Researchers from the Department of Social and Behavioral Sciences at The University of Virginia report on the first MRI study to report differences in brain structure size between low and highly hypnotizable, healthy, right-handed young adults.

[More]

Hypnotic interventions are being tested to determine whether they can help prepare patients for the stress associated with surgery. Initial randomized controlled trials--in which some patients received audiotapes with hypnotic techniques (guided imagery, music, and instructions for improved outcomes) and some patients received control tapes--found that subjects receiving the mind-body intervention recovered more quickly and spent fewer days in the hospital.

Behavioral interventions have been shown to be an efficient means of reducing discomfort and adverse effects during percutaneous vascular and renal procedures. Pain increased linearly with procedure time in a control group and in a group practicing structured attention, but remained flat in a group practicing a self-hypnosis technique. The self-administration of analgesic drugs was significantly higher in the control group than in the attention and hypnosis groups. Hypnosis also improved hemodynamic stability.

Placebo effects are believed to be mediated by both cognitive and conditioning mechanisms. Until recently, little was known about the role of these mechanisms in different circumstances. Now, research has shown that placebo responses are mediated by conditioning when unconscious physiological functions such as hormonal secretion are involved, whereas they are mediated by expectation when conscious physiological processes such as pain and motor performance come into play, even though a conditioning procedure is carried out.

Positron emission tomography (PET) scanning of the brain is providing evidence of the release of the endogenous neurotransmitter dopamine in the brain of Parkinson's disease patients in response to placebo.15 Evidence indicates that the placebo effect in these patients is powerful and is mediated through activation of the nigrostriatal dopamine system, the system that is damaged in Parkinson's disease. This result suggests that the placebo response involves the secretion of dopamine, which is known to be important in a number of other reinforcing and rewarding conditions, and that there may be mind-body strategies that could be used in patients with Parkinson's disease in lieu of or in addition to treatment with dopamine-releasing drugs.

This single arm, pilot study investigated the use of hypnosis to reduce hot flashes in 16 breast cancer survivors. Each patient provided baseline data and received 4 weekly sessions of hypnosis that followed a standardized transcript. Patients were also instructed in self-hypnosis. Throughout the clinical care, patients completed daily diaries of the frequency and severity of their hot flashes. Patients also completed baseline and post-treatment ratings of the degree to which hot flashes interfered with daily activities and quality of life. Results indicated a 59% decrease in total daily hot flashes and a 70% decrease in weekly hot flash scores from their baselines. There was also a significant decrease in the degree to which hot flashes interfered with daily activities for all measures including work, social activities, leisure activities, sleep, mood, concentration, relations with others, sexuality, enjoyment of life, and overall quality of life. This pilot study suggests that clinical hypnosis may be an effective non-hormonal and non-pharmacological treatment for hot flashes. A randomized, controlled clinical trial is planned to more definitively elucidate the efficacy and applicability of hypnosis for reducing hot flashes. Copyright (c) 2006 John Wiley & Sons, Ltd.

Mind-Body Cancer Research Program, Scott and White Memorial Hospital, Temple, TX, USA.

Meditation, one of the most common mind-body interventions, is a conscious mental process that induces a set of integrated physiological changes termed the relaxation response. Functional magnetic resonance imaging (fMRI) has been used to identify and characterize the brain regions that are active during meditation. This research suggests that various parts of the brain known to be involved in attention and in the control of the autonomic nervous system are activated, providing a neurochemical and anatomical basis for the effects of meditation on various physiological activities. Recent studies involving imaging are advancing the understanding of mind-body mechanisms. For example, meditation has been shown in one study to produce significant increases in left-sided anterior brain activity, which is associated with positive emotional states. Moreover, in this same study, meditation was associated with increases in antibody titers to influenza vaccine, suggesting potential linkages among meditation, positive emotional states, localized brain responses, and improved immune function.

