Psychosomatic Medicine Tips for Better Browsing
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Rucklidge, J. J.
Right arrow Articles by Saunders, D.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Rucklidge, J. J.
Right arrow Articles by Saunders, D.
Related Collections
Right arrow Dermatology
Right arrow Therapeutic Interventions
Psychosomatic Medicine 61:355-358 (1999)
© 1999 American Psychosomatic Society

ORIGINAL ARTICLES

Hypnosis in a Case of Long-Standing Idiopathic Itch

Julia J. Rucklidge, PhD and Douglas Saunders, PhD, CPsych

From the Psychiatry Research Unit, Hospital for Sick Children (J.J.R.), and Department of Psychology, Toronto Hospital (D.S.), Toronto, Ontario, Canada.

Address reprint requests to: Dr. Julia Rucklidge, Psychiatry Research Unit, Elm Wing 4th Floor, 555 University Ave., Hospital for Sick Children, Toronto, Ontario, M5G-1X8. Email: julia.rucklidge{at}utoronto.ca


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 Case History
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
OBJECTIVE: This article presents the results of a brief hypnosis treatment of a woman with chronic, idiopathic vaginal and anal itch.

METHODS: The patient was referred after 3 years of unsuccessful outcomes with standard topical and oral treatments prescribed by her family physician and three dermatologists. Treatment consisted of five sessions of self-hypnosis training in techniques of relaxation, deepening, and imagery, and home practice with an individualized instructional tape.

RESULTS: After treatment, the patient reported substantial tissue healing, confirmed by her treating physician, that coincided with significant reductions in her scores of itch intensity, itch-related sleep disruption, and distress from pre- to posttreatment. These improvements continued at 4 months of follow-up, and the patient reported complete resolution of physical symptoms.

CONCLUSIONS: The fact that these changes coincided with only minor improvements in general anxiety scores suggests that the resolution of the patient’s itch condition was treatment-specific rather than the result of methodological artifact, participant reporting bias, or a general sense of feeling better. These findings suggest that hypnosis is a cost-effective treatment for idiopathic itch conditions, especially those that are unresponsive to standard medical treatments.

Key Words: idiopathic itch • hypnosis • dermatology • case study

Abbreviations: SCL-90-R = Symptom Checklist-90-Revised; STAI =State-Trait Anxiety Inventory; SHCS = Stanford Hypnotic ClinicalScale; IRS = itch rating scale; GSI = General Severity Index.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
Case History
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Persistent itch is an unpleasant sensation that elicits an intense desire to scratch, leading to excoriation, prurigo-like lesions, and marked postinflammatory hyperpigmentation, further intensifying the urge to scratch, producing greater itch-related irritation and distress. Patients who experience this itch-scratch cycle over an extended period often report significant sleep disruption, functional disability, and emotional distress (1). Unfortunately, results of medical treatment for these cases are frequently disappointing, with only temporary relief from topical or oral remedies. In addition, patient concerns over the effects of continuous, long-term use of medications may undermine their benefits. This highlights the importance of assessing other treatments, such as hypnosis, to deescalate the itch-scratch cycle by reducing itch preoccupation and emotional distress, leading to greater opportunity for tissue healing and less itch sensation.

Hypnosis and self-hypnosis training have been shown to be useful techniques for eliciting relaxation, controlling pain, and altering uncomfortable, nonpain sensations (2, 3). More specifically, hypnosis has been used successfully to treat the subjective discomfort and distress associated with generalized itch and other stress-related skin disorders, leading to improvements in physical condition (4–10). This article presents the case of a woman presenting with idiopathic vaginal and anal itch.


   Case History
TOP
 ABSTRACT
 INTRODUCTION
 Case History
METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
The patient, Ms. D., was a 43-year-old Hispanic woman referred by her family physician with an unremitting case of vaginal and anal itch lasting approximately 3 years. The family physician had diagnosed Ms. D. as having an "idiopathic itch" after ruling out other possible causes, such as pin worms, yeast infection, leukemia, and collagen. The physician had been unable to treat Ms. D. successfully with various topical and oral treatments and had already referred her to three dermatologists, who had prescribed a variety of medications, including Atarax, Dermorate, Sinequan, prednisone, Benadryl, Rectine, and Pramox/HC.

