Orne, M. T., & Whitehouse, W. G. Nonpharmacological approaches to pain relief: Hypnosis, self- hypnosis, placebo effects. In G. M. Aronoff (Ed.), Evaluation and treatment of chronic pain. Baltimore, MD: Williams & Wilkins, 1999. Pp.579-589.
Recognition of the contribution of distress and suffering in the experience of pain can be traced to ancient times. Over the centuries and across cultures, efforts to relieve disease-related pain, as opposed to that provoked by acute injury, often involved spiritual/psychological interventions, such as the exorcism of evil spirits, letting of presumably virulent bodily fluids, prayer, and attempts to appease the gods, in accordance with extant beliefs (1). The modem scientific zeitgeist that developed in the mid-19th century heralded a shift toward discovering the anatomical structures that give rise to pain as a pure sensory phenomenon, which in turn promised to point the way for developing effective pharmacological and surgical treatments. While the emotional and motivational aspects of pain continued to be appreciated clinically, it took approximately another 100 years before science was prepared to conceptualize and to develop techniques to address the essential multidimensionality of the problem (2-4). Modern day nonpharmacological approaches to pain treatment seek to apply psychological and/or biobehavioral procedures optimally to modify a patient's perceptual, emotional, and evaluative responses to pain. Although these techniques are in many ways derivative of centuries-old antecedents, they have also benefited from significant scientific advances in understanding their mechanisms, specificity, and efficacy. In this chapter, we examine such issues as they pertain to the application of hypnotic and self-hypnotic procedures for pain management.
Consider for a moment being stung by a bee, stubbing a toe, touching a hot utensil, waking up with a toothache, or having stomach cramps after the ingestion of unripe apples. None of these experiences generally tends to be particularly frightening and all are known to cause pain of relatively brief duration. Since our commonsense view of pain is largely based on experiences such as these, one tends to focus on the sensation aspect of the pain experience, considering it as a simple and direct consequence of a noxious stimulus, closely analogous to other sensory experiences.
The sensory experience of pain, however, is greatly modulated by the circumstances under which it occurs. A bee sting to someone with many allergies can be terrifying, as can a toothache to an individual with an unfortunate dental history. Similarly, pain of no greater intensity than a stomach cramp occurring in a cancer patient may involve a vastly greater amount of suffering. Conversely, as Beecher (5, 6) dramatically demonstrated during World War II, soldiers who had lived through the continuous bombardment of the Anzio beachhead and had received serious shrapnel injuries involving compound fractures required little or no opioid medication when they were brought to the medical aid stations. Instead of showing concern, they tended to be euphoric, since their wound meant that they would soon be evacuated and would no longer have to endure the intense stress of combat. Thus, Beecher distinguished between the suffering and the sensation components of the pain experience and documented the profound effects of the psychological significance attached to the wound and to the degree of suffering associated with it.
In addition to the immediate context, many aspects of the individual's history affect his or her responses to pain. Who has not observed a child fall, look doubtfully at his or her mother, and being met with a reassuring smile, return happily to play, while a friend, having the same kind of fall and seeing the mother's horrified expression, promptly begins to cry and apparently experiences considerable pain. To a large extent a child's definition of what constitutes pain is learned and inevitably influences future pain experiences, leading to
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relatively stable differences among various cultural groups and their pain responses.
We have thus far considered acute pain for which the nature of the noxious stimulus is clearly understood. While it is commonly recognized that factors associated with anxiety, motivation, and perception of the meaning of pain affect an individual's experience of pain, most of us are nevertheless astonished when we see a clear-cut example of such psychological factors overriding the neural events that would normally be experienced as severe pain. For instance, it is not uncommon for athletes to suffer injuries during a game without becoming aware of any discomfort; however, once the game is over, they quickly succumb to the exquisite pain of the injury.
HYPNOTICALLY INDUCED ANESTHESIA
The use of hypnosis as the sole anesthetic for major surgery was employed sporadically during the first half of the 19th century but was generally abandoned with the clinical demonstration of the efficacy of ether and chloroform for surgical anesthesia. There continue to be, however, well-authenticated cases in which hypnosis served as the sole anesthetic (7). These range from appendectomies to thyroidectomies, from cesarean sections to open heart surgery (8, 9). Although with today's broad range of safe chemical anesthesias hypnosis is rarely indicated as a surgical anesthetic, the fact that it is possible to carry out major surgery with hypnosis as the only form of anesthesia is perhaps the most dramatic and clear-cut example of the profound effects that psychological factors can exert on the sensation of pain.
