analysis of the scientific literature and data related to the principles, theories, and frameworks on hypnosis, meditation, and near-death experiences (NDEs) as distinguished types of altered states of consciousness. Their therapeutic potential for treating anxiety and improving well-being will be examined and evaluated comprehensively. Hypnosis and meditation are more popular concepts that have gained notable recognition in scientific research, particularly in the last decades. The phenomenon of hypnosis has been known for more than two centuries and has been established as the basis of hypnotherapy, which has been considered a powerful tool for empowering people by introducing them to self-discovery and self-growth and developing the best aspects of themselves (Yapko, 2010). Hypnotherapy has been proven to be highly effective in treating anxiety disorders by more than 400 research publications and 50 randomizedcontrolled studies (Frankel & Macfie, 2010). Similarly, meditation has become a well-known and practiced idea that is supported by empirical evidence. Scientific research has explored the nature and therapeutic effects of different types of meditation, such as mindfulness, transcendental meditation, loving-kindness meditation, etc. Mindfulness has gained particular recognition and has generated various approaches for enhancing wellness, the most famous being the Mindfulness-Based Stress Reduction (MBSR) program created by Jon Kabat-Zinn in 1979 (et al., 2003). The principles of mindfulness, such as non-judgmental attitudes and unconditional acceptance, have been shown to enhance emotion regulation and improve anxiety. NDEs have also gained attention, partly because of their debated nature and their difficulty to investigate scientifically, which has made it difficult for their effect on anxiety to be measured empirically. However, research shows that NDEs are associated with reduced death anxiety, a positive, life-changing impact, and enhanced subjective well-being. These phenomena and their relation to the treatment of anxiety disorders and well-being will be examined thoroughly in this literature review. To contribute to the literature related to transpersonal treatment approaches, this book will assess the effect of mindfulness techniques on symptoms of anxiety. Mindfulness comprises a practical treatment alternative, which is easy to learn and can be practiced in groups and even by the person alone. To examine the potential of mindfulness as an alternative for improving anxiety, we conducted a randomized controlled experiment consisting of a four-day intervention on a sample of university students in Tirana, Albania. The intervention aimed to compare the impact of guided meditation, deep

Introduction

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breathing, and music relaxation in reducing blood pressure, heart rate, cognitive and somatic anxiety, as well as increasing self-esteem. The results, limitations, as well theoretical and practical implications will be analyzed and discussed comprehensively. Overall, this mindfulness intervention produced significant results in improving anxiety symptoms and may comprise a valid reference for future studies. Mindfulness techniques are easy to practice and simply integrating them into one’s daily routine or schedule may have a beneficial effect in inducing a general state of relaxation and improving well-being.

Chapter 2

Consciousness and Its Altered States Since the genesis of the first civilizations, all known human societies have practiced and embedded rituals in their cultures, from ancient shamanic traditions and religious acts of worshipping to modern-day marriages, funerals, and inaugurations. Spiritual and religious rituals in particular have often been associated with practices of magic, shamanism, meditation, prayer, hypnosis, etc. What all of these practices have in common is that they all involve or induce an altered state of consciousness, often referred to as trance, a modern term deriving from the Latin word transire “to cross over” or to “pass away” (“Online Etymology Dictionary|Origin, history and meaning of English words”, 2020). The ability to experience trance states is argued to be an innate part of our biopsychology as human beings, as evidence suggests that trance states happen in ninety percent of human societies, regardless of their different socioeconomic and socio-political levels (Hughes & Melville, 1990). The term trance is commonly used to describe a daydreamy mental state, typically associated with activities one is completely absorbed in such as dancing, meditating, listening to music, watching a documentary, driving on autopilot, or undergoing hypnotic induction. However, most of these descriptions are too generalizing and imprecise to constitute an accepted operational definition that can be assessed through empirical research. Defining altered states of consciousness is as difficult as defining consciousness itself, as our knowledge and understanding of the human consciousness is unsolidified and not well-organized. The existing literature attributes over forty meanings to the term consciousness (some of which overlapping and some being mutually exclusive), mainly categorized as mental function or mental experience (Vimal, 2010). The term “conscious” generally refers to human beings being awake and responsive to sensory stimulation (Rosenthal, 2009), while consciousness refers to the capacity of a system to process and assimilate information (Tononi, 2004). Charles Tart, a pioneer in the field of study of consciousness, and particularly of altered states of consciousness, defines awareness as basic cognition, i.e., perceiving and knowing that something is happening; while consciousness is awareness arising from brain functioning and regulated by the mind (Tart, 1975).

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However, he argues that these definitions are still not precise as our knowledge of the main terms, “awareness”, “consciousness” and “mind”, is fragmented and chaotic. Crick and Koch (1990) attempted to define consciousness from a neurobiological perspective, arguing that it depends majorly on short-term memory and attentional mechanisms. According to their theory, these attentional mechanisms assist in firing relevant neurons in a coherent and semi-oscillatory way (40-70 Hz range); these oscillations in turn, activate short-term memory. Although empirical research has been able to identify several aspects and dimensions of it, consciousness remains an ill-defined phenomenon and its true nature might remain unknown partly because of our cognitive biases; hence, defining altered states of consciousness actually becomes a more ambiguous and complicated task. According to Revonsuo et al. (2009) the notion of “consciousness” in “altered states of consciousness” can mainly be understood in two ways: as primary phenomenal consciousness, which refers to subjective experiences (sensations, perceptions, emotions, mental images, etc.) and reflective consciousness, which refers to the conscious processing (i.e., naming, categorizing, judging, evaluating) of a selected phenomenal content. For an altered state of consciousness to occur there must be a changed pattern of subjective experience, which should be cognitively recognized as somehow significantly different from normal; thus both primary phenomenal and reflective consciousness must be involved (Revonsuo et al., 2009). The term “altered states of consciousness” was first used by psychiatrist Arnold M. Ludwig who defined them as “any mental state(s), induced by various physiological, psychological, or pharmacological maneuvers or agents, which can be recognized subjectively by the individual himself as representing a sufficient deviation in subjective experience or psychological functioning from certain general norms for that individual during alert, waking consciousness” (Ludwig, 1966; p. 225). He argues that trance is clearly a form of altered state of consciousness, and that these states are moderated by many basic processes such as induction procedures, cultural influences, communication factors, transference feelings, individual mental sets, etc. Moreover, they share various common characteristics such as alterations in thinking and emotional expression, disturbed perceptions and sense of time, loss of control, change in meaning and body-image, sense of the ineffable, feelings of rejuvenation, and hypersuggestibility (Ludwig, 1966). The term was later brought into common usage by Tart, who defined altered state of consciousness as a “qualitative alteration in the overall pattern of mental functioning, such that the experiencer feels his consciousness is radically

Consciousness and Its Altered States

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different from the way it functions ordinarily” (Tart, 1972; p.1203) and stated that hypnosis, meditative states and dreams are the most distinct altered states of consciousness (Tart, 1975). Farthing (1992) later gave a similar definition, stating that altered states of consciousness are temporary alterations of subjective experience which led the individual to believe that their mental functioning is significantly changed. Thus, it is clear and further supported by other scholars (e.g., Kallio & Revonsuo, 2003; Kihlstrom, 2018; Peres et al., 2012) that altered states of consciousness can be identified by a distinct change in subjective experience which the individual is eventually aware of. According to Glicksohn and Ohana (2011), trance states are usually characterized by limited or a lack of reflective awareness, detachment from reality, feelings of relaxation and passivity, and a special form of thinking called “trance logic”. They suggest that this logic exhibits more primitive forms of thinking where the individual does not use syllogistic reasoning, does not differentiate between cause and effect, and perceives opposites as coexisting and not contradictory. Winkelman (1986) differentiated several techniques commonly used to induce trance states, such as auditory driving, fasting and nutritional deficits, social isolation, sensory deprivation, meditation, sleep and dream states, sexual restrictions, extensive motor behaviors, endogenous opiates, hallucinogens, and alcohol. A more specific and organized classification of trance states based on their origin and method of induction was suggested by Vaitl et al. (2005): (1) Spontaneously occurring (daydreaming, drowsiness, near-death experiences); (2) Physically induced (extreme environmental conditions, starvation, sexual activity, respiratory maneuvers); (3) Psychologically induced (sensory deprivation/overload, rhythminduced, meditation, hypnosis, biofeedback); (4) Disease induced (psychotic disorders, coma, epilepsy); (5) Pharmacologically induced (hallucinogens, opiates, alcohol). These techniques have different psycho-physiological effects but share basic features. Moreover, four types of transcendence have been identified: group-directed transcendence (sense of unity and belonging after a ritual), theory of mind-evoking transcendence (perception of incorporeal minds and agents), aesthetic transcendence (feelings of astonishment and grace by something beautiful), and epistemic transcendence (unprecedented enlightenment and revelation of truths) (Dein, 2020). Dein (2020) further

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argues that these modes might involve the same cognitive systems, and when associated with ego breakdown they may enhance social bonding, compassion, gratitude and love. Altered states of consciousness have often been associated with religious experiences. Being immersed in the religious experience itself means being in a trance state, a mechanism that may be used for human bonding in large social groups (Dunbar, 2020). Earlier theories assumed that trance states resulted from endorphin activations, which may be related to the sense of unity in religious ceremonies and their cathartic effect (Dunbar, 2020). The theory of endorphin activation has also been associated with dancing trance. Many societies have reported trance related to dancing, such as the whirling of Sufi Muslims and other Near Eastern cultures, Hindu-Buddhist Malaya, Java and Bali, Korea, the West Indies, Native Americans, and African American Baptists (Garfinkel, 2018). The circular rhythmic movements which are common in these traditional dances along with other factors like hyperventilation, exhaustion, whirling and turning have physiological effects which may affect the sense of balance and eventually induce an altered state of consciousness (Garfinkel, 2018). The social bonding enhanced by the endorphin production gives individuals a survival advantage, which suggests that trance experiences, particularly connected to rituals and ritual dancing, are crucial to religions’ origin (Jones, 2020). Sturm (2000) further argues that listening to stories also induces a type of “story-listening trance” as consciousness is altered when listeners experience the story as a result of their perception rather than imagination and engage with its plot and characters, thus inducing an altered state of consciousness. He conducted a qualitative study where subjects identified six characteristics of story-listening which have also been attributed to altered states of consciousness: story and experience realism, lack of awareness of surroundings, engaged receptive channels, loss of control of the process, placeness, and changes in the sense of time. The induction of story-listening trance may be positively influenced by the storytelling style, the listener’s feeling of physical and emotional safety, the story content, the storyteller’s ability, nonverbal (vocal and physical) communication, and the listener’s expectations and personality traits (Stallings, 1988; Stallings & Ellis, 1993; Sturm, 2000). Overall, most trance states like rituals, hypnosis, breathwork, the “shamanic state of consciousness”, out-of-body experiences, near-death experiences, and the lucid dreaming state, share similar neurocognitive aspects. Each of these trance states causes an increase in primary process

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thinking, enhanced awareness, lower perceptual boundaries, and high-voltage, slow-wave hippocampal-septal hypersynchrony (Hartman & Zimberoff, 2002). These states are connected to creativity, enhanced learning, hypnotic suggestibility, meditation and transcendental states of consciousness (Hartman & Zimberoff, 2002; Wilber, 2000).

Hypnotic Trance The phenomenon of hypnotism has fascinated scientists and researchers since it was first discovered by Mesmer more than two centuries ago. Back then hypnotism was believed to be a neurophysiological treatment for nervous diseases called “animal magnetism” (Green et al., 2014), and further named “hypnosis”, a term proposed by Braid (1843) and later adopted by writers and scientists. In 1967 van der Walde defined hypnosis as “the presence of an induced trance or altered state in which the subject automatically and uncritically carries out the suggestions of the person inducing the altered state (the hypnotist)” (van der Walde, 1967; p. 98). He further defined trance states as “a grouping of ego mechanisms designed to allow discharge of the basic drives in a goal-oriented manner and can also serve other adaptive and defensive goals” (p. 95) and argued that hypnosis is strongly dependent on the subject and their motivations, as the subject can achieve gratification from the hypnotic behavior by prescribing the extent and expression of his wishes. Watkins (1954) had previously suggested that hypnosis should be based on a deep understanding of the subject’s personality, ego defenses, and transference needs, as well as the hypnotist’s role abilities and limitations. Hypnotic states typically involve altered subjective experiences and selfrepresentation characterized by several dimensions such as deep mental relaxation and absorption, a diminished tendency to judge, monitor, and censor, altered sense of time, location and self, as well as automatic responses (Rainville et al., 2002). Sturm (2000) also argues that hypnosis is associated with several psychological characteristics, among which altered sense of time and (suggested) reality, narrowed attention, “splitting” of consciousness into separate channels, loss of voluntary motion, and dissociation. The fact that hypnosis involves different psychological domains and processes has led researchers to consider hypnosis a pluralistic phenomenon. Most of these domains are also central to trance states, which supports the idea that hypnosis involves the induction of altered states of consciousness. According to Stallings (1988), hypnotic suggestions share common features with

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storytelling trance, as both require verbal techniques to induce trance states, focused attention, relaxation, and minimized distractions. Pekala et al. (2010) argue that trance and hypnosis are terms often used interchangeably, and that the state reported by the hypnotizable person in response to the hypnotic induction can operationally be defined as trance. This stance is supported by several researchers who emphasized that hypnosis primarily involves altered states of consciousness, suggestibility and expectancy (Baker, 1990; Brown & Fromm, 1986; Pekala et al., 2010; Woody et al., 2005). The notions of hypnotic suggestibility and hypnotic depth are crucial to understanding hypnosis. Hypnotic suggestibility refers to the extent to which a person is responsive to hypnotic induction based on standard hypnotizability tests (Pekala et al., 2010), while hypnotic depth refers to the individual’s behavioral responses to the intensity of hypnotic induction (Tart, 1970; 1979). Overall, most scholars agree that hypnotic suggestions decrease the subject’s awareness of internal and external activities and enhance their responsiveness which affects cognition (Oakley & Halligan, 2009), motor control (Haggard et al., 2004), and perception (Acunzo & Terhune, 2019; Szechtman et al., 1998). Nevertheless, the status of hypnosis as an altered state of consciousness has been controversial and rejected by some researchers. For example, Barber (1969) argued that rather than a trance state, hypnosis was a product of normal psychological processes involving the subject’s motivations, expectations, and attitudes; he later, however, admitted that hypnosis might involve altered states of consciousness, at least in highly hypnotizable individuals (Kihlstrom, 2018; Kirsch & Lynn, 1995). Sarbin and Andersen (1967) also explained hypnosis through the sociocognitive theory, arguing that the hypnotist and the hypnotized individuals were only complying with their socially attributed roles of how the hypnotist and hypnotized people should behave. Later they also admitted that often subjects are so involved in the hypnosis that they are not aware of the roles they are supposed to enact, experiencing involuntary behavioral responses, which indicates that they are in an altered state of consciousness (Kihlstrom, 2018). Other proponents of the socio-cognitive theory claim that hypnotic responses are determined by socio-cognitive variables that affect complex social behaviors like positive attitudes, expectations, and beliefs towards hypnosis, motivation to respond to suggestions, and clear indications on how to respond to hypnotic suggestions; when all of these variables are cooperating, the person is under hypnosis (Fredette et al., 2013; Lynn & O’Hagen, 2009).

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Another theory that rejects hypnosis as an altered state of consciousness is the neo-dissociative theory, which proposes that hypnosis affects the functioning of the executive ego, which deceives the mind about what is happening (for example when hypnotized person raises their arms as a response to the hypnotic suggestion, the executive ego might be accountable for the motion) (Fredette et al., 2013). Recent neurocognitive studies, however, have debunked these theories and provided support for the stance that hypnosis entails real experiences and exhibits characteristics of a distinct state of consciousness. According to Fredette et al. (2013), brain imaging studies have concluded that hypnosis shows patterns of activation in the anterior cingulate cortex and frontal cortical areas, which are also accountable for mechanisms used in other cognitive tasks like focused attention and imagination. PET studies have also shown that hypnosis alters brain activity in structures that are crucial for the basic regulation of states of consciousness, self-monitoring, and self-regulation (Rainville et al., 2002). Moreover, Rainville et al. (2002) assert that alterations in relaxation and absorption may trigger other hypnosis-related effects such as decreased judging, monitoring, and censoring; unusual sense of time, location, and self; and automatic behavioral responses. They argue that these dimensions are strongly dependent on self-representation, whose alterations may imply changes in subjective experience, thus supporting the idea that hypnosis is an altered state of consciousness. Other empirical research has found that hypnosis is related to reduced default mode network activity (usually active in pure resting state) and enhanced activity in prefrontal attentional networks, supporting the stance that an altered cognitive state is induced (McGeown et al., 2009; Oakley & Halligan, 2013). Woody has proposed that hypnosis results in changes in the frontal lobe systems, which are responsible for voluntary behavior, causing the disengagement of the monitoring and controlling functions of consciousness (Woody & Bowers, 1994; Woody & Szechtman, 2003). As such, subjects respond to hypnotic suggestions with involuntary behavioral (i.e., motor) responses, without being aware of their mental activities at the moment (Kihlstrom, 2018).

Hypnotherapy: A General Overview The end of the nineteenth century saw the emergence of psychotherapy, with Freud and Jung being two major figures who used clinical hypnosis to access

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the unconscious and then eventually decided to adopt alternative approaches: Freud decided to use the method of free association and Jung decided to use active imagination (Hartman & Zimberoff, 2013). Both are techniques that could be considered a form of self-hypnosis. Empirical research has shown that hypnosis combined with psychodynamic treatments could produce a highly efficacious treatment approach. In this regard, Hartman and Zimberoff (2013) suggest that hypnotic trance is particularly beneficial to psychoanalytic treatments as it allows access to unconscious thoughts through implicit memories (dominance of theta frequency waves), while still retaining the link to the conscious mind (alpha and beta waves). Moreover, they argue that hypnosis goes beyond the defended ego and persona of the conscious mind, allowing direct access to the individual’s complexes and the relationships between them, also providing corrective emotional experiences for these complexes (e.g., through age regression technique). While psychotherapy was already at its peak of development with its established schools of thought, psychiatrist and psychologist Milton H. Erickson founded therapeutic hypnosis, later known as hypnotherapy, with techniques like solution-focused brief hypnotherapy and strategic family therapy, as he believed that naturalistic and communicational means could facilitate the expression of human potential (Erickson B.A. & Keeney, 2006; Erickson M.H., 1954). Erickson (1954) considered hypnotherapy as a process that could facilitate the use of mental associations, memories, and cognitions, to attain people’s therapeutic goals. In their review of hypnotherapy techniques and goals, Erickson and Rossi (1979) claimed that hypnotic suggestions can evoke an individual’s existing abilities and potentials that may have previously remained underdeveloped or unused. They argue that the hypnotherapist analyzes the subject’s individual life experiences and mental skills, to then assist the subject in using their internal responses to achieve their therapeutic goal, through three main processes: (1) Investigating the subject’s repertory of life experiences and facilitating constructive frames of reference to orient the subject toward therapeutic change; (2) Activating and applying the subject’s cognitive skills during a period of therapeutic trance; (3) Recognizing, evaluating, and validating the therapeutic change that occurs.

