Chronic Pain

South Med J. 1983 Mar;76(3):319-21.
Hypnosis in the treatment of chronic pain.
Savitz SA.

Chronic pain can be treated by combining hypnosis with brief psychotherapy. Hypnosis alone, though useful for acute pain, is seldom effective in relieving chronic pain because it does not address the significant psychologic components in the patient's illness. Treatment using self-hypnosis in conjunction with brief psychotherapy, however, can enable the patient to recognize these components, to change from a passive to an active role in achieving relief, and to modify his attitude toward the pain. This procedure can both reduce suffering and lead the patient to deemphasize pain in his life.

Clin J Pain. 1989 Jun;5(2):161-8.
Self-hypnosis in chronic pain. A multiple baseline study of five highly hypnotisable subjects.
James FR, Large RG, Beale IL.
Department of Psychology, University of Auckland, New Zealand.

The efficacy of self-hypnosis in the treatment of chronic pain was evaluated using a multiple baseline design for five patients referred to the Auckland Hospital Pain Clinic. Subjects were selected for high hypnotisability using the Stanford Hypnotic Clinical Scale. Daily records of pain intensity, sleep quality, medication requirements, and self-hypnosis practice were completed. At four research interviews the Health Locus of Control survey, the McGill Pain Questionnaire, and the Illness Self Concept Repertory Grid (ISCRG) were administered. Subjects also reported on daily activities and quality of life. Postal follow-up assessment occurred after 2 years. Two subjects reported overall improvement, two demonstrated little change in condition, although self-hypnosis was effective on some occasions, and one subject experienced deterioration in her condition. The patients showed an increase in personal locus of control and a shift of self-concept away from physical illness on the ISCRG. The results suggest that self-hypnosis can be a highly effective technique for some patients with chronic pain but not for all. Selection criteria and clinical factors other than hypnotisability need to be considered in further research, since even highly hypnotisable subjects may derive limited benefit from self-hypnosis.

Pain. 1988 Nov;35(2):155-69.
Personalized evaluation of self-hypnosis as a treatment of chronic pain: a repertory grid analysis.
Large RG, James FR.
Department of Psychiatry, University of Auckland, New Zealand.

Self-hypnosis was taught to 5 highly hypnotisable patients referred to Auckland Hospital Pain Clinic. Evaluation included the Illness Self-Concept Repertory Grid (ISCRG) and follow-up was at 1 and 6 months post treatment. Consensus grids indicated the subjects initially identified with physical illness but this association decreased over the course of the study. There appeared, therefore, to be a shift in self-concept away from physical illness, in association with the learning and practice of self-hypnosis. This change was especially evident in the grids of those subjects who experienced the most pain relief. An association between pain reduction and self-concepts is thus noted. This study does not identify whether self-concepts merely reflect therapeutic change or whether strong self-identification with physical illness indicates a poor prognosis for pain relief. This is a question which deserves further study.

Eur J Pain. 2002;6(1):1-16.
Differential effectiveness of psychological interventions for reducing osteoarthritis pain: a comparison of Erikson [correction of Erickson] hypnosis and Jacobson relaxation.
Gay MC, Philippot P, Luminet O. marieclaire.gay@free.fr
Psychology Department, Universite de Paris X, 200 avenue de la Republique, Nanterre, 92000, France.

The present study investigates the effectiveness of Erikson hypnosis and Jacobson relaxation for the reduction of osteoarthritis pain. Participants reporting pain from hip or knee osteoarthritis were randomly assigned to one of the following conditions: (a) hypnosis (i.e. standardized eight-session hypnosis treatment); (b) relaxation (i.e. standardized eight sessions of Jacobson's relaxation treatment); (c) control (i.e. waiting list). Overall, results show 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. An interaction effect between group treatment and time measurement was also observed in which beneficial effects of treatment appeared more rapidly for the hypnosis group. Results also show that hypnosis and relaxation are effective in reducing the amount of analgesic medication taken by participants. Finally, the present results suggest that individual differences in imagery moderate the effect of the psychological treatment at the 6 month follow-up but not at previous times of measurement (i.e. after 4 weeks of treatment, after 8 weeks of treatment and at the 3 month follow-up). The results are interpreted in terms of psychological processes underlying hypnosis, and their implications for the psychological treatment of pain are discussed.

