Eastwood, John D.; Gaskaski, Peter; Bowers, Kenneth S. (1995, November). Frequency of pain reporting and analgesia: Exploration of a possible interaction. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, San Antonio, TX.

Two theories of pain control by hypnosis currently exist: 1. Socio-cognitive model – patient actively copes with noxious stimulus. Hypnotic analgesia should be like cognitive techniques like stress inoculation training. It requires deliberate effort. 2. Dissociative control model – pain reduction requires little cognitive effort.
These 2 theories have different predictions. He explains “ironic effects” theory, in which person must identify pain to reduce pain. Wagner’s reflexivity constraint: any process of mental control must be consistent with state we are trying to create.
This investigation involved 25 Highs and 24 Lows who reported pain, produced by strain gauge. Taught either hypnotic analgesia or stress inoculation. Reported every 5 sec (high load) or 45 sec (low load). Subtracted report from baseline to make pain reduction scores. Highs in hypnosis had no difference in pain reduction under high or low mental load. For the other 3 groups (Highs under stress inoculation; Lows under either hypnosis or stress inoculation) the results were different. That is, for Highs in hypnosis the mean of pain reduction scores was the same even when challenged by frequent reports of how much pain was being experienced.
Results are congruent with Miller and Bowers’ dissociative control model.
Wagner’s ironic process theory is useful. Frequency of pain reporting moderates Ss reports of pain in analgesia. These results challenge the cognitive social model of hypnotic analgesia and support a dissociative control model. Unlike stress inoculation, hypnotic analgesia does not require cognitive effort for high hypnotizable subjects.

Crawford, Helen J. (1994). Brain dynamics and hypnosis: Attentional and disattentional processes. International Journal of Clinical and Experimental Hypnosis, 42 (3), 204-232.

This article reviews recent research findings, expanding an evolving neuropsychophysiological model of hypnosis (Crawford, 1989; Crawford & Gruzelier, 1992), that support the view that highly hypnotizable persons (highs) possess stronger attentional filtering abilities than do low hypnotizable persons, and that these differences are reflected in underlying brain dynamics. Behavioral, cognitive, and neurophysiological evidence is reviewed that suggests that highs can both better focus and sustain their attention as well as better ignore irrelevant stimuli in the environment. It is proposed that hypnosis is a state of enhanced attention that activates an interplay between cortical and subcortical brain dynamics during hypnotic phenomena, such as hypnotic analgesia. A body of research is reviewed that suggests that both attentional and disattentional processes, among others, are important in the experiencing of hypnosis and hypnotic phenomena. Findings from studies of electrocortical activity, event-related potentials, and regional cerebral blood flow during waking and hypnosis are presented to suggest that these attentional differences are reflected in underlying neurophysiological differences in the far fronto-limbic attentional system.

Freeman, R.; Barabasz, A.; Barabasz, M. (1994, October). EEG topographic differences between dissociation and distraction during cold pressor pain in high and low hypnotizables. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, San Francisco

Hilgard once said we should study what is going on inside the skull when we study hypnotic behavior. Theta EEG was studied, in 3.5 and 5.5-7.5 band widths, based on Crawford’s research (no differences between high and low hypnotizables in low range but significant differences in waking state, eyes closed condition).
Also employed new type of distraction procedure. Previously used as comparison conditions things like imagine a pleasant scene, do whatever you can do to reduce pain, or imagine an instructor giving a lecture. Barabasz theorized that highs, given the opportunity, may spontaneously get involved in imagery; so distraction used in some experiments may actually become hypnosis. Here, distraction involved using a storage box, with plexiglass covering front, and 3 lights–subjects were to recall sequence of light changes that occurred during 60 sec when arm was in the cold water.
Cold pressor pain. 3 immersions with simultaneous pain reporting and EEG monitoring. –Waking State –Light array distraction –Hypnotic induction and suggested analgesia (Distraction and hypnosis with analgesia were presented in a balanced design)
Pain Ratings ranged from 0 = no pain, 10 = level would very much like to remove arm from water (rating could exceed 10 however). After removing arm, subjects were to report the maximum amount of pain that they had felt. Pain Scores were obtained at 30 seconds and 60 seconds after immersion in the cold water.
Also got qualitative data. During recovery period after each arm immersion, Subjects were asked what if anything they had done to reduce the pain felt.
30 second pain scores: Waking 7.60 vs 7.50 Distraction 8.60 vs 6.80 Hypnotic analgesia 7.80 vs 4.10 (Significantly different).
60 second pain scores: Showed same trend.
There was no difference whatsoever for the lows.
Results for the 2 EEG sites: P3 left hemisphere parietal in waking and hypnotic analgesia, high theta, had significantly different activity O1 left hemisphere in waking and hypnotic analgesia, was significantly different between highs and lows (same as above).
Results for two theta ranges: Low theta range, T4 temporal right hemisphere, for lows in waking and [missed words] condition–hard to interpret this finding.

