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Tape recorded hypnosis in oral and maxillofacial surgery—basics and first clinical experience
ARTICLE IN PRESS Journal of Cranio-Maxillofacial Surgery (2005) 33, 123–129 r 2004 European Association for Cranio-Maxillofacial Surgery doi:10.1016/j.jcms.2004.06.009, available online at http://www.sciencedirect.com
Tape recorded hypnosis in oral and maxillofacial surgery—basics and first clinical experience Dirk HERMES, Daniel TRUEBGER, Samer George HAKIM, Peter SIEG Department of Maxillofacial Surgery (Prov. Head: Prof. Dr. Dr. P. Sieg), University Hospital SchleswigHolstein/Campus Luebeck, Ratzeburger Allee 160, 23538 Luebeck, Germany Available online 26 January 2005
Background: Surgical treatment of diseases of the oral and maxillofacial region under local anaesthesia is quite commonly restricted by limited patient compliance. ‘Medical Hypnosis’ could be an alternative to treatment under pharmacological sedation. With this method, both autosuggestive and other suggestive procedures are used for anxiolysis, relaxation, sedation and analgesia of the patient. The purpose of this paper was to see whether there could be any potential for this treatment when operating on oral and maxillofacial patients. Methods: During a 1-year-trial period, 209 operations under combined local anaesthesia/medical hypnosis were carried out on 174 non-preselected patients between the ages of 13 and 87 years. The surgical range covered oral, plastic and reconstructive, oncological, septic and trauma operations. Results: Medical hypnosis turned out to be a reliable and standardizable method with high patient compliance. Remarkable improvements in treatment conditions for both patient and surgeons were achieved in 93% of cases. Conclusion: Controlled clinical studies are now necessary to obtain objective data on the effectiveness of hypnosis-induced intraoperative effects in oral and maxillofacial surgery. r 2004 European Association for Cranio-Maxillofacial Surgery
SUMMARY.
Keywords: Oral and maxillofacial surgery; Medical hypnosis; Anxiolysis; Sedation
This is a report on the relevant fundamentals of medical hypnosis in clinical medicine and on the first clinical results achieved in this department.
INTRODUCTION Surgical therapy in the oral and maxillofacial field using local anaesthesia is an equally challenging prospect for both patient and surgeon. It demands a high degree of co-operation from the patient and is for many people a source of great anxiety (Fassbind, 1983; Faymonville et al., 1999; Schuetz and Freigang, 2000). To achieve satisfactory treatment conditions for patient and surgeon, procedures capable of being carried out under local anaesthesia are often performed in combination with pharmacological sedation or even under general anaesthesia. Hypnosis represents a theoretical alternative to this. This suggestive procedure (Greek: hypnos, god of sleep; Latin: somnus; Old Indian: svapnas, dream, sleep) has currently found some success not only in psychotherapy but in somatic medicine as well (Brown and McInnes, 1986; Finkelstein, 1991; Faymonville et al., 1999; Lynch, 1999). Its use is widely accepted nowadays within modern dental medicine (Reindl, 1986; Finkelstein, 1991; Stern, 1991; Schmierer and Kunzelmann, 1993; Schuetz and Freigang, 2000). After clinical studies confirmed the effectiveness of hypnotic recordings used in oral and maxillofacial procedures under conscious sedation or general (anaesthesia) (Enquist et al., 1995; Enquist and Fischer, 1997; Ghoneim et al., 2000), repeat studies on the therapeutic efficiency of the procedure on locally anaesthetized patients seemed appropriate.
BASICS Trance In a normal waking condition, a variety of visual, acoustic, kinaesthetic, olfactory and gustatory stimuli are simultaneously perceived (‘V.A.K.O.G. scheme’). After comparing and aligning these stimuli with previous personal experience, conscious perception of such stimuli is achieved. Just as physiological is the condition of a highly attentive and focused concentration on a strongly reduced number of stimuli, which enable the individual to perform highly specialized activities (e.g. surgical operations). Modification of the waking condition, accomplished by active mental focussing while gradually fading out other stimuli simultaneously is defined as a trance (Stern, 1991; Schmierer and Kunzelmann, 1993). Hypnosis Janet (1925) was the first to observe that the various personalities and conditions of hysterics could be split into various entities. This could in turn be externally accessed in co-operative patients for 123
ARTICLE IN PRESS 124 Journal of Cranio-Maxillofacial Surgery
therapeutic purposes (‘dissociation theory’; Reindl, 1986). As an analogy to this phenomenon, the totality of external working intervention from which the desired modification in consciousness results is nowadays defined as hypnosis (‘neo-dissociation theory’; Kossack, 1993). The English ophthalmologist James Braid coined the term ‘hypnosis’ in 1843 to emphasize the similarities between a hypnotized person and someone who is asleep (Braid, 1843). Actually, a patient in a hypnotic trance is completely conscious and capable of active and complex processing of perceptions and experiences (Kossack, 1993). However, the patient is highly reactive and sensible to individual or collective suggestions (Erickson, 1958). Therapeutic external suggestions are accepted more easily than in a waking condition (Tucker and Virnelli, 1985) and answered by corresponding behavioural changes (Khalil, 1969). Medical hypnosis In psychotherapy, hypnotic behavioural modification as a solution for psychological conflicts lies at the centre of the therapeutic interests. For this, ‘medical hypnosis’ for specialized auto- and external suggestive procedures comes into use, which was developed by the American psychologist and psychiatrist Milton H. Erickson. It is used exclusively for anxiolytic purposes, relaxation, sedation and, ideally, analgesia during medical procedures (Khalil, 1969; Brown and McInnes, 1986; Revenstorf, 1993; Faymonville et al., 1999). As a clinically pragmatic alternative to ‘Live Hypnosis’ which is closely connected to the hypnotherapist, specially designed tape recordings were developed and are now available. They combine