Health Psychol. 2006 May;25(3):307-15.
Randomized clinical trial of local anesthetic versus a combination of local anesthetic with self-hypnosis in the management of pediatric procedure-related pain.
Liossi C, White P, Hatira P. cliossi@soton.ac.uk
School of Psychology, University of Southampton, Southampton, United Kingdom.

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.

Am J Hosp Palliat Care. 1999 Sep-Oct;16(5):665-70.
Hypnosis: useful, neglected, available.
Douglas DB. Lenox Hill Hospital, New York, New York, USA.

Hypnosis is presented as a valuable and frequently neglected resource for many patients with chronic and terminal illness. Particular attention is given herein to the use of hypnosis in attaining relaxation, overcoming insomnia, helping the patient achieve pain relief, and, most particularly, teaching the patient to work with relatives and other persons close to them, as caregivers in a special relationship that can be a very important source of relief to the patient. A brief overview of indications, contraindications, errors, and safeguards is given. Sources of education and training are briefly reviewed and a bibliography is included to identify the nature of professional societies, three in the United States and one international, together with some standard publications. The purpose of this article is to affirm the value of hypnosis as a complementary or alternative therapy for hospice patients, to summarize its clinical applications, and to list the most standard and best known professional societies and publications.

Am J Clin Hypn. 1999 Oct;42(2):122-30.
Empowering the patient: hypnosis in the management of cancer, surgical disease and chronic pain.
Lynch DF Jr. dlynch@picard.evms.edu
Eastern Virginia School of Medicine, USA.

In the past decade, the increasing acceptance of hypnosis as a therapeutic adjunct by physicians and health care professionals both within and outside of the mental health community has resulted in broader use of the technique with patients in both hospital and outpatient settings. In our recent experiences with urologic patients, our staff has found that many bring a surprisingly sophisticated knowledge of clinical hypnosis to the office and often have had experience with some form of therapeutic hypnosis prior to consulting us. Consequently, we find we often encounter a surprising openness to the use of hypnosis as a part of the treatment programs we employ. As a result we have been able to utilize clinical hypnosis successfully in several treatment areas to the benefit of our patients. This paper will describe several programs in place at our practice which utilize clinical hypnosis as an adjunct to treatment.

J Consult Clin Psychol. 1999 Aug;67(4):481-90.
Pain. 1992 Feb;48(2):137-46. Comment in: " Pain. 1992 Aug;50(2):237-8.
Hypnosis or cognitive behavioral training for the reduction of pain and nausea during cancer treatment: a controlled clinical trial.
Syrjala KL, Cummings C, Donaldson GW.
Fred Hutchinson Cancer Research Center, Seattle, WA 98104.

Few controlled clinical trials have tested the efficacy of psychological techniques for reducing cancer pain or post-chemotherapy nausea and emesis. In this study, 67 bone marrow transplant patients with hematological malignancies were randomly assigned to one of four groups prior to beginning transplantation conditioning: (1) hypnosis training (HYP); (2) cognitive behavioral coping skills training (CB); (3) therapist contact control (TC); or (4) treatment as usual (TAU; no treatment control). Patients completed measures of physical functioning (Sickness Impact Profile; SIP) and psychological functioning (Brief Symptom Inventory; BSI), which were used as covariates in the analyses. Biodemographic variables included gender, age and a risk variable based on diagnosis and number of remissions or relapses. Patients in the HYP, CB and TC groups met with a clinical psychologist for two pre-transplant training sessions and ten in-hospital "booster" sessions during the course of transplantation. Forty-five patients completed the study and provided all covariate data, and 80% of the time series outcome data. Analyses of the principal study variables indicated that hypnosis was effective in reducing reported oral pain for patients undergoing marrow transplantation. Risk, SIP, and BSI pre-transplant were found to be effective predictors of inpatient physical symptoms. Nausea, emesis and opioid use did not differ significantly between the treatment groups. The cognitive behavioral intervention, as applied in this study, was not effective in reducing the symptoms measured.

