Int J Clin Exp Hypn. 2007 Jul;55(3):275-87.

Elkins G, Jensen MP, Patterson DR. Texas A & M University College of Medicine and Scott and White Clinic and Hospital. Temple, Texas. USA.

This article reviews controlled prospective trials of hypnosis for the treatment of chronic pain. Thirteen studies, excluding studies of headaches, were identified that compared outcomes from hypnosis for the treatment of chronic pain to either baseline data or a control condition. The findings indicate that hypnosis interventions consistently produce significant decreases in pain associated with a variety of chronic-pain problems. Also, hypnosis was generally found to be more effective than nonhypnotic interventions such as attention, physical therapy, and education. Most of the hypnosis interventions for chronic pain include instructions in self-hypnosis. However, there is a lack of standardization of the hypnotic interventions examined in clinical trials, and the number of patients enrolled in the studies has tended to be low and lacking long-term follow-up. Implications of the findings for future clinical research and applications are discussed.

J Pediatr. 2007 Jun;150(6):635-9.

Kohen DP, Zajac R. Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA. dpkohen@umn.edu

A retrospective review was conducted of outpatient clinical records of 178 consecutive youths referred to the Behavioral Pediatrics Program (University of Minnesota) from 1988 to 2001 for recurrent headaches. All patients were taught self-hypnosis for self-regulation. Intensity, frequency, and duration of headaches before, during, and after treatment were measured. Outcomes included number and frequency of visits, types of medication, and nature of self-hypnosis practice. RESULTS: Data were available for 144 patients in this patient self-selected and uncontrolled observation. Compared with self-reports before learning self-hypnosis, children and youths who learned self-hypnosis for recurrent headaches reported reduction in frequency of headache from an average of 4.5 per week to 1.4 per week (P < .01), reduction in intensity (on a self-rating scale of 0 to 12) from an average of 10.3 to 4.7, P < .01, and reduction in average duration from 23.6 hours to 3.0 hours, (P < .01). There were no adverse side effects of self-hypnosis. CONCLUSIONS: Training in self-hypnosis is associated with significant improvement of chronic recurrent headaches in children and adolescents.

The use of hypnosis during medical procedures has a long-standing tradition but has been struggling for acceptance into the mainstream. In recent years, several randomized-controlled trials with sufficient participant numbers have demonstrated the efficacy of hypnosis in the perioperative domain. With the advancements of minimally invasive high-tech procedures during which the patient remains conscious, hypnotic adjuncts have found many applications. This article describes the procedural environment as well as pharmacologic and nonpharmacologic interventions to reduce distress. Current research findings, controversies in the literature, and safety considerations are reviewed. Implications for clinical practice and training as well as directions for future research are discussed. Obstacles and possible reasons for the slow acceptance of nonpharmacologic interventions, mind-body therapies, and patient-centered approaches are addressed.

Beth Israel Deaconess Medical Center - Harvard Medical School. Boston, Massachusetts. USA. Int J Clin Exp Hypn. 2007 Jul;55(3):303-17

Rapid relaxation (RR) is a brief set of suggestions, given while applying topical anesthetic, to reduce anxiety during local anesthesia and subsequent dental treatment. RR is recommended for managing mild dental anxiety, which is almost universal. RR combines elements of hypnosis, meditation and good basic chairside manner. It is noninvasive, takes little additional time, and empowers patients by providing them with an attractive, immediate alternative to catastrophization. We have found that RR markedly improves the quality of the dental experience.

Department of Oral and Maxillofacial Sciences, Faculty of Dentistry, Dalhousie University, Halifax, Nova Scotia, Canada. jlovas@dal.ca. J Can Dent Assoc. 2007 Jun;73(5):437-40.

Hypnotherapy has increasingly been included in the management of burn patients, particularly in the area of acute pain. To better understand such issues as (1) overall efficacy of hypnotherapy to alleviate acute burn pain, (2) instances in which hypnotherapy is contraindicated, (3) interaction of hypnotherapy with medication, (4) standard induction techniques to use with various age groups, (5) role of nursing and other staff in facilitating hypnotic effects, and (6) future methodological directions, we examined the clinical and methodological merits of recent studies of hypnoanalgesia. Through a computer search of the medical literature and cross-referencing recent bibliographies, we were able to find 17 studies in which hypnotherapy was applied to the management of burns. The literature generally supports the efficacy of this approach to reduce burn pain; however, little else can be concluded from these studies. Several recent studies have applied hypnotherapy to aspects of burn care other than pain using excellent experimental designs. It is suggested that future studies of acute pain management follow suit.

Department of Rehabilitation Medicine, University of Washington, Seattle.

