State and non-state theories .
Hypnosis, which has been used for centuries in different forms, has to be reevaluated in the light of modern medicine and science by biological, psychological, sociological and spiritual approach. Hypnosis has been regaining its popularity in the trend of personalized and holistic medicine without any drug, injection or side effects.
- fantasy proneness
- imaginative capabilities
- eye-movement techniques
- imaginative involvement
Hypnosis is an agreement of a social interaction between a subject (designated as patient) and the hypnotist (healthcare professional) who suggests imaginative experiences to change sensation, cognition, affect, mood, or behavior in perception, memory, and voluntary control of action. Hypnosis promotes relaxation, enhances imagery to therapeutically recover forgotten incidents .
2. History of hypnosis
In mythology, Hypnos (Somnus, in Latin) is the personification of sleep who lived with his twin brother, Thanatos (Θάνατος, “death personified”) in a dark under world cave on Lemnos island (according to Homer or Book XI of Ovid’s Metamorphoses) without any light from the sun or the moon; where flowed Lethe, the river of forgetfulness. His parents were Nyx (Νύξ, night) and Erebus (darkness), and he married with, Pasithea, the goddess of marriage and birth and the deity of hallucination and relaxation. Their sons called Oneiroi (dreams) were bringers of dreams. Among them Morpheus, brought human dreams; Icelus, animal dreams; and Phantasus, dreams of inanimate things. A bronze head of Hypnos is in British Museum in London (Figure 1). The English word “hypnosis” refers to a person put into a sleep-like state (hypnos “sleep” + −osis “condition”). Hypnosis was used in the temples of Aesculapius, the God of Medicine, where priests advised patients during their sleep as gods talking to them in their dreams. Etymologically speaking, Somnus, Latin word for sleep, is the source of many English words such as insomnia (sleeplessness), somnolent (sleepy), hypersomnia (excessive sleep), and hypnotics(sleep inducing drugs) among many others .
Mesmer, founder of modern hypnosis, considered animal magnetism, an invisible magnetic fluid in all living things, as the cause of illness, which could be treated by manipulating with his hands through hypnosis (Figure 2). Although mesmerism was therapeutically effective, a scientific commission of inquiry attributed the effects of hypnosis to imagination in France in 1784 .
The Marquis de Puységur, who experimented with animal magnetism, put a peasant, into a sleep-like-state, a “sleep of senses,” after which he could not recall his responses to the suggestions during his sleep. A will to direct an organic power unites the magnetizer with the subject. Puységur actually evoked the latent capacity of the subject’s mental and emotional state by paying attention and showing a kind of benevolent love. This was the beginning of hypnosis. Puységur noted significant responses from his subject:
sleep-waking state, that he called “magnetic sleep” or “magnetic somnambulism,” resembled natural sleep-walking condition,
rapport, a special connection with the magnetizer,
suggestibility, heightened capacity to imagine vividly,
amnesia in waking state for the events occurred in the state of magnetic sleep,
ability to read the thoughts of the magnetizer, and diagnose the subject’s own illness,
change in the personality of the magnetic subject, with increased alertness and self-confidence .
Freud also used hypnosis considering as hysterical reactions to traumatic experiences in childhood and a mobilization of transference phenomena. Hypnotic techniques helped the soldiers to alleviate the effects of traumatic experiences during World War II and treat “traumatic neuroses” .
By second half of the 19th century, Braid coined the term hypnotism and Erickson promoted new approaches to psychotherapy using hypnosis through storytelling .
3. Neurophysiology and hypnosis
Hypnotic modulation of suffering provokes changes in the anterior cingulate cortex, leaving primary sensory cortex unaffected. Hypnotic modulation of color perception draining or adding color to a stimulus, real or hallucinated, activates the fusiform color area and the inferior temporal region of cerebral cortex with clearer effects in the left cerebral hemisphere than the right. The activation in the left fusiform area is only affected during hypnosis while the right fusiform activation is affected in both hypnotic and control condition. fMRI (functional magnetic resonance imaging) shows heightened activity in the prefrontal cortex. The hypnotized people produce activity in the visual cortex to hallucinate an image. Hypnotic alteration of perception, involves top-down resetting of the intensity of perceptual response, rather than post perception processing changes. There is a decrease in the activity of the dorsal anterior cingulate (dACC) and an increase in connections between the dorsolateral prefrontal cortex and the insula connections between the dorsolateral prefrontal cortex and the default mode network including medial prefrontal and posterior cingulate cortex also weaken) [9, 10].