Arch Phys Med Rehabil. 1983 Nov;64(11):548-52.
Hypnosis compared to relaxation in the outpatient management of chronic low back pain.
McCauley JD, Thelen MH, Frank RG, Willard RR, Callen KE.

Chronic low back pain (CLBP) presents a problem of massive dimensions. While inpatient approaches have been evaluated, outpatient treatment programs have received relatively little examination. Hypnosis and relaxation are two powerful techniques amenable to outpatient use. Seventeen outpatient subjects suffering from CLBP were assigned to either Self-Hypnosis (n = 9) or Relaxation (n = 8) treatments. Following pretreatment assessment, all subjects attended a single placebo session in which they received minimal EMG feedback. One week later the subjects began eight individual weekly treatment sessions. Subjects were assessed on a number of dependent variables at pretreatment, following the placebo phase, one week after the completion of treatment, and three months after treatment ended. Subjects in both groups showed significant decrements in such measures as average pain rating, pain as measured by derivations from the McGill Pain Questionnaire, level of depression, and length of pain analog line. Self-Hypnosis subjects reported less time to sleep onset, and physicians rated their use of medication as less problematic after treatment. While both treatments were effective, neither proved superior to the other. The placebo treatment produced nonsignificant improvement.

Int J Clin Exp Hypn. 2002 Apr;50(2):170-88.
Hypnosis for the control of HIV/AIDS-related pain.
Langenfeld MC, Cipani E, Borckardt JJ.
California School of Professional Psychology-Fresno, 93727-2014, USA.

This intensive case study used an A-B time-series analysis design to examine whether 5 adult patients with various AIDS-related pain symptoms benefited from a hypnosis-based pain management approach. The 3 dependent variables in this study were: (a) self-ratings of the severity of pain, (b) self-ratings of the percentage of time spent in pain, and (c) amount of p.r.n. pain medication taken. Data were collected over a period of 12 weeks, including a 1-week baseline period and an 11-week treatment period. Autoregressive integrated moving-average (ARIMA) models were used to determine the effects of the hypnotic intervention over and above autoregressive components in the data. All 5 patients showed significant improvement on at least 1 of the 3 dependent variables as a result of the hypnotic intervention. Four of the 5 patients reported using significantly less pain medication during the treatment phase.

Int J Clin Exp Hypn. 1997 Oct;45(4):417-32.
Self-hypnosis training as an adjunctive treatment in the management of pain associated with sickle cell disease.
Dinges DF, Whitehouse WG, Orne EC, Bloom PB, Carlin MM, Bauer NK, Gillen KA, Shapiro BS, Ohene-Frempong K, Dampier C, Orne MT.
Unit for Experimental Psychiatry, University of Pennsylvania School of Medicine, Philadelphia 19104-6021, USA.

A cohort of patients with sickle cell disease, consisting of children, adolescents, and adults, who reported experiencing three or more episodes of vaso-occlusive pain the preceding year, were enrolled in a prospective two-period treatment protocol. Following a 4-month conventional treatment baseline phase, a supplemental cognitive-behavioral pain management program that centered on self-hypnosis was implemented over the next 18 months. Frequency of self-hypnosis group straining sessions began at once per week for the first 6 months, became biweekly for the next 6 months, and finally occurred once every third week for the remaining 6 months. Results indicate that the self-hypnosis intervention was associated with a significant reduction in pain days. Both the proportion of "bad sleep" nights and the use of pain medications also decreased significantly during the self-hypnosis treatment phase. However, participants continued to report disturbed sleep and to require medications on those days during which they did experience pain. Findings further suggest that the overall reduction in pain frequency was due to the elimination of less severe episodes of pain. Non-specific factors may have contributed to the efficacy of treatment. Nevertheless, the program clearly demonstrates that an adjunctive behavioral treatment for sickle cell pain, involving patient self-management and regular contact with a medical self-hypnosis team, can be beneficial in reducing recurrent, unpredictable episodes of pain in a patient population for whom few safe, cost-effective medical alternatives exist.

