BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is a common developmental disorder, often persisting into adulthood. Whilst medication is first-line treatment for ADHD, there is a need for evidence-based non-pharmacological treatment options for adults with ADHD who are either still experiencing significant symptoms or for those who have made the informed choice not to start medication. METHODS: We systematically searched PsycINFO, MEDLINE (Ovid), EMBASE, CINAHL and CENTRAL for randomised controlled trials of non-pharmacological treatments for ADHD in adults. After screening of titles and abstracts, full text articles were reviewed, data extracted and bias assessed using a study proforma. RESULTS: There were 32 eligible studies with the largest number of studies assessing cognitive behavioural therapy (CBT). CBT consisted of either group, internet or individual therapy. CONCLUSIONS: The majority found an improvement in ADHD symptoms with CBT treatment. Additionally, mindfulness and cognitive remediation have evidence as effective interventions for the core symptoms of ADHD and there is evidence for the use of group dialectical behavioural therapy and hypnotherapy. However, evidence for these is weaker due to small numbers of participants and limitations due to the lack of suitable control conditions, and a high risk of bias.

Psychol Med. 2020 Mar;50(4):529-541. doi: 10.1017/S0033291720000069. Epub 2020 Feb 10.

Grief is one's reaction to any loss, and the coping mechanisms during grief either deplete or become maladaptive. One of the common ways to cope with grief is alcohol or substance intake. The course and resolution of grief vary depending upon many factors. Hypnotherapy has been useful and effective in addressing grief reactions as well as associated manifestation, such as sleep problems, depressive features, or post-traumatic stress disorder. It might be a good choice of treatment while dealing with patients having underlying issues or maladaptive coping mechanisms. This is a single case study design hypothesized to indicate maladaptive coping of increased alcohol consumption to deal with the death of a young son. The case had been treated as alcohol dependent syndrome with multiple hospitalizations without addressing underlying grief. The treatment approach was changed, and grief was addressed using hypnotherapy. Clinical hypnotherapy helped address grief and facilitated the index case to accept the loss. This resulted in minimizing hospitalizations, abstinence and improved day-to-day functioning along with the use of adaptive mechanisms to cope with the loss. Clinical hypnotherapy is an effective intervention to deal with underlying conflicts or issues that may not be addressed directly in a therapy setting.

Indian J Psychol Med. 2020 Mar 9;42(2):193-197. doi: 10.4103/IJPSYM.IJPSYM_476_19. eCollection 2020 Mar-Apr.

Multiple sclerosis is a chronic, demyelinating disease of the central nervous system mainly affecting young adults. In addition to physical problems, the patients suffer from many psychological problems affecting their psychological well-being. The aim of the present study was to determine the effectiveness of group-based cognitive hypnotherapy on the psychological well-being of patients suffering from multiple sclerosis. This study was designed as a clinical trial with a pretest-posttest control group. From 60 patients diagnosed with multiple sclerosis referred to Beheshti hospital in Yasuj, Iran, 45 patients who met the inclusion criteria were selected by the convenience sampling method. The patients were randomly assigned to intervention (23 individuals) and control (22 individuals) groups through stratified random allocation. After completing the Ryff Scales of Psychological Well-Being, the intervention group attended eight sessions of group-based cognitive hypnotherapy on a weekly basis. The control group did not attend any intervention sessions. At the end of the eight intervention sessions, both groups completed the Ryff's Scale of Psychological Well-being again. The collected data were analyzed using the SPSS software (Version 23). Analysis of Covariance (ANCOVA) and two-way Analysis of variance (ANOVA) tests were used in order to compare the groups. The results indicated that cognitive hypnotherapy had a significant effect on the total score of psychological well-being (F (45, 1) = 6.07, p = .018, ?2 = 0.12) and the dimension of environmental mastery (p < .05). Therefore, it is recommended to use hypnotherapy to promote the psychological well-being of patients suffering from multiple sclerosis.

Am J Clin Hypn. 2020 Apr;62(4):364-379. doi: 10.1080/00029157.2019.1709149.

Despite ongoing efforts by clinicians, researchers, and theorists to resolve fundamental disagreements about what hypnosis is and how it works, a diversity of theories and approaches remains. For example, experts still disagree about whether hypnosis constitutes a special or altered state, whether hypnotizability is best conceived of as a stable trait, and whether the clinical application of hypnosis is appropriately conceptualized as hypnotherapy. Drawing on the ideas of Gregory Bateson, Daniel Siegel, and others, the author articulates a relational characterization of mind and self as a vantage from which to reexamine common assumptions about hypnosis and to reconsider several questions still animating the field.

Am J Clin Hypn. 2020 Apr;62(4):344-363. doi: 10.1080/00029157.2019.1666700.

Post-traumatic stress disorder is a debilitating condition that can develop after exposure to any potentially traumatic event (natural disaster, physical assault, and car accident). This study focused on four pediatric patients presenting with an early stress response after a motor vehicle accident who were offered early therapeutic and a preventive management by hypnotherapy shortly after exposure to the traumatic event. All patients improved after one or several sessions of hypnosis. The results indicate that hypnotherapy can immediately help patients during the early period following a traumatic event.

Am J Clin Hypn. 2020 Apr;62(4):380-391. doi: 10.1080/00029157.2019.1659128.

The feasibility of mindful hypnotherapy (MH) intervention for stress reduction was investigated in a randomized trial. Forty-two college-age participants with elevated stress were randomized into MH intervention or wait-list control condition. MH participants completed an 8-week intervention with 1-hour individual sessions and self-hypnosis audio recordings for daily mindfulness. Results indicated excellent feasibility, determined by participant satisfaction, treatment adherence (84% compliance rate), and low rate of adverse events (4.5%). There were significant differences between the MH and control groups postintervention, with the mindful hypnotherapy intervention resulting in significant and large decrease in perceived distress, p < .001, 15.35 (1.54), Hedge's g = - 1.14, and increase in mindfulness, p < .001, 50.07 (2.04), Hedge's g = 1.36. This study indicates that MH is a feasible intervention for stress reduction and increasing mindfulness.

Int J Clin Exp Hypn. 2020 Apr-Jun;68(2):151-166. doi: 10.1080/00207144.2020.1722028.

