University College London Hospitals NHS Trust The Royal London Homoeopathic Hospital AUTOGENIC TRAINING A non-drug approach to anxiety, panic attacks and insomnia A report on the introduction of Autogenic Training into a Primary Care Group Harrow East and Kingsbury PCG (now Harrow PCT) by Dr A. Bowden. M.B., Ch.B, D.C.H, MFHom. Lead Clinician Autogenic Training UCL Hospitals is an NHS Trust incorporating the Eastman Dental Hospital, Elizabeth Garrett Anderson & Obstetric Hospital, The Heart Hospital, Hospital for Tropical Diseases, The Middlesex Hospital, National Hospital for Neurology & Neurosurgery, The Royal London Homoeopathic Hospital and University College Hospital

FOREWORD: by Dr Chaand Nagpaul, Ex-Chair, Harrow East and Kingsbury PCT

It is a pleasure to write the preface to this report of the provision of Autogenic Training (AT) to the population of Harrow East and Kingsbury Primary Care Group.

As with most Primary Care organisations in London the waiting times for psychological treatments and counselling were unacceptably long, with a minimal wait of 6 months. Therefore, there was an un-met need for patients and AT seemed to meet the criteria of ATherapy which could fill this gap.

While not a conventional treatment available within the NHS, AT is a well-established relaxation technique, which has been provided at the Royal London Homoeopathic Hospital for the past fifteen years. It is taught only by qualified health professionals such as doctors, psychologists, psychotherapists, and nurses, and there are several GPs using it in their practice. It has been the subject of significant scientific evaluation (as evident on a web search) therefore there is a limited evidence base of its effectiveness.

AT is taught in a standardised and structured course over 9 weekly sessions on a group basis, this is time limited and cost effective, the cost per patient being far lower than that of current NHS counselling or psychological therapies. It is therefore an attractive service for Primary Care organisations to commission.

The raison d'etre of AT is to empower patients with a learned tool for self-management of their anxiety with the expectation and hope or reducing future reliance on GPs and other healthcare professionals, hence offering a demand management approach. This contrasts with the common mind-set of dependency amongst some patients with regards to counselling, where they see re-referral at each relapse of their mental state. Furthermore, AT offers an alternative to current services for those patients who do not want a "talking therapy" to manage their anxiety which involves divulging and discussing their personal circumstances and who are therefore deterred from attending or being referred for psychological services.

As a PCG we decided to commission AT from the RLHH to be provided on an outreach basis at Edgware Community hospital, this had the advantage of addressing Clinical Governance issues since it was provided by an NHS provider. All GPs in the group were invited to a launch of the service, which provided education about AT and referral criteria.

The service is provided as a 2-year project with evaluation built in, and this report summarises the evaluation to date.

Other GPs and I have been impressed with the promptness of the service, with patients usually only having to wait 2-4 weeks to start a training course. The feedback from the patients has been remarkably positive, as exemplified by the impressive results detailed in this report.

I believe that providing AT on an outreach basis for a geographical population lends itself well as a PCT commissioned service, and that its provision to the population of Harrow East and Kingsbury has been vitally important in filling a woeful gap in the provision of mental health services for patients with anxiety disorders.

INTRODUCTION

Autogenic Training (AT) has been available to patients in the trust suffering from anxiety, panic attacks and insomnia via referral by their GPs to the Royal London Homoeopathic Hospital. This is a report of the results of the first year of the provision (May 2001-May 2002). Seven 8-week courses were completed and took place in the Physiotherapy Department of Edgware Community Hospital. The results have been very positive.

Extracts from the evaluation forms completed by trainees at the end of the course:

"An understanding of what causes my anxiety and a way to tackle it"
"I am now able to achieve a feeling of calm and well-being at will. I feel more confident in situations that used to unnerve me"

"Autogenic Training (which) has dramatically reduced my anxiety to the effect that I have stopped having panic attacks and my confidence has started to return"

"Much better sleep, able to get to sleep a lot quicker and easier and I'm not waking up"

"Middle to end of course drug-free"

"I can sleep without the help of using any medication"

"AT works for my blood pressure"

AUTOGENIC TRAINING - AN OVERVIEW

Autogenic Training (AT) is a relaxation technique, a psycho-physiologically-based form of autonomic self-regulation, and a self-help resource for health. It is a method of inducing the relaxation response which is opposite to the stress response, bringing about a healthy balance between the sympathetic (fight or flight) and the parasympathetic (rest renewal and repair) activities of the body's autonomic nervous system.

