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Brief presurgery hypnosisreduces distress and painin excisional breast biopsypatientsGuy H. Montgomery a , Christina R. Weltz a , MeganSeltz a & Dana H. Bovbjerg aa Mount Sinai School of Medicine, New YorkPublished online: 31 Jan 2008.

To cite this article: Guy H. Montgomery , Christina R. Weltz , Megan Seltz & DanaH. Bovbjerg (2002) Brief presurgery hypnosis reduces distress and pain in excisionalbreast biopsy patients, International Journal of Clinical and Experimental Hypnosis,50:1, 17-32, DOI: 10.1080/00207140208410088

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BRIEF PRESURGERY HYPNOSIS REDUCES DISTRESS AND PAIN IN EXCISIONAL

BREAST BIOPSY PATIENTS'

GUY H. MONTGOMERY, CHRISTINA R. WELTZ, MEGAN SELTZ, AND DANA H. BOVBJERG"

Mount Sinai School of Medicine, New York

Abstract: Each year, hundreds of thousands of women undergo excisional breast biopsies for definitive diagnosis. Not only do these patients experience pain associated with the procedure, but they also endure distress associated with the threat of cancer. Hypnosis has been demonstrated as effective for controlling patients' pain in other surgical settings, but breast surgery patients have received little attention. To determine the impact of brief presurgical hypnosis on these patients' postsurgery pain and distress and to explore possible mediating mechanisms of these effects, 20 excisional breast biopsy patients were randomly assigned to a hypnosis or control group (standard care). Hypno- sis reduced postsurgery pain and distress. Initial evidence suggested that the effects of hypnosis were mediated by presurgery expectations.

The adverse consequences of breast surgery (e.g., pain, distress) are experienced not only by the more than 150,000 women who undergo lumpectomy and mastectomy for breast cancer each year but also by the hundreds of thousands more women who undergo excisional breast biopsies for definitive diagnosis (Landis, Murray, Bolden, & Wingo, 1999; National Cancer Institute, 1999). From the surgical perspective, there is little difference between excisional biopsy and lumpectomy out- side the need to take a greater surgical margin with the latter (DeVita, Hellman, & Rosenberg, 1997). Thus, finding interventions to reduce aversive sequella of surgery for these patients is of considerable interest.

Chief among the acute aversive side effects of breast surgery are patients' pain and distress. Pain is a nearly ubiquitous side effect of all surgery (Loeser & Melzack, 1999), and women undergoing breast surgery are certainly no exception (Carpenter et al., 1998). In addition to the

Manuscript submitted November 14,2000; final revision received March 19,2001 'TIUS research was supported in part by a research grant from the National Cancer Insti-

tute (R03CA86562-01). 'We would like to thank the Post Anesthesia Care Unit staff and the ambulatory care

staff for their strong support in conducting the study. 'Address correspondence to Dr. Guy H. Montgomery, Box 1130, Ruttenberg Cancer

Center, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029- 6574 or guy [email protected]. The lirtrrnntionnl p i r n a l ufClrnica1 and Expcrimental Hypnosis, Vol 50, No 1, January 2002 17-32 0 2002 The Internationnl Joiirnnl of Clinical and Experimrnlal Hypnosis

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ia GUY H. MONTGOMERY ET AL.

aversiveness of the pain experience, patients’ pain is also important because it is a common reason for delayed hospital discharge (Chung, Ritchie, & Su, 1997) and thereby greater overall cost of medical care. Patients’ distress associated with breast biopsy has received less attention than postsurgical pain overall, but a growing number of reports now indicate that women experience heightened distress associated with breast biopsy (e.g., Northouse, Tocco, & West, 1997; Scott, 1983; Stanton & Snider, 1993). It is interesting to note, however, that none of the published studies have compared distress in excisional breast biopsy patients to that found in healthy volunteers to document the extent of the aversive impact of the surgical procedure on patients.

