Hypnosis and Surgery

1. Hypnosis and Surgery

2. Two or Three words can have a profound change in one’s life. Our words have a profound effect. What and How we say our words will impact our ability to heal.

3. “This shot is ‘gonna hurt, hang on!” “I think you will be pleasantly surprised how little discomfort there will be…..”

4. In the 19th century, John Elliotson and James Esdaile reported the successful use of mesmeric somnambulism as an anesthetic for surgery. Ether and chloroform soon proved to be more reliably effective.

5. Beyond Placebo • Hypnosis is not placebo • Hypnosis itself has its own placebo effects • Hard to control for placebo in hypnosis studies

7. fMRI Neurostructure theory Functional magnetic resonance images (fMRI) elicited by thermal pain in hypnotized subjects. Schulz-Stubner S, Krings T, Meister IG, Rex S, Thron A, Rossaint R.Regional Anesthesia and Pain Medicine - Volume 29, Issue 6 (November 2004) Department of Anesthesia, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 6 JCP, Iowa City, IA 52242-1079, USA. Sebastian-schulz-stubner@uiowa.edu Our observations indicate that clinical hypnosis may prevent nociceptive inputs from reaching the higher cortical structures responsible for pain perception. Whether the effects of hypnosis can be explained by increased activation of the left anterior cingulate cortex and the basal ganglia as part of a possible inhibitory pathway on pain perception remains speculative given the limitations of our study design.

8. fMRI Neurostructure theory Current studies include functional brain imaging. Rainville and his associates showed that strategically worded suggestions can dissociate the two components of pain, selectively altering one but not the other. (Rainville, Duncan, Price, Carrier, & Bushnell, 1997). The two components of pain have different biological substrates: sensory pain in the primary somatosensory cortex, and suffering in the anterior cingulate cortex.

9. pain intensity coding Hypnosis works here prediction of the sensory consequences of pain-related action the onset uncertainty of the impending stimuli

10. Laparoscopy under local anaesthesia and hypnoanaesthesia about 35 cholecystectomies and 15 inguinal hernia repair T. Séfiani a, M. Uscain b, J.-L. Sany c, D. Grousseau b, P. Marchand a,*, D.Villate a, J.-L.Vincent a Annales Françaises d’Anesthésie et de Réanimation 23 (2004) 1093–1101 Laparoscopic surgery for cholecystectomy and hernia repair under local anesthesia with hypnosis were performed with conversion to general anesthesia if patients showed signs of discomfort. Results. Of the 35 cholecystectomies performed, 13/35 needed convert to general anaesthesia, mainly for peritoneal pain induced by CO2 insufflation; 22/35 procedures were completed with patients’ satisfaction. Upon 15-hernia repairs, only one patient needed convert to general anaesthesia, for dissection difficulty. Conclusion. Hypnosis probably cannot be used routinely for intraperitoneal laparoscopic procedures but hypnosis for extraperitoneal laparoscopic hernia repair should be further explored.

11. Hypnosis Reduces Preoperative Anxiety in Adult Patients Anesth Analg 2006;102:1394 –6 Haleh Saadat, MD, Jacqueline Drummond-Lewis, MD, Inna Maranets, MD, Deborah Kaplan, Anusha Saadat, Shu-Ming Wang, MD, and Zeev N. Kain, MD Center for the Advancement of Perioperative Health, Departments of Anesthesiology, Pediatrics, and Child Psychiatry Yale University School of Medicine, New Haven, Connecticut Randomized into 3 groups, a hypnosis group (n 26) who received suggestions of well-being; an attention-control group (n26) who received attentive listening and support without any specific hypnotic suggestions and a “standard of care” control group (n 24). On entrance to the operating rooms, the hypnosis group reported a significant decrease by 56% whereas the attention-control group reported an increase of 10% in anxiety and the control group reported an increase of 47% in their anxiety (P 0.001).

12. Hypnosis Reduces Preoperative Anxiety in Adult Patients Anesth Analg 2006;102:1394 –6 Haleh Saadat, MD, Jacqueline Drummond-Lewis, MD, Inna Maranets, MD, Deborah Kaplan, Anusha Saadat, Shu-Ming Wang, MD, and Zeev N. Kain, MD Center for the Advancement of Perioperative Health, Departments of Anesthesiology, Pediatrics, and Child Psychiatry Yale University School of Medicine, New Haven, Connecticut

13. Hypnosis Reduces Distress and Duration of an Invasive Medical Procedure for Children Pediatrics 2005;115;e77-e85 Lisa D. Butler, Barbara K. Symons, Shelly L. Henderson, Linda D. Shortliffe and David Spiegel Hypnotic relaxation may provide a systematic method for improving the overall medical care of children with urinary tract abnormalities who undergo VCUG. The results of this study suggest that hypnosis provides a systematic, noninvasive method for reducing distress and resistance to VCUG procedures for children and their families, as well as reducing staff time and strain in administering such procedures. Because the VCUG is an essential part of the evaluation of urinary tract infections and vesicoureteral reflux in children, improved relaxation and decreased anxiety during the procedure may improve patient and family compliance with initial as well as follow-up evaluations for this condition.

