Spine and Spinal Cord Surgery

Spring 2001
Volume 12, Number 1

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Understanding the complex nature of pain perception requires the ability to separately analyze its psychological dimensions and their interaction, and relate them to specific variables and responses. This article approaches the different aspects of working with hypnosis for the control of pain, and the multifaceted problems of trying to prove hypnotic suggestions works.

Introduction. “Hypnotic analgesia is one of the most dramatic of all hypnotic phenomena. To watch the tranquil face of a patient undergoing a painful medical procedure, with no anesthetic agent except words, is a remarkable, perhaps unbelievable, experience. To watch the power of his or her imagination bring a sigh of relief to a patient who has been suffering the pain of a disease is a welcome and satisfying sight.” These are the opening words of Joseph Barbers book, “Hypnosis and Suggestion in the Treatment of Pain.”1 Dr. Barber is right. To watch a patient respond to hypnotic suggestion and truly feel pain relief is an extraordinary experience. The potential to reduce pain to a manageable level is a genuine tribute to the capabilities of the human mind, and constitutes one of the most meaningful applications of therapeutic hypnosis.

There has been no specific mechanism identified that can adequately account for the physical effect of hypnosis on the person with pain. Theories about increased endorphins and the fortification of the immune system have been proposed to explain the pain relief and accelerated healing facilitated by hypnosis, but these don’t explain how it “works”. Fortunately, effective use of hypnotic analgesia is not dependent on defining the physiological mechanisms.

Hypnosis can be thought of as an altered condition or state of consciousness characterized by a markedly increased receptivity to suggestion, and the potential for systematic control of a variety of physiological functions. The feature of altering function can be useful in the control of pain, but clearly the most important features are alterations of perception and control of physical functioning.

A Historical Perspective. Healing rituals that employ elements of modern hypnotic technique can be traced as far back as the ancient Hindus, Chinese, and Egyptians.7 Rituals, incantations, mantras, and eye fixation that have been used for pain control since as early as 1500 BC contain similar concepts to today’s hypnotherapy session. Throughout the intervening centuries, a wide variety of techniques for alleviating pain have been proposed, all of which can be traced to these historical antecedents.

In the late eighteenth century interest became focused on mesmerism when it was observed that some patients appear to show a diminished response to surgical pain subsequent to a mesmeric induction procedure. Mesmer used the laying on of hands and breathing over the patients head during his inductions. His treatments often took several days to complete. Even though Mesmer is often thought of as the father of hypnosis, today’s hypnotic technique is much different and we no longer “mesmerize” patients. Hypnosis has become a primarily verbal procedure in which suggestions are administered to a subject who ordinarily is informed about what is being done. Also, most hypnotic procedures only take a few minutes to accomplish.

You must remember that during the preanesthetic days of surgery, any technique that helped with the pain of a surgical procedure sparked interest. In those days, the patient was dragged to the operating table, held there firmly by a dozen or so men, and had their feet and hands tied. The fully conscious patient watched the instruments in the hands of the surgeon (often a barber) and listened to the instructions given to the assistants, including asking for the red-hot burning iron. When the patient could no longer endure the suffering, the assistants held him down even more tightly. This was the time when development of hypnotic technique received a great deal of attention.

The earliest claims for the hypnotic control of surgical pain appeared so dramatic that it is not surprising that it became virtually axiomatic that hypnosis itself was mysterious and magical. This thought is still prevalent today to many people, helped along by the stage hypnotist who can make someone from the audience cluck like a chicken. But hypnosis was being used for real control of real pain, and the patients were asking for hypnotic induction before surgery. It appears the first documented surgical procedure with mesmerism was in 1829. The operation was a mastectomy on a 64 year old woman suffering from breast cancer. During surgery, the patient’s respiration and pulse were stable and there were no noticeable changes in her facial expression. The surgeon, Jules Cloquet, presented his findings to the French Academy of Medicine. He was called a liar and thrown out of the Academy. Despite this, hypnotic technique flourished. However, with the discovery of the anesthetic properties of chloroform, ether, and nitrous oxide during the 1840s, there was a rapid decline in interest in hypnotic technique.