Asubstantial clinical literature has indicated that hypnosis is an effective tool for managing surgical side effects of a variety of other types of surgery (for reviews, see Blankfield, 1991; Finkelstein, 1991; Gravitz, 1988; Kessler & Dane, 1996; Milling & Costantino, 2000; Pinnell, & Covino, 2000; Wood & Hirschberg, 1994). For example, individual studies have demonstrated that hypnosis is effective for reducing postoperative nausea and vomiting in gynecological and elective surgery patients (Faymonville et al., 1995; Williams, Hind, & Sweeny, 1994), emotional distress in dental and coronary patients (Ashton et al., 1995, 1997; Enqvist, von Konow, & Bystedt, 1995), pain in abdominal and dental patients (Egbert, Battit, &Welch, 1964; Enqvist & Fischer, 1997), and time to discharge in a variety of surgical patients (Bonke, Schmitz, Verhage, & Zwaveling, 1986; Evans & Richardson, 1988; Pearson, 1961; Raplun, Straubing, & Holroyd, 1991). Indeed, both the American Medical Associ- ation and the British Medical Association endorsed the use of hypnosis with surgical patients as a valid medical treatment more than 40 years ago (see the Burton Goldberg Group, 1993; Wood & Hirschberg, 1994). To date, however, there have been few investigations of hypnosis with breast surgery patients. The argument for the use of hypnosis as an adjunctive treatment with excisional breast biopsy patients is consider- ably strengthened by the recent work of Lang and colleagues (2000). These investigators have compellingly demonstrated that a brief hypnotic intervention for patients undergoing radiological procedures can be effective in controlling pain and distress, in promoting hemo- dynamic stability, and in reducing procedure times.

The psychological mechanisms responsible for the beneficial effects of hypnosis have yet to be established. Research with patients undergoing other types of surgery has established that higher levels of emotional distress prior to surgery (i.e., anticipatory distress) are associated with more adverse reactions to surgery (e.g., Martinez-Urrutia, 1975). There have also been clinical reports that patients’ presurgery expectations of pain are predictive of their levels of postsurgery pain (Walmsley,

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HYPNOSIS WITH EXCISIONAL BREAST BIOPSY PATIENTS 19

Brockopp, & Brockopp, 1992). These findings are consistent with a psychological literature that has provided compelling experimental docu- mentation that expectations for pain predict subsequent reactions to standardized laboratory challenges (Montgomery & Kirsch, 1996; Mont- gomery & Kirsch, 1997). Such effects may be particularly pronounced in women scheduled for excisional breast biopsy, because they must con- front not only the widely known side effects of invasive surgery and anesthesia (Evans & Stanley, 1990) but also the threat that surgery may reveal cancer (Benedict, Williams, & Baron, 1994; Hughson, Cooper, McArdle, & Smith, 1988; Poole, 1997).

Consistent with these potential psychological mechanisms for the beneficial effects of hypnosis in surgery, a separate area of research has documented that hypnotic suggestions can affect patients’ levels of emotional distress, as well as their expectations of symptoms (see Kirsch, 1990; Kirsch, Tennen, & Wickless, 1983; Rhue, Lynn, & Kirsch, 1993). However, the degree to which preoperative changes in patients’ levels of distress and expectations are responsible for the beneficial impact of hypnosis in surgical settings has received little attention. It is reasonable to hypothesize that a hypnosis session prior to surgery would decrease patient distress, which in turn would ameliorate patient pain (Cook, 1999). Yet, to our knowledge, this mechanism has not been empirically tested. Additionally, hypnosis may alter patients’ expectations of postsurgery pain, which in turn may reduce patients’ experiences of postsurgery pain. Such a mechanism would be consistent with response expectancy theory (Kirsch, 1990; Kirsch, 1999), which states that an expectation for nonvolitional outcomes (e.g., reduced pain) are suffi- cient to cause that outcome without mediation by distress. For example, although the mechanisms are as yet unknown, an expectation for pain relief is hypothesized to lead to pain relief independent of any effects of distress. Such response expectancies are self-confirming and can be disconfirmed if the relation between the expectation and the outcome is mediated by other psychological variables (e.g., distress).

