Hypnosis for Treatment of Acute, Malignancy-Related, and Chronic Pain
March 2000; Volume 3: 30-34
By Nicole Nisly, MD and Teresa Klepser, PharmD
Despite the advent of effective pharmacological interventions, pain remains a difficult and prevalent problem. This is particularly troublesome to clinicians facing children who need to undergo multiple painful procedures or older patients fearing and suffering from advanced malignancy. Despite the recognized importance of psychosocial and behavioral factors in pain perception and response, treatment strategies have focused primarily on biomedical interventions such as drugs and surgery. Pain may be classified as acute, cancer-related, or chronic nonmalignant. We assess below the evidence for the use of hypnosis as an effective adjunctive or alternative procedure in the treatment of pain.1
Historical Background
In the 18th century, Franz Mesmer made popular the use of hypnosis, also known as mesmerism. About 40 years ago, the American Medical Association recognized hypnosis as a valid medical technique. Recently, renewed interest in this technique has merited its use in a variety of conditions with strong psychological components, such as asthma, insomnia, irritable bowel syndrome, and acute and chronic pain syndromes. Recent hypnosis studies have improved our understanding of mechanism of action. A growing number of randomized controlled trials (RCTs) in the field of psychoneuroimmunology are adding scientific heft to historical models.
Definition
Hypnosis induces a deeply relaxed state with increased suggestibility, in which emotional and physiological responses can be modified and modulated. This deeply relaxed state permits selectively focused attention. In combination with enhanced imagery,1 a patient’s selective focusing can be used to therapeutic benefit. (See box on page 31 for hypnosis terminology.)
Mechanism of Action
Hypnosis may alleviate pain by blocking pain’s neurological pathways. Two pain transmission circuits1 have been suggested: 1) A spinal cord-thalamic-frontal-cortex-anterior cingulate pathway may play a role in the subjective psychological and physiological responses to pain, and 2) The spinal cord-thalamic-somatosensory cortex pathway may play a role in pain sensation.
It has been hypothesized that hypnosis blocks pain impulses from entering consciousness by activating the frontal-limbic attention system, thus inhibiting pain impulse transmission from thalamic to cortical structures.
Hypnosis does not appear to influence endorphin production, and its role in the production of catecholamines is unknown.
Procedure
A typical treatment course for a patient with chronic pain takes place over four or five sessions lasting 45-60 minutes each.
In the first session, the therapist assesses the pain characteristics, identifies associations between pain sensation and emotions or images, and describes the procedure. The therapist attempts to assess which images cause relaxation for the patient and which hypnotic suggestions may be well accepted based on the patient’s emotions and personal belief system.
The patient is then guided to a state of deep relaxation, through the use of imagery, deep breathing, or progressive muscle relaxation. When that state is achieved the therapist may suggest that the patient visualize being in a pleasant place rather than the procedure room or change the image of pain from a dark gloomy color to a bright, pleasant one.
During the next sessions, the therapist will repeat the procedure, evaluate the response, and modify the suggestion technique and content to produce the desired outcome. The therapist will teach the patient to induce hypnosis at home by following the same procedure learned at the therapist’s office. A tape recording of the therapist’s suggestions may be used to help the patient achieve the desired response.
Human Studies—Acute Pain
Some evidence exists that hypnosis may be used for reducing postoperative pain and the pain of procedures. Ashton et al evaluated 32 patients undergoing elective coronary bypass surgery for the first time, in an age- and gender-stratified RCT using self-hypnosis vs. standard care control.2 The night before surgery, patients were instructed to focus on and practice breathing deeply, relaxing their jaw and throat muscles, keeping the incisions free from infection, minimizing bleeding, reducing pain and discomfort, and maintaining normal blood pressure. After surgery, they were asked to practice relaxing to reduce pain, discomfort, and infection; to normalize blood pressure and appetite; to heal quickly; and to return to "normal or customary lifestyle."
The authors evaluated the use of intra-operative pharmacotherapy, the amount of analgesic needed for the five initial postoperative days, the Profile of Mood States (POMS), and the length of intensive care and hospital stay. The self-hypnosis group showed a significant reduction in tension (POMS) or anxiety following surgery. No significant differences were found in any other POMS categories. Patients who practiced the self-hypnosis technique postoperatively (65% of hypnosis group) used significantly less medication than those who did not. No other significant differences were found between the groups, including differences in medication use. Three complications, including a sternal dehiscence, occurred in the hypnosis group; one occurred in the control group. Study weaknesses include the small number of patients and the fact that measures of pain were not assessed objectively.
Lang and colleagues evaluated the ability of self-hypnotic (SH) relaxation during interventional radiological procedures to reduce the need for intravenous sedation.3 In a pilot study, 16 male patients were randomized to the SH group and 14 to the control group. Both groups had patient-controlled analgesia. The hypnotherapy staff gave the SH group very brief self-hypnosis training and performed a Hypnotic Induction Profile Test prior to beginning the procedure. The therapist accompanied the patients throughout the length of the procedure and continually reinforced the hypnotic suggestion.
