Hypnosis in Psychosomatic Medicine

Psychiatric Care of the Medical Patient (3 edn)
Barry S. Fogel and Donna B. Greenberg
https://doi.org/10.1093/med/9780199731855.001.0001
Published: 2015 Online ISBN: 9780190213381 Print ISBN: 9780199731855
CHAPTER
16. Hypnosis in Psychosomatic Medicine

José R. Maldonado
https://doi.org/10.1093/med/9780199731855.003.0016 Pages 266–304
Downloaded from https://academic.oup.com/book/25135/chapter/189428287 by guest on 29 May 2023

Published: June 2015
Abstract
Hypnosis is a psychophysiological state of attentive, receptive concentration, with a relative
suspension of peripheral awareness. Hypnotic phenomena occur spontaneously, and the alteration of
consciousness that hypnotized individuals experience has a variety of therapeutic applications. This
chapter provides an understanding of hypnosis applications in the medical setting.
Keywords: hypnosis, consciousness, hypnotherapy, hypnotic induction profile, pain management,

anxiety, smoking cessation, weight management
Subject: Psychiatry
Collection: Oxford Medicine Online
Introduction
Hypnosis is a psychophysiological state of attentive, receptive concentration, with a relative suspension of

peripheral awareness. Hypnotic phenomena occur spontaneously, and the alteration of consciousness that
hypnotized individuals experience has a variety of therapeutic applications.
Hypnosis is a natural state of attentive, focused concentration. As such, most individuals are able to
experience variable trance-like states at di erent times in their daily lives. The hypnotic capacity or
hypnotizability of a given subject (i.e., the degree of natural ability to enter a trance state) will determine the
degree of assistance required to enter trance states. Highly hypnotizable individuals enter trance states with
ease, on many occasions even without being fully aware of it. Individuals with moderate hypnotizability
require more direction or help from a therapist who facilitates the trance experience, while those with low
hypnotizability may not be able to bene t much from hypnosis as a treatment tool.
The ability to enter a trance state is widely and naturally distributed throughout the general population.
Therefore, some patients may experience trance states or inadvertently take suggestions without planning.
This may have potential positive or negative consequences depending on the patient and the circumstances
of the interaction. For example, moderately to highly hypnotizable individuals may use hypnotic techniques
to enhance pain management, stop the use of nicotine, diminish chemotherapy side e ects, assist in
managing the psychological and physical discomfort of intraoperative and postoperative procedures and
childbirth, and assist in the management of various psychosomatic conditions (e.g., asthma, irritable bowel
syndrome, warts). Similarly, high hypnotic capacity may actually become a liability to patients who are
unaware of their hypnotic capacity or of their unconscious use of this mechanism, as in the case of
individuals su ering from a dissociative and somatoform disorder or nocebo (i.e., negative placebo) e ect.
Background
The oldest written record of cures by hypnosis was obtained from the Ebers Papyrus, which gives us an idea
about some of the theory and practice of Egyptian medicine before 1552 BC (Joachim, 1890; Ebbell, 1937). In
the Ebers Papyrus, a treatment was described in which the physician placed his hands on the head of the
patient and, claiming superhuman therapeutic powers, gave forth with strange remedial utterances that

were suggested to the patients and that resulted in cures.
The Egyptians are thought to have originated the “Sleep Temples,” in which the priests gave similar
treatment to their patients through the use of suggestion. These temples became very popular in Egypt and
spread throughout Greece and Asia Minor (Okasha, 1993). Trance experiences were described by ancient
Greeks, often as vehicles for treatment of mental or physical illness. Hippocrates is known to have discussed
the phenomenon, saying, “the a iction su ered by the body, the soul sees quite well with the eyes shut”
(Chadwick, 1950).
Hypnosis was identi ed as a formal phenomenon of psychotherapeutic usefulness in the 18th century. Franz
Anton Mesmer (1734–1815) employed it as an alternative treatment for many ills that now would be labeled
as stress-related or psychosomatic (Lopez, 1993). His work is credited with being the rst Western
conceptualization of a psychotherapy, a therapeutic talking interaction between doctor and patient
(Ellenberger, 1970). Yet, the results of a Royal Commission in France concluded that the e ects of hypnosis
were the result of the “pure gold of imagination.”
Jean-Martin Charcot (1825–1893), chief of neurology at the Salpêtrière Hospital in Paris, rehabilitated
hypnosis as a subject for scienti c study (Charcot, 1890). One of his disciples, Pierre Janet (1859–1947), a
general practitioner and psychologist, laid the early foundation for dissociative reactions and ego states
(Janet, 1887, 1889, 1904, 1907). In fact, the First International Congress for Experimental and Therapeutic
Hypnotism was held in Paris, France, August 8–12, 1889.
More recently, interest in hypnosis seemed to wax and wane depending on the needs of the times. The
extreme symptoms observed in patients with dissociative syndromes prompted the writings of William
James (1902), Boris Sidis (Sidis & Goodhart, 1905), and Morton Prince (1906), who went on to found the
Journal of Abnormal Psychology. The early use of hypnosis in the treatment of physical illness was
championed by James Braid (1843) and James Esdaile (Esdaile, 1957; Ernst, 1995), including
hypnoanalgesia.
Interest in hypnosis revived during World War II, when army psychiatrists found the technique helpful in
treating what was then called “traumatic neurosis” (Kardiner & Spiegel, 1947). This was followed by an era
p. 267 of serious scienti c exploration and the development of various hypnotizability scales (e.g., Stanford
Hypnotic Susceptibility Scales (Hilgard, 1965; Weitzenho er & Hilgard, 1959; Weitzenho er, 1962) in an
attempt to measure the presence and depth of the hypnotic experience. Later on, shorter hypnotizability
scales were developed for use in clinical settings. Investigations included studies of the relationships among
hypnotizability, placebo response, and acupuncture, studies of the di erential hypnotizability of patients
with psychosis and other psychiatric disorders, and investigations used in determining neurophysiological
correlates of the hypnotic state and hypnotic capacity.
It was not until the second part of the 20th century, though, that the various professional associations in
Europe and North America o cially recognized hypnosis as a valuable therapeutic intervention (i.e., British
Medical Association, 1955; American Medical Association, 1958; American Psychological Association, 1960;
American Psychiatric Association, 1960). Since then, two professional hypnosis societies have emerged in
North America: the Society for Clinical and Experimental Hypnosis (SECH, 1949), which emphasizes
research in the eld, and the American Society for Clinical Hypnosis (ASCH, 1957). A division of the
American Psychological Association (Division 30, 1968; also known as the Society of Psychological
Hypnosis) is devoted to the study of hypnosis in the eld of psychology. In 1959 the International Society for
Clinical and Experimental Hypnosis was founded. A more detailed account of the history of hypnosis is
beyond the scope of this chapter and may be found elsewhere (Maldonado & Spiegel, 2008)
Components of the Hypnotic Process

The hypnotic experience may be understood as involving three interconnecting factors: absorption,
dissociation, and suggestibility.
Absorption
Absorption refers to the tendency to engage in self-altering and highly focused attention with complete
immersion in a central experience at the expense of contextual orientation (Hilgard, 1970; Tellegen &
Atkinson, 1974; Tellegen, 1981). Hypnotized individuals can become so intensely absorbed in their trance
experience that they often choose to ignore the environmental context and other peripheral events. It
facilitates complete immersion in a central experience at the expense of contextual orientation and
peripheral awareness. As a person becomes absorbed in a central focus of attention, more peripheral
perceptions, thoughts, and memories become less important. During the hypnotic process, individuals can
become so intensely absorbed in their trance experience that they tend to, or are better able to, ignore many
somatic (e.g., pain) and/or environmental stimuli (e.g., medical procedures).
Dissociation
Dissociation refers to the ability to separate mental processes so they seem to occur independently from
each other. The process of dissociation is complementary to absorption. During hypnosis, the intense
absorption characteristic of the hypnotic state permits keeping out of conscious awareness many routine
experiences that would ordinarily be conscious, by the process of nonpathological dissociation. When
working properly in our daily lives, dissociation allows us to carry out several complex tasks
simultaneously. There are a wide variety of dissociated states that range from the normal ability to carry out
simultaneous tasks to a number of psychiatric disorders. An example of a rather common form of
dissociation is the ability to perform a high-complexity task (i.e., a surgical procedure) while carrying out a
conversation regarding one’s political views or a recent sport event. In fact, not only motor activities can be
dissociated but also rather complex emotional states and sensory experiences as well.
Dissociated a ect and memories can elicit complex motor or pseudoneurologic dysfunction, as in the case
of conversion disorder (Maldonado & Spiegel, 2000; Maldonado, 2007). Complex forms of dissociation can
prevent access to memory, resulting in dissociative amnesia, dissociative fugue, or dissociative identity
disorder (Maldonado, Butler, & Spiegel, 2000).
Another, more common, example of how dissociated memories a ect patients is the hyperemesis
experienced by some chemotherapy patients who experience nausea and vomiting just with the sight, or
sometimes the thought, of the hospital (conditioned nausea and emesis). Memories that are dissociated at
the time of the traumatic experience may reemerge when they are triggered by external cues, as in
ashbacks associated with posttraumatic stress disorder that are often seen in cases of traumatic
experiences such as motor vehicle accidents or traumatic surgical procedures or interventions.
Suggestibility
Suggestibility implies the ability to in uence someone’s beliefs or behaviors by suggestion. Owing to the
intense absorption experienced during trance, hypnotized individuals have a heightened responsiveness to
social cues, including suggestions (formal or not) given by the therapist. This enhanced suggestibility
allows hypnotized subjects to accept instructions more easily. Hypnotized individuals are not deprived of
their will, but they do have a tendency to accept instructions in an uncritical way when under trance, a
process that may be aided by the phenomenon of “source amnesia.” Thus a hypnotized individual receives a

suggestion, internalizes it, forgets the source of origin, then believes s/he generated the idea to which s/he
now responds, thus lowering critical thinking about its validity.
This does not mean that the subject is deprived of will. Nevertheless, highly suggestible individuals do have
a tendency to suspend the usual conscious curiosity that makes us question the reason for our actions and to
respond to suggested ideas in a less critical fashion. Because of this, highly hypnotizable individuals are
p. 268 more prone to accept some suggestions or ideas no matter how irrational or illogical they might appear
to be. A conscientious physician may use this aspect of the hypnotic experience to bypass the patient’s
defenses and facilitate change or symptom relief. On the other hand, because of their decreased awareness,
highly hypnotizable individuals are less likely to identify a physician’s mistakes, and may be misguided and
confused by comments or instructions (whether given under hypnosis or not) that are negative, vague, or
misguided.
Assessment of Hypnotizability or Hypnotic Capacity
There are de nitive advantages associated with knowing a patient’s level of hypnotic capacity. As previously
mentioned, patients’ hypnotizability levels vary considerably. The use of formal hypnotizability
assessments allows physicians to objectively determine their patient’s level of hypnotic capacity. Thus,
while moderate and highly hypnotizable patients may be o ered hypnosis as a treatment option, those with
low capacity may be referred to more appropriate techniques (e.g., progressive relaxation, biofeedback).
Data suggests that hypnotizability is a rather stable trait. The only long-term study published to date
demonstrated that the initial hypnotizability assessment (i.e., SHSS) correlated highly with scores at a 10-
year, 15-year, and 25-year retest, with obtained correlations of .64, .82, and .71, respectively (Piccione,
Hilgard, et al.,1989) As stated by the study authors: “the ux in subjects’ lives over a quarter of a century,
through marriage and child-rearing, occupational shifts, traumas associated with illness, death of loved
ones, and loss by divorce, cannot be assumed to be trivial”(Piccione , et al.,1989).
These ndings compared favorably with other studies of similar sample size and duration, of measures of
individual di erences over time. These include the stability over time of IQ scores (i.e., test–retest
correlations were 0.73 for the full scale IQ, 0.70 for Verbal IQ, and 0.57 for Performance IQ [Kangas &
Bradway, 1971]), personality assessment (i.e., a retest correlation of 0.50 [Huntley & Davis, 1983]), and
occupational interests (i.e., a 20-year test–retest correlation of 0.72 for men 22–25 years old at rst testing
and 0.64 for those 19–21 years old at rst testing [Campbell & Hansen, 1981]). Standardized hypnotizability
assessments can provide therapists with clinical data that allows for rational predictions about patients’
expected responses. For instance, the relative ability, or lack thereof, to restructure one’s inner experience
aided by the use of hypnosis may provide information about a subject’s interpersonal style.
From a therapeutic perspective, these data may help provide clues about likely response to intervention (i.e.,
hypnotic suggestibility predicted di erences in responding to the hypnotic and imaginative analgesia
suggestions, with higher hypnotizability associated with greater response to hypnoanalgesia suggestions).
Hypnotizability levels may even facilitate the di erential diagnosis. For example, we would expect patients
su ering from dissociative disorders, PTSD, and conversion disorder to score high on hypnotizability
measures while those experiencing psychosis and OCD would be expected to score low; discrepancies from
these predictions may make a practitioner rethink the diagnosis.
Brief scales have been designed for quick assessment in the clinical setting— for example, the Hypnotic
Induction Pro le (HIP [Spiegel & Spiegel, 1987, 2004), the Stanford Hypnotic Clinical Scale (SHCS [Hilgard
& Hilgard, 1975]). They are brief—about 5 to 10 minutes are required for the HIP, and 20 minutes for the
SHCS—and extremely accurate. An even briefer test is the use of the Eye Roll Sign (ERS) and its relation to
innate trance capacity (Spiegel, 1972; Frischholz & Nichols, 2010) This is part of the more formal HIP

assessment scale.
There are even group hypnotizability measures, which can be administered to larger groups of individuals at
the same time and rated at the end of the experience to allow for assessments of larger groups. These scales
are usually used in the screening of large groups for study rather than clinical purposes (Shor & Orne, 1962).
All scales involve a structured hypnotic induction, followed by an assessment of the subject’s response to a
variety of suggestions.
The HIP is a brief (5–7 minutes) standardized assessment designed to measure the patients’ natural ability
to tap into and use their hypnotic capacity (Spiegel & Spiegel, 1987). It consists of a rapid hypnotic induction
instruction for an upward gaze, quickly followed by lowering of the eyelids, and suggestions for physical
relaxation and a oating sensation. The induction process is followed by a structured set of instructions.
The individual’s response to them, during and shortly after the test (posthypnotic suggestion), predicts
hypnotic capacity and future response to treatment with hypnosis.
Subjects are rated on ve important items that assess cognitive and behavioral aspects of the hypnotic
experience: (1) hand dissociation; (2) hand levitation, after formal end of trance state; (3) unconscious
compliance with posthypnotic suggestion; (4) response to the cuto signal; and (5) sensory alteration (see
Appendix A for a copy of the HIP and instructions for administration). At least one study suggests that the
HIP compares favorably with longer (about 20–25 minutes) assessments such as the Stanford Hypnotic
Clinical Scale for Adults (SHCS:A), with a 0.41 correlation (p<.01) (Gritzalis, Oster, et al., 2009).
Neurobiology of Hypnosis
There has always been some mystery regarding how hypnosis works. In ancient times it was blamed on
spirits or gods. In medieval times it was believed to be caused by demonic possession. Mesmer believed it
was elicited by manipulation of the body’s energies or “magnetic uid.” The biggest dichotomy occurred
early on between those like Charcot (1825–1893), who believed hypnosis to be the result of a diseased
nervous system and argued that normal people could not be hypnotized (Charcot, 1890), and those like
Bernheim (1840–1919) at the School of Nancy, who believed hypnosis to be a trait mediated by suggestion
and exhibited to di erent degrees by normal individuals (Berheim, 1889/1964; Widlocher & Dantchev,
1994).
p. 269 Since those early days, various research e orts have attempted to correlate the hypnotic experience with
actual physiological changes, which has prompted many theories. Rudolf Heidenhain (1880) explained it by
the physiological mechanism of cortical inhibition (Windholz, 1996). Pavlov (1910) believed it was mediated
via partial cortical inhibition (Windholz, 1996). Yet, to date, the “seat of hypnosis” has not been found in
the brain, although recent research points toward involvement of the frontal and anterior cingulate cortex
(Kropotov, Crawford, et al., 1997; Rainville, Hofbauer, et al., 2002; Spiegel, 2003). There is ample clinical
and research experience indicating that the hypnotic process a ects both electrical and metabolic processes
in the brain. Similarly, as we have observed in clinical experience, hypnotic activity is capable of causing
various physiological changes.
Hypnotizability has been found to be signi cantly correlated with cerebrospinal uid levels of homovanillic
acid, a metabolite of dopamine (Spiegel & King, 1992). This nding provides additional evidence suggesting
the involvement of the frontal cortex in the hypnotic process. Further dispelling the myth of a link between
hypnosis and sleep, studies have shown that the administration of psychostimulants (e.g., amphetamine)
may enhance hypnotizability (Sjoberg & Hollister, 1965), while GABAergic agents and opioids may cause
sedation, decrease absorption and attention, and thus interfere with the hypnotic process. Some have
postulated that the automaticity observed in hypnotic motor behavior could represent an activation of the