Int J Clin Exp Hypn. 1998 Jan;46(1):92-132.
Hypnotic analgesia: 1. Somatosensory event-related potential changes to noxious stimuli and 2. Transfer learning to reduce chronic low back pain.
Crawford HJ, Knebel T, Kaplan L, Vendemia JM, Xie M, Jamison S, Pribram KH.
Department of Psychology, Virginia Polytechnic Institute and State University, Blacksburg 94061-0436, USA. hjc@vt.edu

Fifteen adults with chronic low back pain (M = 4 years), age 18 to 43 years (M = 29 years), participated. All but one were moderately to highly hypnotizable (M = 7.87; modified 11-point Stanford Hypnotic Susceptibility Scale, Form C [Weitzenhoffer & Hilgard, 1962]), and significantly reduced pain perception following hypnotic analgesia instructions during cold-pressor pain training. In Part 1, somatosensory event-related potential correlates of noxious electrical stimulation were evaluated during attend and hypnotic analgesia (HA) conditions at anterior frontal (Fp1, Fp2), midfrontal (F3, F4), central (C3, C4), and parietal (P3, P4) regions. During HA, hypothesized inhibitory processing was evidenced by enhanced N140 in the anterior frontal region and by a prestimulus positive-ongoing contingent cortical potential at Fp1 only. During HA, decreased spatiotemporal perception was evidenced by reduced amplitudes of P200 (bilateral midfrontal and central, and left parietal) and P300 (right midfrontal and central). HA led to highly significant mean reductions in perceived sensory pain and distress. HA is an active process that requires inhibitory effort, dissociated from conscious awareness, where the anterior frontal cortex participates in a topographically specific inhibitory feedback circuit that cooperates in the allocation of thalamocortical activities. In Part 2, the authors document the development of self-efficacy through the successful transfer by participants of newly learned skills of experimental pain reduction to reduction of their own chronic pain. Over three experimental sessions, participants reported chronic pain reduction, increased psychological well-being, and increased sleep quality. The development of "neurosignatures of pain" can influence subsequent pain experiences (Coderre, Katz, Vaccarino, & Melzack, 1993; Melzack, 1993) and may be expanded in size and easily reactivated (Flor & Birbaumer, 1994; Melzack, 1991, 1993). Therefore, hypnosis and other psychological interventions need to be introduced early as adjuncts in medical treatments for onset pain before the development of chronic pain.

South Med J. 1999 May;92(5):521-3.
What if your patient prefers an alternative pain control method? Self-hypnosis in the control of pain.
Nickelson C, Brende JO, Gonzalez J.
Department of Psychiatry and Behavioral Sciences, Mercer University School of Medicine, Macon, GA 31207, USA.

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.

Nurs Clin North Am. 1987 Sep;22(3):699-704.
Hypnosis as an intervention for pain control.
Cotanch PH, Harrison M, Roberts J.