The work of Hilgard and Hilgard (9) and their associates, using normal college students and experimental pain of a kind that mimics important aspects of clinical pain, has gone a long way toward addressing some of the questions concerning the factors that affect hypnotic analgesia. Using immersion in ice water, as well as ischemic muscle pain, they have shown the remarkable lawfulness of the effect of hypnotically induced analgesia on subjects' reports of their pain experience. The single most important factor has turned out to be the individual's ability to respond to hypnosis.
Whereas at one time the basis of the hypnotic phenomenon was sought in the special skill of the hypnotist, modem studies have amply documented that it is the skill of individuals to respond that determines whether they are hypnotized. There are wide individual differences in this ability. Thus, following a standardized hypnotic induction procedure, some persons (5% to 10%) respond to very difficult suggestions, including positive and negative hallucinations, whereas those at the other end of the normal distribution (5% to 10%) cannot respond at all, with most falling between the two extremes (10).
The importance of the subject's skill in being hypnotized is illustrated in a study by Hilgard and Morgan (11), who assessed the response to hypnosis using standardized typical hypnotic suggestions other than analgesia and on this basis subdivided subjects into three groups of high, average, and low hynotizability. They then tested the response of subjects in each group to suggestions of hypnotic analgesia during a cold-pressor test. Using subjects' pain ratings as a criterion, they showed that of 15 highly hypnotizable subjects, only 7% failed to reduce pain by less than 10%, while 67% reduced pain by 33% or more. Conversely, with 16 subjects who had little ability to experience hypnosis, 56% showed less than a 10% pain reduction, and only 13% reduced pain by 33% or more (Figure 40.1). The group with medium hypnotic responsiveness fell between these two extremes. Similar findings were reported by Karlin et al. (12), who simultaneously monitored electroencephalographic (EEG) activation and subjective pain reports during hypnotically induced analgesia for cold-pressor stimulation. These investigators observed that following induction of hypnosis, pain ratings and degree of contralateral hemispheric EEG activation during 1-minute periods of immersion of the hand in ice water were significantly less for highly hypnotizable subjects than they were for those of moderate hypnotic talent, although both groups reported decreased pain during hypnosis. However, findings from an investigation of the cold-pressor paradigm with children 6-12 years of age suggest that there may be developmental limitations on the extent to which hypnotizability is a factor in hypnotic analgesia; younger children appear to derive less benefit from analgesia suggestions administered during hypnosis than older children (13). Nevertheless, the ability of the subject to benefit from hypnotic suggestions of analgesia in a laboratory setting seems generally to be related to the ability to respond to other kinds of hypnotic suggestions.
There have been a great many reports about the effective use of hypnosis to suppress clinical pain. An excellent example is its use with burns in children and adults, in whom the repeated trauma associated with the changing of burn dressings and the debridement of wounds could in many instances be greatly negated (14, 15). Similar reports have been made in the control of pain associated with a wide range of other noxious medical procedures (9). In the few studies that formally assessed hypnotizability, the findings parallel those of laboratory investigations; that is, the amount of benefit derived from the use of hypnotic procedures for pain reduction covaried with the patients' ability to experience hypnosis (15-18). Unfortunately, in the vast majority of clinical studies, relatively little systematic information about the patients' hypnotizability is available.Despite this oversight, it is instructive to note that hypnotic techniques appear to enjoy a remarkably high degree of success in suppressing pain in a dental context (19). Clearly, given what is known about the distribution of hypnotizability in the general population, factors other than hypnosis must also be playing a role in these situations. Next we consider some of the mechanisms that may be involved.
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HYPNOTIZABILITY, THE PLACEBO RESPONSE, AND PAIN RELIEF THROUGH SUGGESTION
One tends to think of the placebo response as a manifestation of the same psychological processes that account for hypnosis. Elsewhere we have reported in-depth findings that challenge this assumption (20, 21). We outline the relevant aspects of this rather complex study here because it addresses some basic questions about the nature of hypnotic analgesia.
The response to suggestions of anesthesia following an induction procedure was compared between two groups of subjects, 12 highly hypnotizable persons and 12 subjects who had repeatedly failed to respond to hypnosis. One of the problems with such a comparison, however, is that the unhypnotizable group not only fail to enter hypnosis but also do not expect hypnosis to help them, whereas those who are able to enter deep hypnosis have every reason to believe that the technique should help them tolerate pain. Since our interest was to compare the effect of hypnosis, we wanted both groups to have the expectation that this method would help them. For this reason the unhypnotizable subjects participated in yet another hypnotic induction session with a different investigator, which was carefully designed to use elaborate relaxation procedures over a long period without any hypnotic suggestions being given, since these subjects would almost certainly have failed to respond to any of these.
