While hypnosis, in the medical setting, has traditionally been used for anxiety and pain control -- its most popular applications -- it has also been used for some of the individual needs of medicine's specialties. Each specialty, dealing with different facets of human problems and treatment, has found ways to apply hypnosis successfully to the problem of improving patient care.

HYPNOSIS IN OBSTETRICS

The practice of hypnotically assisted deliveries has a history of over a century. Falling into disfavor due to competition from chemical anesthesia, hypnosis has seen a revival in the last two decades. One important reason for this comeback is the realization that hypnosis may find usefulness not only in obstetric analgesia or anesthesia, but in all phases of giving birth from pregnancy to postpartum recovery.

Russian medicine has had extensive experience with obstetric hypnosis. Platanov, in the 1920s, became well known for his hypnoobstetric successes. Impressed by this approach, Stalin later set up a nationwide program headed by Velvoski, who originally combined hypnosis with Pavlovian techniques but eventually used the later almost exclusively. Ferdinand Lamaze, having visited Russia, brought back to France "childbirth without pain through the psychological method," which in turn showed more reflexologic than hypnotic inspiration.

In the Western hemisphere, Roig-Garcia used suggestion, given in the hypnotic trance during predelivery training, to decondition, mostly by verbal means, the patient's culturally determined associations to childbirth. Seeking to counter the deeply ingrained but nevertheless learned concepts that equate uterine contraction with pain and fear, Roig- Garcia, in his hypnoreflexogenic method, worked to manage delivery in a state of "vigil," where the patient, fully awake, aware, and conscious of uterine contractions, is free of a "pain complex or component." In hypnotically assisted deliveries, it is found that the well-relaxed patient makes smoother transitions from one stage of labor to the next. Relaxed deliveries are not noted for their rapidity -- nor should they be. Deliveries that are unhurried and made within the context of global physiological and psychological comfort allow all tissues -- the mother's as well as the child's -- to adapt gently to changing conditions.

In the United States there has been an increased interest in these methods since the 1960s. The reasons are undoubtedly complex. Often cited is a trend towards respect for natural physiological processes, and dissatisfaction with chemical, mechanical, or operative interventions. There is, indeed, always some risk to the mother and to the infant when chemical anesthetics are used. Hypnosis, on the other hand, has never been shown to be injurious to either.

Werner, in the United States, delivered over 3000 babies since 1959 with hypnotic adjunctive techniques (before that time he delivered 6000 babies with chemical anesthesia). Ten percent of women did not respond to trance induction; 30% required some and always less, chemical anesthesia; the remaining 60% used no chemical anesthesia at all.

Advantages of using hypnosis in obstetrics The advantages of using hypnosis in the delivery process are summarized below.

1. Hypnosis as a physiological and psychological relaxant can make the delivery process more humane. By giving the patient a sense of handling this natural function by her own mental resources, self-esteem is increased.
2. If adjunctive chemical anesthetics are needed, they can be administered promptly and easily. The interesting feature, however, is that if they need to be used, lesser amounts are clinically effective, with benefits to mother and child (August, 1960; Oystragh 1970).
3. Hypnosis does not inhibit normal emotional responses to the birth process and the immediate bonding to the child, as does chemical anesthesia. If properly negotiated in a natural fashion, giving birth in the state of vigil is a profound, deeply constructive human experience.
4. Hypnosis helps in the preparation for delivery and in the recovery process. Anticipatory anxiety can be lessened and the return to normal functioning can be optimized. Often, chemical anesthetics cause a hangover which can last up to two days. Using hypnotic techniques, there is smoother transition back to normalcy.

