Evidence-Based Reviews

Hypnosis: Brief interventions offer key to managing pain and anxiety

Current Psychiatry. 2004 April;3(4):48-59

References

1. Spiegel D, Jasiukaitis P. Hypnosis: Brain basis. In: Smith BH (ed). Elsevier’s encyclopedia of neuroscience. The Netherlands: Elsevier Science, 1999.

2. Rainville P, Hofbauer RK, Bushnell MC, et al. Hypnosis modulates activity in brain structures involved in the regulation of consciousness. J Cogn Neurosci 2002;14:887-901.

3. Rainville P, Duncan GH, Price DD, et al. Pain affect encoded in human anterior cingulate but not somatosensory cortex. Science 1997;277:968-71.

4. Kosslyn SM, Thompson WL, Costantini-Ferrando MF, et al. Hypnotic visual illusion alters color processing in the brain. Am J Psychiatry 2000;157:1279-84.

5. Spiegel D. Negative and positive visual hypnotic hallucinations: attending inside and out. Int J Clin Exp Hypn 2003;51:130-46.

6. Spiegel D, King R. Hypnotizability and CSF HVA levels among psychiatric patients. Biol Psychiatry 1992;31:95-8.

7. Piccione C, Hilgard ER, Zimbardo PG. On the degree of stability of measured hypnotizability over a 25-year period. J Pers Soc Psychol 1989;56:289-95.

8. Spiegel H, Spiegel D. Trance and treatment: Clinical uses of hypnosis. Washington, DC: American Psychiatric Press, 2004.

9. Wertz JM, Sayette MA. Effects of smoking opportunity on attentional bias in smokers. Psychol Addict Behav 2001;15:268-71.

10. Nishith P, Barabasz A, Barabasz M, Warner D. Brief hypnosis substitutes for alprazolam use in college students: transient experiences and quantitative EEG responses. Am J Clin Hypn 1999;41:262-8.

11. Lang EV, Benotsch EG, Fick LJ, et al. Adjunctive nonpharmacological analgesia for invasive medical procedures: a randomised trial. Lancet 2000;355:1486-90.

12. Spiegel D, Frischholz EJ, Maruffi B, Spiegel H. Hypnotic responsitivity and the treatment of flying phobia. Am J Clin Hypn 1981;23:239-47.

13. Butler LD, Duran EFD, Jasiukaitis P, et al. Hypnotizability and traumatic experience: a diathesis-stress model of dissociative symptomatology. Am J Psychiatry 1996;153:42-63.

14. Spiegel D. Dissociation and hypnosis in post-traumatic stress disorder. J Trauma Stress 1988;1:17-33.

15. Stutman RK, Bliss EL. Posttraumatic stress disorder, hypnotizability, and imagery. Am J Psychiatry 1985;142:741-3.

16. Diagnostic and statistical manual of mental disorders (4th ed, text rev). Washington, DC: American Psychiatric Association, 2000.

17. Maldonado JR, Spiegel D. Trauma, dissociation and hypnotizability. In: Marmar R, Bremmer D (eds). Trauma, memory and dissociation. Washington, DC: American Psychiatric Press, 1998.

18. Lindemann E. Symptomatology and management of acute grief. Am J Psychiatry 1994;151:155-60.

19. Spiegel D. Vietnam grief work using hypnosis. Am J Clin Hypn 1981;24:33-40.

20. Foa EB, Davidson JRT, Frances A. Treatment of posttraumatic stress disorder. J Clin Psychiatry 1999;50:4-69.

21. Brom D, Kleber RJ, Defare PB. Brief psychotherapy for post-traumatic stress disorder. J Consult Clin Psychol 1989;57:607-12.

22. Spiegel D. Hypnosis and implicit memory: automatic processing of explicit content. Am J Clin Hypn 1998;40:231-40.

23. Spiegel D. Multiple personality as a post-traumatic stress disorder. Psychiatr Clin North Am 1984;7:101-10.

24. Kluft RP. Dissociation as a response to extreme trauma. In: Kluft RP (ed). Childhood antecedents of multiple personality. Washington, DC: American Psychiatric Press, 1985:66-97.

25. Marmar CR, Weiss DS, Metzler T. Peritraumatic dissociation and posttraumatic stress disorder. In: Bremner JD, Marmar C (eds). Trauma, memory, and dissociation. Washington, DC: American Psychiatric Press, 1998;229-52.

26. Birmes P. Peritraumatic dissociation, acute stress, and early posttraumatic stress disorder in victims of general crime. Can J Psychiatry 2001;46:649-51.

27. Spiegel D. Hypnosis, dissociation and trauma. In: Burrows GD, Stanley RO, Bloom PB (eds). Clinical hypnosis. New York: John Wiley & Sons, 2001;143-58.

28. Spiegel D, Cardena E. Disintegrated experience: the dissociative disorders revisited. J Abnorm Psychol 1991;100:366-78.

29. Chu JA, Dill DL. Dissociative symptoms in relation to childhood physical and sexual abuse. Am J Psychiatry 1990;147:887-92.

