Feasibility Trial of Medical Hypnosis and Cognitive Behavioral Therapy for Men With Refractory Chronic Prostatitis/Chronic Pelvic Pain Syndrome

ABSTRACT

OBJECTIVE: To determine the feasibility and effectiveness of medical hypnosis and cognitive behavioral therapy (CBT) for relief of pain, improvement of psychological status, and quality of life in men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).

METHODS: Men with refractory chronic pelvic pain who were symptomatic for >3 months were assessed for hypnotic susceptibility after medical, mental health, and social history were obtained. Psychological data from healthy men with no evidence of pain disorders or genitourinary symptoms were used as a comparator group. In 7 weekly sessions, the psychologist/hypnotherapist utilized CBT to challenge and balance negative cognitions associated with symptoms, performed guided imagery and hypnotic intervention, and provided patient training in self-hypnosis for symptom management. Changes in symptom indices, psychometrics, and compliance with home exercises using audiotapes of hypnosis sessions and CBT workbooks were assessed after 3 and 6 months.

RESULTS: Sixteen men with median pain duration of 7 years and high symptomatic pain scores participated. All had moderate to high hypnotic ability. At 6 months after training, the median NIH-CPSI total score decreased 10.5 points (-7 to -27) relative to pretreatment in 57% of patients; McGill pain scores decreased a median of 6.5 points (-2 to -28). Both NIH-CPSI pain and quality of life domain scores significantly improved (P ≤ .02). Most (88%) patients reported continued self-hypnosis effective for symptomatic relief and improved coping.

CONCLUSION: CBT and self-hypnosis training for patients with CP/CPPS was feasible, resulted in decreased symptoms, and provided patient self-directed methods to improve sense of control, ability to cope, and dissociation from pain symptoms. Longer-term follow-up is required to determine the impact of these therapeutic approaches for selected men with this disorder.

KEYWORDS: Prostatitis; Chronic pelvic pain syndrome; Medical hypnosis; Cognitive behavioral therapy

CORRESPONDENCE: Rodney U Anderson, MD, FACS, Department of Urology, S287 Stanford University School of Medicine, Stanford, California 94305-5118, USA ().

CITATION: UroToday Int J. 2011 Aug;4(4):art46. doi:10.3834/uij.1944-5784.2011.08.02.

ABBREVIATIONS AND ACRONYMS: BSI, Brief Symptom Inventory; CAM, complementary and alternative medical; CBT, cognitive behavioral therapy; CNS, central nervous system; CP, chronic prostatitis; CPPS, chronic pelvic pain syndrome; CPSI, Chronic Prostatitis Symptom Index; DSM, Diagnostic and Statistical Manual; GRA, global response assessment; NIH, National Institutes of Health; PPSS, Pelvic Pain Symptom Scale

INTRODUCTION

As with many chronic pain disorders, the etiology of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is poorly understood and poorly characterized; treatment is mostly empirical and unsatisfactory. Chronic pain is a complex phenomenon that may be affected by emotional, cognitive, behavioral, and physiological responses. Therefore, a multimodal treatment approach may be important for some patients. Despite decades of efforts to manage CP/CPPS symptoms using pharmacologic therapies, none have demonstrated proven effectiveness in placebo-controlled clinical trials. In comparison, several types of complementary and alternative medical (CAM) therapies including myofascial release physical therapy [1,2], paradoxical relaxation [1,3], acupuncture [4], electrical neuromodulation [5], and herbal quercitin and pollen extract (Cernilton N) [6,7] have demonstrated beneficial effects and patient compliance. The success of each of these CAM therapies is thought to be due to targeted neuromuscular, neuroendocrine, or neuropsychological systems.

A recently suggested clinical phenotypic classification of patients with urologic chronic pelvic pain includes psychosocial dysfunction as one of the domains that contributes to its multifactorial presentation [8]. A protocol for cognitive behavioral therapy (CBT) based on psychosocial factors has been suggested for CPPS but remains untested [9]. Hypnosis intervention also has been shown to consistently produce significant decreases in pain associated with a variety of chronic pain conditions including cancer pain, low back pain, vulvodynia, and irritable bowel syndrome [10,11,12,13,14]. It has been used for symptom management in patients with fibromyalgia; however, CBT in conjunction with hypnosis produces greater symptom benefits than conventional medical treatment only or CBT without hypnosis [15].

