Imagine away the suffering:

A retrospective analysis of the effects of hypnosis on pain

Jir Barzangi
Institute of Odontology
Karolinska Institutet
Huddinge, Sweden

Abstract
As a therapeutic device hypnosis has been subjected to many supportive, sceptical and
disparaging opinions. Despite repugnance from a majority of colleagues, there are
doctors and dentists using hypnosis in their strategies of treatment in a generally
benevolent population. As a symptomatic treatment device hypnosis has been reported
to be used on painful conditions. The aim of this study was to find literature supported
prove of its pain relieving effects. Significant rates of analgesic and anaesthetic effects
prove its ability in those areas. Also, there are reports showing significant reduction of
pain in acute conditions and there are indications of hypnosis being helpful in chronic
pain conditions. Some indications of hypnotic effects on neurogenic/neuropathic pain
conditions have been demonstrated, but there is a need for more controlled substantial
reports. Although there isn't any clear answer to how hypnosis actually exerts its pain
reducing mechanisms, there are indirect observations indicating a multifactorial activity
with strong momentous psychological and neurophysiological components. Hypnosis
beneficial sides are ought to be considered in specific situations and in presence of
critical conditions. However, there still is a need of reports based on scientific
explorations describing the observed effects dissected from their sites of action.

Introduction
The science of hypnosis, hypnotism, evokes different reactions among the general public.
Regardless of personal factors, a limited range of beliefs and opinions is commonly and
consistently spread over the population. While "therapeutic" hypnosis has been acting behind
the scenes, stage hypnosis, incorporated into magnificent shows, has been the generous
contributor to the general view. Among the beliefs, many are conjectural, discussing hypnosis
as being an omnipotent vehicle. Nevertheless, beyond the pocket watch sights, the opinions
regarding hypnosis are generally positive and there is a benevolent view towards its potential
medical benefits1, 2.
As a phenomenon, medical hypnosis is older than medicine itself and its modern form has
been around since the first half of the 19th century3 . Despite its history, and in conformity with
similar situations to define psychological states, a unitary definition of the condition does not
exist. The practitioners’ individual perceptions and constant addition of newly gained grounds
makes the work even harder. Many endeavours have taken place to agree on a succinct
definition of the phenomenon, without any success: when non is complete, all propositions
are at the same time correct, due to different aspects and approaches. However, today most
scientists and clinicians agree on that hypnosis can at least be described as "an altered state of
consciousness that differs from both the regular states of sleep and wakefulness"4 . Further, it
is a state of mind that often, but not always, is accompanied by relaxation and it uses focused
concentration and imagination and restriction of perception as active elements in the to-be
hypnotised subject to promote changes in sensation, perception and physiology5 . Thus,
hypnosis aims at enhancing these fields and interfering details, such as the regular, logic,