J Burn Care Rehabil. 1987 Jul-Aug;8(4):263-8.

OBJECTIVE: Hypnosis is an adjunctive, noninvasive treatment with few side effects that can be useful in the management of chronic pain. However, it has fallen into disfavor in recent years and is often perceived by physicians as simple charlatanism. We evaluated the efficacy of this treatment as used clinically in a large, mostly rural, pain management center. METHODS: We conducted a chart review of 300 pain patients from the Pain Treatment Center of the Bluegrass who had undergone hypnosis for their pain concerns. A chart audit tool was developed consisting of basic demographics, pre- and posthypnosis pain ratings, a rating of relaxation achieved posthypnosis, and scores on the Beck Depression Inventory, Perceived Disability Scale, and the Pain Anxiety Symptom Scale. RESULTS: The sample consisted of 79 men (26.3%) and 221 women (73.7%) with a mean age of 46.3 years (SD = 9.9, range = 19-78). Pain levels recorded pre- and posthypnosis revealed significant improvement as a result of the intervention (mean difference = 2.5, t (1,298) = 25.9, p < .001). Patients reported an average of 49.8% improvement in relaxation level posthypnosis (SD = 24.2%) and had a mean score of 19.0 on the Beck Depression Inventory (SD = 9.9), indicating moderate levels of depression. Also, patients saw themselves as severely disabled regarding their ability to engage in physical (8.3/10) or job-related (7.7/10) activities. Attempts to identify predictors of hypnosis success were not fruitful with one exception. "Poor" responders to hypnosis reported greater levels of perceived dysfunction in their sexual functioning compared to the "good" responders, F(1,187) = 7.2, p < .01. SIGNIFICANCE OF RESULTS: Hypnosis appears to be a viable adjunct for pain management patients, including those from rural and relatively disadvantaged backgrounds. Prospective trials are needed to examine the utility of this modality in end-of-life and palliative care patients.

The Pain Treatment Center of the Bluegrass, Lexington, Kentucky, USA.

Palliat Support Care. 2007 Jun;5(2):147-52.

Despite the availability of specialized treatments for chronic pain, including biofeedback training, relaxation training, and hypnotic treatment, most physicians rely on the traditional approaches of surgery or pharmacotherapy. The patient in this case study had severe and chronic pain but found little relief from pain medications that also caused side effects. She then took the initiative to learn and practice self-hypnosis with good results. Her physician in the resident's internal medicine clinic supported her endeavor and encouraged her to continue self-hypnosis. This patient's success shows that self-hypnosis can be a safe and beneficial approach to control or diminish the pain from chronic pain syndrome and can become a useful part of a physician's therapeutic armamentarium.

Department of Psychiatry and Behavioral Sciences, Mercer University School of Medicine, Macon, GA 31207, USA.

South Med J. 1999 May;92(5):521-3

Hypnosis in the management of intractable pain is a valuable but frequently overlooked tool for the practicing physician. Two cases are presented which illustrate some of the benefits and limitations of hypnosis in pain management. Hypnosis is most effective when the patient is motivated, and pain is a strong motivating force. Secondary gain from the pain and underlying psychiatric illness must be considered when seemingly routine pain problems do not respond to hypnosis. Hypnosis may be equally effective for pain of organic or psychogenic origin. Ancillary benefits from hypnosis may include a diminution of secondary anxiety and depression. The technic is impractical for some patients because of the time requirements, but proper patient selection can obviate much of this objection. Self-hypnosis and/or the supervised use of a relative as a substitute for the physician enhances effectiveness. Training in hypnosis for adjunctive use in the management of pain is available to primary care physicians.

South Med J. 1980 Mar;73(3):362-4.

Emergency ward physicians are presented daily with patients in pain. Provisions of safe, quick pain control remains one of their major duties. Hypnosis can be used as an effective adjunct or substitute for analgesic medications when these drugs prove to be ineffective or contraindicated. Four such illustrative cases of attempted pain control are presented. The psychological foundations of pain and its assessment are discussed. The emergency ward physician can obtain facility in hypnotic techniques with only modest training. Hypnosis may then become a valuable tool in helping him provide safe and effective pain management.