Recent evidence associating the experience of pain and brain state measured via electroencephalography has heightened interest in interventions that impact the cortical neuromodulation of pain, including behavioral treatments such as self-hypnosis training and biofeedback [16]. To our knowledge, no clinical trial has evaluated therapy with hypnosis alone or in conjunction with CBT in helping patients with symptom management and reduction of the negative effects of CP/CPPS.

The present pilot study was designed to assess the feasibility of utilizing a protocol of combined CBT and hypnosis in men with refractory CP/CPPS. The protocol is designed to target neuro- and bio-psychosocial factors that may contribute to this complex disorder. The goals are to examine the short-term effectiveness of reducing pain and to provide patients with self-hypnosis training as a way of coping with pain and gaining greater self-control over it. This approach is based upon the premise that treating urologists understand the preeminence of psychological variables when managing refractory CP/CPPS. After evaluating a new patient, the urologist teams with a psychologist trained in pain management for the purpose of optimizing treatment outcomes. The patient undergoes a series of individual psychotherapy and hypnosis training sessions, while complying with between-session behavioral homework assignments. Patients may continue to use self-hypnosis after treatment, on an as-needed basis.

METHODS

Study Design

This prospective investigation was conducted at the Stanford University Urology Clinic between October 2009 and October 2010. The protocol was reviewed and approved by the Stanford University Human Subjects' Committee and participants gave signed informed consent. Patients were invited to participate in a 7-session protocol without monetary compensation. Treatments were provided without cost.

Participants

Experimental Group . The participants were 16 men with refractory, long-term CP/CPPS. All participants had failed several prior multimodal therapies. No differentiation was made between inflammatory and noninflammatory prostatitis (National Institutes of Health [NIH] categories IIIA/IIIB), or the specific location of pelvic pain. All participants had symptoms for 3 months within the last 6 months. They had a total NIH-Chronic Prostatitis Symptom Index (CPSI) score of at least 12 and a nonzero pain domain score.

Comparator Group. To further understand the psychological profiles of the men with CP/CPPS and how chronic pain may have affected them, we obtained psychological data from 26 age-matched and demographically similar healthy men with no evidence of pain disorders or genitourinary symptoms as a comparator group. They did not receive CBT or hypnosis therapy. The participants in the comparator population were healthy controls in a larger NIH-sponsored study from the Chronic Prostatitis Collaborative Research Network (CPCRN) that is designed to assess hypothalamic-pituitary-adrenal axis function in CP/CPPS [17].

Evaluation Procedures

After the urological examination, a licensed psychologist (TFN) with extensive experience in the application of hypnosis and CBT for pain management assessed the participants' hypnotic susceptibility and imaginative activity with the Tellegen Absorption Scale [18]. This scale has 34 true-false items that correlate with the ability to maintain a state of attention involvement. The psychologist also administered the Hypnotic Ability Assessment and Training Scale, which was developed by the psychologist/hypnotherapist (TFN). A comprehensive pain, mental health, and social history were obtained.

Symptom and Outcome Assessments. Primary outcomes were compliance and trial feasibility, changes in symptom scores using the NIH-CPSI total and subdomain scores, changes in severity, frequency, and pain location with the Pelvic Pain Symptom Scale (PPSS) [1], and short-form McGill pain questionnaire (SF-MPQ) scores [19]. Assessments were collected before treatment and at 1, 3, and 6 months after completion of therapy. The global response assessment (GRA), a 7-point Likert scale, was administered at each follow-up visit to evaluate patients' perceptions of the overall effect of the therapy: "How are you now in comparison to before CBT and hypnosis?" Responses were: markedly improved, moderately improved, slightly improved, no change, slightly worse, moderately worse, or markedly worse.

Psychological and Psychosocial Assessments. The following self-report instruments were used: 1) Beck Depression Inventory (BDI-II) [20]; 2) Beck Anxiety Inventory (BAI) [21]; and 3) Perceived Stress Scale (PSS) [22]. A psychological profile of distress was evaluated with the Brief Symptom Inventory (BSI) of the Symptom Checklist (SCL-90R), a 53-item inventory measuring nine dimensions: depression, anxiety, somatization, obsessive-compulsive behavior, interpersonal sensitivity, hostility, phobic activity, paranoid ideation, psychoticism (social alienation), and the Global Severity Index (GSI), a composite measure of overall distress [23]. Responses were scored on a 5-point Likert scale ranging from 0 (not at all) to 4 (extremely bothersome). Scores were converted to T scores based on adult male, nonpatient (ie, nonpsychiatric) profiles from a reference population. Detailed medical and psychosocial histories were obtained during sessions with the psychologist in an attempt to determine potential etiological factors associated with the onset and exacerbation of CP/CPPS symptoms.