The use of formal hypnosis and/or positive, comforting suggestions to patients for control of pain, fear, and anxiety is simple and effective. In addition, it is easy to learn and teach to patients. Spiegel states that hypnosis, a group of techniques long associated with fantasies of loss of control, is ironically very helpful in actually enhancing patients' sense of control. The clinicians daring to become proficient in the use of hypnotic trance must begin with a conscious effort to abandon all negative suggestions such as "Do you have pain?"; "How much do you hurt?"; and "Move your bad leg." Simultaneously, a conscious effort is made to increase the use of the following positive suggestions: "How comfortable are you going to be tonight?" "Your hand feels so soft and warm"; "It is important to move this leg." These communication skills are best learned from clinicians skilled in hypnotherapeutic techniques. Simultaneously, it is important to become familiar with the works of Erikson and Barber. The American Society of Clinical Hypnosis will provide information about the national organizations and state hypnosis societies that offer approved workshops, conferences, and training opportunities. Hypnosis as analgesia surely provides rest, relaxation, and comfort for patients without the negative side effects of other analgesics. In addition, the ultimate benefit of hypnotic analgesia lies in enabling patients to potentiate their inner strength, resulting in improved self-esteem and self-control.

Psychopharmacology (Berl). 1983;81(2):140-3.
Naloxone fails to reverse hypnotic alleviation of chronic pain.
Spiegel D, Albert LH.

The hypothesis that the alleviation of chronic pain with hypnosis is mediated by endorphins was tested. Six patients with chronic pain secondary to peripheral nerve irritation were taught to control the pain utilizing self-hypnosis. Each subject was tested at 5-min intervals during four 1-h sessions for the amount of reduction of pain sensation and suffering associated with hypnosis while being given, in a random double-blind crossover fashion, an IV injection of either 10 mg naloxone or a saline placebo through an indwelling catheter. The patients demonstrated significant alleviation of the pain with hypnosis, but this effect was not significantly diminished in the naloxone condition. These findings contradict the hypothesis that endorphins are involved in hypnotic analgesia.

Comment in: Am J Clin Hypn. 2005 Oct-2006 Jan;48(2-3):163-4.
Pain reduction is related to hypnotizability but not to relaxation or to reduction in suffering: a preliminary investigation.
Appel PR, Bleiberg J. philip.r.appel@medstar.net
Psychology Service, National Rehabilitation Hospital, 102 Irving Street, NW, Washington, DC 20010, USA.

The present study examined the facilitation of pain reduction through the use of a pain reduction protocol. The protocol emphasized converting pain sensations into visual and auditory representations, which then were manipulated through therapeutic suggestion. Hypnosis was not mentioned in the intervention, minimizing creation of expectancy effects related to hypnosis. At the conclusion of the study, the Stanford Clinical Hypnotic Scale was administered. Measures of relaxation and reduction of suffering were not related to hypnotizability. However, pain reduction was significantly related to hypnotizability (r = .55, P < .001). High hypnotizables had a greater reduction in pain than low hypnotizables, even though both had equivalent degrees of relaxation.

J Abnorm Psychol. 1991 May;100(2):223-6.
Effects of active alert and relaxation hypnotic inductions on cold pressor pain.
Miller MF, Barabasz AF, Barabasz M.
Psychology Associates of Spokane, Washington.

We contrasted relaxation and active alert hypnotic inductions with or without a specific suggestion for cold pressor pain analgesia. Groups of high (n = 38) and low (n = 27) hypnotizable subjects were tested; hypnotizability had been determined from results of the Stanford Hypnotic Susceptibility Scale, Form C. Cold pressor pain data were obtained after counterbalanced exposure to relaxation and active alert inductions. Highly hypnotizable subjects demonstrated lower pain scores than did low hypnotizable ones. Pain reports did not differ between induction conditions. Highly hypnotizable subjects given an analgesic suggestion showed lower pain scores than did those exposed only to hypnosis. The findings, conceptualized within E.R. Hilgard's (1977a) neodissociation theory, show that relaxation is not necessary for hypnotic analgesia.

J Human Stress. 1978 Jun;4(2):18-21.
Teaching self-hypnosis to patients with chronic pain.
Sacerdote P.