PURPOSE OF REVIEW: Burn pain is often under treated. Burn patients suffer from daily background pain as well as procedural pain. Direct mechanical and chemical stimulation to peripheral nociceptors, peripheral- and central sensitization contribute to the pathophysiology of pain. The purpose of this review is to discuss the current management of burn pain and also to stimulate future studies. RECENT FINDINGS: Background pain is best treated with mild to moderate potent analgesics administered regularly to maintain a steady plasma drug concentration. Procedural pain should be treated vigorously with intravenous opioids, local or even general anesthesia if needed. Opioids are the mainstay of treatment for severe acute pain. PCA should be used wherever applicable. Further opioids should not be substituted by high dose NSAIDs in the management of procedural pain. Hypnosis, therapeutic touch, massage therapy, distracting techniques and other behavioral cognitive techniques have demonstrated some intriguing impact on acute as well as chronic burn pain treatment. SUMMARY: There is no clear evidence to show that the use of opioids in acute pain may increase the likelihood of developing opioid dependency. Thus, pain after burn injury should be aggressively treated using pharmacologic and non-pharmacologic approaches. Further controlled studies are yet to be conducted to define appropriate treatments for different burn patients and to establish standard treatment protocols for burn pain.

aDepartment of Anesthesiology and Critical Care, Massachusetts General Hospital Pain Center, Boston, Massachusetts and bDelaware Back Pain and Sports Rehabilitation Center, Wilmington, Delaware, USA.

Ronald Pekala and fellow researchers from the Biofeedback Clinic of the Coatesville VA Medical Center in Coatesville, PA, studied the effectiveness of a self-hypnosis protocol with chronic drug and alcohol patients in increasing self-esteem, improving affect, and preventing relapse against a control, a cognitive-behavioral (TCB), and a stress management (attention-placebo) group.

Participants were 261 veterans admitted to Substance Abuse Residential Rehabilitation Treatment Programs (SARRTPs). Participants were assessed pre- and post-intervention, and at 7-week follow-up.

[More]

Clinical hypnosis is an established part of the comprehensive treatment of numerous problems in ambulatory pediatrics. Two cases illustrate its utility with pediatric inpatients. These cases demonstrate clinical hypnosis as a teachable, practical, and nonpharmacologic intervention that warrants further investigation in the inpatient setting.

Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota 55455, USA. barn0139@umn.edu

Using microelectrode recordings of postganglionic sympatheticaction potentials, the authors studied the effects of hypnotic suggestion on sympathetic outflow targeted to skin during static handgrip exercise. All subjects performed sustained handgrip at 33% maximal voluntary contraction (MVC) for 2 minutes during 3 consecutive trials. Two subjects randomly assigned to a hypnosis condition received suggestions that the 2nd trial was more difficult and the last trial was less difficult than the first trial. Two subjects randomly assigned to the control condition received no hypnosis or suggestions about task difficulty. In the nonhypnosis condition, skin sympathetic nerve activity (SNA) increased by 6% from baseline during the 2nd trial and 13% from baseline during the 3rd trial. In the hypnosis condition, skin SNA increased by 25% during the 2nd trial (suggestion of increased difficulty) and returned to baseline during the 3rd condition (suggestion of decreased difficulty). Therefore, the impact of central command on skin SNA is suggested by these results.

Baylor University Medical Center, Dallas, Texas 75246, USA. RichardR@BaylorHealth.edu

The aim of this study was to investigate the analgesic effects of hypnotic pain control on experimental pain by measuring pupil reactions as an objective psycho-physiologic parameter. Twenty-two healthy volunteers (11 female and 11 male) aged between 22 and 35 years participated in the study. Pupil diameter was measured as baseline measurement (i.e., static measurement) in the non-hypnotic and in the hypnotic state. Pupil diameter changes to a standardized pain stimulus were measured in the non-hypnotic and hypnotic state and compared. Additionally, a Fourier analysis of pupil oscillations reflecting central nervous activation during the static measurement (25.6 sec) was calculated. During the hypnotic state the pain related pupil dilation was significantly smaller than during the non-hypnotic state. Pupil oscillations were significantly reduced during hypnosis.

