Hypnotherapy: A Useful Adjunctive Therapeutic Modality in Hansen's Disease
Abstract
Hypnotherapy is a useful adjunctive psychotherapeutic procedure used in various conditions such as pain disorders, atopic dermatitis, and alopecia areata. However, it is less utilized in the field of dermatology. Only limited data exist on its role in the management of various skin diseases. There is dearth of literature on the role of hypnotherapy in Hansen's disease (HD). We report two cases of HD, one with very resistant neuralgia and the other with recurrent erythema nodosum leprosum (ENL). Both the patients were assessed using hospital anxiety and depression scale, dermatology life quality index and the neuralgia was assessed using the visual analog scale. Three sessions of hypnotherapy were given to both the patients. There was dramatic improvement in the incidence of ENL and neuralgia and we could rapidly reduce the dose of drugs used for both conditions.
Introduction
What was known?
- Hansen's disease is well-known for occurrence of Lepra reactions (including type 1 and type 2) during its course in some individuals. Mental stress is one of the important precipitating factors.
- Hypnotherapy is a globally accepted mode of psychotherapeutic procedure for stress management used in a various branches of medicine.
Hansen's disease (HD) caused by mycobacterium lepra[1] is well-known to produce the symptoms related to skin and the peripheral nerves in addition to systemic symptoms especially associated with the Lepra reactions and Lepra reactions include type 1 and type 2 reactions. The type 1 Lepra reaction is characterized by erythema, edema, and tenderness of the existing lesions with predominant features of neuritis.[2,3] Type 2 Lepra reaction is characterized by erythema nodosum leprosum (ENL) lesions.[2,3] They include evanescent erythematous tender nodular lesions commonly distributed over face, proximal limbs, and trunk.[3] Associated neuritis and features of systemic toxicity are common. Common precipitating factors include starting multi drug therapy (MDT), infections, vaccinations, and mental stress.[2,3]
Usually, the role of mental stress is not much evaluated in the management of Lepra reactions. Mental stressors activate two major neural pathways, hypothalamo pituitary adrenal axis and sympathetic nervous system producing neurogenic inflammation.[4] Skin being a component of neuro-immuno-cutaneous-endocrine system emotional disturbances can alter immunological status of the individual leading to Lepra reactions. Hypnotherapy is used as an adjunctive procedure in various dermatological conditions such as atopic dermatitis,[5] alopecia areata,[6] pain disorders[7] etc., Hypnosis can be used for general relaxation and ego strengthening. Moreover, it can be oriented to a specific symptom.[7] Three hypnotic sessions were given to both patients at three days interval.
Hypnotic Technique
Hypnosis was induced by means of relaxing suggestions.[6] The method of hypnosis is as follows. The patient is instructed to do the following actions; to lie down comfortably on a coat, to close the eyes and to take deep breath and exhale slowly. The respiratory comment is repeated a few times. Then, the patient is asked to concentrate on body parts from head to foot as per the instruction of the therapist and to imagine that all the parts are completely relaxed. On repeating, this patient will slowly reach the hypnotic trance. Eye movement, respiratory rate, pulse rate, and muscle tone are assessed to understand the depth of hypnosis. After the hypnotic induction, the patients were invited to visualize a place where they felt safe and secure e.g.,: A sea shore. Then, the symptom-oriented suggestions were given. (e.g., in the first case to imagine the healing of damaged nerves and skin, to visualize that the nerves are returning to their pre-diseased state leading to a healthier life. In the second case, the patient was asked to imagine all the bacilli are being killed and they are now non-infectious.). By doing so, we tried to attenuate the negative feelings such as embarrassment, low self-esteem, inability to regain the pre diseased state, anxiety regarding the future, and the fear of spreading the disease to others. The hypnotic sessions were carried out by the first author who is qualified in psychology and has experience in psychotherapy and the hypnosis.
Case Reports
Case 1
A 22-year-old male suffering from Hansen's disease-borderline tuberculoid presented with type 1 reaction. His main symptom was severe neuritic pain of right lower limb and the skin lesions present over the right leg and trunk. The pain was increasing steadily day by day and after a few days, the patient was screaming with pain (visual analog scale [VAS][8] rating showed the worst pain-10). This man was a very active karate black belt holder. After knowing the diagnosis, he thought that his nerves are completely damaged by the disease and there was no more hope in future. This thought lead him to severe depression (hospital anxiety and depression scale.