The purpose of this study was twofold: (a) to establish the beneficial impact of brief hypnosis on postsurgery pain and distress in excisional breast biopsy patients and (b) to investigate the relative contributions of postintervention patient distress and expectations of pain to postsurgery hypnoanalgesic effects. That is, we statistically explored the contributions of patient distress and expectations of pain as mediators of the effect of hypnosis on postsurgical pain control. Total statistical mediation of the effects of hypnosis on postsurgical pain and distress by postintervention distress (after accounting for expectations) would be inconsistent with response expectancy theory (Baron & Kenny, 1986).

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20 G W H. MONTGOMERY ET AL.

METHOD Participants

Patients scheduled for excisional breast biopsy in a large metropolitan hospital were consecutively recruited. To reduce heterogeneity among the patients due to the influence of particular surgeons, all patients were recruited from the practice of a single physician (C.W.). No medications were administered until patients reached the operating rooms. Eligible patients were at least 18 years of age; were never previously diagnosed with any cancer; were scheduled to receive uniform protocols for excisional breast biopsy, anesthesia, and analgesia; were not currently pregnant; and had no other concurrent uncontrolled major illness.

Of the 23 women approached to be in the study, 2 declined to participate due to difficulties understanding spoken English, and 1 stated that she did not have the time to participate. Therefore, 20 women meeting the above criteria participated. Age ranged from 30 to 81 years (mean age = 50.11, SD = 10.94). Fifty percent of the sample described themselves as white, 35% as African American, and 15% as Hispanic. Seventy percent of the sample were married, and 55% had earned a college degree. Twenty-five percent of the sample had undergone wire localization procedures prior to the interventi~n.~ There were no differences between the hypnosis group and the control group on any of these back- ground variables ( p > .20 in all cases).

To provide more of an indication of the magnitude of the distress experienced by women prior to excisional breast biopsy, 20 healthy volunteers (a sample of convenience) were recruited over the same period of time as the excisional breast biopsy patients and were assessed using identical measures of distress. The healthy volunteers had no history of major illnesses, were not taking any prescription medication, were at least 18 years of age, were not currently pregnant, and had answered an advertisement posted in our medical center. All were medical center employees. Age ranged from 26 to 56 years (mean age = 40.52, SD = 9.91). Forty-five percent of the sample described themselves as white, 12.5% as African American, and 25% as Hispanic. Seventy percent of the sample were married, and 55% had earned a college degree. There were no differences between the patients and the healthy comparison group on any of these variables (p > .20 in all cases) except age, F(l, 39) = 28.88, p < .001. Therefore, the comparison of patients’ and healthy volunteers’ distress levels included age as a covariate.

w i r e localization is used when the tissue to be excised from the breast cannot be pal- pated by the surgeon due to its location or size. This radiological procedure involves in- serting a narrow gauge wire into the breast and the tissue to be excised under imaging guidance.

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Measures Demographic information (age, education, marital status, ethnic

group) was collected from patients in the ambulatory surgery waiting areas and from healthy volunteers in an outpatient clinical research area. Patient medical data (heart rate, anesthesia and analgesic use) were collected via chart reviews following surgery.

Based on our previously published research (DiLorenzo et al., 1995; Montgomery & Kirsch, 1996; Montgomery & Kirsch, 1997), 10 cm visual analog scales (VASs) were used to measure participants' distress, pain, expectations, and overall satisfaction with medical care. To assess distress, participants were asked, "How emotionally upset are you feeling right now?" This VAS was anchored by Not at all upset and As upset as I could be. To assess pain, participants were asked, "How much pain do you feel right now?" which was anchored by No pain at all and As much pain as Icould. Assessment of expectations were conducted with the same format. Participants were asked, "How much pain do you expect to feel after the biopsy?" This item was repeated for expected postbiopsy distress. Overall satisfaction with medical care was also assessed with a VAS on which patients were asked, "Overall, how satisfied were you with your medical care today?" It was anchored by Completely unsatisfied and Completely satisfied.

