Petrovic , P. , Petersson , K. M. , Ghatan , P. H. , Stone-Elander , S. , and Ingvar , M. ( 2000 ). Pain-related cerebral activation is altered by a distracting cognitive task . Pain , 85 , 19 \200\22330. Pillai Riddell , R. , Racine , N. , Turcotte , K. , Uman , L. S. , Horton , R. , Din Osmun , L., et al . ( 2011 ). Nonpharmacological management of procedural pain in infants and you ng children: an abridged cochrane review . Pain Res Manage , 16 , 321 \200\223330. Varni , J. W. , Burwinkle , T. M. , and Katz , E. R. ( 2004 ). Th e PedsQL in pediatric can cer pain: a prospective longitudinal analysis of pain and emotional distress . J Dev Behav Pediatr , 25 , 239 \200\223246. Villemure , C. , and Bushnell , M. C. ( 2002 ). Cognitive modulation of pain: how do attent ion and emotion infl uence pain processing? Pain , 95 , 195 \200\223199. Wall , P. D. ( 19 78 ). The gate control theory of pain mechanisms: a Richardson , J. , Smith , J. E. , McCall , G. , and Pilkington , K. ( 2006 ). Hypnosis for procedure-related pain and distress in pediatric cancer patients: a systematic review of ef f ectiveness and methodology related to hypnosis interventions . J Pain Symptom Manage , 31 , 70 \200\22384. re-examination and re-statement . Brain , 101 , 1 \200\22318. Wallace , D. P. , Allen , K. D. , Lacroix , A. E. , and Pitner , S. L. ( 2010 ). Th e \200 \230cough trick \200\231: a brief strategy to manage pediatric pain from immunization injec tions . Pediatrics , 125 , e367 \200\223e373. Ruda , M. A. , Ling , Q. , Hohmann , A. G. , Peng , Y. , and Tachibana , T. ( 2000 ). Alter ed nociceptive neuronal circuits aft er neonatal peripheral infl ammation . Science , 289 , 628 \200\223630. Wang , Z. , Sun , L. , and Chen , A. ( 2008 ). Th e effi cacy of non-pharmacological method s of pain management in school age children receiving venepuncture in a pediatric departmen t: a randomized controlled trial of audiovisual distraction and routine psychological inter vention . Swiss Med Wkly , 138 , 579 \200\223584. Sander , W. S. , Eshelman , D. , Steele , J. , and Guzzetta , C. E. ( 2002 ). Eff ects of d istraction using virtual reality glasses during lumbar punctures in adolescents with cancer . Oncol Nurs Forum , 29 , E8 \200\223E15. Schechter , N. , Berde , C. , and Yaster , M. ( 1993 ). Pain in infants, children and adolescents: an overview . Baltimore, MD : Williams and Wilkins . Wohlheiter , K. A. , and Dahlquist , L. M. ( 2013 ). Interactive versus passive distraction for acute pain management in young children: the role of selective attention and developme nt . J Pediatr Psychol , 38 , 202 \200\223212. World Health Organization. ( 2012 ). Summar y of WHO position papers: recommendations for routine immunization. Available at : < http:/ /www. who.int/immunization/documents/positionpapers/en/ >. Schechter , N. L. , Zempsky , W. T. , Cohen , L. L. , McGrath , P. J. , Meghan McMurtry , C . , and Bright , N. S. ( 2007 ). Pain reduction during pediatric immunizations: evidence-ba sed review and recommendations . Pediatrics , 119 , e1184 \200\223e1198. Schmitt , Y. S. , Hoff man , H. G. , Blough , D. K. , Patterson , D. R. , Jensen , M. P. , Soltani , M. , et al . ( 2011 ). A randomized, controlled trial of immersive virtual realit y analgesia, during physical therapy for pediatric burns . Burns , 37 , 61 \200\22368. Wickens , C. D. ( 1984 ). Processing resources in attention . In R. Parasuraman , and D. R. Davies (eds.) Varieties of attention , pp. 63 \200\223102. Orlando, FL : Academic . Smith , K. E. , Ackerson , J. D. , and Blotcky , A. D. ( 1989 ). Reducing distress during i nvasive medical procedures: relating behavioral interventions to preferred coping style in pediatric cancer patients . J Pediatr Psychol , 14 , 405 \200\223419. Wickens , C. D. ( 2002 ). Multiple resources and performance prediction . Th eoret Issues Ergon Sci , 3 , 159 \200\223177. Windich-Biermeier , A. , Sjoberg , I. , Conkin Dale , J. , Eshelman , D. , and Guzzetta , C . E. ( 2007 ). Eff ects of distraction on pain, fear, and distress during venous port acces s and venipuncture in children and adolescents with cancer . J Pediatr Oncol Nurs , 24 , 8 \200\22319. Stevens , B. J. , Abbott , L. K. , Yamada , J. , Harrison , D. , Stinson , J. , Taddio , A. , et al . ( 2011 ). Epidemiology and management of painful procedures in children in Canad ian hospitals . CMAJ , 183 , E403 \200\223E410. Yoo , H. , Kim , S. , Hur , H. , and Kim , H. ( 2011 ). Th e eff ects of an animation distr action intervention on pain response of preschool children during venipuncture . Appl Nurs Res , 24 , 94 \200\223100. Taddio , A. , Chambers , C. T. , Halperin , S. A. , Ipp , M. , Lockett , D. , Rieder , M. J . , and Shah , V. ( 2009 ). Inadequate pain management during childhood immunizations: the nerve of it . Clin Th er , 31 , S152 \200\223167. CHAPTER 54 Hypnosis and relaxation Christina Liossi , Leora Kuttner , Chantal Wood, and