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The fact that the phenomenon of hypnosis occurs at the mind-brain interface, demonstrating extensive psychological control over both psychological and physical states, makes it an especially useful therapeutic tool. Hypnotic responsivity is in fact measured by testing an individual's capacity to produce alterations in a variety of somatic functions under guided conditions.
The standard hypnotic changes assessed in hypnotizabilty measurements include an alteration of sensation, such as a sense of lightness or heaviness in a hand,- a ... of tingling numbness or warmth in an extremity alteration in motor function such as the ... hand, especially with a sense of lessened control in hand which is instructed to move, alterations in ... that is instructed amnesia to a given series of events, alterations in time sense such as the capacity to ... the past and relive it as though it were the present.
These standard hypnotic phenomena have ... ... analogs in psychosomatic pathology, for exam... glove anesthesia, central pain hearing and ... disturbances, muscle weakness, conversion paralfugue states, and other hysterical dissociations. The ... to produce these "artificial symptoms" using ... in the hypnotizable patient makes hypnosis a ... vehicle for reversing such problems when they ... spontaneously.
..., treatment of chronic psychosomatic ... is quite different. Often far too much emphasis ... on a dissection of the psychological from the ... etiology. Very often patients suffer from a ... combination of physical and psychological .... Even in the most obviously physically disabling ..., such as multiple sclerosis, the psychological ... component to the disability plays an important in overall adjustment. A tremor may become worse anxiety, or the patient's secondary gain from the ... illness may make the difference between being ...-bound and being ambulatory.
... the other hand, there are some classic hysterical version symptoms which may have comparatively ... physical components or which may begin with ... trauma which then heals leaving a residual ...-based physical dysfunction. Once the ... initial diagnostic evaluation has been done and ... preventive and therapeutic physical measures ... been taken, it is rarely useful to pursue an inquest causation. Whatever their reason, patients with chosomatic problems are suffering, and they usually ... to the implication that the problem is "in your mind" ... accusation of malingering, which makes them more ... and makes their rehabilitation more difficult. ... establishes a context wherein recovering from the ... is an admission of guilt and a humilating one hat.
... example, a 43-year-old bricklayer suffered a ... fracture of his left index finger while handling ... ladder on the job.1 The injury healed poorly, ... him with a fixed flexion contracture of all of the ... of his left hand and making his return to work .... He was given disability by his employer's ... company, which sent him to a variety of ... to examine the fixed contracture in his hand. ... of the physicians he went to informed him that he was ..., which enraged the patient who was already ... at losing his prized job and at living on ... one quarter of the income he had ... earned. The insurance company began secretly ... him to prove that he could use his hand, and ... insisted that he have this index finger amputated so that he could rehabilitate the rest of the hand. He sought help from a psychologist using hypnosis. The psychologist determined that the clenched hand represented his symbolic rage at the company which employed him and therefore devoted a number of sessions with the patient to the abreaction of the rage. The symptom was unchanged.
The patient then sought surgical evaluation, and the surgeon informed him that he had contractures of the hand with considerable muscle wasting in the forearm but that a surgical approach to the problem would probably not be beneficial. The patient referred was for psychiatric evaluation. The patient was moderately hypnotizable and responded to an approach which was rehabilitative in nature. He was told that there was no use in exploring why his hand was the way it was, that he could learn a means of rehabilitating the hand if he was interested. He readily assented. He was then instructed to enter a selfhypnotic state and to develop restless, trembling movements in his left hand and forearm. He sat for half an hour with his hand shaking outstretched in front of him and the sweat pouring off his brow. He went home and practiced this exercise a half an hour twice a day, and the contractures began-to ease. By the end of nine months he had complete extension In all of the fingers except the originally injured index finger, and the surgeon instituted dynamic splinting. By the end of the year he had regained full use of his hand and proudly presented his union card to be signed so he could be removed from disability and return to work, some four years after the original injury.
In this case, hypnosis was of no use in sorting out the causation of the injury which obviously had combined traumatic and psychological features. Rather, it provided a framework for a face-saving rehabilitative approach which enabled the patient to acknowledge the possibility of a psychological and physical role in rehabilitating the hand, and indeed both somatic and psychological treatments were involved in his recovery.