Postgrad Med J. 1984 Apr;60(702):263-6

It is well accepted that pain is a multidimensional experience, but little is known of how the brain represents these dimensions. We used positron emission tomography (PET) to indirectly measure pain-evoked cerebral activity before and after hypnotic suggestions were given to modulate the perceived intensity of a painful stimulus. These techniques were similar to those of a previous study in which we gave suggestions to modulate the perceived unpleasantness of a noxious stimulus. Ten volunteers were scanned while tonic warm and noxious heat stimuli were presented to the hand during four experimental conditions: alert control, hypnosis control, hypnotic suggestions for increased-pain intensity and hypnotic suggestions for decreased-pain intensity. As shown in previous brain imaging studies, noxious thermal stimuli presented during the alert and hypnosis-control conditions reliably activated contralateral structures, including primary somatosensory cortex (S1), secondary somatosensory cortex (S2), anterior cingulate cortex, and insular cortex. Hypnotic modulation of the intensity of the pain sensation led to significant changes in pain-evoked activity within S1 in contrast to our previous study in which specific modulation of pain unpleasantness (affect), independent of pain intensity, produced specific changes within the ACC. This double dissociation of cortical modulation indicates a relative specialization of the sensory and the classical limbic cortical areas in the processing of the sensory and affective dimensions of pain.

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

J Neurophysiol. 2001 Jul;86(1):402-11.

Understanding the complex nature of pain perception requires the ability to separately analyze its psychological dimensions and their interaction, and relate them to specific variables and responses. The present study, therefore, attempted to selectively modulate the sensory and affective dimensions of pain, using a cognitive intervention, and to assess the possible relationship between these psychological dimensions of pain and changes in physiological responses to the noxious stimuli. In three experiments, normal subjects trained in hypnosis rated pain intensity and pain unpleasantness produced by a tonic heat-pain stimulus (1-min immersion of the hand in 45.0-47.5 degrees C water). Two experiments were designed to test hypnotic suggestions to decrease (Experiment one (Section 2.5.1)), or increase and decrease (Experiment two (Section 2.5.2)) pain affect. Suggestions in Experiment three (Section 2.5.3) were directed towards an increase or decrease in pain sensation. In Experiments one and two (Sections 2.5.1 and 2.5.2), the significant modulation in pain unpleasantness ratings was largely independent of variations in perceived pain intensity. Moreover, in Experiment two (Section 2.5.2), there was a significant correlation between the stimulus-evoked heart-rate increase and ratings of pain unpleasantness, but not of pain intensity, suggesting a direct functional interaction between pain affect and autonomic activation. In Experiment three (Section 2.5.3), suggestions to modulate the sensory aspect of pain produced significant modulation of pain intensity ratings, with secondary changes in pain unpleasantness ratings. Hypnotic susceptibility (Stanford Hypnotic Susceptibility Scale form A) was specifically correlated to pain unpleasantness modulation in Experiment two (Section 2.5.2) and to pain intensity modulation in Experiment three (Section 2.5.3), suggesting that this factor relates to the primary process toward which hypnotic suggestions are directed. The specific pain dimension on which hypnotic suggestions act depends on the content of the instructions and is not a characteristic of hypnosis itself. Results are consistent with a successive-stage model of pain perception (e.g. Wade JB, Dougherty LM, Archer CR, Price DD. Assessing the stages of pain processing: a multivariate analytical approach. Pain 1996;68:157-167) which provides a conceptual framework necessary to study the cerebral representation of pain perception.

Departement de Psychologie, Universite de Montreal, Quebec, Canada.

Pain. 1999 Aug;82(2):159-71

This study evaluated the efficacy of hypnosis- and relaxation-induced suggestions for analgesia for reducing the strength and unpleasantness dimensions of pain evoked by noxious tooth pulp stimulation and by cold pressor stimulation. The Tellegen Absorption Questionnaire was used to assess hypnotic susceptibility for 28 subjects in order to match treatment groups according to sex and susceptibility scores. Tooth pulp stimulation consisted of a 1 sec train of 1 msec pulses at a frequency of 100 Hz, applied at 20 sec intervals to the central incisor. Six stimuli, selected between subject's pain and tolerance thresholds, were presented 3 times each in random order. Cold pressor stimulation consisted of forearm immersion in a circulating water bath maintained at 0-1 degrees C. Subjects made threshold determinations of pain and tolerance and used Visual Analogue Scales to rate the strength and the unpleasantness of both noxious stimuli before and after receiving either hypnosis- or relaxation-induced analgesia. There were no significant differences in pain reductions between hypnosis- and relaxation-induced interventions. However, the percent reduction in both strength and unpleasantness varied significantly as a function of the type of pain. Both hypnosis and relaxation significantly reduced the strength and the unpleasantness of tooth pulp stimulation, but only the unpleasantness dimension of cold pressor pain. The pain reductions were not correlated with subjects' hypnotic susceptibility levels. The results indicate that the extent and the quality of the analgesia produced by these cognitive-based therapies vary not only according to subjects' characteristics and the efficacy of the intervention, but also according to the nature of the noxious stimuli. Tooth pulp and cold pressor stimulation represent qualitatively different stimuli with respect to both the type of nerves activated and the mode of stimulus application. Discrete, randomly presented levels of noxious electrical stimulation to the teeth activate predominantly small fibers and produce brief pain sensations that vary unpredictably in intensity. In contrast, continuous cold stimulation to the forearm activates a variety of nociceptive and non-nociceptive fibers and produces progressive cold and pain sensations with a predictable increase in intensity from cold sensations to paresthesia and severe pain.

