248                                                                                                      BIRTH 26:4 Decemb...
BIRTH 26:4 December 1999                                                                                         249

250                                                                                            BIRTH 26:4 December 1999

BIRTH 26:4 December 1999                                                                                                  ...
252                                                                                                     BIRTH 26:4 Decembe...
BIRTH 26:4 December 1999                                                                                                  ...
254                                                                                                     BIRTH 26:4 Decembe...
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Hyperemesis hypnosis in Hyperemesis gravidarum


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Hyperemesis hypnosis in Hyperemesis gravidarum

  1. 1. 248 BIRTH 26:4 December 1999 Medical Hypnosis for Hyperemesis Gravidarum Eric P. Simon, PhD, and Jennifer Schwartz, MD ABSTRACT: Hyperemesis gravidarum in pregnancy is a serious condition that is often resistant to conservative treatments. Medical hypnosis is a well-documented alternative treatment. This article reviews the empirical studies of medical hypnosis for treating hyper- emesis gravidarum, explains basic concepts, and details the treatment mechanisms. The importance of a thorough differential diagnosis and appropriate referrals is stressed. The article presents three case studies to illustrate the efficacy of this treatment approach. It is suggested that medical hypnosis should be considered as an adjunctive treatment option for those women with hyperemesis gravidarum. It is also stressed that medical hypnosis can be used to treat common morning sickness that is experienced by up to 80 percent of pregnant women. Its use could allow a more comfortable pregnancy and healthier fetal development, and could prevent cases that might otherwise proceed to full-blown hyper- emesis gravidarum. (BIRTH 26:4 December 1999) Pregnant women frequently suffer from symptoms of of hyperemesis gravidarum patients require hospital- ‘‘morning sickness,’’ and because nausea and vomiting ization (6). For these cases, traditional care usually are so common in the first trimester of pregnancy, includes some combination of bed rest, intravenous it is considered a normal response to the expected fluids with electrolytes and glucose, a fluid diet, multi- hormonal changes of this phase of life. Some women, vitamins, steroids, insulin, antihistamines, phenothi- however, go on to develop full-blown, hyperemesis azines, adrenocorticotropic hormone (ACTH), and gravidarum, often leading to serious risks for the sometimes gastric tube feeding (7–13). mother and her fetus, as well as lengthy and costly Since hyperemesis gravidarum is often resistant to hospitalizations. A woman presenting with hyper- such conservative treatments, alternative modalities are emesis gravidarum can be a common occurrence for sometimes used, such as acupressure and ginger root the maternity care professional. This syndrome in- (Zingiber officinale), both of which have received cludes severe, intractable vomiting associated with de- equivocal support (14,15). The purpose of this paper is hydration, weight loss, irregular heart rate, electrolyte to describe one well-documented alternative treatment imbalances, and sometimes elevated temperature and to hyperemesis gravidarum, that is, medical hypnosis. jaundice (1,2). The condition can become so severe Medical hypnosis can be a powerful adjunct to the that it leads to death (3–5). Base rates for hyperemesis typical medical treatment regimen, and empirical stud- gravidarum indicate that approximately 1 to 5 percent ies have well documented the efficacy of this approach for hyperemesis gravidarum (16–21). Although much of this research is based on case studies, and any sole Eric Simon is in the Department of Psychology, Behavioral Medi- case study would lack rigorous scientific methodology, cine & Health Psychology Service, and Jennifer Schwartz is in a clear trend of empirical treatment efficacy is evident. the Department of Obstetrics and Gynecology at Tripler Regional To address this concern further, a study was conducted Medical Center, Honolulu, Hawaii. with 160 hyperemesis gravidarum patients whose con- Address correspondence to Eric P. Simon, PhD, Department of dition was totally recalcitrant to conservative medical Psychology, Tripler Regional Medical Center, Honolulu, HI 96859; treatment (consisting of antiemetic drug therapy, isola- e-mail: EricSimon@Yahoo.com. tion by hospitalization, and intravenous rehydration) The views expressed in this manuscript are those of the authors (22). Of these 160 women, 22 (13.7%) refused hypno- and do not reflect the official policy of the Department of the Army, therapy, 4 of whom elected for early termination of Department of Defense, or the U.S. Government. their pregnancies. Of the 138 women who participated 1999 Blackwell Science, Inc. in hypnotic treatment, 88 percent stopped vomiting
