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Mark P. Jensen, Ph.D. University of Washington, Seattle, WA, USA
Hypnosis for Chronic Pain Management:
Efficacy and Mechanisms
Plenary talk presented at the 6th Congrés International, Hypnose & Douleur
St. Malo, France, 5 May, 2016
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Overview - Chronic pain is a significant
problem - Hypnosis is effective by itself - Hypnosis enhances the efficacy
of other (pain) treatments - Discuss possible mechanisms
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The problem of chronic pain
15% - 20% (Blyth et al., 2001; Sjogren et al. 2008; Verhaak et al., 1998)
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The problem of chronic pain
5% - 7% (Gerdle et al., 2008)
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The problem of chronic pain
3% - 8% (Gustorff et al., 2008)
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The problem of chronic pain
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The problem of chronic pain
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The problem of chronic pain
Average pain reduction for opioids?
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The problem of chronic pain
Average pain reduction for opioids? 32%
~ Turk, 2002
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The problem of chronic pain
Median response rate for neuropathic pain?
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The problem of chronic pain
Median response rate for neuropathic pain? 35%
~ McQuay et al., 1996
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The problem of chronic pain
à There is a need to develop new effective pain interventions
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Maybe hypnosis?
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Themes/hypotheses underlying program
à Peripheral activity may trigger pain,
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Themes/hypotheses underlying program
à Peripheral activity may trigger pain, but it is the brain that creates the experience of pain
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Themes/hypotheses underlying program
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Hypnotic pain
Derbyshire et al., 2004 - Can one use hypnosis to induce pain? - Does “hypnotic pain” differ from
imagined pain” and “real” pain? - Intensity and cortical activity in
response to painful heat, hypnotic pain, & “imagined pain”.
Derbyshire, S.W.G., Whalley, M.G., Stenger, V.A., & Oakley, D.A. (2004). Cerebral activation during hypnotically induced and imagined pain. NeuroImage, 23, 392-401.
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Hypnotic pain
Effect on pain experience: - Stimulation: 5.7/10 (3-10)
- Hypnotic pain: 2.8/10 (1-9) - Imagined pain: 0/10 (0)
- Response to stimulation and hypnosis was variable
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Hypnotic pain
Derbyshire et al. (2004). Cerebral activation during hypnotically induced and imagined pain. Neuroimage, 23, 392-401.
ACC
Sensory Cor.
Insula
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The evidence indicates that…
- Brain is final common pathway to experience
- Hypnosis can enhance ability to alter experience
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Clinical trial
RCT of Self-Hypnosis Training versus EMG-biofeedback for SCI-related chronic pain
Funded by NIH, NICHD, NCMRR Questions: - What percent of patients benefit? - Do benefits last beyond the sessions? - Is self-hypnosis training more effective than a viable alternative treatment?
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Procedures
N = 37 patients with SCI and chronic pain assigned to hypnosis (HYP) or EMG-assisted relaxation (BIO).
10 sessions of treatment Outcome assessed before and after
treatment, and at 3-month follow-up
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Study participants
Mean age = 49.5 yrs (Range, 19 – 70) 76% males, 24% females 95% Caucasian, 5% Native American 45% Neuropathic pain; 55%
Nonneuropathic pain 28 (76%) completed treatment (5 HYP and
4 BIO dropouts)
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Primary outcome measure
Usual pain intensity - Rating of average (past 24 hours) intensity on 0-10 scale four times in 7 days. - At pre-baseline, post-baseline, post-treatment, and 3-month follow-up. - 4 ratings averaged into single score, range from 0-10. - Assessed by phone by blind RA.
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Secondary outcome measures
Current pain intensity before and after session: 0 – 10 Numerical Rating Scale (NRS).
Frequency and effects of practice (for those in HYP): Number of days of practice and relief on a 0-10 NRS.
