Pediatric Anesthesia 2007

17: 800804

doi:10.1111/j.1460-9592.2007.02224.x

Case report

Brief hypnosis for severe needle phobia using switchwire imagery in a 5-year old
A L L A N M. C Y N A D R C O G D i p C l i n H y p F R C A , D A V I D T O MK IN S F A N Z C A , T O D D MA D D O C K F A N Z C A A N D DAVID BARKER FANZCA
Department of Paediatric Anaesthesia, Womens and Childrens Hospital, Adelaide, SA, Australia

Summary
We present a case of severe needle phobia in a 5-year-old boy who learned to utilize a self-hypnosis technique to facilitate intravenous (i.v.) cannula placement. He was diagnosed with Brutons disease at 5 months of age and required monthly intravenous infusions. The boy had received inhalational general anesthesia for i.v. cannulation on 58 occasions. Initially, this was because of difcult venous access but more recently because of severe distress and agitation when approached with a cannula. Oral premedication with midazolam or ketamine proved unsatisfactory and hypnotherapy was therefore considered. Following a 10-min conversational hypnotic induction, he was able to use switchwire imagery to dissociate sensation and movement in all four limbs in turn. Two days later the boy experienced painless venepuncture without the use of topical local anesthetic cream. There was no movement in the switched-off arm during i.v. cannula placement. This report adds to the increasing body of evidence that hypnosis represents a useful, additional tool that anesthetists may nd valuable in everyday practice. Keywords: needle phobia; hypnosis; communications; hypnotherapy; analgesia; children

Introduction
Needle phobia affects approximately 19% of children aged 46 years (1) and at least 10% of the general population (2). It is therefore a highly relevant issue for the anesthetist (3). Children are less likely than adults to understand the rationale for a procedure making distress more likely. In addiCorrespondence to: Dr Allan M Cyna, Consultant Anaesthetist, Department of Paediatric Anaesthesia, Womens and Childrens Hospital, 72 King William Road, Adelaide, SA 5006, Australia (email: allan.cyna@cywhs.sa.gov.au).

tion, negative memories may result in escalating anxiety with subsequent procedures (4,5). A recent systematic review suggests that hypnosis can help children reduce the pain and distress that accompany needle-related procedures (6). Hypnosis in children has been dened as an alternative state of awareness where the focus of attention is on a particular idea or image (with or without relaxation) with a specic purpose of achieving a goal (7). This state facilitates association with, or dissociation from, external stimuli and enhances a patients response to suggestion (8). A suggestion is a verbal
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or nonverbal communication that elicits a subconscious (nonvolitional) response in patients perception, mood and or behavior (9). Hypnosis has been found to be more effective than nonhypnotic techniques for reducing procedural distress in children and adolescents with cancer (10,11). In addition, it reduces the incidence of anxiety during induction of anesthesia in children compared with midazolam premedication (12) and can be used to provide effective pain relief in both laboratory and clinical settings (13). Although anesthesia and hypnosis have a long history of association (14), few anesthetists currently utilize this technique or formulate suggestions as a therapeutic adjunct to their clinical practice. A resurgence of interest in utilizing hypnosis in both adult (1519) and pediatric anesthesia practices (12,20) is supported by clinical research, and recent neuroimaging studies show that anterior cingulate gyrus activity is affected by hypnotic modulation of pain (2123). The utilization of hypnosis has been shown to be a useful therapeutic strategy for some children when other therapies have failed (24). This case report describes the successful, rapid utilization of a self-hypnosis technique by a 5-year-old boy with severe needle phobia.

Case report
The patient presented for testing at 5 months of age as his older sibling had Brutons disease, an X-linked agammaglobulinemia, which required intravenous (i.v.) infusions of gammaglobulin on a monthly basis. The patient initially had poor venous access and i.v. cannula insertion proved to be difcult and traumatic for both the patient and parents. It was therefore decided that future i.v. access would follow brief inhalational general anesthesia (GA). This arrangement worked well for some time and the child was usually cooperative during the gaseous induction of O2 N20 and sevourane. After a year of having a GA every 4 weeks, the offer to insert an i.v. portal device was refused by the parents. After a further year, i.v. cannula insertion was attempted under oral midazolam sedation, but the child had a paradoxical reaction. He became extremely aggressive and distraught and then pulled out the i.v. cannula soon after it had been inserted. The parents requested a return to GA and they again refused to consider a portal device. By the age of