Highs demonstrated pain reduction in hypnotic analgesia compared to waking and distraction conditions and compared to lows. Lows had no differences in any condition.
Enhanced EEG theta in left parietal area differentiated highs and lows. This suggests that highs generate enhanced disattention that may be controlled by these areas.
P3 area regulates the integration and association of somatic perceptions. The O1 area controls processing of visual imagery. Perhaps high hypnotizables have more ability to alter afferent sensory information through focused attentional processes. Also, the ability to alter the suffering portion of pain experience may involve visual imagery activity.
State and trait differences are apparent.
The low theta range may be more closely related to slower delta range 0-3.5 that is associated with sleep and drowsiness. High theta = low arousal and attention capacity. That’s why theta seems associated with wide range of behaviors that appear contradictory
The qualitative data shows highs reported they spontaneously preferred strategies that were more than distraction (associating colors with warmth, thinking of warm water) and the most frequent responses of lows were “nothing” or “told myself it would be over soon.”
Highs in analgesia condition used no specific strategy: 8/10 reported the arm simply felt more numb.

Kiernan, Brian; Dane, Joseph R. (1994, October). Hypnoanalgesia reduces new physiologic index of pain, the R-III Index, but the role of hypnotic susceptibility remains unclear. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, San Francisco.

Stimulated by work of Basil Finer, and following upon the Neodissociation theory of Hilgard; pain is registered by the body but dissociation that produces analgesia is a function of higher brain centers.
Could hypnotic analgesia be mediated lower, at the level of the spinal cord? Gate at dorsal horn could be open or shut; subject to descending modulation. Is hypnosis involved in descending modulation of activity in the dorsal horn?
Hypothesis: reduced pain intensity would be associated with reduced activity at dorsal horn. From Price & Barber, we wanted to look at affect and intensity aspects of pain. Polysynaptic reflex, R-III, latency consistent with conduction velocity (when hand touches a hot stove); even with severed spinal cord injury we still demonstrate the reflex. The magnitude of reflex is linearly related to the pain sensation. The stronger the electrical pulse, the greater the magnitude of the reflex. Magnitude of reflex is linearly related to subjective pain. It is an index of nociceptive activity.
Procedure: Evoke reflex with electrical stimulus at ankle; measure signal at muscle with EMG. We anticipated that at dorsal horn, descending modulation would dampen signal.
15 healthy volunteers. Sural nerve was stimulated. R III reflex measured via EMG response. Used the visual analogue scale (VAS) to assess pain.

Bejenke, Christel J. (1993, October). A clinician’s perspective. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, Arlington Heights, IL.

Presents point of view of a private practice anesthesiologist in Santa Barbara, California. Used hypnosis for 20 years.
Use of hypnosis as hypnoanesthesia is rare since Esdaile, with brief resurgence in 50’s, because surgery techniques advanced before anesthesias did in areas that were very risky. Now it is a matter of choice, and may be undertaken because of a patient’s extreme fear of anesthesia, previous bad experience with anesthesia, fervent belief in holistic method, allergy, or previous experience with hypnosis. Still advised to use hypnosis for MRIs, radiation procedures, former drug addicts (who may have problems with drugs), burn patients, release of neck contractions, and medical procedures–especially with children–like lumbar puncture.
She disagrees with Kroger’s estimate of only 10% of patients being able to use hypnoanesthesia; she does not believe it requires a lot of training, or profound muscle relaxation.
There is no indication of how many cases are actually done with hypnosis. Also, published cases are not representative of the quantity or complexity of cases; most published cases have a few extraordinary characteristics. The Irish surgeon Jack Gibson has done more than 4000 cases, some very complicated.
I have used it for D & Cs, and complex cases that were not published. Most of my patients elected to be alert during the hypnosis and conversed with their surgeons. The most common benefit is that recovery from anesthesia is not necessary; but these days with newer anesthesias recovery from anesthesia is rapid anyway. However, if as we suspect anesthesia affects immune function, that would be another reason to use hypnosis.
Preparation for surgery may be of three types: 1. formal hypnosis techniques 2. “hypnoidal” techniques that aren’t formal 3. unprepared patients in whom hypnosis is used at last moment.
Examples. 1. Formal hypnosis: This symposium deals with this type of approach. Three groups derive particular benefit — those requiring prolonged artificial ventilation postoperatively (because otherwise sedation must be used, which leads to complications), where prepared patients tolerate interventions calmly and comfortably — cancer patients, for whom this can be first experience of patient to see self as active participant in care rather than a victim of the illness and of complicated technology — pediatric patients. 2. Hypnoidal (hypnosis like) techniques: This is the most important application. Time doesn’t permit much discussion here. Patients are in an altered state when they come for surgery, highly suggestible, and suggestions appear to be as effective as during formal trance state. The doctor can elicit positive responses during “casual conversation” while seemingly giving information to the patient. (The reverse is true also, with inadvertent negative suggestions, to the detriment of the patient.) Scrupulous adherence to medical facts is important during this type of conversation.
Operating room fixtures are useful for focus of attention, and I have published this information in an article.
Recovery room also is place where case specific information and appropriate suggestions can be given. Patient can experience his ability to alter sensations, for the first time, following suggestions.
Remainder of the hospitalization offers opportunity for reinforcing case specific positive suggestions.
Bennett, Henry L. (1993, October). Hypnosis and suggestion in anesthesiology and surgery. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, Arlington Heights, IL.

