Theories of Hypnosis
1. An Introduction to Hypnosis
2. Hypnosis in the Management of Chronic Pain
3. Hypnosis in Conjunction with Chemical Anesthesia
4. Hypnosis in Conjunction with Regional Anesthesia
5. Hypnosis as the Sole Anesthetic
6. Hypnosis in the Intensive Care Unit
7. Hypnosis in the Emergency Unit
8. Hypnosis in Pediatric Surgery
9. Hypnosis in Obstetrics and Gynecology
10. Perspectives from Physician-Patients
Gibbons, Don E. (2001). Experience as an art form: Hypnosis, hyperempiria, and the Best Me technique. San Jose CA: Authors Choice Press. (([available online:] http//
The Best Me Technique is a procedure for constructing suggestions which incorporates many different dimensions of experience — beliefs, emotions, sensations, thoughts, motives, and expectations — for maximum involvement and effectiveness. Best Me suggestions may be used with either hyperempiria, an alert induction based on suggestions of mind expansion and increased alertness and sensitivity, or with more traditional forms of hypnotic induction.

Barabasz, Arreed (2000, August). EEG markers of hypnosis: The induction makes a difference. [Paper] Presented at the annual meeting of the American Psychological Association, Washington, D. C..
Rather than attempt to uncover some simplistic unidimensional EEG “signature” of the hypnotic state, this study obtained EEG Event Related Potentials (ERPs) in response to two conditions: suggestion only and an alert hypnotic induction plus the identical suggestion. The suggestion asked the ten participants to hallucinate having earplugs in their ears to attentuate a series of computer generated tone pips. Hypnotizability testing was completely separated in both time (6-9 months prior) and context from this research. Alert hypnosis (Barabasz, 1985; Barabasz & Barabasz, 1996) was used to preclude effects that might be wrought by relaxation. Only the hypnotizable participants showed statistically significant attenuation of their EEG ERPs in response to the hypnotic induction plus suggestion condition in contrast to the identical suggestion alone. An independent post-experimental inquiry revealed that the one highly hypnotizable participant who responded in an equivalent manner to both conditions spontaneously entered hypnosis in an effort to respond to the essence of the instructions. Consistent with previous research (Barabasz, Barabasz, Jensen, Calvin, Trevisan, & Warner, 1999; Barabasz & Lonsdale, 1983; Spiegel, Cutcomb, Ren, & Pribram, 1985), the data reveal that when responses are time locked to events, robust physiological markers of the hypnotic state emerge that reflect alterations in consciousness corresponding to participants” subjective experiences of perceptual alteration. These effects were not produced by suggestion alone but only by hypnosis in hypnotizable participants. It would appear that hypnotic state induced responses go beyond those wrought by suggestion alone when efforts are made to establish sufficient hypnotic depth. However, it remains important to understand that less demanding effects can also be produced by social influence, context and personal abilities (Kirsch, Council, & Mobayed, 1987; Lynn, Rhue, & Weekes, 1990). Given the leptokertic distribution of hypnotizability in the general population, social influence may account for a number of the more easily produced responses seen particularly in non-clinical university participant research situations where samples are comprised primarily of those with moderate hypnotizability. [Abstract in Psychological Hypnosis: A Bulletin of Division 30, Vol. 10, No. 1, Winter-Spring 2001.]

Eimer, Bruce. N. (2000). Clinical applications of hypnosis for brief and efficient pain management psychotherapy. American Journal of Clinical Hypnosis, 43 (1), 17-40. (July)

This paper describes four specific clinical applications of hypnosis that can make psychotherapy for pain management briefer, more goal-oriented, and more efficient: (1) the assessment of hypnotizability; (2) the induction of hypnotic analgesia and development of individualized pain coping strategies;
(3) direct suggestion, cognitive reframing, hypnotic metaphors, and pain relief imagery; and (4) brief psychodynamic reprocessing during the trance state of emtoional factors in the patient”s experience of chonic pain. Important theoretical and clinical issues regarding the relationship between hypnotizability to the induction of hypnotic analgesia are presented, and attempts to individualize pain treatment strategies on the basis of assessed differences in hypnotizability and patients” preferred coping strategies are described. Some ways are also presented of integrating direct hypnotic suggestion, COGNITIVE-EVALUATIVE reframing, hypnotic metaphors, and imagery for alleviating the SENSORY and AFFECTIVE-MOTIVATIONAL components of pain, with an exploratory, insight-oriented, and brief psychodynamic reprocessing approach during trance for resolving unconscious sources of resistance to treatment, and reducing the emotional overlay associated with chronic pain. Some basic assumptions underlying the use of this approach are discussed, and a brief step-by-step protocol is outlined.

