Imagery and Hypnosis in the Treatment of Cancer Patients

Introduction

Our customary medical approach to the mental and physical aspects of cancer and its progression has separated one from the other. We have failed to adequately address possible interactions between mind and body, except to see mental events as an afterthought. Yet, those ill 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.

Some "alternative" therapists have put forward the extreme and unproven view that mental events directly cause physical change. Thus, "imaging" a white blood cell killing a cancer cell is supposed to result in a comparable physical event. Many patients have been exhorted to practice imaging their immune system attacking cancer cells like PacMen gobbling up the "enemy."[1]

Despite the absence of any evidence that such exercises affect the course of cancer, these techniques are popular. Indeed, Americans spend more out-of-pocket dollars on alternative health care than on hospitalizations, some $13.7 billion dollars annually.[2] Furthermore, since 72% of patients do not tell their doctors that they are seeking alternative treatments, it behooves physicians to become familiar with the unconventional treatments that their patients are seeking.

Despite the apparent similarity among many seemingly related alternative techniques, their effects can vary. Hypnosis, for example, which has long been utilized in medical settings for the control of pain and anxiety, can be quite effective in improving patients' comfort and sense of control over their illness. It is as mistaken to dismiss all psychological techniques as being ineffective in helping patients adjust to their cancer as it is to claim that imaging can cure cancer.

Why Do Patients Seek Alternative Treatments?

Estimates of the prevalence of psychiatric disorders among newly diagnosed cancer patients has ranged from 30% to 44%.[3,4] As many as 80% of breast cancer patients report significant distress during initial treatment.[5,6] Although psychological distress tends to diminish over time,[7-11] as many as one-fifth of cancer patients remain psychiatrically distressed 6 months after initial therapy,[12] 20% to 45% exhibit emotional morbidity 1 to 2 years afterward,[9,13-15] and 10% have severe maladjustment as long as 6 years afterward.[15]

Thus, many cancer patients suffer from considerable anxiety and depression. Even those without such psychiatric symptoms struggle with the existential questions raised by the disease: fears of recurrence and death, pain, and treatment side effects.

Need to Exert Control Over the Illness

Many patients turn to imagery techniques to enhance their sense of control over an illness that makes them feel helpless. An internal sense of control over cancer can be thought of as a two-edged sword. On the one hand, in general, people associate mastery and positive coping with an inner sense of control. On the other hand, when confronted with a progressive and possibly fatal illness, a sense of inner control can be damaging by inducing self-blame for events over which one is, in fact, helpless.

Watson et al[16] distinguish control over the cause of an illness from control over its course. Utilizing a measure called the Cancer Locus of Control Scale, they found that high internal control over the course of the illness was associated with a "fighting spirit" with regard to the cancer. Earlier studies by this group and others have found that this attitude is associated with longer survival. In contrast, high internal control over the cause of the illness was found to be associated with anxious preoccupation about cancer. Thus, imagery techniques, while seemingly harmless enough, could have the effect of rendering people needlessly guilty about disease progression—viewing it as a personal failure rather than an inevitability.

Nonetheless, cancer patients are placed in the position of needing to reconstitute their relationship to their bodies. The diagnosis of cancer is often experienced as a betrayal: "I used to think of my body like a dog: come, sit, fetch. Now it won't do what I want it to," said one patient with metastatic breast cancer. Imaging techniques are one way to attempt to regain that lost influence over bodily sensation and function.[17,18]

Hypnosis

Definition

Hypnosis is a natural state of aroused, attentive focal concentration coupled with a relative suspension of peripheral awareness. This intensity of focus allows the hypnotized person to make maximal use of innate abilities to control perception, memory, and somatic function. Since the ability to experience hypnosis is a normal and widely distributed trait, and since entry into hypnotic states occurs spontaneously, hypnotic phenomena occur frequently. The alteration of consciousness that hypnotized individuals experience has a variety of therapeutic applications.

Hypnotic experience involves three main factors: absorption, dissociation, and suggestibility. Absorption is an immersion in a central experience at the expense of contextual orientation.[23-25] When one is intensely involved in a central object of consciousness, one tends to ignore perceptions, thoughts, memories, or motor activities at the periphery. Since hypnotized individuals are intensely absorbed in their trance experience, many routine experiences that would ordinarily be conscious occur out of conscious awareness. As a result, even rather complex emotional states or sensory experiences may be dissociated.

