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Imagery and Hypnosis in the Treatment of Cancer Patients

Imagery and Hypnosis in the Treatment of Cancer Patients

ABSTRACT: 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. [ONCOLOGY 11(8):1179-1195, 1997]

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]

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