After a procedure lasting some 50 minutes, which induced profound relaxation -- a phenomenon that is often associated with but is not identical to hypnosis -- another lengthy technique was used to induce glove anesthesia of the right hand. Without asking the subject to comment on the anesthesia, he or she was asked to tolerate a mild electric shock, which was administered to both the right and left hands. The subject was subsequently awakened with instructions to have lost track of time but otherwise to recall everything that had happened. (Again, even unhypnotizable individuals become unaware of the passage of time during a lengthy procedure of this kind.)
When asked, all of the subjects indicated that much to their surprise, this time the hypnotic procedure had been effective and that there was indeed a modest but striking difference in the electric shock between the right and left hand. They typically expressed considerable satisfaction that they had finally been able to achieve a hypnotic experience and eagerly looked forward to participating in further studies. The manner in which this result was achieved, however, had little to do with hypnosis. When the experimenter tested the right hand, he simply decreased the amount of current applied to the hand without, of course, informing the subject. The manner in which the testing was presented to subjects conveyed that the experimenter merely wanted to assess their response, and the investigator indicated that he too was pleased that the subject had been able to have the experience. Carefully carried out, the manipulation was extremely plausible and resulted in a group of subjects still unable to respond to hypnosis but sharing the conviction of the hypnotized group that they would benefit from hypnosis when attempting to control pain.
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All subjects subsequently came to the laboratory and participated in an ischemic pain procedure, which involved applying a blood pressure cuff at 200 mm Hg to their arm and then asking that they pump water from one flask to another by repeatedly squeezing a rubber bulb. This task becomes exceedingly painful as the amount of ischemia mounts. Subjects are asked to indicate pain threshold but also to continue pumping as long as possible. Both the time blood flow is occluded and the amount of work performed have been shown by Dorpat and Holmes (22) and Lasagna et al. (23) to be systematically related to pain threshold.
The experimenter was not told which subjects were able to enter hypnosis. After an initial baseline session, subjects were asked to return for a second session that would involve hypnosis. During that session, hypnosis was induced by the same relaxation procedure mentioned earlier, and the experimenter was careful to avoid any test of hypnotic responsiveness that would indicate whether the subject was in fact hypnotizable. He then suggested analgesia of the hand and arm and repeated the same test. Again, pain threshold and tolerance were assessed.
Finally, the subjects were asked to come for yet a third session in which it was explained to them that a powerful analgesic would be employed to assess how long and how much water they could pump if the pain was effectively controlled and the only limiting factor was the amount of anaerobic energy in the muscle. Subjects were given a pill, and about 20 minutes later the ischemic muscle test was repeated. (Although all subjects received placebo, all members of the laboratory other than the director believed that a double-blind comparison was being carried out between propoxyphene hydrochloride (Darvon) and a placebo. Thus the placebo was given with conviction by the investigator, while we had the benefit of having all subjects in the placebo treatment.)
Figure 40.2 summarizes the basic findings for pain thresholds and pain tolerance across all three sessions. It should be noted first that the level of response to placebo in session 3 was virtually the same for the highly hypnotizable group as for the unhypnotizable group. There is no meaningful difference in the level of placebo response between these two groups. Certainly this speaks against the notion that hypnotizability is related to the placebo response.
Looking at the placebo response of the unhypnotizable group, it is interesting that the magnitude of response overall is virtually the same as that to hypnosis. Indeed, there is a correlation of .76 between the amount of pain relief that the unhypnotizable subject obtains from hypnosis and from placebo. However, if one examines the hypnotizable group, it is obvious that the amount of benefit they derive from hypnosis is vastly greater than the amount of benefit they derive from placebo. Of course, it might be possible for hypnosis to be more effective, and still a high correlation between the response to hypnosis and placebo in highly hypnotizable subjects could exist. This is not the case, however; within this group the relation of pain relief from hypnosis and that from placebo is .06.
