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Hypnosis and the relaxation response
GASTROENTEROLOGY
1989:96:1609-11
EDITORIAL
Hypnosis and the Relaxation Response In this issue of GASTROENTEROLOGY Klein and Spiegel (I] have demonstrated clearly that gastric acid secretion can be stimulated and inhibited by hypnosis in highly hypnotizable healthy volunteers. Their contribution leads to the question: how do their findings fit into the context of other physiologic research related to altered states of consciousness? For more than two decades there has been growing interest in nonpharmacologic, self-induced altered states of consciousness because of their alleged benefits of better mental and physical health. The physiologic changes of one such altered state of consciousness, the relaxation response, has been documented (2,3). Despite their apparent diversity, techniques such as hypnosis, progressive relaxation, autogenic training, yoga, and meditation, and those of religious practices that include meditative prayer, all share the common underlying set of physiologic changes that comprise the relaxation response. The physiologic changes of the relaxation response are consistent with generalized decreased sympathetic nervous system activity. Uniform and significant decreases have been observed in oxygen consumption and carbon dioxide elimination with no change in respiratory quotient. In addition, there is a sirnultaneous lowering of blood pressure and heart and respiratory rates and a marked decrease in arterial blood lactate concentration. The electroencephalogram shows increased a-wave and O-wave activity. These acute physiologic changes of the relaxation response are distinctly different from those observed during quiet sitting or sleep and characterize a wakeful hypometabolic state. They are consistent with decreased sympathetic nervous system activity. Longer lasting changes in sympathetic nervous system reactivity were assessed in experimental and control subjects who were exposed to graded orthostatic and isometric stress during monthly hospital visits (4). Between visits, experimental subjects practiced a technique that elicited the relaxation response, whereas the control subjects sat quietly for an equivalent time. Heart rate and blood pressure reactions to the graded stresses did not differ between visits in either group. However, in the experimental group, the levels of plasma norepinephrine corresponding to the graded stresses were signifi-
cantly augmented after elicitation of the relaxation response. No changes in plasma norepinephrine levels were noted in the control group. After completion of this phase, these results were then replicated in the control group in a cross-over experiment. That is, heart rate and blood pressure responses were unchanged, but plasma norepinephrine levels were significantly higher after this group had crossed over to the elicitation of the relaxation responses. Hence, the repeated elicitation of the response resulted in increased plasma norepinephrine levels that were not reflected in increased heart rate or blood pressure responses. These observations are consistent with the notion of reduced norepinephrine end-organ responsivity. An important feature of these changes in sympathetic reactivity is the fact that they last longer than the actual period during which the mental relaxation-response exercise was performed. Physiologic changes similar to those constituting the relaxation response were initially termed the by Hess (5), who was “trophotropic response” awarded the Nobel Prize for his work. He electrically stimulated anterior hypothalamic areas of the cat brain and induced physiologic changes similar to those later noted during the elicitation of the relaxation response in humans. These physiologic changes are opposite to those of the reaction originally described by Cannon in 1914, which he termed the “emergency reaction”-popularly called the fight-or-flight response or the stress response. The physiology of the emergency reaction consists of generalized increased sympathetic nervous system activity and includes increased catecholamine production with associated increases in blood pressure, heart and respiratory rate, and skeletal muscle blood flow (6,7). During the practice of Zen, yoga, and transcendental meditation the physiologic changes of the relaxation response occur (3). There is decreased oxygen consumption, respiratory rate, and heart rate. There are increases in skin resistance and increased production of a-waves. Furthermore, hypnosis, autogenit training, and progressive relaxation elicit similar physiologic changes. Hypnosis (8),an artificially induced state, is characterized by increased suggestibility. A subject is
1610
EDITORIAL
