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Afife Ayla Kabalak*, Aysegul Ceylan, Eymen Aslan, Leyla Bulut, Mehmet Simsek and Ulas Ozcan
Ankara Ulus State Hospital, Ankara, Alt�?±nda�?�?, Turkey
Received date: April 13, 2014; Accepted date: August 08, 2014; Published date: August 18, 2014
Citation: Kabalak AA, Ceylan A, Aslan E, Bulut L, Simsek M, et al. (2014) Clinical Hypnosis for Symptom Management of Cancer Patients in Palliative Care. J Palliat Care Med 4:181. doi: 10.4172/2165-7386.1000181
Copyright: © 2014 Kabalak AA et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Clinical hypnosis is a science increasingly recognized for its therapeutic applications. Applied to the comprehensive treatment of cancer, clinical hypnosis offers unique possibilities due to its capacities for enhancing mind to body communication. Hypnotic therapy in cancer may be directed to many levels of its manifestations. Physical symptoms of cancer, the most common of which are pain and fatigue, and the physical effects of its treatment may be alleviated to enhance quality of life. Additionally hypnosis is useful in the management of the side effects of cancer treatments, major psychological problems and difficulty of compliance with medical treatment. In our article, we apply the results of hypnotherapy evaluated in three patients. We think an important contribution to use of hypnosis in cancer patients for palliative treatment .
Hypnosis; Cancer patient; Symptom management; Palliative care
Complementary and alternative medicine (CAM) is defined by the National Center for Complementary and Alternative Medicine (NCCAM). CAM is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. Complementary medicine is used together with conventional medicine. Alternative medicine is used in place of conventional medicine. Integrative medicine, as defined by NCCAM, combines mainstream medical therapies and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness [1,2]. CAM therapies classifies into five categories by NCCAM. Alternative medical systems (eg. acupuncture, homeopathic medicine), mind-body interventions (eg. cognitive-behavioral therapy, meditation, prayer, hypnosis), biologically based therapies (eg. dietary supplements, herbal products), manipulative and body-based methods (eg. osteopathic manipulation, massage), energy therapies (eg. reiki, therapeutic touch, magnetic fields) [1]. According to the 2007 National Healt Statistics Report, several mind and body practices ranked among the top complementary health approaches used [3]. Hypnosis is one of these approaches and it is recognised in medicine as an effective therapy. Hypnotherapy has been defined as a mind-body therapy by the use of an altered state of consciousness. There exists a need for a broad and inclusive model of integration of mind-body interventions for palliative care. In palliative care patients, symptoms relating to psychological distress and existential concerns are even more prevalent than pain and other physical symptoms among those with life-limiting conditions. The hypnotic model’s purpose is to improve the patient’s total psychological, social, and spiritual well-being [1,2]. In this meaning, hypnotherapy may help to palliative care patients.
Hypnosis is an altered state of patient’s consciousness in receptive to therapeutic suggestion. Hypnosis is the induction of a deeply relaxed state, with increased suggestibility and suspension of critical faculties. Once in this state, patients are given therapeutic suggestions to encourage changes in behavior or relief of symptoms, and hypnotherapy is called. The hypnotherapy used within guidelines in patients with advanced cancer, is a safe complementary therapy to enhance coping. Therefore, most survival treatment plans contains to hypnotherapy, and clinical hypnosis is called. [4,5]. Clinical hypnosis is very effective in enhancing the cancer patient’s coping skills, managing emotional stress and anxiety, reducing pain, nausea, fatigue, hot flushes, breathlessness, sleep dysfunction, and symptoms associated with radiation and chemotherapy [6-8]. There is a synergistic relationship between pain and anxiety, and pain and depression. Hypnosis has been amply documented to be a potent pain modulator [9-11]. In addition, it can repair the immune response [12].
Clinical hypnosis has been commonly described as a safe method when used correctly, having few harmful side effects. In rare cases, hypnosis may cause unwanted side effects such as dizziness, drowsiness, headache, stiff neck, anxiety, stomach upset, cognitive distortion, false memories or confusion. However, most of these effects cleared up within several hours of the hypnotherapy session. Hypnosis is unadvisable for patients with psychological disorders involving delusions. Clinical hypnosis is also becoming popular for their ease of integration into an overall cancer survivorship treatment plan with relatively low risks. In this report, we aimed to present the effectiveness of hypnotherapy to three cancer patient's life quality. We included the patients who accepted hypnosis treatment and at the same time have a kind of cancer. Hypnotherapy specialist who made hypnotherapy this patients have high-graduate certificate of Ankara Hypnose Society in Turkey.
