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This sense of spiritual wellbeing and healing helped the patients and their families near death. The goal of palliative care is to relieve the suffering of patients and their families through the comprehensive assessment and treatment of the physical, psychosocial, and spiritual symptoms that the patients are experiencing.

Palliative care focuses primarily on anticipating, preventing, diagnosing and treating symptoms experienced by patients with a serious or life-threatening illness and helping patients and their families make important medical, psychological and spiritual decisions.

It can be concluded that hypnosis is a reasonable approach for clinicians to use not only for helping patients to cope better with chronic pain, anxiety and reduce the use of analgesic medicines for pain relief, but also for a compassionate palliative care, that will foster growth in dignity and transcendence.

With self-hypnosis, we can cultivate inner spiritual positive mental states like kindness and compassion at the end of life, which definitely lead to better suffering relief and psychological and spiritual healing. Limitations Despite considerable difficulties in recruitment, the intended sample size was nearly reached, although over a longer period of time and with delimited inclusion criteria.

We would have preferred to have organized a randomized trial, however, after an initial short period of randomization, many patients asked to change the therapy group: some patients at the end of life wanted to learn hypnosis to improve their relief from suffering, while others preferred to avoid hypnosis.

We ethically decided to respect the motivations of the patients with severe diseases and at the end of life, and the study was not randomized; We know that chemotherapy regimens that utilize combination therapy may potentiate or decrease the physical pain perceived by patients via different mechanisms of action.

We could not study this variable especially since it is related to many different and multiple chemotherapy variables. Conclusions Our work demonstrated that clinical hypnosis is an emerging field for pain and anxiety relief as adjuvant therapy to medicines in Palliative Care. Future researches and care models should therefore explore the beneficial as well as the potentially harmful aspects of clinical hypnosis within advanced care in severe chronic diseases, thereby focusing on: Ways to optimize multidisciplinary care by adopting clinical hypnosis as an adjuvant therapy; The use of hypnosis and self-hypnosis as adjuvant therapy for patients with advanced severe diseases.

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Our suggestion for future researches is also to compare clinical hypnosis with a group of patients treated with an adjuvant psychotherapy; The development of trials to investigate long-term outcomes of clinical hypnosis in Palliative Care with appropriate comparison groups are required; More researches on the effects and effectiveness of hypnosis are needed in Palliative Care; Another important reflection considering clinical hypnosis is the goal of the treatment.

While our goals were to decrease the intensity of pain, anxiety and the use of analgesic medicines, an arguably important goal may be to increase the quality of life, returning to work or improving function in daily activities or in psycho-social and spiritual healing; We suggest collaboration for multi centric researches on clinical hypnosis in Palliative Care.

These issues should be adequately addressed, both in future researches and in implementation trajectories regarding the use of clinical hypnosis as an adjuvant therapy in Palliative Care. Supplementary Clinical hypnosis and self-hypnosis techniques for pain and anxiety relief in patients receiving palliative care Clinical hypnosis can be described as a cognitive process of sustained attention and awareness towards present-moment sensations and experiences with visual imagery and deep emotional regulation.

Clinical hypnosis is considered as a means of achieving pain and anxiety relief and well-being, and, if practiced properly, can improve psychological health. Some treatments for anxiety incorporate aspects of the practice of clinical hypnosis and show beneficial effects on treatment outcomes.

Nowadays, researches into hypnosis suggest that it influences anxiety symptoms through emotional regulatory mechanisms rumination, reappraisal, worry and non-acceptance by considering emotional regulation as a path through which clinical hypnosis stimulates mental health 31 , The clinical hypnosis techniques used in this research during 2 years of hypnotic training for the hypnosis group are outlined below. We taught different techniques and the patients could decide whether to use just one or several of the preferred self-hypnosis techniques at home.

With clinical hypnosis, we can teach the patient to feel different pleasant sensations rather than pain or anxiety.

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The different interpretation of symptoms technique When a state of a lighter or deeper relaxation and hypnosis is achieved with different techniques, the patient is trained to interpret the feeling of chronic pain coming from a specific place in the body. We can transform it slowly from a feeling of pain to a feeling of a different nature: for example, a pleasant tension, a pleasant pressure, a pleasant warmth or a pleasant cold sensation of an anesthetizing nature.

