Biofeedback can improve cutaneous problems that have an autonomic nervous system component. Examples include biofeedback of galvanic skin resistance (GSR) for hyperhidrosis and biofeedback of skin temperature for Raynaud’s disease. Hypnosis may enhance the effects obtained by biofeedback. Cognitive-behavioral methods may resolve dysfunctional thought patterns (cognitive) or actions (behavioral) that damage the skin or interfere with dermatologic therapy. Responsive diseases include acne excoriée, atopic dermatitis, factitious cheilitis, hyperhidrosis, lichen simplex chronicus, needle phobia, neurodermatitis, onychotillomania, prurigo nodularis, trichotillomania, and urticaria. Hypnosis can facilitate aversive therapy and enhance desensitization and other cognitive-behavioral methods. Hypnosis may improve or resolve numerous dermatoses. Examples include acne excoriée, alopecia areata, atopic dermatitis, congenital ichthyosiform erythroderma, dyshidrotic dermatitis, erythromelalgia, furuncles, glossodynia, herpes simplex, hyperhidrosis, ichthyosis vulgaris, lichen planus, neurodermatitis, nummular dermatitis, postherpetic neuralgia, pruritus, psoriasis, rosacea, trichotillomania, urticaria, verruca vulgaris, and vitiligo. Hypnosis can also reduce the anxiety and pain associated with dermatologic procedures.
The most commonly used biofeedback techniques measure and provide auditory or visual feedback of galvanic skin resistance (GSR), skin temperature, electromyography (EMG), or electroencephalography (EEG) (1). The polygraph is a combined instrument that can measure these simultaneously along with heart rate and respiratory rate. The devices can be separate units or can be combined into one handheld unit. Larger units typically are used in the clinic, while small handheld units may be used by the patient at home.
Cutaneous problems that have an autonomic nervous system component can be improved by biofeedback with or without hypnosis. Examples include biofeedback of GSR for hyperhidrosis and biofeedback of skin temperature for Raynaud’s disease. With training, individuals can learn how to consciously alter the autonomic response, and with enough repetition may establish new habit patterns. Hypnosis or autogenic training may enhance the effects obtained by biofeedback.
A young man with hyperhidrosis, described in Panconese (2) as translated by Sarti (1), had a very low initial GSR at the beginning of treatment and improved slowly over 20 sessions combining GSR biofeedback with autogenic relaxation training. Autogenic training is considered to be a variant of hypnosis. Follow-up at 3 and 6 months after treatment,
during which the patient continued to practice the autogenic training exercises, showed a continued reduction in palmar sweating to near normal levels.
Systemic sclerosis patients with Raynaud’s disease have been able to increase finger skin temperature by an average of about 4°C using either hypnosis or autogenic training (3). Two of six patients using autogenic training in addition to biofeedback reported that they could shorten the duration of Raynaud attacks by autogenic training. Measurement
of finger blood flow in another study with venous occlusion plethysmography, finger temperature, and GSR in patients with Raynaud’s disease showed significant elevations in finger blood flow, finger temperature, and GSR conductance level in those given finger temperature biofeedback compared with those who received autogenic training but no biofeedback (4). A recent large study of Raynaud’s patients compared learned hand warming results using different biofeedback methods and found that attention to emotional and cognitive aspects of biofeedback training was important (5).
A significant correlation between degree of hypnotic ability and ability to lower finger temperature using biofeedback in 30 subjects given the Stanford Hypnotic Susceptibility Scale, Form C (SHSS-C) was found in a study by Piedmont (6).
While the subjects remained under hypnosis, they were instructed to lower the temperature of a finger while receiving biofeedback. Those who scored high on the SHSS-C were able to maintain a lower mean temperature than those who scored low. In another study, biofeedback combined with hypnosis permitted voluntary control of skin temperature
in some individuals with moderate to high hypnotic ability as measured by the SHSS-C (7).
This can be used to increase local peripheral circulation in such conditions as Raynaud’s disease.
Biofeedback of muscle tension via EMG can be used to enhance the teaching of relaxation. Relaxation can have a positive effect on inflammatory and emotionally triggered skin conditions such as acne, atopic dermatitis, lichen planus, neurodermatitis, psoriasis, and urticaria. The mechanism is through influencing immunoreactivity (8). Patients who have low hypnotic ability may be especially suitable for this type of relaxation training.