Figure 40.2 shows that the hypnotizable group derived significantly more benefit from hypnosis than did the unhypnotizable group, but their response to placebo was no different from that of the unhypnotizable group. Thus, the dramatic effect of hypnosis on pain cannot be explained solely in terms of subjects' expectations but rather again turns out to be directly related to hypnotizability. Nonetheless, the unhypnotizable subject also derives considerable benefit from hypnosis. Although it is less than the amount of benefit seen in the hypnotizable person, the effect is still significant. Since this effect is highly correlated with the amount of relief obtained by placebo, we have conceptualized it as a placebo effect of the hypnotic procedure. For some purposes it is useful to think of it in this fashion; however, in the context of the present discussion it points up important effects of the hypnotic induction procedure that occur even if the subject fails to be hypnotized. It appears to us that these effects are worth studying in their own right and may in many instances be extremely important clinically.
THE PLACEBO RESPONSE
In many ways the placebo has the properties of an active drug. More than 40 years ago, Gruber (24) not only showed that placebo was effective in the treatment of headaches but demonstrated that the "dosage" was important and that two placebo pills were almost twice as effective as one. Similarly, Rickels et al. (25) showed that when patients suffering from anxiety consulted a medical practitioner, they obtained considerable relief from placebo, and again the administration of four placebos a day was considerably more effective than one per day.
These and other studies emphasize that the effectiveness of placebo depends on the conviction with which it is administered, the kind of expectations that the therapist conveys when placebo is administered, and the congruence of such expectations with the patient's own attitudes and beliefs. For example, in the study by Rickels et al. (25), patients who were seeking relief in the form of medicine tended to be helped greatly by placebo, whereas those who had sought psychiatric help did not show any improvement with placebo.
The expectancies that the therapist communicates when administering the placebo may actually override a potent drug effect. For example, Fisher (26) administered 10 mg of the stimulant D-amphetamine (Dexedrine) to volunteers who were to help him assess the effectiveness of a new sleeping pill. Under such circumstances, d-amphetamine did not interfere with sleep. Again, Lyerly et al. (27) showed that sleeping medication administered as a new form of stimulant did not cause drowsiness nor, as Fisher had already shown, did amphetamines administered as sedatives cause subjective arousal.
A review (28) of six double-blind studies determined that the index of efficiency of placebo compared with a standard dose of a potent analgesic such as morphine was .56, indicating that placebo is 56% as effective as morphine. Surprisingly, when the index of placebo efficiency was compared
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with aspirin in nine studies, it proved to be .54. Again, the efficiency of placebo when compared with an intermediate-strength analgesic such as propoxyphene hydrochloride or codeine was found to be .56.
The effectiveness of placebo compared with a standard dose of a specific analgesic drug administered in a double-blind study seems to be constant, indicating that placebo is powerful indeed when it is given with morphine but it is proportionately less powerful when it is given with aspirin. Thus, it appears that the doctor's belief about the effectiveness of the active drug determines the effectiveness of the placebo.
Although much has been written about placebo effects and their many fascinating puzzles, such as why red placebos are more effective than blue ones, a limited amount of research has been carried out to understand the mechanisms that determine how a placebo works. As we have seen, the belief of the investigator or doctor about the effectiveness of the drug is a critical determinant of the level of placebo response. In addition, however, early work by Beecher (5) demonstrated that placebo is vastly more effective on the battlefield than in a civilian context. Apparently, the higher the patient's level of anxiety, the more effective the placebo. Similarly, in another study, Beecher (29) showed that when postoperative wound pain was at its greatest, morphine relieved 52% of the patients, whereas placebo relieved the pain of 40% of the same patients. Later, when the pain was much less with these patients, the same standard dose of morphine relieved the pain of 89% of the patients, whereas placebo was effective with only 26%.
Although the concept of placebo was designed as a control for nonspecific factors in treatment, an important area of research involves the elucidation of specific mechanisms, such as the level of state anxiety, that are responsible for what have heretofore been considered general nonspecific effects. As such mechanisms become recognized and better understood, it will be possible to use this information to design more powerful ways of modifying pain in specific treatment programs.
THE EFFECT OF HYPNOSIS VERSUS THE EFFECT OF HYPNOTIC INDUCTION
As was pointed out earlier, people vary in hypnotizability. This ability is a generally stable trait of the individual, and while motivational factors may impede a person's ability to enter hypnosis, for the most part, provided he or she is reasonably cooperative and has a moderately good relationship with the hypnotist, motivation is not particularly important.
Clinically, the use of hypnosis is not limited to those who are profoundly responsive but may be employed with the vast majority of persons, even those who have a minimal skill for entering hypnosis and respond only by relaxation. As long as suggestions that are too difficult for the patient to carry out are avoided, he or she may feel adequately responsive to hypnosis. It is useful, however, to distinguish between the benefit the subject derives from actual hypnosis and benefits that accrue from other nonspecific effects of hypnosis. Again, like the study of placebo effects, it is important to begin to isolate some of the components that can be specified and that will cause a hypnotic induction procedure to help even patients who are not actually hypnotizable.