basal ganglia, which is involved in both implicit memory and routine motor activity (Graf & Schacter, 1985;
Schacter, 1987, 1992; Mishkin & Murray, 1994).
Similarly, the brain electrical pattern of a hypnotized subject actually resembles that of a fully awake and
attentive individual more than the pattern of a person who is asleep. In fact, power spectral analysis of brain
electrical activity has found increased alpha activity among highly hypnotizable individuals, and an alpha
laterality di erence favoring the left hemisphere among highly hypnotizable individuals (Morgan,
Macdonald, et al., 1974; Edmonston & Grotevant, 1975). Finally, some have demonstrated that highly
susceptible subjects show more electric power in the right parietotemporal region than the left, while those
with low susceptibility have left-side predominance or equilibrated power in all derivations (Meszaros &
Szabo, 1999). Yet, not all studies support the right hemispheric dominance theory of the hypnotic process,
suggesting that data analysis techniques led to misinterpretations of previously obtained data (Edmonston
& Moscovitz, 1990).
Meanwhile, others have suggested that hemispheric activation on hypnotic challenge may depend in large
part on the kind of task the challenge involves, and several general aspects of the hypnotic process may
more appropriately be understood to be mediated by the left hemisphere, including concentrated
attentional focus and the role of language in the establishment of hypnotic experience (Jasiukaitis,
Nouriani, et al., 1997).
There may also be frontal versus posterior topographical di erences among highly and poorly hypnotizable
individuals. In fact, more recent studies of power spectral analysis suggest that theta power, especially in
the frontal region, best di erentiates highly hypnotizable from poorly hypnotizable individuals. These
studies found greater theta power in the more frontal areas of the cortex for highly hypnotizable subjects.
During the actual hypnotic induction, theta power increased markedly for both groups in the more posterior
areas of the cortex, whereas alpha activity increased across all sites. In the period just preceding and
following the hypnotic induction, poorly hypnotizable subjects displayed an increase in theta activity,
whereas highly hypnotizable subjects displayed a decrease. Finally, power spectral analysis studies found
that theta power, especially in the frontal region, best di erentiates highly hypnotizable from poorly
hypnotizable individuals, suggesting that anterior/posterior cortical di erences may be more important
than hemispheric laterality for understanding the hypnotic processes (Sabourin, Cutcomb, et al., 1990;
Gra n, Ray, et al., 1995).
Event-related potentials (ERPs) have been used to study the e ects of hypnotic hallucination on brain
electrical activity. These studies are based on the premise that hypnotically induced changes in perception
should be re ected in alterations in ERP amplitude. Several studies have found that highly hypnotizable
subjects who experience a visual hallucination obstructing visual contact with the target exhibited
signi cant reductions in P300 amplitude throughout the scalp and in N200 in the occipital region (Spiegel,
Cutcomb, et al., 1985; Jasiukaitis, Nouriani, et al., 1996)
Hypnotic auditory hallucination studies (using auditory evoked potentials, or AEPs) have yielded similar
results, suggesting P300 di erences among highly hypnotizable individuals hallucinating a reduction or
increase in tones, while subjects with low hypnotizability did not show such a change (Sigalowitz, Dywan, et
al., 1991). Others have con rmed these ndings, backing the hypothesis that hypnotic susceptibility is
associated with e cient attentional processing, such that highly hypnotizable subjects can more e ectively
partition attention toward relevant stimuli and away from irrelevant stimuli than can poorly hypnotizable
subjects (Crawford, Corby, et al., 1996; Lamas & Valle-Inclan, 1998)
Postulating that somatic conversion disorders may represent a form of selective attention, we studied a
group of patients presenting with lateralized (i.e., unilateral) motor de cits (i.e., motor conversion) using

somatosensory event-related potentials (SERPs) (Maldonado, 1997, 2001) We found that subjects exhibited
a “normal N140” on the una ected side (as expected in all “normal controls”), but an enhanced N140 on the
a ected side (Maldonado, 2007) Even more remarkably, when we provided hypnotic suggestions for time
regression (e.g., some time prior to the onset of symptoms), subjects experienced complete normalization
of the SERP’s response. These ndings suggest the possibility of an unconscious autohypnotic model used
by patients su ering from conversion disorder in order to create their symptoms.
Similarly, others have examined the e ects of positive obstructive and negative obliterating instructions on
simultaneous visual and auditory ERPs—P300 signals. They found that highly hypnotizable subjects showed
p. 270 greater ERP amplitudes while experiencing negative hallucinations and lower ERP amplitudes while
experiencing positive obstructive hallucinations, suggesting a rather robust physiological marker of
hypnosis—an alteration in consciousness that corresponds to participants’ subjective experiences of
perceptual alteration (Barabasz, Barabasz, et al.,1999)
Hypnoanalgesia may be similarly explained physiologically by a mechanism by which hypnotic suggestions

facilitate the ltering of somatosensory (electrical) stimulation a ecting ERP amplitude. Thus, suggestions
of a tingling, cool, numbing sensation can be given with the idea that it would lter out any other sensations
in the area by a process such as competitive inhibition. In fact, studies of moderately to highly hypnotizable
adults with chronic low back pain have found that hypnotic analgesia led to signi cant mean reductions in
perceived sensory pain and distress, suggesting that this was an active process that required inhibitory
e ort, dissociated from conscious awareness, where the anterior frontal cortex participates in a
topographically speci c inhibitory feedback circuit that cooperates in the allocation of thalamocortical
activities (Crawford, Knebel, et al.,1998)
Finally, brain imaging studies (i.e., positron emission tomography [PET] scan studies) have demonstrated a
global increase in cerebral perfusion during hypnosis (Ulrich, Meyer, et al., 1987). Further PET studies have
suggested that during hypnosis there is speci c activation of the anterior attentional systems involving
focusing (anterior cingulate) and arousal (frontal, especially on the right) (Posner and Petersen, 1990).
Similarly, PET scans were used to measure regional cerebral blood ow (rCBF) of highly hypnotizable
subjects asked to produce vivid auditory hallucinations (Szechtman, Woody, et al.,1998). Studies found that
subjects capable of producing the hallucinations had increased rCBF in the right anterior cingulate gyrus. Of
interest, the “externality” and “clarity” of the hallucinations were highly correlated with blood ow in this
region.
Subsequent PET studies found that among highly hypnotizable individuals, the hypnotic state was
accompanied by signi cant increases in both occipital rCBF and delta EEG activity, which were highly
correlated with each other (r = 0.70, P < 0.0001) (Rainville, Hofbauer, et al.,1999; Rainville, Hofbauer, et al.,
2002). Peak increases in rCBF were also observed in the caudal part of the right anterior cingulate sulcus and
bilaterally in the inferior frontal gyri. Hypnosis-related decreases in rCBF were found in the right inferior
parietal lobule, the left precuneus, and the posterior cingulate gyrus. Hypnosis with suggestions produced
additional widespread increases in rCBF in the frontal cortices, predominantly on the left side. Moreover,
the medial and lateral posterior parietal cortices showed suggestion-related increases overlapping partly
with regions of hypnosis-related decreases. Results support a state theory of hypnosis in which occipital
increases in rCBF and delta activity re ect the alteration of consciousness associated with decreased arousal
and possible facilitation of visual imagery. Frontal increases in rCBF that are associated with suggestions for
altered perception might re ect the verbal mediation of the suggestions, working memory, and top-down
processes involved in the reinterpretation of the perceptual experience.
15
PET scans studies using O-CO2 in highly hypnotizable subjects who were asked to “see changes in color
patterns” in a number of visual stimuli found both the left and right hemisphere color areas were activated
when they were asked to perceive color, whether they were actually shown the color or the gray-scale

stimulus; moreover, these brain regions had decreased activation when subjects were told to see the gray
scale, whether they were actually shown the color or gray scale stimulus (Kosslyn, Thompson, et al., 2000)
Thus, the observed changes in subjective experience achieved while in a hypnotic state are re ected by
changes in brain function similar to those that occur in perception. These ndings suggest that hypnotic
alteration of perception is more than mere compliance with suggestion; rather, it involves alteration in
sensory experience.
Application of Hypnosis in Psychosomatic Medicine
The literature on the usefulness of hypnosis in the treatment of medical conditions is limited. Most papers
are based on single case reports or small size samples, thus limiting the interpretation of the ndings.
Nevertheless, numerous studies are underway, and the number of rigorous scienti c studies and publication
is growing. We suggest that practitioners interested in the use of hypnosis for the treatment of medical
conditions continue to monitor the literature for newer and more rigorous studies on the subject. Already
published studies that merit discussion will be summarized in the sections to follow.
Suggestions Without Trance: A Potential Trap for the Highly

Hypnotizable
As mentioned before, hypnosis is a natural phenomenon that most patients can experience to a certain
degree. For better or worse, highly hypnotizable individuals can enter trance states with ease and, on
occasion, without even being fully aware of it. Thus, it is important for physicians to know that some
patients may experience trance states even without formal induction. Highly hypnotizable individuals are
extremely receptive to suggestions given by a person in a position of authority (i.e., nurse, physician), and
thus their attitude and comments may have profound e ects, both positive and negative, in these
individuals. This “hypnotic phenomenon” may augment the placebo e ect in either a positive or negative
way, as demonstrated by the following case study.
Case Study 1: Unremitting Pain
A 75-year-old woman was referred to me for treatment of pain with hypnosis. The patient had been
diagnosed with metastatic breast cancer that now was invading her hip bone, which was the source of her
p. 271 pain. When she came for her hypnotic sessions it was evident that she was a highly hypnotizable
individual. In fact, she scored highly in objective hypnotizability measure (9 out of 10).
During her rst session she entered the trance state with ease, and during it she was able to experience
complete pain relief. Even with such success during trance, we were disappointed at the fact that as soon as
she exited the trance state, the pain immediately returned. The same occurred during the second session.
Thus, during the third session instead of working on the issue of pain control we did some hypnotic
exploratory work to address the “reasons why she couldn’t let go of the pain.”

Under a hypnotic regression the patient was asked to “return to the moment when “this pain started.”
Immediately the patient recalled a meeting with her oncologist a few months back. At the time of that
meeting, the patient had just begun to experience pain and brought it to her oncologist’s attention. After
discussing with her the “dangers of addiction if opioid medications were used,” he inadvertently suggested
that she will live the rest of her life with pain. His words were forever “imprinted” in her mind: “I’m sorry,
but there is nothing I can do. You will be in pain until the day you die.” To a highly hypnotizable patient this
meant a lot. In her mind, she made “being in pain” equal to “being alive.”
Once the “source” of her pain was clari ed, the session focused on the meaning of her pain. To her, it served
as a reminder that she was still alive; as long as she could feel the pain at its most severe, even at night, when
it sometimes seemed endless, she knew she was alive. So, her discomfort was a “painful reminder that she
was alive” and thus her need to hold on to the pain.
Her high level of suggestibility allowed her to “take” the initial suggestion. Thus our strategy then was to use
this same hypnotic capacity to reverse the initial damage and help the patient conquer her pain. In her case,
we used hypnosis to alter her perception of pain for a tingling sensation on the a ected site. This tingling
“continued to provide her reassurances about her life” without the need for her to experience the pain. The
suggestion was to have a constant “tingling sensation which would lter the hurt out of the pain.” She was
able to master self-hypnotic techniques, which she continued to practice at home with great success. She later
used her newly learned skills to help control symptoms of nausea and vomiting associated with
chemotherapy.
Anxiety Responses to Medical Procedures
The hypnotic experience can be used to produce a state of relaxation. Therefore, hypnotic techniques can be
used to reduce the anxiety associated with a number of medical procedures (Deyoub, 1980; Covino &
Frankel, 1993). Once patients have been trained in the use of self-hypnosis, they can use it in preparation
for both a hospital visit and for medical tests or interventions, and while in the clinic or the hospital.
Hypnotic techniques have been successfully used to assist phobic patients to undergo a number of
medical/surgical and diagnostic procedures, thus diminishing the need for excessive anesthesia or
antianxiety medication, improving compliance, and eliminating trauma to patients (Covino & Frankel, 1993;
Cadranel, Benhamou, et al.,1994; Ellis & Spanos, 1994; Rape & Bush, 1994; Chandler, 1996; Kessler & Dane,
1996; Lambert, 1996; Lang, Joyce, et al.,1996; Mize, 1996).
Among patients undergoing colonoscopic examination, for whom other forms of anesthesia were not
available, those able to bene t from hypnotic intervention reported less intense pain than patients in whom
hypnosis was unsuccessful (Cadranel, Benhamou, et al., 1994) In addition, the hypnosis group reported a
much better rate of successfully completed colonoscopies (100% versus 50%) and were more compliant
with further testing later on (100% versus 2%, p < 0.001).
Phobic responses to modern imaging studies (i.e., magnetic resonance imaging [MRI], PET scans, and
computerized tomography [CT] scans) are among the most common types of phobias we encounter.
Hypnosis has been highly successful in facilitating the performance of imaging procedures such as MRI and
CT scans (Friday & Kubal, 1990; Phelps, 1990; Chandler, 1996; Simon, 1999).
Case Study 2: Claustrophobia

Take for example the case of a 43-year-old woman who su ered from convulsions that were resistant to
treatment with conventional anticonvulsant therapy. Appropriately, her neurologist wanted to obtain a brain
MRI to assess for the presence of a possible source of irritation that could explain the onset and maintenance
of the seizures. Nevertheless, the patient repeatedly refused the MRI scan because of claustrophobia. On two
occasions the patient presented to the MRI suite. The rst time she took a look at the machine and walked
away. The second time she was premedicated with diazepam (30 mg), but was unable to tolerate the
procedure after just a few minutes and had to stop. Finally, she had a psychiatric evaluation.
In my o ce she proved to be highly hypnotizable (9 out of 10). Under hypnosis we explored the associations
between the scanner and her anxiety. Images of a co n came to mind. These were followed by memories of
her father lying in the funeral home. He had died suddenly, without prior history or warning, of a massive
hemorrhagic stroke associated with a congenital aneurysm. We then explored her anxiety as it related to fears
of what the test might show. This included the possibility of a malformed blood vessel or other pathology that
might a ect her brain, as happened to her father. Once this was discussed she felt that it “was better to know
than to avoid.” She was trained in self-hypnosis. After inducing a relaxed state, she was instructed to “create
in your mind’s eye a place where you can feel safe and comfortable, knowing that sounds and people in the
room will not disturb you.” We also “practiced” going to the MRI scanner room by having her imagine that
she was both the patient in the room and the technician operating the machine. In this fashion she felt more
“in control” of the situation. The next day, we met her at the scanner room. Once she was on the imaging
table she induced a self-hypnotic trance. When the test began I left the room with the agreement that the
technician would let her know when the test was over. She imagined herself walking through a forest and
crossing a river. As she walked to the riverbank, instead of oating she saw herself slowly sinking as she
followed the contours of the river, walking down to the bottom of the river. Once on the bottom she held on to
some algae. When she exhaled, her breath formed a gigantic bubble or “cocoon” that allowed her to breathe
under water and be safe. As the magnets in the MRI shifted in position she imagined that the sound was the
p. 272 clanking sound of motorboat engines on the surface. She remained in this state for approximately 2 hours,
while both noncontrast and contrast tests were performed. She tolerated the procedure well and easily came
out of the trance state once the signal was given.
Hypnosis has been successfully used to help anxious patients tolerate procedures that otherwise would not
be performed, or the patient might need to be exposed to larger than normal doses of antianxiety
medications due to needle phobia. These include needle injections and phlebotomy (Dash, 1981; Zeltzer &
LeBaron, 1982; Bell, Christian, et al., 1983; Kellerman, Zeltzer, et al., 1983; Morse & Cohen, 1983; Nugent,
Carden, et al., 1984; Cyna, Tomkins, et al., 2007; Robertson, 2007; Abramowitz & Lichtenberg, 2009), needle
biopsy and aspiration (Usberti, Grutta d’Auria, et al., 1984; Adams & Stenn, 1992; Ellis & Spanos, 1994; Lang,
Berbaum, et al., 2006), bone marrow aspiration (Hageman-Wenselaar, 1988; Ellis & Spanos, 1994; Liossi &
Hatira, 1999), and lumbar punctures (Hageman-Wenselaar, 1988; Ellis & Spanos, 1994; Simon & Canonico,
2001; Kellerman, Zeltzer, Ellenberg, et al., 1983).