14. Hypnosis Reduces Distress and Duration of an Invasive Medical Procedure for Children Pediatrics 2005;115;e77-e85 Lisa D. Butler, Barbara K. Symons, Shelly L. Henderson, Linda D. Shortliffe and David Spiegel

15. A Randomized Clinical Trial of a Brief Hypnosis Intervention to Control Side Effects in Breast Surgery Patients Guy H . Montgomery , Dana H . Bovbjerg , Julie B . Schnur , Daniel David , Alisan Goldfarb , Christina R. Weltz , Clyde Schechter , Joshua Graff-Zivin , Kristin Tatrow , Donald D . Price , Jeffrey H. Silverstein J Natl Cancer Inst Issue 17 | September 5, 2007 1304 – 12 Vol. 99, 200 patients to undergo excisional breast biopsy or lumpectomy were randomly assigned to a 15-minute presurgery hypnosis session conducted by a psychologist or nondirective empathic listening as a control. Intraoperative anesthesia use lidocaine, fentanyl and the sedatives propofol and midazolam was assessed. Patient-reported pain and other side effects on a visual analog scale as was use of analgesics in the recovery room. Institutional costs and time in the operating room were assessed via chart review. Hypnosis was superior to attention control regarding propofol and lidocaine use; pain, nausea, fatigue, discomfort, and emotional upset at discharge; and institutional cost. Overall, the present data support the use of hypnosis with breast cancer surgery patients.

16. A Randomized Clinical Trial of a Brief Hypnosis Intervention to Control Side Effects in Breast Surgery Patients Guy H . Montgomery , Dana H . Bovbjerg , Julie B . Schnur , Daniel David , Alisan Goldfarb , Christina R. Weltz , Clyde Schechter , Joshua Graff-Zivin , Kristin Tatrow , Donald D . Price , Jeffrey H. Silverstein J Natl Cancer Inst Issue 17 | September 5, 2007 1304 – 12 Vol. 99,

17. A Randomized Clinical Trial of a Brief Hypnosis Intervention to Control Side Effects in Breast Surgery Patients Guy H . Montgomery , Dana H . Bovbjerg , Julie B . Schnur , Daniel David , Alisan Goldfarb , Christina R. Weltz , Clyde Schechter , Joshua Graff-Zivin , Kristin Tatrow , Donald D . Price , Jeffrey H. Silverstein J Natl Cancer Inst Issue 17 | September 5, 2007 1304 – 12 Vol. 99,

18. Adjunctive self-hypnotic relaxation for outpatient medical procedures: A prospective randomized trial with women undergoing large core breast biopsy. Elvira V. Lang et.al. Pain 126 (2006) 155–164

19. Adjunctive self-hypnotic relaxation for outpatient medical procedures: A prospective randomized trial with women undergoing large core breast biopsy. Elvira V. Lang et.al. Pain 126 (2006) 155–164

21. Group Therapy and Hypnosis Reduce Metastatic Breast Carcinoma Pain DAVID SPIEGEL, MD AND JOAN R. BLOOM, PH.D Psychosomatic Medicine Vol. 45, No. 4 (August 1983) The pain and mood disturbance of 54 women with metastatic carcinoma of the breast were studied over the course of one year. A random sample was offered weekly group therapy during the year, with or without self-hypnosis training directed toward enhancing their competence at mastering pain and stress related to cancer. Both treatment groups demonstrated significantly less self-rated pain sensation (t = 2.5p < 0.02) and suffering (t = 2.17, p < 0.03) than the control sample. Those who were offered the self-hypnosis training as well as group therapy fared best in controlling the pain sensation (F = 3.1, p < 0.05). Pain frequency and duration were not affected. Changes in pain measures were significantly correlated with changes in self-rated total mood disturbance on the Profile of Mood States and with its anxiety, depression, and fatigue subscales. Possible mechanisms for the effectiveness of these interventions are discussed.

22. Group Therapy and Hypnosis Reduce Metastatic Breast Carcinoma Pain DAVID SPIEGEL, MD AND JOAN R. BLOOM, PH.D

23. THE EFFECT OF HYPNOTHERAPY ON PROCEDURAL PAIN AND STATE ANXIETY RELATED TO PHYSIOTHERAPY IN WOMEN HOSPITALIZED IN A BURN UNIT Ali Amini Harandi, Akram Esfandani and Fereshteh Shakibaei Department of Psychiatry, Isfahan Medical University, Iran Contemporary Hypnosis (2004)Vol. 21, No. 1, 2004, pp. 28–34 The mean ages of the intervention and control groups were 30.5 ± 12.1 and 36.6 ± 16.6 years, respectively (P = 0.26). The total body surface area that was burned (TBSA) was 30.2% ± 11.3% in the control group and 27.1% ± 9.3% in the intervention group (P = 0.33). Twenty-nine patients had second and third degree burns (66%).