Pain Research Program, Faculty of Dentistry, University of Western Ontario, London, Canada.

Pain. 1988 May;33(2):241-51.

Within the framework of multidimensional pain assessment, this study extended an earlier finding that hypnotic analgesia and relaxation suggestions have differential effects on pain reduction by evaluating these strategies in subjects undergoing a cold pressor protocol. Thirty-two highly susceptible subjects were randomly assigned to an analgesia or a relaxation suggestion treatment group. Six pain reports were taken at 10-sec intervals for each experimental condition. The baseline measures served as covariates. A 2 x 2 x 2 x 6 repeated-measures analysis of covariance (ANCOVA) revealed a significant group (analgesia, relaxation) by pain dimension (intensity, unpleasantness), by condition (suggestion alone, hypnotic induction plus suggestion) interaction. Analysis of the simple-simple main effects, holding both group and condition constant, revealed that application of hypnotic analgesia reduced report of pain intensity significantly more than report of pain unpleasantness. Conversely, hypnotic relaxation reduced pain unpleasantness more than intensity. The clinical implications of the study are discussed.

Department of Psychology, Washington University, St. Louis, Missouri 63130, USA.

J Pain Symptom Manage. 1995 Aug;10(6):464-70

INTRODUCTION: Vulvar vestibulitis syndrome (VVS) is a common cause of vulvar pain. Therapeutic options target different pain systems believed to be involved in its development and maintenance. Most treatments target the pain component with the assumption that sexual function will increase once the pain has decreased, yet this is not necessarily the case. AIMS: Research has supported the effectiveness of hypnosis for many chronic pain disorders, and a case report demonstrated pain reduction and an increase in intercourse pleasure in a woman with VVS. This preliminary study examined the effectiveness of hypnosis on pain and psychosexual function in VVS. METHODS; Eight women suffering from VVS completed a hypnosis screening assessment, an interview, pain and psychosexual questionnaires, a gynecologic examination, vestibular pain threshold measurement, a psychosexual assessment, and six hypnotherapy sessions. The physical examinations, interview, and questionnaires were repeated at 1 and 6 months posttreatment. MAIN OUTCOME MEASURES: These included pain ratings during the gynecologic examination, vestibular pain thresholds, scores on the McGill Pain Questionnaire and Pain Catastrophizing Scale, and responses to questions on intercourse-related and nonintercourse-related pain. Measures of psychosexual function included the Female Sexual Function Index, State-Trait Anxiety Scale, Beck Depression Inventory-II, and the Brief Symptom Inventory. RESULTS: Results indicated significant decreases in gynecologic examination pain and in several measures assessing intercourse pain, and nonsignificant increases in threshold. Some indices of noncoital vulvar pain decreased. Overall sexual function, particularly sexual satisfaction, increased at posttreatment. There were no differences on any psychological measure. Participants reported satisfaction with the treatment and rated their VVS pain reduction as average. CONCLUSIONS: Hypnotherapy appears to be a promising treatment for reducing intercourse pain and some aspects of noncoital vulvar pain, and for restoring sexual function in women with VVS. These results suggest that a large controlled trial should be considered.

Pukall C, Kandyba K, Amsel R, Khalife S, Binik Y. Department of Psychology, Queen's University, Kingston, Ontario, Canada. pukallc@post.queensu.ca

The 12-member National Institute of Health Technology Assessment Panel on Integration of Behavioral and Relaxation Approaches into the Treatment of Chronic Pain and Insomnia (1996) reviewed outcome studies on hypnosis with cancer pain and concluded that research evidence was strong and that other evidence suggested hypnosis may be effective with some chronic pain, including tension headaches. This paper provides an updated review of the literature on the effectiveness of hypnosis in the treatment of headaches and migraines, concluding that it meets the clinical psychology research criteria for being a well-established and efficacious treatment and is virtually free of the side effects, risks of adverse reactions, and ongoing expense associated with medication treatments.