The SH group had significantly less use of medication (12/16 in the SH group did not request medication at all vs. 1/14 in the control group). Pain was classified on a scale of 0 to 10. The maximum pain perception in the SH group (2/10) was much lower than in the control group (5/10). Oxygen desaturation and hemodynamic instability were noted to be worse in the control group. Actual benefit did not correlate with individual hypnotizability.
Based on this pilot, in 1998 the National Center for Complementary and Alternative Medicine (NCCAM) at the NIH funded a larger controlled study at the University of Iowa, now awaiting publication.
Patterson reports a RCT of 61 burn patients undergoing painful treatments.4 Two groups (hypnosis and control attention/relaxation group) had a VAS (visual analogue scales) measurement of pain at two consecutive daily wound debridement sessions. On the first day, both groups submitted baseline VAS ratings. On the second day, subjects received either hypnosis or control attention/brief relaxation instructions from a psychologist during debridement. The post-treatment VAS scores of the two groups did not differ, but hypnosis patients who reported high baseline levels of pain reported less post-treatment pain. The same author participated in two other burn-unit studies,5,6 yielding conflicting results.
Human Studies—Cancer-Related Pain
Liossi and Hatire conducted a RCT comparing the efficacy of clinical hypnosis vs. cognitive behavioral coping skills (CBCS) vs. no intervention for alleviating pain and distress of 30 pediatric patients (ages 5-15 years) undergoing bone marrow aspirations.8 Assessment of pain and pain-related anxiety involved both behavioral observation and self-reports. Nurses observing the procedure completed the Procedure Behavior Checklist, a checklist of distress behaviors. The hypnosis and CBCS groups reported less pain and anxiety than the control group. A self-reported pain scale and an observed distress grading system completed by the nurse observing the procedure indicated that hypnosis and CBCS were similarly effective for pain. Hypnosis was more effective than CBCS for anxiety and distress. The study concluded that hypnosis and CBCS are effective in preparing pediatric patients for bone marrow aspirations.
Syrjala conducted a RCT evaluating the effectiveness of psychological techniques for reducing cancer pain and post-chemotherapy nausea or vomiting in 67 adult, bone marrow patients with hematological malignan- cies.9 Prior to the beginning of the treatment, patients were randomized to four groups: hypnosis (HYP), cognitive behavioral coping skills training (CBCST), therapist attention control (TC), and treatment as usual (TAU) control group. Patients in the HYP, CBCST, and TC groups met with a clinical psychologist for two pretransplant sessions and a total of 10 sessions during the course of transplantation.
Forty-five patients completed the study. Analysis of the study variables indicated that hypnosis was effective in reducing reported and nurse-observed/nurse-rated oral pain from chemotherapy-related mucositis, but opioid use did not differ significantly between the groups. The other symptoms measured, including nausea and vomiting, did not differ significantly between the four groups.
Steggles published an extensive annotated bibliography of the scientific literature published in English from 1985-1995. The bibliography included 37 articles on hypnosis and pediatric cancer patients and covered case reports or studies to experimental and non-experimental group designs.10 In 1995, an NIH Technology Assessment group concluded that hypnosis’ evidence of effectiveness for cancer-related pain is strong.1
Human Studies—Chronic Nonmalignant Pain
Haanen conducted a RCT on 40 patients with refractory fibromyalgia, randomized to either hypnosis or physical therapy for 12 weeks and then followed for another 12 weeks.11 The hypnosis group had significantly less pain and fatigue and had better sleep and global assessments at 12 and 24 weeks. But these improvements were not reflected in an improvement of the "total myalgic score," measured with a dolorimeter.
Dinges followed prospectively a cohort of patients (children, adolescents, and adults) with sickle cell disease who reported experiencing three or more episodes of vaso-occlusive pain the preceding year.12 Following a four-month baseline phase of conventional treatment only, the patients received self-hypnosis training sessions that were implemented over an 18-month period. The sessions took place once a week for the first six months, biweekly for the second semester, and every third week for the remaining six months. This intervention was associated with a significant decrease in the number of "pain days" and the use of pain medications during the self-hypnosis intervention period. Sleep also improved.
Safety
Gravitz describes difficulties in ending the hypnotic trance in two subjects: a medical resident participating in a workshop and a 36-year-old women with chronic pain.13,14 Other similar isolated communications were reported in the literature and reviewed by this author. Concerns have been raised about using these therapies with individuals who have psychotic conditions as well as personality disorders.15 These individuals should be treated only under the supervision of an experienced, licensed health care provider with expertise in the use and limitations of hypnosis in the setting of psychiatric disorders.16
Training and Scope of Practice
Only health care professionals authorized to see patients, including PhD psychologists, counselors, and social workers licensed in counseling, can perform hypnosis. A Certified Hypnotist credential requires 40 hours of education and training, a health care professional degree, and two years’ experience using hypnosis in clinical practice. A Consulting Hypnotist credential requires 120 hours of education and training, a health care professional degree, and evidence of advanced standing in their primary profession.17
Hypnosis training is not considered sufficient to allow for independent practice. The American Psychological Association (APA) Division of Psychological Hypnosis states that hypnosis is not a treatment in and of itself, like psychoanalysis or behavior therapy, but rather a procedure used to facilitate therapy. The APA believes that clinical hypnosis should be performed only by qualified health care professionals who use this procedure within the scope of their specific area of professional expertise.16 For example, a dentist or a social worker may use hypnosis within a profession-specific scope of practice and follow the standards dictated by their particular state licensing boards.16,17 Of course, the patient needs to consent to the use of hypnosis by any health care professional.
