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Does hypnosis contribute to the care of burn patients?
Does Hypnosis Contribute to the Care of Burn Patients? Review of the Evidence A. Jan Willem Van der Does, Clinical Psychologist, and Richard Van Dyck, Professor of Psvchiatry J
Abstract: In burn treatment, hypnosis has been used for the alleviation of pain, the prevention and treatment of anxiety and depression, and the acceleration of wound healing. The successful application of hypnosis decreases the extensive medication needed. Furthermore, if provides a fool to patients with which they may experience more control in situations that are offen experienced as overwhelming. Notwithstanding these important applications and the very positive terms with which the results of studies are generally described, hypnosis has mostly been neglected as a fool to help burn patients. This article reviews the clinical and experimental evidence of the usefulness of hypnosis in the management of burns. Pain reduction and crisis infervknfion are promising applications. However, due to a lack of systematic and controlled research, more specific conclusions are precluded. In the controversial area of wound healing, claims for the effectiveness of hypnosis have been made on the basis of slim evidence and inconclusive studies. This hypothesis needs to be addressed in controlled experiments. In summary, systematic investigations are needed to confirm and supplement available clinical evidence. Recommendations for future research are giuen.
Introduction Although a variety of myths and misconceptions has interfered with the use of hypnosis in hospital settings for a considerable period of time [l], its potential value is nowadays increasingly recognized, especially in the treatment of pain syndromes. More than 30 years ago, the successful use From the Red Cross Hospital, Bevenvijk and Academic Hosrz&4 Universitv of Amsterdam (A.1.W.V.d.D.) and Free Unikersky, Amsteidam (R.V.D.), T6e Netherlands. Address reprint requests to: Drs. A. J. W. Van der Does, Psychiatric Center, Academic Medical Center, Tafelbergweg 25, 1105 BC Amsterdam, The Netherlands.
Gem-ml Hospital Psychiatry 11, 119-124, 1989
0 1989 Elsevier Science PublishingCo., Inc. 655AvenueoftheAmericas,NewYork, NY10010
of hypnosis with severely burned patients was described by Crasilneck et al. [2]. These authors explored the value of hypnosis as a part of the total management of severe burns in eight patients. They reported successful use of hypnosis in six patients, who were said to be excellent hypnotic subjects. Hypnosis was effective in the relief of pain, in stimulating appetite, and in increasing motivation to use and exercise injured parts of the body. Since this publication these results have been confirmed and expanded [2-281. For instance, some authors [3,4] report that hypnosis improved morale on the ward and contributed to a more hopeful therapeutic climate. The results are generally described in very positive terms as “a most valuable method,” and “although hypnosis was not life-saving it was so startingly successful. . . . ,” and even “hypnosis facilitated dramatic enhancement of bum wound surprising that healing” [23]. It is therefore hypnosis is not more widely used in burn units. In the Netherlands, for example, until recently hypnosis was never used at any of the three burn centers in the country. In other European burn centers, hypnosis is probably not very widely practiced either. In view of the citations above, are we now to conclude that for more than 30 years, professionals have been misguided by negative myths and misconceptions about hypnosis and have withheld a valuable treatment modality from their patients? The purpose of this article is to give a critical review of the literature on the use of hypnosis with severely burned patients. Through a computer
119
ISSN 0163-8343/89/$X50
A. J. W. Van der Does and R. Van Dyck search of the medical and psychologic literature in the English language and checking reference lists of all articles, we found 28 publications [2-291 in which hypnosis was used in experimental or clinical studies on burns. These publications show that hypnosis has been used as an adjunct in the treatment of severe burns with three objectives:
measured. It would also be of interest to know in which instances hypnosis is indicated or contraindicated, and in which phase of treatment hypnosis will be most effective. This will also require more knowledge of what constitutes “healthy” ways to cope with these kinds of injuries.
1. Crisis intervention 2. Acceleration of burn wound healing 3. Management of pain
Hypnosis in Burn Wound Healing
The review is organized around these three objectives. Some methodologic requirements for future research are discussed.