Lon nie K. Zeltzer Introduction Psychological approaches to symptom management are among the oldest and are an intrinsic part of medical practice in every cul- ture. Suggestive therapy is probably the oldest of all therapeutic methods and hypnosis under various names has been used for as lon g as records have been kept. Despite the fact that research on clinical hypnosis with child ren is still in an early stage of develop- ment and the child hypnosis literature is predom inantly composed of anecdotal case histories and uncontrolled research studies, one of the best-documented uses of hypnosis is in the treatment of pae- diatric pain where hypnosis ha s achieved status as an evidenced- based/empirically supported intervention. In this chapte r, the current research literature and clinical practice regarding the use of hypnosis in p ediatric pain management will be discussed. First hypnosis is defi ned and theoretical conc eptualizations are briefl y discussed. Second, our current understanding of the mechanisms of hypnotic analgesia is presented. Th ird the research evidence for the effi cacy of hypno sis in the control of acute and chronic paedi- atric pain is reviewed; in both sections rel evant clinical techniques are discussed. Following, a description and discussion of diff er ent relaxation techniques and the evidence for their effi cacy in acute and chronic pain ma nagement is presented. Th e chapter concludes with an attempt to summarize and evaluate the existing literature and make suggestions for future studies and clinical practice. Box 54.1 Hypnotic induction and deepening techniques for young people Favorite activity Imagine building a Lego house at home; just let yourself feel that way no w. Arm levitation Pay special attention to your hand and arm. Something inter- esting and stra nge is going to happen to them \200 you become aware of how warm or cold your arm is, of little muscles in your hand and arm that twitch ever so slightly \200 and now perhaps you would like to imagine \200 that I am fastening a string around your wrist \200 fastene d to the other end of the string \200 over there on the ground \200 lies a balloon that is not yet blown up \200 what color is it? \200 that \200\231s right it is bright yell ow \200 now the balloon is being fi lled with helium \200 you can see the balloon lift off the ground and rise, rise higher and higher \200 the string around your wrist becomes taut \200 watch what happens to the arm \200 yes, it is pulling the hand and arm up \200 Ascending cloud You are relaxing on a warm sunny day, looking at a clear blue sky \200 yo u see a fl uff y white cloud fl oating gently down towards you \200 Hop on the cloud \200 the cloud starts going up again \200 you feel yourself relaxing and drift ing deepe r and deeper into tranquility as you remain immersed in the cloud \200 that goes higher a nd higher \200 you fl oat at a comfortable height. Hypnosis Hypnosis is a psychological state of heightened awareness and focused attention, i n which critical faculties are reduced and sus- ceptibility and receptiveness to ideas is g reatly enhanced. Hypnotic induction procedures usually consist of \200\230an extended init ial sugges- tion for using one \200\231s imagination \200\231 (Green et al., 2005 , p. 262) , or an invitation to focus one \200\231s attention. Hypnotic inductions tradition- ally in volve suggestions to relax, although relaxation is not neces- sary for hypnosis, particular ly with children who respond better to more active inductions. An induction can be quite br ief or longer, depending upon the hypnotic subject \200\231s responsiveness and the cli- ni cian \200\231s preferences. During hypnosis the health care professional makes suggestions for changes in subjective experience, alterations in perception, sensation, emotion, though t or behavior (Green et al., 2005 ; Liossi., 2011) (see Box 54.1 for examples of hypnotic inductions and supplementary online materials for video clips). Hypnosis is a natural state of aroused, attentive focal concentration coupled with relative suspension of peripheral a wareness. Because hypnotic capacity is a normal and widely distributed trait, and because e ntry into hypnotic states occurs spontaneously, hypnotic phenomena occur frequently. Even t herapists who make no formal use of hypnosis can enhance their eff ectiveness by learning t o rec- ognize and take advantage of hypnotic mental states. Children have blurred boundaries between fantasy and reality, a factor that makes them idea l candidates for hypnotic interventions. Th ey are open to new experiences, fi nd hypnosis interesting and CHAPTER 54 hypnosis and relaxation 561 have few if any preconceived ideas and reservations about hypno- sis. Unlike adults, childr en usually move and talk during hypnosis without this meaning that they are disengaging fro m the interven- tion. Young patients can also easily be taught and learn