Center on Stress and Health

Dissociation, and Stress and Trauma

Butler, L. D., B. K. Symons, S. L. Henderson, L. D. Shortliffe and D. Spiegel (2005). "Hypnosis reduces distress and duration of an invasive medical procedure for children." Pediatrics 115(1): e77-85.
OBJECTIVE: Voiding cystourethrography (VCUG) is a commonly performed radiologic procedure in children that can be both painful and frightening. Given the distress that some children experience during the VCUG and the need for children to be alert and cooperative during the procedure, finding a psychological intervention that helps children to manage anxiety, distress, and pain is clearly desirable. This study was designed to examine whether relaxation and analgesia facilitated with hypnosis could reduce distress and procedure time for children who undergo this procedure. METHODS: Forty-four children who were scheduled for an upcoming VCUG were randomized to receive hypnosis (n = 21) or routine care (n = 23) while undergoing the procedure. The sample consisted of 29 (66%) girls and 15 (34%) boys with a mean age of 7.6 years (SD: 2.5; range: 4-15 years). Ethnic/racial backgrounds were 72.7% white, 18.2% Asian, 4.5% Latino, 2.3% black, and 2.3% Filipino. The mean number of previous VCUGs was 2.95 (SD: 2.51; mode: 2; range: 1-15). Potential participants were identified through computerized hospital records of upcoming VCUGs. Parents were contacted by telephone and invited to participate if their child was eligible. To be eligible for the study, the child must have undergone at least 1 previous VCUG, been at least 4 years of age at that time, and experienced distress during that procedure, and both the child and the participating parent had to be English speaking. Each eligible child and parent met with the research assistant (RA) before the day of the scheduled procedure for an initial assessment. Children were queried regarding the degree of crying, fear, and pain that they had experienced during their most recent VCUG. Parents completed a series of parallel questions. Immediately after this assessment, those who were randomized to the hypnosis condition were given a 1-hour training session in self-hypnotic visual imagery by a trained therapist. Parents and children were instructed to practice using the imaginative self-hypnosis procedure several times a day in preparation for the upcoming procedure. The therapist was also present during the procedure to conduct similar exercises with the child. The majority (83%) of those who were randomized to the routine care control group chose to participate in a hospital-provided recreation therapy program (offered as part of routine care). The program includes demonstration of the procedure with dolls, relaxation and breath work training, and assistance during the procedure. On the day of the VCUG, the RA met the family at the clinic before the procedure, and both the child and the parent rated the child's present level of fearfulness. During the procedure, the RA recorded observational ratings of the child's emotional tone and behavior and timed the overall procedure and its phases. Immediately after the VCUG, the child was asked how much crying, fear, and pain he or she had experienced during the procedure; the parent rated the child's experience on the same dimensions and also how traumatic the procedure had been (both generally and compared with their previous one), and the medical staff rated the degree of procedural difficulty. Outcomes included child reports of distress during the procedure, parent reports of how traumatic the present VCUG was compared with the previous one, observer ratings of distress during the procedure, medical staff reports of the difficulty of the procedure overall, and total procedural time. RESULTS: Results indicate significant benefits for the hypnosis group compared with the routine care group in the following 4 areas: (1) parents of children in the hypnosis group compared with those in the routine care group reported that the procedure was significantly less traumatic for their children compared with their previous VCUG procedure; (2) observational ratings of typical distress levels during the procedure were significantly lower for children in the hypnosis condition compared with those in the routine care condition; (3) medical staff reported a significant difference between groups in the overall difficulty of conducting the procedure, with less difficulty reported for the hypnosis group; and (4) total procedural time was significantly shorter-by almost 14 minutes-for the hypnosis group compared with the routine care group. Moderate to large effect sizes were obtained on each of these 4 outcomes. CONCLUSIONS: Hypnotic relaxation may provide a systematic method for improving the overall medical care of children with urinary tract abnormalities and may be beneficial for children who undergo other invasive medical procedures. Because the VCUG is an essential part of the evaluation of urinary tract infections and vesicoureteral reflux in children, lower distress during the procedure may improve patient and family compliance with initial as well as follow-up evaluations. These findings augment the accumulating literature demonstrating the benefits of using hypnosis to reduce distress in the pediatric setting. The present findings are noteworthy in that this study was a controlled, randomized trial conducted in a naturalistic medical setting. In this context, we achieved a convergence of subjective and objective outcomes with moderate to large effect sizes, including those that may have an impact on patient care and procedure cost, that were consistently supportive of the beneficial effects of hypnosis-a noninvasive intervention with minimal risk. The findings, therefore, have immediate implications for pediatric care. Limitations of this study include the lack of participant and staff blindness to the child's condition assignment, which could have introduced bias into reports. However, the objective procedural time differences between groups were consistent with the other, more subjective outcome findings. The sample was also small and primarily white in ethnic/racial makeup, which may have restricted our ability to detect some differences and may limit the generalizability of findings to more representative samples. In addition, the sample comprised children who had already undergone at least 1 VCUG during which they had had difficulty. Consequently, additional research is needed to determine whether hypnosis would be helpful to those who are undergoing their first VCUG. Additional limitations, clinical observations, and directions for future research are also discussed.