Over the years, the field of hypnosis has often given more attention to the state and procedural factors of hypnosis than the relational ones. In an attempt to address this imbalance, the 60th annual meeting of the American Society of Clinical Hypnosis (ASCH) had as its theme "Hypnosis and the Treatment Relationship." A centerpiece of this meeting was a collegial discussion among a panel of psychologists with expertise in relational hypnotherapy. The panel addressed several pertinent questions: (1) What are the healing qualities of relationship in psychotherapy? (2) What makes hypnosis relational in nature? (3) How do relational factors of hypnosis resemble healthy attachment processes and recapitulate stalled developmental maturation? (4) How does relationally informed hypnotherapy influence and strengthen the relationship, process, and outcome of psychotherapy? This article summarizes the factors that led to the creation of this panel; provides an edited transcript of this panel discussion, along with additional commentary on several key points raised; and concludes with a summary of the main themes and recommendations for further clinical practice and study.

Am J Clin Hypn. 2020 Jul-Oct;62(1-2):118-137. doi: 10.1080/00029157.2019.1599319.

Full title: Gazing Back, Playing Forward: Contemporary Psychoanalytic Musings on the Relational Essence of Hypnotherapeutic Action.

To build bridges between hypnosis and contemporary psychoanalysis, this article addresses how hypnosis, when used in psychotherapy, facilitates curative action through its relational essence. The author's extensive experience with hypnosis, psychotherapy, and psychoanalysis orient the narrative toward the unconscious patient-therapist interaction, with particular attention paid to the ethics of the inherent hypnotic seduction. Whether used primarily in relief-oriented ways or geared toward more transformative therapeutic aims, powerful unconscious factors are in play for both patient and therapist and are explicated to illustrate the interactive and frequently unformulated, intersubjective factors that facilitate effective, psychotherapeutic hypnosis. Consequently, therapists attuned to such intersubjective dynamics can make use of their own internal mental activities to understand a patient's current state of mind and level of developmental functioning, and thereby subsequently formulate mutative interventions. For instance, because hypnotizability reflects the ability to play in imaginative space, the regression promoted in hypnotherapy may activate both an illusion of omnipotence and its optimal disillusionment through the relational context. This requires going beyond more traditional, procedural ways of bifurcating hypnotic interventions as being either direct or indirect and instead further distinguish hypnotic interventions in accordance with their maternal and paternal relational dimensions. Arguably, then, the skillful hypnotherapist needs to maintain a coupling interplay between the maternal, maximally receptive and the paternal, more active modes of functioning within hypnotic play space.

Am J Clin Hypn. 2020 Jul-Oct;62(1-2):12-30. doi: 10.1080/00029157.2019.1580558.

Full title: Group hypnosis for stress reduction and improved stress coping: a multicenter randomized controlled trial.

BACKGROUND: The aim of the trial was to investigate the effect of a hypnotherapeutic group program in healthy persons with increased levels of perceived stress. METHODS: In a randomized controlled multicenter trial participants with a self-assessed subjective stress level???40?mm on a visual analogue scale (0-100?mm; VAS) for the previous week and a stable state of health were randomized to either 5 weekly sessions of 120-min duration of a hypnotherapeutic group program for stress reduction and improved stress coping plus 5 hypnosis audiorecords for individual practice at home plus an educational booklet for stress coping (hypnosis group) versus an educational booklet only (control group). The primary outcome parameter was the VAS stress level for the previous week after 5?weeks. Secondary outcome parameters included the VAS stress level after 12?weeks, perceived stress (CPSS), depression (ADS-K), self efficacy (SWE) and quality of life (SF 36) after 5?weeks and 12?weeks. Analysis of covariance with a significance level of 5% using the full analysis set was used for analysis; the model included treatment (fixed effect), VAS baseline value (fixed covariate), and center (random effect). RESULTS: A total of 95 participants were randomized; 47 (40 female, 45?±?13.4?years of age) were allocated to the hypnosis group, and 48 (41 female, 46.9?±?14.3?years) were allocated to the control group. Regarding VAS stress level after 5?weeks, the adjusted VAS mean in the hypnosis group was 41.8?mm [95% confidence interval (CI): 35.2; 48.4] compared to 62.9?mm [56.2; 69.7] in the control group, and the group difference was - 21.2?mm [-?30.1; -?12.2] (P BMC Complement Med Ther. 2020 Nov 13;20(1):344. doi: 10.1186/s12906-020-03129-6.

Full title: You're Going to Do What? Patients' Myths Regarding Hypnotherapy as Described by South African Psychologists.

The aim of this qualitative study was to explore and describe South African registered psychologists' account of their patients' myths regarding hypnotherapy. A social constructivist approach was employed to explore the descriptions of eight psychologists. This article converges on myths of participants' patients and where they originate from, as described by the participants. Psychologists were selected by means of chain referral sampling and engaged in one semi-structured interview. Data were analyzed by means of thematic analysis (TA), and participants elaborated on their experience of patients' myths and the possible origins thereof. Furthermore, conclusions were drawn across themes, which contributed to the findings. The most important finding indicated that while hypnotherapy is of great value, misconceptions stemming largely from unscientific applications contribute to patients' reluctance in utilizing this mechanism. The article concludes with a discussion of the implications, limitations and strengths of the study, as well as recommendations for future research.

Integr Psychol Behav Sci. 2021 Sep;55(3):527-540. doi: 10.1007/s12124-021-09604-0. Epub 2021 Mar 21.

CONTEXT: The World Health Organization (WHO) has defined burnout syndrome (BOS) as resulting from chronic workplace stress that hasn't been successfully managed. Until now, BOS has been treated using allopathic drugs and psychotherapy because it has been confused with major depressive syndrome. OBJECTIVE: The aim of the study was to examine the effectiveness of hypnotherapy combined with cognitive-behavioral therapy in changing the personality traits and lifestyles of people in professions vulnerable to stress who have developed BOS. DESIGN: The research team designed a one-group pre-and posttest study. SETTING: The study was conducted in a private-practice office in Targu Mures, Romania. PARTICIPANTS: Participants were 30 patients at the private practice who had been diagnosed with BOS and volunteered to participate in the study. INTERVENTION: The study alternated hypnotherapy sessions with psychological-counseling sessions, using a general therapeutic plan for all patients and customizing the plan for each participant. OUTCOME MEASURES: The study measured participants' BOS symptomatology and personality dimensions using the Maslach Burnout Inventory (MBI), the DECAS Personality Inventory, the Personality Inventory for DSM-5 (PID5), and the Survey of Work Styles (SWS). RESULTS: Significant changes occurred between baseline an postintervention in the dimensions of extraversion, agreeability, and emotional stability as well as impatience, anger, work involvement, time urgency, job dissatisfaction, and competitiveness. Significant differences existed in almost all personality traits evaluated with the PID-5 (P < .05). CONCLUSIONS: The combination of hypnotherapy and psychological counseling can treat BOS, increasing patients' quality of life by decreasing negative personality traits. The present study is important because it proposes a new therapeutic approach to BOS.