It is particularly applicable as a non-drug approach to conditions such as anxiety, panic attacks and insomnia where the root cause is most often chronic over -arousal due to excessive sympathetic activity. AT can also be of great benefit to many other organic and psychosomatic illnesses where stress and tension play a big part.

In AT (Autogenic meaning self-generated) the patient learns a set of structured mental formulae. Whilst practising, external distractions are removed and an attitude of "allowing to happen that which needs to happen" free of striving for results is established. This allows for autonomic homeostasis where changes such as slower pulse rate, lowered BP, slower regular breathing, improved digestion and release of muscle tension occurs. Excessive arousal is expected to return to lower functional levels.

The techniques developed and used in AT have been designed to support and facilitate the natural self-healing mechanisms that already exist. The emphasis is not on trying to control these systems but in helping them to function more effectively.

Patients who regularly practise AT develop a healthy dynamic balance, a 'hardiness', a collection of psychic qualities such as engagement, self-commitment, taking control, seeing problems not as a threat but as a challenge. A more confident and relaxed approach to life and trust in their own natural healing forces.

"Belief that I can overcome all the symptoms I used to suffer with feeling normal and not feeling my life is over"

"I am feeling more calmer than before - feeling more happier that I am dealing with it (his problem - anxiety, panic attacks, palpitations). More confident, less scared"

"Calmer, able to think more realistically about my problems"

ANXIETY, PANIC ATTACKS AND AUTOGENIC TRAINING

Anxiety is part of everyday life, an emotion that is fundamental to survival. The intensity of the feeling lies in a continuum from a normal healthy adaptive response in the service of survival to the most intense fear, terror and fright. In evolutionary terms this makes us avoid potentially dangerous situations where there is the possibility of physical or mental harm or death. For some this basic animal survival response is inappropriately "switched on" leading to disruption of normal healthy responses and a vicious cycle of anxiety, tension, restlessness, discontent and frustration is established causing great suffering and depression.

The spectrum of Anxiety Disorders includes:

Trait anxiety

State anxiety

Generalised anxiety disorder (GAD)

Panic Disorder

Panic attacks foster the development of a situation where there is a dread of an attack "fearing the fear".

Phobic Disorder

Obsessive Compulsive Disorder

Post Traumatic Stress Disorder

Research and audit (1) (2) have shown AT to be an effective treatment for GAD, and Panic attacks, also with phobias where it can be used in association with other therapies such as Cognitive Behaviour Therapy or Neuro-Linguistic Programming. In an audit (3) of 132 patients who had done AT of 68 with stress, tension and anxiety 60 improved, of 4 with panic attacks all 4 improved and of 17 with depression 10 improved.

Successful practitioners of AT gain a sense of control (having felt out of control) enhanced efficiency and improved stress mastery. This can be a stepping stone to understanding issues such as interpretation of bodily sensations, threat appraisal and management of worrisome situations or thoughts. For some, release of held tensions and new insights are a preparation for further individual therapy.

For many trainees with a high level of anxiety AT gives the experience of feeling calm for the first time and discovering that it is possible to find their own state of inner harmony and well being.

"More confident and feeling less anxious and gained an understanding that the mind can have a great influence on the body"

"Control of panic attacks, significant decrease in anxiety (30-40%) regain control of my life, clear thinking, identifying problems that are the cause of my anxiety"

"A determination to go out and about on my own without fear. The course has given me the tools, the resources are within myself"

"I became more relaxed and able to deal with each issue as it came along. I deal with issues much better, I am not so stressed, more laid back especially at work"

"An understanding that I get very stressed about many things and that through AT I am beginning to develop a new approach and confidence to deal with these problems and not to allow these problems to take over my life."

"An understanding of how to reach a deep state of relaxation without the need for any drugs. Learning how I can put up a defensive mechanism when I feel anxious, that I can fight the symptoms."

"Peace of mind"

AUTOGENIC TRAINING AND INSOMNIA

Sleep is essential for the maintenance of physical and mental health. Lack of it, a deficit, is a significant health hazard causing physiological changes which, even if mild, can result in impaired concentration and reduced daytime alertness or if extreme can result in actual psychotic breakdown as the sleep deprived brain responds to relentless arousal by producing stress chemicals which only serve to perpetuate the sleeplessness.

Sleep problems present in a variety of ways; delay in falling asleep, too early awakening, interruptions in sleep with difficulty in falling asleep again or a general perception that sleep has not been refreshing or restoring or has been disturbed by anxious dreams or nightmares. However the problem is manifested, the result is that the individual becomes anxious about their sleep and the stress symptom spiral "my lack of sleep makes me anxious and depressed - my anxiety stops me sleeping" is established. Some individuals have a sense that they have never slept well from childhood; for others sleeplessness is the result of pain from physical illness and it can be both the cause and effect of depression.

