European Journal of Pain 11 (2007) 463468 www.EuropeanJournalPain.

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Eect of hypnotic suggestion on bromyalgic pain: Comparison between hypnosis and relaxation
Antoni Castel
a

a,*

, Magdalena Perez a, Jose Sala b, Anna Padrol a, Maria Rull

b,c

Pain Clinic and UFISS Palliative Care. Hospital Universitari de Tarragona Joan XXIII and Gestio i Prestacio de Serveis de Salut, C/Doctor Mallafre Guasch 4, 43007 Tarragona, Spain b Pain Clinic, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain c Departament de Medicina i Cirurga, Universitat Rovira i Virgili, Tarragona, Spain Received 25 November 2005; received in revised form 17 June 2006; accepted 24 June 2006 Available online 4 August 2006

Abstract The main aims of this experimental study are: (1) to compare the relative eects of analgesia suggestions and relaxation suggestions on clinical pain, and (2) to compare the relative eect of relaxation suggestions when they are presented as hypnosis and as relaxation training. Forty-ve patients with bromyalgia were randomly assigned to one of the following experimental conditions: (a) hypnosis with relaxation suggestions; (b) hypnosis with analgesia suggestions; (c) relaxation. Before and after the experimental session, the pain intensity was measured using a visual analogue scale (VAS) and the sensory and aective dimensions were measured with the McGill Pain Questionnaire. The results showed: (1) that hypnosis followed by analgesia suggestions has a greater eect on the intensity of pain and on the sensory dimension of pain than hypnosis followed by relaxation suggestions; (2) that the eect of hypnosis followed by relaxation suggestions is not greater than relaxation. We discuss the implications of the study on our understanding of the importance of suggestions used in hypnosis and of the dierences and similarities between hypnotic relaxation and relaxation training. 2006 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Ltd. All rights reserved.
Keywords: Hypnosis; Relaxation; Fibromyalgia; Chronic pain; Psychology

1. Introduction The eciency of methods of hypnosis at reducing pain has been well established (Hilgard and Hilgard, 1975; Barber, 1996; Syrjala and Abrams, 1996; Montgomery et al., 2000; Barber, 2001; Patterson and Jensen, 2003). Hypnosis has also proved to be eective in cognitive-behavioural interventions (Kirsch et al., 1995; Milling et al., 2003) but it has not been shown to be superior to relaxation or autogenic training in the treatment of

Corresponding author. Tel.: +34 977295862; fax: +34 977295805. E-mail address: [email protected] (A. Castel).

chronic pain (Patterson and Jensen, 2003). As far as relaxation is concerned, and despite the fact that it has proved to be eective at treating chronic pain (Arena and Blanchard, 1996; Syrjala, 2001), some studies highlight its drawbacks (Carroll and Seers, 1998; Keel et al., 1998). Although pain is a multidimensional experience, it is usually expressed in terms of its two principal components: the sensory-discriminative component, which refers to the quality, intensity and spatio-temporal characteristics of the sensation, and the motivationalaective component, which refers to its negative valence and aversion (Melzack and Wall, 1965; Melzack and Casey, 1968; Gracely et al., 1978). These

1090-3801/$32 2006 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ejpain.2006.06.006

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components can be measured by verbal descriptors (Melzack, 1975; Gracely et al., 1978). There is growing interest in understanding the eect of hypnosis on the sensory and aective components of pain (Patterson and Jensen, 2003). The results of the various investigations are not totally conclusive on this point and it seems to be accepted that hypnosis has greater inuence on the aect of pain than on the sensation of pain (Price et al., 1987; Meier et al., 1993; Price, 1999). There are also studies that indicate that analgesia suggestions are no more eective than suggestions of wellbeing and comfort at reducing the sensation of pain (Kiernan et al., 1995). Other authors, however, indicate that the specic dimension in which hypnotic suggestion acts depends on the content of the instruction (Rainville et al., 1999) and that analgesia suggestions and relaxation suggestions have dierent eects on the reduction of pain (Sachs, 1970; Dahlgren et al., 1995; De Pascalis et al., 1999). There are very few studies on the eects of hypnosis on bromyalgia, even though bromyalgia is the most common cause of chronic muscularskeletal pain, with an approximate prevalence of 2% in the general population (Russell, 2001; Busquets et al., 2005). Haanen et al. (1991) showed that the muscular pain, fatigue, sleep disorders and overall assessment of patients treated with hypnotherapy improved to a greater extent than in patients treated with physical therapy. These benets were maintained after a follow up of 24 weeks. Wik et al. (1999), in a study in which they measured cerebral blood ow in a sample of patients with bromyalgia, found that the patients experienced less pain during hypnosis than when they were at rest. There are also very few studies on the use of relaxation in bromyalgia (Keel et al., 1998; Fors et al., 2002). In our study, hypnosis is understood to be a social interaction in which one person, designated the subject, responds to suggestions oered by another person, designated the hypnotist, for experiences involving alterations in perception, memory and voluntary action (Kihlstrom, 1985), while relaxation is understood as a systematic approach to teaching people to gain awareness of their physiological responses and achieve both a cognitive and psychological sense of tranquillity (Arena and Blanchard, 1996). Despite dening the concepts of hypnosis and relaxation, we cannot forget that both techniques can dier in terms of their names or of their theoretical context, but be highly similar in practice (Schultz, 1969; Barber, 2001; Gay et al., 2002). The aims of our study are: (1) to compare the relative eects of analgesia suggestions and relaxation suggestions on clinical pain, and (2) to compare the relative eect of relaxation suggestions when they are presented as hypnosis and as relaxation training.