Objections to using hypnosis in obstetrics In 1961, the American Psychiatric Association issued an official statement which contained the following: "Hypnosis is a specialized psychiatric procedure and, as such, is an aspect of the doctor-patient relationship. Hypnosis provides an adjunct to research, to diagnosis, and to treatment in psychiatric practice. It is also of some value in other areas of medical practice and research"; and "whoever makes use of hypnotic techniques, therefore, should have sufficient knowledge of psychiatry, and particularly psychiatric dynamics, to avoid its use in clinical situations where it is is contraindicated or even dangerous." This ruling has dampened the general use of hypnosis in obstetrics, and there are still controversies deriving from it. By all evidence, a rational stance may be embodied in the opinion that obstetric hypnosis is safe in the hands of adequately trained medical personnel. In cases where the patient has shown psychopathology, by history or mental status, it may be argued that special consultation be made with a psychiatrically oriented hypnotherapist.

Is hypnosis too time-consuming? The same question is often posed concerning dental hypnosis. Perhaps, at face value, the patient hours spent for hypnotic training do not appear to be cost-efficient. However, if we look at other factors, such as ease of delivery, increased speed of recovery, and the global benefits to the mother as well as the child, the question may be quickly settled.

Practical considerations Women may receive hypnotic training individually or in groups. While individual sessions suit the needs of many patients, the group experience offers the opportunity to share important feelings.

In training sessions, the patient is taught how to produce a trance, first through the doctor-patient relationship (heterohypnosis), then by herself (autohypnosis). An important part of the program is education: the anatomy, physiology, chronobiology, and physiology of the birth process including an exploration of the feelings commonly encountered and how to experience them in natural perspective, ie, tension as tension, not as pain. Training progresses to the learning of deep relaxation and to the technique of dissociation, ie, "if you begin to feel the uterus contracting strongly, and if you want to take a rest while it does so by itself, simply let yourself drift further into deep trance . . . "

Hypnotic training may begin, ideally, as early as the first trimester of pregnancy. Many patients, however, who have not had the benefit of advance preparation, may be helped by trance induction even when labor has already begun.

Utilized during pregnancy, hypnosis may help patients cope with some of its physiological effects. Nausea and vomiting, a frequent manifestation (up to 50%) of pregnancies, usually starting in the fourth or fifth week and lasting for an indefinite period, can be debilitating and even dangerous. Drugs, of course, should be avoided because of possible teratogenic effects. Hypnotic treatment, of nausea and vomiting has been talked about in Chapter 11. Although resulting from different mechanisms than those responsible for anti-neoplastic drug effects, nausea and vomiting during pregnancy can be successfully approached through these same techniques. Since many women complain of unpleasant metallic tastes in the mouth, suggestions are given for fresh minty breath, as well as for easy transit of foods. Ptyalism (the overproduction of saliva), pruritus, and heartburn are all antenatal conditions which may respond to hypnotic treatment.

Hypnosis and related natural childbirth methods Several methods of preparation for childbirth have been developed in the last few decades, and the number of participants attest to the interest and need of women for a holistic approach to giving birth. The natural childbirth method of Read (1953), the psychoprophylactic method of Velvoski, and the painless childbirth method of Lamaze (1958) all use suggestion to various degrees, emphasize relaxation, and give the patient reassurance and a sense of control over the entire process. Although no formal induction exists in these methods, the degree of similitude to hypnosis is striking.

HYPNOSIS AND SURGERY

The hypnotic phenomenon which perhaps inspires the most awe and drama involves the unanesthetized patient who undergoes major surgery. According to Moll, the first surgical operations on magnetized subjects were those performed by Recamier in 1821. Cloquet followed him in 1829, Elliotson in England, Dr. Albert Wheeler in the United States, and the well-known Dr. Esdaille in India (1840).

In suitable subjects, it is recognized that through hypnotic mechanisms, a sufficient level of anesthesia may be produced to block all subjective perceptions of pain. However, many authors point out that pain is a sensation intimately intertwined with fear and that surgical procedures performed with hypnotic anesthesia owe their success to the abolition of anxiety as much as to the abolition of pain. Furthermore, a careful analysis of historical cases, as well as modern ones, points to the fact that major operations may not have been as pain free as originally supposed.