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Self-Hypnosis training intervention
Induction: variant of Barber’s Rapid Induction Analgesia. “Special Place” imagery: A safe and comfortable place. Decreased unpleasantness: “You can experience being less and less bothered by any sensations…” Diminished pain: “Any sensations are becoming less and less clear, getting smaller and smaller…” Imagined anesthesia: “Picture any areas of discomfort being
engulfed and infused with a powerful psychological anesthesia…”
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Self-Hypnosis training intervention
Sensory substitution: “Notice feelings like numbness or warmth in areas that used to be uncomfortable…” Deep relaxation: “Imagine your right hand becoming more and more relaxed, heavier and heavier…” Post-hypnotic suggestions: Self-hypnosis: “Any time you’d like to feel more comfortable, take a deep, satisfying breath…” Extension of effects: “Benefit will stay with you…become a part of who you are…” Practice: Given practice tape, and encouraged to practice at least daily.
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EMG-Assisted Biofeedback Frontalis EMG-biofeedback to reduce
frontalis activity. Patients given a relaxation audio recording Both treatments described as
“Interventions that contain both relaxation and hypnosis components that have been shown to reduce pain in other populations”
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Results: Pre- to post-session pain
0
1
2
3
4
5
Pre-session Post-session
HYPBIO
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Results: Usual pain intensity
0
1
2
3
4
5
6
7
Pre-Tx Post-Tx 3-mo
HYPBIO
p < .05
p = NS
p = NS
p = NS
Responders: 22% HYP; 10% BIO
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Results: Practice frequency and effects
Of the HYP participants @ 3 -mo: 60% still listened to the audio recording
(Range, 2-25 days) 80% used skills w/o recording (range, 2-30
days) Average relief w/ recording: 3.58; w/o: 3.44 Average hours of relief w/ recording: 3.07; w/
o: 1.42
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Conclusions
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Conclusions Both HYP and BIO have a similar immediate
(substantial) effect on pain intensity
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Conclusions Both HYP and BIO have a similar immediate
(substantial) effect on pain intensity HYP more effective than BIO for daily average pain
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Conclusions Both HYP and BIO have a similar immediate
(substantial) effect on pain intensity HYP more effective than BIO for daily average pain Decreases in usual daily pain with HYP maintain for
at least 3 months
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Conclusions Both HYP and BIO have a similar immediate
(substantial) effect on pain intensity HYP more effective than BIO for daily average pain Decreases in usual daily pain with HYP maintain for
at least 3 months Treatment outcome is variable: Not all benefit
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Conclusions Both HYP and BIO have a similar immediate
(substantial) effect on pain intensity HYP more effective than BIO for daily average pain Decreases in usual daily pain with HYP maintain for
at least 3 months Treatment outcome is variable: Not all benefit But, 80% continue to use skills taught at 3 months,
and report pain relief that lasts 1.5 – 3.5 hours
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Conclusions Both HYP and BIO have a similar immediate
(substantial) effect on pain intensity HYP more effective than BIO for daily average pain Decreases in usual daily pain with HYP maintain for
at least 3 months Treatment outcome is variable: Not all benefit 80% continue to use skills taught at 3 months, and
report pain relief that lasts 1.5 – 3.5 hours
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MS trial (HYP vs. PMR; N = 22)
0
1
2
3
4
5
6
Pre-Tx Post-Tx
HYPPMR
Responders: 47% HYP; 14% PMR
0
1
2
3
4
5
6
Pre-Tx Post-Tx
HYPPMR
Pain Intensity Pain Interference
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“Side effects” of hypnotic analgesia
Asked 30 patients who had received the HYP protocol about the “other effects” of treatment:
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“Side effects” of hypnotic analgesia
Asked 30 patients who had received the HYP protocol about the “other effects” of treatment:
- 40 effects listed
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“Side effects” of hypnotic analgesia
Asked 30 patients who had received the HYP protocol about the “other effects” of treatment:
- 40 effects listed - 9 (23%) pain-related benefits
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“Side effects” of hypnotic analgesia
Asked 30 patients who had received the HYP protocol about the “other effects” of treatment:
- 40 effects listed - 9 (23%) pain-related benefits - 23 (58%) nonpain-related benefits
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“Side effects” of hypnotic analgesia
Asked 30 patients who had received the HYP protocol about the “other effects” of treatment:
- 40 effects listed - 9 (23%) pain-related benefits - 23 (58%) nonpain-related benefits - 5 (13%) ‘neutral’ effects
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“Side effects” of hypnotic analgesia
Asked 30 patients who had received the HYP protocol about the “other effects” of treatment:
- 40 effects listed - 9 (23%) pain-related benefits - 23 (58%) nonpain-related benefits - 5 (13%) ‘neutral’ effects - 3 (8%) ‘negative’ effects
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Pain-related benefits
Pain reduction (40%) Increased control over pain
(40%) “I have a new tool for
managing pain” (30%)
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Nonpain-related benefits
General positive comments (e.g., “It helped”, “I liked it”): 37%
Increased well-being: 33% Increased relaxation: 23% Decreased stress: 17%
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Negative effects
“It did not work” (3%) “Not as effective as I hoped
it would be” (3%) “Effects did not last as long
as I hoped” (3%)
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Imagine a Drug That…
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Imagine a Drug That… Produces a substantial ↓ in pain in 22% (SCI) to
47% (MS) of patients w/ chronic refractory pain
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Imagine a Drug That… Produces a substantial ↓ in pain in 22% (SCI) to
47% (MS) of patients w/ chronic refractory pain Whose “side effects” are mostly positive, and
include ↑’d sense of well-being and relaxation
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Imagine a Drug That… Produces a substantial ↓ in pain in 22% (SCI) to
47% (MS) of patients w/ chronic refractory pain Whose “side effects” are mostly positive, and
include ↑’d sense of well-being and relaxation Whose worst side effects are: has no effect (3%),
not as effective as hoped (3%), or benefits do not last as long as hoped (3%)
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Imagine a Drug That… Produces a substantial ↓ in pain in 22% (SCI) to
47% (MS) of patients w/ chronic refractory pain Whose “side effects” are mostly positive, and
include ↑’d sense of well-being and relaxation Whose worst side effects are: has no effect (3%),
not as effective as hoped (3%), or benefits do not last as long as hoped (3%)
That continues to be effective (no tolerance) and that most patients (80%) continue to use…
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Reviews of Randomized Trials
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Reviews of Randomized Trials Findings consistent; reviews have the
conclusions (Elkins et al., 2007; Montgomery et al., 2000; Jensen & Patterson, 2005; Patterson & Jensen, 2003)
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Reviews of Randomized Trials Findings consistent; reviews have the
conclusions (Elkins et al., 2007; Montgomery et al., 2000; Jensen & Patterson, 2005; Patterson & Jensen, 2003)
Hypnotic analgesia more effective than no treatment and some biomedical treatments (PT, medications)
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Reviews of Randomized Trials Findings consistent; reviews have the
conclusions (Elkins et al., 2007; Montgomery et al., 2000; Jensen & Patterson, 2005; Patterson & Jensen, 2003)
Hypnotic analgesia more effective than no treatment and some biomedical treatments (PT, medications)
Hypnotic analgesia has specific effects over and above placebo (expectancy) effects
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Reviews of Randomized Trials Findings consistent; reviews have the
conclusions (Elkins et al., 2007; Montgomery et al., 2000; Jensen & Patterson, 2005; Patterson & Jensen, 2003)
Hypnotic analgesia more effective than no treatment and some biomedical treatments (PT, medications)
Hypnotic analgesia has specific effects over and above placebo (expectancy) effects
Response to hypnotic treatment is variable
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Reviews of Randomized Trials Findings consistent; reviews have the
conclusions (Elkins et al., 2007; Montgomery et al., 2000; Jensen & Patterson, 2005; Patterson & Jensen, 2003)
Hypnotic analgesia more effective than no treatment and some biomedical treatments (PT, medications)
Hypnotic analgesia has specific effects over and above placebo (expectancy) effects
Response to hypnotic treatment is variable
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Adding hypnosis to other treatments may
also enhance their efficacy
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Hypnosis may enhance CBT
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- Meta-analysis of 18 studies comparing CBT with CBT+HYP
Hypnosis may enhance CBT
