A therapeutic approach is presented which involves the use of prolonged hypnosis for the treatment of diverse medical and/or psychological conditions, including intractable pain. This approach may be indicated either as a complementary tool used in conjunction with other treatment approaches or as the only method of intervention. The technique is based on achieving a prolonged hypnotic response, during which hypno- relaxation serves as the foundation for the delivery of an individualized therapeutic plan which includes self-hypnosis, suggestive procedures, metaphors, and constructive imagery techniques. In debilitated patients, medical supervision and nursing care are essential, and hospitalization is recommended if necessary. Theoretical assumptions underlying this approach are presented, and clinical implications are discussed. The method is illustrated through case presentations.

The general procedure involves: 1. A flexible plan concerning the duration of treatment: days, weeks, or longer. 2. Information is given to the patient, the family and the medical staff if in hospital. Emphasize that while the patient may be in a ‘twilight-like’ state, most of the time he/she is able to fulfill his or her basic physiological needs, (drinking, eating, taking care of personal cleanliness, etc.). 3. The method of hypnotic induction is individualized. 4. The patient is trained in self- hypnosis, and for using signals for induction and dehypnotization either for self hypnosis or for the hypnotist to use. Thus if there is a physiological or emotional need for self-hypnosis the patient can do it. Suggestions and training are given and reinforced concerning the patient’s capability to fulfill his/her basic physiological needs. 5. The family and/or the medical staff are instructed and trained in induction and dehypnotization, until the patient responds to them satisfactorily. 6. At this stage, therapeutic suggestions aimed at ego-boosting and a change of attitudes and meanings towards the symptom and symptom removal/amelioration/substitution are added. 7. Metaphoric constructive imagery is introduced when indicated. 8. If required, other hypnotic phenomena are elicited and used (e.g. dissociation, time distortion, age regression, rehearsal, hypno/analgesia, change of muscular tonus, displacement of emotions, abreaction, etc.). 9. An audio cassette which contains the wording of the therapeutic intervention is used with some patients. 10. The family and/or the medical staff are instructed to supervise the patient properly and to avoid potential complications. 11. Termination of prolonged hypnosis with individualized therapy is gradual to permit appropriate re-orientation towards reality. 12. Treatment is evaluated and a posttreatment plan is outlined.
They provide case reports and discuss precautions. All the cases reported were treated while the patients were hospitalized for their physical condition (although in Case 3, prolonged hypnosis with individualized therapy was also continued at home after the patient’s discharge form the hospital), and the patients were monitored by the medical staff. In very debilitated patients, special care should be taken to avoid potential complications arising from their passivity, mainly the development of decubitus ulcer and of aspiration/choking while drinking or eating. Although precaution is taken routinely with these patients, these measures should be emphasized while the patient is in a state of prolonged hypno-relaxation.

Morse, Donald R.; Martin, John; Moshonov, Joshua (1991). Psychosomatically induced death: Relative to stress, hypnosis, mind control, and voodoo: Review and possible mechanisms. Stress Medicine, 7, 213-232.

A common denominator in psychosomatically induced death is stress. Death can occur slowly, as from the preponderance of chronic stressor, or it can come on suddenly, as from an acute stressor. Sudden death is more likely in an individual with preexistent serious medical conditions, which were outlined. Seven types of individuals more prone to sudden death were outlined. Most cases of sudden death are related to the presence of a severely stressful situation in which there appears to be no means of control or escape. With mind control, hypnosis, and voodoo curses, circumstances can be manipulated to achieve severe stress and uncontrollability.

Evans, Frederick J.; Stanley, R. O. (1990). Psychological interventions for coping with surgery: A review of hypnotic techniques. Australian Journal of Clinical and Experimental Hypnosis, 18, 97-105.

Illness, hospitalization, and surgery pose many severe stresses for many patients, to the extent that their ability to understand and cope with what is happening may be significantly reduced. Many of these stresses result from the nature and significance of patients’ surgical procedures and post-operative treatment. This paper reviews the range of psychological interventions aimed at helping patients cope with pre- and post-operative treatment regimens. The range and content of hypnotic interventions are examined in detail. It is concluded that more rigorous research studies are required to determine the relative effectiveness of different types of interventions and to evaluate the effects of patients’ psychological characteristics on the effectiveness of these interventions.

Gauld, Alan (1990). Mesmeric analgesia and surgery: A reply to Spanos and Chaves. British Journal of Experimental and Clinical Hypnosis, 7, 171-174.

Spanos and Chaves’ criticisms of the author’s paper in this journal (vol. 5, 1988, pp 17-24) on mesmeric analgesia are considered. Spanos and Chaves are unnecessarily dismissive of nineteenth century reports of mesmeric analgesia and, in order to bring these cases within the compass of their theory, they make assumptions about them that are not supported by the facts.

Kaye, J. M.; Schindler, B. A. (1990). Hypnosis on a consultation-liaison service. General Hospital Psychiatry, 12, 379-383.

Studied the use of hypnosis on a consultation-liaison service with a broad spectrum of medically hospitalized patients. Autohypnosis tapes were used for reinforcement. Twenty-nine women and eight men from 24-75 years of age were hypnotized for relief of depression, pain, anxiety, or side effects of chemotherapy. Results were excellent (total to almost total relief of symptoms) in 68%, fair in 22%, and poor in 11%, with no differences among the results with the various conditions. This demonstrates that hypnotherapy is an extremely useful tool in medical management of patients in consultation-liaison psychiatry.

Kihlstrom, John F.; Schacter, Daniel L.; Cork, Randall C.; Hurt, Catherine A.; Behr, Steven E. (1990). Implicit and explicit memory following surgical anesthesia. Psychological Science, 1, 303-306.

Paired associates were presented to 25 surgical patients following the induction of anesthesia by thiopental, vecuronium, and isoflurane. Postoperative testing (immediately or after two weeks) showed no free recall for the list; nor was there significant cued recall or recognition, compared to a matched control list. However, a free-association task showed a significant priming effect on both immediate and delayed trials. At least under some conditions, adequate surgical anesthesia appears to abolish explicit, but not implicit, memory for intraoperative events.

Kraft, Tom (1990). Use of hypnotherapy in anxiety management in the terminally ill: A preliminary study. British Journal of Experimental and Clinical Hypnosis, 7, 27-33.

The aim of this project was to give some preliminary information about the possible value of hypnotherapy in the management of terminally ill patients suffering form widespread cancer. The five phases of the dying process are described, and the case illustrations would suggest that, apart from severely obsessional patients, the terminally ill seem to benefit quite considerably from hypnotherapy.
Matheson, G.; Drever, J. M. (1990). Psychological preparation of the patient for breast reconstruction. Annals of Plastic Surgery, 24, 238-247.

Reviews over 100 women who had undergone rectus abdominis musculocutaneous flap reconstruction, the psychological issues motivating the patient for surgery, and psychological problems to be considered by the surgeon. A method of psychological preparation that was used and a report on the evaluative study of the program is included, and a protocol and verbalization for hypnotic relaxation is included.

McLintock, T. T.; Aitken, H.; Downie, C. F.; Kenny, G. N. (1990). Postoperative analgesic requirements in patients exposed to positive intraoperative suggestions. British Medical Journal, 301 (6755), 788-790.

Sixty-three women undergoing elective abdominal hysterectomy were randomly assigned to a tape of positive suggestions or a blank tape during the operation. Anesthesia was standardized for all of the women. Postoperative analgesia was provided through a patient-controlled analgesia system for the first 24 hours. Pain scores were recorded every 6 hours. The outcome measures were morphine consumption in the first 24 hours and pain scores. Mean morphine requirements were 51.0 mg in women who were played positive suggestions, and 65.7 mg in those played a blank tape (p = 0.028). Pain scores were similar in the two groups. It was concluded that intraoperative suggestions seem to have a positive effect in reducing patients’ morphine requirements in the early postoperative period.

Jirout, J. (1989). Reaction of the cerebral vertebrae in imagined changes in the shape of the cervical spine. Ceskoslovenska Neurologie a Neurochirurgie, 52, 75-77.

Postural reaction of the cervical vertebrae on imagined, but actually not performed, changes in the shape of the cervical spine in the sagittal plane are described. The percentage of reacting vertebrae is relatively high. The findings seem to indicate that, (1) the described phenomena belong to the constant features of the spinal dynamics, (2) that there probably exist residual traces of preceding activities, and (3) that these changes are due to the activation of the polymetameric system of the intrasegmental muscles. Abstracted in American Journal of Clinical Hypnosis, 1990, v. 32, p. 213.

Peebles, M. J. (1989). Through a glass darkly: The psychoanalytic use of hypnosis with post-traumatic stress disorder. International Journal of Clinical and Experimental Hypnosis, 37, 192-206.

A severe case of post-traumatic stess disorder stemming from consciousness (with auditory and pain perception) during surgery was treated with 8 sessions of hypnosis. Abreaction and revivification used alone initially retraumatized the patient, and her symptoms worsened. Ego-mastery techniques were then added; emphasis was placed on the role of the therapist as a new object presence to be internalized in restructuring the traumatic memory; memory consolidation and working-through techniques were instituted. The patient’s symptoms abated and her condition remitted. The similarities between hypnotic and analytic work are highlighted. In addition, the case material provides a clinical example of the existence and potential traumatic effects of conscious awareness during surgery.

Azuma, Nagato; Stevenson, Ian (1988). ‘Psychic surgery’ in the Philippines as a form of group hypnosis. American Journal of Clinical Hypnosis, 31, 61-67.

Psychic surgeons and their patients were observed in the Philippines during a variety of procedures of ‘minor surgery.’ In six cases, subcutaneous tissues (cysts and benign tumors) were removed. Histological examination confirmed the gross diagnoses and left no doubt that the skin had been penetrated. Although the psychic surgeons used no analgesics or anesthetics, the patients appeared to experience little or no pain and only slight bleeding. The authors believe that a supportive group ‘atmosphere’ enables the patients to enter a quasi-hypnotic state that reduces pain and facilitates healing.

Boeke, S.; Bonke, B.; Bouwhuis-Hoogerwerf, M. L.; Bovill, J. G.; Zwaveling, A. (1988). Effects of sounds presented during general anaesthesia on postoperative course. British Journal of Anaesthesia, 60, 697-702.

In a double-blind, randomized study, patients undergoing cholecystectomy were administered one of four different sounds during general anaesthesia: positive suggestions, nonsense suggestions, seaside sounds or sounds form the operating theatre. The effect of these sounds on the postoperative course was examined to assess intraoperative auditory registration. No differences were found between the four groups in postoperative variables.

Postoperative course was evaluated by 5 variables: pain, nausea and vomiting, evaluation by nursing staff, subjective well-being, and duration of postoperative hospital stay. From the chart they used amount of postoperative analgesia, volume of nasogastric suction or drainage and fluid lost through vomiting over 6 days post-operatively; duration of postoperative hospital stay was registered after discharge. See p. 699 for details, including wording of questions. They cite their own earlier study that got positive results, and explain the difference as possibly due to use of only male voices on tapes, lack of difference in the sounds on tapes in this study, insensitivity of outcome measures (patients stayed longer in first study than in this one), and sample too small in this study (106).
Boeke et al. (1988) report that this double-blind, randomized study of positive suggestions, noise or sounds from the operating theatre presented to 3 groups of patients undergoing cholecystectomy during general anaesthesia had positive results for older patients. patients > 55 years who received positive suggestions had a significantly shorter postoperative hospital stay than the other patients in this age category.

Evans, C.; Richardson, P. H. (1988). Improved recovery and reduced postoperative stay after therapeutic suggestions during general anesthesia. Lancet, 2 (8609), 491-493.

The clinical value of suggestions during general anesthesia was assessed in a double-blind randomized placebo-controlled study. 39 unselected patients were allocated to suggestion (N = 19) or control (N = 20) groups who were played either recorded suggestions or a blank tape, respectively, during hysterectomy. The patients in the suggestion group spent significantly less time in the hospital after surgery, suffered from a significantly shorter period of pyrexia, and were generally rated by nurses as having made a better-than-expected recovery. Patients in the suggestion group, unlike the control group, guessed accurately that they had been played an instruction tape.
Goldmann, Les; Ogg, T. W.; Levey, A. B. (1988). Hypnosis and daycase anaesthesia. A study to reduce preoperative anxiety and intraoperative anesthesia requirements. Anesthesia, 43, 466-469.
52 female patients having gynecological surgery as day cases received either a short preoperative hypnotic induction or a brief discussion of equal length. Hypnotized patients who underwent vaginal termination of pregnancy required significantly less methohexitone for induction of anesthesia and were significantly more relaxed as judged by their visual analogue scores for anxiety. Less than half the patients were satisfied with their knowledge about the operative procedure even after discussions with the surgeon and anesthetist. A significant correlation was found between anxiety and perceived knowledge of procedures. Results suggest that preoperative hypnosis can provide a quick and effective way to reduce preoperative patient anxiety and anesthetic requirements for gynecological daycase surgery.

Hawkins, Russell; Le Page, Keith (1988). Hypnotic analgesia and reflex inhibition. Australian Journal of Clinical and Experimental Hypnosis, 16, 133-139.

The major change in thinking about models of analgesia over the last decade or so may be seen as a shift away from the earlier emphasis on a one-way afferent transmission sequence. Analgesia was effected, according to the older models, by a simple blocking of afferent impulses at some level (as achieved by local anaesthesia). Recent models suggest that there are at least two CNS analgesia control systems, each operating via an active mechanism for the inhibition of nociception which includes reciprocal _efferent_ impulses able to respond to input from lower centres by sending control signals which modify their output. One CNS analgesia system has now been quite well described. This “opiate” analgesia system has proved to be naloxone reversible and seems to be mediated by reciprocal pathways between brain stem structures and the dorsal horn and trigeminal caudalis. This is not likely to be the system responsible for all cases of hypnotic analgesia, since the common experience of continued awareness of some elements of a normally painful stimulus, in spite of a freedom from pain, implicates a higher level involvement such as input from the prefrontal cortex.

The authors present a surgery case (of a cystoscopy and urethrotomy performed under hypnotic analgesia, with a highly hypnotizable patient) as an illustration of their position. The patient grimaced when the urethrotome was inserted into the urethra and dilated, but she denied discomfort and did not exhibit a reflex adduction of the thighs that is often observed even under standard general anaesthesia. She had spontaneous amnesia for the entire surgery. Later, under hypnosis, the patient could remember “discomfort and a sharp pain” which lasted for “seconds, if that” (p. 134).
The authors refer to Melzack and Wall’s (1965) gate control theory as well as Hilgard’s (1973) neodissociation interpretation of pain reduction in hypnosis. They review research by Hardy and Leichnetz (1981) with monkeys, in which they “traced the projections of the periaqueductal gray (PAG) to determine the extent of any possible cortical involvement in the endogenous analgesic system. Their work showed that the prefrontal cortex was the principal source of projections to the PAG” (p. 136). They quote the latter as writing that, “Patients who have had prefrontal lobotomies for relief of chronic pain report that while they still feel the pain they are no longer bothered by it … the prefrontal cortex by virtue of its projections to the PAG may play a role in modulating nociception at the spinal level” (Hardy & Leichnetz, 1981, p. 99).
“Hardy and Leichnetz have also suggested that there may be more than one analgesic system within the CNS. The first system is a naloxone-reversible mechanism which can be activated by opiates (presumably both endogenous and exogenous) and by acupuncture. Since hypnotic analgesia has shown itself not to be naloxone-reversible (Goldstein & Hilgard, 1975) it may have little to do with the opiate reception analgesia system. Instead the mechanism of hypnotic analgesia may lie in Hardy and Leichnetz’s second system which is sensitive to affective and cognitive influences” (pp. 136-137).
The authors include a review of the work by Mayer and Price (1976) which established the importance of brain stem structures in analgesia, especially for eliciting stimulation-produced analgesia. They cite Mayer and Price as drawing a distinction between “analgesia achieved by incapacitating a component in a pain transmission system or by activating a pain inhibition system” (p. 137). They also report that Mayer and Price conclude that stimulation-produced analgesia does not result from a “functional lesion” in the brain stem, but results from stimulation of a pain-inhibiting mechanism, suggesting the dorsal horn and trigeminal nucleus caudalis may be involved. This would be consistent with the inhibition of spinal reflexes (the adductor reflex) observed in their urethrotomy case, and the spinal reflex to nociception has also been reported by Finer (1974).
“The concomitant inhibition of reflexes in humans during hypnotic analgesia can be interpreted as evidence that nociception is probably not ascending to the cerebral cortex and that therefore the source of analgesia can be localized to the brain stem areas. It may be the case, however, that the locus of effect of hypnotic analgesia is not uniform across cases and may be identified by the overall pattern of subjective reports and physiological responses. Hypnotic analgesia may be experienced in more than one way subjectively and these differences may be attributable to differing underlying physiological mechanisms. On some occasions the relevant body part may be experienced as totally anaesthetised and all sensation (not only painful sensation) may be lost. This experience matches well with a brain stem involvement, which presumably inhibits any further afferent action. On other occasions, however, and more commonly, patients are still aware of a variety of sensations, which might include pressure in the case of childbirth or even cutting in the case of surgery, but these sensations are not described as painful. This is reminiscent of the effect of frontal lobotomy and it is tempting to focus on the frontal lobe as the locus of hypnotic analgesia effects in such instances” (p. 138).

Houge, Donald R.; Hunter, Robert E. (1988). The use of hypnosis in orthopaedic surgery. Contemporary Orthopaedics, 16, 65-68.

Some patients postpone or refuse indicated orthopaedic surgery because of fear or a medical contraindication to anesthesia. Clinical hypnosis previously has been used mainly as an adjunct to chemical anesthesia. However, hypnosis was shown to be entirely effective when used as the sole anesthesia in three of four orthopaedic cases. These four procedures included a radical head resection, the removal of a sideplate and Richard’s screw from the hip, and two cases of arthroscopic knee surgery. The preparation required for the surgery and the experiences of the patients during these procedures are described, and the kinds of patients most likely to benefit from the use of hypnosis in orthopaedic surgery are reviewed.

Frankel, Fred H. (1987). Significant developments in medical hypnosis during the past 25 years. International Journal of Clinical and Experimental Hypnosis, 35, 231-247.

Selected significant investigative studies on the use of hypnosis in the medical context over the past 25 years are discussed. The topics covered include anxiety and pain, asthma, migraine, skin disease, burns, nausea and vomiting, surgery, haemorrhagic disorders, and cancer and immunity. The importance of hypnotizability ratings in the methodology is emphasized.

Goldmann, Les; Shah, M. V.; Hebden, M. W. (1987). Memory of cardiac anesthesia: Psychological sequelae in cardiac patients of intra-operative suggestion and operating room conversation. Anesthesia, 42 (6), 596-603.

Thirty elective cardiopulmonary by-pass surgery patients were interviewed pre- and postoperatively. A random selection of patients heard a prerecorded audio tape toward the end of surgery after they were rewarmed to 37 degrees C. The tape contained suggestions for patients to touch their chin during the postoperative interview, to remember three sentences, and to recover quickly. The interviewers were blind to the experimental conditions. The experimental group touched their chins significantly more often than the control group (p = .015). Sentence recognition did not reach significance, perhaps due to the small numbers and low salience of the stimuli. Seven patients (23%) recalled intraoperative events, five with the aid of hypnosis. Three reports (10%) were corroborated. Preoperative medication (p < .01) and postoperative anxiety (p < .05) were significant predictors of those patients who reported recall. Jay, Susan M.; Elliott, Charles H.; Katz, Ernest; Siegel, Stuart E. (1987). Cognitive-behavioral and pharmacologic interventions for children's' distress during painful medical procedures. Journal of Consulting and Clinical Psychology, 55, 860-865. This study evaluated the efficacy of a cognitive-behavioral intervention package and a low-risk pharmacologic intervention (oral Valium), as compared with a minimal treatment-attention control condition, in reducing children's distress during bone marrow aspirations. The subjects were 56 leukemia patients who ranged in age from 3 years to 13 years. The three intervention conditions were delivered in a randomized sequence within a repeated-measures counterbalanced design. Dependent outcome measures included observed behavioral distress scores, self-reported pain scores, pulse rate, and blood pressure scores. Repeated-measures analyses of variance indicated that children in the cognitive-behavior therapy condition had significantly lower behavioral distress, lower pain ratings, and lower pulse rates than when they were in the attention- control condition. When children were in the Valium condition, they exhibited no significant differences from the attention control condition except that they had lower diastolic blood pressure scores. NOTES Lonnie Zelzer, M.D., in a UCLA Hypnosis Seminar lecture in 1992, stated that in pre-treatment with Valium the patients did worse during the procedure, vs no pretreatment with Valium, because the medicated patients didn't have clarity of attention during the cognitive behavioral learning. Katz, Ernest R.; Kellerman, Jonathan; Ellenberg, Leah (1987). Hypnosis in the reduction of acute pain and distress in children with cancer. Journal of Pediatric Psychology, 12, 379-394. Hypnosis has been used as a behavioral approach to help children tolerate aversive medical procedures more effectively, but empirical longitudinal research evaluating the outcome of such interventions has been limited. In the present study, 36 children with acute lymphoblastic leukemia between the ages of 6 and 12 years of age undergoing repeated bone marrow aspirations (BMAs) were randomized to hypnosis or play comparison groups. Subjects were selected on their behavioral performance on baseline procedures and received interventions prior to their next three BMA procedures. Major results indicated an improvement in self-reported distress over baseline with both interventions, with no differences between them. Girls exhibited more distress behavior than boys on three of four dependent measures used. Suggestions of an interaction effect between sex and treatment group were noted. The role of rapport between patient and therapist in therapeutic outcome was also evaluated. Results are discussed in terms of potential individual differences in responding to stress and intervention that warrant further research. Minichiello, William E. (1987). Treatment of hyperhidrosis of amputation site with hypnosis and suggestions involving classical conditioning. International Journal of Psychosomatics, 7-8. Hyperhidrosis of an amputation site utilizing hypnosis and/or behavioral strategies has not been reported in the literature. This case report is on the successful use of hypnosis utilizing principles of classical conditioning in the treatment of a patient with hyperhidrosis of an amputated limb with two previous unsuccessful sympathectomies. The patient possessing moderate hypnotic ability as measured by the Stanford Hypnotic Clinical Scale (SHCS), reported a pre-treatment score of 10 on a 0-10 severity and intensity of sweating scale, and a post-treatment score of 0. All gains were maintained at the two-year follow-up. NOTES The patient was hypnotized while an electric fan was blowing on his stump and prosthesis. Direct suggestions were given according to procedures of thermal biofeedback. The suggestions were: 1. You will notice in days ahead that your stump feels increasingly cooler and drier. 2. You will feel throughout the day as if a cool breeze from a fan is blowing on your stump. 3. Whenever you pay attention to your leg during the day, particularly after the first few hours of the morning, you will associate that leg with a cool dry breeze from a fan blowing on it. 4. You will increasingly develop the power to cool and dry your stump. The results were that 2 1/2 weeks later patient reported reduced frequency and intensity of sweating and significant healing of the stump ulcers; rating = 2. One month later, patient reported continued progress with almost normal skin color and stump condition; the patient discontinued disability, and returned to work. Patient returned one month later reporting, "It's cured and my physician can't believe it." Rating = 0. Author concludes that hypnosis should be tried prior to more invasive traditional procedures. In this case two previous sympathectomies failed to correct the condition and a third sympathectomy was being contemplated. 1986 DeBenedittis, Giuseppe; Sironi, Vittorio A. (1986). Depth cerebral electrical activity in man during hypnosis: A brief communication. International Journal of Clinical and Experimental Hypnosis, 34, 63-70. To the authors' knowledge, hypnosis has never been induced in epileptic patients during a depth EEG study. This neurosurgical diagnostic procedure has been routinely used in medically resistant epileptic patients for the preoperative exact delimitation of the epileptogenic lesion. It offers a unique opportunity to obtain fundamental information on the possible neurophysiological mechanisms implicated in hypnosis. Observations were carried out on 1 patient affected by medically resistant partial seizures with complex symptomatology. A chronic deep electrode study explored rhinencephalic structures as well as specific target areas of the cerebral cortex. Background electrical activity during hypnosis showed a significant decrease of slow waves and an increase of alpha and beta rhythms, with constant increase of amplitude, when compared to activity in the pre- and posthypnosis states. Focal interictal abnormalities were dramatically reduced during hypnosis. NOTES Hypnotizability was assessed with the Barber Suggestibility Scale in order to test for suggestibility without a prior induction of hypnosis. The patient's score was 7 out of 8 possible. Patient was hypnotized with a standard induction procedure (Barber & Calverley, 1963). Experimental Protocol: 15 minutes resting baseline; 15 minute test of mental imagery (waking suggestions with imagination instructions); hypnosis with progressive relaxation; suggestions for dissociation; suggestions for amnesia; arousal from hypnosis (the patient was successful with positive hallucinations, catalepsy, total amnesia, and spontaneous analgesia); and posthypnosis awake and alert (5 minutes eyes open, 5 minutes eyes closed, then 15-minute recording of post-treatment waking baseline). EEG background activity was scored for the number of sec/minute of delta (0-4), theta (4-7), alpha (8-12), and beta (13-30) rhythms, for each 5-min period. Score = percent as related to the 1-minute epoch. Number, amplitude, and diffusion of interictal spikes also were measured but ictal activity was not recorded during the periods considered. Experimenters also measured heart rate, respiratory rate, and mean blood pressure. ANOVA for 4 conditions (resting, waking suggestion, hypnosis, and posthypnosis) was computed for background and for focal interictal activities, and the t-test used to evaluate significant differences. ANOVA indicated a significant effect across the four experimental conditions for theta and alpha in the temporal anterior cortex, temporal posterior cortex, and frontal convexity cortex. The effect was attributable only to changes in theta and alpha between baseline and hypnosis (theta decreasing, alpha increasing as the patient went into hypnosis). No other significant difference was found. Following arousal from hypnosis, EEG activity was similar to the EEG activity before the induction. Interictal focal abnormalities were reduced during hypnosis, compared with before hypnosis. The effect was due to changes in the area of Ammon's horn, the amygdala, the posterior temporal cortex, the mesial temporal cortex, and the inferior temporal cortex. In their Discussion, the authors note that their data supports earlier work indicating that the limbic system is implicated in hypnosis. The cite the publications of Arnold (1959, International Journal of Clinical and Experimental Hypnosis) and Crasilneck, McCranie, and Jenkins (1956). The latter authors observed EEG records taken during brain surgery on one patient. Hypnosis terminated every time the hippocampus was stimulated, leading them to suggest that the hippocampus is part of the neural circuit involved in hypnosis. "If it is assumed that a convulsion can be considered a result of both pathophysiological and emotional events operating in the individual, emotions being the most common precipitating factor in epilepsy, then any amelioration of one will raise the convulsive threshold or lower the seizure level (Goldie, 1979; MacCabe & Habovick, 1963). Although 'voluntary control of the alpha rhythm' was achieved over 40 years ago (jasper & Shagass, 1941), only since 1969 has such control been used for clinical purposes (Kamiya, 1969). One striking characteristic of the EEG pattern of many epileptics is the absence of a 12 to 14 c/s rhythm normally recorded from the anterior portions of the brain (sensorimotor rhythm) and the presence of a 4 to 7 c/s rhythm at the same location (Olton & Noonberg, 1980). Biofeedback may enable the individual to increase the amount of sensorimotor rhythm and to decrease the amount of 4 to 7 c/s activity. As a consequence, clinically significant decreases in seizure activity have been found after biofeedback training (Sterman, 1973, 1977). "The present data demonstrate that in this female patient hypnosis induced a highly significant reduction of the interictal activity, concomitant with an increase of alpha and sensorimotor rhythm and a decrease of slow activity, similar to biofeedback but without prior training. " In conclusion, a depth EEG study in one epileptic patient comparing EEG activity during hypnosis and pre- and posthypnosis suggests the following conclusions: (a) hypnosis may be associated with significant decrease of slow activity and an increase of alpha and relatively high frequency, beta activity; (b) electrophysiological correlates of hypnotic behavior support the possible role of the limbic system in mediating the trance experience; and (c) hypnosis is effective in reducing focal interictal abnormalities in this patient and so it can be considered a promising technique to prevent and/or reduce emotional precipitating factors and the tendency to develop seizure activity" (p. 69). The article referenced regarding biofeedback training to reduce ictal activity is: Sterman, M. B. (1973). Neurophysiologic and clinical studies of sensorimotor EEG biofeedback training: some effects on epilepsy. In L. Birk (Ed.), _Biofeedback: Behavioral medicine._ New York: Grune & Stratton, Pp. 147-165. Sterman, M. B. (1977). Effects of sensorimotor EEG feedback training on sleep and clinical manifestations of epilepsy. In J. Beatty & H. Legewie (Eds.), _Biofeedback: Behavioral medicine._ New York: Plenum, 1977, Pp. 167-200. Omer, Haim; Friedlander, Dov; Palti, Zvi (1986). Hypnotic relaxation in the treatment of premature labor. Psychosomatic Medicine, 48, 351-361. Hypnotic relaxation was used as an adjunct to pharmacologic treatment with 39 women hospitalized for premature contractions in pregnancy. The control group received medication alone and consisted of 70 women. Treatment was started at the time of hospitalization and lasted for 3 hr on the average. patients were also given cassettes with a hypnotic - relaxation exercise for daily practice. The rate of pregnancy prolongation was significantly higher for the hypnotic - relaxation than for the medication- alone group. Infant weight also showed the advantage of the hypnotic - relaxation treatment. Background variables of the two groups were compared and it was shown that they could not have explained the treatment effect obtained. 1985 Bennett, Henry L.; Davis, H. S.; Giannini, Jeffrey A. (1985). Non-verbal response to intraoperative conversation. British Journal of Anesthesiology, 57, 174-179. In a double-blind study, 33 patients (herniorraphy, cholecystectomy and orthopedic) were randomly assigned to either suggestion or control groups. Under known clinical levels of nitrous oxide and enflurane or halothane anesthesia, suggestion patients were exposed to statements of the importance of touching their ear during a postoperative interview. Compared with controls, suggestion patients did touch their ear (tetrachoric correlation 0.61, P <0.02). test, U (Mann-Whitney frequently more so did they and LaRiccia, P. J.; Katz, R. H.; Peters, J. W.; Atkinson, G. W.; Weiss, T. (1985). Biofeedback and hypnosis in weaning from mechanical ventilators. Chest, 87, 267-269. Weaning patients from mechanical ventilation can be hindered by both physical and psychologic factors. Biofeedback has been used successfully as an adjunct in difficult weaning problems. We have used a combination of hypnosis and biofeedback to wean a patient with neurologic disease who previously failed weaning by standard procedures. A 30-year-old woman with respiratory failure secondary to multiple sclerosis with transverse myelitis was given eight sessions of biofeedback over 12 days in which the movements of her chest wall, as monitored by magnetometers, were displayed on an oscilloscope. The patient was praised for targeted respiratory rate, amplitude, and rhythm. These sessions included hypnosis in which the patient was given suggestions of well-being and that she could breathe as she had five years earlier. In this manner the patient was successfully weaned. Respiratory biofeedback and hypnosis appear to be useful adjuncts in weaning patients form ventilators. Morris, Don M.; Nathan, Ronald G.; Goebel, Ronald A.; Blass, Norman H. (1985). Hypnoanesthesia in the morbidly obese. Journal of the American Medical Association, 253 (22), 3292-3294. The advent of chemical anesthesia relegated hypnosis to an adjunctive role in patients requiring major operations. Anesthesia can be utilized with acceptable risk in the great majority of patients encountered in modern practice. But an occasional patient will present--such as one with morbid obesity--who needs a surgical procedure and who cannot be safely managed by conventional anesthetic techniques. This report describes our experience with such a patient and illustrates some of the advantages and disadvantages of hypnoanesthesia. The greatest disadvantage is that it is unpredictable. Close cooperation between the patient, hypnotist, anesthesiologist, and surgeon is critical. However, the technique may be utilized to remove very large lesions in selected patients. Hypnoanesthesia is an important alternative for some patients who cannot and should not be managed with conventional anesthetic techniques. 1984 Bishay, Emil; Stevens, Grant; Lee, Chingmuh (1984). Hypnotic control of upper gastrointestinal hemorrhage: A case report. American Journal of Clinical Hypnosis, 27, 22-25. The use of hypnosis for control of bleeding during and after surgical procedures is common practice. It has also been a useful tool for control of bleeding in hemophiliac children, especially during dental procedures, and in traffic accidents. This paper presents the successful treatment with hypnosis of a patient with upper gastrointestinal tract bleeding. After treatment, the patient was discharged from the hospital without the need for surgical intervention. NOTES 1: NOTES The physician explained to the patient that nothing would hurt her and that nobody would do anything against her will, that if she could "relax," then her unconscious mind would help her control her bleeding. [Gives script used in the hypnosis.] Trance terminated after 20 minutes. "One hour later, endoscopy performed under local anesthesia revealed 'non-bleeding gastritis, no ulcers seen.' She had no bleeding following the hypnotherapy" (p. 23). Katcher, Aaron; Segal, Herman; Beck, Alan (1984). Comparison of contemplation and hypnosis for the reduction of anxiety and discomfort during dental surgery. American Journal of Clinical Hypnosis, 27, 14-21. Complex moving visual stimuli are used to induce states of relaxation, hypnosis and revery. To test the efficacy of using aquarium contemplation to induce relaxation, 42 patients were randomly assigned to one of five treatments prior to elective oral surgery: 1) contemplation of an aquarium, 2) contemplation of a poster, 3) poster contemplation with hypnotic induction, 4) aquarium contemplation with hypnosis, and 5) a non intervention control. Blood pressure, heart rate, and subjective and objective measures of anxiety were used as dependent measures. Pretreatment with aquarium contemplation and hypnosis, either alone or in combination, produced significantly greater degrees of relaxation during surgery than poster contemplation or the control procedure. Two-way ANOVA demonstrated that a formal hypnotic induction did not augment the relaxation produced by aquarium contemplation. NOTES The consent form was designed to reduce anxiety about hypnosis by stating that if hypnosis was used, it would be used only to induce relaxation. Patients were then randomly assigned to one of the 5 pretreatment groups, with 8 in each of the four contemplation groups and 10 in the nonintervention control. 1. Aquarium contemplation. Ss contemplated it for 40 minutes; during the 1st 25 min, 5 tests of suggestibility were administered (from the Stanford) which eliminated all tests the authors considered anxiety-provoking such as suggested hallucination. Also, the terms hypnotically relaxed or hypnotic relaxation replaced the term hypnosis throughout the protocol. 2. Poster contemplation was the same, using a color photo of a mountain waterfall. 3. Poster contemplation with hypnosis used a protocol derived from Stanford, with visual fixation on poster, then the 5 tests, then Ss contemplated the poster for 10 minutes under hypnosis and were given post hypnotic suggestion that they could reenter hypnosis during the dental procedure by closing their eyes and visualizing the poster 4. Aquarium contemplation with hypnosis was like #3 except that Ss were asked to look at "either one fish or a portion of the aquarium" during induction and were told to reenter hypnosis during treatment by closing their eyes and visualizing the aquarium 5. Nonintervention control Ss were given no tests of suggestibility; they were seated in a chair and told to "relax." During surgery, an observer recorded overt signs of anxiety or agitation on a check list, making entries at five-minute intervals. The surgeries took variable lengths of time (5-90 minutes) and variable kinds of procedures (multiple injections, removal of bone, etc.) Surgeons varied in management-- gentleness, etc. Blood pressure fell significantly during all 5 pretreatments without any significant differences between groups. Analysis of interaction effects, significant at the 0.1 level for all 3 dependent variables, indicated that hypnosis had a major effect on relaxation only when the S was contemplating a poster. Hypnosis had no significant influence on the levels of relaxation obtained by contemplation of the aquarium. There were no significant differences between groups in the number of suggestions accepted. 1982 Hilgard, Josephine R.; LeBaron, Samuel (1982). Relief of anxiety and pain in children and adolescents with cancer: Quantitative measures and clinical observations. International Journal of Clinical and Experimental Hypnosis, 30, 417-442. Children and adolescents with cancer, chiefly forms of leukemia, aged 6 to 19 years, underwent medical treatments which required repeated bone marrow aspirations, normally a painful and anxiety-provoking experience. Data were obtained in baseline bone marrow observations on 63 patients, who were then offered the opportunity to volunteer for hypnotic help in pain control. Of the 24 patients who accepted hypnosis, 9 were highly hypnotizable. 10 of the 19 reduced self-reported pain substantially by the first hypnotic treatment (the prompt pain reducers) and 5 more reduced self-reported pain by the second treatment (the delayed pain reducers) while none of the 5 less hypnotizable patients accomplished this. The latter benefitted by reducing anxiety. Short case reports illustrate the variety of experiences. Analysis of baseline observations before any therapeutic intervention revealed age and sex differences. The difference between self-reported and observed pain was not statistically significant for patients under age 10 but was significant for the patients age 10 and older (p<.001). There were minor but significant sex differences both in observed pain (p<.01) and in self-reported pain (p<.05), with the females reporting more pain. 1980 Hart, R. (1980). The influence of a taped hypnotic induction treatment procedure on the recovery of surgery patients. International Journal of Clinical and Experimental Hypnosis, 28, 324-331. A study of 40 open heart surgery patients assigned to 1 of 2 equal size treatment groups sought to evaluate the efficacy and utility of a tape-recorded hypnotic induction procedure that preoperatively prepared patients for surgery. The dependent variables included daily blood pressure measurements and postsurgical outcome data pertaining to postoperative units of blood required, state/trait anxiety, and locus of control dimensions. Results of the study tended to provide some support for the tape-recorded hypnotic induction procedure in lessening state anxiety and in promoting a more self- directed attitude toward surgical recovery. 1977 Chertok, Leon; Michaux, D.; Droin, M. C. (1977). Dynamics of hypnotic analgesia: Some new data. Journal of Nervous and Mental Disease, 164, 88-96. Following two surgical operations under hypnotic anesthesia, it was possible, during subsequent recall under hypnosis, to elicit a representation of the past operative experience. It would seem that under hypnosis there is a persistence of the perception of nociceptive information and of its recognition as such by the subject. From an analysis of these two experiments in recall, it is possible to formulate several hypotheses concerning the psychological processes involved in hypnotic analgesia. In consequence of an affective relationship, in which the hypnotist's word assumes a special importance for the subject, the latter has recourse to two kinds of mechanism: a) internal (assimilation to an analogous sensation, not, however, registered as dangerous-- rationalization); and b) external (total compliance with the interpretations proposed by the hypnotist), which lead to a qualitative transformation of nociceptive information, as also the inhibition of the behavioral manifestations normally associated with a painful stimulus. 1995 Ashton RC Jr. Whitworth GC. Seldomridge JA. Shapiro PA. Michler RE.Smith CR. Rose EA. Fisher S. Oz MC. The effects of self-hypnosis on quality of life following coronary artery bypass surgery: preliminary results of a prospective, randomized trial. Journal of Alternative & Complementary Medicine 1995;1(3):285-90 The effects of complementary techniques and alternative medicine on allopathic therapies is generating much interest and research. To properly evaluate these techniques, well controlled studies are needed to corroborate the findings espoused by individuals practicing complementary medicine therapies. To this end, we evaluated the role of one of these therapies, self-hypnosis relaxation techniques, in a prospective, randomized trial to study its effects on quality of life after coronary artery bypass surgery. Subjects were randomized to a control group or a study group. Study group patients were taught self-hypnosis relaxation techniques the night prior to surgery. The control group received no such treatment. Patients then underwent routine cardiac management and care. The main endpoint of our study was quality of life, assessed by the Profile of Moods Scale. Results demonstrated that patients undergoing self-hypnosis the night prior to coronary artery bypass surgery were significantly more relaxed than the control group (p = 0.0317). Trends toward improvement were also noted in depression, anger, and fatigue. This study demonstrates the beneficial effects of self-hypnosis relaxation techniques on coronary surgery. This study also identifies endpoints and a study design that can be used to assess complementary medicine therapies. Results of this preliminary investigation are encouraging and demonstrate a need for further well-controlled studies. 1997 Cruise CJ. Chung F. Yogendran S. Little D. Music increases satisfaction in elderly outpatients undergoing cataract surgery. Canadian Journal of Anaesthesia 1997;44(1):43-8 PURPOSE: Music has long been known to reduce anxiety, minimize the need for sedatives, and make patients feel more at ease. The purpose of the study was to evaluate the effect of music in elderly outpatients undergoing elective cataract surgery with retrobulbar block and monitored anaesthetic care using fentanyl or alfentanil and midazolam. METHODS: One hundred and twenty one patients were prospectively and randomly assigned to hear: relaxing suggestions, white noise, operating room noise or relaxing music via audio-cassette headphones. Vital signs were documented before and after retrobulbar block and every 15 min thereafter. Anxiety was assessed using the State-Trait Anxiety Inventory (STAI) before and after surgery. Visual analogue scales (VAS) were used to assess anxiety and patient satisfaction postoperatively with a standardized questionnaire. Between group comparisons were made using Chi-Square, or ANOVA, where appropriate. RESULTS: There were no differences between groups in STAI or anxiety VAS scores at any time. Differences were noted in systolic blood pressure, but not in other vital signs. Patients' ratings of the whole operative experience, satisfaction with the tape played, general level of relaxation and preference for the chosen tape for subsequent surgery were different (music > relaxing suggestions > white noise and OR noise, P < 0.05). CONCLUSIONS: Elderly patients undergoing cataract surgery under retrobulbar block were more satisfied with their experience if they heard relaxing music, rather than relaxing suggestions or white noise or OR noise. The type of auditory stimuli to which the patients were exposed did not influence the level of anxiety. 1993 Disbrow EA. Bennett HL. Owings JT. Effect of preoperative suggestion on postoperative gastrointestinal motility Western Journal of Medicine. 