SOME EXAMPLES OF THE EFFECT OF THE HYPNOTIC INDUCTION IN THE CLINICAL CONTEXT
The use of a hypnotic procedure alters many aspects of the doctor-patient relationship. Furthermore, by asking the patient to attend to some ideas and to ignore others, important cognitive changes may be brought about. Not only can the hypnotic induction procedure affect the patient directly, but it may also radically change the way the doctor behaves, which in turn can have profound effects on what the patient experiences.
Consider the effect of hypnosis during a dental procedure with an anxious patient. Instead of minimizing the patient's fears and treating him or her with annoyance, the dentist who elects to use hypnosis will show concern about the patient's comfort, establish rapport, and then carefully induce hypnosis, even though this may not be his or her normal chairside behavior. Throughout the hypnotic session, the dentist maintains an almost continuous stream of suggestions and remains very sensitive to the patient's reactions. While he or she may have given suggestions of analgesia, the dentist schooled in the use of hypnosis will promptly terminate any activity that brings about even minor evidence of discomfort, renewing suggestions of relaxation and proceeding subsequently only with great caution, often augmenting hypnotic analgesia with a suitable amount of local anesthetic.
From the patient's point of view, even if he or she is relatively unhypnotizable, the hypnotic situation is radically different from the typical dental encounter. Instead of feeling that the dentist wants urgently to get on with the technical aspects of the procedure, the patient perceives a heightened sense of concern for his or her own level of comfort. Instead of being largely ignored, with the dentist either quietly working or maintaining a conversation with the assistant, there is a continuous show of interest on the part of the dentist and an obvious sensitivity to even slight evidence of discomfort. It is hardly surprising that under such circumstances patients become more relaxed and trusting, and exhibit an increased ability to tolerate discomfort. These effects have little to do with the state of hypnosis; rather, they may be a function of the patient's increased feeling of control and safety.
Several studies have shown that giving subjects control over the timing of painful stimuli (30), instilling the belief that they can control noxious events (31-33), or even instilling only the belief that they can terminate aversive stimuli (34) increases their tolerance for discomfort and decreases their physiological reactivity. Analogously, it is well known that procedures that give patients the feeling of control in a dental context can in and of themselves bring about a marked rise in pain threshold. Similarly, the patient comes to believe
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that the dentist will not inflict serious pain, another factor that increases pain tolerance, since a small amount of pain no longer serves to signal the inevitable advent of more severe pain. The reduction of anxiety associated with the total procedure also decreases the sensitivity to pain. Simply being talked through a dental procedure is infinitely more reassuring than being left to one's own devices, which permits fears and fantasies to multiply. Both the direct and indirect effects discussed here that follow from the use of hypnotic procedures have little to do with the patient's entering hypnosis. Nonetheless, they profoundly alter the patient's experience. This may well account for the high success rate reported for hypnosis in dentistry, although only 15% to 20% of patients are able to achieve a moderately profound hypnotic response that would lead to dental analgesia in the sense of a hypnotically suggested negative hallucination for pain.
HYPNOSIS IN THE TREATMENT OF CANCER PAIN
Although it is estimated that 38 to 70% of patients with advanced cancer have severe pain (35, 36), the profound and progressive sense of isolation, helplessness, and despair as family, friends, and caretakers gradually withdraw, all focus the patient on his or her body and accentuate the seventy of pain. In turn, the pain prevents the patient from enjoying some of the few pleasures that remain, and at times the pain itself and behavior related to pain become the principal means of communication with others.
Orne has had the opportunity to treat a number of patients with terminal cancer, and certainly those who are fortunate enough to have the skill of experiencing deep hypnosis can derive a remarkable degree of relief. However, we have become increasingly aware of the complex and important role that hypnotic induction and its consequences -- not related to the presence of hypnosis -- can sometimes play in reversing what had appeared to be a progressive worsening of the patient's overall condition. Thus, the induction of hypnosis and/or training in self-hypnosis provide the opportunity to offer relief in a manner that entails the patient's active participation.