Hypnosis in Crisis Intervention Wain and Amen [l] suggest that altered states of awareness occur rapidly and spontaneously in patients who experience acute trauma or pain. According to their view, emergency room patients are more receptive to suggestions and directions if these trancelike states are recognized by the hospital staff. In the treatment of bums, this strategy of early hypnosis, making use of spontaneous trancelike states, has been used to counter feelings of acute anxiety and panic [3,11]. In discussing crisis situations in general, Baldwin [30] claims that hypnosis can be used in the enhancement of adaptive coping. He describes how hypnosis creates a relaxed atmosphere that neutralizes many of the negative effects of the crisis state by redistributing of attention, increasing availability of memories from the past, heightening ability for fantasy production, and increasing suggestibility and creativity. Furthermore, hypnosis is said to potentiate the effects of various other therapeutic interventions that follow after the emergency. As such, hypnosis was used to correct detrimental emotional responses of patients to their injury [2], to reach isolated and depressed children [7], and to create a more hopeful, therapeutic climate ]3]. Procedures have also been developed to make hypnosis useful in the rehabilitation of poor Spanish-speaking burn patients in the United States, especially in the treatment of posttraumatic stress [29]. These accounts sound appealing, and systematic studies are needed by which the effectiveness of hypnosis in relieving or preventing anxiety or depressive symptoms or any of the other emotional aspects of the crisis following a burn injury can be
120
According to Ewin [4,11-131 the degree of bum depends on the injury itself (temperature, duration) as well as on the inflammatory response of the body to the burn. He explains that the intact skin acts as an insulator and that it is the later absorption of chemically altered material into the deeper layers that causes most third-degree results. Furthermore, hypnosis is thought to be capable of influencing the inflammatory response. Ewin promotes early hypnosis, within 4 hours of the injury, giving suggestions of coolness and comfort, in order to decrease the inflammatory response of the body and thereby attenuate the depth and severity of the burn. He describes a case report [4,11] of a man whose leg was immersed in molten aluminum at 950°C; he was hypnotized within 30 minutes, developed only a second-degree bum and was discharged on the 19th day without scar tissue formation. An additional case is described by the same author [12,13]. Ewin [4] finds evidence for the thesis that hypnosis can attenuate burn depth in the studies by Chapman et al. [8,9] and Brauer and Spira [31]. The latter authors transferred full-thickness bums made by infrared light on small pigs to normal beds on the same animals, to discover whether viable cells could be shown to exist in burned skin. The percentage of takes in these grafts was estimated at 73%, compared to an average take of 80% for normal skin placed on burn beds. Viable dermal elements could be demonstrated microscopically in the transferred burned skin. The authors also found that a delay of hours before removal of the bum graft materially influenced graft survival in the new bed, although no specific data were provided in the report. Chapman et al. [8] compared the effects of identical standard amounts of noxious stimulation on the left and right forearm, after induction of hypnosis and suggestions of increased vulnerability in one arm and/or suggestions of numbness and insensitivity in the other arm. Compared to normally sensitive arms, they observed decreased inflam-
Hypnosis in the Care of Bum Patients
matory reaction and tissue damage in the “insensitive” arms, and increased inflammatory reaction and tissue damage in “vulnerable” arms. Without denying the importance of these studies, in our opinion the findings have only limited relevance to Ewin’s thesis. The fact that the destruction of skin does not occur immediately does not necessarily mean that the destructive processes can be stopped by hypnosis. Moreover, in the Chapman et al. [8,9] studies, subjects were hypnotized before the noxious stimulation. Based on this, no firm conclusions can be drawn on the effect of hypnosis after the damage has taken place. Ewin [4, p. 1581 also points to studies on the effect of hypnosis on blister formation, stating that “there are multiple reports of hypnotic recollections of a previous burn causing acute inflammation and/or blister formation at the site of the earlier trauma.” Again, however, these studies have no direct relevance to the burn depth attenuation hypothesis: the fact that hypnosis or any other agent may cause inflammation or blister formation does not mean that hypnosis can retard or halt the inflammatory process. Furthermore, careful reading shows that Ewin’s conclusion is not in agreement with the literature on this subject. Ewin himself cites two poorly controlled case histories [5,27] and one experimental study [35] during which subjective and physiologic effects of hypnotic suggestions for blister formation were investigated. Of the 40 subjects in this latter study, not one developed a blister after repeated hypnotic suggestions. Two subjects, however, exhibited localized inflammation. In one subject the inflammation was attributed to self-injury (scratching), because her hand had been itching since the test session. For the other subject the inflammation might have been related to a genuine injury that had occured 6 years earlier. More recently, Spanos et al. [36] suggested age regression under hypnosis to 60 subjects who had been burned in the past in addition to direct suggestions for blister formation. Although 17 subjects reported vividly imaging the bum events, not one showed localized skin-coloration changes or evidence of blister formation. Neither was there a suggestion effect on skin temperature, except for one subject. Therefore, the effect of hypnosis on blistering seems to be an area where clinical and experimental evidence conflict. From the viewpoint of the experimentalist, the effect is far from being convinc-
ingly demonstrated and, if at all possible, reserved to only a small fraction of the population. Some clinicians, however, argue that individual differences in hypnotic capacity disappear in severe crisis situations, and this could make rare findings meaningful. Nevertheless, we would argue that claims with such far-reaching consequences need much better scientific support than is currently available. The effects of hypnosis on burn wound healing have been experimentally investigated in three studies. Hammond et al. [15] investigated the effects of hypnotic analgesia and suggestions of coolness on inflammation and healing of experimentally inflicted first-degree burns. Six subjects with equal (small) burns on both thighs, received hypnotic suggestions for one thigh only. Results showed no significant mean differences in temperature between the experimental and control thighs. However, for the experimental thigh, there was a significantly greater proportion of lower (blind) ratings of redness. Of course, the relevance of this study to the treatment of severely burned patients can be questioned since only first-degree burns were studied. Margolis et al. [19], in a study with 17 patients and a matched control group, tried to determine if a single, early hypnotic induction