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International Journal of Clinical

and Experimental Hypnosis
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The Effects of Hypnosis on

Anxiety, Depression, Fatigue, and
Sleepiness in People Undergoing
Hemodialysis: A Clinical Report
a b
Aurélie Untas , Philippe Chauveau , Catherine Dupré-
c d e
Goudable , Anne Kolko , Fabrice Lakdja & Nicolas
f
Cazenave
a
Paris Descartes University, Sorbonne Paris City , France
b
AURAD-Aquitaine , Gradignan , France
c
Rangueil Hospital , Toulouse , France
d
Association for the Use of Renal Replacement Therapy ,
Paris , France
e
Bergonié Institute, Centre for the Fight Against Cancer
Bordeaux and South-West , Bordeaux , France
f
University of Toulouse-Le Mirail , France
Published online: 19 Aug 2013.

To cite this article: Aurlie Untas , Philippe Chauveau , Catherine Dupr-Goudable , Anne
Kolko , Fabrice Lakdja & Nicolas Cazenave (2013) The Effects of Hypnosis on Anxiety,
Depression, Fatigue, and Sleepiness in People Undergoing Hemodialysis: A Clinical
Report , International Journal of Clinical and Experimental Hypnosis, 61:4, 475-483, DOI:
10.1080/00207144.2013.810485
To link to this article: http://dx.doi.org/10.1080/00207144.2013.810485

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 Intl. Journal of Clinical and Experimental Hypnosis, 61(4): 475–483, 2013
Copyright © International Journal of Clinical and Experimental Hypnosis
ISSN: 0020-7144 print / 1744-5183 online
DOI: 10.1080/00207144.2013.810485

THE EFFECTS OF HYPNOSIS ON ANXIETY,

DEPRESSION, FATIGUE, AND SLEEPINESS
IN PEOPLE UNDERGOING HEMODIALYSIS:
A Clinical Report1
Aurélie Untas2

Paris Descartes University, Sorbonne Paris City, France

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Philippe Chauveau

AURAD-Aquitaine, Gradignan, France

Catherine Dupré-Goudable

Rangueil Hospital, Toulouse, France

Anne Kolko
Association for the Use of Renal Replacement Therapy, Paris, France

Fabrice Lakdja
Bergonié Institute, Centre for the Fight Against Cancer Bordeaux
and South-West, Bordeaux, France

Nicolas Cazenave

University of Toulouse-Le Mirail, France

Abstract: This study investigated the effect of hypnosis on anxiety,

depression, fatigue, and sleepiness in hemodialysis patients.
Twenty-nine patients participated in the 15-day study. A single
hypnosis session was performed on Day 8. Anxiety, depression,
fatigue, and sleepiness were measured at baseline, on Day 8, and on
Day 15 (HADS, MFI, ESS). Daily fatigue was also measured numeri-
cally. Anxiety, depression, and sleepiness significantly decreased after

Manuscript submitted September 24, 2012; final revision accepted September 26, 2012.
1 The authors thank Pippa McKelvie-Sebileau for editorial assistance in English.
2 Address correspondence to Aurélie Untas, Laboratoire de Psychopathologie et

Processus de Santé EA 4057, Institut de Psychologie - Université Paris Descartes,

Sorbonne Paris City, 71 Avenue Edouard Vaillant, F - 92 100 Boulogne-Billancourt, France.
E-mail: aurelie.untas@parisdescartes.fr

475
 476 AURÉLIE UNTAS ET AL.

hypnosis. Weekly measures of fatigue remained stable; however, daily

fatigue decreased.

End-stage renal disease is the complete, or almost complete, failure

of the kidneys to function. About 68,000 individuals live with this dis-
ease in France (Couchoud, 2010). About half of them are treated by
hemodialysis, which is the most frequent technique of renal replace-
ment therapy. This treatment involves cleaning blood through the use
of an artificial-kidney machine. Patients generally receive this treatment
3 days per week for about 4 hours per session, usually in dialysis cen-
ters or satellite units in which health professionals take care of them.
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Beginning dialysis will confront the patient with multiple physical

