Hypnotic Treatment Synergizes the Psychological Treatment of Fibromyalgia: A Pilot Study

Abstract

In this pilot study, we compare the efficacy for fibromyalgia of multimodal cognitive behavioral treatments, with and without hypnosis, with that of a purely pharmacological approach, with a multiple baseline N = 1 design. We randomly assigned six hospital patients to the three experimental conditions. The results suggest that psychological treatment produces greater symptom benefits than the conventional medical treatment only, especially when hypnosis is added. We conclude that hypnosis may be a useful tool to help people with fibromyalgia manage their symptomatology.

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']inical Hypnosis Copyright ©2008
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50:4, Aprii
~,!!)~
Hypnotic Treatment Synergizes the Psychological Treatment
of
Fibromyalgia: A Pilot Study*
Consuelo Martinez-Valero1,Antonio CasteF, Antonio Capafons3,
Jose Sala2, Begofia Espejo
3,
& Etzel Cardefia4
Abstract
In this pilot study, we
compare
the
efficacy
for
fibromyalgia
of
multimodal cognitive behavioral treatments, with and without hypnosis,
with that
of
a purely phannacological approach, with a multiple baseline
N =I design.
We
randomly assigned six hospital patients to the three
experimental conditions. The results suggest that psychological treatment
produces greater symptom benefits than the conventional medical
treatment only, especially when hypnosis
is
added.
We
conclude that
hypnosis may be a useful tool to help people with fibromyalgia manage
their symptomatology.
Keywords: Fibromyalgia, hypnosis, pain, cognitive behavioral treatment.
Fibromyalgia is a chronic pain disorder
of
unknown medical etiology,
characterized by diffuse musclepain
of
more than 3months
of
duration accompanied
by abnormal sensitivity to digital pressure in I I
of
18
sensitive points in specific
anatomical areas (Wolfe et aI., 1990). The pain cannot be explained by degenerative
or inflammatory processes and the laboratory tests are normal.
Fibromyalgia
is
present throughout the world. Although it is not common
among them, it also affects children and its prevalence increases with age. In the
United States between 3-5%
of
the women and 1-2%
of
men suffer from tibromyalgia;
in
England, Australia, Italy, Israel, and Mexico the prevalence
is
similar (Goldenberg,
2002). According to the Spanish Society
of
Reumatology (200!), the prevalence
among Spaniards older than 20 years
is
0.2% among men and 4.2% among women.
According to this Society, 10-20%
of
reumatology and 5-7%
of
primary care
Address correspondence and reprint requests to:
Etzel Cardefia. Ph. D., Thorsen Professor
CERCAP,
Department
of
Psychology
University
of
Lund
P.O.
Box 213, SE-221 00, Lund, Sweden
Email: Etzel.Cardena@psychology.lu.se
311

conferences are devoted to fibromyalgia.
It
is the most frequent cause
of
generalized and with two individuals in each group, with the purpose
of
evaluating whether a more ambitious
chronic muscle pain, which impairs restful sleep and increases fatigue and morning muscular project should
be
undeltaken.
Our
research hypotheses were:
I
rigidity. Sufferers use medication excessively, reduce physical exercise and social activities,
and perceive the pain as something horrible
and
intolerable (Camacho, 1999).
Fibromyalgia has a negative impact on the quality
of
life and requires learning how to
manage
it
to accomplish the necessary adjustments
in
the life
of
the patient (hunilial, social,
occupational, etc.). Because
of
this, the therapeutic approach to fibromyalgia has to be
multidisciplinary. Purely pharmacological interventions are insuftlcient and
it
is
advisable to
combine them with other types
of
treatments (Alarcon & Bradley, 1998; Marder et
aI.,
I
Various studies support a cognitive behavioral approach as the most eflcctive for fibromyalgia
(Nicassio et aI., 1997; Nielson, Walker, & McCain, 1992; Pastoret
aI.,
2003; Vlaeyen et
aI.,
1996;
White & Nielson, 1995). This approach emphasizes the clients' active self-control over the
symptoms to improve quality
of
life. A dissertation (Rosenberg, 2005) reported good results on a
juvenile fibromyalgia sample using "hypnosis/relaxation" within cognitive-behavioral therapy
but did not assess whether hypnosis improved the efficacy
of
CBT.
