Hypnosis - Applications in Dermatology and Dermatologic Surgery
Author: Philip D Shenefelt, MD, MS, Associate Professor, Department of Dermatology and Cutaneous Surgery, University of South Florida College of Medicine; Past Chief, Section of Dermatology, James A Haley Veteran Affairs Medical Center
Updated: Apr 23, 2009
Hypnosis is the intentional induction, deepening, maintenance, and termination of the natural trance state for a specific purpose. For the much maligned stage hypnosis, the purpose is entertainment. For medical hypnotherapy, the purpose is to reduce suffering, to promote healing, or to help the person alter a destructive behavior. The hypnotic phenomenon has been used since antiquity to assist in healing.
All individuals enter spontaneous mild trances daily while absorbed in watching television or a movie, in reading a book or a magazine, or in another activity or meditation. With appropriate training, an individual may intensify this trance state in himself or herself or in another individual and use this heightened focus to induce mind-body interactions that help to alleviate suffering or to promote healing. The trance state may be induced by using guided imagery, relaxation, deep breathing, meditation techniques, self-hypnosis, or hypnosis induction techniques. Individuals vary in their ability to enter the trance state, but most can obtain some benefit from hypnosis.
In dermatology, hypnosis may help decrease pain and pruritus in the skin; intervene in psychosomatic aspects of skin diseases; and lead to the resolution of some skin diseases, including verruca vulgaris. Suggestion without formal trance induction may be effective in some cases. Sulzberger and Wolf1reported on the use of suggestion to treat verrucae.
Precisely defining hypnosis has proven to be challenging. Marmer2described hypnosis as a psychophysiological tetrad of altered consciousness consisting of narrowed awareness, restricted and focused attentiveness, selective wakefulness, and heightened suggestibility. For a more detailed discussion of the definitions of hypnosis, see the texts by Crasilneck and Hall3or Barabasz and Watkins.4Many myths exist about hypnosis that overrate, underrate, or distort the true capabilities of hypnosis.
Hypnosis can regulate blood flow and other autonomic functions that are not usually under conscious control. The relaxation response that occurs with hypnosis also affects the neurohormonal systems that regulate many body functions. Studies on the influence of hypnosis on immediate immune responses have shown the ability of hypnotized volunteers to significantly decrease the flare reaction to the histamine prick test. Similarly, in one study, the effect of hypnotic suggestion on delayed cellular immune responses has shown significant effect on the size of erythema and on palpable induration but no significant effect in other studies.
A report by Braun5on different allergic responses; dermatologic reactions; and effects on seizure disorders, pain control, and healing in the same individual with multiple personality disorder (now called dissociative identity disorder) shows how much influence the mind can have on physiologic reactions and disease processes, depending on the personality present. The report also described the differences in physiologic responses and disease conditions for selected individuals under hypnosis compared with their normal waking state.
Hypnosis may be used to increase healthy behaviors, to decrease situational stress, to reduce needle phobias, to control harmful habits (eg, scratching), to provide immediate and long-term analgesia, to ameliorate symptoms related to diseases (eg, pruritus), to accelerate recovery from surgery, and to enhance the mind-body connection to promote healing. Hypnosis can be especially helpful in dealing with skin diseases that have a psychosomatic aspect. Griesemer,6who was trained both in dermatology and in psychiatry, recorded the incidence of emotional triggering of dermatoses in his patients during 1 year in his practice. He developed an index for various skin diseases, with 100 indicating an absolute psychosomatic component and zero indicating no psychosomatic component to the skin disease.
Good references on the responsiveness of skin diseases to hypnosis are found in the somewhat outdated book by Scott7and in the chapter on the use of hypnosis in dermatologic problems in the text by Crasilneck and Hall.3Koblenzer8also mentions some of the uses of hypnosis in common dermatologic problems. In an excellent resource book for patients, Grossbart and Sherman9discuss mind-body interactions in skin diseases and include hypnosis as recommended therapy for a number of skin conditions.
