Hypnosis/Hypnotherapy

Hypnosis/Hypnotherapy

PEP Topic 
Anxiety
Description 

Hypnosis is a state between wakefulness and sleep; a state of heightened focal concentration and receptivity; and an altered state of consciousness of a state of focused attention that results in suspension of peripheral cues. The effect of a hypnotic state results in alteration in perception and attention. Hypnosis has been tested for effect in pain, anxiety, depression, chemotherapy-induced nausea and vomiting, hot flashes, and fatigue in patients with cancer. Hypnosis has been delivered in various formats, including individual in-person sessions and use of a CD program for induction and training in self-hypnosis.

Effectiveness Not Established

Systematic Review/Meta-Analysis

Landier, W., & Tse, A.M. (2010). Use of complementary and alternative medical interventions for the management of procedure-related pain, anxiety, and distress in pediatric oncology: An integrative review. Journal of Pediatric Nursing, 25, 566–579.

doi: 10.1016/j.pedn.2010.01.009
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Purpose:

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

Search Strategy:

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.

Literature Evaluated:

  • 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.

Sample Characteristics:

  • 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 and Clinical Applications:

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

Results:

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.

Nursing Implications:

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.

Thrane, S. (2013). Effectiveness of integrative modalities for pain and anxiety in children and adolescents with cancer: A systematic review. Journal of Pediatric Oncology Nursing, 30, 320–332.  

doi: 10.1177/1043454213511538
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Purpose:

STUDY PURPOSE: To systematically review the effect of integrative modalities (e.g., hypnosis, acupuncture, massage, virtual reality, folk healing, prayer) on pain and anxiety in children with cancer
 
TYPE OF STUDY:  Systematic review

Search Strategy:

DATABASES USED: PubMed, CINAHL, MedLine, PsycInfo, Web of Science, integrative medicine journals
 
KEYWORDS: pain, anxiety, pediatric, child, oncology, cancer, neoplasm, complementary, integrative, nonconventional, unconventional
 
INCLUSION CRITERIA: Ages 1–18; randomization; use of control group; published in peer-reviewed journals; use of integrative modality except natural products (e.g., herbs, vitamins, supplements); measuring pain and anxiety
 
EXCLUSION CRITERIA: Review article; informational papers

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: 164 articles were retrieved, 25 underwent full-text review using a systematic approach, and 12 met the criteria.
 

Sample Characteristics:

  • 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 and Clinical Applications:

PHASE OF CARE: Mutliple phases of care
APPLICATIONS: Pediatrics 

Results:

Five studies used hypnosis; one study used mind–body therapy; one used distraction and breathing techniques; one used behavioral intervention; one used virtual reality; one used creative-arts therapy; one used massage; and one used music therapy. Sample size for each study was very small, ranging from 8–59. All studies in this review had at least one statistically significant finding except for one study that examined distraction and breathing techniques. Cohen's d calculations show medium (d = 0.70) to extremely large (8.57) effect sizes for overall integrative intervention. Hypnosis was consistently significantly effective for reduction of pain and anxiety with invasive procedures. Distraction and breathing techniques did not demonstrate effectiveness. Virtual reality in one study did not reduce anxiety. Creative arts therapy in one study of 16 children reduced pain during chemotherapy. Massage showed inconsistent results. Music reduced pain and anxiety before and after lumbar puncture. 

Conclusions:

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.

Limitations:

  • 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.

Nursing Implications:

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.

Tomé-Pires, C., & Miró, J. (2012). Hypnosis for the management of chronic and cancer procedure-related pain in children. International Journal of Clinical and Experimental Hypnosis, 60, 432–457.

doi: 10.1080/00207144.2012.701092
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Purpose:

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

TYPE OF STUDY: Systematic review

Search Strategy:

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

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: 81

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

Sample Characteristics:

  • 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 and Clinical Applications:

  • PHASE OF CARE: Mutliple phases of care     
  • APPLICATIONS: Pediatrics

Results:

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.

Conclusions:

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

Limitations:

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

Nursing Implications:

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.

Research Evidence Summaries

Schnur, J.B., Bovbjerg, D.H., David, D., Tatrow, K., Goldfarb, A.B., Silverstein, J.H., . . . Montgomery, G.H. (2008). Hypnosis decreases presurgical distress in excisional breast biopsy patients. Anesthesia and Analgesia, 106, 440–444.

doi: 10.1213/ane.0b013e31815edb13
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Study Purpose:

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

Intervention Characteristics/Basic Study Process:

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.

Sample Characteristics:

  • 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.

Setting:

  • Single site
  • Outpatient setting
  • New York

Phase of Care and Clinical Applications:

Patients were undergoing the diagnostic phase of care.

Study Design:

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

Measurement Instruments/Methods:

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

Results:

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.

Conclusions:

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

Limitations:

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

Nursing Implications:

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.

Snow, A., Dorfman, D., Warbet, R., Cammarata, M., Eisenman, S., Zilberfein, F., . . . Navada, S. (2012). A randomized trial of hypnosis for relief of pain and anxiety in adult cancer patients undergoing bone marrow procedures. Journal of Psychosocial Oncology, 30, 281–293.

doi: 10.1080/07347332.2012.664261
Print

Study Purpose:

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

Intervention Characteristics/Basic Study Process:

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.

Sample Characteristics:

  • 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.

Setting:

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

Phase of Care and Clinical Applications:

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

Study Design:

Randomized controlled trial

Measurement Instruments/Methods:

  • 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.

Results:

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).

Conclusions:

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

Limitations:

  • 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.

Nursing Implications:

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.


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