Download Application - American Society of Clinical Hypnosis

Applications of Clinical
Hypnosis in Mind-Body
Medicine
Name
ASCH-Status
Edited by Eric Spiegel, PhD, 2010
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Table of Contents
Defining Hypnosis
Myths & Misperceptions
Memory
Hypnotic Relationship
Hypnotic Phenomena
Assessment of Hypnotizability
Stages of Hypnosis
Brain Research
Self-Hypnosis
Treatment Planning
Ethics
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Slides 3-14
Slides 15-17
Slides 18-28
Slides 29-30
Slides 31-40
Slides 41-46
Slides 47-51
Slides 52-69
Slides 70-81
Slides 82-93
Slides 94-96
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Slides 98-102
Slides 103-119
Slides 120-146
Slides 147-199
Slides 200-233
Slides 234-287
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Slide 288
Slide 289
• Applications
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Psychology & Psychotherapy
Pain Management
Headaches
Irritable Bowel Syndrome
Anxiety Disorders
Dentistry
Professional Organizations
References
What is Hypnosis?
DEFINITION OF HYPNOSIS:
A state of inner absorption, concentration
or focused attention which assists a client
in altering some aspects of thought,
emotion, behavior or perception.
ASCH SOT, 2010
User-friendly Definition
Hypnosis is …
• Using your mind to help yourself
• Learning how to control your mind / body
• Daydreaming with a purpose
• Learning what you didn’t know you knew
• Controlling what you didn’t know you
could
ASCH SOT, 2010
Process Definition
“Hypnosis is a procedure during which
a health professional or researcher
suggests that a client, patient, or subject
experience changes in sensations,
perceptions, thoughts, feelings or
behavior. The hypnotic context is
generally established by an induction
procedure…most include suggestions
for relaxation, calmness and well-being.”
APA, Div.30 (Kirsch, 1994)
ASCH SOT, 2010
Different responses to hypnosis
altered state of consciousness.
normal state of focused attention
calm, relaxed, pleasant experience
Varied responsiveness to hypnosis
inhibited by fears, concerns, common
misconceptions
(depictions of hypnosis in books,
movies, television)
Executive Committee of the American Psychological Association Division
of Psychological Hypnosis, 1993, Fall. Psychological Hypnosis: A Bulletin
ASCH SOT, 2010
of Division 30, 2, p. 7.
People who have been hypnotized
do not lose control over their behavior
typically remain aware of who / where they are
usually remember what transpired during
hypnosis (unless amnesia has been
specifically suggested)
Hypnosis makes it easier for people to
experience suggestions, but it does not force
them to have these experiences.
ASCH SOT, 2010
Content Definition
• Altered state of consciousness / awareness different
from normal waking / stages of sleep
• Resembles meditative states
narrowly focused attention (absorption) primary
process thinking
ego receptivity
alterations in cognition
dissociations from usual perceptions /
memories
trance logic
• Sometimes indistinguishable from simple physical
and mental relaxation
ASCH SOT, 2010
Division 30
2003 Definition of Hypnosis
Hypnosis typically involves an introduction to the
procedure during which the subject is told that suggestions
for imaginative experiences will be presented. The hypnotic
induction is an extended initial suggestion for using one’s
imagination, and may contain further elaborations of the
introduction. A hypnotic procedure is used to encourage and
evaluate responses to suggestions. When using hypnosis,
one person (the subject) is guided by another (the hypnotist)
to respond to suggestions for changes in subjective
experience, alterations in perception, sensation, emotion,
thought, or behavior. Persons can also learn self-hypnosis,
which is the act of administering hypnotic procedures on
one’s own. If the subject responds to hypnotic suggestions, it
is generally inferred that hypnosis has been induced. Many
believe that hypnotic response and experiences are
characteristic of a hypnotic state. While some think that it is
not necessary to user the word hypnosis as part of the
hypnotic induction others view it as essential.
ASCH SOT, 2010
2003 Definition, continued
Details of hypnotic procedures and suggestions will differ
depending on the goals of the practitioner and the purposes
of the clinical or research endeavor. Procedures traditionally
involve suggestions to relax through relaxation is not
necessary for hypnosis and a wide variety of suggestions
can be used including those to become more alert.
Suggestions that permit the extent of hypnosis to be
assessed by comparing responses to standardized scales
can be used in both clinical and research settings while the
majority of individuals are responsive to at least some
suggestions scores on standardized scales range from high
to negligible. Traditionally, scores are grouped into low,
medium and high categories. As is the case with other
positively scaled measures of psychological constructs such
as attention and awareness, the salience of evidence for
having achieved hypnosis increases with the individual's
score.
ASCH SOT, 2010
All hypnosis is self
hypnosis that can be
used for one’s own
benefit.
Milton Erickson
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Components of
Hypnosis
• Focused attention, absorption
• Dissociation, distortion
• Suggestibility and generalization
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Contraindications
• Do not use hypnosis with any presenting
problem you are unprepared to treat without
hypnosis.
• Hypnotic uncovering work :
caution with fragile ego-strength, extreme
emotional lability, tenuous control, thought
disorder, some medically impaired patients
(e.g., organic brain syndromes).
• Indiscriminate removal of organic pain (can
cloud symptoms, cause further harm)
• Indiscriminate removal of neurotic symptom
• Assess potential for abuse of hypnotic skill by
client.
ASCH SOT, 2010
MYTHS AND
MISPERCEPTIONS
What clients/patients say:
• “What if I don’t wake up?”
• “I don’t want to do anything to
embarrass myself!”
• “I heard everything you said, I must not
have been in trance.”
• “What if I don’t want to do something
you tell me to do?”
• “Am I going to remember something
forgotten from my past?”
ASCH SOT, 2010
Correcting the misperceptions
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Control
Privacy
Amnesia
Sleep / Loss of consciousness
Awareness of surroundings
A priori weak-mindedness
Having "mind weakened"
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MEMORY
Long term Memory
• Declarative/explicit: develops late in
childhood and is dependent on a complex
brain system (hippocampi and medial
temporal-lobe structures)
Semantic: facts independent of context
Episodic: information specific to a context
-depends on perception of particular and
unique events and one’s memory of such
events
-requires conscious recall
ASCH SOT, 2010
Long term Memory
• Procedural or implicit: more primitive parts
of the brain (subcortical structures like the
basal ganglia and cerebellum)
-depends on repetition, is literal, exact and
reproducible
-fixed action pattern (such as, early motor
patterns)
ASCH SOT, 2010
Hypnosis and Memory
All memory is imperfect, adaptive and
reconstructive (rather than reproductive) and
malleable.
Memory should be understood as imperfect,
with or without hypnosis.
Hypnosis may increase confidence in
memory, referred to as false confidence.
Memory is reconstructive (not a videotape of
events as they occurred).
ASCH SOT, 2010
Hypnosis and Memory
Repressed memories do exist as well as false
beliefs about the past. False beliefs are likely to
occur when an interaction of four (4) primary risk
factors are present:
1) Hypnotizability,
2) Uncertainty about past events,
3) Clear evidence of interrogatory suggestive
influence,
4) Extra therapeutic influences, e.g. peer and familial
influences.
ASCH SOT, 2010
• Recall can be improved under some
conditions, including use of hypnosis
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False Memory Debate
• Social factors and demand characteristics
may contribute as much as hypnotizability
to pseudo memory production.
• False memories have been produced in
laboratory situations.
• Such false memories have not involved
the emotional intensity or importance of
traumatic material.
ASCH SOT, 2010
• Memory refreshing is most common situation in
which the performance of hypnosis is scrutinized
by the law.
At issue are 1) the ability to cross-examine a
previously hypnotized witness, 2) simulation, 3)
confabulation, 4)suggestibility, and 5) demand
characteristics.
In addition, difficulties are created by the fact
that the evidence for the efficacy of hypnosis in
amnesia recall and memory enhancement in
both experimental and clinical settings is
equivocal.
ASCH SOT, 2010
Trauma and Memory
 Traumatic memory may be encoded
differently than memory for more ordinary
events.
 Use of hypnosis with traumatized and
abused is key to issue of hypnosis and
memory debate. Evidence suggests that
traumatically induced amnesia exists, as
well as delayed memory or “robust
repression”.
ASCH SOT, 2010
False memory?
• The nature of memory is both creative and
reproductive
“Memories have ways of becoming
independent of the reality they evoke.
They can soften us against those we were
deeply hurt by or they can make us resent
those we once accepted and loved
unconditionally. ” A. Nafisi
ASCH SOT, 2010
Clinical Use of Hypnosis and
Memory
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Use caution
Do not lead patient
Do not suggest outcome
Remain neutral
And remember only outside corroborating
evidence is confirmatory
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ESTABLISHING THE HYPNOTIC
RELATIONSHIP
PHASE 1.
PHASE 2.
EVALUATION
(BUILDING RAPPORT)
EDUCATION
(CONCEPT OF HYPNOSIS,
& INFORMED CONSENT)
PHASE 3. ASSESSMENT OF
HYPNOTIZABILITY
(FORMAL OR INFORMAL)
PHASE 4.
TEACHING SELF HYPNOSIS
(POSITIVE EXPECTANCIES AND MOTIVATION)
ASCH SOT, 2010
PREPARING THE CLIENT FOR
HYPNOSIS
• Define and explain hypnosis
• Dispel misconceptions, myths, and
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unrealistic goals
• Explore client’s motivation and attitude of
cooperation.
• Explore previous hypnosis.
• Explain realerting
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HYPNOTIC PHENOMENA
Characteristics of Hypnosis
• Concentration
• Relaxation
• Trance Logic
• Concrete Thinking
• Perception of Different
State
• Increased Physiologic
Control
• Responsivity
ASCH SOT, 2010
Hypnotic Phenomena
• Rapport
• Ideosensory
Activity
• Dissociation
• Time Distortion
• Induced Dreams
• Hallucination
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Catalepsy
Ideomotor Activity
Depersonalization
Memory modification
Age Pro/Regression
Somnambulism
Structure of Hypnotic Session
• I.
• II.
• III.
• IV.
• V.
Induction
Deepening/ Trance Ratification
Suggestion/Exploration/
Treatment
Alerting
Debriefing
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What is Suggestibility?
Hypnotizability?
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Nature of Susceptibility/Suggestibility vs.
Hypnotizability
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Involves varying talents or skills, including
imaginative involvement, dissociation, and
capacity to be “absorbed” in an experience.
Involves varying capacities to achieve
degrees of “depth”.
Involves alterations in states of
consciousness or willingness to enter into
social contract.
ASCH SOT, 2010
Classic Suggestion Effect
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A sense of involuntariness
It was like magic
Unconscious response
An experience that seems “automatic”
May not recall the hypnotic session
(amnesia)
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Signs Of Increased Suggestibility /Trance
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pupils dilate
eyes defocus
eyelid fluttering
ocular tearing
facial muscles relax
bottom lip fuller (circumoral pallor)
breathing regular (usually shallow and slow), thoracic to
diaphragmatic
in adults, lack of gross body movements, lethargy
jerky movements
“inability” / disinclination to talk
literalness (You can halve your pain or you can have it)
latency of response (time lag)
heightened sensory awareness
clarity of thought
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“It is possible to create a very
grave disease by acting on
the vital principal of the
imagination and to cure it the
same way.”
Dr. Samuel Hahnemann
Organon of Medicine, 1842
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ASSESS HYPNOTIZABILITY
Assessment Tools
• Use of standard measures. (Optional)
Stanford Scales of Hypnotic Susceptibility:
Forms A, B, C. (Hilgard &Weitzenhoffer)
Harvard Group Scales of Hypnotic
Susceptibility (Shor & Orne)
Hypnotic Induction Profile (HIP) (Spiegel/clinical)
• Use of non-standard measures.
Direct or indirect?
Establish motivation? Set up for success?
Address resistance issues- conscious or
unconscious?
ASCH SOT, 2010
Why assess?