Elter-Nodvin, Edeltraud (2000). Computerized content analysis: A comparison of the verbal productions of high hypnotizable, low hypnotizable and simulating subjects (Dissertation). (

: This research was designed to investigate the domain of hypnosis and to explore how the “”state”” of hypnosis, along with the susceptibility to hypnosis relate to lexical choice in verbal productions as well as to primary/secondary process mentation. … College students were screened for level of hypnotic susceptibility … [yielding] 32 high hypnotizable subjects and 57 low hypnotizable subjects [randomly assigned to two groups] … 29 low hypnotizable subjects and 28 low hypnotizable simulating subjects.
Responses to six Thematic Apperception Test (TAT) cards and responses to five free speech story-openings were collected and tape-recorded during [counterbalanced waking and hypnosis conditions]…. verbal productions were transcribed and [computer] analyzed by … the Dartmouth Adaptation of The General Inquirer … and COUNT with the Regressive Imagery Dictionary … .
To summarize, findings suggest that the changes in SECONDARY PROCESS and THOUGHT,as well as the DAGI-III-variable EMOTION and the COUNT-RID-variable EMOTION, may be a result [sic] other than hypnotic ability or the hypnotic experience. The possibility has been raised, that subjects who had been instructed to simulate hypnosis were successful in discerning the experimental, implicit demands to respond with decreased SECONDARY PROCESS and THOUGHT as measured by the DAGI-III and COUNT-RID respectively and to present the appearance of a genuinely hypnotized subject. The same was true for the increase in EMOTION as measured by the DAGI-III as well as by the COUNT-RID. The interaction between the condition (baseline vs. hypnosis) and the group (level of hypnotic susceptibility) would have provided the strongest support for the assertion that hypnosis changes a dimension (e.g. enhances primary process responding or decreases secondary process mentation) in highly hypnotizable subjects.
The likelihood that the hypnotic main-effect can be attributed at least to some extent to demand characteristics has been supported by the current results. The hypnotic state , even though it can be measured through behavioral measures such as the HGSHS and the CAH, cannot be measured by content measures of verbal productions.
Findings are discussed in regard to previous literature suggesting a link between primary process and hypnosis and suggestions for future research are made. In addition, theoretical and practical implications are discussed. – From dissertation at web site

Gibbons, Don (2000). Applied hypnosis and hyperempiria. New York NY: Plenum Press. ([available online:]

The book features both traditional hypnotic procedures and hyperempiric inductions based on suggestions of increased awareness, mind expansion, and increased alertness and sensitivity. It contains sections on the use of suggestion as an instrument of personal growth in areas such as improving study skills, taking examinations, achievement motivation, artistic expression, emotional enrichment, aesthetic appreciation and enjoyment, interpersonal effectiveness, musical performance, problem solving, public speaking, salesmanship, sports performance, theatrical performance, and writing ability.


Alarcsn, A.; Capafons, A.; Bayot, A.; Cardeqa, E. (1999). Preference between two methods of active-alert hypnosis: Not all techniques are created equal.. American Journal of Clinical Hypnosis, 41 (3), 269-276
In a cross-over design (N=80), we compared the differential liking and preference for two hypnotic techniques involving physical activity: active-alert and waking-alert (or alert-hand) procedures. Participants expressed significantly higher liking and preference for the waking-alert as compared to the active-alert procedure. The latter technique, which also had significantly lower suggestibility scores (Cardeqa et al., 1998) was also associated with a significantly higher attrition rate (23%). These significant differences may be explained by the greater physical effort and difficulty associated with the active-alert technique. It seems that the waking-alert method extends the advantages of active hypnosis (e.g., alertness, enhanced self-mastery) to individuals who may dislike or are unable to cope with the greater demands required by the active-alert procedure.
Anderson, Kathryn (1999, November). A test of Barabasz’ alert hypnosis on EEG Beta and Theta production for children with ADHD. [Paper] Presented at Annual Meeting of the Society for Clinical and Experimental Hypnosis, New Orleans, LA.

This study tested the effects of Barabasz”s Instant Alert Hypnosis (IAH), also known as Instantaneous Neuronal Activation Procedure (INAP, Barabasz and Barabasz, 1995) used as an adjunct to neurotherapy. The sixteen children who participated in ths study met DSM – IV criteria for attention deficit hyperactivity disorder (AD/HD). Trials of neurotherapy alone were compared to neurotherapy combined with alert hypnosis on beta-theta ratios at five electrode sites (Fp1, Fp2, Fz, Cz and Pz). The results showed that EEG beta-theta ratio means were significantly higher (more than twice as large) in the trials of neurotherapy combined with alert hypnosis in contrast to neurotherapy alone. Beta was significantly enhanced while theta was inhibited. The clinical implications of these findings with regard to improved treatment efficacy and reduced time in treatment are discussed. [Abstract taken from SCEH “FOCUS”, Winter 2001..]

Cardeqa, E.; Alarcsn, A.; Capafons, A.; Bayot, A. (1998). Effects on suggestibility of a new method of active-alert hypnosis: Alert hand.. International Journal of Clinical and Experimental Hypnosis, 46 (3), 280-294.

Research has shown that the active-alert method described by Banyai and Hilgard (1976) produces a similar increase on suggestibility as relaxation-based techniques, but it has some limitations, including the need for a stationary bicycle and a certain level of physical fitness. The authors compared that method with the new “alert hand” method, which emphasizes activity and alertness, but is simpler and less strenuous. In a repeated measures, counterbalanced design (N=80), the authors found that (a) the alert hand method produced significantly higher objective and subjective suggestibility scores than the active-alert technique, and (b) a high percentage (23%) of volunteers discontinued participation during the active-alert method but not during the the alert hand method. The alert hand method extends the benefits of active hypnosis for people who may have difficulties with the physical demands required by the active-alert method, and it seems to enhance suggestibility.