Altern Ther Health Med. 2021 Mar 31:AT6681.

Using multi-modal brain imaging techniques we found pronounced changes in neuronal activity after hypnotic trance induction whereby state changes seem to occur synchronously with the specific induction instructions. In clinical patients, hypnosis proved to be a powerful method in inhibiting the reaction of the fear circuitry structures. The aim of the present paper is to critically discuss the limitations of the current neuroscientific research database in the light of a debate in defining relevant hypnotic constructs and to suggest ideas for future research projects. We discuss the role of hypnotic suggestibility (HS), the impact of hypnotic inductions and the importance of the depth of hypnotic trance. We argue that future research on brain imaging studies on the effects of hypnosis and hypnotherapy should focus on the analysis of individual cross-network activation patterns. A most promising approach is to simultaneously include physiological parameters linked to cognitive, somatic, and behavioral effects.

Am J Clin Hypn. 2021 Apr;63(4):372-388. doi: 10.1080/00029157.2020.1863185.

by Tim Brunson, PhD

Long before I began pursing my current profession I started noticing that the vast bulk of humanity regularly comes up short when it comes to the goals that they wish to achieve. The attrition rates in our schools and universities are very similar to our failures with patients who desperately seek medical advice, which they fail to follow, or those who never seem to respond as hoped to psychotherapy.

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by Alfred A Barrios, PhD

In my book Understanding Hypnosis: Theory, Scope and Potential (Barrios, 2009), I present an explanation for the cause of schizophrenia that derived from my theory of hypnosis (Barrios, 2001). Based on this explanation, I also present a possible cure for schizophrenia using hypnosis. This article will be a presentation of these very same ideas.

I would like to begin by giving you a brief overview of my theory of hypnosis, focusing especially on how the theory explains hypnotic phenomena such as hallucinations and delusions.

To begin with, I define hypnosis as a state of heightened belief produced by a series of positively-responded-to-suggestions. With each positive response the belief factor is increased (belief in what the hypnotist is suggesting). And I define belief as concentration on a thought to the exclusion of anything that would contradict that thought. Thus, in a state of heightened belief, any stimuli either sensory or cognitive that might contradict the suggestion given by the hypnotist are automatically blocked off. This highly focused state of mind then is capable of amplifying images to the point of becoming hallucinations, and amplifying thoughts to where they can become delusions.

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The authors revisit the question of the existence of a relationship between hypnotizability and dissociative capacity. In the present study, the State Scale of Dissociation (SSD) replaced the commonly employed Dissociative Experiences Scale (DES) as a measure of dissociation, due to the latter capturing primarily pathological aspects of dissociation. Relationships between the Harvard Scale of Hypnotic Susceptibility, Form A (HGSHS:A), the SSD, and the Phenomenology of Consciousness Inventory (PCI) were assessed in the context of hypnosis. Robust results were found when comparing pre- to post-SSD scores, suggesting heightened nonpathological forms of dissociation are indeed related to hypnotizability. The appropriateness of the DES and similar trait-based measures for evaluating hypnotic phenomena is discussed as well as the relationships between PCI and SSD subscales.

Int J Clin Exp Hypn. 2015;63(2):198-214. doi: 10.1080/00207144.2015.1002691. Cleveland JM1, Korman BM, Gold SN.

by Tim Brunson, PhD

Mental and physical pathologies exist. They are conditions and events, which are part of the reality that we endure every second of our lives. They arise based upon external influences and – whether ephemeral or lasting – they permeate our being in a substantial way. They are, however, also encoded in relationship to the other programs and patterns within our minds. It is their relationship with these previous experiences that tend to give undesired (and even desired) states meaning and become the foundation as to how we understand them. A fundamental attribute of hypnotherapy is the probability of altering the relationship of programmed phenomena in a way that changes meaning – and therefore possibly changing our experiences. Most likely the most potent phenomena that we can alter are those that are related to a person's concept of space and time.

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by Tim Brunson, PhD

Over the past several decades the rise of behaviorism within psychology has both been enlightening as well as often disturbing. By reclassifying psychology as the science of behavior rather than the science of the mind, behaviorists have insisted that all human physical and mental activities consist of observable phenomena, which can then be modified should the scientist or clinician understand how to apply or withhold positive or negative reinforcements. As such, this deterministic approach has served to strip away the role of choice, free will, and even calls into question the role of higher-level intelligence.

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Full title: Perceptually-oriented hypnosis: removing a socially learned pathology and developing adequacy: the case of invisible girl.

This is the first case review to explicate perceptual hypnotic principles such as differentiation, characteristics of an adequate personality, and the need for adequacy, as utilized in clinical hypnosis in a complex case that altered the distorted perceptions and personal meanings of an eleven-year-old girl who believed that she had Bipolar Disorder and her body and mind were damaged. This qualitative case study examines aspects of hypnosis during therapy from a perceptual point of view to illustrate frustrations in difficult cases and identify some of the causes and origins of alleged clinical pathology in adverse environments. Some moments of effective self-healing through supporting internally controlled changes in perception during hypnotic experiencing are highlighted rather than externally focusing on observed thoughts and behavior. Factors relevant to social psychological research, such as family dynamics, poverty, and interactions with social service agencies and institutions, creating learned pathology, are pointed out for future research.

Psychol Rep. 2014 Oct;115(2):545-64. doi: 10.2466/02.PR0.115c24z9. Epub 2014 Oct 13.

Woodard FJ. Author information: 1 Woodard Hypnosis and Research, Inc., Milford, New Hampshire.