Spiegel, D. and R. Moore (1997). "Imagery and hypnosis in the treatment of cancer patients." Oncology (Williston Park) 11(8): 1179-89; discussion 1189-95.
Many patients with cancer often seek some means of connecting their mental activity with the unwelcome events occurring in their bodies, via techniques such as imagery and hypnosis. Hypnosis has been shown to be an effective method for controlling cancer pain. The techniques most often employed involve physical relaxation coupled with imagery that provides a substitute focus of attention for the painful sensation. Other related imagery techniques, such as guided imagery, involve attention to internally generated mental images without the formal use of hypnosis. The most well-known of these techniques involves the use of "positive mental images" of a strong army of white blood cells killing cancer cells. Despite claims to the contrary, no reliable evidence has shown that this technique affects disease progression or survival. Studies evaluating more broadly defined forms psychosocial support have come to conflicting conclusions about whether or not these interventions affect survival of cancer patients. However, 10-year follow-up of a randomized trial involving 86 women with cancer showed that a year of weekly "supportive/expressive" group therapy significantly increased survival duration and time from recurrence to death. This intervention encourages patients to express and deal with strong emotions and also focuses on clarifying doctor-patient communication. Numerous other studies suggest that suppression of negative affect, excessive conformity, severe stress, and lack of social support predict a poorer medical outcome from cancer. Thus, further investigation into the interaction between body and mind in coping with cancer is warranted.

Butler, L. D., R. E. Duran, P. Jasiukaitis, C. Koopman and D. Spiegel (1996). "Hypnotizability and traumatic experience: a diathesis-stress model of dissociative symptomatology." Am J Psychiatry 153(7 Suppl): 42-63.
OBJECTIVE: The authors propose a diathesis-stress model to describe how pathological dissociation may arise from an interaction between innate hypnotizability and traumatic experience. METHOD: To support the proposition that pathological dissociation may reflect autohypnotic process, the authors highlight clinical and research data indicating parallels between controlled hypnotic dissociative states and uncontrolled pathological dissociative symptoms and summarize evidence of hypnotizability in persons with psychiatric disorders that manifest these symptoms. The authors present this evidence by examining dissociative symptomatology in four psychological domains: perception, behavior and will, affect, and memory and identity. In addition, modern cognitive and neuropsychological models of dissociation are briefly reviewed. RESULTS: Several lines of evidence converge in support of the role of autohypnosis in pathological dissociation. There is considerable evidence that controlled formal hypnosis can produce a variety of dissociations of awareness and control that resemble many of the symptoms in uncontrolled pathological dissociative conditions; and it is possible to discern in dissociative pathology the features of absorption, dissociation, and suggestibility/automaticity that characterize formal hypnotic states. There is also accumulating evidence of high levels of hypnotic capacity in all groups with dissociative symptomatology that have been systematically assessed. In addition, the widespread and successful therapeutic use of hypnosis in the treatment of many dissociative symptoms and conditions (and the potential for hypnosis to induce dissociative symptomatology) also supports the assumption that hypnosis and pathological dissociation share an underlying process. CONCLUSIONS: High hypnotizability may be a diathesis for pathological dissociative states, particularly under conditions of acute traumatic stress.

