Editorial

Hypnosis: a new anesthetic technique!

M.M. LUCAS-POLOMENI

Service d’Anesthe´sie-Re´animation Chirurgicale 2, Hoˆpital Pontchaillou, Universite´ Rennes 1,

Rennes, France

In parallel with its rapid development in psychotherapy,

hypnosis also finds applications in anesthesia

and surgery. The founding father of modern

hypnosis is Milton Erickson, who was born in 1901

and founded the American Society for Clinical

Hypnosis. He defined hypnosis as a natural phenomenon

that anyone of us can reach. It is an altered

state of consciousness based on the principle of

dissociation, with a concentrated but focused attention

which is different from the state of sleep (1). In

fact, hypnosis corresponds to a state of inner

absorption and such a focused attention that the

individual becomes unconcerned about any other

consideration (2). The analgesic effect of hypnosis in

pain management has been extensively studied (3).

It is used both for acute and chronic pain management

in adults (4–6). Indeed at Liege University, in

Belgium, Faymonville’s team has been using hypnosedation

that is, use of hypnosis as an adjunct to

conscious sedation for surgery performed under

local anesthesia since 1992 (7). Hypnosis and hypnosedation

techniques can easily be adapted to

children who have a natural power of playing, and

for whom an imaginary world is close and accessible.

Anesthetists can have no problem inducing a

formal trance in children. Recall of pleasant life

experiences has served as the hypnotic substratum.

Preoperative anxiety most often reveals a fear of

separation from the parents and familiar environment,

the loss of control and also the confrontation

with an unknown place and people; this anxiety has

significant consequences, especially as it may contribute

to the occurrence of postoperative behavioral

disorders (8). The most common technique to reduce

preoperative anxiety is sedative premedication with

midazolam (9). In our department, hypnosis is used

as premedication instead of rectally administered

midazolam. This practice has reduced preoperative

anxiety and also the incidence of postoperative

behavioral disorders (personal data).

We have also used hypnosedation with success

(hypnosis in combination with conscious intravenous

sedation mainly using low dose remifentanil)

and local anesthesia, for example ilio-inguinal/iliohypogastric

block for hernia repair. This has proved

to be a valuable alternative to traditional anesthesia

techniques with halogenated agents, as previously

reported in adults (10). The child is asked to choose a

pleasant life experience to think about during surgery;

the initiation of the relaxation technique itself

is simple and usually provides the child with a sense

of control. The technique primarily uses indirect

suggestions for developing and deepening a hypnotic

state; the exact content of the specific suggestions

used during the course of induction depends

on the patient’s behavior and on our judgment of

what would most readily elicit a response from the

patient. When the child is thought to be at an

adequate trance level, i.e. occurrence of muscle

relaxation, decrease in heart rate and respiratory

rate, local anesthesia is performed. Sometimes small

amounts of remifentanil are given throughout the

surgical procedure to facilitate conduct of surgery.

At the end of the procedure, the anesthetist can

wake up the child from the trance by changing the

behavior and quality of the tone of voice.

Our hypnotic technique uses indirect suggestion

and distraction to reduce the sensory and affective

dimension of the pain experience (11). Suggestion of

pleasant experiences seems more effective in producing

pain relief than suggestion of declining pain

(12). The resulting hypnotic trance almost always

involves essential dissociation. This unconscious

dissociative mechanism results in decreased pain.

Correspondence to:

d’Anesthe´sie-Re´animation Chirurgicale 2, Hoˆ pital Pontchaillou,

35033-Rennes cedex 9, France (email: marie-madeleine.lucas@

chu-rennes.fr).

Pediatric Anesthesia 2004

Indeed, providing well-being and a relaxed state,

enables the children to actively participate in the

anesthesia and is likely to leave them with a pleasant

memory. This anesthetic technique is based on close

collaboration between the patient, the anesthetist

and the surgeon. Normal working conditions change

dramatically: the operation theatre is calm, the child

is conscious but distracted during surgery, although

surgical manipulation must be gentle and precise.

The anesthetist closely follows the operation to

anticipate the patient needs.

There is no question that the phenomenon of

hypnotic analgesia is real. In order to better understand

what happens during the hypnotic state

during surgery, the brain mechanisms underlying

the hypnotic state have been studied in healthy

volunteers by determining the distribution of regional

cerebral blood flow, taken as an index of local

neuronal activity. Hypnosis is related to the activation

of a widespread, mainly left-sided, set of cortical

areas involving occipital, parietal, precentral, premotor

and ventrolateral prefrontal cortices and a few

right sided regions (occipital and anterior cingulated

cortices). The pattern of activation during the hypnotic

state differs from that induced in normal

subjects by simple evocation of autobiographical

memories. These results suggest that, hypnosis is a

particular cerebral waking state where the subject,

although seemingly somnolent, experiences vivid

multimodal, coherent, memory-based mental imagery

that invades and fills the consciousness (13,14).

Practicing hypnosis does require some contribution

especially in terms of training and competence.

It especially calls for information because hypnosis

is first and foremost a state of mind; the will to

communicate differently and depends on the quality

of the relationship between the child and the person

performing the hypnosis. There are few contraindications,

the main restrictions being deafness and

states of mental retardation. Nonetheless, hypnosis

is a very effective technique for providing relief of

anxiety and pain in surgery under local anesthesia.

References

1 Erickson MH, Rossi EL, Rossi SI.

Induction of Clinical Hypnosis and Forms of Indirect Suggestion

Irvington Publishers Inc., New York, 1976.

2 Price D. Hypnotic analgesia: psychological and neural mechanisms.

Science

3 Montgomery GH, DuHamel KN, Redd WH. A meta-analysis of

hypnotically induced analgesia: how effective is hypnosis?

Clin Exp Hypn

4 Iserson KV. Hypnosis for pediatric fracture reduction.

Med

5 Anbar RD. Self-hypnosis for management of chronic dyspnea

in pediatric patients.

6 Zeltzer LK, Dolgin MJ, LeBaron S

controlled study of behavioral intervention for chemotherapy

distress in children with cancer.

7 Faymonville ME, Fissette J, Mambourg PH

adjunct thereapy in conscious sedation for plastic surgery.

Anesth

8 Kotiniemi LH, Ryhanen PT. Behavioural changes and

children’s memories after intravenous, inhalation and

rectal induction of anaesthesia.

9 Kain ZN, Mayes LC, Wang SM

outcomes in children: effects of sedative premedication.

1999;

10 Schulz-Stubner S. Clinical hypnosis instead of drug-based

sedation for procedures under regional anesthesia.

Pain Med

11 Erickson MH. The interpersonal hypnotic technique for symptom

correction and pain control.

209.

12 Hilgard ER. The problem of divided consciousness; a neodissociation

interpretation.

13 Marquet P, Faymonville ME, Degueldre C

neuroanatomy of hypnotic state.

333.

14 Faymonville ME, Laureys S, Degueldre C

mechanisms of antinociceptive effects of hypnosis.

2000;

976 M.M. LUCAS-POLOMENI