Gibbons, Don (1998). Suggestion as an art form: Alternative paradigm for hypnosis?. [Paper] Presented at annual meeting of American Psychological Association, San Francisco. ([available online:]

This paper proposes a change in the manner in which we think about suggestion-induced phenomena, moving from primary reliance upon a medical/counseling model to a concurrent view of suggestion as an art form and hypnosis as an artistic medium. the rationale for such an alternative paradigm is discussed, and a procedure for scripting suggestions within the new paradigm — the Best Me technique — is presented, along with a specific illustration of its application, possible implications for current clinical practice, and suggestions for transition to the new paradigm.

Bayot, A.; Capafons, A.; Cardeqa, E. (1997). Emotional self-regulation therapy: A new and efficacious treatment for smoking.. American Journal of Clinical Hypnosis, 40 (2), 146-156.

We described emotional self-regulation therapy, a recently-developed suggestion technique for the treatment of smoking, and present data attesting to its efficacy. Of the 38 individuals who completed treatment, 82% (47% of the initial sample)stopped smoking altogether and 13% (8% of the initial sample) reduced their smoking. A follow-up at 6 months showed that 66% (38% of the initial sample) of those who had completed the treatment remained abstinent and reported minimal withdrawal symptoms or weight gain. In a no-treatment comparison group, only 8% reduced their smoking or became abstinent.

DeBenedittis, Giuseppe De (1996). Hypnosis and spasmodic torticollis — report of four cases: A brief communication. International Journal of Clinical and Experimental Hypnosis, 44 (4), 292-306.

Dystonia and particularly spasmodic torticollis are neuromuscular disorders that are extremely resistant to most therapies (physical, medical, or surgical). Torticollis is a unilateral spasm of the neck muscles, particularly of the sternocleidomastoid, that produces violent, tonic turning of the head to one side. The etiology remains uncertain, although the role of psychogenic factors has been emphasized. This article reviews the literature and reports four cases of spasmodic torticollis treated successfully with hypnosis. In all four cases, psychogenic causes were involved. Postural hypnosis (i.e., hypnosis in the standing position) was employed to counteract and minimize muscle spasms due to postural reflexes. A hypnobehavioral approach was adopted along with hypnotic strategies that included hierarchical desensitization, sensory-imaging conditioning, ego-boosting suggestions, and hypnosis-facilitated differential muscle retraining. In two cases, a combined hypnosis and electromyographic-biofeedback approach was used to equilibrate and retrain affected neck muscles. Although the hypnotherapeutic process took several months to induce and stabilize significant changes, outcome results were good to excellent in all cases, with marked reduction of the torticollis and the hypertrophy of the neck muscles as well as a reduced interference of symptoms in daily living. — Journal Abstract

Wark, David (1996). Teaching college students better learning skills using self-hypnosis. American Journal of Clinical Hypnosis, 38 (4), 277-287.

Reports the effects of self-hypnosis used by 51 college students enrolled in a 10-wk course on efficient learning skills. All Ss were administered the Creative Imagination Scale (CIS). Subsequently, they learned to enter and deepen alert self-hypnosis. They gave themselves personal suggestions and then studied in hypnosis. They reported their depth of hypnosis and satisfaction with each session. Grades were collected the quarter before, during and after the course. Satisfaction and depth data indicated the Ss were involved throughout the course. Statistical testing showed that Ss who scored highest on the CIS had the lowest initial GPA, improved most during the course, and significantly increased their GPA in the quarter after

Capafons, A.; Amigs, S. (1995). Emotional self-regulation therapy for smoking reduction: Description and initial empirical data.. International Journal of Clinical and Experimental Hypnosis, 43 (1), 7-19.

Self-regulation therapy (Amigs, 1992)is a set of procedures derived from cognitive skill training programs for increasing hypnotizability. First, experiences are generated by actual stimuli. Clients are then asked to associate those experiences with various cues. They are then requested to generate the experiences in response to the cues, but without the actual stimuli. When they are able to do so quickly and easily, therapeutic suggestions are given. Studies of self-regulation therapy indicate that it can be used sucessfully to treat smoking.

Holroyd, Jean (1995). Handbook of clinical hypnosis, by Judith W. Rhue, Steven Jay Lynn, & Irving Kirsch (Eds.) [Review]. International Journal of Clinical and Experimental Hypnosis, 43 (4), 401-403.

“This is a book for the thinking clinician” (p. 401). “The editors are to be congratulated for making this volume much more coherent than most edited books” (p. 402). “My impression is that the book is best suited for an intermediate or advanced course on hypnotherapy, or for people who are already using hypnosis in treatment. Although there is some material on the basics of hypnotic inductions and a few introductory sample scripts for inductions, a beginners” course should probably use a different book, or this book could be accompanied by an inductions manual. … I recommend it very highly” (p. 403).

Barabasz, Arreed F.; Barabasz, Marianne (1994, October). EEG responses to a reading comprehension task during active alert hypnosis and waking states. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, San Francisco.

