Kenneth V. Iserson, MD, MBA
J Emerg Med. 2014;46(4):588-596.
Background. Hypnosis has been used in medicine for nearly 250 years. Yet, emergency clinicians rarely use it in emergency departments or prehospital settings.
Objective. This review describes hypnosis, its historical use in medicine, several neurophysiologic studies of the procedure, its uses and potential uses in emergency care, and a simple technique for inducing hypnosis. It also discusses reasons why the technique has not been widely adopted, and suggests methods of increasing its use in emergency care, including some potential research areas.
Discussion. A limited number of clinical studies and case reports suggest that hypnosis may be effective in a wide variety of conditions applicable to emergency medical care. These include providing analgesia for existing pain (e.g., fractures, burns, and lacerations), providing analgesia and sedation for painful procedures (e.g., needle sticks, laceration repair, and fracture and joint reductions), reducing acute anxiety, increasing children’s cooperation for procedures, facilitating the diagnosis and treatment of acute psychiatric conditions, and providing analgesia and anxiolysis for obstetric/gynecologic problems.
Conclusions. Although it is safe, fast, and cost-effective, emergency clinicians rarely use hypnosis. This is due, in part, to the myths surrounding hypnosis and its association with alternative-complementary medicine. Genuine barriers to its increased clinical use include a lack of assured effectiveness and a lack of training and training requirements. Based on the results of further research, hypnosis could become a powerful and safe nonpharmacologic addition to the emergency clinician’s armamentarium, with the potential to enhance patient care in emergency medicine, prehospital care, and remote medical settings.
Uses in EM and Emergency Medical Systems
Neurophysiologic studies demonstrate that hypnosis differs from simple imagination, placebos, and sleep. Research using positron emission tomography (PET) shows that hypnosis involves the anterior cingulate cortex and that actual changes occur in the brain’s perception that do not occur when a suggestible person simply follows instructions.[22,23] PET also shows that hypnosis, through the midcingulate cortex modulating a large cortical network, actively decreases a person’s subjective and objective perception of and emotional response to pain.[24,25,26] Scans show that pain under hypnosis is not perceived, rather than simply being experienced with greater tolerance. Further illuminating how powerful hypnosis can be, PET shows that the right anterior cingulate cortex activates both when individuals hear sounds and when hearing sounds is suggested under hypnosis—but not when they simply imagine that they hear sounds.[8,28]
Functional magnetic resonance imaging studies show significant activity and connectivity involving the brain’s default mode network (DMN), as well as other areas, in hypnotized subjects.[29,30,31] The DMN, thought to generate spontaneous thoughts and to be essential for creativity, includes the medial temporal lobe, part of the medial prefrontal cortex, the posterior cingulated cortex, and the adjacent ventral precuneus and inferior parietal cortex.
Similarly, electroencephalography (EEG) demonstrates waveforms under hypnosis that cannot be evoked by waking imagination. When hypnosis is used for anesthesia, EEGs show that the pain relief differs from a simple placebo effect.[33, 34] Finally, as Braid recognized, hypnosis is not a form of sleep. Although relaxation often accompanies hypnotic induction, alert induction methods can also be used with similar effects.
Uses in EM and Emergency Medical Systems
Hypnosis has been sporadically discussed in the emergency medical literature, and is even rarer in the emergency medical systems (EMS)/wilderness medicine literature.[15,37,38,39,40,41,42,43,44] Hypnosis fulfills nearly all requisites of the ideal EM intervention; it is safe, fast, readily available, cost effective, uses minimal personnel and equipment, and has no risks. In addition, it can be used in any age group, including the elderly, with children aged 7 to 14 years old being particularly susceptible.[45,46,47] Men and women are equally hypnotizable. It also may decrease the cost of patient care.
Limited studies and case reports in ED, prehospital and resource-poor settings suggest many potential uses for hypnosis in EM.[6, 49] These mostly relate to analgesia, sedation, and anxiolysis during painful procedures.
