Chief Editor’s note: With this article, we inaugurate another new rubric, which tries to put together various European anaesthesiologists interested in the same field or domain of activity.
The finding that communication between the anaesthesiologist and the patient is helpful in reducing stress and anxiety is not new, but got somewhat forgotten with the availability (and marketing) of a broad range of sedative drugs.
However, non-pharmacological methods such as medical hypnosis are a suitable alternative to drug-based sedation regimens to provide comfort and reduce anxiety. Montgomery et al. conducted a meta-analysis of 20 controlled studies that used hypnosis with surgical patients to determine whether hypnosis has a significant beneficial impact and whether the method of hypnotic induction (live versus audiotape) affects hypnosis efficacy. Their results revealed a significant effect size, indicating that surgical patients in hypnosis treatment groups had better outcomes than 89% of patients in control groups, independent of the technique used.
However, the quality of the included studies was poor and a blinded design is hardly possible by the nature of the technique under investigation. A decade later Tefikow et al. investigated the efficacy of hypnosis in adults undergoing surgical or medical procedures compared to standard care alone or an attention control in another meta-analysis. Thirty-four randomized controlled trials (RCTs) were included, comprising a total of 2597 patients. Benefits of hypnosis on various outcomes (such as emotional distress, pain, medication consumption, and recovery but also physiological parameters and surgical procedure time) were demonstrated.
Wobst provided an overview of the literature and concluded: ‘If hypnosis and autosuggestions provide clinical benefit, they do so without the need for equipment or drugs. What other therapeutic measure appears so devoid of increased cost and demonstrable adverse effects? Personal attention to the patient, emotional support, positive suggestions, and even hypnosis are readily available, safe, inexpensive, and attractive measures that might improve the care of our patients.’ In my personal experience, hypnosis can be used without any additional drugs in cases with a sufficient regional block. Even if no formal hypnosis or relaxation technique is used, ‘therapeutic’ conversation or other non-pharmacological alternative techniques including listening to music or an audio-book by earphones are often sufficient to provide a comfortable atmosphere for the patient during the surgical procedure.
Kekecs et al. looked at suggestive techniques compared to formal hypnosis in a meta-regression and sensitivity analysis by moderating factors on a pool of 26 studies meeting the inclusion criteria. Outcome variables were postoperative anxiety, pain intensity, pain medication requirement, and nausea, and they concluded that suggestive techniques might be useful tools to alleviate postoperative anxiety and pain. However, the strength of the evidence was weak, again because of possible bias in the reviewed articles.
The definition of ‘hypnosis’ by the American Psychological Association is highly operational. They define hypnosis as a state of consciousness involving focused attention and reduced peripheral awareness characterized by an enhanced capacity for response to suggestion, and ‘hypnotisability’ as an individual’s ability to experience suggested alterations in physiology, sensations, emotions, thoughts, or behaviour during hypnosis. Because hypnotic phenomena and trance can be observed spontaneously without a formal hypnotic induction technique and as part of other psychological processes such as religious rituals, meditation, and relaxation techniques, the term hypnosis as a unique entity remains controversial. However, neurobiological research demonstrates distinct features and genetic traits, and creates new theories about the nature of hypnosis and hypnotisability.
Deep trance can be reached in highly hypnotisable patients, but due to a normal distribution of hypnotisability, we are dealing with a majority of moderate to low hypnotisable subjects in our patient population, shifting the focus somewhat to a reduction of negative suggestions and the avoidance of nocebo-effects as part of a ‘therapeutic communication’-concept. Peterson et al. determined, in a meta-analysis, the magnitudes and range of effect sizes of nocebo to be similar to those of placebo effects in mechanistic studies. In studies where nocebo effects were induced by a combination of verbal suggestions and conditioning, the effect size was larger than in studies where nocebo effects were induced by verbal suggestions alone. Since the magnitude of the nocebo effect is variable and sometimes large, this meta-analysis demonstrates the importance of minimizing nocebo effects in clinical practice.
Sometimes the perceived need to provide sedation seems to lie more in the mind of the anaesthesiologist and perhaps in the convenience of the surgeon who might fear an awake and responsive patient.
As anaesthesiologists we are used to giving general anaesthetics successfully and safely, although we do not know for sure how they ultimately work: Perhaps we should give hypnosis a trial in the same way as an adjunct to regional anaesthesia, but certainly incorporate therapeutic communication and avoidance of negative suggestions as an integral part of our routine practice.
In order to generate high-quality research on this topic interested anaesthesiologists are requested to join the author (firstname.lastname@example.org) to form a HYPNosis in Anesthesia and Critical Care (HYPNACC)-Network.