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self-hypnosis training for the management of chronic pain in MS — Hypnosis vs. Progressive Muscle Relaxation

Study title:   A comparison of self-hypnosis versus progressive muscle relaxation in patients with multiple sclerosis and chronic pain.

Int J Clin Exp Hypn. 2009 Apr;57(2):198-221. doi: 10.1080/00207140802665476.
Jensen MP1, Barber J, Romano JM, Molton IR, Raichle KA, Osborne TL, Engel JM, Stoelb BL, Kraft GH, Patterson DR.
Abstract
Twenty-two patients with multiple sclerosis (MS) and chronic pain we recruited into a quasi-experimental trial comparing the effects of self-hypnosis training (HYP) with progressive muscle relaxation (PMR) on pain intensity and pain interference; 8 received HYP and the remaining 14 participants were randomly assigned to receive either HYP or PMR. HYP-condition participants reported significantly greater pre- to postsession as well as pre- to posttreatment decreases in pain and pain interference than PMR-condition participants, and gains were maintained at 3-month follow-up. Most of the participants in both conditions reported that they continued to use the skills they learned in treatment and experienced pain relief when they did so. General hypnotizability was not significantly related to treatment outcome, but treatment-outcome expectancy assessed before and after the first session was. The results support the efficacy of self-hypnosis training for the management of chronic pain in persons with MS.
PMID: 19234967 [PubMed - indexed for MEDLINE] PMCID: PMC2758639

The Full article is found here

http://www.ncbi.nlm.nih.gov/pubmed/19234967

Posted in Evidence, Hypnosis Research, Multiple Sclerosis (MS) | Tagged , , , | Leave a comment

A Comparison of Self-Hypnosis Versus Progressive Muscle Relaxation in Patients With Multiple Sclerosis and Chronic Pain (Full Article)

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This article is posted here for posterity, it is found online for free at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2758639/

It is referenced in this abstract article here

Int J Clin Exp Hypn. Author manuscript; available in PMC 2010 Apr 1.
Published in final edited form as:
Int J Clin Exp Hypn. 2009 Apr; 57(2): 198–221.

doi:  10.1080/00207140802665476

PMCID: PMC2758639
NIHMSID: NIHMS124907

A Comparison of Self-Hypnosis Versus Progressive Muscle Relaxation in Patients With Multiple Sclerosis and Chronic Pain1

See other articles in PMC that cite the published article.

Abstract

Twenty-two patients with multiple sclerosis (MS) and chronic pain we recruited into a quasi-experimental trial comparing the effects of self-hypnosis training (HYP) with progressive muscle relaxation (PMR) on pain intensity and pain interference; 8 received HYP and the remaining 14 participants were randomly assigned to receive either HYP or PMR. HYP-condition participants reported significantly greater pre- to postsession as well as pre- to posttreatment decreases in pain and pain interference than PMR-condition participants, and gains were maintained at 3-month follow-up. Most of the participants in both conditions reported that they continued to use the skills they learned in treatment and experienced pain relief when they did so. General hypnotizability was not significantly related to treatment outcome, but treatment-outcome expectancy assessed before and after the first session was. The results support the efficacy of self-hypnosis training for the management of chronic pain in persons with MS.

Pain is a common and significant problem in many persons with multiple sclerosis (MS). Although the reported rates of pain problems in samples of individuals with MS vary across studies, most surveys report prevalence rates between 40% and 80% (Archibald, McGrath, Ritvo, & Fisk, 1994Beiske, Pedersen, Czujko, & Myhr, 2004Ehde et al., 2003Ehde, Osborne, & Jensen, 2005Goodin, 1999Hadjimichael, Kerns, Rizzo, Cutter, & Vollmer, 2007Indaco, Iachetta, Nappi, Socci, & Carrieri, 1994Rae-Grant, Eckert, Bartz, & Reed, 1999Solaro et al., 2004Stenager, Knudsen, & Jensen, 19911995Svendsen et al., 2003; see also review by O’Connor, Schwid, Herrmann, Markman, & Dworkin, 2008). The presence and severity of pain in persons with MS has also been shown to be associated with higher levels of depression, functional impairment, and fatigue (O’Connor et al.). Despite the frequency and negative impact of pain in persons with MS, however, there are few controlled trials examining the efficacy of treatments for MS-related pain, severely limiting our ability to make empirically based treatment recommendations for individuals with MS and chronic pain.

Preliminary evidence suggests that self-hypnosis training could potentially benefit persons with MS and chronic pain, supporting the need for controlled trials to examine this approach. Literature reviews, for example, have concluded that hypnosis can be effective for a variety of acute and chronic pain conditions (see Jensen & Patterson, 2006Montgomery, DuHamel, & Redd, 2000Patterson & Jensen, 2003), although there are yet to be any published controlled trials studying pain in persons with MS, specifically. In addition, three uncontrolled case reports and case series have reported benefits following hypnotic treatment in patients with MS and chronic pain. In the first of these, Dane (1996) described a patient with MS who was able to maintain stable pain control and some neuromuscular rehabilitation gains for 3 months after hypnotic treatment that also included regular self-hypnosis practice. Similarly, Sutcher (1997) reported benefits from hypnotic treatment in 3 patients with MS, 1 who received treatment specifically targeting pain. More recently, our group reported pretreatment to posttreatment improvements in daily pain intensity among 33 individuals with chronic pain and disabilities, 10 of whom had MS (Jensen et al., 2005). Moreover, a large proportion of the individuals who benefit from self-hypnosis training maintain that benefit for up to 12 months after treatment (Jensen et al., 2008).

Despite these promising findings, there is much that is not known about the effects of self-hypnosis training on pain and other outcome variables in persons with MS. First, as indicated above, no controlled trials examining the efficacy of self-hypnosis training in persons with MS have been published. Such trials are necessary to determine if self-hypnosis training has any specific effects on chronic pain beyond the effects of placebo (expectancy), time, or therapist attention (Jensen & Patterson, 2005). Also, although pain intensity is commonly assessed as the primary outcome variable in hypnotic analgesia studies, with the exception of a very few studies (cf. James, Large, & Beale, 1989Jensen et al., 20052008), other outcome domains, such as the impact of pain on functioning, are rarely assessed in hypnotic-analgesia research. Thus, little is known about the effects of self-hypnosis training on other key outcome variables.

Finally, more needs to be understood about the predictors of hypnotic treatments, both to help test and to refine theories of hypnosis as well as to make practical recommendations to patients and clinicians for better predicting and enhancing the effects of treatment. For example, social-cognitive models of hypnosis contend that patient treatment outcome expectancies play an important role in determining response to hypnosis and hypnotic suggestions, and a number of laboratory studies support this model (see review by Kirsch, 1985). Examining the hypothesized associations between patient outcome expectancies and treatment outcome would help to test the viability of this model in the clinical setting. General hypnotizability has also been found to predict treatment outcome in some, but not all, clinical hypnotic-analgesia studies (see review byPatterson & Jensen, 2003). To the extent that general hypnotizability is found to be associated with treatment outcome, it would support the utility of hypnotizability measures for screening patients for treatment, or at least for modifying treatment to match different levels of hypnotizability.

With these considerations in mind, the current study sought to expand our understanding of the effects of self-hypnosis treatment for chronic pain relative to a control condition. We used an active control treatment, progressive muscle relaxation (PMR), because it controls for therapist attention, time, and patient outcome expectancy, three key nonspecific factors that could potentially explain the effects of self-hypnosis treatment. We hypothesized that if the self-hypnosis treatment protocol produces benefits beyond those produced by these nonspecific factors, then participants in the hypnosis condition would report more treatment benefits than those assigned to the PMR condition. A treatment-outcome study such as this also makes it possible to explore potential predictors of outcome, and we therefore assessed and examined the effects of two such predictors, hypnotizability and participant-reported treatment-outcome expectancy, to determine their association with treatment outcome.

METHOD

Participants

Twenty-two individuals with MS and chronic pain were recruited from a previously completed survey study of pain in persons with MS (Ehde, Osborne, Hanley, Jensen, & Kraft, 2006). Patients were eligible to participate in the current study if they: (a) had a diagnosis of MS; (b) were at least 18 years old; (c) reported chronic daily pain that was rated as being at least 4/10, on average, on a 0–10 Numerical Rating Scale of intensity; and (d) indicated on the survey that they would be willing to be contacted about possible participation in future research studies. Exclusion criteria were (a) evidence of severe psychopathology symptoms of psychosis on interview or endorsement of active suicidal ideation with intent within the past 6 months (two potential participants were excluded on this basis); and (b) a score of 21 or greater on the Telephone Interview of Cognitive Status (Brandt, Spencer, & Folstein, 1988), indicative of severe cognitive deficits that could potentially interfere with the focused attention required for hypnosis (no potential participants were excluded for this reason).

The first 8 eligible participants who agreed to participate in this study were given a standardized self-hypnosis training protocol (HYP), with an initial plan that these participants would be pilot subjects and allow for additional changes in the protocol as needed. These 8 participants were all told that they would be receiving an intervention that had “both hypnotic and relaxation components” that had been shown to be associated with reductions in pain in previous research. However, we determined that no changes in the HYP protocol would be needed based on the use of the protocol with these participants, allowing us to potentially include them in analyses of other HYP participants if (a) no significant differences were found in outcome between these participants and those subsequently randomly assigned and (b) additional participants were needed to provide for adequate power in the planned analyses if recruitment for the planned randomized trial was limited. The next 14 eligible study participants were randomly assigned (via a computer-generated list of random numbers) to one of the two treatment conditions (n = 7 per condition). For these participants, although they knew that they would be randomized to one of two possible treatments, both the HYP and the PMR interventions were described to the participants in the same way. In all, there were 15 participants in the HYP condition and 7 in the PMR condition.

We determined that 7 participants per condition in the randomized portion of this study would be inadequate for testing hypothesized differences between the HYP and PMR treatments, so the outcomes between the 8 participants who were given HYP (without randomization) and the 7 participants who were randomized to HYP were compared on all demographic and outcome variables. No significant differences between these two groups emerged on any variable, justifying combining the two into a single group for subsequent analyses; although including these nonrandomized participants makes the design a quasi-experimental study rather than a randomized clinical trial (Cook & Campbell, 1979).

The mean age of the study participants was 51.7 years (range = 27– 75 years). Most (73%) were women, and 20 (91%) were Caucasian. One participant described himself as an African American, and a second described himself as being both Caucasian and African American. Pre-and posttreatment data were collected from all 22 participants, but 2 of the participants (1 from each treatment condition) did not provide data for the secondary outcome variable (pain interference) at the 3-month follow-up assessment. Therefore, all analyses using the 3-month pain-interference scores had 20 participants.

Intervention Protocols

Both treatment protocols were initially described to the study participants using the same wording to increase the probability that participants would develop similar outcome expectancies for both treatments. Specifically, both interventions were described in the following way: “Treatments that have been shown to produce decreases in pain in individuals with a variety of chronic pain conditions and that included both relaxation and hypnosis components.” Participants were also told that the focus of the interventions was to teach a specific set of skills that could be used to alter how their brain processes pain information and that provide pain relief when they chose to use the skills in the future. They were told that the purpose of the study was to determine if these treatments would be helpful for persons with MS and chronic pain, and also to help us determine if one treatment was more or less effective than the other. In all communication with the study participants, both treatments were referred to as “relaxation and hypnosis” training programs; we specifically avoided labeling one as Hypnosis and the other as Relaxation or Progressive Muscle Relaxation, again, to minimize differences in expectancy between the two treatment conditions that might occur if they were given different labels.

Self-hypnosis training

We refer to the intervention we used in this study self-hypnosis training rather thanhypnosis treatment because of the focus on teaching and encouraging the use of hypnosis outside of the hypnosis sessions. Thus, although the HYP intervention included hypnosis (interactions with a clinician that included an induction followed by a series of suggestions for analgesia and comfort), participants were urged to practice the skills learned during the hypnosis sessions at home, both by listening to audio recordings of the sessions and by using a cue to reexperience hypnosis and the relief that it provides.

The self-hypnosis training (HYP) treatment protocol was a modified version of a treatment protocol described in detail in a previous case series study (Jensen et al., 2005). The modifications to the original protocol were made in an effort to increase the efficacy of the intervention beyond what was found in the previously reported case series. The first modification was the inclusion of a suggestion inviting participants to imagine themselves as being in a “special place” of the participant’s choice. For participants who were comfortable with it, the special place could include a body of water of the participant’s choice (e.g., pool, stream, or ocean) that was “just the right temperature” and that the participant could choose to relax or float in (any participant who was water-phobic or otherwise uncomfortable with the idea of relaxing in a body of water could have opted out of this suggestion; although no one chose to do so). Those who would have been water phobic were encouraged to visualize being in another place of their choosing without water (e.g., a field of flowers, a vacation home, etc.). Second, the induction and special place imagery were followed by a suggestion for experiencing one classic hypnotic phenomenon (such as hand or arm lowering, hands pulled together, head pulled to the side; different phenomenon were tried until one was found that the participant could respond to) to enhance the participant’s sense of successful hypnotic responding.

A third modification came in the number and content of analgesia suggestions. In the original treatment protocol (Jensen et al., 2005), five analgesia suggestions (decreased pain unpleasantness, deep relaxation, sensory substitution, imagined anesthesia, and decreased pain sensations; see Jensen et al., 2005, for a detailed description of these suggestions) were included in all 10 sessions. In the present study, these five suggestions were administered only in the first two sessions. In the remaining eight sessions, only two specific suggestions were used. The first was the suggestion for decreased unpleasantness of any uncomfortable sensations, which we have found to be helpful to the majority of individuals with chronic pain. The second suggestion was selected by the clinician, usually based on the individual participant’s response (i.e., a reported decrease in pain). But other factors were also taken into account, especially when participants reported similar decreases in pain following more than one additional suggestion, such as (a) if the participant reported that he or she particularly enjoyed a suggestion or (b) if the participant reported benefits to a suggestion in addition to changes in pain. This modification was made primarily because a number of participants in the original case series had indicated that they preferred some suggestions over others, and we wanted to allow some flexibility and tailoring in the treatment approach to better match usual clinical practice. The final modification made was that the new protocol allowed for one additional suggestion of the participant’s choosing (e.g., improved sleep, increased general calm or sense of well-being) to further engage the participant in the process.

