Kaplan + Sadock's Synopsis of Psychiatry, 11e

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Chapter 28: Psychotherapies

Trait of Hypnotizability A person’s degree of hypnotizability is a trait that is relatively stable throughout the life cycle and is measurable. The process of hypnosis takes the hypnotizability trait and transforms it into the hypnotized state. Experiencing the hypnotic concentration state requires a convergence of three essential components: absorption, dissociation, and suggestibility. Absorption is an ability to reduce peripheral awareness that results in a greater focal attention. It can be metaphorically described as a psychological zoom lens that increases attention to the given thought or emotion to the increasing exclusion of all context, even including orientation to time and space. Dissociation is the separating out from consciousness ele- ments of the patient’s identity, perception, memory, or motor response as the hypnotic experience deepens. The result is that components of self-awareness, time, perception, and physical activity can occur without being known to the patient’s con- sciousness and so may seem involuntary. Suggestibility is the tendency of the hypnotized patient to accept signals and information with a relative suspension of nor- mal critical judgment; it is controversial whether critical judg- ment can be completely suspended. This trait will vary from an almost compulsive response to input in the highly hypnotizable to a sense of automaticity in the less hypnotizable individual. Table 28.9-1 lists the indicators of trance development. Quantification of Hypnotizability Quantifying a patient’s degree of hypnotizability is useful in a clinical setting because it predicts the effectiveness of hypnosis as a therapeutic modality. Quantification also provides useful information about the way patients relate to themselves and the social environment. Highly hypnotizable patients have an increased incidence of spontaneous trance-like states and so may be unduly influenced by ideas and emotions that are not being appropriately self-critiqued. Neurological testing of individuals in the hypnotized state and those with a high degree of hypnotizability has led to some interesting findings, but no set of changes has been shown to be sensitive or specific for the trance state or hypnotizability trait. Electroencephalographic (EEG) studies have shown that hypnotized persons exhibit electrical patterns that are similar to those of fully awake and attentive persons and not like those found during sleep. Increased alpha activity and theta power in the left frontal region has been reported in highly hypnotiz- able patients as compared with those who are less hypnotizable; these differences exist in the trance and nontrance states. Positron emission tomography (PET) studies that compare regional blood flow in the brain in both hypnotized and non- hypnotized subjects lend further evidence to the hypothesis that hypnosis exerts some of its effects at lower-level modalities of the brain. Hypnotic suggestions to add color to a visual image result in increased blood flow to the lingual and fusiform gyri, the color vision processing centers of the brain; suggestions to remove color have the opposite effect. Similarly, the intensity Neurophysiological Correlates of Hypnosis

that the clinician projects the hypnotic trance onto the patient or has the power to influence the patient. In reality it is the patient who has the hypnotic gift, and the clinician’s role is to assess the patient’s capacity to capitalize on this asset and to help the patient discover and use it effectively. Patient motivation, per- sonality style, and biological predisposition may contribute to the manifestation of this talent. During the hypnotic trance, focal attention and imagination are enhanced and simultaneously peripheral awareness is decreased. This trance may be induced by a hypnotist through formalized induction procedures, but it can also occur spontaneously. The capacity to be hypnotized and, relatedly, the occurrence of spon- taneous trance states is a trait that varies among individuals but is relatively stable throughout a person’s life cycle. History Descriptions of trance states, ecstatic states, and spontaneous dissociative states abound in the Eastern and Western reli- gious, literary, and philosophical traditions. Anton Franz Anton Mesmer (1734–1815) first formally described hypnosis as a therapeutic modality in the 18 th century and believed it to be the result of a magnetic energy or an invisible fluid that the therapist channels into the patient to correct imbalances, restoring health. James Braid (1795–1860), an English physician and surgeon, used eye fixation and closure to induce trance states. Later, Jean Martin Charcot (1825–1893) theorized the hypnotic state to be a neurophysiologic phenomenon that was a sign of mental ill- ness. Contemporaneously, Hippolyte Bernheim (1840–1919) believed it to be a function of the normal brain. Early in his career, Sigmund Freud (1856–1939) used hyp- nosis as part of his psychoanalysis and noticed that patients in a trance could relive traumatic events, a process called abreaction. Later, Freud switched from hypnosis to free association because he wanted to minimize the transference that sometimes accom- panies the trance state. Importantly, the switch did not eliminate the occurrence of spontaneous trance during the analysis. World War I produced many shell-shocked soldiers and Ernst Simmel (1882–1947), a German psychoanalyst, devel- oped a technique for accessing repressed material that he named hypnoanalysis. During World War II, hypnosis played a promi- nent role in the treatment of pain, combat fatigue, and neurosis. Formal recognition of hypnosis as a therapeutic modality did not occur, however, until the 1950s. The British Medical Society recommended its teaching in medical schools in 1955 and the American Medical Association and American Psychiatric Asso- ciation officially stated its safety and efficacy in 1958. Definition Hypnosis is currently understood as a normal activity of a normal mind through which attention is more focused, critical judgment is partially suspended, and peripheral awareness is diminished. The trance state, being a function of the subject’s mind, cannot be forcibly projected by an outside person. The hypnotist, however, may aid in the achievement of the state and use its uncritical, intense focus to facilitate the acceptance of new thoughts and feelings, thereby accelerating therapeutic change. For the subject, hypnosis is typified by a feeling of involuntariness and movements seem automatic.