Hypnosis/Hypnotherapy

STUDY PURPOSE: To synthesize the evidence regarding immediate and sustained effects of hypnosis on anxiety in patients with cancer

TYPE OF STUDY: Meta analysis and systematic review

DATABASES USED: Scopus, Medline, PsycINFO, Academic Search Premier, CINAHL, and SDOL

INCLUSION CRITERIA: Hypnosis used as intervention, children or adults with cancer, sufficient data for meta analysis, anxiety was an outcome variable

EXCLUSION CRITERIA: Hypnosis combined with another psychological intervention, comparison of different types of hypnosis

TOTAL REFERENCES RETRIEVED: 1,483

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Assessment of quality based on the Cochrane guidelines for RCTs. 13 studies were RCTs and 7 were quasi-experimental design

FINAL NUMBER STUDIES INCLUDED: 20 

TOTAL PATIENTS INCLUDED IN REVIEW: 878

SAMPLE RANGE ACROSS STUDIES: 25-87

KEY SAMPLE CHARACTERISTICS: The majority of studies were in breast cancer survivors; 6 studies were in children

Across all 20 studies, the immediate effect size was significant in favor of hypnosis (Hedges g = 1.05, p < 0.01). There was also significant heterogeneity. The sustained effect size was also significant in favor of hypnosis (Hedges g = 1.69, p < 0.01) across five studies. Heterogeneity for sustained effects was also significant. Hypnosis was more effective when it combined therapist delivery with self-hypnosis than self-hypnosis only. Higher effect sizes were seen in studies of children, with procedure-related anxiety and studies with RCT design. Analysis suggested publication bias, and showed that smaller studies tended to report more positive results. With adjustment for bias, the effect size was reduced from 1.05 to 0.46.

Hypnosis can be beneficial to manage anxiety among patients with cancer. Therapist delivered alone or in combination with self-hypnosis was more effective than self-hypnosis alone.

• Limited number of studies included
• High heterogeneity
• Low sample sizes
• Varied timing, method of delivery and measurement of outcomes. Sample was too small to do relevant subgroup analyses

Hypnosis may be a helpful intervention to manage anxiety in adults and children with cancer for short- and long-term effects. Therapist involvement was more effective than self-hypnosis alone. For patients with significant anxiety, this may be an intervention to be considered.

To perform an integrative review of four electronic databases to determine the effectiveness of complementary and alternative medical (CAM) interventions, either alone or as an adjunct to pharmacologic therapy, in alleviating procedure-related pain, anxiety, and distress in children and adolescents with cancer

Databases searched were MEDLINE, CINAHL, PsycINFO, and Cochrane Database.

Search keywords were procedure, pain, anxiety, distress, childhood cancer, pediatric oncology, CAM, and complementary therapies.

Studies were included in the review if

• The studies were case reports or reports of a clinical series or reports of clinical trials that included at least one CAM intervention aimed at reducing procedure-related pain, anxiety, or distress
• The studies reported on a CAM intervention in one of the following: bone marrow aspiration or biopsy, lumbar puncture, injection, venipuncture for the purpose of blood sampling or starting an IV, or percutaneous access (excluding surgical procedure) to an implanted vascular device
• The sample included at least some children and adolescents (that is, young people between the ages of 2 and 18 years) with cancer
• The studies were published in English

Excluded from the review were studies that reported on surgical procedures (except percutaneous access to an implanted vascular device) and on the anxiety and distress of a parent.

• Investigators retrieved a total of 195 references.
• Reviewers read each paper and extracted information, including names of authors, publication year, study design, medical procedure performed, CAM modalities studied, description of study sample, level of evidence, and summary of  results.
• Results were analyzed for themes.

• Thirty-two studies—two meta-analyses, 18 experimental studies, 9 quasi-experimental studies, one nonexperimental study, and two case studies—were included in the review.
• The total sample size was 1,760, with a range across studies of 3–514 participants.
• Eleven studies included children with leukemia only; 13 included children with various cancer diagnoses other than leukemia; and 8 included children with a range of pediatric illnesses, including cancer.
• Seven studies reported on children younger than 10 years, 3 studies reported on older children (10–17 years), and 22 studies included both age groups.

• Phase of care: diagnostic
• Clinical applications: pediatrics, procedure-related

Results suggest that mind-body intervention may be effective, alone or as an adjunct to pharmacologic interventions, in managing procedure-related pain, anxiety, and distress in pediatric patients with cancer. In this population the three most commonly studied mind-body modalities were distraction, hypnosis, and imagery.