24. Labor Pain

25. Pre-operative preparation

26. Pre-op • Stress that you are with them. They are not alone. • Use a relaxation technique for induction. • Dissociation: body here, mind there • Stress words “feeling good, comfortable and happy” • Use the words “sleep” • Place in suggestions for thirst and hunger after abdominal surgery unless contra-indicated.

27. Pre-op • Use a breathing technique to discourage atelectasis. • Use specific post hypnotic suggestions tied to the surgery. “When you have your surgery and awake from anesthesia…” • Tie in a posthypnotic suggestion for pain control to simple every day activity.

28. Pre-op • Augment the drugs. “Your medication can be a signal to start a pleasant daydream in a safe and pleasant location of your choosing” • Augment the procedure. “The whole operating area in your body becomes limp, soft and comfortable throughout the procedure and afterwards.” • Augment the recovery room. “You will awake as from a restful and restorative deep sleep, pleasantly surprised to find the operation complete and the healing beginning”

30. Pre-op • “You will recover quickly, completely and comfortably.” • “You will be pleased to see how easily you can pass water, breathe deeply and move your bowels.” • “You will be pleasantly surprised to see how quickly you will feel like yourself again”

31. Pre-op • “Use a queue for post operative pain control. • Eg. “When the nurse, doctor or others touch you on either shoulder like this {touch the shoulder} you will instantly receive a boost of your own natural pain medicine found within.” • Use guided imagery of a controller and “adjust the discomfort to a level that is best for you.” • Remind the patient “discomfort is an alarm to notify the body of a problem and has done its job well. It is no longer needed unless there is a new development. Your body will let you know and you will become aware of any new developments.”

32. Intra-operative care

33. During the operation • “From this time forward you will pay attention to only a voice that specifically calls you by name first. The rest of the conversations become gibberish and unimportant.” • “Mr/Mrs X your operation is complete and you can look forward to getting better fast. You will awake now in your own time All your bodily functions will return rapidly as the anesthesia wears off. “

34. Research

36. pain scale (VAS/NRS) was reviewed with the participant IV catheter was placed headphones placed with music or hypnotic suggestion randomly assigned 50 mcg of Fentanyl, 3 mg of Midazolam, 100 mg of Propofol, and 8 mg of Decadron 200 mcg of Glycopyrolate, (an antisialogogue given to dry up the oral cavity ) IV Propofol amount was recorded in milligrams on the operative record VAS/NRS reviewed upon discharge VAS/NRS reviewed by phone on the first postoperative day prescription pain relievers use documented

37. treatment (n = 46) control (n = 54) EFFECTS OF HYPNOSIS AS AN ADJUNCT TO INTRAVENOUS SEDATION FOR THIRD MOLAR EXTRACTION: A Randomized, Blind, Controlled Study EDWARD F. MACKEY West Chester University of Pennsylvania, West Chester, Pennsylvania, USA Intl. Journal of Clinical and Experimental Hypnosis, 58(1): 21–38, 2010

38. EFFECTS OF HYPNOSIS AS AN ADJUNCT TO INTRAVENOUS SEDATION FOR THIRD MOLAR EXTRACTION: A Randomized, Blind, Controlled Study EDWARD F. MACKEY West Chester University of Pennsylvania, West Chester, Pennsylvania, USA Intl. Journal of Clinical and Experimental Hypnosis, 58(1): 21–38, 2010

39. EFFECTS OF HYPNOSIS AS AN ADJUNCT TO INTRAVENOUS SEDATION FOR THIRD MOLAR EXTRACTION: A Randomized, Blind, Controlled Study EDWARD F. MACKEY West Chester University of Pennsylvania, West Chester, Pennsylvania, USA Intl. Journal of Clinical and Experimental Hypnosis, 58(1): 21–38, 2010

40. EFFECTS OF HYPNOSIS AS AN ADJUNCT TO INTRAVENOUS SEDATION FOR THIRD MOLAR EXTRACTION: A Randomized, Blind, Controlled Study EDWARD F. MACKEY West Chester University of Pennsylvania, West Chester, Pennsylvania, USA Intl. Journal of Clinical and Experimental Hypnosis, 58(1): 21–38, 2010

41. Post Operative

42. Post Op • Pain control use “controllers”. • Post Hypnotic suggestions and cues. • Ongoing positive statements. “getting better each day and in everyway” • PT, OT, Nursing to learn positive persuasive language skills. • Stress “discomfort” not “pain”.