It is well known that healthy brain activity during sleep consists of alternating periods of slow wave activity which is necessary for the restoring the repair of bodily processes, and paradoxical or rapid eye movement (REM) activity during which dreaming occurs and the subconscious mind can roam free of the confines of the consciousness. It is also known that hypnotics disturb this pattern of brain activity and although they have uses in the short-term doctors are reluctant to prescribe them in the long term. AT can be considered to be an alternative and is a welcome, entirely natural, holistic option for patients.

Studies (1) (2) have shown that as early as two weeks into training there are changes in the sleep patterns and trainees are encourage at this early stage to use the technique before going to bed or before going to sleep or if awake during the night. In an audit (3) of 132 patients who had completed an AT course out of 13 with insomnia 12 improved. Trainees notice that they feel more refreshed in the morning, in a better mood, dreams are recalled more vividly and the pattern and response to anxious dreams may change. Often there is a sleep deficit and during AT practice trainees may yawn or fall asleep as the body and mind relax and let go of the arousal of anxiety and the need to be in control which is overriding the body's "need for sleep" messages. AT practice not only allows the trainee to experience and understand this but it is at the same time beginning to be the solution to the problem as it offers an accessible tool for experiencing deeper rest for both mind and body as exemplified in better sleep.

"I have noticed that doing AT before I go to sleep helps me to sleep much better"

"Much better sleep - able to get to sleep a lot quicker and easier and I'm not waking up - feel more refreshed in the morning"

"Fantastic sleep induction - I no longer have difficulty falling asleep"

"Helps me switch off before going to bed"

"I am less stressed and sleep better"

RESULTS

ANXIETY SCORES

Anxiety scores were recorded at the beginning and end of the course and at follow-up 3 months later using the Hospital Anxiety and depression scale, which gives a numerical score for the intensity of anxiety.

Average anxiety scores for the first 6 courses:

RESULTS FROM EVALUATION FORMS

Question Did your symptoms change with AT practice?

All but one patient reported positive changes in their symptoms

Question What did you find most beneficial?

a. Control of symptoms 25%

AT is not promoted as a specific treatment but it is hoped that by using it regularly symptoms will improve. Symptoms produced by anxiety and panic attacks are most likely to respond directly to relaxation.

b. Relaxation 31 %

As would be expected the majority of patients felt the benefit of being able to relax at will, many experiencing it for the first time. The AT process allows them to build up their own concepts and understanding of what it feels like to be in the state of relaxation, it is all their own work, it belongs to them and can be experienced at any time.

c. Confidence in dealing with your problem 19%

Many of the problems, which the patients brought to their training. were long lasting, as yet no solution, medical or otherwise, had been found. For some AT produced the first small step of change, A sense of renewed potency could start and they were able to take back responsibility for their symptoms and themselves.

d. Group support 25%

Many patients who embarked on a course were experiencing great stress in their lives, at work, with relationships or due to physical illness and felt isolated with their symptoms. A sense of group cohesiveness could develop characterised by warmth, empathic understanding, trust and acceptance and relief that others have problems similar to their own.

CONCLUSION

25-30% of general medical patients have coexisting depressive, anxiety or psychosomatic disorders (4) and it is becoming increasingly clear that medical care can be improved by paying more attention to psychological aspects of assessment and treatment.

Psychological medicine is that area of health care that bridges the gap between organic illness and medical care, and mental illness and psychiatric care. It deals with the human experience, the feelings and emotions that are the cause or consequence of being ill.

General Practitioners, who are the first port of call for most patients, need to have knowledge of, expertise in and access to the various types of psychological medicine, which are available. AT is a branch of psychological medicine; it is an effective non-drug approach to many chronic conditions both as a primary resource or to support existing treatments.

Harrow East and Kingsbury PCG chose to focus on anxiety, panic attacks and insomnia and the results in this report show quite clearly that AT can be an effective treatment for these disorders.

For the patients who completed the courses there have been considerable benefits, not only in current health problems but also in the development of an understanding of the issues that underlie them. However, it requires the patients to have motivation and commitment to attend the course and practise at home and it takes time to reap the full benefits. Regular practice reduces arousal, tension and anxiety and promotes a sense of well being and confidence. It can lead to a reduction in prescribed medication and dependence on the doctor. It is hoped that this report will encourage other PCTs to institute a similar provision so that it can be a useful referral resource for their GPs.