• “…the goal of measuring is to have a
disciplined way of to assess
hypnotizability, which can facilitate more
accurate diagnosis of normal personality
styles and mental illness and help
clinicians make more rational choices for
effective treatment strategies…”
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Spiegel & Greenleaf 2005/2006
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Reasons to Test
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Increase confidence that success is related
to hypnosis
Predict some effect of suggestion (drug
hypersensitivity with anxious patients)
Aid therapeutic alliance by staying within
parameters of patient’s capacity to respond,
though boundaries can be extended in
course of treatment
Adds to clinical assessment of patient
ASCH SOT, 2010
Reasons not to do formal testing
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May prolong establishment of rapport
Standardization (in contrast to
personalization) of inductions may not work,
and establish negative expectancy
Doesn’t identify how patient will use
hypnosis (phenomenology/subjectivity)
Low scores more lead to conclusion that one
isn’t hypnotizable
Dependent upon observable behavior
ASCH SOT, 2010
HIP measures
• 75% have trance capacity
• 20% low
• 48% midrange
• 7% high
• 25% no capacity
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STAGES OF HYPNOSIS,
METHODS OF DEEPENING
Depth
• “The ‘trance’ state is regarded as having
the property of ‘depth’ and can be
measured by subjective report using
simple numerical scales (Tart) and more
qualitatively by self report questionnaires
(Pekala & Kumar)”…or we can “infer depth
from the subject’s response to different
suggestions”
ASCH SOT, 2010
STAGES AND DEPTHS OF
HYPNOSIS
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LIGHT TRANCE
Slower breathing, eyelid and limb catalepsy,
observable relaxation, feelings of lethargy.
MEDIUM TRANCE.
Partial and glove anesthesia, partial age
regression, good mental imagery, time distortion.
DEEP TRANCE. (SOMNAMBULISM)
Full age regression, positive and negative
hallucinations, extensive anesthesia, spontaneous
amnesia. Smell and taste changes.
PLENARY TRANCE. (STUPOROUS)
No awareness of physical body, timelessness,
great decrease in pulse and respiration, being
one with the universe.
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Depth of
Trance
Light trance
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LETHARGY
RELAXATION
EYE CATALEPSY
ARM CATALEPSY
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Tart Scale
Depth of Hypnosis
0 Awake and alert
1 Borderline between sleep and awake
2 Lightly hypnotized
3
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5 Quite strongly hypnotized
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8 Really very hypnotized
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10 Very deeply hypnotized- experience anything suggested
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BRAIN RESEARCH
What Happens to the Brain during Hypnosis?
Although hypnosis is commonly induced with suggestions for relaxation and
even sleep, brain activity in hypnosis more closely resembles that of a person
who is awake.
The discovery of hemispheric specialization, with the left hemisphere geared
to analytic and the right hemisphere to non-analytic tasks, led to the
speculation that hypnotic response is somehow influenced by right-hemisphere
activity.
Studies employing both behavioral and electrophysiological mechanisms have
been interpreted as indicating increased activation of the right hemisphere of
the brain among highly hypnotizable individuals, but positive results have
proved difficult to replicate and interpretation of these findings remains
controversial.
Zastrow, 2010
fMRI Neurostructure theory
Rainville and his associates showed that strategically worded suggestions can
dissociate the two components of pain, selectively altering one but not the other.
(Rainville, Duncan, Price, Carrier, & Bushnell, 1997).
The two components of pain have different biological substrates: sensory pain in the
primary somatosensory cortex, and suffering in the anterior cingulate cortex.
Zastrow, 2010
fMRI Neurostructure theory
Cerebral activation during hypnotically induced and imagined pain.
Derbyshire, Stuart W G. Whalley, Matthew G. Stenger, V Andrew. Oakley, David A.
Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA
15213, USA. [email protected]
Neuroimage. 23(1):392-401, Sept. 2004.
….In contrast with imagined pain, functional magnetic
resonance imaging (fMRI) revealed significant changes during
this hypnotically induced (HI) pain experience within the
thalamus and anterior cingulate (ACC), insula, prefrontal, and
parietal cortices.
These findings compare well with the activation patterns
during pain from nociceptive sources and provide the first
direct experimental evidence in humans linking specific neural
activity with the immediate generation of a pain experience.
Zastrow, 2010
fMRI Neurostructure theory
Clinical Hypnosis Modulates Functional Magnetic Resonance Imaging
Signal Intensities and Pain Perception in a Thermal Stimulation
Paradigm
Schulz-Stubner S, Krings T, Meister IG, Rex S, Thron A, Rossaint R.
Regional Anesthesia and Pain Medicine, Vol 29, No 6 (November-December, 2004: pp
549-556
We can speculate on the basis of our findings of increased BOLD
signals in the left hemispheric ACC and the basal ganglia and less
activation of the classic pain network under hypnosis that the left
ACC and basal ganglia might play a role in increasing inhibitory
signals, which in turn may lead to a loss of signal from painful thermal
stimuli in the more proximal sensory cortex.
Zastrow, 2010
Zastrow, 2010
fMRI Neurostructure theory
Clinical Hypnosis Modulates Functional Magnetic Resonance Imaging
Signal Intensities and Pain Perception in a Thermal Stimulation
Paradigm
Schulz-Stubner S, Krings T, Meister IG, Rex S, Thron A, Rossaint R.
Regional Anesthesia and Pain Medicine, Vol 29, No 6 (November-December, 2004: pp
549-556
Conclusion: Clinical hypnosis may prevent nociceptive inputs
from reaching the higher conical structures responsible for pain
perception. Whether the effects of hypnosis can be explained by
increased activation of the left anterior cingulate cortex and the
basal ganglia as part of a possible inhibitory pathway on pain
perception remains speculative given the limitations of our study
design.
Zastrow, 2010
The anterior cingulate cortex contains distinct areas dissociating
external from self-administered painful stimulation: a parametric
fMRI study.
Mohr, C. Binkofski, F. Erdmann, C. Buchel, C. Helmchen, C.
Neuroimage Nord (NIN), Department of Neurology, University of Lubeck, Ratzeburger Allee 160,
23538 Lubeck, Germany.
Pain. 114(3):347-57, 2005 Apr.
The anterior cingulate cortex (ACC) has a pivotal role in human pain
processing by integrating sensory, executive, attentional, emotional, and
motivational components of pain.
Zastrow, 2010
Cognitive modulation of pain-related ACC activation has been shown by hypnosis, illusion and
anticipation. The expectation of a potentially noxious stimulus may not only differ as to when but also how
the stimulus is applied. These combined properties led to our hypothesis that ACC is capable of
distinguishing external from self-administered noxious tactile stimulation. Thermal contact stimuli with
noxious and non-noxious temperatures were self-administered or externally applied at the resting right
hand in a randomized order. Two additional conditions without any stimulus-eliciting movements served as
control conditions to account for the certainty and uncertainty of the impending stimulus. Calculating the
differences in the activation pattern between self-administered and externally generated stimuli revealed
three distinct areas of activation that graded with perceived stimulus intensity: (i) in the posterior ACC with
a linear increase during external but hardly any modulation for the self-administered stimulation, (ii) in the
midcingulate cortex with activation patterns independent of the mode of application and (iii) in the
perigenual ACC with increasing activation during self-administered but decreasing activation during
externally applied stimulation.
These data support the functional segregation of the human ACC: the
posterior ACC may be involved in the prediction of the sensory
consequences of pain-related action, the midcingulate cortex in pain
intensity coding and the perigenual ACC is related to the onset uncertainty
of the impending stimuli.
Zastrow, 2010
pain intensity coding
prediction of the sensory
consequences of pain-related
action
the onset uncertainty of the impending stimuli
Zastrow, 2010
Amir Raz Phd
Hypnotic suggestion reduces conflict in the human brain
Amir Raz†, Jin Fan‡, and Michael I. Posner
Sackler Institute for Developmental Psychobiology, Weill Medical
College of Cornell University, New York, NY 10021
Contributed by Michael I. Posner, April 13, 2005
Functional MRI data revealed that under
posthypnotic suggestion, both ACC and
visual areas presented reduced activity
in highly hypnotizable persons
compared with either no-suggestion or
less-hypnotizable controls.
Zastrow, 2010
Stroop
In the Stroop task, experienced readers are asked to name the ink color of a
colored word. In responding to the ink color of an incompatible color word (eg,
the word BLUE displayed in red ink), subjects are usually much slower and less
accurate than in identifying the ink color of a control item (eg, XXXX or SHIP
printed in red). This is called the Stroop Interference Effect (SIE), and it is one of
the most robust and well-studied phenomena in attention research.
Reading words is considered to be automatic; a proficient reader cannot withhold
accessing a word's meaning, despite explicit instructions to attend only to the ink
color. Therefore it is the "gold standard" of automated performance.
Zastrow, 2010
Stroop
A simple strategy-free posthypnotic suggestion to circumvent reading within
a classical Stroop design using 32 proficient readers of English naive to the
Stroop task, recruited from a medical students at Cornell University.
Sixteen hypnosis subjects scoring in the highly suggestible range and 16
control subjects scoring in the less-suggestible range on the SHSS-C were
recruited.
Zastrow, 2010
Stroop
Suggestion
Very soon you will be playing the computer game. When I clap my hands,
meaningless symbols will appear in the middle of the screen. They will feel
like characters of a foreign language that you do not know, and you will not
attempt to attribute any meaning to them. This gibberish will be printed in
one of 4 ink colors: red, blue, green or yellow. Although you will only be able
to attend to the symbols' ink color, you will look straight at the scrambled
signs and crisply see all of them. Your job is to quickly and accurately
depress the key that corresponds to the ink color shown. You will find that
you can play this game easily and effortlessly.
Zastrow, 2010
Stroop
Functional MRI data revealed that under
posthypnotic suggestion, both ACC and
visual areas presented reduced activity
in highly hypnotizable persons
compared with either no-suggestion or
less-hypnotizable controls.
Zastrow, 2010
pain intensity coding
Hypnosis works here
prediction of the sensory
consequences of pain-related
action
the onset uncertainty of the impending stimuli
Zastrow, 2010
Amir Raz, Ph.D.
"At least for highly suggestible people, words framed
as part of a carefully-crafted suggestion can change
focal brain activity in a way no drug we have can do"
Zastrow, 2010
SELF-HYPNOSIS
“All Hypnosis Is Self-Hypnosis”
Milton Erickson, 1948
ASCH SOT, 2010
Self-Hypnosis Defined
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Private, internal trance experience
Altered state of consciousness
Focused attention
Inner absorption
Communication between conscious and
unconscious mind
• Patient-initiated experience of hypnosis
independent of therapist
• Experience of self-control and self-efficacy
outside of office
ASCH SOT, 2010
Why Learn Self-Hypnosis?
• Authenticity
• Developing a repertoire
• Sensitivity while “doing hypnosis”
• to our own states of awareness
• to patient/client’s states of
awareness
• Help ourselves cope!
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Helping Ourselves
• Getting back to sleep
• Coping with clinical schedules &
problems
• Changing our own habits
• Alleviating symptoms of stress
• Remembering to do hypnosis
• Rapport, rapport, rapport
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Patient- Specific Goals for
Self-Hypnosis:
Decrease:
Improve:
Stress / Tension
Jaw Clenching / Teeth
Grinding
Fears / Anxieties
/Phobias
Pain
Allergies / Asthma
Skin Problems
Sleeping Problems
Smoking Cessation
Weight Loss
Sports / Music / Acting
Performance
Test Taking
Self-Confidence
Self-Exploration
Parenting
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Application
• Reinforcement of goals for change in behavior
/ cognition / emotion
• Amelioration of physical symptoms
• Stress reduction
• Self-relaxation
• Self-control
• Self-efficacy
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Teach Self Hypnosis
Separate
learning hypnosis
from the presenting problem.
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Introduction of Self-Hypnosis
• After orientation to hypnosis
• After positive trance experience
• After exposure to hypnotic
phenomena
• After development of induction/
deepening skills
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Stages to Teaching SelfHypnosis
Operator fully coaches all steps of
hypnotic experience for patient
Operator only gives reminders of
steps
No Operator involvement – Patient
self-guides hypnotic experience
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Operator/ Coach can
• Manage expectations
• Emphasize skill-building
• Be permissive
• Collaborate on suggestions
• Develop positive suggestions
• Give permission to correct suggestions as
needed
• Elicit feedback about hypnosis experience
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“ There is no such
thing as a failure.”
