SURGERY & ANAESTHESIA - Hypnotherapeutic Intervention in the treatment of Surgery & Anaesthesia

In parallel with its rapid development in psychotherapy, hypnotherapy also finds applications in anaesthesia and surgery. The founding father of modern hypnosis is Milton Erickson, who was born in 1901 and founded the American Society for Clinical Hypnosis. He defined hypnosis as a natural phenomenon that anyone of us can reach. It is an altered state of consciousness based on the principle of dissociation, with a concentrated but focused attention which is different from the state of sleep. In fact, hypnosis corresponds to a state of inner absorption and such a focused attention that the individual becomes unconcerned about any other consideration. The analgesic effect of hypnosis in pain management has been extensively studied. It is used both for acute and chronic pain management in adults.

Hypnosis in surgery has a long history, dating back to the first half of the 19th century. Even after the introduction of chemical anaesthesia, there are examples of major surgeries being carried out using hypnosis instead of general anaesthetics during the 20th and the present century.

Self-hypnosis has also been used by patients instead of general or local anaesthetics in operations in the past, including in the UK, some of which have been recorded on film. The Irish surgeon, Dr. Jack Gibson performed over 4,000 hypnosurgeries involving many serious operations including amputations. The decision to use hypnosis in these cases was made on medical grounds avoiding any sensationalism.

Hypno-anaesthesia is gaining popularity both due to its clinical track record, and because physical pain inflicts stress and suffering, while the drugs that reduce pain can be harmful. In fact, the leading cause of death during surgery is complications due to chemical anaesthesia. For sufferers of chronic pain, using narcotics can lead to impaired mental functioning, other bad side effects, and even addiction.
The terrific news is that hypnosis can almost always reduce—and sometimes eliminate—physical pain, with no dangerous side effects whatsoever. Hypno-anaesthesia is one use of hypnotherapy that the scientific community has proved beyond any doubt.

"Though often denigrated as fakery or wishful thinking, hypnosis has been shown to be a real phenomenon with a variety of therapeutic uses—especially in controlling pain," Scientific American reports. "Sceptics have argued that this effect results from either simple relaxation or a placebo response. But a number of experiments have ruled out these explanations."
Today many clients rely on hypnotherapy to increase their comfort and safety during surgery. Meanwhile, the most common - and likewise well-proven - use of hypno-anaesthesia is to help chronic-pain sufferers experience chemical-free relief.

Hypno-anaesthesia works to some degree for virtually everyone; very well for the majority of clients; and for highly hypnotizable subjects, it can be 100% as effective as chemical anaesthesia.
While by now numerous studies have documented that hypno-anaesthesia works amazingly well, researchers continue to investigate exactly how it does so. The studies indicate that hypno-anaesthesia blocks our higher brain centres from registering painful signals sent up through the spinal column.
Hypno-anaesthesia "definitely does something to reduce the pain signal input into the cortical structure," said Sebastian Schulz-Stubner, M.D., Ph.D., and co-author of the first study to use fMRI to investigate hypno-anaesthesia. Additional brain-imaging research has confirmed this finding.

There is also evidence that hypno-anaesthesia stimulates the brain to release endorphins (natural pain-reducing neuro-chemicals) and regulates the neurotransmitters serotonin and dopamine in a manner that lowers pain. This also may help explain why hypnotherapy clients report feeling so much better mentally and emotionally, as well as physically.

The following compilation of Research into Hypnotherapeutic Intervention in Surgery and Anaesthesia, with specific examples of working with patients and statistical analysis of Hypno-psychotherapeutic interventions which were used in the treatment of these clients. If you have comments on the following research, or simply ideas, approaches, techniques or opinions, please feel free to post in the comment section below.

Please visit our website www.hypnosiseire.com for more details or email ichphq@gmail.com

1995

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

NOTES 1:
Two theories of pain control by hypnosis currently exist: 1. Socio-cognitive model - patient actively copes with noxious stimulus. Hypnotic analgesia should be like cognitive techniques like stress inoculation training. It requires deliberate effort. 2. Dissociative control model - pain reduction requires little cognitive effort.

These 2 theories have different predictions. He explains "ironic effects" theory, in which person must identify pain to reduce pain. Wagner's reflexivity constraint: any process of mental control must be consistent with state we are trying to create.

This investigation involved 25 Highs and 24 Lows who reported pain, produced by strain gauge. Taught either hypnotic analgesia or stress inoculation. Reported every 5 sec (high load) or 45 sec (low load). Subtracted report from baseline to make pain reduction scores. Highs in hypnosis had no difference in pain reduction under high or low mental load. For the other 3 groups (Highs under stress inoculation; Lows under either hypnosis or stress inoculation) the results were different. That is, for Highs in hypnosis the mean of pain reduction scores was the same even when challenged by frequent reports of how much pain was being experienced.

Results are congruent with Miller and Bowers' dissociative control model.

Wagner's ironic process theory is useful. Frequency of pain reporting moderates Ss reports of pain in analgesia. These results challenge the cognitive social model of hypnotic analgesia and support a dissociative control model. Unlike stress inoculation, hypnotic analgesia does not require cognitive effort for high hypnotizable subjects.

1994

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

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

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

NOTES 1:
Hilgard once said we should study what is going on inside the skull when we study hypnotic behavior. Theta EEG was studied, in 3.5 and 5.5-7.5 band widths, based on Crawford's research (no differences between high and low hypnotizables in low range but significant differences in waking state, eyes closed condition).

Also employed new type of distraction procedure. Previously used as comparison conditions things like imagine a pleasant scene, do whatever you can do to reduce pain, or imagine an instructor giving a lecture. Barabasz theorized that highs, given the opportunity, may spontaneously get involved in imagery; so distraction used in some experiments may actually become hypnosis. Here, distraction involved using a storage box, with plexiglass covering front, and 3 lights--subjects were to recall sequence of light changes that occurred during 60 sec when arm was in the cold water.

Cold pressor pain. 3 immersions with simultaneous pain reporting and EEG monitoring. --Waking State --Light array distraction --Hypnotic induction and suggested analgesia (Distraction and hypnosis with analgesia were presented in a balanced design)

Pain Ratings ranged from 0 = no pain, 10 = level would very much like to remove arm from water (rating could exceed 10 however). After removing arm, subjects were to report the maximum amount of pain that they had felt. Pain Scores were obtained at 30 seconds and 60 seconds after immersion in the cold water.

Also got qualitative data. During recovery period after each arm immersion, Subjects were asked what if anything they had done to reduce the pain felt.

30 second pain scores: Waking 7.60 vs 7.50 Distraction 8.60 vs 6.80 Hypnotic analgesia 7.80 vs 4.10 (Significantly different).

60 second pain scores: Showed same trend.

There was no difference whatsoever for the lows.

Results for the 2 EEG sites: P3 left hemisphere parietal in waking and hypnotic analgesia, high theta, had significantly different activity O1 left hemisphere in waking and hypnotic analgesia, was significantly different between highs and lows (same as above).

Results for two theta ranges: Low theta range, T4 temporal right hemisphere, for lows in waking and [missed words] condition--hard to interpret this finding.

RESULTS.

Highs demonstrated pain reduction in hypnotic analgesia compared to waking and distraction conditions and compared to lows. Lows had no differences in any condition.

Enhanced EEG theta in left parietal area differentiated highs and lows. This suggests that highs generate enhanced disattention that may be controlled by these areas.

P3 area regulates the integration and association of somatic perceptions. The O1 area controls processing of visual imagery. Perhaps high hypnotizables have more ability to alter afferent sensory information through focused attentional processes. Also, the ability to alter the suffering portion of pain experience may involve visual imagery activity.

State and trait differences are apparent.

The low theta range may be more closely related to slower delta range 0-3.5 that is associated with sleep and drowsiness. High theta = low arousal and attention capacity. That's why theta seems associated with wide range of behaviors that appear contradictory

The qualitative data shows highs reported they spontaneously preferred strategies that were more than distraction (associating colors with warmth, thinking of warm water) and the most frequent responses of lows were "nothing" or "told myself it would be over soon."

Highs in analgesia condition used no specific strategy: 8/10 reported the arm simply felt more numb.

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

NOTES

Stimulated by work of Basil Finer, and following upon the Neodissociation theory of Hilgard; pain is registered by the body but dissociation that produces analgesia is a function of higher brain centers.