On assessment, Ms. D. was taking Dermorate and finding it limited in its usefulness. She reported that her condition was adversely affecting many areas of her life, including her ability to work, sexual relations, sleep, and psychological state. She reported that she was seeing a psychiatrist twice a week for treatment of bulimia nervosa; she was also a recovered alcoholic and reported a long history of depression, anxiety, and suicidal ideation. Although she was not able to identify a psychological trigger to the itch, she recalled that the onset of the itch coincided with the death of her husband.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 Case History
 METHODS
RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
The study was reviewed with the patient, and written consent was obtained. She was informed that she could withdraw from the study at any point without question and without affecting her current and future medical services. Before treatment, immediately treatment, and at 4 months after follow-up, the patient provided seven consecutive days of ratings for daily itch severity, itch-related distress and sleep disruption, and control over itch. At each of these times, she also completed a global measure of symptom distress, the SCL-90-R (11), and a standard measure of anxiety, the STAI (12). At the time of initial treatment interview, Ms. D. was also assessed for hypnotic responsiveness using the SHCS for adults (13).

After completion of the pretreatment interview and 7-day assessment, the patient was treated with five 1-hour sessions of hypnosis training spanning a 6-week period. Hypnosis training consisted of guided muscle relaxation, a deepening technique to enhance relaxation, visualization of a favorite scene, and, finally, the use of imagery and suggestions to control the itch. This training involved developing an image of the itch (including details of its color, shape, weight, and texture) and then introducing suggestions of how Ms. D. might alter the itch image. Suggestions included images of reducing the intensity of the itch color, replacing the itch color with a more soothing one, modifying the itch texture, soothing the itch sensation with wind or water, attaching a metaphoric thermostat to the itch, and gradually imagining controlling this thermostat to reduce itch intensity.

Sessions were taped, and the patient was asked to practice with the tape at home each day and to record itch intensity before and after each home practice on the same 11-point scale (ie, 0 (no itch) to 10 (worst itch)). The patient was also asked to rate her depth of hypnotic trance reached (again on an 11-point scale from 0 (very little trance) to 10 (very deep trance)).

Assessment Measures
Itch Rating Scale.
The IRS is a seven-item rating scale developed for this project to assess itch severity (right now and average over the day) and duration, itch-related distress (right now and average over the day), itch-related sleep disruption, and itch control. Each item is rated on a 0 (not at all) to 10 (most (worst) you have ever experienced) scale. Itch control was rated from 0 (no control) to 10 (complete control). This scale was modified from similar patient rating scales of chronic pain, instruments found to be valid and reliable measures of symptom intensity (14).

State-Trait Anxiety Inventory.
The STAI (12) is a 20-item self-report measure of general anxiety symptoms; higher total scores reflect greater anxiety.

Symptom Checklist-90-Revised.
The SCL-90-R is a 90-item standard measure of global distress over the previous 7 days (11, 15). Although some studies have failed to support the postulated symptom dimensions of this scale (16–18), there is general agreement supporting the scale’s GSI as a measure of overall distress (11, 15–18).

Stanford Hypnotic Clinical Scale for Adults.
The SCHS-adult (13) is a brief scale designed to measure hypnotic responsiveness, producing a rating of patient hypnotic susceptibility ranging from 0 (low) to 5 (high).


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 Case History
 METHODS
 RESULTS
DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Ms. D. responded remarkably well to hypnosis training despite scoring only at the moderate level on the SCHS-adult (raw score: 2 of 5). She reported trance levels ranging from 7 to 10 during the training sessions and showed a highly developed absorption ability, often reporting quasiphysiological responses to suggestions (eg, Ms. D. reported feeling anxious about losing her balance when given the suggestion of descending stairs). According to her rating charts, Ms. D. often reduced her itch sensation to zero in training sessions and home practice, with comparable effectiveness across both settings.

We assessed the statistical significance of pre- and posttreatment change in IRS scores relative to the 7-day variability in her scores using paired sample t tests. A Bonferroni correction was applied to compensate for multiple comparisons so that only differences with a p value of less than .007 were considered a significant change.

As shown in Table 1 , Ms. D. showed dramatic improvements from pre- to posttreatment rating scores, improvements that continued at the 4-month follow-up examination. Changes were significant for pre- and posttreatment ratings of average daily itch (t(1,6) = 12.050, p < .001), average itch-related distress (t(1,6) = 6.874, p < .001), and itch-related sleep interference (t(1,5) = 12.649, p < .001). At 4-month follow-up, changes were significant for average daily itch (t(1,6) = 12.961, p < .001), average itch-related distress (t(1,6) = 11.342, p < .001), and itch-related sleep interference (t(1,5) = 12.649, p < .001). In addition, changes in immediate ratings of both itch (t(1,6) = 6.315, p = .001) and itch-related distress (t(1,6) = 5.431, p = .002) had become significant at the 4-month follow-up examination. Of note was that Ms. D.’s sense of control actually decreased at 4-month follow-up even though she remained itch-free. She explained that although she felt she could control her itch once started, she did not feel she could stop the actual onset of itch from occurring.