Hypnotizability is a stable trait and assessed using scales based on the behavioral response of the person in a social context which is correlated with objective physiological responses. Brain activity and plasticity changes in hypnosis measured by functional magnetic resonance imaging (fMRI), positron-emission-tomography (PET) and electroencephalography (EEG) showed that hypnosis inhibits the reaction of the fear circuitry structures. Frontal and cingulate cortices are most linked to hypnotic responding .
Frontal functions have a central role in hypnotic responding. In the first phase of hypnosis, during the induction, the subject’s attention on an object stimulates fronto-limbic structures, which are inhibited and/or dissociated in the second phase. In the third phase, right-sided temporo-posterior regions are stimulated. In response to hypnosis, the fronto-cortical activity is reduced and the dorsolateral prefrontal cortex structures are dissociated and the cingulate activity increases or decreases depending on the suggestions. Hypnotic responding demonstrates greater dominance in the right hemisphere than left hemisphere processing, associated with cognitive activities while no difference is found in hypnotizability between left and right hemisphere lesions.
4. Clinical applications
Hypnosis is performed to relieve pain in abdominal, breast, cardiac, genitourinary and orthopedic surgery. Hypnosis is a powerful means of altering pain, anxiety, and various somatic functions, and recovering forgotten incidents. Hypnosis is found efficient in cancer care even in bone cancer, leukemia, and lymphoma, specifically focused on treatment-induced and conditioned anticipatory nausea/vomiting, pain, anxiety/distress, and hot flashes to manage cancer-related pain, anxiety, fear, lack of appetite. Potential method to manage side effects associated with cancer and cancer treatment.
Patients receiving local anesthetic plus hypnosis experience less anticipatory procedure-related anxiety, and demonstrate less behavioral distress. Hypnosis-based interventions for cancer pain have significant pain reduction, especially when used in combination with other psychosocial-behavioral techniques and supportive-group therapy. Beneficial effects of hypnosis to treat anxiety and distress among cancer patients remained for at least 3 months’ post-intervention, without any adverse effect, relative to an educational intervention controlling the effects of time, therapist attention, and participation from pediatric to geriatric patients, among both sexes. Hypnosis delivered by a therapist is found more effective than self-hypnosis. Self-hypnosis training represents a rapid, cost-effective, nonaddictive, safe and efficacious treatment for anxiety prior to tests, surgery and medical procedures and anxiety-related disorders and psychological disorders such as stress, ego strengthening, unipolar depression, smoking cessation, weight loss, and rehabilitation. The hypnotic intervention is twice less expensive than the standard sedation procedure [28, 29, 30, 31, 32].
5. Hypnosis associated phenomena
5.1 Suggestion phenomena
Hypnotic suggestibility relies on different cognitive processes. Sensory Suggestibility requires the ability to imagine a non-existent, but suggested, sensation. Methods that do not rely on trance, but heighten suggestibility are reflex conditioning, abstract conditioning, repetitive sensory stimulation, use of imagination, and misdirection of attention.
primary suggestibility, direct suggestions for facilitation and inhibition of motor activity,
secondary suggestibility, implied suggestions for sensory/perceptual changes;
tertiary suggestibility, attitude changes in response to persuasive communications;
interrogative suggestibility, occurs following misleading post-event information; or placebo response.
Posthypnotic suggestion: the subject takes the posthypnotic suggestion as a conscious act and continues responding to suggestions delivered in hypnosis even after the termination of hypnosis. The subject can receive and carry out posthypnotic suggestions. Periodic reinforcement makes the posthypnotic suggestions more effective because the behavior is experienced automatically without involvement of executive awareness of this activity.
5.2 Ideosensory response phenomena
Anesthesia is reduction or loss of any sensory modality, such as blindness, deafness, anosmia, analgesia, or tactile anesthesia. Self -generated pain control can be recreated using hypnotic suggestion for various conditions such as headache and dystonia. Surgery can be performed using only hypnotic anesthesia for pain management without any drug. Not everybody can achieve the depth of trance required for surgical work, but they can become suggestible enough to produce numbness in hand referred as “glove anesthesia,” then “transferred” by touch wherever needed. Numbness of any part of the body can occur spontaneously so profoundly that needles can be inserted into the body without discomfort. If the hypnotist tells to the subject to reduce its perception through sensation of tingling and numbness, with decreased activity of somatosensory dorsal anterior cingulate cortex (dACC). Hypno-analgesia cannot be reversed by naloxone, an opiate receptor blocker.
5.3 Ideomotor phenomena
Ideomotor responses refer to motor phenomena of muscles responding instantaneously to thoughts and feelings, a movement in response to an idea. The subject moves in response to a suggestion given during hypnosis.
5.4 Memory phenomena
The hypnotic state of the brain activity is a sort of functional amnesia, a reversible dissociation between implicit and explicit memory (post hypnotic amnesia (PHA)).