Hammond DC. University of Utah School of Medicine, Salt Lake City, Utah 84132-2119, USA. D.C.Hammond@utah.edu

The mediator role of response expectancies and the moderator role of hypnotic suggestibility were evaluated in the analogue treatment of pain. Approximately 1,000 participants were assessed for hypnotic suggestibility. Later, as part of a seemingly unrelated experiment, 188 of these individuals were randomly assigned to distraction, cognitive-behavioral package, hypnotic cognitive-behavioral package, hypnotic analgesia suggestion, placebo control, or no-treatment control conditions. Response expectancies partially mediated the effects of treatment on pain. Hypnotic suggestibility moderated treatment and was associated with the relief produced only by the hypnotic interventions. The results suggest that response expectancies are an important mechanism of hypnotic and cognitive-behavioral pain treatments and that hypnotic suggestibility is a trait variable that predicts hypnotic responding across situations, including hypnosis-based pain interventions.

Milling LS, Reardon JM, Carosella GM. Department of Psychology, University of Hartford, Hartford, CT 06117, USA. milling@hartford.edu

A prospective controlled trial was conducted to compare the efficacy of an analgesic cream (eutectic mixture of local anesthetics, or EMLA) with a combination of EMLA with hypnosis in the relief of lumbar puncture-induced pain and anxiety in 45 pediatric cancer patients (age 6-16 years). The study also explored whether young patients can be taught and can use hypnosis independently as well as whether the therapeutic benefit depends on hypnotizability. Patients were randomized to 1 of 3 groups: local anesthetic, local anesthetic plus hypnosis, and local anesthetic plus attention. Results confirmed that patients in the local anesthetic plus hypnosis group reported less anticipatory anxiety and less procedure-related pain and anxiety and that they were rated as demonstrating less behavioral distress during the procedure. The level of hypnotizability was significantly associated with the magnitude of treatment benefit, and this benefit was maintained when patients used hypnosis independently.

Liossi C, White P, Hatira P. School of Psychology, University of Southampton, Southampton, United Kingdom. cliossi@soton.ac.uk

The magnitude of placebo analgesia is influenced by environmental and perceptual factors. Environmental factors include past exposure to effective analgesic agents and verbal suggestions and cues that foster a perception of being given an effective treatment. Environmental factors, in turn, influence the proximate psychologic mediators of placebo analgesia, which include decreased desire for and increased expectations of pain relief. Strategies to maximize placebo analgesic effects in clinical practice could focus on using verbal suggestions and external cues to increase expectations of pain relief and/or decrease the perceived need for pain reduction. Placebo analgesic effects could be minimized in clinical trials by avoiding these same suggestions and cues.

Price DD, Fillingim RB, Robinson ME. Oral and Maxillofacial Surgery, University of Florida, P.O. Box 100416, Gainesville, FL 32610-0416, USA. dprice@dental.ufl.edu

The under-treatment of postoperative pain has been recognised to delay patient recovery and discharge from hospital. Despite recognition of the importance of effective pain control, up to 70% of patients still complain of moderate to severe pain postoperatively.The mechanistic approach to pain management, based on current understanding of the peripheral and central mechanisms involved in nociceptive transmission, provides newer options for clinicians to manage pain effectively. In this article we review the rationale for a multimodal approach with combinations of analgesics from different classes and different sites of analgesic administration. The pharmacological options of commonly used analgesics, such as opioids, NSAIDs, paracetamol, tramadol and other non-opioid analgesics, and their combinations is discussed. These analgesics have been shown to provide effective pain relief and their combinations demonstrate a reduction in opioid consumption.The basis for using non-opioid analgesic adjuvants is to reduce opioid consumption and consequently alleviate opioid-related adverse effects. We review the evidence on the opioid-sparing effect of ketamine, clonidine, gabapentin and other novel analgesics in perioperative pain management. Most available data support the addition of these adjuvants to routine analgesic techniques to reduce the need for opioids and improve quality of analgesia by their synergistic effect. Local anaesthetic infiltration, epidural and other regional techniques are also used successfully to enhance perioperative analgesia after a variety of surgical procedures. The use of continuous perineural techniques that offer prolonged analgesia with local anaesthetic infusion has been extended to the care of patients beyond hospital discharge.The use of nonpharmacological options such as acupuncture, relaxation, music therapy, hypnosis and transcutaneous nerve stimulation as adjuvants to conventional analgesia should be considered and incorporated to achieve an effective and successful perioperative pain management regimen.

Pyati S, Gan TJ. Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA.

By Judith E. Pearson, Ph.D.