Conversion disorders are defined as neurological symptoms arising without organic damage to the nervous system, presumably in relation to various emotional stress factors, but the exact neural substrates of these symptoms and the mechanisms responsible for their production remain poorly understood. In the past 15 years, novel insights have been gained with the advent of functional neuroimaging studies in patients suffering from conversion disorders in both motor and non-motor (e.g. somatosensory, visual) domains. Several studies have also compared brain activation patterns in conversion to those observed during hypnosis, where similar functional losses can be evoked by suggestion. The current review summarizes these recent results and the main neurobiological hypotheses proposed to account for conversion symptoms, in particular motor deficits. An emerging model points to an important role of ventromedial prefrontal cortex (VMPFC), precuneus, and perhaps other limbic structures (including amygdala), all frequently found to be hyperactivated in conversion disorders in parallel to impaired recruitment of primary motor and/or sensory pathways at the cortical or subcortical (basal ganglia) level. These findings are only partly shared with hypnosis, where increases in precuneus predominate, together with activation of attentional control systems, but without any activation of VMPFC. Both VMPFC and precuneus are key regions for access to internal representations about the self, integrating information from memory and imagery with affective relevance (in VMPFC) and sensory or agency representations (in precuneus). It is therefore postulated that conversion deficits might result from an alteration of conscious sensorimotor functions and self-awareness under the influence of affective and sensory representations generated in these regions, which might promote certain patterns of behaviors in response to self-relevant emotional states.

Neurophysiol Clin. 2014 Oct;44(4):323-37. doi: 10.1016/j.neucli.2014.01.003. Epub 2014 Jan 28. Vuilleumier P. Author information: Laboratory for Behavioral Neurology and Imaging of Cognition (LABNIC), Department of Neuroscience (NEUFO), University Medical Center (CMU), 1, rue Micheli du Crest, 1205 Geneva, Switzerland. Electronic address: patrik.vuilleumier@unige.ch.

Copyright © 2014 Elsevier Masson SAS. All rights reserved.

The conversion phenomena of hysteria were the subject of intense study in the late nineteenth and early twentieth centuries, after which work on the subject went into decline. The patients are still with us, however, and I cite an epidemic of hysterical blindness among Cambodian refugees living in the U.S. as a poignant example. Since the advent of brain imaging technology, conversion hysteria has been receiving renewed attention. In this paper, I suggest that examining the ideas about hysteria from the past, especially those of Charcot and Janet are fertile areas of study, including the illness and its relation to hypnosis, shock, suggestion, and dissociation theory. I also address the role of the imaginary and the imagination in the illness and critique the implicit dualist model used in most brain imaging studies that distorts the integration of psyche and soma. I summon Merleau-Ponty's body-subject, infant research on intersubjectivity, and Vittorio Gallese's "embodied simulation" as possible windows onto the problem of hysterical conversion, and finally I suggest that along with imaging studies, more dynamic narrative strategies should be used if we hope to understand the metamorphoses, mimesis, and powerful emotions that all play a part in this mysterious disease.

Neurophysiol Clin. 2014 Oct;44(4):305-13. doi: 10.1016/j.neucli.2013.11.001. Epub 2013 Dec 8.

Hustvedt S. Author information: 544, Second Street, Brooklyn, NY 11215, United States. Electronic address: sirihustvedt55@gmail.com.

Copyright © 2013 Elsevier Masson SAS. All rights reserved.

PURPOSE: Persons who stutter (PWS) should be referred to the most effective treatments available, locally or regionally. A prospective comparison of the effects of the most common stuttering treatments in Germany is not available. Therefore, a retrospective evaluation by clients of stuttering treatments was carried out. METHOD: The five most common German stuttering treatments (231 single treatment cases) were rated as to their perceived effectiveness, using a structured questionnaire, by 88 PWS recruited through various sources. The participants had received between 1 and 7 treatments for stuttering. RESULTS: Two stuttering treatments (stuttering modification, fluency shaping) showed favorable and three treatments (breathing therapy, hypnosis, unspecified logopedic treatment) showed unsatisfactory effectiveness ratings. The effectiveness ratings of stuttering modification and fluency shaping did not differ significantly. The three other treatments were equally ineffective. The differences between the effective and ineffective treatments were of large effect sizes. The typical therapy biography begins in childhood with an unspecified logopedic treatment administered extensively in single and individual sessions. Available comparisons showed intensive or interval treatments to be superior to extensive treatments, and group treatments to be superior to single client treatments. CONCLUSION: The stuttering treatment most often prescribed in Germany, namely a weekly session of individual treatment by a speech-language pathologist, usually with an assorted package of mostly unknown components, is of limited effectiveness. Better effectiveness can be expected from fluency shaping or stuttering modification approaches, preferably with an intensive time schedule and with group sessions. EDUCATIONAL OBJECTIVES: Readers will be able to: (a) discuss the five most prevalent stuttering treatments in Germany; (b) summarize the effectiveness of these treatments; and (c) describe structural treatment components that seem to be preferable across different kinds of treatments.

J Fluency Disord. 2014 Mar;39:1-11. doi: 10.1016/j.jfludis.2014.01.002. Euler HA(1), Lange BP(2), Schroeder S(3), Neumann K(4). Author information: (1)Department of Phoniatrics and Pediatric Audiology, Clinic of Otolaryngology, Head and Neck Surgery, St. Elisabeth Hospital, Ruhr-University Bochum, Bleichstr. 16, D-44787 Bochum, Germany. Electronic address: euler@uni-kassel.de. (2)Department of Medical Psychology and Medical Sociology, Georg-August-University Goettingen, Waldweg 37, D-37073 Goettingen, Germany. Electronic address: benjamin.lange@med.uni-goettingen.de. (3)Max Planck Institute for Human Development, Lentzeallee 94, D-14195 Berlin, Germany; Institute of Psychology, University of Kassel, Hollaendische Str. 36-38, D-34127 Kassel, Germany. Electronic address: sascha.schroeder@mpib-berlin.de. (4)Department of Phoniatrics and Pediatric Audiology, Clinic of Otolaryngology, Head and Neck Surgery, St. Elisabeth Hospital, Ruhr-University Bochum, Bleichstr. 16, D-44787 Bochum, Germany. Electronic address: Katrin.Neumann@rub.de.

Copyright © 2014 Elsevier Inc. All rights reserved.

