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The Efficacy, Safety and Applications of Medical Hypnosis: A Systematic Review of Meta-analyses

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Background: The efficacy and safety of hypnotic techniques in somatic medicine, known as medical hypnosis, have not been supported to date by adequate scientific evidence. Methods: We systematically reviewed meta-analyses of randomized controlled trials (RCTs) of medical hypnosis. Relevant publications (January 2005 to June 2015) were sought in the Cochrane databases CDSR and DARE, and in PubMed. Meta-analyses involving at least 400 patients were included in the present analysis. Their methodological quality was assessed with AMSTAR (A Measurement Tool to Assess Systematic Reviews). An additional search was carried out in the CENTRAL and PubMed databases for RCTs of waking suggestion (therapeutic suggestion without formal trance induction) in somatic medicine. Results: Out of the 391 publications retrieved, five were reports of meta-analyses that met our inclusion criteria. One of these meta-analyses was of high methodological quality; three were of moderate quality, and one was of poor quality. Hypnosis was superior to controls with respect to the reduction of pain and emotional stress during medical interventions (34 RCTs, 2597 patients) as well as the reduction of irritable bowel symptoms (8 RCTs, 464 patients). Two meta-analyses revealed no differences between hypnosis and control treatment with respect to the side effects and safety of treatment. The effect size of hypnosis on emotional stress during medical interventions was low in one meta-analysis, moderate in one, and high in one. The effect size on pain during medical interventions was low. Five RCTs indicated that waking suggestion is effective in medical procedures. Conclusion: Medical hypnosis is a safe and effective complementary technique for use in medical procedures and in the treatment of irritable bowel syndrome. Waking suggestions can be a component of effective doctor–patient communication in routine clinical situations.
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MEDICINE
ORIGINAL ARTICLE
The Efficacy, Safety and Applications of
Medical Hypnosis
A Systematic Review of Meta-analyses
Winfried Häuser, Maria Hagl, Albrecht Schmierer, Ernil Hansen
SUMMARY
Background: The efficacy and safety of hypnotic techniques in somatic medi-
cine, known as medical hypnosis, have not been supported to date by adequate
scientific evidence.
Methods: We systematically reviewed meta-analyses of randomized controlled
trials (RCTs) of medical hypnosis. Relevant publications (January 2005 to June
2015) were sought in the Cochrane databases CDSR and DARE, and in PubMed.
Meta-analyses involving at least 400 patients were included in the present
analysis. Their methodological quality was assessed with AMSTAR (A Measure-
ment Tool to Assess Systematic Reviews). An additional search was carried out
in the CENTRAL and PubMed databases for RCTs of waking suggestion (thera-
peutic suggestion without formal trance induction) in somatic medicine.
Results: Out of the 391 publications retrieved, five were reports of meta-
analyses that met our inclusion criteria. One of these meta-analyses was of
high methodological quality; three were of moderate quality, and one was of
poor quality. Hypnosis was superior to controls with respect to the reduction of
pain and emotional stress during medical interventions (34 RCTs, 2597
patients) as well as the reduction of irritable bowel symptoms (8 RCTs, 464
patients). Two meta-analyses revealed no differences between hypnosis and
control treatment with respect to the side effects and safety of treatment. The
effect size of hypnosis on emotional stress during medical interventions was
low in one meta-analysis, moderate in one, and high in one. The effect size on
pain during medical interventions was low. Five RCTs indicated that waking
suggestion is effective in medical procedures.
Conclusion: Medical hypnosis is a safe and effective complementary technique
for use in medical procedures and in the treatment of irritable bowel syndrome.
Waking suggestions can be a component of effective doctor–patient communi-
cation in routine clinical situations.
Cite this as:
Häuser W, Hagl M, Schmierer A, Hansen E: The efficacy, safety and
applications of medical hypnosis—a systematic review of meta-analyses.
Dtsch Arztebl Int 2016; 113: 289–96. DOI: 10.3238/arztebl.2016.0289
H
ypnosis for purposes of medical treatment goes
back a long way. The British Medical Associ-
ation endorsed the use of hypnosis in somatic medicine
in 1955, on the basis of case reports and series backed
up by expert consensus, and the American Medical As-
sociation followed suit in 1958 (1, 2). Whether robust
evidence exists for the efficacy and safety of hypnosis
in somatic medicine in the era of evidence-based medi-
cine (EBM) (3) remains to be clarified. Because sys-
tematic reviews with quantitative analysis (meta-
analyses) of randomized controlled trials provide the
highest level of evidence in EBM (3), we decided to
carry out a systematic review of meta-analyses on
medical hypnosis.
The aims of this article are as follows:
To define the various forms of hypnosis
To describe the requirements that have to be ful-
filled before therapeutic hypnosis can be carried
out
To provide a historical overview of the use of
hypnosis in medicine and the assessment of its
efficacy
To identify the indications for medical hypnosis
supported by robust evidence
To present the evidence for use of positive sug-
gestions as a component of effective doctor
patient communication.
Definitions
The term “hypnosis” is used to mean both an altered
state of consciousness (synonym: hypnotic trance) and
the procedure by which this state is induced (4). During
a hypnotic trance physiological, cognitive, and affec-
tive processes as well as behavior can be modified. A
hypnotic state and hypnotic phenomena can be induced
by another person (therapist) or alone (self-hypnosis).
The subjective experience of hypnosis is characterized
by a high degree of authenticity (experienced as real)
and involuntariness (“it happens by itself”) (4).
Hypnosis can be distinguished from other states of
consciousness such as normal wakefulness, sleep, deep
relaxation, or meditation by means of electroencepha-
lography (EEG) and imaging modalities (4). A hypnotic
trance is characterized by a number of physiological
Department of Internal Medicine I, Klinikum Saarbrücken, Saarbrücken and Department of Psychosomatic
Medicine and Psychotherapy, Klinikum rechts der Isar, Technische Universität München, Munich:
PD Dr. Häuser
Department of Psychology, Ludwig-Maximilians-Universität München, Munich: Dr. phil. Dipl.-Psych. Hagl
Dental Practice Schmierer & Kratzenstein, Stuttgart: Dr. Schmierer
Department of Anesthesiology,
Universitätsklinikum
Regensburg: Prof. Hansen
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and mental reactions, e.g., altered perception of time,
selective amnesia, regression to a younger age (retriev-
al of memories or experiences from an earlier develop-
mental stage), a marked inward focus, and heightened
suggestibility, i.e., a stronger reaction to suggestions
(4). In clinical situations associated with high affective
participation of the patient, such as emergencies, diag-
nostic and therapeutic interventions, or communication
of a serious diagnosis, hypnotic phenomena may occur
spontaneously (e1, e2).
Suggestions work via verbal and nonverbal signals
that correspond to internal expectations and have a
powerful effect on mental and involuntary somatic pro-
cesses. For example, cutaneous perfusion or the flow of
saliva is not amenable to influence by a deliberate intel-
lectual action, but can be affected by a suggestion, e.g.,
a picture or a story. In general use the word “sugges-
tion” tends to imply manipulation, but in hypnosis it
should be understood as meaning a proposal, an offer of
options (“I suggest”). In contrast to the widespread pre-
conceptions, hypnosis is not authoritarian, passive, and
centered around the therapist, but a resource- and
solution-oriented method in which the focus is on the
patient's own potentials (4).