The main symptom
of
fibromyalgia
is
pain. There
is
good evidence that hypnosis
is
effective lor the management
of
chronic and acute pain (Montgomel)l, DuHamel, & Redd, 2000;
Montgomery & Schnur, 2004; Patterson & Jensen, 2003), and that
it
increases the impact
of
cognitive-behavioral interventions (Schoenberger, 2000). Three studies have found that hypnosis
decreased reports
of
pain among fibromyalgia patients (Castel, Perez, Sala, Padro\' & Rull, 2007;
Hillmen et
aI.,
1991; Wik, Fischer, Bragee, Finer, & Fredrikson, 1999). Castel and collaborators
found that hypnosis with specific suggestions for analgesia was a more effective treatment
than hypnosis with general relaxation or with progressive relaxation, especially lor the sensory
aspect
of
pain. Two studies have reported changcs in electrocOitical activity associated with
(successful) hypnotic treatment for fibromyalgia, one measuring changes
in
blood
now
through
PET (Wik et
aI.,
1999), the other with cerebral perfusion measured through
SPEC-:'1'
(Sala, Afiez,
Bueno, &Ciurana, 200I
).
A study by Haanen and collaborators (1991) compared a group receiving hypnotherapy
with another exposed to physical therapy, with the treatment lasting
12
weeks and a follow-up at
24 weeks. The hypnotic treatment included various hypnotic suggestions and patients were also
provided a selfhypnosis tape with the same suggestions. Physical therapy involved massage
and training
in
relaxation. The hypnosis group reported significant improvements with respect to
pain perception, fatigue upon awakening, sleep pattem, reduction
of
analgesics, and overall
but there was no difference between treatments when muscle pain was evaluated through
apain gauge. There
is
alsoevidence that hypnotic suggestions can enhance self-esteem (Cardena,
Dorch, & Lundborg, 2007), which can be a problem
,mlOng
fibromyalgia patients.
The studies reviewed suggest that hypnosis can improve the efficiency and! or efficacy
of
the psychological treatments
of
fibromyalgia, with hypnosis being a promising intervention.
The
use
of
hypnosis as a therapeutic adjunct
in
our study was framed within a
cognitive~
behavioral perspective (Capafons, 1998a; 200 I), where hypnosis
is
presented as a technique
that uses psychological resources to encourage self-control, lacks major risks, and requires the
collaboration and active participation
of
the person.
We
used the waking hypnosis model
of
Capafons (1999,2001,2004), especially Rapid Self-Hypnosis (Capafons, 1998
a,
b;
M,utfnez-
!
1.
Because fibromyalgia requires new skills to m,mage the symptoms ,mdcognitivc-behavioral
and hypnosis treatments toster self-contlUl,
we
predicted that a psychological treatment that
includes cognitive, behavioral and educational techniques would decrease symptoms as
compared with a purelv ohannacological treatment.
2.
Because hypnosis increases the eftlcacy of cognitive-behavioral (Schoenberger, 2(00) and
othertJealmcnts (Kirsch, Capafons, Cardefia, & Amigo,
1999),
and waking hypnosis increa'les
treatment motivation
,md
expectations
of
treatmentsuccess and self-control (Caoafons.
2fXl
I),
we predicted that adding hypnosis would be better than a cognitive-behavioral treatment with
relaxation ,1$ a substitute for hypnosis.
Methods
Overall sample age was 44.3 years (range 25-60); 39.5 (ages 32-47) for the
contTOI
(C,
medical treatment only) group, 57 (ages 54-60) for the cognitive-behavioral-hypnosis group
(CBH), and 36.5 (ages 25-48) for the cognitive behavioral group (CB).
All
participants were mamed
women, with one (C) currently separated. The average span since diagnosis was 4 years for
all
=4.5, range 1-8;CB
5,range3-7;C=2.5,range
a lawyer and a high school graduate; the
CBB
of
two individuals who had finished elementary
schooL and the CB group
of
an elementary school and a technical school graduates.