Cognitive-behavioral methods address dysfunctional cognitions (thought patterns) or behaviors (actions) that harm the skin or interfere with dermatologic therapy. The first step is to identify specific problems by hearing the patient’s verbalization of thoughts and feelings, such as fear of needles, or by direct observation of behaviors, such as scratching. The second step is for the dermatologist or assisting therapist and patient to determine the goals of cognitive-behavioral therapy, such as a reduction in anxiety about needles or cessation of scratching.
The third step is for the dermatologist or therapist to develop a hypothesis about the underlying beliefs or environmental events that precede (stimulate), maintain (reinforce), or minimize (extinguish) these thought patterns and behaviors. The fourth step is for the dermatologist or therapist to test the hypothesis of cause and effect by altering the
underlying cognitions, the behavior, the environment, or all three, and to observe and document the effects on the patient’s dysfunctional thoughts,
feelings, and actions. The fifth step is for the dermatologist or therapist to revise the hypothesis if the desired results are not obtained or to continue
the treatment if the desired results are obtained until the goals of therapy are reached (modified from Levenson et al. (9)).
This method draws in part on the cognitive therapies of identifying dysfunctional negative selftalk and substituting positive self-talk or reframing the thought picture by offering a new perspective. It also draws in part on alterations of behavior based on the classic conditioning described by Pavlov with dogs and by John B. Watson with people,
and on the operant conditioning described by B. F. Skinner. For a more detailed description of systematic desensitization, aversion therapy, operant
techniques, and assertiveness training as applied to dermatology, see Bär and Kuypers (10).
The picking component of acne excoriée responded in a young adult woman to cognitivebehavioral therapy coupled with biofeedback, minocycline, and sertraline (11). This multimodal approach is often beneficial in resistant cases. Scratching in atopic dermatitis can become a conditioned response (12,13), often associated with and exacerbated by feelings of anxiety or hostility. An itch stimulus was paired with the neutral stimulus of a sound tone (classical conditioning) and the amount of scratching and GSR changes were measured. Atopic patients had a significantly higher scratching and GSR response than did a control group. The atopic patients also scored significantly higher for anxiety level and
level of suppressed hostility. Atopic patients report some relief of anxiety or hostility through scratching (operant conditioning). Substituting other activities for scratching can, with repetition, change the conditioning. Examples of other more constructive activities include sports, music, artwork, meditating, or yoga. Habits such as lip licking or biting produce
factitious cheilitis (14). Topical anti-inflammatory agents combined with cognitive-behavioral counseling were generally effective in producing improvement or resolution.
A 19-year-old woman with severe palmar hyperhidrosis responded with improvement in the hyperhidrosis and in her approach to social situations following assertiveness training and systemic desensitization (10). A 12-month followup showed no return of her prior anxiety about social situations, and she was able to accept the milder hyperhidrosis that she still experienced.
Repetitive focal rubbing and scratching can produce lichen simplex chronicus (LSC). Bär and Kuypers (10) treated a 6-year-old girl with a 3-year history of vulvar LSC by having the mother ignore all scratching behavior but reward nonscratching behavior with a token. The girl exchanged the tokens each night for rewards. After 5 weeks the scratching lessened, and by 13 weeks the condition resolved. They also treated a 33-year-old man with LSC using aversive therapy, with resolution of the scratching behavior after 19 days.
When needle phobia interferes with needed treatment, systemic desensitization using participant modeling has been effective (15). The dermatologist or therapist first gives information about needles and interacts with them in a way that shows that the patient’s fear is unrealistic or excessive. After modeling handling a needle, the dermatologist or therapist has the patient join in this performance, starting with situations that provoke relatively little anxiety and culminating in the performance of the feared activity.
The patient is then instructed in self-directed practice to complete the desensitization. Since about 10% of the population has needle phobia (16), desensitization may be necessary in these individuals to permit performance of dermatologic procedures. Neurotic excoriations can produce neurodermatitis with its typical distribution on the shoulders, neck, extremities, and face, sparing the butterfly pattern on the back where the hands cannot reach. Ratliffe and Stein (17) reported improvement of neurodermatitis in a 22-year-old man using aversion therapy techniques. Rosenbaum and Ayllon (18) used habit reversal treatment for neurodermatitis. They taught awareness of the scratching behavior, reviewed the inconveniences produced by the habit, developed a competing response practice of isometric exercise using fist clenching, which was incompatible with scratching, and did symbolic rehearsal. At the 1-month and 6-month follow-ups, all three patents had improved and healed.
