Download Clinical Hypnosis and Neurofeedback

SPECIAL TOPICS
Clinical Hypnosis and Neurofeedback
D. Corydon Hammond, PhD, ABPH, ECNS, QEEG-D
Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, UT
Keywords: hypnosis, biofeedback, EEG biofeedback
Spring 2005 ⎪ Biofeedback
Hypnosis and neurofeedback each provide unique
therapeutic strengths and opportunities. This paper
reviews some outcome literature in clinical hypnosis,
and then presents suggestions to guide therapists in
choosing hypnosis versus neurofeedback as the initial
intervention of choice.
14
Introduction
Wickramasekera (1989, 1995, 1996; Wickramasekera,
Davies, & Davies, 1996) expressed the belief that with
regard to peripheral biofeedback, individuals who were
low in hypnotic susceptibility responded better to
biofeedback, whereas individuals who were very
responsive to hypnosis did better in treatment that
utilized hypnosis. When one actually reviews the literature in this area there are both supportive and nonsupportive studies for this hypothesis, but whether
true or not, clinical hypnosis and neurofeedback (as
well as other types of biofeedback) each offer unique
ways in which we can influence symptoms and mindbody interactions. Having skills in the use of both
therapeutic modalities can be invaluable. I have far less
clinical experience in working with peripheral biofeedback, and therefore am restricting my comments to a
discussion of neurofeedback and hypnosis.
There are some areas where hypnosis has excellent research validation, but there are also areas
where we currently do not have research support
for neurofeedback. Hypnosis provides a valuable
self-management technique that has proven more
effective than medication for control of irritable
bowel syndrome (Palsson, 2005; Tan & Hammond,
2005). Another area of strong research support for
hypnosis is with chronic and acute pain. As I have
reviewed the voluminous literature on hypnosis and
pain, I have come to believe that hypnosis (and
autogenic training, which is simply a structured
German form of self-hypnosis) is the most effective
nonsurgical, nonmedication treatment for pain.
Willmarth (2005) reviews some of this literature,
and I have provided a partial overview as well.
Hypnosis with Pain, Surgery, and Cancer
In persons low in responsiveness to hypnosis, equivalent nonspecific analgesic effects are obtained whether
the treatment is a placebo pill; cognitive behavior
therapy (distraction, self-talk); acupuncture; or hypnosis (Hilgard & Hilgard, 1983; Knox, Gekoski,
Shum, & McLaughlin, 1981; Miller & Bowers, 1986).
However, patients who are high in hypnotic responsivity generally obtain much more profound analgesic
relief from hypnosis–relief documented to be even
more effective than morphine (Stern, Brown, Ulett, &
Sletten, 1977).
In a randomized, controlled study, Miller and
Bowers (1986, 1993) compared hypnosis, the cognitive-behavioral technique of stress inoculation training, and stress inoculation training masquerading as
hypnotic suggestions. All three conditions produced
pain relief; relief associated with stress inoculation
training (in either condition) was not associated with
hypnotizability, whereas hypnotic analgesia was correlated. Furthermore, when subjects in the cognitivebehavioral stress inoculation training condition
(Miller & Bowers, 1993) were required to engage in a
cognitive task (as chronic pain patients must often do
during the process of daily living), it impaired their
ability to produce analgesic relief. However, hypnotic
analgesia was not impaired by a simultaneous cognitive task. Hypnosis has also proven superior to
acupuncture in producing pain relief (Knox et al.,
1981; Knox, Handfield-Jones, & Shum, 1979; Knox,
Shum, & McLaughlin, 1977, 1978).
McGlashan, Evans, and Orne (1969) compared
hypnotically induced analgesia (in association with
ischemic muscle pain) with “a powerful analgesic
drug” placebo in high and very low hypnotizable subjects in a double-blind, repeated-measures experiment. The 24 subjects received both placebo and hypnotic treatments, and special procedures were used to
induce positive expectancy in both conditions. For
instance, low hypnotizable subjects were not only
reassured that they were very hypnotizable, but an
Hammond
ratings of physical progress and fewer postoperative
complications.