  2. 2. BIRTH 26:4 December 1999 249 completely after 1 to 3 hypnosis sessions. This study heightened state of relaxation or a state of focused was limited by its lack of a control group, but in a attention (31). Finally, investigators from the Stanford clinical setting a real possibility arises of harming the University hypnosis research laboratory elucidated the control group participants (23). Furthermore, given commonalties of hypnosis with dissociation, a mental that these women’s condition was resistant to con- separation of components of experience that would servative treatments, ‘‘spontaneous improvement’’ is ordinarily be processed together (32). considered unlikely, and it can be relatively safely Hypnotized individuals can display a dissociation of concluded that the observed gains were treatment content (33), in which their attention is so completely related. absorbed in the immediate narrow experience that Given the effectiveness of medical hypnosis for other material (e.g., affective, behavioral, and percep- hyperemesis gravidarum, it is therefore not surprising tual information) is relegated to the periphery of con- to find that medical hypnosis has also been reported sciousness where it is temporarily inaccessible. to be an effective treatment for hyperemesis secondary Examples of this include a person’s natural ability to both to chemotherapy (24–26) and to motion sickness block out unnecessary sensory data, such as the ongo- (27). Indeed, hypnosis can be a powerful tool to evoke ing sounds of a computer motor or a ceiling fan, or physiologic change. being so absorbed in a movie that one is largely un- aware of restricted personal space. Using Hypnosis to Evoke Physiologic Change Hypnotized persons can also display a dissociation of context (33), where the narrowing of attention and The Western medical approach has traditionally been increased absorption temporarily suspends higher oriented toward differential diagnosis, leading to surgi- order reflective cognitive structures and processes— cal procedures, pharmacologic curative agents, or both. the individual has the sense that internal experiences In the new mind-body era (28), with an emphasis are beginning to happen all by themselves (autono- on mind-body connectedness, we now understand that mously). This dissociation of context is often what ‘‘alternative’’ treatments can bring about symptomatic leads the individual to be more susceptible to hypnotic relief that is often equivalent, if not superior to, drug suggestions. outcomes. One such approach is hypnosis. With hyp- A trance is associated with many physiologic nosis one can evoke physiologic changes that were changes that include flattening of facial muscles, de- once thought beyond voluntary control. For example, crease in orienting movements, immobility, changes hypnotized individuals have shown ‘‘voluntary con- in blinking and swallowing, catalepsy in a limb, auton- trol’’ over physiologic mechanisms, such as sympa- omous motor behavior, altered breathing and pulse, thetic tone, vasoconstriction and vasodilation, heart fixed gaze, faraway look, changed voice quality, time rate, and muscle tension. Hypnosis is similar to bio- lag in response, literalism, perseveration in response, feedback in that physiologic change is brought under dissociation, relaxed muscles, amnesia, and time an individual’s voluntary control. In biofeedback a distortion. person is taught the method using external feedback of During a hypnotic session, the individual is encour- their physiologic systems, whereas in hypnosis, control aged to focus on the hypnotherapist’s voice and on over these physiologic processes is evoked from within pleasant images, and to fix his or her gaze in some the person. particular manner. During this induction phase, the individual begins to enter a hypnotic trance, at which Definition of Hypnotherapy time the conscious mind becomes less and less vigilant to the immediate surroundings. When this conscious- According to the American Psychological Association unconscious mind dichotomy becomes more salient to Division of Psychological Hypnosis (Division 30), the individual, the unconscious mind becomes more hypnosis can be seen as a procedure during which amenable to suggestions (which are congruent with changes in sensations, perceptions, thoughts, feelings, the person’s belief system) for new possibilities from or behavior are suggested (29). Kihlstrom (30) offered the hypnotherapist. The hypnotherapist serves as a a more specific understanding of hypnosis, describing guide, helping to transport the individual from the it as a set of procedures in which a person designated normal awake state of consciousness to a state of hyp- as the hypnotist suggests that another person (the pa- notic trance. People often describe trance as a pleasant, tient or subject) experience various changes in sensa- relaxed, altered state of consciousness, a type of rev- tion, perception, cognition, or control over motor erie, or both. This ability can be taught so that the behavior. It has an induction phase and an application individual can enter the trance on his or her own and phase. Others have taken issue with the concept of control distressing psychophysiologic symptoms. a ‘‘trance state’’ and simply describe hypnosis as a Because it has been shown that medical problems suc-