The patient was on high dose of systemic steroid (inj. dexamethasone. 2cc once daily for 2 weeks initially and then twice daily for 4 weeks), aspirin (325 mg thrice daily for 2 months), clofazimine (100 mg, initial 1 week, 200 mg next 2 weeks and 100 mg thrice daily for next 5 weeks), and diclofenac sodium (50 mg thrice daily for 2 weeks) daily. As he was not improving, we subjected the patient to hypnotherapy after informed consent. During hypnosis, the patient was asked to visualize his skin, brain, and peripheral nerves according to his mental concept and to imagine that the skin and the nervous system has completely recovered to the pre-diseased state and he is leading a healthy life. After the first session, the patient had a subjective decrease of pain around 70% (VAS scale-3). Two more sessions were given at 3 days interval. The pain markedly decreased after third sitting (VAS-scale-1) and showed excellent improvement psychologically (HADS-4, DLQI-4) and we reduced the drugs very quickly (inj. dexamethasone 2 cc- 1 week, 1 cc- 1 week, tab. Prednisolone 20 mg- 1 week, 15 mg- 1 week, 10 mg 1 week, 5 mg 1 week and stopped. Aspirin 375 mg twice daily-1 week, once daily- 10 days and stopped. Clofazimine 200 mg daily- 2 weeks, 100 mg daily- 2 weeks and stopped and diclofenac sodium was completely stopped) and continued MDT up to 6 months. We followed the patient for 2 years and he had no features of reaction or neuralgia thereafter.
Case 2
A 35-year-old female presented with Hansen's disease-lepromatous lepromatous with recurrent ENL lesions. The patient was on MDT for 8 months, systemic corticosteroids (prednisolone 30 mg oral daily for 6 weeks, then inj. dexamethasone 2 ml daily for 4 weeks) and thalidomide (100 mg twice daily for 4 weeks initially followed by thrice daily for 2 months). The course of the reaction was characterized by repeated remissions and exacerbations necessitating five admissions to the hospital during a span of 3 months. On psychological evaluation, she was observed to be depressed (HAD scale-19, DLQI-29). After obtaining informed written consent, we subjected her to hypno analysis and we could realize that the fear of spreading the disease to her family members was the reason for her stress. We asked her to visualize that her body infected with the lepra bacilli and after taking the MDT all the bacteria were killed completely and not even a single bacterium was left behind to infect her family members. After the first session, her fear was markedly decreased (HAD scale-11, DLQI-18). The ENL lesions stared subsiding. We repeated two more sessions at 3 days intervals. Psychologically she became stable (HAD scale-5, DLQI-6) and the ENL lesions subsided completely by 3 weeks. We could reduce the dose of corticosteroids (inj. dexamethasone 1.5 cc for 1 week, 1 cc for 1 week, Tab. Prednisolone 20 mg 1 week, 15 mg 1 week, 10 mg 1 week, 5 mg 1 week and then stopped) and thalidomide (100 mg thrice daily- 1 week, 100 mg twice daily- 1 week, 100 mg once daily - 2 weeks and stopped by 1 month) quickly. We continued the MDT up to 1 year and followed-up the patient for 2 years. She had no more ENL recurrences and admissions thereafter.
Discussion
There is paucity of information in the medical literature about the efficacy of hypnosis in the management of Hansen's. There are only three studies indexed in PubMed of which only one article is in English. (Reference details not available). There are studies regarding usefulness of hypnotherapy in pain disorders.[7] The probable mechanism involved in the relief of neuralgia in HD may be due to the analgesic effect of endogenous opioids such as endorphins and enkephalins[4] released in the brain during hypnosis. On subsidence of pain, the mental attitude of the patient changes from that of an incurable disease to a curable one. The associated anxiety decreases, self-esteem improves and the overall psychological well-being is boosted up. In the second case, the imagery technique made her realize that all the organisms are killed and the disease is no more infectious to the family members, reduced her anxiety and boosted-up the psychological well-being. The alleviation of the underlying stress may be the reason for absence of recurrences of type 2 reaction.
However, until today, the data on the influence of hypnotic interventions on cytokine production is very scarce.[6] The clinical improvement of our patients must be interpreted in the light of several limitations. First, these patients received hypnosis in addition to other forms of treatment because of ethical concerns. Hence, it is not possible to evaluate how much of the improvement was caused by the hypnotic interventions. Secondly, it is very difficult to make a conclusion based only on the basis of our experience with two cases. In view of the promising response seen in our cases, a randomized controlled trial with sufficient number of patients is indicated to arrive at the correct conclusion as to whether the hypnosis has any role in the management of HD. Despite these limitations, our observations are encouraging and hypnotherapy may be considered as an adjunctive therapeutic procedure in Hansen's disease.[10]
What is new?
Hypnotherapy-a simple, but highly useful psychotherapeutic procedure, underutilized in the field of dermato-venereo-leprology is applied here as an adjunct for the management of Lepra reactions (especially for stress induced neuralgia and ENL).
Footnotes
Source of Support: Nil
Conflict of Interest: Nil.
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