Brown/Fromm, 1986
ASCH SOT, 2010
TREATMENT PLANNING,
STRATEGY AND
TECHNIQUE SELECTION
The symptom
is the solution
ASCH SOT, 2010
Evaluate, Educate and Assess
• Presenting problem, (complexity/intensity)
• Patient diagnosis, ego strength, hypnotic
talent, motivation, insight, previous
hypnotic experiences, beliefs
• Rapport- therapeutic relationship
ASCH SOT, 2010
Getting Started
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Assess the patient’s willingness to work with
hypnosis. (motivation- both conscious and
unconscious, rapport)
Assess the patient’s capacity for hypnosis.
(talent, ego strength)
Address patient’s expectations. (previous
hypnotic experiences, beliefs)
Determine type/s of treatment and how to
integrate hypnosis into it/them.
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So What, Now What
• What is the client’s metaphor for his/her
presenting problem?
• What words does the client use to
describe the problem?
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• “Patient acceptance of the hypnotic
relationship is the primary
determinant of the appropriateness
of the patient for hypnosis.”
Murray-Jobsis, 1993
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ASK
the client/patient
• What outcome do you want?
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Strategy Selection
• Supportive/ ego-strengthening
• Symptomatic:
amelioration
substitution
desensitization
direct/indirect suggestions
• Uncovering, insight oriented, exploratory
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Treatment Planning
Intervention Strategies
Hypnoprojectives: e.g., reading a book,
seeing a scene, meeting the inner self,
message in a cloud, etc.
Creating amnesia: common examples of
forgetting, direct suggestion (advantageous
to do in mid-trance)
Hypernesia: focus intently on an
experience: physical or emotional, acute
recall
ASCH SOT, 2010
Treatment Planning
Intervention Strategies
Analgesia/Anesthesia: (Emotional) Reduce
emotional pain: anger, grief, sadness,
anxiety, shame, etc
Time Regression: take them back to an
earlier time, before symptoms
Time Progression: go forward in time to
when problem resolved; Future pacing
Presupposition: not whether change will
happen, but when?
ASCH SOT, 2010
Treatment Planning
Intervention Strategies
Anecdotes/Metaphor: “My friend John technique,”
Telling stories not only bypasses conscious
scrutiny of the suggestions, but also makes
universal and/or normalizes the client’s dilemma.
Direct Suggestion: Overt communication to the
client regarding the desired response.
Indirect Suggestion: Covert communication
aimed at bypassing conscious scrutiny, and
working more directly with the unconscious.
ASCH SOT, 2010
Contraindications
• Do not use hypnosis with any presenting problem you
are unprepared to treat without hypnosis.
• Hypnotic uncovering work:
caution with fragile ego-strength, extreme emotional
lability, tenuous control, thought disorder, some
medically impaired patients (e.g., organic brain
syndromes).
• Indiscriminate removal of organic pain (can cloud
symptoms, cause further harm)
• Indiscriminate removal of neurotic symptom
• Assess potential for abuse of hypnotic skill by client.
ASCH SOT, 2010
Ethics
ASCH Code of Conduct
• Representation of one’s hypnosis services to the public
• Practicing within the bounds of one’s license and
discipline
• Responsibility for public education
• Continuing education
• Informed consent
• Teaching hypnosis to others
ASCH SOT, 2010
Hypnosis Ethical Issues
• Issue of lay hypnotist (stigma, image)
• Only use hypnosis in areas would be
prepared to treat without hypnosis
• Hypnotic relationships are professional
relationships, even in context of
workshops
ASCH SOT, 2010
Applications
Applications:
Psychology & Psychotherapy
Applications of Hypnosis
• Relaxation/stress
reduction
• Anxiety
• Depression
• Pain management
surgery, chronic
conditions, oncology
• Gynecological
• Dermatological
•
•
•
•
•
•
Obesity
Smoking Cessation
Addictions
Habit disorders
Phobias
Psychosomatic
illness
• Dissociative
disorders
Linden & Draeger-Muenke, 2010
Hypnosis can
•
•
•
•
•
Be utilized with any theoretical approach
Augment and facilitate treatment
Strengthen ego-functioning
Facilitate pain management
Be used adjunctively for acute or chronic
illness
Linden & Draeger-Muenke, 2010
Hypnotic Applications In Psychotherapy
• General Considerations in Psychotherapy:
Hypnosis is universally used to support ego enhancement
and typically is used to augment the therapeutic alliance.
• Psychodynamic:
Hypnosis used to augment transference clarification and
resolution.
Helps in identifying and resolving unresolved childhood
trauma.
• Client Centered:
Hypnosis used to support reality testing.
Suggestion used to reinforce, support and assist in cognitive
restructuring.
Linden & Draeger-Muenke, 2010
Hypnotic Applications In
Psychotherapy
• Interpersonal Psychotherapy
Hypnosis used to improve interpersonal skills.
Suggestion used to clarify feeling states, improve
interpersonal communication.
• Cognitive Therapy
Hypnosis used in identifying and altering cognitive
distortions that maintain symptoms.
• Crisis Intervention Treatment/Trauma
Hypnosis used to augment fragile ego state, interpersonal
resources and gain perspective of traumatic experience.
Linden & Draeger-Muenke, 2010
Hypnotic Applications In Psychotherapy
• Systems Approaches
Hypnosis used to address boundary and hierarchical
difficulties.
Typically used to increase flexibility and problem solving
within the system.
Modifies maladaptive behaviors that have contributed to
system breakdown.
• Behavior Therapy
Hypnosis used as part of relaxation training and
augmenting improved social and assertiveness skills.
Can be used for graded exposure, flooding, modeling and
positive reinforcement.
Linden & Draeger-Muenke, 2010
Applications:
Medical & Psychological
Applications:
Medical & Psychological
Hypnosis for Pain Management
Applications of Hypnosis
for Pain Management
• Symptom relief vs. life style changes
Patterson, 2010
Quick Induction for Acute Pain
David R. Patterson, Ph.D.
• Have subject relax, sit comfortable and elicit cooperation.
• Subject rolls eyes up to look at point on forehead, takes a deep breath,
closes eyelids while eyes are still rolled up and then lets go of breath.
• Suggest to subject that arm is becoming lighter, take arm and suspend in
air.
• Suggest that lowering arm deepens comfort and placement in lap suggests
deep relaxation.
• “When you are at an ideal state of comfort, your mind will signal you by
allowing this finger to raise in the air as if it is being pulled by a string.”
Patterson, 2010
Quick Induction for Acute Pain (con’d)
• “When you know at a very deep level what you need to do
to control your comfort level, your mind will signal you by
allowing this finger to raise in the air as if it is being pulled
by a string.”
• “When you are ready to begin returning to an awake state,
your mind will signal by allowing the same finger to raise.”
• “I am going to count from five to one. When I reach one,
your eyes will open, but only when your mind knows that
you are feeling alert, comfortable, safe and relaxed.”
Patterson, 2010
Rapid Induction Analgesia
Barber, 1977
• Cooperation
• Seeding/Priming
• Deepening (stairs, counting, indirect suggestions,
relaxation)
• Confusion
• Post-hypnotic suggestions/anchoring
• Alerting
Patterson, 2010
Hypnotic Anesthesia
• Difficult to achieve
• Can be accomplished indirectly by building
psychological and emotional situations that
are contradictory to the experience of pain
Patterson, 2010
Hypnotic Analgesia
• Can be partial, complete or selective
• Sensory modifications can be introduced into
patients’ subjective experience (e.g.,
relaxation, numbness, warmth, heaviness)
Patterson, 2010
Amnesia
• Suggestions to forget about pain
• Amnesia can be partial, selective or complete
• “You may find that you become so absorbed in
this pleasant activity that you forget
everything else.”
Patterson, 2010
Direct suggestions for Total Abolition
of Pain
• Can be the most effective approach with
some patients
• Can often fail and discourage patients
• Often limited in duration
Patterson, 2010
Displacement of Pain
• Pain is displaced from one area of the body to
another
• Can be moved to a body area that is less
threatening or functionally limiting
Patterson, 2010
Hypnotic Time Distortion
• Duration of time the patient is in pain is
reduced (e.g., 10 minute episodes are reduced
to 10 or 15 seconds)
Patterson, 2010
Reinterpretation of Pain Experience
• Pain is reinterpreted as another, less
unpleasant sensation (e.g., unbearable pain
is reinterpreted as an itching mosquito bite)
• Meaning of pain can be reinterpreted (e.g.,
pain means patient is alive or healing in
some cases)
Patterson, 2010
Hypnotic Dissociation
• Time disorientation (e.g., reorienting patient
to a time earlier in illness when pain was less
• Body disorientation (e.g., patients induced to
experience themselves apart from their
bodies
Patterson, 2010
Pacing Induction
•
•
•
•
Pace (truism)
Pace (truism)
Pace (truism)
Leading statement
Patterson, 2010
Giving Suggestions
•
•
•
•
Option A
Option B
Option C
Forced Choice
Patterson, 2010
Applications:
Medical & Psychological
Hypnosis for Headaches
Migraines
There are two forms of migraine: Classical (with aura)
and Common (without aura).
Eighty percent of migraine patients do not have aura,
the remaining twenty percent have aura.
Migraine affects twenty-two percent of the population
in the north central United States and women suffer
from the disease three times more than men. 64%
were age 20 or younger when they first experienced
headaches/migraine attacks.
The average age of migraine onset is 20 and migraine
diagnosis was 25.
Zastrow, 2010
Migraines Prevalence
Migraine affects 17% of females and 6% of males in the United
States. Before puberty, the prevalence of migraine is similar
between the sexes or higher in boys than in girls.
In individuals older than 12 years, the prevalence increases in both
males and females, and the incidence declines in individuals older
than 40 years, except for women in perimenopause.
The female-to-male ratio increases from 2.5:1 at puberty to 3.5:1 at
the age of 40 years, after which it declines. The incidence of
migraine in females of reproductive age increased over the last 20
years.
In the United States, white women have the highest incidence of
migraine, whereas Asian women have the lowest incidence.
Currently, 1 of 6 American women has migraine headaches.
Zastrow, 2010
Diagnosis
The diagnosis of migraine is a clinical diagnosis based on criteria established
by the International Headache Society (IHS).
Some patients describe a prodromal phase as early as 48 hours before the
headache. This phase includes irritability, depression, frequent yawning, or
hyperexcitability.
The headache itself is usually described as throbbing or pulsatile. It is usually
unilateral, but the side affected in each episode may be different. The headache
usually lasts 6-24 hours. During a headache, patients prefer to lie quietly in a
dark room. Nausea, vomiting, photophobia, phonophobia, irritability, and malaise
are common.
A history of certain triggers can be elicited. Common triggers include certain
foods (eg, chocolate, cheese, oranges, tomatoes, onions, monosodium
glutamate [MSG], aspartame, red wine, alcohol), hormonal changes (eg,
menstruation, ovulation, oral contraceptives, hormone replacement), head
trauma, physical exertion, fatigue, medications (eg, nitroglycerine, histamine,
reserpine, hydralazine, ranitidine, estrogen), and stress.
Migraine with aura (ie, classic migraine) includes several premonitory visual
symptoms that occur as early as 60 minutes before the headache phase. These
symptoms include flashes of light (photopsia) and wavy linear patterns on the
visual fields (fortification spectra), migrating scotoma, or blurred vision. Other
nonvisual prodromata have been described as well.
Zastrow, 2010
Diagnosis
In the elderly, a stereotypical series of prodrome-like symptoms may entirely
replace the migrainous episode. This series is known as late-life migrainous
accompaniments.
If the headache is always on 1 side, a structural lesion needs to be excluded by
imaging studies. Having a history of recurrent typical attacks and determining the
provoking agent are important because a secondary headache can mimic
migraine.
A new headache, even if it appears typical by its history, should always suggest a
broad differential diagnosis and the possibility of a secondary headache. The most
common symptoms are: nausea, sensitivity to bright light, loud noise, and
sometimes smells. Other symptoms during a severe migraine attack include:
vomiting, abdominal pain, blurred vision and/or tunnel vision, changes in skin color
and temperature between sides of the face, tenderness of the blood vessels in the
temple, and neck stiffness.
Zastrow, 2010
Impact of Migraine
Those surveyed reported their life was disrupted for an average of 19 hours
during an attack and they missed an average of six days of activities over
the past three months due to migraine.
83% reported their migraine attacks were “extremely” or “very” bothersome
and among employed respondents, one third (32%) reported that migraine
attacks have interfered with their career advancement “a great deal” or
“somewhat.”