self-hyp- nosis, w hich is the act of administering hypnotic procedures on one \200\231s own (Gardner and Olne ss, 1981 ). As the therapist guides the individual to experience the hypnotic suggestions a s they develop, this promotes a feeling of being active and creative in the therapeu- tic p rocess and facilitates a kind of \200\230playful \200\231 engagement between the therapist and the child (Kuttner, 1988 ; Liossi and Mystakidou, 1996 ) which is one of the cornersto nes of pain management. Th is engagement, while challenging, is a necessary fi rst step in build- ing a therapeutic alliance in which the patient, family, and therapist work together to achieve a common goal. the social context or relational aspects of the hypnotic interaction (Yapko, 2003 ). Even though debates and controversies in the fi eld of hypnosis have been dominated by the opposition between \200\230state \200\231 and \200\230non- state \200\231 theories, these two theoretical approaches are not mutually exclusive, have several lines of convergence, and none of these can satisfactorily explain all the phenomena associated with hypnosis. Mo re recent theorists have suggested that attempting to explain the eff ects of hypnosis sole ly in terms of one school of thought presents distinctions that are too arbitrary and the d iff erent formu- lations have certainly broadened our understanding of the subject and info rmed clinical practice (Kihlstrom, 1992 ; Kirsch and Lynn, 1995 ; Lynn et al., 2000 ). Although hypnotic analgesia is among the oldest treatments for pain (Elliotson, 1843 ), int erest in its use seems to wax and wane. Currently, interest in hypnotic treatments for acut e and chronic pain in general and pediatric pain in particular appears to be on the rise, p ossibly due to: (1) confi rmation from adult imaging stud- ies that chronic pain is largely infl uenced by, and may at times be primarily the result of, supraspinal neurophysiologica l processes (Jensen, 2009 ); (2) evidence that hypnosis has observable infl uences on the n europhysiological processes associated with pain (Jensen, 2009 ); (3) empirical evidence th at hypnotic analgesia is eff ective for acute pain particularly procedure related and promi sing results from the use of hypnosis in chronic pain management. In pediatric practice, working with children and adolescents means working with parents fro m the very beginning, when evalu- ating the problem and throughout the treatment process. G uiding the parents to focus on and actively facilitate the use of coping strat- egies such as hypnosis by the young patient helps the patient and family gain a sense of control over the pain. Successful parenting strategies oft en strike a balance between protection and ac ting as a \200\230life coach \200\231. In many cases parents can serve as \200\230life co aches \200\231 and guide, especially younger patients, to use hypnosis (see supplemen- tary online materials for video clips). Th eoretical conceptualizations of hypnosis can be loosely classi- fi ed under state and no n-state, intrapersonal and interpersonal, or single and multifactor theories (Yapko, 2003 ) (it is beyond the scope of this chapter to discuss the merits and controversies surroundin g each theory, see Kallio and Revonsuo ( 2003 ), for a review). State, intrapersonal, and s ingle theorists maintain that hypnosis repre- sents a cognitive process distinct from norma l day-to-day cognitive processes and conceptualize it as a trance state or an altered state of consciousness, i.e. the neodissociative (Hilgard and Hilgard, 1994 ) and \200\230disso ciative control \200\231 views (Bowers, 1992 ). Th e neodissocia- tive model regards hypnos is as a state in which one or more forms of consciousness is split off from the rest of men tal processing. Bowers and his colleagues maintained that subsystems of control in the brai n can be activated directly rather than through higher level executive control. In other wo rds, the strategies subjects used to reduce pain were evoked automatically without any type of con- scious strategy (Bowers, 1990 , 1992 ). Mechanisms of hypnotic analgesia Early research on the neurophysiological underpinnings of pain focused on peripheral activity emanating from the site of injury. With the introductio n of the gate control theory (Melzack and Wall, 1965 ) the focus shift ed to the spinal cor d and with recent improvements in imaging technology, there has been a dramatic increase in the study of the central neurophysiological correlates of pain. Now more than ever, we und erstand how multiple integrated pain networks work together to contribute to the global exp erience of pain and that the neurophysiological processes that underlie the experience of p ain have peripheral, spinal, and supraspinal nervous system components (for more detail see Apkarian et al., 2005 ; Byers and Bonica, 2001 ; Craig, 2003 ; Terman and Bonica, 2001 ; R ainville, 2002 ). Current evidence shows that hypnotic suggestions of analgesia may modulate pain processing at multiple levels and sites within the central nervous system. At the peripheral level, hy pnosis may modulate nociceptive input by downregulating A delta and C fi bres stimulation ( Benhaiem et al., 2001 ) and reducing sympa- thetic arousal (De Benedittis et al., 1994 ). A t a spinal level, sensory analgesia during hypnosis has been shown to be linearly related t o a reduction of the nociceptive fl exion (RIII) refl ex, a polysynap- tic spinal refl ex t hat is not subject to voluntary control (Kiernan et al., 1995 ). Using a methodology simila r to that of Kiernan et al. ( 1995 ), Danziger and colleagues (Danziger et al., 1998 ) late r found two patterns of RIII refl ex associated with hypnotic analgesia in 18 individuals w ith high levels of hypnotizability: 11 of their study participants showed clear inhibition and seven showed facilitation of the spinal nociceptive refl ex following hypnotic analgesi a sug- gestions. Although the reasons for the diff erences in response are not easily expla ined, they do indicate that highly suggestible indi- viduals can show changes in spinal noc iceptive refl ex when given hypnotic analgesia suggestions. Th e non-state, interpersonal, and multifactor theorists, also known as sociocognitive theo rists, suggest a social \200\223psychological explanation of hypnosis. Th ese theorists mai ntain that there is nothing unique about hypnosis and argue that most of the hypnotic pheno mena can occur without a hypnotic induction or trance, that neither hypnotic induction nor the existence of an altered state of consciousness are necessary for hypnotic responding, i ncluding responses to suggestions for pain relief (Chaves, 1993 ). Hypnotic analgesia is th ought to reduce pain instead through cognitive \200\223be- havioural mechanisms, in which c hanges in cognitions are thought to alter the aff ective states associated with pain (Chave s, 1993 ). Th e model suggests that the operative variables in hypnosis include contextual cues in the social environment, patient and subject expectancies, demand characteristics of the setting or situation, and role enactment (Kirsch and Lynn, 1995 ; Patterson and Jensen , 2003 ; Spanos and Chaves, 1989 ). Th e intrapersonal theories of hypnosis emphasize the s ubjective and inner states of the hypnotized per- son, whereas the interpersonal models att ach more importance to SECTION 7 psychosocial interventions 562 A number of supraspinal sites have been shown to be involved in the perception of pain, but the areas that have been identifi ed, most consistently, across diff erent imaging studies are the thala- mus, the primary and secondary somatosensory cortex (S1 and S2), the anteri or cingulate cortex (ACC), the insula, and the prefrontal cortex (see also Apkarian et al., 2005 ; DeLeo, 2006). At supraspinal cortical level, neuroimaging studies have shown that h ypnosis has direct eff ects on many supraspinal sites involved in the experience of pain an d that hypnotic suggestions of analgesia can modulate directly both sensory and aff ective dimensions of the pain per- ception. Derbyshire and colleagues, for example, have shown tha t suggestions for feeling pain in the hand in healthy, pain-free indi- viduals resulted in self-reports of pain and increased activity in the thalamus, ACC, insula, prefrontal, and p arietal cortices (Derbyshire et al., 2004 ). Th e eff ects of suggestions on both pain inte nsity and cerebral activation were stronger when the suggestions followed a hypnotic induct ion than when participants were asked to simply \200\230imagine \200\231 pain without a hy pnotic induction. In a follow-up study, Derbyshire and colleagues suggested to individuals with chronic pain that they would experience their clinical pain as being of \200\230low \200\231, \200\230medium \200\231, and \200\230high \200\231 intensity, both following an d not following a hypnotic induction (Derbyshire et al., 2009 ). Suggestions for high pain resulted in increases in both pain and in cortical activity asso- ciated with the experienc e of pain, whereas suggestions for low pain resulted in decreases in pain and in cortical a ctivity in these same areas. Similarly, to their earlier study (Derbyshire et al., 2004 ), the suggestions had larger eff ects following a hypnotic induction. function development of typically late developing functions of cog- nitive and motivation c ontrol, timing and attention as well as of resting state neural networks shows that between childhood and adulthood, concurrent with cognitive maturation, there is progres- sively in creased functional activation in task-relevant lateral and medial frontal, striatal, and pa rieto-temporal brain regions that mediate these higher level control functions. Th is is ac companied by progressively stronger functional inter-regional connectivity within task-rele vant