BACKGROUND: Psychogenic non-epileptic seizures, also known as non-epileptic attack disorder (NEAD), have the outward appearance of epilepsy in the absence of physiological or electroencephalographic correlates. Non-epileptic seizures can occur in isolation or in combination with epileptic seizures. The development and maintenance of non-epileptic seizures has been well documented and there is a growing literature on the treatment of non-epileptic seizures which includes non-psychological (including anti-anxiety and antidepressant pharmacological treatment) and psychological therapies (including cognitive behavioural therapy (CBT), hypnotherapy and paradoxical therapy). Various treatment methodologies have been tried with variable success. The purpose of this Cochrane review was to establish the evidence base for the treatment of non-epileptic seizures with behavioural and psychological therapies only. OBJECTIVES: To assess whether behavioural or psychological treatments for non-epileptic seizures or NEAD result in a reduction in the frequency of seizures or improvement in quality of life, or both, and whether any treatment is significantly more effective than others. SEARCH METHODS: We searched the Cochrane Epilepsy Group's Specialised Register (4 February 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 1) (January 2013), MEDLINE (1946 to 4 February 2013), PsycINFO (4 February 2013) and SCOPUS (4 February 2013). No language restrictions were imposed. We checked the reference lists of retrieved studies for additional reports of relevant studies SELECTION CRITERIA: Randomised controlled trials (RCTs) and before and after controlled and non-controlled studies were eligible for inclusion. Studies were required to assess one or more types of behavioural or psychological interventions, or both, for the treatment of non-epileptic seizures. Studies of childhood non-epileptic seizures were excluded from our review. DATA COLLECTION AND ANALYSIS: Two review authors (JM, JP) independently assessed the trials for inclusion and extracted data. Outcomes included reduction in seizure frequency and improvements in quality of life. MAIN RESULTS: Twelve studies, with a total of 343 participants, met our inclusion criteria (four RCTs and eight before and after non-controlled studies). Of the four RCTs, one examined patients with non-epileptic seizures and three had a mixed diagnosis (pseudoseizures, conversion disorder and somatisation disorder). Most of the non-randomised studies used non-epileptic seizure patients exclusively. Overall, five studies examined the effectiveness of psychotherapy, three examined CBT, two investigated hypnosis, one assessed paradoxical intention and one had a mixed intervention design. We classified two included studies as low risk of bias, one as unclear and nine as high risk of bias. Meta-analysis could not be undertaken due to the heterogeneity of design and interventions. Most included studies reported improved outcomes for the intervention under investigation. One RCT investigating the effectiveness of CBT in this patient group found a significant reduction in seizure frequency compared to controls (P < 0.001). AUTHORS' CONCLUSIONS: There is little reliable evidence to support the use of any treatment, including CBT, in the treatment of non-epileptic seizures. Further randomised controlled trials of CBT and other interventions are needed.

Cochrane Database Syst Rev. 2014 Feb 11;2:CD006370. doi: 10.1002/14651858.CD006370.pub2. Martlew J(1), Pulman J, Marson AG. Author information: (1)Department of Neuropsychology, The Walton Centre, Jubilee House, 10th Avenue, Fazakerley, Liverpool, Mersyside, UK, L9 7AL.

Update of Cochrane Database Syst Rev. 2007;(1):CD006370.

Recent study of consciousnessconsciousness provides an evidence that there is a limit of consciousness, which presents a barrier between conscious and unconscious processes. This barrier likely is specifically manifested as a disturbance of neural mechanisms of consciousness that through distributed brain processing, attentional mechanisms and memory processes enable to constitute integrative conscious experience. According to recent findings a level of conscious integration may change during certain conditions related to experimental cognitive manipulations, hypnosis, or stressful experiences that can lead to dissociationdissociation of consciousness. In psychopathological research the term dissociation was proposed by Pierre Janet for explanation of processes related to splitting of consciousness due to traumatic events or during hypnosis. According to several recent findings dissociation of consciousness likely is related to deficits in global distribution of information and may lead to heightened levels of "neural complexity" that reflects brain integration or differentiation based on numbers of independent neural processes in the brain that may be specifically related to various mental disorders.

Curr Top Behav Neurosci. 2014 May 22. Bob P. Author information: Center for Neuropsychiatric Research of Traumatic Stress, Department of Psychiatry and UHSL, 1st Faculty of Medicine, Charles University, Ke Karlovu 11, 128 00, Prague, Czech Republic, petrbob@netscape.net.

ABSTRACT BACKGROUND: Several pharmacological and non-pharmacological therapeutic options have been used to treat cough that is not associated with a pulmonary or extrapulmonary etiology. METHODS: We conducted a systematic review to summarize the evidence supporting different cough management options in adults and children with psychogenic, tic and habit cough. Medline, EMBASE, the Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and Scopus were searched from the earliest inception of each database to September 2013. Content experts were contacted and we searched bibliographies of included studies to identify additional references. RESULTS: A total of 18 uncontrolled studies were identified enrolling 223 patients (46% males, 96% children and adolescent). Psychogenic cough was the most common descriptive term used (90% of the studies). 95% of the patients had no cough during sleep; barking or honking quality of cough was described in only 8 studies. Hypnosis (3 studies), suggestion therapy (4 studies), and counseling and reassurance (7 studies) were the most commonly used interventions. Hypnosis was effective in resolving cough in 78% of the patients and improving it in another 5%. Suggestion therapy resolved cough successfully in 96% of the patients. The greatest majority of improvements noted with these forms of therapy occurred in the pediatric age group. The quality of evidence is low due to the lack of control groups, the retrospective nature of all the studies, heterogeneity of definitions and diagnostic criteria, and the high likelihood of reporting bias. CONCLUSION: Only low quality evidence exists to support a particular strategy to define and treat psychogenic, habit and tic cough. Patient values, preferences, and availability of potential therapies should guide treatment choice.

Chest. 2014 May 15. doi: 10.1378/chest.14-0795. Haydour Q, Alahdab F, Farah M, Moreno PB, Vertigan AE, Newcombe PA, Pringsheim T, Chang AB, Rubin BK, McGarvey L, Weir KA, Altman KW, Feinstein A, Murad M, Irwin RS.

We live in a global village, comprised of people with diverse cultural and religious orientations. How do we integrate these different beliefs and values into our clinical practice? Mindfulness-based psychotherapy (MBP), an evidence-based psychological intervention, provides a secular template for assimilating various cultural beliefs and wisdoms in therapies. MBP represents a cross-fertilization between Western psychological practice and Eastern meditative disciplines. Guided by MBP, this article describes how intention, mindfulness, acceptance, gratitude, and the "heart" can be combined with cognitive hypnotherapy to catalyze healing of emotional disorders-particularly depression. This integrated approach is referred to as mindfulness-based cognitive hypnotherapy (MBCH) as it assimilates cognitive hypnotherapy with mindfulness strategies. MBCH represents an attempt to broaden the comprehensiveness of hypnotherapy as an integrated form of psychotherapy. Additionally, based on new understanding of the heart as a complex information center, an innovative hypnotherapeutic strategy for generating psychophysiological coherence and psychological well-being is described.