Dyas (2001) evaluated 20 patients where hypnosis
took place prior to sedation for mandibular third
molar surgery compared with 20 control subjects
treated by the same team with the same sedation regimen, but without hypnosis. Sedation included midazolam and fentanyl, and heart rate (taken as an indicator of anxiety and stress), electrocardiogram (ECG),
and pulse oximeter readings were taken throughout
the procedures. Heart rate increase was significantly
lower (p < .001) in patients using hypno-sedation,
with much less intravenous sedation required and a
significantly shorter recovery time (p < .001). In comparison, outcomes in the control subjects were not as
good and they required more IV medication; one
patient required conversion to a full general anesthetic. The results supported the value of hypnosis to augment sedation in oral surgery.
Syrjala, Cummings, and Donaldson (1992) randomly assigned 67 bone marrow transplant patients to
either hypnosis training, a cognitive-behavioral coping
skills training, a therapist-contact control condition, or
treatment as usual. Hypnosis was effective in reducing
pain for the patients undergoing bone marrow transplantation. However, the cognitive-behavioral program, despite its use of progressive muscle relaxation
and autogenic relaxation, was not effective.
Hypnosis has also proven effective for reducing
nausea and vomiting following surgery in a randomized double-blind study (Eberhart, Doring, Holzrichter,
Roscher, & Seeling, 1998) of thyroidectomy patients,
and in a randomized, blinded, prospective study with
women undergoing breast surgery (Enqvist,
Bjorkllund, Engman, & Jakobsson, 1997). In surgeries
associated with preoperative or intraoperative suggestions (Fredericks, 2001; Hammond, 1990), there is commonly also less blood loss (Enqvist, von Konow, &
Bystedt, 1995).
Thus hypnosis can offer unique benefits in working with pain and with surgical patients. Lang and
Rosen (2002) evaluated the cost-effectiveness of hypnosis with patients undergoing interventional radiological procedures. They documented that where standard sedation cost $638 a case, when hypnosis was
used along with sedation, the cost was reduced to only
$300 a case—more than a 50% savings.
Sellick and Zaza (1998) reviewed the randomized
controlled studies of five alternative medicine strate-
Biofeedback ⎪ Spring 2005
illusory demonstration was made to convince them
that they could experience hypnotic analgesia. They
discovered that the placebo significantly increased
pain tolerance, but there was no relationship between
hypnotic susceptibility level and placebo response,
suggesting placebo response is not correlated with
hypnotic response. Subjects who were unresponsive
to hypnosis achieved comparable analgesic effects
from both a placebo and from the hypnosis (which
followed a method causing them to believe they were
hypnotically responsive). High hypnotizable subjects
demonstrated analgesic effects in response to a placebo, and even greater pain tolerance (over and above
placebo effects) after the introduction of hypnosis,
whereas low hypnotizable individuals did not.
Hypnotic preparation for surgery and the use of
suggestions under anesthesia also appear valuable in
the relief of pain, blood loss, controlling nausea and
vomiting, and promotion of healing and reducing
inflammation (Ginandes, Brooks, Sando, Jones, &
Aker, 2003; Ginandes & Rosenthal, 1999). Lang et al.
(2000) documented the effects of hypnotic relaxation
in reducing pain, anxiety, and needs for medication in
surgical patients, as well as in achieving greater
hemodynamic stability. They randomly assigned 241
patients undergoing vascular and renal surgery to
either standard care, structured attention, or self-hypnosis. The patients all had patient-controlled analgesia
and rated their pain levels four times an hour during
and after surgery. Patients receiving standard care
used significantly more analgesic medication compared with the hypnosis and structured attention
groups, which were comparable. However, 10 structured attention group patients and 12 standard care
patients became hemodynamically unstable compared
with only one hypnosis group patient—changes that
were significant at the .004 and .0009 levels of significance, respectively. Furthermore, procedure times
were significantly briefer (p = .0016) for the hypnosis
group (61 minutes) compared with standard care (78
minutes) and with the attention group (67 minutes).
