Functional Strokes – Rehabilitation: Can hypnotic (and allied) techniques help?

If you thought functional neurological disorders were all in the mind or restricted to those people with emotional difficulties then this meeting would have soon altered your perceptions.

Professor Jon Stone started the day by talking about the diagnostic techniques, aetiology and treatment of Functional Motor Disorders. Rather than being a diagnosis formed by exclusion, Professor Stone showed that there are positive diagnostic signs of a functional disorder. Rather than being ‘all in the mind’, they are a disorder of function that may have a variety of psychogenic underpinnings and sometimes no obvious emotional or traumatic trigger. Functional Disorders are something that all humans experience to a greater or lesser extent, from such things as a tension headache to irritable bowel syndrome or functional stroke. Functional Neurological Disorders ‘are no longer assumed to be only the result of ‘conversion’ of psychological conflict but now understood as a complex interplay between physiological stimulus, expectation, learning and attention…. with biopsychosocial predisposing, triggering and perpetuating inputs’.¹

Dr Ranjan Sanyal, a Consultant Stroke Physician, University Hospitals of North Midlands then described how he uses hypnosis with functional strokes. Functional disorders are very common and are responsible not only for a large amount of human suffering, but also a huge cost to the economy of over £14 billion.² 8.4% of all strokes are functional and the condition can be as debilitating as Parkinson’s or Multiple Sclerosis. Dr Sanyal described how he uses hypnosis very successfully with his patients, building rapport, using imagery, and giving appropriate suggestions in hypnosis. Dr Alastair Dobbin then talked about how positive and negative episodic memories that lie outside of conscious awareness can influence our feelings of autonomy, competence and relatedness. Someone with resilience has rapid access to positive emotions which speeds recovery from a threat, so our therapies should seed or prime a growth or recovery model in our patients.

Pauline Halliday, an Occupational Therapist and a Clinical Specialist in stroke, then gave a presentation as to how she used hypnosis to help a ‘difficult’ stroke patient with ‘functional overlay’. By means of a simple breathing induction and using imagery of a safe, calm place and a beach, that the patient could go to in her imagination, her agitation and anxiety were reduced. She was taught how to use this whenever she wanted to feel calmer. This also improved her sleep pattern. Pauline also uses hypnosis with patients with Thalamic or Central Pain Syndrome using the patient’s metaphors in hypnosis to help a change in perception (switches, water, warmth etc.) with a resultant reduction in analgesic medication. She has also used hypnosis successfully to manage fear of going into the MRI Scanner, during Carotid Endarterectomy, with Functional Stroke (mainly with vocal dysfunction), and generalised anxiety.

After lunch, Dr Jason Price, a prominent Consultant Neuropsychologist from South Tees Hospital NHS Trust talked about how the profile of hypnosis in the NHS suffers from ‘alternative therapy’ perception. Far from being an ‘alternative therapy’ Dr Price argues, hypnosis sits comfortably within the ‘3rd Wave’ cognitive therapies such as Mindfulness, Acceptance and Commitment Therapy, Compassion Focused Therapy, DBT and Transdiagnostic Therapy. There is also good evidence of ‘added value’ of hypnosis with other ‘mainstream’ therapies. He pointed out the importance of imagery, not only in hypnosis but also within these other therapeutic approaches. It works in a primary modality and is very powerful in re-scripting/ cognitive restructuring in trauma work.³ Visual Imagery is recommended for post-stroke limb movement recovery (National Clinical Guideline for Stroke 5th edition, 2016) and there are similarities, as well as some differences between hypnosis and mindfulness^4,5 and hypnosis and EMDR.⁶ Hypnosis can both reproduce and remove functional symptoms, ‘turn off’ the neural circuits involved in agency, the executive processes involved in self-monitoring and automatic neuropsychological processes.⁷ With EEG and fMRI evidence the development of cognitive neuroscientific understanding of hypnosis has developed alongside contemporary cognitive neuroscience understanding of Functional Neurological Disorders.^8-11

