Tasks: spend 15 minutes discussing list of problems; 15 minutes discussing things like, “What is your spouse doing that doesn’t help; what can we do to help it?” We get drop in NKC cytotoxicity immediately afterward, returning after 24 hrs to usual levels. Controls don’t drop in NKC cytotoxicity. This measure of stress may be a predictor of survival time.
In Fawzy’s study of group therapy with melanoma patients, they noted a significant difference at 6 months in interferon augmented activity of NK, which didn’t hold up at a year. But at 6 years there were 10 of 40 deaths in control group vs 3 of 40 deaths in treated group. This is a vigorous effect.
Cohen’s study of colds in New England J. of Med is another good clinical study.
There are two broad areas of relevance of hypnotizability to healing: 1. Hypnotizability as a trait: do highs differ in way they regulate body or mind? 2. Is there something you do when in hypnotized state that is different? Studies of treatment of warts with hypnosis are important 3. Transition between states, e.g. circadian rhythms; is there a shift in wakefulness between trance and nontrance states that affects health?
Psychiatric Diagnosis and self regulation. High hypnotizability is associated with certain psychiatric disorders (dissociative reaction, PTSD, MPD, etc.). Schizophrenics score much lower than normals (av. = 4 vs 7; replicated with the Hypnotic Induction Profile (HIP). Stanford Hypnotizability Scales show no difference in means, but do show a difference in range). I don’t know what this means. But schizophrenics can falsely pass some Stanford Scale items, e.g. amnesia which they don’t however reverse; so schizophrenics’ hypnotizability scores may be inflated on Stanford scales. We don’t see extremely high scores in schizophrenics.
Psychoactive medication doesn’t affect scores of schizophrenics, but improves scores of anxiety neurotics (by reducing anxiety). Frischholz has an article coming out in a psychiatry journal that confirms this.
There is a lot of evidence that patients with dissociative disorders are more hypnotizable than other groups. Frischholz et al couldn’t replicate Frankel’s finding of higher scores in phobics. Pettinati et al found higher scores in bulimia and I haven’t seen anything to counter that. Another idea is that high hypnotizables are very good at internal regulation
Spiegel & Ken Kline selected Ss who could regulate gastric activity. They got an 80% increase in gastric acid output while imagining eating; got 40% decrease in output when imagining something pleasant that wasn’t imagining eating. Injected with pentagastrin, which induces gastric output, they still got a decrease in gastric acid output in the relaxation condition.
This suggests that hypnotizability should be a selection criterion for some research. See also Katz et al. 1974 (?) with acupuncture; and McGlashan, Evans & Orne on the placebo response.
Herbert Spiegel found that 2/3 of highs but 1/3 of lows were cured of phobia. Eye roll sign on the HIP, living with spouse/lover, rating self as hypnotizable, and giving a postcard follow-up response at one week post treatment were associated with 89% rate abstinence at 2 years follow-up, when only 23% overall of 223 were abstinent. Absence of those positive predictors was associated with only a 4% rate of abstinence.

Walker, Leslie G. (1992). Hypnosis with cancer patients. American Journal of Preventative Psychiatry & Neurology, 3, 42-49.

Overviews the uses of hypnosis with cancer, for example to ameliorate side effects of treatment, help patients adjust to having cancer and its symptoms, reduce the distress caused by painful procedures, and to attempt to alter mechanisms of immunity with a view to improving prognosis. Studies in these areas are reviewed.

Zachariae, Robert; Petersen, Kirstan S.; Simonsen, Carsten; Thestrup-Pederson, Kristian (1992, October). Effects of guided imagery and relaxation on natural killer cell activity in high and low hypnotizable subjects. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, Arlington, VA.

Author describes work done in Denmark with immediate and delayed hypersensitivity; hypnotically induced emotions and effect on [missed words] chemocytotoxicity (?). Now we are studying cancer patients, because it is popular to believe you can cure yourself with guided imagery and hypnosis.
First study used healthy subjects and was directed at several questions: 1. Do results in previous studies result from immune specific suggestions or from a general effect on homeostasis (like one gets with relaxation)? 2. Few studies consider hypnotizability or use highly hypnotizable Ss. Is hypnotizability a factor? 3. What changes can we expect? 4. To what extent can we determine what a healthy immune response is?
There were 120 undergraduate psychology students (81 female, 39 male), measured with Harvard Scale of hypnotizability. We selected 30 for 3 groups with 5 highs (9-12) and 5 lows (0-6) in each group. The Ss were randomized into 3 groups:
Guided imagery group: Ss were instructed in how guided imagery might affect the immune system. They experienced live, direct intervention with music, and with instruction to imagine the cells of the immune system becoming increasingly effective. Ss were given an audiotape to use 3 times/wk for 2 weeks.
Relaxation group: Ss were not given instructions re the immune system. Control group: Ss were sitting, reading newspaper, magazines. All groups came in on days 1, 8, 15 and 36 (the last time after a 3 week separation). Ss provided 3 blood samples each session.
Music was composed to go along with the imagery (when the suggestions said that cells were active, the music was active). Relaxation imagery was of their own choosing, with instructions to go to some place in nature and relax.
The fourth session was changed so that the relaxation group was given “an intelligence test,” which was a stressor. (They were told that anyone could do it, which wasn’t true.) The Control group listened to what the investigators felt was neutral music.
Results showed no difference in percentage of K cells between the three groups. There are differences within each day. The only difference was in the Relaxation group on the fourth day; with the stress test there was a slight increase.
We also looked at the percentage of increase or decrease. There was tendency for highly hypnotizables to show larger increases and decreases. In the Control group, highs and lows were opposite in this reaction: lows showed large decreases, but highs showed no decreases and no or small increases.
After the stress test the lows had an increase in NKCA; they are the ones responsible for the change seen in the stress condition.
We did another similar study, with 30 Ss but only 2 blood samples each day. We studied the response to PHA, measuring cpm 10 – 3. Controls don’t change, but the two other groups do. So we observed different lymphocyte proliferative response with different agents. Also, the control group that knows it is a control doesn’t show changes at the beginning.
CONCLUSIONS. 1. Effects may vary with the immune parameter measured. 2. The effects of immune specific imagery and relaxation are similar. 3. Changes may be due to a non-specific effect on general homeostasis.
Though costly and time consuming, further studies with a larger number of Ss are needed.
Karen Olness: We found a difference between hypnosis and nonspecific relaxation with children. Research in this area is very expensive, however.