3 years the patient was very cooperative for his anesthetics, showing great trust in the anesthetist, holding the mask himself and often chatting and joking as he went off to sleep. His veins had not been difcult to access for the past 2 years and the whole procedure tended to be easy and brief. Further attempts to sedate the child using oral midazolam and ketamine once again proved to be unreliable and traumatic. Management options were discussed amongst the anesthetists, including the possible use of hypnosis. At this stage, the patient had received inhalational GA for i.v. cannula insertion on 58 occasions. Following a discussion with the patients mother, training the boy in self-hypnosis was considered for facilitating future i.v. cannulations. Two days prior to his planned infusion of gammaglobulin, an anesthetist trained in hypnosis (AMC) saw the child together with his mother as an outpatient. Initial rapport was gained by asking the boy what his favorite activity was. The response by the patient led the anesthetist to ask the boy about how he learned to ride his bicycle. The child responded enthusiastically and became engaged in describing how he initially had both feet on the ground and then rode with one foot and then two feet on the pedals. The anesthetist repeated back to the patient what he was being told, using the boys own words, to conrm that he was being heard and understood. Statements were made where appropriate to reinforce aspects where learning new skills and discovering new ways of doing things had taken place. The patient was then asked why gammaglobulin was required each month and the response was that it made him smart. When asked what it was like learning to ride his bike, he replied that it felt good. The anesthetist then asked the boy if he would like to learn something new today, just like when he learned to ride the bike. He was also asked whether he would like to learn to be the boss of his own body to allow the plastic drip to be inserted as comfortably as possible. The boy readily agreed that he would like to learn things that would allow him to be the boss of his body whenever he needed a drip. The house metaphor was used to explain switchbox imagery, a hypnosis technique modied from Garver (25). The anesthetist explained that in a house there are many wires and switches. Now as you know when you turn the switch off, the light

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switches off and it doesnt work any moreuntil it is switched on again. Similarly, when the switch in the bathroom is turned off, the bathroom light goes off and it doesnt work any moreuntil it is switched on again. It was then suggested that in the brain we also have switches and wires that go to different parts of the body. There is a switch and a colored wire that runs from the brain to the leg. There is another switch that controls the other leg with a different colored wire. There are also switches to the arms with their own special colors. The patient was then asked to nd the switch that turns off the leg so that it doesnt work any more and cannot move or feel anything. The boy nodded, screwed up his eyes, and within 23 s said that he had found the switch and the wire. On further questioning the patient pointed with his hand to show where the greenyellow wire was running down the lateral aspect of the left lower limb just distal to the ankle. He was then asked to switch off that leg so that it doesnt work any more and wont move or feel anything until it is switched on again. The child responded that he found it and that the leg was now switched off. He was then asked to try and move the leg that was switched off and he conrmed that he could not move it. He was then asked if it would be OK for the anesthetist to pinch the leg. Following an afrmative response, the calf was pinched rmly and the patient stated that it felt comfortable. After practicing switching on and off each limb in turn in a similar manner, it became clear that he was able to successfully dissociate sensation and movement in both lower and upper limbs, within a few seconds of being asked to do so. The left arm which normally has an i.v. inserted was also successfully dissociated in this way. Following permission from the patient, skin sensation was tested on the switched off arm using a 22-G i.v. cannula. A tourniquet was attached and permission was gained to wipe the skin with an alcohol antiseptic wipe. The cannula was rmly pressed against the skin and there was no withdrawal response and the patient conrmed that it did not bother him. The patients mother then asked if he should have topical local anesthetic cream in 2 days time when his drip was due to be inserted. The anesthetist asked the boy and he responded that he would just use his switches. This preliminary session lasted approximately 30 min and permission was obtained from the patient and his mother to

video the i.v. cannula insertion. The patient arrived on the day ward fasted in case a GA was required.

Observations of rst i.v. insertion by two nonhypnotherapist anesthetists

The treatment room was prepared with all necessary i.v. equipment placed in a tray so that it was easily available. The mother, the hypnotizing anesthetist (AMC), the cannulating anesthetist (TM), the video camera operator and another observing anesthetist (DB) were present. When the boy was initially asked to come into the treatment room he was absorbed in a computer game with his older brother. He was, however, coaxed into the room quite willingly after asking if he would like to tell people how he learned to ride his bike. The boy seemed a little apprehensive which appeared to affect his ability to focus at rst. However, he became progressively more cooperative and his attention became more focused when asked whether he could remember how he switched off his arms and legs 2 days previously. For each limb in turn, the boy was asked to conrm that he could not move the switched off limb or feel a stimulus (pinch) as painful. Finally, the boy was asked to switch off the arm where the i.v. cannula was to be placed. He conrmed this within 23 s and when asked to move the arm he said he could not. When asked if we could test this with a pinch he conrmed that it did not bother him. The i.v. cannulation was broken down into several component steps which consisted of application of the tourniquet, moving the hand to an optimal position, preparing the skin with an alcohol swab and the insertion of the cannula. Prior to each step, permission to proceed was sought and gained from the patient. Before inserting the cannula, the boy was told that he could cough if needed. Just before the cannula was inserted, the boy was asked to look towards his mother. As the cannula pierced the skin, he coughed once and transiently closed his eyes. He did not move his hand nor show any other signs of distress or discomfort despite the absence of topical local anesthetic cream. Once in place, the boy looked at the cannula and was obviously pleased with his success. At no stage did the boy appear to be hypnotized in the classical trance sense. On the contrary, he appeared quite aware of all that was happening. He appeared to be very keen to be in