judged to be in the hypnotic state if he or she manifests a high level of response to test suggestions such as muscle rigidity, amnesia, hallucination, anesthesia, and posthypnotic suggestion, which are tested by standard scales. The hypnotic-induction procedure usually includes suggestion (autosuggestion for self-hypnosis] of relaxation and drowsiness, closed eyes, and a recumbent or semisupine position. Procedures for self- and hetero-hypnotic induction and for the elicitation of the relaxation response appear to be similar. Furthermore, before hypnotic phenomena are experienced either during traditional or active induction, there is a physiologic state comparable to the relaxation response. It is characterized, in part, by decreased heart rate, respiratory rate, and blood pressure. There is also increased a-waves in the electroencephalogram. After the physiologic changes of the relaxation response occur, the individual proceeds to experience other which include those sughypnotic phenomena, gested by the hypnotist. Perceptual distortions, age regression, posthypnotic suggestion, and amnesia may also be suggested. In the report of Klein and Spiegel (l),the suggestion was of a delicious meal. Autogenic training is a technique of medical therapy that is said to elicit the trophotropic response of Hess (8). The technique is defined as “. . . a selfinduced modification of corticodiencephalic interrelationships” which enables the lower brain centers to activate “trophotropic activity.” There are six “Standard Exercises.” Exercise 1 focuses on feelings of heaviness in the limbs; 2 on cultivation of a sense of warmth in the limbs; 3 on cardiac regulation; 4 on passive concentration on breathing; 5 on warmth of the upper abdomen; and 6 on coolness in the forehead. The subject’s attitude toward the exercises must not be intense and compulsive, but rather of a quiet-let it happen-nature, which is referred to as passive concentration and deemed absolutely essential. During the practice of autogenic training, the physiologic changes of the relaxation response occur. There is decreased respiratory rate, heart rate, and muscle tension, with an increase in skin resistance and production of a-waves. Progressive relaxation (8)is a technique that seeks to achieve increased control over skeletal muscles until a subject is able to induce very low levels of tonus in the major muscle groups. It is practiced in the supine position in a quiet room; a passive attitude is essential because mental images induce slight, measurable tensions in muscles, especially those of the eyes and face. The subject is taught to recognize even slight muscle contractions so that he or she can avoid them. At times when progressive relaxation is being practiced, changes similar to those of the relaxation response take place. Oxygen
GASTROENTEROLOGY
Vol. 96, No. 6
consumption, heart rate, and electromyographic changes voltages all decrease. These physiologic occurring during the practice of progressive relaxation are indistinguishable from those occurring during the use of a simple meditative technique that elicits the relaxation response. The elicitation of the relaxation response is achieved by adherence to mental instructions that include the repetition of a word, sound, prayer, phrase, or muscular action and the passive disregard of everyday thoughts when they occur and return to the repetition (4). One simple set of instructions is as follows (9): Pick a focus word or short phrase that is firmly rooted in your personal belief system. For example, a Christian person might choose the opening words of Psalm 23, “The Lord is my shepherd”; a Jewish person, “Shalom”; a nonreligious individual, a neutral word like “one” or “peace.” Sit quietly in a comfortable position. Close your eyes. Relax your muscles. Breathe slowly and naturally, and as you do, repeat your focus word or phrase as you exhale. Assume a passive attitude. Don’t worry about how well you’re doing. When other thoughts come to mind, simply say to yourself, “Oh, well,” and gently return to the repetition. Continue for lo-20 min. Practice the technique once or twice daily. The relaxation response should not be confused with the state of simple relaxing. The relaxation response is brought about by adherence to specific instructions whose most important elements include the repetition of a sound, word, phrase, thought, or prayer and the adoption of a passive attitude. In addition to these defined physiologic changes that are part of the relaxation response, there is another property that is not as well understood. A change in mental perception occurs after the elicitation of the relaxation response that is characterized by increased suggestibility. This property is clearly utilized in hypnosis with its suggested mental imagery or other mentally suggested instructions. Now Klein and Spiegel have shown that the suggestion of eating and experiencing a most delicious meal increases gastric acid secretion whereas the suggestion of deep relaxation, with no suggested feelings of hunger, decreases gastric acid output. Their findings should encourage the exploration of other gastroenterological alterations that occur during other suggested mental states. Furthermore, Walker et al. (10)have recently proposed that emo-
EDITORIAL
1611
of the diencephalon.
