09 - 28.9 Hypnosis

28.9 Hypnosis

New York: Guilford; 2003. Moulds ML, Nixon RD. In vivo flooding for anxiety disorders: Proposing its utility in the treatment of posttraumatic stress disorder. J Anxiety Disord. 2006;20(4):498–509. Stanley MA, Beidel DC. Behavior therapy. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Vol. 2. Philadelphia: Lippincott Williams & Wilkins; 2009:2781. van der Valk R, van de Waerdt S, Meijer CJ, van den Hout I, de Haan L. Feasibility of mindfulness-based therapy in patients recovering from a first psychotic episode: A pilot study. Early Intervent Psychiatry. 2013;7(1):64–70. 28.9 Hypnosis The concept of hypnosis conjures up myriad perceptions among clinicians and the lay public. Even the term hypnosis can be misleading, coming as it does from the Greek root hypnos (meaning “sleep”). In reality, hypnosis is not sleep. It is more likely a complex process that requires alert focused and receptive attention. Hypnosis is a powerful means of directing innate capabilities of imagination, imagery, and attention. Many also believe the myth that the clinician projects the hypnotic trance onto the patient or has the power to influence the patient. In reality it is the patient who has the hypnotic gift, and the clinician’s role is to assess the patient’s capacity to capitalize on this asset and to help the patient discover and use it effectively. Patient motivation, personality style, and biological predisposition may contribute to the manifestation of this talent. During the hypnotic trance, focal attention and imagination are enhanced and simultaneously peripheral awareness is decreased. This trance may be induced by a hypnotist through formalized induction procedures, but it can also occur spontaneously. The capacity to be hypnotized and, relatedly, the occurrence of spontaneous trance states is a trait that varies among individuals but is relatively stable throughout a person’s life cycle. HISTORY Descriptions of trance states, ecstatic states, and spontaneous dissociative states abound in the Eastern and Western religious, literary, and philosophical traditions. Anton Franz Anton Mesmer (1734–1815) first formally described hypnosis as a therapeutic modality in the 18th century and believed it to be the result of a magnetic energy or an invisible fluid that the therapist channels into the patient to correct imbalances, restoring health. James Braid (1795–1860), an English physician and surgeon, used eye fixation and closure to induce trance states. Later, Jean Martin Charcot (1825–1893) theorized the hypnotic state to be a neurophysiologic phenomenon that was a sign of mental illness. Contemporaneously, Hippolyte Bernheim (1840–1919) believed it to be a function of the normal brain. Early in his career, Sigmund Freud (1856–1939) used hypnosis as part of his psychoanalysis and noticed that patients in a trance could relive traumatic events, a process called abreaction. Later, Freud switched from hypnosis to free association because he wanted to minimize the transference that sometimes accompanies the trance

state. Importantly, the switch did not eliminate the occurrence of spontaneous trance during the analysis. World War I produced many shell-shocked soldiers and Ernst Simmel (1882–1947), a German psychoanalyst, developed a technique for accessing repressed material that he named hypnoanalysis. During World War II, hypnosis played a prominent role in the treatment of pain, combat fatigue, and neurosis. Formal recognition of hypnosis as a therapeutic modality did not occur, however, until the 1950s. The British Medical Society recommended its teaching in medical schools in 1955 and the American Medical Association and American Psychiatric Association officially stated its safety and efficacy in 1958. DEFINITION Hypnosis is currently understood as a normal activity of a normal mind through which attention is more focused, critical judgment is partially suspended, and peripheral awareness is diminished. The trance state, being a function of the subject’s mind, cannot be forcibly projected by an outside person. The hypnotist, however, may aid in the achievement of the state and use its uncritical, intense focus to facilitate the acceptance of new thoughts and feelings, thereby accelerating therapeutic change. For the subject, hypnosis is typified by a feeling of involuntariness and movements seem automatic. TRAIT OF HYPNOTIZABILITY A person’s degree of hypnotizability is a trait that is relatively stable throughout the life cycle and is measurable. The process of hypnosis takes the hypnotizability trait and transforms it into the hypnotized state. Experiencing the hypnotic concentration state requires a convergence of three essential components: absorption, dissociation, and suggestibility. Absorption is an ability to reduce peripheral awareness that results in a greater focal attention. It can be metaphorically described as a psychological zoom lens that increases attention to the given thought or emotion to the increasing exclusion of all context, even including orientation to time and space. Dissociation is the separating out from consciousness elements of the patient’s identity, perception, memory, or motor response as the hypnotic experience deepens. The result is that components of self-awareness, time, perception, and physical activity can occur without being known to the patient’s consciousness and so may seem involuntary. Suggestibility is the tendency of the hypnotized patient to accept signals and information with a relative suspension of normal critical judgment; it is controversial whether critical judgment can be completely suspended. This trait will vary from an almost compulsive response to input in the highly hypnotizable to a sense of automaticity in the less hypnotizable individual. Table 28.9-1 lists the indicators of trance development. Table 28.9-1