Although multiple studies demonstrated the value of CAM interventions, many of the studies were small and incorporated multiple CAM therapies as a single intervention. These types of interventions may be useful, particularly when used in combination with pharmacologic agents, but further research is needed to identify which interventions were valuable.

• FINAL NUMBER STUDIES INCLUDED =  12
• TOTAL PATIENTS INCLUDED IN REVIEW = 358
• KEY SAMPLE CHARACTERISTICS:  Mean age of 8.4 years, age ranged from 1–19 years; 55% male participants; 120 participants from Greece; 62% Caucasian; majority had hematologic cancer; many studies were conducted during painful procedures such as lumbar puncture and venipuncture.

PHASE OF CARE: Multiple phases of care

APPLICATIONS: Pediatrics

Integrative interventions may be very effective for pain and anxiety in children undergoing cancer treatment. Integrative modalities, however, warrant further study with larger sample sizes to better determine their effectiveness in this population.

• No description existed of the time window during which data were extracted.
• Various interventions were combined and analyzed as a unit.
• Only included randomized controlled trials and thus reduced literature sample size
• The sample size for each intervention was small.
• The effect of each intervention is not clear.

This study provided some evidence that complementary modalities can help children undergoing cancer treatment or painful procedures. The usefulness of a particular method should be further examined.

STUDY PURPOSE: To review published trials of hypnotic treatments for children with chronic and cancer-related pain

TYPE OF STUDY: Systematic review

DATABASES USED: MEDLINE, PsycINFO, Cochrane Collaboration

KEYWORDS: Children, hypnosis, pain

INCLUSION CRITERIA: RCT; patients 18 years old or younger; Catalan, English, French, Portuguese, or Spanish languages; included patients with chronic pain or cancer procedure-related pain

EXCLUSION CRITERIA: Abstracts only, not published in full in peer-reviewed journals

TOTAL REFERENCES RETRIEVED: 81

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: No study quality evaluation reported

• FINAL NUMBER STUDIES INCLUDED = 12 (10 in cancer)
• SAMPLE RANGE ACROSS STUDIES: 20–80
• TOTAL PATIENTS INCLUDED IN REVIEW: Total in cancer studies = 394
• KEY SAMPLE CHARACTERISTICS: Procedures involved were bone marrow aspiration, LP, or venipuncture

PHASE OF CARE: Multiple phases of care     

APPLICATIONS: Pediatrics

All studies in children with cancer were related to acute procedure-related pain and anxiety. Hypnotic interventions were better at reducing pain than no treatment, standard care, placebo, and attention control. Compared to other psychological treatments, hypnosis had about the same effectiveness as cognitive behavioral therapy. Comparison of hypnosis to distraction showed mixed results. Younger patients had significantly better responses to hypnosis. Parents of those receiving hypnosis had lower anxiety. Results of hypnosis on anxiety were mixed. One study showed similar effects between hypnosis and play. Calculated effect sizes with hypnosis showed decrease in pain of 20%–80%. In four studies that included follow up at 3–12 months, therapeutic effects appeared to be long-lasting.

Hypnosis is effective in reducing acute procedure-related pain among children with cancer.

Studies tended to have small samples, and many of these studies were done by the same group of researchers.

Findings of this systematic review support the use of hypnosis in children undergoing invasive procedures for reduction in pain. Nurses can advocate for availability of this intervention in pediatric settings.

To compare the effects of self hypnosis, yoga, and cognitive-based therapy (CBT) on psychological and sleep patient outcomes

Women with non-metastatic breast cancer selected whether they wanted to participate in groups receiving CBT, self hypnosis, or yoga interventions. CBT included six weekly 90 minute group sessions led by trained psychologists. The yoga intervention included six weekly 90 minute group sessions of Hatha yoga and a DVD for use in home practice. Self-hypnosis sessions were 2 hours every two weeks for 12 weeks in small groups. The intervention included tasks and discussions inspired by CBT, with a 15 minute hypnosis exercise at the end of the session. They also received a CD with hypnosis exercises and homework assignments between sessions.

• N = 99   
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: All had breast cancer, about 33% participated during treatment with chemotherapy
• OTHER KEY SAMPLE CHARACTERISTICS: On average, all had at least a high school education

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: Belgium

PHASE OF CARE: Multiple phases of care

Prospective, non-random, three-group trial

• Hospital Anxiety and Depression Scale
• EORTC-QLQ-C30
• Mental adjustment to cancer scale
• Insomnia Severity Index
• Self-report of frequency of practice of interventions provided

The majority of patient selected the hypnosis intervention. Anxiety and depression declined significantly in the yoga and hypnosis groups (p < 0.05). Fatigue and insomnia declined in the hypnosis group (p < 0.05). Most attended at least five sessions and practiced at least weekly at home. All three interventions showed medium effect sizes for change in anxiety (Cohen’s d range = 0.57-0.77).