Similar findings were demonstrated by the same
group (Lang et al., 1996) during interventional radiological procedures. Mauer et al. (1999) compared standard medical treatment with and without the addition
of hypnosis for patients following hand surgery. The
hypnosis group demonstrated significantly lower levels of pain intensity, pain affect, and state anxiety. In
addition, the hypnosis group had significantly higher
15
Clinical Hypnosis and Neurofeedback
Spring 2005 ⎪ Biofeedback
gies in the management of cancer pain. Their review
found only one randomized controlled study of
acupuncture; one with massage therapy; six for hypnosis; and none for therapeutic touch, acupuncture, or
biofeedback. They concluded that studies of hypnosis
provide “much support” for its use in managing cancer pain, whereas evidence is either lacking or less
clear for other complementary medicine strategies.
Similarly, the 12-member National Institute of
Health Technology Assessment Panel on Integration
of Behavioral and Relaxation Approaches into the
Treatment of Chronic Pain and Insomnia (1996), following an extensive literature search, concluded that,
“The evidence supporting the effectiveness of hypnosis in alleviating chronic pain associated with cancer
seems strong” (p. 315). Hypnosis is also well established as a treatment for managing nausea and vomiting associated with chemotherapy.
Controlled research has also documented the effectiveness of hypnosis in the treatment of headache and
migraine (Emmerson & Trexler, 1999; Mellis,
Rooimans, Spierings, & Hoogduin, 1991; Olness,
MacDonald, & Uden, 1987; ter Kuile et al., 1994).
16
Obstetrical and Gynecological
Applications of Hypnosis
Hypnosis is also found to be of value during childbirth, where it significantly reduces the amount of
analgesics required. This reduces risks of medications for both mother and child, and it is often found
that the average duration of labor is significantly
reduced (e.g., Jenkins & Pritchard, 1993). In this
large and important study, although it was not randomized, they assessed the effects of hypnotherapy
on the first and second stages of labor in 126 primigravid women with 300 age-matched controls, and
136 parous women having their second baby with
300 age-matched controls. Only women undergoing
spontaneous deliveries were included. Six sessions of
hypnosis were used. The mean lengths of first-stage
labor in primigravid women was 6.4 hours after
hypnosis and 9.3 hours in the control group (p <
.0001), and the mean length of the second stage was
37 and 50 minutes, respectively (p < .001). In the
parous women, the corresponding times were 5.3
and 6.2 hours (p < .01) and 24 and 22 minutes (not
significant). The use of analgesic agents was significantly less (p < .001) in both hypnotized groups
compared with their controls.
Mairs (1995) evaluated the use of hypnosis in pain
control in 28 primigravida women compared with 27
primigravida women not receiving hypnosis training.
Those who received hypnosis training reported significantly lower ratings of both pain and anxiety than
untrained women, and when caesarean section
patients were excluded, the differences were even
more significant. Hypnosis also helped alleviate even
the unexpected and unprepared anxieties of caesarean
sections. Harmon, Hynan, and Tyre (1990) provided a
very important study of the benefits of hypnotic analgesia as an adjunct to childbirth in 60 nulliparous
women. Patients were divided into high and low susceptibility groups before receiving six sessions of
childbirth education and skill mastery using an
ischemic pain task. Half of the patients in each group
received a hypnotic induction at the beginning of each
session; the remaining control subjects received relaxation and breathing exercises typically used in childbirth education. Both hypnotic patients and highly
susceptible patients reported reduced pain.
Hypnotically prepared births had shorter stage 1
labors, less medication, higher Apgar scores, and more
frequent spontaneous deliveries than control patients’
births. Highly susceptible, hypnotically treated
women had lower depression scores after birth than
women in the other three groups.
In a randomized, controlled study of labor and
delivery among prenatal patients, Martin, Schauble,
Rai, and Curry (2001) used a hypnotic childbirth protocol compared with a control condition that received
“supportive counseling.” No prompting occurred during delivery. Patients in the hypnosis group needed
significantly fewer extended stays in the hospital
postdelivery, fewer surgical interventions, and experienced significantly fewer complications. Positive
effects have also been found in a randomized, controlled study by Freeman, MacCauley, Eve, and
Chamberlain (1986), and Brann and Guzvica (1987)
found that with 96 women who were assigned to
either hypnosis or a relaxation (breathing)/distraction
condition that labor was significantly shorter in the
hypnosis group, despite the fact that the distraction
group included more multipara women who would be
expected to have shorter labors.
