Content uploaded by D. Corydon Hammond
Author content
All content in this area was uploaded by D. Corydon Hammond on Mar 03, 2014
Content may be subject to copyright.
Content uploaded by D. Corydon Hammond
Author content
All content in this area was uploaded by D. Corydon Hammond on Feb 16, 2014
Content may be subject to copyright.
263
Review
www.expert-reviews.com ISSN 1473-7175
© 2010 Expert Reviews Ltd
10.1586/ERN.09.140
Most methods of facilitating hypnosis involve
suggestions for relaxation, but the most fun-
damental component in hypnosis appears to
involve facilitating a state of focused atten-
tion and concentration, although several other
factors are also believed to be involved [1].
Responsiveness to hypnosis has commonly
been experimentally defined by an individual’s
response to a series of suggestions for various
hypnosis phenomena (e.g., analgesia or amne-
sia) of varying difficulty. Responsiveness var-
ies, and a small percentage of individuals are
relatively unresponsive to hypnosis. Hypnotic
responsiveness is a very stable trait [2] , with
test–retest reliability after 25 years being
approximately 0.7, and responsiveness is not
easily modifiable [3]. While clinical experience
has shown that a majority of people are suffi-
ciently responsive to hypnosis to obtain anxiety
relief, a higher level of responsiveness is needed
to experience some hypnotic phenomena, such
as profound analgesia or amnesia. However,
despite variations in hypnotic response, most
patients have sufficient ability to benefit clini-
cally [4] . Nonetheless, most individuals have
been found to be more responsive to sugges-
tion after a hypnotic induction has been per-
formed [5]. Although occasionally hypnosis may
be used for unconscious exploration, in a large
proportion of clinical conditions patients are
taught self-hypnosis, which is commonly made
easier to learn through making individualized
self-hypnosis tapes or CDs for the patient [6].
There are many areas of application for self-
hypnosis training, for example in obstetrics
and gynecology, gastroenterology, dermatol-
ogy, asthma, management of chemotherapy
side effects, smoking and enuresis. Controlled
research, for instance, has established the effi-
cacy of hypnosis in controlling acute and chronic
pain [7,8]. This article will review the existing lit-
erature on the use of hypnosis and self-hypnosis
training in the treatment of anxiety, anxiety-
related disorders, stress management associated
with conditions that evoke state anxiety, such
as test and public speaking anxiety, and various
medical and dental procedures.
Anxiety & stress management
Kirsch performed a meta-ana lysis on 18 studies
in which cognitive–behavioral therapy (CBT)
with a variety of conditions (pain, insomnia,
anxiety, public speaking anxiety, obesity, hyper-
tension, phobia and duodenal ulcer) was com-
pared with the same therapy supplemented or
facilitated by hypnosis [9]. The results across
D Corydon Hammond
University of Utah School of
Medicine, PM &R, 30 No.
1900 East, Salt Lake City,
UT 84132-2119, USA
Tel.: +1 801 581 5741
Fax: +1 801 585 5757
d.c.hammond@utah.edu
Self-hypnosis training represents a rapid, cost-effective, nonaddictive and safe alternative to
medication for the treatment of anxiety-related conditions. Here we provide a review of the
experimental literature on the use of self-hypnosis in the treatment of anxiety and stress-related
disorders, including anxiety associated with cancer, surgery, burns and medical/dental procedures.
An overview of research is also provided with regard to self-hypnotic treatment of anxiety-related
disorders, such as tension headaches, migraines and irritable bowel syndrome. The tremendous
volume of research provides compelling evidence that hypnosis is an efficacious treatment for
state anxiety (e.g., prior to tests, surgery and medical procedures) and anxiety-related disorders,
such as headaches and irritable bowel syndrome. Although six studies demonstrate changes in
trait anxiety, this review recommends that further randomized controlled outcome studies are
needed on the hypnotic treatment of generalized anxiety disorder and in documenting changes
in trait anxiety. Recommendations are made for selecting clinical referral sources.
Keywor ds: anxiety • hypnosis • procedural anxiety • self-hypnosis • stress management
Hypnosis in the treatment
of anxiety- and
stress-related disorders
Expert Rev. Neurother. 10(2), 263–273 (2010)
For reprint orders, please contact reprints@expert-reviews.com
Expert Rev. Neur other. 10 (2), (2010)
264
Review Hammond
various conditions found that the addition of hypnosis sub-
stantially enhanced the therapy outcome. The average patient
receiving cognitive–behaviorally oriented hypnosis demonstrated
greater improvement than at least 70% of patients who received
nonhypnotic treatment. In the one study of anxiety cited in the
review, there was a high effect size of 1.4 standard deviations,
indicating that the addition of hypnosis significantly enhanced
the efficacy of CBT [10]. In addition, owing to popular concep-
tions of hypnosis, simply labeling an intervention as hypnosis
may increase its efficacy where the only difference between relax-
ation instructions in a nonhypnotic condition and the ‘hypnotic
induction’ is the use of the term ‘hypnosis’ [11] . A recent meta-
ana lysis of hypnosis for distress associated with medical proce-
dures found that when the intervention was labeled as hypnosis
instead of ‘suggestion’, they were significantly (p < 0.002) more
effective [12].
In a randomized controlled study of acute stress disorder in
civilian trauma survivors, CBT was compared with identical treat-
ment preceded by a hypnotic induction [13]. Positive outcomes
were comparable for the two treatments and hypnosis resulted in
a greater reduction in re-experiencing symptoms of post-traumatic
stress disorder at the completion of treatment than CBT alone.
A 3-year follow-up found that both hypnotically facilitated CBT
and CBT were effective [14].
Two other randomized controlled studies have found that
when hypnotic treatment was added to CBT, superior effects
were found. One study found that the hypnotic CBT treatment
produced significantly greater improvements in depressed patients
on the Beck Anxiety Inventory (as well as the Beck Depression
Inventory, and the Beck Hopelessness Scale) than CBT alone [15].
Another study by Schoenberger examined the effects of a multi-
dimensional CBT of anxiety for public speaking compared with
exactly the same treatment in which the relaxation training was
referred to as a hypnotic induction and automatic thoughts were
referred to as self-suggestions (although some explicit hypnotic
suggestions for improvement were also added) [16]. Other than
labeling the procedure as hypnotic and adding hypnotic sug-
gestions for improvement, the two procedures were the same.
Subjects (n = 62) in both conditions improved more than wait-
list control subjects. However, calling the treatment hypnosis
(and adding a few suggestions) appeared to mildly improve the
treatment effectiveness (effect size: 0.4). These studies suggest
that simply identifying a treatment as hypnosis may generate
greater expectancies for change than nonhypnotic treatments if
the individual has favorable attitudes toward hypnosis, and these
enhanced expectations can improve overall treatment outcome.
As will be discussed later in relation to medical procedures, the
findings of the Kirsch meta-ana lysis are also congruent with two
more recent studies involving the use of hypnosis in association
with acupuncture [17,18].
When the behavioral therapy technique of progressive mus-
cle relaxation was compared with self-hypnosis training it was
found that both treatments produced physiological improve-
ments associated with reduced anxiety, increasing skin tempera-
ture and reducing pulse rate [19]. In another study, however, the
authors found that behavioral progressive relaxation may produce
greater hypnoidal effects than hypnosis among individuals with
low hypnotic responsiveness, and the phenomenological effects
were roughly comparable to those produced with hypnosis among
highly hypnotizable individuals [20] .
O’Neill and colleagues compared self-hypnosis training (which
simply consisted of reading through written instructions several
times and then practicing for 15 min) with the behavioral therapy
technique of progressive muscle relaxation in a randomized study
with ‘stressed, anxious, worried’ patients attending a psychology
clinic [21]. At a 1-month follow-up, both groups showed simi-
lar significant improvement on the Beck Anxiety Inventory and
in both state and trait anxiety (State–Trait Anxiety Inventory).
However, cognitive changes and perceptions of treatment efficacy
were greater for self-hypnosis than for relaxation. The subjects
using self-hypnosis reported higher expectations of success than
those using progressive rela xation exercises, demonstrating a
greater belief that they could now do something to manage their
anxiety. Similarly, comparable success of self-hypnosis in com-
parison to ‘relaxation response’-style medication was also reported
by Benson’s group in a randomized study with ‘anxiety neurosis’
patients on 8-week follow-ups [22].