Instruments
The dependent variables
reported
in
thisruticlc
are:
a) symptoms
of
pain,
fatigue,
museularrigidity
upon
awakening, sleep
quality,
andnumber
of
sensitive
point,,;
lives:
and
c)
belie["
,md
perception
alXlUt
pain. Other variables measured
in
the
study
(percc1Jtion
of
Ii
Ie
quality
related to health, self-esteem, pain coping strategies, and attitudes toward" hypnosis),
overilll
consistent with
the
results reported here,
me
not
included
in
this
paper
for
the
sake
of
clarity.
We
report
here
on
the lollowing:
PainandBeliejsPeft'eption
Iflventoly(PBPI)
(Willimns&TIlOm,
1989),
whose
16
items
evaluate
patients' beliefs about their pain according
to
four subscales: pain
stability,
ignorance about pain,
self-
blame,
and
lack
ofchronicity. The PBPIha'l good psychometric
propertic."
(Morley &Wilkinson,
1995).
FibromyalgiaImpoctQuestioYlllire
(HQ) (Burckhardt, Clark & Bennett,
1991;
De
Gracia,
MaraS,
Ruiz,
&GJrabieta,2fXll), measwesthe physical, psychological,
social,
and
global
impactoffibromyalgia.
Plates CooplWonca, consisting
of
7 scales that measure physical shape, emotional
states, daily activities, changes in health, social activities, health status, and pain, as modified
by
the World Organization
of
Fami
Iy
Doctors (Wonca, 1988). These scales indicate
if
there
is
change across time (Lizan &
Numerical Scales:
The
patient had to choose a
number
betwcen 0 (absence
of
the
variable that
we
evaluated) and
10
(maximum intensity
of
that variable).
In
our study, we used
these scales to measure pain, muscular rigidity upon awakening, sleep quality, and fatigue.
Tendero, Capafons, Weber, & Cardefia, 200 I; Reig, Capafons, Bayot, &Bustillo, 200 I
).
We also employed adrawing
of
ahuman figure on which patients marked the exact
The
objective
of
our study was to compare the efficiency
of
medical-psychological location
of
the pain, a medication record, a semistructured Evaluation Intcrview (to collect I
treatment, with and without hypnosis, with a purely medical treatment, and to determine the infomlation
on
pain history, precursors and consequences
of
Imp","
"f
wMdog
hypoo,i, withio the P'YChol,,:ical treatmeot.
Thi'
was""
expl",",,,')' ,tody 1 data),
'ad
the dioical impressio",
of
the 'hemPi,
..
ts conducting the CB and
CBH
treatments.
31~
3D
C1lJhNi1K

Procedure
Participants were selected by a
pain
specialist
at
the
Hospital Juan xxm ofTarragona, Spain,
accordi
ng
to
these
criteria:
fulfi1ling
diagnostic criteria for fibromyalgia
(Wolfe,
1990),
symptoms
for
at
least a
year,
not having received psychological treatment previously for
this
disease,
no
psychiatric
pathology,
and
not receiving economic compensation nor being
in
the mid,t of legal litigation
concerning the disease. Once selected, a psychologist interviewed them and provided
the
consent
fonn
to
be signed
and
the
various questionnaires.
Measures
were
taken
pre-and
post-treatment,
and
at
I
and
3
months.
The
CB
andCBH
groups
were
also
measured
at
ba<>eline
and
during
the
treatment,
but
not
group C
for
logistical
reasons.
Post-treatment and follow-ups were administered
by
an
experienced, masked independent
rater. Baseline measures for the control group were administered
by
the
medical specialist
who
recruited the participants.
The treatments
for
the
cognitive-behavioral plus hypnosis group (CBH)
and
the
mgnitive
behavioral
(CB)
groupconsisted of
10
weekly
I-hourmeetings. Each session mnsisted
of
review of
therapeutic homework, introduction and practice of therapeutic strategies,
and
assignment
of
new
homework. Thetherapist
for
CBHwas a
woman
and
for
CB
was
a
man.
both
with
wideexperience
in
clinical psychology and treatment of
pain.