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- Meta-analysis of 18 studies comparing CBT with CBT+HYP
- Hypnosis substantially enhanced outcome (average ES = 1.36)
Hypnosis may enhance CBT
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- Meta-analysis of 18 studies comparing CBT with CBT+HYP
- Hypnosis substantially enhanced outcome (average ES = 1.36)
- Effects strongest for treatments of obesity and for long-term f/u
Hypnosis may enhance CBT
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Hypnosis may enhance CBT
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Hypnosis may enhance CBT
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- Pilot study - 4 sessions of ED, CT, HYP, HYP-CT - N = 16 MS and chronic pain - Measured intensity (0-10),
interference (BPI), and catastrophizing (PCI) before and after each module
Hypnosis may enhance CBT
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Average Pain Intensity
Pre Post
.04
Hypnosis may enhance CBT
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Average Pain Intensity
Pre Post
.04
.23
Hypnosis may enhance CBT
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Average Pain Intensity
Pre Post
.04
.23
.56
Hypnosis may enhance CBT
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Average Pain Intensity
Pre Post
.04
.23
.56
.97
Hypnosis may enhance CBT
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Average Pain Intensity
Pre Post
.04
.23
.56
.97
*
*
*
Hypnosis may enhance CBT
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Pain Interference
Pre Post Post
-.03
Hypnosis may enhance CBT
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Pain Interference
Pre Post
-.03
.11
Hypnosis may enhance CBT
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Pain Interference
Pre Post
-.03
.11 .16
Hypnosis may enhance CBT
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Pain Interference
Pre Post
-.03
.11 .16
.46
*
Hypnosis may enhance CBT
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Catastrophizing
Pre Post Post
.19
Hypnosis may enhance CBT
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Catastrophizing
Pre Post Post
.19
.27
Hypnosis may enhance CBT
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Catastrophizing
Pre Post Post
.19
.27
.45
Hypnosis may enhance CBT
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Catastrophizing
Pre Post Post
.19
.27
.45
.61
*
Hypnosis may enhance CBT
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- Ongoing 4-arm RCT
Hypnosis may enhance CBT
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- Ongoing 4-arm RCT - SCI (43), MS (15), MD (3), AMP (1)
Hypnosis may enhance CBT
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- Ongoing 4-arm RCT - SCI (43), MS (15), MD (3), AMP (1) - 4 sessions: ED, CT, HYP, HYP-CT
Hypnosis may enhance CBT
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- Ongoing 4-arm RCT - SCI (43), MS (15), MD (3), AMP (1) - 4 sessions: ED, CT, HYP, HYP-CT - Measure intensity (0-10), depression
(PHQ-9), and interference (BPI), before and after treatment
Hypnosis may enhance CBT
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- Ongoing 4-arm RCT - SCI (43), MS (15), MD (3), AMP (1) - 4 sessions: ED, CT, HYP, HYP-CT - Measure intensity (0-10), depression
(PHQ-9), and interference (BPI), before and after treatment
- RA blind to treatment condition
Hypnosis may enhance CBT
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Average Pain Intensity (0-10 NRS)
Hypnosis may enhance CBT
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Average Pain Intensity (0-10 NRS)
Hypnosis may enhance CBT
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Average Pain Intensity (0-10 NRS)
Hypnosis may enhance CBT
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Average Pain Intensity (0-10 NRS)
Hypnosis may enhance CBT
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Average Pain Intensity (0-10 NRS)
Hypnosis may enhance CBT
* * †
* < .05, † = .066
Effect sizes: ED, d = .73 CT, d = .60 HYP, d = .54 H-CT, d = 1.00
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Average Pain interference (BPI)
Hypnosis may enhance CBT
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Average Pain interference (BPI)
Hypnosis may enhance CBT
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Average Pain interference (BPI)
Hypnosis may enhance CBT
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Average Pain interference (BPI)
Hypnosis may enhance CBT
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Average Pain interference (BPI)
Hypnosis may enhance CBT
* * *
* < .05
Effect sizes: ED, d = .50 CT, d = .60 HYP, d = .71 H-CT, d = 1.51
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Pilot study: Hypnosis focusing on pain reduction > ED & CT
Clinical trial: Hypnosis focusing on pain reduction = ED & CT
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Why different results?