62% of all respondents reported that migraine greatly affects their ability to
participate in exercise or sports activities, and 52% said their
social/recreational activities are limited.
Nearly half reported migraine greatly affects their ability to drive a car (45%),
travel (43%), interact with family and friends (42%) and make/keep plans
(42%).
Employed respondents reported one day of missed work every three months
because of migraine.
Zastrow, 2010
Impact
A migraine attack can last anywhere from four hours to three days and can occur
multiple times a month. They can strike with no warning and often force people to
postpone or cancel plans.
In fact, almost 60 percent of people with migraine miss family or social activities due
to an attack and 67 percent report a 50 percent decrease in their ability to complete
household chores.
Fifty-one percent report reduced productivity at work/school.
Approximately 53 percent of attacks require bed rest; overall, migraine attacks are
associated with an estimated 112 million bedridden days per year.
Approximately 80 million workdays are compromised due to reduced productivity.
Migraine attacks cost $13 billion in missed workdays and reduced productivity and
$1 billion in direct medical costs.
Zastrow, 2010
Abortive Medication Stratification by
Severity
Moderate
NSAIDs
Isometheptene
Ergotamine
Naratriptan
Rizatriptan
Sumatriptan
Zolmitriptan
Almotriptan
Frovatriptan
Dopamine
antagonists
Severe
Naratriptan
Rizatriptan
Sumatriptan (SC,NS)
Zolmitriptan
Almotriptan
Frovatriptan
DHE (NS/IM)
Ergotamine
Dopamine
antagonists
Zastrow, 2010
Extremely Severe
DHE (IV)
Opioids
Dopamine
antagonists
Major Prophylactic Medications
5-HT2 antagonism - Methysergide
Regulation of voltage-gated ion channels - Calcium channel blockers
Modulation of central neurotransmitters - Beta-blockers, tricyclic
antidepressants
Enhancing GABAergic inhibition - Valproic acid, gabapentin
Alteration of neuronal oxidative metabolism by riboflavin
Reducing neuronal hyperexcitability by magnesium replacement.
Zastrow, 2010
Cluster Migraines
Rare, affecting approximately 0.1% of the population
Excruciatingly severe pain on one side of the head, usually
centered around the eye.
The pain is often described as boring or stabbing and is often
likened to someone plunging a red hot poker into the eye.
The pain can spread into the temple, jaw and neck area.
The pain escalates very rapidly going from zero to debilitating in 5
to 10 minutes and stops as quickly as it starts with attacks last
between 15 minutes and 3 hours.
One or more of several physical reactions accompany the pain,
always on the same side as the pain. These include watery eye,
runny and/or stopped up nose, red/bloodshot eye, a drooping
eyelid, forehead and facial sweating and irritability.
Zastrow, 2010
Cluster Migraines
Attacks can occur from once every other day to eight
times per day, usually at the same times each day.
An attack will wake a sufferer from a sound sleep.
Unlike with a migraine, a sufferer cannot lay down during
an attack. Instead, he or she will usually pace the floor, sit
rocking back and forth, bang their head on the floor or
wall, curse, scream and cry from the pain. Also, unlike
migraine, light and sound usually have no effect on the
attack, though there are exceptions to every rule.
Zastrow, 2010
Cluster Migraines
Two sub-groups - Episodic and Chronic.
In Episodic the sufferer usually has attacks every day for several
weeks to several months followed by several months to a year or
more between cycles.
Chronic sufferers get no such break. They suffer day in and day out
for years.
There is currently no cure and treatment is hit and miss at best. What
works for one sufferer may or may not work for another. Treatments
that worked last cycle may not work during the next. Treatments that
have not worked in the past, may work during future cycles.
Zastrow, 2010
Cluster Migraines Treatments
Tryptans
High Flow Oxygen
Beta Blockers
DHE
Lithium
Tricyclics
Verapamil
Zastrow, 2010
Daily Tension Headaches
Usually Daily.
Worsen as the day progresses.
Starts typically in the shoulders and neck and will go up over the top of
the head to the cranium and usually are diffuse.
Seem better on less stressful days or on vacation.
Better with anti-anxiety medicine or muscle relaxer.
Responds to behavior modification.
Zastrow, 2010
Rebound headaches
A certain group of migraine patients have persistent daily headache of mild
to moderate severity which they are unable to break.
When a migraine patient takes these analgesics on a regular basis, more
often than two days a week, the body changes the way it handles these
drugs and chronic daily headache develops.
The treatment of chronic daily headache involves withdrawal and
detoxification from the analgesic product.
Midrin and Darvocet are common offenders.
Zastrow, 2010
Trigeminal Neuralgia
Zastrow, 2010
Zastrow, 2010
Trigeminal Neuralgia
It is often caused by an injury to the end of the Trigeminal nerve by some
type of trauma, most often a dental procedure, a blow to the face or
after.
The pain is usually constant, but can fluctuate in intensity. The pain is
usually described as burning, aching or tightness.
Many times numbness is present.
Zastrow, 2010
Trigeminal Neuralgia
It was first described in medical literature as early
as 1672.
AKA Tic Douloureux.
It is often misdiagnosed as a toothache or TMJ
and many people go undiagnosed for years.
But some people are diagnosed with classic
trigeminal neuralgia when they have a
neuropathic pain.
Zastrow, 2010
Other Headaches
•
•
•
•
•
•
temporal arteritis
space-occupying intracranial lesions
meningeal irritation
meningitis,
lumbar puncture headache
muscular tension referred pain from cranium, neck,
eyes, or ears
• pseudotumor cerebri (benign intracranial
hypertension)
• psychiatric conditions
Zastrow, 2010
Headache Research
Cognitive and behavioral treatment recommendations.
– • Relaxation training, thermal biofeedback combined with relaxation training,
electromyographic biofeedback, and cognitive-behavioral therapy may be
considered as treatment options for prevention of migraine (Grade A). Specific
recommendations regarding which of these to use for specific patients cannot
be made.
– • Behavioral therapy may be combined with preventive drug therapy to
achieve additional clinical improvement for migraine relief (Grade B).
– • Evidence-based treatment recommendations regarding the use of hypnosis,
acupuncture, transcutaneous electrical nerve stimulation, chiropractic or
osteopathic cervical manipulation, occlusal adjustment, and hyperbaric
oxygen as preventive or acute therapy for migraine are not yet possible.
Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review)
Report of the Quality Standards Subcommittee of the American Academy of Neurology
Stephen D. Silberstein, MD, FACP, for the US Headache Consortium* From the American Academy of Neurology, St. Paul, MN.
Zastrow, 2010
Hypnosis Research
•
Headache: The Journal of Head and Face Pain
Volume 31 Page 686 - November 1991
doi:10.1111/j.1526-4610.1991.hed3110686.xVolume 31 Issue 10
•
Treatment of Chronic Tension-type Headache With Hypnotherapy: A Single-blind
Time Controlled StudyPatricia M.L. Melis , M.S. , Wilma Rooimans , M.S. , Egilius
L.H. Spierings , M.D.,Ph.D. and Cornelis A.L. Hoogduin , M.D., Ph.D. SYNOPSIS
•
We investigated the effectiveness of a special hypnotherapy technique in the
treatment of chronic tension-type headache. A waiting list control group was used
to control for the changes in headache activity due to the passage of time. The
results showed significant reductions in the number of headache days (p<0.05),
the number of headache hours (p<0.05) and headache intensity (p<0.05). The
improvement was confirmed by the subjective evaluation data gathered with the
use of a questionnaire and by a significant reduction in anxiety scores (p< 0.01).
Zastrow, 2010
Headache Research
Hypnotherapy for migraine has been used since the mid-19th
century (Bernheim 1887, Braid 1843, Esdaile 1850)
Case studies remain the commonest form of justification for its
use (Daniels 1976, Peter 1992).
A few trials of hypnotherapy with other treatment types have
been reported (Andreychuk and Skriever 1975, Stambaugh and
House 1977) or with drug treatment (Anderson et al 1975).
There are very few reported cases of a systematic approach to
the testing of such a process involving significant numbers
(Drummond 1981).
Zastrow, 2010
Headache Research
Matthews M, Flatt S (1999) The efficacy of hypnotherapy in the treatment of migraine.
Nursing Standard. 14, 7, 33-36. Date of acceptance: September 24 1999.
Zastrow, 2010
Matthews M, Flatt S (1999) The efficacy of hypnotherapy in the treatment of migraine.
Nursing Standard. 14, 7, 33-36. Date of acceptance: September 24 1999.
Zastrow, 2010
Headache Research
• Headache: The Journal of Head and Face Pain
Volume 39 Page 101 - February 1999
doi:10.1046/j.1526-4610.1999.3902101.xVolume 39
Issue 2
• Mast Cell Activation in Children With Migraine
Before and After Training in Self-regulationKaren
Olness, MD; Howard Hall, PhD; Jacek J. Rozniecki,
PhD, MD; Wendy Schmidt, OTR/L, MPA; T.C.
Theoharides, PhD, MD
Zastrow, 2010
Migraine may affect as many as 9% of all schoolchildren and often presents with
abdominal symptoms of pain, nausea, and vomiting. Even though the
pathophysiology of migraine remains unknown, self-regulation techniques
appear to be more effective in prevention of childhood migraine than
conventional pharmacotherapy which is often associated with adverse effects.
Mast cells have been implicated in the pathogenesis of migraine in adults, but
have not been previously studied in children with migraine.Mast cells are found
close to the vessels and nerves in the meninges where they can release
multiple vasoactive, neurosensitizing, and pro-inflammatory mediators.
Therefore, we investigated whether children with migraine may have increased
urinary levels of mast cell mediators and whether practicing relaxation imagery
exercises has an effect on the frequency of headache, as well as on mast cell
activation.Urine was collected for 24 hours from children with and without
migraine after a 5-day amine-restricted diet. Children with migraine also
collected urine during migraine episodes. The mean levels of urinary histamine,
its main metabolite, methylhistamine, and the mast cell enzyme, tryptase, were
higher in children than generally found in adults, but they did not differ
statistically in any of the categories studied. However, in 8 of 10 children who
practiced relaxation imagery techniques and successfully reduced the
number of migraines, the urine tryptase levels were also significantly
lower. There was no relationship between successful practice and sex or age of
the child. These results suggest that stress may activate mast cells which could
be involved in the pathophysiology of migraine.
Zastrow, 2010
Applications:
Medical & Psychological
Hypnosis for Irritable Bowel Syndrome
Hypnosis and Irritable Bowel Syndrome
Hypnosis Research In IBS
• Does hypnosis work for IBS?
Zastrow, 2010
Whorwell
Whorwell PJ; Prior A; Faragher EB.
Controlled trial of hypnotherapy in the treatment of severe refractory irritablebowel syndrome.
The Lancet 1984, 2: 1232-4.
placebo-controlled
Thirty patients with severe symptoms unresponsive to other treatment were
randomly chosen to receive 7 sessions of hypnotherapy (15 patients) or 7
sessions of psychotherapy plus placebo pills (15 patients).
The psychotherapy group showed a small but significant improvement in
abdominal pain and distension, and in general well-being but not bowel activity
pattern.
The hypnotherapy patients showed a dramatic improvement in all central
symptom. The hypnotherapy group showed no relapses during the 3-month
follow-up period.
Zastrow, 2010
Zastrow, 2010
Whorwell
Whorwell PJ; Prior A; Colgan SM.
Hypnotherapy in severe irritable bowel syndrome: further experience. Gut,
1987 Apr, 28:4, 423-5.
Further experience with 35 patients added to the 15 treated with hypnotherapy in
the 1984 Lancet study.
For the whole 50 patient group, success rate was 95% for classic IBS cases, but
substantially less for IBS patients with atypical symptom picture or significant
psychological problems.
The report also observed that patients over age 50 seemed to have lower
success rate from this treatment.
Zastrow, 2010
Harvey
Harvey RF; Hinton RA; Gunary RM; Barry RE.
Individual and group hypnotherapy in treatment of refractory irritable bowel
syndrome.
Lancet, 1989 Feb, 1:8635, 424-5.
This study employed a shorter hypnosis treatment course than other studies
for IBS.
Twenty out of 33 patients with refractory irritable bowel syndrome treated
with four sessions of hypnotherapy in this study improved.