NOTES: Evoked potentials differ between High & Low hypnotizables during hypnosis but not during waking (Barabasz & Lonsdale, 1983; Spiegel et al, 1985; Spiegel & Barabasz, 1988). Showed critical importance of instructions. We may not be aware of the suggestions that subjects are giving themselves. Or experimental cues may lead to de facto instructions.
Freeman, M. Barabasz & I found differences in high theta during cold pressor pain (reported elsewhere in this conference).
Active alert hypnosis improves attentional processing in military pilots (Barabasz, 1985, Journal of Aviation, Space & Environmental Medicine). INAP = Instantaneous Neuronal Activation Procedure. To enhance responsiveness to cockpit cues. Didn”t have way of doing in flight measures of hypnosis. INAP was used clinically with airline pilots (Rhue, Lynn, & Kurtz Handbook on Clinical Hypnosis)
Active alert focused attention hypnosis increases frontal EEG topographic energy and frequency shifts (increased beta) in highly hypnotizable normal and attention deficit disordered children (Barabasz, Crawford & Barabasz, 1993; in press). No significant changes are found with low hypnotizables (Barabasz & Barabasz, 1993). But sample was small.
Can alert focused attention hypnosis alter EEG topography and attentional processing in subjects of average hypnotizability?
MRI type mapping shows that attention deficit kids don”t have normal patterns.
Subjects: all 11 Ss (female) who volunteered for a vitamin B-6 depletion study, with EEG evaluation, also volunteered for hypnosis testing for a $5.00 payment (SHCS score range 2-3).
Used active alert procedure during reading comprehension task, disguised as normal reading procedure. Counterbalanced waking, attentional instructions and alert focused attention hypnosis conditions were imbedded in standard EEG situation.
Nelson Denny H.S. Reading Comprehension Test. “Focus your attention to read faster than normal, paying attention to what you read.”
Used an eye roll induction, and looked for signs of entering hypnosis before they roll their eyes down; were able to cut no. of sessions in neurofeedback training by 50% by using these instructions. To come out next year in Rhue and Lynn.
Reading rate and comprehension increased in alert hypnosis (and words per minute also in attentional instructions). Neurobehavioral feedback for ADD is to decrease theta and increase beta and it ordinarily takes 60 sessions; 40-80 sessions without hypnosis, 15-25 with hypnosis. Eyeroll induction cuts that. (See Barabasz & Barabasz, 1996. Chapter in Lynn, Kirsch, & Rhue, “Casebook of Clinical Hypnosis.” Washington, DC.: APA Press.)

Miller, Mary Frances; Barabasz, Arreed F.; Barabasz, Marianne (1991). Effects of active alert and relaxation hypnotic inductions on cold pressor pain. Journal of Abnormal Psychology, 100 (2), 223-226.

Contrasted relaxation and active alert hypnotic inductions with or without a specific suggestion for cold pressor pain analgesia. Groups of high (n = 38) and low (n = 27) hypnotizability subjects were tested; hypnotizability had been determined from results of the Stanford Hypnotic Susceptibility Scale, Form C. Cold pressor pain data were obtained after counterbalanced exposure to relaxation and active alert inductions. Highly hypnotizable subjects demonstrated lower pain scores than did low hypnotizability ones. Pain reports did not differ between induction conditions. Highly hypnotizable subjects given an analgesic suggestion showed lower pain scores than did those exposed only to hypnosis. The findings, conceptualized within E. R. Hilgard”s (1977a) neodissociation theory, show that relaxation is not necessary for hypnotic analgesia.

NOTES: The relaxation induction was the SHSS, Form B. The active alert induction used the same instructions except suggestions for alertness, invigoration, and freshness were substituted for drowsiness and relaxation. During the active alert induction, the subjects rode a bicycle ergometer at a constant load of 1-3 kg and a constant rate of 1-2 rotations per s (Banyai & Hilgard, 1976).

Cikurel, Katia; Gruzelier, John (1990). The effect of an active-alert hypnotic induction on lateral asymmetry in haptic processing. British Journal of Experimental and Clinical Hypnosis, 7, 17-25.

In order to elucidate further left hemispherical inhibitory dynamics in response to instructions of hypnosis, bilateral haptic processing times were compared before and during a traditional hypnotic relaxation procedure and an active-alert procedure in which subjects pedaled a bicycle ergometer and instructions on mental alertness were incorporated with hypnosis. Previous evidence suggesting a slowing of left hemispherical processing and a facilitation of right hemispherical processing in susceptible subjects was replicated, and was shown to characterize high rather than medium susceptibles, the latter showing a bilateral slowing of processing. These effects occurred with both induction procedures whose influence on susceptibility was highly correlated. In fact the lateral shift in processing in the direction of left hemispherical inhibition and right hemispherical facilitation was favoured by the active-alert procedure, indicating that neuropsychological changes which occur with hypnosis cannot be discounted as a by-product of relaxation.


Malott, James M. (1984). Active-alert hypnosis: Replication and extension of previous research. Journal of Abnormal Psychology, 93 (2), 246-249.