Damage to the nails through rubbing, picking, or tearing at the proximal and lateral nail folds is known as onychotillomania. This differs from onychophagia, the habit of biting the free ends of the nails (19). Onychotillomania can lead to onychodystrophy (20). Teaching picking awareness, a competing response practice of isometric exercise of gripping the hands together and pulling, and rehearsal under observation can help to reverse this habit.
Repetitive hair twisting and pulling can produce hair loss in the form of trichotillomania. Habit reversal training involves self-monitoring of the frequency and duration of hair pulling, habit control motivation by reviewing the inconveniences produced by the behavior, awareness training including situational precursors, competing response training that can be used to prevent or interrupt hair pulling, relaxation training, and generalization training to identify and manage high-risk situations (21). Of three patients using this process, one discontinued hair pulling and the other two noticeably decreased their hair pulling.
Psychosomatic triggering or exacerbation of urticaria was ameliorated in a young professional woman using cognitive-behavioral therapy with specific self-talk and relaxation techniques (11). Biofeedback was also used along with multiagent antihistamines in a multimodal approach to reduce the urticaria. For patients with medium to high hypnotic ability, hypnosis may be employed in cognitivebehavioral therapy to produce desensitization, facilitate relaxation, or produce imagined aversive experiences (22). Especially with aversion therapy, it is much easier and safer to have the patient experience the aversive stimulus in the imagination than in real life. For patients with low hypnotic ability, biofeedback may be more appropriate.
Trance is a normal altered state of consciousness which each of us experiences spontaneously daily while absorbed in watching television or a movie, in reading a book or magazine, in some other activity, or in meditation. One may learn to intensify this trance state in him/herself or in another individual and use this heightened focus to induce mind-body interactions that help to alleviate suffering or to promote healing. The trance state may be induced using relaxation, deep breathing, meditation techniques, guided imagery, selfhypnosis, or hypnosis induction techniques. Hypnosis is the intentional induction, deepening, maintenance, and termination of the trance state for a specific purpose. The purpose of medical hypnotherapy is to reduce suffering, to promote healing, or to help the person alter a destructive behavior. Some people are more highly hypnotizable, others less so, but most can obtain some benefit from hypnosis. Low hypnotizability is to a large extent hard-wired into an individual’s brain and tends to be consistent over time as measured by the Hypnotic Induction Profile (23).
In dermatology, hypnosis can hasten the resolution of some skin diseases, including verruca vulgaris. Hypnosis may also help to reduce skin pain, pruritus, and psychosomatic aspects of skin diseases. Suggestion without formal trance induction may be sufficient in some cases. Bloch (24) and Sulzberger and Wolf (25) used suggestion to treat verrucae.
Marmer (26) defined hypnosis as a psychophysiologic tetrad of altered consciousness consisting of narrowed awareness, restricted and focused attentiveness, selective wakefulness, and heightened suggestibility. Detailed discussions of the definitions of hypnosis are available in Crasilneck and Hall (27) and Watkins (28). Multiple myths about hypnosis exist that distort, overrate, or underrate the true capabilities of hypnosis. The mechanisms by which hypnosis produces improvement in symptoms and in skin lesions are not fully understood. Hypnosis can help regulate blood flow and other autonomic functions not usually under conscious control. The relaxation response that accompanies hypnosis alters the neurohormonal systems that in turn regulate many body functions (8).
In dermatology, hypnosis can be used to help control harmful habits such as scratching. It can also be used to provide immediate and longterm analgesia, reduce symptoms such as pruritus, improve recovery from surgery, and facilitate the mind-body connection to promote healing. Information on skin disease responsiveness to hypnosis is found in a relatively old book by Scott (29) and in the chapter on the use of hypnosis in dermatologic problems in Crasilneck and Hall (27).
Koblenzer (30) also mentions some of the uses of hypnosis in common dermatologic problems. Grossbart and Sherman (31) include hypnosis as recommended therapy for a number of skin conditions in an excellent source book for patients. Dermatoses that have responded to hypnotherapy are discussed below.