Hajek, P. R.; Radil, T.; Jakoubek, B. (1991). Hypnotic skin analgesia in healthy individuals and patients with atopic eczema. Homeostasis in Health and Disease, 33, 156-157.

The cutaneous pain threshold was measured before, during, and after 10 sessions of hypnosis in 14 healthy and 13 atopic eczema patients. A control group of 10 healthy subjects who were not hypnotized was also evaluated. Cutaneous pain threshold increase was correlated with improvement of eczema and was correlated with hypnotizability.

Madrid, Antonio D.; Barnes, Susan v.d.H. (1991). A hypnotic protocol for eliciting physical changes through suggestions of biochemical responses. American Journal of Clinical Hypnosis, 122-128.

We employed brief hypnotherapy to effect physical changes in patients suffering from medical disorders including allergies, rectal bleeding, systemic lupus, hyperemesis, headache, asthma, and chronic pain. We present, in language appropriate to the individual patient, considerations and suggestions to effect the release of healing biochemicals. Ideomotor signals indicated the patient’s awareness of the healing. We hypothesize that the technique triggered novel state-dependent memory, learning, and behavior. NOTES 1:
NOTES: They hypothesize that the technique they use triggers novel state-dependent memory, learning, and behavior (See for example Rossi, 1987, and Rossi & Cheek, 1988).
Hypnotic Protocol: “1. Tell the patient that he can heal himself by allowing his body to supply its own biochemicals needed to make him well. If a specific biochemical is known, such as cortisone or endorphins, name it. “2. Hypnotize the patient. Resistant or hard to hypnotize patients need not be deeply hypnotized because the patients, using this protocol, will automatically go into trance while accomplishing the next task of accessing and using ideomotor signals (Erickson, 1980; Rossi & Cheek, 1988). “3. Tell the patient that his index finger will automatically and involuntarily twitch and float when his body releases the biochemicals he needs. This ideomotor response (Rossi & Cheek, 1988) is the sole physical response required of the patient. Rossi hypothesizes that the ideomotor response correlates with biochemical changes (Rossi & Cheek, 1988). “4. Next, ask the patient to consider some things (as described below). Present the considerations one after another until one of them triggers the ideomotor response. “5. In some instances, ask the patient to practice on his own. Many patients who have dramatic emotional reactions during or at the completion of the task may not need to practice on their own” (p. 123).
They present several ‘considerations’ to the patient, one after the other, tailored to the patient’s specific case, until his finger twitches or floats, indicating a biochemical response. For example, the following ‘considerations’ have been used: “1. Psychodynamic: ‘Consider that you are not blamed for anything; that you are in fact perfect just the way you are; that you are loved by those you care about.’ ‘Consider that you can forgive whoever needs forgiving for hurting you.’ ‘Consider that there are no longer any threats; everything is better; everything is as it used to be.’ “2. Autosuggestion: ‘Tell your body to heal. It knows what to do; so ask it to do it.’ ‘Tell your adrenal glands to produce the steroids that your body needs.’ ‘Allow a glowing light to permeate that injured back, filling it with healing energy.’ “3. Incompatible responses: ‘Cover yourself with a cool breeze, cooling the injured leg.’ ‘Imagine your back getting slack and limp and relaxed.’ ‘Imagine your stomach lining becoming smooth and moving with easy, ocean-like waves.’ “4. Emotion calling: ‘Consider yourself feeling very happy with everything, for no reason at all.’ ‘Consider yourself getting angry at someone–your mother, your wife (husband), your boss, your lawyer.’ “5. Bargaining: ‘Tell yourself that you will heal if you agree to stay away from that job.’ ‘Tell yourself you will heal by allowing your right arm to begin to hurt when you are over- exerting yourself.’ ‘Tell yourself that you will heal in exchange for something else, not so serious, to replace this disease and to serve the same function'” (pp. 123-124).
They present seven cases involving, respectively, allergies, rectal bleeding, systemic lupus, hyperemesis of pregnancy, adult onset asthma, chronic pain, and cluster headaches. Two cases were particularly interesting because they represented patients who did not respond initially.
Their procedure involves reframing the state or emotion originally associated with the onset of disease using considerations, and then giving a suggestion that it is within the power of the person, rather than factors outside, to heal the body. First they instruct the patient that the body can heal itself; then they give the list of suggestions for the patient to consider, persisting with different considerations until they get an ideomotor response. Incorporation of the patient’s psychodynamic issues appears to be very important.
The authors regard it as unimportant if the patient cannot by hypnotized; “As Cheek (Cheek & LeCron, 1968; Rossi & Cheek, 1988) points out, the patient’s inability to be hypnotized may be synonymous with his disease. It is actually beneficial if the patient cannot achieve ideomotor responses at first because both he and the therapist then trust the validity of the response when it does occur after the appropriate consideration” (p. 127).