Success rate was lower demonstrating that a larger number of sessions is
necessary for optimal benefit.
Groups of up to 8 patients seems as effective as individual therapy.
Zastrow, 2010
Prior
Prior A, Colgan SM, Whorwell PJ.
Changes in rectal sensitivity after hypnotherapy in patients with irritable bowel
syndrome.
Gut 1990;31:896.
IBS patients to be less sensitive to pain and other sensations induced via
balloon inflation in their gut while they were under hypnosis.
Sensitivity to some balloon-induced gut sensations (although not pain
sensitivity) was reduced following a course of hypnosis treatment.
Zastrow, 2010
Houghton
Houghton LA; Heyman DJ; Whorwell PJ.
Symptomatology, quality of life and economic features of irritable bowel
syndrome--the effect of hypnotherapy.
Aliment Pharmacol Ther, 1996 Feb, 10:1, 91-5.
Compared 25 severe IBS patients treated with hypnosis to 25 patients with
similar symptom severity treated with other methods
Significant improvement in all central IBS symptoms,
Fewer visits to doctors, lost less time from work than the control group and
rated their quality of life more improved.
Those patients who had been unable to work prior to treatment resumed
employment in the hypnotherapy group but not in the control group.
The study quantifies the substantial economic benefits and improvement in
health-related quality of life which result from hypnotherapy for IBS on top of
clinical symptom improvement.
Zastrow, 2010
Houghton
Houghton LA, Larder S, Lee R, Gonsalcorale WM, Whelan V, Randles J,
Cooper P, Cruikshanks P, Miller V, Whorwell PJ.
Gut focused hypnotherapy normalises rectal hypersensitivity in patients with
irritable bowel syndrome (IBS).
Gastroenterology 1999; 116: A1009.
Twenty-three patients each received 12 sessions of hypnotherapy.
Significant improvement was seen in the severity and frequency of abdominal
pain, bloating and satisfaction with bowel habit.
A subset of the treated patients who were found to be unusually pain-sensitive
in their intestines prior to treatment (as evidenced by balloon inflation tests)
showed normalization of pain sensitivity, and this change correlated with their
pain improvement following treatment.
Zastrow, 2010
Whorwell PJ. Hypnotherapy for irritable bowel syndrome: the response of colonic
and noncolonic symptoms.
Whorwell, Peter J
Journal of Psychosomatic Research. 64(6):621-3, 2008 Jun.
There is now good evidence that hypnotherapy benefits a substantial proportion of
patients with irritable bowel syndrome and that improvement is maintained for many
years. Most patients seen in secondary care with this condition also suffer from a
wide range of non-colonic symptoms such as backache and lethargy, as well as a
number of musculoskeletal, urological, and gynecological problems. These features
do not typically respond well to conventional medical treatment approaches, but
fortunately, their intensity is often reduced by hypnosis. The mechanisms by which
hypnosis mediates its benefit are not entirely clear, but there is evidence that, in
addition to its psychological effects, it can modulate gastrointestinal physiology, alter
the central processing of noxious stimuli, and even influence immune function.
Zastrow, 2010
Koutsomanis
Koutsomanis D.
Hypnoanalgesia in the irritable bowel syndrome.
Gastroenterology 1997, 112, A764.
This French study with a 6-month and 12-month follow-up.
Less analgesic medication use required and less abdominal pain
experienced by a group of 12 IBS patients after a course of 6-8
analgesia-oriented hypnosis sessions.
Zastrow, 2010
Vidakovic
Vidakovic Vukic M.
Hypnotherapy in the treatment of irritable bowel syndrome: methods and results
in Amsterdam.
Scand J Gastroenterol Suppl, 1999, 230:49-51.
Reports results of treatment of 27patients of gut-directed hypnotherapy
tailored to each individual patient. All of the 24 who completed treatment
were found to be improved.
Zastrow, 2010
Galovski
Galovski TE; Blanchard EB.
Appl Psychophysiol Biofeedback, 1998 Dec, 23:4, 219-32.
Eleven patients completed hypnotherapy, with improvement
reported for all central IBS symptoms, as well as improvement in
anxiety.
Six of the patients were a waiting-control group for comparison, and
did not show such improvement while waiting for treatment.
Zastrow, 2010
Hypnotherapy for irritable bowel syndrome in Saudi Arabian patients.
Al Sughayir MA.
Eastern Mediterranean Health Journal. 13(2):301-8, 2007 Mar-Apr.
Saudi Arabian patients with irritable bowel syndrome.
Patients (n=26) were consecutively recruited at a psychiatry outpatient clinic
after diagnosis by a gastroenterologist and a medical evaluation for irritable
bowel syndrome.
Each patient had 12 sessions of hypnotherapy over a period of 12 weeks.
Patients completed a symptom severity scale before and after 3 months.
Hypnotherapy significantly enhanced a feeling of better quality of life more in
male than in female patients, and bowel habit dissatisfaction was reduced
more in female than in male patients.
Zastrow, 2010
Does this therapy hold up over time?
Zastrow, 2010
Gonsalkorale
Gonsalkorale WM, Houghton LA, Whorwell PJ.
Hypnotherapy in irritable bowel syndrome: a large-scale audit of a clinical
service with examination of factors influencing responsiveness.
Am J Gastroenterol 2002 Apr;97(4):954-61.
Largest case series of IBS patients treated to date.
250 unselected IBS patients treated in Manchester England
12 sessions of hypnotherapy over a 3-month period plus home practice
between sessions.
Marked improvement was seen in all IBS symptoms
IBS severity was reduced by more than half on the average after
treatment
All subgroups of patients appeared to do equally well except males with
diarrhea, who improved far less than other patients.
Zastrow, 2010
Zastrow, 2010
Zastrow, 2010
Hypnotherapy for children with functional abdominal pain or irritable
bowel syndrome: a randomized controlled trial.
Vlieger AM. Menko-Frankenhuis C. Wolfkamp SC. Tromp E. Benninga MA.
Gastroenterology. 133(5):1430-6, 2007 Nov.
A randomized controlled trial and compared clinical effectiveness of HT
with standard medical therapy (SMT) in children with FAP or IBS.
CONCLUSIONS: Gut-directed HT is highly effective in the treatment of
children with longstanding FAP or IBS.
Zastrow, 2010
Fifty-three pediatric patients, age 8-18 years, with FAP (n = 31) or IBS (n = 22),
were randomized to either HT or SMT. Hypnotherapy consisted of 6 sessions
over a 3-month period. Patients in the SMT group received standard medical
care and 6 sessions of supportive therapy.
Pain intensity, pain frequency, and associated symptoms were scored in weekly
standardized abdominal pain diaries at baseline, during therapy, and 6 and 12
months after therapy.
Zastrow, 2010
Pain scores decreased significantly in both groups: from baseline to 1 year
follow-up, pain intensity scores decreased in the HT group from 13.5 to 1.3 and
in the SMT group from 14.1 to 8.0.
Pain frequency scores decreased from 13.5 to 1.1 in the HT group and from
14.4 to 9.3 in the SMT group.
Hypnotherapy was highly superior, with a significantly greater reduction in pain
scores compared with SMT (P < .001). At 1 year follow-up, successful
treatment was accomplished in 85% of the HT group and 25% of the SMT
group (P < .001).
Zastrow, 2010
Gut-directed hypnotherapy for irritable bowel syndrome: piloting a primary
care-based randomised controlled trial.
Roberts, Lesley. Wilson, Sue. Singh, Sukhdev. Roalfe, Andrea. Greenfield, Sheila.
British Journal of General Practice. 56(523):115-21, 2006 Feb.
Department of Primary Care and General Practice, Division of Primary Care, Public and Occupational
Health, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK.
Multicenter Study. Randomized Controlled Trial. Research Support, Non-U.S. Gov't.
Zastrow, 2010
Gut-directed hypnotherapy for irritable bowel syndrome: piloting a primary care-based randomised controlled trial.
Roberts, Lesley. Wilson, Sue. Singh, Sukhdev. Roalfe, Andrea. Greenfield, Sheila.
British Journal of General Practice. 56(523):115-21, 2006 Feb.
Department of Primary Care and General Practice, Division of Primary Care, Public and Occupational Health, University of Birmingham, Edgbaston,
Birmingham B15 2TT, UK. [email protected]
Zastrow, 2010
Zastrow, 2010
Gut-directed hypnotherapy for irritable bowel syndrome: piloting a primary care-based randomised controlled trial.
Roberts, Lesley. Wilson, Sue. Singh, Sukhdev. Roalfe, Andrea. Greenfield, Sheila.
British Journal of General Practice. 56(523):115-21, 2006 Feb.
Department of Primary Care and General Practice, Division of Primary Care, Public and Occupational Health, University of Birmingham, Edgbaston,
Birmingham B15 2TT, UK. [email protected]
Zastrow, 2010
Gut-directed hypnotherapy for irritable bowel syndrome: piloting a primary care-based randomised controlled trial.
Roberts, Lesley. Wilson, Sue. Singh, Sukhdev. Roalfe, Andrea. Greenfield, Sheila.
British Journal of General Practice. 56(523):115-21, 2006 Feb.
Department of Primary Care and General Practice, Division of Primary Care, Public and Occupational Health, University of Birmingham, Edgbaston,
Birmingham B15 2TT, UK. [email protected]
Zastrow, 2010
Gut-directed hypnotherapy for irritable bowel syndrome: piloting a primary
care-based randomised controlled trial.
Roberts, Lesley. Wilson, Sue. Singh, Sukhdev. Roalfe, Andrea. Greenfield, Sheila.
British Journal of General Practice. 56(523):115-21, 2006 Feb.
Department of Primary Care and General Practice, Division of Primary Care, Public and Occupational
Health, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK. [email protected]
Multicenter Study. Randomized Controlled Trial. Research Support, Non-U.S. Gov't.
Both groups demonstrated a significant improvement in all symptom dimensions
and quality of life over 12 months. At 3 months the intervention group had
significantly greater improvements in pain, diarrhoea and overall symptom scores
(P<0.05).
No significant differences between groups in quality of life were identified.
No differences were maintained over time.
Intervention patients, however, were significantly less likely to require medication,
and the majority described an improvement in their condition.
CONCLUSIONS: Gut-directed hypnotherapy benefits patients via symptom
reduction and reduced medication usage, although the lack of significant
difference between groups beyond 3 months prohibits its general introduction
without additional evidence. A large trial incorporating robust economic analysis
is, therefore, urgently recommended.
Zastrow, 2010
What is the mechanism of action?
Zastrow, 2010
Olafur Palsson Ph.D.
http://www.ibshypnosis.com/
http://www.med.unc.edu/medicine/fgidc/
Zastrow, 2010
Palsson
Palsson OS, Turner MJ, Johnson DA, Burnett CK, Whitehead WE.
Hypnosis treatment for severe irritable bowel syndrome: investigation of
mechanism and effects on symptoms.
Dig Dis Sci 2002 Nov;47(11):2605-14.
Patients with severe IBS received seven biweekly hypnosis sessions and
used hypnosis audiotapes at home.
Rectal pain thresholds and smooth muscle tone were measured with a
barostat before and after treatment in 18 patients (study I), and treatment
changes in heart rate, blood pressure, skin conductance, finger
temperature, and forehead electromyographic activity were assessed in
24 patients (study II).
Zastrow, 2010
Palsson
All central IBS symptoms improved substantially from treatment in both
studies.
Rectal pain thresholds, rectal smooth muscle tone, and autonomic
functioning (except sweat gland reactivity) were unaffected by hypnosis
treatment.
However, somatization and psychological distress showed large
decreases.
17 of 18 patients in study 1 and 21 of 24 patients in study 2 were judged
substantially improved Improvement was well-maintained at 10-12 month
follow up in study 2.
Zastrow, 2010
Lea
Lea R, Houghton LA, Calvert EL, Larder S, Gonsalkorale WM, Whelan V,
Randles J, Cooper P, Cruickshanks P, Miller V, Whorwell PJ.
Gut-focused hypnotherapy normalizes disordered rectal sensitivity in patients
with irritable bowel syndrome.
Alimentary Pharmacology& Therapeutics 2003 Mar 1;17(5):635-42.
Twenty-three IBS patients were tested before and after 12 weeks of
hypnotherapy.