Hypnotherapy can be used to reduce psychological/behavioral impediments to healing. Hypnosis can facilitate supportive therapies (ego strengthening), direct suggestion, symptom substitution, and hypnoanalysis (29,32–34). Mentioning hypnosis to patients will allow the dermatologist to gauge the patient’s receptiveness to this treatment modality. The time needed to screen patients, educate them about realistic expectations for results from hypnosis, and actually perform the hypnotherapy are similar to or less than those for screening, preparing, and educating patients about cutaneous surgery and then actually performing the surgery. Dermatologists who prefer to refer patients to hypnotherapists or who desire further information about training in hypnotherapy may obtain referrals or training information from the American Society of Clinical Hypnosis or similar professional organizations. Advantages of medical hypnotherapy for skin diseases include nontoxicity, cost-effectiveness, ability to obtain a response where other treatment modalities have failed, and ability of patients to self-treat and gain a sense of control when taught self-hypnosis reinforced by using audiotapes.
Disadvantages include the practitioner training required, the low hypnotizability of some patients, the negative social attitudes still prevalent about hypnosis, and the lower reimbursement rates for cognitive therapies such as hypnosis when compared with procedural therapies such as cutaneous surgery. Patient selection is an important aspect of successful medical hypnotherapy in dermatology. With proper selection of disease process, patient, and provider, hypnosis can decrease the suffering and morbidity from skin disorders with minimal side effects.
Induction of the hypnotic state is achieved in adults by methods that focus attention, soothe, and/or produce monotony or confusion (27,28). The hypnotic state may be induced in children by having the child pretend that he/she is watching television, a movie, or a play or by using some other distractive process that employs the imagination (35).
Supportive (ego strengthening) therapies include positive suggestions and posthypnotic suggestions for self-worth and effectiveness. Recording an audiotape that the patient can use for repeated self-hypnosis further strengthens the effect. The strengthened ego is better able to deal with psychological elements that inhibit healing.
Direct suggestion during hypnosis may be used to decrease the discomfort from pain, pruritus, burning sensations, anxiety, and insomnia. Posthypnotic suggestion and repeated use of an audiotape by the patient for self-hypnosis helps to reinforce the effectiveness of direct suggestion. In highly hypnotizable individuals, direct suggestion may produce sufficiently deep anesthesia to permit cutaneous surgery. Direct suggestion can also reduce compulsive acts of skin scratching or picking, nail biting or manipulating, and hair pulling or twisting (29). Autonomic responses in hyperhidrosis, blushing, and some forms of urticaria can also be controlled by direct suggestion. Verrucae can be induced to resolve using direct suggestion (see below).
Symptom substitution replaces a negative habit pattern with a more constructive one (29). For example, another physical activity, such as grasping something and holding it so tightly for 30 seconds that it almost hurts, can be substituted for scratching. Other activities that can be substituted for scratching include athletics, art, verbal expression of feelings, or meditation.
Hypnoanalysis may help patients with dermatoses unresponsive to other simpler approaches. Using hypnoanalysis, results may also occur much more quickly than with standard psychoanalysis (29).
Medical hypnotherapy for treating specific dermatologic conditions
Older reports of the effectiveness of hypnosis on specific dermatologic conditions are often based on one or a few uncontrolled cases. Since the validity of the findings await further confirmation, “may” is used below to qualify recommendations that are based on weak evidence. The trend toward more controlled trials has produced more reliable information (36), although randomized controlled trial results are still not available for most skin diseases. The list of dermatologic conditions below is not all-inclusive.
Posthypnotic suggestion was successful in reducing or stopping the picking associated with acne excoriée in two reported cases (37). One patient was instructed to remember the word “scar” whenever she wanted to pick her face and to refrain from picking by saying “scar” instead. I have had similar success in one case. Hypnosis may be an appropriate treatment for the picking habit of acne excoriée in conjunction with standard treatments for the acne itself.
A small clinical trial of medical hypnotherapy with five patients having extensive alopecia areata showed a significant increase in hair growth in only one patient. Although three patients had only a slight increase in hair growth and one had no change, hypnosis did improve the psychological parameters in these five patients (38). Hypnosis may be appropriate as a complementary supportive treatment for the psychological impact of having alopecia areata.