You will feel your hand becoming pleasantly cold and pleasantly insensitive … and the anesthesia will increase. Duration: 5 or even only 3 minutes. The transferred symptoms technique After achieving relatively strong analgesia in a certain part of the body with the techniques described above, you aim to mentally transfer the analgesia to another part of the body for instance, from the hands to the abdomen or to the back obtaining this way a gradual and progressive reduction of overall suffering ….

The desensitization of pain and anxiety technique During a deep hypnotic state, the patient does not seem to react to the surrounding environment and usually seems to be less sensitive to painful stimulation. This happens even when some or all of the reflexive or vegetative signs of the painful stimulation are present.

The best use for this technique, therefore, is to induce deep relaxation up until the unconscious can register and activate a minor sensitivity to pain, through hypnotic suggestion, for a longer time, even in a state of normal awakening, The aim of this technique is to diminish anxiety connected with pain, in the case of headaches, for example, where, besides the body pain, a great emotional dysfunction also arises, or in the case of a phantom arm or leg after amputation of an arm or leg, or in the chronic pain of cancer patients.

The methods most used during the state of deep relaxation or hypnosis are: Direct instructions for pain reduction; The use of metaphors; Transportation of the painful symptom; Detachment from pain through metaphors, resilience, self-compassion, imagination.

Self-hypnosis technique for pain and anxiety relief Self-hypnosis is the way to use hypnosis alone, without the therapist. Steps commonly used for self-hypnosis: self-hypnosis requires some distinct steps. Step 1: motivation. Without proper motivation, an individual will find it very difficult to practice self-hypnosis; Step 2: relaxation of the body and mind. The individual must be thoroughly relaxed and must set aside time to perform this act.

Additionally, distractions should be eliminated as full attention is needed; Step 3: concentration. The individual needs to concentrate completely as energy is generated each time the mind focuses on a single image 23 - The self-hypnosis CD method This consists of simply recording by the therapist the desired suggestion on a CD, and then giving the CD to the patient to listen to for self-hypnosis. This will be very effective for people that have difficulty in visualizing.

Self-hypnosis is one of the most efficient techniques for pain and anxiety relief and is carried out using different techniques: You are experiencing a pleasant feeling in deep relaxation: inner peace, serenity, compassion, happiness… You mentally connect this feeling to your symptoms… that are decreasing more and more… You are using it mentally to cancel your symptoms… …The most efficient way to achieve this feeling is to repeat this self-introspective-hypnosis until you achieve your goal and sometimes this will take quite a while.

Acknowledgements The authors would like to express their immense gratitude to all the patients with severe chronic diseases who participated in this study. Footnote Conflicts of Interest: The authors have no conflicts of interest to declare. All patients provided written informed consent. References Bonica JJ. The need of a taxonomy. Pain ; Negative expectations interfere with the analgesic effect of safety cues on pain perception by priming the cortical representation of pain in the midcingulate cortex.

PLoS One ;e Pain and Psychology-A Reciprocal Relationship.

Ochsner J ; Treatment considerations for elderly and frail patients with neuropathic pain. Mayo Clin Proc ;S Evolution of the neuromatrix theory of pain. Pain Pract ; Corticotropin-releasing hormone receptor subtypes and emotion.

Biol Psychiatry ; Motor, cognitive, and affective areas of the cerebral cortex influence the adrenal medulla. Oxytocin and cortisol in the hypnotic interaction. Int J Clin Exp Hypn ; Mind-body medicine: state of the science, implications for practice. J Am Board Fam Pract ; Consciousness: here, there and everywhere?

Synaptic plasticity in the lateral amygdala: a cellular hypothesis of fear conditioning. Learn Mem ; Brugnoli MP. Clinical hypnosis for palliative care in severe chronic diseases: a review and the procedures for relieving physical, psychological and spiritual symptoms. Although ICDs are recognized as side-effect of dopamine replacement therapy DRT , mainly D2 dopamine agonists and levodopa, their pathophysiology is unclear.

It has been hypothesized that, in vulnerable individuals, DRT used to restore dopamine levels in nigrostriatal circuitry may overstimulate the less severely affected mesocorticolimbic circuitry 2. Mesocorticolimbic overstimulation may disrupt prefrontal-dependent executive function, affect and motivation and thus increase vulnerability to ICD.