Schumaker, John F. (1991). Human suggestibility: Advances in theory, research and application. New York: Routledge, Chapman, and Hall.

This book discusses suggestibility in relation to mental illness (e.g., MPD, anorexia nervosa), advertising, education, self-deception, forensics, political persuasion, and the biological aspects of the suggestion process (e.g., the effects of suggestion on the immune system).
Van Der Kolk, Bessel; Van Der Hart, O. (1991). The intrusive past: The flexibility of memory and the engraving of trauma. American Imago, 48, 425-454.
Describes the work of Janet concerning narrative versus traumatic memory, dissociation, and subconscious fixed ideas. Janet (1904) believed PTSD patients suffer from a phobia for the traumatic memory. Repression and dissociation are distinguished. Contemporary concepts of memory processing and the concept of schemas are then reviewed. Finally, a model is presented about how the mind freezes some memories. Evidence for the involvement of autonomic hyperarousal, triggering, and state dependent learning in PTSD is reviewed. They conclude that helplessness and the inability of the PTSD victim to take action (psychological and physical immobilization) facilitates dissociation. Includes practical ideas for the working through of trauma.

p. 443 “Traumatic memories are triggered by autonomic arousal … and are thought to be mediated via hyper-potentiated noradrenergic pathways originating in the locus coeruleus of the brain… The locus coeruleus is the ‘alarm bell’ of the central nervous system, which properly goes off only under situations of threat, but which, in traumatized people, is liable to respond to any number of triggering conditions akin to the saliva in Pavlov’s dogs. When the locus coeruleus alarm gets activated, it secretes noradrenaline, and, if rung repeatedly, endogenous opioids. These, in turn, dampen perception of pain, physical as well as psychological (van der Kolk et al. 1989). These neurotransmitters which are activated by alarm affect the hippocampus, the amygdala and the frontal lobes, where stress-induced neurochemical alterations affect the interpretation of incoming stimuli further in the direction of ’emergency’ and fight/flight responses” (p. 443).

Ader, Robert; Felton, David; Cohen, Nicholas (1990). Interactions between the brain and the immune system. In Cho, Arthur K.; George, Robert; Blaschke, Terrence (Ed.), null (30, pp. 561-602). Palo Alto, CA: Annual Reviews Inc..

(From the SUMMARY)
“Without attempting to cover all the literature, we have used stress effects and conditioning phenomena as illustrations to point out that behavior can influence immune function. We have also described data indicating that the immune system can receive and respond to neural and endocrine signals. Conversely, behavioral, neural, and endocrine responses seem to be influenced by an activated immune system. Thus, a traditional view of immune function that is confined to cellular interactions occurring within lymphoid tissues is insufficient to account for changes in immunity observed in subhuman animals and man under real world conditions.
“These data question seriously the notion of an autonomous immune system. … The immune system is, indeed, capable of considerable self-regulation, and immune responses can be made to take place in vitro. The functions of that component of adaptive processes known as the immune system that are of ultimate concern, however, are those that take place in vivo. There are now compelling reasons to believe that in vivo immunoregulatory processes influence and are influenced by the neuroendocrine environment in which such processes actually take place … . The immune system appears to be modulated, not only by feedback mechanisms mediated through neural and endocrine processes, but by feedforward mechanisms as well. The immunologic effects of learning, an essential feedforward mechanism, suggest that, like direct neural and endocrine processes, behavior can, under appropriate circumstances, serve an immunoregulatory function in vivo. Conceptually, the capacity to suppress or enhance immune responses by conditioning has raised innumerable questions about the normal operation and modifiability of the immune system via neural and endocrine processes.
“We do not yet know the nature of all the channels of communication between the brain and the immune system or the functional significance of the neural and endocrine interrelationships that have been established….
“This integrated circuitry has extensive ascending and descending connections among the regions cited. These regions also share many similarities. They are sites intimately involved in visceral, autonomic, and neuroendocrine regulation. The cortical and limbic forebrain regions mediate both affective and cognitive processes and may be involved in the response to stressors, in affective states and disorders such as depression, in aversive conditioning, and in the emotional context of sensory inputs from the outside as well as the inside world. From an immunologic perspective, these regions are the sites in which lesions result in altered responses of cells of the immune system; they are the regions that respond to immunization or cytokines by altered neuronal activity or altered monoamine metabolism; and they are the regions that possess the highest concentration of glucocorticoid receptors and link some endocrine systems with neuronal outflow to the autonomic and neuroendocrine systems. Thus, this circuitry is the major system of the CNS suspected to play a key role in responding to immune signals and regulating CNS outflow to the immune system” (pp. 587-589).

Andrews, Vivian H.; Hall, Howard R. (1990). The effects of relaxation/imagery training on recurrent aphthous stomatitis: A preliminary study. Psychosomatic Medicine, 52, 526-535.

