Hypnosis - use as pain relief and relaxation in labor and childbirth

Hypnosis

Brief history of hypnosis

The history of hypnosis goes back to the 19th Century when in November 1841 Scottish surgeon James Braid attended the demonstration by the traveling mesmerist Charles Lafontaine. The phenomenon of mesmerism was developed at the beginning of the 19th Century by Franz Anton Mesmer who hypothesized that that living organisms possess magnetic fluid or ethereal medium and developed the system of treatments called mesmerism. Mesmerists channeled the magnetic fluid, sometimes by laying hands on various parts of the body. Reported effects included various feelings: intense heat, trembling, trances, and seizures1.

Braid examined the physical condition of Lafontaine’s mesmerized subjects and concluded that they were, indeed, in quite a different physical state. He became convinced that he had discovered the natural psycho-physiological mechanism underlying these quite genuine phenomena, and within days after Lafontaine’s demonstration he began experimenting with his own method.

James Braid concluded that physiological responses were not due to any supernatural or magnetic force, as claimed, but the result of ordinary psychological and physiological processes such as relaxation, focused attention, and suggestion. Braid coined the term Neuro-Hypnotism, meaning a partial sleep or inhibition of the nervous system, which he himself abbreviated to Hypnosis. Eventually Braid formulated the theory that hypnosis was monoideation, or the fixation of consciousness on a single idea or object.

Braid thought of hypnotism as producing a “nervous sleep” which differed from ordinary sleep. The most efficient way to produce it was through visual fixation on a small bright object held eighteen inches above and in front of the eyes. Braid regarded the physiological condition underlying hypnotism to be the over-exercising of the eye muscles through the straining of attention.

He completely rejected Franz Mesmer’s idea that a magnetic fluid caused hypnotic phenomena, because anyone could produce them in “himself by attending strictly to the simple rules” that he had laid down.

The latter statement is important, as it implies that after appropriate instruction individuals can hypnotize themselves and achieve the same benefits as they would by being hypnotized by a professional.

During the next several decades Braid’s work spread throughout the world and was translated to German and French. In the late 19th century fierce debate ensued between Jean-Martin Charcot and Hippolyte Bernheim, the two most influential figures in late 19th century hypnotism.

Charcot, influenced more by the Mesmerists, argued that hypnotism was an abnormal state of nervous functioning found only in certain hysterical women and that it it manifested in a series of physical reactions. Bernheim argued that anyone could be hypnotised, that hypnosis was an extension of normal psychological functioning, and that its effects were due to suggestion. After decades of debate, Bernheim’s view dominated. Charcot’s theory is now just a historical curiosity.

In 1889 The First International Congress for Experimental and Therapeutic Hypnotism was held in Paris, France, on August 8-12, 1889. Attendees included Jean-Martin Charcot, Hippolyte Bernheim, Sigmund Freud and Ambroise-Auguste Liébeault. The second congress was held on August 12-16, 1900.

At the Annual Meeting of the British Medical Association in 1892 hypnosis was unanimously endorsed for the therapeutic use. Simultaneously the theory of Mesmerism (animal magnetism) was rejected. Even though the British Medical Association recognized the validity of hypnosis, Medical Schools and Universities largely ignored the subject.

The modern study of hypnotism is usually considered to have begun in the 1920s with Clark Leonard Hull (1884–1952) at Yale University. An experimental psychologist, his work Hypnosis and Suggestibility (1933) was a rigorous study of the phenomenon, using statistical and experimental analysis. Hull’s studies emphatically demonstrated once and for all that hypnosis had no connection with sleep. Hull’s experiments showed the reality of some classical phenomena such as mentally induced pain reduction and apparent inhibition of memory recall. However, Hull’s work made clear that these effects could be achieved without hypnosis being seen as a distinct state, but rather as a result of suggestion and motivation.

In 1952 a Hypnotism Act was instituted in Britain to regulate stage hypnotists’ public entertainments. On April 23, 1955, the British Medical Association approved the use of hypnosis in the areas of psychoneuroses and hypnoanesthesia in pain management in childbirth and surgery. At this time, the BMA also advised all physicians and medical students to receive fundamental training in hypnosis.