can alter the physiologic response of the patients to their thermal injury. Hypnosis was induced within 12 hours. Six subjects were dropped from the study for reasons of early discharge, death, or missing data. Results showed no significant differences in length of hospitalization, fluid input, or urine output between the total experimental group and their matched controls. However, when the results of five experimental patients, who were judged as unhypnotized, were deleted, day 2 urine output was significantly higher for the six remaining experimental patients than for their matched controls. As this selection was based on clinical impression, and not on hypnotizability tests, it may not have been free of observer bias. Nonetheless, the authors are correct in suggesting that for these patients, hypnosis might have affected the body’s response to bum injury. It is noteworthy that the intervention was limited to one session only and that the delay in most cases was longer than the presumedly critical 4 hours. The authors also point out that their data cannot be interpreted as supporting Ewin’s burn depth attenuation hypothesis, given the questionable re-
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A. J. W. Van der Does and R. Van Dyck
liability of initial classification of burn depth. The same issue was addressed in more detail by May and DeClement [22], who reached similar conclusions. Although the article contains no reference to the Margolis et al. [19] study (or vice versa) careful reading of both articles strongly suggests that both are discussing the same data from the same patients. A different strategy from Ewin’s early introduction of hypnosis was used by Moore and Kaplan [23]. Treatment was delayed until the second day, and suggestions of warmness were given in order to increase the blood flow to the affected area. This strategy is based on the relatively well documented finding that hypnosis can influence blood flow [32,33,37]. Moore and Kaplan described five cases of bilateral, symmetric burns in which hypnotic suggestions were given for one side only. In four of the five cases, the “experimental side” recovered more rapidly (3 days earlier) than the “control side.” For two patients a rise in temperature on the “experimental side” could be measured after hypnotic suggestion. The fifth patient had rapid healing on both sides. Although the authors conclude that “hypnosis facilitated dramatic enhancement of burn wound healing,” we find it more appropriate to state that there are indications for an effect of hypnosis using this strategy, but that strong experimental evidence is lacking thus far. Bearing in mind the difficulty involved in bum depth classification, it is not uncommon to find different recovery rates for apparently identical burns. In summary, we believe that the evidence for the effectiveness of Ewin’s strategy (suggestions of coolness soon after the injury) is slim. In fact, the issue has not yet been addressed properly. Only the two cases that Ewin himself describes and the Margolis et al. [19] and May and DeClement [22] study offer some perspective. We may further conclude that Ewin’s presentation of the evidence is somewhat unbalanced because negative findings predominate in studies he quotes as supporting his views. Moore and Kaplan [23] published the only study that used the strategy of giving suggestions of warmness at a later stage, apart from a recent uncontrolled case report of self-hypnosis [21]. At this moment it can best be argued that conclusions about possible effects of hypnosis on bum wound healing should be postponed until clinical trials have been completed with more patients under strict experimental conditions. 122
Hypnosis and Pain in Burn Patients Contrary to the other fields of application discussed so far, hypnosis has been documented’extensively in the psychologic laboratory as a method of alleviating (experimentally induced) pain [34]. This effect is clearly correlated to measured hypnotizability. As mentioned above, the effectiveness of hypnosis with bum patients was first described by Crasilneck et al. [2]. Case studies have since been published regularly, in which hypnosis was used for obtaining pain reduction in both adults [10,14,16,18,20,25] and children [6,7,17]. Only two studies have a fair number of patients. Schafer [26] reported the successful use of hypnosis in 14 of 20 treated patients. Five of the six failures were children. Total body surface area (TBSA, second and third degree) varied from 18% to 80%. It is unfortunate that in this study estimates of both pain relief and hypnotic depth were essentially based on clinical judgments by the therapist. The Diagnostic Rating Scale (DRS) [38] that was used for hypnotic depth estimation is seldom used as a hypnotizability measure because of its low level of standardization. Furthermore, the DRS scores were contaminated with patients’ reports of the success of the intervention, which makes them of limited use in a scientific report. Wakeman and Kaplan [28] conducted a controlled experiment comparing a combination of hypnotherapy and medication (experimental treatment) with a combination of emotional support and medication (control treatment). Analgesic medication was available for these patients on demand, and was used as the pain index. Patients of two categories (O%-30% burns and 31%-60% burns) were randomly assigned to either treatment. For both categories of patients, significantly lower levels of medication were used (p < 0.01) by the experimental group than by the control group. The presence of a control group and the use of an objective index to measure pain make this study an important contribution. In our opinion the adequacy of the control treatment is the weaker part of the study. The possibility cannot be ruled out that patients in the experimental group might have been more willing to try and undergo a dressing change with less medication than usual because they were aware that they had received a treatment directly aimed at relieving their pain. Also, only the patients in the experimental group were asked
Hypnosis in the Care of Burn Patients
to sign an informed consent form. The emotional support for the control group involved extra time for talking about progress, family, and physical therapy issues, which was already part of the daily regular treatment program in all patients. The combined use of objective and subjective pain measurement methods may clarify this issue of demand characteristics. It would also be advisable to use more standardized procedures for the experimental as well as for the control treatment. Patterson et al. [24] have recently reviewed these studies on hypnosis and pain in burn patients. They correctly conclude that the effectiveness of hypnosis is generally supported by the literature, but that little else can be concluded, because of the poor description of patients, methods, and procedures that are provided with almost all articles. The importance of better controlled and clearly described studies is emphasized in a recent report by Van der Does et al. [39]. In this small pilot study it was shown that the value of case reports is considerably enhanced by gathering subjective as well as objective data. In some instances the subjective data in this study (clinical judgment, patient’s report) were in conflict with the more objective data (medication use, daily pain ratings). Systematic measurements not only provide more data but may also lead to different conclusions.