2. Method 2.1. Participants Forty-ve patients attended at the Pain Clinic of the Joan XXIII University Hospital in Tarragona, diagnosed with bromyalgia by a rheumatologist following the criteria of the American College of Rheumatology (Wolfe et al., 1990). The participants were required to have been suering from pain for at least 6 months. A total of 86.7% of the sample are women and the remaining 13.3% men. The mean age is 43.7 years old [range 2568]. Of all the participants, 82.2% are married, 6.7% separated, 2.2% widowers and 8.9% unmarried. As far as education is concerned, 60% have completed their primary education, 26.7% secondary education and 13.3% higher education. The mean duration of pain is 106.5 months [range 6360]. All the patients were following conventional pharmacological treatment with analgesics, antidepressants, hypnotics and myorelaxants. 2.2. Measures The description of pain was assessed using the McGill Pain Questionnaire (MPQ) (Melzack, 1975; Spanish adaptation by Lazaro et al., 1994). Although the whole of the test was applied, the study only took into account the Pain Rating Index Sensory (PRI-S) and the Pain Rating Index Aective (PRI-A). Pain intensity was assessed using a Visual Analogue Scale (VAS) which consists of a 10 cm line anchored by two extremes of pain: no pain and worst possible pain. Subjects are asked to make a mark on the line which represents their level of pain intensity. The scale is scored by measuring the distance from the no pain side of the line to the subjects mark. This system is widely used in clinical and experimental contexts, and has been proved to be useful for assessing the intensity of pain in patients with chronic pain (Jensen et al., 1986). 2.3. Procedure The patients were asked to go to the surgery where they were invited to participate in the study. Of the 48 patients who were invited to take part, 45 accepted. After their demographic and clinical data had been collected, the participants indicated the characteristics of their pain with the VAS and the MPQ. They were then randomly assigned to one of the three conditions. The experimental condition and the assessment were carried out by two dierent researchers. The participants were invited to lie down on a comfortable, reclining chair with arm rests and the experimental condition was applied. Once over, the participants got up from the chair and did the VAS and the MPQ once again.

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2.4. Experimental condition procedures Experimental condition 1:Hypnosis with relaxation suggestions. This experimental condition was presented as a hypnosis technique. Participants were asked to stare at an external stimulus and at a particular moment close their eyes. A chain of suggestions were made using palpebral catalepsy, catalepsy of the vocal cords and the raising of an arm. Immediately afterwards, they were asked to visualize a leaf swaying on the branch of a tree and then oating slowly to the ground. This image was associated with the descent of the arm and deeper hypnosis. This procedure lasted for about 10 min. Subsequently, participants were asked to focus their attention on imagining on a pleasant beach (beforehand, they had been asked whether this would be a suitable image). They were advised to think about all the stimuli associated with the image (visual, auditory, tactile, kinaesthetic, olfactory) and also about all the associated sensations of relaxation and well being. The technique lasted for about 20 min. Experimental condition 2:Hypnosis with analgesia suggestions. This experimental condition was presented as a hypnosis technique. The same chaining procedure and deeper hypnosis as in the previous technique were used. After 10 min, instead of being asked to imagine a relaxing image, the participants were asked to imagine a liquid or blue analgesic stream that ltered through their skin and reached dierent parts of their body (muscles, joints, bones, internal organs). It was suggested that the liquid soothed the pain in the most aected areas, eliminated the tension, and created feelings of well being. The technique lasted for about 20 min.

Experimental condition 3:Relaxation. This experimental condition was presented as a relaxation technique. For 5 min, the patients were shown how to relax various parts of the body, beginning with feet and nishing with the head. Then, for 10 min, they were told to focus on their diaphragmatic breathing. Finally, feelings of well-being and general relaxation were suggested for 5 min. The technique lasted for 20 min. The data were statistically analysed using the SPSS programme for Windows.