The capacity for hypnosis to produce somatosensory alterations is helpful in the process of convincing the patient that something can occur which will make a difference. As soon as the patient sensed the tingling and tremors in his left hand, he began to believe that he could overcome the problem. Furthermore, the mystique of hypnosis provides a patient with a face-saving framework. He or she has now learned something new that they did not know before that enables them to overcome the problem. This removes the tremendous inertia of conscious and unconscious guilt about previous failures to recover.
The range of psychosomatic conditions which has been treated by hypnosis is immense. It includes such primarily somatic problems as skin disorders, ulcerative colitis, and asthma, and the treatment focuses primarily on intervening with the psychological reactive component to the somatic distress.
There is a growing amount of experimental literature that demonstrates the effectiveness of hypnosis in controlling a variety of physical functions such as skin temperature2 and capillary blood flow.3'4 While the use of hypnosis in psychosomatic medicine primarily involves intervening with the reactive component, there are situations in which well controlled studies have demonstrated an effect of hypnosis in controlling physical aspects of disease as well. For example, Surman5 randomly divided patients with warts into treatment and control groups. The treatment group were instructed that they would develop tingling and numbness in the warts and they would fall off on one side of their body. At follow-up, nine of seventeen treatment patients had lost the warts on that side of the body. In fact, eight of the nine, contrary to instructions, lost them on both sides of their body, as contrasted with none of the seven patient in the control group. Likewise, there have been reports that patients with psoriasis have experienced significant relief using hypnosis.6 They often imagine the climatic conditions which actually improve the disease, such as a warm, dry, desert climate.
One patient with ulcerative colitis found that at times of renewed bloody diarrhea she became exceedingly anxious and depressed, and her gastroenterologist placed her on increasing doses of steroids, which not only worried her and gave her the typical pattern of side effects but also prevented her becoming pregnant. Despite the active discouragement of her doctor, she undertook training in self-hypnosis and imagined her intestinal mucosa gradually becoming soothed and healed. This, she reported, gave her a sense of control over the course of the illness, which she felt had victimized her in the past. Using this technique she was able to decrease and then discontinue steroids and became pregnant. Even more impressive, her skeptical gastroenterologist asked her to teach him about her self-hypnosis exercises.
There is a large amount of literature on the effectiveness of hypnosis in treating asthma.7"9 The generally accepted notion has been that subjective discomfort improves markedly with hypnosis, despite the lack of evidence of differences in airway resistance, 10-11 although more recent evidence supports the notion that physical parameter altered as well.12-18
One sixteen-year-old asthmatic patient had admitted to the hospital for the third time in as ... months in status asthmaticus and was ... subcutaneous epinephrine. She was taught a hypnosis exercise which simply involved the ... that she would let her hand float up in the air, and with each breath she would breathe a little deeper, ... little easier. She had been sitting bolt upright in knuckles white, audibly wheezing. By the end of minutes of this exercise, while still wheezing, ... notably improved, and less tense. She learned to ... the self-hypnosis exercise that involved this ... and also imagined herself being in a place where she ... it most comfortable to breathe. (Many asthmatics ... that breathing in cool mountain air or being ... seashore makes them feel instinctively more ... She practiced this approach every hour and anytime felt the tightening in her chest. She had one ... readmission to the hospital but continued using the hypnosis as a first recourse before using inhalers or ... medication. Ten-year follow-up revealed that she ... other hospital admissions for asthma, and had ... studying to be a respiratory therapist and teaching ... asthmatics how to control their problem.
Hypnosis has an image acquired from ... experience with it of being the royal road to ... unconscious, of revealing deep hidden secrets. For ... dramatic occasion in which a patient can be ... the time of a traumatic incident and have ... remission of symptoms, there are a hundred in ... hypnosis is used more to interfere with the ... anxiety associated with somatic illness and to ... patients acquire a sense of mastery.
Hypnosis is useful in helping to manage the side ... of certain medications. For example, many car ... have found self-hypnosis useful in countering the ... nausea and vomiting associated with chemo.... Some patients are so troubled by the nausea ... to these medications that they start to become ... in anticipation of an injection or even in ... of a visit to the hospital. Patients have ... vomiting at the sight of a medical center.
