The Mind Prepared: Hypnosis in Surgery

November 29, 2009 Barry Jones

1280 Editorials | JNCI Vol. 99, Issue 17 | September 5, 2007 In 1846, a Scottish surgeon named James Esdaile reported 80%

surgical anesthesia using hypnosis as the sole anesthetic for amputa-

tions in India. His work caused sufficient stir that when ether anes-

thesia was demonstrated in what is now called the Ether Dome at

the Massachusetts General Hospital on October 16 of that same

year, a surgeon strode to the front of the amphitheater and said,

“Gentlemen, this is no humbug,” to distinguish his surgical team’s

demonstration from Esdaile’s report. It has taken us a century and

a half to rediscover the fact that the mind has something to do with

pain and can be a powerful tool in controlling it: the strain in pain

lies mainly in the brain.

In this issue of the Journal, Montgomery et al. (

1 ) report

the results of a randomized trial conducted among 200 patients

who underwent excisional breast biopsy or lumpectomy for breast

cancer. Patients were assigned to either routine anesthesia plus

nondirective empathic listening (the control condition) or a very

brief 15-minute presurgery hypnosis session. The hypnosis, which the

authors describe in very cursory fashion, consisted of “a relaxation-

based induction (including imagery for muscle relaxation), sug-

gestions for pleasant visual imagery, suggestions to experience

relaxation and peace, speciﬁ c symptom-focused suggestions

(i.e., to experience reduced pain, nausea, and fatigue), a deepening

procedure, and instructions for how patients could use hypnosis

on their own following the intervention session.” This brief hyp-

notic preparation was sufﬁ cient to produce a statistically signiﬁ cant

reduction in the use of propofol and lidocaine; yet despite this,

patients in the intervention group reported less pain, nausea, fatigue,

discomfort, and emotional upset than did patients in the control

group. Doing good also meant doing well, in that the use of hypnosis

also resulted in a cost savings of $772.71 per patient, due largely to

shorter time in the operating room

— an average of 10.6 minutes.

This impressive study builds on the work of Lang and col-

leagues, who in a series of studies have shown that use of hypnosis

during interventional radiologic procedures results in reduced use

of anesthetic medication, less pain and anxiety, shorter procedure

time (an average of 18 minutes) (

2 , 3 ), and cost savings of $338 per

procedure (

4 ). These results were, surprisingly, independent of age

and hypnotizability (

5 ). The ability to be hypnotized is a stable

trait that can be reliably measured in 5 minutes or less (

6 ). Children

are, in general, more hypnotizable than adults, and there are simi-

lar ﬁ ndings of relief of distress among children who are taught

self-hypnosis before undergoing voiding cystourethrograms (

7 ).

In a study of a similar population to that of Montgomery et al. (

1 ),

of women undergoing large core needle biopsy for breast cancer

diagnosis, Lang et al. (

) showed that hypnosis statistically sig-

niﬁ cantly reduced anxiety but had a lesser effect on the modest

pain associated with the procedure. Thus, the study in this issue

contributes to an impressive body of research using randomized

prospective methodology in sizeable patient populations to dem-

onstrate that adjunctive hypnosis substantially reduces pain and

anxiety during surgical procedures while decreasing medication

use, procedure time, and cost. If a drug were to do that, everyone

would by now be using it.

So why don’t they? For one thing, there is no mediating indus-

try to sell the product

— dangling watches are out of fashion for

hypnotic inductions. Plus, there is still lingering suspicion that

hypnosis reeks of stage show trickery. After all, the magic wand

originated with Mesmer’s use of a magnetic stick to presumably

alter magnetic ﬁ elds in patients’ bodies. Yet hypnosis is the oldest

Western form of psychotherapy. Hypnosis is a state of highly

focused attention, with a constriction in peripheral awareness and

a heightened responsiveness to social cues (

5 ). It is most similar to

the everyday state of becoming so absorbed in a good movie or a

novel that one enters the imagined world and suspends awareness

of the usual one, a condition playwrights refer to as the “suspen-

sion of disbelief.” This state can exert powerful inﬂ uence on mind

and body. Altering perception using hypnosis results in brain

Correspondence to: David Spiegel, MD, Department of Psychiatry and

Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Rd,

Ste 2325, Stanford, CA 94305-5718 (e-mail:

dspiegel@stanford.edu ).