Compensation
The charge for hypnosis depends on the setting and the geographic location. A one-hour session with a PhD psychologist may cost from $70-150. Hypnosis may be offered as a small portion of the consultation or treatment, as with a dentist or interventional radiologist providing hypnosis in place of medication, analgesia, or sedation. The charge typically would not be coded as hypnosis, but as stress management, counseling, or pain management, and as such, may be covered by insurance.
Conclusion
In a patient population subject to life-long unpredictable episodes of pain and for whom few safe, cost-effective medical alternatives exist, an adjunctive program that involves regular contact with a self-hypnosis team and emphasizes patient self-management techniques is very appealing. Hypnosis appears to be effective and safe as an adjunct or substitute for pharmacological treatment of acute pain and anxiety related to painful medical procedures for both adults and children.3 It may be helpful in the treatment of burns,7 but further studies are needed to confirm this. It is effective as an adjunct treatment of chronic pain associated with cancer, specifically that related to oral mucositis.
Recommendation
Hypnosis should be considered in the adjunctive treatment of acute, chronic, and cancer-related pain, when serious mental health illness has been ruled out. Hypnosis should be administered under the supervision of a licensed health care professional who is trained in the use of hypnosis and who is using this procedure within his or her scope of practice and training.
In clinical trials of self-hypnosis:
a. patients had a significant reduction in tension and anxiety and used significantly less medication postoperatively.
b. chronic pain patients experienced no change in the number of pain days.
c. None of the above.
Dr. Nisly is Assistant Professor, Department of Internal Medicine, University of Iowa College of Medicine, and Dr. Klepser is Assistant Professor, Division of Clinical and Administrative Pharmacy, University of Iowa College of Pharmacy in Iowa City.
References
1. NIH Technology Assessment Statement. Integration of behavioral and relaxation approaches into the treatment of pain and insomnia. Bethesda, MD; October 1995.
2. Ashton C Jr., et al. Self-hypnosis reduces anxiety following coronary artery bypass surgery. A prospective, randomized trial. J Cardiovasc Surg 1997;38:69-75.
3. Lang EV, et al. Self-hypnotic relaxation during interventional radiological procedures: Effects on pain perception and intravenous drug use. Int J Clin Exp Hypn 1996;44:106-119.
4. Patterson DR, Ptacek JT. Baseline pain as a moderator of hypnotic analgesia for burn injury treatment. J Consult Clin Psychol 1997;65:60-67.
5. Patterson DR, et al. Hypnotherapy as an adjunct to narcotic analgesia for the treatment of pain for burn debridement. Am J Clin Hypn 1989;31:156-163.
6. Everett JJ, et al. Adjunctive interventions for burn pain control: Comparisons of hypnosis and Ativan: The 1993 Clinical Research Award. J Burn Care Rehabil 1993;14:676-683.
7. Patterson DR, et al. Factors predicting hypnotic analgesia in clinical burn pain. Int J Clin Exp Hypn 1997;45:377-395.
8. Liossi C, Hatira P. Clinical hypnosis versus cognitive behavioral training for pain management with pediatric cancer patients undergoing bone marrow aspirations. Int J Clin Exp Hypn 1999;47:104-116.
9. Syrjala KL, et al. Hypnosis or cognitive behavioral training for the reduction of pain and nausea during cancer treatment: A controlled clinical trial. Pain 1992;48:137-146.
10. Steggles S, et al. Hypnosis for children and adolescents with cancer: An annotated bibliography, 1985-1995. J Ped Oncol Nurs 1997;14: 27-32.
11. Haanen HC, et al. Controlled trial of hypnotherapy in the treatment of refractory fibromyalgia. J Rheumatol 1991;18: 72-75.
12. Dinges DF, et al. Self-hypnosis training as an adjunctive treatment in the management of pain associated with sickle-cell disease. Int J Clin Exp Hypn 1997;45: 417-432.
13. Gravitz MA. Inability to dehypnotize—implications for management: A brief communication. Int J Clin Exp Hypn 1995;43:369-374.
14. Gravitz MA. Inability to dehypnotize—implications for management. Aust J Clin Exp Hypn 1999;27:62-67.
15. Vickers A, Zollman C. ABC of complementary medicine. Hypnosis and relaxation therapies. BMJ 1999;319:1346-1349.
16. Executive Committee of the American Psychological Association, Division of Psychological Hypnosis. Psychological Hypnosis: A Bulletin of Division 30. Washington, DC. 1993;2:7.
17. Holroyd J, Obarski SK. Hypnosis for the seriously curious. Available at: http://www.hypnosis-research.org/hypnosis/serious.html. Accessed December 28, 1999.
March 2000; Volume 3: 30-34
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