Applications of hypnosis
Depending on the goals, various applications of hyp-
notic techniques can be distinguished (4):
Medical hypnosis
– Alleviation of somatic symptoms
Reduction of mental stress during medical treat-
ment
– Amelioration of disordered physiological/bio-
chemical parameters
– Facilitation of physiological/biochemical heal-
ing processes
Hypnotic communication
– Waking suggestions (suggestions without trance
induction)
Suggestions with the patient under general anes-
thesia
– Use of findings from hypnotherapy for effective
doctor
–patient communication
Hypnotherapy (psychotherapy with the patient in
a trance)
Improvement of problem management by
giving the patient access to their own resources
– Facilitation of changes in behavior
– Restructuring (minimization, reinforcement, new
conditioning) of cognitive–affective patterns
Restructuring of emotionally stressful events
and sensations
Reintegration of non-accessible (dissociated)
feelings
Experimental hypnosis
Basic research on somatic sensations (e.g.,
pain), emotions, and states of consciousness
Stage hypnosis
– Demonstration of hypnotic phenomena to enter-
tain an audience
The perception of hypnosis as an authoritarian,
manipulative technique, nourished particularly by its
use in stage shows, represents the greatest barrier to the
(re)integration of hypnosis into medical treatment.
Phases of medical hypnosis
A session of medical hypnosis generally lasts between 20
and 50 min and can be divided into various phases (4):
Verification of the indication; explanation (cor-
rection of inappropriate anxiety or false expec-
tations); definition of goal(s)
Induction
Consolidation
Therapeutic suggestions
Reorientation, posthypnotic suggestions
Discussion
Integration into daily routine: use of an audio file
at home; behavioral exercises (e.g., exposure train-
ing); possibly learning of self-hypnosis techniques.
A selection of broadcasts (mostly in German) pub-
licly available on the internet can be found in eBox 1.
Formal re quirements
In Israel and Sweden, hypnosis may be carried out only
by physicians and psychologists who have received
appropriate training. In Germany, from the legal point
of view, anyone can offer hypnosis for non-medical
reasons. Treatment of illness by means of hypnosis
requires a license to perform procedures for the purpose
of healing (medical and psychological psychothera-
pists, child and adolescent psychotherapists, naturo-
paths) (e3). Medical hypnosis can be carried out by
physicians of all patient-related specialties in the
framework of basic psychosomatic care. An invoice for
relaxation hypnosis according to the official German
schedules for physicians’ fees (Uniform Value Scale,
Einheitlicher Bewertungsmaßstab) can be submitted
only by persons who possess a qualification in basic
psychosomatic care and have successfully completed a
course in hypnosis comprising two units of 16 hours
each (e4). Most medical and psychological psycho-
therapists and child and adolescent psychotherapists
learn the techniques of hypnotherapy as a supplemen-
tary qualification. As a rule hypnotherapists are also
trained in other methods of psychotherapy.
Details of the history of hypnosis and assessment of
its efficacy prior to the introduction of evidence-based
medicine (EBM) are provided in eBox 2.
Evidence for efficacy and safety
Methods
This review was conducted according to the recom-
mendations of the Cochrane Collaboration for system-
atic reviews of previously published reviews and the
recommendations of the Joanna Briggs Institute for
umbrella reviews (6).
Systematic survey of the literature
The Cochrane databases CDSR and DARE and
PubMed were searched for systematic reviews (SRs)
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published in the period January 2005 to June 2015. The
following search terms were used: “review,” “meta-
analysis,” and “hypnosis”. We searched PubMed with
“((“hypnosis”[MeSH] OR “hypnosis, den
tal”[MeSH])
AND (“meta-Analysis” [Publication Type]
OR “review”
[Publication Type])) OR ((hypnosis OR hypnotherap*)
AND (meta-analy* OR metaanaly*))”. Moreover, the
reference lists of the SRs identified were inspected for
further SRs. With regard to waking suggestions we
searched the databases CENTRAL and PubMed for
randomized controlled trials (RCTs) using the terms
suggestion” [MeSH] and “hypnotic suggestion
”. Finally,
for all topics we asked experts in medical hypnosis
about SRs.
Inclusion criteria
The following conditions regarding study type,
indications, setting, and study population had to be
ful filled:
Study type: We included SRs with meta-analysis of
(quasi-)RCTs on hypnosis as intervention for somatic
medical indications. In the event of serial publications
by the same group of authors we used the most recent
publication. We selected inclusion of at least 400 pa-
tients in quantitative analysis (meta-analysis) of the
study results as a quantitative criterion of robust
evidence (7).
Indications: The endpoints of the meta-analysis had
to be somatic symptoms (e.g., pain or nausea) or
physiological findings (e.g., bleeding time or airway
resistance) and/or mental stress during medical treat-
ments and/or cost-related data (e.g., operating time,
legth of hospital stay, or drug consumption). We
excluded meta-analyses of RCTs on psychiatric and
psychotherapeutic indications (e.g., anxiety disorders,
depressive disorders, addiction/abuse, or behavioral
disorders) and meta-analyses of RCTs on various dis-
eases (e.g., psychosomatic illnesses) in which no sub-
group analyses were conducted for individual diseases.
Setting and study population: No restrictions were
imposed with regard to setting, age, or country.
Methodological quality
The m
ethodological quality of the meta-analyses was
verified using
AMSTAR (A Measurement Tool to Assess
Systematic Reviews) (8). AMSTAR scores of 0–4 were
classified as low, 5–8 as intermediate, and 9–11 as high
m
ethodological quality (9).
Data extraction
The following characteristics of the meta-analyses were
extracted independently by two of the authors (WH,
MH) and discrepancies were resolved by consensus:
The medical indication
The number of RCTs/patients included
The age and sex of the patients
The type and duration of hypnosis
The nature of the control group
The instrument for and results of measurement of
m
ethodological quality of the included RCTs
Publications found in the databases
(n = 464)
PubMed (n = 341)
CDSR (n = 34)
DARE (n = 89)
Publications identified from other sources
(n = 12)
Duplications excluded
(n = 85)
Abstracts inspected
(n = 379) Studies excluded after inspection of
abstract (n = 314)
Full texts checked for suitability
(n = 77) Exclusion (n = 72)
– No meta-analysis (n = 58)
– Meta-analysis with <400 patients
(n = 11)
– Update of meta-analysis available
(n = 1)
– Meta-analysis included
non- randomized studies (n =1)
– No indication-specific subgroup
analysis (n = 1)
Studies included for
qualitative analysis (n = 5)
Inclusion Suitability Screening Search
FIGURE Results of the
lit erature survey
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The databases searched and the period covered
The findings regarding efficacy, tolerance, and
safety
The authors' conclusions
The AMSTAR rating.
Given the heterogeneity of diseases and outcome
variables, no quantitative data synthesis was planned
from the outset.
Results: survey and inclusion
The database survey and the hand search identified
391 publications in total. Seventy-seven full texts
were examined in detail
(Figure)
. Fourteen meta-
analyses (on topics such as chemotherapy-induced
nausea and vomiting, fibromyalgia syndrome, and
temporomandibular disorder) were excluded from
analysis because they included fewer than 400 patients
in their calculations (eTable 1) (e11–e24). Five meta-
analyses were included in our qualitative review
(10–14). The methodological quality was high in one
meta-analysis, intermediate in three, and low in one
(eTable 2). The characteristics of the original articles
investigated in these five meta-analyses are outlined in
Table 1
.