relaxing music and the induction, deepening and termination of medical hypnosis by a hypnotherapist (‘Tape Recorded Hypnosis’). As such tapes consist of several ‘takes’, each with defined purposes, the length and characteristics of intraoperative hypnosis can be adjusted to suit the surgical measures. Trance ability and clinical signs of hypnotic trance Although even to this day a scientific explanation for the change in consciousness occurring during hypnosis has not been found (Eberwein and Schuetz, 1997), the techniques formulated by Erickson successfully induce various degrees of hypnotic trance (Kretschmer, 1946; Khalil, 1969) in 80–90% of patients (Brown and McInnes, 1986; Schuetz and Freigang, 2000) regardless of age (Tucker and Virnelli, 1985). Various subtle but definite trance stages and their corresponding physical symptoms make a clinical estimate of the degree of change in consciousness possible (Table 1). Relative and definite contraindications for medical hypnosis Factors which make the effect of intraoperative hypnosis unpredictable are to be seen in lack of compliance concerning surgery and/or hypnosis, communication problems (e.g. poor knowledge of language, hearing defects) and mental disabilities which cause a lack of ability to concentrate and imagine. Definite contraindications for medical (and not psychological) hypnotherapy are affective or posttraumatic disorders, borderline personality disorders, manifest psychiatric diseases and history of
Table 1 – Objective symptoms and subjective experience of hypnotic trance Depth Hypnoidal Before closure of eyes After closure of eyes
Objective symptoms
Subjective experience
Light physical relaxation Fixation of view Dilatation of pupils Rapid eye movements (REM) Fluttering of eyelids Complete physical relaxation
Sleepiness Heaviness of eyelids Mental relaxation Heaviness of limbs Verbal inhibition
Light trance
Decrease of REM, catalepsy of eyes Delayed reactions Rigid catalepsy Analgesia possible
Motor inhibition, catalepsy of limbs Time distortion
Medium trance
Partial amnesia Post-hypnotic anaesthesia Personality changes Simple post-hypnotic suggestions possible
Complete catalepsy Positive regression Ignorance of outer stimuli Kinaesthetic delusions Complete amnesia
Somnambulistic trance
Ability to open eyes without affecting trance Dilatation of pupils while eyes open Complete somnambulism Surgical anaesthesia possible
Positive post-hypnotic visual/auditory hallucinations Systematised post-hypnotic amnesia
Local anaesthesia (e.g. Glove anaesthesia)
According to Davis and Husband, 1931; Khalil, 1969; Brown and McInnes, 1986; Kossack, 1993; Revenstorf, 1993; Schmierer and Kunzelmann, 1993; Schmierer, 2001.
ARTICLE IN PRESS Tape recorded hypnosis in oral and maxillofacial surgery 125
drug abuse (Kossack, 1993; Revenstorf, 1993; Faymonville et al., 1999; Schmierer, 2001).
MATERIAL AND METHODS The Department of Maxillofacial Surgery of the University Hospital Schleswig-Holstein/Campus Luebeck has established the intraoperative application of medical hypnosis for both in- and out-patient care in 2002. An initial 1-year-clinical testing period attempted to determine the acceptance of medical hypnosis in a current treatment situation and furthermore the extent to which medical hypnosis can be applied in the field as a practicable and efficient therapy option for intraoperative stress reduction and improved treatment modalities. Patient acquisition A brochure placed in the waiting-rooms of the department gave patients interested in hypnosis a first standardized information. Patients then were medically examined and counselled on an individual basis. If personal interest in the combined method of treatment (local anaesthesia and medical hypnosis) was expressed by patients and when specially trained surgeons were available, an explanation of the surgical procedure was given along with a detailed explanation regarding hypnosis and the primary study. Exclusion criteria for study patients were checked. Due to the general aim of the study, no further preselection of patients took place. In particular, no testing of individual acceptance of hypnosis or hypnotic susceptibility was undertaken. Hypnosis After completion of the surgical preparation, patients included in the study received standardized and operating theatre-oriented prehypnotic ‘seedings’. Integral to hypnosis, this preparative technique establishes expectations and behavioural patterns of the patient that will be referred to during the procedure. Positive formulations on several aspects of treatment (e.g. intraoperative sensations, painful and other unpleasant stimuli, postoperative restrictions) were used to reduce preoperative anxiety. Positive and relaxing hypnotic suggestions such as the imagination of ‘a day’s holiday on the beach’ led patients to distance themselves from surgery. All preoperative hypnosis preparations were performed by one surgeon/hypnotherapist. To minimize the therapeutic effort and the influence of surgeons on the combined therapy, standardized ‘Tape Recorded Hypnosis’ was exclusively used for patients participating in this first systematic evaluation of the therapy. Following the pattern of similar studies (Enquist et al., 1995; Enquist and Fischer, 1997; Ghoneim et al., 2000), all patients were given standardized hypnosis by means of a
compact disc (CD Schmierer, 1995) which showed significant anxiolytic effects in a dental treatment situation (Schmierer et al., 1999). Patients were instructed to listen to the CD twice between the preoperative appointment and operation. Surgery under hypnosis On the day of the operation, the standardized seedings were repeated directly before the start of surgery. Hypnosis was induced by a portable CD player (Sony D-E221), headphones (Sony MDR-301, Philipps SBC HP 840) and hypnosis CD (Fig. 1). According to the literature on hypnosis the use of sole hypnoanaesthesia for surgical purposes is timeconsuming and limited to highly susceptible individuals, complete abstinence from pharmacological anaesthesia was not considered worthwhile. Consequently, all patients received local anaesthesia by means of articain (Ultracain DS fortes, Aventis Pharma, Frankfurt) in regular initial doses. Depending on patient request, local anaesthesia was given either before or after induction of hypnosis. Once objective signs of an hypnotic trance had been clinically determined (Table 1), surgery started without further communication with the patient (Figs. 2–4). After completion of the operation, standardized re-orientation of the patient by the ‘dehypnosis’ tracks of the CD was accomplished. Evaluation of treatment Interviews with patients and surgeons were held 30 min after surgical treatment. Patients were questioned about their intraoperative feelings and surgical experience. Surgeons were asked to report on objective trance signs of their patients and assess treatment modalities. Combined treatment (local anaesthesia/medical hypnosis) was classified as ‘a therapeutic success’ on behalf of the patient, if
Fig. 1 – Induction of medical hypnosis in the operating theatre.
ARTICLE IN PRESS 126 Journal of Cranio-Maxillofacial Surgery
perioperative stress and anxiety were significantly reduced in comparison with former experiences or individual expectations.
