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USE OF HYPNOSIS IN SURGICAL APPROACHES Jaidev R. Nath* & Rohit S. Aiyer University of Birmingham - School of Medicine, UK *Email: [email protected]

Abstract: Hypnosis was a popular anaesthetic in the 19th century before the emergence of safe and effective chemical anaesthesia. To determine whether hypnosis has a role in the modern surgical setting, relevant trials are reviewed. Despite considerable variation in techniques amongst t he various studies, surgical patients treated with hypnosis experienced substantial, pre-, intra-, and post-operative benefits. These include reduced preoperative anxiety, less adverse events during surgery, less chemo analgesic requirement during surgery, less procedural duration, and better post-operative outcomes. An expanded role for hypnosis as an adjunctive therapy, and additional randomized control trials with larger sample sizes appear to beindicated .

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A BRIEF HISTORY OF HYPNOSIS AND ITS ENTRY INTO MEDICINE The term hypnosis was coined by Scottish physician James Braid in 1841. Hypnosis was defined by Braid as a „derangement to the state of cerebral spinal centers by fixed stare, absolute repose of the body, immobility of the body, fixed attention on the words of the hypnotist, and suppressed respiration‟.1 Braid‟s definition was a revision of previous theories such as animal magnetism, mesmerism etc. He replaced the supernatural and paranormal aspects of these theories with psycho-physiological ones. In 1846 another Scottish physician by the name of James Esdaile reported that he had performed approximately 300 major surgical procedures, including 19 amputations, in India, using hypnosis as an anesthetic.2 This was a major breakthrough at a time when there were no anesthetics, and patients had to suffer unbearable pains during surgical procedures. Majority of his patients reported little or no discomfort during the procedure and his mortality rates were less than 8% at a time when surgical mortalities were reported to be around 50%.3 This reduction was mainly thought to be due to the alleviation of postoperative shock in Esdaile‟s patients, as a result of hypnosis. However Esdaile‟s victory was short-lived, because a few months later, in October of 1846, physicians from Massachusetts General Hospital announced the discovery of ether anesthesia.3 The concrete scientific mechanisms behind chemical anesthesia were too powerful for hypnosis to overcome, and it was never incorporated into surgical practice as an anesthetic. Hypnotism was subsequently overlooked by majority of the medical profession for more than a hundred years, and continued to live on as a form of Nath R J , Aiyer S R

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entertainment and amusement, performed by charlatans and stage hypnotists. In 1955, the British Medical Association announced that hypnotism can be used in the production of anesthesia and analgesia, and can be an effective method for relieving pain in suitable subjects.4 The BMA also endorsed the teaching of hypnosis in medical schools. The American Medical Association quickly followed suit in 1958 and made a similar announcement.4 Although few schools offer such a course, the acceptance and endorsement by organized medicine, was an important factor in the re-emergence of medical hypnosis. Since then the interest in hypnotic anesthesia has fluctuated, and hypnosis has been mainly studied as a complementary technique, rather than an alternative to chemical anesthesia and analgesia. Scientific limitations have prevented hypnosis from progressing from experimental usage to routine clinical practice. For example, it is difficult to find measureable physiological variables that are associated the hypnotic state. It is also challenging to reproduce and measure a hypnotic trance in a reliable manner, and it is impossible to perform double blind studies with hypnosis. However a recent surge of interest in conscious sedation in anesthesia has paved the way for the reemergence of hypnosis. In fact, a combination of hypnosis and pharmacological analgesia and sedation, known as hypnoanalgesia, has been incorporated into routine medical practice by many clinicians.4 Hypnosis has been used as an adjunct to treat psychiatric conditions such as anxiety and post traumatic stress disorder. It has also been used to complement modern therapies for drug rehabilitation, smoking cessation, weight loss, headache, allergies, impotence, colitis, speech problems, hyperemesis gravidarum and many others.4