View this table:
[in this window]
[in a new window]
  		Table 1. Means and SD of Items on the IRS
 
Changes in the GSI of the SCL-90-R (Figure 1 ) initially paralleled these results (pretreatment GSI = 1.09, 98th percentile; posttreatment GSI = 0.16, 45th percentile). However, although her itch-related symptom and distress ratings continued to drop to zero at 4-month follow-up, her GSI score remained above zero and actually increased slightly (4-month GSI = 0.28, 68th percentile). This relative difference in the pattern of scores was even more pronounced for the STAI (Figure 1) in that her posttreatment score (37, 51st percentile) was only a moderate improvement over her pretreatment score (47, 60th percentile) with no further change at 4 months of follow-up (35, 50th percentile).



View larger version (21K):
[in this window]
[in a new window]
  		Fig. 1. SCL-90-R percentiles, STAI percentiles, and average itch (IRS) plotted against time.

 
Consistent with the changes in her itch ratings, after treatment, Ms. D. reported a reduction in symptoms to such an extent that she had discontinued use of all oral and topical medications. At the 4-month follow-up session, she reported being surprised that her itch and burning sensations were gone without further use of these medications. Her report of complete symptom resolution and tissue healing in the affected area was confirmed by her family physician, who indicated that skin in her vaginal and anal area was clear. Ms. D. also reported having maintained the previously reported improvements in her sleep and mood, feeling in control of her itch condition, being employed for the first time in 3 years, and beginning her first sexual relationship since itch onset. Furthermore, these changes were maintained even after she stopped practicing the hypnosis techniques at home 1 month after treatment. Ms. D. was contacted again 9 months after treatment; she reported that all gains had been sustained throughout that period.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 Case History
 METHODS
 RESULTS
 DISCUSSION
ACKNOWLEDGMENTS
 REFERENCES
 
The results of this study indicate that hypnosis can be an effective treatment for people with persistent, idiopathic itch. The most likely explanation for the success of Ms. D.’s treatment is that hypnosis training effectively used her facility for developing vivid mental images to help her mentally alter and reduce the itch sensation, leading to reduced frequency of scratching and interruption of the itch-scratch cycle. The reduced scratch frequency would likely translate into less tissue irritation and sleep disturbance, reducing its impact on her emotional state and functioning and leading to lower stress, less urge to scratch, and further deescalation of the itch-scratch cycle. Consistent with this explanation, Ms. D. reported that by the second session, her sleep had improved and she was able to substantially alter her itch sensation.

Evidence suggesting that these improvements are a consequence of the hypnosis treatment comes from several considerations. One is the patient’s own report of her surprise at the immediate effects of the hypnosis on her itch, scratching frequency, and associated symptoms. A second is the patient’s reports, confirmed by her physician, of complete tissue healing in the affected area coincident with and subsequent to the treatment. A related consideration is the long-standing, chronic, and unresponsive nature of her condition before the beginning of hypnosis treatment, as evidenced by the repeated physician visits, referrals to specialists, and use of numerous topical medications without relief.

A fourth consideration is that the pattern of changes on the three main outcome measures, IRS (itch-related symptoms), the GSI of the SCL-90-R (overall symptom distress), and the STAI (state anxiety), is consistent with a treatment focus on itch relief only. Thus, although Ms. D.’s ratings on the IRS showed significant reductions across the treatment, her scores on general measures of symptom distress and emotional state showed a different pattern. For example, although the GSI changes paralleled reductions in IRS ratings from before to after treatment, they then increased slightly at 4-month follow-up. Pre- and posttreatment reductions in IRS ratings were coincident with only a moderate change in self-reported anxiety scores (61st to 50th percentile) and no further reduction at follow-up. These two patterns of change are consistent with what would be expected from treatment with a specific focus on symptom relief; namely, it successfully eliminates a major portion but not all symptom distress. In other words, the treatment addressed only anxiety specific to the itch; it was not aimed at addressing anxiety related to her many other psychiatric problems.

One limitation of this study is that it was uncontrolled. Therefore, interpretability of the results is limited by the fact that it is not possible to verify whether the changes noted were specifically a result of treatment. Nevertheless, the consistency of the results with the symptom-specific nature of the treatment supports the interpretation that the reductions in IRS ratings are less likely to be explained as simply the product of a methodological artifact, participant reporting bias, or a general "feel better" effect.

