Hypnotic recall: a positive criterion in the differential diagnosis between epileptic and pseudoepileptic seizures.

PURPOSE: Because the diagnosis of pseudoepileptic seizures (PESs) is mostly made by excluding epilepsy, availability of a positive criterion for PESs is of great importance. This study was aimed at the validation of a diagnostic technique that intends to provide in such a positive criterion. METHODS: In 17 patients with epileptic seizures (ESs) and 20 patients with PESs, a hypnotic procedure was performed by an investigator blind to other data to recover amnesia for the ictus. If recall was obtained, the experimental diagnosis PES was given; if not, ES was diagnosed. The experimental diagnoses were compared with the clinical, EEG-confirmed diagnoses. Hypnotizability was measured to determine the relation between the outcome of the test and hypnotizability of the patients. RESULTS: Recall for the ictus was obtained in 17 patients. Each of these had a clinical diagnosis of PES. Seventeen patients with "no recall" had a clinical diagnosis of ES, and three patients had PESs. This result yields a specificity of 100% and a sensitivity of 85% for the recall technique. Hypnotizability was significantly higher in patients with PESs than in patients with ESs. In some "low hypnotizables," recall was obtained, and in some "high hypnotizables," no recall was obtained. CONCLUSIONS: A positive recall test indicates PES. A sub-group of patients with PESs is characterized by a high level of hypnotizability. Hypnotizability is not crucial for outcome of the recall test. High hypnotic abilities are especially found in disorders in which it is supposed that "dissociation" is involved. It can be speculated that PES may be one of the dissociative phenomena.

The inpatient treatment of patients suffering from (motor) conversion symptoms: a description of eight cases.

This article presents a preliminary study that used two controlled randomized trials to study the effect of hypnosis in the treatment of eight patients with (motor) conversion symptoms. Controlled research into the treatment of conversion symptoms is scarce and can often be criticized on methodological grounds. It would appear, however, that both the use of suggestive and behavioral therapeutic techniques and eclectic treatment programs yield good results in the treatment of conversion symptoms. The results of the study suggest that comprehensive clinical treatment including hypnosis has enough promise to be studied in clinical trials. In the interpretation of the results, special attention is given to primary diagnosis, duration of complaints, traumatic experiences in childhood, dissociative capacity, and hypnotizability.

The diagnosis of psychogenic non-epileptic seizures: a review.

Diagnosing psychogenic non-epileptic seizures (PNES) is a clinical challenge. There is neither a standard in diagnosing PNES nor a comprehensive theoretical framework for this type of seizure. The diagnosis of PNES must be made by excluding epilepsy. However, epilepsy cannot always be determined and PNES and epileptic seizures may coexist. In this study, the characteristics of PNES and patients are discussed. The diagnosis of PNES and epileptic seizures was facilitated by the simultaneous recording of seizures on video tape and EEG. Seizure provoking techniques, hormonal indices, and psychological methods were also used. The benefits and limitations of these techniques are discussed and proposals are made for clinical guidelines.

Does preference for type of treatment matter? A study of exposure in vivo with or without hypnosis in the treatment of panic disorder with agoraphobia.

There is evidence that preference for a given therapy may influence results. Literature also suggests that hypnotizability may be elevated in agoraphobic patients, making hypnosis a potentially powerful method for treatment. Agoraphobic patients (N = 64) were treated with either exposure in vivo or exposure combined with hypnosis in a crossover design. Half of the patients started with the treatment they preferred and the other half received the other treatment first. Although patients' preference clearly shifted in favor of the combined therapy in the course of the study, no effect of preference on outcome was evident. Although hypnotizability clearly correlated to outcome in the combined therapy, no difference in effect between the two therapies was found on behavioral, self-report, and observer measures. No additional effect of hypnosis could be shown and preference was not found to be a powerful mediator of effect.

Depersonalization and derealization during panic and hypnosis in low and highly hypnotizable agoraphobics.