Conclusions In general, the tone of the reviewed studies is in line with the citations in the introduction of this article. Hypnosis is said to be a most valuable, clinically often impressive, method for relieving pain, reducing negative emotions, improving morale on the ward, and even enhancing burn wound healing in burn victims. Only a few studies report one or more patients who did not improve. A closer look at the literature reveals a lack of systematic and Most studies are illuscontrolled experiments. trated with case histories only, and rarely is an attempt made to measure any effects. No study is available with an assessment of hypnotizability using a standardized scale. Compared to the dramatic results suggested by anecdotal reports, attempts at systematic inquiries about the effects of hypnosis in burn patients produce more modest findings. In some instances there was a discrepancy between the data and the conclusions that were drawn from them. In summary, the following conclusions can be drawn:
The accounts of hypnosis in crisis intervention are appealing, and systematic studies in this area are needed. There is as yet no convincing experimental evidence for the effectiveness of hypnosis in attenuating burn depth and accelerating wound healing. Because of the enormous implications positive findings would have, these hypotheses deserve to be seriously studied in a controlled experiment. At present, the use of hypnosis in alleviating pain in bum patients seems to be the most promising area for application. It still remains to be demonstrated that this will be a specific rather than a general or placebo effect. The importance of systematic and controlled research on hypnosis in the treatment of burns should be stressed. In our opinion, future studies should fulfill the following requirements: Clear definition
of the target symptom(s)
Description of the hypnotic wording and timing An adequate
suggestions-type,
control group
Standardization of the hypnotic and control treatment, within the limits of clinical feasibility Careful registration of the extent of bum damage and of medication use Measurement of patients’ standardized test.
hypnotizability
with a
In general, a closer working relationship between clinicians and researchers is essential to arrive at meaningful and reproducible results. The comments of R. E. Spijker, M.D., article are gratefully acknowledged.
on an earlier version of this
References Wain HJ, Amen DG: Emergency room use of hypnosis. Gen Hosp Psychiatry 819-22, 1986 Crasilneck HB, Stirman JA, Wilson BJ, McCranie EJ, Fogelman MJ: Use of hypnosis in the management of patients with burns. JAMA 158:103-106, 1955 Schafer DW: Patients’ reactions to hypnosis on a burn unit. In Frankel FH, Zamansky HS (eds), Hypnosis at Its Bicentennial. New York, Plenum, 1978. pp 2297235 Ewin DM: Clinical use of hypnosis for attenuation of burn depth. In Frankel FH, Zamansky HS (eds), Hypnosis at Its Bicentennial. New York, Plenum, 1978, pp 155-162 123
A. J. W. Van der Does and R. Van Dyck
5. Bellis JM: Hypnotic pseudo-sunburn. Am J Clin Hypn 8310-312, 1966 6. Bernstein NR: Management of burned children with the aid of hypnosis. J Child Psycho1 Psychiatry 4:93, 1963 7. Bernstein NR: Observations on the use of hypnosis with burned children on a pediatric ward. Int J Clin Exp Hypn 13:1-10, 1965 8. Chapman LF, Goode11 H, Wolff HG: Changes in tissue vulnerability induced during hypnotic suggestion. J Psychosom Res 499-105, 1959 9. Chapman LF, Goode11 H, Wolff HG: Augmentation of the inflammatory reaction by activity of the central nervous system. Arch Neurol 1:557-572, 1959 10. Dahinterova J: Some experiences with the use of hypnosis in the treatment of burns. Int J Clin Exp Hypn 15:49-53, 1967 11. Ewin DM: Hypnosis in burn therapy. In Burrows GD, Collison DR, Dennerstein L (eds), Hypnosis 1979. Amsterdam, Elsevier, 1979, pp 269-275 12. Ewin DM: Emergency room hypnosis for the burned patient. Am J Clin Hypn 26:5-S, 1983 13. Ewin DM: Emergency room hypnosis for the burned patient. Am J Clin Hypn 297-12, 1986 14. Finer BL, Nylen BO: Cardiac arrest in the treatment of burns, and report on hypnosis as a substitute for anesthesia. Plast Reconstr Surg 27:49-55, 1961 15. Hammond DC, Keye WR, Grant CW: Hypnotic analgesia with burns: An initial study. Am J Clin Hypn 26:56-59, 1983 16. Hartley RB: Hypnosis for alleviation of pain in treatment of burns: Case report. Arch Phys Med Rehabil 49:39-41, 1968 17. LaBaw WL: Adjunctive trance therapy with severely burned children. Int J Child Psychother 2:80-92,1973 18. Margolis CG, DeClement FA: Hypnosis in the treatment of bums. Burns 6:253-254, 1980 19. Margolis CG, Domangue BB, Ehleben C, Shrier L: Hypnosis in the early treatment of bums: A pilot study. Am J Clin Hypn 26:9-15, 1983 20. Margolis CG: Special pain problems: Bums and cancer. In Dowd ETh, Healy JM (eds), Case Studies in Hypnotherapy. New York, Guilford, 1986, pp 177189 21. Marriott JA: Self hypnosis and the healing process. Austr J Clin Hypnother Hypn 7:9-16, 1986 22. May SR, DeClement FA: Effects of early hypnosis on the cardiovascular and renal physiology of burn patients. Burns 9:257-266, 1983