In 1978 Richard Bloch, co-founder of H&R Block, was diagnosed with cancer. The prognosis was that he would be dead in three months. After two years of aggressive therapy he recovered. Wanting to make a difference in the lives of others struggling with cancer, he sold his interest in H&R Block and founded The Cancer Hotline in 1980, and the Block Cancer Support Center in 1986. He sponsored a national computer database, the Physician's Data Query, with the latest research and treatment protocols for every known form of cancer. Today this database is operated by the National Cancer Institute in Bethesda, Maryland.

Richard and his wife, Annette, wrote Fighting Cancer, a book offering self-help advice. Their second book, A Guide for Cancer Supporters1, is for family and friends of those who have cancer. Both books offer inspiration and hope, encouraging cancer patients to fight to live, instead of waiting to die. These books also recommend that cancer patients supplement medical interventions with psychotherapy, guided imagery, and clinical hypnotherapy. In the 1970's the use of such therapies in the treatment of disease was almost unheard of and to suggest such an idea bordered on heresy. Three decades later, supplemental therapies such as hypnotherapy, acupuncture, therapeutic massage, nutritional counseling, and neuro-feedback are widely considered as essentials in the holistic approach to health and the treatment of disease.

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Effects of a 28-day inpatient multimodal treatment concept measured by Tinnitus-Questionnaire and Health Survey SF-36.

For the first time, the therapeutic effects on subacute and chronic tinnitus of an inpatient multimodal treatment concept based on principles of Ericksonian hypnosis (EH) were examined by standardized criteria of the Tinnitus Questionnaire (TQ) and Health Survey (SF-36) within a controlled prospective, longitudinal study. A total of 393 patients were treated within an inpatient closed-group 28-day-setting based on a resource-oriented, hypnotherapeutic concept. The severity of tinnitus was assessed by TQ at times of admission, discharge and also at a 6- and 12-month follow-up. Health-related quality of life was evaluated before and after therapy using the SF-36. After therapy, a decrease in TQ score was seen in 90.5% of the patients with subacute tinnitus and in 88,3% of those with chronic tinnitus. Assessment of the TQ score at the end of therapy revealed highly significant improvements of 15.9/14.1 points in mean. Effect sizes in the treatment groups (0.94/0.80) were superior to those in the waiting-list controls (0.14/0.23). The TQ score remained stable in the follow-up controls. Significant improvement in health-related quality of life has been observed within the treatment groups depending on initial level of tinnitus serverity I-IV according to TQ. Using a multimodal treatment concept with emphasis on resource-activating approaches of EH the annoyance of tinnitus can be significantly reduced while health-related quality of life is enhanced within a comparatively short treatment period of 28 days.

Practice for Otorhinolaryngology and Psychotherapy, Luisenstrasse 6, 79098, Freiburg, Germany, Dr-Ross@web.

This report describes an open randomized study that aims to determine whether a brief hypnotic intervention during first-trimester surgical abortion reduces requests for pain medication. METHODS: Thirty women undergoing first-trimester surgical abortion at the family planning clinics of a large hospital in Quebec City were randomized into a control group that received standard care and a hypnosis group that received, in addition to standard care, an intervention of hypnosis, including analgesia suggestions 20 min before and throughout the surgical procedure. Patients in both groups were given the option to control their pain with nitrous oxide (N(2)O) sedation administered through a nose mask as often and for as long as they wanted during the procedure. N(2)O sedation as the primary outcome was assessed at each step of the procedure. The patient's self-reported anxiety and pain were also assessed during the procedure as secondary outcomes. RESULTS: Thirty-six percent of patients in the hypnosis group requested N(2)O sedation during the procedure versus 87% in the control group (p<.01). No differences between the groups were found in reports of pain and anxiety during the procedure. CONCLUSION: These results suggest that hypnosis can be integrated into standard care and reduces the need for N(2)O in patients undergoing first-trimester surgical abortion. This reduction in N(2)O consumption did not lead to significant changes in pain or anxiety, and a larger sample size is required to assess the possible effects of hypnosis on those variables.

Chaire Lucie et Andre Chagnon pour l'avancement d'une approche integree en sante, Hopital St-Francois d'Assise, CHUQ, Universite Laval, Quebec City, PQ, Canada G1L 2G1.