Nausea and vomiting (hyperemesis gravidarum)
associated with pregnancy has also been reduced successfully with good to excellent results over 80% of the
time (Fuchs, Paldi, Abramovici, & Peretz, 1980). In
Hammond
with fibromyalgia or chronic fatigue often benefits
from brief self-hypnosis training followed by neurofeedback.
Licensed clinicians desiring training in clinical hypnosis may consult the American Society of Clinical
Hypnosis (www.asch.net) for training opportunities.
Selecting Hypnosis or Neurofeedback
As the Intervention of Choice
Both clinical hypnosis and neurofeedback offer powerful opportunities therapeutically. In choosing
between them, we must first consider the preference
of patients, some of whom are very rational-/scientific-minded, and therefore the technology of neurofeedback may be appealing to them.
There is a considerable body of research that I
have not reviewed in this paper on the effectiveness
of hypnosis in enhancing immune response, working with allergies and asthma, and alleviating dermatologic conditions and other problem areas. In
light of the research evidence, if I am working with
pain or cancer patients or preparing patients for surgery, I personally choose hypnosis as my first intervention. Likewise, when the presenting problem is
stress or generalized anxiety (that is not too severe);
irritable bowel syndrome; allergic responses; habit
disorders; asthma; hyperemesis gravidarum or
preterm labor; preparation for childbirth; the need
to influence blood flow in hemophilia; or dermatologic conditions (e.g., pruritus, warts, dermatitis), I
will also turn to clinical hypnosis as my initial
intervention.
On the other hand, although we do not have strong
outcome research for many areas of application, I will
select neurofeedback as my treatment of choice when I
want to improve cognitive dysfunction following
chemotherapy or radiation, with stroke, uncontrolled
epilepsy, head injury, attention deficit disorder/attention deficit hyperactivity disorder (ADD/ADHD),
learning disabilities, Tourette syndrome, alcoholism,
substance abuse (and cognitive damage from substance
abuse), depression, or obsessive-compulsive disorder.
There are also many cases in which I may utilize a
combination of hypnosis and neurofeedback. Following
the law of parsimony, I may teach an anxiety disorder,
insomnia, or headache patient self-hypnosis as a selfmanagement skill. In some cases this proves sufficient.
When hypnosis only produces partial improvement,
then neurofeedback may be added. Similarly, a patient
References
Brann, L., & Guzvica, S. (1987). Comparison of hypnosis
with conventional relaxation for antenatal and intrapartum use: A feasibility study in general practice.
Journal of Royal College of General Practitioners, 37,
437–440.
Dyas, R. (2001). Augmenting intravenous sedation
with hypnosis, a controlled retrospective study.
Contemporary Hypnosis, 18(3), 128–134.
Eberhart, L. H., Doring, H. J., Holzrichter, P., Roscher, R.,
& Seeling, W. (1998). Therapeutic suggestions given
during neuroleptic-anesthesia decrease post-operative nausea and vomiting. European Journal of
Anaesthesiology, 15, 446–452.
Emmerson, G. H., & Trexler, G. (1999). An hypnotic
intervention for migraine control. Australian Journal
of Clinical & Experimental Hypnosis, 27(1), 54–61.
Enqvist, B., Bjorkllund, C., Engman, M., & Jakobsson, J.
(1997). Preoperative hypnosis reduces postoperative
vomiting after surgery of the breasts. A prospective,
randomized and blinded study. Acta Anaesthesiologica
Scandanavica, 41, 1028–1032.
Enqvist, B., von Konow, L., & Bystedt, H. (1995). Pre- and
perioperative suggestion in maxillofacial surgery:
Effects on blood loss and recovery. International Journal
of Clinical & Experimental Hypnosis, 43, 284–294.
Fredericks, L. E. (2001). The use of hypnosis in surgery and
anesthesiology. Springfield, IL: Charles C. Thomas.
Freeman, R. M., MacCauley, A. J., Eve, L., &
Chamberlain, G. V. P. (1986). Randomized trial of
self-hypnosis for analgesia in labour. British Medical
Journal, 292, 657–658.
Fuchs, K., Paldi, E., Abramovici, H., & Peretz, B. A.