Yoga and self-hypnosis group sessions were associated with decline in anxiety and depression. Self-hypnosis was also associated with improvement in sleep and fatigue scores.

• Small sample (< 100)
• Baseline sample/group differences of import         
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Risk of bias (no appropriate attentional control condition)
• Key sample group differences that could influence results
• Intervention expensive, impractical, or training needs
• Other limitations/explanation:  Only the CBT group did not have any material for home practice.  Sizes of the sample groups were vastly different, with only 10 people in the CBT group.  Though not statistically significant, the effect size for CBT was moderate, suggesting lack of significance was due to the small sample.  There was no differentiation between women currently in treatment and those not in treatment which could influence results -The hypnosis intervention included elements of CBT, so it is difficult to determine to what extent this versus the self hypnosis approach had effectiveness.  Provision of self hypnosis requires availability of appropriately trained providers.

Findings suggest that self hypnosis can be helpful to reduce anxiety, depression and insomnia in women with breast cancer.  If relevant resources are available to clinicians this could be a low risk and beneficial activity for symptom management.

To determine the long-term (nine months) effectiveness of three different group interventions compared to usual care for patients with breast cancer 

Participants were allowed to select one of three groups to receive either cognitive behavioral therapy, yoga, and self-hypnosis. People who declined to participate were in a control group. Measurements were taken T0 through T3 to include before and after the short-term interventions, at month 3, and at month 9 follow-up.

• N =123 total; 21 yoga, 67 self-hypnosis (after dropouts and one who died), 10 CBT, 24 control group 
• AGE: 27-73 across all groups 
• FEMALES: 100%
• CURRENT TREATMENT: Not applicable; mixed numbers of patients who had surgery, chemotherapy, radiation therapy, and hormonal therapy
• KEY DISEASE CHARACTERISTICS: Non-metastatic breast cancer; 18 months postdiagnosis 
• OTHER KEY SAMPLE CHARACTERISTICS: Inclusion criteria were at least 18 years old and can read, speak, and write French

• SITE: Not stated/unknown   
• SETTING TYPE: Not specified    
• LOCATION: Belgium

PHASE OF CARE: Multiple phases of care

Three group intervention self-selection; testing at T0, T1, T2 (month 3), T3 (month 9)

Demographics; medical history; Hospital Anxiety Depression Scale (anxiety and depression emotional distress); Quality of Life 30-item questionnaire (fatigue); Insomnia Severity Index (sleep quality)

Only results from baseline (T0) and the month 9 follow-up (T3) were reported using MANOVA with repeated analysis and post-hoc analysis. 

Post-hoc comparisons of time T0-T1: hypnosis group showed significant decreases in anxiety (p = 0.000), depression (p = 0.004), and fatigue (p = 0.045). Yoga group showed significant decrease in anxiety (p = 0.01). 

Post-hoc comparisons of time at T3: hypnosis group showed decreases in anxiety (p = 0.000), depression (p = 0.000), and fatigue (p = 0.002); yoga group showed decrease in anxiety (p = 0.024).

Self-hypnosis led to improvements in anxiety, depression, and fatigue. Anxiety improved in the yoga group. There were no improvements in the CBT or control groups.

• Small sample (< 100)
• Risk of bias (no random assignment)
• Other limitations/explanation: Control group included some of the non-consenters

Two of the three interventions may be helpful in reducing anxiety, depression, or fatigue when measured at nine months. Self-hypnosis may help patients improve emotional distress such as depression and anxiety, and may also reduce fatigue; yoga may also help improve anxiety. Larger samples and longer follow-up studies are needed.

To test the hypothesis that presurgical distress would be lower in a group that received hypnosis compared to an attentional control group

On the day of surgery, participants completed data collection instruments prior to study interventions and 15 minutes postintervention. Both the hypnosis and control interventions were standardized to last for 15 minutes. The hypnosis intervention included debunking common misconceptions, giving the patient an opportunity to ask questions, and presentation of a scripted relaxation-based induction, guided imagery, deepening, and surgery-specific suggestions for decreasing pain, nausea, and distress. Patients in the control group spent an equal amount of time with study personnel in sessions of empathic listening and supportive remarks from study personnel. All personnel providing interventions were clinical psychologists with advanced training in use of hypnosis in the medical setting.