Numerous case reports describe improvement of atopic dermatitis in both children and adults as a result of hypnotherapy (39). In a nonrandomized controlled clinical trial. Stewart and Thomas (40) treated 18 adults with extensive atopic dermatitis who had been resistant to conventional treatment with hypnotherapy. Included were relaxation, stress management, direct suggestion for nonscratching behavior, direct suggestion for skin comfort and coolness, ego strengthening, posthypnotic suggestions, and instruction in self-hypnosis. The results were statistically significant (p < 0.01) for a reduction in itching, scratching, sleep disturbance, and tension. Patient use of topical corticosteroid decreased by 40% at 4 weeks, 50% at 8 weeks, and 60% at 16 weeks. For atopic dermatitis, hypnosis can be a very useful complementary therapy.
A case of remarkable clearing of congenital ichthyosiform erythroderma of Brocq in a 16-yearold boy was reported following direct suggestion for clearing under hypnosis (41). Similar, though less spectacular results were confirmed in two sisters ages 8 and 6 years (42), a 20-year-old woman (43), and a 34-year-old father and his 4-year-old son (44). Based on these case reports, hypnosis may be potentially very useful as a complementary therapy in addition to emollients.
A reduction in the severity of dyshidrotic dermatitis has been reported with the use of hypnosis as a complementary treatment (45). One case report exists of successful treatment of erythromelalgia in an 18-year-old girl using hypnosis alone followed by self-hypnosis (46).
Permanent resolution occurred. A 33-year-old man with a negative self-image and recurrent multiple Staphylococcus aureus containing furuncles since age 17 years was unresponsive to multiple treatment modalities. Hypnosis and self-hypnosis with imagined sensations of warmth, cold, tingling, and heaviness brought about dramatic improvement over 5 weeks, with full resolution of the recurrent furuncles (47). The patient also improved substantially from a mental standpoint.
Conventional antibiotic therapy is the first line of treatment for furuncles, but in unusually resistant cases with significant psychosomatic overlay, complementary use of hypnosis may help to end the chronic susceptibility to recurrent infection.
Oral pain such as glossodynia may respond well to hypnosis as a primary treatment if there is a significant psychological component (48). With organic disease, hypnosis may give temporary relief from pain Relief of discomfort from herpes simplex is similar to that for postherpetic neuralgia (see below). A reduction in the frequency of recurrences of herpes simplex following hypnosis has also been reported (49). In cases with an apparent emotional trigger factor, hypnotic suggestion may be useful as a complementary therapy for reducing the frequency of recurrence.
Hypnosis or autogenic training may be useful as adjunctive therapies for hyperhidrosis (50). A case of a 33-year-old man with ichthyosis vulgaris, which was better in summer and worse in winter, began hypnotic suggestion therapy in the summer and was able to maintain the summer improvement throughout the fall, winter, and spring (51).
Pruritus and lesions of lichen planus may be reduced in selected cases using hypnosis (29,45). Some cases of neurodermatitis have resolved and have stayed resolved with up to 4 years of follow-up using hypnosis as an alternative therapy (52–55). Reduction of pruritus and resolution of lesions of nummular dermatitis has been reported with the use of hypnotic suggestion (29,45). The pain of herpes zoster and of postherpetic neuralgia can be reduced by hypnosis (29,49).
Hypnosis may be useful as a complementary therapy for postherpetic neuralgia. Hypnosis may modify and lessen the intensity of pruritus (29). A man with chronic myelogenous leukemia had intractable pruritus that was much improved with hypnotic suggestion (56). Hypnosis and suggestion have been shown to have a positive effect on psoriasis (57–59). A 75% clearing of psoriasis was reported in one case using a hypnotic sensory imaging technique (60). In another case of extensive severe psoriasis of 20-years duration, marked improvement occurred using sensory imaging to replicate the feelings in the patient’s skin that he had experienced during sunbathing (61). Another case of severe psoriasis of 20-years duration resolved fully with a hypnoanalytic technique (62). Tausk and Whitmore (63) performed a small, double-blind, randomized controlled trial using hypnosis as adjunctive therapy in psoriasis with significant improvement only in the highly hypnotizable subjects and not in the moderately hypnotizable subjects. Hypnosis can be quite useful as a complementary therapy for resistant psoriasis, especially if there is a significant emotional factor in the triggering of the psoriasis.