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realistic and critical thinking ability, which at this moment is a counteracting element in the
mind of the patient, become disregarded60 . It is characterised as a rather positive, harmless
and non-invasive state. Technically, there are a few basic types of induction, of which the
most interesting in medicine are: regular hypnosis and rapid inducted hypnosis. Regular
hypnosis is immediate ordination of suggestions and setting of the subject into hypnotic state.
Rapid inducted on the other hand is a sophisticated form, where the suggestions have been
given on an earlier occasion and the patient is in an inactive hypnotic state. When wished, the
hypnotic state can be activated by a certain signal/signals, triggering the induction of the
sleeping state. This method is time saving and the patient has been psychologically prepared18,
60
.
As important it is to explain and confine what hypnosis actually is, at the same time it is
equally important to clarify what hypnosis isn't and is incapable of doing. Firstly, it is very
important to emphasise that hypnosis itself is not a form of therapy, but rather a tool to
achieve prolific results within the scope of the therapy. During a session, the patient is fully
aware and has control over him self entirely, a contrast to the common misconception that the
therapist possesses unique and supreme faculties of taking control over the patient and forcing
her to do things against her actual will. The patient herself decides whether to follow or refuse
every specific suggestion and usually she remembers her statements and actions. This fact
also abolishes the theory of using hypnosis as a "truth serum"- no warrantees can be given for
what is said by the patient under hypnosis is the truth and the statements of the therapist are
not ciphers6, 53.
Although hypnosis seems to be simple in its inductive mechanism, not everyone can be
hypnotised. An estimation of general hypnotic suggestibility has showed a resistance to be
found in 10-15% of the population5 . Due to this, practitioners of hypnosis often speak about
the notion hypnotisability. Based on that, the population is divided into categories: high,
moderate and low. This delineating is based on the most spread measurement system in the
field, the Stanford Hypnotic Susceptibility Scales, SHSS. The mechanism map behind the
categorising and the difference is thought to be utterly complex and depended on
combinations of biological and psychological attributes4 . This aspect is still on the level of
theories and perpetual influx of new research-based views magnifies and complicates the
map. Till lately, a vivid ability of imagination was thought to be crucial to the induction of
hypnosis, but newly exhumed cognisance has challenged its determining significance. Still,
there are some kernels in the conception that are interesting. Studies on identical and same-
sex fraternal twins indicate that there might be a hereditary component to hypnotic
susceptibility and responsiveness42 . A successive question is whether the whole process isn't
maintained merely because of subjects constantly faking. Several studies and observations
have put that suspicion to rest. Fakers tend to overplay their role. When given memorial
suggestions, the subjects report detailed, pervasive and absolute, often even exceeding the
ability of the normal memory and rarely, if ever, recounted by real subjects. Scientifically, it
also has been showed by lie-detector tests that real subjects claims show truthfulness wave-
deviations, whereas those of stimulators do not17-18, 42.
Being a member of the psychology family, hypnosis has been a diligently used device at
the home field remedy course: psychotherapy. Principally, psychotherapists use hypnosis in
four purpose areas: symptom amelioration - such as decreasing agony as a response to a
specific stimuli, revealing psychotherapy - such as getting in touch with regressed and
repressed parts of the memory, strategies for overcoming - such as helping patients to cope
with specific psychological stimuli, and memory alternations - such as amnesia and
hypermnesia.
As an addition to the above-mentioned, the capacity of hypnosis reaches beyond the
grounds of psychotherapy. Today hypnosis is well known for its different effects on vital

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biological systems and physiological processes. Fecund surveys have proven hypnosis to be
beneficial in the treatment process of many physical diseases, complaints and conditions.
Paediatrics, dentistry, obstetrics, gynaecology, surgery and internal medicine are a few
examples of institutions using hypnosis as mean in their work. Never less, empirical and
scientific studies have shown evident effects of hypnosis on the cardiovascular and nervous
systems3-4, 17-18, 29. Thus, even changes in the composition of the immune system have been
observed58 , and the benefits of hypnosis in controlling bleeding61 is promising to the level that
it is being used to help patients with haemophilia, both in normal cases, as preventive and
emergency method, and during medical procedures62-63 .
Few hypnosis side effects and complications are known. Minor effects such as headache
and dizziness have been reported on a rate of 5-30%. Other more serious complications, such
as acute depression, unexpected reactions towards specific suggestions, difficulties in re-
bringing into normal state and psychosomatic symptoms, have been reported, but due to their
rarity no statistics analysing their occurrence exist60, 68.
A prominent symptom of many pathological conditions is pain. Per definition the term pain
generally describes "an unpleasant sensory and emotional sensation/experience associated
with actual or potential tissue damage, or described in terms of such damage". Thus, as a
condition the sensation is diversified, meaning that beside the nociception the whole process
include subparts like perception, cognition, behaviour and social relations - thereby making it
strongly correlated with suffering, physical, psychological and emotional impairment and
condescend quality of life41, 69. Many different methods exist, specifically aimed at the
symptomatic treatment of pain including pharmacological, physical and psychological
strategies. These methods often tend to be selective and/or short-ranged and there is a major
population not receiving sufficient/effective help to their inconvenience.
The aim of this essay is to analyse the reported effects of hypnosis on pain, its physiology
and relief.

Hypnosis and pain

Pain is known for embracing every branch of medicine. Both when it comes to pathological
conditions in the nervous system itself and in structures that the nervous system is in touch
with. The concept of pain is highly topical and might be the patient’s cause for the
appointment. As an element in the strategy of treatment, either symptomatic or therapeutic,
hypnosis has been proven to have certain effects on the nervous system and specially pain.