Results: efficacy and safety
Hypnosis was superior to standard treatment or attention
control (controls) in reduction of emotional stress, (10, 13,
14), pain (10, 14), duration of convalescence, and drug
consumption (10) in interventional procedures and oper-
ations. The
effect size on
emotional stress varied: it was
slight in one meta-analysis (10), intermediate in another
(14), and high in a third (13). The
effect size on
pain re-
duction was low (10, 14). The
effect sizes
of hypnosis in
medical interventions were dependent on the
methodo-
logical quality of the original studies
(10, 14).
Gut-directed hypnosis was superior to the treatments
used in the control groups with regard to the number of
patients with an appropriate reduction of symptoms at the
end
of treatment (number needed to treat [NNT] 5) and at
TABLE 1
Characteristics of the randomized controlled studies of medical hypnosis included in the meta-analyses*
* The meta-analyses are listed in alphabetical order
Reference
Kekecs et al.
2014
(10)
Madden et al.
2012
(11)
Schaefert et al.
2014 (12)
Schnur et al.
2008 (13)
Tefikow et al.
2013 (14)
Medical
indication
Minor (n = 11),
major
(n = 14),
or unspecified
(n = 1)
surgical
interven tions
Pain during
labor and
childbirth
Irritable bowel
Medical
interventions
Medical
interventions
Number of
studies/patients
(sample size
range)
26/1890
(12–346)
7/1213 (38–520)
8/464
(24–91)
26/2342
(20–200)
34/2597
(16–347)
Patients' age and
sex
Children and adults,
no further details
Adult women in six
studies; minors in
one study
Adults; range of
mean age 36.3–42
years (median
39.8); average pro-
portion of women:
82 % [79.3; 86.5]
4.8–70.3 years;
no data on sex
distribution
Adults;
median age
40 years; median
proportion of men
40% (experimental
groups), 37% (con-
trol groups)
Type and duration of hypnosis
13 studies with hypnosis,
11 studies with therapeutic
sug gestions, 2 studies with both;
13 studies with live hypnosis and
13 studies with ready-made audio
files;
no data on duration
6 studies on prenatal classes
(3 in groups and 3 in an individual
setting) with at least 3 sessions;
1 study with 45 min (live) during
contractions
Median 8.5 (7–12) live hypnosis
sessions over median 12 (5–12)
weeks, median treatment duration
7 (2.5–12) h; 7 studies with indi -
vidual sessions and 1 study with
group sessions
7 studies with therapeutic sugges-
tions; 20 studies with live hypnosis,
6 studies with ready-made audio
files; no data on frequency and
duration of sessions
21 studies with live hypnosis,
9
studies with ready-made audio
files
, 4
studies with both;
duration of intervention:
3–20 min: 9 studies
21–110 min: 17 studies
110–240 min: 8 studies
Type of control
groups
Standard treatment
or attention control
Standard treatment
(i.e., prenatal instruc-
tion) or attention
control (supportive
treatment)
Standard treatment,
waiting list or atten -
tion control (educa -
tion, supportive
treatment)
Standard treatment
or attention control
Standard treatment
or attention control
Methodological
quality of the
studies
Cochrane Risk
of Bias Tool:
relatively high risk of
bias in the studies
Cochrane Risk
of Bias Tool:
1 study with low and
6 studies with
moder ate to high
risk of bias
Cochrane Risk
of Bias Tool:
6 studies with low
and 2 studies with
high risk of bias
No data
Cochrane Risk
of Bias Tool: most
studies with high or
unclear risk of bias
292
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follow-up 6 months later (NNT 3) (12). Hypnosis was not
more effective than standard treatment or attention control
for pain during
labor and childbirth
(11).
Evaluation of the data on safety of hypnosis in two
meta-analyses (p
ain during labor and childbirth
, irritable
bowel syndrome) (11, 12) revealed no signs of a higher
rate of adverse effects than in controls
(Table 2).
Discussion of the results can be found in
eBox 3
.
Applications of hypnosis in daily clinical
practice
Preparation and performance of interventions
Anesthesia and surgery: The use of hypnosis instead of
local anesthesia in dental surgery (e25) and in place of
anesthesia for more extensive surgery (cholecystectomy,
aortocoronary bypass operation) has been described in case
reports (e26). However, hypnosis is being routinely used as
a complement rather than an alternative to modern, safe
techniques of anesthesia, primarily to minimize anxiety and
stress. Hypnosis has been shown to reduce pain, anxiety,
and the consumption of analgesics and sedatives to a statisti-
cally significant extent in patients undergoing operations
under local or regional anesthesia (e27, e28).
An example of the efficacy of hypnotic communi-
cation—even without formal trance induction—is its
application in waking craniotomies, as performed for
instance for removal of a brain tumor close to the
speech area or for deep brain stimulation. In these pro-
cedures the patient receives regional anesthesia of the
head and remains awake for the whole duration of the
brain surgery for purposes of neurological testing, with
no need for sedation and additional analgesia. Dissoci -
ation to an inner place of tranquility away from the
operating room plays an important part, as does the
reinterpretation of sensory perceptions (e29).
Some German hospitals offer live or audio file–aided
hypnosis as a complement to general and regional anes-
thesia.
Gastroenterology: With the aid of hypnosis—e.g.,
self-hypnosis or hypnosis by means of audio files—
TABLE 2
Results of the meta-analyses of randomized controlled trials on medical hypnosis*
* The meta-analyses are listed in alphabetical order
CI, confidence interval; ns, not significant; p, probability; RR, relative risk; SMD, standardized mean difference; NNT, number needed to treat
Reference
Kekecs et al.
2014
(10)
Madden et al.
2012
(11)
Schaefert et al.
2014 (12)
Schnur et al.
2008 (13)
Tefikow et al.
