Adding Hypnosis to the Therapeutic Toolbox of Pediatric Respiratory Care

A patient with exercise-associated dyspnea

A 16-year-old girl was diagnosed with asthma by her primary care provider when she presented with a year-long history of dyspnea during track competitions, which caused her to stop her participation in varsity track. She had a history since early childhood of developing recurrent upper respiratory infection-associated coughing, wheezing, and dyspnea that responded to therapy with bronchodilators. The primary care provider ordered a methacholine challenge test that revealed a positive reaction consistent with a diagnosis of asthma. Nonetheless, the patient’s dyspnea persisted despite therapy with a number of asthma medications including fluticasone, montelukast, and albuterol prior to exercise. Upon referral to a respiratory care specialist, it became apparent that her exercise-associated dyspnea was associated with difficulty upon inhalation, slight stridor during vigorous exercise, and she reported it felt as if there was an obstruction to her inhalation at the level of the neck. Thus, even though she had underlying asthma, the presumptive diagnosis for her exercise-associated symptoms was stress-induced vocal cord dysfunction, which had led to anterior vocal cord adduction during inhalation.5^,6 The patient was offered and accepted the opportunity to learn how to use hypnotic imagery to relieve her dyspnea even while she was running. Immediately thereafter, she reported she no longer developed dyspnea and was able to resume her participation in varsity track. As her symptoms resolved following use of hypnosis, she did not warrant any further investigations, such as an upper airway laryngoscopic examination following exercise in order to confirm her diagnosis.

A child with cough

A neurologically intact 9-year-old boy was referred for evaluation of chronic cough that had occurred since he was 2 or 3 years old. The cough sounded as if the patient was attempting to clear his throat, always occurred as he was eating, and tended to be louder when the child was at home. Notably, when the patient was 2 years old he was treated for gastroesophageal reflux for few months. The physical examination, pulmonary function, and chest X-ray were normal. The differential diagnosis in this case included aspiration, H-type tracheoesophageal fistula, and gastroesophageal reflux. Additional diagnostic testing that was considered included a 24-h pH probe study, and barium swallow with contrast. The clinician noted that if the cough was solely the result of a physiologic problem, it should not vary in intensity based on the patient’s location. Therefore, instruction in self-hypnosis as a first-line intervention was offered and accepted. Immediately thereafter, the cough resolved, and no further investigation was needed. The final assessment was that the cough was attributable to habit, which perhaps arose when the patient had begun coughing in association with his gastroesophageal reflux in early childhood. When the reflux resolved, the habituated cough persisted. Notably, this was an unusual presentation of a patient with habit cough (also known as psychogenic cough or cough tic). Habit cough typically is triggered by upper respiratory infections, and is characterized by its loud, harsh, “barking,” or “honking” nature. The cough often occurs when patients attempt to fall asleep, ceases when they are asleep, and improves when they are distracted. School attendance frequently is disrupted as a result of habit cough.15

A patient whose wheezing was triggered by odors

A 17-year-old boy with severe milk allergy that twice caused him to develop severe anaphylaxis reported that during recent exposures to milk products he had developed wheezing and tachypnea. Upon review of his history, it became apparent that even the odor of a milk product, such as a cheeseburger, triggered his respiratory symptoms. When the patient was asked to imagine eating a cheeseburger, which he could not do in real life, he developed nasal flaring, tachypnea, and wheezing. When he was told to stop imagining the scenario, his breathing pattern returned to normal. It was hypothesized that some of the patient’s respiratory symptoms upon exposure to his allergens were related to anxiety rather than an anaphylactic reaction. For this reason, he was taught self-hypnosis relaxation techniques, and subsequently no longer developed respiratory symptoms following exposure to milk product odors.

What Is Hypnosis?

Experts in hypnosis have not yet developed a consensus definition for clinical hypnosis. One definition is that hypnosis is a state of inward attention during which the mind is focused on ideas of therapeutic value that can potentiate physiologic change. The ideas can be suggested by a health-care provider, or can be self-suggested by the patient.1^,2^,16

Many people are confused about hypnosis because of its long history of use for entertainment purposes. Contrary to the common perception of a hypnotist taking control of an unwitting subject, for example, by moving a pocket watch in front of the subject’s face, hypnosis does not involve the hypnotist’s control over a subject. In an hypnosis show, for example, volunteers enter hypnosis because they choose to follow the hypnotist’s instructions.