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In their scientific work Erickson and Rossi (1979) emphasize the importance of therapeutic trance, which they define as “a period during which patients are able to break out of their limited frameworks and belief systems so they can experience other patterns of functioning within themselves” (p. 15). Altering the existing beliefs and frames of references allows the subject to perceive other patterns of mental functioning that can facilitate problem solving; this trance dynamic usually takes place through a five-step process: (1) (2) (3) (4) (5)

Fixation of attention; Debilitation of habitual frameworks; Unconscious search; Unconscious processes; Therapeutic response (Erickson & Rossi, 1979).

The induction of hypnotic trance is mainly based on altering the individual’s mental and behavioral activity and instructing him to engage in a different type of behaviors, a technique which requires the individual’s acceptance and cooperation with the externally suggested (active or passive) behaviors (Erickson, 1959). In this context, the main actor in the hypnotherapeutic relationship is the hypnotized subject, not the hypnotist, as the hypnotist can only offer the subject different approaches to the hypnotic experience, however, it is the subject’s potentials and preferences that determine the course of the events (Erickson & Rossi, 1981). In principle, hypnotherapy and psychotherapy are based on the same clinical methods and processes, such as individual expectancies and experiences, positive reinforcement principles, reconditioning, and selfreinforcement. In a competitive analysis, Haley (1993) argues that, on a basic level, both the hypnotist and the psychotherapist aim through a relationship with the patient to extend their range of experience by introducing novel ways of thinking, feeling and behaving and to change the patient’s overall behavioral and sensory response. Hypno- and psychotherapy both follow a procedure that can be outlined in two stages: directing the patient to do something they are able to do voluntarily and directing the patient to respond with involuntary behavior or unconscious thoughts. Although the relationship is voluntary, subjects in both hypno- and psychotherapy tend to resist the suggested directives, thus a considerable amount of persuasion is needed at the beginning of each process to motivate the subjects to cooperate by emphasizing the therapeutic benefits (Haley, 1993). Overall, the addition of

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hypnosis to psychotherapy is intended to facilitate the process of behavior change and maximize the therapeutic gains for the patient. Similarly, to psychotherapy, hypnosis is often used to enhance self-esteem through ego strengthening, a technique named by John Hartland (1971). Ego strength refers to the individual’s ability to adjust and adapt to external and internal environmental demands; hence, ego strengthening is a technique aiming to enhance the individual’s ability to cope with difficult environmental demands, promote psychological growth, personal development, mental strength, and resilience by motivating subjects to relinquish past complexes and attitudes, and cope with demands with confidence and optimism (Lavertue et al., 2002; Yeates, 2014). Yeates (2014a) differentiates between ego-strength and self-esteem, defining self-esteem as a result of high ego strength. According to Lavertue et al. (2002) ego-strengthening can be achieved through direct and indirect suggestions; direct suggestions may involve encouraging and supportive affirmations given to the hypnotized subject, while indirect suggestions may involve stories and metaphors with messages intended to restore the subject’s self-confidence and efficacy in dealing with problems. When subjects achieve a strong ego, they would eventually be more relaxed and clear-minded during the hypnotic induction and would exhibit improvements in behavioural, emotional and attitudinal changes (Yeates, 2014b). Hypnosis can also lead to significant behavioral and personality changes as a result of the reorientation and reliving of past experiences as current events in a more detailed and relaxed way, a technique called age regression (Erickson & Rossi, 2006). According to Erickson, during age regression the therapist directs the subject while in hypnotic trance to revert to earlier phases of personality development and mental states, accessing unsolved complexes and problems in the unconscious, revoking long-lost skills and knowledge and reestablishing previous attitudes (Erickson & Rossi, 2006). Other hypnotic techniques involve automatic writing and drawing (where the subject’s unconscious can manifest itself in an observable form) and mental mechanisms, where problems that seem unsolvable by the conscious mind can be solved by the subject’s unconscious following the hypnotherapist’s suggestions (Erickson & Rossi, 2006) There is a growing range of clinical and empirical evidence that hypnotherapy has positive treatment results related to depression and other disorders and is also a successful method to improve learning processes and enhance personal empowerment (Yapko, 2001). According to Yapko (2010) hypnotherapy entails several key achievements that empower people by

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allowing them to develop the best aspects of themselves and by showing them a path of self-growth and self-discovery. Among these achievements he mentions: • • • • • • • • • •

Helping people create and maintain a positive focus; Facilitating the acquisition of new skills; Enhancing people’s self-image and self-confidence; Facilitating the utilization and generalization of acquired learning; Offering opportunities for multidimensional therapeutic learning of skills and insights; Stimulating enhanced emotional self-regulation); Improving basic perceptual distinctions to overcome overgeneralization; Rehearsing and improving new behavioral responses; Identifying and developing underutilized personal resources; Detaching from feelings of victimization.

He argues that these goals are crucial to overcome depression and increase overall psychological well-being. In fact, a wide range of empirical and clinical studies have shown that hypnotherapy is highly effective for many disorders such as depression (Alladin 2009; 2010), sleep disorders (Ng & Lee, 2008), psychosomatic disorders (Flammer & Aladdin, 2007), anxiety disorders (Frankel & Macfie, 2010; Golden, 2006) eating disorders (Barabasz, 2007), smoking cessation (Barnes et al., 2019), irritable bowel syndrome (Gonsalkorale et al., 2003), weight loss treatment (Cochrane & Friesen, 1986), chronic pain, and fibromyalgia (Haanen et al., 1991). Neuroimaging studies support the idea that hypnosis is an altered state of consciousness and that hypnotherapy can modulate the interconnected network of cortical and subcortical brain regions that are involved in the processing of threatening stimuli and reduce sensory perception (e.g., in the treatment of pain) by decreasing the activity of the extrinsic brain network (Vanhaudenhuyse et al., 2014). Clark (2015) for example, argues that although hypnosis can affect the activation of somatosensory, visual and auditory cortices, the amygdala, and the prefrontal cortex, the result relies heavily on suggestions given by the therapist and the subject’s own experiences and personality. Moreover, a review of neurobiological research conducted by Hartman and Zimberoff (2002) concluded that hypnosis is associated with higher levels of alpha (relaxed mental states) brain waves and theta (memory,

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daydreaming and sleep) brain waves and increased activity in the hippocampus which may be related to enhanced ability to focus one’s attention selectively.

Cognitive Hypnotherapy Empirical research has shown that the integration of hypnosis with other psychotherapy treatments produces better therapeutic results and higher treatment efficacy for various disorders. The integration of various psychotherapy treatments aims to combine different schools of psychotherapy to enrich and complement each other and subsequently achieve better therapeutic results than a specific method of psychotherapy (Stricker & Gold, 2006). Cognitive hypnotherapy uses cognitive behavior therapy (CBT) as the base for theory integration for the treatment of emotional disorders. CBT is one of the most thoroughly researched methods of psychotherapy, used in the treatment of a wide variety of disorders and problems. Various cognitive and behavioral techniques are used in CBT to identify the patient’s dysfunctional and maladaptive thought patterns and behaviors and teach them how to operate in the following ways: monitoring negative automatic cognitions; identifying the connections between cognitions, affect, and behavior; analyzing the evidence for and against the negative automatic cognitions; replacing these cognitions with reality-oriented interpretations; and recognizing and altering the dysfunctional beliefs which distort subjective experiences (Beck, 2011). When combined together, hypnosis and CBT compensate for each other’s deficiencies as hypnosis allows access to unconscious cognitive restructuring, while CBT lacks access to the unconscious; CBT, on the other hand, focuses on systematic cognitive restructuring through reasoning, which hypnosis does not (Alladin, 2008). The treatment in cognitive hypnotherapy begins with an assessment of the behaviors and cognitive mechanisms triggering and maintaining the problem, to further proceed with an individualized treatment plan according to the patient’s clinical needs and symptoms (Alladin, 2008). The treatment generally consists of weekly sessions distributed in the span of sixteen weeks and involves the following stages: (1)

Clinical assessment to determine the diagnosis and identify central psychosocial and physiological features of the patient’s behaviors;

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(2-5)

Identifying and restructuring the dysfunctional cognitions that may be causing the problem via evidence and logic; (6-7) Enhancing the patient’s sense of control and attention, inducing relaxation and divergent thinking, and accessing unconscious mental processes; (8-10) Cognitive restructuring under hypnosis through age regression to the traumatic event and modifying or eliminating the unconscious emotional problems such as guilt, anger, fears, and doubts; (11-12) Attention switching and positive mood induction; (13) Active interactive training; (14) Social abilities training; (15) Behavioral activation; (16) Mindfulness training (Alladin, 2008). A systematic review from Schoenberger (2000) concluded that this integrated model of hypnosis and CBT produces essential benefits in the treatment of a wide range of disorders among which depression (Alladin, 2008; Torem, 2006), migraine headaches (Alladin, 2008; Holroyd, 2006) posttraumatic stress disorder (Alladin, 2008; Dowd, 2000; Linden, 2007; Oster, 2006), psychocutaneous disorders (Hollander, 1959; Shenefelt, 2000), somatization disorder (Alladin, 2008; Frankel, 1994; Maldonado & Spiegel, 2003), insomnia (Alladin, 2008; (Graci, 2005; Graci & Hardie, 2007; Graci & Sexton-Radek, 2006), and sexual dysfunctions (Aaroz et al., 2001; Alladin, 2008).

Mindful Hypnotherapy Hypnosis and mindfulness have long been considered to have essential theoretical compatibility, similar mechanisms for stress reduction, and matching phenomenological and physiological characteristics, thus getting synthesized in mindful hypnotherapy (Olendzki et al., 2020). Mindfulness promotes an embracing and non-judgmental relationship to one’s subjective experiences (perceptions, behaviors, and emotions), thus its synthesis with hypnosis is defined as “an intervention that intentionally uses hypnosis (hypnotic induction and suggestion) to integrate mindfulness for personal and therapeutic benefit”, a method which has been proven to be time-effective and produce significant enhancements in psychological distress (depression, hopelessness, anxiety, and anger) and psychological flexibility (Olendzki et

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al., 2020; p. 153). According to Amundson (2018), the philosophical aspects of mindfulness can be easily applied to hypnosis, as the Buddhist aim of transcendence can be interpreted as liberation from one’s psychological or behavioral problems that may be associated with lower well-being. Him and colleagues (Amondson et al., 2018) argue that both mindfulness and hypnosis are strongly based on dissociation, or the ability to separate one’s self from problematic thoughts, behaviors, and feelings, and they are both highly effective at reducing overall arousal and enhancing cognitive abilities through persuasion, suggestions and self-reflection. Lynn et al. (2006; 2012) have identified several similar facets of hypnosis and mindfulness, such as being multifaceted self-regulation techniques, fostering acceptance, reducing experiential avoidance (an important aspect of anxiety disorders), experiencing trance states and dissociation, inducing relaxation, and using attentional resources to achieve positive therapeutic results. Clarke (2013) argues that rather than attempting to alter one’s subjective experience, mindfulness aims to accentuate acceptance of the present moment, which could be reinforced through hypnosis. He identified several techniques that both hypnosis and mindfulness-based interventions use to produce successful therapeutic results. Among these techniques he mentions: (1) Progressive muscle relaxation, used as an induction technique and to increase body awareness; (2) Breathing awareness, to promote acceptance and a non-judgmental attitude towards one’s internal experiences; (3) Developing a mindful metacognitive set to distinguish between anxious, dysfunctional thoughts and rational truths; (4) Shifting one’s attention to each of the senses for an equal amount of time; (5) Eye fixation, i.e., staring at a reference point while being inducted into trance. Empirical evidence suggests that hypnosis and mindfulness share similar underlying cognitive mechanisms and neurophysiological alterations (Grover et al., 2018), particularly in frontal cortical areas related to executive function and cognitive control, increases in alpha and theta brain oscillations associated with hypnotizability and deep meditation (Holroyd, 2003), and increased ability to focus attention (Elkins, 2020; Fatemi, 2020; Holroyd, 2003). Lifshitz and Raz (2012) argue that both methods involve focused attention (selective

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attention on an experiential process e.g., breathing) and open monitoring (expanding attention to involve the entire momentary experience); both key aspects of attention regulation. Furthermore, both hypnosis and mindfulness exhibit neural changes with significant effects on brain regions such as the anterior cingulate cortex (attention allocation and emotion control), prefrontal cortex (goal setting), insula (emotion regulation and perception), hippocampus (memory and learning skills), and precuneus (meta-cognition and selfawareness) (Fatemi, 2020). Based on these studies, it is likely that hypnosis and mindfulness trigger similar neurophysiological responses to trance-states Grover et al., 2018). Although there is a lack of clinical evidence regarding the effects of mindful hypnotherapy, it is highly plausible, based on the empirical evidence on both methods, that mindful hypnotherapy facilitates the process of relaxation and is thus highly effective in treating anxiety, depression, as well as mental and emotional distress.

Meditation Spiritual disciplines that intend to transcend the normal state of consciousness and/or achieve enlightenment have been practiced in all human societies as early as shamanic rituals in the Paleolithic era, with documented references to meditation in ancient Buddhist writings since the third century BCE (Braboszcz et al., 2010). Scientific research on meditation started in the 1970s within a behavioral framework focusing on symptom reduction and relief, overlooking the potential for healing, personal growth and development (Davidson et al., 2003). However, the study of meditative practices has significantly grown in the past decades, and meditation can now be outlined as a complex range of experiential practices that aim to enhance individual mental abilities such as attentional and emotional self-regulation (Braboszcz et al., 2010; Tang et al., 2015). Different styles and forms of meditation are common among various cultures and religions, among which: (1) Concentration meditation, which relies on focusing one’s attention on a specific object or one of the senses and continually returning attention to the object while being relaxed and focused. The shifting of attention is monitored through regulative abilities, such as recognizing the distraction, removing the attention from the source of distraction, and refocusing on the object;

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(2) Mindfulness meditation, which is based on increasing one’s awareness of the present moment and exploring the ever-changing experience of consciousness. It includes non-reactive monitoring of the present content (i.e., perception, sensation, cognition, and affect) and become more reflectively aware of the nature of one’s emotional and cognitive processes; (3) Transcendental meditation, a systematic mental technique that allows the individual to experience the emergence of a silent, content-free state of awareness, also called “fourth” or “pure” state of consciousness because it may transcend the mental activity and cognitive control of ordinary states of waking, sleeping, and dreaming; (4) Loving-kindness meditation, which encourages a non-judgmental, emotion-free attitude, focused on fostering kindness and goodwill through the silent repetition of mantras (Alexander et al., 1989; Lutz et al., 2008; Manuello et al., 2016). There is a larger variety of meditation types, including yoga, tai chi, and chi gong however, all of these meditation techniques are not mutually exclusive and are often combined in Zen, Vipassana, and Tibetan Buddhism meditation traditions (Cvetkovic & Cosic, 2011). Although different meditation techniques develop different attentional skills and different task specific cortical patterning, they have common components with each other and with relaxation techniques, including hypnotic relaxation, and they have been found to result in decreased self-reported anxiety levels (Davidson & Goleman, 1977). Out of these practices, mindfulness meditation has been an important subject of clinical and empirical research related to psychological and physical health during the last couple of decades. The concept of mindfulness originates from eastern introspective spiritual practices, mainly Buddhist; meanwhile the term “mindfulness” originating from Pali, the sacred language of Buddhism, is composed of two words meaning “awareness” (Sati) and “clear comprehension” (Samprajanya), hence suggesting a clear, fully aware mind (Grecucci et al., 2015). Different types of mindfulness and meditation can be found in various religions such yogic meditation in the Hindu tradition, kabbalah meditation in Judaism, contemplative prayer in Christianity, and Sufi meditation in Islam (Grecucci et al., 2015). The formal literature on meditation still does not agree on a universally accepted definition of the concept. Different researchers have defined meditation as “the awareness that arises through intentionally

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attending in an open, kind and discerning way” (Shapiro et al., 2002; p. 2); “the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmental to the unfolding of experience moment by moment” (Kabat-Zinn, 2003; p. 145); and “a state of psychological freedom that occurs when attention remains quiet and limber, without attachment to any particular point of view” (Thompson & Waltz, 2007; p. 3). Overall, mindfulness can be understood as a set of meditative techniques to improve mindful awareness as well as a way of living in the present moment and experiencing every instant with acceptance. According to Shapiro et al. (2002) mindfulness consists of three separate but interrelated components: intention (our ultimate goal, the reason one does something), attention (being fully attentive to the present moment), and attitude (how we pay attention). Kabat-Zinn (1990) had previously suggested a list behaviors and attitudes that increase one’s mindfulness in daily life, among which: (1) Not judging, having a neutral attitude towards one’s own experiences; (2) Patience, i.e., letting things happen at their own pace; (3) Being open to new possibilities and not being stuck in one’s subjective judgments; (4) Being trustful of one’s self and feelings; (5) Accepting things the way they currently are and letting go. Holzel et al. (2011) propose that the benefits of mindfulness are the result of a combination of separate but intertwined mechanisms such as attention regulation, body awareness, emotion regulation, change in perspective on the self, exposure, extinction, and reconsolidation, which interact with each other and enhance self-regulation. Cardoso et al. (2004) suggest that for meditation to occur, the procedures must be based on a specific technique that includes muscle relaxation throughout the process, logic relaxation (not analyzing, judging, or having any expectations), a self-induced state (therapeutic technique that can be self-applied and does not require dependency from the instructor), and self-focus skills (focusing on an object or own physical processes and avoiding undesirable thoughts). The principles and underlying mechanisms of mindfulness have been integrated in several methods of psychotherapy such as: (1) Dialectical behavior therapy, which reinforces emotion-regulation abilities by combining mindfulness exercises with cognitive behavioral treatment;

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(2) Mindfulness-based cognitive therapy, which combines mindfulness training with cognitive restructuring; acceptance and commitment therapy, which promotes acceptance of one’s thoughts and feelings to improves one’s relationship with their inner experience; (3) Intensive short-term dynamic psychotherapy, which increases one’s ability to focus on and observe the present moment and present emotional and physical responses; (4) Relational and attachment focused psychoanalysis, wherein the individual is encouraged to have an impartial, mindful attitude towards themselves and others (Grecucci et al., 2015). According to Holroyd (2003), many of the principles and attentional mechanisms of meditation are similar to those of hypnosis. First, he argues that both meditation and hypnosis start with progressive relaxation and attention focusing, a process which in the meditation literature is referred to as “letting go” of thoughts, while in hypnosis is known as dissociation, but both result in similar alterations of mental states. Empirical studies comparing results of high hypnotizables and regular meditators concluded that both meditation and self-hypnosis were accompanied by feelings of love and peace, and both resulted in changes in the state of awareness, self-awareness, time sense, perception, and meaning, as well as alterations in imagery vividness and rationality (Holroyd, 2003). Another EEG study concluded that meditation and hypnosis have similar neurophysiology, as they are both associated with activation of the frontal and anterior cingulate cortex, cortical inhibition and high theta oscillations, which explains the absence of thoughts, emotions, body awareness and sense of self (Holroyd, 2003). A wide range of neuroscientific studies have highlighted several features that characterize meditation as an altered state of consciousness. Goleman (1971) was among the first researchers to suggest that meditation may constitute a fourth major state of consciousness. He concluded that many regular practitioners of meditation (e.g., Zen meditators, transcendental meditators, yogis practicing raj yoga, etc.), when assessed with EEG, showed heavy production of alpha oscillations, which are associated with a relaxed, calming state of mind, along with lowered basal metabolism and lactate level. These findings, he argues, are a clear indication that meditation can lead to a unique psychophysiological state of awareness. Venkatesh et al. (1997) found that during meditation, individuals reported being in an altered state of consciousness where they experienced changes in perception, meaning, sense of time, imagery vividness, self-awareness, rationality, arousal and feelings of