Autogenic training (which is a structured German form of
self-hypnosis) was facilitated in a group by Houghton for stress
management with teachers for achieving reduced pulse rates [23].
Over a 14-week period these self-hypnotic exercises allowed
all of the teachers to reduce their pulse rates with significant
(p < 0.0001) consistency. Their success was found to be unre-
lated to gender or behavioral characteristics, such as Type-A
behaviors, speed, impatience, job involvement or being hard
driving. Two studies demonstrated improved heart rate vari-
ability profiles showing improved autonomic function, reduced
sympathetic activity and enhanced parasympathetic activity
following hypnosis [2 4, 25].
Kanji and coworkers compared eight sessions of autogenic
training with attentional control and no treatment groups in a
randomized study [26]. Significant reductions (p < 0.001) in both
state and trait anxiety resulted from autogenic training compared
with both other groups. Significant reductions were also seen in
systolic (p < 0.01) and diastolic (p < 0.05) blood pressure and
pulse rate (p < 0.002). Autogenic training has also been success-
fully used to reduce anxiety with patients undergoing coronary
angioplasty in a study where 59 patients were randomly assigned
to receive either standard care or autogenic training added to
standard care, during which small groups learned autogenic train-
ing for 60 min [27]. Compared with the standard care control
group, the hypnosis group demonstrated lower (p < 0.001) state
anxiety at 2 and 5 months following this brief group treatment
and lower trait anxiety at 2 months (p < 0.001) and after 5 months
(p < 0.04). Four sessions of hypnotic relaxation was also shown to
reduce anxiety (as well as anger and to produce increases in self-
esteem) when used in a study using a repeated measures design
with patients with traumatic brain injuries, stroke or multiple
sclerosis [28]. Importantly, a significantly reduced trait, as well as
state, anxiety was demonstrated in this study.
www.expert-reviews.com 265
Review
Hypnosis in the treatment of anxiety- & stress-related disorders
Stress associated with test anxiety & immune function
A number of investigations have examined the effects of hypno-
sis on immune function and have included measures of anxiety
in their studies. Undoubtedly, every reader has experienced test
anxiety and the stress of midterm and final examinations. Sapp
compared hypnosis with a Hawthorne control group and demon-
strated a decrease in test anxiety and improvements in achievement
for the hypnosis group, which were maintained on 6-week follow-
up [29]. Stanton randomly assigned 40 high school students who
were matched on sex and anxiety scores to either a self-hypnosis
training group that met for two 50-min sessions, or to a control
group who had two 50-min sessions in discussing ways to reduce
test anxiety [30]. Students were retested after two sessions and
6 months later. Anxiety scores were significantly reduced only
for the self-hypnosis group at both evaluation times. Schreiber
similarly examined the effects of group self-hypnosis training on
midterm and final examination grades in comparison with two
control conditions [31]. Students trained in self-hypnosis had sig-
nificantly higher scores on final examinations than controls, but
not on midterm exams.
Several sophisticated research studies have examined not only the
influence of self-hypnosis training in reducing stress, but also its
impact on enhancing immune function. Whitehouse and colleagues
evaluated the effects of self-hypnosis in relieving stress and moderat-
ing immune system reactivity to medical school examination stress
in a 19-week prospective study [32]. In total, 21 first-year medical stu-
dents who were identified as moderate-to-high in responsiveness to
hypnosis were trained in self-hypnosis, encouraged to practice regu-
larly and to keep daily records of mood, sleep, physical symptoms
and frequency of practice. A total of 14 control subjects received
no training, but kept daily ratings. Self-report measures and blood
samples were obtained at the time of orientation, late in the semester,
at an examination period, and post-semester. As one would expect,
significant increases in fatigue and stress were discovered during
the examination period paralleled by increases in B lymphocytes
and activated T lymphocytes, phyto hemagglutinin-induced and
pokeweed mitogen-induced blastogenesis and natural killer (NK)
cell cytotoxity. There were no decreases in immune measures. The
self-hypnosis subjects reported significantly less anxiety and distress
than control subjects, but there was no difference between groups in
immune function. However, in students using self-hypnosis it was
found that their relaxation ratings predicted both the number of
NK cells and NK activity. It is believed that stress connected with
academic demands influences immune function, but that immune
suppression is not inevitable. The authors concluded that the use
of self-hypnosis reduces stress without differential immune effects
overall, but individual responses to self-hypnosis do seem to predict
immune effects. Other studies have concluded that self-hypnosis
training for stress reduction before college examinations can have
sizeable influences on cell-mediated immunity, which has impli-
cations for illness prevention and for patients with compromised
immunity [33,34] .
It is well known that anxiety and stress can evoke herpes
outbreaks. A follow-up study examined the effects of self-hyp-
nosis training using dynamic imagery (rather than just passive
relaxation imagery) with chronic and severe herpes simplex virus
genital herpes [35]. Immune measures were performed prior to and
following 6 weeks of self-hypnosis practice. Self-hypnosis reduced
anxiety and depression, and it almost cut in half the recurrence
rate or herpes, benefiting 65% of patients.
Anxiety-related conditions & anxiety associated with
medical or dental procedures
Tension headaches & migraines
Melis et al., in a single-blind study of chronic tension headaches,
compared hypnosis with a wait-list control condition on 4-week
follow-up, finding not only significantly fewer headaches, but
also significantly lower anxiety [36] . Van Dyck et al. investigated
the relative efficacy of autogenic training and of self-hypnosis
training with tension headaches, finding both equally effective in
reducing anxiety and headaches [37]. A review has documented a
large volume of controlled research on self-hypnosis training for
migraine and tension headaches, which was shown to be statis-
tically superior to or equivalent to commonly used medication
treatments [38] . Furthermore, this literature review found that
simply teaching the use of self-hypnotic relaxation and imagery
techniques for daily self-hypnosis practice is as effective as more
complex hypnotic techniques in the relief of headaches.
Obstetrics & gynecology
Obstetrics and gynecology are specialties where hypnosis and self-
hypnosis training have been used extensively, not only for the relief
of pain with childbirth, but also for anxiety and relief of hyper emesis
gravidarum [39]. Mairs, for instance, used four 1-h self-hypnosis
training sessions with pregnant women (28 primigravida women
compared with 27 primigravida women not receiving hypnosis
training, where there were no significant demographic differences
between groups) [40]. Prebirth questionnaires asked for ratings of
anticipated levels of pain and anxiety, and post-birth questionnaires
were completed. Postbirth, those who received self-hypnosis train-
ing reported statistically significant ratings that were lower for both
pain and anxiety than untrained women, and when Caesarean sec-
tion patients were excluded the differences were even more signifi-
cant. Self-hypnosis also helped alleviate even the unexpected and
unprepared anxieties of Caesarean sections.
Irritable bowel syndrome & ulcers
A prominent anxiety-mediated medical condition is irritable bowel
syndrome (IBS). A variety of research studies have demonstrated
that teaching patients self-hypnosis skills proves of considerable
value for patients with IBS [41–45]. These studies by Whorwell’s
group have found long-term follow-up success rates of 95% with
classical, refractory IBS cases (who had previously failed with an
average of six types of treatment), 43% with atypical cases and 60%
with cases exhibiting significant psychopathology. Patients over
50 years of age responded more poorly (25% success), but patients
below 50 years of age with classical IBS had a 100% success rate.
Galovski and Blanchard obtained Whorwell’s cooperation so that
they were able to apply his exact treatment protocol to systematically
replicate his work [46]. Although worried about how hypnosis would
Expert Rev. Neur other. 10 (2), (2010)
266
Review Hammond
be accepted by a US population, they found that hypnosis was
highly acceptable, with no applicant declining treatment, and “in
fact, patients were seen to be readily amenable to hypnotherapy” [45].
Patients who were taught self-hypnosis (in 12 sessions utilizing an
eye fixation and progressive relaxation hypnotic induction followed
by imagery) improved significantly more than a symptom-monitor-
ing wait-list control group. In total, 82% of self-hypnosis patients
improved (and 27% were symptom free) compared with 0% of con-
trol patients, and when the wait-list patients crossed over to hypnotic
treatment, 67% of them significantly improved. Furthermore, on
2-month follow-up, the effects of treatment were relatively endur-
ing. Significant decreases were also found in not only state, but
also trait anxiety from pre- to post-treatment. The improved physi-
ological symptoms included abdominal pain, constipation, bloating
and flatulence. Although on the Stanford Hypnotic Susceptibility
Scale, Form A, the scores ranged from 2 (very low overall hypnotic
responsiveness) to 12 (high responsiveness), there was not a signifi-
cant relationship between formally measured hypnotizability and
treatment outcome. The authors concluded that the results “bode
well for this form of therapy in general. Many of the subjects in
the current study reported many positive side effects to this form
of therapy. Hypnotherapy thus appears to be beneficial over and above
the effect seen on the gastrointestinal symptoms.” (emphasis added) [45].