Procedure Excisional breast biopsy patients were randomly assigned to the hyp-

nosis group or the control group based on day of surgery. This was done to prevent hypnosis group patients from potentially disclosing study procedures to control group patients (e.g., using hypnotic suggestions for reduced pain in the presence of other patients). Patients in the hypnosis group completed a demographic questionnaire in the ambulatory care waiting area and were then escorted to a private room on the same floor by a research assistant. They were introduced to the experimenter and completed baseline levels of distress and expectations for pain. The hypnosis group then participated in a brief (10-minute) standardized hypnotic induction, based on published procedures (Rhue, Lynn, & Kirsch, 1993). All hypnosis sessions were administered by a clinical psy- chologist (G.M.). Following the administration of the standardized script, patients' levels of distress and expectations were reassessed. Fol- lowing surgery, patients' distress, pain, and satisfaction ratings were assessed after discharge from the recovery room (discharge based on standardized hospital criteria). Patients' blood pressures (systolic and diastolic) were assessed according to standard clinical practice when they first checked in to the ambulatory care center (prior to meeting with study personnel that day) and when they entered the operating rooms for the excisional procedure (after meeting with study personnel). The control group filled out study forms at the same times as the hypnosis

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22 GUY H. MONTGOMERY ET AL.

group but otherwise received standard medical care. Healthy comparison volunteers completed demographic and distress measures in the General Research Clinic area of the medical center.

The hypnotic intervention was closely based on a published induction (Rhue, Lynn, & Kirsch, 1993). The induction included: instructions to the patients that they will remain in control; imagery for progressive muscle relaxation; suggestions to imagine a special place; suggestions for relaxation and peace; a deepening procedure; and instructions for how the patient could use hypnosis on her own (i.e., self-hypnosis). In addition, both positive suggestions (e.g., you will feel comfortable, healthy, confident) and negative suggestions (e.g., you feel very little pain, very little stress) were added for the purposes of the study. The beneficial effects of the intervention were suggested to occur before, during, and after s~rgery .~

RESULTS

Effects of hypnosis on postsurgical outcomes. The results revealed that patients in the hypnosis group benefited from the intervention when compared to the surgical control group (see Figure 1 for means). The hypnosis group demonstrated decreased postsurgery pain, F(1, 18) = 15.48, p < .001, as well as decreased distress, F(1,18) = 5.97, p < .025. The study groups did not statistically differ on their overall postsurgery satisfaction with their medical care (p > .20) on the day of surgery. Further analysis revealed a medium effect size , d = 0.57, (Cohen, 1992) for patient satisfaction, and therefore we would anticipate that a sample size of 128 patients would be necessary to statistically reveal this difference with power = .80 and p c .05 (Cohen, 1992). Thus, definitive conclusions cannot be drawn until a substantially larger sample has been investi- gated. Group differences in the amount of time patients spent in the Post Anesthesia Care Unit (recovery room) were also not significant, p > .20, due to high variability (hypnosis group: SD = 74.46 minutes; control group: SD = 57.08 minutes). Effect size analysis revealed a small effect size, d = 0.15, indicating a far greater sample size would be needed to detect whether the intervention has any effect on time spent in the recovery room.

Analyses of possible mediation of the efecfs of hypnosis on postsurge y pain and distress. We tested three specific hypotheses based on the criteria established by Baron and Kenny (1986): (a) The intervention induces changes in the potential mediator; (b) the mediator is correlated with the outcome; and (c) the mediator statistically accounts for variance previously associated with the intervention in univariate analyses.

h e hypnosis protocol is available upon request.

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Figure 1. Mean postsurgical pain, distress, satisfaction with medical care, and time in the Post Anesthesia Care Unit (PACU) as a function of treatment group.

Note. VAS = Visual analog scale.

