220638 Brief Hypnosis for Severe Needle Phobia Using

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Case report

Brief hypnosis for severe needle phobia usingswitchwire imagery in a 5-year old

A L L A N M . C YN A D R C O G DD R C O G D i pi p CC l i nl i n HH y py p F R C AF R C A , D A VI D T O M K I N S

F A N Z C AF A N Z C A , T O D D M A D D O C K F A N Z C AF A N Z C A A ND

D A VI D B A RK E R F A N Z C AF A N Z C A

Department of Paediatric Anaesthesia, Womens and Childrens Hospital, Adelaide, SA,Australia

SummaryWe present a case of severe needle phobia in a 5-year-old boy who

learned to utilize a self-hypnosis technique to facilitate intravenous(i.v.) cannula placement. He was diagnosed with Brutons disease at

5 months of age and required monthly intravenous infusions. The boy

had received inhalational general anesthesia for i.v. cannulation on 58

occasions. Initially, this was because of difficult venous access but

more recently because of severe distress and agitation when

approached with a cannula. Oral premedication with midazolam or

ketamine proved unsatisfactory and hypnotherapy was therefore

considered. Following a 10-min conversational hypnotic induction, he

was able to use switchwire imagery to dissociate sensation and

movement in all four limbs in turn. Two days later the boy

experienced painless venepuncture without the use of topical local

anesthetic cream. There was no movement in the switched-off armduring i.v. cannula placement. This report adds to the increasing body

of evidence that hypnosis represents a useful, additional tool that

anesthetists may find valuable in everyday practice.

Keywords: needle phobia; hypnosis; communications;

hypnotherapy; analgesia; children

Introduction

Needle phobia affects approximately 19% of chil-dren aged 46 years (1) and at least 10% of the

general population (2). It is therefore a highly

relevant issue for the anesthetist (3). Children are

less likely than adults to understand the rationale for

a procedure making distress more likely. In addi-

tion, negative memories may result in escalating

anxiety with subsequent procedures (4,5). A recent

systematic review suggests that hypnosis can helpchildren reduce the pain and distress that accom-

pany needle-related procedures (6). Hypnosis in

children has been defined as an alternative state of

awareness where the focus of attention is on a

particular idea or image (with or without relaxation)

with a specific purpose of achieving a goal (7). This

state facilitates association with, or dissociation

from, external stimuli and enhances a patients

response to suggestion (8). A suggestion is a verbal

Correspondence to: Dr Allan M Cyna, Consultant Anaesthetist,Department of Paediatric Anaesthesia, Womens and ChildrensHospital, 72 King William Road, Adelaide, SA 5006, Australia(email: [email protected]).

Pediatric Anesthesia 2007 17: 800804 doi:10.1111/j.1460-9592.2007.02224.x

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or nonverbal communication that elicits a sub-

conscious (nonvolitional) response in patients

perception, mood andor behavior (9). Hypnosis

has been found to be more effective than nonhyp-

notic techniques for reducing procedural distress in

children and adolescents with cancer (10,11). In

addition, it reduces the incidence of anxiety during

induction of anesthesia in children compared with

midazolam premedication (12) and can be used to

provide effective pain relief in both laboratory and

clinical settings (13). Although anesthesia and hyp-

nosis have a long history of association (14), few

anesthetists currently utilize this technique or for-

mulate suggestions as a therapeutic adjunct to their

clinical practice. A resurgence of interest in utilizing

hypnosis in both adult (1519) and pediatric an-

esthesia practices (12,20) is supported by clinicalresearch, and recent neuroimaging studies show that

anterior cingulate gyrus activity is affected by

hypnotic modulation of pain (2123). The utilization

of hypnosis has been shown to be a useful thera-

peutic strategy for some children when other ther-

apies have failed (24). This case report describes the

successful, rapid utilization of a self-hypnosis tech-

nique by a 5-year-old boy with severe needle phobia.

Case report

The patient presented for testing at 5 months of age

as his older sibling had Brutons disease, an X-linked

agammaglobulinemia, which required intravenous

(i.v.) infusions of gammaglobulin on a monthly

basis. The patient initially had poor venous access

and i.v. cannula insertion proved to be difficult and

traumatic for both the patient and parents. It was

therefore decided that future i.v. access would

follow brief inhalational general anesthesia (GA).