Anaesthesia versus analgesia

Hypnosis has been diligently used in the symptomatic treatment of pain relief. The results of
the treatments have been in interest for many clinicians, giving it a natural lead to further
research in different mechanism areas. Thus, before approaching the scientific basis of the
subject, it is of interest at this level to clear out the ambiguity in the term pain relief.
Scientifically, the definition is compound of two sections, anaesthesia and analgesia.
Although the aim for both is the same, theoretically and clinically there is a difference.
Anaesthesia is an idiom describing a local or general loss of sensation, artificially induced and
established for surgical and/or invasive purposes. Analgesia on the other hand is a term for
absence of pain in response to stimulation which would normally be painful, with a built-in
concept of relief of existing pain59, 69. Roughly, anaesthesia is for upcoming pain due to
treatment, while analgesia is for active pain due to abnormal, but not always pathological,
conditions. In spite of the division, it is clear that hypnosis has been used to achieve both
conditions.
As retrospective challenges to critical voices and previously and currently received critical
results in reports regarding the use of hypnosis for anaesthetics, one can find spectacular

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reports. Parker, in Dublin, reported 200 surgical procedures, including a painless amputation
carried out under hypnosis13 . A prominent example was demonstrated by Botta (1999), a
surgeon who performed an, according to him self, asymptomatic and successful lipo-suction
on himself using hypnosis as only anaesthetic device36 . Reports of patients recovered after
suffering from lifelong headache conditions are spread3, 9, 45. However, these examples
provide little, if any, scientific confirmation to the question whether hypnosis really does give
pain relief or not. Unfortunately, many reports do not make any distinction between the
mentioned terms per definition, or have mixed them. For instance, many researchers have
used experimentally induced pain on healthy subjects to assess the pain reduction effect of
hypnosis. The assessed effect is described as analgesia, when in fact it is per definition
anaesthesia. This may be trivial at the moment, but its significance to the prospective
conclusions is of vital importance. In a clinical situation, anaesthesia is more critical than
analgesia. The drugs that are being used are usually of stronger character and the situation is
more stressful for the patient. Failures tend to have more profound impact both
physiologically and psychologically. Moreover, the future meaning of the anaesthetic effects
may be neglected due to term classification. With the mentioned reasons as a base, the terms
anaesthesia and analgesia are thereby meant by their proper meanings, while the term pain
relief is ought to be considered as a general name for both idioms.
Anyhow, there are reports, which suggest anaesthetic effects of hypnosis. Bertoni (1999)
has reported 3 cases of paediatric radiotherapy performances where general anaesthesia was
required, but was substituted with hypnosis. His experiences were that the radiation therapy
was delivered successfully and it could be particularly useful in situations necessitating
general anaesthesia but when anaesthesia itself is not possible15 . Rutter D. V. (1981) reported
an unusual case that would have been a task for the medical staff if it hasn’t been for
hypnosis. A female patient, in need of dental care, refused local administration of anaesthesia.
Her medical condition also made it impossible to use general anaesthesia or even sedatives.
With hypnosis as only mean, the patient was able to undergo several sessions in the dental
chair, involving five major fillings, one extraction and scaling and polishing16 . Wright et al.
(2001) examined in a survey how hypnosis influenced on mechanically induced pain. His
results showed a subjective decrease in reported sensation of pain compared to the control
group10 . Odontological reports have been made on successful surgical operations under
hypnosis, including periodontal surgery, endodontic treatment on vital pulps, soft tissue
biopsy and replacement of dental implants59-60 . Reports regarding successful hypno-
anaesthesia during labour also have been widely notified2, 5, 16. Other general hypno-
anaesthetic reports have been made with significantly similar results17-18, 37-38 . Thus, to fortify
the points mentioned above, it has been established that hitherto virtually every body cavity
has been successfully entered and almost every organ has been operated on using hypno-
anaesthesia3 .
When it comes to the analgesic effects of hypnosis, the attempts in the researches have
been bolder. In another research, Wright et al. (2000) investigated the use of hypnosis on
procedural pain during burn care. He found out that not only the subjective reports of pain
decreased significantly, but also the need for narcotic/analgesic drug intake was diminished11 .
In a similar study, Patterson DR et al. (1992) investigated hypnosis and pain control during
burn wound debridement. 30 patients along with their nurses were included in the two day
long studies and 3 randomly selected groups were created at the baseline. On day one the
debridements proceeded conventionally and both the patients (subjectively) and the nurses
(objectively) estimated the level of pain on a Visual Analogue Scale (VAS). Before the
wound debridement on the next day, one group received hypnosis, another group attention
and information and the third group received no treatment. The results showed that only the
hypnotised group reported significant amount of pain reduction relative to day 1 baseline.