Postintervention distress as a mediator of the effects of hypnosis. With regard to postintervention distress as a possible mediator, the results revealed a significant Group (hypnosis vs. control) x Time (preintervention, postintervention) interaction, F(1,18) = 30.40, p < .001, on patients’ distress, consistent with Criterion 1 above. Analyses of simple effects indicated that although the patient groups did not differ in their levels of distress prior to the intervention, F(1,18) = 0.94, p < .35, they did significantly differ following the intervention, F(1,18) = 6.56, p < .02 (see Figure 2). Not surprisingly, two simple one-way ANOVAs revealed that patients’ levels of distress both prior to, F(3,36) = 30.08, p < .001, and following the

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60 7

50 -

40 -

30 -

20 -

E 8

CA CA d > v) v) 0 & c, v1 .H

n

Pre inte rve ntion Pos tinte rvention

Excisional Breast Biopsy Patients

Figure 2. Mean distress in patients before and after the intervention as a function of treatment group, with a comparison to a healthy sample.

Note. VAS = Visual analog scale.

intervention significantly differed from that of healthy women, F(3,36) = 21.30, p < .001, adjusting for age. Post hoc Tukey testing indicated that preintervention distress in both patient groups (hypnosis and control) significantly differed from the healthy comparison group ( p < .001 in both cases); however, distress levels in the surgical patient groups did not differ from each other, p > .13. Post hoc testing of between-group differences in postintervention distress revealed that the healthy comparison group continued to have less distress than either the patient control group, p < .001, or the hypnosis group, p < .001. More important however, the hypnosis group had less distress than the patient control group, p < .01 (see Figure 2 for means).

To assess Criterion 2, relations between patients’ levels of postintervention distress prior to surgery and their subsequent experience of pain and distress following surgery were examined. Postintervention distress was not correlated with postsurgery pain ( r = .20, p > .40), however, postintervention distress was sigruficantly related to postsurgery distress (T = -53, p c .015), meeting Criterion 2. To address Criterion 3, multi- ple regression was then used to determine whether the inclusion of presurgery distress in the predictive model with group (hypnosis vs. control) reduced the variance associated with group (see Table 1). Based on changes in the standardized parameter estimates associated with group, results were consistent with mediation of the intervention’s effects on postsurgery distress by presurgery distress. However, distress did not remain significant when included in the model with group,

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Table 1 Assessment of the Mediation of Group Effects on Postsurgery Distress by Pos tin terven tion Distress

SPE P‘

Group -0.50 .025

Group -0.30 .200

Equation 1

Equation 2

Postintervention Distress 0.38 .116 Note. SPE = standardized parameter estimate.

which rules out distress as a formal mediator (Baron & Kenny, 1986). The failure of distress to remain a signhcant predictor is most likely due to small sample size, because it was significant in bivariate analyses (see above).

To provide a more objective indicator of patients’ distress prior to surgery, we also examined changes in patients’ presurgical blood pressure from before to after the intervention as a check on self-report data. Patients’ blood pressure upon arrival at the ambulatory surgical care center (preintervention) and upon their arrival at the operating room (postintervention) were entered into a repeated measures analyses of variance, with group as the only independent factor (as above). Asignifi- cant interaction of Group (hypnosis vs. control) x Time (2 levels: blood pressure at check in and in the OR prior to surgery) would be consistent with decreases in self-reported distress. Results revealed a significant interaction for systolic blood pressure, F(1,18) = 5.12, p c .04, however, not for diastolic blood pressure, F(1,18) = 4.14, p c .06. On average, the hypnosis group had a 9.1 mm Hg drop in systolic blood pressure from pre- to postintervention and a 9.0 mm Hg drop in diastolic blood pressure. The control group had 6.4 mm Hg and .80 mm Hg mean increases in systolic and diastolic blood pressures, respectively, over the same period. For both systolic and diastolic readings, there were no main effects of group or time, as well as no significant simple effects (between group differences at each time point), p > .10 in all cases. Furthermore, blood pressure did not correlate with postsurgery pain or distress, p > .38 in all cases.