5.5 Perception phenomena
A comprehensive theory of hypnosis should cover both cognitive and interpersonal terms. Throughout twentieth century the theories about hypnosis have been between “state” vs. “non-state” theories.
6.1 State theories
6.1.1 Dissociated control theory (DCT)
DCT claims that normally driving habitual behaviors can be influenced outside of conscious awareness without executive control. According to Ego-state theorists, clinicians can promote behavioral change by hypnosis, and have conversations with different ego states.
6.1.2 Dissociated-experience theory
High hypnotizables respond voluntarily dissociated from conscious awareness.
Another idea could be the use of the protective dissociations in a concept that implies that the natural apparition of hypnotic phenomena during traumas can be fixed as dissociative reactions turned into symptoms, which can be paradoxically utilized by the therapist to facilitate their eradication as “mental or psychic anesthetics.” Directly derived from the concept that hypnosis is not a result of suggestion, this method brings an incredible opportunity to treat the patients rapidly and comfortably in the situation of extreme sufferings and in the treatment of psychosomatic diseases .
6.1.3 Gruzelier’s neurophysiological theory
High and low hypnotizables are characterized by changes in brain function.
6.2 Non-state theories
6.2.1 Spanos’ socio-cognitive theory
Hypnosis is not an altered state of consciousness. Attitudes, beliefs, imaginings, attributions and expectancies form hypnotic experience and outcome depending of the interpretation of the suggestions without active planning and effort. The sociocognitive behavioral model is used together with contemporary cognitive-behavioral psychotherapies focusing the effects of thoughts, beliefs, and imaginings on behavior and emotion.
6.2.2 Kirsch’s response expectancy theory
Proposes that subjects have generalized response expectancy in a hypnotic situation and follow the hypnotists’s instructions and experience involuntary behaviors attributable to external causes (the hypnotist). Two social factors associated with response to hypnosis: rapport (“therapeutic alliance,” “resonance,” and “harmony,”) and social context are taken in account.
6.3 Integrative/middle-way/neither-one-nor-the-other theories
6.3.1 Brown and Oakley’s integrative cognitive theory
Proposes that involuntariness is an attribute to the causes of behavior and suggestions.
a latent cognitive ability for hypnotic response
the subject’s beliefs about his/her hypnotic response
|State theories||Non-state theories|
|Hypnotic inductions produce an altered state of consciousness||Participants respond to suggestion almost as well without hypnosis|
|Hypnotic “trance” is associated with an altered state of brain function||Participants in hypnosis experiments are actively engaged|
|Responses to hypnotic suggestions are a result of special processes such as dissociation or other altered states of consciousness||Responses to suggestions are a product of normal psychological processes such as attitudes, expectancies, and motivation|
|Hypnotizability is remarkably stable over long periods||Suggestibility can be modified with drugs or psychological procedures|
Standardized psychological tests such as the Stanford Hypnotic Susceptibility Scale or the Harvard Group Scale of Hypnotic Susceptibility (SHSS) measure hypnotizability. The Stanford Profile Scales of Hypnotic Susceptibility (SPSHS), in two forms (I and II), evaluates individual strengths and weaknesses. On the individually administered Stanford Scales, each of 12 test suggestions, scored pass-fail, yield a sum score of hypnotizability on a 0-12 scale. The Stanford Hypnotic Susceptibility Scale, Form C (SHSS:C), that contains cognitive suggestions including hallucination and age regression, is the gold standard for measuring hypnotizability. The SWASH (Sussex-Waterloo Scale of Hypnotizability) is a 10-item modified Waterloo-Stanford Group C Scale of Hypnotic Suggestibility (WSGC) to reduce screening time and supplement objective scoring. It measures capacity and altering conscious experience. The Dissociative Experiences Scale, a 28-item scale, assesses dissociative experiences. The Tellegen Absorption Scale, a 34-item questionnaire evaluates the capacity of absorption. Dyadic Interactional Harmony questionnaire (DIH) assesses four domains of hypnotist-subject interaction: intimacy, communion, playfulness, and tension.