Combined treatment was classified ‘successful’ on behalf of surgeons, if
objective signs of trance were observed throughout surgery, good or excellent treatment conditions were achieved.
Combined treatment was classified ‘successful’ on behalf of patient and surgeon, if
Fig. 2 – Multiple dental extractions on a phobic patient.
signs of hypnotic trance were individually experienced and objectively observed before and throughout surgery, enduring and significant improvement of treatment conditions for both patient and surgeon was achieved.
RESULTS
Fig. 3 – Resection of basal cell carcinoma of the nose under medical hypnosis.
Fig. 4 – Cheek rotation flap for closure of a defect of the lower lid and cheek under medical hypnosis.
hypnosis-induced phenomena known from preoperative information were continually experienced during surgery,
Participants of this primary study showed a high degree of acceptance of medical hypnosis as an adjuvant during oral and maxillofacial operations. Only five patients of the non-preselected study group refused to undergo the combined procedure after receiving standardized information. Seven other operations were cancelled by surgeons after learning of existing mental disorders of the patients. Within 1-year, a total of 209 procedures under medical hypnosis were carried out on 174 patients between the ages of 13 and 87 years (Table 2). Evaluation of patients’ and surgeons’ assessment of the combined therapy showed no negative effects of the oral and maxillofacial treatment situation on individual susceptibility and trance ability of the study group. Eight patients (3.8%) did not experience any personal benefit from the combined treatment and did not show any objective signs of trance (therapeutic failure). Four more patients (1.8%) with severe anxiety of treatment indicated objective signs of trance and were treated under good surgical conditions, but experienced no subjective relief of anxiety from the therapy. In all other operations (n ¼ 197; 94.3%), success criteria for patient and surgeon were met. Patients in this group indicated subjective feelings and objective signs of hypnoidal to medium trance (Table 1). Along with marked relaxation and inhibited motor skills, increased tolerance towards physically invasive surgery was particularly noticeable. Active co-operation, along with the option for complete re-orientation at any time, was seen as very helpful in the case of any necessary changes in the surgical procedure (e.g. intraoperative X-ray). Overall improved surgical experience was especially noticeable in patients preoperatively showing severe treatment anxiety.
ARTICLE IN PRESS Tape recorded hypnosis in oral and maxillofacial surgery 127 Table 2 – Oral and maxillofacial surgery and medical hypnosis—surgical range Number of patients Patients with multiple procedures
174 26
Oral surgery (per tooth) Surgical removal of teeth Dental extraction Apicectomy Cystectomy
160 99 42 5
Traumatology Removal of intermaxillary fixation Replantation/fixation of teeth Removal of osteosynthesis material Intermaxillary fixation Septic surgery Incision and drainage of abscess, intraorally Incision and drainage of abscess, extraorally
15 2 2 1
4 1
During postoperative interviews patients reported noticeable relaxation, anxiolysis, and a general feeling of mental distance from the surgical situation. Although some patients experienced temporary pain, subjective distancing from the procedure meant that hardly any patient required additional doses of local anaesthetic. As a result of the typical time distortion occurring from the hypnotic trance, duration of surgery was estimated as being much shorter by the overwhelming majority of patients. A series of patients could only remember parts of the procedure due to the amnesic effects of hypnosis, while five patients did not remember surgery at all. All patients having a positive trance experience would consent to another operation performed under medical hypnosis. Twenty six patients in this group had multiple procedures (2–5) under combined local anaesthesia/medical hypnosis during the study period. On the surgeon’s side, the specific effects of hypnosis improved treatment modalities significantly. Patients with a history of severe treatment anxiety could usually be operated under local anaesthesia. In selected cases, major surgery on susceptible patients at high risk from general anaesthesia was possible with an anaesthetist standing-by. Nevertheless, the special requirements for hypnotic treatment (e.g. consistent reduction of noise and moving inside the operating theatre) initially required serious restructuring of treatment sequences. The necessity of time and cost-intensive training limited the use of this therapeutic option in the daily routine. For brief procedures (e.g. extractions performed on patients with severe treatment anxiety), good therapy conditions were provided through extended preoperative preparation time using hypnosis. In direct comparison with other surgical treatments, a further small but specific disadvantage of the use of medical hypnosis in oral and maxillofacial surgery became evident. Patients had to endure intraoperative stimuli such as movement during tooth
Procedures in total Duration of procedures
209 04–135 min
Plastic and reconstructive surgery Closure of tracheostomy Closure of extensive wounds Skin grafting Correction of ectropion Secondary trimming of flap Correction of facial scars Cheek rotation flap Bilobed flap
5 5 4 4 4 2 1 1
Oncological surgery Excision of basal cell carcinoma, lid/cheek Lateral parotidectomy Excision of squamous cell carcinoma, lip Intraoral resection Excision of basal cell carcinoma, nose
7 3 3 2 1
extraction and/or low-frequency noise or vibrations (e.g. due to drilling). Neither active hypnosis nor hypnotic recordings adequately shielded the patient from such irritants. Consequently, such stimuli (at least with first-time application) regularly led to a short-lived re-orientation with a remission of the hypnotic trance. Interestingly, the majority of patients could not recall such a reaction after surgery.