As with the original protocol, all sessions ended with posthypnotic suggestions that (a) any experience of analgesia and comfort obtained would stay with the participant and linger beyond the sessions, lasting for “hours, days, and even weeks,” and become “a permanent part of how the brain operates”; (b) the more the participant listens to recordings of the sessions, and to the extent that the participants finds the suggestions helpful, the more effective all of the suggestions would be; and (c) over time and with continued practice, the participant will be able to enter “a comfortable relaxed state of hypnosis more and more easily.” Sessions 3 and 4 were recorded, and audiotapes or CDs of these sessions were given to the participants to listen to, with the suggestion that they listen to the recordings at least once every day but more often if they found the recordings helpful. Participants were also encouraged to repeat their experience of hypnosis and any suggestions that they found helpful “on your own” (i.e., without the audio recording) at least once every day, as a way to increase their ability to use and respond to self-hypnosis.

Progressive muscle relaxation

The 10-session progressive muscle relaxation (PMR) intervention was based on the work of Bernstein and Borkovec (1973) and Jacobson (1976) and involved a progressive tightening and relaxing of different muscle groups throughout the body, with ongoing suggestions that this would be associated with an increased sense of perceived relaxation and comfort. Four different scripts were used for the PMR condition. The first script, used in the first two sessions, focused on 16 major muscle groups: right and left hands, right and left arms, forehead, face, jaw, neck, chest/shoulders/ upper back, abdomen, right and left thigh, right and left calf (plantar flexion), right and left shin (dorsi flexion). The second script, used for Sessions 3 through 5, combined some of the muscle groups together, so that seven general muscle group areas were the focus of relaxation. The third script combined muscle groups further into four overall, and the fourth and final script focused only on general body scanning and relaxation. Sessions 3 and 4 were recorded, and audiotapes or CDs of these were provided to participants with the same instructions as those given to participants in the HYP condition (i.e., to listen to the recordings at least once a day but more often if they found the recordings helpful). Participants in the PMR condition were also encouraged to practice on their own without the recordings at least once per day.

Measures

Primary outcome

The primary outcome variable for this study was pain intensity, assessed using 0–10 numerical rating scales (NRSs), with 0 = No pain sensation and 10 = The most intense pain sensation imaginable. Self-report of pain intensity is recognized as the most appropriate primary outcome measure in analgesic clinical trials (Turk et al., 2003), and the 0–10 NRS has been recommended as a useful measure of this pain domain because of (a) the strong evidence for its validity as evidenced by its strong association with other measures of pain intensity and responsivity to analgesic treatment, (b) understandability and ease of use, and (c) ease of administration and scoring (Jensen & Karoly, 2001).

Current pain-intensity ratings were obtained before and after each treatment session by the treating clinician, and each of these ratings was then averaged into composite pre- and postsession scores, to measure the immediate effects of the interventions on pain intensity. Average daily pain intensity was assessed by phone interview by a research assistant blind to treatment condition, before and after treatment as well as at 3-months follow-up. To assess this outcome variable, participants were telephoned on 4 days within a 7-day window and asked to rate their current pain and average, least, and worst pain in the past 24 hours. The 16 ratings obtained at each assessment (four intensity domains assessed on 4 different days each) were then averaged into a composite score representing average daily pain. The use of such composite scores has been recommended as a way to increase measurement reliability in pain clinical trials, such as this one, with limited power due to low sample sizes (cf. Jensen, Turner, Romano, & Fisher, 1999). If a participant could not be contacted four times within a 7-day period, the composite score was made up of an average of the ratings that could be obtained during the assessment window.

Secondary outcomes

The secondary outcome variables in this study were pain interference and frequency and effects of self-hypnosis and relaxation practice. Pain interference was assessed using a modified version of the Pain Interference Scale from the Brief Pain Inventory (BPI; Cleeland & Ryan, 1994Daut, Cleeland, & Flannery, 1983). The original version of this scale asks respondents to rate the degree to which pain interferes with seven daily activities, including general activity, mood, walking ability, normal work, relations with other people, sleep, and enjoyment of life. For use in the current study, we modified the BPI in two ways. First, we changed Item 3 (“Walking ability”) to read “Mobility, that is, your ability to get around,” to be more appropriate for the participants in the current study, many of whom are unable to walk. Second, in order to gain a broader perspective of the extent to which pain interfered with important activities, the current study added three items (self-care, recreational activities, and social activities) important to functioning in persons with disabilities, to both (a) increase the reliability of measurement and (b) increase the content validity of this measure. The BPI interference items are averaged to produce a total composite pain interference score.

The original BPI Pain Interference scale has demonstrated validity through its strong association to pain severity across a number of samples of individuals with cancer and other diseases (Daut et al., 1983; see alsoCleeland & Ryan, 1994), and the modified 10-item version of this scale has demonstrated validity in samples of persons with disabilities, including persons with MS, through its strong association with pain intensity, and even stronger association with measures of physical disability (Osborne, Ehde, Jensen, & Kraft, 2006Tyler, Jensen, Engel, & Schwartz, 2002). The modified BPI was administered once, by telephone, during each assessment window.

Amount and effects of self-hypnosis and relaxation practice after treatment were assessed via telephone interview by a research assistant blind to treatment condition at 1-, 2-, and 3-months posttreatment by asking participants to indicate, during the past 30 days: (a) the number of days they listened to the audio recording they were given; (b) on those days they listened to the audio recording, the usual number of times they listened; (c) the amount of pain relief they experienced when they listened to the audio recording (on a 0–10 scale, with 0 = No relief and 10 = Complete relief); and (d) the hours of relief they usually experienced after listening to the recording. Similar questions were also asked about the frequency and effects of practice on their own, without the recordings.

Predictors/manipulation check

Two predictor variables were assessed in this study: hypnotizability and treatment-outcome expectancy. Hypnotizability was assessed using a modified version of the Stanford Hypnotic Clinical Scale (SHCS; Hilgard & Hilgard, 1994) and was administered by one of the study clinicians (but not the same clinician who provided treatment) at the time of study recruitment. The SHCS, which has demonstrated its validity through its positive association with other measures of hypnotizability (Hilgard & Hilgard), consists of five suggestions for classic hypnotic responses, including hand lowering, suggested cough/throat clearing, amnesia, age regression, and a hypnotic dream. The hand-lowering item was modified to allow for an alternative motor response (e.g., moving the head to the right) for any participants with motor limitations in their arms.

Treatment-outcome expectancy was assessed using the four-item Treatment Expectancy Scale (TES; Holt & Heimberg, 1990) with the items modified to assess expectancies concerning the effects of treatment on pain. Using this measure, participants were asked to rate: (a) the perceived logic of the treatment (“How logical does this type of treatment seem to you?”); (b) their confidence in the treatment for their pain condition (two questions: “How confident would you be that this treatment will be successful in eliminating your pain?” and “How successful do you feel this treatment will be in decreasing your pain?”); and (c) their confidence in the treatment for others (“How confident would you be in recommending this treatment to a friend who was experiencing a great deal of pain?”). The participants were asked to respond to each item on 0-to-10 numerical scales just before and after the first treatment session, and their responses to the items were averaged to form two (pre- and postsession) measures of treatment-outcome expectancy. The original TES has been used successfully in treatment-outcome research to determine the credibility of control conditions (e.g., Heimberg, Dodge, Hope, Kennedy, & Zollo, 1990) and to determine the extent to which treatment-outcome expectancies predict treatment response (Chambless, Tran, & Glass, 1997Safren, 1997). The modified TES used in this study was also used previously to predict response to a hypnotic analgesia intervention, specifically (Jensen et al., 2005). In this study, treatment-outcome expectancy was used both as a predictor variable (to determine the ability of outcome expectancies to predict treatment outcome) and as a manipulation check (to ensure that the two treatment conditions elicited similar outcome expectancies).

Procedures

Following 1 week of pretreatment assessments (to assess average daily pain and pain interference), participants received up to 10 sessions of either HYP or PMR (randomization procedure described above). Current pain intensity was assessed before and after each treatment session, and these ratings were averaged into composite pre- and post-session intensity scores. Posttreatment outcome measures (daily pain intensity and pain interference) were obtained during the 7 days immediately after treatment; amount of hypnosis or relaxation practice with and without the practice recordings was assessed at 1-, 2- and 3-months posttreatment, and daily pain intensity and pain-interference data were obtained during a 1-week period 3 months after treatment.

Data analyses

Differences in treatment-outcome expectancy assessed before and just after the first session were first compared between participants in the two treatment conditions using mixed-design analysis of variance (ANOVA), and subsequent univariate tests as appropriate to explain any significant effects found. A mixed-design ANOVA was also used to determine the immediate effects of each treatment condition on pain intensity. In these analyses, the pre- and postsession pain intensity scores averaged across all sessions were used as the dependent variable, time (presession, postsession) as a repeated measures variable, and treatment condition (HYP, PMR) as a between-subjects variable.

The effects of treatment on daily pain intensity and interference were evaluated by performing two mixed-design ANOVAs. In these analyses, the daily pain intensity composite and BPI interference scores were the dependent variables, time (pretreatment, posttreatment, and 3-month follow-up) was the repeated-measures variable, and treatment condition was the between-subjects variable. Any significant effects or trends were followed up with univariate analyses (paired t tests) to help explain the effects found.

Given the fact that findings concerning average change in pain intensity do not provide information about the rates of positive response among individuals in the sample (a moderate degree of change in average pain for the sample as a whole could be obtained, for example, from a small to medium treatment response in all participants or from a large response in a very few participants), a responder analysis was conducted to determine the number of participants who showed a clinically meaningful change in pain intensity from pre- to postsession as well as from pretreatment to posttreatment and follow-up. A change in pain intensity of 30% was used as the cutoff for identifying a clinically meaningful change in these analyses, given previous research that has shown that improvements of 30% or more are associated with patient reports of meaningful change across a number of chronic pain conditions (Farrar, Young, LaMoreaux, Werth, & Poole, 2001).

The amount and reported effects of self-hypnosis and relaxation practice with and without the use of recordings were computed and then compared between the two treatment conditions. Finally, the associations between the potential predictors of treatment response (hypnotizability, pre- and post first session treatment-outcome expectancy) among those in the HYP condition alone and the combined HYP and PMR participants were estimated by computing correlation coefficients between the predictor variables and three measures of treatment outcome: (a) pre- to posttreatment change in daily pain intensity, (b) pretreatment to follow-up changes in daily pain intensity, and (c) posttreatment to follow-up changes in daily pain intensity. Given the small sample size of the current study, which can limit the ability to detect true effects in the correlational analyses, both the significance levels and the overall magnitude of these associations were interpreted, with rs between .10 and.30 deemed as weak, rs between .30 and .50 deemed as moderate, and rs greater than .50 deemed as large associations (Cohen, 1988).

RESULTS

Treatment-Outcome Expectancy

Treatment-outcome expectancy did not differ significantly between the two treatment conditions either before the first treatment session (TES means [SDs] for the HYP and PMR groups, 6.85 [1.40] and 6.79 [1.22], respectively, t(20) = 0.10, p = ns) or after the first treatment session (means [SDs], 8.08 [1.54] and 7.21 [1.54], t(20) = 1.24, p = ns). An observation of these means suggested a pre- to postsession increase in outcome expectancy among participants in both conditions, and a possibility that this increase was slightly greater in the HYP group than the PMR group. This was explored further using a repeated measures ANOVA, which yielded a significant time effect, F(1, 20) = 7.77, p < .05, but not a significant Time × Treatment Condition interaction, F (1, 20) = 1.82, p = ns. These findings indicate that (a) both conditions had similar effects on outcome expectancies and (b) initial direct experience with either treatment resulted in increases in treatment-outcome expectancy.

Pre- to Postsession Changes in Pain Intensity

The average of the presession and postsession 0–10 pain-intensity ratings for the participants assigned to the HYP and PMR conditions are presented in Table 1. A significant Time × Condition interaction, F(l, 20) = 5.04, p < .05, indicated differences in pre- to postsession changes in pain intensity between the conditions. Subsequent t tests showed a statistically significant, t(14) = 7.43, p < .001, decrease in pain intensity for the HYP condition, and a smaller but nonsignificant, t(6) = 1.44, p = ns, decrease in pain intensity for the PMR condition. Clinically meaningful (30% decrease or more) changes in pain intensity were reported by 13 (87%) of the HYP participants and 4 (57%) of the participants who received PMR. In short, despite similar outcome expectancies in both treatment conditions, and a similar effect on outcome expectancies by both treatments, participants in the HYP condition experienced a greater pre- to postsession decrease in pain intensity than participants in the PMR condition.

Table 1

Means and SDs for the Average of the Current Pain Ratings Obtained Just Before and Just After Each Session for Each Treatment Condition

Changes in Daily Pain Intensity

The means and standard deviations for the pretreatment, posttreatment, and 3-month follow-up daily pain composites are presented in Table 2. A significant, F(2, 19) = 4.08, p < .05, Time × Treatment Condition interaction indicated significant differences between the two treatment conditions in change in daily pain over time. Subsequent ANOVAs for each treatment condition separately showed a statistically significant change in daily pain over the three assessment periods for the HYP condition, F(2, 13) = 9.96, p < .001, but not the PMR condition, F(2, 5) = 0.99, pns. Univariate analyses showed a statistically significant pre- to posttreatment decrease in daily pain for the HYP participants, t(14) = 4.63, p < .001, but not for the PMR participants, t(6) = 0.11, pns. Moreover, although there was a slight increase in daily pain for the HYP participants from posttreatment to follow-up, this increase was not statistically significant, t(14) = 1.07, p = ns, and the decrease in daily pain-intensity scores between pretreatment and 3-month follow-up remained statistically significant, t(14) = 3.02, p < .01, among the HYP participants. However, among the PMR participants, neither the slight decrease in daily pain from posttreatment to follow-up, nor the difference between pretreatment and follow-up daily pain were statistically significant, ts(6) = 1.47 and 1.31, both ps = ns, respectively.

Table 2

Means and SDs for the Daily Pain Intensity Composite and Pain Interference Scores at Pretreatment, Posttreatment, and 3-Month Follow-Up

In terms of the rates of clinically meaningful change in daily pain, 7 (47%) of the HYP participants and 1 (14%) of the PMR participants reported a meaningful decrease in daily pain from pre- to posttreatment. These numbers were 7 (47%) and 2 (29%) at the 3-month follow-up for the HYP and PMR participants, respectively.