This arrangement worked well for some time and

the child was usually cooperative during the gas-

eous induction of O2 N20 and sevoflurane. After ayear of having a GA every 4 weeks, the offer to

insert an i.v. portal device was refused by the

parents. After a further year, i.v. cannula insertion

was attempted under oral midazolam sedation, but

the child had a paradoxical reaction. He became

extremely aggressive and distraught and then pulled

out the i.v. cannula soon after it had been inserted.

The parents requested a return to GA and they again

refused to consider a portal device. By the age of

3 years the patient was very cooperative for his

anesthetics, showing great trust in the anesthetist,

holding the mask himself and often chatting and

joking as he went off to sleep. His veins had not

been difficult to access for the past 2 years and the

whole procedure tended to be easy and brief.

Further attempts to sedate the child using oral

midazolam and ketamine once again proved to be

unreliable and traumatic. Management options were

discussed amongst the anesthetists, including the

possible use of hypnosis. At this stage, the patient

had received inhalational GA for i.v. cannula inser-

tion on 58 occasions. Following a discussion with the

patients mother, training the boy in self-hypnosis

was considered for facilitating future i.v. cannula-

tions. Two days prior to his planned infusion of

gammaglobulin, an anesthetist trained in hypnosis(AMC) saw the child together with his mother as an

outpatient. Initial rapport was gained by asking the

boy what his favorite activity was. The response by

the patient led the anesthetist to ask the boy about

how he learned to ride his bicycle. The child

responded enthusiastically and became engaged in

describing how he initially had both feet on the

ground and then rode with one foot and then two

feet on the pedals. The anesthetist repeated back to

the patient what he was being told, using the boys

own words, to confirm that he was being heard and

understood. Statements were made where appropri-

ate to reinforce aspects where learning new skills

and discovering new ways of doing things had taken

place. The patient was then asked why gammaglob-

ulin was required each month and the response was

that it made him smart. When asked what it was

like learning to ride his bike, he replied that it felt

good. The anesthetist then asked the boy if he

would like to learn something new today, just like

when he learned to ride the bike. He was also asked

whether he would like to learn to be the boss of his

own body to allow the plastic drip to be inserted ascomfortably as possible. The boy readily agreed that

he would like to learn things that would allow him

to be the boss of his body whenever he needed a

drip.

The house metaphor was used to explain switch-

box imagery, a hypnosis technique modified from

Garver (25). The anesthetist explained that in a

house there are many wires and switches. Now as

you know when you turn the switch off, the light

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control and display his new skills. When asked if the

drip had hurt at all he replied no. Prior to leaving

the treatment room it was confirmed with the boy

that he had switched his arm back on and that it

moved easily and felt back to normal.

The patient has now used switchwire imagery

successfully for the past 3 months. The last i.v.

cannula placement (including walking to the treat-

ment room, placing, and taping the i.v. cannula and

returning to the outpatient ward bed) took less than

5 min.

Discussion

We present a case of severe needle phobia in a 5-

year-old child who learned to utilize a self-hypnosis

technique to facilitate i.v. cannula placement. Thisreport adds to the increasing body of evidence that

hypnosis represents a useful, additional tool that

anesthetists may find valuable in their everyday

practice. Our case is remarkably similar to that

reported by Olness nearly 30 years ago of a 7-year-

old child suffering from severe needle phobia and

Brutons disease who was managed with a brief

hypnosis, switch-box imagery intervention (24).

Following a 10 min orientation to a previous learn-

ing experience, both patients were able to use

hypnosis to turn on and off switches in the brain

and subsequently control sensations and movement

in various parts of the body. Olness suggests that the

relatively high hypnotizability in children may be

explained by their greater readiness to engage in

imagery and fantasy with less concern for the logical

cognitive activity and reality testing, impinging on

adults.

The strategy for treating needle phobia in our

patient began with the aim of teaching him how to

achieve mastery and control during his hospital

visits without the need for pharmacological support.