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love and joy. Interestingly, they found that keeping the eyes closed during meditation is an important factor associated with an altered sense of time, meaning, awareness, imagery and absorbed attention. In comparison to keeping the eyes open, the closed eyes condition may enhance the change of perception during meditative states, which may explain why keeping the eyes closed is common during some meditative practices. Aftanas & Golosheikin (2003) argue that as a complex neurocognitive process, meditation induces stable alterations in psychic, cortical, and autonomic functions, which differ from ordinary states of consciousness and thus classify meditation as an altered state of consciousness. Functional and structural magnetic resonance studies have found enhanced neuronal activity in the dorsolateral and medial prefrontal cortex, which are related to momentary self-awareness and self-reference, as well as increased gray matter in the right anterior insula region, related to interoceptive awareness (Farb et al., 2007; Holzel et al., 2008). Moreover, Tang et al. (2015) found that meditators exhibited consistent alterations in eight brain regions: the frontopolar cortex (enhanced meta-awareness); the sensory cortices and insula (body awareness); the hippocampus (memory processes); the anterior cingulate cortex, mid-cingulate cortex and orbitofrontal cortex (self- and emotion regulation); and the superior longitudinal fasciculus and corpus callosum (intra- and inter-hemispherical communication). In the past two decades, research (particularly in positive psychology) has been exploring the beneficial effects that meditation has on well-being, related to healing properties as well as mental and emotional flourishing. In a study conducted by Shapiro et al. (2002) individuals who participated in an eightweek mindfulness-based stress reduction program showed enhanced left-toright ratio of activation of the prefrontal cortex, which has been related to positive emotions (particularly compassion) and mental health. Creswell et al. (2007) also found that individuals who practice mindfulness regularly showed higher engagement of the prefrontal cortex and less emotional reactivity in the midbrain. Overall, meditative practices have been part of many cultures and religions, and since their introduction to the Western world they have become popular to enhance attentional skills, induce relaxation and promote emotional balance. Being easy to practice, as well as cost- and time-efficient, meditation may comprise an important psychotherapeutic factor that may be implemented even more in future psychological treatments.

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Near-Death Experiences (NDEs) The phenomena of NDEs have been occurring in all cultures since the beginning of humankind. Evidence of these transcendental experiences from people that have been close to death have been found in descriptive fragments in the Bible and classic works of philosophy (Valarino, 2007), and the folklore and writings of European, Middle Eastern, African, Indian, East Asian, Pacific, and Native American cultures (Greyson, 2014). Evidence suggests that the effects of NDEs are similar in all societies, implying the existence of a universal pattern of experience among all religions and cultures (Agrillo, 2011). The first formal examinations of near-death phenomena occurred in the late 19th century when geologist and mountain climber Albert Heim had a mystical experience falling down a mountain and shortly after managed to collect a large number of similar near-death testimonies (Corazza, 2008). The term “near-death experience” was first used by Raymond Moody (1975) in his book “Life after life”, where he reported the survivors’ experiences with features like out-of-body experiences, the apparition of a tunnel, intensified feelings of peace and joy, life review, perceiving ethereal beings, and returning to life with distinct changes in attitudes and behaviors. This phenomenon has been researched more thoroughly during the last decades but remains a difficult concept to define because of its debated nature. According to Palmieri et al. (2014) NDEs can be defined as profound psychological experiences marked by an atypical state of consciousness that happens when the individual is unconscious during a life-threatening situation. They identified the most common characteristics reported in the scientific literature among which: awareness of being dead; overwhelming feelings of euphoria, happiness, and peace; out-of-body experiences; entering a tunnellike structure; perception of a light; perception of heavenly or hellish landscape; encounter with deceased relatives, religious figures, or beings of light; experience of a life review; different temporal perception; and perception of sounds or music. NDEs are more common to occur in conditions close to death such as cardiac arrest, shock in postpartum loss of blood, electrocution, coma resulting from traumatic brain damage, intracerebral haemorrhage, attempted suicide, near-drowning or asphyxia, general anaesthesia, temporal lobe epilepsy, electrical brain stimulation, and sleep abnormalities (Blanke et al., 2016; Van Lommel et al., 2001); however, there is evidence of NDEs happening in non-threatening conditions such as during depression, isolation, minor accidents, or critical life events (Palmieri et al., 2014)

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Greyson (1993) argues that there are four distinct types of NDEs, and that each experience is characterized by at least one of the following components: (1) Cognitive near-death experiences which include changes in cognitive processes, i.e., distorted sense of time, accelerated thoughts, and panoramic life review; (2) Affective near-death experiences which include changes in emotional states, i.e., intense feelings of peace, joy, cosmic unity, and encounter with ethereal beings; (3) Paranormal near-death experiences which include psychic phenomena such as extrasensory perception and precognitive visions, out of body experiences, and hyperacute physical sensing; (4) Transcendental near-death experiences, which include mystical elements like encounter with deceased relatives or religious figures, and travel to unearthly realms. He further argues that acceptance of death may be strongly associated with the affective and transcendental components, as the letting go of the ego might allow the experience to occur and produce therapeutic effects. The mysterious nature of NDEs makes it difficult to determine a specific psychological or neurophysiological source for all experiences, however, in his review Jansen (1990) presented four possible psychological explanations for NDEs. The first one is depersonalisation, as NDEs may represent psychological defenses triggered by the critical moment resulting in illusory feelings of being separated from the physical processes; the second is regression in the service of the ego, as confronting death might lead to a regression to pre-verbal levels perceived as mystical events; the third is reactivation of birth memories, which interprets NDEs as reminiscence of memories of one’s own birth elicited by the critical situation; and the fourth is sensory deprivation, which assumes that in extreme situation the lack of sensory input is replaced by the brain with illusory cognitive content. Nevertheless, later studies (e.g., Parnia et al, 2001; Van Lommel et al., 2001) have concluded that NDEs are real experiences and cannot be explained solely through physiological and psychological principles. In a more recent review, Palmieri et al. (2014) propose two main theoretical frameworks to interpret NDEs. The first on is the biological/psychological framework, which assumes that NDEs are a result of functional changes in the brain that happen as a response to perceived death threats, such as cerebral hypoxia and anoxia,

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hypercarbia, serotonin or noradrenaline release alteration, and massive liberation of glutamate or endorphins. They suggest that the out-of-body experience that is typical in NDEs might be a result of a neural dysfunction, i.e., the disintegration between vestibular (personal) and visual (extrapersonal) space. In this regard, Blanke et al. (2016) also suggest that NDEs are generated by many functional and neural mechanisms e.g., visual, vestibular, multisensory, memory, and motor, as well as interference with or damage to the peripheral nervous system and cortical, subcortical, and brainstem mechanisms. The second framework is the survivalist theory (Braithwaite, 2008), which assumes that the mind and body are separated, and the existence of consciousness is not dependent on brain activity, which implies that consciousness may continue to exist beyond brain death. Van Lommel (2011) explains NDEs through the theory of continuity, arguing that NDEs are changing states of consciousness where memories, self-identity, cognition, and emotions continue to function separately from the unconscious body and preserve the possibility of nonsensory perception. He further suggests that the wide variety of the NDE phenomena cannot be explained only by the lack of oxygen, since NDEs have been reported in non-threatening situations like depression and meditation. Several researchers (e.g., Castillo, 1995; Greyson, 1983; 2013; 2014; Musek, 2013; Palmieri et al., 2014; Van Lommel, 2011) consider NDEs to be altered states of consciousness. Castillo (1995), for instance, argues that the phenomena of trance can be classified in three main categories: trances of everyday life (dreams, daydreaming, habitual actions, etc.), medical trance (hypnosis, dissociative amnesia and hallucinations, depersonalisation, etc.), and religious trance where among others (shamanism, meditation, etc.), he includes NDEs. Musek (2003) identified several aspects of NDEs that are characteristic of altered states of consciousness, such as: (1) Alterations in the perception of reality beyond the principles of perception and cognition; (2) Altered sense of time or cessation/evanescence of time at all; (3) Loss of control, or experiencing events passively without being able to resist or control them; (4) Affective changes in terms of enhanced expression of emotion or lack of emotional reactions (e.g., in meditation); (5) Alterations in physical sensations in terms of weight, size, and other physical aspects, or out-of-body experiences;

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(6) Experiencing feelings of enlightenment, absoluteness, meaningfulness; (7) Ineffability of experience due to its radically different content; (8) Feelings of rebirth, renewal, and novelty; (9) Intensified suggestibility.

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To investigate the nature of NDEs, Palmieri et al. (2014) conducted an EEG study where they compared electrical activity recordings of NDE memories with real autobiographical memories and imagined memories, all recalled in both pre- and post-hypnotic states. Their findings showed that NDEs memories were associated with theta brain oscillations, which are related to episodic memory and their spatiotemporal organization, and delta brain oscillations, which are related to past memories and trance states, hallucinations, and meditative states. Overall, Palmieri et al. (2014) concluded that “at a phenomenological level, NDE memories cannot be considered equivalent to imagined memories, and at a neural level, NDE memories are stored as episodic memories of events experienced in a peculiar state of consciousness” (p. 1). Although the origin and content of NDEs is still poorly understood, the empirical evidence is sufficient to determine that NDEs are not merely a product of neurophysiological and psychological events, as they seem to show notable characteristics of altered states of consciousness.

Chapter 3

A General Overview of Anxiety Disorders Anxiety is among the most common disorders to affect the global population, considered the “most pervasive psychological phenomenon of our time” (Spielberger et al., 1971; p. 145) and the “fundamental phenomenon and the central problem of neurosis” (Freud, 1936; p. 85). Symptoms of anxiety were described in 1621 when Robert Burton depicted what seemed as signs of anxiety attacks in his book The Anatomy of Melancholy: “Many lamentable effects this fear caused in man, as to be red, pale, tremble, sweat; it makes sudden cold and heat come over all the body, palpitation of the heart, syncope, etc. It amazed many men that are to speak or show themselves in public” (Bandelow & Michaelis, 2015; p. 327). The concept of anxiety in the form of existential dread was initially discussed in philosophy, particularly in the 19th century, where in 1844 Kierkegaard described it as the dizziness or uncertainty that arises from individual freedom to make choices (Kierkegaard & Thomte, 1982). During the end of the 19th century, anxiety became the subject of psychoanalysis, and it was then classified as a type of neurosis or neurotic disorder, terms mainly used by Freud and Jung (David, 2008); thereafter anxiety became the subject of successive schools of psychotherapy, remaining a central topic of clinical and empirical research up to this day. According to Skinner, anxiety is an emotional state that resembles fear, which results from the encounter with a neutral stimulus that may have been followed by a disturbing stimulus in the past (Estes & Skinner, 1941). This disturbing stimulus does not co-occur nor precede the state but is rather an anticipated outcome. As one of the crucial concepts of psychoanalysis related to the development of personality, anxiety was of critical importance in Freud’s theory of neuroses and their treatments. He differentiated between reality anxiety, neurotic anxiety, and moral anxiety, which do not differ qualitatively but rather regarding their sources. Reality (objective) anxiety is a natural and useful reaction to external danger which is proportionate to the level of threat and does not involve neurotic defense mechanisms; neurotic (subjective) anxiety arises from instinctively perceived danger in situations that are not objectively threatening, is managed through inhibitions and various defense

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mechanisms, and can be exhibited in the form of generalized anxiety, phobias, or panic attacks; moral anxiety lies in personality structure and is triggered by a perception of danger from the conscience, which results in feelings of guilt and shame that one cannot escape from (Crosby, 1976; Hall, 1955). Spielberger et al. (1971) further differentiate between anxiety as a state, which represents a complex emotional reaction characterized by feelings of tension and apprehension, and enhanced autonomic nervous system activity, whose intensity varies from the psychological or situational stresses that affect the individual; and anxiety as a personality trait, which represents individual proneness to anxiety. They argue that people who are high in trait anxiety are more likely to exhibit anxious states, worry in situations where there is minimal or no external stress, and react to situations that may threaten their self-esteem with higher anxiety intensity. Carl Jung, a central figure and founder of analytical psychology, believed in the autonomy of the unconscious mind (which he referred to as the collective unconscious) and considered anxiety as an expression of the fear of knowing one’s depths of the unconscious, arguing that anxiety is “the individual’s reaction to the invasion of his conscious mind by irrational forces and images of the collective unconscious” (Crosby, 1976; p. 238). According to Kandel (1983) anxiety is a natural, innate response to either threat or absence of safety accompanied by an enhanced sense of awareness, deep fear, increased responsiveness, restlessness, and autonomic changes. Carver and Schreier (1988) propose that anxiety itself does not always hinder performance; on the contrary, sometimes it may have an energizing and focusenhancing effect, and that the dysfunctional effect of anxiety is a result of a cognitive rather than an emotional factor. They argue that individual expectancies and confidence about being able to cope with distress and completing their tasks may play a crucial role in enhancing one’s performance and persistence. From an evolutionary perspective, anxiety can be adaptive as it enables individuals with responses to deal with particular threats and heightens environmental mastery. In this context, Nesse (1994) argues that anxiety can be useful in providing safety in four ways: (1) Distancing the individual from the threat through escape or avoidance; (2) Causing harm to the source of threat through aggressive defense; (3) Locating and assessing the threat, which may be benefited from freezing/immobility; (4) Submitting or reconciling when the threat comes from one’s group.

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The notion of anxiety being innate originates with Darwin (1873), who found that just like other animals, humans have inborn defensive behaviors, and further supported by William James (2007) who argued that these defensive behaviors are activated by anxiety. Pavlov’s discovery of classical conditioning provided support for the idea that anxiety can be learned, a claim further extended by Freud who argued that continuous pairing of a neutral stimulus with a disturbing (anxiety-triggering) stimulus can result in the neutral stimulus being perceived as dangerous and thus elicit an anxious reaction (Kandel, 1983).

Theories of Anxiety According to Carver and Schreier (1988), human behavior is regulated through a system of feedback control where individuals constantly establish personal short-term and long-term goals, intentions, and standards, which serve as reference points. During their behavior and decision-making processes, individuals constantly observe and adapt their behavior to correspond to their reference points and reduce any possible discrepancies; this process, however, is not always easy as different reference points may conflict. From a cognitive-behavioral perspective, Carver and Schreier (1988) argue that anxiety arises from situations when an individual’s behavior causes discrepancies among their reference values (e.g., physical safety, social acceptance, personal comfort, or integration) warning the individual to reconsider their behavioral priorities. They propose a control-process perspective on anxiety which posits that anxiety triggers an intrusion in ongoing self-regulation, which leads to an outcome assessment or coping expectancy; individuals with positive expectancies resume their selfregulation process, while individuals with negative expectancies disengage even from further attempts. Salkovskis (1991) proposed that when confronted with fear or anxietyprovoking stimuli, people tend to engage in safety-seeking behaviors, which refer to behaviors carried out with the intent of avoiding or minimizing the chances of a feared outcome. These behaviors contribute to the maintenance of anxiety disorders even though the feared outcomes never occur; for example, people affected by panic disorder who often believe they might die during a panic attack tend to perform safety-seeking behaviors (e.g., breathing, counting one’s breaths, sitting down, etc.), and misattribute the reason for avoiding death to such behaviors. Based on these observations, Clark (1999)

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suggests several principal characteristics of safety-seeking behaviors in anxiety disorders, among which: (1) Even though they are referred to as behaviors, many are mental processes; (2) Because many levels exist of anxiety disorders, affected individuals usually engage in a large number of safety-seeking behaviors during a fear situation; (3) Some of the fear symptoms of anxiety can arise from safety-seeking behaviors (e.g., trying to forcefully avoid or suppress the thought of a panic attack occurring might make the person more anxious, thus possibly generating a panic attack). From a cognitive perspective, Clark (1999) posits that anxiety disorders arise from a distorted evaluation of the dangerousness of the external (e.g., social situations, crowded areas) or internal environment (e.g., sensations, mental events) (Clark, 1999). Several empirical studies have concluded that patients with anxiety exaggerate the threat posed by certain stimuli, and different types of anxiety disorders include different distorted perceptions. Hawke and Provencher (2011) propose a schema model of anxiety disorders, central to which are early maladaptive schemas, or general, pervasive personal characteristics that develop during childhood as a result of early negative experiences; and schema modes, or the individual’s momentary emotional state which includes combinations of early maladaptive schemas that may be activated at the time. In this regard, their cognitive vulnerability-stress theory proposes that anxiety arises from negative cognitive schemas and distorted core beliefs that are triggered when a stressful life event happens that influences the individual’s interpretation of the event, thus leading to anxious symptoms (Hawke & Provencher, 2011). Acknowledging these negative cognitive schemas and beliefs is a step forward in the psychotherapy process to alter and adapt them using cognitive, behavioral, and experiential techniques. Several studies, on the other hand, have emphasized the role of emotional processing and regulation in the development and maintenance of anxiety disorders. According to Leahy (2007) anxiety is highly related to alexithymia, or the inability to properly recognize and describe one’s own emotions and stimuli or situations that trigger specific emotions. He argues that once they recognize an emotion, people still have various interpretations of it and engage in various emotional schemas and strategies when they experience negative

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emotions such as: detecting the emotion and classifying it, and cognitively avoiding the emotion via dissociation, alcohol, or drug use, etc. He further suggests that different anxiety disorders may be characterized by various emotional schemas of the sensations that may include safety-seeking behaviors, cognitive avoidance, suppression, and negative emotional strategies and interpretations such as the inability to comprehend one’s emotions, attaching higher values to one’s feelings, erroneously thinking that the emotional state will last for a long while, fearing loss of control, selfblaming, and experiencing feelings of guilt and shame. Leahy (2007) posits that individuals affected by anxiety disorders are susceptible to a paradoxical belief, where first the individual believes that if cases of very intense anxiety occur, one should apply their emotional schemas even more forcefully; secondly, if anxiety levels do not intensify, the individual will assume that their schemas are working. Amstadter (2008) also concluded that individuals affected by anxiety disorders are prone to emotion regulation dysfunctions and use maladaptive emotion regulation strategies. She suggests that the main maladaptive strategy is suppression, an avoidance strategy that besides increasing negative affect and psychological distress, also restrains positive emotions along with negative ones, which may subsequently lead to the development of depressive symptoms. She proposes two models for the development of anxiety symptoms through suppression; first, anxious individuals have higher levels of negative emotions to regulate and therefore engage in more suppression, which may, in turn, lead to enhancing the anxious symptoms; second, suppression attempts may be casual and subconscious, and the unbalanced attempts may unintendedly intensify the negative emotions. According to Amstadter (2008), another maladaptive strategy of emotion regulation is attentional deployment, or the ability to direct attention at or away from specific stimuli. In anxiously disordered individuals this ability may lack or be dysfunctional, which makes them prone to attentional biases in regards to threatening stimuli and more likely to anticipate negative outcomes. From a neurophysiological perspective, multiple neuroscientific studies have examined and established the importance of three major neurotransmitter systems involved in normal and pathological anxiety states: serotonin, dopamine, and the norepinephrine neurotransmitter system, which are the most affected by effective therapies (Bystritsky et al., 2013). However, it is difficult to reduce the source of anxiety to the absence of specific neurotransmitters or the malfunction of a particular neurotransmitter system, as these neurotransmitter networks are deeply interconnected with several

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feedback mechanisms and complex receptor structures, which account for unforeseeable responses to medication (Bystritsky et al., 2013). A positron emission tomographic (PET) study conducted by Reiman et al. (1989) concluded that anticipatory anxiety is associated with increased blood flow in bilateral temporal lobes, brain regions involved in lactate-induced anxiety attacks. They argue that stimulation in the temporopolar area is related to anxious states and characterized by behavioral inhibition, apparent hypervigilance, and altered facial expressions reflecting arousal, attention, or anxiety. An fMRI study conducted by Bishop et al. (2004) found that the presentation of threat-related stimuli is associated with activations in the anterior cingulate cortex and lateral prefrontal cortex, both involved in processing task-irrelevant, threat-related stimuli and reacting to unexpected cognitive conflict caused by emotional stimuli, suggesting that anxiety may be related to the diminished top-down control of threat-related distractors. Meanwhile, McNally (2007) concluded that the medial prefrontal cortex (which projects to the amygdala) may be involved in suppressing learned fear and that its damage may hinder the elimination of conditioned fears and anxiety. He further argues that the release of stress hormones during an emotionally intense episode (e.g., panic attack, traumatic event, phobic exposure) may consolidate the memory of that experience, which may account for the persistence of fear and anxiety-related thoughts even in the absence of threatening stimuli or situations.