Changes in Pain Interference

The means and standard deviations for the pretreatment, posttreatment, and 3-month follow-up pain-interference scores are also listed in Table 2. The ANOVAs indicated a nonsignificant trend, F(2, 19) = 3.26,p < .10, for the Time × Treatment Condition interaction. Subsequent ANOVAs for each condition separately indicated a significant change in pain interference over time for the HYP condition, F(2, 12) = 7.62, p < .001, but not the PMR condition, F(2,4) = 1.47, pns. Univariate analyses showed a statistically significant pre- to posttreatment decrease in pain interference for the HYP participants, t(13) = 4.06, p < .001, but not for the PMR participants, t(5) = 0.48, pns. As with daily pain intensity, although there was a slight increase in pain interference for the HYP participants from posttreatment to follow-up, this increase was not statistically significant, t(13) = 1.25, p = ns, and the difference between pretreatment and follow-up pain interference remained statistically significant, t(13) = 2.19, p < .05. The slight decrease in pain interference from posttreatment to follow-up reported by the PMR participants was not statistically significant, t(5) = 1.78, p =ns, nor was the difference between pretreatment and follow-up pain interference, t(5) = 0.28, pns.

Practice With and Without Audio Recordings Posttreatment

Participant reports of the frequency and effects of self-hypnosis and relaxation practice are presented in Table 3. Nonparametric statistics (Mann-Whitney test) were used to compare the groups on these variables, because of the marked positive skew of the distributions in both treatment groups. The findings indicate similar responses of participants in both conditions on most variables. The possible exceptions to this included: (a) a larger median number of days of listening to recordings in the HYP participants (Median 33 days) compared to PMR participants (Median 12 days); (b) a longer time of pain relief after listening to the HYP recordings (Median 6 hours) than the PMR recordings (Median 2 hours); and (c) a larger median number of days of practicing on their own (without the recording) among the HYP participants (Median, 64 days) than the PMR participants (Median, 35.5 days). However, the differences in these variables were not statistically significant, perhaps due to the large variability in reported amounts and effects of practice, as well as the small sample size.

Table 3

Self-Hypnosis and Relaxation Practice, With and Without Audio Recording, in the 3 Months Following Treatment (Complete Data from 19 Participants)

Prediction of Treatment Outcome

The association between all three treatment-outcome measures and hypnotizability was negligible in the sample as a whole (rs range, −.02 to .03), and weak and nonsignificant (rs range, −.23 to .28) among the HYP participants (see Table 4). Treatment-outcome expectancy assessed before the first treatment session showed a moderate association with changes in pain from posttreatment to 3-month follow-up in both the sample as a whole (r = .40, p < .10) and the HYP participants (r = .40, pns). On the other hand, treatment-outcome expectancy assessed after the first session, that is, after the participants had an opportunity to experience the treatments directly, showed moderate associations with pretreatment to posttreatment and posttreatment to follow-up changes in pain (rs range, .28 to .45 in the sample as a whole and the HYP sample), and strong associations with pretreatment to follow-up changes in daily pain intensity (rs = .55 and .61 for the sample as a whole and the HYP sample, ps < .01 and .05, respectively).

Table 4

Association (Spearman Rhos) Between Change in Daily Pain Intensity Following Treatment for Participants in the Hypnosis Condition and Both Treatment Conditions Combined

Discussion

There are a number of findings from this study that warrant discussion. First, we found that individuals with MS and chronic pain who received a self-hypnosis training intervention reported significantly more benefits from treatment than individuals assigned to a progressive muscle relaxation condition, despite similar treatment outcome expectancies of the participants in the two conditions. Two other important findings concern the prediction of treatment outcome and the use and reported effects of continued self-hypnosis practice after treatment.

Perhaps the largest challenge in designing methodologically sound hypnosis clinical trials is the selection of the control condition (Jensen & Patterson, 2005). A number of control conditions have been used in published hypnosis trials, such as wait-list controls, standard care, and other (active or effective) treatments, among others. Because each of these controls for different possible confounds, any study that uses one or more of these control conditions contributes to our understanding of the specific and nonspecific effects of hypnotic interventions.

Although this study was quasi-experimental because it did not include randomization of all participants, we were able to compare self-hypnosis training to a PMR intervention. This intervention was designed to meet the need to control for treatment-outcome expectancies. Like the hypnosis treatment, it was based on an intervention that has demonstrated efficacy for treating chronic pain, could be described in a way that elicited positive outcome expectancies, could be labeled similarly to the hypnosis treatment (i.e., as an intervention that includes “both hypnosis and relaxation components”) and could be provided in a way that was also very similar to the hypnotic intervention (e.g., face-to-face in 10 sessions, with an accompanying audio recording, etc.). However, the PMR condition in this study differed from the HYP condition in several critical ways, the most important of which was the fact that the PMR condition consisted of only one (but constantly repeated) direct suggestion: to experience relaxation in specific areas of the body. The hypnotic intervention, on the other hand, included a hypnotic induction followed by a much larger number and variety of suggestions, including, in the first two sessions: (a) a suggestion to experience being in a “special place,” (b) a classic hypnotic suggestion to encourage confidence in responsivity, (c) five different analgesia suggestions, (d) posthypnotic suggestions that the benefits obtained with treatment will last beyond the session and become permanent, as well as (e) any additional suggestion that the participant might want to hear during the sessions (to facilitate greater involvement in the sessions and tailoring of treatment). The five analgesia suggestions provided in the first two sessions were reduced to two suggestions (a suggestion for decreased pain unpleasantness plus whatever other analgesia suggestion the participants appeared to enjoy the most or get the most out of), but all of the other suggestions continued for the remaining eight sessions.

Thus, the HYP and PMR treatment conditions shared many key nonspecific components, including their effects on outcome expectancy but differed with respect to the number and variety of suggestions offered. Moreover, both interventions had similar effects on outcome expectancies. Given the fact that the hypnotic-analgesia protocol was more effective than the PMR comparison condition, the findings suggest (but only suggest; see discussion of limitations of quasi-experimental designs, below) that the hypnotic suggestions included in the HYP treatment had an effect on these outcome variables over and above the effects of therapist attention, time, or outcome expectancy.

We examined two predictors of treatment response in this study: hypnotizability and treatment-outcome expectancy. Of these two, only treatment-outcome expectancy was associated (moderately to strongly) with outcome. The lack of a significant association between hypnotizability and treatment outcome is inconsistent with some previous findings in clinical settings (e.g., Andreychuk & Skriver, 1975Friedman & Taub, 1984;Gay, Philipport, & Luminet, 2002) but is consistent with a previous study by our group using a similar treatment protocol (Jensen et al., 2005). The inconsistencies across studies concerning the relative importance of hypnotizability as a predictor may be related to differences between studies in the way that hypnotizability is assessed, differences in the treatment protocols used, differences in the samples or types of pain studied, or some combination of these.

Even when significant associations between hypnotizability and treatment outcome are found, however, they are not always strong for all outcome measures (Friedman & Taub, 1984Gay et al., 2002). The skills needed to respond to hypnotic suggestions for pain management, even in the best of circumstances, may not always be strongly related to the skills necessary to respond to the hypnotic suggestions contained in common hypnotizability tests, such as suggestions for arm levitation, amnesia, or visual hallucinations. Hypnotic responding is not necessarily a single unified trait and may be composed of multiple abilities (cf.Pekala & Kumar, 2007), some of which may be associated with response to analgesia suggestions and others of which may not. In any case, as a group, these findings suggest that it is probably not useful to screen individuals from hypnotic treatment for chronic pain management based on their response to hypnotizability tests alone. Such screening may, in fact, exclude some patients from a treatment they could benefit from.

On the other hand, treatment-outcome expectancy did show a moderate to strong association with treatment outcome in this study. Although the present findings do not support a conclusion that the effects of self-hypnosis training are entirely due to expectancy effects (otherwise, we would have seen a similar treatment effect for the two conditions), the findings are consistent with the hypothesis that patient expectancies may play a role in both immediate and short-term (at least up to 3 months) outcomes in response to hypnotic analgesia treatment for chronic pain (Kirsch, 1985); although the importance of outcome expectancies in hypnotic responding may be much less than is commonly thought (Benham, Woody, Wilson, & Nash, 2006). Practically, the findings suggest the possibility that clinicians might be able to enhance treatment outcome to some extent by presenting treatment in a way that realistically describes treatment and its possible effects and also facilitates patient expectancies and hope for positive outcomes. This possibility certainly warrants further investigation. Research that identifies ways to enhance outcome expectancies in the clinical setting, and then determines the impact of this enhancement on clinical outcome, could be particularly useful to help (a) provide additional tests of the relative importance of expectancy in determining response to hypnotic treatment and (b) possibly enhance the efficacy of hypnotic analgesia treatment.

Three limitations of the current study should be kept in mind when interpreting the results: (a) the quasi-experimental design; (b) the low sample size; and (c) the “active” nature of the comparison (PMR) condition. Although it was important to include 8 of the participants in the analyses of the HYP condition who had been given HYP from the start in order to increase the power of the analyses, the inclusion of these participants in the analyses limits our ability to draw causal conclusions about the effects of HYP versus PMR from the study. Future research, ideally with larger sample sizes, will be needed to determine the extent to which the findings replicate to other samples. In addition, the low sample size limits the ability of the study to detect effects that might exist in the population but did not emerge in the sample. For example, although both interventions resulted in reduced pain, only the reduction observed in the HYP condition was statistically significant. It is possible that the pain reduction reported by participants in the PMR condition might have been found to be statistically significant had there been a larger number of participants in the study who received PMR. Similarly, some of the differences observed between the two treatment conditions concerning the effects of practice on pain (for example, that the HYP recordings reportedly resulted in more hours of pain relief than the PMR recordings did) might have been statistically significant had we had more resources to recruit additional participants for the study. Future researchers should strive to maximize the numbers of participants in hypnosis clinical trials to be better able to detect true effects or to be more confident that such effects do not exist when a lack of significant difference is found.

The strengths of the PMR comparison condition we used in this study have already been discussed. But all comparison or control conditions used in hypnosis studies have both strengths and weaknesses. A primary weakness of the PMR condition used in this study, already alluded to, is that it is an active condition that, in fact, may benefit individuals via similar mechanisms as hypnosis. PMR has been found to be effective for pain management in other studies (e.g., Baird & Sands, 2004Crockett, Foreman, Alden, & Blasberg, 1986) and was associated with a reduction in pain (at least from pre- to postsession) in the current study. Because PMR is an active (and potentially effective) treatment, the differences noted between HYP and PMR in this study may underestimate the actual effects of the HYP intervention if compared to an inactive control or no treatment. It is difficult to isolate the unique components of the HYP intervention from those we might employ in a comparison condition. Thus, although the comparison condition was useful for testing and confirming an effect of the hypnosis treatment over and above the effects of time, therapist attention, and patient expectancy, because it is an active treatment we may interpret the results in ways that understate the effectiveness of the hypnosis treatment. For this reason, the PMR condition is not useful for determining the effects of hypnosis relative to no treatment or “nonhypnotic” care. Estimating these treatment effects would have required a third condition, such as a wait-list control. Future researchers would be wise to include such a condition whenever possible; although we understand that the resources available for conducting a clinical trial are often limited, and that the requirements for statistical power may require a limitation in the number of treatment conditions offered in any one study.

We have previously argued that no single hypnosis clinical trial can be definitive, and there is no such thing as a perfect control condition for hypnosis studies (Jensen & Patterson, 2005). Rather, in order for our understanding of the effects of hypnosis on pain and other conditions to advance, the field requires multiple clinical trials and studies that compare hypnotic interventions to a variety of control conditions and interventions. Ultimately, such a series of studies will produce a body of evidence that can help to clarify the efficacy and impact of hypnosis on pain and other symptoms. For the present, however, the results we report here encourage further examination of the clinical utility of hypnotic methods for chronic pain management.

Footnotes

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1This research was supported by grants number R01 HD42838 and R01 AR054115 from the National Institutes of Health; grant number H133B031129 from the Department of Education, National Center of Disability and Rehabilitation Research, and the Hughes M. and Katherine G. Blake Endowed Professorship in Health Psychology awarded to MPJ. A portion of this work was conducted through the Clinical Research Center Facility at the University of Washington and supported by the National Institutes of Health, Grant M01-RR-00037. The authors gratefully acknowledge the assistance of Amy Hoffman, Kevin Gertz, Eric Weitz, and Joe Skala in participant recruitment, data collection, and data entry.

