e4-10: Hypnosis

Hypnosis is a procedure that induces an altered state of consciousness in which the patient's mind is more accepting of suggestion. It is believed that during hypnosis the usual evaluative, critical function of the conscious mind is bypassed and more direct communication with the subconscious mind occurs.

Hypnotic phenomena, including trancelike states for medical purposes, have been practiced around the world throughout human history. It was the Scottish surgeon, James Braid, in 1843, however, who coined the term “hypnosis” and laid the foundation for the use of hypnosis in modern medicine. Braid believed the effects of hypnosis were mediated by the mind of the patient. Important early research was conducted in the 1930s by Dr. Clark Hull and his student, Dr. Milton Erickson. In the mid-1950s, the British and American Medical Associations suggested that hypnosis be incorporated into the medical curriculum. In 1960, the American Psychological Association endorsed hypnosis as a branch of psychology. In 1996, an NIH Technology Assessment Panel judged hypnosis to be an effective intervention for alleviating pain.

The mechanism of action of hypnosis has not been fully elucidated, but its effects are seen at multiple levels, including somatosensory cortex, anterior cingulate cortex (modulation of pain affect via limbic system), spinal cord, and autonomic nervous system (eg, reduction of colonic motility in irritable bowel syndrome). Additional evidence regarding the mechanism includes upregulation of immune-related gene expression (eg, effects on tumor necrosis factor) and reduction of mucosal inflammatory response (in ulcerative colitis). Hypnotic trance is a state distinct from sleep or relaxation, and hypnotic analgesia is distinct from placebo analgesia.

Certification for hypnosis, granted through the American Society of Clinical Hypnosis, has the following requirements: (1) health professional degree, (2) 40 hours of workshop training, (3) 20 hours of supervised clinical training, and (4) 2 years of independent practice using clinical hypnosis.

Other certification programs exist. Patients and clinicians should inquire about the training and certification of any practitioner of hypnosis because there are no restrictions limiting its use to licensed health care practitioners.

The procedure of hypnosis can be divided into three phases: induction (or pre-suggestion), suggestion, and post-suggestion. The induction of a trance is accomplished in a variety of ways with the intention of developing relaxation and focused attention. Once the trance is induced, therapeutic suggestions are offered. In the post-suggestion phase, the patient returns to their usual state of consciousness and the suggestions may be discussed and reinforced. Self-hypnosis may be taught to further reinforce the therapeutic suggestions between sessions.

Although most people can respond to hypnosis, there is great variability in hypnotic susceptibility (suggestibility) in the population. This can be measured with standard instruments such as the Harvard Group Scale of Hypnotic Susceptibility and the Stanford Hypnotic Susceptibility Scale. Studies have shown a positive correlation between hypnotic susceptibility and its efficacy.

The ideal candidate for hypnosis is a patient with high suggestibility and motivation, with a condition for which hypnosis has proven benefit. Course of treatment can vary from a single session to several. Sessions are usually 45–60 minutes, with the first session typically lasting 90–120 minutes. It is helpful when referring patients to dispel common myths about hypnosis. For example, it is not true that one loses consciousness in trance or that one cedes control to the hypnotist. Trance state may best be described as a voluntary state of mind not unlike the one experienced when absorbed in reading a book or when daydreaming. It may be useful to explain to patients that the purpose of referral to hypnosis is to learn skills to use the mind-body connection.

Adverse events from hypnosis have not been well studied. As with any psychological therapy, distressing emotions or thoughts may occur. These can manifest as somatic symptoms, such as dizziness, headache, or nausea. Occasionally, uncovering repressed psychic content can evoke strong emotional response, known as abreaction. A minority of hypnosis practitioners believe abreaction is therapeutic. Also, as with other mind-body medicine modalities that include deliberate relaxation, paradoxical anxiety reactions can rarely occur.

There is no consensus on contraindications to hypnosis; however, the use of hypnosis in patients with severe psychiatric disease is controversial. Also, patients who have very low scores on hypnotic susceptibility scales are less likely to derive therapeutic benefit.