The therapeutic strategies
were:
I.
Information about the disease, consisting
of
an
explanation of the causes, evolution,
and treatment of fibromyalgia, including the factors that contribute
to
an
increase in
symptomatology, and infonnation on
the
nature
of
pain and the factors that regulate it.
2.
Coping skills, with instruction
on
cognitive-behavioral strategies
to
manage pain
through cognitive restructuring about beliefs
of
lack of control over some elements
of
the disease, and
of
how cognitions can increase or decrease symptomatology
3.
For the CBH group, suggestions and training in waking hypnosis (Rapid Self-
Hypnosis)
to
help with specific symptoms (see below). For the CB group, traininl! in
relaxation and visualization.
4.
Training in social skills and problem resolution.
5.
Planning
of
daily leisure activities, and physical exercise.
6.
Relapse prevention,
by
consolidating learned skills and maintaining achievements
reached through positive feedback, and anticipating future problems (e.g., relapses
in
nain. stressful situations) and how
to
solve them.
In
the CBB condition, specific suggestions were given for various symptoms. For
there were two types of suggestions. The first uses the imagery
of
a panel of switches,
each one with a different color, that control
the
connection to each part
of
the body. The
participants were told that they could disconnect the sensations
of
discomfort going to the
body part that requires well-being (LeCron, 1964). The second type
of
suggestion for
asked participants to think
of
moving the sensation
of
discomfort or pain
to
a part
of
the
body where it would be less bothersome so they could feel more comfortable and safe.
There was also one suggestion
to
increase self-esteem. After explaining that sickness
and weakness can foster thoughts of incapacity and weakness, the patients were told that
as
they had been able
to
overcome a difficult situation (e.g., raising a family, working, overcoming
the
death
of
close
OJ1(c"s),
they
could
become
more
aware
of
their
capacities
to
overcome
the
disea'lC.
The
l3&t
suggestion
focmed
on
morning
stiffuess
or
insomnia
Par1i:ipants
were
told
to
focu"
their
attention
on
their
breathing
and
note
the
pa"sage
of
fresh
air
through
the
nose
and
throat
to
the
lungs,
filling
tIle
body
with
sensations
of
well-being
and
tranquility.
The
exhaled
air
\\1)uld
cast
out
feelings
of
rigidity
and
tension,
and
incre<'lsingly
the
body
would
have
a
nice
sensation
of
relaxation,
helping
reduce
any
mu«;:;le
rigidity.
314
1 The
suggestions
were
given
and
taught
in
the
context
of
an
easy
fonrn
of
self~hypnosis
that
can
be
employed
covertly
during
everyday
activities
called
"rapid
self-hypnosis"
(Capafuns,
2(X)4,
Martinez-
Tendem
et
al.,
200
I).
Responsiveness
to
hypnotic
suggestion'>
was
evaluated
by
looking
at
nonverbal
behaviors
mnsistent
with
the
suggestion
(e.g.,
a
facial
expre'»sioll
of
c:llmne<;s
after
a
relevant
suggestion)
and
which
they
responded
affinnatively).
Patients
in
the
mntrol
condition
(group
C)
were
just
told
that
they
could
mlJalxmite
in
re~h
on
fibromyalgia
by
filling
oulsomequestionnaires.
They
were
providedinfonnation
on
fibromyalgiafollowing
the
customary
standmd
of
care
ofli::n.'rl
as
part
of
the
medical
treatment
in
the
hospital.
AU
partidpants
in
the
study
I~ived
the
the
sanle
type
of
medication,
mnsisting
ofa
tricyclic
or
dual
antidepressant,
an
SSRI
and
anon-steroid
anti-inflammatory.
Taking into account the exploratory character
of
the study and the small sample size
(N
6),
we
use descriptive sequence graphics
to
illustrate the variables measured during
the pre-post-treatment and follow-up.
Results
Figlrres
1-3
show
the
results
obtained
in
symptom
mea"ure.<;.