Am J Clin Hypn. 2014 Jan;56(3):285-302. Alladin A.

Higher brain dopamine content depending on lower activity of Catechol-O-Methyltransferase (COMT) in subjects with high hypnotizability scores (highs) has been considered responsible for their attentional characteristics. However, the results of the previous genetic studies on association between hypnotizability and the COMT single nucleotide polymorphism (SNP) rs4680 (Val(158)Met) were inconsistent. Here, we used a selective genotyping approach to e-evaluate the association between hypnotizability and COMT in the context of a two-SNP haplotype analysis, considering not only the Val(158)Met polymorphism, but also the closely located rs4818 SNP. An Italian sample of 53 highs, 49 low hypnotizable subjects (lows), and 57 controls, were genotyped for a segment of 805 bp of the COMT gene, including Val(158)Met and the closely located rs4818 SNP. Our selective genotyping approach had 97.1% power to detect the previously reported strongest association at the significance level of 5%. We found no evidence of association at the SNP, haplotype, and diplotype levels. Thus, our results challenge the dopamine-based theory of hypnosis and indirectly support recent neuropsychological and neurophysiological findings reporting the lack of any association between hypnotizability and focused attention abilities.

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by Tim Brunson, PhD

Psychotherapy is currently undergoing one of the most radical periods of change seen for the past hundred or so years. Originally, those who practice what we have come to consider as the sciences of mental health focused either on replicating methodologies associated with medicine or remained in the idealistic realms (i.e. Jungian). However, most recently those in the inner circles are now beginning to think more systemically and thus have created a hybrid that combines science and more holistic thinking. This trend has already crept into official literature. The recently published DSM-5, upon which most psychotherapists heavily rely, incorporates this new way of thinking for the first time – albeit while still holding on to the diagnostic categories contained in previous editions.

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In their journey through life, most people are looking for happiness. Definitions of happiness and the concepts of a pleasant, good, meaningful, and a full life are reviewed. Next, Seligman's (2002) concept of "authentic happiness" and a happiness formula, S+C+V (Set + Circumstances + Variables), are discussed. An integration of happiness, as a goal, and hypnosis, as a facilitative approach, are presented. Hypnotic techniques with case examples are given. Hypnosis is presented as an efficient companion intervention to work on these variables in a creative way and to pave the way to a happy and full life. The following results are presented: (1) hypnosis allows for increased executive attention with control of emotions, (2) focusing on positive imagery contributes to strengthening "happy pathways," and (3) emotions about the past, present, and future are subject to change.

Am J Clin Hypn. 2014 Jan;56(3):269-84. Ruysschaert N.

Full title: Plasma oxytocin concentrations and OXTR polymorphisms predict social impairments in children with and without autism spectrum disorder.

The neuropeptide oxytocin (OXT) and its receptor (OXTR) regulate social functioning in animals and humans. Initial clinical research suggests that dysregulated plasma OXT concentrations and/or OXTR SNPs may be biomarkers of social impairments in autism spectrum disorder (ASD). We do not know, however, whether OXT dysregulation is unique to ASD or whether OXT biology influences social functioning more generally, thus contributing to, but not causing, ASD phenotypes. To distinguish between these possibilities, we tested in a child ASD cohort, which included unaffected siblings and unrelated neurotypical controls (ages 3-12 y; n = 193), whether plasma OXT concentrations and OXTR SNPs (i) interact to produce ASD phenotypes, (ii) exert differential phenotypic effects in ASD vs. non-ASD children, or (iii) have similar phenotypic effects independent of disease status. In the largest cohort tested to date, we found no evidence to support the OXT deficit hypothesis of ASD. Rather, OXT concentrations strongly and positively predicted theory of mind and social communication performance in all groups. Furthermore, OXT concentrations showed significant heritability between ASD-discordant siblings (h2 = 85.5%); a heritability estimate on par with that of height in humans. Finally, carriers of the "G" allele of rs53576 showed impaired affect recognition performance and carriers of the "A" allele of rs2254298 exhibited greater global social impairments in all groups. These findings indicate that OXT biology is not uniquely associated with ASD, but instead exerts independent, additive, and highly heritable influences on individual differences in human social functioning, including the severe social impairments which characterize ASD.

Proc Natl Acad Sci U S A. 2014 Aug 4. pii: 201402236.

Psychosynthesis is one of the first Western transpersonal models of personality and psychotherapy. It was developed in 1910 by the Italian psychiatrist Roberto Assagioli. In this article, basic constructs involving the realms of consciousness, subpersonalities, and the importance of the will, and the neo-Jungian functions, will be introduced and related to the practice of hypnotically mediated psychotherapy. That which makes this model unique is its recognition of the human spirit and how that impacts consciousness and its inclusion as an important element to be included in therapy. A guideline for selecting interventions based upon the patient's symptom will be described as well as a discussion of some of the therapy techniques associated with this model.

Am J Clin Hypn. 2014 Jan;56(3):249-68. Appel PR.

Grapheme-color synesthesia is a perceptual experience where graphemes, letters or words evoke a specific color, which are experienced either as spatially coincident with the grapheme inducer (projector sub-type) or elsewhere, perhaps without a definite spatial location (associator sub-type). Here, we address the question of whether synesthesia can be rapidly produced using a hypnotic color suggestion to examine the possibility of "hypnotic synesthesia", i.e., subjectively experienced color hallucinations similar to those experienced by projector synesthetes. We assess the efficacy of this intervention using an "embedded figures" test, in which participants are required to detect a shape (e.g., a square) composed of local graphemic elements. For grapheme-color synesthetes, better performance on the task has been linked to a higher proportion of graphemes perceived as colored. We found no performance benefits on this test when using a hypnotic suggestion, as compared to a no-suggestion control condition. The same result was found when participants were separated according to the degree to which they were susceptible to the suggestion (number of colored trials perceived). However, we found a relationship between accuracy and subjective reports of color in those participants who reported a large proportion of colored trials: trials in which the embedded figure was accurately recognized (relative to trials in which it was not) were associated with reports of more intense colors occupying a greater spatial extent. Collectively, this implies that hypnotic color was only perceived after shape detection rather than aiding in shape detection via color-based perceptual grouping. The results suggest that hypnotically induced colors are not directly comparable to synesthetic ones.