They conclude that the high outcomes and lack of drop-outs make
self-hypnosis training a viable treatment option.
An audit was taken of the first 250 IBS patients treated on a unit
in England specifically established to provide 12 sessions of self-
hypnosis training over a 3-month period [47]. Marked improve-
ment was seen in all of the symptom measures, quality of life,
anxiety and depression (all probabilities p < 0.001), in keeping
with previous studies. This study clearly demonstrated that self-
hypnosis training is an extremely effective treatment for IBS and
should prove more cost effective as new, more expensive drugs
come on the market.
The mechanism of improvement in the self-hypnotic treat-
ment of IBS had not been ascertained in previous studies.
Therefore, two studies evaluated possible physiological and
psycho logical mechanisms [48]. Patients with severe IBS received
seven biweekly self-hypnosis training sessions and used self-
hypnosis audiotapes at home. Rectal pain thresholds and
smooth-muscle tone were measured with a barostat before and
after treatment in 18 patients in the first study, and treatment
changes in heart rate, blood pressure, skin conductance, finger
temperature and forehead electromyographic (EMG) activity
were assessed in 24 patients in the second study. Somatization,
anxiety and depression were also measured. All central IBS
symptoms improved substantially from treatment in both stud-
ies. Rectal pain thresholds, autonomic functioning (except for
electro dermal response) and rectal smooth-muscle tone were
unaffected by the hypnotic treatment, but somatization and
psychological distress showed large decreases. It was con-
cluded that the practice of self-hypnosis improves IBS symp-
toms through reductions in anxiety, psychological distress and
somatization, since improvements were unrelated to changes in
the physiological parameters measured.
Controlling anxiety associated with medical procedures
Two recent studies examined the use of hypnosis in association
with acupuncture. An intervention involving 20 min of hypnosis
while acupuncture needles were in place was evaluated for the
treatment of chronic pain in children [17]. After six sessions, pain
was not only improved as rated by both parents and children,
but anticipatory anxiety also declined significantly. A somewhat
similar study compared the effects of acupuncture after receiv-
ing an hypnotic induction versus pure acupuncture treatment of
angina pectoris (AP) [18]. A total of 40 patients with AP received
hypnosis with acupuncture, and 31 received pure acupuncture
therapy for 4 weeks (six sessions per week) in a Tibet hospital.
When hypnosis was involved, the result was superior to pure acu-
puncture treatment in reducing both anxiety and depression in
the treatment of AP.
As early as 1982, Zeltzer and LeBaron found that anxiety was
significantly reduced by hypnosis, but not by distraction, in a ran-
domized study of children undergoing bone marrow aspiration
or lumbar puncture [49]. The use of self-hypnosis for relaxation to
reduce the need for intravenous sedation during radiological pro-
cedures was evaluated by Lang’s group [50]. A total of 14 patients
were randomly assigned to a control group, while 16 were randomly
assigned to the experimental group. In total, 30 out of 33 patients
invited to participate were willing to do so, suggesting a great public
openness to this alternative medicine, nonpharmacologic interven-
tion. All patients had the capacity to administer patient-controlled
analgesia. Self-hypnosis training included teaching the patients to
use relaxation and imagery of a pleasant place for hypnotic induc-
tion and deepening. If something unpleasant was experienced,
patients were taught to allow an image to form representing the
feeling, and then to transform the image to neutralize the emotion.
When a possibly painful experience was anticipated (e.g., contrast
medium injection) patients were told to imagine a competing feel-
ing (e.g., numbness, coolness). Often only 5–10 min were spent
with a patient during sterile preparation and administration of
local anesthesia, followed by a few minutes at a later time to deepen
self-hypnotic relaxation, prepare the patient for potentially pain-
ful stimuli or to obtain reports (e.g., pain or anxiety scores). In
comparison to controls, the self-hypnosis patients required less
drugs (0.28 vs 2.01 drug units; p < 0.01) and experienced less pain
(median rating 2 vs 5 on a 0–10 scale; p < 0.01). Control patients
exhibited oxygen desaturation and/or required interventions for
hemodynamic instability significantly more often. Anxiety ratings
were approximately half those of control patients. As noted in other
studies already reviewed, benefits were unrelated to hypnotiz ability,
indicating that a high level of hypnotic talent is not necessary for
this level of intervention focused on relaxation.
In order to determine how patients’ underlying anxiety affects
their experience of distress, use of resources and responsiveness
toward nonpharmacologic analgesia adjunct therapies during inva-
sive procedures, Schupp et al. worked with 236 patients undergo-
ing vascular and renal interventions [51]. Patients were randomly
assigned to receive structured empathic attention or self-hypnotic
relaxation during standard care treatment, and were divided into
two groups: those with low state anxiety scores on the State–Trait
www.expert-reviews.com 267
Review
Hypnosis in the treatment of anxiety- & stress-related disorders
Anxiety Inventory and those with high state anxiety scores. All
patients had access to patient-controlled analgesia with fentanyl
and midazolam. Every 15 min during the procedure, patients
were asked to rate their anxiety and pain on a scale of 0–10 (0:
no pain/anxiety at all; 10: worst possible pain/anxiety). Effects
were assessed by ana lysis of variance and repeated-measures ana-
lysis, and it was found that patients with high state anxiety lev-
els required significantly greater procedure time and medication.
Empathic attention, as well as self-hypnosis, reduced procedure
time and medication use for all patients. These nonpharmacologic
treatments also provided significantly better pain control than
standard care for patients who had low anxiety levels. Anxiety was
found to decrease over the time of the procedure and patients with
high state anxiety levels experienced the most significant decreases
in anxiety with both interventions, whereas patients with low state
anxiety levels coped relatively well under all conditions. Thus,
patients’ state anxiety level was a predictor of trends in procedural
pain and anxiety, need for medication, and procedure duration, but
both low and high state anxiety groups profited from self-hypnosis,
although those with high state anxiety levels benefitted the most.
A randomized controlled comparison evaluated hypnosis versus
CBT or standard care in 30 pediatric cancer patients undergo-
ing bone aspirations [52]. Hypnosis and CBT were equally effec-
tive in reducing pain in comparison with standard care. However,
hypnosis was significantly more effective than CBT in reducing
anxiety (p < 0.0002) and observed distress (p = 0.0025). The same
authors subsequently found training in self-hypnosis was effective in
reducing anxiety and pain associated with pediatric cancer patients
under going regular lumbar punctures in comparison to attentional
controls or standard medical care groups [53]. A further randomized,
blinded study with the same population evaluated the efficacy of an
analgesic cream, versus hypnosis and analgesic cream, versus analge-
sic cream and attention [54]. The addition of hypnosis significantly
reduced both anticipatory anxiety and procedural anxiety (as well as
pain) in comparison with the cream alone (p < 0.001) and attentional
controls (p < 0.001). Furthermore, benefits from self-hypnosis train-
ing were maintained at 6-month follow-up. A parallel blinded study
by this group found that the addition of brief, 15-min self-hypnosis
training to the use of a local anesthetic was significantly superior to
local anesthetics alone or local anesthetic with attentional control,
in reducing anticipatory anxiety and procedure-related anxiety (and
pain) with pediatric cancer patients undergoing venopuncture for
blood sampling [55]. Results were maintained during two follow-up
venopunctures. As an added bonus, the parents of the children who
had been briefly trained in self-hypnosis also experienced less anxiety
during their childrens’ procedures.
A meta-ana lysis of 26 randomized controlled trials (with
2342 patients) of hypnosis associated with medical procedures
found that 82% of patients receiving hypnosis experienced lower
levels of emotional distress [56] . The effect size for hypnosis was
0.88 and it was found that children (who as a group have higher
hypnotic responsiveness [57]) benefited more, but adults still had
a medium effect size. Hypnosis was found to be most effective
when at least part of the hypnotic procedure was performed in
person (versus audio recording) and when at least part of the
hypnosis occurred prior to the beginning of the medical proce-
dure. Hypnosis appeared equally effective when compared with
standard care or an attentional control group, demonstrating that
benefits from hypnosis are not simply due to receiving attention.