Case Study 3: Needle Phobia
One of our patients, a 47-year-old, married, successful businessman was referred for “inability to participate
in medical treatment.” The patient had recently been diagnosed with esophageal cancer, after presenting to
the emergency room with a 3-month history of weight loss, chills, shortness of breath, chest pains, and
di culty swallowing. Imaging studies revealed a large mass. Because of the size and location of the mass,
and the stage of the disease, he was turned down for treatment in his previous hospital. He was presented to
the tumor board of our institution where the gastrointestinal surgeons decided to take his case.
There was only one problem. The patient had experienced “terror of needles” from the age of 7. At that time
he was receiving immunizations at school when he panicked and moved abruptly, causing a needle to break
o the syringe and remain deep in his arm. He required surgery to remove it. From that moment on he did

everything possible to “stay far from them.”
In fact, while at the previous hospital institution he experienced an event which reinforced his fears. He was
asleep when a phlebotomist entered his room. She placed her tray lled with syringes, collection tubes, and
(of course) needles on his bed. As she began to explore his arm veins, he suddenly woke up, saw the needles,
and ed. That was the end of his admission.
He now faced two (and according to him equally di cult) problems: the tumor and his phobia to needles. The
proposed cancer treatment involved an aggressive course of high-dose chemotherapy and radiation. If this
approach was successful at reducing the tumor size, surgery would follow. He discussed his phobia with his
surgeon, who assured the patient that “every possible precaution would be taken.” Nevertheless, the patient
refused to enter the hospital. Finally, a psychiatric consultation was requested.
I saw the patient in my o ce. After reviewing his medical and psychiatric history it was obvious that
aggressive treatment (both physical and psychological) was required if he was to survive. He already had
delayed his chemotherapy and surgical intervention because of his phobia. His surgeon had placed him on
benzodiazepine medications, but despite his level of sedation, the phobia was still preventing him from
obtaining the urgently needed treatment. I suggested the addition of a selective serotonin reuptake-inhibitor
(SSRI), but realized that we might not have the time to wait for the medication to take e ect. Therefore we
decided to supplement his treatment with hypnosis.
The patient underwent his rst hypnotic trance during the rst session. Like many phobic patients, he proved
to be highly hypnotizable with an HIP of 8.5 out of 10. He was trained in self-hypnotic techniques. His
medications were rearranged. He was started on an SSRI, his short-acting benzodiazepine was switched to a
longer-acting drug, and he was ordered to practice his self-hypnotic exercise six times a day. On the third day
after our rst session, he called to say that he thought he was “ready.” I met him in the surgical clinic. With
the patient under hypnosis, a central line was placed to administer his chemotherapy. After 3 weeks of
aggressive chemotherapy and local radiation treatment, the patient was admitted to the hospital for surgical
excision of the mass.
He was able to tolerate every treatment aspect with only minimal discomfort. Unfortunately, his course was
di cult and lled by numerous complications including infections, the creation of several stulas, and the
development of a pneumothorax requiring bilateral chest tube and drainage placements. Nevertheless, he
continued to manage his phobia well. Certainly, given his complications he required multiple needle sticks
and even blood transfusions, but tolerated them well. In fact, the nursing sta was amazed and fascinated by
his “little ritual” prior to injections or blood draws while he “self-induced a hypnotic trance.” Certainly, we
believe that medications helped his overall anxiety and phobic condition. The patient said, “I could not have
gone through this without hypnosis.”
The concomitant use of hypnosis and medications is common practice in the psychosomatic medicine
service. Certainly, as in many other aspects of psychiatry and medicine, the combined used of multiple
complementary treatment modalities is the norm. Sometimes hypnosis is used alone because it is the
patient’s preference, the patient is an extremely good (highly hypnotizable) candidate, there are medical
contraindications to the use of central nervous system depressant agents (i.e., respiratory depression,
intraoperative EEG monitoring), or the clinician is dealing with a relatively simple procedure. Other times,
as in case study 3, the complexity of the situation requires more aggressive and prompt intervention. In that
case, we needed to move so quickly that we didn’t have much time for medication (the SSRI) to work.
Hypnosis played a key role in the patient’s accepting and going through treatment. It became an invaluable
adjunct to his overall treatment.
Dermatological Conditions

Psychogenic factors have been implicated in essentially all skin disorders (Cheek, 1961; Kellner, 1975;
p. 273 Manferto, 1975; Medansky & Handler, 1981; Tobia, 1982; Arone di Bertolino, 1983; Elitzur & Brenner,
1986; Tsushima, 1988; Haustein & Seikowski, 1990; Gherardi, Fabrizio, et al.,1993; Bellini, 1998; Shenefelt,
2000, 2002, 2003)
Hypnosis has been helpful for several speci c skin disorders: pruritus (Arone di Bertolino, 1983; Ament &
Milgrom, 1967; Shertzer & Lookingbill, 1987; Sampson, 1990; Mitchell, 1995; Rucklidge & Saunders, 1999,
2002; Tuerk & Koo, 2008; Tsiskarishvili, Eradze, et al., 2010), eczema (Faure & Burger, 1954; Vlarsky &
Janousek, 1960; Goodman, 1962; Zheltakov, IuK, et al., 1963; Kierland, 1965; Mirvish, 1978; Hajek,
Jakoubek, et al., 1989; Hajek, Jakoubek, et al., 1990; Hajek, Radil, et al., 1991; Mantle, 1999; Ersser, Latter, et
al., 2007), scleroderma (Surwit, Allen, et al., 1982; Freedman, Ianni, et al., 1984; Haustein, Weber, et al.,
1995; Seikowski, Weber, et al., 1995), atopic dermatitis (West, Kierland, et al., 1961; Stewart & Thomas,
1995), genital herpes simplex virus (Putilin, 1961; Arone di Bertolino, 1981; Gould & Tissler, 1984; Elitzur &
Brenner, 1986; Surman & Crumpacker, 1987; Fox, Henderson, et al., 1999; P tzer, Clark, et al., 2005),
psoriasis (Novotny, 1962; Secter & Barthelemy, 1964; Frankel & Misch, 1973; Waxman, 1973; Winchell &
Watts, 1988; Kantor, 1990; Zachariae, Oster, et al., 1996; Tausk & Whitmore, 1999), chronic urticaria
(Shertzer & Lookingbill, 1987), chronic plaque-type psoriasis (Tausk & Whitmore, 1999) and warts, even
though they result from viral agents such as human papillomavirus (Vollmer, 1946; Mc, 1949; Sinclair-
Gieben & Chalmers, 1959; Ullmann, 1959; Wendel, 1959; Seeman, 1960; Ullman & Dudek, 1960; Clarke,
1965; Lyell, 1966; Dudek, 1967; Stankler, 1967; Leidman Iu, 1968; Konig, 1969; Nasemann, 1969; Tenzel &
Taylor, 1969; Surman, Gottlieb, et al., 1972; French, 1973; Leidman Iu, 1973; Surman, Gottlieb, et al., 1973;
Fischer, 1974; Clawson & Swade, 1975; Skalicanova, Nagyova, et al., 1977; Tasini & Hackett, 1977; Cohen,
1978; Dreaper, 1978; Johnson & Barber, 1978; Sheehan, 1978; Wilkening, 1978; Johnson, 1980; Rowe, 1982;
Straatmeyer & Rhodes, 1983; Morris, 1985; Noll, 1988; Spanos, Stenstrom, et al., 1988; Steele & Irwin, 1988;
Spanos, Williams, et al., 1990; Bolton, 1991; Esman, 1992; Ewin, 1992; Ferreira & Duncan, 2002; Herold,
2002; Meineke, Reichrath, et al., 2002; Phoenix, 2007; Ewin, 2011; Kekecs & Varga, 2011).
In chronic urticaria and atopic dermatitis, hypnosis has led to long-term improvements.
In chronic urticaria, remissions of 7 years duration as measured by three self-report parameters were
achieved by hypnosis (Shertzer & Lookingbill, 1987). Of interest, highly hypnotizable subjects had fewer
hives and more frequently related stress as a causative factor of their outbreaks. Improvements were
maintained during a 2-year follow-up in a group of patients su ering from atopic dermatitis resistant to
conventional treatment, who experienced statistically signi cant subjective and objective bene t (p < 0.01)
after treatment with hypnosis (Stewart & Thomas, 1995).
A 3-month randomized, single-blind, controlled trial used hypnosis in adults with stable, chronic, plaque-
type psoriasis. Highly or moderately hypnotizable subjects were randomized to receive either hypnosis with
active suggestions of improvement or neutral hypnosis with no mention of their disease process. The
results demonstrated that highly hypnotizable subjects showed signi cantly greater improvement than did
moderately hypnotizable subjects, independent of treatment group assignment (Tausk & Whitmore, 1999).
Published controlled studies on the use of hypnosis to cure warts are con ned to using direct suggestion in
hypnosis (DSIH), with cure rates of 27% to 55% (Johnson, 1980). Prepubertal children respond to DSIH
almost without exception, but adults often do not. Clinically, many adults (80%) who fail to respond to
DSIH will heal with individual hypnoanalytic techniques that cannot be tested against controls (Ewin, 1992).
A study comparing the e ects of hypnotic suggestions versus topical salicylic acid and placebo found that
subjects in all groups developed equivalent expectations of treatment success, but only the hypnotic

subjects had lost signi cantly more warts than the no-treatment controls at the 6-week follow-up (Spanos,
Williams, et al., 1990).
At least one carefully controlled study demonstrated that simple hypnotic instructions to the e ect that the
warts would “tingle and disappear” resulted in a rate of improvement that was signi cantly better than the
spontaneous rate of remission of warts (Surman, et al., 1973).
The ability of highly hypnotizable individuals to control peripheral skin temperature and blood ow has
been replicated in several well-controlled experiments (Zimbardo, Maslach, et al., 1970; Grabowska, 1971;
Kistler, Mariauzouls, et al., 1999). Some have demonstrated plethysmographic measure changes caused by
hypnotically mediated rapid vasodilatation after direct suggestion in cases of Raynaud’s disease treated
with hypnosis (Conn & Mott, 1984).
Gastrointestinal Conditions
Gastrointestinal conditions helped by hypnosis include in ammatory bowel disease such as ulcerative
colitis, Crohn’s disease, and related conditions (Susmano, Feldfeber, et al., 1960; Grumiller & Strotzka,
1973; Freiwald, Liedtke, et al., 1975; Snape, 1994; Schafer, 1997; Mawdsley, Jenkins, et al., 2008), irritable
bowel syndrome (Byrne, 1973; Whorwell, Prior, et al., 1984; Whorwell, Prior, et al., 1987; Whorwell, 1989,
1991; Snape, 1994; Francis & Houghton, 1996; Houghton, Heyman, et al., 1996; Galovski & Blanchard, 1998,
2002; Vidakovic-Vukic, 1999; Forbes, MacAuley, et al., 2000; Gonsalkorale, Houghton, et al., 2002; Palsson,
Turner, et al., 2002; Gonsalkorale, Miller, et al., 2003; Gonsalkorale & Whorwell, 2005; Tan, Hammond, et
al., 2005; Whorwell, 2005, 2008, 2009; Barabasz & Barabasz, 2006; Palsson, 2006; Palsson, Turner, et al.,
2006; Roberts, Wilson, et al., 2006; Simren, 2006; Whitehead, 2006; Wilson, Maddison, et al., 2006; Al
Sughayir, 2007; Vlieger, Menko-Frankenhuis, et al., 2007; Webb, Kukuruzovic, et al., 2007; Hefner, Rilk, et
al., 2009; Miller & Whorwell, 2009; Carruthers, Morris, et al., 2010; Shinozaki, Kanazawa, et al., 2010),
dysphagia (Magonet, 1961; Black, 1980; Gurian, 1981; Kopel & Quinn, 1996), vocal cord dysfunction (Anbar &
p. 274 Hehir, 2000), esophageal achalasia/cardiospasm (Schneck, 1958; Jones, Cooper, et al., 2006), irritable
bowel syndrome (Houghton, Heyman, et al., 1996), and peptic and duodenal ulcer disease (Bick, 1958; Zane,
1966; Montera, 1968; Kanishchev & Shutova, 1974; Bishay, Stevens, et al., 1984, 1988; Colgan, Faragher, et
al., 1988; Whorwell, 1991; Francis % Houghton, 1996; Soo, Moayyedi, et al., 2005).
The clinical relevance of these studies was illustrated by a controlled trial of hypnosis in relapse prevention
of duodenal ulcers (Colgan, Faragher, et al., 1988). In this study, 30 patients with rapidly relapsing ulcer
disease were randomly assigned after ranitidine treatment to hypnosis or no further treatment. On follow-
up, 100% of the control subjects but only 53% of the hypnosis patients experienced relapse.
A randomized controlled trial demonstrated that IBS-patients treated with hypnosis reported signi cant
improvement in pain, abdominal distension, and diarrhea, as well as emotional well-being compared with a
control group. Absenteeism from work was reduced. These improvements continued during the 18-month
follow-up period (Houghton, Heyman, et al., 1996).
A randomized study comparing the use of “gut-directed hypnotherapy” versus a specially devised
audiotape intervention demonstrated a reduction in median symptom score, from 14.0 to 8.5, in
hypnotherapy patients compared with an unchanged score of 13 in audiotape patients (P < 0.05) (Forbes,
MacAuley, et al., 2000).
Hypnosis has been repeatedly used with great success for symptomatic control in emesis, regardless of the
cause, in both children (Keller, 1995) and adults (Covino & Frankel, 1993; Faymonville, 1995). In an
excellent example of how hypnosis actually exerts direct physiologic changes, researchers monitored the

