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Hypnosis in psychosomatic medicine
DAVID SPIEGEL, M.D. HERBERT SPIEGEL, M.D.
Hypnosis in psychosomatic medicine ABSTRACT: In addition to its well-known therapeutic uses, hypnosis can serve as a useful diagnostic tool for clinicians. The authors outline various categories of hypnotizability and explain how these can be used in the differential diagnosis of psychosomatic conditions. Therapy for psychosomatic illness employing hypnosis is discussed in terms of anxiety relief and pain control.
Hypnosis has been murky territory even for most psychiatrists, and many physicians may well wonder of what possible use this phenomenon could be to them. After all, hypnosis was first explored by Mesmer, whose work was dismissed by a French panel of experts that included Benjamin Franklin as being produced by nothing but the imagination. I Hypnosis has often been lumped in a category with various fringe psychological home remedies, and repeated launderings in the laboratory have not fully removed the aroma of snake oil. We nonetheless contend that an
understanding of hypnotic phenomena is crucial for any welltrained clinician; that it can be helpful in differential diagnosis as well as in treatment of various psychological and psychosomatic disorders; and that some apparent diagnostic mysteries can be clearly and simply explained by reference to a patient's hypnotic capacity. A number of premises guide our work with hypnosis. First, we understand hypnosis to be a form of intense, focal concentration with diminished peripheral awarenessa state of alertness rather than sleep. It can be entered either
Dr. David Spiegel is assistant professor of psychiatry and behavioral sciences at Stanford University S~hool of Medicine. Dr. Herbert Spiegel is clinical prOfessor of psychiatry at the Columbia University College of Physicians and Surgeons. Reprint requests to Dr. Herbert Spiegel, 19 East 88th Street, New York, NY 10028. JANUARY 1980· VOL 21 • NO 1
spontaneously (spontaneous trance), with guidance from a therapist (formal hypnosis), or at the individual's own instigation (selfhypnosis). Hypnosis often occurs spontaneously without anyone's being aware of inducing or participating in a trance. Because the capacity to experience the trance state is inherent in a subject, the physician merely provides an occasion and structure to the setting for exploring the trance experience; he himself projects nothing whatever onto the patient. Dangling watches, crystal balls, and purple robes are as inappropriate to hypnosis as they are to the clinical setting. Whether or not a clinician consciously decides to "use" hypnosis, the fact is that spontaneous trance phenomena will occur in his patients. This may take the more spectacular form of the fugue state, in which a patient suddenly changes behavior and experiences a period of activity of which he later has no conscious memory. This pattern encompasses the so-called multiple personality, that state in which a patient dissociates parts of 35
Hypnosis
his own psyche and has limited memory of his experiences when other parts of self seem to dominate. Other examples are hysterical conversion symptoms such as conversion paralysis or glove anesthesia. Stated simply, some highly hypnotizable patients are prone to use body language rather than words to express a conflict: one patient experiences deafness rather than listening to unwanted information, while another responds to anxiety and stress with bronchoconstriction, vasoconstriction, or hyperperistalsis. The clinician's recognition of a patient's use of sllch body language can help clarify diagnosis and facilitate treatment on a psychological as well as somatic level. Functional or organic complaints? The familiar clinical adage for distinguishing between functional and organic etiology of symptoms is "rule out organicity" and, in the absence of any organic findings, turn then to a functional explanation. While there is no substitute for complete organic workups, it is both efficient and thorough to approach problems from the other direction as well, that is, to look for functional signs that either support or contradict a hypothesis of a functional etiology.2 At times, clear data about functional signs can help avoid prolonged, expensive, and intrusive examinations. Although factors such as a secondary gain from a given symptom can be misleading, they are often helpful in pointing the clinician in the right direction. A patient who is obviOusly frustrated with his symptoms and is exerting every effort to return to normal functioning is, in our experience, more likely to have an organic rather than a functional 36
symptom. On the other hand, the attitude of la belle indifference associated with hysteria in a patient who presents with an apparently disabling and disturbing physical symptom may be a clue to the astute clinician that either the patient is elaborating a minor symptom or the symptom itself is functional. Another clinical assumption with unfortunate ramifications is that if a patient's complaint of pain responds to placebo medication it is necessarily functional. Nothing could be further from the truth. One need only observe major surgery performed with hypnosis as the sole anesthesia to understand that a patient with real organic pain can dissociate and learn to ignore it, utilizing hypnotic techniques instigated by a physician administering a placebo treatment. Highly hypnotizable individuals are quite capable of modifying or eliminating perception of painful stimuli. Often, in fact, the use of hypnosis to treat pain is least effective in those patients whose pain is functional in origin. In these cases the secondary gain factors are greater and the patient's motivation to overcome the pain is correspondingly less. Hypnotizability as a diagnostic probe We have developed a systematic assessment of hypnotizability, the Hypnotic Induction Profile,3 as a diagnostic probe in our practice. It has provided useful information regarding psychiatric diagnosis and the likelihood of organic as opposed to functional disease. The test itself takes five to ten minutes and provides data relating the patient's score on the eye-roll sign-a novel measure of presumed biologic capacity to experience hypnosis-with more traditional be-