Goldie, for example, reported successfully used hypnosis in hundreds of pediatric ED cases over a 2-month period, including incision and drainage, foreign-body removals, suturing, and fracture/dislocation reductions. Although he did not describe their overall success rate, in part because they did not try to put any patients into a sleep state other than those requiring orthopedic manipulation, they cited a series of 28 sequential orthopedic cases in which they used hypnosis as anesthesia. Hypnosis successfully achieved anesthesia in 26 cases; the other 2 were not fractures. During the second month, the ED group was comfortable enough with hypnosis that they used it with more than half of all children presenting with these complaints, and in 92% of suture cases. He noted that “the greatest number of successful applications of hypnosis would seem to be in those patients who come to the hospital, often for the first time, with an injury for which they feel immediate treatment is imperative”.
Case reports of successfully using hypnosis to reduce forearm fractures in four ED patients, ages 3 to 12 years old, and the reduction of major joint dislocations (shoulders and ankles) in six search-and-rescue patients in a wilderness setting, reinforce Goldie’s findings. The same hypnotic relaxation method, which takes only a few minutes, was used in both reports.[15, 37] This author subsequently used hypnosis for shoulder reductions for many years in the ED with great success.
Sampimon and Woodruff began using hypnosis near the end of World War II, due to a lack of sufficient anesthetics while in a hospital for prisoners of war. Beginning with relatively minor cases, they planned to use it in major surgery if they were successful. The war ended before they got very far. Nevertheless, they used hypnosis in 29 patients, producing “deep sleep” in 20; “superficial sleep” in 4; “suggestion only” in 2; and were unsuccessful in 3 patients. Of the unsuccessful cases, one, they later found, was too deaf to hear their instructions and the other two had eyesight insufficient for the “convergence method” of induction, which relies on vision. Using this method, the authors successfully extracted teeth, often more than one: “On being awakened, almost every patient expressed surprise at finding himself in the operating theatre and refused to believe that a tooth had been removed until he located the gap with his tongue.” Their other cases involved hand surgery, including a 40-year-old man with supporative tenosynovitis who “tolerated a 20-minute finger dissection with a tourniquet in place. He remained in a deep sleep. Due to a hypnotic suggestion, he did not recall the operation and had no postoperative pain.” The shortcoming in these cases was that most, but not all, patients were hypnotized once the day before the procedure and then just before the procedure.
A number of case reports demonstrate the use of hypnosis for analgesia and anxiolysis in the ED. Bierman reported four mixed cases that benefitted from hypnosis. Three older children had diffuse abrasions, a scalp laceration, and chronic asthma and a fear of needles. With the children remaining comfortably unaware, the wounds were cleansed, the laceration was closed without analgesia other than hypnosis, and two injections were delivered to the asthma patient without any awareness that he had received them. A 36-year-old man with recurrent shoulder dislocations was reduced without analgesia using hypnotic suggestion rather than manipulation.
Kohen described using hypnosis on five older children, from 8½ to 17 years old, admitted to the ED for lacerations, anxiety about a pelvic examination, vomiting from probable appendicitis, and acute asthma exacerbations. This resulted in decreased anxiety, cooperation, no emesis, and no pain on lidocaine injection.
Similarly, Deltito reported hypnosis was used in the ED for a patient with a painful hematoma that limited ambulation, another with severe ureteric colic in a patient who had previously required significant narcotic analgesia, and a woman with severe herpetic stomatitis that caused a lisp. All obtained significant relief: walking without pain, sleeping without narcotics, and no lisp. He was unable to hypnotize a 40-year-old inebriated patient with a corneal abrasion. Deltito also cites instances where he used hypnosis for acute pain management in cases “associated with orthopedic injuries, acute burns, corneal abrasions, abdominal distress, headaches, menstrual discomfort, renal calculi, herpetic lesions, muscle spasms, and dental syndromes”. Wain and Amen reported a child and an adult with exaggerated pain responses who became cooperative with diminished pain after hypnosis.
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