Since 1950, interest in hypnoanesthesia has rekindled. Suppressed by the discovery of chloroform, ether, and nitrous oxide for over a century, this new interest has been fueled not only by the growing sophistication in understanding hypnosis, but by new philosophies of patient care: patients should have access to any treatment modality capable of easing the stress of disease and its treatments.

If hypnosis is able to achieve pain block in only a small minority of patients, it is pointed out that as a partial anesthetic and a tranquilizer, it may reduce the dosage of premedication and of anesthetics. Seeing that many patients have compromised pulmonary, cardiac and renal status, and that anesthetic deaths account for one per ten thousand cases, hypnotic intervention could have appreciable benefits.

Several modern accounts of surgery using hypnoanesthesia -- usually used because of the patient's poor previous response to anesthetics, and for such procedures as prostatectomy, breast tumor or thyroid nodule excision, and temporal lobectomy among others -- indicate that hypnosis has a wide range of effectiveness for anxiety and pain reduction. In a small proportion of cases where hypnoanesthesia was unaccompanied by any medications, some patients appeared to experience pain sensations, as evidenced by increased blood pressure, increased cardiac and respiratory rate, wincing, and frowning, while others did not. In those who seemed to feel pain, recollection was variable, and in cases where adjunctive medications were used, ie, opiates, local anesthetics, sedatives, and anxiolytics, doses were usually smaller than in the average case.

It is estimated by some investigators that 10% of the population could undergo major procedures with hypnoanesthesia (Lederman et al, 1958); others estimate the figure to be far lower (Wallace and Coppolino, 1960).

Patient selection appears to be very important. Adequate studies are lacking, but we would expect good candidates for hypnoanesthesia to be highly hypnotizable. However, high hypnotizability is not necessarily correlated with heightened ability to achieve anesthesia. The importance of other factors, including motivation and rapport, has not been measured.

Few people today seriously suggest that hypnoanesthesia should be used as the sole anesthetic in major surgery. The percentage of suitable candidates is too few and the variables and unpredictability of responses are too great. The combination of chemical and hypno-anesthesia, however, is stimulating serious interest. Besides the already mentioned effects of reducing doses of sedatives and analgesics, hypnosis may address itself to subconscious mechanisms which may positively influence operative outcome and recovery.

Preoperative preparations The preoperative hypnotic preparation of the patient can be handled in a variety of ways. Some authors recommend that that there be a rehearsal of the operation under hypnosis, with recreated conditions made to be as real as possible, to familiarize the patient with the procedures, the sensations commonly encountered, ie, the wet sponge to prep the skin for incision, the sound of clamps, hemostats, etc (Crasilneck and Hall, 1975).

Less time-consuming, but possibly not as effective, is a preoperative hypnotic induction during which a general description of the procedure is drawn and appropriate suggestions are given. Mention may be made before the operation that the patient will be calm, will rest soundly, and eat or not eat as required, with comfort; that, as anesthesia is given, it is to be accepted willingly and that pain sensations will be blocked; that during the operation, breathing will be restfully slowed and healing dreams are likely to be encountered. For the postoperative period, the patient is told that recovery will be rapid, discomfort minimal, and healing accelerated.

Such hypnotic procedures may be applied to any phase of the operative process. Preoperatively, it allays anticipatory anxiety and allows for more restful adaptation. If the hypnotherapist is to be present during the operation, this should be mentioned to the patient because it will set the stage for future hypnotic rapport.

Commentaries on "anesthesia awareness" It has been assumed for decades that a patient in the deeper or even moderate levels of chemical anesthesia was in a state of other worldliness and had given up all semblance of consciousness. Crile (1947) reported the case of a patient receiving nitrous oxide (as well as his own case in his autobiography) where some awareness of the environment was preserved. While insufficient levels of anesthesia were first invoked, reports of more cases of preservation of partial awareness in documented deep levels of anesthesia prompted studies to investigate this phenomenon.