Treatment Procedures. Participants attended 7 weekly treatment sessions with the psychologist consisting of: (1) teaching CBT (identifying negative cognitions associated with CP/CPPS symptoms generating negative feelings, and then countering them with more adaptive and realistic cognitions); (2) providing a hypnotic exploratory session about psychological factors that may be contributing to symptoms; (3) teaching hypnosis for symptom management (generalized relaxation, guided imagery of a pleasant scene, and glove-anesthesia); and (4) training in self-hypnosis by making an individualized digital recording of a hypnotic session to be used daily at home. The procedures for CBT and self-hypnosis training are shown in the Appendix. Audiotapes and CBT worksheets were provided and CBT and hypnosis compliance logs were collected at each session. Participants were not permitted to receive any additional therapy for CPPS during the course of the study and follow-up period.

Statistical Analysis

Descriptive statistics were generated on all demographic, medical history, and physical examination findings including medians, means, and standard deviations (SD) for continuous variables and frequencies and percentages for categorical variables. Differences between pretreatment and posttreatment NIH-CPSI total and subdomain scores and psychometric profile scores were analyzed with the paired-sample t test. Comparisons of demographic continuous variables, psychometric, and BSI scores between the experimental and control groups were determined with the Mann-Whitney U test (2-tailed); demographic discrete variables were compared with the 2-tailed Fisher's exact test. Statistical significance was considered at P < .05. Statistical analyses were performed using R software, version 2.9 (R Foundation for Statistical Computing; Vienna, Austria).

RESULTS

Sixteen men with CP/CPPS were enrolled and completed all therapy sessions; 1 participant who failed to provide follow-up questionnaires was eliminated from evaluation. For the duration of study and in the preceding months, none of the patients reported the use of any psychotropic medications. The patients had moderate to high hypnotic engagement with a median (25^th percentile, 75^th percentile) Tellegen score of 15 (9.5, 23).

Table 1 contains the characteristics of the experimental and comparator groups and the probability of significant group differences. The men with CP/CPPS had a median age of 43 years (range, 29-53 years). There were no significant group differences in age. The patients had a median duration of CP/CPPS of 7 years (range, 1.25-30 years). The median pretreatment NIH-CPSI total score was 25 out of a 43 maximum (range, 15-38). There was a significant group difference for the total score and all domain scores (all with P < .001). There was also a significant group difference for all of the PPSS domain scores (all with P < .001). There were significantly more participants that were categorized as Hispanic/Pacific Islander ethnicity/race in the control group (P = .007); other ethnic/racial characteristics were similar between groups. Most participants in both groups were educated beyond high school; there were significantly more patients with CP/CPPS that were college graduates (P = .001), but there were significantly more participants in the control group that also had graduate or professional degrees (P = .008). There were significantly more participants in the control group that were married (P = .02); there were significantly more patients in the experimental group that were divorced (P = .01).

The mental health histories obtained by the psychologist prior to commencing the therapy protocol revealed that most patients reported a history of depression, anxiety, or dysthymic disorder. Eight of the 16 patients had received some counseling in college or had psychotherapy for a limited time as young adults. One patient was continuing sessions with a family therapist for depression, and 1 had completed 6 months of prior psychotherapy for depression and panic related to his pelvic pain. The remaining 8 patients had no previous contact with a mental health professional.

The psychologist provided a Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV [24] diagnosis for each patient after his initial assessments; DSM diagnoses were not available in the patients' urology clinic records. DSM-Axis I diagnoses for most patients included adjustment disorders with depressed mood (309), anxiety (309.24), mixed anxiety and depressed mood (309.28), or dysthymic disorder (300.4). All patients carried the Axis I pain disorder associated with psychological factors (307.80). Two patients were diagnosed with posttraumatic stress disorder, delayed onset (309.81). No patient had a DSM-Axis II diagnosis indicative of a personality disorder or mental retardation. Two patients carried an Axis IV diagnosis, indicating sufficiently severe pain symptoms that they were unable to continue working. The median Axis V (Global Assessment of Functioning Scale, range 1-100) score was 61 (range, 57-68). Scores of 61-70 indicate mild symptoms (eg, depressed mood and mild insomnia); scores of 51-60 indicate moderate symptoms (eg, flat affect, circumstantial speech, occasional panic attacks).