  3. 3. 250 BIRTH 26:4 December 1999 cessfully treated with hypnosis often need to be rein- noninvasive treatment. In addition, since the use of forced by self-hypnosis (34), sessions are commonly hypnotic treatment in common cases of morning sick- audiotaped for the client’s regular home practice. ness may reduce the number of those that would have Medical hypnosis, or hypnotherapy, is the clinical ap- otherwise developed into full-blown hyperemesis plication of hypnosis to medical disorders and proce- gravidarum, the treatment may also have value as a dures. In 1955 the British Medical Association declared preventative measure. Future research should examine hypnosis as a legitimate form of medical treatment when this issue empirically. applied by an appropriately trained practitioner, and in 1958 the American Medical Association gave their for- Hypnotic Preparation mal endorsement as well. Health care professionals from a variety of disciplines can be trained to administer It is unfortunate that, due to its portrayal in television, hypnosis. Information about training opportunities can movies, and stage shows, individuals often have ex- be obtained by contacting the American Society of tremely distorted ideas about hypnosis that can be Clinical Hypnosis (www.asch.net), the Milton H. obstacles to initiating treatment if not addressed in Erickson Foundation (www.erickson-foundation.org), the first session. The myths about hypnosis should the Society for Clinical and Experimental Hypnosis be dispelled so that clients understand that, first, all (www.sunsite.utk.edu), or Division 30 (Psychological hypnosis is self-hypnosis; second, going into a trance Hypnosis) of the American Psychological Association is not handing over control to someone else but rather (www.apa.org/divisions/div30). increasing self-control over physiologic processes; third, medical hypnosis does not involve giving sug- Initiating Hypnotic Treatment gestions so that the client will do something that is embarrassing (compared with stage hypnosis); fourth, Given the established effectiveness of medical hypno- one cannot get stuck in a trance (it is not at all like a sis for hyperemesis gravidarum, it is of concern that ‘‘black hole’’); and fifth, hypnosis is not a state of hypnotic treatment is typically initiated only after sleep. It is also beneficial to dispel these myths to ‘‘conservative’’ treatments have already failed. Unfor- hospital staff and provide them with studies on treat- tunately, maternal health caregivers may simply think, ment outcome data so that they have a good under- ‘‘Why not give this a try, nothing else has worked.’’ standing of this special treatment approach. Unlike many medications, medical hypnosis has no Some research has suggested that only certain, unwanted side effects (such as teratogenic influence). ‘‘highly hypnotizable’’ individuals can go into a hyp- Of course, before initiating hypnotic treatment it is notic trance, and considerable evidence suggests that vital for the client to have had a thorough medical hypnotic responsiveness is a trait-like capacity (37). evaluation to diagnose any organic pathology or com- More recent theorists have shown that hypnosis is a orbid conditions. However, after such an evaluation naturalistic human ability (38), however, and with medical hypnosis should be initiated as an adjunct to proper instruction and guidance any client can enter first-line treatment rather than waiting for a potential a trance (39) and use it for psychophysiologic self- treatment failure before initiating hypnotic treatment. regulation. Indeed, for most individuals hypnosis is a Because nausea and vomiting are considered a nor- learned skill that gets better with practice (40,41). mal response to the expected hormonal changes of pregnancy, these symptoms commonly are not treated by the traditional medical approach. This is unfortunate How Does Hypnosis Work To Control because a clear connection is present between de- Hyperemesis Gravidarum? creased morning sickness and a reduction in miscar- riage rates (35). Furthermore, in terms of societal costs, In addition to the empirical literature discussed earlier, it has been estimated that approximately 8.5 million several clinicians have offered specific recommenda- working days per year are lost because of nausea and tions with respect to tailoring hypnotic suggestions for vomiting secondary to pregnancy (36). Therefore, not women with hyperemesis gravidarum. Because some only can the hyperemetic pregnant woman benefit from authors believe that unconscious ambivalence about medical hypnosis, but also women experiencing com- pregnancy is associated with hyperemesis, hypnotic mon morning sickness may benefit from learning psy- suggestions can be given to address this underlying chophysiologic self-regulation through hypnosis. psychological conflict (42,43). Other suggestions have Approximately 80 percent of pregnant women (36) included a hypnotic rheostat device (44), glove anes- may experience extreme discomfort from the condition thesia (45), minty-tasting toothpaste imagery (46), pro- (sometimes for 6 months of a 9-month pregnancy), gressive anesthesia (47), and a focus on the powers of which may be ameliorated by this simple, short-term, the unconscious mind (48).