fronto-striatal and fronto-parieto-temporal networks. Negative age associations are ob served in earlier devel- oping posterior and limbic regions. Th is developmental maturation trajectory could explain the development of increasing pain coping abilities in adolescent s vs. in children. High-level attentional and cognitive control processes rely on the integrity of, and dynami c interactions between, core neurocogni- tive networks. Th e right fronto-insular cortex (r FIC) is a critical component of a salience network (SN) that mediates interactions between large-scale brain networks involved in externally oriented attention (central executive net work (CEN)) and internally oriented cognition (default mode network (DMN)). Structural and func- tional maturation of the right fronto-insular cortex pathways is a critical component of the process by which human brain networks mature during development to support complex, fl exible cognitive processes in adulthood (Uddin et al., 2011 ). Furthermore, neurons wit hin the lateral ventromedial thalamic nucleus (VMl) convey selectively nociceptive informat ion from all parts of the body. VMl neurons driven by \200\230whole-body \200\231 nocicept ive receptive fi elds project to the rostral part of the layer I of the dorsolateral fronta l cortex. Th e VMl comprises a homogeneous, organized subset of thalamic neurons that allow any signals of pain to modify cortical activity in a widespread manner, by interacting wit h the entire layer I of the dorsolateral neocortex (Monconduit and Villanueva, 2005 ). Hypnotic modulation of pain dramatically alters the cortical pain matrix. Th e hypnotic mod ulation of pain intensity produces changes in pain related activity mainly in the S1, while modulation of pain unpleasantness induces changes mainly in the ACC, with the anterior (mi d) cingulate cortex possibly modulating both sen- sory and aff ect components of pain (Faym onville et al., 2000 ; Peyron et al., 2000 ). Two eloquent experimental studies have demons trated that hypnotic suggestions can selectively alter the pain experience and have \200 \230targeted \200\231 eff ects on diff erent cortical areas. In the fi rst, Rainville and c olleagues demonstrated that hypnotic suggestions for decreased and increased pain unpleasan tness succeeded in reducing and increasing ratings of pain unpleasantness, respectively, bu t did not aff ect ratings of pain intensity (Rainville et al., 1997 ). Consistent with the self-report fi ndings, these same hypnotic suggestions resulted in decreases and increases in activity in the ACC only. In a follow-up study, Hofb auer and colleagues showed that hyp notic modulation of the intensity of the pain sensation led to signifi cant changes in pain evoked activity within S1 (and a trend in S2), but not in the ACC (Hofb auer et al., 2001 ). Th is double dissociation of cortical modulation indicates a relative specialization of the sensory and the classical limbic cortical areas in the processing and modula- tion of t he sensory and aff ective dimensions of pain. Overall, in brain development a general pattern of functional and structural increases in c onnectivity and integrative process- ing, and a changing balance between limbic/subcortical and frontal lobe functions that extend well into young adulthood exist. Given the evidence for experience-driven structural plasticity (Markham and Greenough, 2004 ) an exciting yet untested hypothesis is that regular use of hypnosis by young people enhances this top-down pathway and strengthens cortical connectivity. Quantifi cation of intervention-related cha nges in brain structure and function may provide further useful information about the neura l mechanisms underlying the hypnotically induced pain reduction in young peo- ple with pain and also knowing which neural systems have been modifi ed may, in turn, provide additional insights relevant for fi ne- tuning of the initial therapeutic strategy. Hypnosis in acute pain management Th ere is strong support for the effi cacy of hypnosis in procedure- related pain management and hypnosis has achieved status as an empirically vali dated, possibly effi cacious intervention in the man- agement of pediatric procedure-relate d pain (Liossi, 1999 ) accord- ing to the criteria devised by the American Psychological As sociation to judge the effi cacy of psychological interventions (Chambless and Hollon, 1998 ). All studies conducted to date (Butler et al., 2005 ; Hawkins et al., 1998 ; Hilgard and LeBaron, 1982 ; Katz et al., 1987 ; Kellerman et al., 1983 ; Kuttner, 1988 ; Liossi and Ha tira, 1999 , 2003 ; Liossi et al., 2006 , 2009 ; Smith et al., 1996 ; Wall and Womack, 1989 ; However, it has to be noted that these are adult studies and dif- ferences exist between ad ult and child brains. Brain structural and functional development, throughout childhood and into adulthood, underlies the maturation of increasingly sophisticated