In the context of a structured treatment program, those around the patient can be assigned responsibility to help him or her to better achieve the skill of pain control. For the first time in a long while, it may become possible for the patient to accomplish something of personal importance and to focus on one or another aspect of improvement, be it increased pain tolerance, the decrease of nausea, a modest weight gain, or the ability to read a newspaper. The specifics of the accomplishment matter little; the fact that progress can be perceived matters a great deal. Some sign of progress, however slight, is important, not only for the patient but at times even more so to help his or her caregivers maintain their ability to interact meaningfully and to focus on the positive things that can be shared rather than solely the pain and suffering, which may be equally unbearable to all concerned.
Much has been written about the importance of factors such as these in making what remains of life livable and meaningful, but it has rarely been emphasized how the use of the hypnotic situation can provide the context that for many patients permits the kind of changes we have tried to sketch in this chapter. While the patient who is able to experience hypnosis can reap the benefits of suggested analgesia as well as the benefits that follow from the induction procedure, many of the changes that hypnotic techniques, particularly the use of self-hypnosis, can bring about in the patient's perception of the situation and interaction with others have little or nothing to do with the ability to enter hypnosis. On the contrary, they reflect the response on the part of the doctor, who suddenly feels there is something that can be offered to the patient to bring about relief; on the part of the family, who suddenly may be encouraged to share positive experiences with the patient and find the interaction less enervating; and on the part of the patient, who begins again to feel able to control some aspects of his or her experience.
In discussing the effect of hypnosis on cancer pain, we have touched on a kind of pain that involves chronicity as well as the other psychobiological effects of cancer, which others have discussed in more detail elsewhere (35, 37). The treatment of chronic pain inevitably involves dealing with complex psychosocial aspects, partly caused by the pain and partly maximizing the pain and making it difficult for the patient to obtain relief except through drugs that numb consciousness. When one considers the treatment of chronic pain, it becomes particularly useful to consider a variety of approaches to pain.
HYPNOSIS IN THE TREATMENT OF PAIN ASSOCIATED WITH SICKLE CELL DISEASE
Issues quite similar to those in the management of chronic malignant pain also apply to progressive diseases in which pain is a salient, unpredictable, and recurrent symptom. An example of a disorder with these features is sickle cell disease, which is genetically transmitted and affects primarily individuals of African heritage. Persons with this disease have red blood cells that are susceptible to periodic deformation called sickling. When this occurs, the sickle cells occlude blood vessels and capillaries, promoting sudden episodes of ischemic pain, organ failure, and other serious health problems (38, 39). In many patients symptoms develop in early childhood and tend to increase in severity and frequency with age (40). Mild to moderate pain episodes are typically managed at home with nonopioid analgesics; more severe crises may require emergency room treatment, often consisting of hydration and opioids, with occasional blood transfusions for cases involving other serious medical complications (41, 42).
Work by our laboratory suggests that children and adolescents with frequent sickle cell pain may be behaviorally disadvantaged in that they restrict their activities and are absent from school on 30% of the days they have pain (43). We have
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also found that the pain disturbs their sleep, which can exacerbate problems with daytime functioning and school attendance (44). Because there is no way to anticipate the painful episodes, persons with sickle cell disease must learn to cope with and control their pain in such a way that the pain itself, as well as the methods for its control, interfere as little as possible with their everyday activities and quality of life.
Training in self-hypnosis appears to be a particularly useful adjunct to standard medical treatments for the management of sickle cell-related pain (45). Our laboratory's experience with this approach has attempted to exploit both the specific (i.e., related to the ability to enter hypnosis) and nonspecific components (i.e., placebo effects of hypnotic induction, regular group training sessions, supportive involvement of family and friends) of a programmatic cognitive-behavioral intervention centered on self-hypnosis. The principal objective was to teach child, adolescent, and adult patients the requisite skills to induce a condition of self-hypnosis that would enable them to reduce their pain experiences when they occurred. A secondary yet critical aspect of the program was to provide a legitimizing, conducive, and motivating context to ensure that patients would practice these skills and use them as needed. By sharing their concerns and experiences with self-hypnosis in regular group training sessions, patients were able to allay any fears, develop effective therapeutic metaphors for their self-hypnosis exercises, forge a group identity with which to confront their common medical problem, and reinforce the desire to take personal control over their pain.
Compared with a 4-month baseline period during which patients relied only on conventional medical management of sickle cell pain, the subsequent 18 months, during which the cognitive-behavioral and self-hypnosis program was in effect, were associated with a significant reduction in pain days (Fig. 40.3). Both the proportion of bad sleep nights and use of opioid medications also decreased significantly during the self-hypnosis treatment phase. However, patients continued to report disturbed sleep and to require medications on days during which they did have pain. That is, although there was less pain overall during the self-hypnosis treatment phase, that which did occur tended to be the more severe episodes, both in intensity and duration. Such a finding is consistent with expectations that a cognitive-behavioral intervention should be better suited to alleviating less severe rather than severe bouts of pain.