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control and display his new skills. When asked if the drip had hurt at all he replied no. Prior to leaving the treatment room it was conrmed with the boy that he had switched his arm back on and that it moved easily and felt back to normal. The patient has now used switchwire imagery successfully for the past 3 months. The last i.v. cannula placement (including walking to the treatment room, placing, and taping the i.v. cannula and returning to the outpatient ward bed) took less than 5 min.

Discussion
We present a case of severe needle phobia in a 5year-old child who learned to utilize a self-hypnosis technique to facilitate i.v. cannula placement. This report adds to the increasing body of evidence that hypnosis represents a useful, additional tool that anesthetists may nd valuable in their everyday practice. Our case is remarkably similar to that reported by Olness nearly 30 years ago of a 7-yearold child suffering from severe needle phobia and Brutons disease who was managed with a brief hypnosis, switch-box imagery intervention (24). Following a 10 min orientation to a previous learning experience, both patients were able to use hypnosis to turn on and off switches in the brain and subsequently control sensations and movement in various parts of the body. Olness suggests that the relatively high hypnotizability in children may be explained by their greater readiness to engage in imagery and fantasy with less concern for the logical cognitive activity and reality testing, impinging on adults. The strategy for treating needle phobia in our patient began with the aim of teaching him how to achieve mastery and control during his hospital visits without the need for pharmacological support. The initial conversation with the boy identied that his experience of learning to ride a bike could engage him in a focus of attention. The boy clearly demonstrated the ability to learn a new task with ease. The house metaphor was utilized to develop an idea that was to be related to the types of skills and resources that the patient was likely to need. The next stage introduced the patient and his mother to new practical ways of achieving venepuncture comfortably, other than by pharmacological means. We

gradually initiated a learnable sequence using a lower limb well away from the planned venepuncture site. The boys ability to use switch and wire imagery to elicit subconscious responses was then demonstrated to his and his mothers satisfaction. The identied skills were then developed further until they were within the context of a venepuncture, i.e. with tourniquet placement around the arm and wiping the skin with alcohol. Patient cues were identied with each response and the kind of language the child used was repeated by the anesthetist to enhance rapport and ensure that the child knew that he had been heard and understood. The word try was used when the boy was asked to move a switched off limb as this implied that he would indeed fail to move it. When this was conrmed by the patient, positive re-enforcement that the switch was indeed off helped encourage similar future hypnotic responses. The use of particular words can facilitate subconscious responses. For example, calling the boys upper limb the arm rather than your arm encourages the phenomenon of dissociation where the limb no longer feels part of the body. The interesting observation by TM and DB that the boy did not appear to be hypnotized in the classical trance sense is typical in this age group. Kohen reports that children under 6 or 7 years commonly do not visibly relax, a state known as active alert hypnosis (7). Children are usually willing to explore and discover new ways of doing things and are frequently more disposed to experiment than adults. The overriding principle in this approach is to view children as resourceful and to demonstrate how their developing skills can become both relevant and available to them during a new learning experience. As seen with this patient and Olnesss report (24), the successful use of a newly learned skill can lead to a rapid break from old patterns of behavior by both parent and child. The consolidation of what has been learned with each successful event parallels an increasing sense of patient autonomy and control. Many clinicians may view the term hypnosis with a negative connotation that leads them to avoid learning more about the technique or advocating its use. It has been reassuring that in response to a recent survey, 70% of anesthetists in South Australia reported that they believed hypnosis was useful in the management of needle phobia (26). The British

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Medical Association published a report over 50 years ago advocating postgraduate hypnosis training for anesthetists (27). Although it is not a therapeutic panacea in every patient there is a tendency to overlook opportunities where hypnosis might be the treatment of choice (24). There is an increasing body of evidence (28,29), which supports our own clinical experience (19,30), that hypnosis represents a useful, additional tool that anesthetists may nd valuable in their everyday practice. Future research in treating needle phobia in children could investigate the utility of this model compared with other psychological or hypnotherapeutic approaches which have been described previously (3133). Identifying the skills children successfully use during venepuncture needs investigating so that these techniques can be taught more readily to patients who are having difculty.

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Accepted 16 January 2007

2007 The Authors Journal compilation 2007 Blackwell Publishing Ltd, Pediatric Anesthesia, 17, 800804