New
June 1989
tional stress is one component predisposing to ulcers by the production of gastric hypersecretion. Thus, in patients with peptic ulcer disease, it is logical to pursue the exploration of the therapeutic use of the relaxation response and its related states.
5. Hess WR. Functional organization York: Grune 8r Stratton, 1957. 6. Abrahams VC, Hilton SM, Zbrozna dilatation produced by stimulation iol (London) 1960;154:491-513. 7. Cannon WB. Bodily changes New York: Appleton,
HERBERT BENSON, M.D. lVew England Deaconess
Hospital
Harvard Medical School A4indlBody Medical Institute Boston, Massachusetts
Keferences Klein KB, Spiegel D. Modulation of gastric acid secretion by hypnosis. Gastroenterology 1989;96:1383-7. Wallace RK, Benson H, Wilson AF. A wakeful hypometabolic physiologic state. Am J Physiol 1971;221:795-9. Benson H. Beary JF, Carol MD. The relaxation response. Psychiatry 1974;37:37-46. Hoffman JW, Benson H, Arns PA, et al. Reduced sympathetic nervlous system activity associated with the relaxation response. Science 1982;215:190-2.
AW. Active of the brain
in pain,
hunger,
muscle vasostem. J Physfear and rage.
1929.
8. Significant portions of this discussion have been taken from Benson H. The relaxation response: its subjective and objective historical precedents and physiology. Trends Neurosci 1983;6:281-4. Complete references appear in this citation. 9. Benson H. Your maximum mind. New York:Times Books of New York, 1987. 10. Walker P, Luther J. Samloff M, Vieldman M. Life events stress and psychosocial factors in men with peptic ulcer disease. II. Relationships with serum pepsinogen concentration and behavioral risk factors. Gastroenterology 1988;94:323-30.
Address request for reprints to: Herbert Benson, M.D., Section on Behavioral Medicine, New England Deaconess Hospital, 185 Pilgrim Road, Boston, Massachusetts 02215. ‘G 1989 by the American Gastroenterological Association
1989:96:1609-11
EDITORIAL
Hypnosis and the Relaxation Response In this issue of GASTROENTEROLOGY Klein and Spiegel (I] have demonstrated clearly that gastric acid secretion can be stimulated and inhibited by hypnosis in highly hypnotizable healthy volunteers. Their contribution leads to the question: how do their findings fit into the context of other physiologic research related to altered states of consciousness? For more than two decades there has been growing interest in nonpharmacologic, self-induced altered states of consciousness because of their alleged benefits of better mental and physical health. The physiologic changes of one such altered state of consciousness, the relaxation response, has been documented (2,3). Despite their apparent diversity, techniques such as hypnosis, progressive relaxation, autogenic training, yoga, and meditation, and those of religious practices that include meditative prayer, all share the common underlying set of physiologic changes that comprise the relaxation response. The physiologic changes of the relaxation response are consistent with generalized decreased sympathetic nervous system activity. Uniform and significant decreases have been observed in oxygen consumption and carbon dioxide elimination with no change in respiratory quotient. In addition, there is a sirnultaneous lowering of blood pressure and heart and respiratory rates and a marked decrease in arterial blood lactate concentration. The electroencephalogram shows increased a-wave and O-wave activity. These acute physiologic changes of the relaxation response are distinctly different from those observed during quiet sitting or sleep and characterize a wakeful hypometabolic state. They are consistent with decreased sympathetic nervous system activity. Longer lasting changes in sympathetic nervous system reactivity were assessed in experimental and control subjects who were exposed to graded orthostatic and isometric stress during monthly hospital visits (4). Between visits, experimental subjects practiced a technique that elicited the relaxation response, whereas the control subjects sat quietly for an equivalent time. Heart rate and blood pressure reactions to the graded stresses did not differ between visits in either group. However, in the experimental group, the levels of plasma norepinephrine corresponding to the graded stresses were signifi-