He began by saying that he is opposed to using hypnosis for surgery, though he favors a theory of how hypnosis effects physiological change, and cites T. X. Barber’s classic “Changing Unchanging Bodily Processes.”
Relaxation puts patient in a “psychological strait jacket” because surgery is so highly stressful. He gives information “about how to go through the surgery more comfortably,” gets across the idea about coping style, tells them surgery is exertional and that they are tired afterward, that he can help them “using things you already know how to do,” and specifies exactly what they can do–using model of himself as a trainer.
In some recent research he used pairs of pictures, some of which lead to pupillary constriction (blood pressure goes down) or dilation (blood pressure goes up). Instructing them to look, patients looked twice as long at the pictures than they did during free gaze. When not instructed to look, heart rate went down; when told to look, heart rate went up. So the researchers went back to free gaze. He uses this as a metaphor for many of the pre- surgery preparation activities that encourage relaxation “inappropriately.”
He cites Cohen & Lazarus re vigilant copers, Price et al (1957), and some other studies on epinephrine effects. He uses examples of work patients may have done (e.g. planting a garden) when talking with patients prior to surgery, that gives them a sense of accomplishment later.
You have to give specific instructions or suggestion, not general relaxation suggestions.
Question from the audience: Can preoperative instructions (not hypnosis) diminish blood loss.
In Bennett’s answer he seems to be reporting the earlier study: they found 150- 4000 cc blood loss, high variability. Extent of blood loss was determined by extent of surgery, by instructions to patients vs no instructions.
This study was replicated by Enqvist, Bystedt, & von Konow in the Anesthesia conference at Emory University in 1992.
May 1993 Western Journal of Medicine article, Disbrow, Bennett, & Owinos, with 40 lower abdominal surgery patients who got specific instructions or not. The SHCS was used to measure hypnotizability: highs resolved quicker than low hypnotizable patients. They also found that instructed patients did better than those who did not get specific instructions.
There are now 3 replications of McClintock’s study: people use less medications after surgery, when tapes about rapid recovery are played *during* surgery.
Bennett is now using tapes with suggestions for recovery during surgery.

Blankfield, Robert P. (1993, October). Suggestion, hypnosis, and relaxation as adjuncts for surgery patients: Lessons from studies involving cardiac surgery patients. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, Arlington Heights, IL

The author stated that his research and the few other studies of cardiac surgery patients do not support idea that cardiac surgery patients benefit from hypnosis and suggestion.
Types of intervention have varied: hypnosis, suggestion, relaxation; pre-op, during, or post-op; with many different outcome variables.
Aiken & Henrichs (1971) study was nonrandomized, nonblinded, for 30 patients getting open heart surgery. Treated patients had benefits.
Surman, Hackett, Silverberg, & Behrendt (1974) had a randomized, single-blind design for 40 patients taught Self Hypnosis (S-H), for elective mitral valve surgery. No difference in benefits. But 45% of patients taught S-H reported a subjective sense of benefit (though objective indicators didn’t support that). [He says the difference between subjective/objective outcome ratings is important.]
Hart (1980) used randomized, single-blind design for 40 patients who had open heart surgery. No differences found except initial 3 days post surgery.
Greenleaf et al (1992) – see her paper presentation of this date.
Blankfield et al (presented at Society of Clinical and Experimental Hypnosis meeting in 1992) used a randomized, single-blind design for 95 patients, who were randomly assigned to taped suggestions, music, or controls. No differences were found in benefits.
Our data were re-analyzed: patients who felt tape was helpful were compared to the remaining 62 patients, but there again were no differences in amount of narcotics used for pain, though there was a trend in the right direction; nursing assessments failed to identify less anxiety.
The point is, whereas the bulk of publications suggest benefits, there is little evidence with this population. Could these patients be different in personality, ability to respond to intervention, amount of external stimuli? They should be studied because there are a lot of these patients with only a few surgeons and you don’t have to gain the cooperation of a lot of different surgeons to do this kind of research. Also, there is uniformity in cardiac surgery whereas standard operating surgery is in a state of flux in other areas (e.g. movement from generous incisions to micro procedures, and patients receiving this type of surgery remain in hospital for a week whereas this opportunity to study them during inpatient post-surgical period is disappearing in other areas). It is my opinion that cardiac patients may not be highly receptive to suggestion.
Curiously, according to Surman and my research, 1/2 the subjects report benefits. Either some benefits are subtle, or they are reporting a placebo effect.
Future studies need more patients, and the investigators must stratify on personality inventory variables such as Type A personality, hypnotizability, motivation, anxiety, depression, family support, social support systems. This is labor intensive, to determine which characteristics determine differing outcomes. The patients used in this type of research require more presurgery evaluation than previously has occurred.
The MMPI can be self administered and is widely acceptable, but is cumbersome, not well suited to people who are acutely ill. Assessment of Type A personality is important because Type A’s might be less receptive to suggestion. Structured interview is time consuming, but a 52-item questionnaire can be self administered. Other factors listed above are important.

Crawford, Helen J.; Gur, Ruben C.; Skolnick, Brett; Gur, Raquel E.; Benson, Deborah M. (1993). Effects of hypnosis on regional cerebral blood flow during ischemic pain with and without suggested hypnotic analgesia. International Journal of Psychophysiology, 15, 181-195.