3. Results The three groups of participants were homogeneous. No signicant dierences were found in age, distribution by sex, duration of pain, marital status or educational level (see Table 1). Neither were any signicant dierences found between the pre-experimental condition values of VAS, PRI-S and PRI-A in the three groups. As can be seen in Table 2, the t-test for related samples indicates that the VAS, PRI-S and PRI-A values decrease signicantly after the application of each of the techniques, although they do not all decrease in the same proportion. Relaxation suggestions led to a 29% decrease in the pain intensity (VAS), a 39% decrease in sensory aspects (PRI-S) and a 61% decrease in the aective dimension (PRI-A). With analgesia suggestions, the percentages of reduction were 71% (VAS), 76% (PRI-S) and 81% (PRI-A). Finally, relaxation led to reductions of 43% (VAS), 27% (PRI-S) and 53% (PRI-A). To determine whether there was any dierence between the three experimental conditions, the dierence

Table 1 Demographic data Group Age Sex Male General Experimental condition 1 Experimental condition 2 Experimental condition 3 43.7 SD 8.6 48.1 SD 7.5 46 SD 9.3 47.7 SD 9.2 6 (13%) 3 (20%) 1 (7%) 2 (13%) Female 39 (87%) 12 (80%) 14 (93%) 13 (87%) 106.6 SD 795 122.8 SD 99.9 103.7 SD 76.9 93.2 SD 58.9 Pain duration Formal education Low 27 (60%) 10 (67%) 10 (67%) 7 (47%) Mid 12 (27%) 2 (13%) 4 (26%) 6 (40%) High 6 (13%) 3 (20%) 1 (7%) 2 (13%) Marital status Married 38 (84%) 11 (74%) 13 (86%) 14 (93%) Separated 3 (7%) 2 (13%) 1 (7%) 0 (0%) Single 4 (9%) 2 (13%) 1 (7%) 1 (7%)

Table 2 Comparison of pre-experimental condition and after-experimental condition mean pain index Mean pre-after VAS 1VAS 2 PRI-S1PRI-S 2 PRI-AlPRI-A 2
* **

Experimental condition 1 5.53.9** (SD 2.202.44) 22.913.9** (SD 5.478.24) 4.41.7** (SD 2.322.12)

Experimental condition 2 5.81.7** (SD 2.271.68) 26.26.3** (SD 9.326.99) 4.30.8** (SD 2.491.01

Experimental condition 3 5.83.3* (SD 2.682.58) 20.715.1* (SD 7.518.04) 4.72.2** (SD 0.560.50)

p < 0.01. p < 0.001.

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Table 3 Comparison of the eect of the experimental conditions Experimental conditions Condition 1 vs Condition 2 Condition 1 vs Condition 3 Condition 2 vs Condition 3 VAS 2 * *** * PRI-S2 ** *** ** PRI-A2 *** *** ***

* = p < 0.01, ** = p < 0.001, *** = not signicant.

in the pre- and post-session scores was calculated and ANOVA was carried out. Signicant changes were found between the three experimental conditions in the VAS score of pain intensity [F(2, 42) = 6.969; p < 0.002] and in the MPQ-PRI-Sensorial score [F(2, 42) = 17.019; p < 0.0001], but not in the MPQ-PRI-Aective [F(2, 42) = 0.958; p < 0.392] (see Table 3). Post-hoc multiple comparisons showed that there was a signicant dierence in the VAS score for pain intensity between hypnosis with analgesia suggestions and hypnosis with relaxation suggestions (Tukey test, p < 0.005), and between hypnosis with analgesia suggestions and relaxation (Tukey test, p < 0.009). The dierence was even more signicant when the values of the sensorial component of pain (PRI-S) were compared, both between hypnosis with analgesia suggestions and hypnosis with relaxation suggestions (Tukey test, p < 0.0001), and between hypnosis with analgesia suggestions and relaxation (Tukey test, p < 0.0001). On the other hand, there was no dierence between hypnosis with relaxation suggestions and relaxation in any of the measures compared.