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HYPNOSIS AND PAIN PERCEPTION Pain can be separated into two components. First is the physical stimulus that causes the pain, and second, the psychological and emotional reaction to the stimulus. Therefore the pain experience and perception can be greatly influenced by a person‟s reaction and response to it. An example of this is a study done after the Second World War, that compared the pain experiences of a group of soldiers during battle, to a group of patients in Massachusetts General Hospital with similar injuries.5 It was found that the soldiers reported very little pain in comparison to the control group and very rarely requested pain medication (Beecher, 1959).5 Beecher concluded that there is no simple, direct relationship between the extent of an injury and the pain experienced by the patient. A large component of the “pain experience” is therefore determined by one‟s subjective response and reaction to the wound or pain stimulus. This helps explain why soldiers had a different pain perception than civilians; their subjective response in the hospital was a positive one. Having survived in the battlefield they could now spend weeks and months in safety and relative comfort of a hospital. Other studies have replicated Beecher‟s hypothesis by showing that pain perception can be reduced or eliminated by distracting the patient‟s attention away from pain, and thereby preventing them from forming a subjective response to it. Participants reported higher pain as they paid close attention to the stimulus, and they reported lower pain when they were distracted from it (Leventhal, Brown, Shacham & Engquist, 19796; Levine, Gordon, Smith, & Fields, 19827; McCaul & Haugtvedt, 19828).

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Hypnosis has also been shown to affect the first component of pain perception, nociceptive signal transmission. A study by Hofbauer, Rainville, Duncan and Bushnell (2001)9 demonstrated using PET imaging that hypnosis resulted in reduction of nociceptive signals arriving at the primary somatosensory cortex, and changes in the affective component of pain by influencing the limbic system, an area that modulates emotional responses. Another study by Li et. Al (1975)10, showed that the pain threshold can be increased with hypnosis. Patients demonstrated a higher pain threshold when they were under hypnosis, in comparison to the same stimulus applied without hypnosis and applied only using acupuncture. Although various studies have shown that hypnosis can successfully reduce pain, the effects of hypnosis seem to be dependent on the suggestibility of the patient. For example many studies (E. R. Hilgard & Morgan, 197511; Knox, Morgan, & Hilgard, 197412) have shown that ischemic muscle pain perception is dependent on patient suggestibility measured using standardized scales, most commonly the Stanford Hypnotic Susceptibility Scale. Also a recent metaanalysis of hypnosis and pain studies (Montgomery et. Al, 2000)13 demonstrated that hypnoanalgesic effects across a wide variety of settings and studies were correlated with patient suggestibility. This is an important factor to consider when evaluating hypnoalgesic techniques because people have varying degrees of hypnotizability. Studies have also shown that hypnotizability is a stable trait and tends to run in families.14, 15

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HYPNOSIS IN SURGERY There are occasional reports of major surgeries, such as thyroidectomies (Meurisse 1999)16, being performed with hypnosis as the only method of analgesia. The vast majority of hypnoanalgesic studies, however, use hypnosis in conjunction with chemical anesthesia to facilitate the surgery, reduce usage of chemical analgesics, and to improve intra-operative and post-operative outcomes. This was demonstrated in a study by Lang (2000)17 where in addition to being an effective analgesic, hypnosis also reduced procedure time, and increased hemodynamic stability (fewer adverse events). In this study 241 patients undergoing cutaneous vascular and renal procedures, were randomized into 3 groups, all groups received patient controlled conscious sedation, one-third received hypnotherapy as well, one-third received attention manipulation, and the remaining third served as controls. In addition to the decreased procedure time, and increased hemodynamic stability, the hypnosis group also showed less drug use, and less anxiety during the procedure in comparison to the standard care group. These results are illustrated in figures 1-4 below.18

Figure 1. Pain experienced during the surgical procedure for the 3 groups, measured at various intervals on a scale of 1-10.18

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Figure 2. Anxiety experienced during the surgical procedure for the 3 groups, measured at various intervals on a scale of 1-10.18

Figure 3. Units of pain medication requested and received by the 3 groups during the surgery.18 Nath R J , Aiyer S R

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Figure 4. Total number of adverse events during surgery for the 3 groups.18 Hypnosis can also have a role in reducing the costs associated with procedures. A study by Montgomery et. Al (2007)19, randomized 200 breast cancer patients undergoing breast biopsies and lumpectomies into two groups. The first group received hypnosis and standard care and the second group received attention control and standard care. The control group was administered attention control to ensure that they spent similar amounts of pre-operative time with a professional as the hypnosis group. The researchers discovered that the hypnosis group required less intra-operative anesthesia, reported less pain, nausea, fatigue and emotional upset. They also reported that patients in the hypnosis group cost the hospital $772.71 less per patient that patients in the control group. This was mainly due to reduced procedure time for patients in the hypnosis group.