Using 133Xe regional cerebral blood flow (CBF) imaging, two male groups having high and low hypnotic susceptibility were compared in waking and after hypnotic induction, while at rest and while experiencing ischemic pain to both arms under two conditions: attend to pain and suggested analgesia. Differences between low and highly-hypnotizable persons were observed during all hypnosis conditions: only highly-hypnotizable persons showed a significant increase in overall CBF, suggesting that hypnosis requires cognitive effort. As anticipated, ischemic pain produced CBF increases in the somatosensory region. Of major theoretical interest is a highly-significant bilateral CBF activation of the orbito-frontal cortex in the highly-hypnotizable group only during hypnotic analgesia. During hypnotic analgesia, highly-hypnotizable persons showed CBF increase over the somatosensory cortex, while low-hypnotizable persons showed decreases. Research is supportive of a neuropsychophysiological model of hypnosis (Crawford, 1991; Crawford and Gruzelier, 1992) and suggests that hypnotic analgesia involves the supervisory, attentional control system of the far-frontal cortex in a topographically specific inhibitory feedback circuit that cooperates in the regulation of thalamocortical activities.
Everett, John J.; Patterson, David R.; Burns, G. Leonard; Montgomery, Brenda; Heimbach, David (1993). Adjunctive interventions for burn pain control: Comparison of hypnosis and Ativan. Journal of Burn Care and Rehabilitation, 14, 676-683.

Thirty-two patients hospitalized for the care of major burns were randomly assigned to groups that received hypnosis, lorazepam, hypnosis with lorazepam, or placebo controls as adjuncts to opioids for the control of pain during dressing changes. Analysis of scores on the Visual Analogue Scale indicated that although pain during dressing changes decreased over consecutive days, assignment to the various treatment groups did not have a differential effect. This finding was in contrast to those of earlier studies and is likely attributable to the low baseline pain scores of subjects who participated. A larger number of subjects with low baseline pain ratings will likely be necessary to replicate earlier findings. The results are argued to support the analgesic advantages of early, aggressive opioid use via PCA or through careful staff monitoring and titration of pain drugs.

Anonymous (1992, May). Studies: Learning can occur while under anesthesia. Daily Breeze (South Bay, Los Angeles County).

“Surgical patients can absorb information while they’re knocked out, and even learn tips that help with recovery, researchers reported Friday at a symposium on memory and anesthesia.
“Researchers at Papworth Hospital in Cambridge, England, studied 51 cardiac patients, one-third of whom heard a tape of positive ‘therapeutic suggestions’ during surgery. Another third heard batches of word associations; the rest heard a blank tape.
“Patients who were played the suggestion tape – which told them they were doing well, or wouldn’t feel much pain – left the hospital 1 1/2 days earlier on average than other patients.
“Another study, from the University of Arizona College of Medicine, found that surgical patients who heard specific pain-relief suggestions recovered more easily than those hearing vague advice such as, ‘Think of being well.’
“‘These are still early days to invest in every operating suite buying a tape recorder to play for the patients,’ said Dr. Sunit Ghosh, a researcher with the Papworth team. ‘But this definitely does hold promise.’
“Scholars at the second annual Symposium on Memory and Awareness in Anesthesia said patients rarely wake up recalling – unprompted – something that happened during anesthesia.
“But several studies showed subconscious learning while the patients were out cold.
“Not everyone accepted the findings.
“‘It shows an enormous sensitivity on the part of the brain, if it can be shown,’ said Eugene Winograd, an Emory University psychologist and organizer of the Emory- sponsored conference. ‘I’m not confident it has been shown yet.’
“Some researchers in other studies found no association between messages heard during anesthesia and learning.
“Dr. Alan Aitkenhead, professor of anesthesia at the University of Nottingham in England, found no significant difference between patients who heard recuperative suggestions and patients who were treated to a deliberately dull history of the hospital where they were.
“Aitkenhead said his study kept all patients quite deeply anesthetized, and that may be why they might not have learned as much as patients in other studies.
“‘By far, most likely, it’s a difference in levels of anesthesia,’ he said.
“The Papworth researchers, in another study, found that some patients showed strong word associations after hearing tapes of groups of words during surgery; but other patients under a different anesthesia didn’t.
“‘There needs to be standardization of our testing,’ Ghosh said. ‘I think it’s partly related to the anesthesia technique and partly related to the way in which material is presented to the patient.’
Blankfield, Robert; Scheurman, Kathleen; Bittel, Sue; Alemagno, Sonia; Flocke, Sue; Zyzanski, Stephen (1992, October). Taped therapeutic suggestions and taped music as adjuncts in the care of coronary artery bypass graft patients. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, Arlington, VA.