A randomized study of the impact of a combination of hypno-
sis and CBT versus standard care in breast cancer radiotherapy
patients found significantly lower levels (p = 0.0007) of negative
affect and significant levels (p = 0.0035) of positive affect in the
hypnosis and CBT group [58]. Trait anxiety significantly decreased
following the treatment, which consisted of brief hypnosis and pro-
vision of a hypnosis CD to listen to at home, as well as 30 min of
CBT instruction and provision of a CBT workbook for home study.
Another study compared hypnosis with distraction in severely
ill children undergoing painful medical procedures [59]. A sample
of high and low hypnotizable children (n = 27) of diverse eth-
nic backgrounds and suffering from blood or cancer disorders
were trained, along with their parents, to use both self-hypnosis
and distraction for pain and anxiety reduction. Pain and anxiety
measures were obtained from parents and children, and inde-
pendent raters estimated the distress from videotapes. Data were
then collected during painful medical procedures for baseline,
self-hypnosis and distraction conditions. Children who were
hypnotizable demonstrated significantly lower pain, anxiety and
distress scores when hypnotized compared with low hypnotizable
children. Distraction produced significant positive effects only
for observer ratings of distress in the low hypnotizable condition.
One randomized prospective study with out-patient EMG
procedures compared a 20-min hypnosis audio program with a
20-min education about the EMG audio program. Lower anxi-
ety was reported in the hypnosis condition, but it did not reach
statistical significance [60].
A total of 20 min of hypnosis prior to the start of a first-trimes-
ter abortion was found, in a randomized study, to significantly
reduce anxiety (p < 0.0001) at the time of suction evacuation and
to reduce needs for subsequent intravenous sedation [61].
Hypnosis for surgical anxiety
Anxiety is a problem for patients anticipating surgery, with more
than half of them fearing anesthesia or not waking up after sur-
gery [62]. A randomized controlled study with children found that
preoperative hypnotic guided imagery resulted in significantly
less pain and state anxiety, and shorter hospital stays [63]. In a
randomized, placebo controlled study on the effects of ‘relaxation
and guided imagery’ on knee strength, reinjury anxiety and pain
in anterior cruciate ligament knee surgery patients it was shown
that the hypnotic imagery/relaxation patients had significantly
greater knee strength and significantly less reinjury anxiety and
pain at 24 weeks post-surgery than either attentional placebo or
control group participants [64] .
Hypnosis was evaluated as an adjunct to conscious sedation for
plastic surgery by Faymonville et al. [65]. In a study of 337 patients
undergoing minor and major plastic surgery under local anesthesia
and conscious intravenous sedation, they divided patients into
three groups: intravenous sedation (n = 137) using only midazolam
and alfentanil; hypnosis (n = 172), during which relaxation age
Expert Rev. Neur other. 10 (2), (2010)
268
Review Hammond
regression was used; and relaxation (n = 28), consisting of patients
where a rapid hypnotic induction was performed, but without
much depth. In all three groups, midazolam and alfentanil were
titrated to achieve patient immobility, in response to patient com-
plaints and to maintain hemodynamic stability. Intraoperative
anxiety in the hypnosis group and in the brief hypnotic relaxation
group were significantly (p < 0.001) less than in the intravenous
sedation group. Pain scores during surgery were also significantly
greater in the intravenous sedation group than in the hypnosis
group (p < 0.001) and the rapid self-hypnotic relaxation group
(p < 0.01). In addition, midazolam requirements were signifi-
cantly less in the hypnosis group (p < 0.001) and in the relaxation
group (p < 0.01) compared with the sedation group. Alfentanil
requirements were significantly decreased in the hypnosis group
and postoperative nausea and vomiting were reported by 1.2% of
the patients in the hypnosis group, 12.8% in the relaxation group
and in 26.7% in the intravenous sedation group. Greater patient
satisfaction with the anesthetic procedure and greater surgical
comfort were also found in the hypnosis group. Thus, even a very
brief hypnotic induction was found to be helpful, but a deeper level
of hypnosis was even more beneficial.
In a later randomized controlled study with 60 plastic surgery
patients, this same group found that hypnosis was associated with
less peri- and post-operative anxiety and pain, even though there
was a significant reduction in intraoperative needs for midazolam
and alfentanil in the hypnosis group [66] . The patients in the
hypnosis group also felt a greater sense of intraoperative control
than the control group, and experienced significantly less nau-
sea and vomiting than the other patients. Hypnotized patients
demonstrated fewer signs of discomfort and pain.
In yet another study, 130 patients undergoing elective colorectal
surgical procedures were randomly assigned to routine procedure
or guided imagery tape groups [67]. The latter patients listened to
hypnotic type imagery tapes for 3 days before surgery, during the
induction of anesthesia, intraoperatively, in the recovery room and
for 6 days following surgery. Anxiety levels, pain perceptions and
narcotic medication were assessed. Patients in the experimental
group experienced considerably less pre- and post-operative anxi-
ety and pain, and required almost 50% less narcotic medications
than the control group.
Schnur et al. randomly compared excisional biopsy patients
(n = 90) receiving a 15-min presurgical hypnosis session versus
a 15-min presurgical attentional control session (empathic lis-
tening) [68] . The hypnosis group had significantly (p < 0.0001)
less anxiety, depressed mood (p < 0.02) and emotional upset
(p < 0.001) and greater relaxation (p < 0.001) than controls at
post-intervention and presurgical evaluations. Similarly, a ran-
domized comparison of hypnosis (n = 26) and attentive listen-
ing and support without hypnotic suggestions (n = 26) versus
standard care found significantly less (p = 0.0008) preoperative
anxiety with hypnosis compared with the other groups in ambu-
latory surgery patients [69]. On entering the operating room, the
hypnosis group patients had a 56% decrease in anxiety, while
the attentional control group experienced a 10% increase and
the standard care group a 47% increase in anxiety (p = 0.001).
Lang’s group conducted a prospective randomized controlled
study of simple self-hypnotic relaxation, standard care or struc-
tured empathic attention in 236 women undergoing large core-
needle breast biopsy [70]. The women receiving only standard care
experienced a significant increase in anxiety (p > 0.001), while
anxiety did not change in the empathy group, and decreased sig-
nificantly in the self-hypnosis group (p < 0.001). Pain increased
significantly (p < 0.001) in all three groups, although less steeply
with hypnosis and empathy than standard care. It was concluded
that self-hypnosis more powerfully relieved anxiety without
undue cost. Another randomized study by the same group of
201 patients receiving pericutaneous tumor surgeries found that
patients receiving hypnosis experience significantly less state anxi-
ety (pain and medication) than those receiving standard care or
empathic communication [71].
In a randomized study of coronary artery bypass patients, de
Klerk et al. found that 2 h of preoperative hypnotic ‘ego-strength-
ening’ (n = 50) significantly reduced anxiety (and depression)
compared with a standard-care control group (n = 25), and
changes were maintained on 6-week follow-up [72]. Hypnosis has
also been found to significantly (p < 0.01) reduce cardiac sym-
pathetic activity and myocardial ischemia during pericutaneous
transluminal angioplasty [73].
One placebo-controlled study compared midazolam and hyp-
nosis for reducing preoperative anxiety in children and found that
hypnosis was just as effective as midazolam in its effects preop-
eratively (but, of course, without the risks associated with medi-
cation), and hypnosis was more effective (p < 0.05) in reducing
anxiety during the induction of chemical anesthesia [74].
All of these results can still be reasonably summarized by the
findings of a 2002 meta-ana lysis of 20 studies (1624 patients) that
found that an average of 89% of surgical patients benefited from
the inclusion of hypnosis relative to patients in control conditions,
with a high effect size (1.07) for the reduction of negative affect
(anxiety and depression) [56].
Dental anxiety & oral surgery
Dental anxiety is relatively common, but has been shown to be
significantly improved with self-hypnosis training [75]. Hypnosis
has also been used effectively in oral surgery. Dyas found that
hypnosis prior to sedation (midazolam and fentanyl) resulted
in a significantly (p < 0.001) lower heart rate, and much less
(p < 0.001) intravenous sedation than was required compared
with a standard sedation procedure [76]. Outcomes in control
patients were not as positive and they required more intravenous
medication, and one patient required conversion to a full general
anesthetic. Enqvist and Fischer compared a control group with
patients who used a presurgical self-hypnosis tape prior to surgical
removal of molars [77]. Hypnosis patients experienced significantly
less anxiety and required significantly less analgesic medication.
