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HYPNOSIS AS AN ADJUNCT THERAPY IN

THE MANAGEMENT OF DIABETES

Abstract: 

Although diabetes is one of the most serious global health problems, there is no real cure yet for it. The conventional insulin treatment programs aimed at life quality improvement do not take into account the psychological aspects of the disease. Because diabetes has important psychological components, it seems reasonable to consider hypnosis as an adjunct therapy for diabetes. This paper examines the empirical literature on the effectiveness of hypnosis in the management of diabetes, including regulation of blood sugar, increased compliance, and improvement of peripheral blood circulation. Despite some methodological limitations, the literature shows promising results that merit further exploration. Multimodal treatments seem especially promising, with hypnosis as an adjunct to insulin treatments in the management of both Type 1 and Type 2 diabetes for stabilization of blood glucose and decreased peripheral vascular complications.


      Diabetes is rapidly becoming one of the most serious global health problems. It was estimated in 2003 that about 5.1% of the global population of 20- to 79-year-olds had diabetes and that this number will increase to 6.3% by 2025 (International Diabetes Federation, 2003).  

Type 2 diabetes constitutes about 85%–95% of all diabetes in developed countries (World Health Organization, 1994) and accounts for an even higher percentage in developing countries and among some ethnic minorities in industrialized nations (e.g., Hertz, Unger, & Ferrario, 2006).

Diabetes mellitus is an endocrine disorder of carbohydrate metabolism characterized by hyperglycemia and glucose intolerance caused

by insulin deficiency, insulin resistance, or both. The predominant cause of Type 1 diabetes (T1D, insulin-dependent diabetes mellitus) is

polygenically inherited autoimmune destruction of pancreatic beta cells (Atkinson & Maclaren, 1994), although the specific etiology of

Type 2 diabetes (T2D, noninsulin-dependent diabetes mellitus) is not quite understood.


       Manuscript submitted August 2, 2006; final revision accepted September 2, 2006. Address correspondence to Etzel Cardeña, Ph.D., Thorsen Professor, Department of Psychology, Lund University, P.O. Box 213 SE-221 00, Lund, Sweden. E-mail:

[email protected]64 AND ETZEL CARDEÑA 


         Epidemiological evidence indicates that Type 2 diabetes results from the interaction between genetic and environmental factors such

as the excess of fat and sugar as well as calories. Likewise, a sedentary lifestyle leads to obesity and insulin resistance. The identification of

genes that predispose to Type 2 diabetes has suggested that polymorphism in a certain number of genes are important. These include the

genes for the peroxisome-proliferator-activated receptor gamma (PPAR γ), a nuclear receptor important for insulin function; the gene

Kir6.2, which is a potassium channel that is needed for insulin secretion; as well as the promoter region of hepatocyte nuclear factor 4,

which regulates pancreatic beta cell function. However, it is commonly agreed that T2D is caused by a complex interaction between polygenic

inheritance and environmental factors. Risk factors for the onset and severity of T2D include central/abdominal obesity, age over 45,

low activity level, hypertension, dyslipidemia, a history of low glucose tolerance, race/ethnicity, and a history of gestational diabetes for

women.


      No real cure exists yet for diabetes. Both T1D and T2D are chronic diseases requiring constant close monitoring of blood glucose levels

and lifelong daily management aimed at symptom reduction and lifequality maintenance. Though having different causes, the rationale for

their management is the same, namely the stabilization of blood glucose to relieve symptoms and to prevent secondary diseases and longterm complications from chronic hyperglycemia such as retinopathy, nephropathy, neuropathy, peripheral vascular disease, atherosclerosis,

hypertension, and coronary heart disease. Conventional treatment programs usually consist of daily insulin injections and rigorous nutrition-intake control. Regular exercise and weight-loss programs are also highly recommended for obese T2D patients.  With the exception of a single master’s thesis (Warner, 2004), the conventional insulin-treatment programs have usually not taken into account the psychological aspects of the condition. With the autonomic nervous and endocrine systems being the main regulators of blood glucose, it is not a high stretch to think of diabetes as a psychosomatic disorder—namely, a condition with primarily physiological causes that can be greatly exacerbated by psychological stresses through the dysfunctional activation of the autonomic nervous and endocrine systems. A variety of psychological variables have been found to be important in the metabolic control of diabetic patients (Rose, Schirop, Fliege, Klapp, & Hildebrandt, 2002). For instance, Dutour et al. (1996) found that the acute psychological stress produced by a videorecorded public speech played a role in the glycemic instability of brittle T1D patients (unstable diabetes). Other research showed that rats subjected to chronic psychological stress (exposed to chronic stressors

twice daily for 1 hour) showed higher glucose intolerance and lower HYPNOSIS IN DIABETES MANAGEMENT 65 plasma insulin levels than nonstressed rats (Zardouz, 2005). A psychoneuroendocrine model has also been proposed with the hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis as a predictor of the insulin resistance found in T2D (Björntorp, Holm, & Rosmond, 1999; Rosmond & Björntorp, 2000).