18 studies have explored the issue with an experimental design; half used tapes, half didn’t; majority of studies found benefits; 2 were of heart surgery patients.
This study used taped suggestions with coronary bypass patients. Used tape recorder rather than person delivering suggestions because it was more convenient; used tape intra-surgery and post-operatively for more impact.
We hypothesized: shorter length of stay, less narcotic analgesia, less anxiety, faster recovery, more positive mental outlook, resume activities sooner, have less symptoms postoperatively, etc.
Used a prospective, randomized, single-blind trial in 2 community hospitals in Cleveland with coronary artery bypass graft surgery patients. Study was done between Dec 1989 – Feb 1992.
3 groups were involved: (1) Suggestion, (2) music, and (3) tape. Control subjects had a blank tape. Tapes were played continuously and repeatedly with headphones. Postoperatively, a different tape was played.
Excluded: Patients with emergent surgery, hearing impairment, poor comprehension of English, patients who died in hospital, patients whose hospital stay lasted longer than 14 days (3 of them). 5% of sample were eliminated for last 2 reasons.
Music: Herb Ernst, Dreamflight II. Suggestions: Music background, permissive, based on Evans & Richardson’s study.
Outcome Measures: Nurse assessment of anxiety and progress post operatively, Symptom scale, Depression scale.
Mean age 62, 3/4 men, 92% white, 75% married. The groups were same on a variety of preoperative variables (status of heart and arteries). Length of stay was 6.5 in all 3 groups. No difference in narcotics use, in nurse assessment of anxiety or of progress; of depression scale, or activities of daily living.
Recategorized data into patients who said the tapes were helpful (both music and suggestion) N = 33 vs the other patients N = 62. No difference in the variables evaluated.

Hajek, P.; Jakoubek, B.; Kyhos, K.; Radio, T. (1992). Increase in cutaneous temperature induced by hypnotic suggestion of pain. Perceptual and Motor Skills, 74, 737-738.

Eight patients with atopic eczema and six healthy subjects were given hypnotic suggestion to feel pain in the upper part of the back and in one case on the palm. An average local increase in skin temperature of 0.6 degrees centigrade (detected by thermovision) occurred under this condition. For some patients cutaneous pain threshold was increased before the experiment by means of repetitive hypnotic suggestion of analgesia. These subjects reported feeling no pain subjectively, but the local change in skin temperature was equal in both cases. The results suggest a central mechanism induced by measuring changes in pain threshold in the skin, which changes are independent of local changes in blood flow. Local pain in the middle of the upper part of the back, and in one subject for comparative purposes in the region of the right palm, was induced during a single hypnotic session by specific suggestion which emphasized a subjective feeling of local pain lasting for 6 minutes. In four of the eczema patients long-lasting cutaneous analgesia was induced before this experiment by a different suggestion which stressed the impossibility of conducting pain form the skin to the brain and which was repeated in ten consecutive hypnotic sessions. The spatial thermal reaction of the skin surface was monitored, with consecutive recordings taken at 20-sec. intervals before and after finishing the hypnotic suggestion of pain. There was a gradual increase in temperature (1.08 degrees Fahrenheit). In the four eczema patients with long-lasting cutaneous analgesia treated equally, the thermal reaction of the skin was similar to that described above although no subjective feeling of pain was reported. These subjects reported feeling only that their skin was getting warmer at the specified place.

Hargadon, Robin M.; Bowers, Kenneth S. (1992, October). High hypnotizables and hypnotic analgesia: An examination of underlying mechanisms. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, Arlington, VA.

Bowers’ dissociated control adaptation of Hilgard’s neodissociation theory of hypnosis posits that higher control systems are not used if lower systems are activated.
Imagery may be less important for achieving hypnotic effects. It also may contribute differently than previously thought, an uncorrelated factor. If imaginal involvement and imagery is integral to the production of analgesia using hypnosis, one would get results different than if not integral.
Research: 65 Ss rated as high on two hypnotizability tests participated.
Session 1:
Procedure entailed finger pressure pain: baseline, followed by 2 hypnosis treatment trials. Ss were not informed of the second trial before they did the first.
Standard suggestions: imagery congruent with the suggestion (hand like block of wood, protected by a glove)
Imageless condition: your hand will remain comfortably nonresponsive to the pressure; you will not allow other things to come into your mind.
Outcome Measures
Analogue scale for pain 0-10
Nonvoluntary experience rated 0-4
Session 2:
Administered Tellegen Scale, Woody & Oakman Scale, Marks Vividness of Imagery, Bowers’ Effortless Experiencing, and Duality of Experience during age regression.
No difference was found between the standard and imageless conditions in amount of pain reduced. So in high hypnotizables, use of imagery or not doesn’t matter for controlling pain. Some Ss had a clear preference however, for one or the other method (even counter to their own expectations).
Feelings of nonvolition did not differ as a function of imagery use.
Multiple regression showed effects of hypnotizability and effortless experiencing. Ss who have an effortless experiencing of imagery benefit from using it to reduce pain; those who find it more effortful do better without imagery when attempting to reduce pain.
Contrary to last year’s results reported by Bowers, high imagery was related to duality of experiencing in age regression.
Dissociated control theory is consistent with the results but not necessarily demonstrated. It is important to discriminate between imagery as a mediator rather than as a co-occurrence. This research suggests, as did Zamansky’s work on counter suggestions, that imagery is not as critical for hypnotic response as we previously thought.

Block, Robert I.; Ghoneim, M. M.; Sum Ping, S. T.; Ali, M. A. (1991). Efficacy of therapeutic suggestions for improved postoperative recovery during general anesthesia. Anesthesiology, 75, 746-755.