Depersonalization (DP) is characterized by persistent or recurrent episodes of detachment from one's self with reduced pain perception being a common feature. Alterations in the body schema similar to the cortico-limbic disconnection syndrome of pain asymbolia are suggested to be responsible for DP. In this study we used hypnosis to induce DP in healthy subjects and to examine neural patterns of pain perception in the state of DP by means of functional magnetic resonance imaging (fMRI). Methods: Pain perception was investigated in 7 healthy subjects with high susceptibility to hypnosis in three different mental states: waking state (N-W), hypnotic relaxation (H-R) and hypnotic DP (H-DP). Pain was induced with electrical stimulation to the median nerve at the right wrist. fMRI measurements were performed during all states. Results: Nociceptive stimuli led to an activation of the well described pain network including somatosensory and insular regions and the cerebellum. Activation was markedly reduced in the contralateral somatosensory cortex, parietal cortex (Brodmann area 40, BA40), prefrontal cortex (BA9), putamen and the ipsilateral amygdala during H-DP. Subjects also reported a significant decrease in pain intensity from N-W to H-DP. Conclusion: Pain response during H-DP was reduced in sensory and affective pain-related areas, reflecting the diminished intensity of the perceived pain. Moreover, a network of cortical and subcortical areas that have been implicated in the perception of the own body was less responsive during DP, which might point to a specific neural mechanism underlying the 'out-of-body' experience. Although the small number of subjects does not allow a generalization of our findings, H-DP seems to be a promising tool for the investigation of psychological and biological mechanisms of self-inflicted injuries as well as the mind-body interplay within the realm of psychosomatic disorders.

Department of Psychosomatic Medicine and Psychotherapy, Johann Wolfgang Goethe University, Frankfurt, Germany.

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.

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

Chronic abdominal pain is a common feature of most functional gastrointestinal disorders in children, including functional abdominal pain (FAP) and irritable bowel syndrome (IBS). FAP can impair a child's life and often leads to significant school absences. Although the underlying mechanism is likely multifactorial, early pain experiences during a vulnerable period in the developing nervous system can cause long-term changes in the brain-gut axis and ultimately may result in altered pain pathways and visceral hyperalgesia. Care providers often feel uncomfortable managing patients with chronic abdominal pain, as the pathophysiology is poorly understood, and limited data exist regarding safety and efficacy of therapeutic options in children. The primary goal of therapy in FAP is to alleviate pain symptoms and to help the child return to normal daily activities. Treatment should be individualized and chosen based on the severity of symptoms, the existence of comorbid psychological disorders, and the impact the disorder has on the child's school attendance and normal functioning. Various psychological interventions, such as cognitive-behavioral therapy, hypnosis, and guided imagery, have been successfully used in children with chronic abdominal pain. Pharmacologic therapies such as H(2) blockers, proton-pump inhibitors, tricyclic antidepressants, and various serotonergic drugs have been used, but good controlled trials are lacking. More studies are clearly needed to investigate the benefits and safety of pharmacologic therapy in children. Newer pharmacologic agents that target specific receptors involved in nociception, stress, and neurogenic inflammation currently are being developed. Future targets for visceral hyperalgesia should not only be aimed at alleviating symptoms but also should include prevention, particularly in cases with a suspected sensitizing event such as neonatal pain and postinfectious IBS.

Division of Pediatric Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA. amiranda@mail.mcw.edu.

The main aims of this experimental study are: (1) to compare the relative effects of analgesia suggestions and relaxation suggestions on clinical pain, and (2) to compare the relative effect of relaxation suggestions when they are presented as "hypnosis" and as "relaxation training". Forty-five patients with fibromyalgia were randomly assigned to one of the following experimental conditions: (a) hypnosis with relaxation suggestions; (b) hypnosis with analgesia suggestions; (c) relaxation. Before and after the experimental session, the pain intensity was measured using a visual analogue scale (VAS) and the sensory and affective dimensions were measured with the McGill Pain Questionnaire. The results showed: (1) that hypnosis followed by analgesia suggestions has a greater effect on the intensity of pain and on the sensory dimension of pain than hypnosis followed by relaxation suggestions; (2) that the effect of hypnosis followed by relaxation suggestions is not greater than relaxation. We discuss the implications of the study on our understanding of the importance of suggestions used in hypnosis and of the differences and similarities between hypnotic relaxation and relaxation training.

Pain Clinic and UFISS Palliative Care. Hospital Universitari de Tarragona Joan XXIII and Gestio i Prestacio de Serveis de Salut, C/Doctor Mallafre Guasch 4, 43007 Tarragona, Spain.

Lewis Mehl-Madrona MD at the Program in Integrative Medicine of the University of Arizona in Tucson, compared a combination of CAM therapies to conventional treatment for uterine fibroids. Thirty-seven menstruating women, aged 24 to 45 years, with palpable uterine fibroids were enrolled in the study. Half received weekly traditional Chinese medicine, body therapy (somatic therapy, bodywork), and guided imagery for up to 6 months. The other half, matched controls, received standard care. The women were checked for changes in fibroid size, changes in bothersome symptoms, and general level of patient satisfaction.

