ABC of complementary medicine

Hypnosis and relaxation therapies

BMJ 1999; 319 doi: (Published 20 November 1999)
Cite this as: BMJ 1999;319:1346

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Given the wide remit of Vickers and Zollman's informative ABC of Complementary Medicine, it is understandable that some important research findings were not mentioned.(1) As the authors indicate, there is little evidence that hypnosis and relaxation help to combat smoking, substance misuse, or hypertension. In contrast, meta-analyses show that Transcendental Meditation (TM), as taught by Maharishi Mahesh Yogi, leads to significantly greater reductions in use of tobacco, alcohol, and illicit drugs compared to conventional programmes, with or without relaxation methods (even though TM involves no advice on life-style change).(2) Earlier meta-analyses found that TM was more than twice as effective as other meditation and relaxation procedures in reducing anxiety and improving overall mental health. Importantly, in each of these analyses, stronger study design correlated with a greater effect from TM compared to other techniques.(3)

A randomized trial found that TM was more effective in reducing mild hypertension in elderly African Americans than progressive muscular relaxation or a 'usual care' programme.(4) Further analysis showed that TM was effective in both sexes and across a range of risk subgroups; cost-effectiveness compared favourably with drugs. Other randomized studies on TM have shown: improved exercise tolerance in angina pectoris; comprehensive improvements in post-traumatic stress disorder (compared to psychotherapy); and improvements in cognitive functioning, mental health, blood pressure, and longevity among elderly individuals (compared to a relaxation technique, an active mental exercise, or no treatment). Retrospective analyses of health insurance data show markedly lower health care needs and costs among people who practise TM compared to normative control groups.(5)

We would not assume, without empirical evidence, that different drugs have similar effectiveness and safety: is such an assumption any more appropriate for different forms of meditation and relaxation? Interestingly, TM does not fit any of Vickers and Zollman's descriptions of meditation. Thus, this simple, effortless practice does not involve 'stilling or emptying the mind', 'concentration', or 'attempt to reach a state of detached observation'. Reassuringly, TM teachers are qualified to high standards through extensive, well-supervised training courses.

Moreover, TM has an extemely impressive safety record. The growing strength of research on TM was presumably a factor in the recent award by the US National Institutes of Health of grants totalling more than $8 million for research and education in Maharishi's Vedic Approach to Health, in which TM plays a central role.

Roger A. Chalmers

1. Vickers A, Zollman C. ABC of complementary medicine: Hypnosis and relaxation therapies. BMJ 1999:319:1346-1349.

2. Alexander CN, Robinson P, Rainforth MV. Treating and preventing alcohol, nicotine, and drug abuse through Transcendental Meditation: A review and statistical meta-analysis. Alcoholism Treatment Quarterly 1994;11:13-87.

3. Eppley K, Abrams A, Shear J. Differential effects of relaxation techniques on trait anxiety: A meta-analysis. Journal of Clinical Psychology 1989;45:957-974.

4. Schneider RH, Staggers F, Alexander CN, Sheppard W, Rainforth M, Kondwani K, et al. A randomized controlled trial of stress reduction for hypertension in older African Americans. Hypertension 1995;26: 820-827.

5. Herron R, Hills SL, Mandarino JV, Orme-Johnson DW, Walton KG. The impact of the Transcendental Meditation Program on government payments to physicians in Quebec. American Journal of Health Promotion 1996;10:208- 216.

Current Position: general practitioner undertaking NHS locum work in Suffolk and Cambridgeshire. I have also recently resumed a limited amount of private practice combining orthodox and complementary medicine.

Competing interest: I have a longstanding and continuing interest in medical applications of Transcendental Meditation and have campaigned actively since 1978 for its inclusion in health programmes. From 1982- 1987 and from 1992-1996, I worked closely on a full-time, voluntary, unremunerated basis with organizations involved in researching, teaching, and promotion of Transcendental Meditation and related techniques. From 1987-1991, I was engaged in full-time private medical practice using orthodox medicine alongside a complementary system of natural medicine (Maharishi Ayur-Veda) which incorporates Transcendental Meditation as one of its key components.

