Pain management programs assist patients to use their behavioral and cognitive skills for the purpose of rendering their experience of pain as more tolerable in some way. Hypnotic procedures may be included in this perspective. Thus, hypnosis may be best conceived as a set of skills to be deployed by the individual rather than as a state. The authors contend that such an emphasis is more compatible with the approaches of some pain management practitioners who have been generally slow to acknowledge the value of hypnosis and to incorporate hypnosis in their range of treatment skills. In this article, the authors present a minimal and atheoretical definition of hypnosis, and they list the basic properties of hypnosis that may be used in the treatment of pain. For a number of reasons, it is suggested that undertaking hypnosis as though the individual were indeed being placed into a special trance state may in some cases promote an effective outcome. However, it should be acknowledged that there may be instances when the relevant skills may be more effectively engaged at the expense of a strict special trance state by targeting the specific skills that are to be used for therapeutic benefit.
treatment of pain. For a number of reasons, it is suggested that undertaking hypnosis as though the individual were indeed being placed into a special trance state may in some cases promote an effective outcome. However, it should be acknowledged that there may be instances when the relevant skills may be more effectively engaged at the expense of a strict special trance state by targeting the specific skills that are to be used for therapeutic benefit.
Crawford, Helen J.; Knebel, Timothy; Kaplan, Lyla; Vendemia, Jennifer M. C.; Xie, Min; Jamison, Scott; Pribram, Karl H. (1998). Hypnotic analgesia: 1. Somatosensory event-related potential changes to noxious stimuli and 2. Transfer learning to reduce chronic low back pain. International Journal of Clinical and Experimental Hypnosis, 46 (1), 92-132.
Fifteen adults with chronic low back pain (M = 4 years), age 18 to 43 years (M = 29 years), participated. All but one were moderately to highly hypnotizable (M = 7.87; modified 11-point Stanford Hypnotic Susceptibility Scale, Form C [Weitzenhoffer & Hilgard, 1962]), and significantly reduced pain perception following hypnotic analgesia instructions during cold-pressor pain training. In Part 1, somatosensory event-related potential correlates of noxious electrical stimulation were evaluated during attend and hypnotic analgesia (HA) conditions at anterior frontal (Fp1, Fp2), midfrontal (Fe, F4), central (C3, C4), and parietal (P3, P4) regions. During HA, hypothesized inhibitory processing was evidenced by enhanced N140 in the anterior frontal region and by a prestimulus positive-ongoing contingent cortical potential at Fp1 only. During HA, decreased spatiotemporal perception was evidenced by reduced amplitudes of P200 (bilateral midfrontal and central, and left parietal) and P300 (right midfrontal and central). HA led to highly significant mean reductions in perceived sensory pain and distress. HA is an active process that requires inhibitory effort, dissociated from conscious awareness, where the anterior frontal cortex participates in a topographically specific inhibitory feedback circuit that cooperates in the allocation of thalamocortical activities. In Part 2, the authors document the development of self-efficacy through the successful transfer by participants of newly learned skills of experimental pain reduction to reduction of their own chronic pain. Over three experimental sessions, participants reported chronic pain reduction, increased psychological well-being, and increased sleep quality. The development of “neurosignatures of pain” can influence subsequent pain experiences (Coderre, Katz, Vaccarino, & Malzack, 1993; Melzack, 1993) and may be expanded in size and easily reactivated (Flor & Birbaumer, 1994; Melzack, 1991, 1993). Therefore, hypnosis and other psychological interventions need to be introduced early as adjuncts in medical treatments for onset pain before the development of chronic pain.
The authors suggest that “the anterior frontal region deals with the active allocation of attention and disattention, whereas spatiotemporal aspects of the somatosensory perceptions involve the posterior cortical systems” (p. 113) They acknowledge that “other inhibitory pain systems are actively interacting with the frontal attentional system, including the limbic and thalamic systems” and mention evidence that the inhibitory processing “may extend as far as spinal cord antinociceptive mechanisms as evidenced by reductions in brief latency (Hagbarth & Finer, 1963) and R-III amplitude (Kiernan, Dane, Phillips, & Price, 1995) of spinal reflexes” (p. 113). Both pain perception and strategies of pain control may involve the anterior cingulate cortex (Kropotov et al. 1997), which has many connections with anterior frontal cortex “and is thought to be an area that organizes responses to noxious stimuli” (p. 113).
For the chronic low back pain Ss there were reductions in reported low back pain during the experimental sessions, and significant improvements in psychological well-being and sleep quality across the three sessions. “The importance of developing self-efficacy through learning to control experimental pain and the understanding of one’s own attentional and disattentional abilities was demonstrated as being a significant intervention in the modulation and control of chronic pain” (p. 123).
Eimer, Bruce; Freeman, Arthur (1998). Pain management psychotherapy: A practical guide. New York NY: John Wiley & Sons, Inc..
“Pain Management Psychotherapy” (PMP) provides a clear and methodical look at pain management psychotherapy beginning with the initial consultation and work-up of the patient and continuing through termination of treatment. It is a thoughtful and thorough presentation that covers methods for psychologically assessing the chronic pain patient (structured interviews, pain assessment tests and rating scales, instruments for evaluating beliefs, attitudes, pain behavior, disability, depression, anxiety, anger and alienation), treatment planning, cognitive-behavioral therapy techniques, and a range of hypnotic approaches to pain management. The book covers both traditional (cognitive and behavior therapy, biofeedback, assessing hypnotizability, choice of inductions, designing an individualized self-hypnosis exercise) as well as newer innovative techniques (e.g., EMDR, pain-relief imagery, hypno-projective methods, hypno-analytic reprocessing of pain-related negative experiences). An extensive appendix reproduces in their entirety numerous forms, rating scale, inventories, assessment instruments, and scripts.
The senior author, Bruce Eimer, states in his online comments on Amazon.com that “most therapists hold the belief that ‘real’ chronic pain patients are quite impossible to help. This book attempts to dispel these misguided beliefs by providing a body of knowledge, theory, and techniques that have proven value in understanding and relieving chronic physical pain.” He also states that “the challenge for the therapist is to persuade the would-ne patient/client that he or she has something to offer that can help take way pain and bring back more pleasure. This challenge is negotiated through the therapeutic relationship. However, the therapist just can’t be ‘warm, accepting, non-judgmental and empathic’. The therapist must also have knowledge and skills relevant to relieving pain. Only then can the therapist impart such knowledge, and in teaching these skills to the pain patient, help the patient become something of a ‘self-therapist’. . . I dedicate this book to everyone who wants to find ways to make living with pain more comfortable, and to the ongoing search for better ways to relieve pain.”
Weisenberg, Matisyohu (1998). Cognitive aspects of pain and pain control. International Journal of Clinical and Experimental Hypnosis, 46 (1), 44-61.
The cognitive and cognitive-behavioral approaches have been shown to be very effective in controlling pain and its sequelae both in the laboratory and in the clinical setting. As used in most research and treatment, cognitive approaches are concerned with the way the person perceives, interprets, and relates to his or her pain rather than with the elimination of the pain per se. This article reviews some of the origins of cognitive theory and pain theory, as well as examples of the techniques used and the research support for the approach. Special emphasis is given to self-efficacy, perceived control, and stress inoculation therapy. There is also discussion of some of the limitations of the cognitive approach. The overall conclusion is that the cognitive approach is a powerful and effective one for pain control despite its limitations.
of some of the limitations of the cognitive approach. The overall conclusion is that the cognitive approach is a powerful and effective one for pain control despite its limitations.
1997
Dinges, David F.; Whitehouse, Wayne G.; Orne, Emily Carota; Bloom, Peter B.; Carlin, Michele M.; Bauer, Nancy K.; Gillen, Kelly A.; Shapiro, Barbara S.; Ohene-Frempong, Kwaku; Dampier, Carlton; Orne, Martin T. (1997). Self-hypnosis training as an adjunctive treatment in the management of pain associated with sickle cell disease. International Journal of Clinical and Experimental Hypnosis, 45 (4), 417-432.
A cohort of patients with sickle cell disease, consisting of children, adolescents, and adults, who reported experiencing three or more episodes of vaso-occlusive pain the preceding year, were enrolled in a prospective two-period treatment protocol. Following a 4-month conventional treatment baseline phase, a supplemental cognitive-behavioral pain management program that centered on self-hypnosis was implemented over the next 18 months. Frequency of self-hypnosis group training sessions began at once per week for the first 6 months, became biweekly for the next 6 months, and finally occurred once every third week for the next 6 months, and finally occurred once every third week for the remaining 6 months. Results indicate that the self-hypnosis intervention was associated with a significant reduction in pain days. Both the proportion of “bad sleep” nights and the use of pain medications also decreased significantly during the self-hypnosis treatment phase. However, participants continued to report disturbed sleep and to require medications on those days during which they did experience pain. Findings further suggest that the overall reduction in pain frequency was due to the elimination of less severe episodes of pain. Non-specific factors may have contributed to the efficacy of treatment. Nevertheless, the program clearly demonstrates that an adjunctive behavioral treatment for sickle cell pain, involving patient self-management and regular contact with a medical self-hypnosis team, can be beneficial in reducing recurrent, unpredictable episodes of pain in a patient population for whom few safe, cost-effective medical alternatives exist.
Tan, Siang-Yang; Leucht, Christopher A. (1997). Cognitive-behavioral therapy for clinical pain control: A 15-year update and its relationship to hypnosis. International Journal of Clinical and Experimental Hypnosis, 45 (4), 396-416
Since Tan’s (1982) review of cognitive and cognitive-behavioral methods for pain control was published 15 years ago, significant advances have been made in cognitive-behavioral therapy for pain. The scientific evidence for its efficacy for clinical pain attenuation is now much more substantial and is briefly reviewed. In particular, cognitive-behavioral therapy for chronic pain was recently listed as one of 25 empirically validated or supported psychological treatments available for various disorders. A number of emerging issues are further discussed in light of recent developments and research findings. The relationship of cognitive-behavioral therapy to hypnosis for pain control is briefly addressed, with suggestions for integrating hypnotic and cognitive-behavioral techniques.
1996 Amigs, S.; Capafons, A. (1996). Emotional self-regulation therapy for treating primary dysmenorrhea and premenstrual distress.. In Lynn, S. J.; Kirsch, I.; Rhue, J. W. (Ed.), Casebook of clinical hypnosis. (pp. 153-171). Washington, D.C.: American Psychological Association.
A case study on dysmenorrhea and premenstrual distress is presented, using emotional self-regulation therapy. Authors show a step by step approach in how to treat this kind of problem, using suggestions in an awake, alert state. Follow-up data are included.
1996
Dane, Joseph R. (1996). Hypnosis for pain and neuromuscular rehabilitation with multiple sclerosis: Case summary, literature review, and analysis of outcomes. International Journal of Clinical and Experimental Hypnosis, 44 (3), 208-231.
Videotaped treatment sessions in conjunction with 1-month, 1-year, and 8-year follow-up allow a unique level of analysis in a case study of hypnotic treatment for pain and neuromuscular rehabilitation with multiple sclerosis (MS). Preparatory psychotherapy was necessary to reduce the patient’s massive denial before she could actively participate in hypnosis. Subsequent hypnotic imagery and posthypnotic suggestion were accompanied by significantly improved control of pain, sitting balance, and diplopia (double vision), and a return to ambulatory capacity within 2 weeks of beginning treatment with hypnosis. Evidence regarding efficacy of hypnotic strategies included (a) direct temporal correlations between varying levels of pain relief and ambulatory capacity and the use versus nonuse of hypnotic strategies, (b) the absence of pharmacological explanations, and (c) the ongoing presence of other MS-related symptoms that remained unaltered. In conjunction with existing literature on hypnosis and neuromuscular conditions, results of this case study strongly suggest the need for more detailed and more physiologically based studies of the phenomena involved. – Journal Abstract
1995
Holroyd, Jean (1995). Handbook of clinical hypnosis, by Judith W. Rhue, Steven Jay Lynn, & Irving Kirsch (Eds.) [Review]. International Journal of Clinical and Experimental Hypnosis, 43 (4), 401-403.
“This is a book for the thinking clinician” (p. 401). “The editors are to be congratulated for making this volume much more coherent than most edited books” (p. 402). “My impression is that the book is best suited for an intermediate or advanced course on hypnotherapy, or for people who are already using hypnosis in treatment. Although there is some material on the basics of hypnotic inductions and a few introductory sample scripts for inductions, a beginners” course should probably use a different book, or this book could be accompanied by an inductions manual. … I recommend it very highly” (p. 403).
1989
LaClave, Linda J.; Blix, Susanne (1989). Hypnosis in the management of symptoms in a young girl with malignant astrocytoma: A challenge to the therapist. International Journal of Clinical and Experimental Hypnosis, 37 (1), 6-14.
This paper presents the case of a 6.5-year-old girl with malignant astrocytoma of the left brain hemisphere. During the course of her chemotherapy treatment, severe vomiting developed to the degree that on several occasions she became dehydrated. Discontinuation of chemotherapy was being considered when she was referred for hypnotherapy. Despite severe neurological impairments which excluded many traditional techniques, hypnosis was successful in eliminating emesis. Hypnosis was also utilized to decrease pain and to improve sleep patterns. Drawings are presented to help show how this child resolved anxiety associated with treatment and fears surrounding the knowledge of her impending death.
Yousufzai, N. M. (1989). Rheumatoid arthritis and hypnosis: Case report. British Journal of Experimental and Clinical Hypnosis, 6 (3), 178-181.
http://www.imp-muenchen.de/The_effect_of_hypnos.698.1.html
From: Psychology and Health, 2000, vol 14, p. 1089.
Horton-Hausknecht J, Mitzdorf U, Melchart D: The effect of hypnosis therapy on the symptoms and disease activity in rheumatoid arthritis .
In this study we aimed to assess the effectiveness of clinical hypnosis on the symptoms and disease activity of rheumatoid arthritis (RA). 66 RA patients participated in a controlled group design. 26 patients learnt the hypnosis intervention, 20 patients were in a relaxation control group, and 20 patients were in a waiting-list control group. During hypnosis , patients developed individual visual imagery aimed at reducing the autoimmune activity underlying the RA and at reducing the symptoms of joint pain, swelling, and stiffness. Subjective assessments of symptom severity and body and joint function, using standardized questionnaires and visual analogue scales, were obtained. Objective measures of disease activity via multiple blood samples during the therapy period and at the two follow-ups were also taken. These measurements were of erythrocyte sedimentation rate, C-reactive protein, hemoglobin, and leukocyte total numbers. Results indicate that the hypnosis therapy produced more significant improvements in both the subjective and objective measurements, above relaxation and medication. Improvements were also found to be of clinical significance and became even more significant when patients practiced the hypnosis regularly during the follow-up periods.
“The effect of hypnotic suggestion on pain and mobility of joints was remarkable. On the fifth session there was hardly any pain, and shoulder movements were almost normal” (p. 179).
1987
Chaves, John; Brown, Jude (1987). Spontaneous cognitive strategies for the control of clinical pain and stress. Journal of Behavioral Medicine, 10 (3), 263-276.
The spontaneous cognitive strategies employed by 75 patients undergoing dental extractions or mandibular block injections were elicited using a structured interview. Interest focused on the relationship between these strategies and several personality variables, including state and trait anxiety, locus of control, and absorption. In addition, the effect of strategy utilization on perceived pain and stress was assessed. Fourty-four percent of the patients employed cognitive strategies designed to minimize pain and stress, while 37% catastrophized, engaging in cognitive activity which exaggerated the fearful aspects of their experience. Only 19% of the patients denied any cognitive activity during the clinical procedure, and many of these used noncognitive coping strategies. Discriminant analysis revealed that situational anxiety was associated with the use of cognitive coping strategies. Catastrophizing was associated with increasing age, past dental stress, and higher levels of stress vulnerability (high trait anxiety and external locus of control). Copers reported less stress than catastrophizers but not less pain.
1986
Williams, David A.; Thorn, Beverly E. (1986). Can research methodology affect treatment outcome? A comparison of two cold pressor test paradigms. Cognitive Therapy and Research, 10 (5), 539-545.
Examined the effect of fixed or open latency instructions on subjective pain report for the cold pressor test using a single cognitive training strategy with 80 undergraduates. The fixed latency paradigm instructed Ss to leave their hand in the cold water for a fixed amount of time (e.g., 3 min), whereas the tolerance paradigm asked Ss to endure pain for as long as possible. Results suggest that the fixed latency paradigm is associated with lower subjective pain ratings especially when a cognitive strategy is used. The tolerance groups failed to decrease their subjective perception of pain but evidenced longer latencies when a cognitive strategy was used. It is concluded that while other research has used these paradigms interchangeably to assess efficacy, these 2 paradigms apparently pose different challenges to Ss. (15 ref).
1985
Kabat-Zinn, Jon; Lipworth, Leslie; Burney, Robert (1985). The clinical use of mindfulness meditation for the self-regulation of chronic pain. Journal of Behavioral Medicine, 8 (2), 163-190.
90 chronic pain patients were trained in mindfulness meditation in a 10-wk stress reduction and relaxation program. Self-report indices, including the McGill Pain Questionnaire, the Profile of Mood States, and the Hopkins Symptom Checklist, were administered to the Ss to assess multiple aspects of pain and certain pain-related behaviors. Results show statistically significant reductions in measures of present-moment pain, negative body image, inhibition of activity by pain, symptoms, mood disturbance, and psychological symptomatology, including anxiety and depression. Pain-related drug utilization decreased, and activity levels and feelings of self-esteem increased. Improvement appeared to be independent of gender, source of referral, and type of pain. A comparison group of 21 pain patients did not show significant improvement on these measures after traditional treatment protocols. At follow-up, the improvements observed during the meditation training were maintained up to 15 months postmeditation training for all measures except present-moment pain. The majority of Ss reported continued high compliance with the meditation practice as part of their daily lives.
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.
1979
Johnson, L. S.; Wiese, K. F. (1979). Live versus tape-recorded assessments of hypnotic responsiveness in pain control patients. International Journal of Clinical and Experimental Hypnosis, 27 (2), 74-84.
This study compared the effectiveness of live versus tape-recorded hypnotic procedures in producing general hypnotic responsiveness in hospitalized pain patients. 30 patients individually received in counterbalanced order both a live and an audiotaped presentation of the Stanford Hypnotic Clinical Scale (Hilgard & Hilgard, 1975), which contains an induction and a 5-item test of hypnotic susceptibility suitable for bed-ridden patients. The live presentation produced a significantly higher total score than the taped procedure (p<.05), with no significant order effects. The correlation between modes of presentation was .66. Order effects were not significant but a trend in that direction was discussed. The differences were found to hold for the high and medium ranges of susceptibility. Tentative conclusions were drawn that one cannot assume taped procedures to be equivalent to live in hypnotic analgesia research with clinical populations. The non-equivalence of live and taped procedures need not invalidate the clinical use of the latter, should they prove empirically effective. A case study of low back pain is added to illustrate effective tape-induced analgesia for patients unsuccessful with self-hypnosis. 1978 Schafer, Donald W.; Hernandez, A. (1978). Hypnosis, pain and the context of therapy. International Journal of Clinical and Experimental Hypnosis, 26 (3), 143-153. The therapeutic use of hypnosis in pain syndromes assumes that organic pain can be brought under control through hypnotic techniques. Although it might be inferred from laboratory experiments that the hypnotic control of pain is in direct proportion to the individual's hypnotizability, clinical work would indicate that most motivated patients can achieve sufficient levels of hypnosis to alleviate pain. The psychological state of the patient -- regardless of whether the pain was initially organic or psychogenic -- modifies the patient's response to therapeutic hypnosis. This paper presents an approach to the patient that helps insure that the context of hypnotherapy will be optimal. Many patients who might otherwise be classified as unhypnotizable can in the appropriate context be helped to utilize hypnosis for the control of their pain. 1966 Zane, M. D. (1966). The hypnotic situation and changes in ulcer pain. International Journal of Clinical and Experimental Hypnosis, 14 (4), 292-304. This is a study of internal and external hypnotic conditions associated with changes in pain developed during 5 hypnosis sessions in a patient with an acute duodenal ulcer. The 12 increases and 8 decreases in pain studied were found to be related to the interaction of coexisting reactions directed toward shifting social and private goals. Pain was associated with conflict among these reactions; intensification of pain occurred as a train of self-propagating internal events increased the conflict; relief of pain accompanied a reduction in the conflict. Increasing bodily disorganization resulted as shifts in focus of attention among social and private goals resulted in the rapid growth of conflicting mental and physical processes. An external stimulus, in the form of a highly individualized hypnotic suggestion, was often required to stop the disorganizing processes. processes. 1961 Cangello, V. W. (1961). The use of hypnotic suggestion for pain relief in malignant disease. International Journal of Clinical and Experimental Hypnosis, 9, 17-22. Using hypnotic suggestion, pain relief was attempted in 22 cases. 13 of these patients showed a decrease in narcotic requirements. Duration of effectiveness was from 1 week to 41/2 months. It is concluded that this method should be tried before resorting to either chemical or surgical procedures since it is relatively simple to perform, has no harmful complications, and is not unduly time consuming. From Psyc Abstracts 36:02:2II17C. (PsycINFO Database Record (c) 2002 APA, all rights reserved) 1959 Wallace, G. (1959). Hypnosis in anesthesiology. International Journal of Clinical and Experimental Hypnosis, 7 (3), 129-138. The author states that reassurance of surgical patients in a preoperative visit may be enhanced with "the truly interpersonal relationship that hypnosis has as its foundation" (p. 131). He does not use the word "hypnosis" per se with these patients. Suggestions may be given that the patient will tolerate required procedures comfortably. Hypnosis supplements but usually does not replace anesthesia for an entire surgical procedure, but can be used in conjunction with regional techniques such as a nerve block, or in minor procedures on its own. A period of conditioning is necessary for producing true anesthesia, and that often is too time consuming for many anesthesiologists. Hypnosis can be used postoperatively for hiccoughs, for motivating the patient to become suitably active, etc. It is especially useful in a pediatric setting and in obstetrical procedures. He describes specific techniques used for conditioning obstetrical patients. The author also discusses pain management applications of hypnosis. 1956 Stokvis, B. (1956). The appliction of hypnosis in organic diseases. Journal of Clinical and Experimental Hypnosis, 4 (2), 79-82. "SUMMARY. Hypnotherapy, applied as a symptomatic treatment, is especially indicted in those cases of organic diseases in which the patient has neurotically elaborated his physical suffering. In cases presenting neither etiological nor secondary psychic factors one may try to improve the patient's condition by hypnotic treatment. Description of a case (hypnotherapy in a woman with carcinoma mammae)[sic]. The writer's lack of appreciation of hypnotherapy in organic diseases does not include the treatment of diseases which are definitely psychosomatically determined" (pp. 81-82). PAIN THRESHOLD 1998 Danziger, N.; Fournier, E.; Bouhassira, D.; Michaud, D.; De Broucker, T.; Santarcangelo, E.; Carli, G.; Chertock, L.; Willer, J. C. (1998). Different strategies of modulation can be operative during hypnotic analgesia: A neurophysiological study. Pain, 75 (1), 85-92. Nociceptive electrical stimuli were applied to the sural nerve during hypnotically-suggested analgesia in the left lower limb of 18 highly susceptible subjects. During this procedure, the verbally reported pain threshold, the nociceptive flexion (RIII) reflex and late somatosensory evoked potentials were investigated in parallel with autonomic responses and the spontaneous electroencephalogram (EEG). The hypnotic suggestion of analgesia induced a significant increase in pain threshold in all the selected subjects. All the subjects showed large changes (i.e., by 20% or more) in the amplitudes of their RIII reflexes during hypnotic analgesia by comparison with control conditions. Although the extent of the increase in pain threshold was similar in all the subjects, two distinct patterns of modulation of the RIII reflex were observed during the hypnotic analgesia: in 11 subjects (subgroup 1), a strong inhibition of the reflex was observed whereas in the other seven subjects (subgroup 2) there was a strong facilitation of the reflex. All the subjects in both subgroups displayed similar decreases in the amplitude of late somatosensory evoked cerebral potentials during the hypnotic analgesia. No modification in the autonomic parameters or the EEG was observed. These data suggest that different strategies of modulation can be operative during effective hypnotic analgesia and that these are subject-dependent. Although all subjects may shift their attention away from the painful stimulus (which could explain the decrease of the late somatosensory evoked potentials), some of them inhibit their motor reaction to the stimulus at the spinal level, while in others, in contrast, this reaction is facilitated. Abstract from National Library of Medicine, PubMed 1997 Chaves, John F.; Dworkin, Samuel F. (1997). Hypnotic control of pain: Historical perspectives and future prospects. International Journal of Clinical and Experimental Hypnosis, 45 (4), 356-376. Hypnotic analgesia has occupied a pivotal place in experimental and clinical hypnosis. It emerged early in the 19th century when effective clinical techniques for pain management had not yet developed, and the relief of pain and suffering had not even become a well-defined social goal. Its acceptance was further complicated by political struggles surrounding the humanitarian transformation of medicine during this era as well as a redefinition of the physician-patient relationship that wrested control from the patient. The initial struggle for professional acceptance was won only when the debate became almost entirely localized within the professional community. Acceptance of hypnosis by professional organizations has been followed by alternating periods of interest and indifference. While the evidence for the powerful effects of suggestion and related variables has often been observed and reported in nonhypnotic contexts, their relationship to hypnotic phenomena has often not been appreciated. Since the mid-20th century, scientific information about hypnotic analgesia has grown substantially and has had significant influence on strategies for acute and chronic pain management. If recent calls for its wider application in pain management are to succeed, it will require additional data from clinical populations and a balanced and scientifically prudent approach by its advocates. [Journal Abstract] significant influence on strategies for acute and chronic pain management. If recent calls for its wider application in pain management are to succeed, it will require additional data from clinical populations and a balanced and scientifically prudent approach by its advocates. [Journal Abstract] 1994 Zachariae, Robert; Bjerring, Peter (1994). Laser-induced pain-related brain potentials and sensory pain ratings in high and low hypnotizable subjects during hypnotic suggestions of relaxation, dissociated imagery, focused analgesia, and placebo. International Journal of Clinical and Experimental Hypnosis, 42 (1), 56-80. Pain reports and amplitudes of painful argon laser-induced brain potentials were obtained for 10 high and 10 low hypnotizable volunteers following placebo and a randomized sequence of four hypnotically induced conditions of (a) neutral hypnosis, (b) deep relaxation, (c) pleasant dissociated "out of body" imagery, and (d) focused analgesia of the hand. Both high and low hypnotizable subjects exhibited significant reductions of reported pain during conditions of neutral hypnosis, relaxation, dissociated imagery, and focused analgesia. High hypnotizable subjects displayed significantly greater reductions than low hypnotizables in all conditions except placebo. Both high and low hypnotizables exhibited significant reductions of reported pain in all five conditions as well as in the posthypnotic condition, when amplitudes of evoked potentials were compared to the prehypnotic baseline. Only the high hypnotizable group showed significant reductions in amplitudes when the data were recalculated to reflect relative changes compared to the average amplitude of the pre- and postconditions to compensate for a possible habituation effect indicated by the significantly lowered amplitudes in the posthypnotic condition. The results are discussed in light of a number of hypotheses concerning mechanisms of hypnotic analgesia. 1990 Arendt-Nielsen, Lars; Zachariae, Robert; Bjerring, Peter (1990). Quantitative evaluation of hypnotically suggested hyperaesthesia and analgesia by painful laser stimulation. Pain, 42, 243-251. Sensory and pain thresholds to laser stimulation were determined, and the laser-pain evoked brain potentials were measured for 8 highly hypnotizable (Harvard Scores 10-11) student volunteers in 3 conditions: (1) waking, (2) suggestion of hyperaesthesia during hypnosis, (3) suggestion of analgesia during hypnosis. The investigators used a laser beam 3 mm in diameter, with a 200 msec stimulus duration; the same area (but different points within the area) was used for consecutive stimulations. Ss were otherwise maintained in low stimulus conditions so they would not have visual or auditory cues about laser beam onset; they wore goggles, had eyes shut, and had earphones on. Sensory threshold was defined as warmth; pain threshold was defined as a distinct sharp pin prick. The laser intensity used for stimulation corresponded to strong pain. Interstimulus intervals averaged 15 sec (but were randomly varied between 10-20 sec). Sensory and pain thresholds as well as two evoked potential measurements were taken during waking , hypnotized hyperaesthesia, and hypnotized analgesia conditions in a single 1 1/2 hour session. The evoked potential component of interest was the negative complex N1 with latency of 300 msec; amplitude (P1=N1-P2) and latency of this complex (N1) were measured. EEG epochs contaminated by eye movement were omitted from analysis. The standardized induction and deepening of hypnosis required 15-20 minutes; then the suggestion was given that Ss could alter their perception of stimuli such as pain. Hyperaesthesia suggestions were to imagine the right hand was in very hot water, then taken out but still very red, hot, sensitive so that even the vaguest stimulus would be detectable and unpleasant. They were told that they would receive a series of painful but tolerable stimuli, and to raise the left index finger if they could just perceive a laser pulse (sensory threshold), and again if they felt pricking pain (pain threshold). Suggestions for analgesia were to imagine that their right hand was placed on their chest, and that their 'former right hand' was no longer their own but was made of some heavy and completely insensitive material like wood or stone. Sensory and pain threshold measures were then taken. During the evoked potential measurement period they received continuous suggestions of analgesia. They also were told to relax and imagine they were in a pleasant place, ignoring everything except the pleasant, relaxed feelings and imagining pleasant sights, sounds, feelings and the imagined place. They were told that though they would receive stimuli, they probably would be able to ignore the stimuli completely. Results were as follows. 1. In the hypnotic hyperaesthesia condition, sensory and pain thresholds decreased significantly by 47% and 48%, respectively. Three Ss reacted to laser intensities far below what normally can be perceived in the waking state. [The authors ran a separate small control experiment to make sure that the Subjects were not using any other cues, but mention the possibility of light-sensitive skin reacting to the blue laser light, creating evoked potentials.] 2. In the hypnotic analgesia condition, sensory and pain thresholds increased by 316% and 190%, respectively. 7 of 8 Ss did not even respond to pain threshold when the laser intensity was increased to the noxious level of 3W, which is the level at which tissue damage can occur. 3. Pain-related evoked potentials. Amplitude of the first pain-related potential was increased significantly by 14% in the hyperaesthesia condition and reduced significantly by 31% in the analgesia condition. Changes in the evoked potentials were considered minor however compared to those observed for thresholds, which are subjective response measures. Even in Subjects who reported complete analgesia, the experimenters observed the laser pain evoked responses. There were no differences in latencies of the first pain-related potentials for the three conditions (indicating that peripheral and central afferent conduction velocities were the same). Discussion. "There has been some dispute concerning the experimental design and the reliability of the data obtained in studies dealing with hypnotic suggested analgesia [Spanos & Chaves, 1970]. In our design 2 'opposite' conditions were induced, and the 2 inductions gave 'opposite' results. "The experience of pain can be significantly altered by suggestions of analgesia, which is in accordance with a number of other studies (for review see [Barber & Adrian, 1982; Hilgard & Hilgard, 1975]). The finding that suggestions of hyperaesthesia can decrease the sensory and pain thresholds and increase the amplitude of the pain evoked potential is a new observation. Since synchronized auditory and visual stimuli from the laser were blocked, and the stimulus was given at random intervals, the changes might be induced by the hypnotic suggestions" (p. 247). The authors discuss their results in terms of (1) four pain modulation systems (neural/opiate, hormonal/opiate, neural/non-opiate, and hormonal/non-opiate) and (2) focusing and defocusing attention. Because in their pilot study it was necessary to give suggestions continually in order to affect the laser evoked potentials, they conclude that endogenous substances or hormonal/non-opiates would play a minor role, if any, in hypnotic analgesia. (Price and Barber [25] had also found it important to give suggestions continuously.) On the other hand, "event-related potentials [7, 26] and pain-related potentials have, previously, been shown to be sensitive to focused and de-focused attention. Recently, Miltner et al. [23] showed the influence of attention on the late pain-related component of potentials, evoked by painful intracutaneous electrical stimulation. The degree to which the subject paid attention to the painful stimulus had a powerful effect on the pain-related complex. When subjects ignored the pain, it was still possible to record the pain-related complex although all the subjects consistently reported less or no pain. In wakeful subjects where cutaneous pain was abolished by lignocaine infiltration, the pain-related evoked potentials were abolished [4]. In our study, we could also record evoked potentials although the subject subjectively did not feel pain. The reason might be that the S acted as if there was full analgesia to the stimuli, in order to satisfy the hypnotist. During suggested hyperaesthesia the thresholds declined below what normally could be perceived in the wakeful state. The volunteers could, therefore, not act hypersensitive, so something did happen. The authors discuss their results in terms of (1) four pain modulation systems (neural/opiate, hormonal/opiate, neural/non-opiate, and hormonal/non-opiate) and (2) focusing and defocusing attention. Because in their pilot study it was necessary to give suggestions continually in order to affect the laser evoked potentials, they conclude that endogenous substances or hormonal/non-opiates would play a minor role, if any, in hypnotic analgesia. (Price and Barber [25] had also found it important to give suggestions continuously.) On the other hand, "event-related potentials [7, 26] and pain-related potentials have, previously, been shown to be sensitive to focused and de-focused attention. Recently, Miltner et al. [23] showed the influence of attention on the late pain-related component of potentials, evoked by painful intracutaneous electrical stimulation. The degree to which the subject paid attention to the painful stimulus had a powerful effect on the pain-related complex. When subjects ignored the pain, it was still possible to record the pain-related complex although all the subjects consistently reported less or no pain. In wakeful subjects where cutaneous pain was abolished by lignocaine infiltration, the pain-related evoked potentials were abolished [4]. In our study, we could also record evoked potentials although the subject subjectively did not feel pain. The reason might be that the S acted as if there was full analgesia to the stimuli, in order to satisfy the hypnotist. During suggested hyperaesthesia the thresholds declined below what normally could be perceived in the wakeful state. The volunteers could, therefore, not act hypersensitive, so something did happen. "The discrepancy in subjective and objective responses might, however, be useful when investigating levels of the neuroaxis at which hypnosis might work" (pp. 248-249). The authors note that this laser induced pain and the tooth pulp stimulation pain of Mayer & Barber both use the A-delta fibers. Barber & Mayer found it impossible to elicit pain within the output range of the stimulator (up to 150 microA) and reached maximal intensity for all volunteers during suggested analgesia. Using cutaneous laser stimulation the authors found that the skin damage level (3W) could be reached in 7 of 8 volunteers without any reaction of pain. During the hyperaesthesia condition the sensory threshold was sometimes lower than can be detected in the waking state. Although some researchers have suggested that red light from a helium-neon laser might activate cutaneous photosensitive receptors and thereby elicit brain potentials, the authors were unable to elicit potentials in waking Subjects using their blue and green argon laser light with below sensory threshold intensity. The authors also note that previous attempts to use physiological correlates of pain such as heart rate, blood pressure, respiration, and galvanic skin response have yielded confusing results. The physiological indicators are present even when Subjects report analgesia, leading some investigators to conclude that the subjective reports are due to illusion [Sutcliffe, 1961], compliance [Wagstaff, 1986], or a placebo induced by the hypnosis context [Wagstaff, 1986]. "These confusing results lead to the conclusion that both the traditional methods used for induction of pain and the monitored physiological responses have been unsatisfactory. The present study has sought to eliminate some of the methodological difficulties by (1) using brief well-defined argon laser stimuli which in awake volunteers induce very stable perceptions between trials [Arendt-Nielsen & Bjerring, 1988], and (2) recording psychophysical thresholds and objective parameters quantitatively related to the intensity of the pain perceived (1, 3)" (p. 249). 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) 1987 Chaves, John; Brown, Jude (1987). Spontaneous cognitive strategies for the control of clinical pain and stress. Journal of Behavioral Medicine, 10 (3), 263-276. The spontaneous cognitive strategies employed by 75 patients undergoing dental extractions or mandibular block injections were elicited using a structured interview. Interest focused on the relationship between these strategies and several personality variables, including state and trait anxiety, locus of control, and absorption. In addition, the effect of strategy utilization on perceived pain and stress was assessed. Fourty-four percent of the patients employed cognitive strategies designed to minimize pain and stress, while 37% catastrophized, engaging in cognitive activity which exaggerated the fearful aspects of their experience. Only 19% of the patients denied any cognitive activity during the clinical procedure, and many of these used noncognitive coping strategies. Discriminant analysis revealed that situational anxiety was associated with the use of cognitive coping strategies. Catastrophizing was associated with increasing age, past dental stress, and higher levels of stress vulnerability (high trait anxiety and external locus of control). Copers reported less stress than catastrophizers but not less pain. with the use of cognitive coping strategies. Catastrophizing was associated with increasing age, past dental stress, and higher levels of stress vulnerability (high trait anxiety and external locus of control). Copers reported less stress than catastrophizers but not less pain Evans, Frederick J.; McGlashan, Thomas H. (1987). Specific and non-specific factors in hypnotic analgesia: A reply to Wagstaff. British Journal of Experimental and Clinical Hypnosis, 4, 141-147. (Comment in response to Wagstaff, G. (1987). Is hypnotherapy a placebo? Hypnosis, 4, 135-140.) This article is a reply to Wagstaff's (1984) critique of the McGlashan, Evans & Orne (1969) article which was entitled "The nature of hypnotic analgesia and the placebo response to experimental pain," published in Psychosomatic Medicine, 31, 227-246. The paper to which the authors are replying is Wagstaff, G. F. (1984). Is hypnotherapy a placebo? Paper given at the First Annual Conference of the British Society of Experimental and Clinical Hypnosis, University College, London. An abridged version appeared in the British Journal of Experimental and Clinical Hypnosis, 1987, 4, 135-140. The closing comments of this Evans & McGlashan 1987 paper read as follows: "The strategy in this study [i.e. McGlashan, Evans & Orne, 1969] was quite different from the usual experimental design. Our goal was to _maximize_ all of those non-specific factors that we could build into the experimental procedure. Only by attempting to maximize non-specific effects is it possible to see whether hypnosis in appropriately responsive subjects can exceed that degree of pain control which occurs due to the maximal operation of these non-specific effects. These non-specific components of the hypnotic situation may account for a great deal of clinical change. ... The critical finding was that hypnosis did add a level of pain control that occurred after maximizing clinically related non-specific factors contributing to change in pain tolerance, and that this increased tolerance occurred only in subjects markedly responsive to hypnosis, in contrast to the significant non-specific effects which were uncorrelated with measured hypnotizability" (pp. 143-144). The principal findings of the McGlashan, Evans & Orne (1969) study were: "(a) The improved ability to tolerate pain following the ingestion of placebo was roughly the same for high hypnotizable and low hypnotizable subjects. (b) The response to the non-specific aspects of taking a 'drug' among low hypnotizable subjects was identical to, and highly correlated (.76) with, their response to the legitimized expectation that change would occur under hypnosis for low hypnotizable subjects. The placebo component of a believe-in 'drug' ingestion was the same as the placebo component of a believed-in hypnotic experience for these low hypnotizable subjects. (c) The performance of the highly hypnotizable subjects was significantly greater under hypnotic analgesia conditions than it was under placebo conditions. "This last finding is important conceptually, though of less clinical relevance. It should be noted that not all high hypnotizable subjects showed this result. Even among highly hypnotizable subjects, not all of them had the experience that profound analgesia had occurred! Thus, based on their subjective experience of the relatively small degree of analgesia, 6 of the 12 highly hypnotizable subjects behaved exactly as the low hypnotizable subjects had -- their placebo and hypnotic responses were small, significant, but equal. Only 6 out of 12 carefully screened hypnotizable subjects who subjectively experienced marked analgesia showed dramatic objective changes in pain endurance. Dr. Wagstaff might consider the physiological implications of the observation that we became somewhat frightened about the possibility of tissue damage with two of these six subjects. We had to stop their performance at a point where physiologists had assured us that tissue damage could be expected. They had also assured us, wrongly for these subjects, that we did not have to worry about such a critical point because nobody could endure such a degree of occlusion with this procedure. In fact, for these two subjects, anoxia and muscle cramping were not even apparent!" ( p. 144). two of these six subjects. We had to stop their performance at a point where physiologists had assured us that tissue damage could be expected. They had also assured us, wrongly for these subjects, that we did not have to worry about such a critical point because nobody could endure such a degree of occlusion with this procedure. In fact, for these two subjects, anoxia and muscle cramping were not even apparent!" ( p. 144). 1981 Houston, Rodney Earl (1981). The effects of autohypnosis, imagery, or single suggestion on pain threshold and tolerance (Dissertation, University of Cincinnati). Dissertation Abstracts International, 42 (5), 1961-A. Pain threshold, pain tolerance, and subject's subjective opinion of the pain were studied in 94 volunteer subjects (75 female, 19 male), who had been randomly assigned to three treatment groups (self hypnosis, in-vivo imagery, single suggestion) and a control group. (The original randomized sample included 124 Ss, but 30 were lost to the study-- 22 because of initial baseline scores being above maximum, 2 after reading the consent form, and 6 not returning for post-testing.) Mean age was 25; age range was 18-59 years. The pain stimulus was 33 degree F. ice water in which the dominant hand was submerged for as long as the subjects were able. Subjects were told to nod when pain was first felt (threshold), and remove their hand when the pain was more than they could tolerate (tolerance). They were then asked to rate the pain on a 7-point scale, from 'none' to 'extreme.' Thus the three outcome measures were threshold time, tolerance time, and degree of perceived pain. During the week between pretesting and posttesting, the self hypnosis group was to listen to a tape training them in self hypnosis at least twice; the imagery group was to listen to their imagery training tape at least twice; the simple suggestion group received no training. Posttesting was the same as pretesting, except that the simple suggestion group was given the single waking suggestion, "You will be able to withstand the pain much longer this time." The experimental predictions were that treatment groups would increase in threshold levels and tolerance levels more than the control group; and that the treatment groups would decrease more than the control group in reported pain level. Multivariate analysis of variance of difference scores (pre- to posttest) demonstrated significant differences on the three dependent measures when comparing the three treatment groups to the control group. " Significant differences were also found when comparing treatment groups, autohypnosis and imagery to those given the single suggestion. No significant differences were found when comparing the autohypnosis to the imagery treatment. "The results indicate that training in autohypnosis and in-vivo imagery has an effect on threshold, tolerance and pain levels. The results also indicate that the use of a single suggestion may not have an effect on threshold, tolerance, and pain levels" (p. 1961). 1975