1993;158(5):488-92 Autonomic behavior is subject to direct suggestion. We found that patients undergoing major operations benefit more from instruction than from information and reassurance. We compared the return of intestinal function after intra-abdominal operations in 2 groups of patients: the suggestion group received specific instructions for the early return of gastrointestinal motility, and the control group received an equal-length interview offering reassurance and nonspecific instructions. The suggestion group had a significantly shorter average time to the return of intestinal motility, 2.6 versus 4.1 days. Time to discharge was 6.5 versus 8.1 days. Covariates including duration of operation, amount of intraoperative bowel manipulation, and amount of postoperative narcotics were also examined using the statistical model analysis of covariance. An average savings of $1,200 per patient resulted from this simple 5-minute intervention. In summary, the use of specific physiologically active suggestions given preoperatively in a beleivable manner can reduce the morbidity associated with an intra-abdominal operation by reducing the duration of ileus. Enqvist B. Fischer K. Preoperative hypnotic techniques reduce consumption of analgesics after surgical removal of third mandibular molars: a brief communication. International Journal of Clinical & Experimental Hypnosis 1997;45(2):102-8 The effects of hypnosis in connection with surgery have been described in many clinical publications, but few controlled studies have been published. The aim of the present study was to evaluate the effects of preoperative hypnotic techniques used by patients planned for surgical removal of third mandibular molars. The patients were randomly assigned to an experimental (hypnotic techniques) or a control (no hypnotic techniques) group. During the week before the surgery, the experimental group listened to an audiotape containing a hypnotic relaxation induction. Posthypnotic suggestions of healing and recovery were given on the tape together with advice regarding ways to achieve control over stress and pain. The control group received no hypnotic intervention. Only one surgeon who was not aware of patient group assignments performed all the operations. Thirty-six patients in the control group were compared to 33 patients in the experimental group. Anxiety before the operation increased significantly in the control group but remained at baseline level in the experimental group. Postoperative consumption of analgesics was significantly reduced in the experimental group compared to the control group. Evans C, Richardson PH Therapeutic suggestions during general anesthesia Advances 1988;5(4):6-11 Tested the hypothesis that the quality and duration of recovery from surgery would be improved by therapeutic suggestions made while patients were under general anesthesia, in a double-blind randomized controlled study of 39 adult hospital patients who were admitted for an abdominal hysterectomy. Results support the hypothesis. Greenleaf M. Fisher S. Miaskowski C. DuHamel K. Hypnotizability and recovery from cardiac surgery. American Journal of Clinical Hypnosis 1992;35(2):119-28 We studied 32 coronary bypass patients to examine the effect of hypnosis on recovery from surgery. The patients were assessed for hypnotizability with the Hypnotic Induction Profile (HIP) and assigned to experimental groups with a random stratification procedure to equate for differences in hypnotizability, age, and severity of illness. We taught patients in groups one and two formal hypnosis with different treatment strategies; patients in group three were not taught formal hypnosis or a treatment strategy. Scores on the HIP were significant predictors of recovery, independent of experimental treatment with formal hypnosis. Patients who scored "Midrange" stabilized more quickly in the intensive care unit (ICU) than those who scored "High" or "Low" (p = < .05). Patients who scored "High" had more labile blood pressure in the ICU compared to the "Midrange" and "Lows" (p = < .05). Measured hypnotizability was associated with the recovery sequence from surgery. Johnston M, Vogele C Benefits of psychological preparation for surgery: A meta analysis Ann Behav Med. 1993;15(4):245-256 There is now substantial agreement that psychological preparation for surgery is beneficial to patients. It is important, however, to establish which benefits can be achieved by psychological preparation and if all forms of preparation are equally effective. The results of randomized controlled trials of psychological methods of preparing adult patients for surgery were analyzed in terms of eight outputs (negative affect, pain, pain medication, length of stay, behavioral and clinical indices of recovery, physiological indices, and satisfaction). In order to reduce publication bias, published as well as unpublished studies were included in the meta analysis. It was concluded that significant benefits can be obtained on all of the major outcome variables that have been explored. Procedural information and behavioral instructions show the most ubiquitous effects in improving measures of post-operative recovery. The results have implications for the improvement of patient care in surgical units. Lambert SA. The effects of hypnosis/guided imagery on the postoperative course of children. Journal of Developmental & Behavioral Pediatrics. 1996;17(5):307-10 Hypnosis, guided imagery, and relaxation have been shown to improve the postoperative course of adult surgical patients. Children have successfully used hypnosis/guided imagery to significantly reduce the pain associated with invasive procedures and to improve selected medical conditions. The purpose of this study was to examine the effect of hypnosis/guided imagery on the postoperative course of pediatric surgical patients. Fifty-two children (matched for sex, age, and diagnosis) were randomly assigned to an experimental or control group. The experimental group was taught guided imagery by the investigator. Practice of the imagery technique included suggestions for a favorable postoperative course. Significantly lower postoperative pain ratings and shorter hospital stays occurred for children in the experimental group. State anxiety was decreased for the guided imagery group and increased postoperatively for the control group. This study demonstrates the positive effects of hypnosis/guided imagery for the pediatric surgical patient. McLintock TT. Aitken H. Downie CF. Kenny GN. Postoperative analgesic requirements in patients exposed to positive intraoperative suggestions. BMJ 1990;301(6755):788-90 OBJECTIVE--To establish whether positive suggestions given to a patient under general anaesthesia reduce postoperative pain and analgesic requirements. DESIGN--Prospective double blind randomised study. SETTING--Operating theatre and gynaecology ward of a teaching hospital. PATIENTS--63 Woman undergoing elective abdominal hysterectomy were randomised to be played either a tape of positive suggestions or a blank tape during the operation through a personal stereo system. INTERVENTIONS--Three women were withdrawn from the study. Anaesthesia was standardised for all of the women. Postoperative analgesia was provided through a patient controlled analgesia system for the first 24 hours. Pain scores were recorded every six hours. MAIN OUTCOME MEASURES--Morphine consumption over the first 24 hours after the operation; pain scores. RESULTS--Mean morphine requirements were 51.0 mg (95% confidence interval 42.1 to 60.0 mg in the women played positive suggestions; and 65.7 mg (55.6 to 75.7 mg) in those played a blank tape. The point estimate (95% confidence interval) for the difference of means was 14.6 mg (22.4%) (1.9 (2.9%) to 27.3 mg (41.6%] (p = 0.028). Pain scores were similar in the two groups. CONCLUSION--Positive intraoperative suggestions seem to have a significant effect in reducing patients' morphine requirements in the early postoperative period.