Epidemiology Anxiety disorders are among the most prevalent psychological disorders, where according to epidemiological studies 28.8% of the population will experience an anxiety disorder at some point in their lives, while 20.8% will experience a mood disorder (Hawke & Provencher, 2011). The risk factors for developing an anxiety disorder can be classified as hereditary (i.e., a family history of anxiety disorders) which is 30-40 percent significantly lower than for bipolar disorder and schizophrenia, and individual environmental factors (e.g., childhood trauma) which account for most of the liability (Hettema et al., 2001). Results of epidemiological surveys show that anxiety disorders are more prevalent in women during midlife and are considered an economic burden for society because of a significant level of impairment and high healthcare

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utilization (Bandelow & Michaelis, 2015). Multiple studies have concluded that anxiety disorders are associated with reductions in self-esteem (Sowislo & Orth, 2013; Rosenberg, 1962), satisfaction with life (Beutel et al., 2010; Mahmoud et al., 2012), sleep quality (Spira et al., 2009; Zawadzki et al., 2013), and overall lower levels of well-being (Schonfeld et al., 1997; Smalbrugge et al., 2006). Furthermore, the comorbidity of anxiety and depression has been assessed and proved by a wide range of empirical studies (e.g., Alloy et al., 1990; Belzer & Schneier, 2004; Brady & Kendall, 1992; Dobson, 1985; Muris et al., 2001). Fainman (2004) proposes that anxiety and depression are involved in a cyclical relationship, where the symptoms of depression may lead to anxiety about the experienced feelings, while symptoms of anxiety, on the other hand, may hurt individuals’ daily lives or relationships, which may result in them feeling depressed. Several studies support the idea that in some families’ anxiety and depressive symptoms are genetically connected, with up to twothirds of patients with depressive symptoms also exhibiting symptoms of anxiety (Fainman, 2004).

Classification The former fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) in 1994 distinguishes six groups of anxiety disorders: panic disorder (with and without agoraphobia), specific phobia, social anxiety or social phobia, generalized anxiety disorder, obsessive-compulsive disorder, and post-traumatic stress disorder. A major change of the fifth edition (DSM5) published in 2013 was that the category of anxiety disorders was divided into three separate categories: (1) Anxiety disorders (generalized anxiety disorder, specific phobia, social anxiety, panic disorder, and agoraphobia with the addition of separation anxiety disorder and selective mutism); (2) Obsessive-compulsive disorders (obsessive-compulsive disorder, body dysmorphic disorder, hoarding disorder, trichotillomania, and excoriation disorder); (3) Trauma and stressor-related disorders (post-traumatic stress disorder, reactive attachment disorder, disinhibited social engagement disorder, acute stress disorder, and adjustment disorder) (Kupfer, 2015).

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Because of their relation to psychotherapeutic treatments that include altered states of consciousness, this book will provide literature reviews, theoretical frameworks, and empirical evidence of obsessive-compulsive disorders and posttraumatic stress disorders along with those of other anxiety disorders.

Panic Disorder Panic disorder is a common psychological disorder characterized by recurring episodes of panic attacks accompanied by cognitive symptoms such as constant anxiety about the occurrence of future panic attacks and phobic avoidance of the spaces or situations that the affected individual associates with the panic attacks or that may be difficult to escape from in the event of an attack (Roy-Byrne et al., 2006). Panic attacks are sudden, discrete episodes of severe fear and anxiety that may strike the individual because of the absence of a specific trigger and occurrence at random times and places, and brief duration (Craske & Barlow, 2001). Such attacks are often accompanied by severe cardiorespiratory, gastrointestinal, or autonomic symptoms and may become seriously disabling for the individual, especially if accompanied by agoraphobia, which is an extreme phobic avoidance of situations and places where the occurrence of panic attacks might be incapacitating and embarrassing for the individual, and escaping would be very unlikely or difficult (e.g., shopping malls, waiting in line, movie theaters, public transport, crowded restaurants, and being alone) (Craske & Barlow, 2014). Panic attacks alone are not a definitive indication of panic disorder, as the same psychological and physiological features of panic attacks also occur in individuals suffering from specific phobias or social phobia when presented with the feared stimulus. In these situations, however, the individual is aware of the source of their fear or anxiety, unlike in panic disorder where such episodes are unpredictable and inexplicable. The defining feature of panic disorder is the constant anxiety about the future repetition of panic episodes combined with catastrophic cognitions and behavioral changes that may severely impact the individual’s life (Craske & Barlow, 2001). Panic disorder has an annual prevalence of 1-2% and a lifetime prevalence of up to 5% with a modal age of onset in late teenage years and early adulthood, and most of the time co-occurring with other disorders such as specific phobias, social phobia, dysthymia, generalized anxiety disorder, major depressive disorder, and substance abuse (Craske & Barlow, 2001; Goddard, 2017). Both genetic

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factors and chronic stress, particularly in early childhood, have been identified as potential risk factors responsible for the onset of panic disorder (Goddard, 2017; Gorman et al., 2000). Craske and Barlow (2014) concluded that panic disorder is most associated with neuroticism, which is the tendency to experience negative emotions in response to stressful stimuli; negative affect which refers to the general proneness to experience negative emotions in response to a wide range of situations, even in the absence of stressful stimuli; and anxiety sensitivity, or the misbelief that anxiety symptoms may cause detrimental physical, social, and mental outcomes. They argue that the acute fear that develops after a panic attack is caused by catastrophic misinterpretations of physical sensations as signs of loss of control or imminent death, and conditioned fear of internal signals such as increased heart rate because of their association with panic attacks. Thus, minor physiological changes result in conditioned fear of the occurrence of a panic attack, which leads the individual to engage in safety behaviors that may facilitate escaping or avoiding certain situations; these safety behaviors prevent cognitive misinterpretations from being debunked, which further prompts the continuation of panic disorder (Craske & Barlow, 2014). Many theories on the development of panic disorder emphasize the role of classical conditioning. Bouton et al. (2001) propose a model learning theory where continuous exposure to panic attacks leads to the conditioning of anxiety and fear to exteroceptive and interoceptive cues, a process that is mainly based on emotional learning but involves a wider range of cognitive and behavioral symptoms. They argue that when a panic attack occurs, the presence of anticipatory anxiety for the event triggers the next panic attack, which leads to a downward spiral into panic disorder. Meanwhile, Busch & Shapiro (1993) propose a psychodynamic model, in which innate neurophysiological irritability is a predictor of early fearfulness. According to their model, subjection to parental behaviors that increase the feelings of fear and anxiety may cause persistent conflicts between dependence and independence, feelings of loneliness, helplessness, and being trapped and unable to escape. From a neurophysiological perspective, Gorman et al. (2000) found that reactions to a conditioned fear stimulus and panic attacks are both mediated by a “fear network” which consists of the amygdala, the hippocampus, and the prefrontal cortex, where projections from the amygdala to the hypothalamus and brainstem may account for the specific conditioned fear reactions. Goddard (2017) further supports this hypothesis, proposing a neuroanatomic

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network characterized by excessive neural activity composed of the amygdala (a central structure), the hippocampus, hypothalamus, thalamus, brainstem structures (e.g., the locus coeruleus and parabrachial nucleus), and cortical structures (e.g., the prefrontal cortex). He concluded that panic attacks are mediated by the brainstem structures, chronic anxiety is mediated by limbic structures (i.e., amygdala), phobic avoidance is processed through the prefrontal cortex, and fear processing is mediated by the insula cortex and dorsal anterior cingulate cortex.

Specific Phobia Specific phobia is the most prevalent anxiety disorder characterized by an excessive, irrational fear of a specific object or situation, that may cause serious distress and impair one’s daily activities. Individuals suffering from specific phobias are aware that their fear is excessive, however, they tend to develop an avoidance of phobic stimuli and their anxious reaction may result in a predisposed panic attack (Ipser et al., 2013). Four types of specific phobias have been identified up to now: situational (e.g., fear of closed spaces, public transportation, etc.), natural environment (e.g., fear of heights, darkness, water, etc.), animal (e.g., fear of snakes, spiders, etc.), and blood/injection/ injury (e.g., fear of dental or medical procedures, injections, seeing blood, etc.) (Wolitzky-Taylor et al., 2008). Among these, animal and natural environment phobias are the most prevalent. According to Himle et al. (1991), specific phobias differ in their way of onset. They concluded that the majority of phobias are acquired through conditioning, as a result of a traumatic encounter with a phobic stimulus or the experience of a sudden anxiety attack in a neutral situation that eventually became associated with fear. Their studies found that conditioning was the most common way of phobic acquisition for agoraphobia, claustrophobia, blood phobia, and driving phobia, and the least common for animal phobia. Regarding driving phobia, Himle et al. (1991) concluded that more than 40% of affected individuals acquired their phobia as a result of a spontaneous anxiety attack while driving and 20% after a car accident, while some individuals had a persistent irrational fear of getting involved in a car accident even though it had never occurred to them before. Ipser et al. (2013) also support the idea that most phobias arise from fear conditioning processes resulting from previous encounters with phobic stimuli. As for the neuroanatomical correlates of specific phobias, a meta-analysis of functional

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magnetic resonance (fMRI) studies conducted by Ipser et al. (2013) concluded that exposure to phobic stimuli causes activation of the amygdala (involved in responding to external threats), left insula (involved in responding to internal threats), and globus pallidus (involved in the experience of disgust in phobic responses). They argue that the amygdala and the insula are also activated in fear-conditioning paradigms, supporting the idea that specific phobias arise from fear conditioning processes. Epidemiological studies have concluded that 12.5% of the population is affected by a specific phobia at some point in their lives, making it the most common anxiety disorder (Wolitzky-Taylor et al., 2008). According to Bourdon et al. (1990), the prevalence of phobias is higher among people with low socioeconomic status and women, particularly in the range of 18-44 years old, while the typical age of onset is during the teenage years (11-17 years old) with a duration up to thirty years. They further argue that phobias are most likely to co-occur among individuals affected by other disorders, particularly somatization disorder, and considering that the onset age of phobias is very young, it is highly likely that predate the onset of other psychological disorders. Although specific phobias are very situational and have a limited nature, Wittchen et al. (1998) found that they can cause intense episodes of panic or anxiety and lead to severe impairment in individuals’ daily lives.

Social Anxiety Disorder (Social Phobia) Social anxiety disorder (or social phobia) is an anxiety disorder characterized by intense, persistent fear of social situations, social interactions, and social performance that may severely impact individuals’ lives. The diagnostic criteria for social anxiety disorder include: (1) Marked, continuous fear of embarrassment and humiliation in social situations where the individual is exposed to unfamiliar people or possible judgment by others; (2) Exposure to the feared social setting triggers intense anxiety which may turn into a panic attack; (3) The affected individual is aware that their fear is excessive and irrational; (4) The anxious anticipation or phobic avoidance of the feared social settings may severely impact the individual’s normal professional, academic, and social functioning (Bogels et al, 2010).

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Although social anxiety disorder is also known as social phobia, the phobic stimuli in social anxiety are not specific like in other phobias, e.g., fear of judgment may apply to different social contexts/situations and various types of people. Moreover, socially anxious people do not always avoid phobic situations, as they often go through intense social pressure to perform required social roles regardless of the distress they experience (Bogels et al., 2010). Considering that anxiety is an instinctive reaction to a perceived threat, the central threat in social settings is the audience and their possible negative evaluation. Rapee and Heimberg (1997) suggest that socially anxious people consider being evaluated positively as fundamentally important but have the tendency to think that the audience will inherently appraise them negatively. They propose a cognitive-behavioral model of social anxiety, where the individual creates a mental representation of their appearance and behavior and predicts a performance standard by which the audience would presumably evaluate them. The comparison of these two mental constructs creates a discrepancy between the individual’s perception of the audience’s standard of evaluation and their perception of how the audience will evaluate them, resulting in a supposed negative appraisal which, in turn, affects the individual’s self-image and elicits more anxiety (Rapee & Heimberg, 1997). Cognitive-behavioral models emphasize the role of self-focused attention in the maintenance of social anxiety disorder. Clark and Wells (1995) argue that in social situations, socially anxious individuals are too highly selffocused to be able to notice external cues that may debunk their negative mental representations; and self-focused attention, which aims to control and restrain negative internal experiences, further increases the individual’s anxiety. A review conducted by Morrison and Heimberg (2013) found that social anxiety disorder is marked by emotion regulation deficits and emotional hyperactivity. They also found that people affected by social anxiety disorder are more prone to suppressing their emotions, have more difficulties in emotional reactions, have more fear of emotional experiences, and have more negative perceptions about expressing their emotions, as they believe it shows a personal weakness and may result in social rejection. Turk et al. (2008) propose a psychobiological model where two main systems are used to develop and maintain social groups: the defense system, where group structure is maintained through social hierarchies with either dominant or subordinate roles; and the safety system, where group members maintain structure through social reassurance and positive reinforcement instead of threats. Even though the latter creates a friendlier, less threatening social environment with less social comparison and anxiety, Turk et al. (2008)

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argue that socially anxious individuals perceive social interactions as competitions and tend to use the defense system, viewing themselves in submissive roles and perceiving the audience as threatening competitors who aim to dominate them. Epidemiological studies show that up to 13% of the population exhibits diagnostic symptoms of social anxiety disorder at least once during their lives (Rapee & Himberg, 1997). According to Schneier (2006), social anxiety is a chronic disorder with onset usually during the early teenage years and is more prevalent in women, although both women and men seek treatment equally. He argues that the roots are both genetic and environmental, with some studies concluding that hypercritical and overprotective parenting may be a triggering factor. Neuroimaging studies have concluded that social anxiety is associated with increased reactivity in the amygdala and abnormalities in serotonin and dopamine systems, while performance anxiety is linked to increased reactivity in the autonomic nervous system (Schneier, 2006). According to Rapee and Himberg (1997) people affected by social anxiety disorder are prone to experiencing depression, substance abuse, and limited socialization, and may experience severe impairments in their career or academic lives.

Generalized Anxiety Disorder Generalized anxiety disorder is a severe mental disorder characterized by persistent, excessive anxiety, worry, negative thoughts, feelings of loss of control, hypervigilance, and other somatic symptoms of anxiety that last for more than six months (Wittchen, 2002). Generalized anxiety disorder has been considered the “basic” anxiety disorder, because its principal characteristics account for anxious apprehension, the fundamental process of all emotional disorders (Brown et al., 2001). Anxious apprehension is a future-oriented mood state of being prepared to deal with upcoming negative experiences and is associated with high negative affect, constant overarousal, a sense of unpredictability, and increased attentional focus on threatening cues (Brown et al., 2001). Individuals affected by this disorder tend to perceive the external environment as dangerous and threatening and are constantly over-analyzing the environment and looking for signs of the supposed threat. Because this supposed threat is an anticipated event that is not exist in the present, the individual cannot avoid it and their only adaptive coping mechanism becomes excessive worrying, which is perceived as preparation for the upcoming threat.

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The external environment is seen as unpredictable and uncontrollable, which increases the individual’s perceived necessity to be vigilant to be prepared for any possible danger. This enhanced attentiveness makes the individual prone to perceiving and interpreting all external cues, even neutral ones, as dangerous and threatening, which increases attentiveness, even more, thus generating a cycle of constant anxiety. Wells (1995) proposes that individuals affected by generalized anxiety disorder have a meta-cognitive dysfunction marked by negative misbeliefs about engaging in negative, consistent assessment, i.e., active, constant worry. He argues that this active worrying becomes a clinical problem when it evolves into meta-worry, or when the negative effects of worry itself become the subject of anxiety and overthinking. Affected individuals have poor emotion comprehension and often find it difficult to recognize discrete emotions such as anger, joy, fear, sadness, and disgust, often perceiving them as overwhelming and confusing (Turk et al., 2005). According to Turk et al. (2005), these individuals have a dysregulated emotional experience because of several factors such as heightened emotional intensity, inability to identify basic emotions and use them as a source of knowledge, negative reactions towards their emotional states, and dysfunctional emotional management responses. Wells (1995) developed a cognitive model of generalized anxiety disorder, in which the disorder is caused by the combination of using worry as a coping mechanism, negative evaluation of worry, and failed attempts to control the worrying; the interaction of these factors results in dysfunctional meta-beliefs and subjectively reduced cognitive control. Holmes and Newman (2006) assessed various physiological factors associated with a generalized anxiety disorder such as chronic vigilance, scanning, and muscle tension. They concluded that unlike other anxiety disorders, which are associated with enhanced autonomic activation, generalized anxiety is characterized by a lack of autonomic reactivity and low vagal tone, which may be interrelated with information processing difficulties found in people affected by the disorder. Clinical and empirical evidence shows that generalized anxiety disorder is less reactive to psychotherapeutic and pharmacological interventions (Brown et al., 2001). Since the defining features of this disorder may contribute to the development of other anxiety and mood disorders, generalized anxiety has high comorbidity with major depression (almost twothirds of all patients), alcohol abuse (a third of all patients), and panic disorder (a quarter of all patients) (Fricchione, 2004). Moreover, studies have found a similar genetic predisposition in the serotonin-transponder gene for both

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generalized anxiety disorder and major depression, suggesting an explanation for their comorbidity (Fricchione, 2004). Because of its varying definitions and methods of assessment, prevalence studies have found it difficult to acquire precise estimations. Epidemiological studies have found that generalized anxiety disorder has a lifetime prevalence of 4% and an annual prevalence of 3.8%, thus being more common than panic disorder but less common than social and specific phobias (Holmes & Newman, 2006). Unlike other anxiety disorders which have an earlier age of onset, generalized anxiety disorder has the oldest age of onset, with a median age of 31, and 50% of cases being between 20 and 47 years old, while 25% of cases have an onset of 20 years old (Weisberg, 2009). This age of onset is similar to that of major depression, which further supports their similar genetic predisposition and proneness to co-occur.