In
the
CBH
group,
shows
anoticeable decrease
in
all
symptorns,
especially
pain,
rigidity,
and
number
ofsensitive
whereas
patient 2
ha<;
a smaller
but
still
noticeable
decrease.
In the
CB
group,
for
patient
3
pain
the
number of sensitive
points
descend
slightly
at
the
end
oftreatment
and
during
the
follow-up,
and
rigidity
completely
disappears
at
3
months.
However,
sleep
quality
and
fatigue
increa<;e
slightly
after treatment
For
patient
4,
only
the
number
ofsensitive
point<;,
sleep
quality,
and
fatigue
decrease
slightly
at
the
end of
treatment.
At
a I
month
follow-up
there
wa<;
considerable increase
in
symptoms.
In
group
C,
patient 5
showed
almost
no
changes at post treatment or at
follow-UD.
Patient
6's
symptoms
were
very
stable
with
a bit of
variation
for
sensitive
Figures 4-6
show
the
evolution of
the
beliefs and perception
of
pain,
and
the impact of
fibromyalgia
for
each
patient.
For CBH,
beliefs
on
pain
stability
and
ignordIlce
about
pain
deerea-.e
markedly
after treatment
for
patient I
with
a
similar,
but not
a<;
pronounced,
pattcm
for
patient
2.
For
both
CB
patient"
ignordIlce
about pain
decTCases.
For group C, the
only
clear movement
is
for
ignorance
about
pain
to
increase.
With
regard
to
impact
of
the
disea'le,
CBH
patients
showed
noticeable
decreases.
In
contrast,
patient 3 in the
CB
group showed few changes and patient 4 showed fluctuations
at
different
times.
For
the
group
C,
there
wa"
just a
small
tendency
to
deteriorate.
We
also
mllected
the
clinical
impression
from
the
therapists.
They observed that
both
treatment
exhibited
significant
clinical
improvement,
a<;
manifested
by:
I. Increased physical, social, and leisure activities levels, and more willingness to
make future plans for the accomplishment
of
leisure activities.
2.
Notably
reduced consumption
of
medication,
according
to
dIe
patients'self-repolts.
3.
As
with most people with fibromyalgia we have observed, at the beginning our
sample exhibited a sad facial expression -
no
smiling, despondency, behavioral
inhibition, and rigid posture and movements. During
the
treatment
and
the follow-ups,
the
patients exhibited non-verbal behaviors consistent
with
a better mood (smiling,
less
315

Figure
3:
Symptoms
(Control
Group)
rigid movements, more relaxed facial expression, fluency
of
speech, absence
of
pain
grimaces while changing postures, etc.)
4. At the end
of
both
treatment~,
all patients responded affirmatively to the two questions:
Would you recommend this sort
of
treatment to other persons in your same situation?
Do you believe that the time and the effort devoted to the treatment were worth the
effort? It should also
be
mentioned that patient 4 may have worsened at the I-month
tollow-up because
of
a stressful situation she encountered during the treatment, but
unrelated to it.
Figure
I:
Symptoms (Hypnosis Group)
10
'\
16
l
'2
--.-Palienl1
t
\\
:I:
4
sonsiti\€
sensitl'-O
~it1n8lti\,(l
polo!
pre
point
post
pomt
3m
2:
Symptoms (Cognitive-Behavior Group)
10
20
16
l
'>
6
__
Pallenl3
~Patient4
~
~
4
~
$l;nsr!l~
sensitl-..e
sensill\.oli!