A Belgian Study by Meurisse et. Al (1999)16 compared 218 patients undergoing endocrine surgery performed under hypnosedation with 121 patients with closely matched cases who underwent general anesthesia. Although intra-operative outcomes such as operative time, bleeding and hemorrhage were almost identical, the post operative outcomes greatly favored the hypnosis group. These results are illustrated in figures 5 and 6.18

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Figure 5. Comparison of intraoperative variables between the Hypnosis only and GA only groups.18

Figure 6. Comparison of postoperative variables between the Hypnosis only and GA only groups.18 As illustrated by the breast cancer surgery study (Montgomery et. Al, 2007)19, in addition to acting as an analgesic, hypnosis can also reduce adverse postoperative outcomes such as nausea, postoperative pain, fatigue etc. Similar results were found in previous studies, for example a 1997 study by Engvist20 reported that women who were randomized to a preoperative hypnosis group had significantly less postoperative Nath R J , Aiyer S R

vomiting in comparison to the control group, 39% to 68% respectively. In addition to breast surgeries, reductions in adverse post-op outcomes have also been reported in cardiovascular surgeries. For example, postoperative atrial fibrillation (PAF) is the most common complication associated with coronary artery bypass graft surgeries. A study by Novoa & Hammonds (2008)21 reported that 50 patients who underwent preoperative

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hypnosis were significantly less likely to experience an episode of PAF in comparison to 50 case-matched historical controls. Orthopedic surgeries have reported similar success with hypnotherapy. A in the hypnosis group significantly lower perceived pain intensity, anxiety, and medical complications than the control subjects. They also had a significantly higher post-operative recovery rate. Hypnosis can also have a role in a preoperative setting to reduce patient anxiety and apprehension about the upcoming procedure. A study by Calipel et. Al (2005)23 reported that children who were randomized to the hypnosis group had significantly less pre-operative anxiety as measured by the Modified Yale Preanxiety Scale. Similar results were found in adults in a study by Saadat et. Al (2006)24. In this study 76 ambulatory surgery patients between the ages of 18 and 65 were randomized into three groups. The second group received attention control and the third group was comprised of standard care control patients. The hypnosis group had significantly less preoperative anxiety as measured by the State Trait Anxiety Inventory.

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study by Mauer et. Al (1999)22 randomized 60 hand surgery patients into hypnosis and standard care group and a standard care only group. The 30 patients meta-analysis by Cyna et. Al (2004)25 reported that parturient women who underwent hypnosis reported less labor pain and required less chemical analgesia during their labor than patients in control groups. These results were replicated in a study by Martin et. Al (2001)26 which reported that out of 42 teenage patients who were pregnant, those who were randomized to the hypnosis group, experienced less complications, had shorter hospital stays and required less chemical analgesics during labor and post-partum. The limitations of this study were a small sample size, non-random sample selection, and restriction to adolescents. The study also did not report detailed patient demographics; therefore it is difficult to predict whether the benefits of hypnosis can be generalized to all pregnant women. However both of these studies do lend credence to further investigation on the application of hypnosis in an obstetric setting.

These effects of hypnosis can be of particular benefit to pregnant women. A

LIMITATIONS OF HYPNOSIS Hypnosis is a cost effective procedure that has been reported to be an effective adjuvant to chemical analgesics. Studies have shown that it can have an effect in reducing pain, requiring lower dosage of Nath R J , Aiyer S R

analgesics, thereby reducing their side effects and improving post-operative outcomes. However, as mentioned before, it only works on people who are mentally intact, non-resistant, and moderate to highly hypnotizable according to the Hypnotic Induction Profile or the Stanford Hypnotic Susceptibility Scale. Unlike chemoanalgesics, hypnosis does not have a predictable dose-response relationship.