Medical University of Vienna, Dept. of Psychiatry, Austria. henriette.walter@meduniwien.ac.at

During hypnosis it is easy to induce hallucinations having, for the hypnotized subject, the characteristics and the concreteness of reality. This study was performed to put in evidence the physical effects of hypnotic suggestion of warm tub bathing. 18 volunteers screened for high hypnotizability were studied. They underwent suggestion of forearm in warm water (30 min), suggestion of body in warm water (30 min), and hypnosis without any thermal suggestion (30 min), while blood pressure, heart rate, body temperature, forearm flow and resistance, stroke volume, cardiac index and total peripheral resistance were monitored. During suggestion of forearm in warm water, local vasodilation was recorded, with decrease of forearm resistance (-18%, P<0.01) and increase of forearm blood flow (+43%, P<0.01) like in real local passive warming. During suggestion of whole-body in a warm water tub, there was a systemic vasodilation with decrease of total peripheral resistance (-29%, P<0.01) and increase of cardiac index (+54%, P<0.01), like in real total-body passive warming. Body temperature, arterial blood pressure and heart rate were unchanged. During simple hypnosis (sham procedure) no haemodynamic variations were observed. These results are in keeping with the possibility to induce through hypnotic suggestion of heat a physical pattern that is typical of hyperthermia, even without increase in body temperature.

Department of Clinical and Experimental Medicine, University of Padova, Via Giustiniani No. 2, Padova, Italy. edoardo.casiglia@unipd.it

Department of Oral Medicine, School of Dental Medicine, The Hebrew University-Hadassah, Jerusalem, Israel. sharav@cc.huji.ac.il

Suggestion for hypnotic analgesia aimed at a specific body area is termed "focused hypnotic analgesia". It is not clear, however, whether this analgesia is limited to a specific body location or spread all over the body. Focused hypnotic analgesia was studied, in response to ascending electrical stimuli, when analgesia and stimulation were applied to the same area (local), and when analgesia was applied to one location and stimulation was delivered to a different area (remote). The face or leg served alternately as the local or remote areas, and the effect was tested in 12 high-hypnotizable (HH) and 13 low-hypnotizable (LH) subjects. Hypnotic analgesia in the local site produced a significant pain reduction compared to the remote site in HH subjects (P<0.0001) but not in LH subjects (P=0.68). As stimuli increased in intensity the reduction in pain as a result of hypnosis was larger both in HH and LH subjects (P<0.0001). Nevertheless, significant analgesia occurred in the 3 highest intensities in the local and remote location of HH subjects, but only in 2 highest intensities in the local and 1 in the remote of LH subjects. We conclude that in HH subjects focused hypnotic analgesia is mostly confined to the area aimed at, but some spread of analgesia to remote areas cannot be dismissed all together. Alternatively, this "spread" of analgesia could be due to a placebo effect in the remote area. Focused hypnotic analgesia requires increased attention to the body area aimed at, unlike analgesia achieved by distraction of attention.

Two groups of tinnitus patients (n=93) were recruited, one of which was treated with standard infusion therapy and further acute medical intervention, while the other obtained an additional psychotherapeutic intervention. Questionnaires and interviews were taken at beginning of the treatment, and 9 days and 3 years after treatment. The accompanying psychotherapeutic intervention consisted primarily of client-centered counseling, guided relaxational techniques from clinical hypnosis, and some standard and tinnitus-related methods for a better coping with stress. After 9 days, both treatment groups showed significant improvement in several psychological characteristics. However, there was no evidence for the superiority of the combined treatment with psychological intervention. Psychotherapeutic treatment accompanying the acute medical treatment probably shows better effectiveness in an ambulant setting with both patients and medical healthcare professionals rating it as 'very helpful'.This pilot study has contributed initial results for the integrated treatment of the acute tinnitus and has helped in the development of further therapeutic strategies as well as an evidence based concept for further evaluation. This study received one of the two scientific first prizes of the "German Tinnitus League".

Fachbereich Psychologie, Universitat Hamburg

In an investigation of the role of cognitive effort in hypnotic responding, high and low hypnotizable participants produced emotionally neutral imagery in response to effortful versus effortless hypnotic suggestions. Heart-rate increase served as an objective index of cognitive effort, and subjective ratings of imagery vividness, absorption, effort, and control were collected. Compared to lows, high hypnotizable participants experienced their imagery as more vivid and absorbing, yet their heart rates indicated no higher level of cognitive effort than lows. Compared to effortless wording, effortful wording of suggestions increased cognitive effort in lows, as indexed by heart-rate increase, but had no effect on the effort expended by highs. Ratings of subjective control were strongly correlated with subjective effort for lows but unrelated for highs. These results support the dissociated-control theory of hypnosis rather than the dissociated-experience or social-cognitive theories.