Postintervention expecfations as a mediator of the effects of hypnosis. In order to test the possibility that patients’ postintervention expectations account for the beneficial effects of the intervention on pain and distress following surgery, analyses were performed to examine whether expectations of pain and distress met Criteria 1-3. Patients’ postintervention expectations of pain were significantly affected by the intervention, as indicated by a sigruficant interaction between group and time, Ffl, 18) =

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21.43, p < .001, consistent with Criterion 1. Analyses of simple effects indicated that although groups did not differ in their expectations of pain prior to the intervention, F(l, 18) = 1.47, p c .241, they did significantly differ following the intervention, F(1,18) = 6.29, p < .022 (hypnosis group: preintervention mean = 63.80, SD = 21.94; postintervention mean = 24.20, SD = 16.53; control group: preintervention mean = 50.10, SD = 28.22; postintervention mean = 49.90, SD = 27.88). Consistent with Criterion 2, postintervention expectations of pain were significantly correlated with postsurgery pain, r =.69, p < .001. To establish Criterion 3 for mediation, two regression equations were performed. First, with group alone, second, with group and presurgery expectations of pain as predic- tors. Results support partial statistical mediation of the group effect by presurgery expectations of pain because there was a reduction in the absolute value of the standardized parameter estimate (SPE) associated with group when expectations were added to the model (see Table 2). Because we have directional hypotheses regarding mediation, we applied Sobel’s criteria (Baron & Kenny, 1986) for mediator significance using a one-tailed test, z > 1.64. Based on these criteria, patients‘ expectations of pain were a sigruficant mediator of the effect, z = 1.90.

Consistent with Criterion 1, patients’ presurgery expectations of postsurgery distress were impacted by the intervention, as shown by a significant Group x lime interaction, F(1,18) = 8.61, p < .009. Analyses of simple effects again indicated that although groups did not differ in their expectations of distress prior to the intervention, F(1,18) = 0.70, p < .413, they did sigruficantly differ following the intervention, F( 1/18) = 7.53, p < .013 (hypnosis group: preintervention mean = 30.40, SD = 26.31; postintervention mean = 14.60, SD = 13.87; control group: preintervention mean = 41.60, SD = 33.12; postintervention mean = 44.00, SD = 27.88). Consistent with Criterion 2, expectations of distress were significantly correlated with postsurgery distress, T = .71, p c .001. To test Crite- rion 3, in regard to the possibility that postintervention expectations of postsurgery distress mediated the effects of the intervention on postsurgery distress, three simultaneous regression equations were performed (see Table 3). As postintervention distress was shown to predict postsurgery distress previously in bivariate analyses (see above), postintervention distress was also included in the following regression equations as a conservative approach to assessing the role of expectations. The results support total statistical mediation. They demonstrated that patients’ expectations of postsurgical distress totally mediate the effects of the intervention on distress (Baron & Kenny, 1986). Postinter- vention distress did not account for these effects nor for the relations between expectations of and the experience of postsurgical distress. We again applied Sobel’s criteria (Baron & Kenny) for mediator significance using a one-tailed test, z > 1.64. Based on these criteria, patients’ expectations of pain were a significant mediator of the effect, z = 2.12.

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Table 2 Assessment of the Mediation of Group Eflects on Postsurgery Pain by Postintervention Expectations of Pain

SPE P < ~~~ ~~ ~~

Equation 1 Group

Equation 2 Group Postintervention Expectations

-0.68 .001

-0.44 .020 0.46 .016

Note. SPE = standardized parameter estimate.

Table 3 Assessment ofthe Mediation of Group Effects on Postsurgery Distress by Postintervention Distress and Expectations of Postsurgery Distress

Equation 1 Group

Equation 2 Group Postintervention Expectations

Equation 3 Group Postintervention Distress Postintervention Expectations

-0.50 .025

-0.16 .431 0.62 .006

-0.18 .405 0.14 .641 0.72 .027

Note. SPE = standardized parameter estimate.

