Hypnosis And Chronic Pain A Brief Review

The Scottish physician, Esdaile (1850/1957) may have been the first to document the use of hypnosis to control pain. Just prior to the development of chemical anesthesia, Esdaile successfully used hypnosis widely in India as the only form of anesthesia for amputations, tumor removals and complex surgical procedures. Overlooked in Esdaile's reports was the fact that most of his patients survived surgery—a rare event in those days because of hemorrhage, shock, and postsurgical infection. In addition to controlling surgical and post-operative pain, hypnosis may have had autonomic and/or immunological effects that minimized the usual complications of surgical procedures.

Clinical reports document that hypnosis has been used to reduce chronic pain (Sacerdote, 1970), to reduce the pain and severity of debridement procedures in burn patients (Ewin, 1976; see also chapter 19 in this volume), and to assist in the management of pain in the terminally ill (cancer) patient (Domangue & Margolis, 1983). There are relatively few well-controlled empirical studies of the clinical efficacy of hypnosis in the management of acute or chronic pain (Turner & Chapman, 1982). The evidence suggests that about 50% of terminal cancer patients (Hilgard & Hilgard, 1975) and 95% of dental patients (J. Barber, 1977) can be helped with some pain control by the adjunctive use of hypnotic techniques. Recently, a powerful policy statement was issued by the National Institutes of Health Technology Conference (1995) on 'The Integration of Behavioral and Relaxation Approaches into the Treatment of Chronic Pain and Insomnia', finding that 'hypnosis is effective in alleviating chronic pain associated with various cancers ... [and] irritable bowel syndrome, inflammatory conditions of the mouth, temporomandibular disorders, and tension headaches'. Most of the studies which led to this conclusion have been reviewed by Large (1994) and Holroyd (1996).

Studying mixed groups of chronic pain patients, Melzack & Perry (1975) found that a combination of hypnosis and biofeedback was more effective in alleviating pain than either technique alone (N = 24). Elton, Burrows & Stanley (1980) found that hypnosis was more effective than behavioral therapy and pill placebo with 30 chronic pain patients. James, Large & Beale (1989) effectively individualized self-hypnotic strategies in five chronic pain patients, using a multiple baseline study.

Crasilneck (1979) found 69% of 29 consecutive low back pain referrals reported 80% subjective pain relief during outpatient treatment with individualized hypnosis lasting up to 9 months. McCauley, Thelen, Frank, Willard & Callen (1983) found positive results for both hypnosis and relaxation with back pain patients.

Two studies have shown the effectiveness of hypnosis with painful irritable bowel syndrome. Whorwell, Prior & Faragher (1984) found hypnosis reduced subjective pain and abdominal distension in 30 patients compared to supportive psychotherapy. This group (Prior, Colgan & Whorwell, 1990) later found that hypnosis reduced rectal sensitivity in 15 diarrhea-prone patients.

Compared to physical therapy, hypnosis was more effective in improving pain and sleep, but not tender points, in 40 patients with fibromyalgia (Haanen, Hoenderdos, vanRomunde et al., 1991). Medication reduction was observed in 80% of the patients treated with hypnosis. Several anecdotal reports (Margolis, personal communication; Finer, personal communication; Gainer, 1992; Evans, 2001) suggest that hypnosis might be effective in the early phases of reflex sympathetic dystrophy, but formal studies have not yet been completed.

In one of the few studies that measured hypnotic ability, Stam, McGrath & Brooke (1984) found that the more highly hypnotizable of 61 patients with temporomandibular joint pain gained relief with both hypnosis and relaxation compared to a control group. There was little pain reduction with any of the treatments for low hypnotizable patients.

Syrjala, Cummings & Donaldson (1992) found that hypnosis was more effective than cognitive-behavioral therapy in reducing pain, but not nausea, emesis, or opioid use, in 67 bone marrow transplant patients. This result is a little surprising in view of the widely held anecdotal reports that hypnosis is an excellent tool for treating nausea and vomiting in several clinical populations, including hyperemesis in early pregnancy, bulimia and treatment-induced emesis in cancer patients (Evans, 1991).

Several studies have shown the value of hypnosis in treating chronic headache. Olness, MacDonald & Uden (1987) found hypnosis was superior to propranolol or placebo in treating 28 children with migraine headaches. Cedercreutz (1976) treated 100 patients with severe migraine headaches using hypnosis. Of the 55% of patients whose migraines decreased over 3 months, most were highly hypnotizable. It is not clear what measure of hypnotic ability was used, nor were there any control groups. Basker, Anderson & Dalton (1976) compared 47 patients with migraine headaches randomly assigned to hypnosis or drug (prochlorperazine). Complete remission over three months occurred in significantly more of the hypnotized patients (43%) compared to the drug group (12%). At least three studies (N = 55, 56, 79) from Holland (van Dyck, Zitman, Linssen & Spinhoven, 1991;

Spinhoven, Linssen, van Dyck & Zitman, 1992; Zitman, van Dyck, Spinhoven & Linssen, 1992) have found that hypnosis or self-hypnosis, especially among the more hypnotizable, reduces tension headache pain, at least as well as autogenic training, and better than control groups.

This is not a comprehensive or a critical review of existing studies. No attempt has been made to review studies using hypnosis in the treatment of cancer pain, such as the work of Spiegel (1993). It is intended to show that hypnosis may be one valuable technique to help reduce chronic pain of various origins. These studies use a wide variety of hypnotic techniques, and they do not indicate which hypnotic strategies might be more helpful for specific painful conditions. Most of the studies lack appropriate control groups and have inadequate follow-up data. Several of the studies find no difference in efficacy between hypnosis and other active psychosocial treatment modalities, but some show that hypnosis can be as effective as direct medical interventions (e.g. pain medication). Unfortunately, hypnotic ability is rarely related to outcome, neither in the hypnosis nor the comparison groups. Therefore it is not known if the pain reduction is due to hypnosis or to non-specific effects associated with the use of hypnotic interventions. Nor do these studies come to terms with the difficult issue of how best to measure pain reduction. Most have been forced to rely on subjective pain ratings of unknown reliability. The clinical criterion of successful treatment outcome for chronic pain patients is far more complex than mere pain reduction. Multiple outcome measures need to consider decreased depression and medication and opioid use; improved sleep, social and family relations and quality of life; increase in range of motion and activity level; and return to work (Evans, 1989; 2001).

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