Department of Psychology, Wilfrid Laurier University, Waterloo, Ontario, Canada. psadler@wlu.ca

This study explored using hypnosis for pain and anxiety management in 6 colonoscopy patients (5 men, 1 woman), who received a hypnotic induction and instruction in self-hypnosis on the day of their colonoscopy. Patients' levels of anxiety were obtained before and after the hypnotic induction using Visual Analogue Scales (VAS). Following colonoscopy, VASs were used to assess anxiety and pain during colonoscopy, perceived effectiveness of hypnosis, and patient satisfaction with medical care. Hypnotizability was assessed at a separate appointment. The authors also obtained data (time for procedure, number of vasovagal events, and recovery time) for 10 consecutive patients who received standard care. Results suggest that hypnosis appears to be a feasible method to manage anxiety and pain associated with colonoscopy, reduces the need for sedation, and may have other benefits such as reduced vasovagal events and recovery time.

Department of Psychology & Neuroscience, Baylor University, Waco, Texas 76798-7334, USA. Gary_Elkins@baylor.edu

Case study research suggests that hypnosis treatment may provide benefits that are not necessarily the target of specific suggestions. To better understand satisfaction with and the beneficial "side effects" of hypnosis treatment, questions inquiring about treatment satisfaction and treatment benefits were administered to a group of 30 patients with chronic pain who had participated in a case series of hypnotic analgesia treatment. The results confirmed the authors' clinical experience and showed that most participants reported satisfaction with hypnosis treatment even when the targeted symptom (in this case, pain intensity) did not decrease substantially. Study participants also reported a variety of both symptom-related and nonsymptom-related benefits from hypnosis treatment, including decreased pain, increased perceived control over pain, increased sense of relaxation and well-being, and decreased perceived stress, although no single benefit was noted by a majority of participants.

Department of Rehabilitation Medicine, University of Washington, Seattle, Washington 98195-6490, USA. mjensen@u.washington.edu

BACKGROUND: Needle-related procedures are a common source of pain and distress for children. Several psychological (cognitive-behavioral) interventions to help manage or reduce pain and distress are available; however, a previous comprehensive systematic review of the efficacy of these interventions has not been conducted. OBJECTIVES: To assess the efficacy of cognitive-behavioral psychological interventions for needle-related procedural pain and distress in children and adolescents. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 4, 2005), MEDLINE (1966 to 2005), PsycINFO (1887 to 2005), EMBASE (1974 to 2005), the Cumulative Index to Nursing and Allied Health Literature (1982 to 2005), Web of Science (1980 to 2005), and Dissertation-Abstracts International (1980 to 2005). We also searched citation lists and contacted researchers via various electronic list-servers and via email requests. SELECTION CRITERIA: Participants included children and adolescents aged two to 19 years undergoing needle-related procedures. Only randomized controlled trials (RCTs) with at least five participants in each study arm comparing a psychological intervention group with a control or comparison group were eligible for inclusion. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed trial quality. Included studies were coded for quality using the Oxford Quality Scale devised by Jadad and colleagues. Standardized mean differences with 95% confidence intervals were computed for all analyses using RevMan 4.0 software. MAIN RESULTS: Twenty eight trials with 1951 participants were included. Together, these studies included 1039 participants in treatment conditions and 951 in control conditions. The most commonly studied needle-procedures were immunizations and injections. The largest effect sizes for treatment improvement over control conditions exist for distraction (on self-reported pain, SMD -0.24 (95% CI -0.45 to -0.04), combined cognitive-behavioral interventions--reduced other-reported distress (SMD -0.88, 95% CI -1.65 to -0.12; and behavioral measures of distress (SMD -0.67, 95% CI -0.95 to -0.38) with hypnosis being the most promising--self-reported pain (SMD -1.47, 95% CI -2.67 to -0.27), with promising but limited evidence for the efficacy of numerous other psychological interventions, such as information/preparation, nurse coaching plus distraction, parent positioning plus distraction, and distraction plus suggestion. AUTHORS' CONCLUSIONS: Overall, there is preliminary evidence that a variety of cognitive-behavioral interventions can be used with children and adolescents to successfully manage or reduce pain and distress associated with needle-related procedures. However, many of the included studies received lower quality scores because they failed to describe the randomization procedure and participant withdrawals or drop-outs from the study. Further RCTs need to be conducted, particularly for the many interventions for which we could not locate any trials.