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Instead its applicability and efficacy may vary depending on educational backgrounds, socio-economic status, cultural and religious beliefs, and disabilities such as hearing impairment. In a study conducted by Sefiani et. Al (2004)27, 35 cholecystectomies and 15 inguinal hernia repairs were performed using hypnosis and local anesthesia instead of general anesthesia. One inguinal hernia patient had to be converted to general anesthesia due to patient discomfort and thirteen cholecystectomies had to be converted to general anesthesia due to high levels of peritoneal pain and discomfort. This indicates that hypnotism might not be suitable for more invasive surgeries, such as intraperitoneal laproscopic procedures like cholycystectomies; however it might be effective for extraperitoneal laproscopic procedures like inguinal hernia repairs. An interesting study by Egbert and colleagues (1964)28 demonstrated a reduction in postoperative pain, similar to many hypnosis studies, without using hypnosis. In this study, surgical patients were randomized into two groups. The first group received special education by the anesthesiologist about what to expect after the surgery and was given encouragement regarding the procedure. The second group did not receive any special attention and received only the standard pre-operative care. The group that received special attention needed significantly less narcotics postoperatively. This seems to indicate that the use of suggestion and encouragement of a positive outcome, without the formal

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hypnotic procedure, can be just as effective as hypnosis itself. A study by Van Der Laan et. Al (1996)29 found no difference in groups that received preoperative therapeutic suggestions, intraoperative suggestions and a control group that did not receive any suggestions. These patients who underwent various gynecological procedures did not exhibit any significant differences in pain, medication requirement, and postoperative nausea. Their interventions however were not administered by an anesthetist or a professional; instead they were recorded messages played using a cassette player. This may have a role in the outcome, since personal attention and live suggestions from an anesthetist might be more reassuring and relaxing, reducing pre-operative anxiety and improving postoperative outcome. Patient susceptibility can also play an important role in the success of hypnotherapies. As illustrated in figure 7,14 certain percentage of the population is not at all, or very slightly susceptible to hypnotism. Hypnotizability is usually measured by standardized psychological tests such as the Stanford Hypnotic Susceptibility Scale or the Harvard Group Scale of Hypnotic Susceptibility.

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people are more suggestible and can enter a deep hypnotic trance while others are more resistant. There are standardized scales to measure this trait, but it is not a foolproof method and it is hard to predict how even highly suggestible patients will perform in a surgical condition without traditional anesthesia. Even in suggestible patients the amount of muscle relaxation might not be sufficient enough to perform the procedure. In order to save cost and resources, more research is needed to supplement the hypnosis susceptibility scales and to reliably identify and target people who will respond favorably to hypnosis for surgical procedures. Figure 7. Distribution of hypnotizability in a normal population.14

CONCLUSION Hypnosis is a procedure that has virtually no side effects, and a multitude of possible benefits if administered to surgical patients, in conjunction with standard analgesics. These benefits can include, reduced preoperative anxiety, less adverse events during surgery, less chemoanalgesic requirement during surgery, less procedural duration, and better post-operative outcomes. Hypnosis however might never completely replace standard analgesics and anesthetics. This is because there is no uniformity or standards for the administration of hypnosis; each therapist has their own variations and style. Therefore it is important that future researchers use hypnotism manuals that define replicable guidelines. In addition to that patients react to hypnosis in different ways; some Nath R J , Aiyer S R

Hypnosis is an uncharted territory with many promises and potentials. It is already being used to treat chronic pain, and to assist with smoking cessation and weight loss. The greatest obstacle that hypnotism faces is that it cannot live up to the gold standard of double blind randomized control studies, which has become the benchmark for evaluating any new interventions. Due to the nature of hypnosis, and the difficulty in performing fake hypnosis, it is impossible to perform a blind study. This will result in a bias that is unavoidable in every hypnotherapy study. However with more randomized control trials and with bigger sample sizes, it will be possible to define the usefulness of hypnosis for a variety of surgical and clinical procedures. Based on the literature that was reviewed in this paper, adjuvant hypnosis appears to be an effective treatment in a surgical context. Hypnosis plus medication yields better pain relief than medication alone. It is also an intervention that can save costs by reducing the procedural time, medication use, and the length of hospital stay. At the

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very least, hypnosis will increase patient satisfaction by offering them a relaxing respite, and possible stress relief from the hectic and sometimes chaotic tempo of modern medicine.