Methods of Medical Hypnotherapy
Hypnosis is not a therapy in and of itself. Instead, it is a tool that can be used to reveal psychological and behavioral roadblocks to healing. Therapies that can be enhanced by hypnosis include supportive (ego-strengthening) therapy, direct suggestion, symptom substitution, and hypnoanalysis.
In adults, induction of the hypnotic state is achieved by any of a number of methods that focus attention, soothe, and/or produce monotony or confusion. In children, the hypnotic state can be induced by having the child make-believe that he or she is watching television, a movie, or a play or by using some other distractive process that uses the imagination.
Supportive (ego-strengthening) therapy while in a hypnotic state includes positive suggestions of self-worth and effectiveness. Posthypnotic suggestion is often included, and further strengthening of the effect can be obtained by recording an audiocassette tape that the patient can repeatedly use for self-hypnosis later. The strengthened ego is better able to repress or confront discordant elements that inhibit healing.
Direct suggestion while in the hypnotic state is a frequently used method of decreasing discomfort from pain, pruritus, burning sensations, anxiety, and insomnia. Again, posthypnotic suggestion and repeated use of an audiocassette tape for self-hypnosis help to reinforce the effectiveness of direct suggestion. Direct suggestion may produce a sufficiently deep anesthesia in highly hypnotizable individuals for cutaneous surgery. Direct suggestion can also be used to reduce repetitive acts of skin scratching or picking, nail biting or manipulating, and hair pulling or twisting. Unwanted psychophysiologic responses, such as hyperhidrosis, blushing, and some types of urticaria, can also be controlled by direct suggestion. Some skin lesions can even be induced to resolve by using direct suggestion; the classic example is verrucae.
Symptom substitution retrains the subconscious by means of hypnosis to replace a negative habit pattern with a more constructive one. For example, scratching can be replaced by another physical activity, such as grabbing onto something and holding it so tightly for a half minute that it almost hurts. Other stress relievers that can be substituted for scratching include athletic activities, artwork, verbal expression of feelings, or meditation.
Hypnoanalysis may help patients with chronic psychosomatic dermatoses that are nonresponsive to other simpler approaches. LeCron's list of the 7 most common factors causing emotional difficulties and illnesses (ie, conflicts, motivation, the effect of suggestion, organ language, identification, self-punishment, and the effect of past experiences) is a good starting point for exploration in hypnoanalysis. Ewin and Eimer provide a user-friendly method of detecting and neutralizing the emotional impact of sensitizing or precipitating events. They use ideomotor signaling to obtain recollection of significant memories that may be preverbal or nonverbal. Results may occur more rapidly than with standard psychoanalysis. Only well-qualified and appropriately licensed practitioners should perform these types of hypnosis.
The author discusses the successful use of hypnoanalysis in dermatology. The author has slightly modified Ewin's mnemonic for LeCron's 7 key factors to COMPASS, as follows:
- C onflict
- O rgan language
- M otivation
- P ast experiences
- A ctive identification
- S elf-punishment
- S uggestion
The diagnostic value of screening for psychosomatic factors related to skin disorder triggering or exacerbation is illustrated in the above case. It is possible to rule out a likely psychosomatic component if the focused history and COMPASS ideomotor questioning for all 7 factors is negative. With 1 or 2 factors positive, appropriate reframing may be sufficient, but with more factors positive, more intensive psychotherapy would be appropriate.
Advantages and Disadvantages of Hypnotherapy
Hypnosis is currently an underused therapy in dermatology. In appropriately selected patients, it can decrease or eliminate symptoms, and, in some cases, it can induce lasting remissions or cures of skin diseases. Discussing this option with patients allows the dermatologist to gauge the patient's receptiveness to this treatment modality. The time requirements for screening patients, educating them about realistic expectations for results from hypnosis, and performing the hypnotherapy are generally no longer than those for screening, preparing, and educating patients about cutaneous surgery and then performing it.