(1980). Treatment of hyperemesis gravidarum by
hypnosis. International Journal of Clinical &
Experimental Hypnosis, 28, 313–323.
Ginandes, C. S., Brooks, P., Sando, W., Jones, C., & Aker,
J. (2003). Can medical hypnosis accelerate post-surgical wound healing? Results of a clinical trial.
American Journal of Clinical Hypnosis, 45,
333–351.
Ginandes, C. S., & Rosenthal, D. I. (1999). Using hypnosis to accelerate the healing of bone fractures: A randomized controlled pilot study. Alternative Therapies
in Health & Medicine, 5, 67–75.
Biofeedback ⎪ Spring 2005
addition, hypnosis may also assist patients with problems in premature labor. Impressively, Omer (1987)
and Omer, Friedlander, and Palti (1986) documented
that brief hypnotic interventions produced significantly greater prolongation of pregnancy in women with
premature labor than a medication treatment group.
17
Spring 2005 ⎪ Biofeedback
Clinical Hypnosis and Neurofeedback
18
Hammond, D. C. (Ed.). (1990). Handbook of hypnotic
suggestions and metaphors. New York: Norton.
Harmon, T. M., Hynan, and Tyre, T. E. (1990). Improved
obstetric outcomes using hypnotic analgesia and skill
mastery combined with childbirth education. Journal
of Consulting and Clinical Psychology, 58, 525–530.
Hilgard, E. R., & Hilgard, J. R. (1983). Hypnosis in the relief
of pain (2nd ed.). Los Altos, CA: William Kaufmann.
Jenkins, M. W., & Pritchard, M. H. (1993). Hypnosis:
Practical applications and theoretical considerations
in normal labour. British Journal of Obstetrics &
Gynecology, 100, 221–226.
Knox, V. J., Gekoski, W. L., Shum, K., & McLaughlin, D.
M. (1981). Analgesia for experimentally induced pain:
Multiple sessions of acupuncture compared to hypnosis in high- and low-susceptible subjects. Journal of
Abnormal Psychology, 90, 28–34.
Knox, V. J., Handfield-Jones, C. E., & Shum, K. (1979).
Subject expectancy and the reduction of cold pressor
with acupuncture and placebo acupuncture.
Psychosomatic Medicine, 41, 477–486.
Knox, V. J., Shum, K., & McLaughlin, D. M. (1977).
Response to a cold pressor pain and to acupuncture
analgesia in oriental and occidental subjects. Pain, 4,
49–57.
Knox, V. J., Shum, K., & McLaughlin, D. M. (1978).
Hypnotic analgesia vs. acupuncture analgesia in highand low-susceptible subjects. In F. H. Frankel & H. S.
Zamansky (Eds.), Hypnosis at its bicentennial:
Selected papers. New York: Plenum.
Lang, E. V., Benotsch, E. G., Fick, L. J., Lutgendorf, S.,
Berbaum, M. L., Logan, H., & Spiegel, D. (2000).
Adjunctive non-pharmacological analgesia for invasive
medical procedures: A randomized trial. Lancet, 355,
1486–1490.
Lang, E. V., Joyce, J. S., Spiegel, D., Hamilton, D., & Lee, K.
K. (1996). Self-hypnotic relaxation during interventional radiological procedures: Effects on pain perception and intravenous drug use. International Journal of
Clinical & Experimental Hypnosis, 44, 106–119.
Lang, E. V., & Rosen, M. P. (2002). Cost analysis of
adjunct hypnosis with sedation during outpatient
interventional radiologic procedures. Radiology, 222,
375–382.
Mairs, D. A. E. (1995). Hypnosis and pain in childbirth.
Contemporary Hypnosis, 12, 111–118.
Martin, A. A., Schauble, P. G., Rai, S. H. J., & Curry, R.
W. (2001). The effects of hypnosis on the labor
processes and birth outcomes of pregnant adolescents.
Journal of Family Practice, 50, 441–443.
Mauer, M. G., Magaly, H., Burnett, K. F., Ouellette, E. A.,
Ironson, G. H., & Dandes, H. M. (1999). Medical hypnosis and orthopedic hand surgery. International
Journal of Clinical & Experimental Hypnosis, 47(2),
144–161.