NOTES: Compared levels of hypnotic responsiveness resulting from 4 induction procedures: (a) verbal active-alert induction alone, (b) bicycle pedaling alone, (c) verbal active-alert induction plus bicycle pedaling and (d) traditional relaxation induction. Ss were 48 undergraduates. Stanford Hypnotic Susceptibility Scale scores indicated that the verbal induction plus pedaling procedure was significantly more effective than either the verbal- or pedaling-alone procedures. There were no significant differences in scores produced by the verbal plus pedaling and traditional relaxation inductions. Findings are consistent with A. M. Ludwig”s (1966) proposal that there exists a range of stimulation necessary for the maintenance of normal waking consciousness and that levels of stimulation above or below that range are conducive to the production of altered states of consciousness.
This study adds experimental controls to the research design used by Banyai for active alert induction.

Raikov, V. L. (1978). Specific features of suggested anesthesia in some forms of hypnosis in which the subject is active. International Journal of Clinical and Experimental Hypnosis, 26 (3), 158-166.

Experiments are reported in which highly hypnotizable Ss while imagining themselves, during hypnosis, to be cosmonauts with “jammed legs” in a space capsule did not feel an unannounced needle prick that pierced the skin. Control experiments with nonhypnotizable, professional actors showed that imagination alone was unsuccessful in producing this result. Additional experiments using autogenic training showed that the autogenic training alone, without analgesia training, did not alleviate the pain but may have reduced the anxiety connected with the pain; further training involving analgesia reduced the felt-pain as well. Theoretical discussion stresses the importance of attention, imagination, and orientation for experiencing analgesia as well as the added and decisive role played by the modifications of consciousness brought about in deep hypnosis.

Raikov, V. L. (1976). The possibility of creativity in the active stage of hypnosis. International Journal of Clinical and Experimental Hypnosis, 24, 258-268.

Creative capacity was studied by means of suggestions given to Ss under the condition of active hypnosis. In deep hypnosis it was suggested to S that he was a famous person with a specific talent. In a series of experiments Ss performed under active hypnosis such tasks as drawing, playing musical instruments, and playing chess. The results ilustrated that creative processes can be facilitated in Ss capable of deep hypnosis and there is a carry-over of the creative achievements from hypnosis to the waking state. Low hypnotic Ss and control groups did not show improvements in the tasks. A particular significant increase in creativity was observed when Ss capable of deep hypnosis performed several successive creative tasks while hypnotized. The theoretical and experimental definitions of several new approaches to active hypnosis are also discussed.

Donk, Leonard J.; Vingoe, Frank J.; Hall, Roger A.; Doty, Richard (1970). The comparison of three suggestion techniques for increasing reading efficiency utilizing a counter-balanced research paradigm. International Journal of Clinical and Experimental Hypnosis, 18, 126-133.

Reports an experiment in which both Barber-type and alert-trance procedures significantly increased reading speed while maintaining comprehension when compared to a control group; a traditional hypnotic procedure followed by the specific suggestions failed to obtain these results. 32 volunteer undergraduates were randomly assigned to 4 groups in terms of a counterbalanced design. 2 groups were administered trance inductions (traditional and alert) followed by specific suggestions, a 3rd simply the suggestions, while the 4th served as control. Reading suggestions were to eliminate specific problems, increase speed, and increase or maintain comprehension. (Spanish & German summaries) (PsycINFO Database Record (c) 2003 APA, all rights reserved)

Kratochvil, Stanislav (1970). Sleep hypnosis and waking hypnosis. International Journal of Clinical and Experimental Hypnosis, 18, 25-40.

Subjected 6 highly susceptible female students to a short-term training procedure to induce 2 different types of hypnosis: (a) a sleep hypnosis, and (b) an active waking hypnosis. Ss behavior in both types, during the carrying out of 11 standard suggestions, was rated by 2 independent Os. The behavior in both artificially induced types of hypnosis differed significantly at the 1% level in the expected direction. The failure to obtain more dramatic results is attributed to the shortness of training, to the implicit demands concerning activity, or to Ss” personality traits, which may lower the intrapersonal variability. The relevance of the results for the Pavlovian theory of hypnosis is discussed: They do not support the hypothesis that behavioral characteristics which resemble sleep are intrinsic phenomena of the hypnotic state. (Spanish & German summaries) (34 ref.) (PsycINFO Database Record (c) 2003 APA, all rights reserved)


Moret, V.; Forster, A.; Laverriere, M. C.; Lambert, H.; Gaillard, R. C.; Bourgeois, P.; Haynal, A.; Gemperle, M.; Buchser, E. (1991). Mechanism of analgesia induced by hypnosis and acupuncture: Is there a difference?. Pain, 45, 135-140.