cognitive abilities and a shift with age from the recruitment of \200\230bot- tom-up \200\231 processing regi ons towards \200\230top-down \200\231 fronto-cortical and fronto-subcortical connections, suggesting progressive functional integration and segregation with age leading to a more ma ture, and controlled cognition (Rubia, 2012 ). A review (Rubia, 2012 ) of the functional ma gnetic resonance imaging (fMRI) literature on brain CHAPTER 54 hypnosis and relaxation 563 Zeltzer and LeBaron, 1982 ) found hypnosis eff ective in reducing the pain and anxiety of y oung patients during painful medical procedures such as lumbar punctures, bone marrow aspir ations, venepunctures and voiding cystourethrograms. A meta-analysis concluded that hypnosi s is the most promising psychological inter- vention for needle procedures (Uman et al., 20 06 ). Limited support is available in the pediatric literature that hypnosis signifi cantly lowers postoperative pain and anxiety ratings and contributes to shorter hospital stays (L ambert, 1996 ). Box 54.2 Hypnotic analgesic techniques for acute pain management Switchbox Th e therapist explains to the child the idea that pain is transmit- ted by nerve s from various parts of the body to the brain, which then sends a \200\230pain message \200\231 back to the body (colored drawings can be used to facilitate this explanation). Th e patient is asked to choose a switch that can turn off or modulate incoming nerve signals situated whenever they want (e.g. in the brain or near the site of pain). Patients are ask ed to practice turning the switches progressively down for defi ned periods of time startin g with 10 to 15 secs and working up to longer periods. In the most recent prospective controlled trial, the effi cacy of self- hypnosis in combina tion with a local anesthetic (EMLA ) was com- pared with EMLA in the relief of venepu ncture-induced pain and anxiety in 45 pediatric cancer outpatients (age 6 \200\22316 years; Liossi et al., 2009 ). Patients were randomized to one of three groups: local anesthetic, local anesthetic plus hypnosis, and local anesthetic plus attention. Results confi rmed tha t patients in the local anesthetic plus hypnosis group reported less anticipatory anxiety, and less procedure- related pain and anxiety, and were rated as demonstrating less behav- i oural distress during the procedure than patients in the other two groups. Th e therapeutic benefi t of the brief hypnotic intervention was maintained in the follow-up. Moreover, par ents whose children were randomized to the EMLA plus hypnosis condition experienced less an xiety during their child \200\231s procedure than parents whose children had been randomize d to the other two conditions. Th ese fi ndings are particularly important in that this stu dy was a randomized, controlled trial conducted in a naturalistic medical setting. Topical anesthesia Imagine painting numbing medicine or cream onto that part of your body a nd make it go deep into your skin to protect you \200 Moving pain away from the self Imagine for a while that that arm (or other body part) doesn \200\231t belong to you, isn \200\231t part of you \200 see it just fl oating out there by itself, taking all the pain away \200 Directing attention to pain itself Imagine that you have come from another planet far deep in the Universe where there is no pain \200 you have never experienced pain before \200 notice the discomfort very carefully \200 be curious about what sensations you have \200 how does it make you feel \200 Diff erent hypnotic analgesic techniques can be used for acute pain management including di rect suggestions such as pain dis- placement, symptom substitution, time distortion, topica l anaes- thesia, glove anesthesia (see supplementary online materials for video clip), diss ociation (see Liossi, 2002 ), and indirect suggestions such as therapeutic stories and meta phors. Direct and indirect sug- gestions have been found to be equally eff ective (Liossi a nd Hatira, 2003 ) ( Box 54.2 provides examples of hypnotic techniques). Four out of fi ve s tudies (Hilgard and LeBaron, 1982 ; Liossi and Hatira, 2003 ; Liossi et al., 2006 , 2009 ; Wall and Womack, 1989 ) that have examined the relationship between the child \200\231s hyp notizability and pain relief during painful medical procedures reported a signifi cant posi tive relationship between hypnotizability and clinical benefi t following hypnosis treatmen t although the majority of children received some benefi t from the intervention. In all ra ndomized tri- als conducted so far, the role of the parents was critical and only their dir ect involvement in the intervention secured the mainte- nance of the therapeutic eff ect in when children were using self- hypnosis (Liossi et al., 2006 , 2009 ). evidence regarding diet regimens as well as medical and surgical treatments (Di Lorenzo et al., 2005 ). In a randomized controlled trial of 53 pediatric