EXAMPLE ANSWER: Q14

Q14. Read the following article and comment and discuss your views on Epilepsy and Hypnotherapy. .

http://med.stanford.edu/news/all-news/2008/02/hypnosis-helps-doctors-zero-in-on-kids-seizures.html

Hypnosis helps doctors zero in on kids' seizures

FEB 12 2008

02/13/08 

BY KRISTA CONGER

It was no way for an 11-year-old to live. For a month the boy had endured daily episodes of uncontrollable jerking and foaming at the mouth, and his physicians at Lucile Packard Children's Hospital were concerned that the boy had epilepsy. Before starting the boy on a lifetime of antiseizure medications, though, they turned to an unconventional diagnostic tool: hypnosis.

'Children are highly suggestible and they have great imaginations,' said Packard Children's child psychiatrist Richard Shaw, MD. 'We've found that if we suggest that they are going to have one of their events while they are in a hypnotic trance, they will usually have one.'

But wait. Aren't physicians supposed to try to STOP seizures rather than searching for new ways to cause them? In a word, yes. But in order to treat seizures effectively, doctors must learn which parts of the brain are causing the trouble. Many children who seem to be having epileptic seizures are actually having an involuntary physical reaction to psychological stress in their lives. These events require a vastly different treatment than do true epileptic seizures.

The only way to pinpoint the true cause is to monitor the child's brain activity during an event. Connecting a panel of electrodes to a child's scalp is relatively easy and painless. Conducting a 'seizure watch' of indefinite length is another matter.

'It's very difficult for parents to spend three or four days in the hospital hoping their child has a seizure,' said Packard Children's chief of pediatric neurology, Donald Olson, MD. 'It puts them in a very uncomfortable place emotionally.' Furthermore, some hospitalized children, removed from the very stressors that may be causing the events, never have a seizurelike event.

Hypnosis can speed the process considerably, said Shaw and Olson. Together with former medical student Neva Howard, they tested the procedure on nine children between the ages of 8 to 16 whose seizurelike events included twitching, loss of consciousness, shaking, jerking and falling. Their results were published online in January in Epilepsy & Behavior. The physicians needed to know whether these were true epileptic events, which are best treated by medication, or nonepileptic events caused by psychological stress or other neurological problems.

'We can't always distinguish epileptic from nonepileptic events visually, or through descriptions by family or friends,' said Olson, an associate professor of neurology, of neurosurgery and of pediatrics at the School of Medicine. 'But regardless of the cause, these are disabling, life-altering events that need to be treated.'

The authors believe that, although hypnosis may not work for every child, the technique is an important tool that can speed proper diagnosis and treatment for children suffering from seizurelike events.

To hypnotize the subjects, Shaw, an associate professor of psychiatry and behavioral sciences and of pediatrics at the School of Medicine, first used a combination of deep breathing and progressive muscle relaxation to induce a state of relaxation and deep focused attention in the subjects. He then used a combination of imagery and suggestion to induce one of their typical seizurelike events. Children typically visualize being at one of their favorite places - for one teen, it was on a beach in the Bahamas. After a hypnotic trance was established, Shaw would then direct the child to recall the feelings or events that usually precede a typical seizure. Electrodes on the child's scalp recorded their brain activity during the session.

In eight out of nine cases, Shaw could successfully trigger a seizurelike event with this procedure. After an appropriate monitoring interval, Shaw then directed the hypnotized child to 'return' to his or her favorite place and the episode would stop. Using this technique, the physicians found that all eight of the subjects were experiencing nonepileptic events.

'We had a number of clues that these particular children might not have epilepsy,' said Olson, 'but hypnosis helped us confirm our suspicions.' Physicians begin to suspect causes other than epilepsy if an individual has a variety of episodes, if the person's cognition is unaffected despite frequent seizures or if the person has a pre-existing psychiatric diagnosis.

Were the kids in the study relieved to find they didn't have epilepsy? 'Yes and no,' said Shaw. 'It's important to explain very clearly that although these events are psychologically based, they are completely out of a child's control.' He and Olson compare the events, which are a type of condition called conversion disorder, to other well-known ways that stress and emotions affect other bodily functions, such as migraines, ulcers and blushing.

Stanford is part of an ongoing multicenter study of these nonepileptic events to better understand their causes and possible treatments. For now, Shaw often couples psychotherapy with self-hypnosis lessons to teach children how to avoid the events.

'When they're feeling out of control, this is a tool they can use. They know that they were able to 'turn off' an event during the initial hypnosis, and that gives them confidence to try it themselves,' said Shaw.

In general, people are growing more comfortable with the idea of hypnosis in a medical setting, said Olson. 'The first reaction of many people may be to equate hypnosis with some sort of black magic. But once we explain the reasons and benefits, they're very accepting.'

By KRISTA CONGER

Krista Conger is a science writer for the medical school’s Office of Communication & Public Affairs.