McGlashan, T. H., Evans, F. J., & Orne, M. T. (1969). The
nature of hypnotic analgesia and placebo response to
experimental pain. Psychosomatic Medicine, 31,
227–246.
Mellis, P. M., Rooimans, W., Spierings, E. L., &
Hoogduin, C. A. (1991). Treatment of chronic tension-type headache with hypnotherapy: A singleblind controlled study. Headache, 31, 686–689.
Miller, M. E., & Bowers, K. S. (1986). Hypnotic analgesia
and stress inoculation training in the reduction of
pain. Journal of Abnormal Psychology, 95, 6–14.
Miller, M. E., & Bowers, K. S. (1993). Hypnotic analgesia: Dissociated experience or dissociated control?
Journal of Abnormal Psychology, 102, 29–38.
NIH Technology Assessment Panel on Integration of
Behavioral and Relaxation Approaches into the
Treatment of Chronic Pain and Insomnia. (1996).
Integration of behavioral and relaxation approaches into
the treatment of chronic pain and insomnia. Journal of
the American Medical Association, 276, 313–318.
Olness, K., MacDonald, J. T., & Uden, D. L. (1987).
Comparison of self-hypnosis and propranolol in the
treatment of juvenile classic migraine. Pediatrics, 79,
593–597.
Omer, H. (1987). A hypnotic relaxation technique for the
treatment of premature labor. American Journal of
Clinical Hypnosis, 29, 206–213.
Omer, H., Friedlander, D., & Palti, Z. (1986). Hypnotic
relaxation in the treatment of premature labor.
Psychosomatic Medicine, 48, 351–361.
Palsson, O. (2005). Hypnosis treatment of Irritable
Bowel Syndrome: Effects on symptoms and psychophysiology. Biofeedback, 33, 25–30.
Sellick, S. M., & Zaza, C. (1998). Critical review of 5 nonpharmacologic strategies for managing cancer pain.
Cancer Prevention & Control, 2, 7–14.
Stern, J. A., Brown, M., Ulett, G. A., & Sletten, I. (1977).
A comparison of hypnosis, acupuncture, morphine,
Valium, aspirin, and placebo in the management of
experimentally induced pain. Annals of the New York
Academy of Sciences, 296, 175–193.
Syrjala, K. L., Cummings, C., & Donaldson, G. W. (1992).
Hypnosis or cognitive behavioral training for the
reduction of pain and nausea during cancer treatment: A controlled clinical trial. Pain, 48, 137–146.
Tan, G., & Hammond, D. C. (2005). A review of literature on hypnosis and irritable bowel syndrome.
American Journal of Clinical Hypnosis, 47, 161–178.
ter Kuile, M. M., Spinhoven, P., Linssen, A. C. G.,
Zitman, F. G., Van Dyck, R., & Rooijmans, H. G. M.
(1994). Autogenic training and cognitive self-hypno-
Hammond
sis for the treatment of recurrent headaches in three
different subject groups. Pain, 58, 331–340.
Wickramasekera, I. (1989). Clinical behavioral medicine.
New York: Plenum.
Wickramasekera, I. (1995). Somatization: Concepts, data,
and predictions from the high risk model of threat
perception. Journal of Nervous & Mental Disease,
182, 15–23.
Wickramasekera, I. (1996). On the interaction of hypnotizability and negative affect in chronic pain: Implications
for the somatization of trauma. Journal of Nervous &
Mental Disease, 184, 628–635.
Wickramasekera, I., Davies, T. E., & Davies, S. M. (1996).
Applied psychophysiology: A bridge between the biomedical model and the biopsychosocial model in family medicine. Professional Psychology: Research &
Practice, 27, 221–233.
Willmarth, E.K., & Willmarth, K.J. (2005). Biofeedback and
hypnosis in pain management. Biofeedback, 33, 20–24.
D. Corydon
Hammond
Correspondence: D. Corydon Hammond, PhD, ABPH, ECNS, QEEG-D,
Physical Medicine & Rehabilitation at the University of Utah School of
Medicine, 30 North 1900 East, Salt Lake City, UT 84132-2119, email:
[email protected].
Biofeedback ⎪ Spring 2005
19