Indicators of Trance Development QUANTIFICATION OF HYPNOTIZABILITY Quantifying a patient’s degree of hypnotizability is useful in a clinical setting because it predicts the effectiveness of hypnosis as a therapeutic modality. Quantification also provides useful information about the way patients relate to themselves and the social environment. Highly hypnotizable patients have an increased incidence of spontaneous trance-like states and so may be unduly influenced by ideas and emotions that are not being appropriately self-critiqued. NEUROPHYSIOLOGICAL CORRELATES OF HYPNOSIS Neurological testing of individuals in the hypnotized state and those with a high degree of hypnotizability has led to some interesting findings, but no set of changes has been shown to be sensitive or specific for the trance state or hypnotizability trait. Electroencephalographic (EEG) studies have shown that hypnotized persons exhibit electrical patterns that are similar to those of fully awake and attentive persons and not like those found during sleep. Increased alpha activity and theta power in the left frontal region has been reported in highly hypnotizable patients as compared with those who are less hypnotizable; these differences exist in the trance and nontrance states.

Positron emission tomography (PET) studies that compare regional blood flow in the brain in both hypnotized and nonhypnotized subjects lend further evidence to the hypothesis that hypnosis exerts some of its effects at lower-level modalities of the brain. Hypnotic suggestions to add color to a visual image result in increased blood flow to the lingual and fusiform gyri, the color vision processing centers of the brain; suggestions to remove color have the opposite effect. Similarly, the intensity and noxiousness of pain are believed to be processed by different regions of the brain, because different areas of reduced blood flow result when each is minimized through hypnosis. The role of the anterior brain regions, such as the frontal lobes, in hypnosis has been shown physiologically by the positive correlation between homovanillic acid concentrations in the cerebrospinal fluid and degree of hypnotizability. The frontal cortex and basal ganglia have a large number of neurons that use dopamine, of which the metabolite is homovanillic acid. This may explain why pharmacological enhancement of hypnotizability, although difficult, is primarily accomplished with dopaminergic agents, such as amphetamine. The increased activation of the basal ganglia may relate to the increased automaticity of hypnotic motor behavior. CLINICAL ASSESSMENT OF HYPNOTIC CAPACITY Two major procedures exist to clinically evaluate hypnotic capacity: the Stanford Hypnotic Susceptibility Scale and the Hypnotic Induction Profile (HIP) (Table 28.9-2). The Stanford Hypnotic Susceptibility Scale is a long laboratory-based test that has been modified for clinical evaluation and requires approximately 20 minutes to perform. It primarily measures behavioral compliance and suggestibility. The HIP is a shorter test that uses the eye-roll sign as a biological indicator and measures cognitive flow, which differentiates those with no hypnotic capacity because of mental pathology from those mentally normal patients with any inherent hypnotic capacity (Fig. 28.9-1). FIGURE 28.9-1 Administration of the Hypnotic Induction Profile can be a routine part of the initial visit