patients Vlieger and colleagues (Vlieger e t al., 2007 ) compared clinical eff ective- ness of hypnotherapy (HT) with standard medical therapy (SMT) in children with functional abdominal pain (FAP) or irritable bowel syndrome (IBS). Patients were randomized to either HT or SMT. Hypnotherapy consisted of six session s over a 3-month period. Patients in the SMT group received standard medical care and six s essions of supportive therapy. Aft er 3 months of therapy, 59% of the patients in the HT gr oup were in clinical remission with another 26% signifi cantly improved. In the control gro up, receiv- ing standard medical treatment (SMT), only 12% was in remission and 32% improve d. One year aft er treatment, 85% of the patients treated with HT were asymptomatic versus 25% of the children who received SMT. Clinical remission was defi ned as greater than 80% i mprovement in pain scores compared with baseline. Hypnosis in chronic pain management Well-designed clinical trials and accumulated clinical experi- ence (Banez, 2008 ; Galili et al., 2009 ) support the view that hypnosis is the mos t effi cacious treatment for chronic abdomi- nal pain improving pain and disability outcome s and needs to be an integral part of the biobehavioural approach to manage- ment. Chronic abdominal pain (CAP) is long lasting, intermit- tent, or constant pain aff ecting 15% to 30 % of children ages 4 to 18 and presents a diagnostic and treatment challenge to the physici an. Most children with this disorder are found to have no specifi c organic etiology (funct ional abdominal pain), the predictive value of diagnostic tests is questionable, and studie s of the treatment of chronic abdominal pain show inconclusive In a follow-up study, the same investigators (Vlieger et al., 2012 ) explored the long-term eff ects of HT versus standard medi- cal treatment plus supportive therapy (SMT). All 52 p articipants of their previous randomized controlled trial (RCT) were invited to complete a standardized abdominal pain diary, on which pain frequency and pain intensity were scored. All 27 HT patients and 22 out of 25 SMT patients participated in this study. Aft er a mean duration of 4.8 years \200\231 follow-up, HT was still highly superior to conventional ther apy with 68 versus 20% of the patients in remis- sion aft er treatment. Also, somatization scores were lower in the HT group. However, no diff erences were found in quality of life, doctors \200\231 visits, and missed days of school or work between the two groups. SECTION 7 psychosocial interventions 564 Vlieger and colleagues further concluded that the clinical success achieved with HT in thei r studies cannot be explained by improve- ment in rectal sensitivity (Vlieger et al., 2010 ). In one study they randomized 46 patients with FAP (n = 28) or IBS (n = 18) to either 12 weeks of SMT or HT. To assess rectal sensitivity, a pressure-con- trolled intermittent dist ension protocol (barostat) was performed before and aft er the therapy. Interestingly, no r elationship was established between treatment success and rectal pain thresholds. Rectal se nsitivity scores at baseline were not correlated with inten- sity, frequency, or duration o f abdominal pain. Hypnotic strategies and techniques for managing chronic pain, among others, include: creati ng anesthesia or analgesia, a decrease in pain, an increase in comfort and relaxation, chan ges in sensa- tions from unpleasant (burning) to more pleasant (warm) ones, feeling less bo thered by sensations, or changes in the meaning of pain, unconscious exploration to enhance insight or resolve con- fl ict, cognitive-perceptual alteration of pain (and pain behavior ), and decreasing awareness of pain (distraction techniques). Other useful hypnotic approac hes to pain management include self-sug- gestions for relaxation and a sense of global calm ness, ego strength- ening, being in a \200\230special place \200\231 (that is, a place tha t is beautiful, safe, relaxing, and calming to the young patient; see supplementary online material for video clip), decreased tension and emotional suff ering, maintaining an approp riate level of activity, focusing on life goals other than just pain reduction, increasing participation in distracting and healthy activities, appropriate activity pacing and Rossi \200\231s (Rossi et al., 2010 ) mind \200\223body healing approach. In this lat- ter approa ch, hypnotic suggestions can be given during the treat- ment session for the patient to reg ress and access past learning, memory, and experience and use them as therapeutic resources for pain management. Th e multifaceted and complex nature of chronic pain requires elaborate and comprehensive h ypnotic interventions delivered in a number of sessions and regular and consistent use of s elf-hypnosis by the patient (Wood and Bioy, 2008 ). Especially, when considering biopsychos ocial and neuropsychological models of pain, using a