Could hypnotic analgesia be mediated lower, at the level of the spinal cord? Gate at dorsal horn could be open or shut; subject to descending modulation. Is hypnosis involved in descending modulation of activity in the dorsal horn?

Hypothesis: reduced pain intensity would be associated with reduced activity at dorsal horn. From Price & Barber, we wanted to look at affect and intensity aspects of pain. Polysynaptic reflex, R-III, latency consistent with conduction velocity (when hand touches a hot stove); even with severed spinal cord injury we still demonstrate the reflex. The magnitude of reflex is linearly related to the pain sensation. The stronger the electrical pulse, the greater the magnitude of the reflex. Magnitude of reflex is linearly related to subjective pain. It is an index of nociceptive activity.

Procedure: Evoke reflex with electrical stimulus at ankle; measure signal at muscle with EMG. We anticipated that at dorsal horn, descending modulation would dampen signal.

15 healthy volunteers. Sural nerve was stimulated. R III reflex measured via EMG response. Used the visual analogue scale (VAS) to assess pain.

1993

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

NOTES 1:
Presents point of view of a private practice anesthesiologist in Santa Barbara, California. Used hypnosis for 20 years.

Use of hypnosis as hypnoanesthesia is rare since Esdaile, with brief resurgence in 50's, because surgery techniques advanced before anesthesias did in areas that were very risky. Now it is a matter of choice, and may be undertaken because of a patient's extreme fear of anesthesia, previous bad experience with anesthesia, fervent belief in holistic method, allergy, or previous experience with hypnosis. Still advised to use hypnosis for MRIs, radiation procedures, former drug addicts (who may have problems with drugs), burn patients, release of neck contractions, and medical procedures--especially with children--like lumbar puncture.

She disagrees with Kroger's estimate of only 10% of patients being able to use hypnoanesthesia; she does not believe it requires a lot of training, or profound muscle relaxation.

There is no indication of how many cases are actually done with hypnosis. Also, published cases are not representative of the quantity or complexity of cases; most published cases have a few extraordinary characteristics. The Irish surgeon Jack Gibson has done more than 4000 cases, some very complicated.

I have used it for D & Cs, and complex cases that were not published. Most of my patients elected to be alert during the hypnosis and conversed with their surgeons. The most common benefit is that recovery from anesthesia is not necessary; but these days with newer anesthesias recovery from anesthesia is rapid anyway. However, if as we suspect anesthesia affects immune function, that would be another reason to use hypnosis.

Preparation for surgery may be of three types: 1. formal hypnosis techniques 2. "hypnoidal" techniques that aren't formal 3. unprepared patients in whom hypnosis is used at last moment.

Examples. 1. Formal hypnosis: This symposium deals with this type of approach. Three groups derive particular benefit -- those requiring prolonged artificial ventilation postoperatively (because otherwise sedation must be used, which leads to complications), where prepared patients tolerate interventions calmly and comfortably -- cancer patients, for whom this can be first experience of patient to see self as active participant in care rather than a victim of the illness and of complicated technology -- pediatric patients. 2. Hypnoidal (hypnosis like) techniques: This is the most important application. Time doesn't permit much discussion here. Patients are in an altered state when they come for surgery, highly suggestible, and suggestions appear to be as effective as during formal trance state. The doctor can elicit positive responses during "casual conversation" while seemingly giving information to the patient. (The reverse is true also, with inadvertent negative suggestions, to the detriment of the patient.) Scrupulous adherence to medical facts is important during this type of conversation.

Operating room fixtures are useful for focus of attention, and I have published this information in an article.

Recovery room also is place where case specific information and appropriate suggestions can be given. Patient can experience his ability to alter sensations, for the first time, following suggestions.

Remainder of the hospitalization offers opportunity for reinforcing case specific positive suggestions.

Bennett, Henry L. (1993, October). Hypnosis and suggestion in anesthesiology and surgery. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, Arlington Heights, IL.

NOTES 1:
He began by saying that he is opposed to using hypnosis for surgery, though he favors a theory of how hypnosis effects physiological change, and cites T. X. Barber's classic "Changing Unchanging Bodily Processes."

Relaxation puts patient in a "psychological strait jacket" because surgery is so highly stressful. He gives information "about how to go through the surgery more comfortably," gets across the idea about coping style, tells them surgery is exertional and that they are tired afterward, that he can help them "using things you already know how to do," and specifies exactly what they can do--using model of himself as a trainer.

In some recent research he used pairs of pictures, some of which lead to pupillary constriction (blood pressure goes down) or dilation (blood pressure goes up). Instructing them to look, patients looked twice as long at the pictures than they did during free gaze. When not instructed to look, heart rate went down; when told to look, heart rate went up. So the researchers went back to free gaze. He uses this as a metaphor for many of the pre- surgery preparation activities that encourage relaxation "inappropriately."

He cites Cohen & Lazarus re vigilant copers, Price et al (1957), and some other studies on epinephrine effects. He uses examples of work patients may have done (e.g. planting a garden) when talking with patients prior to surgery, that gives them a sense of accomplishment later.

You have to give specific instructions or suggestion, not general relaxation suggestions.

Question from the audience: Can preoperative instructions (not hypnosis) diminish blood loss.

In Bennett's answer he seems to be reporting the earlier study: they found 150- 4000 cc blood loss, high variability. Extent of blood loss was determined by extent of surgery, by instructions to patients vs no instructions.

This study was replicated by Enqvist, Bystedt, & von Konow in the Anesthesia conference at Emory University in 1992.

May 1993 Western Journal of Medicine article, Disbrow, Bennett, & Owinos, with 40 lower abdominal surgery patients who got specific instructions or not. The SHCS was used to measure hypnotizability: highs resolved quicker than low hypnotizable patients. They also found that instructed patients did better than those who did not get specific instructions.

There are now 3 replications of McClintock's study: people use less medications after surgery, when tapes about rapid recovery are played *during* surgery.

Bennett is now using tapes with suggestions for recovery during surgery.

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

NOTES 1:
The author stated that his research and the few other studies of cardiac surgery patients do not support idea that cardiac surgery patients benefit from hypnosis and suggestion.

Types of intervention have varied: hypnosis, suggestion, relaxation; pre-op, during, or post-op; with many different outcome variables.

Aiken & Henrichs (1971) study was nonrandomized, nonblinded, for 30 patients getting open heart surgery. Treated patients had benefits.

Surman, Hackett, Silverberg, & Behrendt (1974) had a randomized, single-blind design for 40 patients taught Self Hypnosis (S-H), for elective mitral valve surgery. No difference in benefits. But 45% of patients taught S-H reported a subjective sense of benefit (though objective indicators didn't support that). [He says the difference between subjective/objective outcome ratings is important.]

Hart (1980) used randomized, single-blind design for 40 patients who had open heart surgery. No differences found except initial 3 days post surgery.

Greenleaf et al (1992) - see her paper presentation of this date.

Blankfield et al (presented at Society of Clinical and Experimental Hypnosis meeting in 1992) used a randomized, single-blind design for 95 patients, who were randomly assigned to taped suggestions, music, or controls. No differences were found in benefits.

Our data were re-analyzed: patients who felt tape was helpful were compared to the remaining 62 patients, but there again were no differences in amount of narcotics used for pain, though there was a trend in the right direction; nursing assessments failed to identify less anxiety.

The point is, whereas the bulk of publications suggest benefits, there is little evidence with this population. Could these patients be different in personality, ability to respond to intervention, amount of external stimuli? They should be studied because there are a lot of these patients with only a few surgeons and you don't have to gain the cooperation of a lot of different surgeons to do this kind of research. Also, there is uniformity in cardiac surgery whereas standard operating surgery is in a state of flux in other areas (e.g. movement from generous incisions to micro procedures, and patients receiving this type of surgery remain in hospital for a week whereas this opportunity to study them during inpatient post-surgical period is disappearing in other areas). It is my opinion that cardiac patients may not be highly receptive to suggestion.

Curiously, according to Surman and my research, 1/2 the subjects report benefits. Either some benefits are subtle, or they are reporting a placebo effect.

Future studies need more patients, and the investigators must stratify on personality inventory variables such as Type A personality, hypnotizability, motivation, anxiety, depression, family support, social support systems. This is labor intensive, to determine which characteristics determine differing outcomes. The patients used in this type of research require more presurgery evaluation than previously has occurred.

The MMPI can be self administered and is widely acceptable, but is cumbersome, not well suited to people who are acutely ill. Assessment of Type A personality is important because Type A's might be less receptive to suggestion. Structured interview is time consuming, but a 52-item questionnaire can be self administered. Other factors listed above are important.

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

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

Everett, John J.; Patterson, David R.; Burns, G. Leonard; Montgomery, Brenda; Heimbach, David (1993). Adjunctive interventions for burn pain control: Comparison of hypnosis and Ativan. Journal of Burn Care and Rehabilitation, 14, 676-683.

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

1992

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

NOTES 1:
"Surgical patients can absorb information while they're knocked out, and even learn tips that help with recovery, researchers reported Friday at a symposium on memory and anesthesia.

"Researchers at Papworth Hospital in Cambridge, England, studied 51 cardiac patients, one-third of whom heard a tape of positive 'therapeutic suggestions' during surgery. Another third heard batches of word associations; the rest heard a blank tape.

"Patients who were played the suggestion tape - which told them they were doing well, or wouldn't feel much pain - left the hospital 1 1/2 days earlier on average than other patients.

"Another study, from the University of Arizona College of Medicine, found that surgical patients who heard specific pain-relief suggestions recovered more easily than those hearing vague advice such as, 'Think of being well.'

"'These are still early days to invest in every operating suite buying a tape recorder to play for the patients,' said Dr. Sunit Ghosh, a researcher with the Papworth team. 'But this definitely does hold promise.'

"Scholars at the second annual Symposium on Memory and Awareness in Anesthesia said patients rarely wake up recalling - unprompted - something that happened during anesthesia.

"But several studies showed subconscious learning while the patients were out cold.

"Not everyone accepted the findings.

"'It shows an enormous sensitivity on the part of the brain, if it can be shown,' said Eugene Winograd, an Emory University psychologist and organizer of the Emory- sponsored conference. 'I'm not confident it has been shown yet.'

"Some researchers in other studies found no association between messages heard during anesthesia and learning.

"Dr. Alan Aitkenhead, professor of anesthesia at the University of Nottingham in England, found no significant difference between patients who heard recuperative suggestions and patients who were treated to a deliberately dull history of the hospital where they were.

"Aitkenhead said his study kept all patients quite deeply anesthetized, and that may be why they might not have learned as much as patients in other studies.

"'By far, most likely, it's a difference in levels of anesthesia,' he said.

"The Papworth researchers, in another study, found that some patients showed strong word associations after hearing tapes of groups of words during surgery; but other patients under a different anesthesia didn't.

"'There needs to be standardization of our testing,' Ghosh said. 'I think it's partly related to the anesthesia technique and partly related to the way in which material is presented to the patient.'

Blankfield, Robert; Scheurman, Kathleen; Bittel, Sue; Alemagno, Sonia; Flocke, Sue; Zyzanski, Stephen (1992, October). Taped therapeutic suggestions and taped music as adjuncts in the care of coronary artery bypass graft patients. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, Arlington, VA.

NOTES 1:
18 studies have explored the issue with an experimental design; half used tapes, half didn't; majority of studies found benefits; 2 were of heart surgery patients.

This study used taped suggestions with coronary bypass patients. Used tape recorder rather than person delivering suggestions because it was more convenient; used tape intra-surgery and post-operatively for more impact.

We hypothesized: shorter length of stay, less narcotic analgesia, less anxiety, faster recovery, more positive mental outlook, resume activities sooner, have less symptoms postoperatively, etc.

Used a prospective, randomized, single-blind trial in 2 community hospitals in Cleveland with coronary artery bypass graft surgery patients. Study was done between Dec 1989 - Feb 1992.

3 groups were involved: (1) Suggestion, (2) music, and (3) tape. Control subjects had a blank tape. Tapes were played continuously and repeatedly with headphones. Postoperatively, a different tape was played.

Excluded: Patients with emergent surgery, hearing impairment, poor comprehension of English, patients who died in hospital, patients whose hospital stay lasted longer than 14 days (3 of them). 5% of sample were eliminated for last 2 reasons.

Music: Herb Ernst, Dreamflight II. Suggestions: Music background, permissive, based on Evans & Richardson's study.

Outcome Measures: Nurse assessment of anxiety and progress post operatively, Symptom scale, Depression scale.

Mean age 62, 3/4 men, 92% white, 75% married. The groups were same on a variety of preoperative variables (status of heart and arteries). Length of stay was 6.5 in all 3 groups. No difference in narcotics use, in nurse assessment of anxiety or of progress; of depression scale, or activities of daily living.

Recategorized data into patients who said the tapes were helpful (both music and suggestion) N = 33 vs the other patients N = 62. No difference in the variables evaluated.

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

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

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

NOTES 1:
Bowers' dissociated control adaptation of Hilgard's neodissociation theory of hypnosis posits that higher control systems are not used if lower systems are activated.

Imagery may be less important for achieving hypnotic effects. It also may contribute differently than previously thought, an uncorrelated factor. If imaginal involvement and imagery is integral to the production of analgesia using hypnosis, one would get results different than if not integral.

Research: 65 Ss rated as high on two hypnotizability tests participated.

Session 1:

Procedure entailed finger pressure pain: baseline, followed by 2 hypnosis treatment trials. Ss were not informed of the second trial before they did the first.

Standard suggestions: imagery congruent with the suggestion (hand like block of wood, protected by a glove)

Imageless condition: your hand will remain comfortably nonresponsive to the pressure; you will not allow other things to come into your mind.

Outcome Measures

Analogue scale for pain 0-10

Nonvoluntary experience rated 0-4

Session 2:

Administered Tellegen Scale, Woody & Oakman Scale, Marks Vividness of Imagery, Bowers' Effortless Experiencing, and Duality of Experience during age regression.

RESULTS.

No difference was found between the standard and imageless conditions in amount of pain reduced. So in high hypnotizables, use of imagery or not doesn't matter for controlling pain. Some Ss had a clear preference however, for one or the other method (even counter to their own expectations).

Feelings of nonvolition did not differ as a function of imagery use.

Multiple regression showed effects of hypnotizability and effortless experiencing. Ss who have an effortless experiencing of imagery benefit from using it to reduce pain; those who find it more effortful do better without imagery when attempting to reduce pain.

Contrary to last year's results reported by Bowers, high imagery was related to duality of experiencing in age regression.

Dissociated control theory is consistent with the results but not necessarily demonstrated. It is important to discriminate between imagery as a mediator rather than as a co-occurrence. This research suggests, as did Zamansky's work on counter suggestions, that imagery is not as critical for hypnotic response as we previously thought.

1991

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

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

NOTES 1:
Patients ages 19-55 were accepted into the study and they were paid for participation. (Older patients were excluded to guard against memory or hearing problems.) Other criteria for exclusion were: ASA physical status 4 or 5 indicating significant systemic disease, visual or hearing problems, middle ear disease (because it increases probability of nausea and vomiting), if their condition might require heavy sedation, if they were currently taking medication that interferes with memory (e.g. benzodiazepines, if there were intolerance to opioids, or if there were a likelihood of using postoperative pain treatment other than opioids.

The Spielberger State-Trait Anxiety Inventory was administered before surgery. Either suggestions (lasting 6 minutes) or a blank tape were played through headphones, starting 5 minutes after the surgical incision. The tape was played once for the first 59 patients, continuously for the remaining 150 patients. The first 139 patients received additional verbal materials on the tape, for memory tests to test possibility of learning under anesthesia. Operating room sounds were recorded by a tape recorder near the patient's head, throughout period of unconsciousness (except when tape was being played).

After the first 25% of cases, the team decided that lack of effect on therapeutic suggestions attributable to type of anesthesia did not warrant restriction to a single anesthetic method; also, multiple presentations of the suggestions on tape did not show an effect different from a single presentation.

After the patient regained consciousness and was reoriented, pain, nausea, retching, and vomiting were assessed every 30 minutes. Pain was rated orally on a scale from 1 to 10 in the recovery room, then on visual analogue scales every 2 hours on the day of surgery and the second day, and every 4 hours on subsequent hospital days during waking hours. Variables that were rated by staff every 24 hours included: opioids, other analgesics, antiemetics, nausea, vomiting, retching, presence or absence of nasogastric tube, passage of flatus, bowel movement, fluid intake, solids intake, urination. Temperature was recorded every 4 hours for the first 2 days after surgery, and after that less often. The anxiety measures were repeated on Day 3 postsurgery, as well as self ratings and nurse ratings on physical and psychological recovery. Staff recorded length of postoperative hospital stay and reasons for any delay of discharge. Separate analyses were performed for patients receiving opioids via patient-controlled analgesia (52%) vs traditional administration (48%), but no differences were found for effects of therapeutic suggestions except on postoperative Day 8.

