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Successful Treatment of Ptyalism

Gravidarum With Concomitant
Hyperemesis Using Hypnosis
a a a
Zuhrah Beevi , Wah Yun Low & Jamiyah Hassan
a
University of Malaya, Kuala Lumpur, Malaysia
Published online: 11 Aug 2015.

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To cite this article: Zuhrah Beevi, Wah Yun Low & Jamiyah Hassan (2015) Successful Treatment of
Ptyalism Gravidarum With Concomitant Hyperemesis Using Hypnosis, American Journal of Clinical
Hypnosis, 58:2, 215-223, DOI: 10.1080/00029157.2015.1013186

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 American Journal of Clinical Hypnosis, 58: 215–223, 2015
Copyright © American Society of Clinical Hypnosis
ISSN: 0002-9157 print / 2160-0562 online
DOI: 10.1080/00029157.2015.1013186

Successful Treatment of Ptyalism Gravidarum

With Concomitant Hyperemesis Using Hypnosis

Zuhrah Beevi, Wah Yun Low, and Jamiyah Hassan

Downloaded by [Heriot-Watt University], [Zuhrah Beevi] at 18:30 12 August 2015

University of Malaya, Kuala Lumpur, Malaysia

Ptyalism gravidarum, or sialorrhea, is the excessive secretion of saliva during pregnancy. Treatment
of ptyalism gravidarum is often challenging due to its unknown etiologies. This article discusses a
case of ptyalism gravidarum with concomitant hyperemesis in which the condition was successfully
treated with hypnosis. A 28-year-old woman presented with ptyalism 2 months into her pregnancy
and hyperemesis 3 months into pregnancy with associated vomiting that occurred following every
meal. Hypnosis was administered at week 16 of pregnancy to eliminate ptyalism and hyperemesis, to
prepare for childbirth, and to increase overall psychological well-being. Ptyalism resolved by week
36, concurrent with the final hypnosis session.
Keywords: hypnosis, pregnancy, ptyalism

The function of the salivary gland is to excrete saliva in aiding digestion, assist in masti-
cation of food, facilitate swallowing, and increase perception of taste (Pedersen, Bardow,
Jensen, & Nauntofte, 2002). However, hyposecretion, such as xerostomia (Ferreira &
Hoffman, 2013), and hypersecretion, such as ptyalism or sialorrhea (Freeman et al.,
1994), impede the natural functions of saliva.
The nature of ptyalism gravidarum, which refers to excessive secretion of saliva dur-
ing pregnancy (Suzuki, Igarashi, Yamashita, & Satomi, 2009), is not clearly understood.
Evidence suggests that the inability to swallow excessive saliva is indicative of anxiety
rather than malfunction of the salivary gland. This anxiety may stem from the belief
that swallowing may result in nausea, which could cause vomiting (Freeman et al.,
1994; Suzuki et al., 2009). Ptyalism gravidarum often leads to difficulty in sleeping
and in the execution of day-to-day activities, such as work and socialization, as there is
a constant need to remove the excessive saliva (Erick, 1998). The incidence of ptyalism
during pregnancy is often accompanied by hyperemesis gravidarum (Freeman et al.,
1994; Suzuki et al., 2009) or severe nausea and vomiting.

Address correspondence to Zuhrah Beevi, Medical Education Research and Development, Faculty of Medicine,
University of Malaya, Kuala Lumpur, 50603, Malaysia. E-mail: zuhrahbeevi@yahoo.com
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/ujhy.
 216 BEEVI ET AL.