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Hypnosis for Pain and Symptom Management in Sickle Cell Anemia Disease

Randomized trial of hypnosis as a pain and symptom management strategy in adults with sickle cell disease.
Integr Med Insights. 2014 Nov 3;9:25-33. doi: 10.4137/IMI.S18355. eCollection 2014.
Wallen GR1, Middleton KR1, Ames N1, Brooks AT1, Handel D2.
Abstract

Sickle cell disease (SCD) is the most common genetic disease in African-Americans, characterized by recurrent painful vaso-occlusive crises. Medical therapies for controlling or preventing crises are limited because of efficacy and/or toxicity. This is a randomized, controlled, single-crossover protocol of hypnosis for managing pain in SCD patients. Participants receive hypnosis from a trained hypnosis therapist followed by six weeks of self-hypnosis using digital media. Those in the control arm receive SCD education followed by a six-week waiting period before crossing over to the hypnosis arm of the study. Outcome measures include assessments of pain (frequency, intensity and quality), anxiety, coping strategies, sleep, depression, and health care utilization. To date, there are no published randomized, controlled trials evaluating the efficacy of hypnosis on SCD pain modulation in adults. Self-hypnosis for pain management may be helpful in modulating chronic pain, improving sleep quality, and decreasing use of narcotics in patients with SCD.
TRIAL REGISTRATION:
ClinicalTrials.gov: NCT00393250.
KEYWORDS:
chronic pain; hypnosis; pain management; sickle cell disease; sleep; symptom management
PMID: 25520557 [PubMed] PMCID: PMC4219848
Source: http://www.ncbi.nlm.nih.gov/pubmed/25520557
Full article is found here
Posted in Analgesia (Pain Reduction), Evidence, Hypnosis Research, Sickle Cell Disease | Tagged , , , , | 1 Comment

Randomized Trial of Hypnosis as a Pain and Symptom Management Strategy in Adults with Sickle Cell Disease (Full Article)

This article is referenced  on this abstract page http://www.hypno-facts.com/hypnosis-research/hypnosis-for-pain-and-symptom-management-in-sickle-cell-anemia-disease

Pasted here for posterity. Original article can be found at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4219848/

Integr Med Insights. 2014; 9: 25–33.
Published online 2014 Nov 3. doi:  10.4137/IMI.S18355
PMCID: PMC4219848

Randomized Trial of Hypnosis as a Pain and Symptom Management Strategy in Adults with Sickle Cell Disease

Abstract

Sickle cell disease (SCD) is the most common genetic disease in African-Americans, characterized by recurrent painful vaso-occlusive crises. Medical therapies for controlling or preventing crises are limited because of efficacy and/or toxicity. This is a randomized, controlled, single-crossover protocol of hypnosis for managing pain in SCD patients. Participants receive hypnosis from a trained hypnosis therapist followed by six weeks of self-hypnosis using digital media. Those in the control arm receive SCD education followed by a six-week waiting period before crossing over to the hypnosis arm of the study. Outcome measures include assessments of pain (frequency, intensity and quality), anxiety, coping strategies, sleep, depression, and health care utilization. To date, there are no published randomized, controlled trials evaluating the efficacy of hypnosis on SCD pain modulation in adults. Self-hypnosis for pain management may be helpful in modulating chronic pain, improving sleep quality, and decreasing use of narcotics in patients with SCD.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00393250

Keywords: hypnosis, symptom management, pain management, sickle cell disease, chronic pain, sleep

Background

Sickle cell disease (SCD) is the most common genetic disease in African-Americans, characterized by recurrent painful vaso-occlusive crises. The disease is caused by a mutated form of hemoglobin that results in red blood cell (RBC) rigidity during low oxygen states. The most common types of SCD are sickle cell anemia (Hb SS), sickle cell hemoglobin SC (Hb SC), and sickle beta thalassemia (Hb Sβthal). When the defective hemoglobin gives up its oxygen, it is prone to polymerize, causing RBC rigidity and accelerated RBC lysis. These phenomena lead to recurrent vaso-occlusive “crises” that are usually accompanied by disabling pain. The pain episodes are commonly termed “crises” as they are unpredictable, frequent, and debilitating.1 The severity and frequency of the crises presents a significant impact on self-determination, independent living, and overall quality of life.2 The symptomatology that drives the SCD patient to medical care falls into three major categories: anemia, pain, and infection.3

The management of SCD in the past was predominantly palliative in nature, using symptomatic and preventative approaches. The standard of care for SCD patients during vaso-occlusive crisis is pharmacologic analgesia, typically with opioids. While this approach is effective for some patients, many are inadequately treated because of high dosage requirements that are difficult to meet over time, and this approach does little to prevent pain crises from occurring. Patients with SCD have a range of frequencies and intensities of painful vaso-occlusive episodes. Acute episodes often require the individual to be hospitalized for aggressive pain management. Characteristically, the management regime involves narcotic administration. Estimates of pain frequency, based on medical records in hospitals, emergency rooms, and sickle cell clinics, indicate that 10–20% of SCD patients have frequent pain, while 40–50% have some pain, and 30–40% have no pain.4,5Yet, it remains unclear how many pain episodes associated with SCD may not involve hospitalization and are managed with a variety of opioid and non-opioid medications at home.6,7 Previous studies show that discharge follow-up was often deficient and ineffective with the patient going home without any pain medication at all. Pain coping strategies were rarely taught.8

Impact of chronic pain in SCD

Pain in SCD is not limited to acute pain; SCD pain can also be classified as chronic pain or a mixture of both chronic and acute pain.9 Chronic pain is not merely the continuation of the acute vaso-occlusive pain; it is often a result of vascular necrosis of bone particularly at the hips, shoulders, and ankles. SCD patients with more frequent or severe pain often have similar pain patterns throughout the lifespan. Pain has also been shown to be associated with sleep deprivation, poor school or work attendance, and decreased daytime functioning.7,10 Ideally, SCD patients with pain should learn to cope with the pain, with as little negative impact on daily function as a result of the pain or its treatment as possible. Evidence focuses on the frequency of pain resulting in emergency department use and number of hospitalizations because of pain crisis in SCD patients; however, few studies focus on these pain manifestations outside the typical health-care delivery system or how patients manage their pain apart from their physician. Furthermore, it is unclear what percentage of patients are able to self-manage their crises at home without accessing health-care professionals.11

Smith and colleagues11 have conducted The Pain in Sickle Cell Epidemiology Study (PiSCES), a longitudinal, etiologic study of pain with an emphasis on non-biologic variables. These investigators vividly describe the frustrations and barriers for both providers and patients related to pain assessment and relief in SCD. Chief among these barriers is that “red cell vaso-occlusion has no observable clinical correlates to validate subjective descriptions of painful crises, which results in physician skepticism and patient dissatisfaction.”11 In addition to measuring psychosocial variables such as stress, mental health status, coping and social support, Smith and colleagues have developed a conceptual explanatory model of pain and utilization in SCD, which examines the relationship of individual demographics, disease-related variables, psychosocial variables, and readiness variables and their effects on distress disability, health care utilization, and pain. We used this conceptual model (Fig. 1) to guide us in the selection of measures evaluating the process and outcome variables of interest.

Figure 1

Explanatory model of pain and utilization in SCD. Conceptual explanatory model of pain and utilization over time in sickle cell disease.11

Therapeutic hypnosis as an intervention

A published review summarized trials of psychosocial interventions as adjuncts to treating SCD.12 These interventions included cognitive-behavioral techniques, hypnosis, and social support procedures wherein self-empowerment and education are strong facets of the supportive care approach. The effects of these techniques on pain control, quality of life, and health care utilization were inconsistent, perhaps because of inadequate study designs (eg, a lack of suitable control groups and non-standardized scripts).

Evidence exists supporting the efficacy of hypnotic analgesia in a variety of experimental1315 and clinical settings, including pain associated with medical or surgical procedures.1619 Gil and colleagues20demonstrated a direct correlation between daily use of pain-coping skills and less major health care contacts. Thus, cognitive measures that influence attitudes and improve pain-coping skills appear to have a significant impact on sleep, functional outcomes such as work and school attendance, use of analgesics, and major health care utilization. Since hypnosis is a cognitive-behavioral strategy that has been shown to have a powerful effect on pain management in a number of settings, it is postulated that a program designed to teach and encourage the use of self-hypnosis may positively impact the pain perception, sleep quality, functional outcomes, quality of life, and satisfaction of SCD patients.

As with other acute and chronic pain conditions, a goal in SCD pain management is to maximize function with the least amount of medication. Hypnotic training may offer an effective approach toward improving coping strategies and lessening focus on pain and its interference in functional outcomes. Hypnosis is a natural state of consciousness characterized by highly focused concentration with a relative suspension of global awareness.21 In addition to addressing conscious processes, as in traditional cognitive-behavioral therapy, hypnosis can also access subconscious and unconscious processes. Hypnosis involves a change in the brain’s perception.22 A study by Rainville and colleagues (2002) using positron emission tomography (PET) provides supportive evidence that distinct brain changes occur during hypnosis particularly in the anterior cingulate cortex, the thalamus, and the pontomesencephalic brainstem during the production of hypnotic states. Furthermore, hypnotic relaxation is distinguished by a decrease in cortical arousal and disinhibition.23

The efficacy of hypnosis has been demonstrated in treating numerous conditions including acute pain, chronic pain, burn injury progression, pulmonary diseases, and hemophilia, to name a few.24 Hypnosis has also become part of a broader model of integrative mind–body interventions for breast cancer25 and palliative care.26,27 Hypnotherapy, including self-hypnosis, has proven particularly effective in pain and symptom management for pediatric pulmonary patients28,29 and pediatric functional abdominal pain.30 For those with clinically significant pain episodes, learning a cognitive-behavioral intervention centered on self-hypnosis for pain management has proved helpful in reducing pain frequency, improving sleep quality, and decreasing use of narcotic pain medications.31 In a 12-month non-randomized prospective trial, Dinges et al.31 demonstrated a reduction in both SCD pain days and non-SCD-related pain days. Analgesic use decreased proportionately in patients who experienced a decrease in pain frequency. The majority of this decrease resulted from a reduction in days with mild pain yet there was no significant reduction in the number of severe-pain days or length of vaso-occlusive episodes. This reduction of mild-pain frequency indicates that self-hypnosis may be most helpful for eliminating mild or moderate pain episodes of vaso-occlusive pain, and less helpful for the management of severe SCD pain episodes. Self-hypnosis training also decreased the frequency of poor-sleep nights, primarily by reducing the frequency of mild-pain nights. These improvements persisted over 12 months.31 Additionally, two case studies have also been published supporting the use of hypnosis for pain management in SCD patients.32,33

Purpose of study protocol

To date, there are no published randomized, controlled trials evaluating the efficacy of hypnosis in SCD pain modulation in adults. Furthermore, there is a need to explore dosing of the hypnosis intervention with limited therapist time, and a model of home-based therapy has yet to be accomplished. This protocol is aimed at longitudinally assessing the effects of hypnosis in such a manner. The major advantage of conducting a longitudinal analysis is the ability to observe and separate changes over time within the study participants from differences among the participants in their baseline characteristics. Using repeated measures allows us to study the trajectory of psychosocial behaviors and pain intensity changes over time after controlling for intrapersonal correlations in order to draw valid scientific inferences regarding the impact of the hypnosis intervention.

Methods/Design

Recruitment

Patients with known or suspected SCD were recruited into this study through referrals by physicians from the National Heart Lung and Blood Institute (NHLBI) Vascular Therapeutic Section of the Cardiovascular Branch. Because Hb SC and S-β-plus-thalassemia patients typically have less pain than hemoglobin SS patients, for this pilot study we enrolled only hemoglobin SS patients.

Participants first underwent a screening history and physical examination to evaluate the presence and severity of SCD. Blood sample results from medical record source documents were utilized to establish hemoglobin genotype and baseline clinical characteristics. Participants had to meet all of the following criteria to be eligible for study enrollment:

Inclusion criteria:

  • ≥ 18 years of age;
  • Diagnosis of hemoglobin SS SCD;
  • Patient identifies history of pain as a significant problem during at least 2 days in the month prior to enrollment; Written informed consent/assent has been obtained.

Exclusion criteria:

  • Less than 18 years of age;
  • Unwilling to experience hypnosis or to have hetero- hypnosis sessions recorded;
  • Non-fluency in written and spoken English;
  • Physical or other disabilities that prevent adequate participation in hypnotic susceptibility testing;
  • Does not wish to be video and audiotaped;
  • Psychosis or psychotic depression;
  • History of seizures or epilepsy.

There has been one published report of a serious consequence related to hypnosis, a seizure in an 18-year-old with a history of epilepsy.34 For this reason, individuals with a history of seizures or epilepsy were excluded from this study. Reports also suggest that hypnosis in individuals with a history of psychosis or psychotic depression may trigger psychiatric illnesses or produce decompensation or recurrent dissociative episodes.35Based on these reports, this pilot study excluded individuals with a history of psychosis or psychotic depression. Although we do not expect that hypnosis will mask the onset of acute vaso-occlusive pain crisis, participants will be monitored and any unexpected adverse events reported to the clinical team as well as the institutional review board. The study complies with the principles of the Declaration of Helsinki and was approved by the institutional review board of NHLBI (NCT00393250).

Sample size

A meta-analysis conducted by Montgomery et al.36 of hypnotically induced analgesia exists estimating an average effect size of 0.74 across 18 studies. However, as previously noted, to date there have been no published randomized studies examining the efficacy of hypnosis-induced pain and symptom control in SCD patients. Because of this lack of evidence for accurately estimating an appropriate effect size for sample size selection, we proposed to conduct this study as a pilot with 20 participants in each group for a total of 40 participants. Based on the feasibility of undertaking this time- and resource-intensive intervention study and the possibility that some patients will be lost to follow-up, we requested an additional five participants in each group as our accrual ceiling.

Design

This is a randomized, controlled, single-crossover, repeated measures study (Fig. 2). After completing the intake interview, each participant was asked to begin daily pain diaries for one week. One week following enrollment, participants were randomized to the treatment or control groups. A random allocation scheme was computer-generated to provide participant group assignments. The study principal investigator (PI) and designees were initially blinded to the patient assignments, which were placed in individual, consecutively numbered, sealed envelopes. When the participant returned for their one week clinic visit, the study PI or designee opened the next numbered envelope to obtain that patient’s assignment.

Figure 2

Hypnosis protocol design and randomization.

One week after enrollment, participants returned to the outpatient clinic and were randomized to the initial hypnosis (Group A) or control arm (Group B) of the study. Participants returned to the outpatient clinic as follows:

Interventions

Hypnosis interventions were conducted in four weekly sessions by an investigator certified in hypnosis (hetero-hypnosis). It is important to note that the sessions were conducted in a two-person-contact format in an outpatient clinic patient room rather than a group setting away from the clinic. Interventions consisted of a hypnotic induction followed by individualized suggestions for analgesia, reducing anxiety, improving sleep hygiene, promoting ego-strengthening (self-efficacy), and enhancing health and well-being (see Table 1 for sample scripts). When appropriate, participants also received therapeutic suggestions specific to other symptoms. Sessions lasted about one hour and were conducted typically in a clinic room. After completion of the self-hypnosis, an assessment was conducted to measure hypnotic ability, using the Stanford Hypnotic Susceptibility Clinical Scale for Adults.37 Hypnosis sessions were videotaped and audiotaped for documentation purposes. Participants were excluded from the study if they did not wish to be video and audio taped because this was the method by which a standard, blinded hypnosis susceptibility score was obtained by an independent rater other than the hypnosis therapist. This hypnosis susceptibility rating was for documentation purposes and as a potential variable that may be associated with the outcomes of the treatment.

Table 1

Self-hypnosis DVD categories and sample hypnotic excerpts.

Following these hetero-hypnosis sessions, participants entered a self-guided hetero-hypnosis phase. Participants were provided a digital video disc (DVD) for self-guided hetero-hypnosis and a DVD player. Each DVD had four selections from which participants can choose. Each selection had a scene from nature with the hypnotist’s voice overlying the accompanying music from the scene. We hypothesized that scenes from nature that were recommended by SCD patients at an open house would provide additional interest and visual focus for the self-guided hetero-hypnosis. The participant only needed to watch one of these selections during a session. Participants were instructed to watch the DVD recording 3–7 times a week for six weeks. Participants were asked to evaluate their self-guided hetero-hypnosis experience in their daily diary (seeAppendix C).