  4. 4. BIRTH 26:4 December 1999 251 We believe that hypnosis can effectively treat hyper- were unremarkable. She was likely exhibiting a condi- emesis in two primary ways. One component of the tioned response to her previous experiences with treatment mechanism is that in a hypnotic state, indi- hyperemesis. During the first session she was taught viduals are often induced into a deep state of physio- about hypnosis, and in the following two sessions, she logic relaxation. This acts to decrease sympathetic was given direct suggestions for symptom alleviation. nervous system arousal, and symptoms associated with After these sessions her nausea and vomiting fully sympathetic hyperarousal then tend to remit concor- remitted for the remainder of her pregnancy. She gave dantly. Despite the data indicating the efficacy of hyp- birth to a girl weighing 7.1 pounds. An excerpt from nosis over and above relaxation strategies and simple one of her hypnotic sessions follows: placebo effects, some critics of hypnosis have mistak- enly argued that a hypnotic trance is merely a deep state . . . From this moment forward, should you ever feel any nausea or even just tension in your stomach or throat . . . of physiologic relaxation. Although deep relaxation is related to your medical condition . . . it will be an immediate a common component of hypnosis, a hypnotic trance signal and cue to you for your muscles to relax . . . you is not defined by or limited to such a state. Research will immediately take 2 deep relaxing breaths . . . and conducted at Stanford University (49) revealed that envision the healing ball causing the muscles to immediately individuals can remain in a trance even during sympa- let go of tension . . . and then absorbing . . . any remaining nausea in those areas . . . . As those muscles relax some thetic hyperarousal (e.g., when pedaling on stationary more . . . and that’s just fine . . . you may be consciously exercise machines). Furthermore (and the second com- aware of carrying out this healing process . . . or maybe ponent of the treatment mechanism), it is well estab- just simply aware of carrying this process out at an uncon- lished that individuals often respond to hypnotic scious level . . . and after this process has been carried suggestions (50) for symptom removal independent of out . . . the healing ball will gradually . . . and methodi- cally . . . roll back down your shoulder . . . down your sympathetic or parasympathetic arousal, and interest- arm . . . down your hand . . . and gently . . . arriving at ingly, often independent of their conscious awareness the tip of your index finger . . . .and quite gently a balloon or memory of the suggestion. Thus, although one area will float down . . . and with a string . . . attach itself to of hypnotic treatment for hyperemesis can involve de- the ball . . . .lifting it . . . up . . . and . . . away . . . creasing sympathetic arousal, a second component taking all sensations of nausea with it . . . once and for all. involves giving the woman indirect and direct sugges- tions for symptom alleviation. This case illustrates that the symptoms of hyper- Women can be provided with suggestions to relax emesis gravidarum can be treated hypnotically by sim- their stomach and throat muscles causing their nausea, ply using a classic conditioning model (physiologic gagging, and vomiting to subside. This can be accom- learning theory). The woman was given direct hypnotic plished by suggesting that muscle tension in the stom- suggestions that counteracted her previously condi- ach and throat and/or nausea become a hypnotic cue tioned response of nausea and vomiting. An explora- to engage in particularly pleasant imagery. In addition, tion into the intrapsychic underpinnings of her women can be given hypnotic metaphors about hurri- symptoms was not warranted or necessary. The woman canes, for example (Case 2), as an indirect suggestion was simply taught an effective method of psychophysi- for increased self-control, increased self-efficacy, and ologic self-regulation. alleviation of symptoms. Case 2 Case Examples Joan was a 26-year-old primipara who was seen at 12 Case 1 weeks’ gestation. With the administration of intrave- nous fluids as well as Phenergan, her condition of Mary was a 28-year-old pregnant woman who had three hyperemesis gravidarum improved. She was then dis- normal deliveries, the last one occurring 2 years earlier. charged from the hospital, with only slight vomiting She had a history of hyperemesis gravidarum during her at a rate of 2 to 3 times per day. Five days later she three previous pregnancies, and on admission at 8 was readmitted suffering from severe vomiting of 6 weeks’ gestation, she was again suffering from severe to 8 times per day, ketoacidosis, and weight loss of 3 hyperemesis. She reported an inability to eat, a loss of pounds. Her symptoms were then resistant to anti- 8 pounds in the past 3 weeks, and ketoacidosis. Before emetic medication (Phenergan and Zofran), and at that initiation of hypnotic treatment, her nausea and vom- point hypnotherapy was initiated. iting of 8 to 10 times per day were resistant to antiemetic Although Joan’s psychological evaluation was neg- medication (Phenergan and Zofran). ative for any formal psychiatric, comorbid condition, The pregnancy was planned, expected, and desired. it became clear that her symptoms had a significant Her psychological evaluation and family dynamics emotional component. The pregnancy was neither
