Hypnosis and surgery

Mounting Evidence on the Benefits of Perioperative Hypnosis

By Ted Wissink, MD, and Ben Hagopian, MD, Dr. Wissink is Attending Physician, Family Medicine Residency and Integrative Medicine Department, Maine Medical Center, Portland, ME. Dr. Hagopian is current resident physician in Family Medicine at Maine Medical Center and is doing the Integrative Medicine in Residency program through the Arizona Center for Integrative Medicine. Dr. Wissink and Dr. Hagopian report no financial relationships relevant to this field of study.

There is no question that advances in surgical technique and anesthesia have contributed greatly to our modern medical system over the last half century. Patient outcomes have improved tremendously, along with reduction in physical and emotional stress associated with undergoing surgical procedures. Many of these advances are directly related to advancement of pharmaceuticals given to patients before, during, and after procedures. Despite these advances, the medical community knows well that pharmaceuticals, including those used before, during, and after surgery, continue to be associated with significant side effects. Medical hypnosis offers an adjunctive treatment to help limit perioperative physical and emotional stress without such side effects. This article will give a brief background on medical hypnosis and then summarize the literature on this subject since two reviews in 2002 and 2007.

History of Surgical Hypnosis

The term “hypnosis” comes from the Greek root hypnos which means sleep. The term was created in 1820 by Etienne Felix d’Henin de Cuvillers1 and defined more recently as “a subjective state in which alterations of perception and memory can be elicited by suggestion.”2

The recorded use of hypnosis in surgery dates back to the 1830s when Jules Cloquet performed mastectomies and John Elliotson performed a variety of other operations with hypnosis as the only anesthetic.3 Anesthetist James Esdaile used hypnosis in more than 3000 minor and 300 major surgeries in India from 1845-1851.4 About this same time, ether and chloroform were introduced as chemical anesthetics and there was rapid acceptance and widespread use of inhaled anesthesia. Directly related to this acceptance, the discontinuation of hypnosis in anesthesia is dated to around 1860.5 Hypnosis then became discredited and mostly practiced by stage hypnotists for entertainment until the mid-1900s.

More Current Applications

In 1955, the British Medical Association made a public statement that hypnotism “is an effective method of relieving pains in childbirth without altering the normal course of labor.”6 In 1958, the American Medical Association endorsed the use of hypnotism by physicians.7 Since this time period, medical hypnosis has been increasingly accepted, used, and studied as a complementary treatment to chemical anesthesia. Especially with the increasing role of conscious sedation, hypnosis has become accepted more into everyday practice perioperatively.

Interesting Background on Hypnosis

During hypnotic inductions, a patient is typically guided through relaxing imagery. The goal is for distraction from aversive stimuli and becoming more open to therapeutic suggestions. An “induction phase” is then followed by an “application phase” in which suggestions are made by the hypnotist to the patient and may include changes in sensory or cognitive processes, physiology, or behavior.8 Common examples of physiologic changes may be heart rate or blood pressure, and sensory changes often focus on pain perception.

There has been debate about what underlying mechanism is responsible for effects of hypnosis. Some equate hypnosis with acting and say the patient is just adopting a role that is more relaxing. Others claim that hypnosis is a distinct psychological state of focused attention that allows one to dissociate sensations and guide one’s mental resources in a variety of ways.9 An interesting experiment using PET brain scans showed similar brain activity in hypnotized individuals being told to observe certain colors (vs grayscale) as in those actually observing these changes in color.10

Most of the research studies about hypnsosis use one of the many scales designed to measure hypnotizability in people. Although it makes sense that greater hypnotizability in an individual would lead to potentially greater therapeutic responses, the research on this shows that hypnotizability does not necessarily correlate with therapeutic benefit in surgical applications.11

In a physiology lab testing human participants, Casiglia et al submerged participants’ hands in ice water and found that hypnosis reduced subjective pain by half while objective pain more than doubled.12 They found the reflex vasoconstriction accompanying pain was reduced significantly as well. Their conclusion was that if hypnosis merely dissociated painful experience from consciousness, a normal cardiovascular reflex response to pain would occur even during hypnosis, which it failed to do.