There have been claims that the postoperative course of patients may be improved by presentation during general anesthesia of therapeutic suggestions which predict a rapid and comfortable postoperative recovery. This study evaluated the effectiveness of such therapeutic suggestions under double-blind and randomized conditions. A tape recording predicting a smooth recovery during a short postoperative stay without pain, nausea, or vomiting was played during anesthesia to about half the patients (N = 109), while the remaining, control patients were played a blank tape instead (N = 100). The patients were primarily undergoing operations on the fallopian tubes, total abdominal hysterectomy, vertical banding gastroplasty, cholecystectomy, and ovarian cystectomy or myomectomy. The anesthesia methods consisted of either isoflurane with 70% nitrous oxide in oxygen to produce end-tidal concentrations of 1.0, 1.3, or 1.5 MAC; or 70% nitrous oxide in oxygen combined with high or low doses of opioids. Assessments of the efficacy of the therapeutic suggestions in the recovery room and throughout the postoperative hospital stay included: the frequency of administration of analgesic and antiemetic drugs; opioid doses; the incidence of fever; nausea, retching, and vomiting; other gastrointestinal and urinary symptoms; ratings of pain; ratings of anxiety; global ratings of the patients’ physical and psychological recoveries by the patients and their nurses; and length of postoperative hospital stay. There were no meaningful, significant differences in postoperative recovery of patients receiving therapeutic suggestions and controls. These negative results were not likely to be due to insensitivity of the assessments of recovery, as they showed meaningful interrelations among themselves and numerous differences in recovery following different types of surgery. Widespread utilization of therapeutic suggestions as a routine operating room procedure seems premature in the absence of adequate replication of previously published positive studies. (Key words: Anesthesia, depth: Awareness, Memory, Recall, Learning.)

Patients ages 19-55 were accepted into the study and they were paid for participation. (Older patients were excluded to guard against memory or hearing problems.) Other criteria for exclusion were: ASA physical status 4 or 5 indicating significant systemic disease, visual or hearing problems, middle ear disease (because it increases probability of nausea and vomiting), if their condition might require heavy sedation, if they were currently taking medication that interferes with memory (e.g. benzodiazepines, if there were intolerance to opioids, or if there were a likelihood of using postoperative pain treatment other than opioids.
The Spielberger State-Trait Anxiety Inventory was administered before surgery. Either suggestions (lasting 6 minutes) or a blank tape were played through headphones, starting 5 minutes after the surgical incision. The tape was played once for the first 59 patients, continuously for the remaining 150 patients. The first 139 patients received additional verbal materials on the tape, for memory tests to test possibility of learning under anesthesia. Operating room sounds were recorded by a tape recorder near the patient’s head, throughout period of unconsciousness (except when tape was being played).
After the first 25% of cases, the team decided that lack of effect on therapeutic suggestions attributable to type of anesthesia did not warrant restriction to a single anesthetic method; also, multiple presentations of the suggestions on tape did not show an effect different from a single presentation.
After the patient regained consciousness and was reoriented, pain, nausea, retching, and vomiting were assessed every 30 minutes. Pain was rated orally on a scale from 1 to 10 in the recovery room, then on visual analogue scales every 2 hours on the day of surgery and the second day, and every 4 hours on subsequent hospital days during waking hours. Variables that were rated by staff every 24 hours included: opioids, other analgesics, antiemetics, nausea, vomiting, retching, presence or absence of nasogastric tube, passage of flatus, bowel movement, fluid intake, solids intake, urination. Temperature was recorded every 4 hours for the first 2 days after surgery, and after that less often. The anxiety measures were repeated on Day 3 postsurgery, as well as self ratings and nurse ratings on physical and psychological recovery. Staff recorded length of postoperative hospital stay and reasons for any delay of discharge. Separate analyses were performed for patients receiving opioids via patient-controlled analgesia (52%) vs traditional administration (48%), but no differences were found for effects of therapeutic suggestions except on postoperative Day 8.
“The inability to detect beneficial effects of therapeutic suggestions probably was not due to insensitivity of the measures of recovery. These measures were sensitive enough to show numerous significant differences in recovery after different types of surgery” (p. 751). The authors supported their contention that the measures were sufficiently sensitive by demonstrating meaningful correlations among the measures themselves; and by demonstrating adequate statistical power for detecting the effects of theoretical interest–at least 1 day in postoperative hospital stay or one half day in fever.
Discussion: The authors note that a recent investigation that found positive results in a double-blind, randomized design with 39 hysterectomy patients (Evans & Richardson, 1988. Improved recovery and reduced postoperative stay after therapeutic suggestions during general anaesthesia. Lancet, 2:491-493) may not have controlled for variables such as presence of malignancy, physical status of patients before surgery, or ethnicity. Authors note that Evans and Richardson observed shorter periods of pyrexia despite there being no relevant suggestions, but no differences in pain intensity, nausea, vomiting, or urinary difficulties despite there being suggestions relating to those symptoms. There also were no differences in mood and anxiety test scores postoperatively for the experimental and control groups.
The authors note that McLintock, Aitken, Downie, & Kenny (Postoperative analgesic requirements in patients exposed to positive intraoperative suggestions. Br M J 301:788-790. 1990) reported a 23% reduction in opioids by patients receiving suggestions, but no reduction in pain, nausea, or vomiting. They contrast the present study with these earlier studies that had obtained positive results.
“We studied patients who had more than one type of surgery to obtain a large sample size and to assess the possibility that beneficial effects of therapeutic suggestions would be restricted to certain types of operations. Had this been the case, interactions of therapeutic suggestions with type of surgery would have been significant in the overall analyses, and follow-up analyses would have indicated that they were attributable to beneficial effects of therapeutic suggestions for certain surgeries. This did not occur. The two types of surgeries involving the largest numbers of patients seemed particularly promising for demonstrating beneficial effects. It has been reported that therapeutic suggestions presented during anesthesia are likely to be less successful with major and extensive surgery. Certainly, surgery on the fallopian tubes and gastric stapling did not involve a great deal of tissue trauma and blood loss. Patients were motivated to have the surgery and to recover quickly; particularly motivated were those having operations on the fallopian tubes, who were very eager to become pregnant, and those having vertical banding gastroplasties, who wanted desperately to lose weight” (pp. 753-754).
“In practice, we observed no beneficial effects of therapeutic suggestions, and there was no hint that anesthesia methods influenced the efficacy of the therapeutic suggestions. Interestingly, anesthetic methods also did not influence learning under anesthesia in the implicit memory tests we have used previously. Patients anesthetized with nitrous oxide and opioids did not differ from those anesthetized only with inhalational agents. In general, implicit or unconscious memory occurs in patients regardless of anesthesia methods or dosages of drugs” (p. 754).
“The few significant effects of therapeutic suggestions in our study did not point toward a beneficial influence of these suggestions. We found, in fact, an increased frequency of retching (but not nausea or vomiting) in the experimental group. The multiple variables examined in this study increased the likelihood of significant differences arising by chance, such that the null hypothesis was rejected when it should have been accepted. This is the way we interpret the effect on retching—i.e., as a type I error. We used in our therapeutic suggestions one negative or exclusionary sentence, ‘You won’t feel nauseous or have to vomit’, among several positive or affirmative statements, e.g., ‘You will enjoy eating, drinking…You will swallow to clear your throat and everything will go one way, straight down. . . The food will taste good….Your stomach will feel fine.’ We do not think that the negative sentence led to paradoxical results. Evans and Richardson (personal communication) used in their therapeutic suggestions a negative sentence (‘You will not feel sick’), which they repeated, yet the reported incidence of nausea and vomiting did not differ between the experimental and control groups” (p. 754).

