Mr. M, a world-class athlete, collapsed suddenly in an alley. He was rushed to a hospital emergency room, where he nearly died of internal bleeding from a grapefruit-sized abdominal lymphoma. He was hospitalized and placed on chemotherapy.
Increasing doses of opiates hardly reduced his pain, and he became extremely anxious. Staff described him as “climbing the walls.” He lay in bed writhing, and his parents feared he was becoming a “drug addict.”
Anxiety about his life-threatening illness was clearly compounding his pain, so his attending physician ordered a psychiatric evaluation. When I interviewed the patient, I felt that hypnosis could help.
Hypnosis—as a state of highly focused attention—can help us treat patients’ anxiety, phobias, pain, posttraumatic stress disorder (PTSD), and dissociative disorders. With training, an experienced psychiatrist can quickly start using hypnosis as an adjunct to other therapies.
This article describes how hypnosis helped Mr. M and a young woman traumatized by a criminal assault. Based on my experience and the literature, I discuss what hypnosis is, what training is required, how to measure hypnotizability, and the value of hypnosis in helping patients control their anxiety, posttraumatic, and dissociative states.
Case continued: ‘Surfing’ in Hawaii
When I met Mr. M in the hospital, I acknowledged his distress and the reasons for it, saying “You don’t really want to be here, do you?”
“How many years of medical training did it take you to figure that out?” he replied.
“Well then,” I said, “let’s go somewhere else. Where would you like to be right now?”
He responded, “I’ve never surfed.”
“Good,” I replied, “let’s go to Hawaii.” In hypnosis, I had him picture himself surfing. He continued to groan, but the pattern changed. “What happened?” I asked. “I fell off the surfboard,” he replied. “OK, get back on, and do it right,” I told him.
He learned to practice self-hypnosis, which markedly reduced his anxiety and pain. Two days later he was off pain medications and joking with the nurses in the hall. The attending physician noted in the patient’s record: “Patient off pain meds. Tumor must be regressing.”
What is hypnosis?
Mr. M’s response, though unusually strong, underscores the fact that hypnosis can rapidly produce analgesia and anxiolysis in the medical setting. Hypnosis—often called “believed-in imagination”—is characterized by an ability to sustain a state of attentive, receptive, intense focal concentration with diminished peripheral awareness. The hypnotized person is awake and alert, not asleep. Hypnosis’ three main components are absorption, dissociation, and suggestibility.
Biological basis. The hypnotic state has no brain “signature” per se, but brain imaging portrays hypnosis as a state of alertness with altered anterior cingulate gyrus activation, which helps to focus attention.1-3 Hypnotized persons can demonstrably alter blood flow in brain regions involved in perceptual processing in response to suggestions of altered perception, whether somatosensory, visual, or olfactory.4,5 Thus, patients report not only reduced pain but changes in how they experience pain with hypnotic analgesia.
The brain’s dopamine neurotransmitter system—especially in the frontal lobes—also may be involved in hypnosis, as highly hypnotizable persons have elevated levels of dopamine metabolites in their cerebrospinal fluid.6
Hypnotic trance. The trance experience is often best explained to patients as similar to being absorbed in a good novel. One loses awareness of one’s surroundings and enters the imagined world. When the novel is finished, the reader requires a moment of reorientation to the surrounding world.
A trance is a state of sustained, attentive-receptive concentration in response to a signal from within or from someone else. The signal activates this shift of awareness and permits more-intensive concentration in a designated direction.
All hypnosis is self-hypnosis. Much of its clinical value is that it can be self-induced throughout the day and whenever symptoms emerge. During the first weeks, patients can be encouraged to practice every 1 or 2 hours.
Applying hypnosis to practice. A well-trained clinician can learn to use hypnosis in classes offered by the two professional hypnosis societies or the American Psychiatric Association (Box 1) Because hypnosis is not something “done to” a patient but rather a capacity to be measured, tapped, and utilized, psychiatrists can integrate hypnosis into clinical practice after some initial training, with ongoing learning and supervision.
Who can be hypnotized?
Not everyone is equally hypnotizable, and hypnotizability is a stable and measurable trait. Approximately one-quarter of adults cannot respond to hypnotic instructions, whereas 10% are extremely hypnotizable.7
Brief, clinically useful tests of hypnotic responsiveness have been developed, such as the Hypnotic Induction Profile (HIP).8 The clinician usually can induce the trance experience and systematically measure the patient’s response within 5 minutes. A HIP score of 5 indicates usable hypnotizability.