Hypnosis and acupuncture can alleviate experimentally induced pain but the mechanism of analgesia remains unclear for both techniques. Experimental pain was induced by cold pressor test (CPT) in 8 male volunteers. Analgesic effect of hypnosis (HA) and acupuncture (AA) was assessed before and after double-blind administration of placebo or naloxone, in a prospective, cross-over study. We found that pain intensity was significantly lower with HA as compared with AA, both with naloxone (P < 0.001) and placebo (P < 0.001). Within HA or AA groups, pain scores did not differ significantly when naloxone or placebo was administered. During AA, however, pain scores were similar to control values when naloxone was given (P = 0.05) but decreased significantly with placebo (P < 0.002). Analog scales for pain intensity and pain relief showed a good correlation (r = 0.94). Plasma levels of B-endorphins did not change significantly in any combination. Heart rate, peripheral arterial blood pressure and skin conductance were very insensitive indices to assess pain intensity or relief, as well as intensity of acupuncture stimulation or depth of hypnotic trance. We conclude: (1) HA and AA can significantly reduce pain from CPT , and HA is more effective than AA; (2) HA and AA are not primarily mediated by the opiate endorphin system; and (3) plasmatic levels of B- endorphins are not significantly affected by HA or AA nor by naloxone or placebo administration. NOTES The authors measured blood pressure, heart rate, skin conductance, mood (Clyde Mood Scale), beta endorphin levels, and hypnotizability. Before the experimental sessions they obtained Ss' opinions about the analgesia effectiveness of hypnosis and acupuncture. For each Subject they established a value for 'intolerable' pain (the longest duration of arm immersion in cold water). Efficacy of treatment was defined as none (0% on the efficacy scale) for this Control session.. During the experimental sessions they gave hypnosis or acupuncture analgesia for 20 minutes, then an injection of either naloxone or placebo. Double-blind controls were used. Five minutes after the injection they began CPT and the Subject was told to maintain their hand in the water for the same amount of time as in the control session. Pain intensity and treatment efficacy were scored, then the S completed a mood scale. Five blood samples were collected over the course of the procedure: (a) first rest period, (b) treatment period, (c) after injection, (d) after CPT, (e) second rest period. Results (see Abstract). "When naloxone was administered, HA was no more effective than AA in alleviating pain (P = 0.109). However HA was significantly more effective than AA when placebo was administered (P<0.05). Whichever technique was used there was no significant alteration in pain relief by either naloxone or placebo (P = 0.426 within the HA group and P = 0.519 within the AA group)" (p. 137). "Compared to the control session, the pain relief was significantly better with HA, both when placebo (62.53%, P < 0.001) and when naloxone (49.3%, P < 0.001) was administered. This was not true with AA and placebo (15.21%, P = 0.1) nor with AA and naloxone (13.38%, P = 0.5)" (p. 137). "When naloxone or placebo was administered, the mean pain relief scores did not differ significantly with HA (P = 0.56) or with AA (P = 0.852). There was a good correlation (r = .94) between ratings of pain and treatment efficacy" (pp. 137-138). Outcome was not related to Subjects pre-experimental beliefs about efficacy of hypnosis or of acupuncture. During the experimental sessions, all Ss reported that hypnosis was more effective than acupuncture. Neither hypnosis nor acupuncture affected beta endorphin plasma levels; neither naloxone nor placebo affected beta endorphin plasma levels. Mood was somewhat affected by treatments. "When compared with the baseline value (i.e., before each session), mean scores for happiness were significantly lower after AA with placebo than after AA with naloxone (P = 0.05). The other evaluated categories of mood (friendliness, aggressiveness, clear thought, sleepiness and dizziness) were not affected by either session" (p. 139). In the Discussion, authors indicated that "variables such as heart rate, arterial blood pressure and skin conductance were very insensitive indices for assessing pain or pain relief as well as intensity of acupuncture stimulation or depth of hypnotic trance" (p. 139). Why was hypnoanalgesia better than acupuncture analgesia? "Firstly, a preconceived opinion could favor hypnosis; this was not the case amongst these subjects. Secondly, the influence of what was felt to be a more pleasant experience (HA) might help to lower pain ratings. Subjective preference for hypnosis was frequently expressed informally; however, scores from the Clyde Mood Scale did not suggest mood enhancement after HA. Thirdly, the intensity of analgesia might have been more uniform with HA than with AA. ... Interestingly, we found no difference in pain ratings between good and poor hypnotic subjects, even if theoretically poor hypnotic subjects could be expected to experience less pain relief with HA" (p. 139). Effect of naloxone. "Although the failure to achieve statistical significance may be due to the small number of subjects, our results suggest that, if opiate receptors play a role in HA or AA, it is not of primary importance" (p. 139). The authors go on to state that the data on plasma beta-endorphin and CSF beta-endorphin are confusing, and elaborate the discussion of that variable on p. 139. 1984 Lewith, G. T.; Kenyon, J. N. (1984). Physiological and psychological explanations for the mechanism of acupuncture as a treatment for chronic pain. Social Science & Medicine, 1367-1378. Many suggestions have been made about the possible mechanism of acupuncture as an analgesic therapy. This review provides a comprehensive account of the neurological, neurohumoral and psychologically-based hypotheses put forward. Although the exact mechanism of this treatment remains unclear, it is apparent that reproducible neurological and chemical changes occur in response to acupuncture, and that these changes almost certainly modify the response to, and perception of, pain. The mechanism of chronic pain is incompletely understood, but within this framework we understand acupuncture as completely as most other types of analgesic treatment. 