Effect size for ED differed à Pilot d = .04; trial d = .73
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Why different results?
Effect size for ED differed à Pilot d = .04; trial d = .73 Effect size for HYP the same à Pilot d = .56; trial d = .54
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Why different results?
Effect size for ED differed à Pilot d = .04; trial d = .73 Effect size for HYP the same à Pilot d = .56; trial d = .54 Effect size for HYP-CT the same à Pilot d = .97; trial d = 1.00
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What was consistent?
Hypnotic cognitive therapy doubles the efficacy...
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What was consistent?
Hypnotic cognitive therapy doubles the efficacy (over CT or hypnosis focusing only on pain reduction)
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What was consistent?
Hypnotic cognitive therapy doubles the efficacy (over CT or hypnosis focusing only on pain reduction)
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HYP-CT > HYP and CT
Why?
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What’s wrong with CT alone?
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What’s wrong with CT alone?
It does not take advantage of the increase in cognitive flexibility produced by hypnosis
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What’s wrong w/ HYP à Pain reduction?
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What’s wrong w/ HYP à Pain reduction?
It focuses on….
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What’s wrong with pain-focused HYP?
It focuses on….pain
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What’s wrong with pain-focused HYP?
It focuses on….pain
Image courtesy of FreeDigitalPhotos.net
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What’s wrong with pain-focused HYP?
It focuses on….pain
Image courtesy of FreeDigitalPhotos.net
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What’s wrong with pain-focused HYP?
It focuses on….pain
Image courtesy of FreeDigitalPhotos.net
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What’s wrong with pain-focused HYP?
It focuses on….pain
Image courtesy of FreeDigitalPhotos.net
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What’s right with HYP-CT?
It focuses on….
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What’s right with HYP-CT?
It focuses on….Life
Images courtesy of FreeDigitalPhotos.net
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What’s right with HYP-CT?
It focuses on….Life
Images courtesy of FreeDigitalPhotos.net
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What’s right with HYP-CT?
It focuses on….Life
Images courtesy of FreeDigitalPhotos.net
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What’s right with HYP-CT?
It focuses on….Life
Images courtesy of FreeDigitalPhotos.net
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What’s right with HYP-CT?
It focuses on….Life
Images courtesy of FreeDigitalPhotos.net
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How does hypnosis work?
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How does hypnosis work?
Imagery research on location of effects
EEG research on mechanisms of effects
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Imagery evidence Rainville et al. (1997). Pain affect encoded in human anterior cingulate but not
somatosensory cortex. Science, 277, 968-971.
Painful heat stimulation in alert and hypnosis conditions resulted in CBF increases in:
• Sensory cortex 1 [S1] and 2 [S2]; and • Anterior cingulate gyrus [ACC]). Hypnotic suggestions for increased or decreased unpleasantness altered • Perception of pain affect (81/100 à 45/100); and • activation in ACC only
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Imagery evidence
à No difference in activity in sensory cortex
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Imagery evidence
à Large difference in activity in ACC
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Imagery evidence
à The ACC responds to suggestions for changes in pain unpleasantness.
ACC
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Imagery evidence Hypnotic suggestions for increased or decreased pain intensity altered perception of pain intensity (70/100 à 33/100) and activation in sensory cortex but not ACC. ~ Hofbauer et al., 2001
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Imagery evidence
Hypnosis targets specific brain areas and processes
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Mechanisms of effects Frequency Frequency Band Name Bandwidth State(s) Example
Raw EEG 0-45 Hz Awake Delta 0.5-3.5 Hz Deep sleep Theta 4-7.5 Hz Drowsy/
Focused
Alpha 8-12 Hz Relaxed Beta/gamma 13-30/>30 Hz “Thinking”
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Theta and hypnosis
- More baseline theta à ↑ Hypnotic responding
Crawford, H. J., & Gruzelier, J. H. (1992). A midstream view of the neuropsychophysiology of
hypnosis: Recent recearch and future directions. In E. Fromm & M. R. Nash (Eds.), Contemporary Hypnosis Research (pp. 227-266). New York: Guilford Press.