Obsessive Compulsive Disorder Obsessive-compulsive disorder (OCD) is characterized by the occurrence of intrusive cognitions (obsessions) and repetitive actions (compulsions) (Abramowitz & Reuman, 2020). In the DSM-IV OCD was classified as a subcategory of anxiety disorders. However, some authors proposed that although OCD may cause persistent, intense anxiety, they have more similarities to obsessive-compulsive-related disorders than to anxiety disorders, (Abramowitz & Reuman, 2020). Therefore, in the DSM-5, OCD was reclassified in a separate category along with body dysmorphic disorder, hoarding disorder, trichotillomania, and excoriation disorder. Obsessions are repetitive and persistent thoughts, impulses, and images that the individual experiences as intrusive and actively tries to ignore or suppress, which may cause severe anxiety (Stein, 2002). Examples include intrusive thoughts of being hurt or hurting others, sexually repulsive thoughts, constant awareness of one’s bodily sensations (blinking, breathing), etc. Compulsions, on the other hand, are repetitive actions or mental acts that the individual performs meticulously and often with strict rules in response to an obsession, to reduce anxiety or prevent a threatening event, although these behaviors are unrealistic and not related to the situation (Abramowitz & Reuman, 2020). Examples include switching the lights off and on a specific number of times (e.g., five or ten), checking if the doors are locked multiple times, rigorous handwashing, praying, repeating words, etc. These obsessions and compulsions become clinically problematic when they cause intense

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anxiety and distress, are highly time-consuming (may take longer than two hours per day) and significantly interfere with the individual’s daily professional or academic life and relationships (Stein, 2002). Although the diagnostic criteria for OCD may appear somewhat similar to other anxiety disorders, the associated symptoms can usually be distinguished easily. For example, unlike excessive worries in generalized anxiety disorder, which are inflated concerns about realistic circumstances that may potentially happen in the future, obsessions in OCD are usually unrealistic (e.g., the necessity for symmetrical things) and experienced as inappropriate (Foa & Franklin, 2001). Affected individuals are aware that these obsessions and compulsions are irrational, but they feel little or no control over them and need to perform them correctly regardless of the constant distress they feel. (Kraft T. & Kraft D., 2006). Shafran et al. (1996) propose that a major factor that may influence the development and maintenance of OCD is thought-action fusion, in which the individual interprets intrusive thoughts as especially significant and therefore experiences an excessive responsibility for them. They further argue that this perceived responsibility to suppress their thoughts or perform specific behaviors may be a misinterpretation of the link between cognitive intrusions and the need for action as a way to prevent potential harm. Mowrer (1947) proposed a two-stage theory for the development and maintenance of fear and obsessive behaviors based on classical conditioning, where an initially neutral event becomes feared when constantly accompanied by an anxiety-provoking stimulus, and thereafter avoidance behaviors are developed to decrease the anxiety caused by these stimuli. Salkovskis (1985) proposed an extended cognitive evaluation of OCD, arguing that intrusive obsessions are stimuli that may trigger negative automatic thoughts that lead to mood disturbances when a discrepancy exists between the intrusion and the individual’s belief system. Contemporary cognitive-behavioral models of OCD posit that obsessions and compulsions originate from dysfunctional beliefs about one’s intrusive thoughts. According to Abramowitz and Reuman (2020) when intrusive thoughts become highly important and threatening to the individual they develop into obsessions, which stimulates the individual to try to suppress and neutralize them, in an attempt to reduce anxiety and avoid the anticipated harmful outcome. The repeated preventive actions, in turn, are reinforced by the instantaneous anxiety reduction and the prevention of the anticipated harmful consequence, and thus turn into compulsions. Executing the compulsions serves as a reminder for the obsession to persist even more; thus, creating an anxiety-generating cycle (Abramowitz & Reuman, 2020). From a

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neurophysiological perspective, empirical studies have shown that symptoms of OCD are associated with the hyperactive frontal-striatal thalamic-frontal circuit, which plays a role in monitoring events and creating error signals when the events are incompatible with an individual’s internal standards or goals (Gehring et al., 2000). Results from fMRI studies have concluded that OCD is marked by enhanced activity in the orbitofrontal cortex (involved in the cognitive processes of decision-making), the cingulate cortex (involved in emotion processing), and striatum (involved in facilitating voluntary motions), and associated with temporal dysfunction (Stein, 2002). Epidemiological studies show that OCD has an annual prevalence of 1.2% and a lifetime prevalence of 2.3%, meanwhile up to one-third of the population has experienced obsessions or compulsions at least once in their lives (Ruscio et al, 2010). According to Ruscio et al. (2010) the mean age of onset is 20 years, however, men tend to have an earlier onset age (before 10), while women tend to have a later onset age; both have few cases of onset after the early thirties. They argue that almost all (up to 90%) individuals affected by OCD are also affected by other anxiety disorders, mood disorders, impulsecontrol disorders, and substance use, and may have severe impairments in their social lives, relationships, and daily tasks.

Post-Traumatic Stress Disorder The American Psychological Association (APA) defined post-traumatic stress disorder (PTSD) as an anxiety disorder that arises in individuals who were exposed to an event that involved the threat of death or serious injury and to which they reacted with intense fear and helplessness (Cooper, 2001). The classification, definition, and diagnostic criteria of PTSD were changed and further extended in the DSM-5, where PTSD was removed from the category of anxiety disorders. Because empirical research had shown that PTSD involves a variety of emotions (e.g., anger, guilt, shame) that are outside the fear/anxiety spectrum, the disorder was re-classified under the category of “trauma and stressor-related disorders” (Pai et al., 2017). According to the DSM-5, the definition of trauma must include direct exposure to the traumatic event; indirect exposure through witnessing in person a stressor event; learning loved one’s traumatic experiences related to a violent or accidental event; or repeated or extreme exposure to aversive details of a gruesome trauma (Carmassi et al., 2013). Meanwhile, the diagnostic criteria for PTSD include negative alterations in cognition and

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mood, hyperarousal, involuntary and intrusive distressing memories of the traumatic event, persistent distorted blame of self or others about the cause or consequences of the trauma, persistent negative emotional states, and reckless or self-destructive behavior (Carmassi et al., 2013). PTSD is one of the few disorders in which the cause or triggering event is usually known, and it may include violent personal assault (e.g., sexual assault, physical attack), war, being taken hostage or kidnapped, confinement as a prisoner of war, torture, terrorist attacks, severe car accidents, natural disasters, sexual abuse during childhood, and unexpected death of a loved one, etc. (Javidi & Yadollahie, 2012; Kirkpatrick & Heller, 2014). Affected individuals experience reactions that last for more than a month, characterized by phenomena that can be classified into three main domains: reminders of the exposure (including flashbacks, intrusive thoughts, and nightmares); activation (including hyperarousal, insomnia, agitation, irritability, impulsivity, and anger); and deactivation (including numbing, avoidance, withdrawal, confusion, derealization, dissociation, and depression) (Sherin & Nemeroff, 2011). When these symptoms last for less than three months, it is a case of acute PTSD, while if they last for longer, it is a case of chronic PTSD, and the severity depends on several internal and external factors, such as the intensity of the trauma, individual personality traits and neuroticism (Javidi & Yadollahie, 2012). Since it was first introduced in the DSM-III in 1980, researchers have attempted to explain the underlying cognitive processes that prompt the development and maintenance of PTSD. Many researchers (e.g., Keane et al., 1985; Kilpatrick et al., 1985) have explained the principles of PTSD by applying Mowrer’s (1947) two-stage learning theory of fear and anxiety. Keane and Barlow (2002) argue that human beings are prone to biological vulnerabilities (a genetic predisposition to experience negative affect) and psychological vulnerabilities (reduced sense of control, anxious apprehension, cognitive biases towards external and internal cues, etc.). They propose that these biological and psychological vulnerabilities provoke a true alarm (response to actually threatening stimuli) when the trauma occurs and associate this reaction with external and internal cues related to the trauma, which in turn activates anxious apprehension, the avoidance of triggering cues, and emotional numbing. Regarding learning theories, Resick et al. (2008) argue that memories of the traumatic experience become associated with fear and anxiety, and they are avoided to reduce negative affect; this avoidance is negatively reinforced which maintains the link between the trauma cues and anxiety. In a cognitive

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theory of PTSD Epstein (1991) suggested that traumatic events may alter four basic beliefs: the belief that the external environment is benevolent, that the world is meaningful, the individual is self-worthy, and that other people are trustworthy. Social-cognitive theories posit that cognitive processing is operated by a completion tendency, or the psychological need for novel information to be assimilated with pre-existing beliefs, which creates a conflict with the necessity to avoid emotional pain (Resick et al., 2008). When trauma-related cues become overwhelming, defense mechanisms attempt to avoid them, and because the trauma never becomes fully assimilated it can trigger intrusive cognitions and avoidant behaviors (Resick et al., 2008). Meanwhile, emotional processing theories propose that the fear structure that constitutes PTSD involves several non-threatening stimuli that are mistakenly associated with danger, and because a large number of stimuli can be interpreted as threatening, individuals affected by PTSD perceive the world as utterly dangerous (Cahill & Foa, 2007). Moreover, the individual’s reactions and behaviors at the time of the traumatic event are perceived as self-incompetent, which reinforces false cognitions and aggravates the severity of PTSD. Neurophysiological studies have found that PTSD is related to increased activation of the amygdala, dorsal anterior cingulate cortex, medial prefrontal cortex, and hippocampus, which may explain the attentional bias towards the threat, dysfunctional emotion regulation, and persistence of traumatic memories (Pitman et al., 2012; Shin & Liberzon, 2010). Sherin & Nemeroff (2011) concluded that PTSD is also associated with changes in the insula and orbitofrontal cortex, which are involved in the adaptation to stress and fear conditioning. They also found that PTSD is related to impaired regulation of cortisol (primary stress hormone) and thyroid hormones (involved in mood regulation); as well as impaired regulation of catecholamine, serotonin, amino acid, peptide, and opioid neurotransmitters, which are found in brain circuits that regulate stress and fear responses. Moreover, PTSD is associated with aggressive impulses, irritability, hyperarousal symptoms, excessive startle, hypervigilance, and higher autonomic responses (e.g., heart rate) when exposed to external trauma-related cues, which may imply an acquired sensitization of the nervous system (Chemtob et al., 1988; Pitman et al., 2012; Shin & Liberzon, 2010). Javidi & Yadollahie (2012) found that 84% of individuals affected by PTSD experience constant feelings of shame, despair, and hopelessness, and may also be affected by other psychological disorders such as alcohol abuse, conduct disorder, and major depressive disorder, anxiety, and sleep disorders.

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Epidemiological studies have concluded that exposure to trauma has a prevalence of 21% (Perrin et al., 2014), while PTSD has a lifetime prevalence of 12.9% for conflict-affected populations, and a global prevalence of 3.5%, with onset between childhood years and 25 years, and a decline after 55 years (Charlson et al., 2016). Duckers et al. (2016) found a vulnerability paradox in the global prevalence of PTSD. Their results showed that PTSD is positively associated with exposure to trauma, but negatively associated with country vulnerability, i.e., vulnerable countries are related to reduced, rather than increased risk for PTSD, while countries high in exposure and low in vulnerability have a risk of three times higher. They argue that this could be because countries with low vulnerability may have more individualistic cultures and may lack community engagement and support for trauma victims, and that because there are higher expectations about achieving goals, the impact of the traumatic experience on the long-term goals may be greater. Perrin et al. (2014) found several factors related to the risk of development of PTSD, among which were pre-existing psychological disorders (e.g., bipolar disorder, alcohol dependence, and separation anxiety disorder), which may increase vulnerability to traumatic exposure, and personality features like level of neuroticism and antisocial personality disorder. No evidence was found for a genetic contribution to PTSD.

Psychological and Pharmacological Treatments A wide range of empirical and clinical studies have concluded that among various methods of treatment, cognitive behavior therapy (CBT) is the most effective in the treatment of mood and anxiety disorders. CBT is a method of psychotherapeutic treatment that is based on identifying automatic negative thoughts and maladaptive behaviors and eventually altering them and replacing them with individual coping strategies, using cognitive restructuring, behavioral activation, exposure, and relaxation training (Hawke & Provencher, 2011). Chambless and Gillis (1993) concluded that CBT shows high rates of improvement and maintenance of treatment gains among patients by stimulating cognitive alteration of maladaptive symptoms related to the reduction of anxiety and the duration of the treatment gains. In comparison to supportive therapy, education, behavioral therapy, and placebo pills, CBT has been proven to be more effective in the treatment of the panic disorder, generalized anxiety disorder, specific phobias, and social phobia, with

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relatively low dropout rates (8% for panic disorder, 14% for generalized anxiety disorder, and 13% for social phobia) (Chambless & Gillis, 1993). Different anxiety disorders require different combinations of CBT techniques, which may involve psychoeducation about the nature of fear and anxiety, self-monitoring of symptoms, somatic exercises, cognitive restructuring (e.g., logical empiricism and disconfirmation), imaginal and in vivo exposure to feared stimuli, and relapse prevention (Otte, 2011). As a treatment approach, CBT is directive and collaborative, as the therapist and the patient establish clear and specific treatment goals and evidence-based techniques are used to alter the patient’s somatic sensations, irrational cognitions, and dysfunctional behaviors (Bystritsky et al., 2013). Deacon and Abramowitz (2004) argue that the main strength of CBT in comparison to other methods of psychotherapy is that CBT techniques arise from the logical application of empirically supported theoretical frameworks of anxiety disorders, thus there exists a theoretically and scientifically coherent relationship between the treatment methods and the symptoms they treat. They further suggest that the most widely applied behavioral technique is systematic exposure to stimuli and situations that trigger fear or anxiety, which through habituation (repeated and prolonged exposure) informs the individual about the objective features and level of threat that the stimuli or situation pose and reduces anxiety. Systematic exposure refers to the gradual and consistent presentation of anxiety and fear-inducing stimuli for a long enough time that the patient experiences a gradual reduction in their level of anxiety without engaging in avoidant behavior until the outcome of not feeling anxious anymore would be achieved (Bystritsky et al., 2013). A meta-analysis conducted by Silverman et al. (2008) concluded that while other methods were classified as possibly efficacious or experimental, individual and group CBT was classified as the most effective treatment for patients (particularly children) affected by anxiety disorders, providing long-lasting outcomes. However, in cases of very severe anxiety disorders and critically serious symptoms, pharmacological treatment has shown higher effect sizes than CBT and most psychological therapies, with gains attained in a shorter time (Bandelow et al., 2015). Several studies (e.g., Baldwin & Polkinghorn, 2005; Cuijpers et al., 2013; Farach et al., 2012; Koen & Stein, 2011) have assessed the effectiveness of pharmacological treatments and have found positive outcomes. Bandelow et al. (2014) propose that higher results are achieved when psychotherapy, including CBT, is combined with pharmacological treatment, i.e., grade A (selective serotonin reuptake inhibitors (SSRI) and

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serotonin-norepinephrine reuptake inhibitors (SNRI)) and grade B recommendations (tricyclic antidepressant clomipramine for panic disorder. and pregabalin for generalized anxiety disorder). A metaanalysis conducted by Bystritsky et al. (2013) compared the effectiveness and patient preferences for CBT and medication (specifically SSRI) and concluded that CBT showed greater treatment effect for panic disorder, while medications showed better effects for social anxiety disorder. Nevertheless, they argue that the treatment of anxiety disorders remains yet to be improved because there is a lack of CBT therapists and generally affordable sessions. Although CBT and SSRIs are the most empirically supported treatments for anxiety, they cannot always be completely effective for all anxiety disorders because certain disorders (e.g., generalized anxiety disorder) are more difficult to treat than others (e.g., simple phobia of dogs). The majority of clinical and empirical studies confirm that CBT is considered the gold standard in psychotherapy and has long-lasting positive results in the treatment of a wide range of disorders including panic disorder (Allen et al., 2010; Gloster et al., 2011), generalized anxiety disorder (e.g., Borkovec & Costello, 1993; Newman et al., 2011), specific phobias (e.g., Paquette et al., 2003; Schienle et al., 2009), social anxiety disorder (e.g., Heimberg, 2002; Leichsenring et al., 2013), OCD (e.g., Olatunji et al., 2013; Storch et al., 2007), and PTSD (e.g., Cohen et al., 2012; van Dam et al., 2013).