2013 (14)
Datatabases and period
covered by literature
survey
PubMed, PsycINFO,
CINAHL, ProQuest from
1980 to February 2014
Cochrane Pregnancy and
Childbirth Group’s Trials
Register/Central, PubMed,
Embase up to January
2012
Allied und Complementary
Medicine Database,
Central Register of
Controlled Trials, CINAHL,
PubMed, PsycINFO,
Scopus up to June 2013
(restricted to studies
published in journals)
PsycINFO and PubMed
from beginning to Febru-
ary 2008 (restricted to
English-language studies
published in journals)
Central, PubMed, Web of
Science, ProQuest up to
September 2011
Results for efficacy [95 % CI];
number of studies/patients (no data on number of studies/
patients per outcome variable)
Postoperative anxiety: SMD 0.40 [0.13; 0.66]; 21/1479
Postoperative pain: SMD 0.25 [0.00; 0.50];
no p-value given; 15/1197
Postoperative consumption of painkillers:
SMD 0.16 [0.16; 0.47], ns; 12/854
Postoperative nausea: SMD 0.38 [0.06; 0.81), ns at
α-level of p<0.01; 16/647
Drug treatment for pain:
RR 0.63 [0.39; 1.01], ns; 6/1032
Spontaneous vaginal delivery:
RR 1.35 [0.93; 1.96], ns; 4/472
Satisfaction with pain reduction:
RR 1.06 [0.94; 1.20], ns; 1/264
At end of treatment:
Adequate reduction of symptoms:
RR 1.69 [1.14; 2.51]; NNT 5 [3; 10]; 5/280
Reduction of global gastrointestinal symptoms:
SMD 0.32; [ 0.08; 0.56]; 6/361
Follow-up (6 months):
Adequate reduction of symptoms:
RR 2.17 [1.22; 3.87]; NNT 3 [2; 10]; 1/90
Reduction of global gastrointestinal symptoms:
SMD 0.57 [–0.26; 1.40], ns; 2/171
Emotional stress:
SMD 0.88 [0.57; 1.19]; 26/2342
Emotional stress: SMD 0.53 [0.37; 0.69)
Pain: SMD 0.44; [0.26; 0.61]
Drug consumption: SMD 0.38 [0.20; 0.56]
Physiological parameters: SMD 0.10 [0.02; 0.18]; ns
Duration of convalescence: SMD 0.25 [0.04; 0.46]
Operation time: SMD 0.25 [0.12; 0.38]; ns
Results for tolerability and safety [95% CI];
number of studies/patients
No data
Resuscitation of newborns:
RR: 0.67 [0.11;3.96], ns; 1/520
Intensive care of newborns:
RR: 0.58 [0.12; 2.89], ns; 2/347
Intensive care of mothers:
RR: 1.47 [0.25; 8.68], ns; 1/305
Inpatient re-admission of newborns:
RR: 1.39 [0.64; 3.02], ns; 1/267
Data from five studies: one patient reported
dizziness, but continued treatment; one
patient discontinued treatment due to a panic
attack during hypnosis
No data
No data
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diagnostic esophagogastroduodenoscopy procedures
can be carried out without sedation (e30). The use of
audio files is also efficacious in irritable bowel syn-
drome (e31). These files can be given to patients with
irritable bowel syndrome by their primary care phy -
sician or internist, and the progress with regard to
symptom control can be discussed with the patients in
the framework of basic psychosomatic care (e32). This
aproach can greatly facilitate the clinical application of
hypnosis. Gastroenterology departments in Great Brit-
ain (e33), Austria (e34), and the USA (e35) have inte-
grated psychosocial services that offer live and audio
file–aided hypnosis to patients with functional gas-
trointestinal disorders who do not respond well to
conventional medicinal treatment (see eBox 1 for more
on gut-directed hypnosis). Some office-based gastroen-
terologists in Germany offer hypnosis as an alternative
to sedation in esophagogastroduodenoscopy.
Dentistry: The German Dental Hypnosis Society
(
Deutsche Gesellschaft für Zahnärztliche Hypnose
) has
trained around 3000 dentists in hypnosis. The society's
website lists over 600 dentists who offer this service to
their patients. The indications for which hypnosis is avail-
able are pronounced fear of dental treatment, gag reflex,
intolerance of local anesthetics, and craniomandibular dys-
function. Hypnosis in the following forms is offered (e25):
The use of CDs developed specially for dental
treatment (e.g. “Beim Zahnarzt ohne Spritze
[Dental surgery without injection]
). At the begin-
ning of the treatment session track 1 is played
repeatedly over headphones, and at the end of
treatment the patient is woken by track 2.
Delegation of the hypnosis to a trained member of
staff (hypnosis assistant). In this case the dentist
must also be trained in hypnosis, because he/she
is responsible for the patient's welfare and must be
able to deal with the rare cases of adverse reaction
to hypnosis.
Induction of hypnosis by the dentist him-/herself.
This takes 2 to 5 min for relaxation prior to an
injection, about 10 min for treatment without
local anesthesia.
It is advantageous to combine nitrous oxide and
hypnosis, because the gas has an anxiolytic effect
and increases suggestibility.
Some dentists who concentrate on treatment of
patients with anxiety or craniomandibular
dysfunction draw on the services of an external
hypnotist.
Live hypnosis versus audio file–aided hypnosis
A meta-analysis of hypnosis in medical interventions
demonstrated no significant differences in efficacy be-
tween live hypnosis and suggestion by means of audio
files (14). Another meta-analysis by a different group of
authors concluded that only live hypnosis, which is
more apt to provide the context of a personal relation-
ship, significantly reduced postoperative anxiety and
pain. Both live and audio file–aided hypnosis signifi-
cantly decreased postoperative nausea and consump-
tion of analgesics (10).
Waking suggestions in doctor
–patient c
ommunication
The German Medical Assembly 2015 spoke out in favor
of strengthening physicians’ communicative competence
(15). In our opinion, together with authentic and empa-
thetic interaction (16), effective doctor–patient com-
munication has to include avoidance of negative sugges-
tions (16–19) and targeted use of positive waking sug-
gestions (18). In this context, communication could be
improved by applying basic principles of hypnotherapy
such as employment of indirect suggestions and the es-
tablishment of a trusting doctor–patient relationship (rap-
port). Three RCTs on invasive radiological procedures
found that positive suggestions and empathy, with and
without techniques of self-hypnosis, were superior to the
standard treatment in reducing pain and anxiety and in
decreasing consumption of analgesics (20–22). In two
RCTs, neutral or positive instructions before blood samp -
ling (“I'm going to start taking the blood sample now”) or
TABLE 3
Examples of positive waking suggestions at premedication and before induction of anesthesia (modified from [18, 19])
Positive statements instead of negations
Use of positive suggestions (safety, support, well-being)
Combine explanations with positive suggestions
Combine information about procedures with positive suggestions
Combine references to the patient's autonomy with positive suggestions
Combine information about possible complications with positive suggestions
“Everything will be fine” “We'll do this together” rather than “You don't need to
worry.”
“We'll keep a close eye on you until you've completely recovered from the
operation.”
“We're attaching a blood pressure cuff and ECG leads so we can take good
care of you.”
“After the operation you can stay in the recovery room until you wake up
naturally, and when you feel well enough we'll take you back to your room.”
“You can help us to increase the safety of the anesthesia by not eating
anything for 12 hours before the operation.”
Please tell us straightaway if you get a headache after the spinal anesthesia.
We have good medication for treating this kind of headache.”
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induction of local anesthesia led to lower levels of pain
than (unintended) negative suggestions (“this may hurt a
bit”) (23, 24). A RCT in a hospital emergency room
found that the pain-relieving effect of intramuscular di-
clofenac was not reinforced by a waking suggestion
(“this is a
powerful
painkiller”) in patients with acute
headache (25)
(eTable 3)
. Therapeutic waking sugges-
tions can be used by all physicians in a medical context
(see
Table 3
for examples).
Psychosomatic medicine
Examples of the application of medical hypnosis by
psychotherapists in somatic medicine are given in the
Box.
Conclusion
Hypnosis techniques have long been used—and their
efficacy assessed—in somatic medicine. The modern
evidence-based indications (emotional stress associated
with medical interventions, functional disorders such as
irritable bowel syndrome) correspond with the appli-
cations of mesmerism in medicine in the middle of the
19
th
century (e5). Learning techniques of self-hypnosis
empowers patients to participate in their own treatment
and grants them independence. Hypnosis techniques
such as the building of a trusting relationship with the
patient and therapeutic waking suggestions can con-
siderably reinforce the communicative competence of
physicians (15).