Many dermatologists choose to refer patients with complex cutaneous surgical problems to competent specialists in dermatologic surgery. Likewise, many dermatologists choose to refer patients with complex psychosomatic dermatologic problems to competent specialists in hypnosis-assisted therapy. Those dermatologists who prefer to refer patients to hypnotherapists may obtain referrals and information from the American Society of Clinical Hypnosis or similar professional organizations.
Advantages of medical hypnotherapy for skin diseases include the ability to obtain a response where other treatment modalities have failed; the ability to reduce relapses; and the ability of patients to self-treat and gain a sense of control when taught self-hypnosis reinforced by using audiotapes, nontoxicity, and cost-effectiveness. Adding this treatment can result in pleased and grateful patients.
Disadvantages of medical hypnotherapy in dermatology include the extensive training required; the low hypnotizability of some patients; the negative social attitudes still prevalent about hypnosis; and the lower reimbursement rates for cognitive therapies, such as hypnosis, when compared with procedural therapies, such as cutaneous surgery. The low hypnotizability of some individuals is consistent over time, as measured by the Hypnotic Induction Profile.
Training in Medical Hypnotherapy
The American Society of Clinical Hypnosis offers weekend, regionally held, 20-hour courses in beginning, intermediate, and advanced hypnosis. Information may be obtained from its Web site (ie, American Society of Clinical Hypnosis . Other organizations also offer training. Mentors are available once the practitioner has obtained the necessary basic training.
Legal Requirements for Practicing Medical Hypnotherapy
In the United States, a state license is required to practice medicine. The exact details in terms of legal limitations vary from state to state; therefore, checking state statutes is recommended and imperative. In some states (eg, Florida), the practice of hypnotherapy is limited to licensed practitioners. The training requirements depend on the type of license. Outside of the United States, most jurisdictions have their own laws or statutes that dictate who may legally practice hypnosis. One should check for details in his or her local area.
As with all medical procedures, informed consent is crucial before proceeding with medical hypnotherapy. Although it does not need to be a written consent, informed consent should be well documented in the patient's chart if no written form is signed by the patient.
In many states, prior hypnosis may be considered to taint the memory with respect to legal testimony given by patients if they are plaintiffs, victims, or witnesses. If the area to be addressed by medical hypnotherapy might be open to future litigation, the credibility of the patient's testimony may suffer. This potential legal issue should be included in the informed consent discussion.
Delving into repressed memories is a legally risky issue because of legal claims by patients that therapists have created false memories. Only adequately trained physicians, psychiatrists, and psychologists who know how to avoid asking leading questions should venture into this area.
The above information is not warranted to be legally correct. If indicated by the situation, conferring with a qualified attorney to obtain legal advice is recommended.
Suitable candidates for the use of hypnosis are patients who are mentally intact; not psychotic or intoxicated; motivated, not resistant; and preferably moderately or highly hypnotizable, as rated by the Hypnotic Induction Profile described by Spiegel and Spiegel or by the Stanford Hypnotic Susceptibility Scale and its variants. However, a moderate or high degree of hypnotizability is not critical to the success of self-guided imagery for relaxation and discomfort reduction.
Patient selection is an important aspect of successful medical hypnotherapy in dermatology. Hypnosis-assisted therapy works best in moderately to highly hypnotizable patients who are appropriately motivated and who have dermatoses with a large psychosomatic component or are otherwise known to be responsive to intervention with hypnosis. As with any therapy, starting with simple, easy cases is best, referring the more complex cases to those with more experience. As the practitioner gains experience, more difficult cases may be added.
When appropriately applied, hypnosis can be effective and gratifying in many cases. It is not a panacea. Although it appears to work miracles for some and to fail completely for others, most results lie somewhere in between. A key factor in producing positive results is the specific type of therapy chosen to be assisted by hypnosis. Careful selection of the disease process, the patient, and the provider, as well as appropriate use of hypnosis, can decrease suffering and morbidity from skin disorders with minimal adverse effects.
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