DISCUSSION Parallel with other surgical and technical developments in oral and maxillofacial surgery, improving patient comfort and addressing severe treatment anxiety is increasingly important (Desjardins, 2000). Several therapy options are available nowadays, all with pros and cons. All the pharmacological methods (premedication, sedation, general anaesthesia) have disadvantages such as technical requirements, pharmacological side effects and extra costs of recovery and admission etc. Reaching the limits of a patient’s active co-operation can particularly complicate oral surgery. A therapeutically helpful and enduring reduction of treatment anxiety is only achievable by non-pharmacological, primarily anxiolytic methods (De Jongh et al., 1995; Joehren et al., 2000). Non-pharmacological methods for reducing treatment anxiety such as psychotherapeutic intervention, acupuncture, audioanalgesia have only come with limited use due to a lack of acceptance, therapeutic dependence on other methods and time-consuming implementation. It can be concluded that a rational, widely accepted method free of side effects to improve surgical conditions is currently not in use. Hypnosis is such an option. It has been used in various surgical fields (Blankfield, 1991; Montgomery et al., 2002) and dentistry (Schmierer, 2001) for at least 50 years. Although numerous case reports and clinical studies
ARTICLE IN PRESS 128 Journal of Cranio-Maxillofacial Surgery
illustrate its theoretical potential, it has to date been used and investigated very little in oral and maxillofacial surgery. Three clinical studies have been published, designed by orthodontists and anaesthetists (Enquist et al., 1995; Enquist and Fischer, 1997) or by a maxillofacial surgeon with anaesthetists and psychologists (Ghoneim et al., 2000). Enquist et al. (1995) demonstrated significant effects of pre- and intraoperative Tape Recorded Hypnosis (lowered intraand postoperative blood pressure and blood loss) of a study group which underwent bimaxillary osteotomies under general anaesthesia. Enquist and Fischer (1997) showed that a similar technique significantly reduced intraoperative treatment anxiety and postoperative consumption of analgesics after surgical removal of third molars under local anaesthesia. Ghoneim et al. (2000) described identical anxiolytic effects of preoperative Tape Recorded Hypnosis in an experimental study groups. Those patients underwent dental extractions or surgical removal of teeth under local anaesthesia and conscious sedation (fentanyl, midazolam, nitrous oxide). There was an unexplained significant increase of postoperative vomiting in the experimental group. The intention of our preliminary investigations was to gain information about the effects of standardized hypnosis during a wider range of oral and maxillofacial operations on locally anaesthetized and non-sedated patients. The basic questions were, (1) how far subjective and clinical effects of such a procedure justify its increased application and (2) would an evaluation by controlled clinical studies be worthwhile. In this respect, systematic applications of medical hypnosis in this department indicated interesting perspectives. Medical hypnosis is a suggested procedure for perioperative stress reduction, showing a high degree of theoretical (Hermes and Sieg, 2002) and practical patient compliance. Procedural standardization for special purposes (e.g. Tape Recorded Hypnosis vs. Live Hypnosis) minimizes changes needed in the surgical setting and reduces variables in the design of clinical studies. Meta-analysis of the adjunctive use of hypnosis in surgery (Montgomery et al., 2002) proved that such standardization does not reduce the effectiveness of hypnosis. Results of our primary maxillofacial study support this thesis as the data matches the reported success rates of intraoperative hypnosis (Brown and McInnes, 1986; Schuetz and Freigang, 2000; Tucker and Virnelli, 1985). Furthermore, it shows that the specific treatment situation in oral and maxillofacial surgery does not reduce trance ability and intensity for patients. Positive intraoperative effects of hypnosis include sedation, anxiolysis, inhibited motor skills and increased tolerance towards physically and psychologically demanding surgical procedures. Overall preparation time (information, seedings and induction) is approximately 15 min, complete postoperative reorientation of the patient within less than 1 min and low technical costs are further advantages of
hypnosis when compared with established pharmacological procedures. Nevertheless, hypnosis cannot serve as a serious substitute for sedation or general anaesthesia. Specific limitations and contraindications have to be considered, detailed knowledge of surgeons, individual patient preparation and special treatment modalities are necessary. Its therapeutic use is limited to mentally healthy and fully co-operative patients who are at least open to the procedure.
CONCLUSION A 1-year-trial period of clinical testing showed intraoperative hypnosis to be an interesting supplementation to anxiolytic pharmacological procedures. The indication for its adjuvant use during oral and maxillofacial operations was steadily expanded and its application intensified. The effects of medical hypnosis for both patient and surgeon require further clinical studies.
References Blankfield RP: Suggestion, relaxation, and hypnosis as adjuncts in the care of surgery patients: a review of the literature. Am J Clin Hypn 33: 172–186, 1991 Braid J: Neurohypnology. J. Churchill, London, 1843 Brown H, McInnes D: Hypnosis and its effects on pain control. Brit Dent J 161: 222–225, 1986 Davis LW, Husband RW: A study of hypnotic susceptibility. J Abnorm Psychol 26: 175–182, 1931 De Jongh A, Muris P, Ter Horst G, Van Zuuren F, Schoenmakers N, Makkes P: One-session treatment of dental phobia: preparing dental phobics for treatment by reconstructuring negative cognitions. Behav Res Ther 33: 947–954, 1995 Desjardins PJ: Patient pain and anxiety: the medical and psychological challenges facing oral and maxillofacial surgery. J Oral Maxillofac Surg 58: (Suppl. 