Following the course of hypnotherapy, the mean pain sensory threshold
increased in the hypersensitive subgroup and tended to decrease in the
hyposensitive group, although the reduction in gut pain sensitivity was
associated with a reduction in abdominal pain.
These results suggest that hypnotherapy may work at least partly by
normalizing bowel perception in those patients who have abnormal gut
sensitivity, while leaving normal sensation unchanged.
Zastrow, 2010
Is it all in the head?
Zastrow, 2010
Gonsalkorale
Gonsalkorale WM, Toner BB, Whorwell PJ.
Cognitive change in patients undergoing hypnotherapy for irritable bowel
syndrome.
J Psychosom Res. 2004 Mar;56(3):271-8.
Cognitive changes were evaluated in 78 IBS patients who completed a 12session hypnosis treatment course, using the Cognitive Scale for Functional
Bowel Disorders.
Hypnotherapy resulted in improvement of symptoms, quality of life, anxiety and
depression.
Unhelpful IBS-related cognitions improved significantly, with reduction in the total
cognitive score and all component themes related to bowel function.
Overall symptom reduction correlated with an improvement on the cognitive
scale.
Zastrow, 2010
Since there are so few trained medical
hypnotists, does taped hypnosis work?
Zastrow, 2010
Palsson
Palsson OS, Turner MJ, Whitehead WE.
Hypnosis home treatment for irritable bowel syndrome: a pilot study.
Int J Clin Exp Hypn. 2006 Jan;54(1):85-99.
A 3-month home-treatment version of a scripted hypnosis protocol previously
shown to improve all central IBS symptoms was completed by 19 IBS patients.
Outcomes were compared to those of 57 matched IBS patients from a separate
study receiving only standard medical care.
Ten of the hypnosis subjects (53%) responded to treatment by 3-month follow-up
(response defined as more than 50% reduction in IBS severity) vs. 15 (26%) of
controls. Hypnosis subjects improved more in quality of life scores compared to
controls.
Anxiety predicted poor treatment response. Hypnosis responders remained
improved at 6-month follow-up. Although response rate was lower than
previously observed in therapist-delivered treatment, hypnosis home treatment
may double the proportion of IBS patients improving significantly across 6
months.
Zastrow, 2010
Scripts or no scripts?
Zastrow, 2010
Barabasz
Barabasz A, Barabasz M.
Effects of tailored and manualized hypnotic inductions for complicated irritable
bowel syndrome patients.
Int J Clin Exp Hypn. 2006 Jan;54(1):100-12.
Eight IBS patients previously unresponsive to any treatment were assigned
randomly to either the individualized tailored induction or standardized Palsson
script.
The tailored group continued to improve and showed better results than the
standardized group at 10-month follow-up, and the post-treatment emotional
distress had decreased significantly.
Zastrow, 2010
Conclusions: Acupuncture in IBS is primarily a placebo
Zastrow, 2010
response.
American College of Gastroenterology Functional Gastrointestinal
Disorders Task Force
1992
Behavioral therapy is more effective
than placebo at relieving individual IBS
symptoms (Grade B Recommendation)
Level I Evidence: Randomized controlled trials with p values
0.05, adequate sample sizes, and appropriate
methodology
Level II Evidence: Randomized controlled trials with p values
0.05 and/or inadequate sample sizes and/or
inappropriate methodology
Level III Evidence: Nonrandomized trials with
contemporaneous controls
Level IV Evidence: Nonrandomized trials with historical
controls
Level V Evidence: Case studies
Grade A Recommendations: Recommendations supported
by Level I evidence
Grade B Recommendations: Recommendations supported
by Level II evidence
Grade C Recommendations: Recommendations supported
by Level III–IV evidence
Zastrow, 2010
Evidence Based Grade B
• The American College of gastroenterologist rated
behavioral therapy as class B but did not break out
hypnosis by itself.
• This equates to Level II Evidence: Randomized controlled
trials with p values 0.05 and/or inadequate sample sizes
and/or inappropriate methodology
Hypnosis and other behavior modalities were
lumped together.
Zastrow, 2010
Review article Irritable Bowel Syndrome Howard R. Mertz, M.D.
N Engl J Med 2003;349:2136-46.
Zastrow, 2010
Systematic review: the effectiveness of hypnotherapy in the
management of irritable bowel syndrome.
Wilson, S; Maddison, T; Roberts, L; Greenfield, S; Singh, S; Birmingham IBS
Research Group.
Aliment Pharmacol Ther. 24(5):769-80, 2006 Sep 1.
Systematic review the literature evaluating hypnotherapy in the management of
irritable bowel syndrome (IBS).
Eligible studies involved adults with IBS using single-component hypnotherapy
including all studies, except single case or expert opinion.
Out of 299 unique references identified, 20 studies (18 trials of which four were
randomized, two controlled and 12 uncontrolled) and two case series were eligible.
These tended to demonstrate hypnotherapy as being effective in the management of
IBS.
Numbers of patients included were small. Only one trial scored more than four out of
eight on internal validity.
Zastrow, 2010
Systematic review: the effectiveness of hypnotherapy in the
management of irritable bowel syndrome.
Wilson, S; Maddison, T; Roberts, L; Greenfield, S; Singh, S; Birmingham IBS
Research Group.
Aliment Pharmacol Ther. 24(5):769-80, 2006 Sep 1.
CONCLUSION: The published evidence suggests that hypnotherapy is
effective in the management of IBS. Over half of the trials (10 of 18) indicated
a significant benefit.
A randomized placebo-controlled trial of high internal validity is necessary to
establish the effectiveness of hypnotherapy in the management of IBS.
Until such a trial is undertaken, this form of treatment should be restricted to
specialist centers caring for the more severe forms of the disorder.
Zastrow, 2010
Cochrane Database of Systematic Reviews.
Hypnotherapy for treatment of irritable bowel syndrome, 2007.
Webb, A N. Kukuruzovic, R H. Catto-Smith, A G. Sawyer, S M.
Royal Children's Hospital Melbourne, Gastroenterology, Flemington Road, Parkville Victoria 3052,
Melbourne, Australia. [email protected]
MAIN RESULTS: Four studies including a total of 147 patients met the inclusion
criteria. Only one study compared hypnotherapy to an alternative therapy
(psychotherapy and placebo pill), two studies compared hypnotherapy with waitinglist controls and the final study compared hypnotherapy to usual medical
management. Data were not pooled for meta-analysis due to differences in outcome
measures and study design.
The therapeutic effect of hypnotherapy was found to be superior to that of a waiting
list control or usual medical management, for abdominal pain and composite
primary IBS symptoms, in the short term in patients who fail standard medical
therapy.
Harmful side-effects were not reported in any of the trials.
However, the results of these studies should be interpreted with caution due to poor
methodological quality and small size.
AUTHORS' CONCLUSIONS: The quality of the included trials was inadequate to
allow any conclusion about the efficacy of hypnotherapy for irritable bowel
syndrome. More research with high quality trials is needed.
Zastrow, 2010
Zastrow, 2010
A Wolfe in Regulator's Clothing:
Drug Industry Critic Joins the
FDA
JANUARY 9, 2009
A Wolfe in Regulator's Clothing: Drug Industry Critic Joins the FDA
Over three decades, Dr. Wolfe, head of the health group at advocacy organization
Public Citizen that Ralph Nader founded, has helped push 16 drugs off the
market and slap restrictions on several multibillion-dollar products.
He has been so hostile to the FDA under President George W. Bush that he
decried its 100th-anniversary celebration in 2006 as a "propaganda campaign" to
hide its "unprecedented assault on the American public."
Zastrow, 2010
Testimony of Sidney M. Wolfe M.D.
Director, Public Citizen’s Health Research Group
Before FDA Gastrointestinal Drugs and Drug Safety Advisory Committee Hearing
Concerning Alosetron
April 23, 2002
Benefits of Alosetron: Serious Problem with Irritable Bowel Syndrome Studies
Because of Very High Placebo Response Rate
In a review of 27 randomized placebo-controlled studies testing various
treatments for irritable bowel syndrome (see below), the median placebo
response rate was 47% (measured as % improved) with rates as high as 84%
and 11 studies had placebo response rates of 60% or greater. The study
concluded that this placebo response rate was approximately three times the
size of the difference between placebo and drug response (median 16%).
Zastrow, 2010
That this problem of a large placebo response is applicable to
alosetron can be seen in a reanalysis by Public Citizen’s Health
Research Group of Glaxo data that was published in the
Lancet, shown below. The mean pain and discomfort scores
over a three-month period were quite similar in the alosetron
and placebo groups even though there was a statistically
significant difference between the groups as analyzed by Glaxo
and the FDA.
Zastrow, 2010
It is inherently hard to use a placebo blind in hypnosis studies. To date
there are no studies of hypnosis in IBS where one group is given just
an induction and alerted while and another receives active suggestion.
Previous studies on hypnosis and pain control have shown that
Hypnosis, itself has a placebo component.
Given the scientific evidence at hand, should future drug studies in IBS
be done against a hypnotic active group as well as a control group to
more clearly locate how much the drug separates from placebo?
Zastrow, 2010
Conclusions
Often a specific therapy pre-dates the basic science, basic IBS hypnosis research
is catching up to the clinical findings.
High quality trials with standardization are needed.
The therapeutic effect of hypnotherapy was found to be superior to that of a
waiting list control or usual medical management, for abdominal pain and
composite primary IBS symptoms but to what extent is still in question.
The downside risk is minimal to none. This therapy is safe and appears to be long
lasting.
Hypnosis seems to work through the reduction in the perception of pain and
probably has something to do the ACC.
We need to have an fMRI study for IBS hypnosis before and after with a control
group.
Zastrow, 2010
Conclusions
The effectiveness of hypnosis is improved with an individualized personal
approach rather than tapes so more trained therapists will need to be needed.
The symptom reduction is robust at 53-81% improvement and exceeds any
current drug.
We need medication vs hypnosis study as well as placebo.
Lotrenox studies given the high placebo improvement are in question and
ischemic colitis is a serious side-effect. We need an IBS drug studies to run
against an active hypnosis arm.
Hypnosis is not a Svengali movie and the patients do not cluck like chickens!
Zastrow, 2010
Applications:
Medical & Psychological
Hypnosis for Anxiety Disorders
Anxiety Disorders
• Most common psychological disorder
• Comorbid with most disorders
• Four major components of anxiety
–
–
–
–
Physiological reactivity e.g., elevated HR, BP
Affective (subjective) e.g., tense, nervous, agitated
Cognitive (catastrophize, worst happening)
Behavioral (avoidance)
Alladin, 2010
Definition of Anxiety
• Anxiety has to do with future
– Anticipatory anxiety
– Fear of harm, discomfort, embarrassment, loss
of control, and going crazy
• Carl Sagan (astrophysicist – Cosmos)
– Human beings most successful specie
– Ability to think, communicate and plan
– Ability to anticipate
– Catastrophic anticipation
– Origin of neurosis
Alladin, 2010
Treatment of Anxiety Disorders
• Majority of anxiety disorders treated by anxiolytics,
MAOIs, and SSRIs.
• CBT most effective psychotherapy
• Why hypnosis?