van der Hart, O. and D. Spiegel (1993). "Hypnotic assessment and treatment of trauma-induced psychoses: the early psychotherapy of H. Breukink and modern views." Int J Clin Exp Hypn 41(3): 191-209.
The role of hypnotizability assessment in the differential diagnosis of psychotic patients is still unresolved. In this article, the pioneering work of Dutch psychiatrist H. Breukink (1860-1928) during the 1920s is used as early evidence that hypnotic capacity is clinically helpful in differentiating highly hypnotizable psychotic patients with dissociative symptomatology from schizophrenics. Furthermore, there is a long tradition of employing hypnotic capacity in the treatment of these dissociative psychoses. The ways in which Breukink used hypnosis for diagnostic, prognostic, and treatment purposes are summarized and discussed in light of both old and current views. He felt that hysterical psychosis was trauma-induced, certainly curable, and that psychotherapy using hypnosis was the treatment of choice. Hypnosis was used for symptom-oriented therapy, as a comfortable and supportive mental state, and for the uncovering and integrating of traumatic memories. For the latter purpose, Breukink emphasized a calm mental state, both in hypnosis and in the waking state, thereby discouraging emotional expression, which he considered dangerous in psychotic patients. In the discussion, special attention is paid to the role and dangers of the expression of trauma-related emotions.

Spiegel, D. (1992). "The use of hypnosis in the treatment of PTSD." Psychiatr Med 10(4): 21-30.

Spiegel, D. and F. Cardena (1991). "Comments on hypnotizability and dissociation." Am J Psychiatry 148(6): 813-5.

Spiegel, D. and E. Cardena (1990). "New uses of hypnosis in the treatment of posttraumatic stress disorder." J Clin Psychiatry 51 Suppl: 39-43; discussion 44-6.
Hypnosis is associated with the treatment of posttraumatic stress disorder (PTSD) for two reasons: (1) the similarity between hypnotic phenomena and the symptoms of PTSD, and (2) the utility of hypnosis as a tool in treatment. Physical trauma produces a sudden discontinuity in cognitive and emotional experience that often persists after the trauma is over. This results in symptoms such as psychogenic amnesia, intrusive reliving of the event as if it were recurring, numbing of responsiveness, and hypersensitivity to stimuli. Two studies have shown that Vietnam veterans with PTSD have higher than normal hypnotizability scores on standardized tests. Likewise, a history of physical abuse in childhood has been shown to be strongly associated with dissociative symptoms later in life. Furthermore, dissociative symptoms during and soon after traumatic experience predict later PTSD. Formal hypnotic procedures are especially helpful because this population is highly hypnotizable. Hypnosis provides controlled access to memories that may otherwise be kept out of consciousness. New uses of hypnosis in the psychotherapy of PTSD victims involve coupling access to the dissociated traumatic memories with positive restructuring of those memories. Hypnosis can be used to help patients face and bear a traumatic experience by embedding it in a new context, acknowledging helplessness during the event, and yet linking that experience with remoralizing memories such as efforts at self-protection, shared affection with friends who were killed, or the ability to control the environment at other times. In this way, hypnosis can be used to provide controlled access to memories that are then placed into a broader perspective. Patients can be taught self-hypnosis techniques that allow them to work through traumatic memories and thereby reduce spontaneous unbidden intrusive recollections.