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Theta and hypnosis
- More baseline theta à ↑ Hypnotic responding
- Hypnotic procedures ↑ theta Crawford, H. J., & Gruzelier, J. H. (1992). A midstream view of the neuropsychophysiology of
hypnosis: Recent recearch and future directions. In E. Fromm & M. R. Nash (Eds.), Contemporary Hypnosis Research (pp. 227-266). New York: Guilford Press.
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Theta and hypnosis
- More baseline theta à ↑ Hypnotic responding
- Hypnotic procedures ↑ theta à Working hypothesis: Theta
activity facilitates hypnotic responding.
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What does theta do?
Plays a key role in all learning and memory tasks
Buzsáki, G. (2006). Rhythms of the brain. Oxford ; New York: Oxford University Press. Bastiaansen, M., & Hagoort, P. (2003). Event-induced theta responses as a window on the
dynamics of memory. Cortex, 39(4-5), 967-992.
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What does theta do?
Plays a key role in all learning and memory tasks
When theta is present: - Easier to recall and recreate experience - The record button is “on” Buzsáki, G. (2006). Rhythms of the brain. Oxford ; New York: Oxford University Press. Bastiaansen, M., & Hagoort, P. (2003). Event-induced theta responses as a window on the
dynamics of memory. Cortex, 39(4-5), 967-992.
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Predicting ∆ pain from baseline EEG
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Predicting ∆ pain from baseline EEG Hyp
δ
τ α β γ
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Predicting ∆ pain from baseline EEG Hyp
δ
τ α β γ
= Moderate (.30+) positive association; more of this = more response
= Moderate (-.30) negative association;
less of this = more response = Statistically significant (p < .05)
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Predicting ∆ pain from baseline EEG
δ
τ α β γ
Hyp Sham tDCS
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Predicting ∆ pain from baseline EEG Hyp
δ
τ α β γ
= Moderate (.30+) positive association; more of this = more response
= Moderate (-.30) negative association;
less of this = more response = Statistically significant (p < .05)
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Predicting ∆ pain from baseline EEG Hyp
δ
τ α β γ
= Moderate (.30+) positive association; more of this = more response
= Moderate (-.30) negative association;
less of this = more response = Statistically significant (p < .05)
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Predicting ∆ pain from baseline EEG Hyp
δ
τ α β γ
Unique to hypnosis?
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Predicting ∆ pain from baseline EEG Hyp Med NF tDCS Sham tDCS
δ
τ α β γ
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Summary
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Summary Chronic pain is a significant problem
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Summary Chronic pain is a significant problem Hypnosis can: Reduce pain intensity and negative
impact
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Summary Chronic pain is a significant problem Hypnosis can: Reduce pain intensity and negative
impact Enhance the efficacy of other pain
treatments
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Summary (cont’d) Effects strong – double the effect
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Summary (cont’d) Effects strong – double the effect Focusing on enhanced life quality
more effective than focusing (only) on symptom reduction
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Summary (cont’d)
Hypnosis may ↑ efficacy via its effects on brain states (theta)…
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Summary (cont’d)
Hypnosis may ↑ efficacy via its effects on brain states (theta)…
Which provides easier access to the “recall” and “record” functions
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Summary (cont’d)
Hypnosis may ↑ efficacy via its effects on brain states (theta)…
Which provides easier access to the “recall” and “record” functions
à We are in the process of testing these ideas more thoroughly
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Acknowledgements Funding: National Multiple Sclerosis Society The Craig H. Neilson Foundation NIH, National Center for Medical
Rehabilitation Research, R01 HD070973, R21 HD058049
NIH, National Center for Complementary and Alternative Medicine, R01 AT008336
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Thank you!
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