DISCUSSION The results of the present study revealed that a brief hypnosis inter-

vention can be an effective means to reduce postsurgical pain and distress in women undergoing excisional breast biopsy. Postsurgical pain was reduced in patients receiving hypnosis relative to a standard care control group. The intervention was also an effective means for decreas- ing patients’ distress, both before and after surgery. The evidence of heightened distress prior to surgery in this prospective study is consistent with previous retrospective studies in breast biopsy patients (8ene- dict et al., 1994; Northouse et al., 1997). In this small sample, the intervention did not affect patients’ sense of satisfaction with their medical care or the amount of time spent in the surgical recovery area, although studies having substantially greater sample sizes would be necessary before clearer conclusions can be drawn. The overall results of the present study support the efficacy of brief hypnotic interventions with this pop- ulation of surgical patients for control of commonly experienced postsurgical pain and distress.

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Additional analyses in the present study were consistent with the hypothesis that patients' postintervention response expectancies mediate the effects of hypnotic suggestion (Kirsch, 1991). In this sample, however, mediation of the postsurgical hypnoanalgesic effect was partial and not total (Baron & Kenny, 1986), indicating that other factors may also be responsible for the beneficial impact of the intervention on pain reduction. Although we found no additional contributions of distress with the measures used here, our assessments of distress could conceiv- ably have failed to characterize patients' experiences. The possibility remains that patients' distress may account for some portion of this effect. For example, all patients were asked about their distress "right now" and peak intensity of distress may have been missed (e.g., occurred earlier or later). Similarly, our VAS approach to the measure- ment of distress may not have captured the full richness of the phenome- non, although such assessment techniques have proven sensitive in past research with cancer patients (DiLorenzo et al., 1995). Interestingly, patients' expectations did totally mediate the effects of the intervention on postoperative distress. That is, expectations for postsurgery distress assessed after the intervention but prior to surgery accounted for the effects of brief hypnosis in reducing postsurgical distress, even after accounting for postintervention distress in the model. These results would indicate that interventions specifically targeting patients' expectations are likely to have a beneficial impact on postoperative pain and distress.

The present study has limitations, and these include a small sample size. However, the extensive literature with patients undergoing other types of surgery, as well as the significant effects found here, indicate that the effects of hypnosis are robust. Additional research with a larger sample would enhance confidence in the generalizability of the results and allow more thorough dissection of potential mediating and moder- ating variables. For example, it would be of interest to assess patients' levels of hypnotic suggestibility, which has been demonstrated to correlate with responses to hypnoanalgesic suggestions (Montgomery, DuHamel, & Redd, 2000). Because the present study was focused on examining mediators of hypnotic effects and not moderators, we leave these questions of moderator variables as an opportunity for future research with larger samples. Future research also might consider using more extensive measurements of pain and distress to more fully capture the richness of patient experiences. It should be noted, however, that the VAS measurements used here have the advantages of being brief, less burdensome to patients, and less likely to interfere with ongoing medical treatments. Furthermore, previous work has demonstrated that VASs are sensitive to expectancy-induced changes (Montgomery & Kirsch, 1996).

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In conclusion, a brief presurgery hypnosis intervention was effective in managing patients’ postsurgical pain and distress after excisional breast biopsy. The intervention was also effective in reducing distress prior to surgery, a time of heightened distress for most women. Based on these results, it would appear that hypnosis has a strong beneficial impact for women undergoing excisional breast biopsies and should possibly be more widely implemented as part of standard clinical care. Furthermore, based on the results of Lang et al., (2000), it would appear that a larger scale investigation of these effects with excisional breast biopsy patients is warranted, because such a study may reveal both physiological benefits as well as cost savings.

Postsurgery hypnoanalgesic effects of the intervention were partially mediated by patients’ expectations, and the effects of hypnotic suggestion on reducing patients’ postsurgery distress were perfectly media ted by postintervention expectations. These results are consistent with response expectancy theory and suggest that brief interventions that tar- get patients‘ expectations are likely to be effective for these women who must endure not only invasive medical procedures but also the fear of a cancer diagnosis.