"The inability to detect beneficial effects of therapeutic suggestions probably was not due to insensitivity of the measures of recovery. These measures were sensitive enough to show numerous significant differences in recovery after different types of surgery" (p. 751). The authors supported their contention that the measures were sufficiently sensitive by demonstrating meaningful correlations among the measures themselves; and by demonstrating adequate statistical power for detecting the effects of theoretical interest--at least 1 day in postoperative hospital stay or one half day in fever.

Discussion: The authors note that a recent investigation that found positive results in a double-blind, randomized design with 39 hysterectomy patients (Evans & Richardson, 1988. Improved recovery and reduced postoperative stay after therapeutic suggestions during general anaesthesia. Lancet, 2:491-493) may not have controlled for variables such as presence of malignancy, physical status of patients before surgery, or ethnicity. Authors note that Evans and Richardson observed shorter periods of pyrexia despite there being no relevant suggestions, but no differences in pain intensity, nausea, vomiting, or urinary difficulties despite there being suggestions relating to those symptoms. There also were no differences in mood and anxiety test scores postoperatively for the experimental and control groups.

The authors note that McLintock, Aitken, Downie, & Kenny (Postoperative analgesic requirements in patients exposed to positive intraoperative suggestions. Br M J 301:788-790. 1990) reported a 23% reduction in opioids by patients receiving suggestions, but no reduction in pain, nausea, or vomiting. They contrast the present study with these earlier studies that had obtained positive results.

"We studied patients who had more than one type of surgery to obtain a large sample size and to assess the possibility that beneficial effects of therapeutic suggestions would be restricted to certain types of operations. Had this been the case, interactions of therapeutic suggestions with type of surgery would have been significant in the overall analyses, and follow-up analyses would have indicated that they were attributable to beneficial effects of therapeutic suggestions for certain surgeries. This did not occur. The two types of surgeries involving the largest numbers of patients seemed particularly promising for demonstrating beneficial effects. It has been reported that therapeutic suggestions presented during anesthesia are likely to be less successful with major and extensive surgery. Certainly, surgery on the fallopian tubes and gastric stapling did not involve a great deal of tissue trauma and blood loss. Patients were motivated to have the surgery and to recover quickly; particularly motivated were those having operations on the fallopian tubes, who were very eager to become pregnant, and those having vertical banding gastroplasties, who wanted desperately to lose weight" (pp. 753-754).

"In practice, we observed no beneficial effects of therapeutic suggestions, and there was no hint that anesthesia methods influenced the efficacy of the therapeutic suggestions. Interestingly, anesthetic methods also did not influence learning under anesthesia in the implicit memory tests we have used previously. Patients anesthetized with nitrous oxide and opioids did not differ from those anesthetized only with inhalational agents. In general, implicit or unconscious memory occurs in patients regardless of anesthesia methods or dosages of drugs" (p. 754).

"The few significant effects of therapeutic suggestions in our study did not point toward a beneficial influence of these suggestions. We found, in fact, an increased frequency of retching (but not nausea or vomiting) in the experimental group. The multiple variables examined in this study increased the likelihood of significant differences arising by chance, such that the null hypothesis was rejected when it should have been accepted. This is the way we interpret the effect on retching---i.e., as a type I error. We used in our therapeutic suggestions one negative or exclusionary sentence, 'You won't feel nauseous or have to vomit', among several positive or affirmative statements, e.g., 'You will enjoy eating, drinking...You will swallow to clear your throat and everything will go one way, straight down. . . The food will taste good....Your stomach will feel fine.' We do not think that the negative sentence led to paradoxical results. Evans and Richardson (personal communication) used in their therapeutic suggestions a negative sentence ('You will not feel sick'), which they repeated, yet the reported incidence of nausea and vomiting did not differ between the experimental and control groups" (p. 754).

1990

NOTES 1:
Sensory and pain thresholds to laser stimulation were determined, and the laser-pain evoked brain potentials were measured for 8 highly hypnotizable (Harvard Scores 10-11) student volunteers in 3 conditions: (1) waking, (2) suggestion of hyperaesthesia during hypnosis, (3) suggestion of analgesia during hypnosis.

The investigators used a laser beam 3 mm in diameter, with a 200 msec stimulus duration; the same area (but different points within the area) was used for consecutive stimulations. Ss were otherwise maintained in low stimulus conditions so they would not have visual or auditory cues about laser beam onset; they wore goggles, had eyes shut, and had earphones on. Sensory threshold was defined as warmth; pain threshold was defined as a distinct sharp pin prick.

The laser intensity used for stimulation corresponded to strong pain. Interstimulus intervals averaged 15 sec (but were randomly varied between 10-20 sec). Sensory and pain thresholds as well as two evoked potential measurements were taken during waking , hypnotized hyperaesthesia, and hypnotized analgesia conditions in a single 1 1/2 hour session.

The evoked potential component of interest was the negative complex N1 with latency of 300 msec; amplitude (P1=N1-P2) and latency of this complex (N1) were measured. EEG epochs contaminated by eye movement were omitted from analysis.

The standardized induction and deepening of hypnosis required 15-20 minutes; then the suggestion was given that Ss could alter their perception of stimuli such as pain. Hyperaesthesia suggestions were to imagine the right hand was in very hot water, then taken out but still very red, hot, sensitive so that even the vaguest stimulus would be detectable and unpleasant. They were told that they would receive a series of painful but tolerable stimuli, and to raise the left index finger if they could just perceive a laser pulse (sensory threshold), and again if they felt pricking pain (pain threshold).

Suggestions for analgesia were to imagine that their right hand was placed on their chest, and that their 'former right hand' was no longer their own but was made of some heavy and completely insensitive material like wood or stone. Sensory and pain threshold measures were then taken. During the evoked potential measurement period they received continuous suggestions of analgesia. They also were told to relax and imagine they were in a pleasant place, ignoring everything except the pleasant, relaxed feelings and imagining pleasant sights, sounds, feelings and the imagined place. They were told that though they would receive stimuli, they probably would be able to ignore the stimuli completely.

Results were as follows.

1. In the hypnotic hyperaesthesia condition, sensory and pain thresholds decreased significantly by 47% and 48%, respectively. Three Ss reacted to laser intensities far below what normally can be perceived in the waking state. [The authors ran a separate small control experiment to make sure that the Subjects were not using any other cues, but mention the possibility of light-sensitive skin reacting to the blue laser light, creating evoked potentials.]

2. In the hypnotic analgesia condition, sensory and pain thresholds increased by 316% and 190%, respectively. 7 of 8 Ss did not even respond to pain threshold when the laser intensity was increased to the noxious level of 3W, which is the level at which tissue damage can occur.

3. Pain-related evoked potentials. Amplitude of the first pain-related potential was increased significantly by 14% in the hyperaesthesia condition and reduced significantly by 31% in the analgesia condition. Changes in the evoked potentials were considered minor however compared to those observed for thresholds, which are subjective response measures. Even in Subjects who reported complete analgesia, the experimenters observed the laser pain evoked responses. There were no differences in latencies of the first pain-related potentials for the three conditions (indicating that peripheral and central afferent conduction velocities were the same).

Discussion. "There has been some dispute concerning the experimental design and the reliability of the data obtained in studies dealing with hypnotic suggested analgesia [Spanos & Chaves, 1970]. In our design 2 'opposite' conditions were induced, and the 2 inductions gave 'opposite' results.

"The experience of pain can be significantly altered by suggestions of analgesia, which is in accordance with a number of other studies (for review see [Barber & Adrian, 1982; Hilgard & Hilgard, 1975]). The finding that suggestions of hyperaesthesia can decrease the sensory and pain thresholds and increase the amplitude of the pain evoked potential is a new observation. Since synchronized auditory and visual stimuli from the laser were blocked, and the stimulus was given at random intervals, the changes might be induced by the hypnotic suggestions" (p. 247).

The authors discuss their results in terms of (1) four pain modulation systems (neural/opiate, hormonal/opiate, neural/non-opiate, and hormonal/non-opiate) and (2) focusing and defocusing attention. Because in their pilot study it was necessary to give suggestions continually in order to affect the laser evoked potentials, they conclude that endogenous substances or hormonal/non-opiates would play a minor role, if any, in hypnotic analgesia. (Price and Barber [25] had also found it important to give suggestions continuously.)