A 48-year-old women patient with a diagnosis of breast carcinoma established four years previously was referred by her doctor for hypnotic treatment of back pain. A recent examination revealed a solitary lesion in the thoracal spine. She achieved a hypnotic trance with an hand numbness technique. This technique recruits the ability of the mind to experience imagined sensations. “Imagine cold breeze from a mountain with snow through your hand. The numbness in your hand can travel into your thigh. You may be able to visualize of numbness spreading within your body in all directions. Her pain degree evaluated with visual analog scale (VAS; 0 no pain, 10 overly excruciating). Her VAS degree was seven before hypnosis treatment. Hypnotherapy was made for three times at one week. Her pain degree was reduced to three after treatment. She also recruited self-hypnosis to heighten energizing feelings of optimism and self-esteem. This ability now becomes your own, and you will be able to use it in self-hypnosis." Through this exercise, she successfully applied self-hypnosis to modulate her pain.
A 56-year-old male with gastric carcinoma disease was receiving combination chemotherapy. Although physically tolerating this regimen, he became increasingly distressed by post-treatment nausea. Induction made use of the hypnotic technique of awareness of breath. Eyes closed, he was asked to dispatch his feelings into his breathing and open his perception to the sensation of air touching the inside of his lungs. To counter nauseous feelings, sensations of hunger were elicited. He imagined a typical treatment session gradually pairing treatment scenarios with intestinal comfort. Hypnotherapy was made for two times at one week. During the fourth session, he was able to visualize himself receiving treatment with no distress. In the actual treatment situation, he experienced only mild nausea but no vomiting, and he was able to finish his entire chemotherapy protocol.
A 33-year-old women with non Hodgkin lymphoma complained that the oppressive thoughts, fatigue, and sleep dysfunction about her cancer were constantly present. Hypnosis was used to gradually expand minuscule "thought-free" periods from minutes to hours and to increase the ability of unconscious mechanisms to repress anxiogenic thought intructions. Hypnotherapy was made for four times at one week. Her feeling of fatigue is reduced with the reduction of anxiety at three sessions. She was able to sleep comfortably with reduced pain and her fatigue.
Adjunctive hypnotic therapy in cancer may be directed to many levels of its manifestations. Physical symptoms of cancer, the most common of which are pain and fatigue, and the physical effects of its treatment may be alleviated to enhance quality of life.
In recent years, the anecdotal and sometimes exaggerated evidence for the effectiveness of hypnosis to decrease sensitivity to pain - known as hypno-analgesia - has been supplemented by well- controlled experiments. In their 2003 review of controlled clinical studies found that hypno-analgesia is associated with significant reductions in: ratings of pain, need for analgesics or sedation, nausea and vomiting, and length of stay in hospitals [13,14].
When used adjunctively with analgesics, hypnosis can serve to reduce their dosage. The current approaches may be used singly or concomitantly in any patient, depending upon their hypnotic proficiencies. Hypnotic relaxation, direct suggestions for pain removal, hand anesthesia with extension and diffusion, altering the configuration of pain, altering the qualitative aspects of pain, imagery, dissociation [15].
A study of breast cancer patients found that those assigned to treatment (standard care or expressive-supportive therapy) that included clinical hypnosis demonstrated significantly less pain. In addition, patients who underwent hypnosis reported significantly less of an increase in pain over time [16].
Elkins et al. conducted a prospective, randomized study of 39 advanced-stage (Stage III or IV) cancer patients with malignant bone disease. Patients were randomized to receive either weekly sessions of supportive attention or a hypnosis intervention. Patients assigned to the hypnosis intervention received at least four weekly sessions in which a hypnotic induction was completed following a standard transcript. The transcript included suggestions for relaxation, comfort, mental imagery for dissociation and pain control, and instruction in self-hypnosis. The hypnosis intervention group demonstrated an overall decrease in pain (p<.0001) for all sessions combined. The mean rating of the effectiveness of self-hypnosis practice outside the sessions was 6.5 on a 0-to-10 scale Results showed the hypnosis intervention group had a significant overall decrease in pain [17].
Nash and Tasso described two studies of special interest to clinicians and clinical researchers. Both are randomized controlled studies, exclusively focused on female patients. The first study tests whether a year-long weekly group intervention including hypnosis can reduce cancer pain among women with metastatic breast cancer. Findings suggest the intervention slowed the increase in reported pain over a 12-month period relative to controls. The second study examines the effect of hypnosis in women suffering from temporomandibular disorder (TMD), with a special focus on function as well as pain. Hypnosis reduced TMD pain as measured by a numerical-rating scale [18].