cantly augmented after elicitation of the relaxation response. No changes in plasma norepinephrine levels were noted in the control group. After completion of this phase, these results were then replicated in the control group in a cross-over experiment. That is, heart rate and blood pressure responses were unchanged, but plasma norepinephrine levels were significantly higher after this group had crossed over to the elicitation of the relaxation responses. Hence, the repeated elicitation of the response resulted in increased plasma norepinephrine levels that were not reflected in increased heart rate or blood pressure responses. These observations are consistent with the notion of reduced norepinephrine end-organ responsivity. An important feature of these changes in sympathetic reactivity is the fact that they last longer than the actual period during which the mental relaxation-response exercise was performed. Physiologic changes similar to those constituting the relaxation response were initially termed the by Hess (5), who was “trophotropic response” awarded the Nobel Prize for his work. He electrically stimulated anterior hypothalamic areas of the cat brain and induced physiologic changes similar to those later noted during the elicitation of the relaxation response in humans. These physiologic changes are opposite to those of the reaction originally described by Cannon in 1914, which he termed the “emergency reaction”-popularly called the fight-or-flight response or the stress response. The physiology of the emergency reaction consists of generalized increased sympathetic nervous system activity and includes increased catecholamine production with associated increases in blood pressure, heart and respiratory rate, and skeletal muscle blood flow (6,7). During the practice of Zen, yoga, and transcendental meditation the physiologic changes of the relaxation response occur (3). There is decreased oxygen consumption, respiratory rate, and heart rate. There are increases in skin resistance and increased production of a-waves. Furthermore, hypnosis, autogenit training, and progressive relaxation elicit similar physiologic changes. Hypnosis (8),an artificially induced state, is characterized by increased suggestibility. A subject is
1610
EDITORIAL
judged to be in the hypnotic state if he or she manifests a high level of response to test suggestions such as muscle rigidity, amnesia, hallucination, anesthesia, and posthypnotic suggestion, which are tested by standard scales. The hypnotic-induction procedure usually includes suggestion (autosuggestion for self-hypnosis] of relaxation and drowsiness, closed eyes, and a recumbent or semisupine position. Procedures for self- and hetero-hypnotic induction and for the elicitation of the relaxation response appear to be similar. Furthermore, before hypnotic phenomena are experienced either during traditional or active induction, there is a physiologic state comparable to the relaxation response. It is characterized, in part, by decreased heart rate, respiratory rate, and blood pressure. There is also increased a-waves in the electroencephalogram. After the physiologic changes of the relaxation response occur, the individual proceeds to experience other which include those sughypnotic phenomena, gested by the hypnotist. Perceptual distortions, age regression, posthypnotic suggestion, and amnesia may also be suggested. In the report of Klein and Spiegel (l),the suggestion was of a delicious meal. Autogenic training is a technique of medical therapy that is said to elicit the trophotropic response of Hess (8). The technique is defined as “. . . a selfinduced modification of corticodiencephalic interrelationships” which enables the lower brain centers to activate “trophotropic activity.” There are six “Standard Exercises.” Exercise 1 focuses on feelings of heaviness in the limbs; 2 on cultivation of a sense of warmth in the limbs; 3 on cardiac regulation; 4 on passive concentration on breathing; 5 on warmth of the upper abdomen; and 6 on coolness in the forehead. The subject’s attitude toward the exercises must not be intense and compulsive, but rather of a quiet-let it happen-nature, which is referred to as passive concentration and deemed absolutely essential. During the practice of autogenic training, the physiologic changes of the relaxation response occur. There is decreased respiratory rate, heart rate, and muscle tension, with an increase in skin resistance and production of a-waves. Progressive relaxation (8)is a technique that seeks to achieve increased control over skeletal muscles until a subject is able to induce very low levels of tonus in the major muscle groups. It is practiced in the supine position in a quiet room; a passive attitude is essential because mental images induce slight, measurable tensions in muscles, especially those of the eyes and face. The subject is taught to recognize even slight muscle contractions so that he or she can avoid them. At times when progressive relaxation is being practiced, changes similar to those of the relaxation response take place. Oxygen