Therapeutic use of media

In addition to experiencing therapeutic hypnosis during face-to-face encounters in this study (hetero-hypnosis), participants also experienced self-guided hetero-hypnosis through digital media. The use of media technology for this study was twofold. The first reason was that videos allowed for a visual focus. While listening to the hypnotist, the patient was able to watch a scene from nature, thus complementing the audio and further removing them from their environment with the intent of making them more sensitive to suggestion. The other factor was closely tied to self-guidance. The patient had a choice of scenes to select from and therefore could match how they were feeling to what would assist them in visualizing relief.

Study processes for the control group were designed to control for the attention, interpersonal exchange, and positive expectation inherent in the therapeutic hypnosis experiences. Participants in the control group received age-appropriate education on SCD pathophysiology, inheritance, prevalence, common complications, and management in four weekly sessions. Education was delivered by a qualified nurse investigator. Sessions lasted about one hour and were typically conducted in a clinic room. Participants in the control arm received a DVD with educational material that they could use during the six weeks following the face-to-face education sessions. Following the 11th week, participants in the control arm crossed over to the hypnosis arm of the study and completed both the four weeks of hetero-hypnosis and the six weeks of self-hypnosis. All patients could receive standard medical therapy while on the study regardless of study group assignment.

Outcome measures

The primary outcome measures in this study were patients’ diary reports of pain severity and pain intensity as measured by the pain numerical rating scale during follow-up clinic assessments. Participants were instructed on daily documentation of pain incidence, pain severity, sleep quality, medications taken, visits to a hospital, emergency room, or physician’s office, and absence from school or work. Secondary outcome measures (pain impact, mood, anxiety, sleep, and coping) were collected during face-to-face interviews prior to randomization, at the end of the four-week education or hypnosis interventions, and at two-week intervals until the end of the six-week self-hypnosis (intervention) or education (control) CD/DVD phases. See Table 2 for a list of validated outcome measures.11,31,3855

Table 2

Measures.

Analysis plan

Initial analysis will be descriptive and exploratory. Our hypotheses for the analysis phase of the protocol are as follows:

  • Therapeutic hypnosis, guided by a hypnotherapist (hetero-hypnosis) and followed with self-hypnosis using customized digital media, improves disease-related pain, anxiety, coping strategies, sleep, and depression compared to an education control intervention in patients with SCD.
  • Therapeutic hypnosis, guided by a hypnotherapist (hetero-hypnosis) and followed with self-hypnosis using customized digital media, reduces health care utilization compared to an education control intervention in patients with SCD.

Statistical analysis for each of the main outcomes will involve comparing the patients assigned to the hetero-and self-guided hetero-hypnosis intervention to patients who do not initially receive hypnosis using the appropriate scale/instrument for that outcome. Each scale/instrument will be analyzed separately and the general statistical approach will employ multiple-way analysis of covariance (ANCOVA) to compare the mean scores of the two groups. The analyses will control for specific patient factors (eg, genotype, hematologic measures, treatment, co-morbidity, age, gender, education) as indicated by the conceptual model. Mixed linear modeling will be used to account for some of the expected missing data in this repeated measures study.

Discussion

Previous research related to SCD patients has focused on the frequency of pain resulting in emergency department use and number of hospitalizations because of pain crisis in SCD patients. Few studies focus on these pain manifestations outside the typical health-care delivery system or on how patients manage their pain apart from their physician. Little is known about the percentage of patients who are able to self-manage their crises at home without accessing health-care professionals.

Recent findings suggest that patients may have two types of positive outcomes following hypnosis treatment: 1) a reduction in the severity of ongoing daily pain intensity; and 2) the ability to use self-hypnosis to experience greater intervals of comfort.56 However, to date, there are no published randomized, controlled trials evaluating the efficacy of hypnosis in SCD pain modulation. This protocol is aimed at longitudinally assessing the effects of hypnosis in such a manner. The design of this study provides information related to daily diary reports of pain incidence, pain severity, sleep quality, medications taken, as well as visits to a hospital, emergency room, or physician’s office, and absence from school or work. Additional secondary outcome measures (pain impact, mood, anxiety, sleep, and coping) were collected during face-to-face interviews.

The major advantage of conducting a longitudinal analysis is its capacity to observe and delineate changes over time within the study participants from differences among the participants while controlling their baseline characteristics. Therefore, repeated measures and mixed linear modeling will allow us to study the trajectory of psychosocial behaviors and pain intensity changes over time after controlling for intrapersonal correlations in order to draw valid scientific inferences regarding the impact of the hypnosis intervention. Limitations exist in this protocol including the lack of qualitative inquiry to explore the patient experience while utilizing hypnosis as a self-care strategy for pain and symptom management. Although this is a randomized, controlled, crossover design, the sample size will not yield conclusive results in terms of treatment or dose efficacy, but rather will serve as a proof of concept for future randomized controlled trials (RCTs) testing hypnosis as a potential non-pharmacological approach to managing chronic pain and symptoms in adults with SCD.

Supplementary Files

Appendix A. This file shows the format for subjects’ morning diary entries.

Appendix B. This file shows the format for subjects’ nightly diary entries.

Appendix C. This file shows the format for subjects’ diary entries evaluating self-hypnosis exercises.

Acknowledgments

We thank the NHLBI staff and research participants. We would like to especially acknowledge the following people for their support of this study: Ann Berger, MD; James Nichols, RN; Claiborne Miller-Davis, RN; Caterina Minniti, MD; Gregory J. Kato, MD; and Sinthujah Velummylum.

Footnotes

Author Contributions

Conceived and designed the experiments: GW, DH, NA. Wrote the first draft of the manuscript: GW, KM, AB. Contributed to the writing of the manuscript: GW, KM, AB, DH. Agree with manuscript results and conclusions: GW, KM, NA, AB, DH. Jointly developed the structure and arguments for the paper: GW, KM. Made critical revisions and approved final version: GW, KM, NA, AB, DH. All authors reviewed and approved of the final manuscript.

ACADEMIC EDITOR: Christopher Chang, Editor in Chief

FUNDING: The funding for this study was provided by the NIH intramural programs of the NIH Clinical Center (CC) and the National Heart Blood and Lung Institute (NHLBI). The authors confirm that the funder had no influence over the study design, content of the article, or selection of this journal.

COMPETING INTERESTS: Authors disclose no potential conflicts of interest.

Paper subject to independent expert blind peer review by minimum of two reviewers. All editorial decisions made by independent academic editor. Prior to publication all authors have given signed confirmation of agreement to article publication and compliance with all applicable ethical and legal requirements, including the accuracy of author and contributor information, disclosure of competing interests and funding sources, compliance with ethical requirements relating to human and animal study participants, and compliance with any copyright requirements of third parties.

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Hypnotic Approaches for Chronic Pain Management – Full Article

This article is referenced , and the abstract is found here http://www.hypno-facts.com/hypnosis-research/460

For posterity – Copied from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4465776/

Hypnotic Approaches for Chronic Pain Management

Clinical Implications of Recent Research Findings

Chronic pain remains a significant burden for both individuals and society. Standard medical treatment for chronic pain is often inadequate (Turk, Wilson, & Cahana, 2011), and it is common for frustrated patients to seek costly treatments from multiple health care professionals without significant relief. Although a number of psychological approaches to the treatment of chronic pain have demonstrated important success over the last few decades (see Jensen & Turk, 2014, this issue), there is a need for additional and robust treatment options that could benefit individuals with chronic pain.

Growing awareness of the limitations of currently available pain treatments make training patients in self-hypnosis an attractive component of pain treatment. For example, there are increasing concerns about the overreliance on analgesic medications, which can have negative side effects, have limited evidence for long-term efficacy, and can result in significant problems associated with addiction or diversion (i.e., nonprescription use) (Manchikanti & Singh, 2008Maxwell, 2011). There is a corresponding need for effective pain treatments that have minimal negative side effects; we are not aware of any pain treatment option with fewer adverse effects than hypnosis (Jensen et al., 2006).

In spite of the promise of this treatment, however, general acceptance of and research on hypnosis continues to be limited. This may be due in part to the lack of a widely accepted definition of hypnosis (Barnier & Nash, 2008). Hypnosis incorporates a number of components, such as relaxation, focused attention, imagery, interpersonal processing, and suggestion. There continue to be differences in expert opinion regarding which of these elements represents the core component(s) of hypnosis, making it difficult to determine if a specific treatment should be classified as hypnosis or not. Despite the lack of consensus, we think it is important for clinicians and researchers to specify the definition they use in their work. Our preferred definition has been that proposed by Kihlstrom (1985, p. 385): “a social interaction in which one person, designated the subject, responds to suggestions offered by another person, designated the hypnotist, for experiences involving alterations in perception, memory, and voluntary action.” (For further discussion regarding different definitions of hypnosis that have been proposed, and the theoretical models underlying them, see Barnier & Nash, 2008.)

Hypnosis has been used to treat every type of pain condition imaginable over centuries and across cultures (Pintar & Lynn, 2008). What is new about hypnotic analgesia is the compelling empirical evidence that has emerged in the last two decades regarding its efficacy and mechanistic underpinnings. Much of the earlier research studying hypnotic analgesia focused on acute pain induced in laboratory settings or pain associated with medical procedures (Chaves, 1994Ewin, 1986). This work continues, and there have also been a number of recent innovative applications of this modality to treat acute procedural pain (e.g., Patterson, Wiechman, Jensen, & Sharar, 2006). Other recent advances in understanding have come from imaging studies examining the brain functions associated with hypnosis and hypnotic analgesia (Barabasz & Barabasz, 2008Oakley, 2008Oakley & Halligan, 2010D. Spiegel, Bierre, & Rootenberg, 1989). In addition, there has been a recent and dramatic increase in research on the efficacy of hypnosis for chronic pain conditions (Montgomery, DuHamel, & Redd, 2000Stoelb, Molton, Jensen, & Patterson, 2009Tomé-Pires & Miró, 2012).

Clinical outcome studies on acute and chronic pain as well as neurophysiological studies in the laboratory have demonstrated that hypnosis is effective over and above placebo treatments and that it has measurable effects on activity in brain areas known to be involved in processing pain. Equally important, recent clinical trials provide significant findings useful to the clinical application of hypnosis for the management of chronic pain. The ensuing review and discussion highlight the clinical relevance of these findings to the use of hypnosis for chronic pain and present the issues that we believe should be considered in future clinical and theoretical work.

Findings From Hypnosis Clinical Trials

Two general findings from hypnosis trials have particular clinical and theoretical relevance: (a) There is a high degree of variability in response to hypnotic analgesia, and (b) the benefits of hypnosis treatment go beyond pain relief.

Response to Hypnosis Treatment Is Highly Variable

In hypnosis/pain clinical trials, the standard primary analysis compares group average differences in pain reduction between patients who receive treatment and patients in a control condition (e.g., relaxation training, standard care, attention). However, it is unwise to draw conclusions regarding the efficacy of any treatment based only on the statistical significance of averaged results. Statistically significant group differences can emerge even when there are very small (i.e., essentially meaningless) improvements in outcome in all or nearly all study participants. More important, perhaps, nonsignificant results can emerge for treatments that have large and meaningful effects in many study participants if the study sample is too small or if the treatment is highly effective for a small subset of patients. In short, average group differences tell us little about the variability of treatment response among the individuals who receive the treatment.

Responder analyses have been recommended as an alternative strategy for determining the meaningfulness of treatment effects in pain clinical trials once a significant treatment effect has been established (Dworkin et al., 2008). In a responder analysis, the investigator identifies the amount of improvement in the outcome variable needed to determine that an improvement is clinically meaningful and then reports the proportion of “responders” in the different treatment conditions. For example, one early clinical trial of hypnosis for migraine headache (Anderson, Basker, & Dalton, 1975) used “complete remission” as a criterion indicating a meaningful treatment response. More recent studies use a 30% reduction in average daily pain intensity to represent a clinically meaningful improvement in chronic pain conditions (Dworkin et al., 2005).

We were able to identify four hypnosis studies that reported the results of responder analyses in addition to group average results. In the first of these (Anderson et al., 1975), 47 patients with migraine headache were randomly assigned to receive 12 months of either (a) six or more sessions of hypnosis (with instructions to practice self-hypnosis daily) or (b) medication management (administration of the prophylactic drug Stemetil 5 mg four times per day for the first month and two times per day for the remaining 11 months of the trial). A responder analysis indicated that “complete remission” of headaches during the last three months of treatment was achieved by 44% of the participants in the hypnosis condition and 13% of the participants in the medication-management condition.

In an early uncontrolled case series and two follow-up controlled trials, we examined response to 10 sessions of self-hypnosis training in a combined total of 82 individuals with various diagnoses associated with physical disability who also had chronic pain (Jensen, Barber, Romano, Hanley, et al., 2009Jensen, Barber, Romano, Molton, et al., 2009Jensen et al., 2005). A 30% or more reduction in average pain identified treatment responders, and analyses showed treatment-response rates varied from a low of 22% for individuals with spinal cord injury to 60% for persons with acquired amputation. Moreover, in one of these studies, a significant Time × Treatment Condition × Pain Type (neuropathic vs. nonneuropathic) interaction also emerged, explained by the fact that all of the participants who reported a clinically meaningful decrease in pain intensity had neuropathic pain, but none of the participants with nonneuropathic pain reported a meaningful pain reduction following hypnosis treatment (Jensen, Barber, Romano, Molton, et al., 2009).

When discussing variability in response to hypnosis treatment, it is important to consider the issue of hypnotizability. Hypnotizability reflects a person’s tendency (or, as some investigators in the field view it, a trait, talent, or ability) to respond positively to a variety of different suggestions following a hypnotic induction. A number of standardized measures of hypnotizability exist (e.g., the Hypnotic Induction Profile, H. Spiegel & Spiegel, 2004; the Stanford Hypnotic Susceptibility Scale, Weitzenhoffer & Hilgard, 1962; the Harvard Group Scale of Hypnotic Susceptibility, Shor & Ome, 1962; and the Stanford Hypnotic Clinical Scale, Morgan & Hilgard, 1978–1979). Each of these measures consists of a standardized hypnotic induction followed by a series of suggestions (for changes in sensory experiences, amnesia, etc.), and the subject’s hypnotizability score is the simple sum of positive responses to the suggestions.