In 1956 Pope Pius XII gave his approval of hypnosis. He stated that the use of hypnosis by health care professionals for diagnosis and treatment is permitted.

In 1958, the American Medical Association approved a report on the medical uses of hypnosis. It encouraged research on hypnosis although pointing out that some aspects of hypnosis are unknown and controversial. Two years later the American Psychological Association endorsed hypnosis as a branch of psychology.

Modern uses for hypnosis

Medical hypnosis is used either as sole treatment or as an addition to conventional treatment for many medical conditions. The list of ailments where it is beneficial includes, but is not limited to, irritable bowel syndrome, hypertension, headaches, asthma, tinnitus, insomnia, neuroses and dermatitis. It has been shown to be beneficial for improving healing after surgery, for reducing nausea and vomiting in patients undergoing chemotherapy, treatment of obesity and cessation of smoking5.

Hypnosis in surgery and anesthesia

The documented use of hypnosis as an adjunct to surgical therapy dates back to the 1830s when Jules Cloquet and John Elliotson performed major surgical procedures with hypnosis as the only anesthetic6. The Scottish physician James Esdaile, who used hypnosis for anesthesia in approximately 300 surgical patients in India between 1845 and 1851, became the best known early hypnoanesthetist. Almost simultaneous with Esdaile’s report, chemical anesthetics (ether in 1846, chloroform 1847) were successfully introduced into surgical practice. Subsequently routine use of hypnosis for anesthesia was discontinued in about 1860, the beginning of the rapid adoption of inhaled anesthesia. Anesthesiologists apparently paid little attention to hypnosis until 1955 when the British Medical Association declared that “there is a place for hypnotism in the production of anesthesia or analgesia for surgery and dental operations, and in suitable subjects it is an effective method of relieving pains in childbirth without altering normal course of labor”.

More recently, the trend towards greater prominence of conscious sedation in anesthesia has reawakened the interest in hypnosis. In its current form, hypnoanesthesia is the combination of hypnotic and pharmacological techniques.

The effect of hypnosis on pain has been studied in volunteers. Pain caused by the stimulation of the supra-orbital nerve, immersion of hand in ice cold water or electrical stimulation of a finger has been significantly reduced by hypnotic suggestions. Moreover, suggestions to evoke exaggerated pain response increased the sensation of pain. Pain relieving effect of hypnosis is not blocked by naloxone, the opioid antagonist, which suggests that hypnosis does not act similarly to opioids. This fact demonstrates that pain has two components: physiological and affective, or emotional. The latter component is modified by hypnotic suggestions.

Hypnosis improves recovery after surgery. Recent review7 published in 2002 focused on the effect of hypnosis on various clinical indicators: negative affect (for example, anxiety and depression) measured by both self-report and observation by others (e.g.medical nurse), pain (both self-report and observation by others), pain medication, physiological indicators ((e.g., blood pressure, heart rate, and stress hormone, recovery (return of muscular strength, postoperative vomiting, and fatigue) and treatment time (length of procedure and inpatient stay). 20 published studies were analysed in the review. The effect of hypnosis on outcomes has been calculated using specialized statistical techniques.

The meta-analysis revealed a significant beneficial effect of hypnosis on studied outcomes. Overall the results indicated that surgical patients in hypnosis treatment conditions demonstrated better outcomes than 89% of patients in the control conditions. Patients in hypnosis groups also reported significantly more satisfaction than those in control groups.

There are reports of hypnosis successfully used to supplement pharmacological sedation for various surgical procedures and even its use as the sole anesthetic. One of the latest reports is that of a professional hypnotist Alex Lenkei, who in April 2008 successfully hypnotised himself before having surgery on his hand and was in no pain throughout the 80 minute operation. His blood pressure and heart rate were also monitored and remained normal, indicating that he was not experiencing any pain.

There are also many reports – albeit less dramatic – of hypnosis used to supplement sedation during various invasive procedures. Such procedures, for example cardiac catheterization, lumbar puncture, liver biopsy, can be performed under local anesthesia alone. Addition of hypnosis improved patient’s relaxation, reduced anxiety and increased patient satisfaction.