4. Discussion The study has two essential ndings: (1) that hypnosis followed by suggestions of analgesia has a greater eect on the intensity of pain and the sensorial dimension of pain than hypnosis followed by suggestions of relaxation; (2) that the eect of hypnosis followed by suggestions of relaxation is no greater than that of relaxation. Under the condition of hypnosis we used two dierent types of suggestion. The suggestion of a blue, analgesic stream ltering into the painful area can be regarded as an indirect suggestion of focused analgesia. The relaxing suggestion of visualizing a pleasant beach can be regarded as a dissociative imagery suggestion (Price, 1999). The changes in pain intensity and in the sensorial components of pain were greatest with the suggestion of focused analgesia. This result shows that the content of the suggestion is important and indicates that some suggestions are more eective than others at controlling pain (Sachs, 1970; Stacher et al., 1975; Dahlgren et al., 1995; De Pascalis et al., 1999; Rainville et al., 1999). If we focus on pain intensity variable, our ndings are congruent with those of De Pascalis et al. (1999). When

they compared the analgesic eects produced by the experimental conditions of deep relaxation, dissociative imagery, focused analgesia and placebo, they found that focused analgesia was the technique that most reduced pain. Stacher et al. (1975) also indicate that hypnosis plus suggestions of analgesia decreases the intensity of pain to a greater extent than hypnosis plus suggestions of relaxation, although they only measured the intensity of the pain to determine the eect of the changes produced. Dahlgren et al. (1995) conclude, as we do, that analgesic hypnosis reduces the intensity of pain to a greater extent than the aective dimension, whereas relaxing hypnosis reduces the aective component to a greater extent than the intensity. As far as the sensory and aective dimensions of pain are concerned, our results indicate that analgesic suggestion has a greater eect on the sensation of pain than the suggestion of relaxation. On the other hand, the suggestion of analgesia has not proved to be more eective than the suggestion of relaxation on the aective dimension of pain. This result is congruent with the ndings of Rainville et al. (1999), who show that the suggestion of analgesia modies both the sensory and the aective components of pain. However, suggestion that aims to modulate the aective component, does not modify the sensory component. Modulation of the sensory dimension of pain seems to produce a parallel modulation in the aective dimension (Price, 1999). Our results also coincide with those of Kiernan et al. (1995) because they show that suggestions of analgesia do not modify the aective components of pain any dierently to suggestions of comfort and well-being. Our results are dierent, however, because they indicate that suggestions of sensory analgesia are not more eective than suggestions of well-being at modifying the sensory component of pain. The second conclusion from our study indicates that there is no dierence between the results obtained by hypnosis with suggestions of relaxation and the results obtained by relaxation. This corroborates the data that are available on this issue in the literature (Patterson and Jensen, 2003). As has already been pointed out in the introduction, dening the dierence between hypnosis and relaxation is a complex task because both procedures contain components of relaxation and the focusing of attention (Syrjala and Abrams, 1996; Gay et al., 2002) and there seem to be no empirical dierences between them (Syrjala et al., 1995). In our study, hypnosis with suggestions of relaxation diered from relaxation in that the procedure was given the label of hypnosis and in that participants were asked to visualize relaxing images. In the procedure described as relaxation, the patients only had to focus their attention on the bodily sensations of relaxation and on their own breathing. We believe that the lack of dierence between the results

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of both procedures is due to the fact that they both use suggestions that are exclusively of well-being and comfort, thus focusing only on the aective component of pain. Our results corroborate those of De Pascalis et al. (1999), who concluded that hypnotic analgesia is neither the result of relaxation, nor a question of distracting attention. Our study has several, important drawbacks. The relatively small number of participants is a drawback that limits the power of the statistical analyses and the generalization of the results obtained, although the signicance of the dierences between the experimental conditions suggests that they are important. Another drawback was the fact that the application of each experimental condition was not completely homogeneous. There may have been prosodic changes in language or other variations as a function of the participants responses. It should also be borne in mind that the same researcher (the rst author) applied all the experimental conditions. Although this is not exceptional in this sort of study (see Faymonville et al., 1997; Benhaiem et al., 2001; Patterson and Jensen, 2003) and it limits the strength of the results, it cannot completely conceal their importance. Another important drawback of the study is that hypnotic suggestibility was not measured. There is evidence to suggest that highly suggestionable subjects are more responsive to hypnotic suggestion in experimental pain. In clinical pain, however, scale-assessed suggestibility is much less predictive of the response to intervention with hypnosis (Montgomery et al., 2000; Barber, 2001; Patterson and Jensen, 2003). In clinical samples, patients with low suggestibility have similar levels of response to hypnotic suggestions as patients with high suggestibility (Jensen and Barber, 2000; Gay et al., 2002). Despite the studys drawbacks, these ndings indicate that analgesic suggestion can decrease pain intensity and the sensation of pain in patients with bromyalgia. Analgesia suggestion should be studied in the context of intervention programmes designed for this type of patients. Finally, the ndings of this study have implications for: (1) understanding the importance of the suggestions used in hypnosis; (2) understanding the dierences or similarities between hypnotic relaxation and relaxation training.

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