gastric acid secretion among 28 highly hypnotizable subjects (Klein & Spiegel, 1989). When subjects were
hypnotized and instructed to eat an imaginary meal, basal acid output rose 89%. Similarly, when instructed
to use hypnosis to experience deep relaxation they exhibited a signi cant (39%) drop in basal acid output.
Cardiac Conditions
In the treatment of cardiovascular problems, applications of hypnosis have been discussed in angina
pectoris (Kobayashi, Ishikawa, et al., 1970; Wilkinson, 1981; Zaitsev, Sha kova, et al., 1990), essential
hypertension (Friedman & Taub, 1977, 1978; Gay, 2007), and recovery from myocardial infarction and
cardiac surgery (Gruen, 1972; Kavanagh, Shephard, et al., 1974; Zaitsev, Sha kova, et al., 1990; Greenleaf,
Fisher, et al., 1992; Kosov, Zamotaev Iu, et al., 1997; Baglini, Sesana, et al., 2004).
Hypnosis can a ect the patient’s perception of exertion and in uence the relation between the sympathetic
and vagal systems. Gemignani et al. (2000) studied the physiological and EEG responses of highly
hypnotizable volunteers su ering from simple phobia. Under hypnotic suggestion, subjects exposed to
aversive stimuli experienced signi cant increases in heart rate (HR) and respiratory rate (RR), with a shift
of the sympathovagal indexes toward a sympathetic predominance. These subjects also experienced a
signi cant increase in the EEG gamma band with left frontocentral prevalence.
Finally, Williamson and colleagues (2001), using healthy, highly hypnotizable volunteers, demonstrated
dramatic changes in ratings of perceived exertion (RPE) when asked to imagine themselves in an uphill
bicycle grade. They found signi cant increases in RPE, HR, mean blood pressure (BP), rCBF in the right
insular cortex, and right thalamic activation. Conversely, when subjects were asked to imagine themselves
on a perceived downhill grade they observed decrements in both the ratings of perceived exertion RPE and
rCBF in the left insular cortex and anterior cingulate cortex, but it did not alter exercise HR or BP responses.
Pulmonary Conditions
Hypnosis has been useful for asthma (Herraiz Ballestero, Rodriguez Fontela, et al., 1952; Magonet, 1952;
White, 1961; Maher-Loughnan, Mason, et al., 1962; Fry, Mason, et al., 1964; Brown, 1965, 1968; Gilder,
1968; Luparello, Lyons, et al., 1968; Maher-Loughnan, 1970; Smith, Colebatch, et al., 1970; Moore eld,
1971; Arono , Arono , et al., 1975; Collison, 1975; Ben-Zvi, Spohn, et al., 1982; Neinstein & Dash, 1982;
Lewis, Lewis, et al., 1983; Zamotaev, Sultanova, et al., 1983; Ewer & Stewart, 1986; Pastorello, Codecasa, et
al., 1987; Morrison, 1988; Spector & Kinsman, 1988; Murphy, Lehrer, et al., 1989; Wilkinson, 1989; Isenberg,
Lehrer, et al., 1992; Kohen & Wynne, 1997; Hackman, Stern, et al., 2000; Anbar, 2003; Brown, 2007), hay
fever (Langewitz, Izakovic, et al., 2005), and hyperventilation (Clarke & Gibson, 1980).
Patients can learn to use self-hypnotic techniques rather than medication when they begin to feel an
anxiety-precipitated asthmatic attack coming on. This may help interrupt the vicious cycle of anxiety and
bronchoconstriction (Arono , Arono , et al., 1975; Collison, 1975; Gluzman & Ziselson, 1987; Kohen, 1987;
Kohen & Wynne, 1997)
A common technique is to have asthmatic patients enter a state of self-hypnosis and imagine that they are
somewhere they naturally breathe easily, such as breathing cool ocean spray (Spiegel & Spiegel, 1987). In
asthmatic patients, hypnotizability is correlated with treatment response (Collison, 1975). A study of 120
adult asthma patients experienced signi cant bene t from the use of hypnosis (Collison, 1975). The authors
described that 21% of subjects had an “excellent response” to treatment, becoming completely free from
asthma and requiring no drug therapy. An additional 33% had a “good response” with “worthwhile
decrease in frequency and severity of the attacks of asthma” or a decrease in drug requirements.
Furthermore, about half of the 46% who did not respond had a marked subjective improvement in general

well-being. Others have reported similar results in children (Arono , Arono , et al., 1975; Kohen, Olness, et
al., 1984; Gluzman & Zisel’son, 1987; Kohen, 1987).
A randomized controlled trial including 39 adults with mild to moderate asthma demonstrated that after
brief treatment with hypnosis, patients with a high susceptibility score showed marked improvement
p. 275 (74.9%) in the degree of bronchial hyperresponsiveness to a standardized methacholine challenge test,
and a reduction in the use of bronchodilators by 26.2% (Ewer & Stewart, 1986).
Another study found that after self-hypnotic treatment and training, patients with treatment-resistant
asthma reported a two-thirds decline in the number of hospital admissions (due to complications of
asthma), decreased need for the use of PRN-steroid medications, reduced length in hospital stay, and an
overall improvement in their perception of illness (Morrison, 1988). A retrospective analysis of 121
asthmatic patients who were treated by hypnotherapy showed that 21% of the subjects had an excellent
response to treatment, becoming completely free from asthma and requiring no drug therapy (Collison,
1975). And an additional 33% had a good response, with worthwhile decrease in frequency and severity of
the attacks of asthma or a decrease in drug requirements.
Oncological Care
Hypnosis improves the tolerance of treatments such as chemotherapy (Hilgard & LeBaron, 1982; Zeltzer,
Kellerman, et al., 1983; Zeltzer, LeBaron, et al., 1984; Katz, Kellerman, et al., 1987; Syrjala, Cummings, et al.,
1992; Jacknow, Tschann, et al., 1994; Genuis, 1995; Steggles, Damore-Petingola, et al., 1997; Renouf, 1998;
Marchioro, Azzarello, et al., 2000; Richardson, Smith, et al., 2006; Figueroa-Moseley, Jean-Pierre, et al.,
2007; Neron & Stephenson, 2007; Richardson, Smith, et al., 2007; Jakubovits, 2011), anticipatory anxiety
and side e ects (Ho man, 1982; Redd, Andresen, et al., 1982; Axelrod, Vinciguerra, et al., 1988; Marchioro,
Azzarello, et al., 2000), external beam radiation therapy (Bertoni, Bonardi, et al., 1999; Steggles, 1999),
interventional radiology (Lang, Joyce, et al., 1996; Lang, Benotsch, et al., 2000; Spiegel, 2006), and surgery,
its recovery, and painful procedures (Kessler & Dane, 1996; Lambert, 1996; Spiegel & Moore, 1997; Wild &
Espie, 2004).
As discussed before, hypnosis may be of assistance in the management of the discomfort and anxiety
associated with many of the procedures needed in the treatment of cancer, such as chemotherapy, radiation
therapy, claustrophobia, and the need for repeated diagnostic tests.
Obstetrics and Gynecology
Hypnosis has multiple applications in the eld of obstetrics and gynecology (Mun, 1964; Ferraris, 1975;
Goldman, 1992; Oster, 1994; Baram, 1995; Schauble, Werner, et al., 1998; Brown & Hammond, 2007;
VandeVusse, Irland, et al., 2007). These include assistance in obstetrical delivery and pain management
during labor (Winkelstein, 1958; Werner, 1959; Rodger, 1961; Gueguen, 1962; Gross & Posner, 1963; Roden,
1970; Johnson, 1980; Freeman, Macaulay, et al., 1986; Oster, 1994; Schauble, Werner, et al., 1998; Brown &
Hammond, 2007; VandeVusse, Irland, et al., 2007; Landolt & Milling, 2011), management of premature
contractions (Omer, Friedlander, et al., 1986), hypnotic breech to cephalic conversion (Mehl, 1994; Boog,
2004; Tiran, 2004), hyperemesis gravidarum (Kroger & De, 1946; Giorlando & Mascola, 1957; Mun, 1964;
Piscicelli, 1968; Muzelak, 1974; Savel’ev, 1974; Fuchs, Paldi, et al., 1980; Smith, 1982; Poliakov, 1989;
Frankel, 1994; Iancu, Kotler, et al., 1994; Torem, 1994; Simon, 1999; Simon & Schwartz, 1999; Brent, 2002;

Buckwalter & Simpson, 2002; McCormack, 2010), pregnancy-induced hypertension (Smith, 1989), sexual
dysfunction (Baram, 1995), urinary incontinence (Baram, 1995), condylomata acuminata (Straatmeyer &
Rhodes, 1983; Klapper, 1984), chronic pelvic pain (Baram, 1995), and functional infertility (Mun, 1964;
Gravitz, 1995).
Authors have reported the use of hypnotic preparation for labor and delivery, suggesting various advantages
over Lamaze techniques (Oster, 1994). Among the advantages of using hypnosis are an improvement in the
mother’s psychological comfort, a heightened sense of involvement in the birth process, a diminished level
of anxiety, and improved pain management.
A study of the e ect of hypnotic relaxation as an adjunct to pharmacological treatment of premature

contractions demonstrated that the rate of pregnancy prolongation was signi cantly higher for the
hypnotic-relaxation group than for the medication-alone group (Omer, Friedlander, et al., 1986).
Unfortunately, most of the writings in this area are in the form of case reports or small series.
A prospective case series comparing 100 pregnant women whose fetuses were in breech position at 37 to 40
weeks’ gestation and a matched comparison group of women with similar obstetric and sociodemographic
parameters derived from clinical databases showed that 81% of the fetuses in the hypnotic intervention
group converted to vertex presentation compared with only 48% of those in the comparison (control) group
(Mehl, 1994). Others have further commented on the topic, but no other studies have been published (Boog,
2004; Tiran, 2004).
Pain Management
The experience of pain does not exist in isolation. It is usually interpreted within the context of the
subjective distress associated with a major medical illness or somatic trauma and in the context of the
patient’s life experiences and temporal social circumstances. The “pain experience” represents a
combination of both tissue damage and the emotional reaction to it. There is ample evidence suggesting
that psychological factors greatly in uence the pain experience in either positive or negative ways (Beecher,
1956). In fact, the intensity of pain is directly associated with its meaning. Hypnosis, by the mechanisms of
dissociation and absorption, can mediate an alteration in the subjective experience of pain.
Various well designed studies have described the usefulness of hypnotic intervention as adjunct to analgesia
(Moskowitz, 1996). The use of hypnosis has been shown to increase tolerance to the procedure among
angioplasty patients (Weinstein & Au, 1991). Similarly, patients on the hypnosis group reported lower levels
p. 276 of intraoperative pain scores during surgery compared to patients receiving conscious intravenous sedation
(control group [Faymonville, Fissette, et al., 1995]). Both studies found that hypnotized patients required
less narcotic pain medication during the procedure compared to controls.
A randomized clinical trial of metastatic breast cancer patients demonstrated that a combination of
hypnosis and group psychotherapy resulted in a 50% reduction in pain, which was accompanied by
similarly signi cant reduction in mood disturbance (Spiegel, Bloom, et al., 1981).
Among subjects undergoing interventional radiologic procedures, the use of hypnosis was associated with a
signi cant reduction in the need of anesthesia in the form of intravenous conscious sedation or patient-
controlled anesthesia (Lang, Joyce, et al., 1996). The hypnosis group used less drug (0.28 vs. 2.01 drug units;
p < .01) and reported less pain (median pain rating 2 vs. 5 on a 0–10 scale; p < .01). In addition, signi cantly
more control patients exhibited oxygen desaturation and/or needed interruptions of their procedures for
hemodynamic instability, thus suggesting that self-hypnotic relaxation can reduce the need for sedative

medications and improve the safety of the procedure.
A study of moderately to highly hypnotizable adults with chronic low back pain demonstrated that they
were able to signi cantly reduce pain perception following hypnotic analgesia instructions during cold-
pressor pain training (Crawford, Knebel, et al., 1998). During the hypnotic condition there was evidence of
an enhanced N140 in the anterior frontal region, suggesting inhibitory processing; reduced amplitudes of
P200(bilateral midfrontal and central, and left parietal) and P300 (right midfrontal and central), suggesting
decreased spatiotemporal perception. Meantime, subjects reported highly signi cant mean reductions in
perceived sensory pain and distress, reduction in chronic pain, increased psychological well-being, and
increased sleep quality.
Most hypnoanalgesia treatment techniques involve the creation of a state of physical relaxation coupled
with visual or somatic imagery, which allows a substitute focus of attention away from the physical
sensation of pain. The technique to be used depends on the patient’s hypnotic capacity. Highly hypnotizable
individuals are much better at dissociating body parts or moving the pain to another part of the body or even
away from the body. They can use fairly simple and direct imagery such as “seeing the pain melting away”
or “being washed away by the river’s waters.” Some highly hypnotizable individuals may create a sensation
of numbing at the a ected area just by suggesting it.
Meanwhile, poorly suggestible patients may need more assistance from the therapist—for instance, more
direct or concrete suggestions such as imagining injection of a local anesthetic into the a ected area
accompanied by its associated tingling numbness. A useful suggestion is to have subjects remember what a
Novocain shot felt like the last time they went to the dentist. Then remind them of how slowly the gum, then
the cheeks and the tongue became numb and “went to sleep.” Once they can hold the image on their mind,
they can imagine “the same shot” being administered “wherever it is needed in your body. Then slowly
imagine the progressive numbing that follows as the medication spreads through the . . . (skin, nerves,
muscle, or whatever the patient needs).” Other images, such as changes in temperature, either warmth or
coolness, of the area may also be helpful. Like “imagine the feeling of immersing your hand in cold water or
snow until it is numb.”
The images or metaphors that are selected for pain control may be used to lter the hurt or to transform the
painful experience. Most patients who use hypnoanalgesia can still feel the pain, but may be unable to
distinguish between the signal of pain and the discomfort caused by the signal. Thus, patients are taught not
to ght but to transform painful signals into less uncomfortable ones. Fighting pain may only enhance it by
focusing attention on the pain and increasing physical tension, which can place traction on painful body
parts thereby increasing the sense of discomfort in adjacent tissues.
Regardless of any speci c induction or metaphor use, there are four speci c steps in the use of hypnosis
that can make psychotherapy for pain management briefer, more goal-oriented, and e cient: (1) the
assessment of hypnotizability; (2) the induction of hypnoanalgesia and development of individualized pain
coping strategies; (3) the use of direct suggestion, cognitive reframing, hypnotic metaphors, and pain relief
imagery; and (4) brief psychodynamic reprocessing, during the trance state, of emotional factors in the
patient’s experience of chronic pain (Eimer, 2000).
The precise mechanisms that mediate hypnotic analgesia are not known. Some time ago it was believed that
hypnoanalgesia somehow involved the release or production of endogenous opioids (Frid & Singer, 1979).
By now, several studies have not only failed to prove this theory but have proven that hypnotic analgesia is
completely una ected by the administration of opioid antagonist agents such as naloxone (Goldstein &
Hilgard, 1975; Spiegel & Albert, 1983; Moret, Forster, et al., 1991). Despite lack of de nitive explanation
regarding its mechanism of action, there is no doubt that hypnotic analgesia works (DeBenedittis, Panerai,
et al., 1989).