Hypnosis and the Treatment of Anxiety Disorders Cognitive Hypnotherapy The efficacy of hypnotherapy in treating anxiety disorders has been assessed and approved by more than 400 research publications, 50 randomizedcontrolled studies, and several meta-analytic reviews of the scientific literature (Frankel & Macfie, 2010). Hypnotherapy is usually short-term therapy that can directly alleviate physical and cognitive symptoms of anxiety by accentuating direct suggestions of mastery and creating a safe relaxing place for the patient, which in turn begins to experience a heightened sense of control and less stress from their cognitive and physical symptoms (Frankel & Macfie, 2010). According to Kraft T. and Kraft D. (2006), one of the principal anxietyreducing methods applied in hypnotherapy is systematic desensitization, where the patient is first recommended to imagine a safe place where they feel

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calm and free from anxiety. This safe place can be an imaginary situation such as the beach or a forest, or a real situation such as one’s childhood home or playground. As soon as the patient is feeling secure in their safe place, the hypnotherapist can start investigating the source of anxiety by encouraging the patient to explore different anxiety-inducing situations, and whenever the patient begins to experience distress from the anxiety they can return to their safe place (Kraft T. & Kraft D., 2006). This procedure is repeated several times over multiple sessions until the patient eventually gets habituated to the anxiety-provoking stimuli and the anxiety levels decrease. This process can be conducted in hypnotherapy, or in real life where patients are accompanied by the therapist in anxiety-provoking situations (e.g., also referred to as in vivo desensitization (Kraft T. & Kraft D., 2006). Spiegel (2013) argues that from the perspective of therapeutic strategy, anxiety employs pathological distraction of attention from important daily functions and a snowball effect, or a negative feedback cycle between mental and physical discomfort, in which anxiety and somatic tension continuously stimulate each other. For example, when an anxious individual experiences shortness of breath, they are likely to misinterpret this symptom as an indicator of an anxiety episode and subsequently respond with intensified anxiety; this further reinforces the physical symptoms (i.e., shortness of breath), generating more anxiety, and so on. Besides inducing relaxation through escaping into the perceived safe space, Spiegel (2013) argues that hypnosis employs dissociation which simplifies the differentiation of the psychological and physical components of anxiety. He further suggests that overall, the main phenomena that co-occur during hypnosis such as dissociation, absorption (highly focused attention), and suggestibility, are naturally aroused during trauma as they may comprise an adaptive defense mechanism against intense anxiety or fear; thus, hypnosis and its components may constitute an important reaction to stressors and trauma. Several empirical and clinical studies have found that people affected by anxiety disorders, particularly phobic people, exhibit greater hypnotic suggestibility (Evans & Coman, 1998; Kraft T. & Kraft D., 2006). Evans and Coman (1998) suggest that this heightened hypnotic suggestibility, along with other components of hypnosis such as the patient’s focus of attention, reduced capacity for critical reasoning, heightened imagery, and distortions of memory, can be utilized and implemented in many anxiety management interventions and can further be effectively adjunct to other treatment approaches for anxiety disorders. They further argue that hypnosis plays a crucial role in enhancing the patient’s expectations of change and

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improvement, as their attempts to seek help are fostered with the hope that their problems will be overcome. Hypnotherapy has been proven to be highly effective in reducing general stress levels and improving stress-related medical conditions such as tension headaches and migraines (Alizamar et al., 2018; Brown & Hammond, 2007; Frankel & Macfie, 2010). According to Alizamar et al. (2018) hypnotherapy can adjust the patient’s thinking patterns to manage their stress levels. They argue that hypnotherapy can decrease excessive hormone levels, thus decreasing general stress levels in various contexts, for example in university students dealing with overwhelming academic work. A wide range of empirical studies has found that self-hypnosis can be significantly beneficial in reducing not only stress levels but also anxiety related to various sources such as public speaking, exam taking, coping with a cancer diagnosis, anxiety experienced by burn patients and those going through childbirth (Brown & Hammond, 2007). Scientific evidence shows that hypnosis can be as effective as psychopharmaceutical treatments, precisely 1 mg of alprazolam, in reducing anxiety symptoms among university students, as hypnosis can alter not only sensory input but sensation itself, thus creating a potent tool in modulating pain and anxiety (Nishith et al., 1999; Spiegel, 2013). A study conducted by Kraft T. and Kraft D. (2006) assessed the treatment of sleep problems with psychotherapy, which aimed to analyze the underlying emotional factors that triggered sleep problems, and hypnotherapy, which aimed to alleviate the patient’s sleeping problems and help them fall asleep faster. Patients were encouraged to practice self-hypnosis two times per day, particularly before going to bed at night where they would visualize relaxing and enjoyable scenes. Their results showed that the patients’ target symptoms were significantly improved, and their overall well-being was heightened, as the patients reported feeling less irritable, more relaxed, and more able to enjoy leisure time. These results are an indicator that self-hypnosis is a highly effective practice as it enables patients to feel in control of their symptoms rather than being their victim (Kraft T., & Kraft D., 2006). According to Hammond (2010), learning and practicing self-hypnosis has been proven to increase patients’ self-esteem and perceptions of self-efficacy from succeeding to developing self-mastery skills. Self-hypnosis can be highly beneficial for people affected by PTSD (Spiegel, 1988), different phobias, medically-related anxiety (Spiegel, 2013), panic attacks, and agoraphobia, as the patient can enter a self-hypnotic state before being confronted with an anxiety-inducing situation and rehearse their coping strategies (Evans &

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Coman, 1998). Moreover, hypnosis has been proven to be effective in treating generalized anxiety disorder (Kraft T. & Kraft D., 2006) and various phobias, among which dental phobia (Forgione, 1988; Halsband & Wolf, 2015), injection phobia (Cyna et al., 2007; Daniels, 1976), flying phobia (Hirsch, 2012; Spiegel et al., 1981), contamination phobia (Scrignar, 1981), driving phobia (Hill & Bannon-Ryder, 2005), and environmental phobia (Walters & Oakly, 2003). According to Rogers (2008), hypnosis can be substantially useful in detecting the sources of phobic behavior and facilitating attention to past and present achievements as a reminder of the patient’s abilities, hence demonstrating high efficacy in the treatment of specific phobias. There is not much empirical evidence testing the effect of hypnosis as a sole approach, uncombined with other treatments, on anxiety disorders. Stanton (1984) was among the first to investigate the potential of hypnosis as a sole treatment for social anxiety. His study consisted of sixty adult participants suffering from social anxiety who were divided into a control group and two experimental groups. The first experimental group underwent a hypnotic treatment including positive suggestions and mental imagery, while the second group listened to Mozart symphonies; both groups received thirtyminute-long treatments for three weeks. His results showed that while the control group exhibited minor changes in their anxiety levels, both experimental groups showed a significant decrease in their anxiety levels, with the hypnosis group being the only to experience a larger decrease and maintaining the therapeutic gains six months after the treatment (Fredette et al., 2013). On the other hand, the empirical evidence for the efficacy of hypnosis combined with other treatments, particularly CBT, on anxiety disorders is much larger. Cognitive hypnotherapy can be a powerful method of accessing and healing emotional injuries for anxiety disorders and it consists of four distinct but interrelated phases including the analysis, case conceptualization, and establishment of the therapeutic relationship; the management of symptoms; the process of detecting and healing self-wounds; and the encouragement of acceptance and gratitude (Alladin, 2016). Schoenberger et al. (1997) assessed participants suffering from public speaking anxiety by dividing them into a control group and two experimental groups. The first group received CBT treatment only, which consisted of cognitive restructuring and in-vivo exposure, while the second group received CBT combined with hypnotherapy, where relaxation training was replaced by hypnotic inductions and suggestions (Fredette et al., 2013). Both experimental treatments resulted in a significant decrease in anxiety levels compared to the

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control group; the participants who received hypnotherapy, however, differed significantly in the subjective and behavioral measures of fear (Fredette et al., 2013). Golden (2006), on the other hand, argues that cognitive hypnotherapy is also more effective than hypnosis alone, as the fear-reducing suggestions and trance-induced coping self-statements are both cognitive restructuring strategies that increase the effectiveness of cognitive hypnotherapy in comparison to other treatments. Evans and Coman (1998) propose that when used during hypnosis, cognitive restructuring can be a highly advantageous addition that can facilitate creating new, rational cognitions to replace old, maladaptive cognitions and thoughts, resulting in enhanced therapeutic results. They suggest that during desensitization in hypnosis the patients not only visualize anxiety-inducing situations but also reinforce their effective coping strategies without the emotional response that they would normally experience in a waking state of consciousness. This facilitates the development of new cognitions regarding the patients’ capability to cope with the anxiety-inducing situation in real life without actually experiencing anxiety or uncontrolled emotional reactions, creating a heightened sense of control; this sense of control, on the other hand, enhances the patients’ self-esteem and self-efficacy (Evans & Coman, 1998). The changes in the patient’s perceived capacity to cope with anxietyinducing situations can be attained via cognitive control by emphasizing the belief that the patient is independently capable of managing anxiety-inducing situations, and via behavioral control by actively performing certain actions to reduce anxiety (Evans & Coman, 1998). Somer (1995) assessed the treatment of phobic anxiety by simultaneously combining hypnosis, cognitive restructuring, and biofeedback. He found that the integration of these approaches was highly effective as it enlivens the phobic stimuli to reinforce the credibility of the imagined stimuli; it allows the alterations of anxietyrelated cognitions and the implementation of effective coping behaviors; and it provides objective, reliable evidence that the applied coping strategies are effective, making the patient gain self-efficacy in changing his psychophysiological arousal. Kirsch et al. (1995) conducted a meta-analysis of studies comparing the effectiveness of CBT and cognitive hypnotherapy for a variety of disorders (among which pain, insomnia, anxiety, public speaking anxiety, obesity, hypertension, and phobias). They found that cognitive hypnotherapy was significantly more efficacious in treating the various disorders than CBT alone, implying that the addition of hypnosis results in considerably enhanced

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therapeutic outcomes. In a more recent review of several meta-analyses, Wark (2008) also found that hypnotherapy is more effective than CBT in treating public speaking anxiety and anxiety related to asthma attacks, while selfhypnosis is highly effective in reducing test anxiety. Kraft (2011) concluded that hypnosis is a powerful addition to therapeutic approaches like CBT (e.g., Lipsett, 1998) and psychodynamic therapy (e.g., Frankel & Macfie, 2010), especially when combined with positive enhancement and ego-strengthening techniques, and a rigorous psychodynamic analysis of the patient’s dependency and separation, avoidant behavior, feelings of guilt, and fears of rejection in both present-time relationships and childhood. A clinical case study described by Kellis (2011) shows the effectiveness of integrating hypnosis components (i.e., ego strengthening, positive suggestions) with CBT in enhancing the patient’s comprehension of cognitivebehavioral principles by reframing cognitive distortions, reinforcing frustration tolerance, and developing positive expectations and increased control. Kellis (2011) argues that cognitive hypnotherapy significantly improved the patient’s level of self-confidence, relaxation, and self-control while reducing levels of anxiety and depression. Similar results were found in a study conducted by Holdevici and Craciun (2013), which compared CBT with cognitive hypnotherapy. Their results indicate that both interventions led to significant improvement in levels of anxiety, depression, and negative mood, with cognitive hypnotherapy resulting in significantly superior therapeutic outcomes for anxiety disorders. Moreover, using hypnotherapy and relaxation techniques has been proven to be effective in the treatment of anxious-depressive disorders associated with insomnia, as hypnosis can help the patients explore the connections between their cognitions and behaviors (Holdevici, 2014). Forouzandehfar et al. (2019) compared the efficacy of group CBT with group hypnotherapy in treating social anxiety and found that while both interventions led to significant reductions in levels of social anxiety, hypnotherapy caused more significant alterations in the brain and behavioral systems activity, thus showing higher efficacy. Overall, substantial scientific evidence exists to validate the multidimensional positive effects of hypnotherapy for a wide variety of conditions such as anxiety in cancer patients (Chen et al., 2017; Kellerman et al., 1983), anxiety in patients undergoing dental surgery (Glaesmer et al., 2015; Katcher et al., 1984), preoperative anxiety (Goldmann et al., 1988; Saadat et al., 2006), test anxiety (Hammer et al., 2020; Stanton, 1994) and pain anxiety (Jafarizadeh et al., 2018; Olmsted et al., 1982).

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In addition to being a powerful treatment for anxiety disorders as defined by the DSM-5, hypnotherapy has also been proven to be highly effective in the treatment of OCD and PTSD. Hypnotherapy and deep relaxation can neutralize the anxiety symptoms of OCD patients, particularly if integrated with ego-strengthening techniques (Meyerson & Konichezky, 2011; Moore & Burrows, 1991). Moreover, hypnotherapy can control and regulate the cognitive and attentional processes that characterize OCD by directly promoting cognitive behavioral treatment strategies (Meyerson & Konichezky, 2011). A highly efficient technique to treat obsessive cognitions is “thought stopping”, in which the patient is encouraged to focus on their obsessive rumination under hypnotic trance until the therapist firmly says “stop” and the patient is then encouraged to focus on another thought, thus breaking the obsessive cycle (Kraft T. & Kraft D., 2006). Cognitive restructuring under hypnosis is another highly efficient technique to identify maladaptive cognitions and behaviors and replace them with beneficial ones. Reframing cognitions can be achieved by first identifying the positive and meaningful aspects of the patient’s obsessive thoughts and then presenting them to the patient; the compulsive behaviors are subsequently associated with the positive cognitions and interpreted as actions that contain positive intentions in their life, which are then instilled gradually in the patient during hypnotic trance (Meyerson, 2010). Regarding PTSD, the integration of hypnotherapy with cognitive behavior strategies, exposure techniques, and hypnotic relaxation has been proven to produce highly effective therapeutic outcomes (Carter, 2005; Moore, 2001; Peebles, 1989). Patients suffering from PTSD exhibit high hypnotic susceptibility and are encouraged to practice self-hypnosis to enhance their sense of control (Kraft T. & Kraft D., 2006; Spiegel, 1988). During hypnotherapy, the patient is encouraged to visualize a safe, comfortable place and then gradually reexperience the components of the original traumatic event, while the hypnotherapist ensures that the patient’s anxiety levels remain low so that the negative emotions associated with the traumatic event can be reduced (Kraft T. & Kraft D., 2006). A meta-analysis conducted by Rotaru & Rusu (2016) concluded that overall hypnotherapy has a significantly positive impact on the immediate and long-term reduction of PTSD symptoms.

Mindful Hypnotherapy Although cognitive hypnotherapy is the most researched and applied technique, there has been an increasing number of studies assessing the

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efficacy of mindful hypnotherapy and its impact on stress and anxiety disorders. Hypnosis uncovers the underlying relation between one’s mind and body and enhances self-regulation, while mindfulness focuses attention on the present moment, fostering feelings of acceptance and non-judgmental attitudes (Ajinkya et al., 2015). The combination of both practices has resulted in a new therapeutic approach that aims to alter personal experiences and perceptions and replace old maladaptive response patterns with new positive ones, which has resulted in positive therapeutic outcomes for enhancing personal growth and treating depressive disorders, substance abuse disorders, chronic pain and anxiety disorders (Ajinkya et al., 2015). Furthermore, its integration with biofeedback and behavioristic principles has been documented as a highly effective treatment for phobic anxiety as it enables the patient to identify the historical origin of their anxiety, gain control of their cognitions, and enhance their sense of self-mastery (Iglesias & Iglesias, 2005). The patient is encouraged to dissociate their identity from their anxious thoughts and simply focus on the present moment with feelings of acceptance, which desensitizes them from somatic anxiety-related cues and assists the patient in accepting anxiety as a normal mental event (Ajinkya et al., 2015). A useful technique for patients suffering from panic disorder is individualized ego strengthening through suggestions of resilience, strength, comfort, and security, which aim to enhance the patient’s self-esteem and develop their “inner strength” (Iglesias & Iglesias, 2005). Telehypnosis and Ericksonian hypnosis, in which the patient is provided with indirect suggestions for relaxation, has also been proven to result in positive outcomes in decreasing anxiety levels, particularly when incorporating mindfulness, yoga, and biofeedback (Fulweiler & John, 2018). Moreover, mindful hypnotherapy has been documented as a highly effective treatment for stress and distress. A study conducted by Olendzki (2016) compared the efficacy of mindful hypnotherapy with mindfulness interventions delivered in non-hypnotic states and concluded that mindful hypnotherapy is significantly more efficacious in reducing levels of anxiety, global distress, anger, and increasing self-compassion and mindfulness. A more recent study conducted by Olendzki et al. (2020) also concluded that mindful hypnotherapy is highly effective in reducing perceived stress, levels of depression, hopelessness, and psychological distress, while also enhancing overall psychological flexibility, mindfulness, and well-being levels. The increasing empirical interest in mindful hypnotherapy and its therapeutic outcomes may have positive practical implications related to the clinical use

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of this approach, as it comprises an empathetic treatment that reduces or avoids the use of pharmaceuticals, has very few reported adverse effects, and promotes overall psychological well-being and feelings of acceptance.

Meditation and the Treatment of Anxiety Disorders Interest in meditative practices has grown considerably since the 1960s, and lately, there has been an increasing body of research uncovering the psychological and somatic benefits of meditation. The existing scientific literature provides meaningful insight into the underlying mechanisms through which meditation benefits and contributes to the treatment of anxiety disorders. Meditation promotes feelings of acceptance, non-judgmental awareness, open attitudes, and detachment from one’s mental activities. These metacognitive abilities, particularly detached observation in which the individual perceives their mental states and their affiliated emotions as separate entities, involve primary process thinking, a mental functioning mode characterized by intuitive conceptual flexibility (Lin et al., 2008). This can be highly beneficial to individuals suffering from anxiety disorders, as by nurturing non-judgmental attitudes toward the present moment they can accept their anxiety and learn how to separate it from the affiliated emotional content of fear, distress, or discomfort. Various scientific approaches, such as experimental studies, meta-analyses, and neuroimaging studies, have investigated the positive impact that meditation has on emotion regulation. Tang et al. (2015) argue that meditation has several positive effects on emotional processing, including reduced emotional interference by unpleasant stimuli, decreased physiological reactivity after responding to a stressor, facilitation of emotion regulation, reduced frequency and intensity of negative affect, and enhanced positive mood states. They posit that non-judgmental awareness and acceptance increase sensitivity to affective cues and may thus be central factors that promote cognitive control. Moreover, meditation enhances emotion regulation by heightening prefrontal cognitive control mechanisms and downregulating the activity of areas involved in affect processing such as the amygdala (Tang et al., 2015). In an early study, DeBerry (1982) found that daily use of cassette tapes for meditation-relaxation is highly effective in lowering the levels of state anxiety, trait anxiety, and somatic symptoms of depression, achieving a stable level of decreased autonomic reactivity for state anxiety. A later longitudinal

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study conducted by DeBerry et al. (1989) compared meditation therapy with a control group and found that meditation resulted in reduced state anxiety but not trait anxiety, suggesting that “it is easier to reduce anxiety on a short-term basis by producing a pleasant mental state than it is to change a belief system that has been defensively entrenched for years” (Beauchemin et al., 2008; p. 37). In a similar vein, Peterson and Pbert (1992) concluded that a meditationbased stress reduction program resulted in a significant decrease in the symptoms of depression, generalized anxiety disorder, panic disorder, and panic disorder with agoraphobia, an improvement which was maintained even after a three-month follow-up study. Moreover, they found that the severity and frequency of panic attacks decreased significantly and were stable for a long-term period. Anderson et al. (1999) assessed the effects of meditation on occupational stress and concluded that the practice of meditation significantly reduced employees’ perception of stress, burnout, and their symptoms of state and trait anxiety, arguing that through meditation individuals may learn how to respond adaptively to the environment and enhance their skills to resist stress. Similarly, Lemay et al. (2019) found that a 6-week intervention including meditation and yoga was successful in reducing university students’ perceptions of anxiety levels and enhancing mindfulness skills. The scientific interest in the beneficial aspects of meditation has grown even more considerably during the last decades, with a wide body of research supporting the positive impact of meditation on anxiety levels and symptoms (e.g., Diaz, 2018; Menezes & Bizarro, 2015; Sarris et al, 2012; Srivastava et al., 2011). The reduction of stress and anxiety in meditative states while maintaining mental alertness may contribute to the development of both selfreported and measured self-actualization (Coppola & Spector, 2009). Several studies have shown that even short-term meditation may lead to positive health outcomes. According to Malinski and Todaro-Franceschi (2011), even a single session of meditation produces a substantial decrease in heart rate, respiration, and systolic blood pressure, and enhanced perceived balance and relaxation, while trait anxiety may be maintained stable one-month post-intervention. Menezes and Bizarro (2015) concluded that short-term meditation may have a positive impact on various psychological variables (for example attentiveness) and that the early exhibition of these benefits may be particularly important to enhance the individual’s motivation to keep engaging in meditative practices. Their study investigated the effect of 20-minute meditation for five consecutive days and found that self-report trait anxiety