2), 1–3, 2000 Eberwein E, Schuetz G: Die Kunst der Hypnose. Dialog mit dem Unbewussten. Junfermann, Paderborn, 1997 Enquist B, Fischer K: Preoperative hypnotic techniques reduce consumption of analgesics after surgical removal of third mandibular molars: a brief communication. Int J Clin Exp Hypn 45: 102–108, 1997 Enquist B, von Konow L, Bystedt H: Pre- and postoperative suggestion in maxillofacial surgery: effects on blood loss and recovery. Int J Clin Exp Hypn 43: 284–294, 1995 Erickson MH: Hypnosis in painful terminal illness. Am J Clin Hypn 1: 117–121, 1958 Fassbind O: Zahna¨rztliche Indikationen fu¨r Hypnose. Schweiz Mschr Zahnheilk 93: 375–376, 1983 Faymonville ME, Meurisse M, Fissette J: Hypnosedation: a valuable alternative to traditional anaesthetic techniques. Acta Chir Belg 4: 141–146, 1999 Finkelstein S: Hypnotically assisted preparation of the anxious patient for medical and dental treatment. Am J Clin Hypn 33: 187–191, 1991 Ghoneim MM, Block RI, Sarasin DS, Davis CS, Marchman JN: Tape-recorded hypnosis instructions as adjuvant in the care of patients scheduled for third molar surgery. Anesth Analg 90: 64–68, 2000 Hermes D, Sieg P: Zahna¨rztliche Hypnose bei oralchirurgischen Patienten. Zahnaerztl Mitt 92: 2296–2301, 2002 Janet P: Psychological healing. A historical study. Crowell-Collier and MacMillan, New York, 1925
ARTICLE IN PRESS Tape recorded hypnosis in oral and maxillofacial surgery 129 Joehren P, Thom A, Jackowski J, Sartory G, Gaengler P: Fear reduction in patients with dental treatment phobia. Br J Oral Maxillofac Surg 38: 612–616, 2000 Khalil GA: Hypnosis in surgery—why and when. South Med J 69: 1466–1468, 1969 Kossack HC: Hypnose. in: Handbuch der Entspannungsverfahren, Vol 1: . Beltz Psychologie Verlagsunion, Weinheim, 1993 Kretschmer E: Ueber gestufte Aktivhypnose. Dtsch Med Wschr 29: 232–262, 1946 Lynch Jr. DF: Empowering the patient: hypnosis in the management of cancer, surgical disease and chronic pain. Am J Clin Hypn 42: 122–130, 1999 Montgomery GH, David D, Winkel G, Silverstein JH, Bovberg DH: The effectiveness of adjunctive hypnosis with surgical patients: a meta-analysis. Anesth Analg 94: 1639–1645, 2002 Reindl V: Selbsthypnose in der Zahnmedizin. Exp Klin Hypn 2: 143, 1986 Revenstorf D: Klinische Hypnose. Springer, Heidelberg, 1993 Schmierer A: Beim Zahnarzt ganz entspannt. CD. Hypnos, Stuttgart, 1995 Schmierer A: Einfuehrung in die Zahna¨rztliche Hypnose. Quintessenz, Berlin, 2001
Schmierer A, Kunzelmann KH: Hypnose in der Zahnheilkunde. in: Klinische Hypnose. Springer, Berlin, pp. 393–420, 1993 Schmierer A, Hautkappe HJ, Maldoff G: Untersuchungen zur Anwendung eines Hypnosetonbandes in einer zahna¨rztlichen Praxis. HyKog 16: 111–119, 1999 Schuetz G, Freigang H: Zahna¨rztliche Hypnose. Hypnos, Stuttgart, 2000 Stern R: Medizinische Hypnose in der Zahnmedizin. Schw Mschr Zahnmed 101: 467–471, 1991 Tucker KR, Virnelli FR: The use of hypnosis as a tool in plastic surgery. Plast Reconstr Surg 76: 140–146, 1985
Dirk HERMES, MD, DMD, Department of Maxillofacial Surgery, University Hospital Schleswig-Holstein/Campus Luebeck, Ratzeburger Allee 160, 23538 Luebeck, Germany. Tel.: +49 451 500 2269; Fax: +49 451 500 4188. E-mail: [email protected] Paper received 10 July 2003 Accepted 21 June 2004
Tape recorded hypnosis in oral and maxillofacial surgery—basics and first clinical experience Dirk HERMES, Daniel TRUEBGER, Samer George HAKIM, Peter SIEG Department of Maxillofacial Surgery (Prov. Head: Prof. Dr. Dr. P. Sieg), University Hospital SchleswigHolstein/Campus Luebeck, Ratzeburger Allee 160, 23538 Luebeck, Germany Available online 26 January 2005
Background: Surgical treatment of diseases of the oral and maxillofacial region under local anaesthesia is quite commonly restricted by limited patient compliance. ‘Medical Hypnosis’ could be an alternative to treatment under pharmacological sedation. With this method, both autosuggestive and other suggestive procedures are used for anxiolysis, relaxation, sedation and analgesia of the patient. The purpose of this paper was to see whether there could be any potential for this treatment when operating on oral and maxillofacial patients. Methods: During a 1-year-trial period, 209 operations under combined local anaesthesia/medical hypnosis were carried out on 174 non-preselected patients between the ages of 13 and 87 years. The surgical range covered oral, plastic and reconstructive, oncological, septic and trauma operations. Results: Medical hypnosis turned out to be a reliable and standardizable method with high patient compliance. Remarkable improvements in treatment conditions for both patient and surgeons were achieved in 93% of cases. Conclusion: Controlled clinical studies are now necessary to obtain objective data on the effectiveness of hypnosis-induced intraoperative effects in oral and maxillofacial surgery. r 2004 European Association for Cranio-Maxillofacial Surgery
SUMMARY.
Keywords: Oral and maxillofacial surgery; Medical hypnosis; Anxiolysis; Sedation
This is a report on the relevant fundamentals of medical hypnosis in clinical medicine and on the first clinical results achieved in this department.
INTRODUCTION Surgical therapy in the oral and maxillofacial field using local anaesthesia is an equally challenging prospect for both patient and surgeon. It demands a high degree of co-operation from the patient and is for many people a source of great anxiety (Fassbind, 1983; Faymonville et al., 1999; Schuetz and Freigang, 2000). To achieve satisfactory treatment conditions for patient and surgeon, procedures capable of being carried out under local anaesthesia are often performed in combination with pharmacological sedation or even under general anaesthesia. Hypnosis represents a theoretical alternative to this. This suggestive procedure (Greek: hypnos, god of sleep; Latin: somnus; Old Indian: svapnas, dream, sleep) has currently found some success not only in psychotherapy but in somatic medicine as well (Brown and McInnes, 1986; Finkelstein, 1991; Faymonville et al., 1999; Lynch, 1999). Its use is widely accepted nowadays within modern dental medicine (Reindl, 1986; Finkelstein, 1991; Stern, 1991; Schmierer and Kunzelmann, 1993; Schuetz and Freigang, 2000). After clinical studies confirmed the effectiveness of hypnotic recordings used in oral and maxillofacial procedures under conscious sedation or general (anaesthesia) (Enquist et al., 1995; Enquist and Fischer, 1997; Ghoneim et al., 2000), repeat studies on the therapeutic efficiency of the procedure on locally anaesthetized patients seemed appropriate.