Front Hum Neurosci. 2014 Apr 28;8:220. doi: 10.3389/fnhum.2014.00220. Anderson HP(1), Seth AK(2), Dienes Z(1), Ward J(1). Author information: (1)School of Psychology, University of Sussex Brighton, UK ; Sackler Centre for Consciousness Science, University of Sussex Brighton, UK. (2)School of Psychology, University of Sussex Brighton, UK ; School of Engineering and Informatics, University of Sussex Brighton, UK.

A young male patient was successfully treated for parasomnia overlap disorder (POD) using hypnosis. In 2006, this 16-year-old patient underwent a clinical evaluation for episodes of sleep talking, sleepwalking, and dream enactment. This initial assessment was followed by polysomnographic evaluation, a brain MRI, and three sessions of treatment using hypnosis. From the beginning, until the last contact in December 2011, benefits from the hypnotic suggestions were noted and documented.

Behav Sleep Med. 2014 Apr 16:1-10. Kohler WC(1), Kurz PJ, Kohler EA. Author information: (1)a Florida Sleep Institute , Spring Hill.

This case study details how hypnosis aided fixed role therapy (HAFRT) was employed in the successful treatment of a case of social phobia with a history of refractory outcomes to previous therapy trials. The treatment consisted of 10 office sessions, scheduled every two weeks, of HAFRT along with twice a day self-hypnotic sessions where the patient performed multiple visualization rehearsals of the vignettes that were successfully mastered in hypnosis during office visits. The results indicated that this patient was able to engage in social and professional affairs that were impossible prior to treatment. The patient retained the therapy gains at follow up 6 months later.

Am J Clin Hypn. 2014 Apr;56(4):405-12. Iglesias A, Iglesias A.

Full title: Current issues in the treatment of specific phobia: recommendations for innovative applications of hypnosis.

Specific phobia is the most common and treatable of the anxiety disorders. Exposure-based therapies are the treatment of choice and empirically validated protocols are available that promise rapid and effective results. In many cases, however, patients are reluctant to comply with demanding schedules of exposure, increasing the risk of treatment failure. Furthermore, in clinical practice, patients often present with multiple phobias and other Axis I and Axis II disorders that can further complicate therapy. This article covers four important issues that have been addressed in the literature: (a) managing resistance to treatment, (b) reducing length of treatment, (c) clarifying the optimal application of relaxation training, and (d) applying advances in cognitive neuroscience. These issues are reviewed and recommendations proposed for ways in which to modify current treatments. Specific suggestions are provided for implementing these recommendations including examples of innovative applications of standard hypnotic techniques.

Am J Clin Hypn. 2014 Apr;56(4):389-404. Spiegel SB.

Full title: A causal model explaining the relationships governing beliefs, attitudes, and hypnotic responsiveness.

The author developed a new scale aimed at measuring beliefs about "hypnotic states" and investigated the influence of such beliefs and attitudes on hypnotic responses in a large sample of Japanese undergraduate students. Exploratory factor analysis of this new questionnaire examining beliefs about hypnotic states yielded four factors: Dissociative or Depersonalized Experience, Loss of Self-Control, Therapeutic Expectation, and Arousing Extraordinary Ability. The results of structural equation modeling showed that Therapeutic Expectation and Arousing Extraordinary Ability influenced hypnotizability through attitudes toward hypnosis, while also directly affecting subjective experiences without mediating attitudes. Present findings suggest that it is more effective to enhance therapeutic expectations than to correct misconceptions about hypnotic states in modification of patients' beliefs before initiating treatment.

Int J Clin Exp Hypn. 2014;62(2):231-50. doi: 10.1080/00207144.2014.869142. Shimizu T.

Author information: a Akita University , Japan.

Full title: Childhood anxiety and psychophysiological reactivity: hypnosis to build discrimination and self-regulation skills.

Clinically anxious, worried, and fearful children and teens need clinicians' assistance in reducing their exaggerated psychophysiological stress reactivity. Affective neuroscience finds that chronic activation of the body's emergency response system inhibits neurogenesis, disrupts neuronal plasticity, and is detrimental to physical and mental health. Patterns of faulty discrimination skills, for example, over-estimation of threat and danger and under-estimation of their coping capacity, fuel this over-arousal. Similarly, contributory patterns of reduced self-regulation skills are shown by "stuck" attention to and poor control of their exaggerated psychophysiological reactivity and somatization. This article considers the literature and focuses on cognitive hypnotherapy to enhance these under-developed capacities. A case illustration highlights various hypnotic phenomena and techniques, psychoeducation, and relaxation training that address the goals of interrupting these unproductive, interconnected patterns and fostering new patterns of more realistic and accurate discrimination capacities and sturdier psychophysiological self-regulation skills.

Am J Clin Hypn. 2014 Apr;56(4):343-67. Kaiser P.

Involuntary movements occur in a variety of neuropsychiatric disorders and culturally influenced dissociative states (e.g., delusions of alien control and attributions of spirit possession). However, the underlying brain processes are poorly understood. We combined suggestion and fMRI in 15 highly hypnotically susceptible volunteers to investigate changes in brain activity accompanying different experiences of loss of self-control of movement. Suggestions of external personal control and internal personal control over involuntary movements modelled delusions of control and spirit possession respectively. A suggestion of impersonal control by a malfunctioning machine modelled technical delusions of control, where involuntary movements are attributed to the influence of machines. We found that (i) brain activity and/or connectivity significantly varied with different experiences and attributions of loss of agency; (ii) compared to the impersonal control condition, both external and internal personal alien control were associated with increased connectivity between primary motor cortex (M1) and brain regions involved in attribution of mental states and representing the self in relation to others; (iii) compared to both personal alien control conditions, impersonal control of movement was associated with increased activity in brain regions involved in error detection and object imagery; (iv) there were no significant differences in brain activity, and minor differences in M1 connectivity, between the external and internal personal alien control conditions. Brain networks supporting error detection and object imagery, together with representation of self and others, are differentially recruited to support experiences of impersonal and personal control of involuntary movements. However, similar brain systems underpin attributions and experiences of external and internal alien control of movement. Loss of self-agency for movement can therefore accompany different kinds of experience of alien control supported by distinct brain mechanisms. These findings caution against generalization about single cognitive processes or brain systems underpinning different experiences of loss of self-control of movement.