Spiegel, D. (1989). "Hypnosis in the treatment of victims of sexual abuse." Psychiatr Clin North Am 12(2): 295-305.
The relevance of hypnosis to the treatment of sexual assault derives from two sources: the fact that hypnotic phenomena are mobilized spontaneously as defenses during assault, becoming part of the syndrome of posttraumatic stress disorder (PTSD) and the usefulness of formal hypnosis in treating PTSD. The role of dissociative defenses during and after traumatic experiences is reviewed; an analogy between the major elements of formally-induced hypnosis--absorption, dissociation, and suggestibility, and the major elements of PTSD--is drawn. Special problems relevant to sexual assault in childhood are discussed, including extreme self-blame and a profound sense of personality fragmentation. Uses of hypnosis in the treatment of sexual assault victims are reviewed, with an emphasis on helping such patients restructure their memories of the experience, both by reviewing them with greater control over their physical sense of comfort and safety and by balancing painful memories with recognition of their efforts to protect themselves or someone else who was endangered. The use of a split-screen technique in hypnosis is described with a clinical example. Special considerations in such treatment, including the traumatic transference and forensic complications of such psychotherapeutic work, are enumerated.

Spiegel, D. (1988). "Commentary. The treatment accorded those who treat patients with multiple personality disorder." J Nerv Ment Dis 176(9): 535-6.

Spiegel, D., T. Hunt and H. E. Dondershine (1988). "Dissociation and hypnotizability in posttraumatic stress disorder." Am J Psychiatry 145(3): 301-5.
The authors compared the hypnotizability of 65 Vietnam veteran patients with posttraumatic stress disorder (PTSD) to that of a normal control group and four patient samples using the Hypnotic Induction Profile. The patients with PTSD had significantly higher hypnotizability scores than patients with diagnoses of schizophrenia (N = 23); major depression, bipolar disorder--depressed, and dysthymic disorder (N = 56); and generalized anxiety disorder (N = 18) and the control sample (N = 83). This finding supports the hypothesis that dissociative phenomena are mobilized as defenses both during and after traumatic experiences. The literature suggests that spontaneous dissociation, imagery, and hypnotizability are important components of PTSD symptoms.

Spiegel, D. (1984). "Multiple personality as a post-traumatic stress disorder." Psychiatr Clin North Am 7(1): 101-10.
This article examines multiple or dissociative personality syndrome as a multiple post-traumatic stress disorder, discussing these patient's developmental histories, their high hypnotizability, and their profound capacity to dissociate spontaneously to protect themselves from emotional and physical pain.

Spiegel, D. and J. R. Bloom (1983). "Group therapy and hypnosis reduce metastatic breast carcinoma pain." Psychosom Med 45(4): 333-9.
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 = 2.5 p less than 0.02) and suffering (t = 2.17, p less than 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 less than 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.

Spiegel, D. (1981). "Vietnam grief work using hypnosis." Am J Clin Hypn 24(1): 33-40.

Spiegel, D. and R. A. Chase (1980). "The treatment of contractures of the hand using self-hypnosis." J Hand Surg [Am] 5(5): 428-32.
The successful treatment of a man with severe posttraumatic contractures of the hand using a combined psychological and physical rehabilitation approach is reported. The contractures had functional and organic components, as did the treatment, which involved teaching the patient self-hypnosis exercises and the use of a splint. The patient obtained virtually complete return of movement after 3 1/2 years of total disability. The importance of identifying and mobilizing rather than challenging the patient's motivation for recovery using a rehabilitation approach is discussed. Hypnosis can facilitate recovery in such psychosomatic disorders in patients with the requisite hypnotic capacity and motivation.

Spiegel, D. and R. Fink (1979). "Hysterical psychosis and hypnotizability." Am J Psychiatry 136(6): 777-81.
The very existence of hysterical psychosis as a diagnostic entity has been questioned as part of the general difficulty in defining both hysteria and psychosis. However, several recent investigations have documented a syndrome that usually involves brief and intense periods of psychotic behavior, generally with graphic decompensation, severe environmental stress, and rapid recompensation, in individuals with other hysterical features. The authors assert that such a syndrome does exist as a clinical entity and that the differential diagnosis can be facilitated by using a standardized measure of hypnotic trance capacity. They hypothesize that patients with hysterical psychosis are highly hypnotizable, while those who are schizophrenic and psychotic have low hypnotizability. The authors review the literature and present two case examples.

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