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23. Moore LE, Kaplan JZ: Hypnotically accelerated bum wound healing. Am J Clin Hypn 26:16-19, 1983 24. Patterson DR, Questad KA, Boltwood MD: Hypnotherapy as a treatment for pain in patients with burns: Research and clinical considerations. J Bum Care Rehabil8:263-268, 1987 25. Pellicane AJ: Hypnosis an adjunct to treatment of burns. Am J Clin Hypn 2:153-156, 1960 26. Schafer DW: Hypnosis use on a burn unit. Int J Clin Exp Hypn 23:1-14, 1975 27. Ullman M: Herpes simplex and second degree bum induced under hypnosis. Am J Psychiatry 103:828830, 1947 28. Wakeman RJ, Kaplan JZ: An experimental study of hypnosis in painful burns. Am J Clin Hypn 21:3-12, 1978 29. Dobkin de Rios M, Friedmann JK: Hypnotherapy with Hispanic burn patients. Int J Clin Exp Hypn 35:87-94, 1987 30. Baldwin BA: Crisis Intervention and enhancement of adaptive coping using hypnosis. Am J Clin Hypn 21:38-44. 1978 31. Brauer d, Spira M: Full-thickness burns as source for donor graft in the pig. Plast Reconstr Surg 37:2130, 1966 32. Clawson ThA, Swade R: The hypnotic control of blood flow and pain. Am J Clin Hypn 3:160-169,1975 33. Grabowska MJ: The effect of hypnosis and hypnotic suggestion on the blood flow in the extremities. Pol Med J 10:1044-1051, 1971 34. Hilgard ER, Hilgard JR: Hypnosis in the relief of pain. Los Altos, CA, Kaufmann, 1975 35. Johnson RFQ, Barber ThX: Hypnotic suggestions for blister formation: Subjective and physiological effects. Am J Clin Hypn 18:172-181, 1976 36. Spanos NP, McNeil C, Stam HJ: Hypnotically ‘reliving’ a prior burn: Effects on blister formation and localized skin temperature. J Abnorm Psycho1 91:303-305, 1982 37. Barabasz AF, McGeorge CM: Biofeedback, mediated biofeedback, and hypnosis in peripheral vasodilation training. Am J Clin Hypn 21:28-37, 1978 38. Ome MT, O’Connell DN: Diagnostic ratings of hypnotizability. Int J Clin Exp Hypn 143326332, 1967 39. Van der Does AJW, Van Dyck R, Spijker RE: Hypnosis and pain in patients with severe bums: A pilot study. Burns 14:399-404, 1988
Abstract: In burn treatment, hypnosis has been used for the alleviation of pain, the prevention and treatment of anxiety and depression, and the acceleration of wound healing. The successful application of hypnosis decreases the extensive medication needed. Furthermore, if provides a fool to patients with which they may experience more control in situations that are offen experienced as overwhelming. Notwithstanding these important applications and the very positive terms with which the results of studies are generally described, hypnosis has mostly been neglected as a fool to help burn patients. This article reviews the clinical and experimental evidence of the usefulness of hypnosis in the management of burns. Pain reduction and crisis infervknfion are promising applications. However, due to a lack of systematic and controlled research, more specific conclusions are precluded. In the controversial area of wound healing, claims for the effectiveness of hypnosis have been made on the basis of slim evidence and inconclusive studies. This hypothesis needs to be addressed in controlled experiments. In summary, systematic investigations are needed to confirm and supplement available clinical evidence. Recommendations for future research are giuen.
Introduction Although a variety of myths and misconceptions has interfered with the use of hypnosis in hospital settings for a considerable period of time [l], its potential value is nowadays increasingly recognized, especially in the treatment of pain syndromes. More than 30 years ago, the successful use From the Red Cross Hospital, Bevenvijk and Academic Hosrz&4 Universitv of Amsterdam (A.1.W.V.d.D.) and Free Unikersky, Amsteidam (R.V.D.), T6e Netherlands. Address reprint requests to: Drs. A. J. W. Van der Does, Psychiatric Center, Academic Medical Center, Tafelbergweg 25, 1105 BC Amsterdam, The Netherlands.