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A new randomized, controlled clinical trial from France investigated the effectiveness of 8-session Eriksonian hypnosis and 8-session Jacobsonian progressive relaxation for the reduction of osteoarthritis pain, using subjects with knee or hip pain. Patients were randomly assigned to one of the intervention groups or a control group. Overall, results demonstrated that the two experimental groups had a lower level of subjective pain than the control group, and that the level of subjective pain decreased with time. In addition, pain reduction occurred more rapidly for the hypnosis group. Results also showed that both hypnosis and relaxation are effective in reducing the amount of analgesic medication taken by participants.

Kristine Kwekkeboom and her team from The University of Iowa College of Nursing have been studying predictors of the successful use of guided imagery for some time now. This pilot study, with a one-group pretest-posttest design, examines whether peoples' ability to effectively use imagery as a pain management strategy can be predicted for individual cancer patients.

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by John Iler

Hypnosis helps patients cope with pain and anxiety Handel coaches patients in therapeutic hypnosis The 14-year old boy was terminally ill and in severe pain. A brain tumor was causing blinding headaches and he suffered multiple fractures of his ribs because of the metastases spreading throughout his side. At night, he clutched a stuffed teddy bear to keep from crying out.

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About 70 % of amputees will suffer from phantom limb pain sooner or later. Nearly all of the amputees will feel some phantom sensations. Phantom limb pain not only impairs quality of life, but also impedes considerably social rehabilitation.

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Mental stress induces endothelial dysfunction, that is a reduction of the post-occlusion brachial artery flow-mediated vasodilation (FMD). This does not occur in subjects highly susceptible to hypnosis (Highs) in either the waking or hypnotic state.

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One of the most challenging roles of medical providers serving children is to appropriately assess and treat their pain. Pain is one of the most misunderstood, underdiagnosed, and undertreated/ untreated medical problems, particularly in children.

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In this randomized, controlled, clinical trial, researchers from The University of Pittsburgh School of Medicine examined the effects of a biofeedback-assisted stress-reduction program on pain, psychological function, and perceived physical function in patients with systemic lupus erythematosus (SLE) experiencing pain.

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In this unblinded, randomized, controlled study, researchers from Cincinnati Children's Hospital investigated the effectiveness of imagery when used alongside routine analgesics for reducing tonsillectomy and/or adenoidectomy pain and anxiety after ambulatory surgery (AS) and at home.

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One of the most complex patient treatment situations encountered by the clinician is the patient who presents with the cluster of signs and symptoms that lead to the diagnosis of fibromyalgia syndrome. While physicians focus primarily on pharmacologic treatment, a number of nonpharmacologic modalities have been shown to benefit patients as well. No one therapy is uniformly effective in every patient; treatment programs consisting of a combination of pharmacologic and nonpharmacologic therapies must be individualized to the patient, and the clinician may have to try several different modalities before reaching an optimal improvement in the patient's symptoms.

Arthritis Associates, Kingsport, TN, USA. arthritis@charter.net

Pain-rating scores were obtained from 10 high, 10 medium, and 10 low hypnotizable subjects who were holding a painful cold bottle in their left hands and were exposed to pain reduction treatments while they were performing a secondary oddball task. All subjects received suggestions of dissociative imagery and focused analgesia as cognitive strategies for pain reduction. The following measures were obtained for tone targets of the auditory oddball task: (a) reaction time; (b) P300 peak amplitude of the event-related potentials; (c) skin conductance levels and skin conductance responses. Focused analgesia produced the most pain reduction in high, but not medium or low, hypnotizable subjects who showed shorter reaction times, higher central and parietal P300 peaks, and higher skin conductance responses. These findings were discussed vis-a-vis the dissociated-control model assuming that capacity demands of hypnotic suggestion are low.

Department of Psychology, University of Rome, La Sapienza, Rome, Italy. v.depascalis@caspur.it

Patients are often prepared for procedural discomforts with descriptions of pain or undesirable experiences. This practice is thought to be compassionate and helpful, but there is little data on the effect of such communicative behavior. This study assesses how such descriptions affect patients' pain and anxiety during medical procedures. The interactions of patients with their healthcare providers during interventional radiological procedures were videotaped during a previously reported 3-arm prospective randomized trial assessing the efficacy of self-hypnotic relaxation.

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The NIH Clinical Center is sponsoring an 12 week study to examine whether hypnosis can reduce the frequency and intensity of pain in patients with sickle cell disease.

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Chronic pain conditions are a complex and multifactorial problem generally requiring a multidisciplinary-type approach. The central nervous system at some point clearly becomes involved in the processing of these painful conditions with an integration of complex changes in neurophysiology and behavior.

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