Dr Paul Molyneux, a Consultant Neurologist from West Suffolk Hospital Trust and Addenbrookes, then reported how he uses hypnosis within an out-patient department treating Non-Epileptic Seizures and migraine. In a busy clinic there is very little time to make a diagnosis let alone treat the condition but informal hypnotic techniques can help. This involves using reflective listening, with attention to body language, confirming and explaining the diagnosis while building rapport, together with the careful use of language and metaphor, especially when breaking the diagnosis of Non-Epileptic Seizures.¹² He stressed the importance of touch and giving reassurance by physical examination and then using a simple hypnotic induction to increase the effectiveness of the positive suggestions given. Dr Molyneux also described how he uses hypnosis and metaphorical imagery to help patients with migraines. Self-hypnosis gives the patient a life long tool.

This was followed by Devin Terhune from Goldsmith’s University of London describing his recent meta-analysis of hypnotic suggestibility in functional and dissociative disorders which support an increased hypnotic susceptibility. The limitations of methodology give rise to a weak scientific evidence base despite the fact that patients and doctors find hypnosis helpful and empowering.

The final presentation of the day was given by Professor Charles Warlow, Emeritus Professor of Medical Neurology at Western General Hospital, summarising why hypnosis has been underutilised in the past and how it could be used in the future.

A most fascinating day was ended by a general panel discussion between the presenters and the audience on the way forward for hypnosis in the management of Functional Neurological Disorders.

References

1. Complex regional pain syndrome and functional neurological disorders: time for reconciliation. Popkirov S, Hoeritzauer I, Colvin L, Carson A & Stone J (2018) Journal of Neurology, Neurosurgery & Psychiatry. Published Online First: 24 October 2018. doi: 10.1136/jnnp-2018-318298
2. The cost of somatisation among the working‐age population in England for the year 2008–2009. (2010) Bermingham S, Cohen A, Hague J & Parsonage M. Mental Health in Family Medicine. Vol 7(2): 71–84.
3. Imagery re-scripting and reprocessing therapy after failed prolonged exposure for post-traumatic stress disorder following industrial injury. (2007) Grunert B K, Weis J M, Smucker M R, Christianson H F. Journal of Behaviour Therapy & Experimental Psychiatry. Vol 38 (4) 317-28.
4. Do Hypnosis and Mindfulness Practices Inhabit a Common Domain? Implications for Research, Clinical Practice, and Forensic Science. (2012) Lynn S, Malaktaris A, Maxwell R, Mellinger D & van der Kloet D. Journal of Mind-Body Regulation. Vol 2 (1) 12-26
5. Metacognition of intentions in mindfulness and hypnosis. (2016) Lush P, Naish P & Dienes Z. Neuroscience of Consciousness. Volume 2016, Issue 1, 1 January 2016
6. Introduction to the Special Section: Hypnosis and EMDR. (2001) Frischholz J, Kowal J & Hammond, D. The American Journal of Clinical Hypnosis. Vol 43(3-4) 179-182
7. Hypnosis as therapy for functional neurologic disorders. (2017) Deeley Q. Handbook of Clinical Neurology. Vol 139, 585-595
8. Brain Activity and Functional Connectivity Associated with Hypnosis. (2017) Jiang H, White M, Greicius M, Waelde L & Spiegel D. Cerebral Cortex. Vol 27 (8) 4083-4093.
9. Neuro-hypnotism: prospects for hypnosis and neuroscience. (2013) Kihlstrom J. Cortex. Vol 49 (2) 365-74.
10. Hypnotic induction is followed by state-like changes in the organization of EEG functional connectivity in the theta and beta frequency bands in high-hypnotically susceptible individuals. (2014) Jamieson G & Burgess A. Frontiers in Human Neuroscience 2014 (8) 528.
11. Improving working memory performance in brain-injured patients using hypnotic suggestion. (2017) Lindeløv J, Overgaard R & Overgaard M. Brain. Vol 140 (4) 1100- 1106.
12. Acceptability and effectiveness of a strategy for the communication of the diagnosis of psychogenic nonepileptic seizures. (2010) Hall-Patch L, Brown R, House A, Howlett S, Kemp S, Lawton G, Mayor R, Smith P, Reuber M; NEST collaborators. Epilepsia. Vol 51(1) 70-8.