What is hypnosis?

Although no consensus definition of hypnosis exists, the studies indicate that hypnosis involves the induction of the state of mind in which a person’s normal critical or sceptical nature is bypassed. This state of heightened receptivity for suggestions (induction) is developed with the cooperation of the patient and is followed by the delivery of positive suggestions. Hypnosis is also described as an “attentive, receptive focal concentration” with the trance state being a “normal activity of a normal mind”, which occurs regularly, as when reading an absorbing book, watching an engrossing movie or performing monotonous activity. During hypnosis the subconscious mind is in a suggestible state while the conscious mind is distracted or guided to become dormant.

Hypnosis may be compared with meditation, which involves quieting of the mind. Meditation is achieved by focusing the attention of repetitive neutral stimulus, such as breathing, continuously repeated word or phrase (mantra), posture or movement, such as in yoga or Tai Chi.

Throughout hypnotic session the person is fully conscious and is free to exert his or her own will at any time. It is not possible to make hypnotised person to perform actions against his or her wishes.

Hypnosis for pain relief in labor

Women can be coached to achieve the state of hypnosis during labor and follow their own suggestions for relieving pain8. Most commonly used suggestions are:

Glove Anesthesia. Imagine that your hand is numb, as if placed in ice water. Then move the hand over the painful area to transfer the numbness there.

Time Distortion. View the time with pain as shorter and the time between painful episodes as lasting longer than in reality.

Imaginative Transformation. Interpret the pain as a benign, acceptable sensation (such as labor contractions being surges of energy that cause only a feeling of slight pressure) and, therefore, not problematic.

The use of hypnosis for relieving pain in labor has been summarized in two meta-analyses. One was conducted by the research group from Adelaide, Australia and published in 2004. The reviewers searched for all relevant trials where hypnosis was compared with non-hypnosis, no treatment or alternative suggestion at any time during pregnancy and childbirth9.

Case reports, case series with no comparison groups were excluded from the review, as were trials where primary goal was not assessment of pain in labor. Five randomized controlled trials (RCTs) and fourteen non-randomized comparisons (NRCs) that were of acceptable quality and together included 8395 women were selected for the analysis.

Once again, this review emphasized problems presented with studying effects of various interventions in obstetric anesthesia, especially such complex and vaguely defined as hypnosis. There was significant variability of actual methodology between individual studies.

Depending on the study, the role of hypnotist was performed by different people: medical student, psychologist, nurse, obstetrician, medical hypnotist. Methods included standard scripts, relaxation, focused attention, self-hypnosis prompts. In some studies patients received individual weekly sessions from 32 weeks of pregnancy with suggestions of relaxation and analgesia. In one study patients attended sessions in groups of 15 and received tape for daily use at home with instructions of use. Other studies included number of individual sessions starting from certain time during pregnancy, teaching of self-hypnosis, auto-relaxation and auto-analgesia.

Randomized studies that assessed the effect of hypnosis on pain reported significantly reduced use of opioids. However, these studies did not offer epidural analgesia as the option for pain relief. In one study where epidural was available there was no difference in its use between hypnosis group and control. On the other hand, those those patients rated to have a good or moderate response to hypnosis had relatively fewer epidurals than those rated poorly responsive. Two NRCs reported lower pain scores and reduced analgesia requirements among those who received hypnosis.

Two studies reported shorter labours in hypnosis groups by over 2 hours. On the other hand, one study found that among those who received ante-natal hypnosis labor was longer by the average of 1.7 hours. Two studies reported significantly reduced need for labor augmentation with oxytocins. One study reported increased rate of spontaneous vaginal delivery (in other words, reduced need for instrumental assistance and caesarean section), though two other studies addressing this issue did not observe this difference.