... this situation, the dissociative aspects of hypnosis particularly helpful. Patients have been taught in ... that they have to deliver their bodies to the ... but can psychologically be somewhere else. It is ... very helpful to teach those patients who are ... to use an imaginary screen on which to ... their favorite place where they feel most .... It might be a room in their home, or a ... outdoor spot. They are taught to practice for visits to the hospital by picturing the spot and ... the associations that the image conjures up. ... once they deliver themselves to the hospital, they are ... to immediately enter the self-hypnotic trance ... and focus on this image of pleasant surroundings. approach helps to encounter the sense of helplessof being overcome by a physical sensation which is ... unpleasant, and has enabled many patients to ... their nausea and vomiting and feel more like ... partners in their chemotherapy.
... approach used in restructuring the experience of a to the hospital is not one of telling the patients, "You not be nauseated." This merely reinforces their ... on the theme of nausea and vomiting. Instead, focus is shifted and the dissociation of the trance state ... to separate psychological from physical reality.
... have been effectively treated with hypnosis. In ..., Williams and his group19'"0 have reported that even ... with clearly documented organic seizures control ... better when they use a combination of medication self-hypnosis. Many epileptics report awareness of a ... period during which time a certain kind of ... state seems to abort the development of the .... On the other hand, some patients with clearly ... conditions do respond to hypnotic interven....
A housewife in her 40s suffered from incapacitating ... which necessitated her being accompanied ... by a member of the family, lest she hurt herself ... a seizure.21 She went to a series of physicians who ... unable to document a seizure focus, and who tried ... to control these seizures with medication. ... when one physican suggested that she be placed in a hospital for the "incurable" did the patient herself become rather frightened about the illness.
She was referred for psychiatric evaluation and was found to be extremely hypnotizable. She was taught first to put herself into a self-hypnotic trance, and then to develop movement sensations which would become a fullblown seizure. This she promptly did. In the past, physicians had been frightened by her seizures. Now the patient was being instructed that she could control them, but indirectly, by demonstrating to her that she could start them. She learned to bring on increasingly milder and milder seizures which gradually became nothing more than a brief closing of the eyes and nodding of the head. Both she and her family were extremely proud of her ability and exhibited no curiosity whatsoever about the etiology of these seizures. Follow-up for the ensuing ten years revealed no recurrence of the seizure or other psychiatric symptoms.
There are many times when patients become trapped by their own symptoms and humiliated by their occurrence. They are looking for an honorable way out, and often simple techniques such as these are all that is required.
Hypnosis has remarkable psychosomatic effects both in normal individuals and in patients. Often it is effective simply by demonstrating the degree of psychological control over the soma. Symptoms which seem frightening are redefined as mere spontaneous trance dissociations, and patients are taught that they have a greater degree of control over somatic reactions than they would have thought. In this way hypnosis can be a useful tool in distinguishing psychological and somatic aspects of illness and redefining the meaning of disability and symptoms to patients, and in teaching them means of controlling them.
Hypnosis often provides a means of translating somatic metaphors as it is likewise a means for expressing them. It is important that the clinician be aware of situational or intrapsychic aspects of a symptom. A two-pronged approach is often useful, in which the patient is supported in exploring those aspects of the symptom which are statements of psychological distress while controlling these somatic manifestations. Often when patients overcome the humiliating aspects of being trapped by the symptom, they are more able to examine and explore the psychological significance of it.
Hypnosis can be useful not only in the treatment of conversion symptoms, but also in differential diagnosis. Such hypnotic phenomena seem to be particularly clear illustrations of the mind-brain interface, for example, psychologically produced alterations in sensation of pain or in motor control. It makes sense that the conversion of psychological distress to somatic symptoms should be significantly related to hypnotic capacity and subject to influence via hypnotic experience.