Recurrent aphthous stomatitis (RAS) is one of the most common diseases of the oral mucosa. Although etiology remains unknown, immunological and emotional disturbances have been implicated in the pathogenesis of RAS. No consistently effective therapeutic regimen has been found. The present study investigates the voluntary modulation of RAS employing hypnosis-like relaxation/imagery training procedures. A multiple baseline design was used to evaluate change in frequency of ulcer recurrence. The role of psychological distress, ratings of perceived pain, and hypnotizability in the treatment of RAS were also examined. Results suggest that the relaxation/imagery treatment program was associated with a significant decrease in the frequency of ulcer recurrence for all subjects. Psychological distress was examined for relationship to ulcer recurrence and symptomatic changes with treatment, but no pattern was found. Finally, little support was found for the role of high hypnotic ability in the treatment of RAS.

Hajek, P.; Jakoubek, B.; Radil, T. (1990). Gradual increase in cutaneous threshold induced by repeated hypnosis of healthy individuals and patients with atopic eczema. Perceptual and Motor Skills, 70, 549-550.

Gradual increase in cutaneous pain threshold was found in healthy subjects and patients with atopic eczema during repeated hypnotic sessions with specific suggestions. This increase was less in the former than in the latter group. Repeated threshold measurements did not influence the threshold. The analgesic effect outlasted the hypnotic sessions by several months. It could be, however, suddenly reduced by appropriate hypnotic suggestion.

Cutaneous pain threshold was measured in “time in seconds from onset of heat source of defined size, distance from skin, and temperature, to subjective threshold percept of pain” (p. 549). Used two symmetrical locations on both forearms, at healthy areas of the skin. Ten hypnotic sessions were induced in each S three times weekly, each lasting one hour.
Suggestions were the following type: “The “conduction of switch to the brain is interrupted.” Your “immunologic system will digest the damaged skin cells like a shark.”
Subjects were 14 healthy subjects and 13 patients with atopic eczema treated for years with the usual medications, unsuccessfully or with complications.
There was gradual increase in cutaneous pain threshold across the 10 sessions, especially for the patient group. Control experiments with repeated threshold measurements in repeated sessions without hypnosis showed no changes.
“Time of increases in cutaneous pain threshold was associated with improvement of atopic eczema. Both effects correlated significantly (r = 0.8) with hypnotizability as measured by the Stanford scale” (pp. 549-550).
“In 9 patients without further hypnotic sessions a slow spontaneous decay of the cutaneous pain threshold was observed during a 17-mo. period. Special experiments performed with six repeatedly hypnotized healthy subjects showing increased thresholds did prove, however, that the cumulative analgesic effect could be reduced to control values immediately by using the hypnotic suggestion that the ‘skin sensitivity returns to normal values.’
“These results suggest a close association between hypnosis and activation and/or deactivation of endogenous analgesic systems (irrespectively whether they are of opioid or nonopioid nature)” (p.550)

Spanos, Nicholas P.; Williams, Victoria; Gwynn, Maxwell I. (1990). Effects of hypnotic, placebo, and salicylic acid treatments on wart regression. Psychosomatic Medicine, 52, 109-114.

Subjects with warts on their hands and/or feet were randomly assigned to a hypnotic suggestion, topical salicylic acid, placebo, or no treatment control condition. Subjects in the three treated groups developed equivalent expectations of treatment success. Nevertheless, at the six-week follow-up interval only the hypnotic subjects had lost significantly more warts than the no treatment controls. Theoretical implications are discussed.

Study involved 15 females, 25 males (18-35 yrs old) with warts on at least one hand or foot, recruited through posters and newspaper ads; N = 10 in each condition. Hypnotic treatment consisted of 10 minute induction (modified from T. X. Barber’s 1969 book) and a suggestion for wart regression that was 2 minutes in duration (the skin around warts was ‘beginning to tingle and grow warm’; ‘vividly imagine the warts shrinking and dissolving away’; 30 second break; repeated the suggestions). For Ss with warts on more than one limb the complete suggestion procedure was repeated for each wart-infected limb.
Results indicate psychological factors can influence course of some virally produced disorders; that self-medicating with over-the-counter products doesn’t explain suggestion-induced wart regression; that expectation of treatment success is the most important variable in psychologically induced wart regression. “Hypnotic subjects attained significantly higher CURSS:S scores than did control subjects. Nevertheless, it is unlikely that between group differences in hypnotizability accounted for the group differences in wart regression. Two previous experiments (3) that used the CURSS found that hypnotizability failed to predict wart loss in either hypnotic suggestion, nonhypnotic suggestion, or placebo treatments, and even in the present study the hypnotic treatment failed to differ from either the real or placebo treatment on CURSS:S scores, and none of the treatments differed significantly on the CURSS:O scores. Our finding and earlier findings that hypnotic subjects reported more intense suggested sensations than placebo subjects is consistent with the hypothesis that vivid suggested imagery facilitates wart loss (7, 8) .
“An alternative hypothesis emphasizes that only our hypnotic suggestion treatment encouraged subjects to see themselves as developing cognitive control over their own wart regression. This hypothesis suggests that subjects’ subjective sense of cognitive involvement in and control over treatment outcome (as opposed to the vividness of their suggested imagery) may have been the important psychological factor in wart regression. It would be of interest in a future study to manipulate subjects’ sense of cognitive involvement in their treatment independently of suggested imagery in order to assess the relative contributions of these variables to wart regression” (pp. 113-114).