Sensory and pain thresholds to laser stimulation were determined, and the laser-pain evoked brain potentials were measured for 8 highly hypnotizable (Harvard Scores 10-11) student volunteers in 3 conditions: (1) waking, (2) suggestion of hyperaesthesia during hypnosis, (3) suggestion of analgesia during hypnosis.
The investigators used a laser beam 3 mm in diameter, with a 200 msec stimulus duration; the same area (but different points within the area) was used for consecutive stimulations. Ss were otherwise maintained in low stimulus conditions so they would not have visual or auditory cues about laser beam onset; they wore goggles, had eyes shut, and had earphones on. Sensory threshold was defined as warmth; pain threshold was defined as a distinct sharp pin prick.
The laser intensity used for stimulation corresponded to strong pain. Interstimulus intervals averaged 15 sec (but were randomly varied between 10-20 sec). Sensory and pain thresholds as well as two evoked potential measurements were taken during waking , hypnotized hyperaesthesia, and hypnotized analgesia conditions in a single 1 1/2 hour session.
The evoked potential component of interest was the negative complex N1 with latency of 300 msec; amplitude (P1=N1-P2) and latency of this complex (N1) were measured. EEG epochs contaminated by eye movement were omitted from analysis.
The standardized induction and deepening of hypnosis required 15-20 minutes; then the suggestion was given that Ss could alter their perception of stimuli such as pain. Hyperaesthesia suggestions were to imagine the right hand was in very hot water, then taken out but still very red, hot, sensitive so that even the vaguest stimulus would be detectable and unpleasant. They were told that they would receive a series of painful but tolerable stimuli, and to raise the left index finger if they could just perceive a laser pulse (sensory threshold), and again if they felt pricking pain (pain threshold).
Suggestions for analgesia were to imagine that their right hand was placed on their chest, and that their ‘former right hand’ was no longer their own but was made of some heavy and completely insensitive material like wood or stone. Sensory and pain threshold measures were then taken. During the evoked potential measurement period they received continuous suggestions of analgesia. They also were told to relax and imagine they were in a pleasant place, ignoring everything except the pleasant, relaxed feelings and imagining pleasant sights, sounds, feelings and the imagined place. They were told that though they would receive stimuli, they probably would be able to ignore the stimuli completely.
Results were as follows.
1. In the hypnotic hyperaesthesia condition, sensory and pain thresholds decreased significantly by 47% and 48%, respectively. Three Ss reacted to laser intensities far below what normally can be perceived in the waking state. [The authors ran a separate small control experiment to make sure that the Subjects were not using any other cues, but mention the possibility of light-sensitive skin reacting to the blue laser light, creating evoked potentials.]
2. In the hypnotic analgesia condition, sensory and pain thresholds increased by 316% and 190%, respectively. 7 of 8 Ss did not even respond to pain threshold when the laser intensity was increased to the noxious level of 3W, which is the level at which tissue damage can occur.
3. Pain-related evoked potentials. Amplitude of the first pain-related potential was increased significantly by 14% in the hyperaesthesia condition and reduced significantly by 31% in the analgesia condition. Changes in the evoked potentials were considered minor however compared to those observed for thresholds, which are subjective response measures. Even in Subjects who reported complete analgesia, the experimenters observed the laser pain evoked responses. There were no differences in latencies of the first pain-related potentials for the three conditions (indicating that peripheral and central afferent conduction velocities were the same).
Discussion. “There has been some dispute concerning the experimental design and the reliability of the data obtained in studies dealing with hypnotic suggested analgesia [Spanos & Chaves, 1970]. In our design 2 ‘opposite’ conditions were induced, and the 2 inductions gave ‘opposite’ results.
“The experience of pain can be significantly altered by suggestions of analgesia, which is in accordance with a number of other studies (for review see [Barber & Adrian, 1982; Hilgard & Hilgard, 1975]). The finding that suggestions of hyperaesthesia can decrease the sensory and pain thresholds and increase the amplitude of the pain evoked potential is a new observation. Since synchronized auditory and visual stimuli from the laser were blocked, and the stimulus was given at random intervals, the changes might be induced by the hypnotic suggestions” (p. 247).