BASICS Trance In a normal waking condition, a variety of visual, acoustic, kinaesthetic, olfactory and gustatory stimuli are simultaneously perceived (‘V.A.K.O.G. scheme’). After comparing and aligning these stimuli with previous personal experience, conscious perception of such stimuli is achieved. Just as physiological is the condition of a highly attentive and focused concentration on a strongly reduced number of stimuli, which enable the individual to perform highly specialized activities (e.g. surgical operations). Modification of the waking condition, accomplished by active mental focussing while gradually fading out other stimuli simultaneously is defined as a trance (Stern, 1991; Schmierer and Kunzelmann, 1993). Hypnosis Janet (1925) was the first to observe that the various personalities and conditions of hysterics could be split into various entities. This could in turn be externally accessed in co-operative patients for 123
ARTICLE IN PRESS 124 Journal of Cranio-Maxillofacial Surgery
therapeutic purposes (‘dissociation theory’; Reindl, 1986). As an analogy to this phenomenon, the totality of external working intervention from which the desired modification in consciousness results is nowadays defined as hypnosis (‘neo-dissociation theory’; Kossack, 1993). The English ophthalmologist James Braid coined the term ‘hypnosis’ in 1843 to emphasize the similarities between a hypnotized person and someone who is asleep (Braid, 1843). Actually, a patient in a hypnotic trance is completely conscious and capable of active and complex processing of perceptions and experiences (Kossack, 1993). However, the patient is highly reactive and sensible to individual or collective suggestions (Erickson, 1958). Therapeutic external suggestions are accepted more easily than in a waking condition (Tucker and Virnelli, 1985) and answered by corresponding behavioural changes (Khalil, 1969). Medical hypnosis In psychotherapy, hypnotic behavioural modification as a solution for psychological conflicts lies at the centre of the therapeutic interests. For this, ‘medical hypnosis’ for specialized auto- and external suggestive procedures comes into use, which was developed by the American psychologist and psychiatrist Milton H. Erickson. It is used exclusively for anxiolytic purposes, relaxation, sedation and, ideally, analgesia during medical procedures (Khalil, 1969; Brown and McInnes, 1986; Revenstorf, 1993; Faymonville et al., 1999). As a clinically pragmatic alternative to ‘Live Hypnosis’ which is closely connected to the hypnotherapist, specially designed tape recordings were developed and are now available. They combine
relaxing music and the induction, deepening and termination of medical hypnosis by a hypnotherapist (‘Tape Recorded Hypnosis’). As such tapes consist of several ‘takes’, each with defined purposes, the length and characteristics of intraoperative hypnosis can be adjusted to suit the surgical measures. Trance ability and clinical signs of hypnotic trance Although even to this day a scientific explanation for the change in consciousness occurring during hypnosis has not been found (Eberwein and Schuetz, 1997), the techniques formulated by Erickson successfully induce various degrees of hypnotic trance (Kretschmer, 1946; Khalil, 1969) in 80–90% of patients (Brown and McInnes, 1986; Schuetz and Freigang, 2000) regardless of age (Tucker and Virnelli, 1985). Various subtle but definite trance stages and their corresponding physical symptoms make a clinical estimate of the degree of change in consciousness possible (Table 1). Relative and definite contraindications for medical hypnosis Factors which make the effect of intraoperative hypnosis unpredictable are to be seen in lack of compliance concerning surgery and/or hypnosis, communication problems (e.g. poor knowledge of language, hearing defects) and mental disabilities which cause a lack of ability to concentrate and imagine. Definite contraindications for medical (and not psychological) hypnotherapy are affective or posttraumatic disorders, borderline personality disorders, manifest psychiatric diseases and history of
Table 1 – Objective symptoms and subjective experience of hypnotic trance Depth Hypnoidal Before closure of eyes After closure of eyes
Objective symptoms
Subjective experience
Light physical relaxation Fixation of view Dilatation of pupils Rapid eye movements (REM) Fluttering of eyelids Complete physical relaxation
Sleepiness Heaviness of eyelids Mental relaxation Heaviness of limbs Verbal inhibition
Light trance
Decrease of REM, catalepsy of eyes Delayed reactions Rigid catalepsy Analgesia possible
Motor inhibition, catalepsy of limbs Time distortion
Medium trance
Partial amnesia Post-hypnotic anaesthesia Personality changes Simple post-hypnotic suggestions possible
Complete catalepsy Positive regression Ignorance of outer stimuli Kinaesthetic delusions Complete amnesia
Somnambulistic trance
Ability to open eyes without affecting trance Dilatation of pupils while eyes open Complete somnambulism Surgical anaesthesia possible
Positive post-hypnotic visual/auditory hallucinations Systematised post-hypnotic amnesia
Local anaesthesia (e.g. Glove anaesthesia)
According to Davis and Husband, 1931; Khalil, 1969; Brown and McInnes, 1986; Kossack, 1993; Revenstorf, 1993; Schmierer and Kunzelmann, 1993; Schmierer, 2001.
ARTICLE IN PRESS Tape recorded hypnosis in oral and maxillofacial surgery 125
drug abuse (Kossack, 1993; Revenstorf, 1993; Faymonville et al., 1999; Schmierer, 2001).