One of the most consistent research findings is that hypnotizability scores are very stable, even across decades (Morgan, Johnson, & Hilgard, 1974). Another consistent finding is that general hypnotizability (i.e., response to suggestions not involving analgesia) predicts response to hypnotic analgesia in the laboratory setting (Hilgard & Hilgard, 1975). This has led to speculations that hypnotizability might explain the variability in response to hypnotic treatments of chronic pain. However, a growing body of evidence indicates that general hypnotizability demonstrates weak and inconsistent associations with hypnotic treatment of chronic pain in the clinical setting (Patterson & Jensen, 2003). The weak associations with clinical pain and the fact that the majority of patients show at least some benefits of hypnotic treatment (Montgomery et al., 2000) partially account for the fact that hypnotizability screenings are seldom used in clinical approaches to hypnotic pain control.

Hypnosis Treatment Has Significant Benefits Beyond Pain Relief

Clinicians in our hypnosis clinical trials anecdotally noted that the overwhelming majority of participants reported high levels of treatment satisfaction whether or not they experienced clinically meaningful pain relief. Moreover, we also found that a large proportion of patients—including many who did not report clinically meaningful decreases in average or characteristic pain with treatment— reported at follow-up that they continued to practice the self-hypnosis skills taught (Jensen, Barber, Romano, Hanley, et al., 2009;Jensen, Barber, Romano, Molton, et al., 2009). To help understand what appeared to be an anomalous finding, we contacted a cohort of patients who received self-hypnosis training to determine their reasons for continued use of self-hypnosis skills despite an apparent lack of benefit on average daily pain intensity. Consistent with what the study clinicians reported, almost all of the study participants reported high levels of treatment satisfaction (Jensen et al., 2006). In addition, the great majority of those who continued to practice self-hypnosis reported that they experienced temporary pain relief when they listened to audio recordings of the treatment sessions or practiced self-hypnosis on their own without the recordings.

In short, we have found that hypnosis treatment has two potential effects on chronic pain. First, as described above, the treatment can result in substantial reductions in average pain intensity that is maintained for up to 12 months in some—but not all—patients. We interpret this finding as support for the hypothesis that hypnosis treatment can result in sustained changes in how the brain processes sensory information in subgroups of patients (larger or smaller subsets, depending on the specific pain condition studied). However, for greater numbers of patients, hypnosis treatment teaches self-management skills that patients can (and most do) continue to use regularly and that can result in temporary pain relief.

We also asked our sample to describe the positive and negative effects of hypnosis, and of the 40 different effects elicited, only three were negative (Jensen et al., 2006). Moreover, and to our surprise, only nine (23%) of the positive descriptions of hypnosis were pain-related. Non-pain-related beneficial treatment effects included improved positive affect, relaxation, and increased energy. These non-pain-related benefits were reported despite the fact that the hypnotic intervention was script driven and focused exclusively on pain management.

These results are consistent with qualitative comments in the literature regarding the beneficial “side effects” of hypnosis (Crawford et al., 1998Stewart, 2005). They also reflect another important finding in the pain literature: People who report positive changes and satisfaction with treatment do not always report substantial reductions in pain intensity (Turk, Okifuji, Sinclair, & Starz, 1998). As we discuss in greater detail below, the use of hypnosis to improve quality of life in people with chronic pain often involves focusing on outcome variables other than just pain relief.

Clinical Implications of Findings From Hypnosis Clinical Trials

The key findings from the hypnosis clinical trials reviewed above have three important implications for maximizing the benefits of hypnotic pain treatment. Specifically, they indicate that clinicians should (a) include suggestions for both immediate and long-term pain relief, (b) include suggestions for benefits in addition to pain reduction, and (c) use the knowledge about the multiple benefits of hypnosis to enhance treatment outcome expectancies.

Immediate and long-term pain relief with self-hypnosis

Given the evidence that hypnotic analgesia treatment can result in both (a) long-term pain relief and (b) learning skills that produce immediate but shorter lasting (i.e., a matter of hours) relief, clinicians providing hypnosis treatment should ensure that they take full advantage of both of these outcomes. Specifically, they should include hypnotic suggestions for “automatic” and long-term reductions in pain and related distress. They should also provide suggestions, such as the following, that can facilitate the regular use and practice of self-hypnosis:

And when you practice self-hypnosis, your mind can easily enter this state of comfort, and the comfort will stay with you for minutes and hours … the more you practice, the easier and more automatic this will be … and the longer the beneficial effects will last.

Addressing issues beyond pain reduction

Given the established beneficial effects of hypnosis on other outcome domains, hypnotic suggestions for addressing additional pain-related issues should also be included in the hypnotic treatment (Jensen, 2011Patterson, 2010). In chronic pain, there are almost always associated symptoms that deserve attention. For example, between 50% and 88% of patients with chronic pain report problems with sleep (Smith & Haythornthwaite, 2004). For such patients, hypnotic suggestions can be provided for an increased ability to fall asleep, to return to sleep if they awaken, and to feel rested in the morning (Jensen, 2011).

Effective chronic pain treatments also often target increased activity and adaptive coping responses. Patients who are involved in physical therapy or who are maintaining a regular exercise program can be given suggestions that they will feel confident in their ability to engage in and maintain exercise. Those who experience fatigue might be given suggestions such as being able to draw on an inner strength and experience reserves of energy when needed and appropriate (Jensen, 2011).

It is also important to remember that people with chronic pain often suffer from clinically significant depression and anxiety (Patterson, 2010), and mood states can be addressed by hypnosis (Alladin, 2010;Yapko, 2001). Hypnosis can also include suggestions for improving activity levels, adaptive coping responses, adaptive pain-related cognitions, and sleep quality (Jensen, 2011). Thus, clinicians should take full advantage of all potential hypnotic effects to help patients achieve a number of treatment goals; suggestions should rarely, if ever, focus exclusively on pain reduction.

Good practice involves giving patients with chronic pain realistic hope

It is clear, based on research findings, that not all patients with chronic pain are going to experience pain relief with hypnosis. This brings up the question of how expectations for treatment can be enhanced, given that outcome expectancy is an important factor that can enhance any clinical intervention. Because of our finding that the great majority of the participants in our clinical trials report some benefits through learning hypnosis, even when those benefits do not necessarily include pain relief, we now tell patients something along the lines of the following to enhance outcome expectancies without giving unrealistic expectations:

Many patients find that they experience meaningful reductions in their pain that maintain for a year or more after treatment. Others report that they use the skills they learn to experience pain relief for a few hours at a time when they use self-hypnosis for just a minute or two. Even when the treatment does not result in significant pain relief, almost everyone reports some benefit, such as improved sleep, an increased sense of overall calmness and well-being, or reduced stress. I don’t know at this point which of these benefits you would experience if you choose to learn self-hypnosis … want to find out?

The Effects of Hypnotic Analgesia on Pain-Related Brain Activity

To date, the primary imaging techniques used to study the neurophysiological effects of hypnosis include positron emission tomography (PET; cortical metabolic activity), functional magnetic resonance imaging (fMRI; changes in blood flow in the brain and spinal cord), and electroencephalography (EEG; cortical electrical activity). PET and fMRI are most useful for identifying locations of brain activity, and EEG is most useful for assessing brain states. Rather than repeating what has been reported in a number of reviews on cortical responses to hypnotic analgesia (Barabasz & Barabasz, 2008Oakley, 2008Oakley & Halligan, 2010D. Spiegel et al., 1989), we discuss four key findings from this body of research that have important clinical implications for applying hypnosis to chronic pain management.

Hypnotic Analgesia Influences Pain Processing at Multiple Sites

One of the most important findings from recent neurophysiological studies of pain is that there is no single “pain center” in the brain that is responsible for the processing of pain. We now know that pain is associated with activity in and interaction between a number of different areas of the peripheral and central nervous systems, each of which contributes to the overall experience of pain (Apkarian, Hashmi, & Baliki, 2011). The cortical areas most often activated during pain are the thalamus, anterior cingulate cortex (ACC), insular cortex, primary and secondary sensory cortices, and prefrontal cortex. The relative contribution of each of these areas to the experience of pain varies as a function of the nature of the pain stimuli (Apkarian et al., 2011).

Some of the earliest research on the cortical effects of hypnotic analgesia was reported by D. Spiegel and colleagues (1989), and this body of research has gained substantial momentum over the last decade (Abrahamsen et al., 2010Derbyshire, Whalley, & Oakley, 2009Derbyshire, Whalley, Stenger, & Oakley, 2004Faymonville, Boly, & Laureys, 2006Raij, Numminen, Narvanen, Hiltunen, & Hari, 2005;Vanhaudenhuyse et al., 2009). Each of the brain areas involved in pain processing has been shown to respond to hypnosis in more than one study: insula (Abrahamsen et al., 2010Derbyshire et al., 2004), prefrontal cortex (Derbyshire et al., 2009Derbyshire et al., 2004Raij et al., 2005), thalamus (Derbyshire et al., 2009Derbyshire et al., 2004Vanhaudenhuyse et al., 2009Wik, Fischer, Bragee, Finer, & Fredrikson, 1999), primary or secondary cortex (Derbyshire et al., 2009Hofbauer, Rainville, Duncan, & Bushnell, 2001), and cingulate cortex (Derbyshire et al., 2009Derbyshire et al., 2004Faymonville et al., 20002006;Raij et al., 2005Rainville, Duncan, Price, Carrier, & Bushnell, 1997Vanhaudenhuyse et al., 2009Wik et al., 1999). Moreover, hypnosis has also been shown to influence the processing of aversive stimulation at the level of the spinal cord (see review by Jensen, 2008). Thus, hypnotic analgesia appears to influence different areas of the nervous system that are involved in the processing of pain rather than having a single, unilateral mechanism.

Hypnotic Suggestions Can Target Specific Brain Areas

In a hallmark study, Rainville and colleagues (1997) demonstrated that hypnotic suggestions for reduced painunpleasantnessinfluenced activity in the corresponding area of the brain expected (ACC) but not in other brain areas, including the sensory cortex. Subsequently, this research group demonstrated that hypnotic suggestions for less pain intensity influenced activity in the primary sensory cortex but did not influence activity in the ACC (Hofbauer et al., 2001). Together, these studies indicate that hypnotic suggestions can be targeted to specific effects in brain activity. Thus, not only the hypnotic induction but the content of the specific hypnotic suggestions is of critical importance to the benefits derived from hypnosis.

Hypnotic Inductions Are Associated With Changes in Brain States Consistent With Pain Relief

Cortical neurons fire at different frequencies, and the speed at which they fire is associated with different brain states. Moreover, the experience of pain is associated with more neurons firing at relatively fast (beta, 13–30 Hz) frequencies and fewer neurons firing at slower (alpha, 8–13 Hz) frequencies (Bromm & Lorenz, 1998Chen, 2001). Importantly, hypnotic suggestions result in changes in brain activity consistent with those observed in individuals who experience pain relief; with hypnosis, there is a decrease in relative beta activity and an increase in relative alpha activity (Crawford, 1990Williams & Gruzelier, 2001). Thus, the neurophysiological processes associated with pain perception appear to be related not only to the site of activity but also to general activity levels that likely transcend specific areas of functions. Therefore, hypnotic analgesia may influence pain both by altering activity in specific areas and by facilitating shifts in general brain states.

Hypnosis Is More Than Simple Imagination

In 2004, Derbyshire and colleagues published an important study comparing the subjective and neurophysiological effects of (a) noxious stimulation (painful heat applied to the palm), (b) imagined pain (asking participants to imagine the pain they experienced during the noxious stimulation “as vividly as possible”), and (c) hypnotic pain (providing a hypnotic induction followed by suggestions to reexperience the pain experienced during the noxious stimulation) (Derbyshire et al., 2004). The fMRI results for the noxious stimulation condition were consistent with those of many other fMRI pain studies, showing activation in the thalamus, ACC, secondary sensory cortex, insula, and prefrontal cortex (as well as, in this case, activity in the cerebellum and parietal cortex). Moreover, the pattern of brain activity during the hypnotic pain condition was similar to that observed during the noxious stimulation condition, with overlap of activity in the ACC, insula, prefrontal cortex, and parietal cortex. However, the intensity of this activity in the stimulation condition tended to be stronger than that in the hypnotic pain condition, and activation of the primary sensory cortex occurred only in the hypnotic pain condition. In the imagined pain condition, there was some (but much less than either of the other two conditions) activation in the ACC, insula, and secondary sensory cortex. The findings add support to the aforementioned notion that hypnotic suggestions are localized to specific areas of the brain but also add important support for the conclusion that such effects involve more than a process of simple imagination.

Clinical Implications of the Findings From Hypnosis Imaging Studies

The key findings from the studies on the effects of hypnotic analgesia on neurophysiological processes discussed above have two important clinical implications. First, to maximize efficacy, hypnotic treatment should target multiple specific pain domains. Second, clinicians should take full advantage of the calming effects of hypnosis on brain activity and processes.

Hypnotic suggestions should target multiple pain domains

We have already discussed the importance of providing suggestions to improve outcomes other than just pain relief (sleep quality, well-being, activity level, etc.) when treating chronic pain with hypnosis. This same principle applies when treatment targets pain relief, because pain is a multidimensional construct with sensory, affective, and evaluative components. Each of these domains can be influenced by hypnotic suggestions.

It follows that clinicians using hypnosis for pain management should target their suggestions to the different brain areas that process pain. In fact, clinicians will likely be more effective if they are guided by knowledge of the specific brain areas that are linked to pain (Jensen, 2008). Some of the pain-related domains that appear to have specific cortical associations include intensity and quality (sensory cortices), bothersomeness or unpleasantness (ACC), a sense of comfort and physical integrity (insula), reduced threat value and negative implications of the pain (prefrontal cortex), and the ability to “screen out” discomfort and “let in” comfortable sensations (spinothalamic tract). Current thinking in pain physiology suggests that hypnotic suggestions should target several of these domains rather than any one of them (Jensen, 2011Patterson, 2010).