The vascular blush component of rosacea has been reported to improve in selected cases of resistant rosacea where hypnosis has been added as complementary therapy (29,45). Several reports of successful adjunctive treatment of trichotillomania have been published (64–66). It appears that hypnosis may be a useful complementary therapy for trichotillomania. Two cases of urticaria responded to hypnotic suggestion in one study. An 11-year-old boy had an urticarial reaction to chocolate that could be blocked by hypnotic suggestion so that hives appeared on one side of his face but not the other in response to hypnotic suggestion (67). In 15 patients with chronic urticaria of 7.8-years average duration, hypnosis with relaxation therapy resulted in 6 patients being cleared within 14 months and another 8 patients improved, with decreased medication requirements reported by 80% of the subjects (68). Hypnosis may be useful as a complementary or even as an alternative therapy for selected cases of chronic urticaria.
Reports by Bloch (24) and Sulzberger and Wolf (25) on the efficacy of suggestion in treating verruca vulgaris have since been confirmed numerous times to a greater or lesser degree (69–72), but have failed to be confirmed in a few studies (73,74). A recent study that showed negative results was criticized for using a negative suggestion of not feeding the warts rather than a positive suggestion about having the warts resolve (75).
Many reports confirm the efficacy of hypnosis in treating warts (76–91). One study (92) that tried to replicate the remarkable success reported in Sinclair-Gieben and Chalmers (93) of using hypnotic suggestion to cause warts to disappear from one hand but not the other in persons with bilateral hand warts was unsuccessful. A wellconducted randomized controlled study resulted in 53% of the experimental group having improvement of their warts 3 months after the first of five hypnotherapy sessions, while none of the control group had improvement (94). Hypnosis has been proved to be helpful as a complementary or alternative therapy for warts.
Cases of vitiligo have improved using hypnotic suggestion as complementary therapy (29,45), but it is unclear whether the recovery was simply spontaneous. Hypnosis may be appropriate as a complementary supportive treatment for the psychological impact of having vitiligo.
Medical hypnotherapy for reducing procedure anxiety
Hypnosis can help reduce anxiety, needle phobia, and pain during dermatologic surgery, as well as reduce postoperative discomfort. Fick et al. (95) used self-guided imaging during nonpharmacologic analgesia in the radiology procedure suite on 56 nonselected patients referred for percutaneous interventional procedures. A standardized protocol and script was used to guide patients into a state of self-hypnotic relaxation. All 56 patients developed an imaginary scenario. The images they chose were highly individualistic. They concluded that average patients can engage in imaging, but topics chosen are highly individualistic, making prerecorded tapes or provider directed imaging less effective than self-directed imaging.
I have used this technique with good success in dermatology patients (96). Lang et al. (97) conducted a larger randomized trial of adjunctive nonpharmacologic analgesia for invasive radiologic procedures consisting of three groups: percutaneous vascular radiologic intraoperative standard care (control group), structured attention, and self-hypnotic relaxation.
Pain increased linearly with time in the standard and the attention group, but remained flat in the hypnosis group. Anxiety decreased over time in all three groups, but more so with hypnosis. Drug use was significantly higher in the standard group than in the structured attention and self-hypnosis groups. Hemodynamic stability was significantly higher in the hypnosis group than in the attention and standard groups. Procedure times were significantly shorter in the hypnosis group than in the standard group, with the attention group being intermediate. A cost analysis of this study (98) showed that the cost associated with standard conscious sedation averaged $638 per case, while the cost for sedation with adjunct hypnosis was $300 per case, making the latter considerably more cost effective.
A meta-analysis of hypnotically induced analgesia found that hypnosis has been demonstrated to relieve pain in patients with headache, burn injury, heart disease, cancer, dental problems, eczema, and chronic back problems (99). For most purposes, light and medium trance is sufficient, but deep trance is required for hypnotic anesthesia for surgery (28). Pain reduction mediated by hypnosis localized to the midanterior cingulate cortex in a study (100) using positron emission tomography (PET).
For conventional hypnosis to be of benefit, patients must be mentally intact, not psychotic nor intoxicated; motivated, not resistant; and preferably medium or high hypnotizable as rated by the Hypnotic Induction Profile (23) or Stanford Hypnotic Susceptibility Scale and its variants. However, for self-guided imaging, a moderate or high degree of hypnotizability is not critical to success. Letting the patient choose his/her own self-guided imagery allows most individuals to reach a state of relaxation during procedures.