The authors discuss their results in terms of (1) four pain modulation systems (neural/opiate, hormonal/opiate, neural/non-opiate, and hormonal/non-opiate) and (2) focusing and defocusing attention. Because in their pilot study it was necessary to give suggestions continually in order to affect the laser evoked potentials, they conclude that endogenous substances or hormonal/non-opiates would play a minor role, if any, in hypnotic analgesia. (Price and Barber [25] had also found it important to give suggestions continuously.)
On the other hand, “event-related potentials [7, 26] and pain-related potentials have, previously, been shown to be sensitive to focused and de-focused attention. Recently, Miltner et al. [23] showed the influence of attention on the late pain-related component of potentials, evoked by painful intracutaneous electrical stimulation. The degree to which the subject paid attention to the painful stimulus had a powerful effect on the pain-related complex. When subjects ignored the pain, it was still possible to record the pain-related complex although all the subjects consistently reported less or no pain. In wakeful subjects where cutaneous pain was abolished by lignocaine infiltration, the pain-related evoked potentials were abolished [4]. In our study, we could also record evoked potentials although the subject subjectively did not feel pain. The reason might be that the S acted as if there was full analgesia to the stimuli, in order to satisfy the hypnotist. During suggested hyperaesthesia the thresholds declined below what normally could be perceived in the wakeful state. The volunteers could, therefore, not act hypersensitive, so something did happen.
“The discrepancy in subjective and objective responses might, however, be useful when investigating levels of the neuroaxis at which hypnosis might work” (pp. 248-249).
The authors note that this laser induced pain and the tooth pulp stimulation pain of Mayer & Barber both use the A-delta fibers. Barber & Mayer found it impossible to elicit pain within the output range of the stimulator (up to 150 microA) and reached maximal intensity for all volunteers during suggested analgesia. Using cutaneous laser stimulation the authors found that the skin damage level (3W) could be reached in 7 of 8 volunteers without any reaction of pain.
During the hyperaesthesia condition the sensory threshold was sometimes lower than can be detected in the waking state. Although some researchers have suggested that red light from a helium-neon laser might activate cutaneous photosensitive receptors and thereby elicit brain potentials, the authors were unable to elicit potentials in waking Subjects using their blue and green argon laser light with below sensory threshold intensity.
The authors also note that previous attempts to use physiological correlates of pain such as heart rate, blood pressure, respiration, and galvanic skin response have yielded confusing results. The physiological indicators are present even when Subjects report analgesia, leading some investigators to conclude that the subjective reports are due to illusion [Sutcliffe, 1961], compliance [Wagstaff, 1986], or a placebo induced by the hypnosis context [Wagstaff, 1986]. “These confusing results lead to the conclusion that both the traditional methods used for induction of pain and the monitored physiological responses have been unsatisfactory. The present study has sought to eliminate some of the methodological difficulties by (1) using brief well-defined argon laser stimuli which in awake volunteers induce very stable perceptions between trials [Arendt-Nielsen & Bjerring, 1988], and (2) recording psychophysical thresholds and objective parameters quantitatively related to the intensity of the pain perceived (1, 3)” (p. 249).

Harmon, Teresa M.; Hynan, Michael T.; Tyre, Timothy E. (1990). Improved obstetric outcomes using hypnotic analgesia and skill mastery combined with childbirth education. Journal of Consulting and Clinical Psychology, 58, 525-530.

Studied the benefits of hypnotic analgesia as an adjunct to childbirth in 60 nulliparous women. Subjects were divided into high- and low-susceptibility groups before receiving six sessions of childbirth education and skill mastery using an ischemic pain task. Half of the subjects in each group received a hypnotic induction at the beginning of each session; the remaining control subjects received relaxation and breathing exercises typically used in childbirth education. Both hypnotic subjects and highly susceptible subjects reported reduced pain. Hypnotically prepared births had shorter Stage 1 labors, less medication, higher Apgar scores, and more frequent spontaneous deliveries than control subjects’ births. Highly susceptible, hypnotically treated women had lower depression scores after birth than women in the other three groups. The authors believe that repeated skill mastery facilitated the effectiveness of hypnosis in the study.