Evidence-Based Reviews

Hypnosis: Brief interventions offer key to managing pain and anxiety

Current Psychiatry. 2004 April;3(4):48-59

References

1. Spiegel D, Jasiukaitis P. Hypnosis: Brain basis. In: Smith BH (ed). Elsevier’s encyclopedia of neuroscience. The Netherlands: Elsevier Science, 1999.

2. Rainville P, Hofbauer RK, Bushnell MC, et al. Hypnosis modulates activity in brain structures involved in the regulation of consciousness. J Cogn Neurosci 2002;14:887-901.

3. Rainville P, Duncan GH, Price DD, et al. Pain affect encoded in human anterior cingulate but not somatosensory cortex. Science 1997;277:968-71.

4. Kosslyn SM, Thompson WL, Costantini-Ferrando MF, et al. Hypnotic visual illusion alters color processing in the brain. Am J Psychiatry 2000;157:1279-84.

5. Spiegel D. Negative and positive visual hypnotic hallucinations: attending inside and out. Int J Clin Exp Hypn 2003;51:130-46.

6. Spiegel D, King R. Hypnotizability and CSF HVA levels among psychiatric patients. Biol Psychiatry 1992;31:95-8.

7. Piccione C, Hilgard ER, Zimbardo PG. On the degree of stability of measured hypnotizability over a 25-year period. J Pers Soc Psychol 1989;56:289-95.

8. Spiegel H, Spiegel D. Trance and treatment: Clinical uses of hypnosis. Washington, DC: American Psychiatric Press, 2004.

9. Wertz JM, Sayette MA. Effects of smoking opportunity on attentional bias in smokers. Psychol Addict Behav 2001;15:268-71.

10. Nishith P, Barabasz A, Barabasz M, Warner D. Brief hypnosis substitutes for alprazolam use in college students: transient experiences and quantitative EEG responses. Am J Clin Hypn 1999;41:262-8.

11. Lang EV, Benotsch EG, Fick LJ, et al. Adjunctive nonpharmacological analgesia for invasive medical procedures: a randomised trial. Lancet 2000;355:1486-90.

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In randomized trials, simple self-hypnosis training has reduced pain and anxiety during medical procedures, reducing procedure time by an average 17 minutes and resulting in fewer complications.¹¹

A typical hypnotic instruction for managing anxiety is provided in Box 2. This approach teaches patients how to deal with stressors that complicate their anxiety and to control their somatic response. Hypnosis expands patients’ repertoire of responses and enables them to feel less helpless.

Confronting phobias

Phobic symptoms of fear and avoidance or exposure with distress respond especially well to brief hypnosis interventions. Although behavior modification and antidepressants also can treat phobias successfully, one or two hypnosis sessions often can reduce or cure phobic symptoms.

For example, one can help patients with airplane phobia prepare for flight by going into a hypnotic state and learning three concepts:

Think of the airplane as an extension of the body, such as a bicycle.
Float with the plane.
Think about the difference between probability and possibility.

The hypnotic state—with its focused attention and physical relaxation—can amplify this cognitive restructuring technique. Phobic patients can feel more in control of their somatic reactions and, by extrapolation, the flying experience itself. In one study, 52% of patients taught this self-hypnosis exercise remained improved or cured at least 7 years later.¹²

Treating traumatic reactions

Evidence is growing that trauma elicits dissociation. Thus, hypnosis could help us understand and treat traumatic reactions, including patients with acute and posttraumatic stress disorder (PTSD) and dissociative disorders.

The hypnotic state’s controlled dissociation can be used to model the uncontrolled dissociation represented by posttraumatic phenomena such as flashbacks, numbing, and amnesia.¹³ This view is supported by evidence that PTSD is associated with high hypnotizability.^14,15

Acute stress disorder—as introduced in DSM-IV¹⁶—is characterized by prominent dissociative symptoms, with intrusion, avoidance, and hyperarousal. These diagnostic criteria recognize that acute dissociation is a common and predictable reaction to trauma.

Hypnosis involving grief work, exploration of trauma-related transference issues, and emotional expression are effective psychotherapies for persons exposed to trauma. Becoming familiar with hypnotic states can teach patients to recognize, understand, and control their dissociative states.

Evidence suggests that hypnosis’ intense concentration may reverse the dissociative mind fragmentation caused by trauma.¹⁷ Traumatic memories may seem less overwhelming and intrusive once patients discover they can:

exert greater control over memory access and retrieval
work through and assimilate disturbing thoughts.

The controlled experience of hypnotic abreaction (reliving traumatic and other memories with strong emotion) provides boundaries for psychotherapeutic grief work.^18,19 Instead of telling patients not to ruminate over a traumatic event, the clinician instructs the patient how to think about the experience.

The inferred message is that the patient can work on other things—such as relationships and daily living problems—after this therapeutic work is done.

Patients are slowly separated from the victim role. The goal is to help them restructure their memories, both cognitively and emotionally. They bear the memories’ impact, yet come to see the information differently.⁷ Traumatic input becomes more bearable when linked to a cognitively restructured recognition of an adaptive response.^,20 For example, patients may acknowledge what they did during a traumatic event that was self-protective or helped others.

PTSD. Hypnosis shares common elements with other cognitive and behavioral treatments for PTSD, including exposure to traumatic memories for cognitive and emotional processing. Few studies have examined using hypnosis to treat PTSD, but evidence suggests it is at least as effective as other cognitive-behavioral treatments.^20,21

Patients can be taught to view PTSD’s intrusive memories and bodily symptoms as re-experiencing painful memories. The memories often intrude less frequently after patients find a controlled method—such as self-hypnosis—to access and work them through.²²

Box 3

Split-screen revelation: ‘He wants to kill me’

Ms. J hoped hypnosis could help her better visualize the face of an assailant who had attacked her as she returned at dusk from the grocery store. She had fought off his attempt to drag her into her apartment and rape her. The police showed little interest in pursuing him, however, because the sexual assault had not been completed. After the police left, she had a grand mal seizure. She had suffered a basalar skull fracture.

Ms. J was highly hypnotizable and learned the split-screen technique. While visualizing the assault on the left screen, she realized something that had not been clear to her before: “From the look on his face, I can see he wants to kill me. If he gets me into my apartment, he will kill me.”

She focused on this realization and the image of his hatred and threat to her. The therapist asked her to picture on the right screen something she had done to protect herself. She said: “He is surprised that I am fighting so hard. He doesn’t expect me to put up such a fight.”

She emerged from hypnosis understanding that she had been in more danger than she realized. Thus, despite the disappointment of having no clearer idea of what he looked like (it was quite dark when he attacked her), she had a restructured perspective about what had occurred.

Before this session, Ms. J had felt guilty that she had gotten herself so seriously injured. Afterward, she could better tolerate the memory of the attack because it was coupled with cognitive awareness that her actions may have saved her life.