Hypnotic responsivity has been used as a diagnostic probe in the differential diagnosis of conversion versus organic symptoms. The presumption is that the greater psychosomatic flexibility demonstrated by highly hypnotizable individuals renders them relatively more prone to conversion symptoms under duress. Thus, if a patient with a suspicious symptom turns out to be not at all hypnotizable, some therapists are more inclined to look carefully for an organic etiology. One young woman, for example, insisted that her episodes of loss of balance were a conversion symptom related to stress in her life. She proved to be not at all hypnotizable, however, and an extensive neurological workup revealed multiple sclerosis.' On the other hand, an extremely hypnotizable patient began to develop hearing loss.22'23 However, he was himself suspicious that the hearing loss was related to his depression, and his very curiosity about the possibility of a psychological etiology made it seem less likely that this was in fact a conversion symptom. It turned out that he had middle-ear disease which was surgically corrected with full restoration of his hearing.
There is no doubt, however, that many hypnotizable individuals find themselves employing their ... capacity as a vehicle to express conflict. One such ... who initially sought help for pigmentary glaucoma elevated intraocular pressure using hypnosis ... that she periodically suffered from deafness.22 glaucoma was a documented organic disease ... became worse when her intraocular pressure ... These elevations in pressure were related to stress ... was able to manage the pressure quite effectively and medications. The deafness, however, seemed ... related to conversations with certain individuals were saying things she did not want to hear. She had example, a sister who insisted that the patient "... right to be happy." Once, as the sister was giving ... these lectures, she found that her hearing ... disappear. She was instructed to enter a self-... state and to diminish her hearing artificially and restore it upon a signal. When she was able to see easily she could alter her hearing, it was easier for ... accept the hypothesis that her hearing dysfunction ... expression of emotional conflict and to handle it ... directly. She noted, in fact, that she started ... more assertive with people around her and ... expressing anger more openly.
Given our growing understanding of the ... the mind-body interaction and especially of the ... ness with which psychological factors affect the body, surprising that we have been so slow to generally ... and utilize the century-old knowledge that hypnosis be effective in controlling pain. In the middle of nineteenth century in India, Esdaile reported ... surgical anesthesia using hypnosis.24 Nonetheless, ... recently medical efforts at pain control have been ... exclusively pharmacological; yet hypnotic techniques be remarkably effective tools in controlling pain.
THE TWO-COMPONENT THEORY OF PAIN
Central to various hypnotic techniques for control pain is a theory that divides the pain experience into components: the sensation of the painful stimulus ... and the reactive component to it. This distinction was ... established clinically by Beecher25 when he observed ... the experience of pain and demands for pain ... were proportional to the meaning of the pain ... rather than to the extent of tissue damage. Sold wounded on the Anzio beachhead demanded far less ... medication than a less seriously injured group of ... patients at Massachusetts General Hospital.
While there is evidence that the use of ... influences the sensation of pain itself,26 it seems ... help patients manage the reactive component ... pain. Some have speculated that the mechanism by ... hypnotic analgesia works involves the phenomof hypnotic amnesia; in essence, the patient forgets member the painful experience.26 Others postulate the phenomenon is related to the intensity of focal ... in the hypnotic trance.21'27 Hypnosis can be ... as aroused attentive focal concentration with ... constriction of peripheral awareness. By ... on an alternative sensation or metaphor, the ... individual relegates the painful stimuli to the ... of attention.
... has been reported to be of help in a variety of ... pain situations, including obstetrics,28'30 can... surgery,35'36dentistry,"" and migraine headaches.38 ... acute and chronic types of pain have been ... treated using hypnosis. What is most useful ... the application of this tool is that recent ... emphasize teaching patients self-hypnosis ... than insisting on repeated sessions with a therapist, has the dual virtue of giving a patient a greater sense ... over the painful experience and making ... use of the therapist's time. The artificial sense of ... on a therapist using hypnosis, which was ... by older authoritarian approaches, can be more or dispensed with.
... a wide variety of approaches exist and patients ... discover by themselves which are the most effective ... metaphors to use in controlling pain, some ... are available. First of all, it is useful to question patient about what physical remedy provides the most relief. Some patients find that warmth provides ... others, icy numbness. Some can easily sense a ... sensation; others find the image of dental ... most vivid.
is no accident that many of the most effective ... metaphors for controlling pain involve altera... in temperature sensation, since pain and temperafibers run together in the periphery and through the ... spinothalamic tract. Highly hypnotizable individare often capable of making the affected part of the ... numb. It is sometimes helpful to suggest a sensation ... in a more neutral part of the body first, such ... hand and arm, and have the patient transfer this ... of numbness to the painful area. This alteration ... is reinforced by emphasizing to the patient he or she is learning to filter Uae hurt out of the pain, her than telling the patient not to feel pain one teaches them to develop a psychological filter through which they experience the pain.