Previous studies have indicated that there is no specific successful treatment for
ptyalism gravidarum. In fact, treatment is often challenging due to its unidentified eti-
ologies (Suzuki et al., 2009). The use of various coping mechanisms, such as chewing
gum, is often only a temporary fix. Drugs, such as phenothiazine and belladonna, used
to treat the production of excessive saliva have been successfully used to treat ptyalism
gravidarum, although side-effects such as xerostomia (dry mouth) and constipation have
been noted (Freeman et al., 1994).
The use of complementary medicine (e.g., hypnosis) has been shown to ease various
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pregnancy symptoms, such as nausea and vomiting (Adams, 2012; Simon & Schwartz,
1999). The current published case reports on ptyalism investigated the effectiveness of
medical intervention (Freeman et al., 1994), but none examined the use of hypnosis
as a mode of treatment. Hypnosis for the treatment of ptyalism gravidarum with con-
comitant hyperemesis could be helpful, as it has been shown to be successful in the
treatment of hyperemesis gravidarum (Simon & Schwartz, 1999; Torem, 1994). Thus,
relief from hyperemesis through hypnosis may also aid in the relief of anxiety underlying
the ptyalism.
This case report discusses a patient who had experienced ptyalism gravidarum with
concomitant hyperemesis in which the condition was successfully treated with hypnosis.

Case Presentation

A 28-year-old woman began experiencing ptyalism as her pregnancy entered the 2nd
month. Subsequently, the incidence of ptyalism had progressively worsened as her preg-
nancy advanced. The patient began experiencing hyperemesis 1 month following the
onset of ptyalism largely due to nausea and the inability to swallow saliva. The patient’s
complaint corresponded with evidence from the literature indicating that excessive saliva
due to ptyalism caused nausea and vomiting (Freeman et al., 1994; Suzuki et al., 2009).
The patient emphasized that the excessive saliva caused embarrassment, as she had
to frequently dispose of it at work and in public places. She was working in a biochem-
istry lab in a hospital and her condition impaired her ability to successfully perform her
work. The patient’s sleep pattern was disturbed as she needed to awaken to remove the
excessive saliva.
The patient’s diet was poor, consisting mostly of dried sour fruits because consump-
tion of other types of food resulted in vomiting. She was steadily losing weight from
week 8 to week 16 of pregnancy, with a total weight loss of 11 pounds due to vomiting
and lack of appetite. The patient had made this remark prior to the first hypnosis session
at week 16, “Why would I waste my energy on eating food as I would vomit right after?”
The patient had previously experienced this condition during her first pregnancy.
Similarly, ptyalism began as her pregnancy entered its 2nd month, later accompanied by
hyperemesis. Subsequently, ptyalism persisted into the third stage of labor. This led to
difficulty in having a satisfying birth experience, as the patient felt the need to constantly
 SUCCESSFUL TREATMENT OF PTYALISM GRAVIDARUM 217

remove excessive saliva up to the third stage of labor. Ptyalism spontaneously remitted
immediately following birth. The patient had expressed concerned that the recurrence of
ptyalism would cause the same difficulties during labor as in her first pregnancy.
Prior to the hypnosis session, medical investigations were conducted to identify the
cause of the patient’s ptyalism. These investigations included full blood count and uri-
nalysis to rule out infections. Infections in the mouth and throat, for example, could
cause excessive salivation (Mayo Clinic, 2014). Results showed that the patient did not
have any infections. Ultrasound examination was performed to rule out molar pregnancy.
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Molar pregnancy results from the abnormal growth of placenta with some fetal develop-
ment (partial molar) or without the fetus (complete molar) but mimics the symptoms of
an actual pregnancy (MedlinePlus, 2014), and in some patients, this condition has been
shown to elevate thyroid hormones (Azezli, Bayraktaroglu, Topuz, & Kalayoglu-Besisik,
2007; Moskovitz & Bond, 2010). The elevation of thyroid hormones during pregnancy
may cause hyperemesis gravidarum, which may in turn, cause ptyalism. Ultrasound
results indicated that the patient had a normal pregnancy and normal thyroid hormones
levels (Ogunyemi & Isaacs, 2014). The experience of ptyalism gravidarum without any
known physiological etiologies is consistent with other studies in this area (Freeman
et al., 1994; Suzuki et al., 2009).
Hypnosis intervention was given at week 16 of pregnancy to eliminate ptyalism and
hyperemesis, to prepare for childbirth, and to increase overall psychological well-being.
In the interval between the hypnosis and the onset of labor, the patient did not receive
any conventional treatment for ptyalism.