Just as with the design of interventions for the relief of chronic pain, the use of hypnotic procedures for the treatment of recurrent episodic pain requires a great deal of attention, not only to training of the appropriate hypnotic, imaginal, and relaxation skills, but most important, to contextual factors that ultimately determine the extent to which patients can integrate these skills into their daily lives. The ability to derive benefit from self-hypnosis for pain management is not the exclusive province of a handful of patients who happen to possess considerable hypnotic talent. Rather, the very multidimensionality of the pain experience virtually assures that given an appropriately supportive context, even minimally hypnotizable patients who have an earnest desire to improve their quality of life can be expected to realize tangible benefits from regularly carrying out their self-hypnosis treatment exercises. While the basis for improvement in many patients may reside in nonspecific -- including placebo -- aspects of treatment, the doctor should be concerned foremost with developing the most effective care delivery program available for each patient, regardless of the specific mechanisms that contribute to treatment outcome.
EFFECTIVE TREATMENT OF CHRONIC PAIN: A MANDATE FOR FURTHER RESEARCH
Perhaps because most of us are fortunate enough that our personal experiences have included only acute pain, we tend to have little understanding of the nature of chronic pain. Severe chronic pain is not so common as severe acute pain and is very different from a continuing acute pain. Behavior modification and cognitive-behavioral interventions, for example, have little role in the treatment of acute pain but are effective in the treatment of chronic pain, particularly to alter pain-related behavior that prevents the patient from undertaking activities that would in themselves help ameliorate suffering (46, 47).
It is useful to distinguish between the treatment of pain associated with end-stage malignant disease and other forms of chronic pain. The cancer patient suffers not only from physical pain but also from a debilitating illness that progressively diminishes the ability to function, making him or her acutely aware of the inevitable outcome. Although severe pain as such is a problem in many patients, it can generally be controlled by analgesic drugs, which should not be withheld because of an undue fear of addicting a dying patient. By the same token, psychological factors play a major role in the patient's ability to tolerate growing incapacity, to withstand the side effects of cancer treatment, and to be able to live his or her remaining days with a sense of dignity and a modicum of satisfaction.
The treatment of chronic pain associated with non-life-threatening illnesses is complicated by the fact that many painkilling drugs are addictive. For example, the doctor treating a condition such as shingles, which may involve extreme pain over long periods, knows the patient is suffering and yet must be rightfully concerned about the addictive potential of opioid drugs that would provide true relief. The very considerable number of persons who suffer from severe chronic pain find their lives profoundly affected by the fact that they are unable to obtain safe and enduring relief. These patients suffer all the more because they know that there are drugs that can provide virtually instant relief but that must be withheld as soon as it becomes clear that the problem is chronic. By that time, the patient's course is likely to be already complicated by varying degrees of addiction, making it even more difficult for the doctor to assess the nature of the chronic pain. Too often the doctor, concerned with addiction, further complicates the patient's treatment by a judgmental attitude, in effect blaming the patient for seeking relief from suffering.
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While more basic information about the nature of the pain experience and how it may be modified is ultimately relevant to the treatment of all pain, the treatment of chronic pain in particular is an area demanding innovative approaches that must, in the final analysis, be evaluated with the patient population. During the past several years, there has been an increasing amount of research on the neurobiology of pain. However, there has been less scientific progress in understanding the psychological factors that affect pain. Thanks to the evolution of multidisciplinary pain clinics, the importance of psychological factors has been more generally recognized; however, their systematic study has continued to lag. Although it will always be appropriate to support isolated studies to document the effect of some particularly important aspect of motivation or the examination of some relevant cognitive factors on the pain experience, we need to begin to go about the study of psvchological factors affecting the pain experience in a more programmatic and multidisciplinary fashion.
The development of multidisciplinary pain clinics that seek to apply our current knowledge must be matched with the development of multidisciplinary pain research groups, as proposed by Bonica (37), which will seek to increase our understanding of the pain experience. Fortunately, effective laboratory models can be used for systematic exploration of the effect of psychological factors in modifying the pain experience under tightly controlled conditions. Such research group
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of course, must have an appreciation of clinical pain and blend a wide variety of skills and techniques -- ranging from psychophysical scaling to the use of signal detection techniques and from the assessment of behavior to the study of the experience by means of interviews and psychophysiological measures -- in a concerted effort to objectify the pain experience.