The process of hypnosis consists of a hypnotic induction, a deepening procedure, and symptom-specific suggestions. Hypnosis is a state of highly focused attention, with dissociation of thoughts and sensations toward awareness. It is comprised of three components: absorption, dissociation, and suggestibility. Absorption is full involvement in a perceptual, imaginative or ideational experience for self-altering attention. Dissociation is a mental segregation of components of behavior in a dream-like state of being both actor and observer when re-experiencing autobiographical memories in involuntary motor functions or discontinuities in the sensations of one part of the body compared with another. Suggestibility complies with hypnotic instructions. It is not a loss of will but rather a suspension of judgment due to the absorption and effortless self -loss in what is concentrating on. The hypnotized person does not have control over his/her thoughts and actions and follows the suggestions without looking for alternatives and analyzing their context. The principle of hypnosis is to recall traumatic memories and manage their associated affect and physiological responses by reevaluating their meaning in a new perspective. Hypnosis is a set of techniques to fortify concentration, by decreasing the effect of distractions, and increase to change the subject’s s thoughts, feelings, behavior, or physiological state. Hypnosis is not psychotherapy. Hypnotic perceptual and cognitive changes the equilibrium between suggestion, expectation, and task instructions [47, 48, 49].
A new non-pharmacological technique called virtual reality hypnosis (VRH), combines VR hardware/software and hypnotic induction. In hypnosis, the subject constitutes his own world by the hypnotist’s suggestions through absorption and dissociation. Virtual reality hypnosis (VRH) does not depend upon the skill of hypnotist and the openness of the subject. The subjects need less imagination and absorption due to visual and auditory stimuli presented in virtual reality [50, 51, 52].
Five psychological factors are most important for the success of hypnosis: hypnotizability, expectancies, motivation, absorptive capacity/fantasy proneness, and attitudes toward hypnosis. The specific type and wording of suggestions influence outcome. Expectancies determine the extent how much the subject believes in the experience and response to the hypnotic intervention. Past experience, current context, and interaction influence expectancies.
In psychoanalytic approach to hypnosis, the hypnotist is similar to an authority figure of the subject from his earlier life experience. Frequently punished children would try not to displease the hypnotist and would show high level of dissociation. Negative parental behavior (punishment and overprotection) is related to the phenomenological and emotional dimensions of hypnotic response leading to higher hypnotizability. Parental behavior of the subject influences hypnotic behavior, experiences, and emotional bond with the hypnotist. A warm- supportive parental style provokes more positive feelings toward the hypnotist, whereas cold-punishing parental behavior is correlated to negative feelings about the hypnotist and hypnosis itself. One consistent pattern in females is that maternal punishment predicts only negative affect in hypnosis, while punishing parental behavior in men, predicts both positive and negative responses to hypnosis. Alexithymia, the decreased ability to identify and verbalize someone’s own emotions, mediates between parental punishment and fear in hypnosis. Therefore, hypnotherapist should search before the hypnotherapeutic intervention the subject’s memories of their parents, which will influence his/her expectations about hypnosis and the hypnotist. Subjects remembering punishing, and/or emotionally unresponsive parents would stay away from the hypnotist even if they know that hypnotherapy would correct the source of the problem. They may feel stress and anxiety in the hypnotic state which can be regulated by the sense of security and mutual trust [60, 61, 62, 63].
Mindfulness meditation and hypnosis remain in opposing ways to awareness of intentions. Hypnosis and meditation may be combined as a psychosomatic technique to control mind and body regulation. Phenomenology, and neuropsychology of hypnosis and meditation follow common features:
focused attention is the base of induction
an intentional control of biologic-somatic activities
The “mirror neurons” in the human brain provide empathy to sense the intentions of others by observing their behavior and related brain activity. They function as a rapport zone mediating between observing consciousness, the gene expression/protein synthesis cycle, and brain plasticity in hypnotherapy and psychosomatic medicine. (Emerging science recognizes human experience not as disease but as manifestations of individual adaptive self-regulating system) .
Tandem hypnotherapy considers the unity of body and mind as a quantum process, since the embryonic period of life. Tandem has two meanings: (1) a multi-seater bicycle, (2) a mosaic word: Touch of Ancient and New generations with a Dialog Experiencing Oneness of Minds (TANDEM). Hypnotherapy, psychodrama, family therapy, Hellinger’s systemic-phenomenological approach, and holding-therapy are united in Tandem theory. More than two persons in a physical closeness touching each other take part in therapy: (1) patient(s), (2) one or more co-therapists or antagonists in psychodrama. The therapist takes the responsibility of the tandem of patient(s) and co-therapist(s). Sensory-motor level of development is originated from fetal period of life. In uniting mode of experiencing, object and subject are not seen as different from each other. The most effective stimulus is the physical closeness and touching in intimate situation as a form of body psychotherapy. The psychological factors for hypnosis are hypnotizability, expectations, motivation, absorption/imaginative involvement/fantasy proneness, and attitudes toward hypnosis, and a rapport as social factors lead to “resonance” and “harmony” [67, 68].
Hypnosis and hypnotherapy, which have been experienced for centuries, emerged as new solitary or complementary approach based on science for the wellness of people.