     

      Further, an early report investigated how emotions and stress related to blood-glucose levels in 2 diabetics (Meyer, Bollmeier, & Alexander, 1945). Both patients developed diabetes under the strain of emotional conflicts, and the presence of emotional stress caused by unsatisfied demands of attention and love was shown to be responsible for the increases in their urine sugar output, whereas emotional stability related to the temporary renouncement of their demanding attitudes resulted in decreased urine sugar. The importance of psychological factors in diabetic management is now beginning to receive more and more attention. Petrak and collaborators  (2005) provided evidence-based support for psychosocial factors in both T1D and T2D, which were integrated into treatment guidelines by the German Diabetes Association.


Hypnosis and Diabetes

      There is considerable evidence that the disregard of extraneous concerns and increased focus of hypnotic suggestions can affect various

physiological functions often considered completely autonomous (Barber, 1983) and that these changes can have important clinical

implications (Lynn, Kirsch, Barabasz, Cardeña, & Patterson, 2000). Therefore, it is reasonable to consider whether hypnosis can help regulate autonomic processes such as blood glucose and peripheral blood flow in the treatment of diabetes. Diment (1991) also suggested that

diabetes itself can be a stressor that will in turn exacerbate the condition and provided arguments for a pragmatic use of hypnosis as an

adjunct in diabetes counseling to reduce stress for both diabetes related anxiety and general life stress to improve metabolic control. Despite the anecdotal reports and the theoretical rationales for using hypnosis, no large-scale study has been conducted to assess the effectiveness of hypnosis in diabetic management. This is an area that should be explored further. The increased suggestibility shown during the hypnotic state would also be helpful in increasing compliance for exercise, diet, and other lifestyle changes.


Hypnosis and Regulation of Blood Glucose

       Some studies have evaluated the effect of hypnosis on blood-glucose levels. In an experiment designed to assess the effect of hypnotically induced acute emotional stress on carbohydrate and lipid metabolism in diabetics, Vandenbergh, Sussman, and Titus (1966) were surprised to find a decreased level of blood glucose instead of an 66 YUAN XU AND ETZEL CARDEÑA increased one as they had hypothesized. They speculated that the hypnotic induction itself might have been responsible for the decrease. McCord (1968) reported a case where a 58-year-old man, who was primarily treated with hypnosis for incontinence and for diabetes, was given suggestions about following his recommended diet more closely. He reported a changed attitude toward food and a surprising spontaneous reduction in his daily insulin intake despite the fact that

insulin was never mentioned in his session. Hypnosis to Increase Compliance One of the most widely quoted articles to support the claim that

hypnosis is effective in the metabolic control of diabetes is an experiment conducted by Ratner, Gross, Casas, and Castells (1990). Seven

adolescents with T1D and poor metabolic control were admitted with no changes in their old management program except the addition of

hypnosis (both hetero- and self-hypnosis). After 6 months, their glycated hemoglobin (HgbA1C) and fasting blood-glucose values

dropped significantly. The study did not use hypnosis to target the disease itself but to redirect the goals of the patients to secure compliance

with the insulin injections, glucose testing, and diet-control programs.


Hypnosis for Weight Loss

       Research suggests that not only T1D patients but T2D patients also have a low level of compliance: they only follow dietary recommendations about 60% of the time, exercise recommendations 34% of the time, and foot-care recommendations 47% of the time (Toobert, Hampson, & Glasgow, 2000). The healthy lifestyle required for diabetic management is essentially the same as the one for weight loss, with regular exercise and a healthy diet. Obesity is a well-established risk factor for T2D (Willett, Dietz, & Colditz, 1999). T2D patients are very often,

though not always, overweight. The drastic increase in the prevalence of diabetes in recent decades has been strongly associated to the

increase in obesity. Therefore, one of the key factors in the management of diabetes, especially T2D, is weight control. Evolutionary selection might be partly responsible for our innate preference for energyrich food and an inactive lifestyle, making weight loss excessively difficult for some. Therefore, reprogramming of the “reward” and “pleasure” centers in the brain is required for our adaptation to the modern

lifestyle.


       Hypnosis has long been suggested as a treatment for weight loss, and it has been examined in various studies. For instance, Cochrane

and Friesen (1986) showed at a 6-month follow-up that both audiotaped and nonaudiotaped suggestions induced significantly greater

weight loss than control in women at least 20% overweight and not in other treatment programs. Hypnotizability was not a predictor of how

HYPNOSIS IN DIABETES MANAGEMENT 67 much weight was lost, but there was a trend toward greater weight loss with higher suggestibility scores. Two reviews (Pittler & Ernst, 2005; Vanderlinden & Vandereycken, 1994) that analyzed results from several different studies both arrived at the conclusion that hypnosis is effective in weight loss although considered the effect to be small. 

   

     In contrast, specific meta-analyses on the use of hypnosis for obesity found a 0.98 standard deviation effect size when hypnosis was an adjunct to treatment and that the benefits of hypnosis increased substantially over time (Kirsch, Capafons, Cardeña, & Amigó, 1999). Pittler and Ernst also concluded that hypnosis with cognitive-behavioral therapy was more effective than cognitive-behavioral therapy alone, and that hypnotherapy directed at stress reduction was more effective than dietary advice. Vanderlinden and Vandereycken proposed a multifaceted hypnotherapy program for obesity, consisting of a beginning phase with suggestions for relaxation, self-control, and physical exercise, a middle phase for altering self-esteem and body image, strengthening motivation, exploring ambivalence towards change, and a final

phase for consolidation of improvement and prevention of relapse. 