Hypnosis Intervention

Hypnosis was conducted by the first author of this paper, who is a trained hypnotist. The
hypnosis session was conducted at the antenatal clinic of a teaching hospital in Kuala
Lumpur, Malaysia.
Hypnosis was conducted four times at weeks 16, 20, 28, and 36 of pregnancy. There
were long gaps between the sessions as the patient could only participate in the hypnosis
session during her antenatal check-up at the teaching hospital.
During the first induction session at week 16 of pregnancy, the patient was asked to
bring her thumb and index finger together from either the left or the right hand. Following
this, the patient was asked to close her eyes and was guided through a progressive muscle
relaxation, beginning from the feet and moving up to her legs, abdomen, chest, back,
throat, face, and head and then moving down to her shoulder, arms, hands, and finger
tips. During the progressive muscle relaxation, suggestions were given for the relaxation
of throat muscles. The therapist observed that the patient’s breathing slowed and her
body began to relax.
Following the progressive muscle relaxation, suggestions were given to the patient
for the discomfort experienced during pregnancy to move down her arms down to her
 218 BEEVI ET AL.

thumb and index finger and instantly leave her body. The following suggestions were
given during hypnosis to help decrease the symptoms of ptyalism and hyperemesis:

Every time you breathe out, the discomfort you experienced during this pregnancy will move down
your arm to your thumb and index finger and leave your body. That discomfort is replaced by the
feeling of comfort . . . feeling of pleasure . . . feeling of satisfaction . . . allowing you to enjoy your
pregnancy in a state of deep and complete relaxation.

The use of the index finger and thumb as described above was also emphasized during
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self-hypnosis suggestions. Following hypnosis, the patient was provided with additional
ego strengthening, including suggestions about how the experience of pregnancy can
be very positive, including maternal bonding with the unborn baby and anticipation of
a fulfilling birth experience. Upon re-alerting from hypnosis, the patient was advised
to practice self-hypnosis. The patient was also instructed to bring her thumb and index
finger together whenever she felt discomfort due to her pregnancy.
The therapist observed that prior to the start of the hypnosis session, the patient was
either spitting excessive saliva into a bag she brought with her or removing the excess
with tissues. However, during the hypnosis session, the patient was swallowing her saliva
naturally.

Follow-Up

The therapist met with the patient after 4 weeks. The patient reported positive changes
following her first session. Hyperemesis completely ceased, although the ptyalism still
remained. The patient gained a total of 10 pounds, as appetite improved following the
cessation in vomiting.
The patient was still apprehensive that swallowing saliva would cause her to vomit, as
she was continuing to experience nausea whenever she attempted to swallow the saliva.
The suggestions for the relaxation of the throat muscles in aiding the swallowing of
saliva without feeling nauseous were strengthened during the second session.
Following the third session at week 28, the incidence of ptyalism decreased, as the
patient was able to swallow saliva occasionally and had ceased waking up at night to
remove the excessive saliva. Her sleep had improved tremendously.
During the fourth session meeting, the patient reported that the incidence of ptyalism
had decreased substantially. Saliva could be swallowed with much more ease. Ptyalism
was completely eliminated a few hours following this last session (as confirmed by
patient).

Measures

The patient’s negative emotional states (stress, anxiety, and depression) were measured
at baseline (prior to the start of the first hypnosis session) and at weeks 20, 28, and 36 of
 SUCCESSFUL TREATMENT OF PTYALISM GRAVIDARUM 219