When I meet with preteen and teenage patients, I explain as follows:

For younger children, an introduction to hypnosis rarely is necessary. Hypnosis techniques for younger children should vary, depending on the developmental age of the child. For example, preschoolers tend to respond to story-telling, while school age children often benefit from pretending they are favorite characters from books, movies, or television.1

Several therapeutic modalities can have hypnotic features such as biofeedback,17 guided imagery,18 meditation,19 and suggestion therapy.20 The advantages of self-hypnosis instruction as compared to these other modalities for medical purposes include its rapid effect, relative simplicity, and the ability of the patient to utilize the technique independently and without need for special equipment.

Evidence for the Efficacy of Hypnosis for Respiratory Disease

There have been few published randomized clinical trials regarding the use of hypnosis for patients with respiratory disorders. A preliminary randomized study of 25 children with asthma showed no significant effect of 4 weekly hypnosis sessions on the patients’ forced expiratory volume in 1 s (FEV₁) or daily symptom scores.21 However, in a multicenter year-long trial, 252 children and adults with moderate and severe asthma were randomized to monthly hypnosis sessions and daily self-hypnosis, or to a control group in which patients used daily relaxation and were taught breathing exercises. Hypnosis was associated with an increase in FEV₁ of 4.3% (P < 0.05). There was no significant difference between the groups in their incidence of wheezing or medication use.22 In another randomized controlled study of 39 adults with mild to moderate asthma, patients who were highly skilled in hypnosis (high hypnotizable) demonstrated a significant reduction in reactivity to methacholine challenge testing (PC₂₀ 9.1 versus 15.9, P < 0.01), decreased chronic bronchodilator use (26% reduction, P < 0.05), and decreased subjective scores for nocturnal symptoms (62%, P < 0.05), wheeze (53%, P < 0.01), and activity limitation (40%, P < 0.01). In contrast, patients who did not use hypnosis well (low hypnotizable) or the control group demonstrated no significant changes in these parameters.23 In a 2-year randomized study of 28 children with asthma, those who were taught hypnosis had a significantly larger reduction in wheezing as compared to the control group (52% versus 35%, P < 0.05). The hypnosis group also had fewer school absences as a result of wheezing (1.5 versus 6.1 days/school year, P < 0.001).24 Hypnosis also has been shown to help in the management of asthma in several anecdotal reports.25

Several case series of patients using hypnosis for respiratory disorders in children have been reported by the SUNY Upstate Medical University Pediatric Pulmonary Center. For example, hypnosis was reported to help achieve resolution of habit cough in 90% of 51 children.15 Chronic dyspnea, which occurred with or without exercise, resolved in 81% and improved in the remaining 19% of 16 children who had normal lung function at rest, following 1 or 2 sessions of hypnosis instruction.11 Two case series showed that vocal cord dysfunction resolved in 54% and improved in an additional 38% of 37/51 children who returned for follow-up after instruction in hypnosis by a pediatric pulmonologist or social worker.7^,10 Among 49 patients with cystic fibrosis (CF), 86% reported that hypnosis was helpful for them. The most frequent uses of hypnosis among patients with CF were to relax, improve their tolerance to medical procedures and treatments, and cope with headaches. Some of these patients reported that hypnosis helped improve their adherence to their prescribed therapies.3 Difficulty with sleep onset was reported to improve in 90% of 75 children following hypnosis and counseling. In the same study, nighttime awakenings were reported to resolve in 52% and improve in 38% of 21 children.26

Notably, at this Center, instruction in hypnosis was offered to 36% of 6–11-year-old children and 55% of 12–18-year-old children who were newly referred for evaluation of pulmonary symptoms during an 18-month period of study, because it was felt that there was a significant psychological component in their presentation.9 Thus, hypnosis appears to be applicable to a large number of pediatric patients with respiratory disorders.

Replication of such case series at other sites and additional randomized trials of clinical hypnosis will help validate the reported findings.

Practical Application of Hypnosis in Practice

Introduction of hypnosis soon after the beginning of a patient’s evaluation and treatment is indicated whenever it is suspected that a patient is likely to respond to a psychological intervention, based on demonstration of symptoms suggestive of psychological difficulties (Table 1). Further medical workup and therapy may be required if a patient’s symptoms do not resolve with use of hypnosis. Incomplete response to medical therapy also may be an indication for a trial of hypnosis, as in such situations psychological issues often complicate patients’ presentations.

When a patient is identified as having an issue that might be addressed with hypnosis, the possibility of this therapy can be introduced to the patient and family during a regular clinic visit. In my experience, most patients are receptive to instruction in this simple mind/body modality that often can help them immediately. Some, of course, will require referral to a mental health provider because of the degree of psychosocial issues that may complicate their clinical presentation.