Of necessity, much of the research will focus on acute pain. Nonetheless, as has already been pointed out, we must be equally concerned with chronic pain and the psychological concomitants of such pain. Chronic pain cannot be studied entirely in the laboratory context because only a few animal models exist. It must be studied with chronic pain patient volunteers. It is essential for pain research centers to maintain close contact with clinical pain services and doctors who treat chronic pain on a day-to-day basis.
It is difficult to convey the plight of the chronic pain patient. Not surprisingly, a person who is exposed to continual severe pain becomes difficult to be with; the doctor who has been unable to provide relief often seeks to avoid the patient, and those around him or her (made equally uncomfortable by the suffering) may shun the person in pain. Such circumstances, combined with the patient's inability to obtain relief, often lead to suspiciousness and hostility well above the norm, as well as definite signs of depression. This patient group, who have sought and failed to obtain relief from conventional medicine, may prevail upon alternative or complementary medical interventions that have yet to be scientifically accepted (48); worse, they may be victimized by charlatans and quacks.
It is not only possible but essential that the effectiveness of procedures developed for the treatment of chronic pain be scientifically evaluated. Because of the nature of the problems, chronic pain patients given the opportunity of participating in a research study are almost always eager to do so. In providing an opportunity to take part in research on chronic pain, the investigator not only may help assess procedures that could provide enduring relief in an acceptable fashion but also helps the patient, who can identify with the project and feel he or she is working toward a solution, to gain renewed hope of ultimate relief.
The fact that major surgery can be carried out in suitable patients, with hypnosis as the sole anesthetic, serves to illustrate the power of psychological factors to modify the pain experience. An effort has been made to show that it is possible to identify a number of different psychological mechanisms that alter the experience of pain. Furthermore, it has been suggested that a concerted effort should be made to develop pain research centers to study the psychological factors affecting pain experience. Such centers should concern themselves with the difficult but essential task of developing appropriate measures for pain so that this essentially private experience can be objectified more effectively. Such techniques will facilitate the study of both clinical and laboratory pain. In addition, the programmatic study of chronic pain, recognizing its special features, is particularly important.
As our understanding of pain grows, the links between research focusing on neurobiological mechanisms and research seeking to clarify psychological processes that affect the pain experience are bound to become increasingly strong. While this discussion is at the level of psychological and psychosocial factors, the experience of pain ultimately has a physiological basis. The links that must be formed to understand psychological and neurobiological aspects of pain should lead to important scientific insights as we seek to provide more effective tools to alleviate the suffering of our fellow man.
The substantive research on which this chapter is based was supported in part by the following agencies: Grants M H 19156 and M H 44193 from the National Institute of Mental Health, the van Amerigen Foundation, Hasbro Foundation, MBNA America Bank, N.A., Stratford Foundation, Arcadia Foundation, Curry Foundation, The Auxiliary of Pennsylvania Hospital, the Commonwealth of Pennsylvania, and the Institute for Experimental Psychiatry Research Foundation. We are grateful to our colleagues, Emily Carota Orne and David F. Dinges, for their valuable suggestions and thoughtful review of this paper.
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Figure 40.1 (p. 581) (from Hilgard, E.R., & Morgan, A.H. Heart rate and blood pressure in the study of laboratory pain in man under normal condtions and as influenced by hypnosis. Acta Neurobiologiae Experimentalis, 1975, 35, 741-759) is reproduced here with the kind permission of the editor of the Acta Neurobiologiae Experimentalis.
Figure 40.2 (p. 583) (from McGlashan, T.H., Evans, F.J., & Orne, M.T. The naure of hypnotic analgesia and placebo response to experimental pain. Psychosomatic Medicine, 1969, 31, 227-246.). © 1969 by American Psychosomatic Society, Inc. is reproduced here with the kind permission of Lippincott Williams & Wilkins ©.
Figure 40.3 (p. 587) (from Dinges, D.F., Whitehouse, W.G., Orne, E.C., Bloom, P.B., Carlin, M.M., Bauer, N.K., Gillen, K.A., Shapiro, B.S., Ohene-Frempong, K., Dampier, C., & Orne, M.T. Self-hypnosis training as an adjunctive treatment in the management of pain associated with sickle cell disease. International Journal of Clinical and Experimental Hypnosis, 1997, 45, 417-432.) is reproduced here with the kind permission of the Editor-in-Chief of The International Journal of Clinical and Experimental Hypnosis.