havioral performances, such as hand levitation and a sense of differential control in the levitated hand. It is presumed that in a statistical sense a normal population shows a higher correlation between the eye-roll measure and the behavioral measures than does a patient population beset with psychiatric and neurologic disease; this presumption has been supported by research data.· According to this test, there are two categories of low hypnotizability. One is within the realm of normal variation, in which the patient has a zero eye-roll and a correspondingly low performance on the test. The other type of low hypnotizability is seen in the patient who may have a low, mid-range, or high eye-roll but whose performance does not equal this biologic expectation. Presumably, the patient's disorder of thought, personality, or affect, or his neurologic impairment interferes with his ability to concentrate. and thus with the expression of his basic hypnotic capacity. The profile of this second low-hypnotizability type of patient is called non-intact; such profiles have been associated with severe psychopathology. Patterns of hypnotizability relate to the differential diagnosis of psychosomatic disease as follows: • The person with intact but low hypnotizability, that is, whose eyeroll is low and whose performance is low, is presumed to be undramatic and objective about reporting physical sym ptoms. He does not tend to elaborate on symptoms or use them for communicative purposes. We take the physical complaints of this type of patient the most seriously from an organic point of view. (continued) PSYCHOSOMATICS
Hypnosis
• A high score on the Hypnotic Induction Profile sets us on a search for the symbolic significance of the symptom or for environmental cues that lead to the expression of a symptom. A patient who is highly hypnotizable is, in our experience, more likely to express psychological conflict in metaphorical physical terms. Case 1 A woman who proved to be highly hypnotizable was being treated for anxiety and accompanying elevated ocular pressure which complicated her case of pigmentary glaucoma. Her physician had casually mentioned to her that hearing loss often accompanies this illness. Shortly thereafter, she noted that her hearing began to deteriorate. When the patient was in a trance, it was suggested to her that as an experiment she would suddenly note her hearing would be very poor until a signal was given; then it would return to normal. When the patient came out of the trance, her hearing did not disappear, but she noted that the voices in the room at first sounded more distant to her and then suddenly became normal when the cutoff signal was given. She was able to recognize that she had accepted her physician's casual comment as a prediction of hearing loss. She was also able to connect the hearing loss with a recent visit to her sister who had "told me some things I didn't want to hear-that I had no right to be happy." This patient went on to report that she often used somatic sensations to express feelings. She had, in fact, used self-hypnotic techniques to control her pruritus, which was a common and chronic problem for her. She noted that almost as soon as the itching ceased she began to feel quite angry and she identified what had made her angry and had it out with the person involved. She had translated her psychological discomfort into a physical one and subsequently re-
versed the process and dealt with the interpersonal problem.
This is not to say that highly hypnotizable individuals do not suffer real somatic problems, even some that appear to be functional complaints, as in the following case. Case 2 Another highly hypnotizable patient who had been in a profound traumatic depression related to loss during combat experience suddenly noted a deterioration of his hearing which interfered with his efforts to continue his education. The patient was quite concerned about this and was worried that he would lose his hearing completely. He asked, "Is it possible that this is a psychological problem that is expressing itself in this way?" The absence of any obvious secondary gain plus the patient's own question regarding the possibility that this was a functional disorder led us to suspect an organic problem. Before long, his obstructive middle ear disease was surgically corrected and his hearing dramatically improved.
• The third group in our differential diagnosis based on hypnotizability consists of those patients with non-intact profiles, discussed earlier. In view of the association between this pattern of performance and more serious psychiatric disturbance, we are inclined to interpret physical complaints from patients in this group in the light of their probable psychopathology as possible somatic delusions. Of course, organicity remains a possibility also. At times, also, the assessment of hypnotizability can lead to the diagnosis of a psychiatric illness that is presenting with unusual somatic complaints. One of the more common examples is depression expressed as physical pain.
Case 3 A middle-aged auto-body repairman complained of diffuse muscle pain and fatigue severe enough to hamper his efforts to work. He had a good work history and denied any emotional problems, although he conceded that his relationships with women were somewhat unstable and problematic. He seemed genuinely distressed by the limitations on his capacity to work. He was evaluated with the Hypnotic Induction Profile with the goal of using hypnosis to overcome his pain and fatigue. As it turned out, however, his pattern of performance on the test revealed little usable hypnotizability but was consistent with the hypothesis that he might be more seriously depressed than he appeared and that his depression was interfering with his ability to concentrate, therefore hampering his hypnotizability. Further questioning revealed that his sleep was mildly disturbed and his appetite somewhat diminished. He was placed on a tricyclic antidepressant. Almost exactly three weeks after the medication was administered, he noted his pain and fatigue lessening and his spirits improving. The problem was resolved, but not before he had undergone an extensive medical workup that included ruling out pitUitary dysfunction and myasthenia gravis. In this case, the patient's depression presented as somatic pain with fatigue, and the problem was resolved by treating the depression. The test for hypnotizability served to help clarify both the diagnosis and the treatment choice.