Abelson, James L.; Curtis, George C. (1989). Cardiac and neuroendocrine responses to exposure therapy in height phobics: Desynchrony within the ‘physiological response system’. Behaviour Research and Therapy, 27 (5), 561-567.

Monitored subjective, behavioral, cardiovascular and neuroendocrine responses in 2 men (aged 19 and 34 yrs) with height phobias over a full course of exposure therapy and at 6 and 8 month follow-up. Both Ss showed rising cortisol responses and stable, nonextinguishing norepinephrine responses to height exposure over the course of treatment, while improvement occurred in subjective and behavioral response systems. They had differing heart rate responses. Despite desynchrony among anxiety response systems and within the physiological system at treatment conclusion, Ss had successful outcomes with general measures of change (phobia rating scales, the Fear Survey Schedule, and the SCL-90) showing substantial improvement for both Ss. These outcomes were preserved at follow-up.

Hall, Howard R. (1989). Research in the area of voluntary immunomodulation: Complexities, consistencies, and future research considerations. International Journal of Neuroscience, 47, 81-89.

It is speculated that the successful voluntary alteration of one’s immune functioning is a complex phenomenon associated with a number of possible factors. Evidence suggests the importance of prior experience in self-regulation and the role of practice, the ability of subjects to become relaxed and reduce sympathetic arousal, the importance of the nature and content of images, the complex role of hypnosis and hypnotizability, the importance of individual differences, and the choice of immune measures. Conclusions are drawn about the need for more experimental attention to these variables and future research with both experienced and inexperienced subjects.

Reid, S. (1989). Recalcitrant warts: Case report. British Journal of Experimental and Clinical Hypnosis, 6, 187-189.