The initial conversation with the boy identified thathis experience of learning to ride a bike could

engage him in a focus of attention. The boy clearly

demonstrated the ability to learn a new task with

ease. The house metaphor was utilized to develop an

idea that was to be related to the types of skills and

resources that the patient was likely to need. The

next stage introduced the patient and his mother to

new practical ways of achieving venepuncture com-

fortably, other than by pharmacological means. We

gradually initiated a learnable sequence using a

lower limb well away from the planned venepunc-

ture site. The boys ability to use switch and wire

imagery to elicit subconscious responses was then

demonstrated to his and his mothers satisfaction.

The identified skills were then developed further

until they were within the context of a venepunc-

ture, i.e. with tourniquet placement around the arm

and wiping the skin with alcohol. Patient cues were

identified with each response and the kind of

language the child used was repeated by the

anesthetist to enhance rapport and ensure that the

child knew that he had been heard and understood.

The word try was used when the boy was asked to

move a switched off limb as this implied that he

would indeed fail to move it. When this was

confirmed by the patient, positive re-enforcementthat the switch was indeed off helped encourage

similar future hypnotic responses. The use of par-

ticular words can facilitate subconscious responses.

For example, calling the boys upper limb the arm

rather than your arm encourages the phenomenon

of dissociation where the limb no longer feels part of

the body. The interesting observation by TM and DB

that the boy did not appear to be hypnotized in the

classical trance sense is typical in this age group.

Kohen reports that children under 6 or 7 years

commonly do not visibly relax, a state known as

active alert hypnosis (7).

Children are usually willing to explore and

discover new ways of doing things and are fre-

quently more disposed to experiment than adults.

The overriding principle in this approach is to view

children as resourceful and to demonstrate how

their developing skills can become both relevant and

available to them during a new learning experience.

As seen with this patient and Olnesss report (24),

the successful use of a newly learned skill can lead to

a rapid break from old patterns of behavior by both

parent and child. The consolidation of what has beenlearned with each successful event parallels an

increasing sense of patient autonomy and control.

Many clinicians may view the term hypnosis with a

negative connotation that leads them to avoid

learning more about the technique or advocating

its use. It has been reassuring that in response to a

recent survey, 70% of anesthetists in South Australia

reported that they believed hypnosis was useful in

the management of needle phobia (26). The British

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Medical Association published a report over

50 years ago advocating postgraduate hypnosis

training for anesthetists (27). Although it is not a

therapeutic panacea in every patient there is a

tendency to overlook opportunities where hypnosis

might be the treatment of choice (24). There is an

increasing body of evidence (28,29), which supports

our own clinical experience (19,30), that hypnosis

represents a useful, additional tool that anesthetists

may find valuable in their everyday practice. Future

research in treating needle phobia in children could

investigate the utility of this model compared with

other psychological or hypnotherapeutic approaches

which have been described previously (3133).

Identifying the skills children successfully use dur-

ing venepuncture needs investigating so that these

techniques can be taught more readily to patientswho are having difficulty.

References1 Majstorovic M, Veerkamp JS. Relationship between needle

phobia and dental anxiety. J Dent Child 2004; 71: 201205.2 Hamilton JG. Needle phobia:a neglected diagnosis. J Fam Pract

1995; 41: 169175.3 Rice LJ. Needle phobia: An anesthesiologists perspective. J

Pediat 1993; 122: S9S13.4 Chen E, Zeltzer LK, Craske MG et al. Childrens memories for

painful cancer treatment procedures. Child Dev 2000; 71: 933947.

5 Butler LD, Symons BK, Henderson SL et al. Hypnosis reducesdistress and duration of an invasive medical procedure forchildren. Pediatrics 2005; 115: 7785.

6 Uman LS, Chambers CT, McGrath PJ et al. Psychologicalinterventions for needle-related procedural pain and distressin children and adolescents. Cochrane Database Syst Rev 2006;CD005179.

7 Kohen DP. Applications of Clinical Hypnosis with Children.In: Burrows GD, Stanley RO, Bloom PB, eds. InternationalHandbook of Clinical Hypnosis. Brisbane: John Wiley & sons, Ltd,2001: 309325.

8 Gamsa A. Hypnotic analgesia. In: Melzack R, Wall PD, eds.Handbook of Pain Management. London: Churchill Livingstone,2003: 521531.

9 Yapko MD. Responding to misconceptions. In: Yapko MD, ed.

Trancework: An Introduction to the Practice of Clinical Hypnosis.Florence, KY USA: BrunerMazel, 1989: 2547.