Wilson and Turner (1969), in a study involving questioning of 150 postcesarean patients, found three who accurately recalled factual events and 46 who maintained some dreamlike experiences of the operation. More recent studies have focused on the hypnotic recollection of the operative experience. While consciously, patients may have little or no recall, some -- especially highly hypnotizable ones -- are able in the context of trance, to reexperience important events within the operative procedure. It has been reasonably established that such patients are attuned, in such situations, to meaningful communications by the treating personnel, especially the perceived significant personnel, ie, the surgeon and anesthesiologist. This has prompted hypnotherapists in their preoperative hypnotic induction to add suggestions to protect their patients against inadvertently negative communications which may be reacted to, physiologically and psychologically, with stress reactions. If, for example, one of the surgeons mentions "there's a lot of blood loss here," the patient may respond with a rise in blood pressure and increased heart rate, making cardiac instability more likely.

Uses of hypnosis during the operation The clinical implications of the maintenance of some awareness during anesthesia, as far as the hypnotherapist is concerned, is that some degree of hypnotic contact may be established during the course of the operation for purposes of helping the patient adjust to its vicissitudes. It is well known, for example, that given some tightness of the abdominal muscles, surgeons often ask for more anesthesia. This may not be necessary, if the hypnotherapist gently whispers suggestions to that effect to his deeply anesthetized patient.

Hypnosis in the postoperative period If the patient has been adequately prepared in the preoperative hypnotic session, very little time need be spent in the postoperative induction. The patient, readily entering the trance, can be given suggestions for dealing with all phases of the recovery process: rest, comfort, biological functions, control of bleeding, etc.

HYPNOSIS IN BURN PATIENTS

Patients who are severely burned characteristically show a variety of major problems. In addition to severe constant pain and the trauma engendered by the need for repeated treatments such as debridement, there are loss of appetite, contractures, poor mobility, and often severe psychological symptoms: despair, hopelessness, helplessness, regression, and a psychological set of "giving up." Nausea and anorexia compound the problem by causing weight loss.

The treatment of the burned patient may start as early as a few minutes to several hours after the time of the burn. Some clinicians report that post-burn hypnotic anesthesia can decrease the inflammatory response and lead to lessened destructiveness of the injury. Suggestions may be given for coolness of all burned areas by using imagery of ice and snow (Ewin, 1978).

The burned patient has a long, arduous road to recovery, and hypnosis may be of help in reestablishing adequate physiological functions and in maintaining hope and the will to live.

HYPNOSIS AND DENTISTRY

The use of hypnosis in dentistry has a long history. In 1837, Oudet, a French dentist, used hypnoanesthesia for a dental extraction -- the first reported case. Ribaud and Kiaro, in Poitiers, France, similarly excised a tumor of the jaw in 1847. Since then, many reports dealing with hypnodontia -- the use of hypnosis in dentistry -- have attested to the increasing sophistication of hypnotic procedures to deal with the special problems of the dental patient. Besides smoothing out dental procedures by way of its generalized antianxiety effects, it can increase overall patient comfort, make the dental experience acceptable and bearable, decrease resistance to future intervention, and through posthypnotic suggestions, encourage more rapid recovery.

The orofacial region holds special importance for its connections to vital functions and for its place in the individual's psychosexual development. This area is inherently connected to major sensory pathways -- vision, hearing, sight, smell, and touch -- and has intimate jurisdiction over breathing, food intake, and communication of speech and feelings. Freud (1953) labeled the oropharynx as an erotogenic zone and Erickson (1950) described early oral experiences as of central importance to the development of basic trust. Teeth, in reality and symbolically, have priceless value.