Learning outcomes: 1.3

Student answer The question of whether a person who is epileptic should have hypnotherapy does not have a clear cut response. Whether it is actually more appropriate to consider whether someone with a diagnosis of epilepsy is compliant with and/or is receiving medical treatment which has a degree of control over their condition or whether it should be avoided at all costs is a matter of opinion. The General Hypnotherapy Standards Council state that hypnosis may be contraindicated for epilepsy. However for non-epileptic seizures, underlying triggers such as stress may be effectively addressed using hypnotherapy and hypnotherapy may also have a place in the diagnosis of epilepsy. Krista Conger’s article describes the use of hypnosis to assist in the diagnosis of the cause of seizures. It demonstrates the effectiveness of hypnotherapy both as a diagnostic aid and as a method by which to gain control within non-epileptic seizures. There are many other reasons for seizures than epilepsy and it is important to understand the cause in order to provide the most appropriate and non invasive treatment. Epileptic events are best treated by medication whereas non-epileptic events may be caused or triggered by stress, psychological factors or different neurological problems. In order to differentiate, brain activity during a seizure is monitored via electrodes on the scalp. This then requires the patient to remain ’wired up’ until they have a seizure. This is in a false environment and one which may have the original stress removed but additional stresses of waiting being added. Conger reports the use of hypnosis by Dr Shaw of Lucile Packard Children's Hospital for children who are undergoing these tests. Shaw found that if a suggestion is made that the child is going to have one of their events while they are in a hypnotic trance, they will usually have one. The children had a state of relaxation induced and then created a ‘relaxing place.’ They were then asked to recall the precursor experiences that normally precede their seizure and this triggered a ‘seizurelike event’ in 8/10 children. They were then re-directed to their ‘relaxing place’ which stopped the episode for all 8 children. This led to the diagnosis that all 8 were experiencing non-epileptic seizures rather than epileptic ones. The use of hypnotherapy meant that this testing could be done in a time effective manner and one in which the stress of the situation could be reduced. Further work was done to encourage the control that the children could develop within a seizure and promoting the confidence that they could be more in command of their bodies. Whilst the use of hypnotherapy to stop a seizure like event may be an appropriate diagnostic aid in a medically controlled environment such as during a scan, it would be inappropriate to create this type of environment in a non medical setting. From Shaw’s work one may deduce that if they had not been able to assert control over the seizure, hypnotherapy would have assisted in the diagnosis of epilepsy but the outcome could well be the triggering of an epileptic seizure and whilst this can be supported (see question 15), this should be avoided. (LO 1.3 Sophisticated thinking, within the bounds of law and ethics, but beyond the confines of unnecessarily dogmatic rules sometimes asserted in training, supervision and reading)

Tutor feedback (DO NOT delete/edit feedback. Write amendments, additional information & thoughts underneath this table) Correct. I enjoyed reading your response to the reading of this article and the viewpoints it has inspired from you. A very good demonstration of your sophisticated thinking and all that this entails.

(Further student work goes here if requested through feedback)

Further Example Student Answer:  Having met several people who are diagnosed as Pseudo fitters, some have no control over their seizures others are merely pretending for a number of reasons (attention seekers or to avoid something or someone)

The ones who are deemed to have no control are not epileptics in the normal sense of the word but as suggested in the article may be subject to a stress reaction thou many are the result of other medical conditions such as alcohol withdrawal or non prescription drug use.

One patient in particular stated he has seizures in response to pain from nerve damage in his arm, he has claimed to fit for up to a staggering 3 hours, thou the length of time was not witnessed, his wife on arrival back from a long shopping trip was able to talk him out of his fit in a few minutes, giving credibility to the argument that the patient can have some control over their seizures.

The use of hypnosis to induce a seizure must be carefully scrutinised as has been shown in many stage hypnosis shows, a good subject can be persuaded to do and experience many things which could potentially include reproducing a seizure from memory to please the physician but not induce an actual epileptic fit which the patient might actually suffer from but brought on by another trigger.

I believe the subject should have further research and must include a full brain scan of a patient undergoing both a hypnotic induced seizure and a naturally occurring seizure to ensure both are produced from the same parts of the brain and the hypnotic seizure is not just a memory.

Such a study must be carried out by highly trained individuals under appropriately prepared conditions with full medical support as seizures can be life threatening and no research is worth a death of a patient.

Personally I would be very reluctant to work with anyone suffering from Epilepsy unless under strict medical supervision as it is almost impossible to know what triggers a seizure and if, as the article suggests, it is possible to induce a seizure under hypnosis it is not a certainty that you could communicate sufficiently well with a patient in a seizure to end the episode effectively before the patient sustains harm.

Q14. Correct. Your answer demonstrates the sophisticated thinking that this advanced course promotes, within the bounds of law and ethics, though also being beyond the confines of dogmatic rules, using your personal experience to come to your conclusions. Having witnessed the ceasing of a seizure in the manner described is a valuable experience to share with other less experienced hypnotherapists and I encourage discussion on this topic at peer support and on the online forums. You make a good point also of the difficulties in communication when a client is in trance and fitting is induced. The brain scanning comparison is also a useful if not vital element to bring into this scenario.