For the past twenty years hypnotherapy and self-hypnosis have been utilized as valid tools for the successful management of severe protracted pain. Control often has been achieved in cases where other modalities of pain management had been inadequate. Hypnosis properly applied can bring some degree of improvement to 90 percent of patients. More remarkable degree of pain relief is achievable in the 25 percent of patients who have high hypnotic "talent," and with very limited expenditure of time and effort. The author discusses basic theories of pain, pain-control pain-control and hypnosis, and he clarifies the effects of physiological, biochemical, and psychological variables which can affect the procedures and the results. Presentation of a clinical case with quoted excerpts of verbalization serves to illustrate the most important points.

J R Soc Med. 1992 Oct;85(10):620-4.
Hypnoanalgesia for chronic pain: the response to multiple inductions at one session and to separate single inductions.
Lewis DO.

Serial hypnotic inductions conveying the same analgesic message produce a progressively longer response in an increasing number of patients. The resulting analgesia appears to be independent of the spacing of inductions--whether given at a single session or on separate occasions--and to depend upon their number. However, multiple inductions at a single session save time. Elimination of pain can be achieved, by either approach, for a year or more in up to 70% of patients.

Hosp J. 1992;8(1-2):89-119.
Hypnosis and related techniques in pain management.
Spira JL, Spiegel D.

Hypnosis has been used successfully in treating cancer patients at all stages of disease and for degrees of pain. The experience of pain is influenced not only by physiological factors stemming from disease progression and oncological treatment, but also from psychosocial factors including social support and mood. Each of these influences must be considered in the successful treatment of pain. The successful use of hypnosis also depends upon the hypnotizability of patients, their particular cognitive style, their specific motivation, and level of cognitive functioning. While most patients can benefit from the use of hypnosis, less hypnotizable patients or patients with low cognitive functioning need to receive special consideration. The exercises described in this chapter can be successfully used in groups, individual sessions, and for hospice patients confined to bed. Both self-hypnosis and therapist guided hypnosis exercises are offered.

Int J Clin Exp Hypn. 2006 Apr;54(2):130-42.
Hypnosis delivered through immersive virtual reality for burn pain: A clinical case series.
Patterson DR, Wiechman SA, Jensen M, Sharar SR. davepatt@u.washington.edu
University of Washington School of Medicine, Seattle, Washington, USA.

This study is the first to use virtual-reality technology on a series of clinical patients to make hypnotic analgesia less effortful for patients and to increase the efficiency of hypnosis by eliminating the need for the presence of a trained clinician. This technologically based hypnotic induction was used to deliver hypnotic analgesia to burn-injury patients undergoing painful wound-care procedures. Pre- and postprocedure measures were collected on 13 patients with burn injuries across 3 days. In an uncontrolled series of cases, there was a decrease in reported pain and anxiety, and the need for opioid medication was cut in half. The results support additional research on the utility and efficacy of hypnotic analgesia provided by virtual reality hypnosis.

J Psychosoc Nurs Ment Health Serv. 2006 Feb;44(2):22-30.
Hypnosis for pain management.
Valente SM. sharon.valente@va.gov
Research and Education, Department of Veteran Affairs, Los Angeles, California, USA.

Nurses are in a key position to learn and use hypnosis with patients to reduce pain and enhance self-esteem. However, most nurses lack knowledge about the clinical effectiveness of hypnosis and may seek continuing education to become skilled in its use. Painful procedures, treatments, or diseases remain a major nursing challenge, and nurses need complementary ways to relieve pain from surgery, tumors, injuries, and chemotherapy. This article examines the evidence base related to hypnosis for pain management, as well as how to assess and educate patients about hypnosis.

Psychiatr Med. 1992;10(1):101-17.
Pain as a biopsychosocial entity and its significance for treatment with hypnosis.
Wain HJ. Department of Psychiatry, Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences.

Pain is a subjective metaphorical experience. Effective treatment of the pain patient remains an enigma. The present paper considers and reviews the significance of pain from a biopsychosocial perspective. The need to understand and recognize the variables contributing to the biopsychosocial aspects of the pain patient and its use in creating an effective treatment strategy with hypnotic intervention is described. Case reports where several techniques as well as collaborative efforts with other specialties are presented to highlight the discussion.