Indications for using hypnosis in dentistry It is understandable, in view of these considerations, that many individuals have anxieties about dental procedures. Some, in fact, are so phobic that they prefer to allow serious pathology to develop, rather than to seek help. Apprehensive patients usually have difficulties citing specific fears they may have about dental procedures -- fears of pain while constrained in the chair, a variant of claustrophobia is often cited, as is the fear of choking or drowning in secretions, the fear of mutilation, the fear of fainting, of being unable to talk, and the fear of disapproval by the dentist for lack of self care. Some of these fears may tie into other, more primitive ones, such as the fear of castration, helplessness, or oral aggression.

While some anxiety and tension is normal with most dental procedures, higher levels interfere significantly with the treatment. Some investigators place the incidence of dental phobias at 6.9% of the general population, and 16% in school-age children (Gale and Ayer, 1969).

When mild, an anxiety tension response can be managed by the dentist through the use of reassurance, explanation, and suggestions for relaxation. Of significant benefit is mellifluous music as well as the pleasant chattiness of the dentist.

When phobias are more severe, the patient is commonly found sitting stiffly in the chair or exhibiting strained movements, The facial and nuchal muscles are contracted, the jaw barely open, and attempts at evaluation and treatment are met with stiff unvolitional opposition. Ordinary relaxation procedures are partially and inadequately effective. A sedative hypnotic taken an hour before the visit is also only partially effective and has the drawback of sedating the patient for several hours. Such a patient may benefit from a formal hypnotic induction with the examination and treatment done in the trance state or in a posthypnotic relaxed state. While some dentists may balk at the idea of taking time to tap into the benefits of hypnosis, it is pointed out that once the patient is relaxed, procedures are done much more quickly and subsequent procedures are handled much more smoothly through the use of posthypnotic suggestions.

Sample suggestions may include the following "as you sit relaxed, I'd like you to listen to the music around you, letting yourself flow with it. It takes you automatically into relaxation, your whole body becoming more relaxed with each breath; your jaw and mouth and gums and throat become so relaxed that the muscles get softer. While you're listening to the music, your entire mouth can feelfeel to be further and further away from you -- you feel it but it is out there in the distance; and as I open your jaw gently and take a look at your gums, you may feel your whole body becoming more comfortable and relaxed. As I do my work, I'll describe everything that I do beforehand so that you know what is going on."

Some dental phobias may require hypnobehavioral techniques, ie, hypnodesensitization, flooding (anxiety evoking stimuli are presented to the hypnotized patient in stepwise fashion or the hypnotized patient is presented with maximally anxiogenic material). Other approaches include psychotherapy or hypnotic age regression. Stolzenberg (1950) used the latter method to elicit from two patients the fact that they were frightened because of dental stories that they had heard several years previously.

Gagging is connected to anxiety and can present major problems for the dental patient. Some patients find it very difficult to have impressions taken or to wear dentures. Hypnosis has had marked success in the control of this unpleasant reflex.

Hypnosis for dental analgesia Using hypnosis in dentistry for analgesia presents several benefits over chemical anesthesia. It does not produce chemical numbness, which annoys the patient for several hours after the procedure and is responsible for patients slurring their speech or inadvertently biting their inner cheek; it avoids chemical risk factors; and it avoids the often dreaded needle. As in hypnoanesthesia used in surgery, unfortunately, it can only be satisfactorily and completely effective when used alone in about 10% of the population. However, it is partially and significantly effective in a much larger percentage, and when more extensive dental work is necessary it is able to reduce chemical anesthetic dosages.

Extractions, root canal procedures, deep filling, and periodontal work can all be made to be more pleasant and paradoxically less time-consuming by attempting a simple induction and giving suggestions for numbness and relaxation. In the dental setting, numbness of the index finger can first be produced; the patient's hand is then guided into his mouth to touch the gums and teeth. Seeing the interrelationship of pain and anxiety previously mentioned, suggestions are also provided for calm and for "being here now," to dissipate anticipatory ideation. In an alternative technique, the dentist, while the patient is in a trance, touches the area of the jaw, first externally then internally with paired suggestions for relaxation and numbness, gradually extending numbness to the entire oropharynx, with preservation of essential reflexes such as swallowing and gagging.