Studies have shown the superiority of hypnotic analgesia over placebo (McGlashan, Evans, et al., 1969) and
acupuncture (Knox & Shum, 1977). In fact, a study using hypnosis as a method of analgesia reported
signi cant increases of tolerance of pain and distress during hypnosis as compared to the waking state, thus
hypothesizing that highly hypnotizable subjects were able to experience a hypnotically induced dissociation
between the sensory/discriminative and the a ective/motivational dimensions of pain (DeBenedittis,
Panerai, et al., 1989). After measuring plasma concentrations of beta-endorphin and adrenocorticotropic
hormone (ACTH), they concluded that hypnotic analgesia was not mediated either by endorphins or by
ACTH.
A number of studies have proposed new potential biological mechanisms mediating hypnoanalgesia. One
study examined the changes in motor neuron excitability to electrical stimulus during conditions of resting
wakefulness (not hypnotic) and suggestions for hypnotic analgesia. Its ndings suggest that hypnotic
sensory analgesia was, at least in part, (Kiernan, Dane, et al., 1995) mediated by either descending spinal
cord antinociceptive mechanisms or by diminished nociceptive awareness mediated by other brain
mechanisms.
p. 277 Other studies utilizing SERP measures to noxious stimuli seem to con rm the presence of active inhibitory
processes during cognitive strategies in hypnotic analgesia, and to con rm that these inhibitory processes
also regulate the autonomic activities in pain perception (De Pascalis, Magurano, et al., 2001). For example,
33 subjects’ neural responses (EEG) were measured during the 40–540 ms period following phasic electrical
stimulations to the right hand, under control and hypnosis conditions (Croft, Williams, et al., 2002).
Resultant amplitudes were computed and grouped into seven scalp topographies, and for each frequency
relations between these topographies and pain ratings, performance, and stimulus intensity measures were
assessed. Gamma activity (32–100 Hz) over prefrontal scalp sites predicted subject pain ratings in the
control condition (r=0.50, P=0.004), and no other frequency/topography combination did. This relation was
unchanged by hypnosis in the poorly hypnotizable subjects but was not present in the highly hypnotizable
subjects during hypnosis, suggesting that hypnosis interferes with this pain/gamma relation.
In a group of patients with bromyalgia, hypnoanalgesia studied using PET scans found that patients
experienced less pain during hypnosis than at rest. At the same time, the cerebral blood ow was bilaterally
increased in the orbitofrontal and subcallosal cingulate cortices, the right thalamus, and the left inferior
parietal cortex, and was decreased bilaterally in the cingulate cortex, supporting the notion of the
multifactorial nature of hypnotic analgesia with contributions from cortical and subcortical brain regions
(Wik, Fischer, et al., 1999).
Another PET study compared brain images of subjects in a hypnotic resting state with mental imagery and a
hypnotic state with stimulation; namely, warm non-noxious versus hot noxious stimuli applied to right
thenar eminence (Faymonville, Laureys, et al., 2000). Statistical parametric mapping demonstrated that
noxious stimulation caused an increase in rCBF in the thalamic nuclei, anterior cingulate, and insular
cortices, while the hypnotic state induced a signi cant activation of a right-sided extrastriate area and the
anterior cingulate cortex. The interaction analysis showed that the activity in the anterior (mid-) cingulate
cortex was related to pain perception and unpleasantness di erently in the hypnotic state than in control
situations. Hypnosis decreased both pain sensation and the unpleasantness of noxious stimuli, which
suggests that hypnotic analgesia with an instruction that the pain will not be bothersome (rather than
literally reduced in intensity) is mediated by reduced activity in the anterior cingulate cortex (Faymonville,
Laureys, et al., 2000).
A follow-up study among highly hypnotizable right-handed volunteers using H2(15)O-PET found that
hypnosis, compared to the resting state, reduced pain perception by 50%, while the pain perception during
rest and mental imagery was not signi cantly di erent (Faymonville, Roediger, et al., 2003). Analysis of
PET data showed that the hypnotic state compared to normal alertness (i.e., rest and mental imagery)

signi cantly enhanced the functional modulation between midcingulate cortex and a large neural network
encompassing bilateral insula, pregenual anterior cingulate cortex, pre-supplementary motor area, right
prefrontal cortex, and striatum, thalamus, and brainstem. These ndings point to a critical role for the
midcingulate cortex in the modulation of a large cortical and subcortical network underlying its in uence
on sensory, a ective, cognitive, and behavioral aspects of nociception in the speci c context of hypnosis.
More recently, PET imaging studies have con rmed that hypnosis, when used to produce hypnotic
analgesia, can modulate the cerebral network involved in noxious perception (Faymonville, Boly, et al.,
2006). In fact, when compared to the resting state, hypnosis reduced pain perception in somatosensory
cortex by approximately 50%. In these subjects, hypnoanalgesia-induced reduction of a ective and sensory
responses to noxious thermal stimulation was modulated by the activity in the midcingulate cortex (area
24a’). Also, compared to normal alertness (i.e., rest and mental imagery) the hypnotic state signi cantly
enhanced the functional modulation between midcingulate cortex and a large neural network involved in
sensory, a ective, cognitive, and behavioral aspects of nociception.
After determination of the heat pain threshold of 12 healthy volunteers, fMRI scans were performed during
repeated painful heat stimuli (Schulz-Stubner, Krings, et al., 2004). Subjects under the hypnosis paradigm
exhibited less activation in the primary sensory cortex, the middle cingulate gyrus, precuneus, and the
visual cortex when compared with responses without hypnosis. An increased activation was seen in the
anterior basal ganglia and the left anterior cingulate cortex. There was no di erence in activation within the
right anterior cingulate gyrus in our fMRI studies, and no activation was seen within the brainstem and
thalamus under either condition. These ndings suggest that clinical hypnosis may prevent nociceptive
inputs from reaching the higher cortical structures responsible for pain perception.
The development of “neurosignatures of pain” can in uence subsequent pain experiences (Melzack, 1991;
Coderre, Katz, et al., 1993; Melzack, 1993) and may be expanded in size and easily reactivated (Melzack,
1991, 1993; Elbert, Flor, et al., 1994). Therefore, hypnosis and other psychological interventions need to be
introduced early as adjuncts in medical treatments for onset pain before the development of chronic pain
(Crawford, Knebel, et al., 1998).
Application of Hypnosis in Psychiatric Disorders Pertinent to
Psychosomatic Medicine
The use of hypnosis in the management of psychiatric disorders in general is beyond the scope of this
chapter and has been discussed elsewhere. (Maldonado & Spiegel, 2002, 2008). Yet, there are some speci c
psychiatric disorders that are particularly pertinent for the psychosomatic medicine specialist, such as the
management of traumatic events related to posttraumatic stress disorder (Maldonado & Spiegel, 1994,
1998, 2002, 2008; Cardeña, Maldonado, et al., 2008), acute phobic reactions interfering with medical care
(e.g., claustrophobia or needle phobia), behavioral modi cation (e.g., smoking and weight management,
p. 278
sleep disturbances), and treatment of some somatoform disorders (i.e., conversion disorder [Maldonado &
Spiegel, 2000; Maldonado, 2007).

Posttraumatic Stress Disorder
Initially, the principal role for hypnosis in the psychotherapy of trauma was limited to abreaction, based on
Freud’s cathartic method. The idea was that some intense a ect associated with the traumatic event needed
to be released, and that simply repeating the event with its associated emotion in the trance state would
su ce to resolve the symptoms. However, it became clear to Freud that conscious cognitive work must be
done on the material for it to be successfully worked through (Freud, 1914/1958).
A number of studies among individuals su ering from posttraumatic stress disorder (PTSD) have
demonstrated that these patients usually score in the high hypnotizability range (Stutman & Bliss, 1985;
Spiegel, Hunt, et al., 1988; Cardeña, Maldonado, et al., 2008). Reports also suggest high hypnotizability
scores among children who were victims of severe punishment during childhood (Nash, Lynn, et al., 1984;
Spiegel & Cardeña, 1991). Some researchers in the eld suggest a possible explanation, that the impact of
the stress su ered during trauma encourages a more e ective use of dissociative defenses and self-
hypnotic abilities, thus enhancing or mediating symptomatology (Spiegel, Detrick, et al., 1982; Kluft, 1984,
1992). If this hypothesis is correct, then the controlled use of hypnosis in the clinical setting may assist in
modulating and managing symptoms associated with PTSD and, over time, help to integrate memories of
trauma (Maldonado & Spiegel, 1994).
In fact, the major categories of symptoms in PTSD are similar to the components of the hypnotic process
(American Psychiatric Association, 1994; Maldonado & Spiegel, 1994, 2007; Maldonado, Page, et al., 2002).
Hypnotic absorption is similar to the intrusive reliving of traumatic events. When in a ashback, trauma
victims become so absorbed in reexperiencing the traumatic event that they lose touch with their present
surroundings and even forget that the events took place in the past. Similarly, patients su ering from PTSD
may dissociate feelings to the extent of experiencing the so-called “psychic numbing,” which allows them
to disconnect current a ects from their everyday experience in an attempt to avoid emotions triggering
memories associated with the trauma. Finally, suggestibility is comparable to hyperarousal. The heightened
sensitivity to environmental cues observed in patients su ering from PTSD is similar to that experienced by
a hypnotized individual who responds to suggestions of coldness by shivering.
For therapy to be e ective in cases of traumatic stress, cognitive restructuring, emotional expression, and
relationship management must accompany the patient’s controlled reexperiencing of the traumatic events.
To that e ect, the therapeutic environment must provide the patient with an enhanced sense of control over
the memories of the experience. One of the ways to accomplish that is through symbolic restructuring of the
traumatic experiences during work with hypnosis (Spiegel & Spiegel, 1987) and the use of a grief work
model (Spiegel, 1981). Hypnosis can be used to provide controlled and safe access to the dissociated or
repressed memories of the traumatic experience at a pace the patient can tolerate, and then can assist
patients to restructure their memories of the events.
Given the growing evidence that many people enter a dissociated state during physical trauma (Spiegel &
Cardeña, 1991; Cardeña & Spiegel, 1993; van der Kolk, Hostetler, et al., 1994; van der Kolk & Fisler, 1995;
Butler, Duran, et al., 1996; Cardeña, Maldonado, et al., 2008) and the principle of state-dependent memory
(Bower, 1981; Bremner, Krystal, et al., 1996; Butler, Duran, et al., 1996), it makes sense that enabling
patients to enter a structured dissociative state in therapy would facilitate their access to memories of the
traumatic experience—memories that can be worked through to resolve the posttraumatic
symptomatology. In the more immediate context of the medical setting, the use of hypnosis can help to
control the dissociative symptoms and traumatic ashbacks, help manage anxiety symptoms, and improve
sleep. Over the long term, though, hypnosis can be helpful in allowing the victim to review aspects of the
trauma in a controlled manner. Memories can be experienced or reviewed for a time with the assurance that

they can be put aside afterward. In the context of hypnotic facilitated psychotherapy, patients can be quickly
taught how to produce a state of physical relaxation despite whatever psychological stress they experience,
thereby dissociating the somatic reaction from the psychological preoccupation and allowing for
modulation of the traumatic memory and an enhanced sense of control over the experience. Patient and
therapist can then nd a condensation image that symbolizes some aspect of the trauma.
The Split Screen Technique

It is often helpful to have patients project the images of the traumatic event on an imaginary screen, which
gives them some sense of distance from the event. It is also useful to divide the screen in half, having the
patient picture on one side some aspect of the event (e.g., a trauma victim’s image of the accident) and on
the other side of the screen some positive aspect of the event (e.g., having survived and being able to be with
the family; veering the car into a divider in order to prevent hurting someone else). This exercise enables the
patient to restructure his or her view of the incident—facing it, but not simply in the familiar terms of the
powerlessness, victimization, pain, and fear with which it was initially associated. Patients can then be
taught a self-hypnosis exercise in which they grieve and work through traumatic memories while
p. 279 enhancing their sense of control over the process (Spiegel, 1981).
p. 280
Case Study 4: Treatment-Related Posttraumatic Stress Disorder
Hypnosis can also be very e ective in the management of patients who may have phobia due to previous bad
medical experiences or have PTSD secondary to previous past procedures or treatment. One of our patients
was a 75-year-old married woman who had been recently diagnosed with breast cancer. She had discovered
a “lump” in her breast a few months earlier, which she brought to her primary care physician’s attention. He
suspected breast cancer and immediately referred her to a surgeon in our institution. She was soon scheduled
to undergo a needle biopsy. She informed him that she had su ered from claustrophobia all her life and
didn’t know whether she could tolerate a surgical procedure. He reassured her that “You will be sound asleep
and will notice nothing.”
She was admitted to the one-day surgical suite thinking, “Everything has been taken care of.” Soon after

arriving, she received her rst “shock” when a nurse came into her area to place an IV line. The patient
thought that someone would “give me something to take care of my anxiety.” After the IV was in place,
someone injected a “sedative” but she didn’t feel any anxiety relief. Soon afterward her stretcher was
wheeled to the surgical suite and before she had time to protest, her arms and legs were placed in restraints,
she was draped, her face was covered, and then “the mask was placed.” She recalls that as “the most
traumatic experience in my life.” For whatever reason she did not respond to the anesthesia well and
remembers being conscious “most of the time.”
After surgery she was shaken. In fact, she exhibited many symptoms of PTSD. One thing was clear in her
mind: “I will never go through this again.” A few days later, when she went to the surgeon’s o ce to get the
results of her biopsy, she was informed that she had cancer and would need further treatment. Her options
were a lumpectomy followed by radiation therapy or a radical mastectomy. She knew two things: she didn’t
want to have further surgery. But if she needed surgery, she wanted to “preserve the breast if she could,” so
she decided to explore the rst option.
She made an appointment with the radiation oncology clinic for an evaluation as part of the
lumpectomy/XRT treatment plan. When she arrived at the hospital she found that the XRT Clinic was in the
basement of the building. It took her over three hours of pain and agony in the lobby “trying to force myself
to get down there.” Finally, the social worker for the oncology service found her and brought her down. As she
walked through the unit the patient had a panic attack. Frightened and anxious, she ran out of the building
and decided she could not go through the treatment. Her surgeon was noti ed of the events and he quickly
called her. She informed him that she “couldn’t do it.”
After much talking over the phone, the patient agreed to “think about it for a while.” When 2 months had
passed with no news from the patient, the surgeon called her again and stressed the need to do something
quickly. The patient asked for some more time. The surgeon gave her one more week to think about it. A week
later, the surgeon called her again to nd out her decision. If she could not undergo radiation therapy (XRT),
she needed to do the radical mastectomy as soon as possible. She dreaded this alternative as much as the XRT,
so she agreed to try the presurgical meeting with the radiation therapy group again. During her second visit
to the XRT suite, the patient was greeted and escorted by a social worker and a nurse, who stayed with her the
entire time. Nevertheless, once again the patient had a panic attack and left the unit before she could
complete the necessary pretreatment measurements. Finally a psychiatric consult was requested. It took her
about 4 weeks to nd the courage to make an appointment with my o ce.
I received her in the waiting room of our o ce building. It took her about 10 minutes to walk from the
receiving area to the end of the hallway leading to my o ce. This walk usually takes me one minute or less.
During this walk her anxiety and discomfort were evident. Once in my o ce she insisted that the door and the
window blinds remain open. Similarly, she requested that the blinds to my windows be wide open. During my
initial interview with her she made clear that she had su ered from claustrophobia all her life, but had
always managed it by altering her life in a way that she was always able to avoid claustrophobic situations.
For example, she had never taken an elevator in her life, and her husband did all the shopping.
Nevertheless, she remained very functional, managing a small 3-storey apartment building. She reported a
remarkably small number of panic attacks given her extreme agoraphobia and claustrophobia. She had
managed to do so well because, “I knew what to do. I would never force myself into those situations.” This
was the rst time in her life when she found herself completely “out of control.” She also described classic
PTSD symptoms following her painful experience during her last operation. She had experienced ashbacks,
recurrent dreams, and autonomic reactivity by just thinking of a radiation machine or lying on a medical
table.
We discussed her biopsy, the XRT suite, and the events leading to the referral. She made it clear that she
would like to “preserve the breast,” but “I don’t think I could go through it again.” Worse yet, she not only
would not go back to the XRT suite but she had up made her mind that she couldn’t go through surgery,

either. We discussed her treatment options including the use of medication, psychotherapy, and/or hypnosis.
Given the fact that it had taken so much time to get to me, we were running out of time. Her surgeon had
made it clear during our conversation that she should have initiated treatment weeks ago. She expressed a
terrifying fear of medication side e ects, “especially those that control the mind.”
Finally, she agreed to try hypnosis as an alternative. We discussed how hypnosis might help control some of
her anxiety and at the same time allow her to regain some of the control she felt she had lost over her mind,
her body, and her life. Like many phobic patients she proved to be a highly hypnotizable subject. She scored a
10 on the 10-point HIP scale. Over the following 3 weeks I saw her four times. During those sessions she
learned to use self-hypnosis and to dissociate from unpleasant environments. In fact, she used self-hypnotic
exercises to “practice going through surgery and being in the XRT suite.”
During the third and fourth weeks we worked on the surgery phobia. She had multiple unpleasant memories
of her rst surgery. The idea of been placed on the operating room table was unbearable. She could not even
conceive the idea of being tied to the table and placed under anesthesia. A new phobia, to be intubated, had
been developed.
She practiced under hypnosis coming to the hospital, sitting in the waiting room, changing into the hospital
gown, going into the surgical suite, and inducing a self-hypnotic trance before “being put to sleep.” Under
hypnosis she put herself into a trance. She also imagined that she played the role of the anesthetist. In her
mind, she intubated herself and she operated the gas and drips. Thus she had complete control over what was
going on. Finally, toward the end of the fourth week, she underwent a lumpectomy. We worked in concert
with the anesthesiologist who was fully aware of what we were doing. He allowed her time to put herself
under. After she gave him the signal that she was ready, as we had discussed, he walked her through the
procedure. The patient did beautifully in surgery.
After surgery we were faced with the real test, a prolonged course of XRT. By now the patient had mastered
the use of self-hypnosis, but now she had to deal with con ned spaces, loud machines, and prolonged periods
of isolation for the next 3 months. During weeks 5 to 7 while she was recovering from the surgery, we had
time to prepare, and we worked intently on her claustrophobia and panic attacks. She was then able to use
her self-hypnosis exercise to undergo the rst treatment of the 3-month, ve-times-a-week radiation
therapy course.
Not only did she do well during this surgery and subsequent course of radiation treatment, but about a year
later this patient was faced with an additional surgical procedure when a follow-up mammogram revealed
another mass. Once again, after a single hypnosis session, the patient was able to undergo the biopsy
procedure without any di culty. Fortunately, the mass was benign and no further treatment was required.
Conversion Disorders
As rst suggested by Janet (1907), it is our belief that the symptoms of conversion disorder can be
understood in part as re ecting the presence of uncontrolled hypnotic states. Studies have already reported
that conversion patients are very hypnotizable (an average 9.7 on the HIP 12-point scale [Bliss, 1984])
Others have corroborated that conversion patients are more highly hypnotizable than the population at
large (Maldonado, 1996, 1997; Maldonado & Jasiukaitis, 2003). For example, studies suggest that the
percentage of the general population that is highly hypnotizable is between 20%–30% compared to about
69% in patients su ering from psychogenic seizures (Peterson, Sumner, et al., 1950; Peterson, Sumner &
Jones, 1950). Maldonado and colleagues have hypothesized that patients su ering from a conversion
disorder may indeed be using their own capacity to dissociate in order to displace the uncomfortable
feelings or a ects into a chosen part of the body, which then becomes dysfunctional (Maldonado, 1996,
1997; Maldonado & Jasiukaitis, 2003).

Even though most patients are not aware of it, highly hypnotizable individuals have an unusual capacity to
control (albeit unconsciously) somatic functions. This is evident by the high hypnotizability levels observed
in subjects experiencing psychosomatic disorders and conversion reactions. Years ago, Charcot correctly
reported an association between conversion disorder and high hypnotic capacity (1890). However, he
incorrectly assumed that they both indicated similar central nervous system dysfunction. The symptoms of
conversion disorder can be understood in part as re ecting the presence of uncontrolled hypnotic states.
Indeed, hypnosis may be useful in both the diagnosis and treatment of many psychosomatic illnesses and
conversion symptoms (Maldonado, 1996, 2007; Maldonado & Spiegel, 2000; Maldonado & Jasiukaitis, 2003)
Hypnosis by itself is not treatment. It should always be used as an adjuvant to, rather than in lieu of, medical
treatment. In cases of conversion symptoms and psychosomatic processes, hypnosis is used not to treat but
to allow patients to control the e ects on their bodies of their emotional stress and mind states. It is not
advised to force a cure in a patient. Rather, patients are trained in the use of self-hypnotic techniques and
then allowed to improve at a pace that feels comfortable, while the clinician provides suggestions for
improved control and mastery and explores the unconscious psychological reasons behind the presence of
symptoms, including the possibility of secondary gain.
When considering the treatment of conversion disorders, hypnosis may be useful in two ways. First, it may
assist in con rming the diagnosis. Second, it may be therapeutic (i.e., part of a comprehensive treatment
plan that includes therapy to help the patient develop more mature and adaptive defense mechanisms; see
(Maldonado, 2007). Clinicians treating patients with conversion symptoms must pay attention to verbal and
nonverbal cues given to the patient. It is also not unusual for patients with conversion to present wide
variations of symptoms during the course of a session. In fact, during a hypnotic induction the clinician may
bring on symptoms, worsen, or ameliorate them. Even though it may be tempting to “cure your patient,”
you must be aware that premature “cures” (i.e., before the patient feels safe and has developed the
necessary tools to deal with whatever emotional distress caused the conversion to begin with) usually are
followed by the development of symptom substitution. Also, educate the professionals for whom you are
consulting to make certain they do not give the patient the message that the problem is “all in your head.”
There are several steps to be considered (Maldonado, 2007) in the comprehensive treatment of patients
with conversion disorder (see Box 16.1). The rst step is a thorough neurological and medical evaluation,
given the high comorbidity between conversion diagnoses and organic conditions (Krumholz &
Niedermeyer, 1983; Barsky, 1989). The second step is timely diagnosis. Studies show a 6-year to 8-year
delay before the diagnosis of conversion disorder is made (Bowman, 1993), usually because of previous
misdiagnosis of and treatment for medical, neurological, or other psychiatric conditions. The failure to
make a timely diagnosis and the use of excessive diagnostic tests or inappropriate treatments may lead to
iatrogenic problems or may “validate” the patient’s perceived de cits. Some treatments, particularly
psychoactive medications (e.g., anticonvulsants, benzodiazepines, barbiturates, antipsychotics) may
worsen conversion symptoms by causing neurological side e ects (e.g., balance problems, memory de cits)
and promote dissociative states (e.g., depersonalization, derealization, mental slowing).
Box 16.1 Management of conversion disorder requires
1. A thorough neurological and medical evaluation.
2. A timely diagnosis of conversion disorder.
3. Therapeutic reassurance by both sets of clinicians that there is a good level of certainty that the
symptoms are not due to a deadly medical or neurological condition.
4. A coordinated e ort by both sets of clinicians to not let the patient fall between the cracks, to not

have unnecessary tests, to not prescribe medications that worsen the symptoms, and to
reinforce the mind–body connection in the symptoms.
5. Continuous surveillance to accurately diagnose and aggressively treat any comorbid psychiatric
disorder.
6. Help the patient to develop more mature and adaptive defense mechanisms to prevent the
development of future conversion episodes. The ultimate goal is the development of an
appropriate level of control and mastery.
The third step involves the therapeutic reassurance by both sets of doctors (i.e., internist or neurologist and
therapist) that there is a good level of certainty that the symptoms are not due to a deadly medical or
neurological condition (e.g., “you don’t have a brain tumor,” “you don’t have a seizure disorder”) but are
p. 281 secondary to underlying psychological factors. Usually, an explanation of the mind/body interaction and
how unconscious and psychological processes may a ect the body in more common medical conditions is of
help. Patients often feel reassured when physicians explain that psychological factors, pressures, and stress
can create havoc in the body and be as serious nevertheless, thus in need of prompt attention.
The fourth step involves the development of a coordinated e ort by both sets of clinicians that ensures the
patient does not fall through the cracks, that no unnecessary tests and procedures are performed,
medications that may worsen symptoms are not prescribed, and the mind/body connection is continuously
reinforced. The fth step is continuous surveillance to accurately diagnose and aggressively treat any
comorbid psychiatric disorder. This is particularly important given the high comorbidity between
conversion disorder and other Axis-I disorders (especially mood, anxiety, dissociative, and other
somatoform disorders). The most common psychiatric diagnoses are major depressive disorder and
dissociative disorders, both of which have been found in about 85% of acute conversion cases (Ziegler,
Imboden, et al., 1960; Roy, 1980; Bowman, 1993).
The sixth (and last step) involves working through the patients’ defenses and helping them develop more
mature and adaptive defense mechanisms to prevent the development of future conversion episodes. The
ultimate goal is the development of an appropriate level of control and mastery. This can be achieved with
any number of psychotherapeutic modalities, but hypnotically facilitated psychotherapy is particularly
useful and e ective (Maldonado, 2007).
The use of hypnosis in the treatment of conversion disorder itself involves several phases (Maldonado &
Spiegel, 2002; Maldonado, 2007). The rst phase involves exploring the meaning of the symptoms: it is
important never to eliminate a symptom fully without understanding its purpose and replacing it with a
more mature and adaptive defense. The second phase involves symptom alteration—that is, taking the
patient’s mind away from the presenting symptoms while allowing him or her to nd more appropriate
ways to cope with anxiety. This may be accomplished by prescribed symptom substitution, in which a given
symptom is exchanged for another that is less impairing or pathological until the patient is ready to give up
the original symptom (e.g., changing the perception of intense cancer pain to a numbing, tingling sensation
in the same area), or by symptom extinction, in which the patient agrees to “give up” the symptom after
working through the problem in psychotherapy. The third phase involves maximizing the patient’s level of
functioning. Hypnosis may be used to increase the patient’s motivation, enhance his or her sense of
mastery, and strengthen his or her defenses.
Behavior Modification

Primary Insomnia
Even though the word hypnosis literally means sleep, hypnosis is not a form of sleep and it is not related to
sleep. In fact, if you fall asleep you come out of trance. Nevertheless, because hypnosis can be helpful in
inducing a state of physical relaxation and because by focusing intently on a pleasant scene you can avoid
your mind wandering about the many problems causing sleep disturbance, it may facilitate a state of
physiological sleep. In fact, the hypnotic experience can create a state of physical relaxation which in turn
may diminish sympathetic tone. The hypnotic trance may provide patients a structured way of managing
preoccupation with anxiety-producing problems, thereby facilitating entrance into a restful sleep.
After inducing a state of self-hypnosis, patients are taught to create a sensation of buoyancy, oating, or
any other sensation that they associate with physical relaxation. Images such as oating on an in atable
mattress in a pool, or oating down the river on an inner tube could be rather e ective. After patients are
successful at this exercise they may proceed to put their worries or thoughts on hold for tonight, knowing
that they can always deal with them tomorrow. There are a number of imagery techniques that patients can
use to put problems on hold. For example, patients can project these thoughts onto an imaginary screen,
and then imagine either changing the content of the screen (as you would change television channels),
putting the podcast on pause, or simply turning it o .
Subjects can also imagine themselves sitting by a riverbank observing leaves owing down the stream. They
can then imagine themselves placing their thoughts over the leaves and watching them oating away, not
holding on to any particular thought, while allowing the body to feel progressively relaxed; or they may
imagine themselves lying restfully in a comfortable and safe place while they see themselves placing the
disturbing thoughts onto the clouds, watching the breeze slowly carrying them away.
It is important to point out that any hypnotic approach should be accompanied by sound sleep hygiene
p. 282 practices. These include going to bed always at the same time, avoiding large meals or exercise just prior
to bedtime, keeping the bedroom as a place to sleep, avoiding doing work or reading in bed, and avoiding
looking at the clock when awakened. It is important to trace the source of the problem, di erentiating
primary insomnia from sleep disturbances that occur secondary to physiological disorders such as sleep
apnea, or serious psychiatric conditions such as major depression or anxiety disorders.
There are very few research data available on the e cacy of hypnosis in the treatment of sleep disorders
(Bauer & McCanne, 1980; Stanton, 1989; Nielsen, 1990; Becker, 1993). Most of the literature is limited to
case reports, or studies with such a small sample that it is di cult to interpret the results. Yet, they have
reported that 50% of patients su ering from chronic dyssomnia experienced improvement in their sleep
patterns lasting over 16 months after a simple 2-session treatment course (Becker, 1993). The largest
reported study included 45 patients treated with hypnosis, stimulus control, or placebo (Staton, 1989). It
demonstrated signi cant improvement in early insomnia in the hypnosis group compared to comparators.
Few formal studies have been reported, but most case reports suggest that hypnosis is useful in the
treatment not only of primary insomnia but other sleep disturbances as well (Bauer & McCanne, 1980;
Schenck & Mahowald, 1995).
Smoking Cessation
E ective smoking cessation consists of pharmacotherapy and behavioral support. Counseling increases
abstinence rates parallel to the intensity of support. Nearly 100 articles dealing with the topic can be found
in the published literature, all suggesting that hypnosis is useful in assisting in nicotine abstinence. Nearly
half have been published in the last decade.

A meta-analysis demonstrated that unassisted smoking cessation (i.e., “cold turkey”) has been reported to
have a low success rate of as little as 7.3% at 10-month follow-up (Baillie, Mattick, et al., 1995) A Cochrane
review examined pooled data from 17 trials of brief advice versus no advice (or usual care) and found an
unassisted quit rate of 2% to 3%, and that a brief advice intervention can increase quitting by a further 1% to
3% (Stead, Bergson, et al., 2008).
First-line pharmacological drugs for smoking cessation include nicotine replacement therapies (i.e., patch,
gum, inhaler, nasal spray, lozenge/tablets), the nicotinic acetylcholine receptor partial agonist (i.e.,
varenicline) and antagonists (i.e., bupropion) with scienti cally well documented e cacy when used for 2–
3 months and mostly mild side e ects. Nicotine replacement therapy has a 12%–25% e cacy after 16 weeks
on active treatment, but the abstinent rate drops to 17% at 1-year follow-up o active treatment (Tonnesen,
Norregaard, et al., 1991). The newer agents have results. For weeks 9 through 12, the 4-week continuous
abstinence rates were 44.0% for varenicline versus 17.7% for placebo (P<.001) and versus 29.5% for
bupropion SR (P<.001). But for weeks 9 through 52, the continuous abstinence rates were 21.9% for
varenicline versus 8.4% for placebo (P<.001) and versus 16.1% for bupropion SR (Gonzales, Rennard, et al.,
2006). In summary, the data suggests that at present, with the most optimal drugs and counseling, a 1-year
abstinence rate is approximately 25% (Tonnesen, 2009).
Studies show that the success rate in cigarette cessation after hypnotic treatment ranges from 20% to 64%
(Crasilneck & Hall, 1968; Spiegel, 1970; Hyman, Stanley, et al., 1986; Schwartz, 1987; Williams & Hall, 1988).
These abstinence rates are superior to the rates of unassisted quitting (Gritz & Bloom, 1987). The success
rate depends on a number of factors, including the patient’s motivation and hypnotizability as well as the
therapist’s expertise. A variation of the single-session treatment approach, consisting of one to ve
sessions with or without the use of audiotapes or self-hypnotic training, as needed, is widely used in
medical settings (Dengrove, Nuland, et al., 1970; Spiegel, 1970; Pederson, Scrimgeour, et al., 1975; Watkins,
1976; Stanton, 1978, 1991; Berkowitz, Ross-Townsend, et al., 1979; Javel, 1980; Rabkin, Boyko, et al., 1984;
Barabasz, Baer, et al., 1986; Frank, Umlauf, et al., 1986; Hyman, Stanley, et al., 1986; Neufeld & Lynn, 1988;
Williams & Hall, 1988; Elkins & Rajab, 2004)
The single-session approach (Spiegel, 1970) emphasizes training a susceptible subject on the use of self-
hypnosis rather than relying on endless hypnotic sessions induced by a physician. The goal is to teach
individuals to tap into their ability to enter a self-hypnotic trance, then provide them with a strategy that is
intrinsically self-reinforcing (Spiegel & Spiegel, 1987). This allows patients to practice the technique
whenever the urge to smoke comes. It uses cognitive restructuring to emphasize how the act of smoking is
destructive to the body and how the e ects of smoking limit what one can do with one’s life due to a
shortened life span and deteriorating quality of life. Repetitive self-hypnotic experiences are used to
emphasize patients’ commitment to protect their bodies from the poison in cigarettes.
The approach is based on the cognitive restructuring model. It involves emphasizing that smoking is
destructive speci cally to the patient’s body and thereby limits what he or she can do. The focus during
hypnosis is then placed on protecting the patient’s body from poison in the same way that the patient would
protect an infant or a pet from ingesting noxious food. This approach enables the patient to balance the urge
to smoke against the urge to protect the body from damage. In other words, the focus is on what the patient
is for rather than what he or she is against (Spiegel, 1970).
This method also reinforces the idea of self-control. The patient is trained in self-hypnosis and on how to
think, rather than to avoid thinking about smoking. Once the technique has been learned, it is up to the
patient to use it or not. Initially patients are asked to practice the technique a few times a day at prescribed
times, plus at any other time the patient experiences nicotine cravings. Later on, as patients become more
pro cient and have less craving they are instructed to use the technique whenever they feel the urge to
smoke. This approach requires that patients examine their priorities and balance their urge to smoke

against the need to protect the body from the damage caused by further smoking. Smokers are instructed to
p. 283 focus on what they are for (i.e., protecting their bodies) rather than what they are against (i.e., smoking).
Thus, while there is no evidence that treatments using hypnosis are more e ective than other interventions
for smoking, they may well be more e cient in that they enable patients to employ self-hypnosis to
reinforce a cognitive restructuring strategy, while at the same time providing an episode of physical
relaxation. Strategies for smoking cessation, including the use of medications, are discussed in chapter 53.
Weight Management
Unlike the case of hypnosis intervention for smoking cessation, there are few data on the long-term e ects
of hypnosis for weight control. Clinical experience suggests that patients who are within 20% of their ideal
body weight may obtain the most bene t from restructuring techniques that use self-hypnosis in
combination with a medical regimen.
A meta-analysis performed on 18 studies in which a cognitive behavioral therapy (CBT) was compared with
the same therapy supplemented by hypnosis indicated that the addition of hypnosis substantially enhanced
CBT’s outcome (Kirsch, Montgomery, et al., 1995) In fact, the analysis suggested that the average client
receiving cognitive behavioral hypnotherapy showed greater improvement than at least 70% of clients
receiving nonhypnotic treatment. E ects seemed particularly pronounced for treatments of obesity,
especially at long-term follow-up, indicating that unlike those in nonhypnotic treatment, clients to whom
hypnotic inductions had been administered continued to lose weight after treatment ended.
Similarly, various studies suggested a signi cant correlation between hypnotizability scores and weight
reduction (Andersen, 1985; Kirsch, Montgomery, et al., 1995; Kirsch, 1996) A meta-analysis of the e ects of
CBTs and hypnosis for weight reduction found that the mean weight loss in the group using CBT plus
hypnosis was twice that of the group treated with CBT alone—in other words, the mean weight loss was
6.03 lbs. (2.74 kg) in the CBT/nonhypnosis and 14.88 lbs. (6.75 kg) in the CBT plus hypnosis, with an e ect
size of of 0.98 SD (Kirsch, 1996). Correlational analyses suggested that the bene ts of hypnosis increased
substantially over time (r = .74). For example, in a study of 109 subjects who completed a behavioral
treatment with or without hypnosis, the hypnosis group experienced signi cant additional weight loss at
the 8-month and 2-year follow-ups, while those in the behavioral treatment exhibited little further change.
Moreover, the subjects who used hypnosis were better able to achieve and maintain their personal weight
goals (Bolocofsky, Spinler, et al., 1985).
When hypnosis is used for weight management, it must be applied within the context of a comprehensive
medical treatment plan that includes sensible eating habits and an exercise program tailored to the
patient’s needs and capabilities. Just as in the case of smoking cessation, the goal of hypnosis is to
restructure the patient’s experience around food and eating practices. The intent is that the patient will
modify his or her perception of food and understand what new approaches are for (e.g., lower body weight,
healthier lifestyle, better controlled blood sugars and blood pressure) and not what they are against (e.g.,
food). In addition, hypnosis can be used to help patients provide positive self-reinforcement for compliance
with a revised eating regimen (Crasilneck & Hall, 1985).
During the course of psychotherapy, in and out of hypnotic trance, patients are asked to examine their
relationship with food and their food intake practices and to consider the damaging e ects of overeating or
starvation on their bodies. The ultimate purpose is to restructure the eating experience so that it becomes an
exercise about learning to eat with respect for one’s body. Once again, the emphasis is on what the patient is
for rather than what he or she is against.
When used as part of a weight loss program, the most important component of this approach consists in

teaching patients how to use self-hypnosis to control their eating patterns. Patients are asked to prepare a
list of foods that are consistent with their goals and their commitment to eating with respect for their
bodies. Patients are then asked to compare their craving to eat with their stated goals and the healthy items
they placed in their list. If the desired food is on the list, the patient is encouraged to eat it like a gourmet,
focusing intently on all aspects of the eating experience and enjoying it. If the food is not on the list, the
patient is asked to recognize the desire for it rather than to ght it or ignore it. At that point, the patient
uses self-hypnosis to examine this urge in light of the commitment to protect and treat the body with
respect and, therefore, to eat with respect.
Using this method, patients see their desire to eat not as an occasion to feel deprived, but rather as an
occasion to enhance their mastery over their urges by choosing to protect their bodies. The use of self-
hypnosis also allows patients to learn to respond in a planned way rather than to react to somatic signals of
hunger and satiety—to eat when they are hungry but stop eating as soon as they are satis ed. But hypnotic
capacity may play an even deeper role.
The literature suggests that aspects of hypnotizability may be involved in the etiology and maintenance of
self-defeating eating. There may be further relationships between weight, shape, dietary concerns,
hypnotizability, dissociative capacity, and fantasy proneness that are not fully understood (Hutchinson-
Phillips, Gow, et al., 2007). A study of 102 female college students (mean age 21) completed the Eating
Attitudes Test and the Goldfarb Fear-of-Fat Scale and were assessed for hypnotizability on the Harvard
Group Scale of Hypnotic Susceptibility (Groth-Marnat & Schumaker, 1990). The results indicated that level
of hypnotizability was related to attitudes toward food intake and the fear of becoming overweight, and
support the thesis that hypnotizability may be one of a variety of predisposing factors in the development
and maintenance of extreme attitudes toward eating and weight regulation.
One thing to consider is that the approach to all forms of disordered eating should not be the same. For
example, patients su ering from bulimia have been found to be signi cantly more hypnotizable than
control subjects (p < .003; Covino, Jimerson, et al., 1994). Not surprisingly, they have also scored higher on
self-report scales of dissociative experiences (p <.02). These results are consistent with previous reports on
p. 284 hospitalized patients and college students and suggest that psychological factors associated with
hypnotizability might play a role in the etiology and treatment of bulimia nervosa (Kranhold, Baumann, et
al., 1992). In that regard, a psychotherapeutic regimen that includes hypnotic exploration and training in
self-hypnosis to promote self-control would be recommended. Chapter 32 outlines a comprehensive
approach to weight control and reduction.
Dentistry
Hypnosis has long been used to advantage in dentistry as (1) an adjunct to dental procedures and in the
management of dental phobia (Lu, 1994; Rustvold, 1994; Wilks, 1994; Hammarstrand, Berggren, et al.,
1995; Moore, Abrahamsen, et al., 1996; Peretz, 1996; Robb & Crothers, 1996; Shaw & Niven, 1996; Shaw &
Welbury, 1996; Kroll, 1962; Seidner, 1967; Gall, 1969; Smith, 1969; McAmmond, Davidson, et al., 1971;
Newman, 1973; 1974; Benson, 1974, 1975; Lucas, 1975; Schey, 1976; Weyandt, 1976; Kevesater, 1977; Kisby,
1977, 1978; Romanson & Clark, 1981; Fassbind, 1983; Reis e Almeida, 1983; Katcher, Segal, et al., 1984;
Smith, 1986; Forgione, 1988; Schmierer & Schmierer, 1990; Moore, Brodsgaard, et al., 2002; Gaspar,
Linninger, et al., 2003); (2) an analgesic (or adjuvant to analgesic) for minor dental procedures (Herod,
1995; Enqvist, Bjorklund, et al., 1997); (3) the sole method of analgesia for patients with a history of
hypersensitivity to local anesthetic agents (Kleinhauz & Eli, 1993); and (4) for the treatment of associated

painful conditions such as temporomandibular dysfunction (Golan, 1989; Oakley, McCreary, et al., 1994;
Simon & Lewis, 2000) and bruxism (LaCrosse, 1994).
It has been helpful for periodontal disease (Wood & Zadeh, 1999), promotion of routine ossing (Kelly,
McKinty, et al., 1988), excessive gagging (Morse, Hancock, et al., 1984), placement of dental implants
(Gheorghiu & Orleanu, 1982), dental extractions (McCay, 1963; Lucas, 1965), and psychogenic oral pain
(Golan, 1997).
Hypnosis in Pediatric Care
All children are highly hypnotizable, and hypnotic interventions can be very useful in the care of the
pediatric patient. Several authors have also reported on the usefulness of hypnotic interventions in a variety
of pediatric problems (Dikel & Olness, 1980; Olness, 1981; Olness & MacDonald, 1981; Place, 1984; Lambert,
1996, 1999).
Various researchers have described their experiences treating a large number of adolescents and children (n
= 505) with hypnosis (Kohen, Olness, et al., 1984; Kohen, 1986, 1987; Kohen & Wynne, 1997). The problems
treated included enuresis, acute pain, chronic pain, asthma, habit disorders, obesity, encopresis, and
anxiety. In this population, half of the sample (51%) achieved complete resolution of the presenting
symptom after hypnotic intervention (Kohen, Olness, et al., 1984). In addition, another third (32%)
achieved signi cant improvement. Hypnotic interventions were used with children as young as 3 years old.
Impressively, their results suggest that maximum bene t was achieved after only four visits.
Similarly, others have described the usefulness of hypnosis in the management of side e ects associated
with the treatment of cancer in pediatric patients such as nausea and vomiting, fear, and discomfort
(Olness, 1981; Gardner & Lubman, 1982; Hall, 1982; Hilgard & LeBaron, 1982; Redd, Andresen, et al., 1982;
Zeltzer & LeBaron, 1982; Kellerman, Zeltzer, et al., 1983; Zeltzer, Kellerman, et al., 1983; Kaye, 1984;
Hockenberry & Cotanch, 1985; Katz, Kellerman, et al., 1987; Fortuin, 1988; Hageman-Wenselaar, 1988;
Feldman & Salzberg, 1990; Zeltzer, Dolgin, et al., 1991; Morrow & Hickok, 1993; Ellen & Burrows, 1994; Ellis
& Spanos, 1994; Jacknow, Tschann, et al., 1994; Genuis, 1995; Keller, 1995; Spiegel & Moore, 1997; Steggles,
Damore-Petingola, et al., 1997; Bertoni, Bonardi, et al., 1999; Liossi & Hatira, 1999; Lynch, 1999;
Marchioro, Azzarello, et al., 2000; Wild & Espie, 2004; Richardson, Smith, et al., 2006). In pediatric cancer
patients, hypnosis has been demonstrated to be useful as adjunct in invasive procedures, such as bone
marrow aspirations and lumbar punctures (Hageman-Wenselaar, 1988; Ellis & Spanos, 1994; Rape & Bush,
1994; Liossi & Hatira, 1999). The use of hypnosis in these cases lowered pediatric morbidity by removing
exposure to sedative hypnotic and anxiolytic agents. It also diminished later anxiety to multiple invasive
examinations common in patients su ering from hematologic and malignant diseases. The use of imagery
and hypnotic techniques with suggestions for a favorable postoperative course has been associated with
signi cantly lower postoperative pain ratings and shorter hospital stays (Lambert, 1996, 1999).
Several randomized controlled studies on behavioral intervention for chemotherapy in children with cancer
have found that children in the hypnosis group had the greatest reduction of both anticipatory and post-
chemotherapy symptoms compared to controls (Zeltzer & LeBaron, 1982; Zeltzer, Kellerman, et al., 1983;
Zeltzer, LeBaron, et al., 1984; Zeltzer, Dolgin, et al., 1991; Steggles, Damore-Petingola, et al., 1997). The
cognitive distraction/relaxation intervention appeared to have a maintenance e ect in which symptoms did
not get much worse or much better, while children in the control group had symptoms that consistently
became worse over time.
A prospective randomized and controlled single-blind trial of pediatric patients among cancer patients
receiving chemotherapy found that those randomized to the hypnosis group used less PRN antiemetic

medication than control subjects (p < .02). In addition, the hypnosis group experienced less anticipatory
nausea than the control group at 1 to 2 month after diagnosis (p < .02; Jacknow, Tschann, et al., 1994).
Hypnosis has been used successfully in children to signi cantly reduce the pain associated with invasive
procedures (Hilgard & LeBaron, 1982; Rape & Bush, 1994). In fact, hypnosis was superior to an attentional
control condition for analgesia among children undergoing painful procedures (Zeltzer & LeBaron, 1982). A
prospective randomized study assigned 44 children scheduled for an upcoming voiding cystourethrography
p. 285 (VCUG) to receive hypnosis (n = 21) or routine care (n = 23) while undergoing the procedure (Butler,
Symons, et al., 2005). Eligible children and parents met with the research assistant (RA) before the day of
the scheduled procedure for an initial assessment. Immediately after this assessment, those who were
randomized to the hypnosis condition were given a 1-hour training session by a trained therapist in self-
hypnotic visual imagery. Parents and children were instructed to practice using the imaginative self-
hypnosis procedure several times a day in preparation for the upcoming procedure. The therapist was also
present during the procedure to conduct similar exercises with the child. Results indicate signi cant
bene ts for the hypnosis group compared with the routine care group in the following 4 areas: (1) parents of
children in the hypnosis group compared with those in the routine care group reported that the procedure
was signi cantly less traumatic for their children compared with their previous VCUG procedure; (2)
observational ratings of typical distress levels during the procedure were signi cantly lower for children in
the hypnosis condition compared with those in the routine care condition; (3) medical sta reported a
signi cant di erence between groups in the overall di culty of conducting the procedure, with less
di culty reported for the hypnosis group; and (4) total procedural time was signi cantly shorter—by
almost 14 minutes—for the hypnosis group compared with the routine care group. Moderate to large e ect
sizes were obtained on each of these four outcomes.
Among 75 children with urological diseases (i.e., in patients with total epispadias, exstrophy, and trauma of
the urinary bladder), postoperative hypnotherapy helped in training and restoration of micturition, as a
result of which a second operative intervention was not needed (Shulman, 1995).
Because children are highly hypnotizable and are easily absorbed in images, the main focus for children
undergoing painful procedures is on imagery rather than relaxation. Images can be as simple as suggesting
that they are playing an imaginary baseball game, picturing themselves going to another room in the house,
or imagining themselves watching a favorite cartoon or television show. This enables them to restructure
their experience of what is going on and dissociate themselves psychologically from pain and fear of the
procedure.
Hypnosis has been long reported as a useful tool in the management of asthma and dyspnea in children
(Arono , Arono , et al., 1975; Kohen, Olness, et al., 1984; Kohen, 1987; Kohen and Wynne, 1997; Anbar,
2000, 2001, 2003). Like their adult counterparts, asthmatic children treated with hypnosis reported a
signi cant (50%) improvement in their symptoms (Arono , Arono , et al., 1975). Others have described
that 20% of asthma patients (children between the ages of 2 and 5 years) experienced “complete symptom
resolution” and an additional 33% experienced a “considerable improvement in symptoms” after hypnotic
treatment and training (Collison, 1975; Kohen, Olness, et al., 1984; Gluzman & Ziselson, 1987; Kohen, 1987;
Kohen & Wynne, 1997). Yet others reported that hypnosis use (n = 303 children) was associated with
improvement in 80% of patients with persistent asthma, chest pain/pressure, habit cough,
hyperventilation, shortness of breath, sighing, and vocal cord dysfunction (Anbar, 2002). No patients’
symptoms worsened, and no new symptoms emerged following hypnotherapy.
Several authors have described the utility of hypnosis training in the management of chronic dyspnea
(Anbar, 2001). On a small retrospective study, 16 patients were taught to use self-hypnosis in one session. A
second session was provided to three patients within 2 months. Thirteen of 16 subjects reported their
dyspnea and any associated symptoms had resolved within one month of their nal hypnosis instruction