Another meta-analysis addressing, among other interventions, hypnosis in labor is Cochrane Database review published in 2007. Its study selection criteria were somewhat stricter, and only five randomized trials were included, four of them the same as in the meta-analysis covered in the earlier paragraphs10. Total sample size of the studies included in the analysis was 749 women were included in the studies selected for the analysis (somewhat 10 times smaller than in the previous review). Four out of five randomized trials were small and included between 40 and 82 patients. One new study published in 2004 included 520 patients.

The findings are similar to the earlier review and it stated in the conclusion that “Current available evidence shows that hypnosis reduces the need for pharmacological pain relief, including epidural analgesia in labor. Maternal satisfaction with pain management in labour may be greater among women using hypnosis. Other promising benefits from hypnosis appear to be an increased incidence of vaginal birth, and a reduced use of oxytocin augmentation. There was no evidence of any adverse effects on the mother or neonate. Potentially, medical hypnosis could be used alone for pain relief as part of a woman’s care during childbirth. In practice, however, hypnosis may be best seen as an adjunct to facilitate and enhance other analgesics.”

Complications of hypnosis

Hypnosis is generally safe, and the fact that its use does not require medication makes it very attractive for obstetric analgesia. Few complications have been described, most of them during the use of hypnosis for therapeutic purposes. Few cases have been described in the literature where patients displayed “unanticipated” adverse behaviour after hypnosis. The most common suspected adverse reactions included drowsiness, dizziness, stiffness, headaches, anxiety and, occasionally, more serious reactions, such as organic symptoms. However, there have been no serious complications reported after the use of hypnosis during labor.

Place of hypnosis in obstetric analgesia

Although the use of hypnosis in labor shows promising results, up to date there has been no study comparing hypnosis with epidural, currently golden standard of pain relief for childbirth, and therefore it is impossible to estimate the magnitude of this intervention. There is no standardized methodology of hypnosis, and its efficiency is likely to vary considerably from patient to patient. Selection bias is not likely to be eliminated even in best designed studies, and hypnosis group will always have patients who believe in this method.

Not all women are appropriate candidates for hypnosis. For example, a woman who is unable to follow verbal directions (e.g., a woman with severe mental retardation) would probably not be successful at self-hypnosis. Other contraindications to hypnosis in labor are:

  • severe psychiatric illness such as paranoia or delusions
  • undiagnosed, untreated medical illness presenting with pain
  • active involvement in personal injury litigation related to pain
  • little or no ability to be hypnotized due to disinterest or disbelief in its efficacy, or conflicts with religious beliefs.

Current research shows some positive results, and hypnosis is a viable alternative of pain relief during childbirth for those who want to avoid medication during the process.

References:

1. http://en.wikipedia.org/wiki/Mesmerism#.22Mesmerism.22 

2. http://en.wikipedia.org/wiki/James_Braid_(surgeon)#Mesmerism

3. http://www.ukhypnosis.com/Definitions.htm

4. http://en.wikipedia.org/wiki/Hypnosis

5. Stewart JH. Hypnosis in contemporary medicine. Mayo Clin Proc. 2005 Apr;80(4):511-24. Review.

6. Wobst AH. Hypnosis and surgery: past, present, and future. Anesth Analg. 2007 May;104(5):1199-208.

7. Montgomery GH, David D, Winkel G, Silverstein JH, Bovbjerg DH. The Effectiveness of Adjunctive Hypnosis with Surgical Patients: A Meta-Analysis. Anesth Analg 2002;94:1639–45

8. Ketterhagen D, VandeVusse L, Berner MA Self-hypnosis: alternative anesthesia for childbirth. MCN Am J Matern Child Nurs. 2002 Nov-Dec;27(6):335-40; quiz 341. Review.

9. Cyna AM, McAuliffe GL, Andrew MI. Hypnosis for pain relief in labour and childbirth: a systematic review. Br J Anaesth 2004; 93: 505–11

10. Smith CA, Collins CT, Cyna AM, Crowther CA. Complementary and alternative therapies for pain management in labour. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD003521. DOI: 10.1002/14651858.CD003521.pub2.

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Dr. Eugene Smetannikov is a practicing anesthesiologist with the interest in obstetric anesthesia. He is the author of the most comprehensive book on the subject, The Truth About Labor Epidural