Conflict of interest statement
Dr. Häuser receives royalties from the sale of CDs on medical hypnosis in
irritable bowel syndrome and fibromyalgia syndrome from Hypnos Verlag. He
is an instructor for hypnosis of the German Society for Medical Hypnosis and
Autogenous Training (Deutsche Gesellschaft für Ärztliche Hypnose und Auto-
genes Training).
Dr. phil. Dipl.-Psych. Hagl has received honoraria for authorship or co- authorship
of yearly reviews of hypnosis research from the Milton H. Erickson Society for
Clinical Hypnosis (Milton H. Erickson Gesellschaft für Klinische Hypnose).
Dr. Schmierer has received an honorarium for authorship or co-authorship
from Quintessenzverlag (dental hypnosis).
Prof. Hansen is a member of the scientific advisory board of the Milton H.
Erickson Society for Clinical Hypnosis (Milton H. Erickson Gesellschaft für
klinische Hypnose).
Manuscript submitted on 28 September 2015, revised version accepted on
7 January 2016
Translated from the original German by David Roseveare
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BOX
Potential applications of medical hypnosis in daily clinical practice
(case reports and/or case series)
All patient-related areas: waking suggestions
Explanation of diagnosis and treatment (e36)
Communication before and during medical treatment (19)
Emergency service (e37)
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Corresponding author
PD Dr. med. Winfried Häuser
Klinik Innere Medizin I
Klinikum Saarbrücken
Winterberg 1, 66119 Saarbrücken, Germany
whaeuser@klinikum-saarbruecken.de
@
Supplementary material
For eReferences please refer to:
www.aerzteblatt-international.de/ref1716
eBoxes und eTables:
www.aerzteblatt-international.de/16m0289
KEY MESSAGES
Medical hypnosis comprises the use of hypnotic techniques, with or
without induction of a trance.
Robust evidence (from meta-analysis of randomized controlled
trials including at least 400 patients) of the efficacy of medical
hypnosis exists for reduction of pain and emotional stress, duration
of interventions, drug consumption during medical interventions,
and reduction of irritable bowel symptoms.
The preparation and conduct of medical interventions can be
facilitated by hypnosis.
Waking suggestions, taking advantage of patients' heightened sug-
gestibility, have a pain-reducing effect in diagnostic and therapeutic
interventions.
Hypnotic techniques such as the creation of a trusting relationship
with the patient and therapeutic waking suggestions can be used in
daily clinical practice by all physicians and dentists and can form an
effective component of overall doctor–patient communication.
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I
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Supplementary material to:
The Efficacy, Safety and Applications of Medical Hypnosis
A Systematic Review of Meta-analyses
by Winfried Häuser, Maria Hagl, Albrecht Schmierer, and Ernil Hansen
Dtsch Arztebl Int 2016; 113: 289–96. DOI: 10.3238/arztebl.2016.0289
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eBOX 1
Selection of German-language videos and podcasts from public broadcasters on
medical hypnosis
3Sat 2015
Hypnosis in irritable bowel syndrome (gut-directed hypnosis): www.youtube.com/watch?v=AjBHaKq8B_g (6 min)
ZDF Abenteuer Wissen 2009
Medical hypnosis in the treatment of chronic pain and in surgery: www.youtube.com/watch?v=MdLQvrl84hU
Plastic surgery, dental treatment (12 min)
ARD W wie Wissen 2014
The power of hypnosis: http://www.daserste.de/information/wissen-kultur/w-wie-wissen/videos/die-kraft-der-hypnose-
100.html
Dental treatment, brain MRI showing how hypnosis alleviates pain, brain surgery with the patient awake (7 min)
SWR Odysso 2014
Medicine: The healing power of the psyche: http://www.swr.de/odysso/medizin-die-heilkraft-der-psyche/-/
id=1046894/did=14145774/nid=1046894/wrks2i/index.html
Documentary on healing thoughts; the importance of waking suggestions and a positive attitude for the success of heart
surgery (46 min)
SWR Odysso 2011
Hypnosis instead of general anesthesia: http://www.swr.de/odysso/hypnose-statt-vollnarkose/-/
id=1046894/did=7345782/nid=1046894/3hlrni/index.html
The anesthesia technique of hypnosedation, successfully used in over 8000 surgical patients in Belgium. This technique
combines hypnosis with very light sedation and local anesthesia; the patient remains awake.
WDR Planet Wissen 2016
How negative thinking makes us ill: www1.wdr.de/mediathek/video/sendungen/planet-wissen-wdr/video-wie-uns-negative-
gedanken-krank-machen-100.html
Video about placebo and nocebo effects (58 min)
3sat 2012
Hypnosis instead of anesthesia: www.3sat.de/mediathek/?display=1&mode=play&obj=30167
Maxillary surgery on hypnosedated patients (5 min)
BBC exklusiv
www.youtube.com/watch?v=qJAnCLIBBus&feature=youtu.be
Surgery with hypnosis instead of anesthesia; experimental pain; brain MRI showing how hypnosis alleviates pain (11 min)
HR alles wissen 2015
Hypnosis to counteract fear of the dentist: www.ardmediathek.de/tv/alles-wissen/Hypnose-gegen-Zahnarztphobie/hr-fernse
hen/Video?documentId=29814680&bcastId=3416170
Dental treatment, brain MRI showing how hypnosis alleviates pain (6 min)
Radio: SWR 27.05.2015
Hypnotherapy: trance induction to combat anxiety and pain: www.ardmediathek.de/radio/SWR2-Wissen/Hypnotherapie-
Trance-als-Mittel-gegen-%C3%84/SWR2/Audio-Podcast?documentId=28528316&bcastId= 220656
(27 min)
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eBOX 2
The history of hypnosis and assessment of its
efficacy before the advent of evidence-based
medicine (EBM)
Owing to their unconventional approach, hypnosis techniques attracted the
attention of both orthodox physicians and the general public at an early stage.
The scientific basis of hypnotic procedures was investigated as early as the 18
th
century.
The theory and techniques of “animal magnetism,” put forward by the Vien -
nese physician Franz Anton Mesmer, are viewed as the precursor of modern hyp-
nosis. Mesmer failed in his attempt to have animal magnetism accredited by the
Académie des Sciences in Paris in 1784 (e5). The scientific committee appointed
by King Louis XVI refuted the theory of magnetism and attributed Mesmer's suc-
cessful treatments to psychological mechanisms, namely the “arousal of powers
of imagination and of imitation” (e6). The concept of magnetism persisted, how -
ever, and came to be adopted by a number of physicians. The English surgeon
James Esdaile (1808–1859), working in India, carried out 345 major operations
(amputations of arm, leg, breast, and penis, as well as excision of tumors) using
the technique of “mesmerism” and recorded not only good analgesia but also low
mortality (e7). The British physician John Elliotson (1791–1868) became profes-
sor at the University of London in 1831. Under pressure from the journal Lancet,
which rejected his practice of animal magnetism, he resigned his post in 1838.
From 1843 to 1856 he published a journal called The Zoist, dedicated exclusively
to animal magnetism. However, this technique rapidly receded into the back-
ground with the introduction of ether and chloroform anesthesia in 1846/47 (e3).
The Scottish ophthalmologist Braid developed the theory of monoideism,
where by concentration on a single thought by means of optic fixation was held to
lead to a neurologically conditioned state of sleep. This physiological explanation
of hypnotic phenomena helped “hypnotism” attain recognition by physicians at a
time when medicine was developing along scientific lines (e3). In 1891 the British
Medical Association (BMA) commissioned a group of physicians to investigate
hypnotism. After due appraisal the expert committee concluded that hypnotism
was effective in the treatment of pain, sleep disorders, and functional symptoms.