The primary aim of the present study was to investigate the association between spontaneous experiences of depersonalization or derealization (D-D) during panic states and hypnosis in low and highly hypnotizable phobic individuals. Secondarily, the association among level of hypnotizability, capacity for imaginative involvement, and severity of phobic complaints was also assessed. Sixty-four patients with panic disorder with agoraphobia according to the DSM-III-R (American Psychiatric Association, 1987) criteria participated in the study. Proneness to experience D-D during hypnosis was positively related to hypnotizability, but only for agoraphobic patients who had already experienced these perceptual distortions during panic episodes. Correlations of level of hypnotizability and capacity for imaginative involvement with severity of agoraphobic complaints were not significant. These findings suggest that hypnotizability may be a mediating variable between two different, although phenotypically similar, perceptual distortions experienced during panic states and hypnosis. Implications for both theory and clinical practice are discussed.

The case for a dissociative interpretation of pseudoepileptic seizures.

A pseudoepileptic seizure (PES) can be considered as a paroxysmal behavior pattern that mimics epilepsy and is initiated by psychological mechanisms. There is no evidence that the symptomatology of PES forms a specific syndrome. This paper presents evidence for the explanatory value of the concept of dissociation in at least a subgroup of PES. Characteristics of patients with PES and possible factors in the etiology of PES are reviewed. Based on the dissociation hypothesis, some suggestions are offered to explain the relatively high comorbidity of PES and epilepsy.

Dissociative and hypnotic experiences in eating disorder patients: an exploratory study.

Hypnotizability, subjective experiences during hypnotizability assessment, and dissociation were studied in 53 eating disorder patients in order to explore the relationship between these phenomena. Dissociation was measured with a newly developed self-reporting Dissociation-Questionnaire (DIS-Q), level of hypnotizability was assessed with the Stanford Hypnotic Clinical Scale (SHCS), subjective experiences during hypnosis with the Dutch Phenomenology of Consciousness Inventory (DPCI), and the Dutch Resistance to Hypnosis Scale (DRHS). Compared with normals, eating disorder patients scored significantly higher on the DIS-Q and SHCS. Compared with restricting anorexics, anorexics of the mixed type as well as bulimics report higher scores on both the DIS-Q and SHCS, but a significant difference was found only for the DIS-Q subscale loss of control. Although positive correlations between the DIS-Q and SHCS were found, the magnitude of the correlations shows that both instruments probably are measuring different constructs. Some implications of these findings are discussed.

Pseudo-epileptic seizures: hypnosis as a diagnostic tool.

In this pilot study hypnosis was used in an attempt to provide evidence of a psychogenic component of pseudo-epileptic seizures. The criterion for psychogenesis was the reversal of the amnesia, which is often present in epileptic- and pseudo-epileptic seizures. The technique has been validated by a semi-blind referral of cases for analysis after the clinician had been able to make a firm diagnosis based on electro-encephalic corroboration of the nature of the seizure. In eight out of nine patients (of the original 13 patients, three patients dropped out and one patient was not evaluable), the experimental diagnosis corresponded with the clinical diagnosis. As pseudo-epileptic seizures can be characterized by their dissociative nature, a reasonable hypothesis is that patients with pseudo-epileptic seizures are more responsive to hypnosis than patients with epileptic seizures. Measurements of hypnotizability among seven patients with epileptic seizures and six patients with pseudo-epileptic seizures supported this supposition.

Treatment of panic disorder with agoraphobia: comparison of fluvoxamine, placebo, and psychological panic management combined with exposure and of exposure in vivo alone.