and psychological stressors. Previous studies have shown that dialysis
patients are more likely to have a poorer quality of life than the gen-
eral population (Cukor et al., 2008; Fukuhara et al., 2003; Kimmel &
Peterson, 2005). Several other factors have shown to be impaired and
related to the physical and the mental components of patients’ quality
of life as anxiety, depression, and fatigue.
Anxiety and depression are prevalent in the hemodialysis popula-
tion. Previous studies have shown that about 20% to 50% of patients are
anxious and/or depressed (Cukor et al., 2008; Kimmel, Cukor, Cohen, &
Peterson, 2007; Untas et al., 2011). Fatigue is another important conse-
quence of hemodialysis; its prevalence ranges from 60% to 97% (Jhamb,
Weisbord, Steel, & Unruh, 2008). There are dialysis- and illness-related
causes of fatigue such as dialysis adequacy, uremia, anemia, and sleep-
ing disorders. High fatigue may lead to daytime sleepiness (Parker,
Bliwise, Bailey, & Rye, 2003). High depression and fatigue are important
to consider in dialysis patients’ global care as these factors are associ-
ated with a higher rate of mortality (Boulware et al., 2006; Jhamb et al.,
2011) and are receptive to interventions.
Hypnosis has been used in various fields of medicine (cancer, burns,
surgery, etc.). It is a well-known fringe technique for pain manage-
ment. Randomized controlled studies with clinical populations have
shown that hypnosis has a reliable and significant impact on acute
and chronic pain (Patterson & Jensen, 2003). Hypnosis has also shown
interesting results in the treatment of mental health (Hammond, 2010;
Yapko, 2010) and, combined with cognitive-behavioral therapy, in
radiotherapy-related fatigue (Montgomery et al., 2009). With the excep-
tion of a few case reports (Dimond, 1981; Martin, McHugh, & Millar,
1983; Surman & Tolkoff-Rubin, 1984), no study has yet investigated the
effect of hypnosis in hemodialysis patients. Hypnosis may help patients
treated by hemodialysis to face anxiety and depression symptoms and
to manage fatigue and sleepiness. The aim of this study was to test
the effectiveness of a hypnosis intervention on hemodialysis patients’
anxiety, depression, fatigue, and sleepiness.
 HYPNOSIS AND HEMODIALYSIS 477

Materials and Methods

Participants
Patients were recruited from four dialysis centers in France. Inclusion
criteria were undergoing chronic hemodialysis, being at least 18 years
old, being able to respond to self-reported scales, and to sign an
informed consent. Patients undergoing peritoneal dialysis, having a
renal transplant, or suffering a psychotic or dementia disorder were
excluded. Twenty-nine hemodialysis patients took part in this study.

Measures
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Anxiety and depression. The Hospital Anxiety and Depression Scale

(HADS; Zigmond & Snaith, 1983) consists of 14 items, seven assess-
ing anxiety symptoms and seven assessing depressive symptoms. The
French adaptation has good psychometric properties (Razavi, Delvaux,
Farvacques, & Robaye, 1989) and has been validated within a sample
of patients having dialysis (Untas et al., 2009). In our sample, internal
consistency was satisfactory with .75 for anxiety and .83 for depression.
Fatigue. The Multidimensional Fatigue Inventory (MFI) was used to
evaluate global fatigue over the past week (Smets, Garssen, Bonke, &
De Haes, 1995). The scale consists of 20 items that provide a measure
of global fatigue. The French adaptation has satisfactory psychometric
properties (Gentile, Delarozière, Favre, Sambuc, & San Marco, 2003).
In our sample, global fatigue had a high internal consistency of .86.
Daily fatigue was also measured with one item stating: “Today, I felt
. . . .” The person answered selecting from a numeric scale from 0 (not
tired at all) to 10 (extremely tired).
Sleepiness. The Epworth Sleepiness Scale (ESS; Johns, 1992) is a mea-
sure designed to assess daytime sleepiness through eight items. The
French adaptation has satisfactory psychometric properties (Kaminska
et al., 2010). In our sample, internal consistency was .83.

Intervention: Hypnosis Session

The hypnosis session lasted about 1 hour and was adapted to each
patient. First, common myths about hypnosis were addressed (e.g.,
loss of control). Second, questions were asked to determine a resource-
ful place in which the patient could feel secure and relaxed. Then,
a hypnotic induction including suggestions for mental and physical
relaxation was done. Guided imagery of the place chosen was followed.
Specific suggestions were done to reduce distress and fatigue and to
increase relaxation, well-being, safety, and energy. Finally, posthypnotic
suggestions focused on the patient’s feelings of energy beyond the
session and his or her ability to recapture these feelings through a cue
for entering hypnosis on his or her own.
 478 AURÉLIE UNTAS ET AL.

Procedure
The study was presented to each participant during a dialysis ses-
sion or a medical consultation by one of the authors. The patients
were advised of their right to withdraw from the research and notified
that information was strictly confidential and solely used for scientific
purposes. After they gave their approval, they signed an informed-
consent form. Each patient began the study on a dialysis day (Day 1,
D1). Hypnosis was performed during a dialysis session 1 week later
(D8) by a psychologist qualified in hypnosis. Sociodemographic and
medical characteristics were collected on D1. The HADS, the MFI, and
the ESS were completed in the morning on D1, D8 (before hypnosis),
and D15 (end of study). Daily fatigue was self-reported each evening
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(D1–D15).

Statistical Analysis
Spearman’s nonparametric bivariate correlations and repeated-
measures analyses of variance with Bonferroni correction to address
multiple comparisons were used. Statistical analyses were performed
using SPSS, version 14.

Results
Patient Characteristics
The patients ranged in age from 34 to 84 with a mean age of 62.6 years
(SD = 16.8). About half of them were men (51.7%) and half were
married (44.8%). Concerning highest education level and professional
status, most patients completed high school or less (58.6%), and most
were retired (62%). Patients had been receiving dialysis for 6 months to
20 years with a mean duration of 7.4 years (SD = 6.9). Most patients
were treated in a hospital center (62.1%) and had dialysis three times a
week (72.4%) (Table 1).

Associations Between Anxiety, Depression, Fatigue, and Sleepiness

At study entry (D1), depression was significantly associated with
anxiety, fatigue, and sleepiness (r = .44, p < .05; r = .46, p < .05; r =
.49, p < .01, respectively). Fatigue was strongly associated to sleepiness
(r = .77, p < .001). No significant correlation was observed between anx-
iety and fatigue or sleepiness. Correlations remained the same over time
(D8 and D15).

Anxiety, Depression, Fatigue, and Sleepiness Before and After Hypnosis

Anxiety, depression, and sleepiness decreased significantly after the
hypnosis session, F(28, 56) = 6.95, p < .01; F(28, 56) = 5.29, p < .01; F(28,
 HYPNOSIS AND HEMODIALYSIS 479

Table 1
Patient Baseline Characteristics

Characteristic N = 29

Highest Education Level

Completed high school or less (%) 58.6
Attended college (%) 41.4
Occupational Status
Retired (%) 62.0
Employed (%) 17.2
Disabled (unable to work) (%) 10.4
Unemployed (%) 10.4
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Marital Status
Married (%) 44.8
Single or divorced (%) 55.2
Medical
Mean years on hemodialysis (SD) 7.4 (6.9)
Dialysis Site
Hemodialysis in hospital centres (%) 62.1
Hemodialysis in satellite units (%) 37.9
Dialysis Frequency
Three times a week over 3 to 4.5 hours 72.4
6 days a week over 2 hours 27.6

Table 2
Mean (Standard Deviation) Anxiety, Depression, Fatigue, and Sleepiness at Study
Entry, Before Hypnosis Session, and at Study End

Study Start Prehypnosis Study End Significant

Measure (D1) Session (D8) (D15) F Contrasts

Anxiety 8.17 (3.6) 7.90 (2.4) 6.59 (3.8) 6.95∗∗ D1 = D8 > D15
Depression 6.66 (3.7) 6.93 (3.4) 5.45 (3.1) 5.29∗∗ D1 = D8 > D15
Fatigue 62.86 (11.0) 63.76 (9.9) 61.66 (8.8) 1.37
Sleepiness 6.28 (3.67) 6.55 (3.36) 5.07 (3.13) 4.63∗ D1 = D8 > D15

Note. Anxiety and Depression were measured with the French validation of the Hospital
Anxiety and Depression Scale (HADS), Fatigue with the French validation of the
Multidimensional Fatigue Inventory (MFI), and Sleepiness with the French validation
of the Epworth Sleepiness Scale (ESS).
∗ p < .05. ∗∗ p < .01.

56) = 4.63, p < .05. Fatigue remained stable before and after the hypnosis
session, F(28, 56) = 1.37, p > .05. However, the mean daily fatigue of the
first week was significantly higher than that of the mean daily fatigue
of the second week, 4.87 (SD = 1.7) versus 3.78 (SD = 1.4); F(28, 28) =
11.76, p < .01 (Table 2).
 480 AURÉLIE UNTAS ET AL.

Discussion

The present study shows that hypnosis has a positive effect on anx-
iety, depression, daily fatigue, and sleepiness in hemodialysis patients.
Some authors have previously underlined the benefits of using hypno-
sis in dialysis units; however, these reports were case studies. A key
strength of our study is that it is based on quantitative methodol-
ogy, confirming that hypnosis is a promising intervention to improve
hemodialysis patients’ well-being.
The decrease of anxiety and depression is in line with results
found in other studies undertaken with various health-related prob-
lems (Hammond, 2010; Yapko, 2010). To our knowledge, it is the first
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time that a decrease in sleepiness has been reported.