pont
pre point post
pOlnl
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316
1
10
20
16
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6
12
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e
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6
"
§4
"
sensill\()
sensih\€
senslti\E
POint
pre
POint
post
POint
3m
}'igure
4:
Pain
& Beliefs
Perception
Inventory
and
Fibromyalgia
Impact
Questionnaire
(Hypnosis
Group)
25
100
20
80
1/1
15 60
0
-+_
Patient 1
"
-o-Pehent
2
~
40
~
5
~
20
P$
PS
PG
IP
IF'
lP
SB SB SB
CA
CA CA FI pre
Fl
post
Fi3m
post
3m
pre
post pre post
3m
pre
post
3m
317

Hypnotic
Treatment
and
Fibromyalgia
Figure
5:
Pain
&
Beliefs
Perception
Inventory
and
Fibromyalgia
Impact
Questionnaire
(Cognitive-Behavioral
Group)
'00
80
Xl
60
)15
V
--+--
Patient 3
-a-Patlent4
~
~
v
40
'E
8'
2G
~
PS PS
PS
IP
lP
IP
5B
5B
SB
CA CA CA
FI
pre
Fl
post
FI
:m
pre
past
3m
pre post
3m
pre
post
2m
pre post
Figure
6:
Pain
&
Beliefs
Perception
Inventory
and
Fibromyalgia
Impact
Questionnaire
(Hypnosis
Group)
100
25
80
20
.----.--.... t
60
15
~Patlent5
-a-
Patient 6
40
~'~
20
PS
PS PS
IP
jP
SB S8
58
CA CA
FI
pre
FI
post
Fla-n
pre
pasl
3m
pre post
3m
pre:
post
~:lm
pre
post
3m
Discussion
We
had predicted that the psychological interventions would improve
pharmacological treatment, and that hypnosis would synergize the cognitive-behavioral
treatment. Overall, CBH had the best results for
all
symptom variables. CB patient 3 also
improved whereas results were mixed for patient 4. Participants in the group C did not improve
noticeably throughout treatment.
We
also predicted that change in symptoms would correlate
with changes
in
the
impact
of
the disease, and the beliefs and perception about oain. Our
Martinez-Valero,
Castel,
Capafons, Sala, Espejo,
Cardena
results suggest that symptom improvement does decrease the impact
of
the disease. With
to perception and beliefs on pain, CBH and CB were associated with a reduction of the
beliefs on the stability
of
the pain and ignorance about it, whereas for group C there seemed to
be an increase
of
the beliefs
of
the stability
of
pain and ignorance about its mechanisms.
In summary, it seems that CB, with or without hypnosis, is noticeably better than a
purely pharrnacological strategy, and provides greater control over pain and other symptoms
by offering information and providing strategies
of
control that rcduce the belief that nothing
can
be
done about pain. These results support other investigations
on
the greater efficacy
of
CB plus medication over only pharmacological treatments with promising new data on the
use
of
hypnosis as
an
adjunct.
Our study does have methodological and clinical limitations, foremost the small
N.
We
are aware that we could not control potentially relevant variables such as SES, cultural
level, age, and family situation despite the heterogeneity
of
people with fibromyalgia with
respect to psychosocial and adjustment characteristic (Okifuji & Turk, 1999); whether the
etliciency
of
the treatments is mediated or moderated by these variables should be assessed.
group C was not evaluated perfectly, as there were no measures
of
symptoms at
baseline or during treatment because
of
the logistics
of
these patients coming
to
the hospital
only
to
be evaluated.
It
would also be advisable
to
extend assessment during the baseline
period and to increase the follow-up
to
at least
12
months.
Both CB and CBH groups had greater contact time with a therapist, so a control group
that included this variable would help isolate the specific therapeutic elements
of
the
psychological treatment. Also, experimenter bias cannot be completely ruled out because
the
CBH therapist knew the experimental hypotheses and there could also be an effect for
gender because the CBH therapIst was a woman and the CB therapist was a man. Finally,
although augmented by clinical observations,
our
measures are self-reports, with the
consequent limitations
of
basing
our
conclusions only on that source. Despite these
limitations, however, this pilot study suggests that hypnosis is a promising intervention for
fibromyalgia and deserves replication with a more elaborate design.
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Author's Notes
'Centro
de
Aplicaciones Psicol6gicas, Valencia, Spain.
'Hospital Juan
XXIII,
Tarragona, Spain.
University of Valencia, Spain.
'Lund University. Sweden
We
are grateful to Arintxu, a chronic care nurse
at
the
hm;pital
Juan XXIII, for administering the
measures,
and
Caroline
Watt,
Ph.
D.,
for
her editorial help.
321