Recalcitrant warts which persisted for 5 years despite treatment cleared in 51 days with hypnotherapy. A cause/effect relationship between hypnotherapy and resolution was shown by at first excluding and then including the left hand from the suggestions given.
Spiegel, David; Bloom, J. R.; Kraemer, H. C.; Gottheil, E. (1989, October 14). The beneficial effect of psychosocial treatment on survival of metastatic breast cancer patients: A randomized prospective outcome study. Lancet, 888-891.
The effect of psychosocial intervention on time of survival of 86 metastatic breast cancer patients was studied using randomized prospective design. The one-year treatment consisted of weekly supportive group therapy with training in self-hypnosis for pain management, and resulted in significant reductions in mood disturbance and pain. Both the treatment and control groups had routine oncologic care. At ten-year follow-up, only three of the original 86 patients were still alive, and death records were obtained for the other 83. Survival from the time of randomization and onset of intervention was 36.6 (sd = 37.6) months for the treatment group, compared with 18.9 (sd = 10.8) months for the control group, and this difference was highly significant (Z = 3.94, p <.0001) using the Cox life table regression model. Kaplan-Meier survival analysis indicated that the divergence in survival began at 20 months after entry into the study, or 8 months after the treatment intervention ended. These unexpected findings suggest that intensive psychosocial support affects the course of the illness, although the mechanism by which it does so is not clear. Zachariae, Robert; Bjerring, P.; Arendt-Nielsen, L. (1989). Modulation of type I mediated and type IV delayed immunoreactivity using direct suggestion and guided imagery during hypnosis. Allergy, 44 (8), 537-542. Cutaneous reactivity against histamine skin prick test (Type I) and purified tuberculin protein derivative (Mantoux reaction, Type IV) was studied in eight volunteers under hypnosis. Types I and IV immunoreactivity were modulated by direct suggestion (Type I) and guided imagery (Type IV). When the highly susceptible volunteers underwent hypnotic suggestion to decrease the cutaneous reaction to histamine prick test, a significant (P less than 0.02) reduction of the flare reaction (area of erythema) was observed compared with control histamine skin tests. The wheal reaction did not respond to hypnotic suggestion. Neither wheal nor flare reaction could be increased in size by hypnotic suggestion compared with control histamine skin-prick tests. A hypnotic suggestion of increasing the Type IV reaction on one arm and decreasing the reaction on the other revealed a significant difference in both erythema size (P less than 0.02) and palpable induration (P less than 0.01). In two cases the reactions were monitored by laser doppler blood flowmetry and skin thickness measurement by ultrasound. The difference between the suggested increased and decreased reaction was 19% for the laser doppler bloodflow (in favor of the augmented side), and 44% for the dermal infiltrate thickness. This study objectively supports the numerous uncontrolled case reports of modulation of immunoreactivity in allergic diseases involving both Type I and Type IV skin reactions following hypnotic suggestions. 1988 Colgan, S. M.; Faragher, E. B.; Whorwell, P. J. (1988, June 11). Controlled trial of hypnotherapy in relapse prevention of duodenal ulceration. Lancet, 1299-1300. 30 patients with rapidly relapsing duodenal ulceration were studied to assess the possible benefit of hypnotherapy in relapse prevention. After the ulcer had healed on treatment with ranitidine, the drug was continued for a further 10 weeks during which time patients received either hypnotherapy or no hypnotherapy. The two randomly selected groups were comparable in terms of age, sex, smoking habits, and alcohol consumption. Follow-up of both groups of patients was continued for 12 months after the cessation of ranitidine. After 1 year, 8 (53%) of the hypnotherapy patients and 15 (100%) of the control subjects had relapsed. The results of this study suggest that hypnotherapy may be a useful therapeutic adjunct for some patients with chronic recurrent duodenal ulceration. NOTES The aetiology of duodenal ulceration is poorly understood but it is probably multifactorial. ... Stress, both psychological and physical, has since been shown to affect gastric emptying and the secretion of acid and pepsin, but attempts to causally link stress and peptic ulcer disease have produced conflicting results. "Hypnotherapy can modify the response to betazole-stimulated gastric acid secretion, although the mechanism by which this is mediated remains unclear" (p. 1299). "The active [treatment] group received 7 sessions of hypnotherapy and were given an audio tape for daily autohypnosis; the other group were seen as often, but did not receive any hypnotherapy. The ranitidine was then stopped and both groups were reviewed every 3 months for a further year, with the active group receiving hypnotherapy at their follow-up visits. All subjects had an endoscopy at the end of the study, or sooner if a symptomatic relapse occurred. "Hypnosis was induced as previously described, with attention focused on the abdomen by the use of the patient's hand. They were asked to imagine warmth beneath the hand and to relate this to the control of gastric secretion. Reinforcement by visualization was used if the patient had this ability" (p. 1299). At the end of a year, on follow up, the patient relapse rate was 53% and controls relapse was 100%, a difference significant at p = 0.01. In their Discussion, the authors state, "This study shows that hypnotherapy is helpful in maintaining remission in those patients with duodenal ulceration who are particularly prone to relapse. ... In this model, hypnotherapy might operate at a variety of levels in the disease process: it could act in a nonspecific psychotherapeutic sense increasing 'coping' capacities and decreasing perceived stress. Alternatively, hypnotically induced relaxation may affect gastric acid secretion, and there is some experimental evidence for this. "The early relapse rate in the hypnotherapy subjects was similar to that of controls, but subsequently the curves showed a much greater separation. This finding could indicate that there is a subgroup of subjects who are particularly response to therapy. However, a detailed review of psychological and clinical parameters did not reveal any specific feature that could be used to predict a response to this form of treatment" (pp. 1299-1300). NOTES 2: Current etiology of duodenal ulcers includes the presence of bacteria Helicobacter pylori which is important in relapse. In order to compare treatments we must know what is the status of each group regarding the presence of this bacteria. Current treatment of duodenal ulcer includes metronidazole, amoxicillin and tetraciclin to kill it. [Editor's Note: This appears to be a critique of the research methodology rather than notes on the article itself.] 1987 Bongartz, Walter (1987, October). Influence of hypnosis on white blood cell count and urinary level of vanillyl mandelic acid. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, Los Angeles. NOTES They hypothesized that hypnosis benefits to immunology are due to alterations in white blood cell counts (WBC). Found that (1) blood samples before and after hypnosis with relaxation scenes led to significant decrease in WBCs compared to watching film of Mesmer or doing mental arithmetic, and (2) Vanillyl Mandelic Acid also was reduced. After physical exercise, video game, or reading, within 20', the WBCs return to pre-relaxation levels, i.e. they hadn't left the bloodstream. Key to understanding this result: only 50% of WBCs are in circulation, and others adhere to vessel walls; the experience of hypnotic relaxation leads to less sympathetic nervous activation and less epinephrine or hormonal response. WBCs also increased over a day period with mental arithmetic, but remained the same with hypnosis. This research is only preliminary and exploratory. Locke, Steven E.; Ransil, Bernard J.; Covino, Nicholas A.; Toczydlowski, Janice; Lohse, Christopher M.; Dvorak, Harold F.; Arndt, Kenneth A.; Frankel, Fred H. (1987). Failure of hypnotic suggestion to alter immune response to delayed-type hypersensitivity antigens. Annals of the New York Academy of Sciences, 496, 745-749. The ability to alter delayed-type hypersensitivity via hypnotic suggestion was tested in 12 highly hypnotizable, untrained subjects and 30 non-hypnotized controls. Subjects were skin tested bilaterally with a standardized panel of delayed hypersensitivity antigens and instructed either to enhance or suppress the skin test response (STR) unilaterally. Compared to controls, STR's showed no effect of hypnotic suggestion with regard to either the area of induration or the degree of inflammation assessed histologically. 1986 Crawford, Jeffrey Cleon (1986, February). The effects of hypnosis and imagery on immunity (Dissertation, University of Texas Health Science Center at Dallas). Dissertation Abstracts International, 46, 2800-B. "The present study explored the effects of hypnosis and imagery on Total T-Lymphocytes, T-Helper, T-Suppressor, Natural Killer Lymphocytes and level of Salivary IgA. Twenty-four volunteers (15 females and 9 males) between the ages of 23 and 41, with a mean age of 30, were assigned to an experimental or no-treatment control group in a modified random sequence. Participation was limited to individuals who were clinically free of disease, not using medication known to influence immunity, and scored above the mean on self-report pencil and paper measures of life stress (Life Experiences Survey and Stress Coping Rating Scale). Blood and saliva samples were obtained one day before, immediately before, one hour after, and eight days after a one hour hypnotic session. A relaxation induction, a variation of [H. R.] Hall's method, was utilized to induce hypnosis, and its effect measured by the Long Stanford Scale. The subjects were encouraged to imagine the cells of their immune systems multiplying and destroying pathogens. An adaptation of the IMAGE-CA was used to assess the effectiveness of the imagery. Finally, the experimental subjects were instructed in and asked to practice self- hypnosis and imagery twice daily for a week. The data were analyzed in six two-factor repeated measure analyses of variance, and Newman-Keuls tests were utilized to make multiple comparisons between the levels of Group and Time. The analyses produced no evidence for the confirmation of the overall hypothesis that the experimental group would increase in percent of T-Lymphocytes, percent of T-Helper cells, percent of Natural Killer cells and level of Salivary IgA, and decrease in percent of T-Suppressor lymphocytes. Post-hoc analyses revealed correlations that served as a basis for interesting speculation, but there was no revision in the overall conclusion that there was not evidence that hypnosis and imagery, as employed in this study, influenced in the selected measures of immunity. These results extend, but are not analogous, to the results of previously published studies using "fractional" measures of immunity" (pp. 3055-3056). Olness, Karen N. (1986, March). Hypnotherapy in children: New approach to solving common pediatric problems. Postgraduate Medicine, 79 (4), 95-105. Hypnotherapy, once thought of as magical and mysterious, is rapidly becoming accepted as an appropriate form of treatment for a wide range of disorders. Some primary care physicians are beginning to discover the value of hypnotherapy in controlling chronic disease and pain, in changing negative behavior, and in facilitating self- regulation of autonomic responses. Dr. Olness explores such use of hypnotherapy in children, the age-group that most readily acquires self-hypnosis skills and in which this technique has had dramatic results. Rogers, Malcolm; Reich, Peter (1986). Psychological intervention with surgical patients: Evaluation outcome. Advances in Psychosomatic Medicine, 15, 23-50. NOTES The Notes are a direct quotation of the authors' Conclusions. "There is well documented evidence that psychological and behavioral preparation prior to surgery can effect post-operative recovery. In almost all instances, except when patients are characterized by avoidance or denial defenses predominantly, the outcome results have been positive. The effect of interventions have been most consistently positive in reducing length of hospitalization and post-operative pain, but a variety of other improvements in affect and physiologic stability have been shown. As others such as Auerbach have pointed out [76], in all but a handful of studies different intervention approaches have been combined, making it impossible to sort out the specific effects of information, psychotherapeutic relationship, relaxation training, or suggestion given either with or without hypnosis. Indeed it is not only likely that each has had an effect, but there may also be synergistic effects. "More recent investigations have begun to include measurements of personality differences between patients so that the nature of the intervention can be more specific and appropriate to the individual's coping style. "The reduction in length of hospitalization alone (clearly shown to result from pre- operative psychologic preparation) argues forcefully on a cost benefit basis for the inclusions of careful pre-operative preparation. The reduction in pain is also of major importance, and may well reduce future avoidance behavior or post-traumatic disorders, although these latter potential outcomes have not been investigated. It should be kept in mind that there are also a number of studies which have failed to demonstrate the efficacy of psychological intervention on these outcome measures. Moreover, it is extremely difficult in studies of this nature to control adequately for the subtle effects on behavior of experimenter and subject expectation. "A few points can be made about future strategies in this field. The evidence accumulated to date suggests that all patients undergoing surgery or certain difficult procedures be given the option of pre-operative psychological preparation. The preparation should emphasize what the patient will experience and when, and how to cope with it, i.e., how to move, or breathe, or relax. Rapidly evolving audiovisual capabilities and hospital televisions connected by cable to health education channels will routinely offer such preparation in the future. Patients could choose or not choose to watch (thereby protecting mechanisms of denial). "Finally, future studies should focus on outcome measures uniquely important to a particular operation and also on longer term rehabilitation outcome measures. An example of the former might be post-operative sexual functioning after prostatectomy. A study by Zokar et al. [77] has shown that the likelihood of this post-operative function is correlated with not only the level of pre-operative anxiety and general 'life satisfaction', but also whether the patient received a pre-operative explanation of what to expect from the surgery" (pp. 45-46). 1985 Domangue, Barbara B.; Margolis, Clorinda; Lieberman, D.; Kaji, H. (1985). Biochemical correlates of hypnoanalgesia in arthritic pain patients. Journal of Clinical Psychiatry, 46, 235-238. Self-reported levels of pain, anxiety, and depression, and plasma levels of beta-endorphin, epinephrine, nor-epinephrine, dopamine, and serotonin were measured in 19 arthritic pain patients before and after hypnosis designed to produce pain reduction. Correlations were found between levels of pain, anxiety, and depression. Anxiety and depression were negatively related to plasma norepinephrine levels. Dopamine levels were positively correlated with both depression and epinephrine levels and negatively correlated with levels of serotonin. Serotonin levels were positively correlated with levels of beta-endorphin and negatively correlated to epinephrine. Following hypnotherapy, there were clinically and statistically significant decreases in pain, anxiety, and depression and increases in beta-endorphin-like immunoreactive material. Gottschalk, Louis A. (1985). Hope and other deterrents to illness. American Journal of Psychotherapy, 39, 515-524. Reviews animal and human research demonstrating that events during early development influence vulnerability to physical and mental illness. In addition, effectiveness of coping methods used to deal with problems of living can affect susceptibility to illness. The intervening mechanisms between stressful life experiences and illness appear to involve physiological homeostasis and immune competence. 1984 Achterberg, J. (1984, October). Cancer, immunology, psychological factors, and imagery. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, San Antonio, TX. NOTES Author developed a way of scoring imagery (which will be published in Imagery and Disease.). In terms of predicting who will die and who will survive, the content of the images doesn't seem to be as important as the quality (strength, vividness, etc.), which supports Bernauer Newton's (1984) findings. "The image seems to be a basic pre-verbal component of our species that has survival value." Hall, Howard R. (1984, October). Hypnosis, imagery, and the immune system. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, San Antonio, TX. NOTES Studied the relationship of hypnosis to immune functions, using imagery methods like the Simontons did with their cancer patients. Twenty normal volunteers were hypnotized and asked to imagine their white blood cells (WBCs) attacking weak germs like strong sharks would attack something, and they were told that the sharks would continue working after they came out of hypnosis (a post-hypnotic suggestion). They were asked to "feel it and experience it any way you can," to avoid emphasizing visual imagery too much. Then they were taught self hypnosis and sent home to practice twice a day for a week. Three blood measures increased after hypnosis: --B-cells increased with pokeweed stimuli (an allergen) for younger Ss, not older Ss --WBC's increased for highly hypnotizable Ss who were young, not for poor hypnotizable Ss or for any older Ss (Age range was 22-80.) --Lymphocyte count increased, approaching significance for highly hypnotizable Ss who were young but not for poor hypnotizable Ss or for older Ss. A personality test administered before the hypnosis, the SLC-90, suggested that the higher the distress level, the lower the lymphocyte count before hypnosis training. Two scores that summed up the distress level correlated -.49 and -.53, respectively. The psychological distress measured by the personality test decreased after the week of self-hypnosis practice. Of the two scores that summed up distress, one decreased for everyone (General Severity Index) and the other decreased only for highly hypnotizable Ss (Positive Symptom Total). Thus, a week of self hypnosis with imagining one's WBC's eating up weak germs in the blood led to both an increase in immune response indicators and a decrease in psychological distress. Psychological distress decreased as lymphocytes increased. Dr. Hall repeated these procedures with a small number of Ss who were told just to "lie down and rest" rather than being hypnotized and given instructions to imagine their WBC's increasing. None of the above changes occurred. However, he cautions that his research doesn't indicate whether the positive effects are due to relaxation, imagery, or hypnosis since all three were involved. Newton, Bernauer (1984, October). The use of imagery in the treatment of cancer patients. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, San Antonio, TX. Several hundred cancer patients were treated with the Simonton visualization method, with the additional factor that they were hypnotized for the visualization. In a long term follow-up study, those patients who were treated for at least 6 months and are still alive had imagery that was vivid, persistent, positive, and passive ("passive" here meaning an underlying sense of calm). Those who died had the opposite kind of images, and retrospective review of clinical notes indicates their aggressive images reflected desperation. Of the patients who were treated less than six months, a few lived. Their images also were vivid, persistent, and positive. Schneider, John; Smith, C. Wayne; Whitcher, Sarah (1984, October). The relationship of mental imagery to white blood cell (neutrophil) function in normal subjects. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, San Antonio, TX. NOTES Reports three studies in which normal healthy volunteers visualized various things happening with their white blood cells. He used imagery rather than hypnosis with college student volunteers who knew the goal of the study was to have people increase their white blood cell (WBC) count, and who thought they might be able to do it. Actually, the physiological model is that neutrophils increase, become sticky so that they stick to the blood vessel wall, and then insinuate themselves through the wall. So he did three studies to check out each aspect of the model. Study l: Author asked Ss to increase WBC's though his three goals actually were to decrease WBC count, increase stickiness, and [missed words]. The neutrophil count dropped significantly, and he interpreted that result as due to the fact that the increased number of cells had already moved through the vessel walls. Also, stickiness decreased (counter to prediction), and there was a negative relationship between imagery vividness and stickiness. The more people visualized "sticky" the less sticky the neutrophils became. He concluded they may have been too successful, as there had been a 60% drop in number of neutrophils (so perhaps the more successful neutrophils had left!) So he designed a second study, not to let the neutrophils leave the bloodstream. Study 2: Author asked the Ss not to decrease the WBC but to increase the stickiness of the cells. As a result, the neutrophil count did not change. In fact, adherence did increase. Imagery ratings correlated positively with adherence. Study 3: Author asked Ss to have their WBC's become less sticky, to leave the wall of the blood vessel and go into the blood. He found that stickiness decreased, but there was no increase in the number of WBC's though it was predicted. Imagery ratings correlated positively with adherence. Schneider concluded that neutrophil functioning (becoming sticky) can be affected by training and specific imagery, but that the relationship between imagining and the increase or decrease in WBC's is more complex. Relaxation decreases WBC's, imagery increases them, hyperventilating increases them. We don't know what biofeedback or hypnosis would do. (A discussant pointed out that WBC count depends on blood volume, which wasn't measured in either this group of studies or in Hall's study of hypnosis and imagery effects on WBCs.) 1983 Smith, Shirley J.; Balaban, Alvin B. (1983). A multidimensional approach to pain relief: Case report of a patient with systemic lupus erythematosus. International Journal of Clinical and Experimental Hypnosis, 31 (2), 72-81. A multidimensional approach to the relief of intense pain associated with a chronic, debilitating disease (Systemic Lupus Erythematosus) is illustrated in this case report. Techniques associated with behavioral therapy (deep muscle relaxation, systematic desensitization); hypnosis (trance states, guided imagery, age regression, anesthetic induction and transfer and auto-hypnosis); and psychodynamic psychotehrapy (dyadic interchange, suggestion, encouragement, interpretation of resistance and the transference/countertransference relationship) were utilized in obtaining virtual freedom from disabling pain and the necessity for analgesic and tranquilizing medications. Follow-up over a 3-year period demonstrated the utility of the approach.