OBJECTIVE: The purpose of this comparative outcome study was to investigate whether the effects of exposure in vivo treatment for panic disorder with agoraphobia could be enhanced by adding interventions specifically for panic attacks before the start of exposure treatment. The additional effect of two types of treatment for panic attacks--pharmacological (fluvoxamine) and psychological (repeated hyperventilation provocations and respiratory training)--was examined. Thus, the combined treatment of panic interventions with exposure in vivo could be compared to exposure in vivo alone. METHOD: Ninety-six patients were randomly assigned to four treatment conditions: double-blind, placebo-controlled fluvoxamine followed by exposure in vivo, psychological panic management followed by exposure, and exposure in vivo alone. Outcome was assessed by self-report measures, a standardized multitask behavioral avoidance test, and continuous monitoring of panic attacks. Seventy-six patients completed the study. RESULTS: All four treatments were effective and resulted in a significant decrease of agoraphobic avoidance. Moreover, the combination of fluvoxamine and exposure in vivo demonstrated efficacy superior to that of the other treatments and had twice as large an effect size (difference between pre- and posttreatment scores) on self-reported agoraphobic avoidance. The other treatments did not differ among each other in effectiveness. CONCLUSIONS: Results of the study indicate that the short-term outcome of exposure in vivo treatment can be enhanced by adding fluvoxamine treatment. Psychological panic management combined with exposure was not superior to exposure alone of equal duration.

Respiratory training prior to exposure in vivo in the treatment of panic disorder with agoraphobia: efficacy and predictors of outcome.

Thirty-two patients suffering from panic disorder with agoraphobia were treated with repeated hyperventilation provocations and respiratory training, followed by exposure in vivo. The treatment was evaluated with a comprehensive set of outcome measures, including self-report questionnaires, a multitask behavioural avoidance test and continuous monitoring of panic. The treatment was found effective for the majority of patients in diminishing the frequency of panic attacks and agoraphobic avoidance. The clinical relevance of the treatment effect was evidenced by the considerable number of patients that recovered. The effect of the treatment was sustained over a three and six month follow-up period. The prognostic value of a number of variables for treatment outcome was also investigated. Three variables accounted for the majority of the variance in treatment outcome: a higher pretreatment level of agoraphobic complaints, use of psychotropic medication and a longer duration of the disorder were associated with poorer outcome. Other variables, such as the therapeutic relationship and the quality of the marital bond, had no prognostic value.

Autogenic training and self-hypnosis in the control of tension headache.

This study compares autogenic training and training in multiple self-hypnosis strategies in a sample of 56 patients diagnosed as having chronic tension headache on the basis of medical evaluation by a neurologist. At posttreatment and follow-up, no differences between the two treatment regimens in the reduction of headache and psychological distress were observed. During treatment, patients reduced their headache activity and level of psychological distress significantly in contrast to the waiting-list period (p < 0.05). Follow-up measurements indicated that therapeutic improvement was maintained (p < 0.05). Short-term and long-term pain reduction was accompanied by an increase in perceived pain control (p < 0.003). Moreover, those patients who attributed the pain reduction obtained during therapy to their own efforts manifested long-term pain reduction (p < 0.003).

Hypnosis and autogenic training in the treatment of tension headaches: a two-phase constructive design study with follow-up.

Tension headaches can form a chronic (very long duration) condition. EMG biofeedback, relaxation training and analgesia by hypnotic suggestion can reduce the pain. So far, no differences have been demonstrated between the effects of various psychological treatments. In a constructively designed study, we firstly compared an abbreviated form of autogenic training to a form of hypnotherapy (future oriented hypnotic imagery) which was not presented as hypnosis and secondly we compared both treatments to the same future oriented hypnotic imagery, but this time explicitly presented as hypnosis. The three treatments were equally effective at post-treatment, but after a 6-month follow-up period, the future oriented hypnotic imagery which had been explicitly presented as hypnosis was superior to autogenic training. Contrary to common belief, it could be demonstrated that the therapists were as effective with the treatment modality they preferred as with the treatment modality they felt to be less remedial.

The function of agoraphobia in the marital relationship.