1981 Knox, V. Jane; Gekoski, W. L.; Shum, Kit; McLaughlin, Deborah M. (1981). Analgesia for experimentally induced pain: Multiple sessions of acupuncture compared to hypnosis in high- and low-susceptible subjects. Journal of Abnormal Psychology, 90 (1), 28-34. Repeated trials with cold-pressor pain were used to (a) determine whether the modest relation between hypnotic susceptibility and response to acupuncture analgesia obtained in previous experiments is enhanced over a series of treatments; (b) compare acupuncture and hypnotic analgesias; and (c) assess whether acupuncture analgesia increases with repeated treatments. Twenty high and 20 low hypnotically susceptible subjects participated on 5 different days. For half of each susceptibility group, Sessions 1- 3 consisted of a baseline trial followed by an acupuncture analgesia trial. The remaining subjects had two no-treatment trials on each of these sessions. For all subjects Session 4 was a baseline followed by a hypnotic analgesia trial, and Session 5 was a repetition of the procedures followed in Sessions 1-3. Repeated exposures to acupuncture did not alter its analgesic effect in either susceptibility group; there were no instances of significant postacupuncture pain reduction. High susceptibles, but not low susceptibles, reported marked pain reduction after hypnotic analgesia. From these and previous findings it is concluded that the effect of acupuncture on experimentally induced pain is at best small and fragile. NOTES 1: NOTES: 8 of 10 highly hypnotizable subjects but only 3 of 10 low hypnotizable subjects thought hypnosis was more effective than acupuncture 1978 Mendelson, G. (1978). Acupuncture analgesia. 2. Review of current theories. Australian and New Zealand Journal of Medicine, 8, 100-105. An experiment was designed to evaluate the protective effects of different agents - acupuncture, hypnosis, Morphine, aspirin, Diazepam and placebo - upon experimentally-induced pain in humans. Twenty normal, healthy volunteers were subjected to cold water and tourniquet- induced pain and the protective effects of 35 minutes of hypnotic suggestion, electro- stimulation of both acupuncture points and non-acupuncture points, 10 mg/kg of Morphine, 5 grains of aspirin, 10 mg of Diazepam and a mild sugar placebo were evaluated. Data was collected on subjective evaluation of pain, EKG, EEG, respiration, skin temperature, peripheral vascular activity and EMG. A special study was also done to evaluate the effects of all the above agents on the somatosensory evoked potentials and EEG. The data were further analyzed on the basis of hypnotic susceptibility of the volunteers. The results indicated: 1) Hypnosis, acupuncture at specific sites with electrical stimulation and Morphine Sulphate had about the same reduction in experimental pain. 2) Hypnosis produced different effects from those resulting from acupuncture stimulation on EEG. 3) Acupuncture stimulation in specific loci resulted in a latency increase in the early secondary response on somatosensory evoked potential. 4) Cold water pain was remarkably reduced after true acupuncture point stimulation. 5) Tourniquet (ischemic) pain was reduced by both hypnosis and true acupuncture site stimulation. 6) Skin temperature was significantly reduced on the side of acupuncture points (true) stimulation. Ulett, George A.; Parwatikar, Sakashiv D.; Stern, John A.; Brown, Marjorie (1978). Acupuncture, hypnosis and experimental pain: II. Study with patients. Acupuncture and Electro-Therapeutic Research: International Journal, 3, 191-201. The experiment was designed to explore the correlation between the protective effects of hypnosis and acupuncture on externally induced short lived pain and to evaluate various data retrospectively in relation to acupuncture treatment responders and non-responders. Twenty patients with a history of chronic pain were subjected to cold water induced pain and the data on the effect of 35 min of hypnotic suggestion and 20 min of acupuncture stimulation on the pain and other physiological variables was gathered in a controlled setting. These patients had previously had acupuncture treatment. Eleven had benefitted from it in excess of 50% and nine had reported less than 50% improvement in their condition. Findings indicate: (1) acupuncture responsive patients experience less acute pain when such pain is induced externally. (2) hypnotic susceptibility and response to acupuncture are independent of each other and the former cannot be used as a predictor of acupuncture treatment success. (3) Hypnosis appears to have more definite and predictable protective effect than acupuncture. (4) Younger patients appear to have a better response to acupuncture treatment than do older patients. It is suggested that the research in acupuncture be furthered in view of the fact that acupuncture seems to have positive effect in certain patients. 1977 Berk, Stephen N.; Moore, Mary E.; Resnick, Jerome H. (1977). Psychosocial factors as mediators of acupuncture therapy. Journal of Consulting and Clinical Psychology, 45 (4), 612-619. This study investigated a number of psychosocial variables that have been suggested as possible mediating factors in acupuncture therapy. Forty-two volunteers with bursitis and/or tendonitis of the shoulder served as subjects. All were randomly assigned to one of four treatment groups: acupuncture - positive milieu, acupuncture - negative milieu, placebo acupuncture - positive milieu, and placebo acupuncture - negative milieu. Pretreatment and posttreatment subjective pain reports and shoulder motion studies, as well as pretreatment assessments of hypnotic susceptibility and suggestibility, were determined for each subject. Results indicated that (a) acupuncture and placebo acupuncture were equally effective in producing highly significant (p <.001) reductions in subjective pain reports; (b) neither treatment effectively improved objective shoulder motion; (c) subjects treated in the positive milieu reported more improvement than those in the negative milieu (p <.053); and (d) hypnotic susceptibility, suggestibility, belief in the treatment, and the satisfaction of expectations showed no relationship to treatment outcome. It is concluded that acupuncture therapy provides a powerful placebo. Treatment