      This is one of the most comprehensive programs found. Many of the proposed ideas could be easily adapted to diabetes management as well. In one of the most recent analysis from the Cochrane Collaboration, known for its rigorous standards for evidence-based medicine, Shaw, O’Rourke, Del Mar, and Kenardy (2005) concluded that not enough research is available to reach a conclusion for the effectiveness of hypnosis for obesity, although the meta-analyses mentioned above make this an arguable point. Nonetheless, more empirical studies, especially well-controlled large-scale randomized control studies, are required in this area, especially on the effect of hypnotic suggestions for weight loss on diabetes management and metabolic control.  Hypnosis for Increasing Peripheral Circulation Another important aspect of diabetic management is diabetic foot care. Chronically high blood-glucose values damage blood vessels and impair peripheral circulation. Being one of the furthermost extremities of the body, the foot is especially affected. The poor peripheral blood circulation caused by diabetes makes the foot prone to infection and wound healing very difficult. On top of that, diabetic peripheral neuropathy makes the foot numb so it is difficult to feel anything when

damage is done to it. If not managed properly, even a small injury could result in potential amputation. Because the vascular system is

rather sensitive to psychological stimuli (Barber, 1983), hypnosis could be effective in increasing blood flow to the extremities and in reducing

the diabetic foot problem.


       An early study conducted by Grabowska (1971) showed that suggestions of warmth increased the mean skin temperature by 2.7% and

68 YUAN XU AND ETZEL CARDEÑA the velocity of capillary blood flow by a surprising 163%. Significant clinical improvements occurred among the diabetics in this study; they reported intermittent claudication and coldness in the toes after 4 weeks of treatment with hypnosis and autogenic training. Piedmont (1981) investigated the effect of hypnosis with biofeedback on skin temperature regulation. Biofeedback for lowering skin temperature was given both with and without hypnosis and participants showed a greater decrease in skin temperature when both treatments were applied. Though not a study aimed at improving blood circulation in diabetics, it provides interesting possibilities on the significance of

hypnosis for vascular regulation. Finally, Galper, Taylor, and Cox (2003) reviewed the application of mind-body interventions for vascular complications of diabetes and found thermal biofeedback used together with hypnosis to be effective in relieving diabetic angiopathy.  In general, the efficacy of hypnosis looks promising in diabetic foot care.


DISCUSSION

     The studies reviewed in this paper argue for the effectiveness of  hypnosis for diabetes management. However, despite the promising

and interesting results, most of the reports consist of a small number of clinical cases or poorly controlled studies. Clearly, large-scale masked

studies with placebo controls are needed to fully evaluate the potential of hypnotic interventions. Finding a placebo treatment to replace hypnosis is a somewhat difficult but not insurmountable problem (Lynn et al., 2000). The placebo effect has long been recognized in the medical

tradition, and there is evidence that placebo-induced expectancies can truly alter physiology in clinically significant ways (Cardeña & Kirsch,

2000). Kirsch (1994) even refers to hypnosis as a “nondeceptive placebo.” However, there is strong evidence that hypnosis interventions

can have a clinically significant effect over placebo in irritable bowel syndrome (e.g., Whorwell, Prior, & Faragher, 1984).


      Other control comparisons are possible in hypnosis studies. Relaxation without hypnosis and/or suggestions given without a hypnotic

induction could be evaluated. These and other strategies might be considered in future hypnotic research for better evaluation of the active

therapeutic ingredients. However, the more controlled and standardized the trials get, the more of the uniqueness of each patient and the

importance of the doctor-patient relationship may be jeopardized. Thus, both the efficacy and efficiency of hypnosis as an adjunct for the

traditional management of diabetes need to be evaluated. Although some clinicians may assume that hypnotic interventions may consume time and add a cost to the patient, the analysis by Lang and Rosen (2002) suggests that hypnosis may actually save considerable HYPNOSIS IN DIABETES MANAGEMENT 69 time and money in the management of medical conditions. Even in a chronic condition like this, after a few sessions of hetero-hypnosis, the patients could be taught self-hypnosis for home practice.


       We have proposed various rationales to develop a multifaceted program with hypnotic techniques for both Type 1 and Type 2 diabetes

management. The interventions should include suggestions for increasing compliance to existing medical, exercise, and diet programs,

stress reduction and relaxation for better metabolic control, and thermal vascular regulation of distal limbs. This development might not

only add diabetes to the list for which hypnosis may be an effective therapeutic adjunct (besides preoperative preparation, asthma, dermatological disorders, irritable bowel syndrome, hemophilia, postchemotherapy nausea and emesis, and various obstetric conditions; Maré

Pinell & Covino, 2000) but it would address an urgent and global health problem.


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70 YUAN XU AND ETZEL CARDEÑA

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