A secondary analysis was carried out of data from a previous experiment on the treatment of agoraphobia. This analysis shows that, contrary to some reports in the literature, agoraphobics do have more problems in the relationship with their partner than the average members of the normal population. The analysis also shows that individual-oriented behavioural treatment of the agoraphobia significantly improves the marital relationship. The findings contradict the theory that agoraphobia serves a function in the relationship with the partner.

Hypnosis: placebo or nonplacebo?

According to Grünbaum's definition of placebo, a therapeutic procedure can be considered a nonplacebo if it can be demonstrated that its effects are produced according to the theory upon which the therapy is based. If the theory is adopted that hypnotic effects depend upon mobilization of the patient's hypnotizability, which is a measurable characteristic, a testable theory is provided. Experimental literature is reviewed that shows that placebo effects are not related to hypnotizability. Clinical outcome studies make it clear that results of hypnotherapy are related to hypnotizability in some disorders such as pain and anxiety, but not in the treatment of addiction or habit disorders. An example of a procedure is given in which hypnosis is nonetheless usefully applied for its placebo value as a method to generate positive expectancies.

Hypnosis and conversion disorders.

A review of the literature shows that presently held views on the relation between hypnosis and conversion disorders had their origin in the previous century. This also holds for therapeutic techniques as they are still applied today. A case report illustrates that successful symptom removal may be independent of the patient's hypnotizability and of the techniques used.

Does hypnosis contribute to the care of burn patients? Review of the evidence.

In burn treatment, hypnosis has been used for the alleviation of pain, the prevention and treatment of anxiety and depression, and the acceleration of wound healing. The successful application of hypnosis decreases the extensive medication needed. Furthermore, it provides a tool to patients with which they may experience more control in situations that are often experienced as overwhelming. Notwithstanding these important applications and the very positive terms with which the results of studies are generally described, hypnosis has mostly been neglected as a tool to help burn patients. This article reviews the clinical and experimental evidence of the usefulness of hypnosis in the management of burns. Pain reduction and crisis intervention are promising applications. However, due to a lack of systematic and controlled research, more specific conclusions are precluded. In the controversial area of wound healing, claims for the effectiveness of hypnosis have been made on the basis of slim evidence and inconclusive studies. This hypothesis needs to be addressed in controlled experiments. In summary, systematic investigations are needed to confirm and supplement available clinical evidence. Recommendations for future research are given.

The effectiveness of standardized versus individualized hypnotic suggestions: a brief communication.

The results of a number of studies indicate that hypnotizability is a relatively stable trait that has some predictive value for therapy outcome. Some authors argue, however, that hypnotizability scores are artifacts of standardized test procedures, and that more people will benefit from hypnosis when a broader range of suggestions is used. The present study was designed to investigate the effectiveness of standardized versus individualized suggestions. In a crossover design, counterbalanced for order of presentation, 48 Ss were tested twice: once with the Stanford Hypnotic Clinical Scale: Adult (SHCS: Adult) of Morgan and J. R. Hilgard (1975) and once with an individualized equivalent of SHCS: Adult. The results of this comparison showed no significant differences between the 2 methods. The present study does not support the concept of hypnotizability scores as artifacts of standardized measurements.

Hypnosis and pain in patients with severe burns: a pilot study.

This report presents a pilot study on the effectiveness of hypnosis in the control of pain during dressing changes of burn patients. Eight patients were treated, and all evaluated the interventions as beneficial. The treatment of four patients was more closely analysed by obtaining pain and anxiety ratings daily. Results show a 50-64 per cent decrease in reported pain level for three patients and a 52 per cent increase of pain for one patient. The mean decrease for these four patients was 30 per cent (for overall as well as worst pain during dressing changes). A 30 per cent reduction of anxiety level and a modest reduction of medication use were achieved concurrently. It is concluded that hypnosis is of potential value during dressing changes of burn patients. Comparison of global evaluations and daily pain ratings shows that systematic research in some cases leads to conclusions opposite from clinical observations or follow-up evaluations. Limitations of this study are discussed and recommendations for future studies are given.