Hypnotizability can thus provide an additional clue from a psychiatric point of view regarding the likelihood of a particular symptom's having a conversion or functional basis as opposed to an organic one. It does not provide an absolute answer, of course, but can assIst the diagnostician's thinking in terms of probabilities. (continued)
JANUARY 1980· VOL 21 • NO 1
39
Hypnosis Treatment of psychosomatic conditions The guiding principle in using hypnosis for a variety of psychosomatic complaints is the treatment of anxiety.s Hypnosis can help a patient restructure his relationship to his body, and the natural dissociation of the trance state can assist the clinician in separating somatic from psychological distress. J A wide variety of disorders exists that are either primarily caused or at least worsened by psychological stress. These range from pure hysterical seizures, for example, to such disorders as asthma, ulcerative colitis, and hypertension. Regardless of one's theory about the relative importance of psychological factors in the etiology or exacerbation of such illnesses, teaching a patient a means to control anxiety is usually beneficial, even if the anxiety occurs only in response to a physical insult. In our use of hypnosis we emphasize these aspects: the assessment of hypnotizability, teaching the patient self-hypnosis, and teaching the patient to use hypnosis to restructure his approach to the problem. Often treatment can be accomplished in one session using this educational model because the patient learns to employ the hypnotic restructuring on his own. The basic technique for anxiety containment is to teach a patient to put himself in the trance state. The instructions we use are simple. "One, you will do one thing: look up. Two, do two things: slowly close your eyes and take a deep breath. Three, do three things: let your breath out, let your eyes relax as you keep them closed, and let your body float. Then with y'our body 'floating,' concentrate on developing a sense oflightness in one hand 40
or the other and let it float into the upright position." Once a patient has put himself in this state of self-hypnosis, he is instructed to maintain the physical sensation of floating while at the same time visualizing various situations on an imaginary screen. It often helps to make the first visualization something pleasant so there is a natural association between the physical sensation of floating relaxation and the visualized image. Then, the patient is encouraged to use the screen to picture problems that need resolution, difficult interpersonal encounters, or work that needs attention-all the while maintaining the physical sensation of floating. Should the patient become physically tense, he is encouraged to stop visualizing problems and to reestablish the floating feeling. Gradually, patients learn that their somatic expressions of anxiety such as tachycardia, diaphoresis, and tense musculature need not accompany an anxietyprovoking situation. Indeed, they discover they can think through their response to the problem much better in this trance state of physical relaxation with intense concentration. This also gives the patient a sense of something to resort to when under stress. As the patient learns to put himself in a trance, he and the therapist can explore what the symptom communicates. Case 4 A 59-year-old woman with metastatic
carcinoma of the lung found herself unable to swallow food. She proved to be moderately hypnotizable and used the trance state to relax while concentrating on her psychological problems on the imaginary screen. She came to realize that she was employing a metaphor that had become so-
matico She was really telling herself that she could not "swallow" the idea of having cancer and also could not "swallow" the recent deaths of several friends due to cancer. When she recognized this. she found it much easier to eat and gained four pounds during the following week. The trance state also provides a helpful technique for using the patient's imagination as a way of reinforcing any physical remedies that are helpful. For instance, some asthmatic patients who obtain relief from their attacks by breathing cool fresh air can put themselves into a trance state and imagine that they are outside breathing such fresh air; this helps them abort an attack. Other asthmatic patients have learned to resort to a simple self-hypnosis exercise, thereby allowing each breath to be a little deeper, a little easier, and picturing themselves in an environment where they find breathing naturally more pleasurable. These patients inhale bronchodilators less and less often and report a new sense of mastery over their illness. One such patient subsequently undertook formal training to become a respi-. ratory therapist. It is not clear whether the psychological relief elicited with hypnosis is reflected in any objective physical changes,6.7 that is, whether there is actual physical as well as psychological improvement. I ' 13 However, a number of studies and case reports indicate that there is considerable improvement in functioning in patients with such clearly psychosomatic illnesses as asthma,l4.16 I Further, there is evidence that hypnotized patients can alter blood flow in the extremities, as measured by sk.in temperature l7.11 and by hemostasis,, 9 •20 These physical PSYCHOSOMATICS
changes lend added credence to the usefulness of hypnosis in dealing with psychosomatic problems. Of course, the extensive psychological and perceptual changes that have been demonstrated in relation to hypnosis are well known and provide opportunities for relief of subjective distress. 21 For whatever reason, a variety of stress- and anxiety-related psychosomatic illnesses can be at least alleviated by teaching patients selfhypnosis. By utilizing the concept of choice, a patient has something positive to resort to under stress, a learned technique to restructure his understanding and relationship to his body instead of fighting the symptoms.