Clinical Research Reviews on Hypnosis

A 2002 meta-analysis by Montgomery et al of 22 studies including more than 1600 patients found that 89% of surgical patients benefited from adjunctive hypnosis interventions relative to control conditions.13 The benefits shown in each of the outcome categories included negative affect, pain, pain medication, physiological indicators, recovery, and treatment time. Thirteen of the studies were randomized and 14 included live hypnosis. An interesting point to note from this review is that hypnosis benefits were also significant regardless of whether the hypnotic intervention was live or taped. There was great variability in design among the studies so results need to be interpreted with caution.

A 2007 review article summarized clinical outcomes from research up to that point in time. The reviewed studies were diverse as to what outcomes were being analyzed. But to summarize, the review concluded that faster wound healing, earlier postoperative gastrointestinal recovery, and less nausea have been reported when hypnosis or positive suggestions were part of perioperative management.14

Specifically for children, hypnosis has been shown to decrease anxiety and shorten the hospital stay.15 Children have been shown to be open and highly receptive to therapeutic suggestion in the emergency department, where hypnosis has been used successfully for forearm fracture reduction with children who had no possible access to other analgesia.16

Recent Research

One study by Montgomery et al at Mount Sinai School of Medicine in New York looked at women who were hypnotized immediately before undergoing breast biopsy or lumpectomy.17 During the procedure, the hypnotized women required 22% less analgesia and 34% less sedation. After the procedure, they reported 53% less pain intensity, 74% less nausea, and 46% less fatigue. They also spent 11 fewer minutes in surgery, resulting in a cost savings of almost $800 per patient (10% reduction in hospital costs).

Another fairly recent study specifically addressed hypnosis and the effect on perioperative distress and anxiety. A study by Saadat et al at Yale University School of Medicine examined the effect of one 30-minute preoperative hypnosis session on anxiety when entering the operating room and postoperatively.18 The hypnosis group was compared to both an “attention-control” group that received empathic listening and a control group. The hypnosis group reported a 56% decrease in anxiety upon entering the operating room, while the attention-control group and the control group reported anxiety increased by 10% and 47%, respectively (P = 0.001). Similarly, postoperatively, the hypnosis group was significantly less anxious than either of the other two groups (ANOVA, P = 0.008). Both blood pressure and heart rate were similar among all three groups.

Finally, an interesting study by Lew et al from City of Hope in Duarte, California, used a standardized, nurse-administered hypnosis protocol to examine its effects on 20 patients undergoing surgical breast procedures.19 Nurses used a 15-minute scripted “hypnotic experience provided within an hour of surgery.” Although pain and nausea were not significantly decreased, investigators noted reductions in anxiety (40% reduction), sadness (25% reduction), irritability (20% reduction), and feelings of distress (15% reduction).

Side Effects and Cautions

The main caution about hypnosis would be its use by untrained providers. Clinicians should not use clinical hypnosis to treat a condition unless they also are qualified to treat the condition without hypnosis. Caution should be advised for patients who:

  • consume a large amount of alcohol or drugs,
  • have delusions or hallucinations, or
  • have a history of psychosis.

Conclusion

In summary, although the physiologic basis of hypnosis is not fully understood, it seems to be a useful adjunctive tool for managing perioperative side effects. The two recent meta-analyses as well as more recent follow-up studies demonstrate that perisurgical hypnosis has wide-ranging benefits for most patients (89% in the review by Montgomery, et al13) who utilize this intervention. Benefits can be both physical and psychological and include reduced anxiety and distress, pain reduction, faster recovery time, and less time spent in the operating room. One downside to using hypnosis is the cost, although minimal, associated with administering it. Some studies have found strategies to address this issue, including the use of tapes or training nurses in basic hypnosis. In addition, one study noted a generous hypnosis-induced cost savings due to shorter operating room time.17

Although hypnosis appears to have wide-ranging benefits, its adoption is far from full. An Australian survey of anesthesiologists noted that 63% of respondents believed their level of knowledge about perioperative hypnosis was below average.20 One can only imagine the low familiarity level among U.S. primary care physicians and surgeons.

Future work in this field should focus on discovering the mechanism of action of hypnosis, the cost effectiveness of different methods of hypnosis administration (live vs taped), and the ideal timing of administration of a perioperative hypnosis intervention.