In another study, listening to an 18-min self-hypnosis tape prior
to maxillofacial surgery was found to result in significantly less
postsurgical edema (p < 0.000), pyrexia (p < 0.006) and use
of anxiolytics (p < 0.003) postoperatively in comparison with
matched controls [78].
www.expert-reviews.com 269
Review
Hypnosis in the treatment of anxiety- & stress-related disorders
Eitner examined anxious and nonanxious patients during
oral/maxillofacial (dental implant) surgery, finding that hypno-
sis significantly reduced anxiety and physiologically monitored
parameters on the day of surgery [79]. Findings were even more
significant in highly anxious patients.
Patients who have a history of drug dependence often experience
considerable anxiety regarding surgical sedation. Lu and cowork-
ers found hypnotic augmentation of standard sedation to be very
beneficial in 18 such patients where previous attempts at oral sur-
gery had proven unsuccessful because of their fears [80]. Hypnotic
induction preceded use of intravenous sedation (midazolam or
diazepam plus methohexital), but followed intra muscular sedation
(meperidine plus promethazine). Treatment outcomes were good
or excellent in 11 out of 18 of these refractory patients. When the
treatment outcome was poor or fair it was found that five out of
seven patients had the possibility of tolerance or crosstolerance
between their drug of abuse and the sedative agent, while this
possibility was only found in one out of 11 patients having good or
excellent outcomes. It was concluded that hypnosis can be used to
augment sedation in drug-dependent patients, but it is important
to use sedatives where tolerance is unlikely.
Burn patients
Burn patients not only experience pain, but also a great deal of
anxiety, especially in anticipation of dressing changes. A prospective
randomized study compared hypnosis against another stress-reduc-
ing strategy (SRS) for controlling peri-dressing-change pain and
anxiety in severely burned patients [81]. A total of 30 patients with a
total burned surface area of 10–25%, requiring a hospital stay of at
least 14 days, were randomly selected to receive either self-hypnosis
training or SRSs adjunctively to routine intramuscular pre-dressing-
change analgesia and anxiolytic drugs. Visual analogue scale (VAS)
scores for anxiety, pain, pain control and patient satisfaction were
recorded at 2-day intervals throughout the 14-day study period,
before, during and after dressing changes. The psychological inter-
ventions were provided on days 8 and 10 after hospital admission.
The comparison of the two treatment groups indicated that VAS
anxiety scores significantly decreased before and during dressing
changes when the hypnotic technique was used instead of SRS. No
differences were observed for pain, pain control and satisfaction,
although VAS scores were always better in the hypnosis group.
Anxiety in cancer patients
When someone receives a diagnosis of cancer, anxiety naturally
increases. Laidlaw and Willett studied the outcome from using self-
hypnosis tapes in 27 cancer patients versus breathing techniques
in a randomized study [82]. Outcome measures included incidence
of acute anxiety episodes and ratings of both positive and negative
emotions, which were collected prior to and post-intervention.
Patients showed significant improvement in both incidence of acute
anxiety attacks and in experiencing more positive and less negative
mood states.
Another study explored the use of autogenic training to increase
coping ability in patients diagnosed with cancer [83]. It was believed
that reduction in arousal and anxiety could help cancer patients to
perceive their environment as less hostile and threatening, improve
coping ability, relieve symptoms and increase the overall sense of
wellbeing. Each of the 18 subjects completed a Hospital Anxiety
and Depression Scale and the Profile of Mood States questionnaire
before and after a 10-week training course. Patients experienced
a statistically significant reduction in anxiety and an increase in
fighting spirit compared with before training, with an improved
sense of coping and improved sleep being other apparent benefits.
One study randomly assigned 50 advanced cancer patients to
receive either standard palliative medical care with supportive
cognitive existential counseling or to receiving four group self-
hypnosis training sessions along with standard medical care [84] .
The self-hypnosis group was found to result in significantly better
overall quality of life measures (p < 0.01), less psychological dis-
tress (p < 0.01), less physical distress (p < 0.01) and lower levels of
anxiety (p < 0.01) and depression (p < 0.01) compared with stand-
ard care. Thus, even in terminally ill cancer patients, self-hypnosis
training appears effective in reducing anxiety and distress.
Conclusion
This review has demonstrated that the inclusion of hypnosis with
other treatment modalities (e.g., CBT or acupuncture) commonly
improves the outcomes obtained by the other therapeutic modali-
ties alone. It has been further shown that self-hypnosis training and
practice results in improvements in physiological measures (e.g.,
heart rate) and has the potential to enhance immune function as it
reduces stress. Hypnosis has also been shown to have comparable
effects in comparison with well-established treatments, such as
progressive relaxation.
Considerable evidence exists that training in self-hypnosis not
only reduces generalized stress, but is also effective in reducing anx-
iety associated with public speaking, test taking and coping after
being diagnosed with cancer, as well as in reducing anxiety expe-
rienced by burn patients and those going through childbirth. The
evidence is especially compelling regarding the ability of hypnosis
to significantly reduce anxiety associated with a variety of surgical,
medical and dental procedures (e.g., incisional biopsy, venepunc-
ture, having radiological and imaging procedures, dentistry or oral
surgery). Self-hypnosis training has been documented to produce
improvements in stress related medical conditions, such as ten-
sion headaches, migraines and IBS, and in reducing the frequency
of anxiety-provoked herpes outbreaks. Results also demonstrate
that the process of learning self-hypnosis commonly increases self-
esteem and perceptions of self-efficacy from having developed a self-
mastery skill. However, despite the fact that this review has identi-
fied extensive evidence from randomized controlled studies for the
value of hypnosis in reducing state anxiety associated with a large
variety of stressful conditions, and that significant improvements
occur in anxiety-related disorders after self-hypnosis training, only
six studies of self-hypnosis or autogenic training have adequately
documented outcomes of reduced trait anxiety [20,23–25,41,56]. It was
surprising not to have uncovered more studies focused on general-
ized anxiety disorder. Thus, while the available scientific evidence is
very supportive of the value of hypnosis and self-hypnosis training
with problems of anxiety associated with many things, this review
Expert Rev. Neur other. 10 (2), (2010)
270
Review Hammond
has also documented that a need exists for further controlled stud-
ies focused on generalized anxiety disorder and that also include
measures of trait anxiety. When the State–Trait Anxiety Inventory
is used in research it is recommended that outcomes on both the
state and trait measures be reported, rather than overall State–Trait
Anxiety Inventory improvements.
Chambless et al. established the following criteria to obtain
the status of a well-established treatment in clinical psychol-
ogy [85]. First, there must be at least two experiments that show
efficacy through demonstrating that it is superior statistically to
another treatment or to a pill or psychological placebo, or that it
is “equivalent to an already established treatment in experiments
with adequate sample sizes.” Alternatively, a treatment may be
considered to be well established through “a large series of single
case design experiments (n > 9) demonstrating efficacy” that must
have used good experimental designs and compared the treat-
ment to another intervention. Furthermore, a well-established
treatment must have been conducted with a treatment manual,
must clearly specify the characteristics of the client samples and
the positive outcomes must have been demonstrated by at least
two different investigators or research teams.
According to these standards for judging efficacy of psycho-
logical treatments, hypnosis with anxiety that is associated with
medical procedures and of hypnosis utilized presurgically has
been demonstrated to be statistically superior or equivalent in
comparison to commonly used medication treatments and CBT,
and in comparison to attentional control conditions that could
be considered as an equivalent of a placebo-control condition.
Thus, it can be said that hypnosis meets the criteria for being a
well-established treatment that is both efficacious and specific.
Six studies of hypnosis in association with trait anxiety, which we
might judge to be fairly synonymous with a diagnosis of generalized
anxiety disorder, have also demonstrated its effectiveness.