Competing interests: None declared

Roger A Chalmers

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Dear Editors,

While the article on hypnosis and relaxation techniques was a well- balanced overview, the use of guided imagery in clinical medicine is far broader than reported. Guided imagery has been shown to be helpful in reducing pain, anxiety, and post-operative complications in surgery when used as a pre-operative preparation, and has similarly been demonstrated to reduce nausea of chemotherapy. It has also been shown in numerous studies to be effective in increasing numbers and aggressiveness of natural killer T-cells in patients with chronic viral illness and cancer.

Beyond it's direct applications for such procedures, it is also useful to help people make difficult medical decisions,to resolve conflicts about treatments,to complete grieving processes that may affect their ability to adhere to medical regimens, and to find meaning in their suffering, which can reduce the intensity of that suffering.

Modern usage of guided imagery employs an interactive use, where the imagery guide helps the patient to become aware of their own images relating to illness and health, and teaches them skills they can use to understand and/or change their internal relationship with both these states.

Competing interests: None declared

Martin L Rossman, Dept. of Medicine, University of California, San Francisco Medical School

Academy for Guided Imagery, Mill Valley, California

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Qigong ("exercise of vital energy") is a trance-based form of Chinese healing system which consists of meditational and/or diverse styles of movement exercise, induced by using a highly culture-syntonic set of suggestions based on the concept of qi (vital energy). It has been estimated that not less than 5% of China's 1.3 billion people practise qigong, suggesting that this may be the most common of "hypnosis" practised globally. Vickers and Zollman (1999) rightly pointed out that qigong is very similar to hypnosis, but it may be premature to conclude that adverse events associated with this widely practised form of "Chinese hypnosis" are "extremely uncommon". In the last two decades, many reports of qigong-induced mental disorders have been reported in the Chinese psychiatric literature. In the Chinese Classification of Mental Disorders, second revised edition (CCMD-2-R), qigong induced mental disorder is found as a culture-related mental disorder. In psychologically vulnerable individuals, qigong induced health disturbances or pian cha are believed to arise from the inappropriate application of qigong and/or the inability to "terminate the qigong" (shougong). When severe, they are known as zou ("run") huo ("fire") ru ("enter") mo ("devil"), which means that the flow of qi deviates from the jing luo conduits and becomes "fire", as a result of which devil intrudes into the person (metaphorically, referring to the emergence of psychotic symptoms).

The condition violates the paradigms of quietness, relaxation and internal harmony that are followed in qigong practice. Its symptoms include somatic discomforts, uncontrolled motor activity, anxiety, fright, weepiness, irritability, delusions, identity disturbance, hallucinations, mania, depression, suicidal, bizarre and violent behaviour. As qigong induced mental disorders are usually short-lasting, some cases probably never come to medical attention. The exact proportion of people engaging in qigong and developing psychiatric complications remains unknown, but similar problems are much less frequently described in the meditational practices of other cultures. Although qigong-induced mental disorders have recently become a political issue in China, empirical studies of the adverse effects of this widely practised form of Chinese trance practice are worthwhile. Interested readers are referred to Lee (1996) for further information.

Lee S (1996). Cultures in psychiatric nosology: the CCMD-2-R and international classification of mental disorders. Culture, Medicine & Psychiatry, 20, 421-472.

Competing interests: None declared

Sing Lee, Associate Professor (Psychiatry)

The Chinese University of Hong Kong

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23 November 1999

I think the whole series of these articles on Complementary Medicine to have been excellent, and with promise of yet more still to come.

I also think the BMJ should be congratulated for having had the considerable courage to publish these articles. They are all superbly researched and extremely informative to anyone interested in this field.

The key point for me is that they might encourage some long-overdue change in the future of medicine and usher in a new age of greater medical tolerance and partnership, such as already exists in countries like India and China, where several divergent healing systems work happily side by side.

I also look forward to purchasing the book when it appears next Spring.

Competing interests: None declared

Peter Morrell, Research Associate/Lecturer

Stoke College

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