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These findings were also corroborated by the nurses’ VAS rating12 . Other surveys reflect the
same type of results21-22 .
In a meta-analysis Montgomery GH et al. (2000) analysed the existing results of the
studies made on the effectiveness of hypnotically induced pain relief. Their results answered
many important questions: there was a significant amount of pain relief, reaching from
moderate to large range. In addition, it was noticed that hypnosis was equally effective in
reducing both clinical and experimental pain9 .
As an addition, hypnosis has been demonstrated to relieve pain in patients suffering from
multiple sclerosis55 , heart disease, arthritis, cancer and eczema 9 .

Acute versus chronic pain

Regardless of the universal definition of pain, terminologically and physiologically there are
different types of pain. Generally, the sensation is classified as one of two types based on
speed of onset, quality of sensation and duration: acute pain and chronic pain8 . Acute pain
occurs very rapidly and is felt as shallow, sharp and fast. Chronic pain on the other hand sets
on later than acute, and tends to increase in intensity and is often excruciating. Empirically,
these terms have got new meanings depending specifically on the duration of the sensation.
Because of that, today acute pain also describes continuous pain for less than 3-6 months,
while chronic pain describes pain exceeding the 3-6 months limit71 .
Another classification of pain is based on the "onset" mechanism. Following this
classification there are 4 types of pain: nociceptive pain, neurogenic/neuropathic pain,
idiopathic pain and psychosomatic/psychogenic pain. The nociceptive mechanism is the
“regular” mechanism, following the normal physiology of pain onset in an intact nervous
system as a reaction to painful stimuli. The neurogenic/neuropathic pain is initiated or caused
by a primary lesion or dysfunction in the nervous system. The final two types are signs of
more complex conditions and pathologies, mostly bonded to psychological defects. Later, all
these types of pain have been classified under the two main types, where the nociceptive type
is often described as acute, while the other three types are commonly described as chronic
conditions71, 72.
In clinical situations, the distinction acute versus chronic pain is often a part of the base
that the treatment stands on. The philosophy of the treatment often differ and by that also the
strategies. Even though, there are records of hypnosis being used in both situations.
As for the use of hypnosis in acute pain, the examinations have been broad. Deltito (1984)
has reported 4 cases of hypnosis being effectively used in the emergency setting25 . In reviews
characterised as general overlooks on the psychological strategies in acute pain management,
many reports indicate promising and beneficial effects provided by hypnosis26-27 . Never the
less, there are reviews of controlled studies on the use of hypnosis on acute pain in children
that endorse its benefits23-24 . In addition, Peebler-Kleiger (2000) discusses hypnosis as being a
safe intervention, both solitary and in adjunct with chemicals, in emergency pain medicine.
While hypnosis is known to work well on acute pain, the opinions differ when chronic pain
is discussed: Due to the division of this paper, psychosomatic/psychogenic and idiopathic
pain will be discussed. Reports regarding hypno-reduction of pain sensation have established
its utility. Many surveys indicate benefits in the treatment of chronic back problems 9, 28-29 .
Chronic conditions in the oral-facial area have also been investigated and several reports
show significant reduction of pain in patients with temporomandibular joint dysfunction64, 73.
Gerschman et al. (1978) have presented results from a study on the treatment outcomes of
patients attending an oro-facial pain clinic. They noticed significant improvement in 68% of
the patients, regardless of the pain origin. A common opinion is that alone hypnosis shouldn't
be considered as a sufficient method in the treatment of chronic pain, due to its complex

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nature. Thus, if treated by only psychological means, hypnosis has to be combined with
psychotherapy5, 18, 28, 37, 59, an opinion that also Gerschman et al. agreed on.

Nociceptive versus neuropathic/neurogenic pain

As for the classification based on the physiology of pain, the concentrated reports of direct
effects of hypnosis on acute hypnosis indicate that it can act as an extinguisher on the
nociceptive pain. The cause of the neurogenic/neuropathic pain is often complex and it does
not always follow a certain pattern. Thus, there have been surveys made that illuminate the
area from different angles. The controlled reports on the use of hypnosis on
neurogenic/neuropathic pain are limited to a few case reports indicating pain reduction39 .
There are also reports that indicate on limited beneficial effects of hypnosis on pain associated
with herpes zoster and of postherpetic neuralgia 40 , and trigeminal neuralgia59 . It is however
clear that there is a great need for controlled reports in the field.