Finally, hypnosis offers the combined benefits of being cost-effective (33% cheaper than the standard medical treatments used in this case) and a nonmedication treatment for this condition. This is important given the common side effects of the medications used to treat Ms. D.’s itch, which include dry mouth, nausea, dizziness, insomnia, and allergic reaction. There are no known side effects of hypnosis.

The evidence from this study supports the potential utility of hypnosis as an alternative treatment to standard topical medications for managing symptoms of persistent itch. Further research is required to investigate whether the benefits documented in this case can be generalized to a larger group of individuals with persistent, idiopathic itch conditions.


   ACKNOWLEDGMENTS
TOP
 ABSTRACT
 INTRODUCTION
 Case History
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
REFERENCES
 
We acknowledge Dr. Paul Kelly for his assistance in developing the treatment protocol.

Received for publication September 29, 1998.

Revision received January 15, 1999.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 Case History
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 

  1. Laurent A, Boucharlat J, Bosson J, Derry A, Imbert R. Psychological assessment of patients with idiopathic pruritus ani. Psychother Psychosom 1997; 66: 163–6.[Medline]
  2. Bowers K, Kelly P. Stress, disease, psychotherapy, and hypnosis. J Abnorm Psychol 1997; 88: 490–505.
  3. Rhue JW, Lynn SJ, Kirsch I. Handbook of clinical hypnosis. Washington DC: American Psychological Association; 1993.
  4. Ament P, Milgrom H. Effects of suggestion on pruritus with cutaneous lesions in chronic myelogenous leukemia. J Am Soc Psychosom Dent Med 1967; 14: 122–5.[Medline]
  5. Scott MJ. Hypnosis in skin and allergic diseases. Springfield (IL): Charles C Thomas; 1960.
  6. Shertzer CL, Lookingbill DP. Effects of relaxation therapy and hypnotizability in chronic urticaria. Arch Dermatol 1987; 123: 913–6.[Abstract]
  7. Teshima H, Kubo C, Kihara H, Imada Y, Nagata S, Ago Y, Ikemi Y. Psychosomatic aspects of skin diseases from the standpoint of immunology. Psychother Psychosom 1982; 37: 165–75.[Medline]
  8. Frankel F, Misch RC. Hypnosis in a case of long-standing psoriasis in a person with character problems. Int J Clin Exp Hypn 1973; 21: 121–30.[Medline]
  9. Gray SG, Lawlis F. A case study of pruritic eczema treated by relaxation and imagery. Psychol Rep 1982; 51: 627–33.[Medline]
  10. Sampson RN. Hypnotherapy in a case of pruritus and Guillain-Barre syndrome. Am J Clin Hypn 1990; 32: 168–73.[Medline]
  11. Derogratis LR. SCL-90-R administration, scoring, and procedures manual-II. 2nd ed. Baltimore: Clinical Psychometric Research; 1983.
  12. Spielberger CD, Gorsuch RL, Lushene RE. Manual for the State-Trait Anxiety Inventory (self-evaluation questionnaire). Palo Alto (CA): Consulting Psychologist Press; 1970.
  13. Morgan AH, Hilgard JR. The Stanford hypnotic clinical scale for adults. Am J Clin Hypn 1979; 21: 134–47.
  14. Jenson MP, Karoly P, Braven S. The measurement of clinical pain a comparison of 6 methods. Pain 1986; 27: 117–26.[Medline]
  15. Edwards DW, Yarvis RM, Mueller DP, Zingale HC, Wagman WJ. Test-taking and the stability of the adjustment scales. Eval Q 1978; 2: 275–91.
  16. Cyr JJ, McKenna-Foley JM, Peacock E. Factor structure of the SCL90-R is there one? J Pers Assess 1985; 49: 571–7.[Medline]
  17. Carpenter KM, Hittner JB. Dimensional characteristics of the SCL-90-R an evaluation of gender differences in dually diagnosed inpatients. J Clin Psychol 1995; 51: 383–90.[Medline]
  18. Rauter UK, Leonard CE, Swett CR. SCL-90-R factor structure in an acute, involuntary, adult psychiatric population. J Clin Psychol 1996; 52: 625–9.[Medline]




This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Rucklidge, J. J.
Right arrow Articles by Saunders, D.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Rucklidge, J. J.
Right arrow Articles by Saunders, D.
Related Collections
Right arrow Dermatology
Right arrow Therapeutic Interventions

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS