Saperstein, Guy; Montgomery, Guy; Kirsch, Irving (1993, August). Cognitive-behavioral hypnotherapy: A meta-analysis. [Paper] Presented at the annual meeting of the American Psychological Association, Toronto, Canada.
Meta-analysis was used to compare the effectiveness of cognitive-behavior therapy (CBT) to that of cognitive-behavior therapy with hypnosis (CBHT). A review of the literature revealed 18 studies in which 20 hypnotic treatments were compared to similar non-hypnotic treatments and in which sufficient data were presented for the calculation of effect sizes. Effect sizes were weighted for sample size and then averaged. This resulted in a mean effect size of 1.37 standard deviation units, indicating that the average client receiving cognitive-behavioral hypnotherapy is better off than 90 percent of clients who receive the same treatment in a nonhypnotic context. Substantial variance in effect sizes was found, indicating the presence of a moderator variable. Further analyses indicated that this variance was limited to treatments in which obesity was the presenting problem. The mean effect size for the addition of hypnosis to treatments of obesity was larger (M = 1.98) and more variable (variance = 4.10) than that for the addition of hypnosis to treatments for other presenting problems (M = .52; variance = .06). Also, studies of clinical samples yielded larger effects (M = 1.72) than analogue studies with college student samples (M = .07). The effect of hypnosis was independent of whether relaxation training was included in the nonhypnotic treatment or whether the hypnotic treatment included suggestions that were not included in the nonhypnotic treatment. Consistent with response expectancy theory, these data indicate that the substantial positive effect obtained was due to labeling the treatment ‘hypnosis,’ rather than to any substantive change in clinical procedure. (ABSTRACT from Bulletin of Division 30, Psychological Hypnosis, Fall 1993, Vol. 2, No. 3.)
1992
Hollander, Ellen L.; Baw, Saul D. (1992, October). Improving outcomes in sex therapy through the use of hypnotic methods. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, Arlington, VA.
This is a report on the Cornell University Medical College Human Sexuality Program and Behavior Therapy Program. Cognitive-behavioral treatment is the principal approach in sex therapy these days (in contrast to insight treatment before 1954).
The authors find hypnosis to be useful in cases that were previously thought to be treatment refractory. Insensuality, inability to be absorbed, seems at the root of these problems. Hypnosis is useful for diagnosis and for developing task relevant immersion.
Three types of disorders: Desire phase Excitement phase Orgasm phase
Each phase has specific obstacles that can be elicited with a detailed interview: 1. Desire: anti-fantasy or the person focuses on unpleasant images 2. Excitement: performance anxiety or rumination about sexual potency (especially in men) 3. Orgasm: spectatoring or self-observation
Basic treatment strategy is to promote maintenance of absorption while dealing with the material that had been eliciting anxiety. In past we traditionally assumed absorption was present. Often this isn’t the case. It can be addressed with hypnotic methods. Conceptualized as a skill, hypnosis can improve the patient’s ability to shift from peripheral to focal awareness.
Reports in the literature address sexual dysfunction as one unitary phenomenon, using direct suggestions, anxiety/stress reduction techniques, metaphorical suggestions, ego strengthening devices, hypnoanalytic procedures to uncover the unconscious determinants of dysfunction.
devices, hypnoanalytic procedures to uncover the unconscious determinants of dysfunction.
Kirsch, Irving (1992, August). Cognitive-behavioral hypnotherapy. [Paper] Presented at the annual meeting of the American Psychological Association, Washington, DC.
The use of hypnosis to augment cognitive behavior therapy was described. Hypnotic inductions establish a context in which the effects of therapeutic interventions can be potentiated for clients with positive attitudes and expectancies toward it. Hypnosis can also provide a disinhibiting context for both clients and therapists, allowing them to behave in ways that are therapeutic, but that might seem awkward in other contexts. A meta-analysis of outcome studies in which the effects of a cognitive-behavioral treatment were compared to the effects of the same treatments supplemented by hypnosis resulted in a mean effect size of 0.87 standard deviations, indicating the average client receiving cognitive-behavioral hypnotherapy is better off at the end of it than more than 80 percent of clients who receive the same treatment in a nonhypnotic context. (ABSTRACT from the Bulletin of Division 30, Psychological Hypnosis, Fall, 1992, Vol. 1, No. 3.)
Patterson, David R.; Everett, John J.; Burns, G. Leonard; Marvin, Janet A. (1992). Hypnosis for the treatment of burn pain. Journal of Consulting and Clinical Psychology, 60, 713-717.
The clinical utility of hypnosis for controlling pain during burn wound debridement was investigated. Thirty hospitalized burn patients and their nurses submitted visual analog scales (VAS) for pain during 2 consecutive daily wound debridements. On the 1st day, patients and nurses submitted baseline VAS ratings. Before the next day’s wound debridement, Subjects received hypnosis, attention and information, or no treatment. Only hypnotized Subjects reported significant pain reductions relative to pretreatment baseline. This result was corroborated by nurse VAS ratings. Findings indicate that hypnosis is a viable adjunct treatment for burn pain. Theoretical and practical implications and future research directions are discussed.
The treatment of burn patients involves a number of very painful procedures, including frequent removal of necrotic tissue, application of anticeptics, and bandaging. “Dressing changes often present pain so severe that the maximum dosages of opioids, even when supplemented by anxiolytics or inhalants, are often inadequate (Everett et al., 1990; Perry et al., 1981)” (p. 713). Previous research on the use of hypnosis with burn pain patients demonstrates many of the limitations found in the literature on clinical hypnosis and pain: nonrandomization of samples, nonstandardized hypnotic inductions, unreliable pain measures, inadequate control groups, unreported levels of analgesias used.
The present research controls for experimenter/therapist attention as well as ‘expectancy’ of both patient and hospital staff. (Both patients and their nurses were blind to group assignment.)
Patients who rated their most recent dressing change as 5 or greater (on a 1-10 scale) were invited to participate and then were randomly assigned to one of three groups: hypnosis, attention/information (pseudo hypnosis), or no treatment control. Interventions began within three days of admission to the acute burn care unit (though some had previously been on an intensive care unit). The patients were continued on opioid medication during the two days of the study, and an attempt was made to keep medication dosage constant. On Day 1 the patients received opioid medication before the dressing change, and on Day 2 they received the same medication plus their assigned treatment.
Hypnosis – Induction was administered by psychologist in patient’s room before the dressing change. It was based on Barber’s Rapid Induction Analgesia, modified specifically for burn wound debridement as described by Patterson, Questad, and deLateur (1989), and required 25 minutes
Attention and information (pseudo hypnosis) – The psychologist told patients they would get hypnosis, then spent 25 minutes with them, during which time the psychologist took a history of the accident and their emotional response; educated them about burn pain; encouraged them to differentiate sensations felt during dressing changes from signals of harm or danger; and informed them that their “sensation” indicated the presence of viable tissue and was a sign of healing. Toward the end of the session, patients were told “we have found that it is useful to close your eyes, count to 20, and imagine yourself in a relaxing place prior to dressing change” and were given 30 seconds to practice the “hypnosis.” They were told after that brief practice session that the nurse would prompt them to begin hypnosis before their next dressing change by giving them some instructions and touch them on the shoulder.
No-treatment control condition – Patients received only the opioid medication.
“A standard set of instructions for dressing changes was given to the nurse for each S in the hypnosis and attention and information groups … (a) having the subject sit comfortably in the tank (or lie on the table), (b) instructing the S to picture the staircase and count from 1 to 20, (c) touching the subject on the shoulder four times during wound care, and (d) telling the subject to let the area being worked on ‘become relaxed and numb'” (p. 714).
No treatment control condition – Subjects received only opioid medication for both Day 1 and Day 2 dressing changes.
A Visual Analog Scale (VAS) for rating pain was used by both the patients and the nurses, within three hours of the dressing change.
-tive 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.
plus their assigned treatment.
Hypnosis – Induction was administered by psychologist in patient’s room before the dressing change. It was based on Barber’s Rapid Induction Analgesia, modified specifically for burn wound debridement as described by Patterson, Questad, and deLateur (1989), and required 25 minutes
Attention and information (pseudo hypnosis) – The psychologist told patients they would get hypnosis, then spent 25 minutes with them, during which time the psychologist took a history of the accident and their emotional response; educated them about burn pain; encouraged them to differentiate sensations felt during dressing changes from signals of harm or danger; and informed them that their “sensation” indicated the presence of viable tissue and was a sign of healing. Toward the end of the session, patients were told “we have found that it is useful to close your eyes, count to 20, and imagine yourself in a relaxing place prior to dressing change” and were given 30 seconds to practice the “hypnosis.” They were told after that brief practice session that the nurse would prompt them to begin hypnosis before their next dressing change by giving them some instructions and touch them on the shoulder.
No-treatment control condition – Patients received only the opioid medication.
“A standard set of instructions for dressing changes was given to the nurse for each S in the hypnosis and attention and information groups … (a) having the subject sit comfortably in the tank (or lie on the table), (b) instructing the S to picture the staircase and count from 1 to 20, (c) touching the subject on the shoulder four times during wound care, and (d) telling the subject to let the area being worked on ‘become relaxed and numb'” (p. 714).
No treatment control condition – Subjects received only opioid medication for both Day 1 and Day 2 dressing changes.
A Visual Analog Scale (VAS) for rating pain was used by both the patients and the nurses, within three hours of the dressing change.
Of 87 patients who met the inclusion criteria (for age, psychiatric and language status, and length of hospital stay) only 30 were in the final group. (31 had pain rating scores below 5; 13 declined to participate; 5 were in other investigations; 5 were not able to participate because of hypnotherapist unavailability; and 3 who began the study did not complete it. Those in the final subject group averaged 34.1 years old; mean total burn surface area was 16%.
No subjects in the placebo group questioned whether they had actually been hypnotized. Nevertheless, Experimenters did a manipulation check to determine whether the pseudo hypnosis group thought they were hypnotized. Subjects rated on a scale of 1-5 the extent to which they believed the hypnotic intervention was ‘effective’; means were 4.0 for hypnosis and 3.4 for placebo, a non-significant difference.
Pain medication was converted to morphine equivalents (MD) and was equivalent across the three groups.
“The hypnosis group reported a significant reduction in pain from pre- to posttreatment, whereas the attention and information and the no-treatment control groups did not change significantly … In addition, the hypnosis group had a significantly lower posttreatment pain rating than both the attention and information and the no-treatment control groups, which did not differ significantly” (p. 715).
“Nurses’ ratings of subjects in the hypnosis group showed a significant reduction in pain from pretreatment to posttreatment, whereas there were no significant pain reductions for the attention and information and the no-treatment control groups … The three posttreatment means did not differ significantly … [and] correlations between patient baseline and posttreatment pain ratings and those submitted by nurses were r (27) = .16, p = .423, for baseline ratings and r(27) = .29, p = .127, for posttreatment ratings” (p. 716).
In their Discussion, the authors note that patients’ reports evidenced more treatment effect than that of nurses. Also, they observed that the treatment effects might have been stronger if they had not been following a research protocol very strictly. “We might also mention that hypnotized subjects reported lower pain scores in spite of problems that they may have had in remembering the actual amount of pain they experienced. There is an increasing body of evidence suggesting that subjects have difficulty remembering clinical pain (Carlsson, 1983). Considering these factors, we feel that the treatment effect was a robust one” (p. 716).
The low correlation between nurses’ ratings and patients’ ratings is consistent with earlier reports that nurses are often unable to assess patients’ pain accurately (Choiniere et al., 1990; Iafrati, 1986; Walkenstein, 1982). The authors discuss why this might be, giving references. “Yet in this study, nurses [blind to group assignment] still reported a significant pain reduction for the hypnosis group” (p. 716).
“Our findings were consistent with theoretical approaches that argue that hypnotized subjects undergo an altered state–or at least a different form of cognitive processing–as opposed to a placebo effect” (p. 716).
“The question of whether hypnosis is superior to opioid pain medication, or can be used in its stead, was never addressed in this study. All subjects received opioids throughout hospitalization, including the study period. Our bias is that opioid drugs are the primary treatment of choice for burn pain. Attempting to replace opioids with hypnosis for the purpose of satisfying the hypnotist’s curiosity or convictions, while occasionally successful, may often result in unnecessary patient suffering” (p. 716).
-tings and those submitted by nurses were r (27) = .16, p = .423, for baseline ratings and r(27) = .29, p = .127, for posttreatment ratings” (p. 716).
In their Discussion, the authors note that patients’ reports evidenced more treatment effect than that of nurses. Also, they observed that the treatment effects might have been stronger if they had not been following a research protocol very strictly. “We might also mention that hypnotized subjects reported lower pain scores in spite of problems that they may have had in remembering the actual amount of pain they experienced. There is an increasing body of evidence suggesting that subjects have difficulty remembering clinical pain (Carlsson, 1983). Considering these factors, we feel that the treatment effect was a robust one” (p. 716).
The low correlation between nurses’ ratings and patients’ ratings is consistent with earlier reports that nurses are often unable to assess patients’ pain accurately (Choiniere et al., 1990; Iafrati, 1986; Walkenstein, 1982). The authors discuss why this might be, giving references. “Yet in this study, nurses [blind to group assignment] still reported a significant pain reduction for the hypnosis group” (p. 716).
“Our findings were consistent with theoretical approaches that argue that hypnotized subjects undergo an altered state–or at least a different form of cognitive processing–as opposed to a placebo effect” (p. 716).
“The question of whether hypnosis is superior to opioid pain medication, or can be used in its stead, was never addressed in this study. All subjects received opioids throughout hospitalization, including the study period. Our bias is that opioid drugs are the primary treatment of choice for burn pain. Attempting to replace opioids with hypnosis for the purpose of satisfying the hypnotist’s curiosity or convictions, while occasionally successful, may often result in unnecessary patient suffering” (p. 716).
Spanos, Nicholas P.; Simulates, Ann; de Faye, Barbara; Mondoux, Thomas J.; Gabora, Natalie J. (1992-93). A comparison of hypnotic and nonhypnotic treatments for smoking. Imagination, Cognition and Personality, 12, 23-43.
Three experiments administered variants of Spiegel’s (1970) smoking cessation procedure to smokers in hypnotic and nonhypnotic treatments. Follow-up periods were from twelve to twenty-four weeks depending on the experiment. Complete abstinence was an infrequent outcome in all three experiments. Greater-than-control reductions in smoking for treated subjects were obtained in two of the experiments but, in both cases treatment and control subjects failed to differ significantly before the end of the follow-up period. Hypnotic and nonhypnotic treatments produced equivalent smoking reductions in all studies, and neither hypnotizability nor questionnaire assessments of motivation to quit correlated significantly with treatment outcome. Implications are discussed.
When the experimenters compared number of treatments they simply compared two sessions of Spiegel’s one-session treatment with four sessions of it. The authors make the point that perhaps they should vary the four sessions.
“In all three of the present experiments the abstinence rates associated with the Spiegel treatment were very low. Our abstinence rates were similar to those reported in one earlier study [4 – Perry et al.], but substantially lower than those reported in three other studies [2, 22, 25]. The reasons for these discrepancies between studies remains unclear, but experiment 3 suggests that these discrepancies cannot be accounted for simply in terms of whether the subjects were drawn from a university or nonuniversity population, and experiment 2 suggests that the discrepancies are unrelated to the number of treatment sessions administered to subjects.
“The finding that hypnotic and nonhypnotic subjects in all three experiments attained equivalent reductions in smoking is consistent with other comparison studies in this area which indicate that hypnotic treatments are no more effective than various nonhypnotic procedures at inducing reductions in smoking [22, 25, 30]. More generally, these findings are consistent with comparison studies on a wide variety of clinical disorders (headache pain, warts, phobias, obesity) which indicate that hypnotic treatments are no more effective than nonhypnotic ones at producing therapeutic change (see [3] for a review).
“The failure to find significant correlations between smoking reduction and hypnotizability among treated subjects is also consistent with the findings of most studies in this area [3], but the reasons why significant correlations between these variables are found in some studies and not others remains unclear. Spanos [3] suggested that significant correlations between these variables are particularly likely when hypnotizability testing is integrated into the treatment protocol. Under these circumstances subjects are likely to form strong expectations about treatment success on the basis of their self- observed responses to the hypnotizability scale. Such expectations may, in turn, influence subjects’ motivations to comply with the treatment regimen, the self-statements they make concerning their likelihood of quitting, etc. In all of the present experiments hypnotizability was assessed at the end of the follow-up period and, therefore, could not influence subjects’ expectations of treatment success” (pp. 40-41).
1991
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.)
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).
-ach 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).
Evans, Frederick J. (1991). Hypnotizability: Individual differences in dissociation and the flexible control of psychological processes. In Lynn, Steven J.; Rhue, Judith W. (Ed.), Theories of hypnosis: Current models and perspectives (pp. 144-170). New York: Guilford Press.
“In summary, some of our recent data suggest that there are a number of interacting reliable correlates of hypnotizability … . None relate to suggestibility in the traditional sense. … Hypnotizability is related to the ability to process cognitive information during sleep, to the physiological ease of falling asleep, and to a dimension of subjective sleep characteristics we have labeled the ‘control of sleep’ (involving … the ability to fall asleep easily and readily at will, and the tendency to take naps). Additional data have suggested that the concept of absorption can be meaningfully divided into subfactors that reflect the volitional control over the absorption process that correlates with hypnotizability in both normal and patient populations. … (C)ontrolled absorption correlates significantly with hypnotizability in both normal and patient populations–a result that might be predicted from the concept of multiple pathways as correlates of hypnotizability (J. R. Hilgard, 1970). … Finally, both the control-of-sleep dimension and hypnotizability relate to the reductions of symptoms and psychopathology even when psychiatric patients are not treated with hynotic techniques” (pp. 164-165).
Haanen, Huub C.M.; Hoenderdos, Henk T.W.; Van Romunde, Leo K.J.; Hop, Win C.J.; Malle, Constant; Terwiel, Jack P.; Hekster, Gideon B. (1991). Controlled trial of hypnotherapy in the treatment of refractory fibromyalgia. Journal of Rheumatology, 18 (1), 72-75.
In a controlled study, 40 patients with refractory fibromyalgia were randomly allocated to treatment with either hypnotherapy or physical therapy for 12 weeks with followup at 24 weeks. Compared with the patients in the physical therapy group, the patients in the hypnotherapy group showed a significantly better outcome with respect to their pain experience, fatigue on awakening, sleep pattern and global assessment at 12 and 24 weeks, but this was not reflected in an improvement of the total myalgic score measured by a dolorimeter. At baseline most patients in both groups had strong feelings of somatic and psychic discomfort as measured by the Hopkins Symptom Checklist. These feelings showed a significant decrease in patients treated by hypnotherapy compared with physical therapy, but they remained abnormally strong in many cases. We conclude hypnotherapy may be useful in relieving symptoms in patients with refractory fibromyalgia.
The patients in this study were 38 women and 2 men, ages 30-65, who had had fibromyalgia for an average of 8.5 years (range 1.5 – 40 years). Of these, 25 were on sick leave or incapacitated, and 6 were unemployed. Patients were randomly assigned to hypnotherapy, or to training in muscle relaxation plus massage (designated “physical therapy”). They were withdrawn from analgesics, except for paracetamol (like Tylenol), at the beginning of this program. Hypnotizability was not measured.
Hypnosis treatment consisted of an
Hypnosis treatment consisted of an arm levitation induction, imagery deepening techniques, ego strengthening suggestions, and suggestions for control of muscle pain, relaxation, and improved sleep. Patients received eight one-hour sessions in decreasing frequency over three months; after Session 3 they were given a 30-minute audiotape to assist in daily self hypnosis. Seventeen patients completed hypnotherapy but three were dissatisfied and withdrew after 3 sessions.
Patients did self ratings on (1) duration of morning stiffness, (2) muscle pain, (3) fatigue on awakening, (4) sleep disturbance, and (5) global assessment, the last four using visual analog scales (VAS). Patient assessment at 12 and 24 weeks was the primary outcome measure, since fibromyalgia is diagnosed principally from patient’s self described symptoms.
Independent observers did not know to which group the patient belonged. The physician’s evaluation included (1) dolorimeter measures of point tenderness (for a Total Myalgic Score, TMS), (2) presence of tender points at 30 points, with 5 control points, (3) overall pain rating with visual analogue scale.
The Hopkins Symptom Checklist (HCL-90) also was used to evaluate outcome.
Using analysis of variance techniques and correcting for initial values, the study found significantly more favorable values in the hypnosis group than in the physical therapy group for muscle pain, fatigue on awakening, sleep disturbance, patient’s overall assessment, and HCL total score. However, differences were not significant for morning stiffness, physician’s overall assessment, or T.S. There were no differences between Weeks 12 and 24 for both groups; therefore the mean value for weeks 12 and 24 for each patient were used to calculate percentage change relative to baseline.
The reduction in pain medication used by the hypnosis group was quite remarkable. “Median (range) analgesic drug use at the initiation of the study (mostly paracetamol) was in the hypnotherapy group 3.0 (0-42) tabletsweek and in the physical therapy group 4.5 ( 0-21)/week. At Week 12 this was 1.0 (0-21) tablet/week for the hypnotherapy group and 7.0 (0-34) tablets/week for the physical therapy group. At the end of the study, 10 of 12 patients in hypnotherapy group and 3 of 12 patients in the physical therapy group had reduced their paracetamol use (Fisher exact test: p = 0.006)” (pp. 73-74).
Although it was observed that the total number of tender points decreased (regardless of treatment group), the Total Myalgic Score assigned by the physician had not changed either at week 12 or at week 24. In fact, even the control points were tender in 44% of the patients; most patients showed some pain response to a control point in one or two sessions of the three. “Only 12 of 40 patients had consistently nontender control points, 4 in hypnotherapy group and 8 in the physical therapy group. … No relation was found between the initial HCL total score and the changes in the other variables studied” (p. 74).
Figures taken from Table 2, showing percent change as compared to baseline:
Physical Therapy (%) Hypnotherapy (%) Morning stiffness (minutes) 0.0 -25.0 Muscle pain (VAS) -6.8 -10.2** Fatigue on awakening (VAS) -0.3 -16.7** Sleep disturbance (VAS) -1.0 -23.1** Overall assessment
patient -8.4 -33.2**
physician +5.7 -3.2 T.S. (kg/3 cm2) -11.1 -2.4 HCL total score -0.9 -13.0**
In their Discussion, the authors write, “In this controlled therapeutic trial in patients with refractory fibromyalgia hypnotherapy was more successful than physical therapy in improving complaints. The assessment of fatigue on awakening, sleep disturbance, muscle pain, the patient’s overall assessment and the total score of the HCL showed a significant decrease in the hypnotherapy group at the end of the hypnotherapy at 12 weeks. This decrease persisted for 3 months after finishing the hypnotherapy. The variables studied in the physical therapy group had not changed significantly at 12 and 24 weeks.
“However, the patients in the hypnotherapy group improved only subjectively. This improvement was not seen via more objective variables (T.S. and number of tender points), in accordance with others [Carette et al., 1986]. This suggests that coping with the disease may be positively influenced by hypnotherapy though the underlying disorder is still present.
“Correction of the sleeping disturbance by hypnotherapy was the most consistent finding and possibly played an important role in the subjective improvement of fibromyalgia” (p. 74).
The authors noted that the HCL yielded scores in the pathological range during the baseline period. “Thus, in our study, patients with long-standing fibromyalgia often showed pathological feelings of discomfort. In the hypnotherapy group the total score of the HCL decreased significantly suggesting that the physical disturbance may be secondary to long-standing fibromyalgia. It is worth noting that only 3 of the 57 questions on the HCL-90 concern fibromyalgia” (p. 74).
The authors express the opinion that their data do not support a distinction between fibromyalgia and psychogenic rheumatism [Simms, Goldenberg, Felson, & Mason, 1988; Campbell, Clark, & Tindall, 1983] based on pain reported at control points. “Most patients in our study had variable tender control points. The finding of tender control points in fibromyalgia is consistent with others [Wolfe, Smythe, Yunus, et al., 1990; Scudds, Rollman, Harth, & McCain, 1987]. Also we found a positive correlation between the number of tender points and the presence of tender control points. Therefore, it seems more likely that there is a fairly large overlap between fibromyalgia and psychogenic rheumatism (tender all over)” (p. 75).
after finishing the hypnotherapy. The variables studied in the physical therapy group had not changed significantly at 12 and 24 weeks.
“However, the patients in the hypnotherapy group improved only subjectively. This improvement was not seen via more objective variables (T.S. and number of tender points), in accordance with others [Carette et al., 1986]. This suggests that coping with the disease may be positively influenced by hypnotherapy though the underlying disorder is still present.
“Correction of the sleeping disturbance by hypnotherapy was the most consistent finding and possibly played an important role in the subjective improvement of fibromyalgia” (p. 74).
The authors noted that the HCL yielded scores in the pathological range during the baseline period. “Thus, in our study, patients with long-standing fibromyalgia often showed pathological feelings of discomfort. In the hypnotherapy group the total score of the HCL decreased significantly suggesting that the physical disturbance may be secondary to long-standing fibromyalgia. It is worth noting that only 3 of the 57 questions on the HCL-90 concern fibromyalgia” (p. 74).
The authors express the opinion that their data do not support a distinction between fibromyalgia and psychogenic rheumatism [Simms, Goldenberg, Felson, & Mason, 1988; Campbell, Clark, & Tindall, 1983] based on pain reported at control points. “Most patients in our study had variable tender control points. The finding of tender control points in fibromyalgia is consistent with others [Wolfe, Smythe, Yunus, et al., 1990; Scudds, Rollman, Harth, & McCain, 1987]. Also we found a positive correlation between the number of tender points and the presence of tender control points. Therefore, it seems more likely that there is a fairly large overlap between fibromyalgia and psychogenic rheumatism (tender all over)” (p. 75).
Holroyd, Jean (1991). The uncertain relationship between hypnotizability and smoking treatment outcome. International Journal of Clinical and Experimental Hypnosis, 39, 93-102.
Literature on the relationship between hypnotizability and smoking treatment outcome was reviewed. 91 private patients treated for smoking with hypnotherapy participated in an investigation designed to correct problems in some of the earlier research. 43% quit smoking by the end of treatment but only 16% abstained at least 6 months. Neither immediate quitting nor continued abstinence correlated with hypnotizability. Other variables hypothesized to predict smoking cessation also were not correlated with outcome: number of treatment sessions, need to smoke, motivation to quit, and gender. The low abstention rate may have impeded verification of a relationship between hypnotizability and treatment outcome.
In the Discussion, the author notes that the low overall abstention rate works against finding the predicted relationships, as did restricted range on the hypnotizability measure. “Secondly, the present research design in effect tested the potency of hypnosis (hypnotizable patients) against nonhypnotic treatment (nonhypnotizable control patients) in a research design recommended by Orne (1977). Intensive nonhypnotic involvement with the nonhypnotizable individuals over several sessions may have worked against finding differences between low and high hypnotizables” (p. 99).
“Patients generally did not complete the recommended four sessions … and they generally were non-adherent to recommended follow-up telephone contact. The observed relationship between initial quitting and number of treatment sessions may exist because people who are responding to treatment
to treatment stay in treatment longer, or because more treatment sessions provide a more potent intervention, or both” (p. 99). “Treatment contracts between patients and therapist increased the number of sessions that patients completed but did not increase their abstinence rate” (p. 100).
Millis, P. M.; Rooimans, W.; Spierings, E. L.; Hoogduin, C. A. (1991). Treatment of chronic tension-type headache with hypnotherapy: A single-blind controlled study. Headache, 31, 686-689.
Compared effectiveness of a special hypnotherapy technique with chronic tension headache with a waitlist control group. There were significant reductions (p<.05) in number of headache days, hours, and intensity. Improvement was confirmed by subjective evaluation and questionnaire data showing a significant anxiety scores (p<.01). Miller, Mary Frances; Barabasz, Arreed F.; Barabasz, Marianne (1991). Effects of active alert and relaxation hypnotic inductions on cold pressor pain. Journal of Abnormal Psychology, 100 (2), 223-226. Contrasted relaxation and active alert hypnotic inductions with or without a specific suggestion for cold pressor pain analgesia. Groups of high (n = 38) and low (n = 27) hypnotizability subjects were tested; hypnotizability had been determined from results of the Stanford Hypnotic Susceptibility Scale, Form C. Cold pressor pain data were obtained after counterbalanced exposure to relaxation and active alert inductions. Highly hypnotizable subjects demonstrated lower pain scores than did low hypnotizability ones. Pain reports did not differ between induction conditions. Highly hypnotizable subjects given an analgesic suggestion showed lower pain scores than did those exposed only to hypnosis. The findings, conceptualized within E. R. Hilgard''s (1977a) neodissociation theory, show that relaxation is not necessary for hypnotic analgesia. The relaxation induction was the SHSS, Form B. The active alert induction used the same instructions except suggestions for alertness, invigoration, and freshness were substituted for drowsiness and relaxation. During the active alert induction, the subjects rode a bicycle ergometer at a constant load of 1-3 kg and a constant rate of 1-2 rotations per s (Banyai & Hilgard, 1976). Primavera, J. P.; Patterson, S. (1991). A tape-recorded test of hypnotic susceptibility for screening headache patients: A feasibility study of the Harvard Group Scale of Hypnotic Susceptibility, Form A. Headache, 31, 619-621. In 9 chronic, daily headache patients, compared with 10 control subjects, results did not suggest a correlation between hypnotic susceptibility and reduction of headache pain. Rapkin, David A.; Straubing, Marsha; Holroyd, Jean (1991). Guided imagery, hypnosis and recovery from head and neck cancer surgery. International Journal of Clinical and Experimental Hypnosis, 39, 215-226. The value of a brief, preoperative hypnosis experience was explored with a sample of 36 head and neck cancer surgery patients. 15 patients volunteered for the experimental hypnosis intervention. 21 patients who received usual care (no hypnosis) were followed through their hospital charts and were used as a comparison group. Hypnotic intervention and usual care groups were comparable in terms of relevant demographic variables. Postoperative hospitalizations for the hypnotic intervention group were significantly shorter than for the usual care group. Within the hypnotic intervention group, hypnotizability was negatively correlated with surgical complications and there was a trend toward a negative correlation between hypnotizability and blood loss during surgery. Findings suggest that imagery-hypnosis may be prophylactic, benefitting patients by reducing the probability of postoperative complications and thereby keeping hospital stay within the expected range. Recommendations are presented for a controlled, randomized, clinical trial with a sufficiently large sample to provide the opportunity for statistical analysis with appropriate power. Actual stay in hospital, post-surgery, was 8.7 days (SD = 3.7) for the Hypnosis group and 13.9 days (SD = 9.7) for the Usual Care group; the range was 3-17 days for the Hypnosis group and 5-42 days for the usual care group. The hypnosis script included an indirect, permissive induction; positive suggestions for relaxation and healing imagery; images of calm situations that would lead to expectation for healing (e.g. a 'healing pool'); suggestions for patients to develop their own images of pleasurable, comforting situations. The only direct suggestions were for minimal blood loss during surgery, modeled after those given in the waking situation by Bennett, Benson, and Kuiken (1986). As measured by the Stanford Hypnotic Clinical Scale, there were five highly hypnotizable patients (scores 4-5), six mediums (scores 2-3), and four lows (scores 0-1). "Hypnotizability correlated negatively with complications (r = -.54, p<.04, two-tailed test). There was a trend toward a negative correlation with length-of-stay (r = -.37, p<.18, two-tailed test) and estimated blood loss (r = -.40, p<.15, two-tailed test). Note that these correlations represent moderate to large effects, and the significance levels are due in part to low power associated with a small N (Cohen, 1988). The means for blood lost during surgery for the three hypnotizability groups were: highs = 904 cc, mediums = 1465 cc, and lows = 2056 cc" (p. 222). Data on cost could not be published in this article but later was published in a letter to the Editor of the Newsletter of the Society of Clinical and Experimental Hypnosis (February 1994, Vol. 35, No. 1, p.8). "The average savings for the intervention group was $6,725. While this difference fell short of statistical significance on the Wilcoxon test (Z=- 1.5402, p < .10), it is rather striking on its face. The range actually was $7849 to $27,782 for Intervention Group patients and $9,390 to $53,627 for Usual Care group patients. "In 1990 a semi-private room at UCLA Center for the Health Sciences cost $405 to $529 per day, depending on quality; standard ICU care (one nurse for two patients) was $1236 per day, and more intensive care (one nurse for one patient) was $2471/day. Head and neck surgery patients may remain in the ICU, driving up costs, solely because they have not learned to suction their own tracheostomies, usually a motivational factor that might be affected by hypnosis. UCLA is a tertiary care hospital in a high-cost area (and is therefore reimbursed at higher rates than many other hospitals), and costs may be driven up by the many additional procedures required for long-stay patients. Therefore the cost savings could not be expected to be as great where expected length of stay is brief, ICU use is limited, and community costs are lower" (p. 8). Schwarz, Shirley P.; Blanchard, Edward B. (1991). Evaluation of a psychological treatment for inflammatory bowel disease. Behaviour Research and Therapy, 29 (2), 167-177. Compared the effectiveness of a multicomponent behavioral treatment package, which included inflammatory bowel disease (IBD) education, progressive muscle relaxation, thermal biofeedback, and training in use of cognitive coping strategies, with the effectiveness of symptom-monitoring as a control condition. The treatment group consisted of 11 IBD patients (aged 25-62 yrs); 8 of 10 persons (aged 25-71 yrs) in the control group completed treatment. At posttreatment, the treatment group showed fewer reductions in symptoms (5) than the symptom-monitoring controls (8). However, treated Ss perceived themselves as coping better with IBD and as feeling less IBD-related stress. It is hypothesized that the differences in treatment responses may be related to differences between Ss with ulcerative colitis and Ss with Crohn's disease. 1990 Fromm, Erika; Kahn, Stephen (1990). Self-hypnosis: The Chicago paradigm. New York: Guilford Press. In addition to extensive research on self hypnosis, this book refers to a number of clinical investigations that involved self hypnosis with patients, as at least part of the treatment protocol: 1. J. R. Hilgard & LeBaron (1984) 34 patients, ages 4-1, with cancer pain 2. Spinhoven (1989) headache control; low back pain 3. Wakeman (1988) 50 patients with third degree burns (helping half of them to return to work in high temperature environments) 4. Katz, Kellerman, & Ellenberg - 36 children with acute lymphoblastic leukemia who needed to undergo bone marrow aspirations 5. Spiegel & Bloom (1983) - 54 women with metastasized carcinoma of the breast 6. Wark (1988) improving reading comprehension - 7 students 7. Aronson (1986) adolescent psychiatric inpatients 8. Swirsky-Sacchetti & Margolis (1986) severe hemophiliacs, reducing Factor VIII (the coagulant deficiency of hemophilia A) 9. Kohen, Olness, Colwell, & Heimel (1984) - 505 pediatric patients with a variety of problems (enuresis, pain, obesity, anxiety reactions, habit problems, encopresis, headache, fear of pelvic examinations) 10. Anderson, Basker, & Dalton (1975) - migraine patients 11. Hammond, Watkins-Bartch, Grant, & McGhee (1988) compared self-directed and tape-assisted self-hypnosis in 48 Ss Plus many papers with single cases or just a few cases. Prior, A.; Colgan, S. M.; Whorwell, P. J. (1990). Changes in rectal sensitivity after hypnotherapy in patients with irritable bowel syndrome. Gut, 31, 896-898. Fifteen patients with irritable bowel syndrome were studied to assess the effect of hypnotherapy on anorectal physiology. In comparison with a control group who received no hypnotherapy, significant changes in rectal sensitivity were found in patients with diarrhoea-predominant irritable bowel syndrome both after a course of hypnotherapy and during a session of hypnosis (p<.05). Although patient numbers were small, a trend towards normalization of rectal sensitivity was also observed in patients with constipation- predominant syndrome. No changes in rectal compliance or distension-induced motor activity occurred in either subgroup nor were any changes in somatic pain thresholds observed. The results suggest that symptomatic improvement in irritable bowel syndrome after hypnotherapy may in part be due to changes in visceral sensitivity This research involved 15 patients diagnosed with irritable bowel syndrome (IBS), which was defined as abdominal pain with abdominal distension and 'an altered bowel habit'--10 had diarrhea mostly and 5 had constipation mostly. Patients with this disease usually have an exaggerated colon sensitivity to many different stimuli, as well as lower threshold to a balloon inflated in the bowel for diagnostic purposes. The patients were treated with ten sessions of hypnosis, 30 minutes each, over a three month period. Dependent variables included self ratings of abdominal pain, abdominal distention, and 'bowel habit disturbance.' Each of the three variables received a score of 0-10; the total score therefore could range from 0-30. Other ratings were obtained using the inflation of a rectal balloon as stimulus. "After a basal period of at least 15 minutes the rectal balloon was serially inflated with air at intervals of 1 min in 20 ml increments up to 100 ml and then in 50 ml increments up to the sensation of discomfort. The study was repeated after a rest period of 15 minutes. After hypnotherapy the S was restudied first in the waking state and then, after 15 min, following induction of hypnosis" During this procedure they measured balloon volume, rectal compliance (a function of volume and pressure), and presence or absence of repetitive rectal contractions. In order to learn whether the analgesia being experienced in the rectal or bowel area transferred to other areas, patients experienced cold water immersion induced pain on one hand, for a measure of time until discomfort was felt (pain threshold, essentially). The control group of 15 patients diagnosed with IBS received the same measures of balloon volume, rectal compliance, and presence or absence of repetitive rectal contractions. The total symptom score (which might have ranged 0-30) dropped from 23.5 to 9.6, and 13 of the 15 patients rated their symptoms as much improved. The two Ss who did not experience improvement also did not return for the assessment using the balloon. Therefore, the physiological assessment included only 13 Subjects, the ones who rated themselves as 'improved.' "In patients with diarrhoea-predominant irritable bowel syndrome a decreased rectal sensitivity occurred after hypnotherapy which was significant for the sensations of gas and urgency. This was most pronounced in patients who could initially tolerate only small rectal balloon volumes (Fig 1). During hypnosis the results for rectal sensitivity in the diarrhoea-predominant group were similar to those noted after the course of hypnotherapy but were of a greater magnitude, reaching significance for all sensations (Fig 2). "In the constipation-predominant Subjects there was a tendency for rectal sensitivity to move towards normal values both after the course of hypnotherapy and during hypnosis. Patient numbers in this subgroup were small, however, and the changes were not significant (Figs 1 and 2). Rectal compliance and distension induced motor activity were unaffected by hypnotherapy in both the diarrhoea and constipation- predominant patients" (p. 897). It was noted that of patients who had manifested depression and/or anxiety (8 of 13), most showed psychological improvement--3 of them to a great degree--but there was no correlation between psychological improvement and the degree that visceral sensitivity was diminished. Also, the ten sessions of hypnotherapy did not affect length of time subjects could tolerate hand immersion in cold water. "In the control group of 15 patients with the irritable bowel syndrome who did not receive hypnotherapy no changes in rectal sensory or motor parameters occurred when manometry was repeated on the same day or on a second study day nine to 12 weeks later (Table II)" (p. 897). In their Discussion, the authors remark that "hypnotherapy seemed to produce a trend towards normalization of visceral sensitivity (Figs 1 and 2). This was most pronounced in the patients with diarrhoea-predominant irritable bowel syndrome who initially had particularly low sensation thresholds" (p. 898). They continue, "The pathophysiological abnormalities which lead to the symptoms of the irritable bowel syndrome remain unclear. The increased visceral sensitivity found in the large [7-9] and small intestine [18, 19] in some patients with the irritable bowel syndrome may contribute to their perception of pain. In addition, an increase in rectal sensitivity might also contribute to the symptoms of urgency and frequency of defecation seen in many patients with diarrhoea-predominant irritable bowel syndrome. ... Hypnotherapy also induces an improvement in well being by increasing coping capacities, and may therefore decrease perceived stress" (p. 898). "The present study suggests therefore that hypnotherapy might operate by a variety of mechanisms in patients with the irritable bowel syndrome. In those with visceral hypersensitivity it seems to alter the perception of rectal sensation, although the mechanism by which this is achieved is unknown. Modification at a cortical level or more locally along afferent pathways are possibilities. This does not, however, explain the symptomatic improvement in all subjects and hypnotherapy is probably also acting in a non-specific psychotherapeutic sense" (p. 898). with diarrhoea-predominant irritable bowel syndrome who initially had particularly low sensation thresholds" (p. 898). They continue, "The pathophysiological abnormalities which lead to the symptoms of the irritable bowel syndrome remain unclear. The increased visceral sensitivity found in the large [7-9] and small intestine [18, 19] in some patients with the irritable bowel syndrome may contribute to their perception of pain. In addition, an increase in rectal sensitivity might also contribute to the symptoms of urgency and frequency of defecation seen in many patients with diarrhoea-predominant irritable bowel syndrome. ... Hypnotherapy also induces an improvement in well being by increasing coping capacities, and may therefore decrease perceived stress" (p. 898). "The present study suggests therefore that hypnotherapy might operate by a variety of mechanisms in patients with the irritable bowel syndrome. In those with visceral hypersensitivity it seems to alter the perception of rectal sensation, although the mechanism by which this is achieved is unknown. Modification at a cortical level or more locally along afferent pathways are possibilities. This does not, however, explain the symptomatic improvement in all subjects and hypnotherapy is probably also acting in a non-specific psychotherapeutic sense" (p. 898). Schwarz, Shirley P.; Taylor, Ann E.; Scharff, Lisa; Blanchard, Edward B. (1990). Behaviorally treated irritable bowel syndrome patients: A four-year follow-up. Behaviour Research and Therapy, 28 (4), 331-335. A 4-yr longitudinal study evaluated 19 patients (aged 23-60 yrs) suffering from Irritable Bowel Syndrome (IBS) who had completed a multicomponent treatment involving progressive muscle relaxation, thermal biofeedback, cognitive therapy, and IBS education at baseline. 17 Ss rated themselves as more than 50% improved. Six of the 12 Ss who submitted symptom monitoring diaries met the criteria for clinical improvement, (i.e., achieving at least a 50% reduction in primary IBS symptom scores). The means on all measures at long-term follow-up were lower than those obtained prior to treatment. When follow-up symptom means were compared with pretreatment means, significant reductions were obtained on abdominal pain/tenderness, diarrhea, nausea, and flatulence. 1989 Palan, B.M.; Chandwani, S. (1989). Coping with examination stress through hypnosis: An experimental study. American Journal of Clinical Hypnosis, 31, 173-180.