milieu variables warrant future study in the attempt to understand the acupuncture phenomena. Berk, Stephen N.; Moore, Mary E.; Resnick, Jerome H. (1977). Psychosocial factors as mediators of acupuncture therapy. Journal of Consulting and Clinical Psychology, 45 (4), 612-619. This study investigated a number of psychosocial variables that have been suggested as possible mediating factors in acupuncture therapy. Forty-two volunteers with bursitis and/or tendonitis of the shoulder served as subjects. All were randomly assigned to one of four treatment groups: acupuncture - positive milieu, acupuncture - negative milieu, placebo acupuncture - positive milieu, and placebo acupuncture - negative milieu. Pretreatment and posttreatment subjective pain reports and shoulder motion studies, as well as pretreatment assessments of hypnotic susceptibility and suggestibility, were determined for each subject. Results indicated that (a) acupuncture and placebo acupuncture were equally effective in producing highly significant (p <.001) reductions in subjective pain reports; (b) neither treatment effectively improved objective shoulder motion; (c) subjects treated in the positive milieu reported more improvement than those in the negative milieu (p <.053); and (d) hypnotic susceptibility, suggestibility, belief in the treatment, and the satisfaction of expectations showed no relationship to treatment outcome. It is concluded that acupuncture therapy provides a powerful placebo. Treatment milieu variables warrant future study in the attempt to understand the acupuncture phenomena. Stern, John A.; Brown, M.; Ulett, George A.; Sletten, Ivan (1977). A comparison of hypnosis, acupuncture, morphine, Valium, aspirin, and placebo in the management of experimentally induced pain. Annals of the New York Academy of Sciences, 296, 175-193. What general conclusions can we come to on the basis of these investigations? We conclude that hypnosis and suggestions of analgesia, morphine, and acupuncture stimulation (of LI 4, 14, and 15 on the arm exposed to painful stimulation) are effective in reducing experimentally induced pain. This is true for both a cold pressor pain-induction procedure and an ischemic pain-induction procedure. Hypnotic suggestibility does not account for the effectiveness of acupuncture stimulation, though good hypnotic Ss show better protection against pain with hypnotic suggestion and morphine. "Good hypnotic Ss experience more pain than is true for Poor hypnotic Ss when exposed to the same pain-induction procedure. The effect is more marked for the cold-pressor than the ischemic pain procedure. Good hypnotic Ss are more responsive -- i.e., show grater reduction in pain perception -- to drugs and intervention procedures that produce significant subjective sensations (morphine and diazepam) than is true of Poor hypnotic Ss. This is not true for aspirin and p0lacebo. Last, but not least, Ss low in hypnotic susceptibility tend to perceive painful stimuli as more painful when under the influence of diazepam as compared to the nondrug condition" (p. 192). 1976 Chaves, John F.; Barber, Theodore Xenophon (1976). Hypnotic procedures and surgery: A critical analysis with applications to 'acupuncture analgesia'. American Journal of Clinical Hypnosis, 18 (4), 217-236. Although hypnotic procedures are useful for reducing the anxiety of surgery and helping patients tolerate surgery, they do not consistently eliminate pain. Six factors that are part of or associated with hypnotic procedures help patients tolerate surgery. These factors pertain to patient selection, the patient-physician relationship, the preoperative 'education' of the patient, the adjunctive use of drugs, and the use of suggestions of analgesia and distraction. It appears that the same factors account for the apparent successes of 'acupuncture analgesia' as well. A frequently-overlooked fact, that most internal tissues and organs of the body do not hurt when they are cut by the surgeon's scalpel, is also important in understanding how surgery can be performed with either 'hypnoanesthesia' or 'acupuncture analgesia.' Moore, Mary E.; Berk, Stephen N. (1976). Acupuncture for chronic shoulder pain: An experimental study with attention to the role of placebo and hypnotic susceptibility. Annals of Internal Medicine, 84 (4), 381-384. One half of 42 Ss treated for painful shoulders received classic acupuncture, and one half received a placebo in which the needles did not penetrate the skin. Half of each of these groups was treated in a positive setting to encourage the subject, and half in a negative setting designed to keep encouragement at a minimum. All patients were independently rated for susceptibility to hypnosis. Although range of motion did not improve, the majority of patients reported significant improvement in shoulder discomfort to a blind evaluator after treatment; placebo and acupuncture groups did not differ in this respect, however. The positive and negative settings did not affect treatment outcome. In all groups, those who were not rated as highly susceptible to hypnosis tended to fail to achieve the highest levels of relief, but such differences were not statistically significant. NOTES: There were 42 subjects, and they were tested with the Spiegel Hypnotic Induction Profile. "Both acupuncture and placebo proved to be effective in relieving shoulder discomfort. 69% of the total group made lower assessments of discomfort on the post-treatment rating than on the pretreatment rating" (p. 382). "Acupuncture was not more effective than placebo in relieving discomfort, however. The average percentage of improvement among those who had acupuncture was not, statistically, significantly different from those who had placebo. Indeed, what little difference there was actually was in the opposite direction, the placebo group improving on the average somewhat more than the acupuncture group" (pp. 382-383). "In the negative setting, however, where the subject was required to suffer in silence, acupuncture seemed to be less effective than the placebo in relieving discomfort" (p. 383). "Although the subjects perceived that the treatment relieved their shoulder discomfort, there was no objective evidence of improvement in the shoulder as measured by change in the range of motion scores before and after treatment" (p. 383).