At its annual conference in 1892 the BMA unanimously recommended the thera-
peutic application of hypnosis (e8).
With the increasing importance of evidence-based medicine (EBM) in the 20
th
and 21
st
centuries, advocates and practitioners of clinical hypnosis came to see
the necessity of controlled trials and synthesis of the findings in systematic
reviews. The first German-language systematic review and meta-analysis of the
efficacy of hypnosis was published in 2002 (e9). An expert report on evaluation of
hypnotherapy as a psychotherapeutic technique according to the criteria of the
German Scientific Advisory Committee on Psychotherapy (Wissenschaftlicher
Beirat Psychotherapie) (§ 11, Psychotherapy Act) was produced in 2003 (e3).
The Scientific Advisory Committee on Psychotherapy concluded that hypnothera-
py can be considered a scientifically valid technique for the treatment, in adults,
of mental and social factors in somatic diseases and of addiction and abuse
(smoking cessation and methadone withdrawal) (ICD-10 F54, F10, F11) (e10).
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eBOX 3
Discussion of the findings concerning the evidence of the efficacy
of medical hypnosis
Three meta-analyses (10, 13, 14) of the use of hypnosis in medical interventions fulfilled our criterion of
including at least 400 patients. If these meta-analyses were to be based largely on the same original
studies, the evidence could be overestimated. Indeed, inspection revealed the following overlapping of
the randomized controlled trials (RCTs) included: Kekecs et al. (10) and Tefikow et al. (14): N = 12;
Kekecs et al. (10) and Schnur et al. (13): N = 8; Schnur et al. (13) and Tefikow et al. (14): N = 10. At
least 50% of the RCTs in each of the three meta-analyses were also included in one or both of the
others (Kekecs et al.: 16 of 26; Tefikow et al.: 18 of 34; Schnur et al.: 13 of 26). Nevertheless, each of
the three covered an appreciable number of original studies that were not featured in the others. This
can be explained by the variation in focus: Kekecs et al. (10) and Tefikow et al. (14) restricted them -
selves to studies on adults, while Schnur et al. (13) also included children. Whereas Schnur et al. (13)
confined themselves to “emotional stress” as endpoint, Kekecs et al. (10) and Tefikow et al. (14) each
calculated several effect sizes for several outcome variables, with Kekecs et al. (10) concentrating
solely on postoperative endpoints. Therefore, since differentiated conclusions can certainly be drawn,
we chose to present the results of all three meta-analyses of medical hypnosis in diagnostic, inter -
ventional, and surgical procedures.
Recommendations on the use of medical hypnosis in medical procedures are limited, however, by
the poor methodological quality of many original studies. Moreover, on statistical criteria the effect
strengths were mostly low. Blinding of the therapists and the patients is usually not possible (interven -
tion bias) in RCTs with hypnosis (and other psychological techniques). In fact, at least in some studies in
which audio files were used for hypnosis the medical personnel or diagnosticians were blinded, which is
associated with conservative effect sizes (10, 14). Therefore, using the Cochrane Risk of Bias Tool the
danger of bias is higher in RCTs that use psychological techniques than in RCTs where medications are
administered. Two of the three systematic reviews of hypnosis in medical procedures point to low or
uncertain quality of the existing RCTs and recommend that further studies with high-quality methodology
should be carried out (10, 14). Because the original studies reported only average data and no
re sponse rates (e.g., the proportion of patients with only slight postoperative pain or no postoperative
nausea), the meta-analyses could not calculate the number needed to treat for an additional benefit
(NNTB). The clinical benefit of medical hypnosis in interventions is therefore difficult to estimate.
The quality of the data is better for irritable bowel syndrome: the risk of bias was low in most of the
studies included (12). Response rates with a clinically meaningful benefit (NNT 5 and 3 respectively)
were computed for adequate symptom reduction at the end of treatment and at 6-month follow-up. With
regard to these NNTs, it should be remembered that most of the RCTs included patients who had shown
insufficient reduction of symptoms in response to an established regimen of medication (12).
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Supplementary material
eTABLE 1
List of excluded systematic reviews with meta-analysis*
* In alphabetical order
RCTs, randomized controlled trials
Reference
Adachi et al. 2014 (e11)
Bernardy et al. 2011 (e12)
Birnie et al. 2014 (e13)
Bowker et al. 2014 (e14)
Enck et al. 2010 (e15)
Flammer et al. 2007 (e16)
Ford et al. 2014 (e17)
Glazener et al. 2005 (e18)
Huang et al. 2011 (e19)
Köllner et al. 2012 (e20)
Lee et al. 2014 (e21)
Richardson et al. 2007
(e22)
Smith et al. 2006 (e23)
Zhang et al. 2015 (e24)
Medical indication (target group)
Chronic pain (adults)
Fibromyalgia syndrome (adults)
Pain and stress from injections (children
and adolescents)
Pain in physically disabling diseases
(adults)
Irritable bowel syndrome (adults)
Psychosomatic diseases
(children and adults)
Irritable bowel syndrome (adults)
Bed-wetting (children )
Bed-wetting (children )
Fibromyalgia syndrome (adults)
Irritable bowel syndrome (adults)
Nausea and vomiting in chemotherapy for
cancer (children and adults)
Pain during labor and childbirth
(adolescents and adults)
Temporomandibular disorder
(adolescents and adults)
Number of RCTs/patients
6/237 (+ 6 controlled trials/432)
5/191
7/222
6/237 (+ 4 non-randomized or only partly
randomized trials)
2/40
18/916
5/278
2/98
3/172
4/102
7/374
6/206
5/729
3/159
Reason(s) for exclusion
Non-randomized trials were included
N <400
N <400
N <400
N <400; meta-analysis with >400 patients
available (12)
Not evaluated for each indication
N <400;
meta-analysis with >400 patients
available (12)
N <400; update of corresponding
Cochrane group available (e19)
N <400
N <400
N <400; meta-analysis with >400 patients
available (12)
N <400
Update of corresponding Cochrane group
available (11)
N <400
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Supplementary material
VII
eTABLE 2
Assessment of the methodological quality of the meta-analyses of controlled trials of medical hypnosis by means of AMSTAR (8)
*a priori design: protocol, internal review board approval, or research question previously published
A
MSTAR, A Measurement Tool to Assess Systematic Reviews
Kekecs
et al.
2014 (10)
Madden
et al.
2012 (11)
Schäfert
et al.
2014 (12)
Schnur
et al.
2008 (13)
Tef ikow
et al.
2013 (14)
No
Yes
No
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
No
No
No
No
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
6
10
8
4
8
Reference
Was an ‘a priori' design
provided?*
Was there duplicate study
selection and data extraction?
Was a comprehensive literature
search performed?
Was the status of publication
(i.e. grey literature) used as an
inclusion criterion?
Was a list of studies (included
and excluded) provided?
Were the characteristics of the
included studies provided?
Was the scientific quality of the
included studies assessed and
documented?
Was the scientific quality of the
included studies used appropri -
ately in formulating conclusions?
Were the methods used to
combine the findings of studies
appropriate?
Was the likelihood of publication
bias assessed?
Was the conflict of interest
included?