A. Pain

There are at least 40 controlled studies of variable methodologic quality on the use of hypnosis for treating acute pain in adult and pediatric populations. All but three studies show superiority of hypnosis over a control condition (usual care, no treatment, or attentional control). Hypnosis has been shown to be effective for periprocedural and perioperative pain in patients undergoing breast lumpectomy, excisional and core breast biopsy, bone marrow aspiration, pectus excavatum repair (Nuss procedure), percutaneous transluminal coronary angioplasty and other percutaneous vascular and renal procedures, burn wound care, dental procedures, and plastic surgery. Many studies also report less procedure-related anxiety and lower analgesic medication requirement. According to a 2013 meta-analysis, additional documented benefits include reduced recovery and surgical procedure times. A 2014 meta-analysis concludes that hypnosis is superior to some other psychological interventions for the treatment of chronic pain. A small 2013 three-arm randomized controlled trial suggests live hypnosis is superior to both recorded hypnosis and placebo for reducing anxiety during dermatologic procedures. A 2016 randomized controlled trial of 53 older hospitalized patients (mean age 80 years) found that hypnosis caused a greater reduction in pain than massage, and it also significantly improved mood.

For chronic pain, individual studies have shown efficacy for headache, orofacial pain, dyspepsia, low back pain, vulvodynia, sickle cell crisis, fibromyalgia, multiple sclerosis, and spinal cord injury.

B. Cancer-Related Symptoms

There are at least 15 randomized controlled trials that have specifically evaluated the efficacy of hypnosis for cancer-related pain, distress, fatigue, nausea, and hot flashes in adults, usually involving adults with breast cancer. All trials showed benefit compared with no treatment or usual care. In addition, three of four trials showed significant benefit of hypnosis for reducing anticipatory nausea and vomiting from chemotherapy. Other randomized controlled trials concluded that (1) hypnosis decreased hot flash scores by 68% in breast cancer survivors; (2) self-hypnosis plus empathic attention was superior to empathic attention alone for reducing pain, anxiety, and medication usage in 201 patients undergoing percutaneous tumor treatment; (3) hypnosis preoperatively reduced institutional costs for breast cancer patients; (4) hypnosis reduced the doses of anesthesia medications required and reduced pain, fatigue, nausea, and emotional upset in breast cancer patients; and (5) a combined intervention of hypnosis with CBT reduced fatigue in one study of breast cancer patients undergoing radiation therapy and, in another study, reduced negative affect and increased positive affect in a similar patient population.

C. Irritable Bowel Syndrome

There are more than 20 studies of hypnosis for irritable bowel syndrome in adults, seven of which are controlled (placebo pill, CBT, or wait-list control). All seven controlled studies show reduction in pain and bowel symptoms, and some show improved quality of life and reduced anxiety. There are also five follow-up studies showing maintenance of benefits for 1–7 years. Two large studies (one prospective randomized controlled trial and one retrospective trial) examined refractory irritable bowel syndrome patients and found efficacy for hypnosis. The American College of Gastroenterology includes hypnosis among its recommended behavioral therapies for the treatment of irritable bowel syndrome. Among the pediatric population, a 2017 prospective randomized controlled study of 250 children with irritable bowel syndrome and functional abdominal pain found that home-based hypnotherapy with an audio file was noninferior to individual hypnotherapy performed by therapists. This study adds another treatment option for these patients.

D. Smoking Cessation

A 2012 Cochrane review of 11 trials concluded that whether hypnosis is superior to other interventions or to no treatment for smoking cessation cannot be determined because of conflicting results and statistical weaknesses in head-to-head trials. Similarly, a 2012 meta-analysis found hypnosis may possibly aid smoking cessation, but a large confidence interval in the final statistical analysis prevented the authors from stating any definitive conclusion. A 2016 randomized controlled three-arm trial in 164 hospitalized patients concluded that hypnotherapy was superior to nicotine replacement therapy as measured by abstinence rates at 12 and 26 weeks' post-hospitalization (however, the statistical significance of this conclusion was questionable). A 2017 randomized controlled study of 140 veterans did not find any significant improvements when hypnosis was used for smoking relapse prevention.