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Kurze Hypnose vor der Operation vermindert Leidensdruck und Schmen der Patientinnen bei Exzisionsbiopsie der Brust

Guy H. Montgomery, Christina R. Weltz, Megan Seltz und Dana H. Bovbjerg

Zusammenfassung: Alljiihrlich werden bei hunderttausenden von Frauenzur Abklarung einer Diagnose Exzisionsbiopsien der Brust durchgefiihrt. Diese Patientinnen erleben nicht nur die mit dem Eingriff verbundenen Schmerzen, sondern auch den durch Verdacht auf Krebs ausgelosten Leidensdruck. Hypnose ist zwar im Zusammenhang mit anderen operativen Eingriffen bei Schmerzbewaltigung als effektiv nachgewiesen, aber Patientinnen mit Brustoperationen wurden bisher wenig beachtet. Zur Feststellung des Effekts einer k u n e n Hypnose vor der Operation auf Schmen und Leidensdruck dieser Patientinnen nach der Operation und zur Erforschung der moglichen vermittelnden Mechanismen dieses Effekts wurden 20 Patientinnen mit Exzisionsbiopsie der Brust randomisiert einer Hypnose-Gruppe und einer Kontrollgruppe (Standardbehandlung) zugewiesen. Bei Hypnose waren postoperativer Schmen und Leidensdruck reduziert. Erste Befunde deuten

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an, dass die Wirkung der Hypnose durch Erwartungen vor der Operation beeinflusst wurde.

ROSEMARIE GREENMAN University of Tennessee, Knoxville, TN, USA

Une hypnose b r h e avant intervention chirurgicale reduit l'angoisse et la douleur chez les patients ayant une biopsie chirurgicale du sein

Guy H. Montgomery, Christina R. Weltz, Megan Seltz, et Dana H. Bovbjerg

Resume Chaque annee des centaines de milliers de femmes subissent des biopsies chirurgicales du sein afin d'etayer un diagnostic. Ces patientes vivent non seulement une situation douloureuse physique mais aussi l'angoisse du cancer du sein. I1 a ete montrd que I'hypnose Ctait efficace dans le contrele de la douleur d'autres interventions chirurgicales, mais il y eu peu de travaux dans la chirurgie du sein. Afin de determiner l'impact d'une hypnose breve avant une intervention sur la douleur post operatoire des patientes et sur leur angoisse, et afin d'explorer les mCcanismes possibles de la mediatisation des effets, 20 biopsies chirurgicales randomisees furent accompagn4es de seances d'hypnose, face ?t un groupe contr6le. L'hypnose a diminue la douleur post- operatoire et I'angoisse. Cette evidence dCjh connue sugghre que les effets de I'hypnose sont mediatises par les attentes qui precedent l'intervention.

VICTOR SIMON Psychosomatic Medicine & Clinical Hypnosis Institute, LilZe, France

La hipnosis breve pre-quinirgica reduce la angustia y el dolor en 10s pacientes con biopsia excisional del sen0

Guy H. Montgomery, Christina R. Weltz, Megan Seltz, y Dana H. Bovbjerg

Resumen: Cada aiio, cientos de miles de mujeres experimentan biopsias excisionales del sen0 para obtener un diagn6stico definitivo. No solo experimentan estas pacientes el dolor asociado a1 procedimiento, sino que tambiCn deben soportar la angustia asociada a la amenaza de cincer. Se ha demostrado que la hipnosis es eficaz en el control de dolor en otras intervenciones quinirgicas, per0 10s pacientes de cirugia de sen0 han recibido poca atencibn. Para determinar el impact0 de la hipnosis breve pre-quinirgica en el dolor y angustia post-quirdrgicos,y para explorar 10s posibles mecanismos mediadores de estos efectos, 20 pacientes fueron asignados aleatonamente a un grupo de hipnosis o uno control grupo (cuidado estindar). La hipnosis redujo el dolor y la la angustia post-quircirgicos. La evidencia inicial sugiere que 10s efectos hipn6ticos estin mediados por las expectativas previas a la cirugia.

ETZEL CARDERA University of Texas, Pail American, Edinburg, TX, USA

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on: 15 september 2013, at: 14:26 reduces distress and pain...

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