Control of bleeding The purported ability of hypnosis to decrease bleeding has been widely mentioned in the literature (Newman, 1974). Anecdotal reports attest to a phenomenon found in hypnotized patients in which incisions are remarkably free of bleeders. A study comparing clotting before and during the hypnotic trance did not demonstrate significant changes. Hypnosis, however, if indeed it has effects on bleeding, probably does so at the tissue arteriolar level rather than on clotting time.

Because bleeding in dental procedures is not a serious problem, the use of hypnosis to control bleeding has mostly been indicated for hemophiliacs.

Pediatric dental hypnosis Good dental education is best done early. Due to the impressionable and highly suggestible nature of children, it is especially important to provide, from the start, programs of dental care which are as free of discomfort as possible and even possibly somewhat fun. Some dentists, for example, with commendable imagination, mention to their young patients that the dental office can be thought of as a modified spaceship.

In most cases, an unhurried empathic attitude, combined with reassurances will suffice. Hypnosis may be indicated for the child needing more involved work or the child who has had previous negative experiences.

Hypnotic work with children, while similar to adult hypnosis in substance, requires some modifications. The shorter attention span of children requires more absorbing, interesting, and innovative induction procedures. The suggestions and language must correspond to the child's verbal capabilities. The child needs immediate reward and praise for his hypnotic achievements. Successful techniques are more apt to use fantasy or imagery, concrete suggestions using specific images, and ego -- strengthening methods to enhance the child's self-image for mastering the problems at hand.

HYPNOSIS IN OTHER MEDICAL CONDITIONS AND SPECIALTIES

The hypnotherapist, to be maximally effective and innovative, needs to develop knowledge of the wide ranges of possible applications of hypnotic techniques in different medical settings and for different medical problems. The literature contains many examples of how hypnosis has been applied, often creatively, to aid in the overall management of patients with specialized problems.

Neurological applications have included using hypnosis in Parkinsonism since psychological factors tend to aggravate the expression of disease. Along with chemotherapy, hypnosis can be applied to relaxation, to the improvement of ambulation and speech, and to the diminution or abolition of negative scenarios the patient may have built up about his illness.

The symptoms of multiple sclerosis, whose remissions and exacerbations can be accompanied -- and contributed to -- by anxiety, depression, and stress, can be better managed by the adjunctive use of hypnosis. Although the pathophysiology of the lesions is not altered by hypnosis, the subjectively ominous or catastrophic reactions to exacerbations can be softened.

In orthopedics, hypnosis can be used for helping the patient adjust to different positions required for longer-term healing. In the emergency situation, hypnosis can assist the frightened and tense patient who needs a reduction procedure.

In plastic surgery, similarly, when it may be necessary for the patient to maintain an uncomfortable position for successful skin or pedicle grafting, hypnosis can minimize bodily irritations and the desire to move.

In gynecology, clinicians have used hypnosis for functional dysmenorrhea, premenstrual and menopausal syndromes, and special procedures.

The ophthalmological and otolaryngeal specialties have found hypnosis to have positive effects on glaucoma (Berger and Zamet, 1960) and suppression of amblyopia; it has also been used in cataract removal and for the adjustment to contact lenses. Globus hystericus, hysterical aphonia, gagging, and tinnitus are other conditions with strong psychogenic overlays which are especially responsive to hypnotherapy.

In urology, hypnosis has found applications in cystoscopy and vasectomy, not only to make the procedures more comfortable, but to help ensure smooth psychological adjustment.

All symptoms and all diseases have or are repercussions on some aspect of mental functioning. Keeping this fact in mind, the clinician may, when applicable and appropriate, think about using hypnosis to enhance total patient care.

SUGGESTED READING AND REFERENCES