On the other hand, "event-related potentials [7, 26] and pain-related potentials have, previously, been shown to be sensitive to focused and de-focused attention. Recently, Miltner et al. [23] showed the influence of attention on the late pain-related component of potentials, evoked by painful intracutaneous electrical stimulation. The degree to which the subject paid attention to the painful stimulus had a powerful effect on the pain-related complex. When subjects ignored the pain, it was still possible to record the pain-related complex although all the subjects consistently reported less or no pain. In wakeful subjects where cutaneous pain was abolished by lignocaine infiltration, the pain-related evoked potentials were abolished [4]. In our study, we could also record evoked potentials although the subject subjectively did not feel pain. The reason might be that the S acted as if there was full analgesia to the stimuli, in order to satisfy the hypnotist. During suggested hyperaesthesia the thresholds declined below what normally could be perceived in the wakeful state. The volunteers could, therefore, not act hypersensitive, so something did happen.

"The discrepancy in subjective and objective responses might, however, be useful when investigating levels of the neuroaxis at which hypnosis might work" (pp. 248-249).

The authors note that this laser induced pain and the tooth pulp stimulation pain of Mayer & Barber both use the A-delta fibers. Barber & Mayer found it impossible to elicit pain within the output range of the stimulator (up to 150 microA) and reached maximal intensity for all volunteers during suggested analgesia. Using cutaneous laser stimulation the authors found that the skin damage level (3W) could be reached in 7 of 8 volunteers without any reaction of pain.

During the hyperaesthesia condition the sensory threshold was sometimes lower than can be detected in the waking state. Although some researchers have suggested that red light from a helium-neon laser might activate cutaneous photosensitive receptors and thereby elicit brain potentials, the authors were unable to elicit potentials in waking Subjects using their blue and green argon laser light with below sensory threshold intensity.

The authors also note that previous attempts to use physiological correlates of pain such as heart rate, blood pressure, respiration, and galvanic skin response have yielded confusing results. The physiological indicators are present even when Subjects report analgesia, leading some investigators to conclude that the subjective reports are due to illusion [Sutcliffe, 1961], compliance [Wagstaff, 1986], or a placebo induced by the hypnosis context [Wagstaff, 1986]. "These confusing results lead to the conclusion that both the traditional methods used for induction of pain and the monitored physiological responses have been unsatisfactory. The present study has sought to eliminate some of the methodological difficulties by (1) using brief well-defined argon laser stimuli which in awake volunteers induce very stable perceptions between trials [Arendt-Nielsen & Bjerring, 1988], and (2) recording psychophysical thresholds and objective parameters quantitatively related to the intensity of the pain perceived (1, 3)" (p. 249).

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

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

1988

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

NOTES 1:
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.

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.

1987

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?

NOTES 1:
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).

Goldmann, Les (1987, October). Ways of maximizing patient memory for events during anesthesia. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, Los Angeles.

NOTES 1:
Reported a series of experiments: 1. Under atropine, we did not get an orienting response to things having to do with the operation, but did get an orienting response to jokes, dogs barking, and the name of a polite anesthetist. 2. Replicated the research by Bennett and didn't get ear pulling response. 3. Studied cardiac patients. Gave subjects a pre-anesthesia speech of importance [of hearing under anesthesia? Notes here are not clear.] and a chin touch suggestion that was successful. 7 of 30 subjects gave reports of recall - usually recalled something of particular interest to them. These 7 subjects appeared more anxious postoperatively than previously. 4. Recognition study: Pre-op "IQ" test. Gave subjects answers to the questions while they were under anesthesia, and postoperatively they had better performance than previously. 5. Recall study, double blind. Interviewer learned something about the patient, and told them something about what was learned about the patient during anesthesia e.g., You have a lovely garden. After surgery they were hypnotized by someone who did not know what information was given, and then recall for information "heard" under anesthesia was tested. 6. 10 female patients who were good hypnotic subjects, all received the same statement under anesthesia, that they would believe for a moment that they had green hair. During the interview, one said she was fascinated by green things, one wanted to go home and wash her hair.

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.

Hilgard, Ernest R. (1987). Research advances in hypnosis: Issues and methods. International Journal of Clinical and Experimental Hypnosis, 35, 248-264

There are substantial areas of agreement upon the classical phenomena of hypnosis, illustrated by what we now have learned about hypnotic talent, amnesia, hallucinations, analgesia, and dissociative processes. While genuine advances in knowledge about hypnosis have been made in recent decades, differing orienting attitudes have kept some controversy alive, particularly in the interpretation of empirical findings. Differences of interpretation of the phenomenal and behavioral facts are to be expected in the present stage of developmental, cognitive, and social psychology.

NOTES 1:
The author writes of the "domain of hypnosis" as within the larger domain of social psychology (because it is usually interpersonal); cognitive psychology (because of alterations in perception, imagination, memory, and thought); developmental and personality psychology (because of individual differences); and physiological psychology (because of neurophysiological aspects).

In terms of what we know about hypnotic talent, he notes that high hypnotizability is not generally associated with psychopathology; that it may however be associated with a personality measure called absorption; and that there may be some inherited ability (Morgan, 1973). In the author's view, hypnosis is no longer considered simply a response to suggestion, since imagination and/or fantasy are very important.

In reviewing evidence of posthypnotic amnesia the author writes, "Subtleties in language require making careful distinctions among concepts such as compliance, suggestion, compulsivity, belief, self-deception, automaticity, the voluntary, the involuntary, and a happening. If these distinctions are glossed over, the choice of words (e.g., substituting compliance for response to suggestion) may give the impression that a finding departs more widely from conventional views than it does. We, too, have found that Ss used varied strategies or skills during amnesia, but this need not deny augmentation by suggestion.

"It takes genuinely high Ss to illustrate truly high posthypnotic amnesia... Many of the truly high hypnotizable individuals cannot break amnesia, no matter how hard they try" (p. 253).

Regarding the evidence for hypnotic hallucinations and trance logic, the author suggests that trance logic is not a clear concept because the Subject is capable of good logic while tolerating some inconsistencies. "It is ordinary logic to assume that if your hallucination is your own construction, it is you who can influence it by your own wishes. In the rare cases of transparent or diaphanous hallucinations there is still an 'out there' quality. People who report that they see wispy ghosts also see them as 'out there,' so that they qualify as hallucinations. The distinction appears to be one of perception and perception-like experiences within hypnosis rather than of logic" (p. 256).

In reviewing the evidence for hypnotic analgesia, the author acknowledges that pain relief is available with other kinds of interventions, or by using other kinds of psychological processes, but that does not diminish the contribution of hypnosis (which has a long and impressive clinical history). Following laboratory studies, it is noted that "the amount of alleviation of pain through hypnosis is positively correlated with the hypnotizability of the candidate for pain reduction. This result is not universally accepted, because some clinicians are convinced that those unsuccessful in hypnotic pain reduction are resisting hypnosis" (p. 256-257). In the present paper he acknowledges but does not review physiological literature on hypnoanalgesia.

Regarding the concept of dissociation, the author indicates that he considers it a more useful concept than the concept of trance or hypnotic state "when a person is only slightly or moderately involved in hypnosis ... . The advantage is that dissociations, as compared with altered states, can be described according to limited or more pervasive changes in the cognitive or motor systems that are being activated or distorted through suggestion in the context of hypnosis. Perhaps when all-inclusive enough, such changes can justify the use of the term trance or altered state, but I believe that these terms should be used, if at all, only for those for whom the immersion in the hypnotic experience is demonstrably pervasive" (pp. 258-259).

The author goes on to describe his initial discovery of the 'hidden observer' in an experimental context, and to relate the 'hidden observer' to others' earlier observations of a secondary report of an experience previously concealed from S's consciousness (Binet, 1889-1890/1896; Estabrooks, 1957; James, 1899; Kaplan, 1960). "The issues are still being worked on, but as in the case of trance logic the heart of the problem is not whether to speak of a hidden observer, but to recognize that there may be cognitive distortions in hypnosis even while some more realistic information is being processed in parallel, so that everything is not reportable by S" (p. 260).

1986

Farthing, G. William; Venturino, Michael; Brown, Scott W.; Lazar, Joel D. (1986, April). Internal vs. external distraction in the control of pain as a function of hypnotic susceptibility. [Paper] Presented at the annual meeting of the Eastern Psychological Association, New York.

NOTES

This study tested the prediction, derived from their 1984 study: for highly hypnotizable subjects, pain reduction methods involving either attention to external distracting stimuli or attention to internally generated distracting images will be effective in reducing pain. However, for low hypnotizables only external stimulus distraction will be effective, and internal images will not be effective distractors for reducing pain.

Used independent groups of college students, with 1/3 highs, 1/3 mediums, and 1/3 lows. Used five conditions: (n=12 per subgroup 3H x 5T) 1. Suggestion - Subjects told "to image as vividly as you can that your hand is numb and insensitive, as if it were made of rubber." (No hypnotic induction was used.) 2. Guided imagery - Subjects told to listen to a story that would be read to them, and to try to imagine the scenes as vividly as possible. (Story included scenes where the s was the main character.) 3. Word memory - Subjects told to listen to a list of words that would be read to them and try to remember them for later recall test (30 abstract nouns, at rate of 1 every 2 seconds. 4. Pursuit rotor - which subjects did during the ice water immersion. 5. Placebo control - included suggestion, "For this test you will find that you can succeed in not being disturbed by the cold water if you carefully follow the following instructions. While your hand is in the water you should not try to control your thoughts. Just let your mind wander freely to whatever feelings or thoughts or ideas happen to come to you."

1985

Eich, Eric; Reeves, John L.; Katz, Ronald L. (1985). Anesthesia, amnesia, and the memory/awareness distinction. Anesthesia and Analgesia, 64, 1143-1148.

Several studies have shown that surgical patients cannot consciously recall or recognize events to which they had been exposed during general anesthesia. Might evidence of memory for intraoperative events be revealed through the performance of a postoperative test that does not require remembering to be deliberate or intentional? Results of the present study, involving the recognition and spelling of semantically biased homophones, suggest a negative answer to this question and imply that intraoperative events cannot be remembered postoperatively, either with or without awareness.

NOTES 1:
"In this experiment, we attempted to apply the distinction between memory and awareness of memory to the question of whether adequately anesthetized and apparently unconscious patients can register and retain what is said in their presence during surgery. Prior research relating to this question has focused, for the most part, on the ability of postoperative patients to recall or recognize a specific item....The inference need not be drawn, however, that 'patients in so-called surgical planes of anesthesia cannot hear' (15, p. 89) or that anesthetized patients cannot encode and store in memory events that transpire during their surgery. The possibility remains that even though the effects of memory for intraoperative events may not--and probably cannot--be revealed in postoperative tests of retention that require remembering to be deliberate or intentional, such effects might be evident in the performance of tests that do not demand awareness of remembering.

"To explore the possible dissociation between memory and awareness of memory for intraoperative events, we modeled our experiment after a recent neuropsychological study by Jacoby and Witherspoon (5)" (p. 1143).

"...it appears that the prior presentation of a word has a substantial impact on its subsequent interpretation and spelling, regardless of whether or not the word is correctly classified as 'old' in a later test of recognition memory" (p. 1144).

"Approached from the standpoint of anesthesia theory and practice, the idea that recognition and spelling tap different memory processes or systems raises an interesting question for research. Specifically, suppose that during surgery, an anesthetized patient listens to a series of short, descriptive phrases, each consisting of a homophone and one or two words that bias the homophone's less common interpretation (e.g., war and PEACE, deep SEA). Suppose further that several days after surgery, the patient is read a list composed chiefly of old and new homophones (i.e., ones that either had or had not been presented intraoperatively) on two successive occasions. On one occasion, the patient is simply asked to spell each list item aloud; on the other occasion, the patient is asked to state aloud which list items he or she recognizes as having been presented during surgery. Given the situation sketched above, might the patient spell significantly more old than new homophones in line with their less common interpretations, and yet fail to reliably discriminate between the two types of items in the test of recognition memory" (p. 1144).

1984

Gillett, Penny L.; Coe, William C. (1984). The effects of rapid induction analgesia (RIA), hypnotic susceptibility and the severity of discomfort on reducing dental pain. American Journal of Clinical Hypnosis, 27, 81-90.

ACT The study was designed to address three issues involved in hypnotic analgesia for dental pain: 1) The effectiveness of J. Barber's (1977) hypnotic procedure for producing analgesia in its usual form and a shortened form, 2) the relationship of hypnotic susceptibility to analgesic responsiveness, and 3) the effect of dental procedure discomfort level on hypnotic analgesia. Sixty unselected dental patients were administered either J. Barber's (1977) RIA or a shortened version of it (SI) before their dental treatment. Measures of hypnotic susceptibility were obtained as were dentists' ratings of the discomfort levels involved in the various dental procedures administered. The 52% success rate of the present study failed to replicate Barber's very high (99%) success rate, although procedural differences might explain the lower rate. RIA and SI were equally effective. Hypnotic susceptibility level did not relate significantly to success with hypnotic analgesia. The level of dental procedure discomfort was the clearest predictor of success with hypnotic analgesia. The greater the discomfort rating of a procedure the less likely that hypnotic analgesia would be successful.

1980

Edwards, William Henry (1980). Direct versus indirect hypnosis for the relief of chronic pain in spinal cord injured patients (Dissertation, United States International University). Dissertation Abstracts International, 40 (10-B), 4996.

NOTES 1:
This study compared effectiveness of direct hypnosis and indirect hypnosis (Rapid Induction Analgesia, developed by Joseph Barber) in reducing experimental and clinical pain in spinal cord injured patients. The 30 male paraplegic patients who had chronic benign pain volunteered for the study. They were administered three tests: the Pain Estimate Scale (Sternbach, 1974), Ischemic Muscle Pain Test (IMPT), and the Stanford Profile Hypnotic Susceptibility Scale, Form II -- SPHSS -- (Weitzenhoffer and Hilgard, 1967). Each patient experienced three sessions: (1) Baseline Control, (2) Direct Hypnosis, and (3) Indirect Hypnosis. Patients were randomly assigned to Sessions (2) and (3). The results indicated no significant statistical difference in the effectiveness of direct versus indirect hypnotic analgesia in these chronic pain patients. Direct and indirect hypnosis were equally effective; hypnotizability was not associated with outcome. Furthermore, there was no interaction between treatment effects and pretreatment pain level. The results were similar for both clinical and experimental pain.

1979

Barber, Joseph; Donaldson, David; Ramras, Susan; Allen, Gerald D. (1979). The relationship between nitrous oxide conscious sedation and the hypnotic state. Journal of the American Dental Association, 99, 624-626.

NOTES 1:
Nitrous oxide-oxygen produces a state of consciousness in the patient that is reported to be similar to the hypnotic state. In this investigation, the authors test the hypothesis that nitrous oxide-oxygen heightens a patient's responsiveness.

This study apparently did not have a control group receiving nitrous oxide but no suggestions, to evaluate the amnesia and analgesic effects of the drug alone.

Bennett, Henry L.; Giannini, Jeffrey A.; Kline, Mark D. (1979, September). Consequences of hearing during general anesthesia. [Paper] Presented at the annual meeting of the American Psychological Association, New York.

A double blind 2X2 study exposed 23 herniorraphy and cholecystectomy patients to either a 45 minute suggestion tape or to the actual sounds of the operation. Structured interviews conducted postoperatively assessed hypnotic susceptibility and regressed patients under hypnosis to operative events. Ten patients accurately recalled significant events from surgery but only under hypnosis. Recall was greater and more accurate in patients scoring high on the Stanford Clinical Hypnosis Scale. Fewest number of pain medications were given postoperatively to patients receiving the suggestion tape. Hernia patients showed better recall than gallbladder patients.

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.

1976

Chaves, John F.; Barber, Theodore Xenophon (1976). Hypnotic procedures and surgery: A critical analysis with applications to 'acupuncture analgesia'. American Journal of Clinical Hypnosis, 18 (4), 217-236.

Although hypnotic procedures are useful for reducing the anxiety of surgery and helping patients tolerate surgery, they do not consistently eliminate pain. Six factors that are part of or associated with hypnotic procedures help patients tolerate surgery. These factors pertain to patient selection, the patient-physician relationship, the preoperative 'education' of the patient, the adjunctive use of drugs, and the use of suggestions of analgesia and distraction. It appears that the same factors account for the apparent successes of 'acupuncture analgesia' as well. A frequently-overlooked fact, that most internal tissues and organs of the body do not hurt when they are cut by the surgeon's scalpel, is also important in understanding how surgery can be performed with either 'hypnoanesthesia' or 'acupuncture analgesia.'