Fatigue is a multidimensional and complex concept, which is asso-
ciated with anxiety, depression, and sleepiness as supported by our
results. Therefore, it is surprising that weekly fatigue remained sta-
ble, whereas daily fatigue decreased. This result might be explained
by the single-session intervention. A longer intervention with several
hypnosis sessions might be required and/or at least an audiotaped ses-
sion to which the patient could listen whenever he or she wants. In the
study from Montgomery et al. (2009), a CD player and prerecorded CD
of the hypnosis intervention were given to each patient to listen to at
home. This intervention combined with cognitive-behavioral therapy
prevented increases in daily and weekly fatigue for patients treated by
radiotherapy. However, the contribution of each intervention to clinical
effects was not studied and is an important area for future research.
The main limitation of this study is the lack of a control popula-
tion. However, the baseline week before the hypnosis session gives
a reliable measure supporting the positive effect of the intervention.
Nonetheless, this study shows that hypnosis can help patients treated
by hemodialysis deal with anxiety, depression, daily fatigue, and sleepi-
ness. The method could be easily performed during dialysis to enhance
patient global care in nephrology.

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Effekte von Hypnose auf Angst, Depression, Erschöpfung und Schläfrigkeit

bei Hämodialysepatienten: ein klinischer Report

Aurélie Untas, Philippe Chauveau, Catherine Dupré-Goudable, Anne

Kolko, Fabrice Lakdja und Nicolas Cazenave
Abstrakt: Diese Studie untersuchte die Effekte von Hypnose auf Angst,
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Depression, Erschöpfung und Schläfrigkeit bei Hämodialysepatienten.

29 Patienten nahmen an der 15tägigen Studie teil. Eine Hypnoseeinzelsitzung
wurde am achten Tag durchgeführt. Angst, Depression, Erschöpfung und
Schläfrigkeit wurden zu Beginn der Studie, am achten und am fünfzehnten
Tag gemessen (HADS, MFI, ESS). Die tägliche Erschöpfung wurde zusätzlich
numerisch gemessen. Angst, Depression und Schläfrigkeit nahmen nach
Hypnose signifikant ab. Die wöchentlichen Messungen der Erschöpfung
blieben stabil, wobei die tägliche Erschöpfung abnahm.
Stephanie Reigel, MD

Les effets de l’hypnose sur l’anxiété, la dépression, l’épuisement et la

torpeur chez des personnes subissant une hémodialyse: Un rapport clinique

Aurélie Untas, Philippe Chauveau, Catherine Dupré-Goudable, Anne

Kolko, Fabrice Lakdja et Nicolas Cazenave
Résumé: Les auteurs de cette étude ont examiné les effets de l’hypnose sur
l’anxiété, la dépression, la fatigue et la somnolence chez des patients traités
par hémodialyse. Vingt-neuf patients ont participé à cette étude d’une durée
de 15 jours. Une séance d’hypnose a été tenue le 8e jour. L’anxiété, la dépres-
sion, la fatigue et la somnolence ont été mesurées (HADS, MFI, ESS) au 1er ,
au 8e et au 15e jours. La fatigue a également été mesurée numériquement.
L’anxiété, la dépression et la somnolence ont diminué de façon significa-
tive après la séance d’hypnose. Les mesures hebdomadaires de fatigue sont
restées stables, mais on a constaté une diminution de la fatigue quotidienne.
Johanne Reynault
C. Tr. (STIBC)

Efecto de la hipnosis en ansiedad, depresión, fatiga, y somnolencia en

personas sometidas a hemodiálisis: Un reporte clínico

Aurélie Untas, Philippe Chauveau, Catherine Dupré-Goudable, Anne

Kolko, Fabrice Lakdja, y Nicolas Cazenave
Resumen: Este estudio investigó los efectos de la hipnosis en ansiedad,
depresión, fatiga, y somnolencia en pacientes en hemodiálisis. Veintinueve
sujetos participaron en un estudio de 15 días. Se realizó una sola sesión
 HYPNOSIS AND HEMODIALYSIS 483

hipnótica en el día 8. Se midieron la ansiedad, depresión, fatiga, y somno-

lencia en estado basal, en el día 8, y el día 15 (HADS, MFI, ESS). También se
midió la fatiga diaria de forma numérica. La ansiedad, depresión y somnolen-
cia disminuyeron significativamente después de la hipnosis. Las mediciones
semanales de fatiga permanecieron estables, sin embargo la fatiga diaria
disminuyó.
Omar Sánchez-Armáss Cappello, PhD
Autonomous University of San Luis Potosi,
Mexico
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