Expert commentary
Perspective is provided by comparing self-hypnosis training with
other treatment options. CBT has proven effective in reducing
anxiety, but may often require a larger number of sessions to
accomplish the objective. Medication treatment is widely used,
but clearly has limitations. A review of the research on 13 anxi-
ety medications found that psychopharmacologic treatment was
superior to a placebo less than half of the time (48%) [86] , while,
as noted previously, hypnosis has been documented as superior
to placebo and at least equivalent to medication in numerous
studies of procedural or surgical anxiety. Similarly, an independ-
ent ana lysis of drug company research obtained from the US
FDA through the Freedom of Information Act found that anti-
depressants on average only have an 18% effect over and above
placebo effects [87], while another review found an average drug
versus placebo difference of only 16.8% in randomized controlled
trials [88]. Such findings have been referred to as the ‘dirty little
secret’ in the pharmaceutical literature and with the FDA [89].
In comparison to medication treatment, self-hypnosis train-
ing offers patients a method for rapidly self-administering what
we may think of as a naturalistic tranquilizer. Advantages of
self-hypnotic treatment of anxiety include freedom from adverse
side effects and drug interactions, lack of addictive risks and
problems with drug withdrawal, and the fact that it increases the
patient’s sense of mastery and self-efficacy, knowing that he or she
possesses a self-management skill. Once learned, this skill may be
used to cope with general stress, anxiety associated with specific
situations (e.g., public speaking, fear of flying, medical and dental
procedures) and to assist in managing insomnia, irritable bowel
symptoms and headaches or migraines. Hypnosis has proven
cost effective in healthcare, commonly requiring only three to
five office visits or less for self-hypnosis training for generalized
anxiety, and as little as 10–20 min in association with medical/
dental procedures [90–92]. However, clinicians do not have to think
in either/or terms. The choice does not have to be to either use
self-hypnosis training or other treatments, such as medication,
biofeedback or CBT. Particularly in patients with more severe
problems, self-hypnosis training may be very easily combined
with other forms of treatment.
Caution must be exercised, however, in identifying competent
referral sources for hypnosis services because of the large number
of unlicensed lay hypnotists. Therefore, it is recommended that
referral only be made to licensed healthcare professionals who
are also trained in hypnosis. Such individuals may be identified
through contacting the American Society of Clinical Hypnosis [101]
or the Society for Clinical and Experimental Hypnosis [102], both
of which also provide hypnosis training to licensed professionals.
Five-year view
Although hypnosis has been a treatment modality for more than
200 years it has been underutilized owing to misconceptions
among professionals about the nature of hypnosis. However, inter-
est in and openness to alternative and complementary medicine
techniques has rapidly increased at the same time that the public
has become increasingly dissatisfied with and wary of reliance
on only medication treatment. Studies cited have shown that the
vast majority of the public have an openness to the use of hypno-
sis as part of treatment. These factors combined with increasing
healthcare costs and unfavorable economic conditions create a
climate in which a rapid and cost-effective treatment modality,
such as self-hypnosis training, will become increasingly appealing.
Economic factors reinforce the importance of the principle of par-
simony in guiding treatment selection – utilizing the least complex
and most rapid methods of treatment first, and only turning to
invasive or more time-consuming treatments in the more chronic
or complex cases where less complicated methods have not proven
sufficient. When offered by licensed healthcare professionals as a
psychotherapy procedure, services are also usually reimbursable.
Financial & competing interests disclosure
The author has no relevant affiliations or financial involvement with any
organization or entity with a financial interest in or financial conflict with
the subject matter or materials discussed in the manuscript. This includes
employment, consultancies, honoraria, stock ownership or options, expert
testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.
www.expert-reviews.com 271
Review
Hypnosis in the treatment of anxiety- & stress-related disorders
Key issues
• Hypnosis has been shown to be effective in reducing state anxiety associated with cancer, surgery, burns and a variety of
medical/dental procedures.
• Self-hypnosis training has also been demonstrated to effectively treat anxiety-related disorders, such as tension headaches, migraines
and irritable bowel syndrome.
• Six studies have demonstrated changes in trait anxiety from self-hypnosis training, but further randomized controlled outcome studies
would be desirable on the hypnotic treatment of generalized anxiety disorder and in further documenting changes in trait anxiety.
• Self-hypnosis training has been demonstrated to be a rapid, cost-effective, nonaddictive, side-effect free and safe alternative to
medication for the treatment of anxiety-related conditions, and the public has been shown to be open to hypnosis treatment.
• Economic factors reinforce the importance of the principle of parsimony in guiding treatment selection – utilizing the least complex and
most rapid methods of treatment first and only turning to invasive or more time-consuming treatments in the more chronic or complex
cases where less complicated methods have not proven sufficient.
• In patients with more severe problems, self-hypnosis training may very easily be combined with other forms of treatment.
• Caution must be exercised in identifying competent referral sources for hypnosis services because of the large number of unlicensed
lay hypnotists.
References
1 Hammond DC. An integrative, multi-
factor conceptualization of hypnosis. Am. J.
Clin. Hypn. 48(2–3), 131–135 (2006).
2 Piccione C, Hilgard ER, Zimbardo PG.
On the degree of stability of measured
hypnotizability over a 25-year period.
J. Pers. Soc. Psychol. 56, 289–295 (1989).
3 Perry C. Is hypnotizability modifiable?
Int. J. Clin. Exp. Hypn. 25, 125–146 (1977).
4 Montgomery GH, David D, Winkel G,
Silverstein JH, Bovbjerg DH. The
effectiveness of adjunctive hypnosis with
surgical patients: a meta-analysis. Anesth.
Analg. 94, 1639–1645 (2002).
5 Hilgard ER. Hypnotic Susceptibility.
Harcourt, Brace & World, NY, USA
(1965).
6 Hammond DC, Bartsch C, Grant CW,
McGhee M. A comparison of tape-assisted
and self-directed self-hypnosis. Am. J. Clin.
Hypn. 31(2), 119–124 (1988).
7 Montgomery GH, DuHamel K N,
Redd WH. A meta-analysis of hypnotically
induced analgesia: how effective is
hypnosis? Int. J. Clin. Exp. Hypn. 48(2),
138–153 (2000).
8 Elkins G, Jensen MP, Patterson DR.
Hypnotherapy for the management of
chronic pain. Int. J. Clin. Exp. Hypn. 55(3),
275–287 (2007).
9 Kirsch I, Montgomery G, Sapirstein G.
Hypnosis as an adjunct to cognitive-
behavioral psychotherapy: a meta-analysis.
J. Consult. Clin. Psychol. 63(2), 214–220
(1995).
10 Sullivan DS, Johnson A, Bratkovitch J.
Reduction of behavioral deficit in organic
brain damage by use of hypnosis. J. Clin.
Psychol. 30, 96–98 (1974).
11 Lazarus AA. “Hypnosis” as a facilitator in
behavior therapy. Int. J. Clin. Exp. Hypn.
21, 25–31 (1973).
12 Schnur JB, Kafer I, Marcus C,
Montgomery GH. Hypnosis to manage
distress related to medica l procedures:
a meta-analysis. Contemp. Hypn. 25(3 –4),
114–128 (2008).
13 Bryant R, Moulds M, Guthrie R, Nixon R.
The additive benefit of hypnosis and
cognitive–behavioral therapy in treating
acute stress disorder. J. Consult. Clin.
Psychol. 73, 334–340 (2005).
14 Bryant R, Moulds M, Nixon R,
Mastrodomenico J, Felmingham K,
Hopwood S. Hypnotherapy and cognitive
behaviour therapy of acute stress disorder:
a 3-year follow-up. Behav. Res. Ther. 44(9),
1331–1335 (2006).
15 Alladin A, Alibhai A. Cognitive
hypnotherapy for depression: an empirical
investigation. Int. J. Clin. Exp. Hypn.
55(2), 147–166 (2007).
16 Schoenberger NE, Kirsch I, Gearan P et al.
Hypnotic enhancement of a cognitive
behavioral treatment for public speaking
anxiety. Behav. Ther. 28(1), 127–140 (1997).
17 Zeltzer LK, Tsao JC, Stelling C, Powers M,
Levy S, Waterhouse M. A Phase I study on
the feasibility and acceptability of an
acupuncture/hypnosis intervention for
chronic pediatric pain. J. Pain Sympt.
Manage. 24(4), 437–446 (2002).
18 Li X, Zheng Q, Song S et al. A study on
hypnotic acupuncture therapy for angina
pectoris and its effects on plasma ET and
NO. Chinese J. Clin. Psychol. 10(1), 63–64,
67 (2002).
19 Forbes EJ, Pekala RJ. Psychophysiological
effects of several stress management
techniques. Psychol. Rep. 72 (1), 19–27
(1993).
