Hypnosis can be an effective therapeutic option for a variety of problems. The neurophysiologic processes by which hypnosis can effect change in such a wide range of complaints are still a subject of exploration. One current theory uses information processing as a heuristic model, with the body, brain, cells, and organs regarded as an information-processing system. In the brain, semantic information (encoded in language) is transduced into molecular information, which uses neurochemical and neurohormonal channels to cause changes in diverse organ systems.
Recent brain imaging studies, employing PET and MRI, have shown that the hypnotic state is related to a widespread set of cortical areas involving the occipital, parietal, precentral, premotor, and ventrolateral prefrontal and anterior cingulate cortices. The anti-nociceptive effects of hypnosis correlated with activity in the mid-cingulate cortex.
In deciding whether to use hypnotic procedures with patients (or to refer them to a hypnotherapist), it is important to consider patients’ beliefs about hypnosis, their openness to other therapeutic modalities, and their locus of control. Some religious groups (e.g., Jehovah’s Witnesses) forbid use of hypnosis, and some patients may fear that they will surrender control to a powerful “other,” who can then control their minds. Brief education by the physician about the nature of hypnosis and its usefulness as a tool to help patients increase control over their symptoms may correct these beliefs. If the patients are not convinced, they are probably not good candidates for hypnosis.
Furthermore, some patients may resist hypnosis because they infer that the physician thinks the problem “is all in their head.” For such patients, anything other than a biomedical intervention may be viewed with suspicion. Assuring them that hypnosis is simply part of a comprehensive medical management of their problem may increase their openness.
Locus of control—internal or external—is also a significant factor. Patients with an internal locus of control believe that they can influence many of life’s rewards or punishments, and they may be better candidates for hypnosis than those with an external locus of control. This latter group may respond better to biofeedback, which relies on equipment that is external to the patient.
In the following brief descriptions of clinical situations, hypnosis can be considered as an adjunctive or, in some cases, primary treatment.
Relaxation & Stress Management
One of the physiologic effects of therapeutic hypnosis is stimulation of the parasympathetic nervous system (see Chapter 34, Figure 34-2). Several stress-related conditions have been attributed to hyperstimulation of the sympathetic nervous system, which is modulated by the parasympathetic nervous system in a dynamic interrelationship. Sympathetic activation can be part of the fight-or-flight response to perceived threats. Given the plethora of real or perceived threats in today’s world, stress-related illnesses may be a common presentation of patients’ habitual levels of sympathetic arousal (see Chapter 34). Sympathetic responses include tachycardia, muscle tension, adrenaline release, pupil dilation, inhibited intestinal mobility, shortness of breath, and sweating. This autonomic activation is downregulated during hypnosis, and with parasympathetic stimulation the individual becomes relaxed, leading to energy restoration, conservation, and renewal.
Hypnosis can be quite effective as a primary or adjunctive treatment for anxiety. Patients with an internal locus of control will find self-hypnosis an especially satisfying alternative to anxiolytic medication. When introducing this as an alternative treatment, the physician can say:
Doctor: You have a powerful pharmacy in your brain that can produce significant healing effects. Through hypnosis you can learn to mobilize that pharmacy and let it work cooperatively with the other approaches we use.
The clinician can devote 15–20 minutes to inducing a trance, during which the patient is led to form a full sensory recall of an experience in which he or she felt deeply relaxed. In this process, it is important that clinicians avoid imposing their own images of relaxation, instead facilitating the patient’s exploration by means of non-specific suggestions. These suggestions can lead the patient through each sensory modality (e.g., vision) and submodality (e.g., color, brightness, and quality of reflected light) to allow the patient to become absorbed in a full sensory representation of an actual experience associated with relaxation. If the session is audio recorded, patients can take the recording home for daily practice, thereby learning to self-induce trances and regulate their own levels of autonomic nervous system arousal. The extra time taken for the hypnotic induction can often be compensated by a decrease in time spent on phone calls from anxious patients, since the audio recording allows the patient to access the clinician’s voice and suggestions whenever needed.