MATERIAL AND METHODS The Department of Maxillofacial Surgery of the University Hospital Schleswig-Holstein/Campus Luebeck has established the intraoperative application of medical hypnosis for both in- and out-patient care in 2002. An initial 1-year-clinical testing period attempted to determine the acceptance of medical hypnosis in a current treatment situation and furthermore the extent to which medical hypnosis can be applied in the field as a practicable and efficient therapy option for intraoperative stress reduction and improved treatment modalities. Patient acquisition A brochure placed in the waiting-rooms of the department gave patients interested in hypnosis a first standardized information. Patients then were medically examined and counselled on an individual basis. If personal interest in the combined method of treatment (local anaesthesia and medical hypnosis) was expressed by patients and when specially trained surgeons were available, an explanation of the surgical procedure was given along with a detailed explanation regarding hypnosis and the primary study. Exclusion criteria for study patients were checked. Due to the general aim of the study, no further preselection of patients took place. In particular, no testing of individual acceptance of hypnosis or hypnotic susceptibility was undertaken. Hypnosis After completion of the surgical preparation, patients included in the study received standardized and operating theatre-oriented prehypnotic ‘seedings’. Integral to hypnosis, this preparative technique establishes expectations and behavioural patterns of the patient that will be referred to during the procedure. Positive formulations on several aspects of treatment (e.g. intraoperative sensations, painful and other unpleasant stimuli, postoperative restrictions) were used to reduce preoperative anxiety. Positive and relaxing hypnotic suggestions such as the imagination of ‘a day’s holiday on the beach’ led patients to distance themselves from surgery. All preoperative hypnosis preparations were performed by one surgeon/hypnotherapist. To minimize the therapeutic effort and the influence of surgeons on the combined therapy, standardized ‘Tape Recorded Hypnosis’ was exclusively used for patients participating in this first systematic evaluation of the therapy. Following the pattern of similar studies (Enquist et al., 1995; Enquist and Fischer, 1997; Ghoneim et al., 2000), all patients were given standardized hypnosis by means of a
compact disc (CD Schmierer, 1995) which showed significant anxiolytic effects in a dental treatment situation (Schmierer et al., 1999). Patients were instructed to listen to the CD twice between the preoperative appointment and operation. Surgery under hypnosis On the day of the operation, the standardized seedings were repeated directly before the start of surgery. Hypnosis was induced by a portable CD player (Sony D-E221), headphones (Sony MDR-301, Philipps SBC HP 840) and hypnosis CD (Fig. 1). According to the literature on hypnosis the use of sole hypnoanaesthesia for surgical purposes is timeconsuming and limited to highly susceptible individuals, complete abstinence from pharmacological anaesthesia was not considered worthwhile. Consequently, all patients received local anaesthesia by means of articain (Ultracain DS fortes, Aventis Pharma, Frankfurt) in regular initial doses. Depending on patient request, local anaesthesia was given either before or after induction of hypnosis. Once objective signs of an hypnotic trance had been clinically determined (Table 1), surgery started without further communication with the patient (Figs. 2–4). After completion of the operation, standardized re-orientation of the patient by the ‘dehypnosis’ tracks of the CD was accomplished. Evaluation of treatment Interviews with patients and surgeons were held 30 min after surgical treatment. Patients were questioned about their intraoperative feelings and surgical experience. Surgeons were asked to report on objective trance signs of their patients and assess treatment modalities. Combined treatment (local anaesthesia/medical hypnosis) was classified as ‘a therapeutic success’ on behalf of the patient, if
Fig. 1 – Induction of medical hypnosis in the operating theatre.
ARTICLE IN PRESS 126 Journal of Cranio-Maxillofacial Surgery
perioperative stress and anxiety were significantly reduced in comparison with former experiences or individual expectations.
Combined treatment was classified ‘successful’ on behalf of surgeons, if
objective signs of trance were observed throughout surgery, good or excellent treatment conditions were achieved.
Combined treatment was classified ‘successful’ on behalf of patient and surgeon, if
Fig. 2 – Multiple dental extractions on a phobic patient.
signs of hypnotic trance were individually experienced and objectively observed before and throughout surgery, enduring and significant improvement of treatment conditions for both patient and surgeon was achieved.
RESULTS
Fig. 3 – Resection of basal cell carcinoma of the nose under medical hypnosis.
Fig. 4 – Cheek rotation flap for closure of a defect of the lower lid and cheek under medical hypnosis.
hypnosis-induced phenomena known from preoperative information were continually experienced during surgery,
Participants of this primary study showed a high degree of acceptance of medical hypnosis as an adjuvant during oral and maxillofacial operations. Only five patients of the non-preselected study group refused to undergo the combined procedure after receiving standardized information. Seven other operations were cancelled by surgeons after learning of existing mental disorders of the patients. Within 1-year, a total of 209 procedures under medical hypnosis were carried out on 174 patients between the ages of 13 and 87 years (Table 2). Evaluation of patients’ and surgeons’ assessment of the combined therapy showed no negative effects of the oral and maxillofacial treatment situation on individual susceptibility and trance ability of the study group. Eight patients (3.8%) did not experience any personal benefit from the combined treatment and did not show any objective signs of trance (therapeutic failure). Four more patients (1.8%) with severe anxiety of treatment indicated objective signs of trance and were treated under good surgical conditions, but experienced no subjective relief of anxiety from the therapy. In all other operations (n ¼ 197; 94.3%), success criteria for patient and surgeon were met. Patients in this group indicated subjective feelings and objective signs of hypnoidal to medium trance (Table 1). Along with marked relaxation and inhibited motor skills, increased tolerance towards physically invasive surgery was particularly noticeable. Active co-operation, along with the option for complete re-orientation at any time, was seen as very helpful in the case of any necessary changes in the surgical procedure (e.g. intraoperative X-ray). Overall improved surgical experience was especially noticeable in patients preoperatively showing severe treatment anxiety.
ARTICLE IN PRESS Tape recorded hypnosis in oral and maxillofacial surgery 127 Table 2 – Oral and maxillofacial surgery and medical hypnosis—surgical range Number of patients Patients with multiple procedures
174 26
Oral surgery (per tooth) Surgical removal of teeth Dental extraction Apicectomy Cystectomy
160 99 42 5
Traumatology Removal of intermaxillary fixation Replantation/fixation of teeth Removal of osteosynthesis material Intermaxillary fixation Septic surgery Incision and drainage of abscess, intraorally Incision and drainage of abscess, extraorally
15 2 2 1
4 1
During postoperative interviews patients reported noticeable relaxation, anxiolysis, and a general feeling of mental distance from the surgical situation. Although some patients experienced temporary pain, subjective distancing from the procedure meant that hardly any patient required additional doses of local anaesthetic. As a result of the typical time distortion occurring from the hypnotic trance, duration of surgery was estimated as being much shorter by the overwhelming majority of patients. A series of patients could only remember parts of the procedure due to the amnesic effects of hypnosis, while five patients did not remember surgery at all. All patients having a positive trance experience would consent to another operation performed under medical hypnosis. Twenty six patients in this group had multiple procedures (2–5) under combined local anaesthesia/medical hypnosis during the study period. On the surgeon’s side, the specific effects of hypnosis improved treatment modalities significantly. Patients with a history of severe treatment anxiety could usually be operated under local anaesthesia. In selected cases, major surgery on susceptible patients at high risk from general anaesthesia was possible with an anaesthetist standing-by. Nevertheless, the special requirements for hypnotic treatment (e.g. consistent reduction of noise and moving inside the operating theatre) initially required serious restructuring of treatment sequences. The necessity of time and cost-intensive training limited the use of this therapeutic option in the daily routine. For brief procedures (e.g. extractions performed on patients with severe treatment anxiety), good therapy conditions were provided through extended preoperative preparation time using hypnosis. In direct comparison with other surgical treatments, a further small but specific disadvantage of the use of medical hypnosis in oral and maxillofacial surgery became evident. Patients had to endure intraoperative stimuli such as movement during tooth
Procedures in total Duration of procedures
209 04–135 min
Plastic and reconstructive surgery Closure of tracheostomy Closure of extensive wounds Skin grafting Correction of ectropion Secondary trimming of flap Correction of facial scars Cheek rotation flap Bilobed flap
5 5 4 4 4 2 1 1
Oncological surgery Excision of basal cell carcinoma, lid/cheek Lateral parotidectomy Excision of squamous cell carcinoma, lip Intraoral resection Excision of basal cell carcinoma, nose
7 3 3 2 1
extraction and/or low-frequency noise or vibrations (e.g. due to drilling). Neither active hypnosis nor hypnotic recordings adequately shielded the patient from such irritants. Consequently, such stimuli (at least with first-time application) regularly led to a short-lived re-orientation with a remission of the hypnotic trance. Interestingly, the majority of patients could not recall such a reaction after surgery.