and evaluation. The test begins with the eye-roll sign, a presumptive measure of biological ability to experience dissociation. In the test procedure for eye-roll sign measurement, the patient is told “Hold your head looking straight forward; while holding your head in that position, look upward, toward your eyebrows—now toward the top of your head [up-gaze]. While continuing to look upward, close your eyelids slowly [roll].” The up-gaze and roll are scored on a 0 to 4 scale by observing the amount of sclera visible between the lower eyelid and the lower edge of the cornea. If an internal squint occurs, the degree is scored on a 1 to 3 scale. The squint score is added to the roll score. This procedure takes about 5 seconds. The eye-roll is a part of the hypnotic induction, which is also scored as an initial indicator of the potential for hypnotic experience. (Courtesy of Herbert Spiegel, M.D., Marcia Greenleaf, Ph.D., and Davig Spiegel, M.D.) Table 28.9-2 Hypnotic Induction Profile–Derived Method of Self-Hypnosis INDUCTION Many different induction protocols follow the same basic principles and pattern, but may be better suited to the patients with different levels of hypnotizability. Doctor: Take a long, deep breath—inhale and exhale; now close your eyes and relax. Pay particular attention to the muscles in and about your eyes—relax them to the point that they just won’t work. Are you trying to do that? Good. If you really have

them relaxed, right at this very moment, no matter how hard you try, they just won’t open. Test them. The harder you try, the faster they stick together, just as if they were glued together. That’s fine! Now you can open your eyes; that’s good. When I tell you to and not before, open and close your eyes once more, and, when you close them this time, you will be ten times as relaxed as you are right now. Go ahead, open and close, and feel that surge of relaxation go through your whole body, from the top of your head to the tip of your toes. Very good! Now once again, open and close your eyes, and this time, when you close them, you will double the relaxation that you now have. Fine. If you have followed my suggestions, right at this very moment, when I lift your hand and let it drop into your lap, it will drop like a wet cloth, heavy and limp. That’s very, very good. You now have good physical relaxation, but medical relaxation consists of two phases: physical, which you now have, and mental, which I will now show you how to achieve. When I ask you to and not before, I want you to start counting backward from 100. I know you can count; that is not what we’re after. I just want you to relax mentally. As you say each number, pause momentarily until you feel a wave of relaxation cover your whole body, from the top of your head to the tip of your toes. When you feel this wave of relaxation, then say the next number, and each time you say a number, you will double the relaxation you had before you said the number. If you do this properly, an interesting thing will happen—as you say the numbers and relax, the succeeding numbers will start to disappear and vanish from your mind. Command your mind to dispel these numbers. Now, aloud and slowly, start counting backward from 100. Patient: One hundred. Doctor: Very good. Patient: Ninety-nine. Doctor: Make them start to disappear now. Patient: Ninety-eight. Doctor: Now they’re fading away, and after the next number they’ll all be gone. Make them disappear. Let the numbers go. Patient: Ninety-seven. Doctor: And now they’re all gone. Are they gone? Fine. If there are any numbers still lurking in your mind, when I lift your hand and drop it, they will all disappear. (Courtesy of William Holt, M.D.) INDICATIONS A patient’s degree of hypnotizability and the technique of hypnosis are clinically useful in diagnosis and in treatment, respectively.