Gem-ml Hospital Psychiatry 11, 119-124, 1989
0 1989 Elsevier Science PublishingCo., Inc. 655AvenueoftheAmericas,NewYork, NY10010
of hypnosis with severely burned patients was described by Crasilneck et al. [2]. These authors explored the value of hypnosis as a part of the total management of severe burns in eight patients. They reported successful use of hypnosis in six patients, who were said to be excellent hypnotic subjects. Hypnosis was effective in the relief of pain, in stimulating appetite, and in increasing motivation to use and exercise injured parts of the body. Since this publication these results have been confirmed and expanded [2-281. For instance, some authors [3,4] report that hypnosis improved morale on the ward and contributed to a more hopeful therapeutic climate. The results are generally described in very positive terms as “a most valuable method,” and “although hypnosis was not life-saving it was so startingly successful. . . . ,” and even “hypnosis facilitated dramatic enhancement of bum wound surprising that healing” [23]. It is therefore hypnosis is not more widely used in burn units. In the Netherlands, for example, until recently hypnosis was never used at any of the three burn centers in the country. In other European burn centers, hypnosis is probably not very widely practiced either. In view of the citations above, are we now to conclude that for more than 30 years, professionals have been misguided by negative myths and misconceptions about hypnosis and have withheld a valuable treatment modality from their patients? The purpose of this article is to give a critical review of the literature on the use of hypnosis with severely burned patients. Through a computer
119
ISSN 0163-8343/89/$X50
A. J. W. Van der Does and R. Van Dyck search of the medical and psychologic literature in the English language and checking reference lists of all articles, we found 28 publications [2-291 in which hypnosis was used in experimental or clinical studies on burns. These publications show that hypnosis has been used as an adjunct in the treatment of severe burns with three objectives:
measured. It would also be of interest to know in which instances hypnosis is indicated or contraindicated, and in which phase of treatment hypnosis will be most effective. This will also require more knowledge of what constitutes “healthy” ways to cope with these kinds of injuries.
1. Crisis intervention 2. Acceleration of burn wound healing 3. Management of pain
Hypnosis in Burn Wound Healing
The review is organized around these three objectives. Some methodologic requirements for future research are discussed.
Hypnosis in Crisis Intervention Wain and Amen [l] suggest that altered states of awareness occur rapidly and spontaneously in patients who experience acute trauma or pain. According to their view, emergency room patients are more receptive to suggestions and directions if these trancelike states are recognized by the hospital staff. In the treatment of bums, this strategy of early hypnosis, making use of spontaneous trancelike states, has been used to counter feelings of acute anxiety and panic [3,11]. In discussing crisis situations in general, Baldwin [30] claims that hypnosis can be used in the enhancement of adaptive coping. He describes how hypnosis creates a relaxed atmosphere that neutralizes many of the negative effects of the crisis state by redistributing of attention, increasing availability of memories from the past, heightening ability for fantasy production, and increasing suggestibility and creativity. Furthermore, hypnosis is said to potentiate the effects of various other therapeutic interventions that follow after the emergency. As such, hypnosis was used to correct detrimental emotional responses of patients to their injury [2], to reach isolated and depressed children [7], and to create a more hopeful, therapeutic climate ]3]. Procedures have also been developed to make hypnosis useful in the rehabilitation of poor Spanish-speaking burn patients in the United States, especially in the treatment of posttraumatic stress [29]. These accounts sound appealing, and systematic studies are needed by which the effectiveness of hypnosis in relieving or preventing anxiety or depressive symptoms or any of the other emotional aspects of the crisis following a burn injury can be
120
According to Ewin [4,11-131 the degree of bum depends on the injury itself (temperature, duration) as well as on the inflammatory response of the body to the burn. He explains that the intact skin acts as an insulator and that it is the later absorption of chemically altered material into the deeper layers that causes most third-degree results. Furthermore, hypnosis is thought to be capable of influencing the inflammatory response. Ewin promotes early hypnosis, within 4 hours of the injury, giving suggestions of coolness and comfort, in order to decrease the inflammatory response of the body and thereby attenuate the depth and severity of the burn. He describes a case report [4,11] of a man whose leg was immersed in molten aluminum at 950°C; he was hypnotized within 30 minutes, developed only a second-degree bum and was discharged on the 19th day without scar tissue formation. An additional case is described by the same author [12,13]. Ewin [4] finds evidence for the thesis that hypnosis can attenuate burn depth in the studies by Chapman et al. [8,9] and Brauer and Spira [31]. The latter authors transferred full-thickness bums made by infrared light on small pigs to normal beds on the same animals, to discover whether viable cells could be shown to exist in burned skin. The percentage of takes in these grafts was estimated at 73%, compared to an average take of 80% for normal skin placed on burn beds. Viable dermal elements could be demonstrated microscopically in the transferred burned skin. The authors also found that a delay of hours before removal of the bum graft materially influenced graft survival in the new bed, although no specific data were provided in the report. Chapman et al. [8] compared the effects of identical standard amounts of noxious stimulation on the left and right forearm, after induction of hypnosis and suggestions of increased vulnerability in one arm and/or suggestions of numbness and insensitivity in the other arm. Compared to normally sensitive arms, they observed decreased inflam-
Hypnosis in the Care of Bum Patients