Table 2 presents the personal and medical history and major life stressors associated with onset of initial CP/CPPS symptoms. The results of these assessments call to attention the multiple psychosocial and biologic factors that might contribute to this disorder.

Table 3 shows median BSI scores, the interquartile range, and the centile rank for the experimental and comparator groups and the probability of significant group differences. The BSI scores for distress from physical symptoms were significantly elevated in all scales for men with CP/CPPS (all with P < .0001), with the exception of phobic anxiety. Men in the experimental group ranked in the 91^st centile on the global severity index of the BSI, compared with the 46^th centile for men in the control group (the 50^th centile represents an average score for an adult male without a psychiatric disorder). The psychometric profile scores in the BSI for the men with CP/CPPS remained unchanged in the 6 months of follow-up.

Fifteen participants completed 3 months of follow-up; 14 participants completed 6 months. Table 4 shows the significant improvements in NIH-CPSI total scores evident within the first month after therapy (P = .001), which were either sustained or further improved through 6 months of follow-up. NIH-CPSI total scores decreased a median of 10.5 points (range, -7 to -27 points) in 8 out of 14 patients (57%) at month 1 and month 6. The scores represented a median decrease of 42% (range, 30% to 59%) from baseline. Pain domain scores decreased at month 6 relative to pretreatment; however, no durable changes in urinary symptoms were evident. Quality of life domain scores were significantly improved as early as within the first month and throughout 6 months after therapy (P = .001). The PPSS score decreases were commensurate with NIH-CPSI scores. McGill pain questionnaire scores were significantly decreased at months 3 and 6 (P ≤ .03). Most patients reported that they would continue to use the skills they learned in treatment; they reported that they experienced pain relief and improved coping when they continued the program. The global response assessments at month 1 indicated that 7 out of 15 patients (47%) reported moderate to marked improvements after therapy; at month 6, 36% of the patients indicated these levels of improvement.

Table 5 contains the psychometric scores of both participant groups at baseline and 6 months after treatment and the probability of significant differences. Results indicate that men with CP/CPPS had significantly elevated perceived stress and anxiety scores before CBT and self-hypnosis training when compared with participants in the control group (P < .001). Scores for depression and anxiety decreased significantly in the patients with CP/CPPS after therapy (P < .05).

DISCUSSION

The objective of CBT and self-hypnosis training was to provide tools for the participant to use for symptom management. Although a treatment schema was employed, the psychotherapy sessions were individualized to address each patient's specific issues that could be modulated by CBT and hypnosis methods. The guided imagery and hypnotic interventions also addressed areas uncovered in the hypnotic inquiry that may not have been identified in the medical and psychological history. These interventions targeted aspects believed to be involved in the development and maintenance of the CP/CPPS pain cycle.

Substantial individual differences can exist in the ability to be hypnotized or practice self-hypnosis; not all individuals are able to enter a hypnotic state. All participants in our study had moderate to high hypnotic ability, as identified with the Tellegen Absorption Scale. Because the number of participants was limited in this feasibility study, we had intended to exclude those with low hypnotic ability; we did not find it necessary to implement this exclusion criterion. Therefore, the study outcomes might be biased toward those who can achieve a hypnotic state. Reports indicate that high hypnotic ability is not necessary for successful hypnotic pain intervention. Although greater hypnotic pain relief is associated with high hypnotic suggestibility, those with medium suggestibility (representing about one-third of the general population) can also appreciate clinically significant hypnotic analgesia [25].

The experience of chronic pain is the result of complex interactions between multiple supraspinal central nervous system (CNS) sites. The involvement of CNS sites, structures, and processes contributing to pain gives the clinician a large variety of interventions from which to choose, including psychological interventions that affect cortical activity such as hypnosis. For patients whose pain experience is related to neurophysiological processes that can be influenced by hypnotic suggestions, a marked decrease in pain intensity can be expected.

The present clinical trial used therapeutic methods to alter the body-mind relationships in CP/CPPS by utilizing tools to deal with the psychosocial issues associated with chronic pain. Perceived stress and cognitive/behavioral variables such as catastrophizing have been related to greater pain intensity and disability in CP/CPPS [26,27]. We have consistently observed that the psychological profiles of men with CP/CPPS differ greatly from age-matched healthy men with no pain disorders [17]. This was also confirmed in our participants with CPPS, who had significantly greater indices of overall distress than the comparator group with a history of no pelvic pain. This is in agreement with several earlier reports of psychological disturbances (eg, depression, catastrophic thinking, anxiety, elevated scores on somatic scales, anger-hostility) observed in conjunction with chronic CP/CPPS [27,28]. Psychosocial distress associated with chronic pain could be interpreted as a result of the pain or a contributory factor in the patient's distress regarding their perceived pain. The feed-forward relationship between chronic pain and psychopathology is described by the diathesis-stress model [29]. This model illustrates how the stress of coping with chronic pain exacerbates an individual's semidormant but preexisting characteristics (diathesis), eventually resulting in psychopathology. Thus, individuals with a dysthymic disorder, major depression, or an anxiety disorder probably experience more pain or suffering when compared with the person who was in excellent mental health previously.