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and negative affect were reduced while attention-related capabilities were strengthened. The proliferation of scientific and clinical research on meditation has been an important factor contributing to the increased popularity of meditative practices among the general population in the Western world, with countless retreat and meditation centers, institutes, and programs. In particular, transcendental meditation and mindful meditation are among the most spread and well-known practices that have gained a considerable amount of attention from both practitioners and researchers, being a cost-effective, highly accessible treatment with low stigma for several mental symptoms such as anxiety. The beneficial effects of transcendental meditation have been supported by multiple empirical studies since the 1970s. Dillbeck (1977) investigated the effect of twice-daily transcendental meditation over two weeks and found that after the intervention the participants’ anxiety levels were significantly reduced. Similar results were also found by Zuroff and Schwartz (1978), who conducted a nine-week study on participants who had no prior experience with meditation and found a substantial decrease in trait anxiety. Krisanaprakornkit et al. (2006) conducted a systematic review to assess the effectiveness of meditation therapy in treating anxiety disorders and found that transcendental meditation is associated with reduced anxiety symptoms comparable to results found in electromyography-biofeedback and relaxation therapy. A more recent study from Burns et al. (2011) concluded that transcendental meditation is an effortless and simple method that leads to a significant decrease in selfreported trait anxiety, stress, depression, and perfectionistic thoughts. The positive impact of transcendental meditation has been further validated by several meta-analyses that support its benefits in the treatment of anxiety disorders and improving well-being (e.g., Eppley et al., 1989; Montero-Marin et al., 2019). Nevertheless, mindful meditation remains the most well-researched and well-known form of meditation. The concept of mindfulness was mainly introduced and made popular by Jon Kabat-Zinn, one of the crucial figures who took mindfulness from the Buddhist framework and put it in a scientific context, spreading it worldwide and making it an empirically supported practice. In 1979 Kabat-Zinn founded the Stress Reduction Clinic at the University of Massachusetts and adapted Buddhist principles of mindfulness to develop the Stress Reduction and Relaxation Program, which was subsequently restructured into an eight-week course and renamed Mindfulness-Based Stress Reduction program. (Tacon et al., 2003). The

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MBSR program is a psycho-educational program that includes metacognition, quiet sitting meditation, body scanning, and moving meditation (Bergen-Cico & Cheon, 2014). It consists of weekly 2.5-hour-long classes over the span of eight weeks, where participants are taught different types of meditation practices that can be applied in class or at home during daily activities like running, driving, eating, and communicating (Irving et al., 2009). The program is structured in a group format and is based on several principles, among which: a non-goal orientation; expectation of relief; active engagement in the process; time commitment and home practice; responsibility for outcomes; variation of meditation practices; and a long-term perspective (participants are encouraged to continue the meditative practices even after the course is completed) (Irving et al., 2009). Kabat-Zinn (1994) proposed that mindfulness results from the synchronous cultivation of three principles: (1) Clearly defined intention for the practice (e.g., for self-regulation, self-exploration, or self-liberation); (2) Attention to the present moment with a non-judgmental attitude, hence lacking subjective interpretation; (3) Attending the present moment with a sense of acceptance, compassion, openness, patience, and non-evaluation (Carmody et al., 2009). Based on this definition, Shapiro et al. (2006) developed a model aiming to explain the mechanisms through which mindfulness may influence wellbeing. They suggest that the cultivation of mindfulness as proposed by KabatZinn triggers a fundamental shift in one’s perspective, or “reperceiving”, a meta-mechanism of change related to one’s perceived experience that promotes self-regulation, objectivity, clarification, and cognitive and emotional flexibility (Carmody et al., 2009). A wide range of scientific studies have supported the effectiveness of mindfulness (including the MBSR program) on both clinical and non-clinical samples for reducing anxiety, stress, depression, chronic pain, fibromyalgia, mood disturbances, self-criticism, self-judgment, improving self-esteem, emotional processing and sense of control (e.g., Bergen-Cico & Cheon, 2014; Hoge et al., 2013; Ratanasiripong et al., 2015; Tacon et al., 2003). Tacon et al. (2003) assessed the efficacy of the MBSR program on anxiety in women with heart disease and concluded that mindfulness significantly decreased the levels of anxiety and the behavioral tendency to control or suppress negative

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emotions. Bergen-Cico and Cheon (2014) also concluded that the cultivation of mindfulness through the practice of meditation results in reduced trait anxiety and enhanced self-compassion. According to Toneatto and Nguyen (2007), continuous symptoms of anxiety and depression may represent deficiencies in coping mechanisms that MBSR may be ameliorated, therefore the regular practice of mindfulness may result in the improvement of anxiety symptoms by decreasing the individual’s tendency to react to negative mental and somatic states with maladaptive behavior. They further suggest that the improvement of anxiety and depression symptoms may represent an important pathway to enhancing mental and physical health in healthy individuals as well as individuals affected by chronic conditions (e.g., cancer and fibromyalgia). Mindfulness-based interventions have also proven to be successful when delivered online through the Internet, as a study from Boettcher et al. (2014) found that internet-based mindful interventions involving exercises with audio files resulted in a significant reduction of anxiety, depression, and insomnia symptoms and greater quality of life. Meditation and mindfulness-based interventions are essentially similar to CBT regarding the examination of somatic symptoms, however, CBT encourages the individual to recognize the relationship between their cognition and physiological arousal, whereas mindfulness encourages the individual to attend to and accept the physiological sensations without relating them to any cognitions (Schreiner & Malcolm, 2008). A ten-week-long study on mindfulness meditation conducted by Schreiner and Malcolm (2008) concluded that the mindfulness course significantly decreased the severity levels of affective states, reduced muscle tension, and overall reduction of the somatic symptoms of anxiety. Beauchemin et al. (2008) investigated the effect of a 5-week mindfulness intervention on adolescents diagnosed with a learning disorder and found that participants who completed the program showed reduced state and trait anxiety and selffocused attention, improved social skills, and enhanced academic performance. Evans et al. (2008) developed a mindfulness-based cognitive therapy for individuals affected by a generalized anxiety disorder and concluded that after an 8-week group mindfulness course the participants exhibited a significant reduction in their anxiety levels, worry, and depressive symptoms, and a general increase in mindful awareness of everyday life. According to Goldin and Gross (2010), mindfulness enhances emotion regulation processes through direct enhancement of attention regulation, which happens during breath-focused mindful attention. Furthermore, fMRI

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studies show that through amygdala inhibition mindfulness may reduce negative emotions, avoidance, and reactivity, employing both emotion and attention regulation to control anxiety disorders (Goldin et al., 2013). Another fMRI study conducted by Zeidan et al. (2014) compared the effects of focusing attention on breathing (pre-meditation) and mindfulness meditation on anxiety symptoms. They found that while attending to the breath did not improve anxiety, mindfulness meditation had a positive effect in reducing state anxiety, which was related to activation of the anterior cingulate cortex (emotion assessment and autonomic regulation), ventromedial prefrontal cortex (emotional processing and self-perception) and anterior insula (interoceptive awareness). Moreover, they found that individuals who reported greater levels of anxiety showed greater activation of default-related activity in the posterior cingulate cortex, which is related to the control of self-directed thoughts, thus suggesting that mindfulness may regulate anxiety via mechanisms involved in the regulation of self-focused cognitions. Mindfulness may also be substantially beneficial in reducing alexithymia, or the difficulty of identifying and expressing emotions related to operative thought processes, by enhancing one’s emotional intelligence and emotional functioning (Braboszcz et al., 2010). According to Edenfield and Saeed (2012), the slow and attention-focused breathing techniques involved in mindful meditation may play a significant role in balancing sympathetic and parasympathetic responses, resulting in decreased heart, metabolic, and breathing rates and alleviating somatic symptoms of distress. They suggest that practicing mindfulness enables the individual to activate the body’s relaxation response intentionally and continuously, which may improve stress management abilities, awareness, and attentive processes, and decrease symptoms of anger, anxiety, and depression. Results from their study show that individuals with higher trait mindfulness not only report lower levels of anxiety, depression, and stress, but also exhibit enhanced sleep quality, emotional awareness, adaptivity, and coping skills, as well as greater perceived quality of life and overall sense of psychological well-being. The psychological benefits of practicing mindfulness are further supported by multiple meta-analyses that investigated the efficacy of mindfulness on anxiety disorders (e.g., Breedvelt et al., 2019; Chen et al., 2012; Hofmann et al., 2010; Montero-Marin et al., 2019). A meta-analysis conducted by Hofmann et al. (2010) in particular, found that mindfulnessbased therapy has the potential to ameliorate symptoms of depression and anxiety even when these symptoms are related to other disorders or medical problems and across a wide range of severity. They suggest that this effect

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may be attributed to the fact that mindfulness encouraged individuals to experience and accept their physical symptoms free of judgment, which may in turn make their consequences less disturbing when they occur. Besides being a highly efficacious treatment method for anxiety disorders as defined in the DSM-5, mindfulness and meditative practices have also been found to produce substantial improvements in the symptoms of OCD and PTSD. Empirical evidence on the potential benefits of transcendental meditation on OCD is relatively limited, while interest continues to grow. Delfiner (2016) assessed the effects of transcendental meditation on patients’ OCD symptoms and found that patients post-intervention reported improved symptoms without any negative side effects, and an overall optimistic and progressive evaluation of the treatment. He posits that the frequency of practicing transcendental meditation is crucial to the perceived benefit from the patient. Meanwhile, empirical research on mindfulness is much more extensive, with several studies supporting the benefits of mindfulness for the treatment of OCD. In a study conducted by Patel and Simpson (2010) patients affected by OCD were taught mindfulness meditation practices such as mindful breathing, daily living, and body-scan, throughout eight group meetings. Their results showed that the intervention had a significantly positive effect on OCD symptoms, mindfulness, thought-action fusion, and the ability to let go, suggesting that mindfulness may comprise alternative therapy for OCD. Individuals affected by OCD are characterized by assigning greater importance to their thoughts, which results in the negative evaluation of internal negative events and leads to engaging in compulsive behaviors as a solution. According to Key et al. (2017) mindfulness reduces the reactivity to internal experiences and may be an alternative response for OCD patients to regulate their intrusive thoughts and reduce their habitual responses such as suppression or compulsive behaviors. They argue that mindfulness techniques may improve OCD symptoms by affecting crucial processes that underlie the creation and maintenance of obsessions and compulsions, such as negative thought appraisals and avoidance strategies, and that the sense of acceptance enhanced by mindfulness may decrease obsession-related stress. A study on the effect of mindfulness-based cognitive therapy on OCD symptoms conducted by Key et al. (2017) found that the intervention resulted in a substantial reduction of OCD symptoms, levels of self-reported depression and anxiety, as well as an overall increase in mindfulness skills (particularly non-judgmental attitudes and non-reactivity) and self-compassion.

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The evidence for meditative practices having beneficial outcomes on the treatment of PTSD is much more extensive, as different types of meditation have been assessed about their effect on PTSD symptoms. A study conducted by Barnes et al. (2013) found that transcendental meditation led to the reduction of PTSD symptoms (e.g., traumatic brain injury, depression, and substance of abuse) in active-duty soldiers, with a notable decrease in distress and improvement in social behavior. They propose that since PTSD is characterized by chronic symptoms of intensified arousal and increased sympathetic response to stimuli, transcendental meditation may comprise a counter-reacting response through deep relaxation. They further argue that transcendental meditation has acute as well as long-term beneficial effects in reducing the levels of baseline cortisol, which has elevated levels in PTSD patients. In a similar vein, Seppala et al. (2014) also found that breathingbased meditation has a significantly positive effect on hyperarousal symptoms in PTSD patients and patients with generalized anxiety disorder. They suggest that breathing exercises activate both the sympathetic and parasympathetic systems, resulting in a state of both alertness and calm which activates a relaxation response from the body. Loving-kindness and compassion meditation are other types of meditative practices that have been proven to have a positive effect on PTSD symptoms. According to Kearney et al. (2013), practicing loving-kindness meditation results in increased self-compassion and mindfulness skills, and reduced PTSD and depression symptoms, even after three months post-intervention. Their study results show that the regular use of personally meaningful affirmations setting the intention of happiness, peace, safety, and health, may comprise an effective alternative for PTSD patients. A similar study conducted recently by Lang et al. (2020) also found that compassion meditation was rated as highly credible and satisfactory by veterans with PTSD, as their intervention resulted in improved PTSD and depression symptoms in veterans affected by PTSD, as well as an enhanced sense of calm. In addition, several empirical studies and meta-analyses support the positive impact of mindfulness meditation on PTSD symptoms (e.g., Gallegos et al., 2017; Hilton et al., 2017). The status of mindfulness as a potential PTSD treatment alternative and the underlying mechanisms through which mindfulness affects symptoms of PTSD were assessed by Lang et al. (2012). They argue that mindfulness encompasses three main mechanisms potentially involved in the treatment of PTSD. The first is increased attentional control, which increases control over intrusive thoughts and enhances coping and problem-solving skills; the second

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is focus on the present moment which reduces the level of worry and rumination; and the third is the encouragement of non-judgmental attitudes which reduces cognitive distortions and avoidance (Lang et al., 2012). Moreover, they propose the potential mechanisms that underlie the use of mantras and compassion skills and their effects. The use of mantras results in reduced physiological arousal, which redirects attention and intentional distractions and improves emotional self-regulation; while enhanced compassion results in increased positive emotion and social connectedness, which may have a significant role in reducing stress-related reactivity and increasing coping and resilience skills (Lang et al., 2012). Kimbrough et al. (2010) investigated the effect of MBSR on PTSD symptoms of distressed survivors of childhood sexual abuse and found that the eight-week intervention resulted in significantly reduced avoidance and numbing symptoms and overall improvement of PTSD symptoms. The practice of mindfulness facilitates skills acquisition and goal-setting abilities and it can easily be incorporated into daily life activities (Fiore et al., 2014). Overall, the vast amount of empirical and clinical data strongly indicates that meditative practices, and particularly mindfulness, may comprise a valuable alternative intervention for the treatment of anxiety disorders, OCD, and PTSD, as they are generally cost-effective, nonstigmatized, and easy to learn and implement into one’s daily routine. Although research directed to the efficacy of meditation as a sole and primary treatment for anxiety disorders is relatively limited, the existing literature shows that meditation and mindfulness have a great potential in uncovering and enhancing human capabilities and may be further integrated with other therapeutic approaches to achieve greater therapeutic results.

The Impact of Near-Death Experiences on Life Aspects The nature of NDEs has been the subject of empirical and clinical research, particularly during the last decades, and it has substantially helped to shed some light on the neural correlates that characterize these experiences. However, because of their ambiguous nature, the scientific literature on NDEs lacks a stable analytical framework. NDEs are unpredictable and impossible to induce artificially in a scientific context, therefore the scientific investigation of their effect on anxiety disorders or other neuro-psychological constructs is exceptionally difficult to measure empirically. Nonetheless, there is a significant body of evidence that documents how NDEs, regardless of their

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cause, can substantially and permanently impact the attitudes, beliefs, and overall well-being of individuals who experience them. The majority of individuals who have experienced NDEs have reported them as overall pleasant and peaceful experiences and accompanied by positive personality changes. Since the early 90s, several researchers have reported that individuals who experienced NDEs perceived it as a turning point that led to positive life changes, such as feelings of inner peace and fulfillment, self-understanding, open attitudes, less concern about material success, enhanced altruism, awareness and appreciation for life, and reduced death anxiety (Greyson, 1997; Jansen, 1990; Sutherland, 1990). These changes are similar to those documented following a spiritual awakening, selftransformation, and self-transcendence, and are not related to previous religious affiliations, nor do they have the distinctive qualities of traumatic experiences (Khanna & Greyson, 2014). The significant decrease in death anxiety following an NDE experience has been particularly documented by scholars (e.g., Agrillo, 2011; Chung et al., 2000; Tassell-Matamua & Lindsay, 2016). According to Chung et al. (2000), 41% of survivors of life-threatening incidents or illnesses showed a significant reduction in fear of death, which was perceived as a crucial aspect of their experience and associated with a sense of peace of tranquility. Furthermore, they argue that individuals who experienced an NDE during a life-threatening cardiac arrest reported a notable decrease in death anxiety immediately after the event, in comparison to those who experienced a cardiac arrest without an NDE. Six-month follow-up studies have concluded that NDE experiencers continued to score low on both the Death Anxiety Scale and the Death Concern Scale, indicating that this effect is long-term and likely to be permanent (Chung et al., 2000). This loss of death anxiety is often reported to co-occur with enhanced belief in life after death; feeling a heightened connection with God, religion, or spirituality; a new sense of purpose; enhanced self-esteem; greater self-actualization; increased ability to express feelings; increased focus on the present; search for knowledge; and greater appreciation for nature (Khanna & Greyson, 2014; Tassell-Matamua & Lindsay, 2016). According to Khanna and Greyson (2014), the more intense the NDE experience is, the more powerful and meaningful its effect is. They argue that individuals who experienced profound NDEs reported a stronger level of connection with their inner self (or “spiritual self”) and with their surrounding environment, which may explain why NDE experiencers often show higher levels of subjective well-being than those who were close to death without

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NDEs. According to Bianco et al. (2019), studies have shown that death anxiety is substantially reduced in 80% to 100% of individuals who experienced an NDE, meanwhile, only 2% to 42% of individuals who were close to death without experiencing NDEs showed reduced death anxiety. The causes and underlying mechanisms in which NDEs affect individuals’ personalities and lives are yet to be investigated, however, several possible explanations have been discussed in the scientific literature. Jensen (1990) provides a psychodynamic explanation for the positive life changes, arguing that during an NDE the individual experiences “ego death”, or loss of self-identity, which is followed by “re-birth”, or what individuals experience as a positive turning point in their lives. Tassell-Matamua and Lindsay (2016) propose that NDEs incite feelings of heightened awareness and focus on the present moment, and this ability of the individual to be mindful may account for the reduced death anxiety. Bianco et al. (2019) suggest that the decrease in death anxiety is attributed to an enhanced belief in the afterlife and altered representation of death as a radical transformation or transition to a different state of existence, rather than absolute annihilation. A neurophysiological study conducted by Beauregard et al. (2009) found that NDEs are associated with neural changes in brain regions involved in positive emotions, mental imagery, attention, and spiritual experiences, which are similar to brain changes found during the practice of some forms of spiritual meditation. Overall, empirical data and survivors’ experiences indicate that NDEs have a positive, life-changing impact and can significantly improve subjective well-being. Further research needs to be conducted to uncover more of NDEs’ therapeutic aspects, as their replication may be significantly useful in psychiatry.