– Hypnosis acts as a strong placebo and adds leverage to
treatment
– Adding hypnosis to CBT increases effect size (Alladin &
Alibhai, 2007; Bryant et al., 2005; Kirsch et al.,1995;
Schoenberger, 2002)
Alladin, 2010
The Power of Hypnosis
Hypnosis Adds Leverage to Treatment
Alladin, 2010
Rationale for Combining Hypnosis with CBT
• Hypnosis addresses the 4 components of anxiety
– Controls physiological reactivity (relaxation)
– Increases perceived self-efficacy by increasing
confidence and sense of self-control (via catalepsy
demo, Anchoring Technique)
– Provides prolonged and modulated exposure to fearful
stimuli (S.D., exposure)
– Alters anxious reality (projection, integration)
– Provides a vehicle for unconscious exploration and
restructuring (abreaction, rewriting)
Alladin, 2010
First Goal for Utilizing Hypnosis with Anxiety
Disorders:
Reducing Physiological Reactivity
Alladin, 2010
Hypnosis for Reducing Physiological Reactivity
• Three methods described
– Hypnotic induction of deep relaxation
– Anchoring Technique
– Self-hypnosis
Alladin, 2010
Hypnosis for Reducing Physiological Reactivity
• Hypnotic Induced Relaxation
• Ability to “let go”
• Floating away to a tranquil setting (Spiegel & Spiegel, and
Stanton, in Hammond, 1990, p.157-159)
• Feeling distant from tension-producing sensation
(Finkelstein; Stickney, in Hammond, 1990, p.158-160)
• Age regression to peaceful scenes and times (Field, in
Hammond, 1990, 170-172)
• Can control feelings and sensations
• Ability to control, “mind over body”
• PHS
• Self-hypnosis tape
Alladin, 2010
Catalepsy to Demonstrate Power of Mind
over Body
Alladin, 2010
Hypnosis for Reducing Physiological
Reactivity
• Anchoring Technique
– For generalizing learning to real situations
– Provides situational or positive self-hypnosis
• Anchoring established following amplification of
relaxation and sense of control
• Relaxation and sense of control conditioned to
clenched fist
• Consolidated by PHS
• Utilize as “see-saw” method or “until you tame
the demon”; second nature
Alladin, 2010
Hypnosis for Reducing Physiological
Reactivity
• Self-Hypnosis
– Homework
– Listen to CD
– Counter NSH
Alladin, 2010
Second Goal of Using Hypnosis with
Anxiety Disorders:
Reducing Emotional Reactivity
Alladin, 2010
Hypnosis for Reducing Emotional Reactivity
• Four methods described
– Cognitive restructuring
– Editing the Anxiety File
– Split-Screen Technique
– Unconscious restructuring
Alladin, 2010
Hypnosis for Reducing Emotional
Reactivity
• Cognitive Restructuring
• Two steps
– Self-monitoring of negative cognitions
– Replacement of these cognitions with constructive rational
ones
• Explained in terms of NSH
• Positive self-hypnosis
• Rational therapeutic suggestions formulated through
use of two-column method
Alladin, 2010
Hypnosis for Reducing Emotional Reactivity
Cognitive Restructuring
Sample of Two-Column Method
• Automatic Negative Thoughts
• I will die
Alladin, 2010
•Rational Thoughts
•I may feel anxious, but I will
not die.
•Anxiety is uncomfortable, but it
does not kill.
•I can use self-hypnosis to
control my anxiety.
•Or I can use the Anchoring
Technique.
Hypnosis for Reducing Emotional Reactivity
• Editing and Deleting Old Anxiety files
– Computer metaphor
– Deep trance and ego-strengthening
– Induce positive affect, sense of success, and selfcontrol
– Opening “personal file”
– Edit, delete, or replace file
– PHS
Alladin, 2010
Hypnosis for Reducing Emotional Reactivity
• Split-Screen Technique
–
–
–
–
–
–
–
–
–
Hypnotic induction
Deepening
Intensify positive feeling
Intensify “adult ego” state
Imagine sitting in front of a large split screen (left and
right)
Project adult ego state to right side of screen
Project anxious part to left side of screen
Imagine ego from right side helping left side
Integrate the 2 parts
Alladin, 2010
Hypnosis for Reducing Emotional Reactivity
• Unconscious Restructuring: Hypnotic Regression
– Similar to flooding
– In regression, the stimulus is a traumatic memory
– Indicated when patient can’t provide any information
about the onset of anxiety or phobia
– Client asked to recall events, further and further back
in time
– Reframing procedure
– Rewriting the experience
Alladin, 2010
Hypnosis for Reducing Emotional
Reactivity
• Hypnotic Regression Suggestions
• “And, as you already know, you are able to
remember things when you are in a trance that
you have repressed…memories, events, feelings,
that are related to your problem…And you can tell
me about them now…as you remember them.”
• Golden et al. 1987, cited in Golden, 1994, p.272
Alladin, 2010
Hypnosis for Reducing Emotional Reactivity
• Unconscious Restructuring: Reframing Procedure
–
–
–
–
–
–
–
–
Case of Janet: Situational Panic Attacks
Married, 32 year-old, with 2 children
History of anxiety and panic attacks over 10 years
Referred for psychological treatment by GP
CBT and SD negligible effect on panic attacks
Hypnotic age regression
Fear of trapped and burnt
“Black Magic” acted as trigger
– Reframed to safety and still being alive
Alladin, 2010
Hypnosis for Reducing Emotional Reactivity
• Unconscious Restructuring: Rewriting Experience
– Case of Betty: Fear of Ward Round
– 30 yr-old Resident had public speaking anxiety
– Had such anxiety for many years, became a serious
problem since residency
– On anxiolytics for 3 years, little effect
– Self-referred for hypnotherapy
– Had CBT and relaxation training, little effect
– Age regression – “derobed” by father when 13
– Rewrote experience
Alladin, 2010
Third Goal of Using Hypnosis with
Anxiety Disorders:
Decreasing Avoidance and Increasing Self-Efficacy
Alladin, 2010
Hypnosis for Decreasing Avoidance and
Increasing Self-Efficacy
• Hypnotic Systematic Desensitization (SD)
– In SD, client confronts fear, or phobia, in a gradual one
step-at-a-time manner
– A Hierarchy is constructed where the phobia is broken
down into steps
– Steps rank-ordered from least to most anxietyproducing
– Each item of the hierarchy rated on a Subjective Units
of Distress Scale (SUDS)
– From 1-100, where 100 is most anxiety-producing
Alladin, 2010
Hypnosis for Decreasing Avoidance and Increasing
Self-Efficacy
John’s Anxiety (flying phobia) Hierarchy with SUDS
• Situation
SUDS
• 1. Looking at travel brochure
30
• 2. Visiting travel agency
35
• 3. Driving to airport
40
• 4. Booking flight
45
• 5. Visiting a plane
60
• 6. Checking in
70
• 7. Boarding
80
• 8. Take off
90
• 9. Turbulence
100
__________________________________
Alladin, 2010
Hypnosis for Decreasing Avoidance and
Increasing Self-Efficacy
• Hypnotic SD Continued…
– Prior to confronting these steps in reality, client receive imaginal
desensitization
– While in a relaxed state, client imagines confronting each step of
the hierarchy
– Therapist proceeds from one item to next, ensuring client feels
relaxed before going to the next step
– If client reports anxiety while imagining an item, therapist helps to
reduce anxiety through use of therapeutic suggestions and
relaxation instructions
Alladin, 2010
Hypnosis for Decreasing Avoidance and
Increasing Self-Efficacy
• Hypnotic SD Continued…
– Number of steps dealt with during each session
depends on client
– Important to proceed at a pace comfortable to client
– For homework, client encouraged to confront
situations in reality
– In vivo desensitization can be gradual
Alladin, 2010
Hypnosis for Decreasing Avoidance and Increasing
Self-Efficacy
• Flooding Technique
– Anxiety-producing situation or image confronted until
situation no longer elicits anxiety
– Similar to SD, flooding can be broken down into steps
– Hypnotic flooding useful when not enough time to do
SD procedure
– Repeat until client report significant reduction in
anxiety
Alladin, 2010
Hypnosis for Decreasing Avoidance and Increasing
Self-Efficacy
• Flooding Technique Script
– “Imagine that you’re now on the plane and the
seatbelt sign goes on. You take some slow deep
breaths, just as you can do right now to reduce some
of the anxiety. You don’t have to reduce it all. Just
enough to feel more in control. The turbulence begins.
It’s uncontrollable but it’s safe. It’s just a normal part of
airplane travel. You’ll be all right. You take long slow
deep breaths, just as you can now.”
– Golden, 1994, p.271
Alladin, 2010
Fourth Goal for Utilizing Hypnosis with
Anxiety Disorders:
Integration of experience
Alladin, 2010
Hypnosis for Integration of Experiences
• Harmonizing Heart and Mind
• Two components
– Education
– Hypnotic integration
Alladin, 2010
Hypnosis for Harmonizing Heart-Mind
(1) Education
• Desynchrony of Experience
•
•
•
•
•
Desynchrony among components of anxiety
Desynchrony interferes with healing
We use feeling to validate reality
Reduces credibility of treatment
Multimodal therapy addresses components but
don’t integrate
• Models of integration or harmonizing lacking
• Hypnosis provides a model
Alladin, 2010
Hypnosis for Harmonizing Heart-Mind
(1) Education Cont/d…
• Models of Mind
• Western model of mind
–
–
–
–
Brain is the seat of existence
Splitting of intellect and feeling
Don’t know how to integrate
Confusion – validate reality by the way we feel
• Eastern/Non-Western model of mind
– Heart is the seat of existence
– Feeling at heart validate reality
– Peace at heart provides peace of mind
Alladin, 2010
Hypnosis for Harmonizing Heart-Mind
(2) Hypnotherapy
•
•
•
•
•
•
•
•
Deep trance – mind and body totally relaxed
Breathing with heart
Focus on the centre of your heart
Breathe in and out with your heart
Slow breathing to 5 sec cycle
Focus on something that you appreciate
Notice the good feeling in your heart
Notice the harmony in your mind and heart
Alladin, 2010
Applications:
Dentistry
Hypnotic Phenomena and
Dental Applications
Phenomena
• Ideomotor phenomena:
- hands moving
together
- arm lowering
-eye closure
-ideomotor signals
- passive arm
catalepsy
- levitation
Dental Applications
• Induction methods and
training patients
physiological control
Filo, 2010
Hypnotic Phenomena and
Dental Applications
Phenomena
- inhibition of voluntary
Dental Applications
• Trance ratification
control
1.
2.
3.
4.
automatic movements
finger lock
eye catalepsy
limb rigidity /
immobilization
Filo, 2010
Hypnotic Phenomena and
Dental Applications
Phenomena
• Ideosensory
activities
Dental Applications
• Trance ratification
• Sensory reframes
•
• ‘safety’ mechanism
e.g. safe room
• Fugue from Tx
Dissociation
Filo, 2010
Hypnotic Phenomena and
Dental Applications
Phenomena
• Analgesia
Anesthesia
Dental Applications
• Minimize chemical
analgesia /
anesthesia
• Substitute for
chemical analgesia /
anesthesia
Filo, 2010
Hypnotic Phenomena and
Dental Applications
Phenomena
• Hypnotic dreams
•
Post hypnotic
suggestion
Dental Applications
• Procedure rehearsal
• Tx interventions
• Behaviour
modification
• Reinduction cue
Filo, 2010
Hypnotic Phenomena and
Dental Applications
Phenomena
• Hypermnesia & age
regression (partial
and revivification)
•
Dental Applications
• Reframing past
experiences
Amnesia
• Amnesia for the
dental experience
Filo, 2010
Hypnotic Phenomena and
Dental Applications
Phenomena
• Time distortion
•
Hidden Observer or
Ego state
Dental Applications
• Modify perception of
treatment duration
• Bruxism / habit
awareness &
management
Filo, 2010
Hypnotic Phenomena and
Dental Applications
Phenomena
• Hallucinations:
negative and
positive
- V,A,K,O,G
Dental Applications
• Modification of
treatment experience
by changing sensory
perceptions
Filo, 2010
Hypnotic Phenomena and
Dental Applications
Phenomena
• Classic suggestion
effect: experiencing
phenomena as
involuntary
Dental Applications
• Trance ratification
Filo, 2010
Dental Fear Categories
Category of Dental fear
Psychiatric Diagnosis Equivalent
Type I
Conditioned fear of specific stimuli
(drills, needles, sounds, smells)
Type II
Anxiety about somatic reactions
during treatment
(allergy,syncope,gagging,panic)
Type III
Patients with strong anticipating
anxiety or other complicating
anxiety or phobias
Type IV
Distrust of dental personnel
(after Moore et. al., 1991 excerpted from
Psychiatric disorders in dental practice, Enoch & Jagger)
A directly conditioned socially
reinforced simple (specific) phobia
Agoraphobic disorders withor
without panic and somatic neurotic
focus with possible somatoform
disorders.
Summations of simple phobias or
GAD having an impact on dental
fear
Social phobic disorders with pain
conditioning, Pure social
embarrassment ,GAD or fear
reinforcement
Filo, 2010
Specific Applications
A review of the usual areas of dental
applications
A homage to the hypnodontic luminaries by
offering the kernels of their methods as
they relate to the dental areas
Filo, 2010
Phobias & Fears
Louis L. Dubin DDS, PhD *
•
Exploration for traumatic experience
•
Visualize calendar with years on it,
months and days
•
Scan until precipitating incident is
illuminated.