Cortex. 2014 Apr;53:107-19. doi: 10.1016/j.cortex.2014.01.004. Deeley Q(1), Oakley DA(2), Walsh E(3), Bell V(4), Mehta MA(4), Halligan PW(5). Author information: (1)Cultural and Social Neuroscience Research Group, Forensic and Neurodevelopmental Sciences, Kings College London, Institute of Psychiatry, London, UK; South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham, Kent, UK. Electronic address: q.deeley@iop.kcl.ac.uk. (2)Division of Psychology and Language Sciences, University College London, UK. (3)Cultural and Social Neuroscience Research Group, Forensic and Neurodevelopmental Sciences, Kings College London, Institute of Psychiatry, London, UK. (4)Cultural and Social Neuroscience Research Group, Centre for Neuroimaging Sciences, Kings College London, Institute of Psychiatry, London, UK. (5)School of Psychology, Cardiff University, UK.

Copyright © 2014 Elsevier Ltd. All rights reserved.

Full title: Prevalence and pattern of psychiatric morbidity and health related quality of life in patients with ischemic heart disease in a tertiary care hospital.

BACKGROUND: Psychiatric morbidity and Health Related Quality of Life (Hr-QoL) in Ischemic Heart Disease (IHD) are relatively less studied in our country. AIMS: This cross-sectional observational study was undertaken to assess the common psychiatric disorders and Hr-QoL in IHD. MATERIALS AND METHODS: One-hundred and thirty patients with IHD were evaluated for psychiatric morbidity and Hr-QoL. Tools used were SCID-1, Euro QoL-5D, and Socio-demographic data sheet. The data were analyzed using SPSS v 10.0 software, Chi-square test, T-test, ANOVA were used as needed. RESULTS: Psychiatric morbidity was assessed using psychiatric assessment schedule SCID-I for generating diagnosis as per DSM-IV criteria. Major depressive disorder was found in 34.6% (n=45) patients. 23.8% (n=31) patients had a diagnosis of depression due to general medical condition. Anxiety disorder due to general medical condition was present in 36.9% (n=48) patients. Around 95.4% of patients reported psychiatric symptoms, either depression or anxiety. Though widely disputed, low educational status was reported as significantly associated with psychiatric morbidity in IHD. Female sex of the patient and the presence of diabetes mellitus were associated with psychiatric morbidity in a significant manner. Majority of patients with poor quality of life were in the domain of anxiety/depression. CONCLUSION: The findings of our study reveal a high rate of psychiatric morbidity and impaired quality of life in IHD Patients.

Indian J Psychiatry. 2013 Oct;55(4):353-9. doi: 10.4103/0019-5545.120554. John S. Department of Psychiatry, Amala Institute of Medical Sciences, Thrissur, Kerala, India.

Full title: Prevalence and pattern of psychiatric morbidity and health related quality of life in patients with ischemic heart disease in a tertiary care hospital.

BACKGROUND: Psychiatric morbidity and Health Related Quality of Life (Hr-QoL) in Ischemic Heart Disease (IHD) are relatively less studied in our country. AIMS: This cross-sectional observational study was undertaken to assess the common psychiatric disorders and Hr-QoL in IHD. MATERIALS AND METHODS: One-hundred and thirty patients with IHD were evaluated for psychiatric morbidity and Hr-QoL. Tools used were SCID-1, Euro QoL-5D, and Socio-demographic data sheet. The data were analyzed using SPSS v 10.0 software, Chi-square test, T-test, ANOVA were used as needed. RESULTS: Psychiatric morbidity was assessed using psychiatric assessment schedule SCID-I for generating diagnosis as per DSM-IV criteria. Major depressive disorder was found in 34.6% (n=45) patients. 23.8% (n=31) patients had a diagnosis of depression due to general medical condition. Anxiety disorder due to general medical condition was present in 36.9% (n=48) patients. Around 95.4% of patients reported psychiatric symptoms, either depression or anxiety. Though widely disputed, low educational status was reported as significantly associated with psychiatric morbidity in IHD. Female sex of the patient and the presence of diabetes mellitus were associated with psychiatric morbidity in a significant manner. Majority of patients with poor quality of life were in the domain of anxiety/depression. CONCLUSION: The findings of our study reveal a high rate of psychiatric morbidity and impaired quality of life in IHD Patients.

Indian J Psychiatry. 2013 Oct;55(4):353-9. doi: 10.4103/0019-5545.120554. John S. Department of Psychiatry, Amala Institute of Medical Sciences, Thrissur, Kerala, India.

BACKGROUND: Prisoners are having high percentage of psychiatric disorders. Majority of studies done so far on prisoners are from Western countries and very limited studies from India.AIM: Study socio-demographic profile of prisoners of a central jail and to find out current prevalence of psychiatric disorders in them. MATERIALS AND METHODS: 118 prisoners were selected by random sampling and interviewed to obtain socio-demographic data and assessed on Indian Psychiatric Interview Schedule (IPIS) with additional required questions to diagnose psychiatric disorders in prisoners. RESULTS: Mean age of prisoners was 33.7 years with 97.5% males, 57.6% from rural areas and 65.3% were married. Average education in studied years was 6.6 years and 50.8% were unskilled workers. 47.4% were murderers while 20.3% of drugs related crimes. 47.5% were convicted and history of criminal behavior in family was in 32.2% prisoners. Current prevalence of psychiatric disorders was 33%. Psychotic, depressive, and anxiety disorders were seen in 6.7%, 16.1%, and 8.5% prisoners respectively. 58.8% had history of drug abuse/dependence prior to imprisonment. CONCLUSION: One prison of Hadoti region of Rajasthan is full of people with mental-health problems who collectively generate significant levels of unmet psychiatric treatment need. Prisons are detrimental to mental-health. Beginning of reforms is the immediate need.

Indian J Psychiatry. 2013 Oct;55(4):366-70. doi: 10.4103/0019-5545.120562. Kumar V(1), Daria U(2). (1)Department of Psychiatry, Jhalawar Medical College, Jhalawar, Rajasthan, India. (2)Department of Anesthesia, Jhalawar Medical College, Jhalawar, Rajasthan, India.