According to this view, in medicated PD patients, we should expect a correlation between ICD and cognitive, affective and motivational factors. However, data in the literature are inconclusive. Studies on cognition, affective processing and motivation conducted in small cohorts of PD patients with and without ICD i. Conversely, other studies found similar performances for inhibition 9 , 16 — 18 , set-shifting 19 , 20 , working memory 3 , 11 , 17 , 21 , 22 , and reward-related decision-making 16 , 17 , 20 , Reports on affective factors are also inconclusive, as self-reported depression and anxiety were sometimes found to be associated with ICD 18 , 20 , 21 , 25 — 28 , and sometimes not 3 — 6 , 17 , 19 , 22 , 29 — A recent meta-analysis identified several cognitive subdomains i.

Finally, the relationship between cognition-emotion and cognition-motivation, critical to understanding the broader context in which ICDs develop, was not explored in the previous meta-analysis To reconcile discordant findings in the literature about cognitive, affective and motivational correlates of ICD in medicated PD patients, a systematic review and meta-analysis was conducted.

Moreover, this work is meant to address the issues of a previous meta-analysis and to offer new information on this topic.

Moreover, we included studies with affective and motivational measures, so that any cognitive change could be interpreted within the broader context of cognition-emotion and cognition-motivation relationships A clear understanding of cognitive, affective and motivational changes in ICD may indirectly increase our understanding of ICD pathophysiology and in turn its management.

The systematic review was further updated on March 8th A total of 40, papers were identified. After exclusion of duplicates, 10, papers were title and abstract screened.

A further inclusion criterion was independence of samples.

Only baseline data for prospective studies and the study with the largest sample for multiple studies published by the same author s were included. We excluded reviews, case studies, commentaries, letters, abstracts and dissertations, and postal surveys. Studies in which PD patients underwent non-pharmacological treatments such as deep brain stimulation DBS were excluded. Other exclusion criteria were: cognition assessed by self-report measures or by general screening tools e.

However, screening questionnaires e. Data Extraction Following exclusion of duplicate and irrelevant articles through title and abstract screening, 79 papers were included for full-text evaluation. Reference lists of these studies were manually searched to identify additional relevant articles, and two papers were included at this stage.


Disagreements were resolved through discussions. Disagreement concerned one paper 42 over the 75 selected for full-text examination inter-rater agreement: Twenty-five articles were included for quantitative analysis Figure 1.

Corresponding authors of five studies were contacted for exact data. Means and standard deviations were obtained for two studies, which reported median and interquartile ranges 20 , 25 , according to a proposed formula Primary outcomes were cognitive, affective, and motivational scores.

Cognitive tests were categorized on the basis of the main cognitive process involved Affective and motivational measures were categorized as depression, anxiety, anhedonia, apathy, and impulsivity. Cognitive processes assessed in a single study i. When a study reported multiple measures for the same outcome, the most relevant one was chosen by two reviewers with expertise on neuropsychological assessment AM, DDL. Data Analysis Data were analyzed using ReviewManager v5.

Effect size was estimated as standardized mean difference SMD , which is comparable to Hedges' adjusted g value. Effect sizes of 0.

I2 percentages of 25, 50, 75 are considered as low, moderate and high, respectively Random-effect model was applied, as patients differ in clinical e.

In contrast to fixed-effect models, random-effect models consider both within and between study variances. As heterogeneity was moderate to high for some outcomes i.

Conversely, if random-effect models are applied with effect sizes that vary only due to sampling error as when heterogeneity is low i. Moreover, following this approach, studies were not excluded because of their small sample size, because in random-effect models effect sizes are weighed by their variance, which is higher in smaller studies. Funnel plots of outcomes with less than ten studies were not inspected since the power is too low to discriminate publication bias's asymmetry from chance Sensitivity analysis was performed by excluding one study at time and verifying its impact on the overall effect size.

Sensitivity analysis was not performed for outcomes with two studies. Moderator analysis via meta-regression was performed using SPSS version As suggested by Borenstein 51 , moderator analysis was conducted only for outcomes in which there were at least 10 studies to one covariate. Results After removal of duplicates, 10, records were screened by title and abstract, 79 full-text articles were assessed for eligibility, and 54 were excluded Figure 1.Standardized mean difference represents Hedges's g effect size.

Future studies should be conducted following blinding procedures. By the same token, if patients start out with higher mesocorticolimbic baseline levels of dopamine, DRT causes dopamine over-activity in the mesocorticolimbic system. In stock. Lancet Oncol ; J Pain Symptom Manage ;

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