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Clinical Studies in the Modern Era
Even before systematic laboratory studies appeared to support the practice, clinicians in the field were returning to hypnosis. In part, the revival of interest in clinical hypnosis was stimulated by the successful use of the technique during World War II, where chemical analgesics and anesthetics were not always available for the treatment of wounded soldiers. In preparing their authoritative review of Hypnosis in the Relief of Pain, Hilgard and Hilgard uncovered more than two dozen cases, published between 1955 and 1974, in which hypnosis served as the sole analgesic or anesthetic agent (Hilgard & Hilgard, 1975). One enthusiastic practitioner of clinical hypnosis even had a film made of her own cosmetic dermabrasion, essentially sandpapering off whole layers of facial skin with hypnosis as the sole analgesic, just to show it could be done. Recently, a group of Belgian investigators reported a series of 1,650 surgical cases attempted with "hypnosedation", in which fewer than 1% required a switch to general anesthesia (Faymonville, Meurisse, & Fissette, 1999). Nevertheless, the general consensus is that vanishingly few patients, far fewer than the 10% or so who qualify as hypnotic virtuosos, are hypnotizable enough to tolerate such procedures with hypnosis alone. This should only be attempted as a last resort, and the real applications of hypnosis lie elsewhere.
One of these applications is obstetrics. So far as labor pain is concerned, regional and general anesthetics will do the job, but ever since Queen Victoria took chloroform during the delivery of her eighth child, there has been concern that drugs might increase the risk to the fetus, detract from the experience of childbirth, or interfere with the mother-child bond. These concerns help explain why chemical anesthesia, quickly embraced for other surgical procedures, was not widely adopted for obstetrics until late in the 19th century (Pernick, 1985). By the 1950s, obstetricians were already familiar with other psychological techniques for pain reduction, such as Dick-Readís "natural childbirth", the "Lamaze method", and Schultzís autogenic training. It seems likely that the desire to avoid drugs whenever possible explains why some of them looked to hypnosis as a scientifically respectable, more mainstream alternative.
In any event, a pioneering large-scale study by Ralph August reported on 1000 consecutive cases, in which hypnosis was attempted in 850 (August, 1961). Of these, 58% required no medication at all, 38% required only minor analgesics such as Demerol, and 4% abandoned hypnosis entirely in favor of local or general anesthetics. At about the same time, Davidson reported that the benefits of hypnosis were equal to those of natural childbirth in the first stage of labor, and superior in the second stage (Davidson, 1962). Other early reports indicated that hypnosis is associated with decreased frequency of premature labor (and thus spontaneous abortion), reduced duration of labor, more rapid recovery from birth asphyxia in the neonate, and increased satisfaction with the childbirth experience on the part of the mothers. Click on the images to view enlarged versions.
Similar results were obtained in cancer treatment. Some enthusiasts have tried to treat cancer directly with hypnosis, suggesting that subjects imagine "good cells" fighting off "bad cells" and the like. This rarely works, of course, and when it does seem to work the remission is almost certainly adventitious and has nothing to do with hypnosis. Nevertheless, the patients often obtain considerable relief from pain caused either by cancer or its treatment. Cangello studied 81 patients, 73 of whom seemed to be at least moderately hypnotizable (Cangello, 1961). Of this subgroup, his clinical impression was that almost 70% achieved good to excellent relief of chronic pain. For the 22 patients for whom narcotics had been prescribed for pain control, 63% showed an immediate decrease in medication usage to 50% or less of base levels; this reduction lasted for a week in 54%, and for 1 to 3 months in 18%, with no reinforcement of the hypnosis. Click on the image to view an enlarged version.
Unfortunately, these studies appeared on the eve of a revolution in medical practice. Clinical medicine has always been based on biology, of course, but the golden age of antibiotics, in the 1940s and 1950s, culminated in the apparent conquest of infectious disease and prompted advances in immunology that promised to prevent disease at its source. New generations of analgesics and anesthetics came onto the market, as well as new procedures such as epidural anesthesia for childbirth and conscious sedation for outpatient procedures. These developments led physicians once again to turn away from hypnosis and toward drugs.
A study of hypnosis in dentistry makes the point (Gottfredson, 1973). Gottfredson found that 56% of hypnotizable patients were able to complete their procedure without any chemical analgesic at all, and this figure was 75% for those of relatively high hypnotizability. However, local anesthetic produced a comparable effect, without any individual differences in response. Although mesmeric coma was used for dentistry prior to the introduction of chemical anesthesia, and many dentists still use hypnosis to treat anxiety in the chair, chemical analgesics and anesthetics are simply more reliable, and these days hypnosis is rarely used for the relief of dental pain. Click on the image to view an enlarged version.
In the late 1970s, Joseph Barber (Barber, 1977) claimed a 99% success rate with an innovative technique, which he calls "rapid induction analgesia", in a series of unselected patients. A follow-up study by Gillett and Coe (Gillett & Coe, 1984) yielded a success rate more like Gottfredsonís, 52%. Outcome was uncorrelated with hypnotizability, however, suggesting that whatever effects RIA has are not mediated by hypnosis.
Despite these promising
results, there have been virtually no controlled, quantitative studies of
hypnotic analgesia in clinical settings (Chaves, 1989; Chaves & Dworkin,
1997; D'Eon, 1989; Holroyd, 1996; Milling & Costantino, 2000; Pinnell &
Covino, 2000). One exception is in the area of obstetrics, where more recent
studies have confirmed and extended the early results of August and Davidson (Brann
& Guzvica, 1987; Freeman, MacCauley, Eve, & Chamberlain, 1986; Jenkins
& Pritchard, 1993). Another is cancer, where a number of studies support the
use of hypnosis. In a pioneering study, Josephine Hilgard and Sam LeBaron
(Hilgard & LeBaron, 1982) offered hypnosis to 63 consecutive children who
were receiving bone marrow aspirations required for treatment of leukemia. Of
the 24 who accepted the referral, 19 proved to be at least moderately
hypnotizable. After only one session of training, 10 of these patients were able
to reduce felt pain during the procedure by at least three points on a 10-point
scale; with a single additional training session, the success rate rose to 15 of
19 when the procedure was repeated about six weeks later. None of the five less
hypnotizable subjects reported substantial relief of pain on either occasion.
Similar findings were obtained in another study of children with leukemia being
treated with bone marrow transplants (Syrjala, Cummings, & Donaldson, 1992).
Click on the image to view an enlarged version.
Click on the next section, Mechanisms of Hypnotic Analgesia
Or, click on other sections:
Prelude to the Modern Era
Laboratory Research on Hypnotic Analgesia
Efficacy of Hypnotic Analgesia
John F. Kihlstrom, PhD
Plenary address presented at the annual meeting of the American Pain Society, Atlanta, Georgia, November 3, 2000. The point of view represented in this paper is based on research supported by Grant #MH-35856 from the National Institute of Mental Health. I thank Lucy Canter Kihlstrom for her comments. Painting by Richard Bergh (1887).
Copyright © 2000 Institute for the Study of Healthcare Organizations & Transactions
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