Taking advantage of the cortical calming effects of hypnosis

The hypnotic induction itself— even before any suggestions are made for pain relief— results in a shift of brain activity in a direction consistent with that of someone experiencing pain relief. Hypnosis is certainly not necessarily the only technique that can be used to shift brain states. Some clinical trials comparing hypnosis to relaxation training have failed to detect differences in outcome for these two treatments, at least for headache pain relief (Patterson & Jensen, 2003). Importantly, response to relaxation training appears to be associated with hypnotizability (Patterson & Jensen, 2003). Many meditation strategies have also has been shown to result in shifts in EEG bandwidth activity consistent with those that follow hypnosis (i.e., an increase in the slower alpha rhythms; Fell, Axmacher, & Haupt, 2010). Like these other “hypnotic-like” treatments, the induction phase of hypnosis may have analgesic effects in and of itself for some patients.

It can sometimes be difficult to distinguish among hypnosis, relaxation/autogenic training, and guided imagery interventions. Certainly, relaxation training and guided imagery often contain elements that look very much like a hypnotic induction, and hypnosis often includes suggestions for relaxation and use of imagery. However, clinical hypnosis usually involves suggestions not only for perceptual changes but also for other clinical benefits (Jensen, 2011Patterson, 2010), while these other techniques tend to focus on just a single outcome (e.g., relaxation training focuses mostly on perceived relaxation). Understanding that it is often difficult to distinguish among hypnosis, relaxation training, and guided imagery in a clinical situation, we would argue that hypnosis allows clinicians to target a much larger variety of outcomes (i.e., changes in sensory experiences, thoughts, emotions, and behavior) than many other treatments do.

We have cited the important finding that hypnosis has larger effects on pain than does simple imagination (Derbyshire et al., 2004). The implication is that hypnosis is more powerful than simple imagery; however, it is important to acknowledge the potential beneficial impact of imagery in changing perceptual processes. For many patients, including imagery for pain reduction can be a powerful component of the hypnotic intervention. The possibilities for using imagery in this way are endless (“Imagine that your pain has a color. That color is now changing” or “Notice that you are lying with your low back in a stream of healing water … cool and comfortable”). Many patients will benefit from the inclusion of imagery as long as it does not bring up unpleasant or irritating memories. However, clinicians should realize that not all patients enjoy imagery or find visual processing easy and that a variety of other components of hypnosis should also be typically included (e.g., enhanced relaxation, changing the focus of attention, altering negative cognitions;Jensen, 2011Patterson, 2010).

Unresolved Clinical and Theoretical Questions

Our understanding of hypnotic analgesia has increased substantially in the past two decades. An important review in the early 1980s (Turner & Chapman, 1982) noted that there were no randomized, controlled trials to support its utility as a viable treatment for chronic pain. Based on the findings from the clinical trials and neurophysiological studies cited in this article, we can conclude that hypnosis and hypnotic analgesia have specific effects beyond those attributable solely to placebos. Yet, as we discussed in our introduction, there remains a lack of consensus on what hypnosis is, and there are significant unanswered questions regarding the mechanisms and best clinical use of this approach to pain management. We conclude this article with a brief discussion of four of these critical questions: (a) What is/are the mechanism/s of hypnotic analgesia? (b) How can hypnosis best be combined with other therapies? (c) What is the best dose of hypnosis, and does ongoing hypnosis practice improve outcome? and (d) Can hypnosis enhance acceptance of pain?

What Is/Are the Mechanism/s of Hypnotic Analgesia?

We cannot address possible mechanisms of hypnotic analgesia without at least introducing some of the different theoretical perspectives of hypnosis. During much of the latter part of the 20th century, a substantial amount of effort was put into arguing the relative merits of two primary theoretical models of hypnosis: neodissociation and sociocognitive models. However, despite significant debate and decades of research, neither perspective has been universally adopted by experts in the field. In the last decade, there has been a growing call to view hypnosis from multiple perspectives (e.g., Holroyd, 2003Kihlstrom, 2003). Some preliminary work to develop more integrative models has also been published (e.g., Barnier, Dienes, & Mitchell, 2008Pekala et al., 2010b). Despite the fact that the field is beginning to move beyond these two narrow (and conflicting) notions of hypnosis, it is still useful to understand the original models, because each will likely contribute important ideas to an overarching biopsychosocial model of hypnotic analgesia.

Neodissociation and dissociated control models

The neodissociation theory of hypnosis proposed by Ernest Hilgard (Hilgard & Hilgard, 1975) and the dissociated control theories offered by Bowers (1990) and Woody and Sadler (2008) stress the sense of automaticity and effortlessness with respect to behavioral and perceptual changes that often occur with hypnosis. The perceived effortlessness is thought to be associated with a shift in the control of responses from higher executive functions (evaluative and more effortful responding) to those cognitive subsystems that have a direct influence on the behavioral responses without the (usual) layer of judgment or critical screening. In short, dissociation theories hypothesize that hypnosis involves a qualitative shift in the nature of cognitive processes. Dissociation models of hypnosis are also consistent with the views of a number of researchers studying the brain processes associated with hypnotic analgesia.Rainville and Price (2004), for example, argued that hypnosis creates a shift from an active to a passive form of attention and noted that these attentional shifts are associated with a reduction in the monitoring of control and the censoring of experience. Because dissociation theories hypothesize a qualitative shift in neurophysiological states during hypnosis, these models are often referred to as state models of hypnosis.

As mentioned above, hypnotizability is a trait-like capability that remains highly stable across decades (Morgan et al., 1974). Moreover, an individual’s baseline hypnotizability score is a much more powerful predictor of subsequent response to hypnotic suggestions than is any one of a number of interventions designed to boost hypnotic responding (Frischholz, Blumstein, & Spiegel, 1982). State theorists have argued that hypnotizability is a genetically loaded characteristic that helps predict which subjects are more likely to respond to suggestions. This may explain the consistent associations found between measures of hypnotizability and response to hypnotic analgesia in laboratory settings, although, as we have noted, general hypnotizability is less able to predict response to hypnosis in the clinical context (Jensen, 2011Montgomery, Schnur, & David, 2011Patterson & Jensen, 2003).

Sociocognitive models

Researchers who espouse sociocognitive models of hypnosis argue that the concept of an altered state is not needed to understand or explain hypnosis. Rather, they maintain that hypnosis is best explained by the same sociopsychological factors that explain all behaviors whether or not they involve hypnosis: subject expectancy, subject motivation, contextual cues in the social environment, demand characteristics, and role enactment (Kirsch & Lynn, 1995Lynn, Kirsch, & Hallquist, 2008).

In support of this line of reasoning, Montgomery and colleagues (2010) have shown that measures of outcome expectancies partially mediate the benefits of hypnotic analgesia. In addition, the clinical approach of such theorists working with chronic pain (Chaves, 1993) will often appear very similar to conventional cognitive-behavioral interventions that have been popular for the past three decades (Holzman, Turk, & Kerns, 1986; see also Ehde, Dillworth, & Turner, 2014, this issue).

Understanding the effects of hypnosis on pain from the perspective of more integrated theories

We anticipate that in the same way that biopsychosocial models have replaced more restrictive psychological or biological models of pain (Novy, Nelson, Francis, & Turk, 1995; see also Gatchel, McGeary, McGeary, & Lippe, 2014, this issue), models of hypnotic analgesia that take into account both neurophysiological states (Oakley, 2008Oakley & Halligan, 2010) and traditional psychological factors (such as expectancies, motivation, social cues, etc.) may ultimately prove to have more explanatory power than models that exclude either category of factors. We can envision at least two directions that such theories might take in understanding hypnotic analgesia.

First, it is possible that state and nonstate theories explain different components of hypnotic analgesia; each model may ultimately prove to be most useful with different subsets of patients. For example, patients who score high on tests of hypnotizability may respond better to hypnotic analgesia interventions based on a state approach (e.g., hypnotic inductions and suggestions that focus on dissociation), whereas those who score in the medium or low range on hypnotizability measures may respond better to hypnotic treatments based on sociocognitive hypnotic protocols or at least may be less influenced by their general hypnotizability (e.g.,Martínez-Valero et al., 2008).

Alternatively, some investigators have hypothesized that hypnotizability is not a trait that lies on a single continuum but rather that there may be different types of hypnotic responding. For example, T. X. Barber (2000) proposed three basic types of hypnotic responders: fantasy-prone, amnesia-prone, and positive-set responders (see also Pekala et al., 2010a). To the extent that people can be reliably classified into different types of responders, hypnotic interventions might be developed that could best match each individual, ultimately resulting in more positive outcomes for more people. Research examining these questions would be very useful.

Which potential mechanisms of hypnosis might be considered in the development of a more complete model? Several mechanisms have been postulated as important elements of hypnosis (Barnier & Nash, 2008), and all of these have been hypothesized to be associated with pain reduction. These include relaxation (Edmonston, 1991), the use of distracting imagery (Chaves, 1994), focused attention (Barabasz & Barabasz, 2008), and expectancy (Wagstaff, David, Kirsch, & Lynn, 2010). The field has also gained an understanding of some potential mechanisms that do not contribute to the effects of hypnotic analgesia; we know, for example, that although hypnotic responding can be influenced by outcome expectancies, hypnosis has specific effects over and above those associated with placebos (Hilgard & Hilgard, 1975). Research suggests that the effects of hypnotic analgesia are not mediated by endogenous opioids (J. Barber & Mayer, 1977) or distraction mechanisms such as those produced by immersive virtual reality (Patterson, Hoffman, Palacios, & Jensen, 2006).

We have discussed how hypnotic suggestions can affect specific areas of the brain that process pain depending on the wording of the hypnotic suggestions. One important next step is to investigate how hypnosis allows subjects to better access and impact those areas of the brain. We speculate that subjects experiencing hypnosis suspend critical monitoring and judgment and, as a result, have more direct access to and influence over critical areas of the central nervous system. This process may be enhanced by any number of factors: focused attention, deep relaxation, and disruption of linear (i.e., critical) thinking. Neurophysiological research provides preliminary support for these ideas in that individuals who score high on tests of hypnotizability (highs) clearly process information differently from those who score low on hypnotizability tests (lows) and that many of the differences in processing are associated with those (frontal) areas of the brain associated with executive control (Jensen et al., 2013). Research is needed to further examine the potential role of frontal/ executive brain areas in response to hypnotic analgesia and other hypnotic treatments.

What Are the Additive Effects of Hypnosis?

In 1995, Irving Kirsch and colleagues published an important meta-analysis of the additive effects of hypnosis when combined with other treatments (Kirsch, Montgomery, & Sapirstein, 1995). These authors reviewed 18 studies in which cognitive-behavioral psychotherapy was provided in a hypnotic context and compared with the same therapy without hypnosis. They reported that adding hypnosis to cognitive-behavioral psychotherapy enhanced the average study effect size by 0.5 standard deviation units. Further, “the average client receiving cognitive-behavioral hypnotherapy benefitted more than at least 70% of clients receiving the same treatment without hypnosis” (Kirsch et al., 1995, p. 218). However, only one of the studies reviewed by Kirsch and colleagues studied chronic pain.

To our knowledge, there has been only one study published since Kirsch and colleagues’ (1995) review that examined the effects of combining hypnosis with another intervention in the treatment of chronic pain (Jensen et al., 2011). Although the findings from this study were positive—a “hypnotic cognitive therapy” intervention resulted in additional reductions in pain intensity, catastrophizing cognitions, and pain interference, over and above the effects of either hypnotic analgesia or cognitive therapy alone—it was essentially a pilot study. More research examining the effects of combining hypnosis with other established pain treatments is clearly warranted.

A related issue is whether adding hypnosis to treatment results in health care cost offsets. Two significant studies have addressed this question. Lang and colleagues (2000) randomly assigned 241 patients undergoing cutaneous vascular and renal procedures to groups receiving self-hypnotic relaxation (n = 82) or standard care (n = 79). Patients who received hypnosis used less procedure room time, had more hemodynamic stability, used fewer sedating/analgesic medications, and reported less pain and anxiety than those who did not receive hypnosis. In a secondary analysis using data from this study, Lang and Rosen (2002) reported that the participants in the hypnosis group incurred medical care costs that were less than half those incurred by the participants in the control group. Montgomery and colleagues (2007) reported even more dramatic cost savings in 200 patients who were scheduled to undergo breast cancer procedures. Patients in the hypnosis group received fewer sedating or analgesic drugs (propofol and lidocaine) and reported less pain, fatigue, nausea, discomfort, and emotional upset than patients in the control group. In a cost analysis, the authors reported that care of the hypnosis group cost the institution an average of $772.71 less per patient than did care of the control group, a difference that was accounted for largely by reduced surgery time and personnel and equipment costs for the hypnosis group.

Can Hypnosis Enhance Acceptance of Pain?

The notion of enabling patients to manage their chronic pain through such approaches as mindfulness meditation training (and therapies that incorporate mindfulness) is becoming increasingly popular (McCracken & Vowles, 2014, this issue). In such approaches, efforts to directly resist or reduce chronic pain are thought to contribute to suffering. Put another way, having a goal of a direct reduction in chronic pain might decrease the quality of life for some patients.

Clearly, as discussed in this review, hypnosis can be used to reduce pain intensity or otherwise change the experience of pain for some individuals. However, without going into an extensive discussion of mindfulness, hypnosis could potentially serve some patients well as a tool for helping them to accept rather than seek to change their experience of pain. For example, during the hypnotic process, patients can be encouraged to examine pain from a distance or to accept the notion that all perceptual experiences are temporary (Patterson, 2010). Fordyce (1988) taught us long ago that the primary problem many patients face is suffering rather than pain. Accordingly, he counseled patients to focus away from pain with the understanding that dwelling on it only enhanced pain-related suffering. There are parallels to this thinking in some Eastern philosophies that view suffering as a direct result of a person’s resisting or seeking to change his or her experience, as opposed to accepting it. In any case, it is possible that hypnosis can not only facilitate the ability of patients to reduce their pain but can also increase their acceptance of their experience of pain, which would ultimately result in a decrease in suffering (Patterson, 2010).

Summary and Conclusions

Chronic pain management remains one of the largest challenges in health care, and hypnosis is an undeveloped but highly promising intervention that can help to address this problem. Findings from controlled trials indicate that hypnosis is effective for reducing chronic pain intensity on average but that there is also substantial individual variation in outcome. Importantly, hypnosis for chronic pain has few negative side effects. In fact, with hypnotic treatment, most patients report positive side effects, such as an improved sense of well-being, a greater sense of control, improved sleep, and increased satisfaction with life, independent of whether they report reductions in pain. A burgeoning literature on the neurophysiological impact of hypnotic analgesia has guided both theoretical and clinical work. We have learned that hypnosis has a measureable impact on neurophysiological activity and functioning of pain. Importantly, depending on the specific wording, hypnotic suggestions can target specific pain domains and outcomes, as well as activity in specific brain areas.