  5. 5. 252 BIRTH 26:4 December 1999 planned nor expected, but she initially reported an ment she was vomiting 6 to 8 times per day. Hypnother- unambivalent desire to give birth to the child. As the apy was postponed because her medical assessment evaluation progressed, her ambivalence about the child was not complete. She was soon found to have nephro- became clearer—she had many concerns about the lithiasis, which was causing her visceral abdominal limitations associated with caring for a newborn, and pain manifesting as nausea and vomiting. After receiv- she held fears about being an incompetent mother and ing a splint, her nausea and vomiting remitted. wife. It also became clear that Joan was struggling This case highlights the importance of evaluating with difficulties associated with the pressures and ex- all medical causes of hyperemesis gravidarum before pectations of her mother-in-law, and with her hus- initiating hypnotic treatment. band’s inability to set firm boundaries for his primary family. Discussion and Conclusions Because she was a Jehovah’s Witness, much of the focus in the first session was dedicated to dispelling the common myths about hypnosis and addressing her It should be stressed that before embarking on hypno- concerns about how hypnosis might conflict with her therapy for hyperemesis, the pregnant woman should religious views. After this session she was seen for undergo a thorough medical evaluation. The differen- three hypnosis sessions and instructed to practice self- tial diagnosis for hyperemesis gravidarum includes hypnosis with an audiotape of the sessions. This client gastroenteritis, cholecystitis, pancreatitis, hepatitis, was given direct suggestions similar to those given to nephrolithiasis, peptic ulcer disease, pyelonephritis, the client in Case 1 to address the symptoms at the fatty liver of pregnancy, pelvic inflammatory disease, level of physiologic conditioning. In addition, hypnotic appendicitis, and hyperthyroidism. Furthermore, cli- suggestions were given to normalize her feelings of ents may well benefit from a psychiatric evaluation if guilt about secretly wishing she were not pregnant, so psychiatric comorbidity is suspected, in which case a that she did not need to continue to ‘‘make herself referral to a mental health practitioner may be war- sick’’ over all of this. A metaphor of a hurricane was ranted. In addition, although the American Medical used to increase her sense of self-control, both over Association declared in 1958 that hypnosis is a legiti- her physiologic symptoms and her family environment. mate form of medical treatment, it should be empha- Her nausea and vomiting remitted after this time and sized that an appropriately trained practitioner of for the duration of her pregnancy. She gave birth to a medical hypnosis must apply this treatment. boy weighing 8.5 pounds. This is an excerpt from one Hyperemesis gravidarum that is resistant to medical of her hypnotic sessions: treatment can lead to great risks for the health of the fetus and the pregnant woman, as well as lengthy . . . It is interesting to note that certain areas of the country tend to experience a greater frequency of hurricanes during and costly hospitalizations. Professionals engaged in particular seasons of the year . . . and the amazing thing maternity care can become legitimately frustrated and . . . is that despite all of the chaos and dis-ease created by concerned with unsuccessful treatments. the power of winds sometimes in excess of 100 miles per Psychotherapeutic treatment often requires many hour, in the eye of the hurricane, there exists complete and sessions that could extend over weeks or even months. utter calm . . . .That’s right . . . in the I of the hurricane, one can really enjoy complete peace and calm . . . where The woman suffering from hyperemesis gravidarum, it is totally quiet, and totally calm. however, requires immediate care and immediate reso- lution of symptoms to ensure the safety of her and This case illustrates several points. First, before her fetus. Although medications are often effective initiating hypnotic treatment, it is absolutely vital to in alleviating symptoms, they often present dangers address any concerns about hypnosis and dispel any related to teratogenic influence, especially in the first myths that the woman may have learned, otherwise trimester of pregnancy. By contrast, medical hypnosis treatment compliance would be difficult to achieve. presents no danger to the woman or her fetus, and the Second, the psychophysiologic response can be modu- treatment results can be accomplished in a short period. lated by direct hypnotic suggestions. Third, psycholog- Medical hypnosis has received strong empirical ical issues related to the symptoms of nausea and support as a special alternative treatment modality for vomiting can be meaningfully addressed through indi- this medical disorder, but the technique remains un- rect hypnotic suggestions. derused. We hope that medical hypnosis will achieve greater exposure with health care professionals en- Case 3 gaged in maternity care so that it will be considered as an adjunctive treatment option for hyperemesis Linda was a 26-year-old pregnant woman seen at 26 gravidarum. We further hope that medical hypnosis weeks’ gestation. Before initiation of hypnotic treat- will be considered earlier in the logarithm of treatments
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