We cannot discern whether the elevated scores on almost all domains of the BSI for personality characteristics represent traits resulting from the stress effect of coping with chronic pain, a state phenomenon, or inherent personality characteristics that further contribute to the exacerbation and maintenance of CP/CPPS. Changes in trait have been observed with treatment of various pain conditions and associated with improved pain scores [30]. In this study, the observation period was probably too short to appreciate any personality changes within the BSI survey that might possibly occur.

After CBT and self-hypnosis training, the participants experienced significant decreases in both McGill Pain Questionnaire scores and NIH-CPSI symptom scores. However, these improvements were not reflected in the GRAs at months 1 and 6 when only 47% and 36% of the patients, respectively, reported moderate to marked improvements after therapy. This could be interpreted as the patients having very high expectations for therapy outcome because these patients with refractory, chronic pelvic pain had previous therapy failures. However, it also highlights a disconnect that we have often observed in our clinical experience in that scores on validated questionnaires for outcome measures used in clinical trials such as the NIH-CPSI, which have supposedly clinically meaningful decreases do not coincide with patient satisfaction. The reverse of satisfaction with improved symptom scores is also often observed.

In consideration of our results, it is useful to highlight some of the methodological issues that may have impacted our findings. The uncontrolled study examined the feasibility of multimodal CBT, hypnotic intervention, and daily self-hypnosis in a small cohort of men with refractory CP/CPPS who were highly motivated to explore a new therapeutic modality. However, the number of sessions was limited and continued psychologist intervention would likely have been advantageous. This was not an instruction manual-based program of guided imagery; rather, therapy sessions were individualized for each patient and required a skilled practitioner. We could not objectively measure compliance, and longer-term follow-up is needed to determine duration of pain reduction in individuals who continue use of self-hypnosis. A prospective, randomized trial comparing intensive intervention with a therapist providing education, discussion, emotional venting, and empathy compared with CBT and self-hypnosis would have merit in discerning the most valuable alternative modality for men with CP/CPPPS.

CONCLUSION

Results indicate the feasibility of CBT intervention and self-hypnosis training for selected patients with refractory CP/CPPS. The self-directed methods improved the patient's sense of control and ability to cope with and dissociate from pain symptoms. Longer-term follow-up is required to determine the impact of this therapeutic modality for men with this disorder and its application in multimodal therapy. However, the therapeutic value of a cooperative relationship between the urologist and psychologist cannot be underestimated.

ACKNOWLEDGMENT

Supported by a grant from National Institutes of Health, NIDDK, DK065297

Conflict of Interest: None declared.

APPENDIX

CBT and Hypnosis Procedures

Session 1. Extensive Case History Evaluation

Psychosocial, educational, developmental, family, physical and mental health, marital, work, major losses, and life transitions history (~ 90 minutes)

Session 2. Introduction to CBT

Overview: negative emotions (eg, sadness, resentment, guilt, hopelessness) are caused by negative cognitions about life events rather than the actual events, either external (situational) or internal (physical pain sensations)
Guidance in use of CBT paradigm: identification of 10 cognitive distortions (all-or-nothing thinking, overgeneralization, dwelling on the negatives, discounting the positives, jumping to conclusions, magnification or minimization, reasoning from your feelings, should statements directed at self or others, labeling yourself according to your behavior, blaming); learning how to alter the distortions with the following paradigm:

- Event: occurrence in patient's life that seemed to cause an emotional reaction
- Automatic thought: self-talk that actually caused the patient's mood to change (eg, "I'll never get over this pain")
- Emotion: a one-word feeling (eg, angry, sad, guilty, shameful, worried)
- Behavior: action taken by the patient when feeling a negative emotion (eg, avoiding a social engagement, drinking alcohol or taking excessive medication, confiding in a close friend or family member)
- Counter-arguments to the automatic thought (the lynchpin of the homework assignment): creating a counter argument that effectively negates the automatic thought generating the negative emotion