• The study reported on a sample of 90 female patients.
• Mean patient age was 45.7 years (range = 19–77).
• All patients were scheduled for excisional biopsy. Almost all patients did not have previous breast cancer; 22.2% had previous excisional biopsy.
• Of the sample, 64% were Caucasian, and 68.7% had a college or graduate degree.

• Single site
• Outpatient setting
• New York

Patients were undergoing the diagnostic phase of care.

A single-blind, randomized controlled trial design was used.

• Profile of Mood States–short version (POMS)
• Visual analog scale (VAS) for depressed mood, emotional upset, and level of relaxation – 100 mm

Patients in the hypnosis group demonstrated significantly lower general upset (d = 0.85, p < 0.001), depressed mood (d = 0.67, p < 0.002), and anxiety (d = 0.85, p < 0.001), and higher relaxation (d = 0.76, p < 0.001) on VAS and POMS scores.

Findings demonstrate that a brief hypnosis intervention reduced symptoms of depression and anxiety and increased relaxation prior to excisional breast biopsy.

The study had a small sample, with less than 100 participants.

Hypnosis can be an effective intervention to reduce distress prior to breast biopsy. Additional research to determine longer-term effects on post-biopsy patient symptoms is warranted. This intervention was accomplished in 15 minutes, suggesting that hypnosis can be a practical intervention in the clinical setting. This type of intervention does require specific expertise.

To determine whether hypnosis, administered before and during a bone marrow procedure, can ameliorate pain and anxiety

Patients were randomized to a group that received standard care or a group that received standard care plus hypnosis just prior to the procedure. Patients learned of their group assignment just before the procedure. In the hypnosis arm, after the local anesthetic was administered, the oncology nurse and physician left the room. A specially trained oncology social worker performed the hypnosis. After 15 minutes, the oncology nurse and physician returned to start the procedure. The social worker continued to deliver the scripted hypnosis until the procedure was completed. In the standard-care arm, the oncology social worker was not present during the procedure. Study outcome measures were obtained immediately before and after the procedure.

• The study was composed of 80 patients with cancer who required bone marrow evaluation.
• In the hypnosis group, mean patient age was 58 years (SD = 14 years); in the standard-care group, mean patient age was 61 years (SD = 14 years).
• The entire sample was 52.5% male and 47.5% female.
• Diagnoses included, among others, leukemia, lymphoma, plasma cell dyscrasias, myelodysplastic syndrome, myleoproliferative disorder, and aplastic anemia.
• Patients were English-speaking, unpaid volunteers undergoing bone marrow aspiration or biopsy. Of all patients, 71% did not take analgesic or anxiolytic medications.

• Single
• Outpatient
• Cancer treatment center associated with Mount Sinai Medical Center, New York City

• Phase of care: diagnostic
• Clinical application: late effects and survivorship

Randomized controlled trial

• Visual analog scales (VASs), to measure pain and anxiety.
  • For pain: Anchors were no pain at the biopsy site versus very severe pain at the biopsy site.
  • For anxiety: Anchors were no anxiety versus very severe anxiety.  
• State-Trait Anxiety Inventory, Trait section, to assess whether the two groups were equivalent in terms of chronic levels of anxiety.
• Blood pressure and heart rate before and after the procedure.
• Patient satisfaction with the visit, assessed by means of a seven-step scale of verbal descriptors: very satisfied, pretty satisfied, somewhat satisfied, neutral, somewhat dissatisfied, pretty dissatisfied, or very dissatisfied.

The pain scores were slightly lower for the hypnosis group; however, the difference was not statistically significant (t(78) = 0.916, ns). The reduction in anxiety was substantially greater in the hypnosis group than in the standard-care group, with nonparametric tests showing that the difference was statistically significant (median test, p = 0.026).

Pre-procedure hypnosis was effective in reducing procedure-related anxiety.

• The study had a small sample, with fewer than 100 participants.
• Assessment of pain experience should encompass sensory and affective components of the experience, differences in hypnotherapists, differences in physicians performing the procedure, and differences in cancer type.
• Hypnosis induction was during the interval between administration of local anesthesia and start of the procedure, a period of 15 minutes. Some questioned whether induction was complete in some cases.
• In-depth training is needed to implement this intervention; in this study, the intervention was implemented by a mental health expert.

Hypnosis may be an effective intervention to reduce procedure-related anxiety. Although not demonstrated in this study, hypnosis has been shown to be effective in reducing procedure-related acute pain. Nurses can advocate for use of hypnosis to benefit appropriate patients. Provision of this intervention requires an appropriately trained and educated provider.