session. Eleven believed that resolution of their dyspnea was attributable to hypnosis, because their
symptoms cleared immediately after they received hypnosis instruction or with its regular use. The
remaining three reported that their dyspnea had improved. Patients were followed for a mean 9 months
(range: 2–15 months) after their nal hypnosis session. Ten of the 16 regularly used self-hypnosis at home
for at least one month after the nal hypnosis session. There was no recurrence of dyspnea, associated
symptoms, or onset of new symptoms in patients in whom the dyspnea resolved. Under supervision of the
pediatric pulmonologist, two of seven patients discontinued their chronic antiin ammatory therapy when
they became asymptomatic after hypnosis.
Others have reported on the use of hypnosis in children with cystic brosis (Belsky & Khanna, 1994). The
experimental group demonstrated signi cant changes in locus of control, health locus of control, self-
concept, and trait anxiety, and signi cantly increased peak expiratory ow rates using an air ow meter
immediately after self-hypnosis when compared to the control group.
Hypnosis has also been used for the treatment of nocturnal enuresis (Krupnova, 1985; Banerjee, Srivastav,
et al., 1993). When compared with imipramine, hypnotic suggestions for the management of functional
nocturnal enuresis had equally positive response (i.e., all dry beds, with 76% on imipramine vs. 72% in the
hypnosis group). Nevertheless, during a 9-month follow-up, 68% of patients in the hypnosis group
maintained a positive response whereas only 24% of the imipramine group did (Banerjee, Srivastav, et al.,
1993).
Hypnosis has been reported to be successful with various childhood dermatological disorders such as
eczema (Mantle, 1999) and psoriasis (Winchell & Watts, 1988). There have been reports of a 95%
“immediate improvement” of severe resistant atopic dermatitis with the use of hypnosis, which was
maintained for up to 18 months after treatment (Stewart & Thomas, 1995).
The use of hypnosis for the treatment of warts in children has long been established (Mc, 1949; Wendel,
1959; Seeman, 1960; Dudek, 1967; Leidman Iu, 1968, 1973; Tasini & Hackett, 1977; Wilkening, 1978; Noll,
1988). An intriguing case reported the use of hypnosis for the treatment a 7-year-old female with 82
common warts. The lesions had been present for 12–18 months and were refractory to routine dermatologic
treatment. Hypnotic suggestions were given for the facial warts to disappear before warts from the rest of
the body. After 2 weeks, eight of 16 facial warts were gone, with no other changes. After three additional
biweekly sessions, all 82 warts were gone (Noll, 1988).
p. 286 A prospective randomized controlled study found that children could be trained in self-hypnosis with
speci c suggestions for control of salivary IgA (p < .01), although there were no signi cant changes in
salivary IgG (Olness, Culbert, et al., 1989). Several papers have reported on bene cial hypnosis treatment in
the management of other medical disorders in pediatric patients including headaches management
(Kuttner, 1993) and migraine (Olness & MacDonald, 1981), functional abdominal pain, and irritable bowel
syndrome (Vlieger, Menko-Frankenhuis, et al., 2007).
Further Information, Training, Certification, and Referrals
The two factors to consider are (1) does your patient su er from a condition amenable to hypnotic
intervention, and (2) is your patient hypnotizable? If the answer to both questions is positive, the next
question is, should you use hypnosis? If you are trained in the use of hypnosis within the context of
psychotherapy or your psychosomatic training, you are on your way to assisting your patients to develop
mastery over their symptoms by providing them with a valuable tool to explore and control what they
experience.

If, on the other hand, you are not skilled in the use of hypnotic skills you may need to refer the patient to a
practitioner or therapist who is. And you are not alone. Unfortunately, the number of clinicians and
psychiatrists well trained in hypnosis is very small. In a study of 400 physicians in central Texas, the
majority of physicians (79%) and residents (67%) had received no prior training, and even fewer had
experienced hypnosis themselves (Elkins & Wall, 1996). This study highlighted the need for patient and
physician education, given the high rate of endorsed misconceptions about hypnosis held by patients and
medical practitioners alike. On the other hand, it was somewhat encouraging to nd that 85% of medical
practitioners expressed interest in learning more about hypnosis.
Unfortunately, hypnosis training is widely variable within psychiatric residency programs and is dependent
on the faculty and training director interests within each individual training program (Walling & Baker,
1996; Walling, Baker, et al., 1996). In a nationwide survey of all psychiatric residency directors in the United
States, 63% of responding program directors report o ering either required or elective courses in hypnosis.
Yet, of the programs o ering hypnosis training, the mean number of hours provided was 8 over the course
during the 4-year residency program. This would suggest that many psychiatrists have only rudimentary
understanding and training, and a very limited exposure to hypnosis during their formative years. The
limited training is not standardized and likely inadequate to allow psychiatric trainees to be pro cient or
comfortable in the use of hypnosis in their clinical practice.
Despite the limited availability during residency, psychiatric residents seem to be interested in the topic.
Studies show that 50% of interviewed psychiatric residents have sought additional hypnotherapy training
beyond the standard lectures and seminars o ered during by their residency programs, and almost 30% had
attended external hypnosis workshops or presentations.
In the U.S. there are two reputable professional organizations providing training and fostering research in
clinical hypnosis: the Society for Clinical and Experimental Hypnosis, which emphasizes research in the
eld, and the American Society for Clinical Hypnosis. Each of these organizations holds annual scienti c
meetings, publishes a journal, and o ers well-organized regional and national workshops providing basic
training seminars and advanced training courses. ASCH o ers a board examination and certi cation in
clinical hypnosis. Faculty members from Stanford University o er basic and advanced workshops in clinical
hypnosis during the annual meeting of the American Psychiatric Association and the Academy of
Psychosomatic Medicine. For more information, contact Jose Maldonado, MD, course director (650-725-
5599), or call one of the professional organizations listed. There are many similar professional
organizations in Europe and throughout the world, including the International Society for Hypnosis, the
European Society of Hypnosis, the British Society of Clinical Hypnosis, and the Australian Society of
Hypnosis.
There are many excellent books and chapters devoted to providing practitioners basic training in clinical
hypnotic techniques, and speci c instructions and hypnotic suggestions (Erickson, 1967; Crasilneck & Hall,
1985; Spiegel & Spiegel, 1987; Watkins, 1987; Hammond, 1990; Maldonado & Spiegel, 1996, 2002, 2008;
Spiegel & Spiegel, 2004) Despite how comprehensive these may be, they are no substitute for hands-on
training and professional supervision.
Summary
Hypnosis is a natural human trait that can be measured, taught, and mastered. The ability to use this
hypnotic capacity varies throughout the population. This natural capacity to enter hypnosis may be a
liability in certain cases, such as phobic and conversion disorders, pain syndromes, and certain
psychosomatic and medical conditions. Nevertheless, hypnosis may also be used during the medical

therapeutic process to help patients deal with a number of psychological, psychosomatic, and medical
conditions. Patients may learn this technique during brief sessions and continue to derive long-lasting
bene ts through the ongoing use of self-hypnosis exercises.
Hypnosis may enhance other therapeutic processes, such as physical therapy, that can speed recovery and
response to treatment. Thus, aided by the use of hypnosis patients may gain a di erent perspective on the
relationship between psychological and physical states. Physicians using hypnosis as adjuncts to their
primary treatment modalities are encouraged to train their patients in the use of self-hypnosis. This
facilitates an enhanced sense of mastery and independence in patients. It allows patients to use their
hypnotic capacity, rather than be used by it.
p. 287
Clinical Pearls
• The hypnotic capacity or hypnotizability of a given subject (i.e., the degree of natural ability to enter a
trance state) will determine the degree of assistance required to enter trance states.
• High hypnotic capacity may actually become a liability to patients who are unaware of their hypnotic
capacity or of their unconscious use of this mechanism, as is the case of individuals su ering from a
dissociative and somatoform disorder, or nocebo (i.e., negative placebo) e ect.
• The hypnotic experience may be understood as involving three interconnecting factors: absorption,
dissociation, and suggestibility.
• Absorption refers to the tendency to engage in self-altering and highly focused attention with

complete immersion in a central experience at the expense of contextual orientation (Hilgard, 1970;
Tellegen & Atkinson, 1974; Tellegen, 1981).
• Dissociation refers to the ability to separate mental processes so they seem to occur independently
from each other.
• Suggestibility implies the ability to in uence someone’s beliefs or behaviors by suggestion.
• Formal assessments of hypnotizability allow physicians to objectively determine the patient’s level of
hypnotic capacity.
• Hypnotizability is a rather stable trait.
• The Hypnotic Induction Pro le (HIP) is a brief (5–7 minutes), standardized assessment designed to
measure patients’ natural ability to tap into and use their hypnotic capacity (Spiegel & Spiegel, 1987).
• For better or worse, highly hypnotizable individuals can enter trance states with ease and, on occasion,
without even being fully aware of it. Thus it is important for physicians to know that some patients
may experience trance states even without formal induction.
• A common technique is to have asthmatic patients enter a state of self-hypnosis and imagine that they
are somewhere where they naturally breathe easily, such as breathing cool ocean spray (Spiegel &
Spiegel, 1987).
• Most patients who use hypnoanalgesia can still feel the pain but may be unable to distinguish between
the signal of pain and the discomfort caused by the signal. Thus, patients are taught not to ght but to
transform painful signals into less uncomfortable ones.
• Regardless of any speci c induction or metaphor use, there are four speci c steps in the use of
hypnosis that can make psychotherapy for pain management briefer, more goal-oriented, and
e cient:
• the assessment of hypnotizability;
• the induction of hypnoanalgesia and development of individualized pain coping strategies;
• the use of direct suggestion, cognitive reframing, hypnotic metaphors, and pain relief imagery; and
• brief psychodynamic reprocessing, during the trance state, of emotional factors in the patient’s
experience of chronic pain. (Eimer, 2000).
• In the speci c context of hypnosis, the midcingulate cortex appears to have a critical role in the
modulation of a large cortical and subcortical network underlying its in uence on sensory, a ective,
cognitive, and behavioral aspects of nociception.
• It is unlikely that opioid neurotransmission underlies the midcingulate activation or the mechanism of
hypnosis.
• The development of “neurosignatures of pain” can in uence subsequent pain experiences (Melzack,
1991, 1993; Coderre, Katz, et al., 1993) and may be expanded in size and easily reactivated (Melzack,
1991, 1993; Elbert, Flor, et al., 1994). Therefore, hypnosis and other psychological interventions need to
be introduced early, before the development of chronic pain, as adjuncts in medical treatments
(Crawford, Knebel, et al., 1998).
• Individuals su ering from PTSD usually score in the high hypnotizability range (Stutman & Bliss,
1985; Spiegel, Hunt, et al., 1988; Cardeña, Maldonado, et al., 2008).

• The major categories of symptoms in PTSD are similar to the components of the hypnotic process
(American Psychiatric Association, 1994; Maldonado & Spiegel, 1994, 2007; Maldonado, Page, et al.,
2002)
• For therapy to be e ective in cases of traumatic stress, cognitive restructuring, emotional expression,
and relationship management must accompany the patient’s controlled reexperiencing of the
traumatic events.
• Many people enter a dissociated state during physical trauma (Spiegel & Cardeña, 1991; Cardeña &
Spiegel, 1993; van der Kolk, Hostetler, et al., 1994; van der Kolk & Fisler, 1995; Butler, Duran, et al.,
1996; Cardeña, Maldonado, et al., 2008).
• Clinicians treating patients with conversion symptoms must pay attention to verbal and nonverbal
cues given to the patient.
• It is often helpful to have patients project the images of the traumatic event on an imaginary screen
which gives them some sense of distance from the event.
• As rst suggested by Janet (1907), the symptoms of conversion disorder can be understood in part as
re ecting the presence of uncontrolled hypnotic states.
• Even though most patients are not aware of it, highly hypnotizable individuals have an unusual
p. 288 capacity to control (albeit unconsciously) somatic functions.
• In cases of conversion symptoms and psychosomatic processes, hypnosis is used not to treat but to
allow patients to control the e ects on the body of their emotional stress and mind states. It is not
advised to force a cure on a patient.
• Hypnosis may rst assist in con rming the diagnosis of conversion disorder. Second, it may be
therapeutic—part of a comprehensive treatment plan that includes therapy to help the patient develop
more mature and adaptive defense mechanisms (Maldonado, 2007).
• Educate professionals caring for the patient to make certain they do not give the patient the message
that the problem is “all in their head.”
• Even though the word hypnosis literally means sleep, hypnosis is not a form of sleep and it is not
related to sleep. In fact, if you fall asleep, you come out of trance.
• The ultimate purpose of hypnosis for weight management is to restructure the eating experience so
that it becomes an exercise about learning to eat with respect for one’s body.The emphasis is on what
the patient is for, rather than against.
Disclosure Statement
Dr. Maldonado has no actual or potential con ict of interest to disclose, including any nancial, personal or
other relationships with other people or organizations within twelve years of the submission of this work
that could inappropriately in uence, or be perceived to in uence the concept discussed in this chapter.

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p. 301
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p. 304
Hypnotic Induction Profile Evaluation Sheet
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Hypnotic Induction Profile Protocol

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Psychiatric Care of the Medical Patient (3 edn)

Barry S. Fogel and Donna B. Greenberg

16. Hypnosis in Psychosomatic Medicine

https://doi.org/10.1093/med/9780199731855.003.0016 Pages 266–304

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Keywords: hypnosis, consciousness, hypnotherapy, hypnotic induction profile, pain management,

Hypnosis is a psychophysiological state of attentive, receptive concentration, with a relative suspension of

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Components of the Hypnotic Process

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Assessment of Hypnotizability or Hypnotic Capacity

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Hypnoanalgesia may be similarly explained physiologically by a mechanism by which hypnotic suggestions

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Application of Hypnosis in Psychosomatic Medicine

Suggestions Without Trance: A Potential Trap for the Highly

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Anxiety Responses to Medical Procedures

Case Study 2: Claustrophobia

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A study of the e ect of hypnotic relaxation as an adjunct to pharmacological treatment of premature

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The Split Screen Technique

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Box 16.1 Management of conversion disorder requires

1. A thorough neurological and medical evaluation.

2. A timely diagnosis of conversion disorder.

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Hypnosis in Pediatric Care

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Further Information, Training, Certification, and Referrals

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• Suggestibility implies the ability to in uence someone’s beliefs or behaviors by suggestion.

• Hypnotizability is a rather stable trait.