In practice, only a minority of parents and patients express doubt that mind/body therapy is applicable in their situation. For those families, I suggest that the mind can influence the perception of a symptom. For example, sometimes athletes are unaware of an injury while they are participating in a competitive activity because they are so focused on the game that they pay little or no attention to their injury. Another example involves patients with asthma who have suffered from exacerbations leading to stressful medical evaluations and treatment. It is common for them to become anxious when their asthma subsequently acts up.27 Further, anxiety can cause cough, dyspnea, and tachycardia that can add to the patients’ perception of the severity of their symptoms.28^,29 I explain that by teaching children how to calm themselves with hypnosis, they may be able to reduce the psychological impact in their presentations, which in turn often greatly simplifies their medical management.

Following such an explanation, most parents and children are interested in a trial of hypnosis in the respiratory specialist’s office. It is likely that those who do not express an interest may not have established sufficient rapport with their respiratory specialist, or have a conflict that precludes their willingness to use hypnosis, such as secondary gain that can prevent hypnosis from working.30^,31 For example, a child who has been taken out of an unpleasant gym class situation as a result of chest pain is less likely to be receptive to hypnosis that might resolve his chest pain because then he might be expected to return to that physical education class. [AQ: Please avoid gender bias, if possible] Notably, secondary gain issues also can interfere with a patient’s receptiveness to other medical therapies.

Once patients decide to learn hypnosis, the initial instruction can be accomplished within 5–30 min with older children, particularly as clinicians develop increasing expertise through training and practice, and even within less time with younger children. Thus, such instruction can be incorporated easily within a regular medical office appointment. There are many examples of successful hypnotic approaches in the literature.1^,32^,33 Keys to successful hypnosis include establishment of rapport with the parent and child, adapting the hypnotic work to the developmental age of the child, facilitating the child’s self-mastery, and following the child’s expectations, motivation, lead, and interests.1^,2 For example, a child who enjoys playing baseball will tend to be much more responsive to hypnotic suggestions that involve his favorite sport (including how he might improve his athletic performance) than relaxation suggestions that involve thinking about a place that may appeal to the health-care provider, but which the child finds “boring.”

A simple hypnosis session with a preteen or teenager involves teaching the child to imagine a favorite place with all of his senses. Frequently, as the child follows the instructions to do so, he reports that the experience seems real. Then, the child may be taught progressive relaxation of the muscles from head to toe, or from toe to head. The child may be asked to pick a gesture that will serve as a relaxation cue when he is not doing hypnosis. This gesture is rehearsed during hypnosis. Instructions during hypnosis sometimes are modified based on the symptoms of the child. For example, a child with habit cough might be taught to imagine a dial that controls the cough frequency when it is manipulated. A child with vocal cord dysfunction might be taught to imagine a creature or object that is obstructing the airway, and instructed to remove the imagined obstruction. A child with a discomfort, for example, in association with a medical procedure, might be taught to imagine the discomfort as represented by a particular color, and then changing the imaginary color to a soothing color, with an associated improvement in the discomfort. The child then is encouraged to return to a usual state of awareness when he is ready. Once he alerts, the child is encouraged to report about his experiences during hypnosis. As a way of validating the hypnosis experience, the child may be prompted to employ his relaxation cue, and usually becomes more relaxed, which reinforces that something “different” has occurred, and thus validates the experience. For treatment of symptoms that require on-going hypnosis work, for example, exercise-induced vocal cord dysfunction or anxiety-associated dyspnea, the child can be instructed to use hypnosis and/or the relaxation cue on his own, on a regular basis.7^,15^,33

Follow-up to the hypnosis intervention can be very brief, such as when a patient reports a successful outcome of self-hypnosis application to a respiratory issue. When patients state that their symptoms have not improved sufficiently but have not used hypnosis as recommended, a discussion regarding reasons for the lack of “adherence” should take place, and solutions regarding how hypnosis might be utilized more reliably are developed with the patient placed in the role of active consultant, for example, “I wonder how you could do this to help yourself even more?” When patients state that they have done hypnosis but it has not been helpful, modification of the hypnotic imagery can be recommended.

Clinical hypnosis can be billed as hypnotherapy or as counseling time under an evaluation and management code.16 When time-based billing is used, the clinician must indicate in the medical record that “Over half of the encounter time was devoted to counseling.”