20 Pekala RJ, Forbes E. Hypnoidal effects
associated with several stress management
strategies. Aus. J. Clin. Exp. Hypn. 16,
121–132 (1988).
21 O’Neill LM, Barnier AJ, McConkey K.
Treating anxiety with self-hypnosis and
relaxation. Contemp. Hypn. 16(2), 68 –80
(1999).
22 Benson H, Fra nkel FH, Apfel R et al.
Treatment of anxiety: a comparison of the
usef ulness of self-hypnosis and a
meditational relaxation technique.
Psychother. Psychosom. 30, 229–241
(1978).
23 Houghton DM. Autogenic training:
a self-hypnosis technique to achieve
physiological change in a stress
management programme. Contemp. Hypn.
13(1), 39–43 (1996).
24 DeBenedittis G, Cigada M, Bianchi A.
Autonomic changes during hypnosis: a
heart rate variability power spectrum
analysis as a marker of sympathico–vagal
balance. Int. J. Clin. Exp. Hypn. 42,
140–152 (1994).
25 Hippel CV, Hole G, Kaschka W P.
Autonomic profile under hypnosis as
assessed by heart rate variability and
spectral analysis. Pharmacopsychiatry 34,
111–113 (2001).
26 Kanji N, White AR, Ernest E. Autogenic
training to reduce anxiety in nursing
students: randomized controlled trial.
J. Adv. Nurs. 53(6), 729–735 (2006).
27 Kanji N, White AR, Ernest E. Autogenic
training reduces anxiety after coronar y
angioplasty: a randomized clinical trial.
Am. Heart J. 147(3), K1-K4 (2004).
28 Sapp M. Rela xation and hypnosis in
reducing anxiety and stress. Aus. J. Clin.
Hypnother. Hypn. 13(2), 39–55 (1992).
Expert Rev. Neur other. 10 (2), (2010)
272
Review Hammond
29 Sapp M. Hypnotherapy and test anxiety:
two cognitive-behavioral constructs. The
effects of hypnosis in reducing test anxiety
and improving academic achievement in
college students. Aus. J. Clin. Hypnother.
Hypn. 12(1), 26 –32 (1991).
30 Stanton HE. Self-hypnosis: one path to
reduced test anxiety. Contemp. Hypn. 11(1),
14–18 (1994).
31 Schreiber EH. Use of group hypnosis to
improve college students’ achievement.
Psychol. Rep. 80 (2), 636– 638 (1997).
32 Whitehouse WG, Dinges DF, Orne EC
et al. Psychosocial and immune effects of
self-hypnosis training for stress
management throughout the first semester
of medical school. Psychosom. Med. 58,
249–263 (1996).
33 Gruzelier J, Smith F, Nagy A,
Henderson D. Cellular and humoral
immunity, mood and exam stress: the
influences of self-hypnosis and personality
predictors. Int. J. Psychophysiol. 42(1),
55–71 (2001).
34 Kiecolt-Glaser JK, Marucha PT,
Atkinson C, Glaser R. Hypnosis as a
modulator of cellular immune
dysregulation during acute stress.
J. Consult. Clin. Psychol. 69(4), 674–682
(2001).
35 Gruzelier J, Champion A, Fox P et al.
Individual differences in personality,
immunology and mood in patients
undergoing self-hypnosis training for the
successful treatment of a chronic viral
illness, HSV-2. Contemp. Hypn. 19(4),
149–166 (2002).
36 Melis PM, Rooimans W, Spierings EL,
Hoogduin CA. Treatment of chronic
tension-type headache with hypnotherapy:
a single-blind controlled study. Headache
31, 686–689 (1991).
37 Van Dyck R, Zitman FG, Linssen A,
Corry G, Spinhoven P. Autogenic training
and future oriented hypnotic imagery in
the treatment of tension headache: outcome
and process. Int. J. Clin. Exp. Hypn. 39,
6–23 (1991).
38 Hammond DC. Review of the ef ficacy of
clinical hypnosis with headaches and
migraine. Int. J. Clin. Exp. Hypn. 55(2),
207–219 (2007).
39 Brown DC, Hammond DC. Evidence-
based hypnosis for obstetrics, labor and
delivery, and preterm labor. Int. J. Clin.
Exp. Hypn. 55(3), 355–371 (2007).
40 Mairs DAE. Hypnosis and pain in
childbirth. Contemp. Hypn. 12(2), 111–118
(1995).
41 Byrne S. Hypnosis and the irritable bowel:
case histories, methods and speculation.
Am. J. Clin. Hypn. 15, 263–265 (1973).
42 Harvey RF, Hinton RA, Gunary RM, Barry
RE. Individual and group hypnotherapy in
treatment of refractory irritable bowel
syndrome. Lancet 1(8635), 424–425 (1989).
43 Prior A, Colgan SM, Whorwell PJ. Changes
in rectal sensitivity after hypnotherapy in
patients with irritable bowel syndrome. Gut
31(8), 896–898 (1990).
44 Whorwell PJ, Prior A, Faragher EB.
Controlled trial of hypnotherapy in the
treatment of service refractory irritable-bowel
syndrome. Lancet 2, 1232–1233 (1984).
45 Whorwell PJ, Prior A, Colgan SM.
Hypnotherapy in severe irritable bowel
syndrome : further experience. Gut 28,
423– 425 (1987).
46 Galovsk i TE, Blanchard EB. The treatment
of irritable bowel syndrome with
hypnotherapy. Appl. Psychophysiol.
Biofeedback 23(4), 219–232 (1999).
47 Gonsalkorale W M, Houghton LA,
Whorwell PJ. Hypnotherapy in irritable
bowel syndrome: A large-scale audit of a
clinical service with examination of factors
influencing responsiveness. Am. J.
Gastroenterol . 97(4), 954–961 (2002).
48 Palsson OS, Turner MJ, Johnson DA,
Burnelt CK, W hitehead WE. Hypnosis
treatment for severe irritable bowel
syndrome : investigation of mechanism and
effects on symptoms. Dig. Dis. Sci. 47(11),
2605–2614 (2002).
49 Zeltzer L, LeBaron S. Hypnosis and
nonhypnotic techniques for the reduction
of pain and anxiety during painful
procedures in children and adolescents
with cancer. Behav. Pediatr. 101,
1032–1035 (1982).
50 Lang EV, Joyce JS, Spiegel D, Hamilton D,
Lee KK. Self-hypnotic relaxation during
interventional radiologica l procedures:
effects on pain perception and intravenous
drug use. Int. J. Clin. Exp. Hypn. 44 (2),
106–119 (1996).
51 Schupp CJ, Berbaum K, Berbaum M,
Lang EV. Pain and anxiety during
interventional radiologic procedures: effect
of patients’ state anxiety at baseline and
modulation by nonpharmacologic analgesia
adjuncts. J. Vasc. Interv. Radiol. 16(12),
1581–1584 (2005).
52 Liossi C, Hatira P. Clinical hypnosis versus
cognitive behavioral training for pain
management with pediatric cancer patients
undergoing bone marrow aspirations. Int. J.
Clin. Exp. Hypn. 47(2), 104–116 (1999).
53 Liossi C, Hatira P. Clinical hypnosis in the
alleviation of procedure-related pain in
pediatric oncology patients. Int. J. Clin.
Exp. Hypn. 51, 4–28 (2003).
54 Liossi C, White P, Hatira P. Randomized
clinical trial of local anesthetic versus a
combination of local anesthetic with
self-hypnosis in the management of
pediatric procedure-related pain. Health
Psychol. 25(3), 307–315 (2006).
55 Liossi C, White P, Hatira P. A randomized
clinical trial of a brief hypnosis inter vention
to control venepuncture-related pain of
paediatric cancer patients. Pain 142,
255–263 (2009).
56 Montgomery GH, David D, Winkel G,
Silverstein JH, Bovbjerg DH. The
effectiveness of adjunctive hypnosis with
surgical patients: a meta-analysis. Anesth.
Analg. 9(4), 1639–1945 (2002).
57 Morgan AH, Hilgard ER. Age differences
in susceptibility to hypnosis. Int. J. Clin.
Exp. Hypn. 21, 78–85 (1973).
58 Schnur JB, David D, Kangas M, Green S,
Bovbjerg DH, Montgomery GH.