Suggestibility is enhanced in hypnosis. Because of their intense absorption in the trance experience, hypnotized individuals usually accept instructions relatively uncritically. Hypnotized individuals are not deprived of their will, but rather, have suspended the usual conscious editing function that raises the question, "Why?" when an instruction is given.

Hypnotic Analgesia

Pain is the ultimate psychosomatic phenomenon, always representing both tissue injury and the psychological reaction to it. The first formal study of hypnosis in pain occurred more than a century ago in India when a Scottish surgeon named Esdaile[26] reported that hypnosis was 80% effective in producing surgical anesthesia for amputations. He was immediately censured by his colleagues and 10 years later withdrew his findings when a report from Massachusetts General Hospital stated that ether anesthesia was 90% effective. Indeed, one of Boston surgeons strode to the front of the amphitheater and announced, "Gentlemen, this is no humbug!" to distinguish the use of ether from hypnosis.

Nonetheless, it is clear that psychological factors are major variables in the intensity of the pain experience. Ninety years later, also at Massachusetts General Hospital, Beecher[27] demonstrated that the intensity of pain was directly associated with its meaning. To the extent that pain represented a threat and the possibility of future disability, it was more intense than it was among a group of combat soldiers to whom the pain of injury meant that they were likely to get out of combat alive.

Behavioral approaches to pain control emphasize changing patterns of social reinforcement that are contingent on pain-related behavior. Pain is classified as primarily operant, ie, influenced by secondary gain, or respondent, ie, driven by a noxious physical stimulus. Respondent pain may gradually be transformed to operant pain as attention and sympathy reinforce pain behavior.

This process can be reversed by providing positive reinforcement for nonpain behavior. For example, nurses and family members can be trained to pay a great deal of attention to patients when they increase their activity level or converse about subjects other than their pain. Social contacts involving the pain itself, such as demands for medication, are best kept brief and formal. This approach can be quite helpful in increasing levels of physical activity and diminishing excessive analgesic medication use, especially in patients with chronic pain syndromes.

Hypnotic Techniques Used for Pain Control—Hypnosis facilitates alteration of the subjective experience of pain.[28] The techniques most often employed involve physical relaxation coupled with imagery that provides a substitute focus of attention for the painful sensation. Patients can be taught to develop a comfortable floating sensation, and highly hypnotizable individuals may simply imagine receiving an injection of a local anesthetic in the affected area, producing a sense of tingling numbness.

Some patients prefer to move the pain to another part of their body, or to develop a sensation of floating above their own body, creating distance between themselves and the painful sensation. More moderately hypnotizable patients often choose to focus on a change in temperature, either warmth or coolness, imagining that they are floating in a warm bath or a cool mountain stream or immersing a painful hand in a bucket of ice chips. The effectiveness of temperature metaphors may be related to the fact that pain and temperature fibers run together in the lateral spinothalamic tract, separate from other sensory fibers. Less hypnotizable patients may benefit from distraction techniques in which they concentrate hard on sensations in other parts of their body.

General Principles—Regardless of the metaphor selected, certain general principles can be employed with all uses of hypnosis for pain control: The first principle involves teaching patients to "filter the hurt out of the pain." They learn to transform the pain experience by acknowledging that even though it may exist, there is a distinction between the signal itself and the discomfort that the signal causes. The hypnotic metaphor helps them transform the signal into one that is less uncomfortable.

Second, patients are taught to expand the perceptual options available to them. Rather than viewing a pain experience from only one of two perspectives—either the pain is there or it is not—they are able to perceive a third option; namely, that the pain is there but is transformed by the presence of such competing sensations as tingling, numbness, warmth, or coolness.

Third, patients are taught to not fight the pain. Fighting pain only enhances it by focusing attention on it, intensifying related anxiety and depression, and increasing physical tension, which can literally put traction on painful parts of the body and amplify the pain signals generated peripherally.

For example, a world-class competitive swimmer had collapsed in an alley as a result of hemorrhage of an undiagnosed lymphoma in his abdomen. During his chemotherapy, he lay writhing in bed, screaming and demanding increasing amounts of analgesic medication, even though he was on high doses of opiates. He would literally "climb the walls" in pain.