the follow-up hypnosis sessions. Stress, anxiety, and depression were measured accord-
ing to the Depression, Anxiety and Stress Scale–21 (DASS-21) (Lovibond & Lovibond,
1995). Each dimension of depression, anxiety, and stress consists of seven items. These
items are measured on a 4-point Likert scale ranging of “did not apply to me at all”
(score of 0), “applied to me to some degree or some of the time” (score of 1), “applied
to me to a considerable degree” (score of 2), and “applied to me very much or most of
the time” (score of 3). The intensity of stress, anxiety, and depression ranges from nor-
mal, mild, moderate, severe, to extremely severe. The higher the score, the greater the
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intensity of stress, anxiety, and depression (Lovibond & Lovibond, 1995; Musa, Fadzil,
& Mohd Zain, 2007; Musa, Ramli, Abdullah, & Sarkarsi, 2011). The patient was given
the Malay version of the DASS-21, which was validated for the Malaysian population
(Musa et al., 2007). The Malay version of the DASS-21 was used as a measure of the
experience of depression, anxiety, and stress on hyperemesis gravidarum in Malaysia
(Tan et al., 2014).
At baseline, the patient’s stress and anxiety scores were normal as indicated by the
DASS-21. However, her depression scores were rated at the moderate level. Stress and
anxiety scores remained within normal parameters during the second hypnosis session
at week 20 (follow-up 1) of pregnancy. Depression scores decreased from moderate
to normal. Although the patient’s stress scores had slightly increased during the third
and fourth hypnosis sessions (follow-ups 2 and 3, respectively), they remained within
the normal parameters. Anxiety and depression scores remained at the normal level at
follow-ups 2 and 3 (Figure 1).

16
Mean Value for Stress and Depression

14

12

10

0
Baseline Follow‐up 1 Follow‐up 2 Follow-up 3
Hypnosis Sessions

Stress Depression

FIGURE 1 Mean scores for stress and depression from baseline to follow-up 3.
Note. Anxiety is excluded, as the mean scores for anxiety in all four sessions were rated as 0.
 220 BEEVI ET AL.

Two items on the DASS-21 that measure depression were of particular concern as
the patient rated them as “applied to me to a considerable degree.” These items were
“I just couldn’t seem to get going” and “I feel that I had nothing to look forward to.”
As discussed earlier, the ptyalism caused difficulty in digesting food, at work, and in
social situations. Furthermore, the patient was not looking forward to her labor due to
fear of experiencing similar difficulties to those of her first pregnancy. By the second and
third hypnosis sessions, the aforementioned items were rated as “applied to me to some
degree or some of the time,” and by the final hypnosis session, she rated these items as
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“did not apply to me at all,” which coincides with the reduction in her depression scores
(Figure 1).
The patient gave birth through a spontaneous vaginal delivery, without the incidence
of ptyalism, to a healthy female infant weighing 3200 gm with an Apgar score of 9/10.

Discussion

This case report highlights the benefits of hypnosis in the treatment of physical symp-
toms during pregnancy. Additionally, this research illustrates the possibility of lowering
the incidence of stress, anxiety, and depression by eliminating physical symptoms.
Past studies have indicated associations between the experience of physical symptoms
and stress, anxiety, and depression; for instance, women with hyperemesis gravidarum
reported higher levels of depression, stress, and anxiety, but vomiting cessation reduced
those scores, particularly for stress and depression (McCarthy et al., 2011).
Without proper care and techniques, stress, anxiety, and depression may lead to fur-
ther adverse effects for women, their fetuses, and their infants later in life (Breedlove,
2011). These adverse effects include premature birth and low birth weight. However,
stress, anxiety, and depression tended to be diagnosed only after those adverse effects
had occurred (Breedlove, 2011).
Although past studies have shown the association between physical symptoms and
psychological conditions (e.g., anxiety) studies in the area of hypnosis in obstetrics were
more focused on its efficacy during labor (Cyna, Andrew, & McAuliffe, 2006; Mehl-
Madrona, 2004). Early intervention in the elimination of physical symptoms is necessary
to increase the well-being of pregnant women (Breedlove, 2011). A study by Madrid,
Giovannoli, and Wolfe (2011), for example, showed that successfully treating nausea
early during pregnancy helps women to alleviate fears and grief related to past traumas.
Although ptyalism gravidarum is rare, only affecting a small portion of pregnant
women (about 0.3% in a study involving pregnant Japanese women) (Suzuki & Fuse,
2013), the effect is detrimental. Thus far, there has been no other study on hypnosis for
this condition using a larger sample, probably due to difficulties in finding an appropriate
pool of participants who meet the criteria for the diagnosis.
Since this is the first case report regarding the efficacy of hypnosis in the treatment
of ptyalism gravidarum, more research is needed to determine whether hypnosis does
 SUCCESSFUL TREATMENT OF PTYALISM GRAVIDARUM 221