Mechanisms
There is little doubt in the fact that hypnotic suggestion can engender analgesia and
anaesthesia. Since neural fibres are propagating the signals of pain and the process of pain
sensation is progressed in the higher centre of the nervous system, the questions of the
connection between these two arise: How does hypno-analgesia and hypno-anaesthesia occur
and what are the mechanisms? Is it physiologically possible, or are there other explanations?
And most important of all: Is there only one answer?
There have been many suggestions to on what level the pain relieving effect occurs. To
understand them, we have to clarify the complexity of the multiple dimensions of pain. It is
considered that pain has sensory-discriminative, cognitive-evaluative and affective-
motivational dimensions. Therefore, by separating these dimensions along with the pain
evoking factors, one cannot get an accurate and logic picture of the mechanisms behind the
pain reduction. By that, the influencing hypotheses are to be explored in order to disregard the
unnecessary digressions.

Pseudo-analgesia
One major hypothesis is questioning the authenticity of hypno-analgesia, simply by the claim
that the phenomenon represents compliance with demand characteristics. Thus, the subjects
cognitively state a less intense pain sensation compared to the base line, basically answering
by a "pseudo-placebo" reaction. This claim is supported to a limited extend by some
observations on physiological responses to pain, showing that parallel reactions that occur
during uninfluenced conditions, such as increased heart rate and blood pressure, often still do
occur during hypnotically induced reports of greatly reduced pain30, 42 . However, there are
reports that challenge this “role enactment” theory. In an experiment, narrated by Price et al.
(2000), 2 scientists, Greene and Reyher, put the assumption on test. By testing truly
hypnotised against simulators in suggestion analgesia, they could conclude that the simulators
had significantly lower pain tolerance and intensity thresholds in comparison with the truly
hypnotised. Also, in a classic experiment, McGlashan TH et al. (1969), narrated by Nash MR
(2001), found out that low-rated hypnotised subjects reported equal grades of pain reduction
between hypnosis and placebo pills, while a group of high-rated hypnotised subjects benefited
from the hypnosis three times the placebo grade. Thus, all the multi-grouped experiments cast
doubts in to this theory, since they aren't their own references, but rather each other’s. Other
reliable challenging reports also oppose to this theory47-48 . On a more characteristic
personal/patient deflective level, the argument of this hypothesis reason with an aspect that
might be interpreted in a way that obscures the patients’ integrity, particularly in patients with
pathological pain conditions that have reported hypnotic relief. Thus, the thought of these

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patients pretending not having pain when they in fact are in search of pain relief is quite
absurd and may in fact be apprehended as ridicule.

Psychological explanations
Due to the membership of hypnosis in the psychological family, there have been reports
trying to explain its effects on a psychological level. Argumentatively, hypnotic analgesia has
been closely related to the multiple dimensions of pain and to the psychological stages of the
processing of pain, suggested to be sites of alternation.
Especially interesting has the affective-motivational dimension been. As a target,
suggestions have been suggested to have an alternation effect on the dimension in different
ways. There are suggestions, which reinterpret sensations as being more pleasant than they
actually are, or influencing the implicative perception of threat or harm. Then there are
suggestions designed specifically to alter the quality or intensity of sensation, so they that
they are experienced as less painful, not at all painful, or absent altogether. Here, also
suggestions that replace sensations are included and the category is called by the term
dissociation. By altering the immediate implications of pain and expectations, psychological
variables has been proven to be able to selectively and often powerfully reduce affective
responses to experimental pain43 .
Due to the reported evidence of reduced pain intensity during hypnosis, there are surveys
that indicate physiological reaction in the organism that is at least a part in the pain relieving
chain reaction. Hilgard et al. (1983), narrated by Price et al. (2000), have proposed that during
hypnosis there is reduced awareness of pain that occurs after the arrival of nociceptive
information to higher centres, i.e. the body does register the pain, but due to the hypnotic
analgesia there is covert awareness of the pain. This theory is called neo-dissociation46 , and it
is based on experiments comparing reported rates of pain overtly and covertly. The results
showed that during non-hypnotic suggestion for analgesia there was about a 40% reduction in
both overtly and covertly reported pain intensity, while hypnotic suggestion induced
significant amount of additional reduction in overtly induced analgesia, but not covertly
reported pain. This additional part is proposed to reflect amnesia or dissociation mechanisms
that are available only during hypnotic state. Thus, the pain reduction is thought to also have
been accompanied by reductions in automatic and reflex responses to pain.