1975

Carli, G. (1975). Some evidence of analgesia during animal hypnosis [Abstract]. Experimental Brain Research, 23, 35.

The purpose of this study was to investigate the response to painful stimuli during animal hypnosis. The experiments were performed on unanesthetized, free-moving rabbits carrying implanted electrodes for recording the EEG and EMG activity and nerve stimulation. Injection of formaline into the dorsal region of the foot produced long lasting EEG desynchronization and motor pain reactions. In some rabbits a procedure of habituation was used to reduce hypnosis duration below 45 sec. Hypnosis was induced by inversion. The following results were obtained: 1) Polysynaptic reflexes eliced [sic] by electrical stimulation of cutaneous and muscle afferents were depressed during hypnosis. 2) Hypnosis transitorily suppressed all the painful manifestations due to formaline injection and was characterized by hygh [sic] voltage slow wave activity in the EEG, 3) In habituated rabbits, a significant increase in hypnotic duration and EEG synchronization was observed when hypnosis was preceded by formaline injection. Hypnosis duration was not potentiated by painful stimuli when Naloxone (5mg/Kg i.v.) was injected before hypnosis induction. 4) In habituated rabbits a recovery in hypnotic duration coupled to EEG synchronization was obtained, in absence of painful stimuli, following subanalgesic injection of Morphine (1mg/Kg). It has been previously shown that in the rabbit administration of 5-20 mg/Kg of Morphine produces EEG synchronization and strong reduction of pain reactions. It is suggested that, during animal hypnosis in a condition of continuous nociceptive stimulation, the pain response is blocked by a mechanism which exibit [sic] similar effects of Morphine both at spinal cord (polysynaptic reflexes) and at cortical levels (EEG synchronization).

1974

haves, John F.; Barber, Theodore Xenophon (1974). Acupuncture analgesia: A six-factor theory. Psychoenergetic Systems, 1, 11-21.

The dramatic successes claimed for acupuncture suggest that Western medicine has failed to identify important factors that pertain to the nature of pain and its control. This may not be the case, as there are at least six factors which are often overlooked by writers describing the absence of pain (i.e., analgesia) during acupuncture: (a) the patients accepted for surgery under acupuncture usually believe that it will work, (b) drugs are frequently used in combination with acupuncture, (c) the pain associated with surgical procedures is less than is generally assumed, (d) the patients are prepared in special ways for surgery under acupuncture, (e) the acupuncture needles distract the patient from the pain of surgery and, (f) suggestions for pain relief are present in acupuncture treatment. It is concluded that more research is needed to determine whether additional factors are needed to help explain the phenomenon of acupuncture analgesia.

Chaves, John F.; Barber, Theodore Xenophon (1974). Cognitive strategies, experimenter modeling, and expectation in attenuation of pain. Journal of Abnormal Psychology, 83 (4), 356-363.

Verbal reports of pain were obtained from 120 subjects during a base-level pretest and also during a posttest conducted under one of several experimental treatments. The pain stimulus was a heavy weight applied to a finger for two minutes. During the posttest, subjects who had been asked to utilize cognitive strategies for reducing pain (to imagine pleasant events or to imagine the finger as insensitive) showed a reduction in pain as compared to uninstructed control subjects. Subjects led to expect a reduction in pain, but not provided with cognitive strategies, also showed reduced pain during the posttest as compared to control subjects, but the reduction was smaller than for subjects using cognitive strategies. An experimenter modeling procedure, used with one half of the subjects under each experimental treatment, was effective in reducing verbal reports of pain only for subjects with high pretest levels who were asked to imagine pleasant events.

1970

Evans, Michael B.; Paul, Gordon L. (1970). Effects of hypnotically suggested analgesia on physiological and subjective responses to cold stress. Journal of Consulting and Clinical Psychology, 35 (3), 362-371.

Relative effects of suggested analgesia and hypnotic induction were evaluated with regard to reduction of stress responses (self-report, heart rate, pulse volume) to the physical application of ice-water stress. Four groups (N = 16 each) of undergraduate female Ss, equated on hypnotic susceptibility, were run individually, receiving (a) hypnotic induction plus analgesic suggestion, (b) hypnotic induction alone, (c) waking self-relaxation plus analgesic suggestion, or (d) waking self-relaxation alone. The major findings were that suggestion, not hypnotic induction procedures, produced reductions in the self-report of distress, and that the degree of reduction was related to hypnotic susceptibility in both "hypnotic and "waking" conditions. Neither suggestion nor hypnotic induction procedures resulted in reduction of the physiological stress responses monitored in this study. Several methodological issues are discussed. Although findings add to the bulk of evidence supporting the "skeptical" view of hypnotic phenomena, results are related to other literature, suggesting that an adequate evaluation of hypnotic analgesia as used clinically has not yet been undertaken.

1969

Barber, Theodore Xenophon (1969). An empirically-based formulation of hypnosis. American Journal of Clinical Hypnosis, 12 (2), 100-130.

A formulation is presented which does not invoke a special state of consciousness ("hypnosis" or "trance") to account for the behaviors that have been historically associated with the word hypnotism. Instead, so-called hypnotic behaviors - e.g., "analgesia," "hallucination," "age-regression," and "amnesia" - are conceived to be functionally related to denotable antecedent variables which are similar to those that control performance in a variety of interpersonal test-situations. The antecedent variables which determine behavior in a "hypnotic" situation include Ss' attitudes, expectancies, and motivations with respect to the situation, and the wording and tone of instructions- suggestions and of questions used to elicit subjective reports. The formulation is exemplified by several dozen experimental studies, and prospects for further research are delineated.

1965

Barber, Theodore Xenophon (1965). Physiological effects of 'hypnotic suggestions': A critical review of recent research (1960-64). Psychological Bulletin, 201-222.

Recent studies are reviewed which were concerned with the effectiveness of suggestions given under "hypnosis" and "waking" experimental treatments in alleviating allergies, ichthyosis, myopia, and other conditions and in eliciting deafness, blindness, hallucinations, analgesia, cardiac acceleration and deceleration, emotional responses, urine secretion to sham water ingestion, narcotic-like drug effects, and other phenomena. The review indicates that a wide variety of physiological functions can be influenced by suggestions administered under either hypnosis or waking experimental treatments, and direct and indirect suggestions to show the particular physiological manifestations are crucial variables in producing the effects.

Bernstein, Norman R. (1965). Observations on the use of hypnosis with burned children on a pediatric ward. International Journal of Clinical and Experimental Hypnosis, 13 (1), 1-10.

Several cases are described and observations made about the interplay of forces between staff, patient, and therapist, as well as the expectations of the patients to assess how these factors influenced the use of hypnosis. Hypnosis appears to be a particularly useful means for reaching isolated and depressed children with burns and for improving the morale of the staff team working with these children. The results may be along specific lines in terms of pain tolerance and improved eating, or in general improvement of cooperativeness and mood on the part of the child. (PsycINFO Database Record (c) 2002 APA, all rights reserved)

1964
 Attar, A.; Muftic, M. (1964). Narcohypnosis in abdominal surgery. British Journal of Medical Hypnotism, 16 (1), 29-32.

Effectiveness of a relaxation technique to increase the comfort level of patients in their first postoperative attempt at getting out of bed was tested on 42 patients, aged 18 to 65, who were hospitalized for elective surgery. Study group patients were taught the relaxing technique; control group patients were not taught the technique. Each group had an equal distribution of cholecystectomy, herniorrhaphy, and hemorrhoidectomy patients. Blood pressure, pulse, and respiratory rates of subjects in both groups were compared prior to surgery and after the postoperative attempt to get out of bed. Subjects' reports of incisional pain and bodily distress were measured via a pain and distress scale after their attempt at getting out of bed. Amount of analgesics used in the first 24 hrs following surgery was examined. Mean differences in report of incisional pain and body distress, analgesic consumption, and respiratory rate changes were statistically significant, supporting the hypothesis that use of a relaxation technique to reduce muscular tension will lead to an increased comfort level of postoperative patients.

1961

Hilgard, Josephine R.; Hilgard, Ernest R.; Newman, Martha (1961). Sequelae to hypnotic induction with special reference to earlier chemical anesthesia. Journal of Nervous and Mental Disease, 133, 461-478.