indeed assist in resolving its symptoms. Future research on hypnosis in obstetrics should
focus on alleviating depression in pregnant women, as studies have shown the effective-
ness of using hypnosis, especially cognitive hypnotherapy, in the treatment of depression
(Alladin & Alibhai, 2007). Similarly, in this case report, the reduction and elimina-
tion of physical symptoms coincide with the reduction in the experience of depression.
Although hypnosis may have helped decrease the patient’s depression score, her stress
score did increase. It is possible that initially ptyalism may have contributed to the
increase in the depression score and the reduction in salivation may have led to its
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decrease at follow-up. The experience of stress may be due to other factors, such as
a hectic work schedule, being pregnant, and taking care of another child at home rather
than due to the excessive salivation. Future hypnosis sessions should consider address-
ing various aspects of a patient’s difficulties to cultivate more positive psychological
well-being.
This case report illustrates how hypnosis may be of benefit during pregnancy. Based
on this evidence, perhaps other physical symptoms could be relieved as well such as
nausea, vomiting, back pain, leg cramps, heart burn, and leg swelling (which could be a
symptom of preeclampsia, a condition that may cause fatality). Once the physical symp-
toms are alleviated early in pregnancy, women will be able to enjoy their pregnancy with
a more positive outlook and may look forward to their labor and postpartum periods.
Although this case is based on a single patient, there is increased credibility given
that the patient did experience similar conditions during her first pregnancy and that the
symptoms of ptyalism spontaneously resolved following delivery of her baby. However,
for her second pregnancy, the symptoms of ptyalism decreased following the third hyp-
nosis session and were resolved at the conclusion of the fourth session. As noted earlier,
during the first hypnosis session, the patient had the ability to swallow normally, indicat-
ing temporary relief of her condition, which was aided by suggestions during hypnosis
for the relaxation of the throat muscles.
This case report is not without its limitations. First, hypnosis was conducted with a
long gap between sessions. Although the patient’s complication was severe, the patient
could only attend the session during her regular antenatal check-up at the hospital. The
prolonged time required for the patient’s recovery from ptyalism gravidarum may be due
to the effect of time, as the completion of the hypnosis intervention took 20 weeks, or
5 months, in total. The patient may have employed other strategies to recover from her
condition. Second, this case is based solely on the report of one patient. Studies with
more patients will lead to a stronger conclusion on the efficacy of using hypnosis in
the treatment of ptyalism gravidarum. Using a single case research design as the study
methodology would have led to a more reliable conclusion that hypnosis did indeed
assist in eliminating the patient’s symptoms, as the goal of a single case research design
is to identify the changes in a dependent variable (e.g., stress, anxiety, and depression)
over time (Smith, 2012). Third, although at the end of the hypnosis session the therapist
and patient had a discussion regarding the possibility of the patient associating nausea
 222 BEEVI ET AL.

and subsequent vomiting with ptyalism, a more structured approach, including providing
a clear explanation of how hypnosis could have aided in resolving her symptoms, may
have contributed to a speedier recovery.

Conclusions

The link between physical symptoms and pregnant women’s emotional states should be
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taken into consideration. Suitable interventions, such as hypnosis, may reduce physical
symptoms and increase women’s emotional well-being during pregnancy.

Ethical Statement

This study was approved by the University of Malaya Medical Ethics Committee, Kuala
Lumpur, Malaysia (Medical Ethics Committee Reference 901.5). The patient in this case
report provided consent to be included in this study, as required by the Medical Ethics
Committee.
This case report is based on an ongoing Ph.D. research project of the first author,
who is registered at the University of Malaya, Kuala Lumpur, Malaysia. The research is
focused on the efficacy of hypnosis intervention during pregnancy, labor, and postpartum
period.

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