DISCUSSION Parallel with other surgical and technical developments in oral and maxillofacial surgery, improving patient comfort and addressing severe treatment anxiety is increasingly important (Desjardins, 2000). Several therapy options are available nowadays, all with pros and cons. All the pharmacological methods (premedication, sedation, general anaesthesia) have disadvantages such as technical requirements, pharmacological side effects and extra costs of recovery and admission etc. Reaching the limits of a patient’s active co-operation can particularly complicate oral surgery. A therapeutically helpful and enduring reduction of treatment anxiety is only achievable by non-pharmacological, primarily anxiolytic methods (De Jongh et al., 1995; Joehren et al., 2000). Non-pharmacological methods for reducing treatment anxiety such as psychotherapeutic intervention, acupuncture, audioanalgesia have only come with limited use due to a lack of acceptance, therapeutic dependence on other methods and time-consuming implementation. It can be concluded that a rational, widely accepted method free of side effects to improve surgical conditions is currently not in use. Hypnosis is such an option. It has been used in various surgical fields (Blankfield, 1991; Montgomery et al., 2002) and dentistry (Schmierer, 2001) for at least 50 years. Although numerous case reports and clinical studies
ARTICLE IN PRESS 128 Journal of Cranio-Maxillofacial Surgery
illustrate its theoretical potential, it has to date been used and investigated very little in oral and maxillofacial surgery. Three clinical studies have been published, designed by orthodontists and anaesthetists (Enquist et al., 1995; Enquist and Fischer, 1997) or by a maxillofacial surgeon with anaesthetists and psychologists (Ghoneim et al., 2000). Enquist et al. (1995) demonstrated significant effects of pre- and intraoperative Tape Recorded Hypnosis (lowered intraand postoperative blood pressure and blood loss) of a study group which underwent bimaxillary osteotomies under general anaesthesia. Enquist and Fischer (1997) showed that a similar technique significantly reduced intraoperative treatment anxiety and postoperative consumption of analgesics after surgical removal of third molars under local anaesthesia. Ghoneim et al. (2000) described identical anxiolytic effects of preoperative Tape Recorded Hypnosis in an experimental study groups. Those patients underwent dental extractions or surgical removal of teeth under local anaesthesia and conscious sedation (fentanyl, midazolam, nitrous oxide). There was an unexplained significant increase of postoperative vomiting in the experimental group. The intention of our preliminary investigations was to gain information about the effects of standardized hypnosis during a wider range of oral and maxillofacial operations on locally anaesthetized and non-sedated patients. The basic questions were, (1) how far subjective and clinical effects of such a procedure justify its increased application and (2) would an evaluation by controlled clinical studies be worthwhile. In this respect, systematic applications of medical hypnosis in this department indicated interesting perspectives. Medical hypnosis is a suggested procedure for perioperative stress reduction, showing a high degree of theoretical (Hermes and Sieg, 2002) and practical patient compliance. Procedural standardization for special purposes (e.g. Tape Recorded Hypnosis vs. Live Hypnosis) minimizes changes needed in the surgical setting and reduces variables in the design of clinical studies. Meta-analysis of the adjunctive use of hypnosis in surgery (Montgomery et al., 2002) proved that such standardization does not reduce the effectiveness of hypnosis. Results of our primary maxillofacial study support this thesis as the data matches the reported success rates of intraoperative hypnosis (Brown and McInnes, 1986; Schuetz and Freigang, 2000; Tucker and Virnelli, 1985). Furthermore, it shows that the specific treatment situation in oral and maxillofacial surgery does not reduce trance ability and intensity for patients. Positive intraoperative effects of hypnosis include sedation, anxiolysis, inhibited motor skills and increased tolerance towards physically and psychologically demanding surgical procedures. Overall preparation time (information, seedings and induction) is approximately 15 min, complete postoperative reorientation of the patient within less than 1 min and low technical costs are further advantages of
hypnosis when compared with established pharmacological procedures. Nevertheless, hypnosis cannot serve as a serious substitute for sedation or general anaesthesia. Specific limitations and contraindications have to be considered, detailed knowledge of surgeons, individual patient preparation and special treatment modalities are necessary. Its therapeutic use is limited to mentally healthy and fully co-operative patients who are at least open to the procedure.
CONCLUSION A 1-year-trial period of clinical testing showed intraoperative hypnosis to be an interesting supplementation to anxiolytic pharmacological procedures. The indication for its adjuvant use during oral and maxillofacial operations was steadily expanded and its application intensified. The effects of medical hypnosis for both patient and surgeon require further clinical studies.
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Dirk HERMES, MD, DMD, Department of Maxillofacial Surgery, University Hospital Schleswig-Holstein/Campus Luebeck, Ratzeburger Allee 160, 23538 Luebeck, Germany. Tel.: +49 451 500 2269; Fax: +49 451 500 4188. E-mail: [email protected] Paper received 10 July 2003 Accepted 21 June 2004