Didactic information and instructions on pain management given to the patient:

- Factors exacerbating pain perception: sleep deprivation, increased daytime pelvic muscle tension, dwelling on pain, having a negative mood (eg, anger or despair)
- Factors mitigating pain perception: increasing amount of sleep, remembering to relax pelvic floor muscles, increasing fun or play activities daily, increasing social or normal activities rather than avoiding or cancelling them, and increasing physical exercise rather than avoiding or cancelling them

Homework assignments:

- Read Feeling Good: The New Mood Therapy[31] and A Headache in the Pelvis [3]
- Keep a CBT log of negative cognitions, feelings, and counter-arguments to their negative cognitions

List major life transitions: positive and negative life events (eg, divorce, death of family member, moving to a new house, changing jobs) that occurred before the onset of their chronic pain

Session 3. CBT and Introduction to Hypnosis

Review CBT log: fine tune patient's understanding of the basic concepts and assist with development of counter-arguments to their negative cognitions
Explain hypnosis and its use in treating pain conditions, including 4 aspects: relaxation, symptom management (pain management), investigation, and training in self-hypnosis
Hypnosis training and evaluation session (20 minutes) including imaginative exercises and focus of attention on the most vivid sensory aspects (sight, hearing, smell, touch, or kinesthetic input)
Homework assignments: continue with CBT log and reading of Feeling Good: The New Mood Therapy

Session 4. CBT and Hypnotic Intervention

Review CBT log sheets for emphasis on aggressively developing counter arguments to their negative cognitions
First hypnotic session (~ 25 minutes), including: generic relaxing imagery (eg, an ocean beach, meadow, another place in nature); awareness of altered physical sensations to be used as cues that they have achieved hypnotic trance (eg, subjective feelings of lightness, heaviness, warmth, coolness, paraesthesia, other sensations); remembering a pleasant, proud, or happy moment from their past in vivid detail
Homework assignments: continue keeping CBT log with focus on specific negative emotions that recur and developing effective counter-arguments to them; read Feeling Good: The New Mood Therapy; practice some aspect of the relaxing imagery experienced in hypnosis

Session 5. CBT and Hypnotic Intervention

Review CBT log sheets
Hypnotic intervention (preparation of digital recording of ~ 25-minute session that is accompanied by a handout and used for homework): imagine a pleasant place in nature, remove a backpack filled with stressful events and negative thoughts, loosen and relax each muscle from head to toe, lie down in the sunshine and notice warmth in certain parts of the body, place one hand in warm water, let the hand grow numb (inducing glove anesthesia), move the hand to the pelvic area and transfer the numbness to areas in pain, and contemplate an important positive thought or goal about the patient's life or health
Homework assignment: Continue keeping CBT log; use hypnosis recording at least once per day

Session 6. CBT and Hypnotic Intervention

Review CBT log sheets
Exploratory hypnotic session (~ 40 minutes): inquiry about psychological factors and traumatic events that might be contributing to or causing pelvic pain through ideomotor questioning; inquiry themes include history of family member with pelvic pain or chronic pain, having been told that they would suffer chronic or pelvic pain some day by someone in their past, any personal experience that caused or contributed to the pain (eg, childhood sexual molestation, other physical or psychological trauma), engaging in self-punishment for some perceived infraction (eg, an infidelity), having an ongoing negative emotion that causes or contributes to the pain (eg, anger, fear, sadness, guilt, shame), chronic pelvic pain as a reflection of the ongoing psychological stressor, secondary gain from retention of symptom(s) (eg, avoid sex with a difficult spouse, receive long-term disability insurance), visualize a calendar with a particular month and week when the symptoms could be significantly diminished or disappear completely
Homework assignment: continue keeping CBT log; engage in two hypnotic sessions (~ 25 minutes) per day, once using the recording and once on their own

Session 7. CBT and Hypnotic Intervention

Review CBT log sheets, assess success with self-hypnosis practice; evaluate mood and problem areas that arose in prior hypnotic inquiry session
Hypnotic session (~ 25 minutes) and review imagery for relaxation and pain reduction
Take-away instructions: continue using self-hypnosis in a preventive manner (eg, early in the day or before pain symptoms worsen or if anticipating a pain-inducing or stressful experience); practice CBT methods as a matter of course, until they become automatic

REFERENCES

Anderson RU, Wise D, Sawyer T, Chan C. Integration of myofascial trigger point release and paradoxical relaxation training for treatment of chronic pelvic pain in men. J Urol. 2005;174(1):155-160.

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