Dalhousie University, Department of Psychology, Life Sciences Centre, 1355 Oxford Street, Halifax, Nova Scotia, Canada. luman@dal.ca

The main objective of the present study was to empirically verify the effect of hypnotic training programs on the academic performance of students. A pre and posttest design was used. Two experimental and two control groups (total sample N=119) of volunteer second year psychology students at the University of Stellenbosch in South Africa comprised the sample. One of the experimental groups was exposed to active alert hypnosis and the other to relaxation hypnosis. One control group was exposed to progressive relaxation, while the other did not receive any intervention. The participants' April grades were used as a pretest, while their June grades served as a posttest. The two hypnotic training programs had a significant effect on the academic achievement of the participants, which was not found in the control groups. Regarding the efficacy of the two programs, however, no significant difference was found.

Department of Psychology, University of the Free State, P.O. Box 339, Bloemfontein, 9300, South Africa.

The use of general anaesthetics has facilitated great advantages in surgery within the last 150 years. General anaesthesia is composed of several components including analgesia, amnesia, hypnosis and immobility. To achieve these components, general anaesthetics have to act via multiple molecular targets at different anatomical sites in the central nervous system. Much of our current understanding of how anaesthetics work has been obtained within the last few years on the basis of genetic approaches, in particular knock-out or knock-in mice. Anaesthetic drugs can be grouped into volatile and intravenous anaesthetics according to their route of administration. Common volatile anaesthetics induce immobility via molecular targets in the spinal cord, including glycine receptors, GABA(A) receptors, glutamate receptors, and TREK-1 potassium channels. In contrast, intravenous anaesthetics cause immobility almost exclusively via GABA(A) receptors harbouring beta3 subunits. Hypnosis is predominantly mediated by beta3-subunit containing GABA(A) receptors in the brain, whereas beta2 subunit containing receptors, which make up more than 50% of all GABA(A) receptors in the central nervous system, mediate sedation. At clinically relevant concentrations, ketamine and nitrous oxide block NMDA receptors. Unlike all other anaesthetics in clinical use they produce analgesia. Not only desired actions of anaesthetics, but also undesired side effects are linked to certain receptors. Respiratory depression involves beta3 containing GABA(A) receptors whereas hypothermia is largely mediated by GABA(A) receptors containing beta2 subunits. These recent insights into the clinically desired and undesired actions of anaesthetic agents provide new avenues for the design of drugs with an improved side-effect profile. Such agents would be especially beneficial for the treatment of newborn children, elderly patients and patients undergoing ambulatory surgery.

Department of Anesthesiology, Experimental Anesthesiology Section, University of Tuebingen, Schaffhausenstr. 113, D-72072 Tuebingen, Germany. christian.grasshoff@uni-tuebingen.de

This prospective comparative clinical study evaluated the effectiveness of clinical hypnosis and its long-term effect in oral and maxillofacial treatment. A total of 45 highly anxious and nonanxious subjects were evaluated by subjective experience and objective parameters. Parameters were EEG, ECG, heart rate, blood pressure, blood oxygen saturation, respiration rate, salivary cortisol concentration, and body temperature. During and subsequent to the operative treatment, hypnosis led to a significant reduction of systolic blood pressure, and respiration rate and to significant changes in the EEG. The subjective values of the parameters evaluated existing anxiety mechanisms and patterns and possible strategies to control them, whereas the objective parameters proved the effectiveness of hypnosis and its long-term effect.

Department of Prosthodontics, Friedrich Alexander University, Erlangen-Nuremberg, Germany. seitner@prothetik-erlangen.de