30. Kluft RP. Childhood antecedents of multiple personality. Washington, DC: American Psychiatric Press, 1985.

31. Spiegel D. Dissociating damage. Am J Clin Hypn 1986;29:123-31.

32. LeDoux J. Synaptic self: How our brains become who we are. New York: Viking Press, 2002.

33. Putnam FW. Using hypnosis for therapeutic abreactions. Psychiatr Med 1992;10:51-65.

The HIP test includes instructions to produce a sense of lightness in the left arm and hand, with tests of response to this instruction. Response is characterized by dissociation, hand elevation after it is lowered, involuntariness, response to the cutoff signal, and altered sensation.

Turning hypnotic induction into a test of hypnotic capacity transforms the initial encounter by:

removing pressure on the clinician to successfully hypnotize the subject
reducing patients’ experiences of complying with the clinician’s wishes, rather than exploring and discovering their own hypnotic capacity.

Placing the hypnotic experience in the context of a test also makes it consonant with other medical examinations and procedures.⁸

Once a patient’s hypnotizability is determined, structured measurement is no longer necessary. The test-retest correlation for hypnotizability scores is 0.7 over 25 years, which is more consistent than IQ testing.⁷ Subsequent inductions usually can be generated by the patient or signaled by the clinician, and only seconds are required for the shift into trance.

Box 1

Sources of training in hypnosis for psychotherapy

Effective, safe work with hypnosis requires clinical expertise in diagnostic assessment and choosing treatment options. Psychiatrists can learn techniques for inducing, measuring, and using hypnotic responsiveness in introductory and advanced workshops, supplemented by local supervision.

Courses in hypnosis are offered by many medical schools. Postgraduate training is available at annual meetings of the American Psychiatric Association, Society for Clinical and Experimental Hypnosis, and American Society of Clinical Hypnosis. The two hypnosis societies offer intensive workshops for psychiatrists, psychologists, and other health care professionals.

Useful text books also are available:

Spiegel H, Spiegel D. Trance and treatment: clinical uses of hypnosis. Washington, DC: American Psychiatric Publishing, 2004.
Zarren JI, Eimer BN. Brief cognitive hypnosis: facilitating the change of dysfunctional behavior. New York: Springer Publishing, 2002.
Lynn SJ, Kirsch I, Rhue JW. Casebook of clinical hypnosis. Washington, DC: American Psychological Association, 1996.
Fromm E, Kahn SP. Self-hypnosis: the Chicago paradigm. New York: Guilford Press, 1990.

Reducing anxiety

Anxiety can be understood as a vaguely defined but immobilizing sense of distress. Lack of clarity about the discomfort’s source enhances the patient’s sense of helplessness and avoidance. One therapeutic challenge is to convert anxiety into fear—to give it a focus so that something can be done about it.

Box 2

‘Imagine yourself floating:’ Hypnotic instruction for treating anxiety

Imagine yourself floating in a bath, a lake, a hot tub, or just floating in space. With each breath out, let a little more tension out of your body. Just enjoy this pleasant sense of floating, and notice how you can use your store of memories and fantasies to help yourself and your body feel better.

“While you imagine yourself floating, in your mind’s eye visualize an imaginary screen: a movie, TV, or computer screen, or, if you wish, a piece of clear blue sky. On that screen project your thoughts, fears, worries, ideas, feelings, or memories, while you maintain the pleasant sense of floating in your body. You establish this clear sense of your body floating here, while you relate to your thoughts and ideas out there.

“Once you have established this screen, divide it in half. Use the left side as your ‘worry screen.’ Picture one thing that causes you anxiety on this screen and learn to manage the feelings of discomfort that accompany it. Now use the right side as your ‘problem-solving’ screen. Brainstorm something you can do about the problem on the left, all the while maintaining a sense of floating in your body.

“You may have to ‘freeze’ what is on the ‘worry screen’ and re-establish the floating several times. This allows you to develop new means of coping with the things that are making you anxious, one at a time.”

Anxiety sets up a negative feedback cycle between psychological preoccupation and somatic discomfort, a “snowball effect” in which subjective anxiety and somatic tension reinforce each other. Hypnosis can help reduce anxiety and induce relaxation,⁹ and its dissociative component can help separate anxiety’s psychological and somatic components.

Hypnosis is as effective at reducing anxiety as 1 mg of alprazolam, at least in a study of college students.¹⁰ Student volunteers with high and low hypnotizability were given alprazolam, 1 mg, and a hypnotic suggestion based on their reactions to the drug. Four days later, when students received hypnosis only and hypnosis plus alprazolam:

combination therapy reduced anxiety more effectively than did hypnosis or alprazolam alone, as measured by the Profile of Mood States tension-anxiety scale
improvement was comparable with hypnosis or alprazolam alone
highly hypnotizable students showed significantly greater relaxation than did those with low hypnotizability in all three treatment groups
EEG data showed similar frontal and occipital changes in the alprazolam and hypnotic suggestion groups.