Chapter 4

Empirical Study The existing body of literature provides substantial evidence about the beneficial effects of mindfulness on reducing anxiety symptoms and improving overall well-being. Mindfulness comprises an alternative psychotherapeutic approach that is highly accessible, affordable, and easy to master, and may be an efficacious addition to other treatment modalities. Therefore, these empirical data aim to add to the existing body of literature by investigating the impact of mindfulness relaxation techniques on physiological and somatic symptoms of anxiety. The effect on self-esteem will also be measured since research shows that the non-judgmental and acceptance-based principles of mindfulness may enhance self-esteem. The chosen mindfulness relaxation techniques are guided meditation, guided meditation followed by deep breathing, and music relaxation, which will be the control condition. Anxiety will be assessed in terms of cognitive and somatic symptoms of anxiety. Somatic symptoms of anxiety include increased physiological arousal signs which manifest in the form of hyperventilation, sweating, muscle aches, dry mouth, and gastrointestinal distress. Cognitive symptoms of anxiety, on the other hand, are related to thought processes and are reflected in intrusive thoughts, fears, phobias, obsessions, difficulty in focusing attention, impaired emotional processing, etc. According to scientific evidence anxiety is characterized by increased activity of the parasympathetic nervous system, which is related to increased blood pressure and heart rate (Ariga, 2019). Therefore, to gain deeper insight into the levels of anxiety indicators, systolic and diastolic blood pressure and heart rate will also be measured pre-and post-intervention. A wide range of studies, as elaborated on in previous chapters, have provided evidence for meditation being effective in reducing blood pressure and heart rate (e.g., Bai et al., 2015; Barnes et al., 2004; Shi et al., 2017; Sudsuang et al., 1991) as well as anxiety symptoms and self-esteem (e.g., Chen et al., 2012; Koole et al., 2009; Zeidan et al., 2014). Thus, it is expected that guided meditation will have a positive impact on anxiety symptoms and their physiological correlates. Deep breathing is another important aspect of mindfulness that may significantly reduce anxiety symptoms. Edenfield and

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Saeed (2012) suggest that the slow and attention-focused breathing techniques involved in mindful meditation may play a significant role in balancing sympathetic and parasympathetic responses, resulting in decreased heart, metabolic, and breathing rates and alleviating somatic symptoms of distress. Perciavalle et al. (2017) argue that deep breathing techniques can not only result in significant enhancement of mood and self-reported stress levels but also reduced heart rate and cortisol levels. This may be because respiratory activity and the autonomic nervous system have been associated with the experience of emotions, and deep breathing may significantly reduce negative affect (Jerath et al., 2015). The addition of deep breathing techniques to guided meditation is expected to emphasize its beneficial effects and result in a larger decrease in anxiety symptoms, blood levels, and heart rate. Music relaxation is another relaxation technique that has been proven to reduce anxiety symptoms; however, the scientific literature investigating music relaxation is relatively limited. Since ancient times, music has been considered a powerful tool to improve health and well-being. According to Lee et al. (2005), music therapy provides a substantial contribution to reducing psychophysiological responses to anxiety via the activation of body rhythms. Moreover, music relaxation interventions have been found to produce behavioral, emotional, and physiological changes, and improve anxiety management skills (Robb et al., 1995). Considering that it is not a direct mindfulness technique, but still shows beneficial effects on anxiety, music relaxation will be used as a control condition in this book, to compare with guided meditation, and guided meditation with deep breathing. Based on the evidence provided by existing empirical data, and the potential of mindfulness to be an alternative psychotherapeutic approach for treating anxiety disorders, this book aims to assess and compare the effects of guided meditation, guided meditation followed by deep breathing techniques, and music relaxation on anxiety levels, blood pressure, heart rate, and self-esteem.

Methodology Participants In the first phase, the study was promoted among university students, where the study’s aims, relevance, methods, location, inclusion criteria, and selection

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procedure were explained. One hundred and three students from university applied to participate in the study. Six individuals volunteered to assist with the study, four of which assisted in the physiological measurements (e.g., blood pressure and heart rate), and two of which assisted in organizing the diet program. To be included in the study the participants had to fulfill the following requirements: (1) (2) (3) (4) (5) (6)

They had to be between twenty and thirty years old; They were never diagnosed with any type of chronic illness; They were not taking any medications; They were never diagnosed with a psychological disorder; They did not consume alcohol or any recreational substances; They could not smoke during the study, even if they were smokers.

After applying the exclusion criteria, only thirty-eight participants were recruited for the study, out of which seven (18.4%) were men. The participants were randomly assigned to three groups. The first experimental group consisted of thirteen participants (two men and eleven women) who practiced guided meditation. The second experimental group consisted of thirteen participants (three men and ten women) who practiced guided meditation and deep breathing. The control group consisted of twelve participants (two men and ten women) who practiced music relaxation. During the intervention five participants were excluded from the sample for not complying with the study requirements (three female and two male participants), two of which were from the first experimental group; two from the second experimental group; and one from the control group). Thus, only thirty-three participants, out of which 15.2% were male, were included in the data analysis.

Materials/Measures To assess the effect of meditative practices on participants’ physiological aspects, their heart rate and blood pressure were measured before and after the intervention. Participants’ heart rate pulse was measured using a heart rate monitor, while their systolic and diastolic blood levels were measured using a blood pressure monitor. In addition, the participants completed a personality assessment before the intervention, as well as an anxiety assessment and selfesteem assessment before and after the intervention. Anxiety levels were measured using the State-Trait Inventory for Cognitive and Somatic Anxiety

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(STICSA), a validated survey instrument designed to assess cognitive and somatic symptoms of anxiety (Gros et al., 2007).

Research Design This book employed a randomized experimental design with a 3x2 betweensubjects design. The independent variables were the practice of guided meditation, the practice of guided meditation accompanied by deep breathing, and music relaxation. The dependent variables were the participants’ heart rate, levels of blood pressure, self-esteem levels, and anxiety levels. This book aimed to assess and compare the effects of guided meditation, music relaxation, and guided meditation followed by deep breathing techniques on anxiety levels and self-esteem. To assess the research question, a sample of thirty-eight participants underwent a four-day-long mindfulness intervention, where they were randomly assigned to two experimental groups and a control group. The experimental groups practiced guided meditation and guided meditation followed by deep breathing respectively, each at scheduled times during the four days. The control group practiced music relaxation for the same duration and at the same times as the experimental groups. All participants had their blood pressure, heart rate, cognitive and somatic symptoms of anxiety, and self-esteem levels measured before and after the intervention, to investigate the effect of the intervention on these variables. Our hypotheses were as follows: (1) Guided meditation and deep breathing results in a larger decrease in blood pressure and heart rate than guided meditation alone and music relaxation. (2) Guided meditation and deep breathing results in a larger decrease in anxiety levels and increase in self-esteem levels than guided meditation alone and music relaxation. (3) All relaxation techniques (guided meditation, guided meditation with deep breathing, and music relaxation) result in lowered levels of blood pressure, heart rate, anxiety, and increased levels of selfesteem. (4) Participants’ personality traits mediate the relationship between the used relaxation techniques and heart rate, blood pressure, anxiety, and self-esteem levels.

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Procedures In the first phase of the study university students were informed about the study and its aims, scientific relevance, inclusion criteria, and methods. After collecting all the applications and excluding participants that did not fulfill the inclusion criteria, the chosen participants (N = 38) read and signed an informed consent form and received instructions on the details of the study. The participants were randomly assigned to two experimental groups; thirteen participants in the guided meditation group; thirteen participants in the guided meditation and deep breathing group; and a control group (music relaxation) of twelve participants. In the second phase of the study, the participants met each other before the intervention on the university campus at a scheduled time. Through organized means of transportation, the participants were brought to a private camp on Lezhë Island (Ishull-Lezhë). Upon their arrival at the camp, the participants were accompanied to their rooms and were given the schedule they had to follow every day. The participants were assigned to random rooms located at a certain distance from each other, to avoid bias (e.g., social desirability). On the first day of the intervention, participants were gathered in a conference hall at noon and were informed about their tasks and roles during the next four days. Each participant took a personality assessment, an anxiety assessment (STICSA), and a self-esteem assessment. Subsequently, the participant’s heart rate and blood pressure were measured and noted. The two experimental groups were brought to a conference room, where they practiced guided meditation as instructed by a Buddhist Theravada monk. The first group sat in the front of the conference room, while the second group sat in the back. Both groups practiced guided meditation for thirty minutes, and the first group was instructed to leave and proceed with measurements. After a two-minute relaxation session, the first group’s blood pressure and heart rate were measured. Meanwhile, the second group, still in the conference room, practiced deep breathing for fifteen minutes. During the first three minutes, the participants practiced 1-4 breathing (counting from one to four while inhaling and exhaling); for the next three minutes, they practiced 1-5 breathing (counting from one to five while inhaling and exhaling, without holding one’s breath). The participants were advised to slightly raise their arms while inhaling and lower them while exhaling. During the remaining eight minutes the participants were instructed to breathe slowly in a regular way. After completing their deep breathing practice, the participants underwent a two-

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minute relaxation session, and they had their blood pressure and heart rate measured. The control group, on the other hand, was exposed to music relaxation for thirty minutes while sitting on comfortable chairs outside of the camp’s field. Their physiological measurements were also taken after the procedure was completed. These procedures were repeated regularly each of the four days of the intervention. On the first day of the intervention, all the participants completed their practices according to the assigned group two times during the day (at 2:00 PM and 7:00 PM); on the second and third days they completed the practices four times a day (at 6:00 AM, 9:00 AM; 2:00 PM; and 7:00 PM); and on the fourth day, they completed the tasks twice a day (at 6:00 AM and 9:00 AM). The two experimental groups heard the same script during guided meditation at all times of the day except 6:00 AM, when the last ten minutes of the script were changed into loving-kindness meditation to enhance self-esteem. The control group listened to the same music at the same volume at all times every day and had no interaction with the other groups. During the intervention, five participants dropped out, two from each experimental group and one from the control group. Two of the participants dropped out for personal emergencies, while three participants were excluded from the data for not complying with the study requirements but were still allowed to participate in the meditation sessions. After the intervention, the remaining participants (N = 33) completed the anxiety and self-esteem assessments. Follow-up assessments were also completed one-month post-intervention.

Data Analysis To assess mean differences for gender in levels of somatic anxiety, cognitive anxiety, self-esteem, systolic blood level, diastolic blood level, and heart pulse rate before and after the intervention, independent samples t-test were conducted at a p < .05 significance level. To evaluate the impact of the interventions on the levels of somatic anxiety, cognitive anxiety, self-esteem, systolic blood level, diastolic blood level, and heart pulse rate for each intervention group, and the overall impact of the intervention on all groups, paired samples t-tests were conducted at a p < .05 significance level to determine whether there were any meaningful differences. To gain a deeper comprehension of any pre-intervention differences among groups, ANOVA tests were also conducted.

Chapter 5

Results Independent Samples T-Tests Independent-samples t-tests were conducted to assess gender differences preand post-intervention in levels of somatic anxiety, cognitive anxiety, selfesteem, systolic blood level, diastolic blood level and heart pulse rate (Table 1). Table 1. Results of the independent samples t-test for gender differences pre- and post-intervention Pre-Intervention F M Variable M SD M SD Somatic 18.1 4 14.57 3.5 anxiety Systolic 115.72 7.18 127.35 8.69 blood level Diastolic 67.87 4.73 72.91 6.02 blood level Post-Intervention Self-esteem 15.92 1.87 14 2.82 Cognitive 16.84 4.59 13.42 2.22 anxiety Systolic 108.24 8.01 119.65 10.32 blood level M = Mean. SD = Standard deviation. m = Male. f = Female

t

p

2.131

.0041

3.640

.01

2.362

.025

2.157 2.773

.039 .011

3.147

.04

The results of the independent samples t-test showed that there were significant differences in the means of somatic anxiety, systolic blood levels, and diastolic blood levels for males and females before the intervention. For instance, males exhibited lower somatic anxiety (p = .041), higher systolic blood levels (p = .01) and higher diastolic blood levels (p = .025) than females. No gender differences were found for levels of cognitive anxiety, self-esteem, and heart pulse rate before the intervention. In addition, significant gender differences were also found for the means of self-esteem, cognitive anxiety,

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and systolic blood levels during post-intervention assessments. Males exhibited overall lower levels of self-esteem (p = .039), lower cognitive anxiety (p = .011), and higher diastolic blood pressure (p = .04) than females. No gender differences were found for levels of somatic anxiety, systolic blood pressure, and heart rate pulse after the intervention. Follow-up assessments one month after the intervention found no significant gender differences.

Paired-Samples T-Tests A paired-samples t-test was conducted to evaluate the impact of the interventions on students’ scores in the levels of somatic anxiety, cognitive anxiety, self-esteem, systolic blood level, diastolic blood level and heart pulse rate for different groups of interventions (Table 2). Table 2. Results of the paired samples t-test for mean differences between the three conditions (guided meditation, guided meditation and deep breathing, and control group) Variable

Pre-intervention Post-intervention t M SD M SD

Guided Meditation Systolic blood level 123.24 9.88 118.12 Diastolic blood level 71.65 6.55 76.63 Guided Meditation + Deep Breathing Systolic blood level 118.19 6.88 105.45 Diastolic blood level 68.68 4.16 65.92 Heart pulse rate 75.64 10.43 71.42 Cognitive anxiety 19.54 4.00 15.45 Control Group (Music Relaxation) Systolic blood level 113.14 6.91 108.42 Heart rate pulse 86.03 8.25 76.77 Somatic anxiety 16.90 5.12 13.09 M = Mean. SD = Standard deviation. η2 = Partial Lower limit. UL = Upper limit.

9.79 6.25 8.07 4.90 7.10 3.47

4.511 -4.896 13.84 4.005 2.93 2.507

6.21 3.617 6.37 9.451 1.81 2.80 eta square value.

p

η2

η2 95% CI [LL, UL]

.000 .67 [2.59, 7.64] .000 .70 [-7.25, -2.71] .000 .002 .015 .031

.95 .61 .46 .32

[10.68, 14.78] [1.22, 4.28] [1.01, 7.43] [.45, 7.72]

.000 .56 [1.81, 7.62] .000 .89 [7.07, 11.43] .019 .43 [.78, 6.84] CI = Confidence interval. LL =

The results of the paired samples t-test for the first experimental group found a significant decrease in systolic blood levels and an increase in diastolic blood levels from pre-intervention time to post-intervention time. The mean decrease in systolic blood level was 5.11 (p < .000) with a 95% CI [2.59, 7.64]. The partial η2 (.67) indicated a large effect size. The mean increase in diastolic

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blood level was -4.98 (p < .000) with a 95% CI [-7.25, -2.71]. The partial η2 (.70) indicated a large effect size. No significant mean differences were found for heart rate pulse, cognitive anxiety, somatic anxiety, and self-esteem. Follow-up assessment one month after the intervention found a significant decrease in self-esteem levels. The mean decrease in self-esteem level was 1.54 (p < .043) with a 95% CI [0.062, 3.028]. The partial η2 (.35) indicated a large effect size.

Guided Meditation and Deep Breathing Group The paired samples t-test for the second experimental group found significant decreases for systolic blood level, diastolic blood level, heart pulse rate, and cognitive anxiety from pre-intervention time to post-intervention time. The mean decrease in systolic blood level was 12.73 (p < .000) with a 95% CI [10.68, 14.78]. The partial η2 (.95) indicated a large effect size. The mean decrease in diastolic blood level was 2.75 (p < .002) with a 95% CI [1.22, 4.28]. The partial η2 (.61) indicated a large effect size. The mean decrease in heart pulse rate was 4.22 (p < .015) with a 95% CI [1.01, 7.43]. The partial η2 (.46) indicated a large effect size. The mean decrease in cognitive anxiety scores was 4.09 (p < .031) with a 95% CI [0.45, 7.72]. The partial η2 (.32) indicated a large effect size. No significant differences were found on the follow-up assessments.

Music Relaxation (Control Group) The paired samples t-test for the control group found significant decreases in systolic blood levels, heart rate-pulse, and somatic anxiety from preintervention time to post-intervention time. The mean decrease in systolic blood level was 4.72 (p < .000) with a 95% CI [1.81, 7.62]. The partial η2 (.56) indicated a large effect size. The mean decrease in heart pulse rate was 9.25 (p < .000) with a 95% CI [7.07, 11.43]. The partial η2 (.89) indicated a large effect size. The mean decrease in somatic anxiety scores was 3.81 (p < .019) with a 95% CI [.78, 6.84]. The partial η2 (.43) indicated a large effect size. Overall, guided meditation and deep breathing led to a larger decrease in blood pressure (systolic and diastolic) than guided meditation alone and music relaxation. Moreover, guided meditation and deep breathing led to a larger decrease in heart rate than guided meditation only, but music relaxation

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showed a larger heart rate decrease. Thus, the first hypothesis stating that guided meditation and deep breathing would result in larger decrease in blood pressure and heart rate than guided meditation alone and music relaxation, is partially supported by the data. Furthermore, guided meditation and deep breathing resulted in a significant decrease in cognitive anxiety, but no changes in somatic anxiety and self-esteem levels; music relaxation resulted only in decreased somatic anxiety, while guided meditation only resulted in no changes in anxiety or self-esteem levels. Thus, the second hypothesis stating that guided meditation and deep breathing would result in a larger decrease in anxiety levels and increase in self-esteem levels than guided meditation alone and music relaxation is rejected. Moreover, a paired-samples t-test was conducted to evaluate the overall impact of the interventions on students’ scores of somatic anxiety, cognitive anxiety, self-esteem, systolic blood level, diastolic blood level and heart pulse rate (Table 3). Table 3. Results of paired samples t-test for overall mean differences pre- and post-intervention Variable

Pre-intervention M SD

Somatic anxiety

17.42

4.20

14.39

3.78

3.36

Cognitive anxiety

19.54

4.56

16.12

4.40

3.803

Systolic blood level 118.19

8.82

110.67

9.62

8.286

Heart rate pulse

9.77

75.15

7.45

6.305

80.51

Post-intervention M SD

t

M = Mean. SD = Standard deviation. η2 = Partial eta square value. Lower limit. UL = Upper limit.

η2 95% CI [LL, UL] .002 .26 [1.19, 4.86] .001 .31 [1.59, 5.25] .000 .68 [5.67, 9.37] .000 .55 [3.62, 7.09] CI = Confidence interval. LL = p

η2

The results of the paired samples t-test for overall mean differences among all groups showed that there was a significant decrease in the means of somatic anxiety, cognitive anxiety, systolic blood levels, and heart rate pulse after the intervention. The mean decrease in somatic anxiety scores was 3.03 (p < .002) with a 95% CI [1.19, 4.86]. The partial eta η2 (.26) indicated a large effect size. The mean decrease in cognitive anxiety scores was 3.42 (p < .001) with a 95% CI [1.59, 5.25]. The partial η2 (.31) indicated a large effect size. The mean decrease in systolic blood level was 7.52 (p < .000) with a 95% CI [5.67, 9.37]. The partial η2 (.68) indicated a large effect size. The mean decrease in heart

Results

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pulse rate was 5.35 (p < .000) with a 95% CI [3.62, 7.09]. The partial η2 (.55) indicated a large effect size. No significant differences were found for levels of self-esteem and diastolic blood pressure. In the follow-up assessments, a statistically significant decrease was found for cognitive anxiety between pre-intervention (M = 19.54, SD =4.56) and post-intervention (M= 17.03, SD = 4.26), t(32) = 2.771, p