matory reaction and tissue damage in the “insensitive” arms, and increased inflammatory reaction and tissue damage in “vulnerable” arms. Without denying the importance of these studies, in our opinion the findings have only limited relevance to Ewin’s thesis. The fact that the destruction of skin does not occur immediately does not necessarily mean that the destructive processes can be stopped by hypnosis. Moreover, in the Chapman et al. [8,9] studies, subjects were hypnotized before the noxious stimulation. Based on this, no firm conclusions can be drawn on the effect of hypnosis after the damage has taken place. Ewin [4, p. 1581 also points to studies on the effect of hypnosis on blister formation, stating that “there are multiple reports of hypnotic recollections of a previous burn causing acute inflammation and/or blister formation at the site of the earlier trauma.” Again, however, these studies have no direct relevance to the burn depth attenuation hypothesis: the fact that hypnosis or any other agent may cause inflammation or blister formation does not mean that hypnosis can retard or halt the inflammatory process. Furthermore, careful reading shows that Ewin’s conclusion is not in agreement with the literature on this subject. Ewin himself cites two poorly controlled case histories [5,27] and one experimental study [35] during which subjective and physiologic effects of hypnotic suggestions for blister formation were investigated. Of the 40 subjects in this latter study, not one developed a blister after repeated hypnotic suggestions. Two subjects, however, exhibited localized inflammation. In one subject the inflammation was attributed to self-injury (scratching), because her hand had been itching since the test session. For the other subject the inflammation might have been related to a genuine injury that had occured 6 years earlier. More recently, Spanos et al. [36] suggested age regression under hypnosis to 60 subjects who had been burned in the past in addition to direct suggestions for blister formation. Although 17 subjects reported vividly imaging the bum events, not one showed localized skin-coloration changes or evidence of blister formation. Neither was there a suggestion effect on skin temperature, except for one subject. Therefore, the effect of hypnosis on blistering seems to be an area where clinical and experimental evidence conflict. From the viewpoint of the experimentalist, the effect is far from being convinc-
ingly demonstrated and, if at all possible, reserved to only a small fraction of the population. Some clinicians, however, argue that individual differences in hypnotic capacity disappear in severe crisis situations, and this could make rare findings meaningful. Nevertheless, we would argue that claims with such far-reaching consequences need much better scientific support than is currently available. The effects of hypnosis on burn wound healing have been experimentally investigated in three studies. Hammond et al. [15] investigated the effects of hypnotic analgesia and suggestions of coolness on inflammation and healing of experimentally inflicted first-degree burns. Six subjects with equal (small) burns on both thighs, received hypnotic suggestions for one thigh only. Results showed no significant mean differences in temperature between the experimental and control thighs. However, for the experimental thigh, there was a significantly greater proportion of lower (blind) ratings of redness. Of course, the relevance of this study to the treatment of severely burned patients can be questioned since only first-degree burns were studied. Margolis et al. [19], in a study with 17 patients and a matched control group, tried to determine if a single, early hypnotic induction can alter the physiologic response of the patients to their thermal injury. Hypnosis was induced within 12 hours. Six subjects were dropped from the study for reasons of early discharge, death, or missing data. Results showed no significant differences in length of hospitalization, fluid input, or urine output between the total experimental group and their matched controls. However, when the results of five experimental patients, who were judged as unhypnotized, were deleted, day 2 urine output was significantly higher for the six remaining experimental patients than for their matched controls. As this selection was based on clinical impression, and not on hypnotizability tests, it may not have been free of observer bias. Nonetheless, the authors are correct in suggesting that for these patients, hypnosis might have affected the body’s response to bum injury. It is noteworthy that the intervention was limited to one session only and that the delay in most cases was longer than the presumedly critical 4 hours. The authors also point out that their data cannot be interpreted as supporting Ewin’s burn depth attenuation hypothesis, given the questionable re-
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liability of initial classification of burn depth. The same issue was addressed in more detail by May and DeClement [22], who reached similar conclusions. Although the article contains no reference to the Margolis et al. [19] study (or vice versa) careful reading of both articles strongly suggests that both are discussing the same data from the same patients. A different strategy from Ewin’s early introduction of hypnosis was used by Moore and Kaplan [23]. Treatment was delayed until the second day, and suggestions of warmness were given in order to increase the blood flow to the affected area. This strategy is based on the relatively well documented finding that hypnosis can influence blood flow [32,33,37]. Moore and Kaplan described five cases of bilateral, symmetric burns in which hypnotic suggestions were given for one side only. In four of the five cases, the “experimental side” recovered more rapidly (3 days earlier) than the “control side.” For two patients a rise in temperature on the “experimental side” could be measured after hypnotic suggestion. The fifth patient had rapid healing on both sides. Although the authors conclude that “hypnosis facilitated dramatic enhancement of burn wound healing,” we find it more appropriate to state that there are indications for an effect of hypnosis using this strategy, but that strong experimental evidence is lacking thus far. Bearing in mind the difficulty involved in bum depth classification, it is not uncommon to find different recovery rates for apparently identical burns. In summary, we believe that the evidence for the effectiveness of Ewin’s strategy (suggestions of coolness soon after the injury) is slim. In fact, the issue has not yet been addressed properly. Only the two cases that Ewin himself describes and the Margolis et al. [19] and May and DeClement [22] study offer some perspective. We may further conclude that Ewin’s presentation of the evidence is somewhat unbalanced because negative findings predominate in studies he quotes as supporting his views. Moore and Kaplan [23] published the only study that used the strategy of giving suggestions of warmness at a later stage, apart from a recent uncontrolled case report of self-hypnosis [21]. At this moment it can best be argued that conclusions about possible effects of hypnosis on bum wound healing should be postponed until clinical trials have been completed with more patients under strict experimental conditions. 122