GASTROENTEROLOGY
Vol. 96, No. 6
consumption, heart rate, and electromyographic changes voltages all decrease. These physiologic occurring during the practice of progressive relaxation are indistinguishable from those occurring during the use of a simple meditative technique that elicits the relaxation response. The elicitation of the relaxation response is achieved by adherence to mental instructions that include the repetition of a word, sound, prayer, phrase, or muscular action and the passive disregard of everyday thoughts when they occur and return to the repetition (4). One simple set of instructions is as follows (9): Pick a focus word or short phrase that is firmly rooted in your personal belief system. For example, a Christian person might choose the opening words of Psalm 23, “The Lord is my shepherd”; a Jewish person, “Shalom”; a nonreligious individual, a neutral word like “one” or “peace.” Sit quietly in a comfortable position. Close your eyes. Relax your muscles. Breathe slowly and naturally, and as you do, repeat your focus word or phrase as you exhale. Assume a passive attitude. Don’t worry about how well you’re doing. When other thoughts come to mind, simply say to yourself, “Oh, well,” and gently return to the repetition. Continue for lo-20 min. Practice the technique once or twice daily. The relaxation response should not be confused with the state of simple relaxing. The relaxation response is brought about by adherence to specific instructions whose most important elements include the repetition of a sound, word, phrase, thought, or prayer and the adoption of a passive attitude. In addition to these defined physiologic changes that are part of the relaxation response, there is another property that is not as well understood. A change in mental perception occurs after the elicitation of the relaxation response that is characterized by increased suggestibility. This property is clearly utilized in hypnosis with its suggested mental imagery or other mentally suggested instructions. Now Klein and Spiegel have shown that the suggestion of eating and experiencing a most delicious meal increases gastric acid secretion whereas the suggestion of deep relaxation, with no suggested feelings of hunger, decreases gastric acid output. Their findings should encourage the exploration of other gastroenterological alterations that occur during other suggested mental states. Furthermore, Walker et al. (10)have recently proposed that emo-
EDITORIAL
1611
of the diencephalon.
New
June 1989
tional stress is one component predisposing to ulcers by the production of gastric hypersecretion. Thus, in patients with peptic ulcer disease, it is logical to pursue the exploration of the therapeutic use of the relaxation response and its related states.
5. Hess WR. Functional organization York: Grune 8r Stratton, 1957. 6. Abrahams VC, Hilton SM, Zbrozna dilatation produced by stimulation iol (London) 1960;154:491-513. 7. Cannon WB. Bodily changes New York: Appleton,
HERBERT BENSON, M.D. lVew England Deaconess
Hospital
Harvard Medical School A4indlBody Medical Institute Boston, Massachusetts
Keferences Klein KB, Spiegel D. Modulation of gastric acid secretion by hypnosis. Gastroenterology 1989;96:1383-7. Wallace RK, Benson H, Wilson AF. A wakeful hypometabolic physiologic state. Am J Physiol 1971;221:795-9. Benson H. Beary JF, Carol MD. The relaxation response. Psychiatry 1974;37:37-46. Hoffman JW, Benson H, Arns PA, et al. Reduced sympathetic nervlous system activity associated with the relaxation response. Science 1982;215:190-2.
AW. Active of the brain
in pain,
hunger,
muscle vasostem. J Physfear and rage.
1929.
8. Significant portions of this discussion have been taken from Benson H. The relaxation response: its subjective and objective historical precedents and physiology. Trends Neurosci 1983;6:281-4. Complete references appear in this citation. 9. Benson H. Your maximum mind. New York:Times Books of New York, 1987. 10. Walker P, Luther J. Samloff M, Vieldman M. Life events stress and psychosocial factors in men with peptic ulcer disease. II. Relationships with serum pepsinogen concentration and behavioral risk factors. Gastroenterology 1988;94:323-30.
Address request for reprints to: Herbert Benson, M.D., Section on Behavioral Medicine, New England Deaconess Hospital, 185 Pilgrim Road, Boston, Massachusetts 02215. ‘G 1989 by the American Gastroenterological Association