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Li, CL, Ahlberg, D, Landsdell, M, et al. Acupuncture and hypnosis: effects on induced pain. Exp Neurol 1975; 49: 281– 90. 11) Hilgard, ER, & Morgan, AH. Heart rate and blood pressure in the study of laboratory pain in man under normal conditions and as influenced by hypnosis. Acta Neurobiologiae Experimentalis 1975; 35: 741–759. 12) Knox, VJ, Morgan, A H, & Hilgard, ER. Pain and suffering in ischemia: The paradox of hypnotically suggested anesthesia as contradicted by reports from the “hidden observer.” Archives of General Psychiatry 1974; 30: 840–847. 13) Montgomery, GH, DuHamel, KN, & Redd, WH. A meta-analysis of hypnotically induced analgesia: How effective is hypnosis? International Journal of Clinical and Experimental Hypnosis 2000; 48: 138–153. 14) Hilgard ER: Hypnotic Susceptibility. New York, Harcourt, Brace and World, 1965. 15) Spiegel H, Spiegel D: Trance and Treatment: Clinical Uses of Hypnosis. New York, Basic Books, Inc. 1978. 16) Meurisse, M, Defechereux, T, Hamoir, E, Maweja, S, et. Al. Hypnosis with conscious sedation instead of general anaesthesia? Applications in cervical endocrine surgery. Acta Chir. Belg. 1999; 99: 151–158. 17) Lang EV, et. al. Adjunctive nonpharmacological analgesia for invasive medical procedures: A randomised trial. Lancet 2000; 355: 1486-1500. 18) Kihlstrom, JF (2001). Hypnosis in Surgery: Efficacy, Specificity, and Utility. Retrieved February 27, 2009, from the Institute for the Study of Healthcare Organizations & Transactions website: http://www.instituteshot.com/hypnosis_pain_utility.htm

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19) Montgomery GH, Bovbjerg DH, Schnur JB, David D, Goldfarb A, Weltz CR, Schechter C, Graff-Zivin J, Tatrow K, Price DD, Silverstein JH. A randomized clinical trial of a brief hypnosis intervention to control side effects in breast surgery patients. J Natl Cancer Inst. 2007; 99: 1304-1312. 20) Engvist B, Bjorklund C, Engman M, Jakobsson J. Preoperative hypnosis reduces postoperative vomiting after surgery of the breasts. A prospective, randomized and blinded study. Acta Anaesthiological Scandinavica 1997; 41: 1028-1032. 21) Novoa R, Hammonds T. Clinical hypnosis for reduction of atrial fibrillation after coronary artery bypass graft surgery. Cleve Clin J Med 2008; 75 22) Mauer, MH, Burnett, KF, Ouellette, EA, Ironson, GH, & Dandes, HM. Medical hypnosis and orthopedic hand surgery: Pain perception, postoperative recovery, and therapeutic comfort. International Journal of Clinical and Experimental Hypnosis 1999; 47: 144–161. 23) Calipel S, Lucas-Polomeni MM, Wodey E, Ecoffey C. Premedication in children: hypnosis versus midazolam. Pediatr Anesth 2005; 15: 275– 81. 24) Saadat H, Drummond-Lewis J, Maranets I, et al. Hypnosis reduces preoperative anxiety in adult patients. Anesth Analg 2006; 102: 1394–1396. 25) Cyna AM, McAuliffe GL, Andrew MI: Hypnosis for pain relief in labour and childbirth: a systematic review. Br J Anaesth 2004; 93(4): 505-511. 26) Martin, A., Schauble, P., Rai, S., Curry, R. Effects of hypnosis on the labor processes and birth outcomes of pregnant adolescents. Journal of Family Practice 2001; 50(5): 441-450.

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27) Sefiani T, Uscain M, Sany JL, et al. Laparoscopy under local anaesthesia and hypnoanaesthesia about 35 cholecystectomies and 15 inguinal hernia repair. Ann Fr Anesth Reanim 2004; 23: 1093–101. 28) Egbert LD, Battit GE, Welch CE, Bartlett MK. Reduction of postoperative pain by encouragements and instruction of patients. N Engl J Med 1964; 270: 825–7. 29) van der Laan WH, van Leeuwen BL, Sebel PS, et al. Therapeutic suggestion has no effect on postoperative morphine requirements. Anesth Analg 1996; 82: 148–52. 30) Wobst, Albrecht HK. Hypnosis and surgery: past, present, and future. Anesth Analg 2007; 104: 1199-208. 31) Patterson DR, Jensen MP. Hypnosis and clinical pain. Psychological Bulletin 2003; 129: 495-521.

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