Neurophysiological explanations
An additional light of physiological explanations has been projected on descending spinal
cord inhibitory mechanisms. There are multiple reports of indirect evidence for and against
such an explanation. In the scope of the headline, the question whether endogenous opioids
has a role have also been risen, due to its crucial bonding to the brain-to-spinal cords
inhibitory paths. In an attempt to clarify this picture, Moret et al. (1991) made an important
experiment. He tested whether naxolone, a known opioid antagonist, did reverse the effect of
hypnotic analgesia. His results showed no influence of naxolone on hypnotically induced
analgesia. Other observations and replications, indicating independence of hypno-analgesia
from endogenous opioid mechanisms support his results30-31 . However, Moret omits an
absolute conclusion due to another observation in the same experiment. When looked on
plasmatic levels of ß-endorphins, an opioid and a pain inhibitor, the measurements showed no
changes pre- and post-hypnotically or by naxolone. This may indicate indeed that the opioid
system after all has a minor role in hypno-analgesia. Further, the lack of evidence for opioid
mechanisms in hypno-analgesia does not automatically exclude the possibility of a
descending inhibitory system. Non-opioid brain-to-spinal cord descending control
mechanisms have been identified67, 72. Because of eager to identify and localise certain
autonomic, neurochemical or electrocortical evidence, most reports have failed giving

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certainty in the physio-hypnotic connection. However there are studies which strengthen the
suspicions. In a study of R-III, a nociceptive spinal withdrawal reflex, changes during
hypnotic reduction of pain sensation were measured. The results showed partial yet reliable
relation of reduced R-III to hypnotic analgesia in combination with significantly reduced pain
intensity, suggesting that the hypno-analgesia is at least in part mediated by descending anti-
nociceptive mechanisms that exert control at spinal levels in response to hypnotic
suggestion35 . The reduced pain intensity also indicates that mechanisms reducing awareness
of pain are involved. Replications have received significantly similar results and drawn the
same conclusions73 .
More specific studies have also participated and contributed to the explanations. Regional
cerebral blood flow studies by image studies of the brain (positron emission tomographic
brain imaging, PET) have recently shown an association between hypnotic state and increase
in activity in occipital cortical regions and decrease in posterior parietal cortical regions 30-32 .
Theoretically, the decreased activity in the posterior parietal regions would indicate decreased
somatosensory activity, but the authors do not give any direct scientific confirmation to the
observation. At the same time, it is also clear that the presence of hypnotic state is not
sufficient to produce reduction in pain or pain evoked activity in the cerebral cortex30-31 . In
addition and as a contrast, it has been proved that analgesia suggestions under hypnotic state
are greater than normal. This evidently verifies that hypnosis uniquely increases
responsiveness to suggestion and at the least facilitates suggestive analgesia. Also, one has to
keep in mind that there are individuals, preferably with high hypnotic susceptibility, who can
alone produce sufficient analgesia, clearly giving other thoughts to the theory. Thus, more
precise analysis of the central nervous system, especially PET-mappings has illustrated
interesting new aspects to the issue. In a study, Rainville and Carrier et al. (1999) analysed
neural images of cerebral activity before and during hypnosis while the subjects were exposed
to heat induced pain. The hypnotic suggestion was selectively given to only alter the affective
dimension of pain and the subjects were to estimate the level of different rates of
unpleasantness. At the baseline, significant pain-related activation was observed in the areas
somatosensory area I, anterior cingulate cortex (area 24, i.e. a part of the limbic system), and
anterior insular cortex. The final results were interesting in several aspects: no differences
occurred in somatosensory area I in any rate of unpleasantness. As a contrast, activity in
anterior cingulate cortical area 24 was significantly and remarkably greater in high as
compared to low unpleasantness condition. This result indicates that the modulation that
hypnosis applies on the affective dimension of pain preferably is associated with changes in
limbic regional activity. As a support to this study, its design was exactly replicated in a new
study with the exception that this time the selective hypnotic suggestion was targeted toward
the sensory intensive dimension of pain34 . The results showed that the suggestions were able
to alter both the sensory and the affective dimensions. The difference was that in this study
both the activity in somatosensory area I and pain sensation rate were higher in the high as
compared to the low sensory intensity condition.
Also there have been EEG tests made to further enrich the knowledge core. Tests of pain-
related EEG have shown significant reduction under hypno-analgesia, with a secondary
normalisation after interruption of the suggestions. This observation also put doubt into the
theory of endogenous mechanisms, since they tend to slowly "peter out"66 . Further, some
associations have been weakly suggested between delta waves and hypnotic states during
activities. However, in the mainline, no further significant association between certain EEG
patterns and hypno-analgesia of interest have been demonstrated because of the ambivalence
of the majority of reports. By that, its relevance is still unknown50-52 . A highly interesting
rider to the neurophysiological discussion is the use of hypnosis in the amelioration of
Phantom Limb Sensation, PLS and Phantom Limb Pain, PLP. Considered a neuropathic