10 Murat I, Gall O, Tourniaire B. Procedural pain in children:evidence-based best practice and guidelines. Reg Anesth PainMed 2003; 28: 561572.

11 Liossi C, Hatira P. Clinical hypnosis in the alleviation of pro-cedure-related pain in pediatric oncology patients. Int J ClinExp Hypn 2003; 51: 428.

12 Calipel S, Lucas-Polomeni MM, Wodey E et al. Premedicationin children: hypnosis versus midazolam. Pediatr Anesth 2005;15: 275281.

13 Australian New Zealand College of Anaesthetists. Non phar-macological techniques. In: Macintyre P, ANZCA WorkingParty, ed. Acute Pain Management: Scientific Evidence, 2nd edn.Melbourne: Commonwealth of Australia, 2005: 134141.

14 Fuge C. Bedford Square. A connection with mesmerism.Anaesthesia 1986; 41: 726730.

15 Faymonville ME, Fissette J, Mambourg PH et al. Hypnosis asadjunct therapy in conscious sedation for plastic surgery. RegAnesth 1995; 20: 145151.

16 Bejenke CJ. Painful medical procedures. In: Barber J, ed. Hypnosis and Suggestion in the Treatment of Pain: A ClinicalGuide. London: WW Norton, 1996: 209261.

17 Montgomery GH, DuHamel KN, Redd WH. A meta-analysisof hypnotically induced analgesia: how effective is hypnosis?Int J Clin Exp Hypn 2000; 48: 138153.

18 Fredericks LE. Hypnosis as a sole anesthetic. In: Fredericks LE,ed. The Use of Hypnosis in Surgery and Anesthesiology . Spring-field, IL: Charles C Thomas, 2000: 99118.

19 Cyna AM, Andrew MI, McAuliffe GL. Antenatal self-hypnosisfor labour and childbirth: a pilot study. Anaesth Int Care 2006;34: 464469.

20 Lucas-Polomeni MM. Hypnosis: a new anesthetic technique!Pediatr Anesth 2004; 14: 975976.

21 Faymonville ME, Laureys S, Degueldre C et al. Neural mech-anisms of antinociceptive effects of hypnosis. Anesthesiology2000; 92: 12571267.

22 Maquet P, Faymonville ME, Degueldre C et al. Functionalneuroanatomy of hypnotic state. Biol Psychiat 1999; 45: 327333.

23 Nash M. The truth and the hype of hypnosis. Sci Am 2001; 285:4649, 5255.

24 Olness K, Gardner GG. Some guidelines for uses of hypno-therapy in pediatrics. Pediatrics 1978; 62: 228233.

25 Garver RB. Control switch visualisation. In: Corydon Ham-mond D, ed. Handbook of Hypnotic Suggestions and Metaphors.London: WW Norton, 1990: 61.

26 Coldrey JC, Cyna AM. Suggestion, hypnosis and hypnother-apy: a survey of use, knowledge and attitudes of anaesthetists.Anaesth Int Care 2004; 32: 676680.

27 BMA Working Party. Medical use of hypnotism. In: BMASubcommittee to Council, ed. Supplementary Report of BMJ,App X. CD005179, 1955: 190193.

28 Lang EV, Benotsch EG, Fick LJ et al. Adjunctive non-pharma-cological analgesia for invasive medical procedures: a rand-omised trial. Lancet 2000; 355: 14861490.

29 Smith CA, Collins CT, Cyna AM et al. Complementary andalternative therapies for pain management in labour. CochraneDatabase Syst Rev 2006; CD003521.

30 Cyna AM. Hypno-analgesia for a labouring parturient withcontra-indications to central neuraxial block. Anaesthesia 2003;58: 101102.

31 Duff AJA. Incorporating psychological approaches into routinepaediatric venepuncture. Arch Dis Child 2003; 88: 931937.

32 Dash J. Rapid hypno-behavioral treatmentof a needle phobia ina five-year-old cardiac patient. J Pediatr Psychol 1981; 6: 3742.

33 Trijsburg RW, Jelicic M, van den Broek WW et al. Exposureand participant modelling in a case of injection phobia.Psychother Psychosom 1996; 65: 5761.

Accepted 16 January 2007

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220638 Brief Hypnosis for Severe Needle Phobia Using

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