Hypnosis and Pain in Burn Patients Contrary to the other fields of application discussed so far, hypnosis has been documented’extensively in the psychologic laboratory as a method of alleviating (experimentally induced) pain [34]. This effect is clearly correlated to measured hypnotizability. As mentioned above, the effectiveness of hypnosis with bum patients was first described by Crasilneck et al. [2]. Case studies have since been published regularly, in which hypnosis was used for obtaining pain reduction in both adults [10,14,16,18,20,25] and children [6,7,17]. Only two studies have a fair number of patients. Schafer [26] reported the successful use of hypnosis in 14 of 20 treated patients. Five of the six failures were children. Total body surface area (TBSA, second and third degree) varied from 18% to 80%. It is unfortunate that in this study estimates of both pain relief and hypnotic depth were essentially based on clinical judgments by the therapist. The Diagnostic Rating Scale (DRS) [38] that was used for hypnotic depth estimation is seldom used as a hypnotizability measure because of its low level of standardization. Furthermore, the DRS scores were contaminated with patients’ reports of the success of the intervention, which makes them of limited use in a scientific report. Wakeman and Kaplan [28] conducted a controlled experiment comparing a combination of hypnotherapy and medication (experimental treatment) with a combination of emotional support and medication (control treatment). Analgesic medication was available for these patients on demand, and was used as the pain index. Patients of two categories (O%-30% burns and 31%-60% burns) were randomly assigned to either treatment. For both categories of patients, significantly lower levels of medication were used (p < 0.01) by the experimental group than by the control group. The presence of a control group and the use of an objective index to measure pain make this study an important contribution. In our opinion the adequacy of the control treatment is the weaker part of the study. The possibility cannot be ruled out that patients in the experimental group might have been more willing to try and undergo a dressing change with less medication than usual because they were aware that they had received a treatment directly aimed at relieving their pain. Also, only the patients in the experimental group were asked
Hypnosis in the Care of Burn Patients
to sign an informed consent form. The emotional support for the control group involved extra time for talking about progress, family, and physical therapy issues, which was already part of the daily regular treatment program in all patients. The combined use of objective and subjective pain measurement methods may clarify this issue of demand characteristics. It would also be advisable to use more standardized procedures for the experimental as well as for the control treatment. Patterson et al. [24] have recently reviewed these studies on hypnosis and pain in burn patients. They correctly conclude that the effectiveness of hypnosis is generally supported by the literature, but that little else can be concluded, because of the poor description of patients, methods, and procedures that are provided with almost all articles. The importance of better controlled and clearly described studies is emphasized in a recent report by Van der Does et al. [39]. In this small pilot study it was shown that the value of case reports is considerably enhanced by gathering subjective as well as objective data. In some instances the subjective data in this study (clinical judgment, patient’s report) were in conflict with the more objective data (medication use, daily pain ratings). Systematic measurements not only provide more data but may also lead to different conclusions.
Conclusions In general, the tone of the reviewed studies is in line with the citations in the introduction of this article. Hypnosis is said to be a most valuable, clinically often impressive, method for relieving pain, reducing negative emotions, improving morale on the ward, and even enhancing burn wound healing in burn victims. Only a few studies report one or more patients who did not improve. A closer look at the literature reveals a lack of systematic and Most studies are illuscontrolled experiments. trated with case histories only, and rarely is an attempt made to measure any effects. No study is available with an assessment of hypnotizability using a standardized scale. Compared to the dramatic results suggested by anecdotal reports, attempts at systematic inquiries about the effects of hypnosis in burn patients produce more modest findings. In some instances there was a discrepancy between the data and the conclusions that were drawn from them. In summary, the following conclusions can be drawn:
The accounts of hypnosis in crisis intervention are appealing, and systematic studies in this area are needed. There is as yet no convincing experimental evidence for the effectiveness of hypnosis in attenuating burn depth and accelerating wound healing. Because of the enormous implications positive findings would have, these hypotheses deserve to be seriously studied in a controlled experiment. At present, the use of hypnosis in alleviating pain in bum patients seems to be the most promising area for application. It still remains to be demonstrated that this will be a specific rather than a general or placebo effect. The importance of systematic and controlled research on hypnosis in the treatment of burns should be stressed. In our opinion, future studies should fulfill the following requirements: Clear definition
of the target symptom(s)
Description of the hypnotic wording and timing An adequate
suggestions-type,
control group
Standardization of the hypnotic and control treatment, within the limits of clinical feasibility Careful registration of the extent of bum damage and of medication use Measurement of patients’ standardized test.
hypnotizability
with a
In general, a closer working relationship between clinicians and researchers is essential to arrive at meaningful and reproducible results. The comments of R. E. Spijker, M.D., article are gratefully acknowledged.
on an earlier version of this
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