com- bination of pain-specifi c and no n-pain-related suggestions maybe par- ticularly eff ective because these suggestions can ta rget not only pain itself, but emotional (e.g. suggestions for improved mood), cognitive (e .g. suggestions for increased self-effi cacy), and behavioral (e.g. sug- gestions for impro ved sleep) factors that play an important role in the pain experience (Dillworth and Jensen , 2010 ). Details of the interven- tions will diff er depending on the exact nature of the problem, the purposes of the clinical endeavor, the goals of the health care pro- fessional , and the abilities and preferences of the young patient and their family (Liossi., 2011). Box 54.3 shows an example of a hypnotic session for chronic pain management and the case ex ample illustrates a hypnosis based therapeutic approach across time. However, it needs to be acknowledged that chronic pain in children is a multifactorial cond ition not easily addressed by one technique only. Multidisciplinary management is required and hypnosis should be part of a cognitive-behavioral treatment framework (see also Zeltzer and Blackett-Schlank, 2005 , Kuttner, 2010 ). Box 54.3 Example of a hypnotic treatment session for chronic pain management Induction and deepening suggestions Get ready to go aboard a submarine for an extraordinary journey under the sea ! Dive deeper and deeper until the water is dark blue \200 look th rough your periscope, peek under fl aps, put your scuba diving equipment on \200 open an airlock \200 and dive into the ocean \200 Analgesic suggestions Th e water temperature is pleasant \200 your body relaxes \200 yo u fl oat happily \200 any discomfort that you may be experiencing is leaving your body \200 dissolving into the water \200 meet ocean animals \200 look at the bottom of the sea \200 Imagine going back in time \200 to a time some time ago, before any pain or discomfort, w hen you were full of energy and had a sense of complete well-being \200 when you come back to the here and now you will feel again th e same sense of well-being \200 Now see the pain \200 what shape is it? \200 see its color? \200 feel its texture? \200 now change the shape, color and texture \200 Ego-strengthening You are going to feel physically stronger and fi tter in every way \200 you will be surprised how enthusiastically you fi nd yourself working on your physio exerc ises \200 you will notice feeling more alert \200 more wide awake \200 every day \200 you \200\231ll be more curious and interested in school and extracurricular activitie s \200 in your friends and family \200 in whatever is going on around you \200 so tha t your mind will become completely distracted away from yourself and your diffi culties \200 you will be able to think more clearly \200 and notice how you become emotionally c almer \200 every day \200 you will feel more and more independent \200 every day \200 you will feel a greater feeling of well-being \200 Post-hypnotic suggestion From now, each and every time you feel these sensations (pain) in your muscles and bones you will immediately take in a deep breath, and as you breathe out y our whole body will relax \200 Termination Now I would like you to count backwards from 5 to 1 \200 1 you are feeling ref reshed and alert and ready to continue with whatever you were doing before \200 CHAPTER 54 hypnosis and relaxation 565 Case example AB, a 17-year-old athlete sustained a severe injury to her shoulder in an unexpected fall. She had several months of physiotherapy with little progress and surgery was recommended to stabilize her shoulder joint. Following surgery she developed a frozen shoulder compli- ca tion resulting in a severely restricted range of motion and exquisitely tender shoulder cap sule. She continued with physiotherapy but now had signifi cant limitations in her capacity to care for herself. Daily pain became part of her life. As a result of continuous pain, she walked protecting h er shoulder from accidental bumps, avoiding crowded places and became increasingly anxious about incurring further pain. Aft er almost 2 years of living with daily pain, physical lim itations, and increasing despair, she was referred for pain management. She presented as an organized, motivated teen, who tearfully stated that pain was a steady part of her life. Despite pain and mobility restrictions, she successfully passed her exams . She complained of continual exhaustion and diffi culty sleeping. She experienced second- ary neck and back pain and presented as emotionally vulnerable and mildly depressed. Treatment Combined with ongoing physiotherapy and pharmacotherapy, hypnosis, and relaxation were used to repattern her brain-body connec- tion so that she could learn to: \227\206 Successfully release tension and relax more eff ectively. \227\206 Develop an awareness of well-being. \227\206 Experience her body as capable of healing. \227\206 Decrease intensity and areas of pain.