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condition, PLP is thought to be caused by multileveled neuroplastic changes, i.e. peripheral

neurochemical and physiological factors, spinal plasticity and cerebral reorganisation.
Although psychological factors haven’t been totally acquitted from participation suspicions,
they are thought to be of minor significance. Hypnotic suggestions have been shown to be
very useful in controlling phantom limb sensations, especially painful ones. PET studies have
shown that hypnotic effects are on brain level and, interestedly enough, indicating a "site of
significance" activation49, 69-70 .
Hitherto, there isn’t any generally applicable explanation to the phenomenon. There are
many theories and indirect indications, which cannot be repudiated by the reason of being
conjectural, neither approved due to the insufficient coherence between the facts and the
scarcity of direct evidence. Paradoxically, the uncertainty in the cluster of hypothesis suggests
an explanation that might be more logic than every one of them individually: a combination.
Still also being on the level of hypothesis, this contribution might be the solving answer. An
alternation of the perception of pain combined with a hypno-inducted neural (opioid and/or
non-opioid) inhibition of the signals. Since pain is processed in many ways and on many
levels, and since hypnosis has been shown to individually affect many of these stages, a
combination of effects, minor or major, on few or several levels, might be the answer.

Discussion
Although hypnosis has been proven to have various anaesthetic effects, most reports do not
recommend solitary hypnotic anaesthesia, but rather as an adjunct to chemically induced
anaesthesia3, 13, 19, 20, 25, 44. The same is asserted in the question of analgesia, despite promising
results showing veritable equal effects to chemical analgesics/narcotics11, 12, 21, 23, 24. This
might be caused by several factors. Beside the common classification of
susceptibility/responsibility factors, studies on "total" hypno-anaesthesia have shown that in
obstetrics it is limited to 25 per cent of the selected patients and only to 5-10 percent in major
surgery cases29 . In a case-report by Barber J (1977), narrated by Badiei O (1998), an
astonishing success rate of 99% (sic!) was reported60 . 100 patients had received odontological
treatment in form of fillings, endodontic treatments, crown preparations and extractions and
RIA, Rapid Induction Anaesthesia/analgesia, had been used as sole anaesthesia. The
exceptionally high success rate has been doubted and remade studies haven’t succeeded to
replicate similar rates. However, there have been substantial differences in the methodology
that seem to be of vital importance. The major opposing survey had used tape-recorded
suggestions. Barber on the other hand inducted the suggestions personally and could thereby
on one hand get in personal touch with the patient, on the other adapt and complete the
suggestions individually for each of the patients. Further, in the major opposing survey, the
suggestions were regarded as abortive as soon the patients signalled positive sensation of
pain. Barber on the other hand did ordinate suggestions to the patients in need of it during the
whole procedure. So, the combination of patient/situation/practitioner might be the answer to
the unexpected low rates of the major surgeries and the unexpected high rates of minor
operations. Thus, its clinical relevance isn't negligible. The fact that hypno-anaesthesia hasn't
yet been fully understood might also be a contributor to the chilly interest. The uncertainty in
what actually occurs in the critical surgical situation might be repelling. In addition, the time
factor is a determining element. It is customary and recommended as demonstrated above that
during major surgical procedure, beside an emergency backup in form of an anaesthesiologist,
the patient receives constant influx of suggestions from a practitioner to preserve the hypnotic
state5, 60. This might be impractical and costly. Never the less, by its constant successful
updating and surpassing precursors, contemporary pharmacological methods have by their
present-day perfection outstripped alternative ways 37 . But as in every medical device and
method, its wings do not enclose the whole population. Sometimes different reasons such as