Total
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Supplementary material
eTABLE 3
Overview of randomized controlled trials on the effect of waking suggestions in medical treatment procedures*
Refe-
rence
Lang et
al. 2000
(20)
Lang et
al. 2006
(21)
Lang et
al. 2008
(22)
Ott et al.
2012 (23)
Oktay et
al. 2014
(25)
Type of medical
treatment
Percutaneous
vascular
intervention
Breast biopsy
Radiofrequency
ablation or
embolization of
carcinomas
Sampling of
venous blood
Acute headache
Type of suggestion
Number of patients
Structured attention
control**; N = 80
Structured attention
control
plus self-relaxation and
self-hypnosis;
N = 82
Structured attention
control**; N = 82
Structured attention
control
plus self-relaxation and
self-hypnosis;
N = 78
Structured attention
control**; N = 65
Structured attention
control
plus self-relaxation and
self-hypnosis;
N = 66
“I'm going to start taking the
blood sample now”
N = 50
“This drug is a powerful
pain killer for your head-
ache. Its analgesic effect
peaks at about 20 to 30
minutes. We are expecting
that your headache will
resolve in 45 minutes”
N = 50 (group 1)
Control intervention
Number of patients
Standard treatment;
N = 79
Standard treatment;
N = 76
Standard treatment;
N = 70
“This will hurt a bit”
N = 50
“A nurse is going
to administer you a pain
killer called ... by
intramuscular injection”
N = 50 (group 2)
“If your headache does
not resolve in 45 minutes,
we can administer you a
more potent pain killer”
N = 53 (group 3)
Result
Increase in pain: significantly greater for standard treatment (mean
0.09 pain score/15 min) and attention control (mean 0.04/15 min)
than for hypnosis (no increase)
Drug consumption: significantly higher increase in standard treatment
group (mean 1.9 units) than in attention control group (mean 0.07)
and hypnosis group (mean 0.11)
Reduction of anxiety: no significant difference between attention
control (mean –0.07) und hypnosis (mean –0.11); significantly lower
with standard treatment (mean 0.04)
Hemodynamic instability: significantly lower for hypnosis (1.2%) than
for attention control (12.5%) and standard treatment (15.2%)
Duration of intervention: significantly shorter for hypnosis (mean 61
min) and attention control (mean 67 min) than for standard treatment
(mean 78 min)
Increase in pain: significantly greater for standard treatment (mean
0.53) than for attention control (mean 0.37) and hypnosis (mean 0.34)
Drug consumption: significantly higher increase in standard treatment
group (mean 0.18) than in attention control group (mean 0.04) and
hypnosis group (mean –0.27)
Reduction of anxiety: significantly
less reduction
in standard treatment
group (mean 0.18) than in attention control group (mean – 0.04) and
hypnosis group (mean –0.27)
Complications: no significant differences among standard treatment
(8.9%), attention control (13.8%), and hypnosis (3.7%)
Duration of intervention: no significant differences among hypnosis
(mean 39 min), attention control (mean 43 min), and standard treat-
ment (mean 46 min)
Increase in pain: significantly greater for standard treatment (median
2.5 units) and attention control (median 2.5 units) than for hypnosis
(median 0 units)
Reduction of anxiety: no significant differences among standard treat-
ment group (median 2 units), attention control group (median 2 units),
and hypnosis group (median 1 unit)
Complications: significantly higher rates in attention control group
(48%) compared to hypnosis group (12%) and standard treatment
group (26%)
Duration of intervention: no significant differences among hypnosis
(median 110 min), attention control (median 120 min), and standard
treatment (median 110 min)
Mean pain intensity, as measured on an 11-point (0–10) numeric
rating scale (NRS) was 2.7 in the “This will hurt” group compared with
1.6 in the
“I'm going to”
group (p = 0.001).
58 % of the probands in the “This will hurt” group but only two pro-
bands (4.2 %) in the
“I'm going to”
group rated the pain intensity of the
injection at 1 on the NRS, the threshold value for mild to moderate
pain (p <0.001).
Pain reduction on a 0–100 visual analog scale 45 min after injection
(p = 0.49):
group 1: 43 ± 30
group 2: 39 ± 29
group 3: 36 ± 24
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Supplementary material
IX
* Trials listed in alphabetical order
** Agreement with the patient's verbal and non-verbal communication patterns; attentive listening; reinforcement of feeling of autonomy (“Let us know at any time what we can do for you”);
swift action in response to the patient's wishes; avoidance of negative suggestions (“How bad is your pain? “You will now feel a prick and a burning sensation“); positive suggestions (focus
on sensations of fullness, coolness, warmth during painful stimuli)
Significant, p <0.05
Refe-
rence
Varel-
mann et
al. 2010
(24)
Type of medical
treatment
Local anesthesia
before creation
of access for
peridural or spi-
nal anesthesia in
pregnant women
before delivery
Type of suggestion
Number of patients
“We are now going to give
you a local anesthetic so
that it's comfortable for
you when we perform the
epidural spinal anesthe-
sia”
N = 33
Control intervention
Number of patients
“You will now feel a prick
and a burning sensation in
your back as though you
have been stung by a bee;
that's the worst part of the
whole procedure”
N = 32
Result
Pain was rated significantly stronger by patients who received the
second instruction
(median pain intensity 5 versus 3 on an 11-point
scale
) .
... Invasive dental procedures are not uncommon, and surgical procedures such as extractions or implantations are daily routine procedures in the dental practice. Medical hypnosis, i.e., the efficacy and safety of hypnosis techniques in somatic medicine, was investigated in a systematic review of meta-analyses of randomized clinical trials [34]. It could be determined that hypnosis is a safe and effective complementary technique for the use in medical procedures [34]. ...
... Medical hypnosis, i.e., the efficacy and safety of hypnosis techniques in somatic medicine, was investigated in a systematic review of meta-analyses of randomized clinical trials [34]. It could be determined that hypnosis is a safe and effective complementary technique for the use in medical procedures [34]. Suggestions in an awake state can also be part of an effective doctor-patient communication in daily clinical routine [34]. ...
... It could be determined that hypnosis is a safe and effective complementary technique for the use in medical procedures [34]. Suggestions in an awake state can also be part of an effective doctor-patient communication in daily clinical routine [34]. ...
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... A first important difference concerns the methodology: in hypnosis, it is central the hypnotherapist's ability to induce the hypnotic state, whereas in meditation the emphasis is on the autonomous mental practice of the meditator, although both states can be led by real people or audio guides (Häuser et al., 2016;McClintock et al., 2019). ...
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... Recientemente, una revisión sistemática que incluyó 29 estudios identificó que la hipnosis disminuyó el dolor en comparación con la atención estándar y los grupos control (Kendrick et al.,2016). De igual forma, otra revisión sistemática identificó que los ensayos controlados aleatorios fueron superiores 50 % para aliviar la percepción del dolor y 20 % más eficaces para mejorar la percepción de la calidad de vida relacionada con la salud y el malestar psicológico (Häuser et al., 2016;Zech et al., 2017). ...