The existence of spontaneous, trance-like states in everyday life and the potential of individuals to uncritically accept emotions and information in these states make a person’s degree of hypnotizability a factor in the way the world is viewed and processed. A relation is seen between various conditions and hypnotizability. For example, patients with paranoid personality disorder are low and patients who are histrionic are higher on the hypnotizability spectrum. Patients with dissociative identity disorder are highly hypnotizable. Patients with eating disorders are difficult to hypnotize. A 32-year-old man presented to the emergency department with a severe headache. He was a chronic migraine sufferer and had been unable to control the pain on this occasion with his propranolol (Inderal). The emergency department recognized that he had high hypnotic capacity. The imagery of an icepack being placed on his forehead was suggested. Initially some real ice was placed on his forehead to help. The patient was able to control his pain completely with this imagery. He did not require narcotics, as he had on previous visits. On follow-up several weeks later the patient reported being able to use this strategy to control, as well as prevent, migraine attacks, and he no longer had to rely on frequent emergency department visits for pain relief. (Courtesy of A. D. Axelrad, M.D., D. Brown, Ph.D., and H. J. Wain, Ph.D.) A 22-year-old male patient was brought to the emergency room with bilateral blindness. Following an evaluation by ophthalmology, it was determined that the blindness was psychogenic. After initial evaluation by psychiatry, a therapeutic alliance was developed, and hypnosis was used to take the patient to a safe place and then back to the time immediately prior to the blindness. After two sessions the patient was able to describe seeing his wife in an adulterous relationship. At that moment the patient vocalized a desire to harm his wife and her suitor. Immediately after this vocalization, he became amnesic for the event and blind. On describing this under hypnosis, he was given a suggestion that when he became alert “He would only remember what he felt comfortable remembering.” Subsequent to the patient becoming alert, he had no idea what had occurred, and each day after the hypnotic intervention was initiated the patient’s anger was reframed. When the patient felt comfortable he then confronted his wife. The patient became aware that the amnesia was being used to prevent him from acting out. Use of a psychodynamic, cognitive reframing approach with a hypnotic milieu helped this patient to gain control and understanding of his symptoms. The patient and his wife were then referred for marital counseling. (Courtesy of A. D. Axelrad, M.D., D. Brown, Ph.D., and H. J. Wain, Ph.D.) Therapeutically, hypnosis’s effectiveness in facilitating acceptance of new thoughts and feelings makes it useful in treating habitual problems and also with symptom management. Smoking, overeating, phobias, anxiety, conversion symptoms, and chronic

pain are all indications for hypnosis. They can often be treated in a single session, in which a patient is taught to perform self-hypnosis. Hypnosis can also aid in psychotherapy, notably for posttraumatic stress disorder, and it has been used for memory retrieval. A 29-year-old woman was referred for evaluation and treatment of ongoing facial pain that was not responding to traditional methods of intervention. Neurological evaluation showed no objective physical correlations. Her high midrange performance on the HIP added support to the potential of a psychological mechanism for the pain. Initially the pain was controlled by a hypnotic intervention, but it returned 24 hours later. Her self-hypnotic technique ceased to be effective. A decision was made to explore more completely the meaning of the pain. Age regression under hypnosis was used, and the patient was regressed to a time prior to the pain. She related that her brother had been injured by a car while he was running in the street. The patient was babysitting at the time, and her father was so angered that he hit her. Recently her friend’s dog ran away, and she felt responsible. As she began to recognize her need to punish herself because of her guilt over what had occurred, she was able to understand her feelings and reframe her thoughts in a more productive manner. An “affect bridge” was also used, and the patient was asked to go to back to a previous time when she felt guilty and was punished. She then was able to describe her feelings of being hit by her alcoholic, abusive father. She continued to gain insight and mastery over the past and was able to ablate her pain. (Courtesy of A. D. Axelrad, M.D., D. Brown, Ph.D., and H. J. Wain, Ph.D.) A 42-year-old married mother of three children had been kidnapped and locked in a large packing trunk. After she had freed herself and broken out, her abductors had stabbed her multiple times, tied her up, put her back in the trunk, and thrown her down a cliff. She had eventually managed to break out and crawl to safety. Eventually she had been picked up by a passerby. She reported that others had seen her lying on the road and appeared frightened to approach her. Eventually 911 had been called and she had been transported to a hospital. Following medical stabilization she had been discharged and found herself developing nightmares, reexperiencing avoidance, and having hyperarousal symptoms. She was referred by her internist for treatment and was initially started on 25 mg of sertraline (Zoloft), which was increased to 50 mg 4 days later. She was evaluated on the HIP and determined to be a mid- to high-range hypnotic subject. She was taught to go to a safe place and to use a split-screen technique. She was also given permission to describe her nightmares, reexperiences, and overwhelming anxieties and fears that she faced while being captive, as well as her feelings of abandonment while lying on the road. She was reinforced for her ingenuity in breaking out of the trunk. Her feeling of blame for her capture was reframed while she was under hypnosis. She was taught to calm herself and to reframe her negative feelings about her helplessness. Hypnotic age regression was used to help her master her experiences and facilitate their