NOTES
Although a review of relevant literature turned up little in the way of statistical studies, some case studies were located in which unintended or unexpected results of hypnosis were observed. The authors located 15 cases in which the symptoms that developed subsequent to symptom removal using hypnosis were more disturbing than the original symptom. This type of response occurred in patients with extensive psychiatric history, prior to the hypnosis experience. However, it could not be determined whether the undesired response was due to hypnosis or to the psychotherapy that was provided to these patients.

In order to avoid the complications introduced by studying undesired sequelae in psychiatric patients receiving posthypnotic suggestions for therapeutic purposes, this investigation used a sample of non-patient university students (114 male and 106 female) who volunteered for research. Subjects were asked about "aftereffects" in followup interviews. Aftereffects that might be considered sequelae are exemplified by statements such as, "I was 'in a fog' for one hour" and "Things were hazy and vague for four hours."

Of the 220 Subjects, 17 (7.7%) reported sequelae, many of them "minor and fleeting." None of the sequelae was of psychotic proportions. Only 2.3% of the sample experienced sequelae that lasted as long as a few hours. Although the relationship of sequelae to hypnotizability was slight, there seemed to be a relationship to having had a difficult experience with chemical anesthesia in early childhood. They present six case studies, three who had difficulty with chemical anesthesia and three for whom the sequelae appeared to relate to a different kind of childhood experience.

The investigators concluded that "a routine experience of hypnosis is generally harmless in a student population, but E (or therapist) should be alert for possible aftereffects, and provisions should be at hand for occasional brief psychotherapy, even though the experiments themselves are not oriented toward therapy" (p. 477).

The authors present a psychodynamic explanation for the sequelae observed. "It is conjectured that the conflicts within the induction phase of hypnosis that produce either immediate or delayed symptoms are primarily those having to do with the exercise of power and the reaction to authority, hence, conflicts between the conscious willingness to be hypnotized and the unconscious resistance to or fear of the submissive role required. The individual forms that such conflicts take are highly varied.

"The conflicts within the established state differ, in that the state is not reached unless the conflicts of the induction are at least temporarily resolved. The new state, which has regressive characteristics, makes S vulnerable to conflicts based on reality distortions (as in suggested hallucinations) or ethical-social issues (as in suggested behavior violating his moral code or superego demands). Sometimes specific suggestions revive early experiences that were traumatic or provocative of fear.

"While the language of psychodynamics is appropriate in the discussion of these cases, the many redintegrative factors also suggest that learning theory can have much to say in explanation of them. Because learning theory has ways of dealing with conflict and conflict resolution, it can also encompass some of the problems discussed as conflicts over authority, commonly treated in psychodynamics as transference problems.

"The many reflections of earlier childhood experiences in the sequelae, including some of the dreams, suggest the promise of a developmental theory of hypnosis" (p. 477).

1960

Hernandez-Peon, R.; Dittborn, J.; Borlone, M.; Davidovich, A. (1960). Changes of spinal excitability during hypnotically induced anesthesia and hyperesthesia. American Journal of Clinical Hypnosis, 3, 64. (From 21st International Congress of Physiology, Buenos Aires, 1959, pg. 124, Abstracts)

Although hypnosis is well established, the physiological mechanisms of the hypnotic state and their related sensory phenomena are far from clear. Hernandez-Peon and Donoso have found that the magnitude of photic evoked potentials in the optic radiations of awake human subjects changed in response to previous verbal suggestions concerning the intensity of the expected photic stimulus. This striking observation led the cited authors to propose that certain hypnotic sensory phenomena might be explained, at least partially, by changes occurring as far down as second-order sensory neurons by centrifugal mechanisms controlling the sensory input to the brain. In the intact subject it is impossible to record uncontaminated electrical indexes of afferent impulses from those lower sensory neurons. 

However, it is possible to gain indirect evidence of tactile sensory inflow to the spinal cord by recording cutaneous reflexes. In young males, a forearm skin reflex evoked by a single square pulse of 0-.1 msec. duration was recorded with cathode- ray oscilloscope. The amplitude of the evoked potentials was often reduced during the hypnotic state, and it was further reduced by verbally suggesting to the hypnotized subject complete anesthesia of the forearm. Reciprocally, during hypnotically suggested hyperesthesia the cutaneous reflex was enhanced. It is concluded that during hypnotic anesthesia and hyperesthesia excitability changes occur at the spinal level, and it is suggested that these changes probably involve the spinal internuncial system interposed between the dorsal root ganglion cells and the motoneurons. (From Abstracts, 21st Internat. Cong. Physiol., Buenos Aires, 1959, p. 124.)

Barber, Theodore Xenophon; Coules, John (1959). Electrical skin conductance and galvanic skin response during 'Hypnosis'. International Journal of Clinical and Experimental Hypnosis, 7 (2), 79-92.

ABSTRACT: No Abstract available

NOTES 1:
"Summary and Conclusions

"Six 'good' hypnotic Ss were given a ten-minute 'hypnotic induction' and a series of 'hypnotic tests.' Both basic skin conductance and momentary variations in skin conductance (GSR) were recorded during the experiment.

"The results were as follows:

1. There was no significant variation in skin conductance during the 'hypnotic induction procedure.'

2. Skin conductance generally increased throughout the remainder of the experiment, ie., when the Ss wre given suggestions of 'sensory hallucinations,' 'age-regression,' 'analgesia,' 'negative hallucinations,' and 'post'-hypnotic behavior.

3. The Ss usually showed a GSR when they were given 'hallucinatory' suggestions, i.e., when they were told that they were becoming 'itchy,' 'thirsty,' and 'very hot.'

4. The GSR to a pinprick was essentially the same before the experiment and during 'hypnotic analgesia.' Also, the GSR was essentially the same, during 'hypnotic analgesia,' (a) when three Ss were told they would receive a pinprick but did _not_ receive the pinprick, (b) when they were told they would receive a pinprick and _did_ receive the pinprick, and (c) when they received a pinprick without being told they would receive it.

5. Four Ss showed a GSR each time they were asked to look at a 'negatively hallucinated' object and person. Two Ss did _not_ show a GSR when they were asked to look at the 'negatively hallucinated' object (or person). The four Ss who showed a GSR stated, during or after the experiment, that they were by no means convinced that the person or object was no longer in the room. The two Ss who did not show GSR stated, after the experiment, that they had been 'certain' that the object (or person) was not present in the room.

6. Although the Ss stated that they did not 'remember' the 'post'-hypnotic suggestion (or anything else about the experiment), they usually showed a GSR when the E made the _preliminary_ movements to give the signal for the 'post'-hypnotic behavior. (They also showed a GSR when E gave the signal for the 'post'hypnotic behavior.)

"Since skin conductance is an index of the S's level of 'activation,' 'arousal,' or 'excitation,' these results indicate the following:

1. Ss do not necessarily become more 'passive' or 'relaxed' during the 'hypnotic induction procedure.'

2. Ss often become more and more 'excited' and 'aroused' when they are given a series of 'active' suggestions such as 'sensory hallucinations,' 'age-regression,' etc.

3. Ss often show momentary 'excitement' when they are 'hallucinating.'

4. A pinprick can 'arouse' a S to the same extent during 'hypnotic analgesia' as it can during 'normal waking.' In addition, 'hypnotic analgesic' Ss are often just as much 'aroused' by the threat of a pinprick as they are by an actual pinprick.

5. Many Ss become momentarily 'excited' when they are asked to look directly at an object (or person) which they have been told they will not be able to see. However, _some_ Ss do _not_ show this momentary 'excitement.'

6. Although Ss may state that they do not 'remember' the 'post'-hypnotic suggestion, they often become momentarily 'excited' when the E makes _preliminary_ motions to give the signal for the 'post'-hypnotic act" (pp. 90-92).

1955

Ament, Phillip (1955). A psychosomatic approach to the use of anesthesia for a hysterical dental patient: A case history. Journal of Clinical and Experimental Hypnosis, 3, 120-123. (Abstracted in Psychological Abstracts 56: 1280)

NOTES 1:
Author describes a case highly resistant both to anesthesia and dentistry. Although very responsive to hypnosis, she continued moaning and moving from side to side (later determined to be her way of preventing dental work even though anesthetized). Ultimately a combination of hypnosis and multiple anesthetics was needed, including nembutal, sodium pentothal, nitrous oxide and novocain. In the author's experience, most other patients require only hypnosis or hypnosis plus novocaine.