Because cortical elaboration of nociception is a component of pain, hypnosis can be used to shift the focus of attention away from pain sensations. In some surgical or dental procedures, hypnosis can be used as an adjunct to, or instead of, anesthesia. In addition, patients with chronic pain can be taught to relax the muscles they tense around areas of pain as part of their “guarding” or bracing efforts. This hypnotic relaxation reduces the component of the pain that is due to muscle contraction. Patients with migraine headaches can be taught to dilate blood vessels in their hands and feet through hand- and foot-warming imagery—sitting in front of a campfire, for example. In the early prodromal stage of migraine, this procedure can sometimes reverse the progress of the headache, possibly by increasing peripheral vasodilation and allowing relaxation of blood vessels in the head. Temporomandibular disorders, pain from repetitive strain injuries, and tension headaches have also been treated effectively with hypnosis. For pain relief during childbirth, a meta-analysis showed that hypnosis reduces analgesia requirements in labor. In one study, older female patients with osteoarthritis experienced significant increase in their health-related quality of life following a 12-week treatment using guided imagery with relaxation. Brain imaging studies have suggested that in hypnosis-induced analgesia prefrontal and anterior cingulate cortices form important structures in a descending pathway that modulates incoming nociceptive input.
Hospice & Palliative Care
Hypnosis has been used adjunctively with other therapies to help patients with chronic and terminal illnesses. Relaxation, overcoming insomnia, relief from pain and dyspnea, and enhancing relationships with relatives and other support persons are some of the benefits of this modality in the hospice setting.
There is evidence that hypnosis is effective in alleviating the chronic pain associated with cancer. In addition, hypnosis can control symptoms such as nausea, anticipatory emesis, and learned food aversion; it is also helpful in managing anxiety and other emotions associated with cancer. Hypnosis may also be effective in reducing hot flashes in breast cancer survivors.
Certain dermatological conditions, such as warts and alopecia, have been treated successfully with hypnosis. While in trance, patients are given the suggestion to experience tingling or flushing in the affected area. Warts may respond to these suggestions by shrinking in size or—in some cases—disappearing. Burns have also responded to hypnotherapeutic suggestion, both in lessening the degree of the burn and in controlling pain. Other dermatoses for which therapeutic hypnosis may be helpful are acne, atopic dermatitis, herpes simplex, hyperhidrosis, pruritus, psoriasis, and rosacea.
Hypnosis has been used successfully to treat genital herpes, both in reducing the number of flare-ups and in decreasing the duration of flare-ups. Hypnosis has been shown to decrease blood levels of herpes simplex virus and to increase T-cell effectiveness, NK-cell activity, secretory immunoglobulin A (IgA), and neutrophil adherence. A meta-analysis has shown that hypnosis can reliably alter immune system function. Hypnosis incorporating immune suggestions showed a positive influence on total salivary IgA concentration and neutrophil adherence, along with a modest suppression of intermediate-type hypersensitivity erythema. These effects were mediated through relaxation. Some studies have shown differential delayed skin sensitivity reactions on the right and left arm of subjects depending on which arm was suggested under hypnosis to show no changes.
Patients with asthma have been taught to use self-hypnosis to expand airways and minimize stress-induced attacks, as well as reduce anticipatory anxiety about having an attack. Some patients are able to decrease their bronchodilator use with daily self-hypnosis. Weaning patients off a ventilator in the intensive care unit has been facilitated by the use of hypnosis.
Hypnosis for relaxation can be a useful adjunct to other therapies for hypertension. Individual hypnosis treatments for eight sessions was shown to reduce mild essential hypertension immediately posttreatment and at one-year follow-up.
Problems such as irritable bowel syndrome (IBS), are amenable to adjunctive treatment with hypnosis. The primary approach is to reduce anxiety, induce relaxation, incorporate abdominal breathing, and suggest warmth in the abdomen and proper functioning in the bowels. Preoperative suggestions have been used successfully to promote an early return of gastrointestinal motility following intraabdominal surgery, leading to shorter hospital stays.
Sleep-onset insomnia—associated with anxiety, obsessive worrying, or sympathetic arousal conditioned to the cue of getting into bed—can be treated with hypnotherapy. By making an audio recording of an induction in which the patient is led into a relaxed state and invited to form positive associations with lying in bed before falling asleep, the clinician can give the patient a new nightly ritual that will enhance relaxation. A relaxing trance can also help the patient return to sleep more quickly after waking up.