Our theoretical understanding of hypnotic pain relief is plagued by a lack of consensus on a basic definition of hypnosis as well as by the lack of a comprehensive biopsychosocial theory that explains its impact. Although it appears that the various components that often constitute hypnosis (e.g., focused attention, relaxation, imagery) have beneficial effects on their own, we have yet to fully understand how the sum of these parts has beneficial effects. We look forward to the increased understanding that will come with further research and theoretical developments.

Acknowledgments

This research was supported by the National Institutes of Health, the National Institute of Child Health and Human Development, National Center for Medical Rehabilitation Research Grant R01 HDD070973, and National Institute of Arthritis and Musculoskeletal and Skin Diseases Grant R01 AR054115. The views presented here are not necessarily those of the National Institutes of Health.

We would like to express our appreciation to Lisa C. Murphy and Jenny Nash for their valuable comments and feedback on an earlier version of this article.

Biographies

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Mark P. Jensen

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David R. Patterson

Footnotes

Mark P. Jensen is the author of two books (2011, Oxford University Press) related to the topic of this article (Hypnosis for Chronic Pain Management: Therapist Guide and Hypnosis for Chronic Pain Management: Workbook), and David R. Patterson is the author of one book (2010, American Psychological Association) related to the topic of this article (Clinical Hypnosis for Pain Control). They receive royalties for the sale of these books.

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Posted in Evidence, Hypnosis Research | Tagged | 1 Comment

Hypnotic Analgesia may Influence Pain Both by Altering Activity in Localized “Specific” Areas and by Facilitating Shifts in General Brain States

Hypnosis has been used to treat every type of pain condition imaginable over centuries and across cultures. What is new about hypnotic analgesia is the compelling empirical evidence that has emerged in the last two decades regarding its efficacy and mechanistic underpinnings.

hypnotic analgesia may influence pain both by altering activity in specific areas and by facilitating shifts in general brain states.

hypnotic suggestions are localized to specific areas of the brain but also add important support for the conclusion that such effects involve more than a process of simple imagination

The findings from these clinical trials also show that hypnotic treatments have a number of positive effects beyond pain control.
Study:

Hypnotic approaches for chronic pain management: clinical implications of recent research findings.
Am Psychol. 2014 Feb-Mar;69(2):167-77. doi: 10.1037/a0035644.
Jensen MP1, Patterson DR1.
1Department of Rehabilitation Medicine, University of Washington.
Abstract
The empirical support for hypnosis for chronic pain management has flourished over the past two decades. Clinical trials show that hypnosis is effective for reducing chronic pain, although outcomes vary between individuals. The findings from these clinical trials also show that hypnotic treatments have a number of positive effects beyond pain control.
Neurophysiological studies reveal that hypnotic analgesia has clear effects on brain and spinal-cord functioning that differ as a function of the specific hypnotic suggestions made, providing further evidence for the specific effects of hypnosis. The research results have important implications for how clinicians can help their clients experience maximum benefits from hypnosis and treatments that include hypnotic components.
PsycINFO Database Record (c) 2014 APA, all rights reserved.

Entire Article is found  here

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Neurofeedback Enhances Pain Reducing Hypnotic Analgesia in Individuals With Multiple Sclerosis (MS)

Hypnosis for pain reduction, Hypnotic Analgesia, works on pain reduction, including Multiple Sclerosis (MS) conditions, the use of EEG neurofeedback enhances the benefits of Hypnotic Analgesia.
Study:
Use of Neurofeedback to Enhance Response to Hypnotic Analgesia in Individuals With Multiple Sclerosis.
Jensen MP1, Gianas A1, George HR1, Sherlin LH2, Kraft GH1, Ehde DM1.
Int J Clin Exp Hypn. 2016 Jan-Mar;64(1):1-23. doi: 10.1080/00207144.2015.1099400.
Author information
1a University of Washington , Seattle , USA.
2b Southwest College of Naturopathic Medicine , Tempe , Arizona , USA.
Abstract

This proof of principle study examined the potential benefits of EEG neurofeedback for increasing responsiveness to self-hypnosis training for chronic pain management. The study comprised 20 individuals with multiple sclerosis (MS) who received 5 sessions of self-hypnosis training-1 face-to-face session and 4 prerecorded sessions. Participants were randomly assigned to have the prerecorded sessions preceded by either (a) EEG biofeedback (neurofeedback) training to increase left anterior theta power (NF-HYP) or (b) a relaxation control condition (RLX-HYP). Eighteen participants completed all treatment sessions and assessments.
NF-HYP participants reported greater reductions in pain than RLX-HYP participants. The findings provide support for the potential treatment-enhancing effects of neurofeedback on hypnotic analgesia and also suggest that effective hypnosis treatment can be provided very efficiently.
http://www.ncbi.nlm.nih.gov/pubmed/26599991
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Even moderate weight loss can prevent and cure obstructive sleep apnoea

An Article:

Even a moderate weight reduction can prevent the progression of obstructive sleep apnoea (OSA), and even cure it, according to a 4-year Finish follow-up study published recently in Sleep Medicine. The study focused on the effects of weight loss on OSA and demonstrated, for the first time, that a sustained weight loss of just 5% was enough to prevent the disease from worsening and even cure it in a long-term follow-up.

Obstructive sleep apnoea (OSA) has become a major burden for our health care systems over the last years. Although it is one of the most increasingly prevalent non-communicable diseases, the vast majority of people with OSA still remain undiagnosed. OSA has also been found to be tightly linked with metabolic abnormalities, particularly type 2 diabetes, and cardiovascular morbidity. OSA is a chronic, progressive disease, and it is well-documented that moderate to severe forms of OSA are associated with an increased risk for cardiovascular morbidity and mortality. Obesity is the most important risk factor for OSA. Based on current knowledge about the evolution of OSA, weight gain represents a high risk for the further progression of the disease towards the more severe forms, particularly in patients who already have a partial obstruction of their upper airways associated with mild OSA. However, there has been a lack of well-designed studies on the effects of weight reduction on OSA. Furthermore, thus far, no studies have focused on the prevention of the progression of OSA. There are no national programmes for screening OSA or preventing the progression of the disease, nor are such programmes even planned at the moment around the world. However, before larger scale programmes may be implemented or even planned in clinical settings, as have been done for the prevention of type 2 diabetes, there is a need for more reliable scientific evidence.

The study was conducted in Kuopio University Hospital, Finland, in collaboration with the University of Eastern Finland between 2004 and 2013. The study participants were moderately obese adult patients with mild OSA. The participants underwent either a 12-month supervised lifestyle intervention programme or were given standard care consisting of general verbal and written information about diet and physical activity. The main hypothesis was that even a moderate (5%, i.e. -5kg) but sustained weight reduction can achieve an improvement in OSA, thus preventing the progression of the disease when the treatment is started in the early stages of OSA.

This study provides first time long-term evidence that even a modest weight reduction can result in marked improvements of OSA and metabolism in overweight patients, and these positive changes are sustained even four years after the cessation of the active intervention, and the progression of the disease is thus prevented.

The Study

Even moderate weight loss can prevent and cure obstructive sleep apnoea
Wednesday 12 February 2014

The impact of weight reduction in the prevention of the progression of obstructive sleep apnea – explanatory analysis of a 4-year observational follow-up trial, Author: Henri Tuomilehto MD, PhD, Juha Seppä MD, PhD, Matti Uusitupa MD, PhD, Markku Peltonen PhD, Tarja Martikainen MSc, Johanna Sahlman MD, PhD, Jouko Kokkarinen MD, PhD, Jukka Randell MD, PhD, Matti Pukkila MD, PhD, Esko Vanninen MD, PhD, Jaakko Tuomilehto MD, MA, PhD, Helena Gylling MD, PhD on behalf of the Kuopio Sleep Apnea Group, Sleep Medicine (2014) doi:10.1016/j.sleep.2013.11.786

University of Eastern Finland

The impact of weight reduction in the prevention of the progression of obstructive sleep apnea: an explanatory analysis of a 5-year observational follow-up trial

Henri Tuomilehtoemail address
,
Juha Seppä
,
Matti Uusitupa
,
Markku Peltonen
,
Tarja Martikainen
,
Johanna Sahlman
,
Jouko Kokkarinen
,
Jukka Randell
,
Matti Pukkila
,
Esko Vanninen
,
Jaakko Tuomilehto
,
Helena Gylling
,
Kuopio Sleep Apnea Group

Received 8 September 2013; received in revised form 22 October 2013; accepted 1 November 2013. published online 03 February 2014.
Corrected Proof

Highlights

•Obstructive sleep apnea (OSA) is a chronic progressive disease.

•Severe OSA is associated with an increased risk for cardiovascular morbidity and mortality.

•Obesity is the most important risk factor for OSA.

•Weight reduction has been shown to improve OSA, but there is lack of long-term evidence.

•Even a moderate weight reduction can prevent the progression of OSA in 5-year follow-up.

Abstract
Background

Obstructive sleep apnea (OSA) is a chronic progressive disease, and it is well-documented that severe OSA is associated with an increased cardiovascular morbidity and mortality. Weight reduction has been shown to improve OSA; however, we need further evidence to determine if it may prevent the progression of OSA in the long term. The aim of our study was to assess the impact of weight change during a 5-year observational follow-up of an original 1-year randomized controlled trial.
Methods

The participants were divided into the two groups according to the weight change at 5-year follow-up using the 5% weight loss as a cutoff point, which was later referred to as the successful (n=20) or unsuccessful groups (n=27). The change in apnea–hypopnea index (AHI) was the main objective outcome variable.
Results

Fifty-seven patients participated in the 5-year follow-up. At 5years from the baseline, the change in AHI between the groups was significant in the successful group (-3.5 [95% confidence interval {CI}, -6.1 to -0.9]) compared with the unsuccessful group (5.0 [95% CI, 2.0–8.5]) (P=.002). Successful weight reduction achieved an 80% reduction in the incidence of progression of OSA compared to the unsuccessful group (log-rank test, P=.016).
Conclusions

A moderate but sustained weight reduction can prevent the progression of the disease or even cure mild OSA in obese patients.

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Cortical representation of the sensory dimension of pain

Neurophysiol. 2001 Jul;86(1):402-11.
Cortical representation of the sensory dimension of pain.

Hofbauer RK, Rainville P, Duncan GH, Bushnell MC.

Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec H3G 1Y6, Canada.
Abstract

It is well accepted that pain is a multidimensional experience, but little is known of how the brain represents these dimensions. We used positron emission tomography (PET) to indirectly measure pain-evoked cerebral activity before and after hypnotic suggestions were given to modulate the perceived intensity of a painful stimulus. These techniques were similar to those of a previous study in which we gave suggestions to modulate the perceived unpleasantness of a noxious stimulus.

Ten volunteers were scanned while tonic warm and noxious heat stimuli were presented to the hand during four experimental conditions: alert control, hypnosis control, hypnotic suggestions for increased-pain intensity and hypnotic suggestions for decreased-pain intensity.

As shown in previous brain imaging studies, noxious thermal stimuli presented during the alert and hypnosis-control conditions reliably activated contralateral structures, including primary somatosensory cortex (S1), secondary somatosensory cortex (S2), anterior cingulate cortex, and insular cortex.

Hypnotic modulation of the intensity of the pain sensation led to significant changes in pain-evoked activity within S1 in contrast to our previous study in which specific modulation of pain unpleasantness (affect), independent of pain intensity, produced specific changes within the ACC. This double dissociation of cortical modulation indicates a relative specialization of the sensory and the classical limbic cortical areas in the processing of the sensory and affective dimensions of pain.

PMID: 11431520 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/pubmed/11431520

Full article:

http://jn.physiology.org/content/86/1/402.long

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Dissociation of sensory and affective dimensions of pain using hypnotic modulation

Pain. 1999 Aug;82(2):159-71.
Dissociation of sensory and affective dimensions of pain using hypnotic modulation.

Rainville P, Carrier B, Hofbauer RK, Bushnell MC, Duncan GH.

Département de Psychologie, Université de Montréal, Québec, Canada.
Abstract

Understanding the complex nature of pain perception requires the ability to separately analyze its psychological dimensions and their interaction, and relate them to specific variables and responses. The present study, therefore, attempted to selectively modulate the sensory and affective dimensions of pain, using a cognitive intervention, and to assess the possible relationship between these psychological dimensions of pain and changes in physiological responses to the noxious stimuli.

In three experiments, normal subjects trained in hypnosis rated pain intensity and pain unpleasantness produced by a tonic heat-pain stimulus (1-min immersion of the hand in 45.0-47.5 degrees C water). Two experiments were designed to test hypnotic suggestions to decrease (Experiment one (Section 2.5.1)), or increase and decrease (Experiment two (Section 2.5.2)) pain affect. Suggestions in Experiment three (Section 2.5.3) were directed towards an increase or decrease in pain sensation. In Experiments one and two (Sections 2.5.1 and 2.5.2), the significant modulation in pain unpleasantness ratings was largely independent of variations in perceived pain intensity. Moreover, in Experiment two (Section 2.5.2), there was a significant correlation between the stimulus-evoked heart-rate increase and ratings of pain unpleasantness, but not of pain intensity, suggesting a direct functional interaction between pain affect and autonomic activation. In Experiment three (Section 2.5.3), suggestions to modulate the sensory aspect of pain produced significant modulation of pain intensity ratings, with secondary changes in pain unpleasantness ratings.

Hypnotic susceptibility (Stanford Hypnotic Susceptibility Scale form A) was specifically correlated to pain unpleasantness modulation in Experiment two (Section 2.5.2) and to pain intensity modulation in Experiment three (Section 2.5.3), suggesting that this factor relates to the primary process toward which hypnotic suggestions are directed. The specific pain dimension on which hypnotic suggestions act depends on the content of the instructions and is not a characteristic of hypnosis itself. Results are consistent with a successive-stage model of pain perception (e.g. Wade JB, Dougherty LM, Archer CR, Price DD. Assessing the stages of pain processing: a multivariate analytical approach. Pain 1996;68:157-167) which provides a conceptual framework necessary to study the cerebral representation of pain perception.

PMID: 10467921 [PubMed - indexed for MEDLINE]

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