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allergies, critical medical conditions and psychological factors exclude the use of
pharmacological devices despite their necessity. Hypnosis, if possible, might then be a
grateful alternative to the dilemma. As for the impracticality and cost factors, for hypnosis
being one of few solutions in rare cases, these should be considered irrelevant. Further, the
idea of the possibility of being able to reduce the amount of injected/orally administered
pharmaceutical preparations might be appealing even in milder critical cases. Toxic
complications can manifest them selves even in tolerant healthy patients. Thus, the risk might
be potentially higher in patients estimated to be in risk situations. By that, a combination of
pharmacological and hypnotic anaesthesia might secure the situation. It is equally important
that the discussion doesn't get into preposterous proportions. Hypnosis is not a miracle
method and shouldn't be considered as one, but rather an unusual method for unusual and/or
critical cases. Its promising research results should in the future make it one of the prominent
alternative methods.
When it comes to analgesia in the different pain conditions, the answer might rather be
found in secondary factors. Meta-analysis has shown that subjects generally estimated of
being in the midrange of suggestibility were significantly relieved of pain by hypnosis in a
percentage of 75%9 . Scepticism towards it, as in the case of anaesthesia, has defined the
expansion of its application. Deeper knowledge of the subject would certainly increase
interest. By that, hypnosis needs common attention from other sources than stage forms. The
medical benefits need to be mediated to the public. Thus, its success in the paediatric
institution makes a suggestion that hypnosis in fact can be meticulously adapted to the
receiving ability of the patient and to the delicacy of the situation.
Time factor is an important issue even here. Clinical experiences have shown that in
resemblance to anaesthesia, the analgesic state isn't persistent 46 , and a clinical solution to this
would be highly impractical and costly. However, there is another alternative that has been
promising - self-hypnosis. By teaching the patient how to induce hypnosis self-handily, she
can give herself the necessary suggestions when needed.
The Society for Clinical and Experimental Hypnosis do not recommend hypnosis as a sole
medical or psychological intervention for any disorder, due to its easy public access42 .
However, one has to make a distinction between therapeutic hypnosis and other types of
hypnosis. By gained recognition, hypnosis could be classified as a medical device and by that
restricted to only being used for therapeutical purposes by authorised practitioners. Hypnosis
started its path in medicine and needs to be let back on track again.
A factor, probably the most important one for success, is the patient factor. A contact on
personal level between the practitioner and the patient is crucial. Thus, proper selection of
patients, suggestions and words creates the best conditions to successful pain relief. An
elaborate and accurate investigation of the patients’ mental status should be done before the
use of hypnosis. Beside somatic side effects, it is known that hypnosis can, in rare cases, bring
forth repressed and regressed memories and thereby creating potential psychological
problems for the patient. Caution is thereby highly recommended and the practitioner should
narrow his work-spectrum to the areas included in his work-field and problems he is capable
in solving even in conventional ways. This way, the risk for side effects and complications is
being properly diminished. However, when possible, every patient should be screened for it
and proposed to it. In addition, there are reports strongly suggesting a psychological
dependence of succeeded pharmacological treatments, regardless of compliance75 . Being a
positive psychological vehicle hypnosis already includes components aimed at positively
fortifying the psychological status of the patient towards the treatment. As always, a well-
informed patient is a satisfied and co-operating patient.

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Conclusion
In conclusion, more controlled scientific reports are needed both to clarify the obscure and to
gain trust in the sceptical medical staff. The neurobiological explanations are limited and
rather incoherent. Still, their parts haven’t been excluded. Hypnosis has been shown to be
beneficial in amelioration of patients with parkinsonian tremor54 , Multiple Sclerosis55 ,
Rhythmic Movement Disorder56 and of the voluntary motor movement recovery in stroke57 .
Categorised as mainly neural dysfunctions, these reports are indicating an after all close
relationship between hypnosis and the nervous system. Thus, the wide range of functions that
the nervous system has makes a suggestion that by "controlling" the nervous system, one
could secondary monitor many structures in the body. As future vision one might project this
hypothesis on the possibilities of hypnosis as being an alternative implementation or an
adjunct to conventional treatments of different diseases. But with the obstructions in the path
of today, one might have to be forced to think the idea "you have to crawl before you can
walk". The question is if hypnosis, after all, hasn't in some cases crawled enough?

Acknowledgement
I would like to state my gratitude and deepest respect to my mentor, Professor Lars Frithiof,
for his help, guidance and patience. My appreciation to Professor Björn Appelgren for letting
me lay claim to his precious time in consulting.

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