Finding a Provider

Most hypnotherapists are licensed medical doctors, registered nurses, social workers, or family counselors who have received additional training in hypnotherapy. For example, members of the American Society of Clinical Hypnosis (ASCH) must hold a doctorate in medicine, dentistry, podiatry, or psychology, or a master’s level degree in nursing, social work, psychology, or marital/family therapy with at least 20 hours of ASCH-approved training in hypnotherapy. For a directory of hypnotherapists, contact:

  • The American Society of Clinical Hypnosis: www.asch.net
  • The Society for Clinical and Experimental Hypnosis: www.sceh.us

If one cannot find a local hypnotherapist, audiotape recordings are an option. These have been used in research studies and can be an effective and efficient way to administer hypnosis. At this time, we cannot recommend specific recordings but there are several available.

Recommendation

Due to its minimal cost and significant benefit in a large majority of patients, we feel it is in all surgical patients’ best interests to be offered at least one preoperative hypnosis session of least 15 minutes, either live or taped, depending on facility resources. Some patients may benefit from hypnosis more than others and for this reason, we strongly recommend offering this service to patients with high levels of pre-procedure anxiety and distress, including children, patients with a history of significant anxiety/intolerance of surgical procedures, and patients undergoing diagnostic procedures to detect potential malignancy.

References

1. Riskin JD, Frankel FH. A history of medical hypnosis. Psychiatry Clin North Am 1994;17:601-609.

2. Orne MT. The construct of hypnosis: Implications of the definition for research and practice. Ann N Y Acad Sci 1977;296:14-33.

3. Rosen G. History of hypnosis. In: Schneck J, ed. Hypnosis in Modern Medicine. Springfield, MO: Charles C Thomas; 1953: 3-27.

4. Esdaile J. Mesmerism in India, and Its Practical Application in Surgery and Medicine. New York: Arno Press; 1976.

5. Collins VJ. Principles of Anesthesiology. Philadelphia: Lea & Febiger; 1976.

6. Report of a subcommittee appointed by the Psychological Med Group Committee of the Br Medical Association. Medical use of hypnotism. BMJ 1955;1:190-193.

7. Rosen H. Hypnosis — applications and misapplications. JAMA 1960;172:683-687.

8. Kirsch I. How Expectancies Shape Experience. 1st ed. Washington, DC: American Psychological Association; 1993.

9. Kihlstrom JF. The cognitive unconscious. Science 1987;237:1445-1452.

10. Kosslyn S, et al. Hypnotic visual illusion alters color processing in the brain. Am J Psychiatry 2000;157:1279-1284.

11. Kessler R, Dane JR. Psychological and hypnotic preparation for anesthesia and surgery: An individual difference perspective. Int J Clin Exp Hypn 1996;44:189-207.

12. Casiglia E, et al. Hypnosis prevents the cardiovascular response to cold pressure test. Am J Clin Hypnosis 2007;49:255-256.

13. Montgomery GH, et al. The effectiveness of adjunctive hypnosis with surgical patients: A meta-analysis. Anesth Analg 2002;94:1639-1645.

14. Wobst A. Hypnosis and surgery: Past, present, and future. Anesth Analg 2007;104:1199-1208.

15. Lambert SA. The effects of hypnosis/guided imagery on the postoperative course of children. J Dev Behav Pediatr 1996;17:307-310.

16. Iserson KI. Hypnosis for pediatric fracture reduction. J Emerg Med 1999;17:53-56.

17. Montgomery G, et al. A randomized clinical trial of a brief hypnosis intervention to control side effects in breast surgery patients. J Natl Cancer Inst 2007;99:1304-1312.

18. Saadat H, et al. Hypnosis reduces preoperative anxiety in adult patients. Anesth Analg 2006;102:1394-1396.

19. Lew MW, et al. Use of preoperative hypnosis to reduce postoperative pain and anesthesia-related side effects. Int J Clin Exp Hypn 2011;59:406-423.

20. Coldrey JC, et al. Suggestion, hypnosis and hypnotherapy: A survey of use, knowledge and attitudes of anaesthetists. Anaesth Intensive Care 2004;32:676-680.