Pediatricians and family physicians skilled in hypnosis find it a useful adjunct in the treatment of children. Children are often amenable to the use of imagination and story-telling as trance induction techniques. Some of the conditions that respond well to primary or adjunctive use of hypnosis include nocturnal enuresis, night terrors, functional abdominal pain, surgical and other office procedures, chronic dyspnea, and symptoms related to cystic fibrosis. Hypnosis was shown to be effective in reducing distress and the duration of an invasive diagnostic test in children with urinary tract abnormalities. In a review of studies on psychological interventions to reduce needle-related procedural pain in children, hypnosis showed the most promise in reducing self-reported pain.
Hypnosis has been used successfully to reduce symptoms of hyperemesis gravidarum. Habitual aborters have been helped to relieve anticipatory anxiety and lessen the psychogenic risks of spontaneous abortion when organic etiologies have been ruled out.
Preparing for Surgical and Other Difficult Procedures
Patient expectations appear to play a role in the degree of pain and distress felt with surgery and procedures such as colonoscopy. Hypnosis has been used to anesthetize patients who are allergic to anesthetic drugs and to decrease the use of postoperative pain medication. Usually hypnotic anesthesia requires a deep level of trance, which calls for advanced skill on the part of the hypnotist along with the patient’s ability to be hypnotized. Using the naturally occurring trance of patients anticipating surgery, physicians can make simple suggestions to enhance surgical wound healing and reduce postoperative pain. Referring to pain as “discomfort” or an “unusual sensation,” the physician can offer the patient a statement such as:
Doctor: No matter what you’ve been thinking about the time after surgery, you’ll be pleasantly surprised at how little discomfort you have.
Presurgical hypnosis can also decrease disorientation and confusion following surgery.
For patients in the preparation/determination or action stage of readiness to stop smoking or to change eating behavior (Chapter 19), hypnosis can be a useful ally. The ritual pattern of patient behavior around smoking can be viewed as a trance phenomenon. There is an automatic, other-than-conscious sequence of kinesthetic (tactile, visceral, emotional, and postural) awareness and behavior usually set in motion by contextual cues (e.g., finishing a meal, drinking coffee or alcohol, and talking on the telephone). Hypnosis can be described to patients in the preparation/determination stage as a useful tool “to help you come out of the smoker’s trance and into a more satisfying, health-promoting trance.” The clinician can call patients’ attention to the automatic behavioral sequence while taking a smoking history (Table 5-1). Asking patients to describe in detail which hand they use to pick up the cigarette pack, take the cigarette out of the pack, hold the lighter or strike the match, and so on, will call their attention to the automatic, trance-like nature of their behavior. After inducing a hypnotic trance, the clinician can suggest that patients visualize in slow motion the entire sequence prior to lighting each cigarette. When the previously automatic behavior is raised to the level of awareness, patients are able to break the previous pattern and approach each episode of smoking with increased deliberation. Once patients are in the action stage of cessation, the parasympathetic effects of self-hypnosis can be used as an alternative stress-reducing activity.
Table 5-1.Hypnotic smoking-cessation interview. ||Download (.pdf) Table 5-1. Hypnotic smoking-cessation interview.
|The following questions are designed not only to gather information about the patient’s smoking behavior and its parameters but also to raise the patient’s awareness about behaviors that are usually automatic and unconscious. The interview presupposes that the patient has already expressed a desire to stop smoking. |
Have you ever quit smoking before? How long were you successful at curtailing your smoking? What allowed you to succeed at not smoking for that long?
What other habits have you overcome? How have you done that?
What brand of tobacco have you been using?
What motivates you to continue smoking?
Where do you have your first cigarette of the day?
Where do you have your second cigarette?
What is the sequence of activities that precede the first cigarette of the day?
Describe the different situations in which you are likely to smoke.
Describe the mood or emotional state that usually precedes smoking.
Describe the urge to smoke in detail.
Describe how you light a cigarette (if the response is vague, offer the following prompts):
Which hand do you use to reach for the pack?
Which hand do you use to pull the cigarette out of the pack?
Which hand do you use to put it in your mouth?
Which hand do you use to light it?
Which hand do you use to continue smoking?
Will you describe in detail all of the reasons that you can think of for not taking a first puff after you have stopped smoking?
How long will you have to stop before you realize that you are permanently free of smoking?
How will you tell people that you have stopped smoking?
Hypnosis, when combined with cognitive-behavioral therapy, has been shown to be effective in promoting weight loss.