Syrjala and colleagues studied 45 cancer patients to evaluate the efficacy of hypnosis for pain relief following chemotherapy [19]. Participants were randomized into the following conditions: hypnosis, cognitive behavioral therapy (CBT), attention control, and standard care. There were no reported significant differences among the groups for nausea, presence of emesis, nor opioid intake; however, the hypnosis group showed a significant reduction in oral pain. Montgomery and colleagues studied 200 patients undergoing excisional breast biopsy or lumpectomy [20]. Participants in this study were randomly assigned to a hypnosis session or to a control condition involving nondirective empathic listening. The hypnosis group had significant reductions in pain intensity, self-reported pain unpleasantness, nausea, fatigue, and discomfort compared with the control. Results indicated that hypnosis reduced pain and anxiety compared to empathetic attention, which only showed a reduction in pain.
It has been reported that 70% to 80% of all cancer patients who receive chemotherapy experience nausea and vomiting [19]. Clinical hypnosis has been studied for relief of nausea and vomiting secondary to chemotherapy. In a randomized study of the efficacy of hypnosis in reducing nausea and vomiting in children receiving chemotherapy, researchers found children participating in hypnosis had less anticipatory nausea and vomiting and less overall vomiting compared with controls who did not undergo hypnosis [20]. This finding was replicated in a later study also demonstrating that patients using clinical hypnosis showed a reduced need for antiemetic medication [21]. A review by Richardson and colleagues of six randomized, controlled trials suggests there were large effect sizes for hypnotic treatments when compared with treatment as usual, and these were at least as large as the effects of CBT [22].
Cancer-related fatigue has long been recognized as one of the most difficult symptoms to manage during cancer treatment, and it remains the most common unrelieved symptom of cancer [23]. Research suggests that fatigue is a multidimensional syndrome which results from both cancer and cancer therapies, such as chemotherapy and radiotherapy. Estimates of the prevalence of fatigue in cancer patients undergoing radiotherapy are diverse. Literature suggests that fatigue can affect 60% to 90% of patients receiving chemotherapy or radiation therapy [24]. This condition is managed through education of patients and caregivers about current evidence-based strategies to reduce fatigue, nonpharmacological interventions including exercise, and pharmacological therapies [23]. Despite the high prevalence of cancer-related fatigue, few intervention options exist [25]. A study was conducted to test the effectiveness of CBT and hypnosis for radiotherapy-related fatigue. Breast cancer patients were randomly assigned to receive either standard care or CBT and hypnosis. Results show that with the cognitive-behavioral/hypnosis intervention, patients’ fatigue did not increase over the course treatment, whereas fatigue among patients receiving standard care increased linearly [26].
While sleep disorders can be treated with pharmacotherapy, this treatment modality carries with it the inherent risks of dependence and potentially dangerous drug interactions. Furthermore, pharmacotherapy does not treat the underlying source of the sleep disturbance. Hypnosis provides cancer patients with a safe alternative treatment option that not only improves the ability to obtain restful sleep, but also leads to improvements in other symptom areas (anxiety, depression, pain, fatigue, treatment-related side effects) [27]. A study conducted by Elkins et al supports the efficacy of clinical hypnosis in improving the quality of sleep for cancer patients [28].
Clinical hypnosis for the treatment of hot flashes has been investigated. In two studies of breast cancer survivors, participants received five sessions of hypnotherapy, and were instructed in selfhypnosis. The results showed a 69% reduction of hot flashes relative to baseline [27,28].
Studies report positive results including statistically significant reductions in anticipatory. Meta-analysis revealed a large effect size of hypnotic treatment when compared with treatment as usual, and the effect was at least as large as that of cognitive–behavioural therapy. Further research into the effectiveness, acceptance and feasibility of hypnosis, particularly in adults, is suggested [29].
Clinical hypnosis is a viable option for cancer patients may employ these techniques to manage myriad symptoms. While current research into the efficacy of clinical hypnosis for the palliative treatment of cancer patients is extremely encouraging.
In our experience for three cancer patients, we have found hypnosis to be very effective for quality of life. Additional research will be needed for clinical hypnosis to become a well-established evidence-based treatment for the palliative care of cancer patients. However, the existing evidence from all clinical research supports inclusion of clinical hypnosis as an effective adjunct therapy in the palliative cancer treatment milieu, and therefore hypnosis should be considered for patients with cancer on a case-by-case basis. Future studies should assess suggestibility and provide full details of the hypnotic intervention.
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