Throughout its early history, organized medicine expressed opposition to the use of hypnotic procedures for the relief of pain. Complicating the evaluation of hypnotic technique for the reduction of pain is the underlying assumptions that are made about pain itself. The perception of pain is seen as the outcome of a linear pathway of well-defined neural connections that terminate in circumscribed pain centers in the brain. It provides no obvious mechanisms for the attenuation of pain by any other means outside of that pathway, including psychological means.

Hypnotic Technique vs. the Scientific Method. Studies of hypnotic pain control have labored under many burdens, including the totally subjective component of pain itself. Pain scales are unreliable, making the patient suspect. Does the patient actually feel less pain, or are other forces at work. Substantial controversy exists concerning the inferences that can legitimately be drawn about the subjects experiences when suggestions produce decrements in pain ratings or enhancements in pain tolerance. Several hypotheses have been advanced with respect to these issues. One states that perhaps the attention/cognitive activities induced by suggestions temporarily reduce the ability of subjects to perceptually discriminate levels of noxious stimulation. Another hypothesis holds that cognitive variables influence the manner in which subjects interpret and report their sensory experiences but leaves their ability to discriminate intensities of sensory stimulation unchanged. This holds that subjects who report pain reductions have re-evaluated their experiences and in this sense feel less pain. Another theory states that people frequently respond to social pressure by doing and saying the things that authority figures demand of them. Considerations of this kind have been raised for well over a century in support of the hypothesis that hypnotic analgesia may be explicable in terms of compliance. So, does hypnosis change the pain intensity, or the pain tolerance, or the pain affect, or are subjects just trying to please the experimenter?

While it is widely recognized that experimental and clinical pain differ in important ways, the generalizations that have emerged from laboratory studies of experimental pain have relevance for understanding possible mechanisms underlying the reduction for many of these conclusions.

• Hypnotic analgesia is unlikely to involve the central pain inhibitory mechanism since hypnotic analgesia is not altered by naloxone hydrochloride, a specific narcotic antagonist.2
   
• Hypnotic suggestion was used to alter the unpleasantness of noxious stimuli without changing the intensity of the stimuli. In these subjects, positron emission tomography revealed significant changes in pain evoked activity within the anterior cigulate cortex without any noted changes in the primary somatosensory cortex activation. These findings provide direct experimental evidence in humans linking the frontal lobe limbic activity with pain affect.5
   
• The effect of hypnotically induced analgesia on the flare reaction of the cutaneous histamine flare test demonstrated a number of results. There was a mean reduction in subjectively felt pain of 71% compared to baseline after hypnotic induction. A 50% mean reduction of the evoked potentials was found in the hypnotic analgesic condition compared with pre-hypnotic and post-hypnotic condition. A significant difference was measured in the histamine flare area between the pre-hypnotic (1.04) and the hypnotic analgesic condition (0.78). These results support the hypothesis that higher cortical processes can be involved in the interaction of inflammatory and pain processes.8
   
• Volunteers were asked to rate a series of shocks both before and after hypnotic induction. Those subjects who received hypnotic analgesia suggestions had altered perceptions of the intensity without changing their perceptions of the unpleasantness of the shocks.
    
• Those who received hypnotic relaxation suggestions felt a reduction in the unpleasantness but not the perceived intensity of the stimuli.4
   
• This study attempted to define the differences in the attenuation of the nociceptive reflex, the reduction in perceived intensity and the reduction in the unpleasantness of the pain sensation. Hypnosis activated all 3 systems. The percentage reduction in sensory intensity of about 30% was greater than the 20% reduction in the nociceptive reflex, suggesting that the additional 10% were provided by supraspinal inhibition. Similarly, the 40% reduction in unpleasantness ratings suggested the 10% increase over the reduction in sensory ratings was provided by a reduction in the amount of unpleasantness associated with a specific sensory magnitude.3
   
• The dissociation between pain sensation and pain affect was confirmed by this study. They showed that when hypnotic suggestions were designed to influence pain affect specially without altering pain sensation, it modulated cerebral activity in the cingulate cortex. When hypnotic suggestions were aimed at pain sensation rather than at the emotions associated with pain, not only werethere changes in both unpleasantness and intensity ratings, but there were also changes in the S1 (primary  somatosensory cortex) and the cingulate cortex.6

Clinical Applications. Hypnotically induced analgesia is truly one of the most remarkable capacities of human physiology. The potential to reduce pain to a manageable level is a genuine tribute to the capabilities of the human mind, and constitutes one of the most meaningful applications to therapeutic hypnosis. Working with patients with pain requires a very broad base of understanding of hypnotic principles, human physiology, psychological motivations, human information processing, and interpersonal dynamics. Therefore approaching the person in pain must be done sensitively, with an appreciation that the totality of pain is more than physical pain: It is a source of anxiety, feelings of helplessness and depression, increased dependency, and restricted social contact. Even pain emanating from clearly organic causes had psychological components to it, particularly how the suffering person experiences the pain and its consequences. Fear and anxiety, feelings of helplessness, and negative expectations can all be reduced with the use of hypnosis. The physical components of the pain are also addressed by the use of hypnosis, evidenced in the various healing strategies employing hypnotic patterns.

Using hypnosis in the management of pain is advantageous for some very important reasons. First, is the opportunity for greater self-control and, therefore, greater personal responsibility for one’s level of well being. The person in pain often feels victimized, and having self-control is extremely important. Hypnosis facilitates its acquisition. Second, because the ability to experience trance is a natural one existing within the person, pain medication may be reduced or even eliminated. Hypnosis has no side effects and is not addicting. The pain is reduced in varying degrees in different people, but regardless of the result, the attempt at pain control is obtained safely and naturally. Third, hypnosis permits a higher level of functioning and enhances the healing process in persons who use hypnotic patterns. The expectation of wellness, the experience of comfort, and the diminished anxiety and fear can all be important factors in facilitating recovery, at most, or retarding decline, at least.

The pain control derived from hypnosis spans all areas of the pain spectrum. Dentists have utilized hypnosis for the acute pain of repairing a cavity or pulling a tooth. Chronic migraine headaches have responded well to hypnotic patterns, both to stop the ongoing headache, and to abort future headaches. Cancer pain is one of the most responsive pains to deal with using hypnotic technique.

Low back pain can respond to hypnotic suggestion when all else has failed. Since this issue of the CNI Review has focused on lumbar problems, I will focus a bit more on that topic. Hypnosis does not replace the work-up and acute treatments for lumbar pain. Surgical intervention is always an acceptable alternative to a life of pain. Much has been done in the arena of both conservative and operative intervention for low back pain. Minimally invasive procedures have been developed over the last several years, which are helpful to the amelioration of pain. Those who use hypnosis in their practices also have to keep up with the advances in the surgical and conservative treatments of lumbar pain. The complexity of the pain patterns of most patients requires the thoughtfulness of an expert to plan hypnotic suggestions that will work for the patient in a multifactorial manner. When the patient considers hypnosis, it usually is the last resort. The patient needs to be approached with confidence and professionalism. Just as the surgeon’s hands are important for the success of the proposed surgery, so is the hypnotherapist’s understanding of the pain, and their hypnotic suggestions, important for the success of hypnosis to relieve pain.

Conclusion. In summary, hypnosis can offer physical relief and an emotional wellspring of positive possibilities to the person in pain. Over time, and with practice, such persons can benefit from the increased self-control and self-reliance hypnosis may afford.

Address comments and questions to:

Cynthia Norrgran, MD
499 E. Hampden Avenue
Suite 140
Englewood, CO 80113

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