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Pediatric patients represent a special challenge both for the management of anesthesia and for communication, especially the anxious and screaming child. Children have specific features of fears, cognition, comprehension and skills depending on the stage of development. In addition, behavior and anxiety are strongly shaped by the parents who have to be incorporated. This article presents the special features of children as well as practical strategies and aids for dealing with children in a perioperative setting. In children suggestibility and susceptibility to placebo and nocebo effects are increased. This makes them more sensitive to negative factors but can also be utilized for positive, constructive effects. Possibilities are presented which make use of the special characteristics of children. A number of examples from daily clinical routine are given. A child's imagination, creativity and capability for dissociation in particular allow an effective application of indirect suggestion, metaphors, stories, changes in focus of attention, retreat to an inner or imagined safe place, reframing of disturbing noises and events, pacing and leading in small steps and an activation of inner resources. A hand puppet, a pet toy, a little magic trick, introducing a magic friend, acupoint for palpitations with self-affirmation, stick figure drawings, ceiling pictures or holding hands can be quite helpful. All medical devices and interventions can be explained in a way that children can understand and in positive statements without lying or neglecting the need for information. Meeting at eye level, talking to the child instead of just about it, a language appropriate for children but not childish, comprehensible information and explanations, return of control and care more than pure technical distance, all play an important role. A serious look into such communication strategies can help the anesthetist to overcome uncertainties that a child can easily sense.
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The premedication visit is often a difficult situation for the anaesthetist. On the one hand the patient needs to be informed in detail, but on the other he must not be alienated unnecessarily. Furthermore, a hospital stay represents an exceptional situation for the patient in which he behaves differently than in everyday life and shows a limited ability to process information. Following certain communication strategies allows to convey information to the patient in a comprehensible manner and to describe his individual anaesthesiological risk without needlessly creating fear. © Georg Thieme Verlag Stuttgart · New York.
Article
Eine Wachkraniotomie ist induziert bei der tiefen Hirnstimulation (THS) zur Therapie bestimmter Bewegungsstörungen wie M. Parkinson und bei der Operation von Hirntumoren nahe der Sprachregion. Standard dafür ist die sog. Schlaf-Wach-Schlaf-Technik, bei der die Narkose oder Analgosedierung für die neurologischen Testungen intermittierend unterbrochen wird. Bei der THS weisen die Stereotaxie, die Mikroelektrodenableitung und die intraoperative Symptomverbesserung auf die optimale Position der Sonden hin. In der Tumorchirurgie zeigt die elektrische Stimulation auf der Hirnoberfläche die individuelle Lage der zu schützenden eloquenten und motorischen Zentren an. Das anästhesiologische Vorgehen ist recht variabel und stellt eine Gratwanderung zwischen Überdosierung mit Beeinträchtigung von Atmung und Vigilanz und Unterdosierung mit Schmerz und Stress dar. Bei allgemein guter Akzeptanz werden doch regelmäßig und z. T. erhebliche Komplikationen berichtet, und die psychische Belastung des Patienten kann beträchtlich sein. Zudem ist ein Gefühl des Alleingelassen- und Ausgeliefertseins nicht adäquat mit Pharmaka zu behandeln. Die Testung ist andererseits umso aussagekräftiger, je weniger der Patient mit Anästhetika belastet ist. Eine kraniale Leitungsanästhesie kann helfen, Medikamente einzusparen, da sie besser als lokale Infiltrationen Schmerzfreiheit am Kopf gewährleisten kann. Zusammen mit einer vertrauensvollen therapeutischen Beziehung und einer spezifischen Kommunikation, die u. a. zu einer Dissoziation an einen inneren Wohlfühlort und einer Uminterpretation störender Geräusche anregt, kann ganz auf eine Sedierung und ganz oder weitgehend auf eine zusätzliche Opioidgabe verzichtet werden. Jede der verwendeten Wachkraniotomiemethoden kann von den Prinzipien dieser Wach-Wach-Wach-Technik profitieren.
Article
Objective: The therapeutic response of a patient cannot purely be explained by the method of therapy or the efficacy of a drug. Clinician-patient interaction, psychosocial factors, patients' expectations, hopes, beliefs and fears are all related to the healing outcome. Malleability and suggestibility are also important in the placebo or nocebo effect. The purpose of this study was to evaluate whether adding brief verbal suggestions for pain relief could change the magnitude of an analgesic's efficacy. Methods: This prospective study was performed in the emergency department of a university hospital. Patients who were ordered analgesia with diclofenac sodium for primary headache were divided into three groups. All groups were informed that they would be administered a pain killer by intramuscular injection. The second and third groups were given positive and reduced treatment expectations about the therapeutic efficacy, respectively. Patients were asked to rate their pain on a VAS at 0 and 45 minutes and if they needed any additional analgesic 45 minutes after the injection. Results: A total of 153 patients were included in the study. The paired univariate analyses showed significant differences for all groups between 0- and 45-minute VAS scores. However, there was no difference between the three groups according to the differences in VAS scores between 45 and 0 minutes and according to the administration of an additional drug. Conclusion: Simple verbal suggestions did not alter the efficacy of an analgesic agent for headache in an emergency setting. The contributions of suggestibility, desire and expectation in acute primary headache patients should be further investigated.
Article
Background: Suggestive interventions such as hypnosis and therapeutic suggestions are frequently used to alleviate surgical side effects; however, the effectiveness of therapeutic suggestion intervention has not yet been systematically evaluated. In the present study, we tested the hypotheses that (1) suggestive interventions are useful for reducing postoperative side effects; (2) therapeutic suggestions are comparable in effectiveness to hypnosis; (3) live presentation is more effective than recordings; and (4) suggestive interventions would be equally effective used in minor and major surgeries. Methods: We performed random effect meta-analysis with meta-regression and sensitivity analysis by moderating factors on a pool of 26 studies meeting the inclusion criteria (N = 1890). Outcome variables were postoperative anxiety, pain intensity, pain medication requirement, and nausea. Results: Suggestive interventions reduced postoperative anxiety (g = 0.40; 99% confidence interval [CI] = 0.13-0.66; P < 0.001) and pain intensity (g = 0.25; 99% CI = 0.00-0.50; P = 0.010), but did not significantly affect postoperative analgesic drug consumption (g = 0.16; 99% CI = -0.16 to 0.47; P = 0.202) and nausea (g = 0.38; 99% CI = -0.06 to 0.81; P = 0.026). No significant differences were found for intervention type, presentation method, and severity of surgery; however, sensitivity analysis only supported the effectiveness of hypnosis (g = 0.62; 99% CI = 0.31-0.92; P < 0.001) and live presentation (g = 0.55; 99% CI = 0.23-0.88; P < 0.001) for decreasing postoperative anxiety, and that of live presentation for alleviating postoperative pain (g = 0.44; 99% CI = 0.07-0.82; P = 0.002). Sensitivity analyses also suggested that suggestive interventions are only effective for decreasing pain intensity during minor surgical procedures (g = 0.39; 99% CI = 0.00-0.78; P = 0.009). Conclusions: Suggestive techniques might be useful tools to alleviate postoperative anxiety and pain; however, strength of the evidence is weak because of possible bias in the reviewed articles. The lack of access to within-subjects data and the overlap between moderator conditions also limit the scope of the analysis. More methodologically correct studies are required with sensitivity to moderating factors and to within-subjects changes. For clinical purposes, we advise the use of hypnosis with live presentation to reduce postoperative anxiety and pain, until convincing evidence is uncovered for the effectiveness of therapeutic suggestions and recorded presentation. Pain management with adjunct suggestive interventions is mostly encouraged in minor rather than major surgeries.