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Empirical Support for Efficacy
Let us set theoretical considerations aside and return to the practical utility of hypnotic analgesia in clinical situations. Perhaps the best evidence in this regard comes from two randomized studies reported by Lang and her colleagues with patients undergoing a variety of invasive diagnostic and treatment procedures (Lang et al., 2000; Lang, Joyce, Spiegel, Hamilton, & Lee, 1996). In the more recent of these, reported in the Lancet earlier this year, all patients received standard patient-controlled conscious sedation for the procedure, with one third receiving hypnosis and another a structured attention manipulation. The addition of hypnosis afforded significantly greater pain relief than did conscious sedation alone, with the attentional manipulation falling somewhere between. In addition, patient anxiety levels were also lower with hypnosis. Both groups receiving the adjunctive psychological treatment requested, and received, less medication than did those in the standard group. Finally, there were fewer adverse events, such as oxygen desaturation, hemodynamic instability, bleeding from the puncture site, oversedation, and vomiting to distract the surgical team. Perhaps for these reasons, the surgical procedures took significantly less time for the hypnosis group than for the standard care group, by about 15 minutes on average. Unfortunately, Lang and her colleagues did not assess hypnotizability in their patients, but it is a pretty certain bet that these benefits were much greater for those who were at least moderately hypnotizable. Click on the images to view enlarged versions.
Twice in its history, hypnosis has sought a place in the clinician’s repertoire of methods for pain control. The first time was in the middle of the 19th century, before hypnosis even had its name. Unfortunately, it was quickly overshadowed by the discovery of chemical anesthetics. The second time was in the middle of the 20th century, in parallel with the emergence of a substantial body of laboratory research on hypnosis and its underlying mechanisms. This time, although the scientific status of hypnosis was widely acknowledged, the practical use of hypnosis fell victim to the renewed biologization of medical practice. Even so, there is no question that hypnotic analgesia deserves the status of an empirically supportive psycholoical treatment for pain (Chambless & Hollon, 1998; Lynn, Kirsch, Barabasz, Cardena, & Patterson, 2000; NIH Technology Assessment Panel, 1996). To be blunt, hypnotic analgesia is efficacious and specific: its efficacy is supported by a large number of methodologically sophisticated studies conducted by many independent investigators; it is not merely a placebo; in those who are hypnotizable, it is superior to both placebo and alternative psychological treatments such as stress inoculation. Based on the available evidence, approximately 50% of unselected patients can obtain significant pain relief from hypnosis.
The current environment of healthcare, in which consumers are seeking effective alternatives to the chemical interventions that are the standard of care, provides hypnosis with an opportunity to rise again. It is complementary medicine that works, and which rests on an impressive base of laboratory research. But this same environment also offers hypnosis a new challenge: that it be not simply effective, but cost-effective as well. These days, when I tell practitioners about hypnosis, they believe the evidence, but they ask whether it is reimbursable by managed care. Fortunately, many health plans now pay for complementary treatments, so long as there is evidence of their effectiveness. But this practice is likely to continue only so long as the treatments in question are cost-effective as well. The available evidence strongly indicates that adjunctive hypnosis can improve the quality of care, by reducing patient anxiety and the number of adverse events; and that it is cost-effective, by reducing the length of procedures and the use of expensive medications. Now that healthcare consumers have become interested in "natural" alternatives to traditional medicine, and demanding that their health plans pay for them, the time is ripe for a new look at hypnosis and pain, with quality of care and cost-effectiveness in mind.
Click on the final section, References.
Or, return to previous sections:
Prelude to the Modern Era
Laboratory Research on Hypnotic Analgesia
Clinical Studies of Hypnotic Analgesia
Mechanisms 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
Last modified: 04.08.2010 02:58 PM