becoming like a bad movie. Initially her startle response was used as a signal for her to go to her comfort zone. Age progression was used to help her to rehearse the future. The treatment used the milieu of hypnosis along with exposure, cognitive reframing, psychodynamic approaches, and pharmacology. (Courtesy of A. D. Axelrad, M.D., D. Brown, Ph.D., and H. J. Wain, Ph.D.) CONTRAINDICATIONS No intrinsic dangers to the hypnotic process exist. Because of the increased dependence that the hypnotized patient has toward the therapist, a strong transference may occur, however, in which the patient exhibits feelings for the therapist that are inappropriate in regards to their relationship. Strong attachments may occur, and it is important that these are respected and properly interpreted. Negative emotions may also be brought out in the patient, especially those who are emotionally fragile or who have poor reality testing. To minimize the likelihood of this negative transference, caution should be taken when choosing patients who have problems with basic trust, such as those who are paranoid or who require high levels of control. The hypnotized patient also has a reduced ability to critically evaluate hypnotic suggestions and, thus, the hypnotist must have a strong ethical value system. Controversy exists about whether patients can perform acts during a trance state that they would otherwise find repugnant or that run contrary to their moral system. REFERENCES Altshuler KZ, Brenner AM. Other methods of psychotherapy. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Vol. 2. Philadelphia: Lippincott Williams & Wilkins; 2009:2911. Axelrad, DA, Brown, D, Wain, HJ. Hypnosis. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Vol. 2. Philadelphia: Lippincott Williams & Wilkins; 2009:2804. Faymonville ME, Roediger L, Del Fiore G, Delgueldre C, Phillips C, Lamy M, Luxen A, Maquet P, Laureys S. Increased cerebral functional connectivity underlying the antinociceptive effects of hypnosis. Brain Res Cogn Brain Res. 2003;17:255. Finkelstein S. Rapid hypnotic inductions and therapeutic strategies in the dental setting. Int J Clin Exp Hypn. 2003;51:77. Ginandes C, Brooks P, Sando W, Jones C, Aker J. Can medical hypnosis accelerate post-surgical wound healing? Results of a clinical trial. Am J Clin Hypn. 2003;45:333. Gullickson T. Hypnosis and hypnotherapy with children. PsycCRITIQUES. 2004. Liossi C, Hatira P. Clinical hypnosis in the alleviation of procedure-related pain in pediatric oncology patients. Int J Clin Exp Hypn. 2003;51:4. Montgomery GH, David D, Kangas M, Green S, Sucala M, Bovbjerg DH, Hallquist MN, Schnur JB. Randomized controlled trial of a cognitive-behavioral therapy plus hypnosis intervention to control fatigue in patients undergoing radiotherapy for breast cancer. J Clin Oncol. 2014;32(6):557–563. Patterson DR, Jensen MP. Hypnosis and clinical pain. Psychol Bull. 2003;129:495. Ploghaus A, Becerra L, Borras C, Borsook D. Neural circuitry underlying pain modulation: Expectation, hypnosis, placebo. Trend Cogn Sci. 2003;7:197.