He was found to be moderately hypnotizable, and was taught a self-hypnosis exercise that involved his imagining that he was somewhere else he preferred to be. "I'm a great swimmer, but I've never surfed," he said. "Good, let's go to Hawaii," I suggested. He continued to wince, but with a different tone in his voice. "What happened?" I asked. "I fell off the surfboard," he responded. "This time, do it right," I replied. He did this self-hypnosis exercise regularly, and 48 hours later was off all pain medications, joking with the nurses in the hallway.

For children undergoing painful procedures, the main focus is on imagery rather than relaxation, since they are highly hypnotizable and become easily absorbed in the images. Some children find it helpful to play in an imaginary baseball game, picture themselves going to another room in the house, or watching a favorite TV show. This enables them to restructure their experience and dissociate themselves psychologically from the pain and fear of the procedure[29-32] It is also helpful to have parents assist and to go through several rehearsals of the procedure so that the children do not encounter anything unfamiliar.

Mechanisms—Hypnotic analgesia seems to work via two mechanisms: physical relaxation and attention control.[28,29,33] Patients in pain tend to immobilize the painful area instinctively, and yet this enhanced muscle tension around a painful region often increases the pain. Most patients find that they can enhance their physical repose by focusing on a variety of images that connote physical relaxation, such as a sense of floating.

Second, and probably more important, since hypnosis involves an intensification and narrowing of the focus of attention, it allows individuals to place pain at the periphery of their awareness by replacing it with some competing metaphor or sensation at the center of their attention. Thus, by focusing on a memory of dental anesthesia and spreading that numbness to the affected area, making the area warmer or cooler, substituting a sense of tingling or lightness, or focusing on sensation in some nonpainful part of the body, hypnotized individuals can diminish the attention that they pay to painful stimuli.

There is recent evidence that hypnotic alteration of perception results in altered amplitude of the event-related potentials to somatosensory[34] or visual[35] stimuli. When hypnotized individuals imagine that a stimulus is blocked, their cortical response to those stimuli is reduced. Indeed, recent research indicates specific involvement of the left occipital cortex, a brain region strongly involved in image generation, in this hypnotic effect.[36]

Efficacy Studies—Whatever the mechanism, hypnotic analgesia is efficacious. Recent systematic studies have demonstrated that hypnosis provides superior analgesia to a control condition of sympathetic attention alone in children undergoing painful procedures.[30] Furthermore, in a randomized prospective study, a combination of hypnosis and group psychotherapy was shown to result in a 50% reduction in pain among patients with metastatic breast cancer,[37] along with a corresponding reduction in mood disturbance.[38]

Hypnotic analgesia has also been shown to be more potent than either placebo analgesia[39] or acupuncture analgesia,[40] although there is a correlation between hypnotizability and responsiveness to acupuncture.[41] Thus, hypnotic mechanisms of pain control may be mobilized by other treatment techniques, but the explicit use of hypnosis in hypnotizable patients has proved to be a more powerful means of controlling pain.

In a review of studies, Hilgard and Hilgard[29] estimated a 0.5 correlation between hypnotizability and treatment responsiveness for pain control. More recent studies have confirmed the importance of hypnotic capacity in the successful use of this technique for pain control.[42] The ability of hypnotizable individuals to focus their attention and alter their response to perception while at the same time producing a physical state of relaxation gives them an unusual ability to restructure their pain experience and thereby develop a sense of mastery over it. Since the pain experience is both psychological and physical, the technique mobilizes and focuses cognitive experience while producing a sense of physical relaxation. It can be especially helpful in giving patients a sense of mastery. After all, the strain in pain lies mainly in the brain.

Many therapeutic approaches using hypnosis involve changing the patient's perspective of the relationship between his or her psychological and physical state, dissociating mental from physical stress, adopting a stance of protectiveness toward his or her body rather than fighting destructive urges, or learning to see sudden discontinuities in consciousness as understandable and controllable hypnotic phenomena. An alteration in consciousness that has long been associated with a mythology of losing control can actually be mobilized as a powerful therapeutic tool in enhancing patients' control over their behavior, perceptions, somatic functions, and cognition.[19]