This filter transforms the experience. Mid-range subjects often find temperature alterations helpful, imagining themselves floating in ice water or in a warm bath. One patient undergoing a thoracotomy utilizing hypnosis as the sole anesthesia because of his severely compromised respiratory status reported that he had been "distracted by the penguins in the operating room." Initially the surgical team became worried that the patient had had a psychotic episode, but the patient explained that in order to reinforce the vividness of the sense of icycold numbness in his chest, he had imagined himself floating in the antarctic and had pictured penguins walking around on the ice floes. Hypnosis has been defined as believed-in imagination.39 The vividness with which this patient experienced the visual metaphor is a good illustration of this. He was so intensely absorbed in this ice-water image that the pain was relegated to the periphery of his attention. In fact," he asked the surgeon why he had made a pencil line on his chest before starting the operation. What the patient perceived as a pencil line was in fact the incision being made with the scalpel.
Less hypnotizable subjects often find distraction techniques of more use. They can focus on sensations in another part of their body, such as the delicate sensations in their fingertips while rubbing them together. Also, for such patients with chronic pain, it sometimes helps to use an actual physical stimulus to augment the psychological one. Such patients may use a heating pad or an ice pack to reinforce the hypnotic sensation of warmth or cold.
An important part of this hypnotic pain experience is the sense of mastery which it imparts to patients. They have a sense of something to resort to when they experience pain, rather than being helpless victims of it.
These strategies suggested are but a small sample of the available means of employing hypnotic dissociation in the restructuring of the pain experience. One patient with chronic and severe lower back pain employed an image of a spigot at his knee. When he opened the spigot he felt the pain flowing out of his leg as though it were a black viscous substance. The image was so vivid for him that he became concerned that he had left a mess on the therapist's carpet. A female patient with lower back pain found that she could easily develop a sense of tingling in her back, which helped her combat the chronic muscle tension that aggravated her pain. She discovered that daily activity that previously would have left her bedridden was enjoyable and exhilarating rather than demoralizing.
Some individuals are clearly not responsive to this kind of treatment, and it is wise to advise patients taking analgesics to use the self-hypnosis first and then employ medication as a backup. This is particularly important since most analgesic medications are sedating and sedation hampers hypnotic concentration. Therefore, they are more likely to succeed when they are not suffering from sedative side effects of analgesic drugs.
There has been speculation that hypnotic analgesia is mediated by the endorphin system,40 and this is certainly plausible. It would make sense that hypnotic analgesia might work via a release of endorphins. The analogy between hypnotic analgesia, selectively helping patients filter out the pain, and opiate analgesia, which likewise seems to help patients ignore painful stimuli, is sufficiently obvious that such a mechanism would make sense. However, several studies have demonstrated no naloxone reversal of hypnotic analgesia, either in laboratory pain41,42 or in chronic clinical pain.43
Hypnosis has been demonstrated to be an effective adjunctive tool in the psychological management of a variety of psychosomatic problems. It is useful when the patient is hypnotizable and motivated toward ... when secondary gain is not a major obstacle, regardless of the level of insight the patient has ... problem. It is often less important to find out ... patient has a psychosomatic symptom than to ... rehabilitation model.
The experience of hypnosis, with its often ... demonstration of the patient's ability to alter ... sensory and motor function, can be used to ... patient how to alter physical sensation and ... Then curiosity sometimes leads to greater insight, ceremony of hypnosis often provides a face-saving from an impasse in which improvement had meant ... patient admitting having caused the symptom in ... place. By utilizing the hypnotic mode, the patient ... new approach to the problem, which makes the ... failure to control it acceptable. Thus, the ... concentration, the varied somatosensory alterations the social ceremony surrounding hypnosis in a ... setting all contribute to its usefulness in treating a variety of psychosomatic conditions.
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