•
Superimpose the better way
•
This superimposed image will prevail
Filo, 2010
Supplement or Substitute for Surgical
Premedication
- psychosomatic premedication
Filo, 2010
Pain Management:
acute and chronic
A patient in acute pain, especially of traumatic
etiology, likely is in trance; the object is to
enhance and modify the trance state for
patient’s benefit.
Filo, 2010
Pain Management:
acute and chronic
Victor Rausch DDS *
• acute distress authoritarian
•
no distress permissive
• ” I realize you are in extreme discomfort and I can help
you. For me to do that you must help. Listen very
carefully to what I say and follow my instructions. Do you
understand? “
• use finger pressure to induce anesthesia, using pressure
as focus
Filo, 2010
Denture Adaptation
• full and partial dentures may lead to
problems for patients, both mechanical
and emotional in nature.
• mechanical issues once addressed and
resolved may still not alleviate
psychological concerns.
Filo, 2010
Denture Adaptation
Physical manifestations of psychic problems
during fabrication and post insertion include:
• gagging
• lip and circumoral muscle tensing
• defensive (offensive- depending on your perspective)
tongue
• hyperventilation
• excessive salivation
• lacrimation
• coughing
• sweating
• vomiting
Filo, 2010
Denture Adaptation
Hypnosis may help by:
•
•
positive suggestions to enhance ability
to tolerate dentures
suggestions to enhance motivation for
work required to adapt to dentures
Filo, 2010
Denture Adaptation
Techniques: desensitization
• for the gagger spoon,
 plastic disc on floss
 once tolerance increased,
impression tray to wear at
home
 trial acrylic bases
• all of the preceding worn at home with
incrementally increasing time
Filo, 2010
Denture Adaptation
Techniques: ego strengthening
• visual imagery
• reframing
• split screen
[Barsby, in Hypnosis in Dentistry]
Filo, 2010
Treatment of Syncope
Thomas W. Frost LDS
•
•
if patient is prone to syncope utilize
relaxation or hypnosis
once relaxation or trance is established,
suggestions for comfort and the
impossibility of fainting
Filo, 2010
Treatment of Syncope
Ilana Eli and Moris Kleinhauz
•
•
syncope usually due to injection and
anxiety
hypnosis permits eliminating the injection
and the relaxation during the trance
eliminates or reduces the anxiety
Filo, 2010
Habit Management
Irving I Schecter DDS MA *
Tongue Thrusting
-
-
imagine negative theater scene
imagine positive theater scene
associate tongue thrust with
negative scene and feelings
correct position with positive feelings
Filo, 2010
Habit Management
Garland H. Fross DDS
Thumb sucking
•
suggest that by sucking thumb he is
showing favoritism to thumb
•
to be fair, should give all the fingers equal
time – easiest all at once
•
difficulty in compliance with this leads to
dropping of habit
Filo, 2010
Patient Management
Rapport between patient and dentist crucial to
patient satisfaction
Patients change dentists more for interpersonal
reasons cf to technical competence
• decreases stress for patient and dentist
• improves job satisfaction
• can expedite and facilitate treatment
• confers valuable life skill to patient
Filo, 2010
Patient Management
Lawrence M Staples DMD *
• The Let’s pretend game imaginary TV
Filo, 2010
TMD / TMJ
Multifactorial multietiological:
1.
functional (bruxing);
2.
structural (occlusion);
3.
psychological (anxiety, tension, aggression, stress)
Bruxers personalities include:
•
interpersonally and expressively aloof
•
inhibited
•
hard driving
•
dissatisfied with their lives
•
apprehensively worried and guilt ridden
Filo, 2010
TMD / TMJ
Hypnodynamic assessment (refer Eli & Somer in
Hypnosis in Dentistry) to gather information that
reveals unconscious meaning and motivation.
Techniques:
 theater or television
 cloud
 hypnotic dreams
 automatic writing
 revivification and age regression
 affect bridge
The preceding require training or the employ of a
psychologist in a multidisciplinary treatment model.
Filo, 2010
TMD / TMJ
Harold Golan DMD *
•
•
•
•
•
•
•
secret weapon  laugh at world
explanation of stress/parafunction
‘method for retaining just enough nervous
energy to do task and spill off rest’
at night say ‘nothing is important enough in life
to eat myself up’
during the night abnormal tooth contact will
awaken you, smile, realizing subconscious is
protecting you, roll over go back to sleep
ratify with glove anesthesia
control your body, rather than it controlling you
Filo, 2010
TMD / TMJ
Ellis J. Neiburger DDS *
– suggestions to place tongue between
teeth upon becoming aware of clenching
–
–
the longer this is done the more relaxed the
muscles will become
Filo, 2010
TMD / TMJ
Milton H. Erickson MD *
- ‘when you put your head down’ instantly fall asleep
- suggest that the possibility of bruxing may occur
- describe it as unpleasant
- also suggest awakening on bruxing
- develop a good hand grip and arm muscles instead
- replace bruxing with nocturnal gum chewing habit –
not likely to persevere at it
Filo, 2010
TMD / TMJ
Dov Glazer DDS *
TMD & Tension headache
tension – press hands fingers together
with hands at face level
experience tension throughout face
relax - top to bottom
enjoy calmness, tranquility, serenity
massage same mm groups after
mental relaxation
Filo, 2010
TMD / TMJ
Louis L. Dubin DDS, PhD *
Bruxing
Describe neuroanatomy, etc. about the joint.
Describe ‘activation’ of a protective reflex that will
cause awakening as soon as clenching detected;
for good night’s sleep, subconscious will condition
muscles to stay slightly apart.
Filo, 2010
TMD / TMJ
Milton H Erickson MD *
Bruxism in Children
When the child is old enough, discuss the bruxism
movements
Earnestly hope that he doesn’t awaken
Suggest hearing the bruxing and awakening
Filo, 2010
Motivation: Oral Hygiene
- increase relaxation,
- improve concentration improve
reception and retention of health
promotion information
- efficacy needs research
Filo, 2010
Motivation: Oral Hygiene
Promotion of Flossing
Maureen A. Kelly DDS, Harlo R. McKinty, Richard Carr *
- suggestions for oral health
- suggestions for improved personal appearance
via attractive, healthy mouth
- improved social acceptability
Filo, 2010
Gagging: control of excessive ‘reflex’
•
•
•
•
•
gag reflex activated to protect the airway
and remove noxious stimuli from GI tract
somatogenic and psychogenic factors
involved
hypnosis alone or in combination with
systematic desensitization
gagging as an avoidance reaction after
previous traumatic experience
gagging as a defense mechanism
Filo, 2010
Gagging: control of excessive ‘reflex’
Hal Golan *
- denture wear  relaxation, suggestions about body as
prize possession
- control of body and not the reverse
- explanation of gagging causes
- glove anesthesia with ratification  needle
eyes open trance, remove needle,
keep anesthesia in oral cavity, ratify by having all
surfaces of oral cavity touched
- with kids, substitute arm catalepsy cf needle
alert, proceed to dentistry with reinforcing prn
Filo, 2010
Gagging: control of excessive ‘reflex’
J.Henry Clarke DMD, Stephen J. Persichetti *
Imagery breathing through the neck
(cricothyroid region)
Rationale: they focus on pharynx well, have them
focus lower on breathing
bypassing pharynx – relates to concern with
breathing
practice denture, impression trays at home
with audio tape
Filo, 2010
Gagging: control of excessive ‘reflex’
Donald R. Beebe DDS *
Denture and gagging
- post immediate denture: in trance,
explanation of extraction pain, sense of
bulkiness as talk, sensations will fade
sense of normality on alerting.
- sensation will remain
- return in one week to reinforce
hypnotically
Filo, 2010
Gagging: control of excessive ‘reflex’
Louis L. Dubin DDS, PhD *
Gag reflex
spiel about impossibility of gagging while
holding breath if belong to
- membership in human race
demonstrate
or, temporal tapping
Filo, 2010
Reduction in Chemical Anesthetics, Analgesics,
and Sedation – compliment to N20
Replacement for Local
- direct suggestion: numbness; cold;
glove anesthesia
- changing colours: pain = colour;
comfort = different colour;
third pain free colour = numbness;
change as required
- switch- box (gate control theory)
Filo, 2010
Reduction in Chemical Anesthetics, Analgesics,
and Sedation – compliment to N20
Relative analgesia – N2O
1. nitrous hypnotic induction
2. hypnosis synergy with nitrous
enhance acceptance with modeling
under hypnosis
Filo, 2010
Reduction in Chemical Anesthetics, Analgesics,
and Sedation – compliment to N20
Intravenous Sedation
Hypnosis is used prior to drug injection to permit
lower drug dosage, and to minimize paradoxical
drug effects.
Filo, 2010
Reduction in Chemical Anesthetics, Analgesics,
and Sedation – compliment to N20
General Anesthesia
Hypnosis establishes advantageous
communication with patient;
decreases post operation pain, analgesia usage;
and length of hospital stay.
[Shelagh Thompson in Hypnosis in Dentistry ]
Filo, 2010
Reduction in Chemical Anesthetics, Analgesics,
and Sedation – compliment to N20
Irving I.Schecter DDS *
- teach hypno-anesthesia
- any stimulus will henceforth
cause anesthesia
Filo, 2010
Reduction in Chemical Anesthetics, Analgesics,
and Sedation – compliment to N20
William T. Heron PhD *
suggest that need for x-rays, etc. needed
to determine way to proceed
- discuss pleasure when eating food
touching gag triggers
- suggest pt. recall same pleasant
sensations during procedure
Filo, 2010
Reduction in Chemical Anesthetics, Analgesics,
and Sedation – compliment to N20
Louis L. Dubin DDS, PhD *
Paresthesia from induced anesthesia or nerve
damage from manipulation:
- go back to the time when there was full
sensation and function
- overlay this feeling on the present one –
ideomotor confirmation
- when healing takes place or local
dissipates the normal feeling will prevail
Filo, 2010
Reduction in Chemical Anesthetics, Analgesics, and
Sedation – compliment to N20
Louis L. Dubin DDS, PhD *
Anesthesia and alteration of pain awareness:
1. dissociation
2. increased tolerance
3. role-playing
4. recall
Filo, 2010
Reduction in Chemical Anesthetics, Analgesics,
and Sedation – compliment to N20
William S. Kroger MD *
- luxate tooth with finger and suggest
numbness
- demonstrate anesthesia by explorer
bilaterally highlighting difference
Filo, 2010
Control of Hemorrhage and Salivary Flow
Salivation
Irving I. Schecter DDS *
saliva increases when there is food
as start of digestion
since no food no need for saliva
imagine turning off water faucet
swallow, note dryness
turn on faucet only to moisten mouth
Filo, 2010
Control of Hemorrhage and Salivary
Flow
Selig Finkelstein DDS *
Tooth extraction
- progressive muscle relaxation
- ‘applying topical anesthetic to tooth and gums’
squeezing it into gums to get complete anesthesia
- exert even more pressure around the tooth
pushing
material down around the root
- so proud will not feel tooth being removed
Filo, 2010
Control of Hemorrhage and Salivary Flow
Vascular control,clotting, and normal healing
- tooth is out
- let socket fill with blood normally
- surprise at minimal discomfort, swelling, etc.
- rapidly heals
Filo, 2010
Professional Organizations
• ASCH The American Society of Clinical Hypnosis
www.asch.net
• SCEH Society for Clinical and Experimental Hypnosis
www.sceh.us
• ISH International Society of Hypnosis www.ish-web.org
• The Milton Erickson Foundation
www.erickson-foundation.org
• The American Psychological Association
www.apa.org (Division 30 Psychological Hypnosis)
• Component Sections of ASCH, i.e. www.gpsch.org
References
• Alladin, A. (2010) Hypnotherapy for Anxiety Disorders.
• American Society of Clinical Hypnosis (2010) Standards
of Training in Clinical Hypnosis, Introductory Workshop.
American Society of Clinical Hypnosis annual meeting.
• Filo, G. (2010) Hypnodontics – Interventions.
• Patterson, D. (2010). Hypnosis and Pain Management.
• Zastrow, J. (2010) Hypnosis and Irritable Bowel
Syndrome.
• Zastrow, J. (2010) Hypnosis and Headaches.