A randomized trial of a cognitive-
behavioral therapy and hypnosis
intervention on positive and negative affect
during breast cancer radiotherapy. J. Clin.
Psychol. 65(4), 443– 455 (2009).
59 Smith JT, Barabasz A, Barabasz M.
Comparison of hypnosis and distraction in
severely ill children undergoing painful
medical procedures. J. Counsel. Psychol.
43(2), 187–195 (1996).
60 Slack D, Nelson L, Patterson D, Burns S,
Hakimi K, Robinson L. The feasibility of
hypnotic analgesia in ameliorating pain
and anxiety among adults undergoing
needle electromyography. Am. J. Phys. Med.
Rehabil. 88, 21–29 (2009).
61 Marc I, Rainville P, Masse B et al.
Hypnotic analgesia intervention during
first-trimester pregnancy termination: an
open randomized trial. Am. J. Obstet.
Gynecol. 199, 469e1–469e9 (2008).
62 Klafta JM, Roizen MF. Current
understanding of patients’ attitudes toward
and preparation for anesthesia: a review.
Anesth. Analg. 83, 1314–1321 (1996).
63 Lambert SA. The effects of hypnosis/
guided imager y on the postoperative course
of children. J. Dev. Behav. Pediatr. 17(5),
307–310 (1996).
64 Cupal DD, Brewer DW. Effects of relaxation
and guided imagery on knee strength,
reinjury anxiety, and pain following anterior
cruciate ligament reconstruction. Rehabil.
Psychol. 46(1), 28–43 (2001).
www.expert-reviews.com 273
Review
Hypnosis in the treatment of anxiety- & stress-related disorders
65 Faymonville ME, Fissette J,
Mambourg PH, Roediger L, Joris J, Lamy
M. Hypnosis as adjunct therapy in
conscious sedation for plastic surgery. Reg.
Anesth. 20 (2), 145–151 (1995).
66 Faymonville ME, Mambourg PH, Jori J
et al. Psychological approaches during
conscious sedation. Hypnosis versus stress
reducing strategies: a prospective
randomized study. Pain 73(3), 361–367
(1997).
67 Tusek D, Church JM, Fazio V W. Guided
imager y as a coping strategy for
perioperative patients. AORN J. 66(4),
644–649 (1997).
68 Schnur JB, Bovbjerg DH, David D et al.
Hypnosis decreases presurgical distress in
excisional breast biopsy patients. Anesth.
Analg. 106(2), 440– 444 (2008).
69 Saadat H, Drummond-Lewis J, Maranets I
et al. Hypnosis reduces preoperative anxiety
in adults. Anesth. Analg. 102, 1394–1396
(2006).
70 Lang EV, Berbaum KS, Faintuch S et al.
Adjunctive self-hypnotic relaxation for
outpatient medical procedures:
a prospective randomized trial
nonpharmacologic analgesia adjuncts.
J. Vasc. Interv. Radiol. 16(12), 1581–1584
(2005).
71 Lang EV, Berbaum KS, Pauker SG et al.
Beneficial effects of hypnosis and adverse
effects of empathic attention during
percutaneous tumor treatment: when being
nice does not suffice. J. Vasc. Interv. Radiol.
19, 897–905 (2008).
72 de Klerk JE , Steyn HS, du Plessis SF,
Botha M. Hypnotherapeutic ego-
strengthening with male South Africa
coronary artery bypass patients. Am. J.
Clin. Hypn. 47(2), 79–92 (2004).
73 Baglini R, Sesana M, Capuano C,
Guecchi-Ruscone T, Ugo L, Danzi GB.
Effect of hypnotic sedation during
percutaneous transluminal coronary
angioplasty on myocardial ischemia and
cardiac sympathetic drive. Am. J. Cardiol.
93, 1035–1038 (2004).
74 Calipel S, Lucas-Polomeni M-M, Wodey E,
Ecoffey C. Premedication in children:
hypnosis versus midazolam. Pediatr.
Anesth. 15, 275–281 (2005).
75 Moore R, Brodsgaard I, Abrahamsen R.
A 3-year comparison of dental anxiety
treatment outcomes: hypnosis, group
therapy and individual desensitization vs.
no specialist treatment. Eur. J. Oral Sci.
110(4), 287–295 (2002).
76 Dyas R. Augmenting intravenous sedation
with hypnosis, a controlled retrospective
study. Contemp. Hypn. 18(3), 128 –134
(2001).
77 Enqvist B, Fischer K. Preoperative hypnotic
techniques reduce consumption of
analgesics after surgical removal of third
mandibular molars. Int. J. Clin. Exp. Hypn.
45(2), 102–108 (1997).
78 Enqvist B, von Konow L, Bystedt H.
Stress reduction, preoperative hypnosis and
perioperative suggestion in maxillo-facial
surgery: somatic responses and recovery.
Stress Med. 23(2), 76–82 (1996).
79 Eitner S, Wichmann M, Schultze-Mosgau
S et al. Neurophysiologic and long-term
effects of clinical hypnosis in oral and
maxillofacial treatment – a comparative
interdisciplinar y clinical study. Int. J. Clin.
Exp. Hypn. 54(4), 457–479 (2006).
80 Lu DP, Lu GP, Hersh EV. Augmenting
sedation with hypnosis in drug-dependent
patients. Anesth. Prog. 42(3 –4), 139–143
(1995).
81 Frenay MC, Faymonville ME, Devlieger S,
Albert A, Vanderkelen A. Psychological
approaches during dressing changes of
burned patients: a prospective randomised
study comparing hypnosis against stress
reducing strategy. Burns 27(8), 793–799
(2001).
82 Laidlaw TM, Willett MJ. Self-hypnosis
tapes for anxious cancer patients: an
evaluation using personalised emotional
index (PEI) diar y data. Contemp. Hypn.
19(1), 25–33 (2002).
83 Wright S, Courtney U, Crowther D.
A quantitative and qua litative pilot study of
the perceived benefits of autogenic training
for a group of people with cancer. Eur. J.
Cancer Care 11(2), 122–130 (2002).
84 Liossi C, White P. Efficacy of clinical
hypnosis in the enhancement of quality of
life of terminally ill cancer patients.
Contemp. Hypn. 18(3), 145–160 (2001).
85 Chambless DL, Baker MJ, Baucaom DH
et al. Update on empirically validated
therapies II. Clin. Psychol. 51, 3–16 (1998).
86 Khan A, Khan S, Brown WA. Are placebo
controls necessary to test new
antidepressants and anxiolytics? Int. J.
Neuropsychopharmacol. 5, 193–197 (2002).
87 Kirsch I, Moore TJ, Scoboria A,
Nicholls SS. The emperor’s new drugs: an
analysis of antidepressant medication data
submitted to the U.S. Food and Drug
Administration. Prevent. Treat. 5(1),
ArtID23 (2002).
88 Papakostas GI, Fava M. Does the
probability of receiving placebo influence
the likelihood of responding to placebo or
clinical trial outcome ? A meta-regression of
double-blind, randomized clinical trials in
MDD. Neuropsychopharmacology 31, s158
(2006).
89 Hollon SD, DeRubeis RJ, Shelton RC,
Weiss B. The emperor’s new drugs: effect
size and moderation effects. Prevent. Treat.
5(1), ArtID27 (2002).
90 Lang EV, Benotsch EG, Fick LJ,
Lutgendorf S, Berbaum ML, Berbaum KS.
Adjunctive non-pharmacologic analgesia
for invasive medical procedures:
a randomized trial. Lancet 355, 1486–1490.
91 Lang EV, Rosen MP. Cost analysis of
adjunct hypnosis with sedation during
outpatient inter ventional radiologic
procedures. Radiology 222, 375–382
(2002).
92 Montgomery GH, Bovbjerg DH,
Schnur JB et al. A randomized clinical trial
of a brief hypnotic intervention to control
side effects in breast surgery patients.
J. Natl Cancer Inst. 99(17), 1304–1312
(2007).
Websites
101 The American Society of Clinical Hypnosis
(ASCH)
www.asch.net
102 The Societ y for Clinical and Experimental
Hypnosis (SCEH)
www.sceh.us
Affiliation
• D Corydon Hammond, PhD, ABPH
University of Uta h School of Medicine,
PM&R, 30 No. 1900 East, Salt Lake City,
UT 84132-2119, USA
Tel.: +1 801 581 5741
Fax: +1 801 585 5757
d.c.hammond@utah.edu