sensation spread. Subjects whose hypnotizability falls in a mid-range often do best with instructions to concentrate on the sensation of warmth or cold. Less hypnotizable individuals may find it more useful to combine such a concentration exercise with the actual application of warmth or cold. They may also find distraction techniques more useful, in which they discipline themselves to focus on an alternative sensation. Hypnotic numbness is presented to these patients as a filter that can "remove the hurt from the pain." The physician acknowledges the existence of the pain, but distinguishes it from the suffering it inflicts. Summary
Hypnosis for pain control Using hypnosis for pain control for some patients is one of the least debated issues in the field. Ever since Esdaile's dramatic descriptions in 1846 of surgical anesthesia with hypnosis in India,22 reports of the effectiveness of hypnosis in treating both acute and chronic pain have abounded. 24,25 Yet, despite the effectiveness of hypnosis for pain control, it is not well recognized. In fact, the pain-relieving effects reported for acupuncture were considered unrelated to hypnosis until recent studies demonstrated that response to acupuncture among pain patients is positively correlated with hypnotizability26 and is not related to needle specificity,27 Trance state dissociation can be employed in a variety of ways, depending on the hypnotizability of the patient. Highly hypnotizable individuals are capable of producing numbness in the affected body part, sometimes by reliving dental anesthesia and having the numb JANUARY 1980· VOL 21' NO 1
Hypnosis is a useful diagnostic and therapeutic adjunct and it should be removed from the realm of mysticism and mistrust in which it is commonly viewed, The assessment of hypnotizability proves useful in the difficult differential diagnosis of functional from organic disease. Moreover, the trance state is a naturally occurring intense form of concentration accompanied by a pleasant sense of physical relaxation, and provides a useful means of approaching psychosomatic problems. Taught appropriate restructuring strategies, a patient can learn to make maximal use of whatever trance state he is capable of to dissociate psychological stress from somatic response. 0
REFERENCES 1. Ellenberger HF: Discovery of the Unconscious: The History and Evolution of Dynamic PSYChiatry. New York, Basic Books, 1970. 2. Olin BO: Treatment of psychosomatic illness. Psychosomatics 19.585-586,1973. 3. Spiegel H, Spiegel 0: Trance and Treatment: Clinical Uses of Hypnosis. New York, Basic Books, 1978.
4. Spiegel H, Flelss JS, Bridger AA, et al: Hypnotizability and mental health, in Arieti S (ed)'
New Dimensions m Psychiatry. A World View. New York, John Wiley & Sons, 1975.
5. Frankel FH: Hypnosis as a treatment method in psychosomatic medicine. Int J Psychiatry
Med 6:75-85, 1975. 6. Smith JM, Burns CL: The treatment of asthmatic children by hypnotic suggestion. Br J Dis Chest 54: 78-81, 1960. 7. White HC: Hypnosis in bronchial asthma. J Psychosom Res 5.272-279,1961. 8. Brown EA: The treatment of asthma by means of hypnOSIs as viewed by the allergist. J Asthma Res 3:101-110,1965. 9. Kelly E, Zeller B: Asthma and the psychiatrist. J Psychosom Res 13:377-395,1969. 10. Edwards G: Hypnotic treatment of asthma: Real and illusory results. Br Moo J 2:492-497, 1960. 11. Edwards G: Hypnotic treatment of asthma, in Eysenck HJ (ed): Experiments in Behavior Tf>erapy. Oxford, Pergamon Press, 1964. 12. McLean AF: HypnOSIS in 'psychosomatic' illness. Br J Med Psycho/33 211-230, 1965. 13. Moorefield CW: The use of hypnosis and behavior therapy In asthma. Am J Clin Hypn 13:162-168, 1971. 14. Maher-Loughnan GP: Hypnosis and autohypnosis for the treatment of asthma. Int J Clin Exp Hypn 18.1-14, 1970. 15. Collison DR: Hypnotherapy in the management of asthma. Am J Clin Hypn 11.6-11, 1968. 16. Collison DA: Which asthmatic patients should be treated by hypnotherapy? Med J Aust 1.766-781,1975. 17, Maslach C, Marshall G, and Zimbardo PH: Hypnotic control of peripheral skin temperature: A case report. Psychophysiology 6 600-605, 1972. 18. Grabowska GJ: The effect of hypnosis and hypnotic suggestion on the blood flow In the extremities Polish Med J 10' t 044-1 051, 1971, 19. Dubin LL, Shapiro SS: Use of hypnosis to facilitate dental extraction and hemostasis In a classic hemophiliac with a high antibody titer to factor VIII. Am J Clin Hypn 17:79-83, 1974. 20. Newman M. Hypnotic handling of the chroniC bleeder in extraction: A case report. Am J.
Clin Hypn 13.126-127,1971. 21. Erickson MH: Hypnotic investigation of psychosomatic phenomena. Psychosom Mad 5.51-58,1943. 22. Esdaile J: Hypnosis in Medicine and Surgery (1846 reprint). New York, Julian Press, 1957, 23. Sacerdote P: Additional contributions to the hypnotherapy of the advanced cancer patient. Am J Clm Hypn 7:308-319, 1965, 24. Sacerdote P: Theory and practice of pain control in malignancy and other protracted or recurring painful illnesses. Int J Clin Exp Hypn 18: 160-180, 1970. 25. Hilgard EA, Hilgard JA: Hypnosis in the Relief of Pain. Los Altos, California, William Kaufman, Inc, 1975. 26. Katz AL, Kao CY, Spiegel H, et al: Acupuncture and hypnosis. Adv Neurol 4.819-825, 1974. 27. Kepes EA, Chen M, SChapira M: A critical evaluation of acupuncture in lhe treatment of pain. Adv in Pam Res Ther 1:817-822,1976.
41
Hypnosis in psychosomatic medicine ABSTRACT: In addition to its well-known therapeutic uses, hypnosis can serve as a useful diagnostic tool for clinicians. The authors outline various categories of hypnotizability and explain how these can be used in the differential diagnosis of psychosomatic conditions. Therapy for psychosomatic illness employing hypnosis is discussed in terms of anxiety relief and pain control.
Hypnosis has been murky territory even for most psychiatrists, and many physicians may well wonder of what possible use this phenomenon could be to them. After all, hypnosis was first explored by Mesmer, whose work was dismissed by a French panel of experts that included Benjamin Franklin as being produced by nothing but the imagination. I Hypnosis has often been lumped in a category with various fringe psychological home remedies, and repeated launderings in the laboratory have not fully removed the aroma of snake oil. We nonetheless contend that an
understanding of hypnotic phenomena is crucial for any welltrained clinician; that it can be helpful in differential diagnosis as well as in treatment of various psychological and psychosomatic disorders; and that some apparent diagnostic mysteries can be clearly and simply explained by reference to a patient's hypnotic capacity. A number of premises guide our work with hypnosis. First, we understand hypnosis to be a form of intense, focal concentration with diminished peripheral awarenessa state of alertness rather than sleep. It can be entered either
Dr. David Spiegel is assistant professor of psychiatry and behavioral sciences at Stanford University S~hool of Medicine. Dr. Herbert Spiegel is clinical prOfessor of psychiatry at the Columbia University College of Physicians and Surgeons. Reprint requests to Dr. Herbert Spiegel, 19 East 88th Street, New York, NY 10028. JANUARY 1980· VOL 21 • NO 1
spontaneously (spontaneous trance), with guidance from a therapist (formal hypnosis), or at the individual's own instigation (selfhypnosis). Hypnosis often occurs spontaneously without anyone's being aware of inducing or participating in a trance. Because the capacity to experience the trance state is inherent in a subject, the physician merely provides an occasion and structure to the setting for exploring the trance experience; he himself projects nothing whatever onto the patient. Dangling watches, crystal balls, and purple robes are as inappropriate to hypnosis as they are to the clinical setting. Whether or not a clinician consciously decides to "use" hypnosis, the fact is that spontaneous trance phenomena will occur in his patients. This may take the more spectacular form of the fugue state, in which a patient suddenly changes behavior and experiences a period of activity of which he later has no conscious memory. This pattern encompasses the so-called multiple personality, that state in which a patient dissociates parts of 35
Hypnosis
his own psyche and has limited memory of his experiences when other parts of self seem to dominate. Other examples are hysterical conversion symptoms such as conversion paralysis or glove anesthesia. Stated simply, some highly hypnotizable patients are prone to use body language rather than words to express a conflict: one patient experiences deafness rather than listening to unwanted information, while another responds to anxiety and stress with bronchoconstriction, vasoconstriction, or hyperperistalsis. The clinician's recognition of a patient's use of sllch body language can help clarify diagnosis and facilitate treatment on a psychological as well as somatic level. Functional or organic complaints? The familiar clinical adage for distinguishing between functional and organic etiology of symptoms is "rule out organicity" and, in the absence of any organic findings, turn then to a functional explanation. While there is no substitute for complete organic workups, it is both efficient and thorough to approach problems from the other direction as well, that is, to look for functional signs that either support or contradict a hypothesis of a functional etiology.2 At times, clear data about functional signs can help avoid prolonged, expensive, and intrusive examinations. Although factors such as a secondary gain from a given symptom can be misleading, they are often helpful in pointing the clinician in the right direction. A patient who is obviOusly frustrated with his symptoms and is exerting every effort to return to normal functioning is, in our experience, more likely to have an organic rather than a functional 36
symptom. On the other hand, the attitude of la belle indifference associated with hysteria in a patient who presents with an apparently disabling and disturbing physical symptom may be a clue to the astute clinician that either the patient is elaborating a minor symptom or the symptom itself is functional. Another clinical assumption with unfortunate ramifications is that if a patient's complaint of pain responds to placebo medication it is necessarily functional. Nothing could be further from the truth. One need only observe major surgery performed with hypnosis as the sole anesthesia to understand that a patient with real organic pain can dissociate and learn to ignore it, utilizing hypnotic techniques instigated by a physician administering a placebo treatment. Highly hypnotizable individuals are quite capable of modifying or eliminating perception of painful stimuli. Often, in fact, the use of hypnosis to treat pain is least effective in those patients whose pain is functional in origin. In these cases the secondary gain factors are greater and the patient's motivation to overcome the pain is correspondingly less. Hypnotizability as a diagnostic probe We have developed a systematic assessment of hypnotizability, the Hypnotic Induction Profile,3 as a diagnostic probe in our practice. It has provided useful information regarding psychiatric diagnosis and the likelihood of organic as opposed to functional disease. The test itself takes five to ten minutes and provides data relating the patient's score on the eye-roll sign-a novel measure of presumed biologic capacity to experience hypnosis-with more traditional be-
havioral performances, such as hand levitation and a sense of differential control in the levitated hand. It is presumed that in a statistical sense a normal population shows a higher correlation between the eye-roll measure and the behavioral measures than does a patient population beset with psychiatric and neurologic disease; this presumption has been supported by research data.· According to this test, there are two categories of low hypnotizability. One is within the realm of normal variation, in which the patient has a zero eye-roll and a correspondingly low performance on the test. The other type of low hypnotizability is seen in the patient who may have a low, mid-range, or high eye-roll but whose performance does not equal this biologic expectation. Presumably, the patient's disorder of thought, personality, or affect, or his neurologic impairment interferes with his ability to concentrate. and thus with the expression of his basic hypnotic capacity. The profile of this second low-hypnotizability type of patient is called non-intact; such profiles have been associated with severe psychopathology. Patterns of hypnotizability relate to the differential diagnosis of psychosomatic disease as follows: • The person with intact but low hypnotizability, that is, whose eyeroll is low and whose performance is low, is presumed to be undramatic and objective about reporting physical sym ptoms. He does not tend to elaborate on symptoms or use them for communicative purposes. We take the physical complaints of this type of patient the most seriously from an organic point of view. (continued) PSYCHOSOMATICS
Hypnosis
• A high score on the Hypnotic Induction Profile sets us on a search for the symbolic significance of the symptom or for environmental cues that lead to the expression of a symptom. A patient who is highly hypnotizable is, in our experience, more likely to express psychological conflict in metaphorical physical terms. Case 1 A woman who proved to be highly hypnotizable was being treated for anxiety and accompanying elevated ocular pressure which complicated her case of pigmentary glaucoma. Her physician had casually mentioned to her that hearing loss often accompanies this illness. Shortly thereafter, she noted that her hearing began to deteriorate. When the patient was in a trance, it was suggested to her that as an experiment she would suddenly note her hearing would be very poor until a signal was given; then it would return to normal. When the patient came out of the trance, her hearing did not disappear, but she noted that the voices in the room at first sounded more distant to her and then suddenly became normal when the cutoff signal was given. She was able to recognize that she had accepted her physician's casual comment as a prediction of hearing loss. She was also able to connect the hearing loss with a recent visit to her sister who had "told me some things I didn't want to hear-that I had no right to be happy." This patient went on to report that she often used somatic sensations to express feelings. She had, in fact, used self-hypnotic techniques to control her pruritus, which was a common and chronic problem for her. She noted that almost as soon as the itching ceased she began to feel quite angry and she identified what had made her angry and had it out with the person involved. She had translated her psychological discomfort into a physical one and subsequently re-
versed the process and dealt with the interpersonal problem.
This is not to say that highly hypnotizable individuals do not suffer real somatic problems, even some that appear to be functional complaints, as in the following case. Case 2 Another highly hypnotizable patient who had been in a profound traumatic depression related to loss during combat experience suddenly noted a deterioration of his hearing which interfered with his efforts to continue his education. The patient was quite concerned about this and was worried that he would lose his hearing completely. He asked, "Is it possible that this is a psychological problem that is expressing itself in this way?" The absence of any obvious secondary gain plus the patient's own question regarding the possibility that this was a functional disorder led us to suspect an organic problem. Before long, his obstructive middle ear disease was surgically corrected and his hearing dramatically improved.
• The third group in our differential diagnosis based on hypnotizability consists of those patients with non-intact profiles, discussed earlier. In view of the association between this pattern of performance and more serious psychiatric disturbance, we are inclined to interpret physical complaints from patients in this group in the light of their probable psychopathology as possible somatic delusions. Of course, organicity remains a possibility also. At times, also, the assessment of hypnotizability can lead to the diagnosis of a psychiatric illness that is presenting with unusual somatic complaints. One of the more common examples is depression expressed as physical pain.
Case 3 A middle-aged auto-body repairman complained of diffuse muscle pain and fatigue severe enough to hamper his efforts to work. He had a good work history and denied any emotional problems, although he conceded that his relationships with women were somewhat unstable and problematic. He seemed genuinely distressed by the limitations on his capacity to work. He was evaluated with the Hypnotic Induction Profile with the goal of using hypnosis to overcome his pain and fatigue. As it turned out, however, his pattern of performance on the test revealed little usable hypnotizability but was consistent with the hypothesis that he might be more seriously depressed than he appeared and that his depression was interfering with his ability to concentrate, therefore hampering his hypnotizability. Further questioning revealed that his sleep was mildly disturbed and his appetite somewhat diminished. He was placed on a tricyclic antidepressant. Almost exactly three weeks after the medication was administered, he noted his pain and fatigue lessening and his spirits improving. The problem was resolved, but not before he had undergone an extensive medical workup that included ruling out pitUitary dysfunction and myasthenia gravis. In this case, the patient's depression presented as somatic pain with fatigue, and the problem was resolved by treating the depression. The test for hypnotizability served to help clarify both the diagnosis and the treatment choice.
Hypnotizability can thus provide an additional clue from a psychiatric point of view regarding the likelihood of a particular symptom's having a conversion or functional basis as opposed to an organic one. It does not provide an absolute answer, of course, but can assIst the diagnostician's thinking in terms of probabilities. (continued)
JANUARY 1980· VOL 21 • NO 1
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Hypnosis Treatment of psychosomatic conditions The guiding principle in using hypnosis for a variety of psychosomatic complaints is the treatment of anxiety.s Hypnosis can help a patient restructure his relationship to his body, and the natural dissociation of the trance state can assist the clinician in separating somatic from psychological distress. J A wide variety of disorders exists that are either primarily caused or at least worsened by psychological stress. These range from pure hysterical seizures, for example, to such disorders as asthma, ulcerative colitis, and hypertension. Regardless of one's theory about the relative importance of psychological factors in the etiology or exacerbation of such illnesses, teaching a patient a means to control anxiety is usually beneficial, even if the anxiety occurs only in response to a physical insult. In our use of hypnosis we emphasize these aspects: the assessment of hypnotizability, teaching the patient self-hypnosis, and teaching the patient to use hypnosis to restructure his approach to the problem. Often treatment can be accomplished in one session using this educational model because the patient learns to employ the hypnotic restructuring on his own. The basic technique for anxiety containment is to teach a patient to put himself in the trance state. The instructions we use are simple. "One, you will do one thing: look up. Two, do two things: slowly close your eyes and take a deep breath. Three, do three things: let your breath out, let your eyes relax as you keep them closed, and let your body float. Then with y'our body 'floating,' concentrate on developing a sense oflightness in one hand 40
or the other and let it float into the upright position." Once a patient has put himself in this state of self-hypnosis, he is instructed to maintain the physical sensation of floating while at the same time visualizing various situations on an imaginary screen. It often helps to make the first visualization something pleasant so there is a natural association between the physical sensation of floating relaxation and the visualized image. Then, the patient is encouraged to use the screen to picture problems that need resolution, difficult interpersonal encounters, or work that needs attention-all the while maintaining the physical sensation of floating. Should the patient become physically tense, he is encouraged to stop visualizing problems and to reestablish the floating feeling. Gradually, patients learn that their somatic expressions of anxiety such as tachycardia, diaphoresis, and tense musculature need not accompany an anxietyprovoking situation. Indeed, they discover they can think through their response to the problem much better in this trance state of physical relaxation with intense concentration. This also gives the patient a sense of something to resort to when under stress. As the patient learns to put himself in a trance, he and the therapist can explore what the symptom communicates. Case 4 A 59-year-old woman with metastatic
carcinoma of the lung found herself unable to swallow food. She proved to be moderately hypnotizable and used the trance state to relax while concentrating on her psychological problems on the imaginary screen. She came to realize that she was employing a metaphor that had become so-
matico She was really telling herself that she could not "swallow" the idea of having cancer and also could not "swallow" the recent deaths of several friends due to cancer. When she recognized this. she found it much easier to eat and gained four pounds during the following week. The trance state also provides a helpful technique for using the patient's imagination as a way of reinforcing any physical remedies that are helpful. For instance, some asthmatic patients who obtain relief from their attacks by breathing cool fresh air can put themselves into a trance state and imagine that they are outside breathing such fresh air; this helps them abort an attack. Other asthmatic patients have learned to resort to a simple self-hypnosis exercise, thereby allowing each breath to be a little deeper, a little easier, and picturing themselves in an environment where they find breathing naturally more pleasurable. These patients inhale bronchodilators less and less often and report a new sense of mastery over their illness. One such patient subsequently undertook formal training to become a respi-. ratory therapist. It is not clear whether the psychological relief elicited with hypnosis is reflected in any objective physical changes,6.7 that is, whether there is actual physical as well as psychological improvement. I ' 13 However, a number of studies and case reports indicate that there is considerable improvement in functioning in patients with such clearly psychosomatic illnesses as asthma,l4.16 I Further, there is evidence that hypnotized patients can alter blood flow in the extremities, as measured by sk.in temperature l7.11 and by hemostasis,, 9 •20 These physical PSYCHOSOMATICS
changes lend added credence to the usefulness of hypnosis in dealing with psychosomatic problems. Of course, the extensive psychological and perceptual changes that have been demonstrated in relation to hypnosis are well known and provide opportunities for relief of subjective distress. 21 For whatever reason, a variety of stress- and anxiety-related psychosomatic illnesses can be at least alleviated by teaching patients selfhypnosis. By utilizing the concept of choice, a patient has something positive to resort to under stress, a learned technique to restructure his understanding and relationship to his body instead of fighting the symptoms.
sensation spread. Subjects whose hypnotizability falls in a mid-range often do best with instructions to concentrate on the sensation of warmth or cold. Less hypnotizable individuals may find it more useful to combine such a concentration exercise with the actual application of warmth or cold. They may also find distraction techniques more useful, in which they discipline themselves to focus on an alternative sensation. Hypnotic numbness is presented to these patients as a filter that can "remove the hurt from the pain." The physician acknowledges the existence of the pain, but distinguishes it from the suffering it inflicts. Summary
Hypnosis for pain control Using hypnosis for pain control for some patients is one of the least debated issues in the field. Ever since Esdaile's dramatic descriptions in 1846 of surgical anesthesia with hypnosis in India,22 reports of the effectiveness of hypnosis in treating both acute and chronic pain have abounded. 24,25 Yet, despite the effectiveness of hypnosis for pain control, it is not well recognized. In fact, the pain-relieving effects reported for acupuncture were considered unrelated to hypnosis until recent studies demonstrated that response to acupuncture among pain patients is positively correlated with hypnotizability26 and is not related to needle specificity,27 Trance state dissociation can be employed in a variety of ways, depending on the hypnotizability of the patient. Highly hypnotizable individuals are capable of producing numbness in the affected body part, sometimes by reliving dental anesthesia and having the numb JANUARY 1980· VOL 21' NO 1
Hypnosis is a useful diagnostic and therapeutic adjunct and it should be removed from the realm of mysticism and mistrust in which it is commonly viewed, The assessment of hypnotizability proves useful in the difficult differential diagnosis of functional from organic disease. Moreover, the trance state is a naturally occurring intense form of concentration accompanied by a pleasant sense of physical relaxation, and provides a useful means of approaching psychosomatic problems. Taught appropriate restructuring strategies, a patient can learn to make maximal use of whatever trance state he is capable of to dissociate psychological stress from somatic response. 0
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4. Spiegel H, Flelss JS, Bridger AA, et al: Hypnotizability and mental health, in Arieti S (ed)'
New Dimensions m Psychiatry. A World View. New York, John Wiley & Sons, 1975.
5. Frankel FH: Hypnosis as a treatment method in psychosomatic medicine. Int J Psychiatry
Med 6:75-85, 1975. 6. Smith JM, Burns CL: The treatment of asthmatic children by hypnotic suggestion. Br J Dis Chest 54: 78-81, 1960. 7. White HC: Hypnosis in bronchial asthma. J Psychosom Res 5.272-279,1961. 8. Brown EA: The treatment of asthma by means of hypnOSIs as viewed by the allergist. J Asthma Res 3:101-110,1965. 9. Kelly E, Zeller B: Asthma and the psychiatrist. J Psychosom Res 13:377-395,1969. 10. Edwards G: Hypnotic treatment of asthma: Real and illusory results. Br Moo J 2:492-497, 1960. 11. Edwards G: Hypnotic treatment of asthma, in Eysenck HJ (ed): Experiments in Behavior Tf>erapy. Oxford, Pergamon Press, 1964. 12. McLean AF: HypnOSIS in 'psychosomatic' illness. Br J Med Psycho/33 211-230, 1965. 13. Moorefield CW: The use of hypnosis and behavior therapy In asthma. Am J Clin Hypn 13:162-168, 1971. 14. Maher-Loughnan GP: Hypnosis and autohypnosis for the treatment of asthma. Int J Clin Exp Hypn 18.1-14, 1970. 15. Collison DR: Hypnotherapy in the management of asthma. Am J Clin Hypn 11.6-11, 1968. 16. Collison DA: Which asthmatic patients should be treated by hypnotherapy? Med J Aust 1.766-781,1975. 17, Maslach C, Marshall G, and Zimbardo PH: Hypnotic control of peripheral skin temperature: A case report. Psychophysiology 6 600-605, 1972. 18. Grabowska GJ: The effect of hypnosis and hypnotic suggestion on the blood flow In the extremities Polish Med J 10' t 044-1 051, 1971, 19. Dubin LL, Shapiro SS: Use of hypnosis to facilitate dental extraction and hemostasis In a classic hemophiliac with a high antibody titer to factor VIII. Am J Clin Hypn 17:79-83, 1974. 20. Newman M. Hypnotic handling of the chroniC bleeder in extraction: A case report. Am J.
Clin Hypn 13.126-127,1971. 21. Erickson MH: Hypnotic investigation of psychosomatic phenomena. Psychosom Mad 5.51-58,1943. 22. Esdaile J: Hypnosis in Medicine and Surgery (1846 reprint). New York, Julian Press, 1957, 23. Sacerdote P: Additional contributions to the hypnotherapy of the advanced cancer patient. Am J Clm Hypn 7:308-319, 1965, 24. Sacerdote P: Theory and practice of pain control in malignancy and other protracted or recurring painful illnesses. Int J Clin Exp Hypn 18: 160-180, 1970. 25. Hilgard EA, Hilgard JA: Hypnosis in the Relief of Pain. Los Altos, California, William Kaufman, Inc, 1975. 26. Katz AL, Kao CY, Spiegel H, et al: Acupuncture and hypnosis. Adv Neurol 4.819-825, 1974. 27. Kepes EA, Chen M, SChapira M: A critical evaluation of acupuncture in lhe treatment of pain. Adv in Pam Res Ther 1:817-822,1976.
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