DOI: 10.1093/jnci/djm131

For Permissions, please e-mail: journals.permissions@oxfordjournals.org.

changes that literally reduce pain perception [rather than merely

altering the response to pain (

9 – 12 )]. Indeed, simply changing the

wording of the hypnotic instruction from “you will feel cool, tin-

gling numbness more than pain” to “the pain will not bother you”

alters the brain location of the analgesia from the somatosensory

cortex to the anterior cingulate gyrus (

9 , 13 ). Hypnotic alteration

of color perception results in bidirectional changes in blood ﬂ ow

in the portions of the visual cortex that process color vision — blood

ﬂ ow in this region increases when color is imagined rather than

seen and decreases when color is hypnotically drained from a col-

orful stimulus ( 14 ). Thus, there is good neurophysiologic reason

to believe that hypnosis is potentially a powerful tool to alter per-

ception of pain and associated anxiety.

You have to pay attention to pain for it to hurt, and it is

entirely possible to substantially alter pain perception during sur-

gical procedures by inducing hypnotic relaxation, transforming

perception in parts of the body, or directing attention elsewhere.

The key concept is that this psychological procedure actually

changes pain experience as much as many analgesic medications

and far more than placebos (

15 – 17 ). There is recent evidence

from studies of the placebo effect that activity in the anterior cin-

gulate gyrus is linked to that in the periaqueductal gray, a brain-

stem region that is crucial to pain perception (

18 ). Hypnotic

analgesia is real, no less palpable an analgesic than medication,

although the pathways are different and do not seem to involve

endogenous opiates (

19 ). Rather, hypnosis seems to involve brain

activation via dopamine pathways (

20 – 22 ). Thus, it is not surpris-

ing that hypnosis, which mobilizes attention pathways in the

brain, can be used effectively to reduce pain perception and atten-

dant anxiety.

Cancer is a disease that hijacks patients’ attention. Those com-

ing for diagnostic surgery are understandably anxious about the

outcome. They are thus hyperattentive to every pain and its possi-

ble implications. The operating room is a novel environment, and

humans have evolved to pay special attention to new and poten-

tially threatening situations. Thus, a means of redirecting atten-

tion while using the brain to induce physical relaxation rather than

promote muscle tension can be especially helpful to cancer patients

during their initial surgery. It is now abundantly clear that we can

retrain the brain to reduce pain: “ﬂ oat rather than ﬁ ght.” Esdaile

would have been proud to read this issue of the Journal. He might

even have said, “Ladies and Gentlemen, this is no humbug.”

References

(1) Montgomery

GH , Bovbjerg

DH , Schnur JB , David

D , Goldfarb A ,

Weltz C , et al

. A randomized clinical trial of a brief hypnosis intervention

to control side effects in breast surgery patients

. J Natl Cancer Inst

2007 ;

99 : 1304 – 12 .

(2) Lang

E , Benotsch

E , Fink L ,

Lutgendorf S , Berbaum

M ,

Berbaum K ,

et al

. Adjunctive non-pharmacological analgesia for invasive medical

procedures: a randomised trial

. Lancet

2000 ; 355 : 1486 –

90 .

(3) Lang

E , Joyce

J . Self-hypnotic relaxation during interventional radiologi-

cal procedures: effects on pain perception and intravenous drug use

. Int

J Clin Exp Hypn

1996 ; 44 : 106 –

19 .

(4) Lang

EV , Rosen MP . Cost analysis of adjunct hypnosis with sedation dur-

ing outpatient interventional radiologic procedures

. Radiology 2002 ; 222 :

375 – 82

(5) Lutgendorf SK , Lang EV , Berbaum

, Russell

D , Berbaum

ML ,

Logan H , et al . Effects of age on responsiveness to adjunct hypnotic

analgesia during invasive medical procedures

. Psychosom Med

2007 ; 69 :

191 – 9 .

(6) Spiegel

H ,

Spiegel

D. Trance and treatment: clinical uses of hypnosis

Washington (DC)

: American Psychiatric Publishing

; 2004 .

(7) Butler

LD , Symons

BK , Henderson

SL , Shortliffe LD , Spiegel D .

Hypnosis reduces distress and duration of an invasive medical procedure

for children

. Pediatrics

2005 ; 115 : e77

– 85 .

(8) Lang

EV , Berbaum KS , Faintuch

S ,

Hatsiopoulou O , Halsey N , Li X ,

et al

. Adjunctive self-hypnotic relaxation for outpatient medical proce-

dures: a prospective randomized trial with women undergoing large core

breast biopsy

. Pain 2006 ; 126 : 155 –

64 .

(9) Rainville P ,

Duncan

GH , Price

DD ,

Carrier B ,

Bushnell MC . Pain affect

encoded in human anterior cingulate but not somatosensory cortex

Science 1997 ; 277 : 968 –

71 .

(10) Rainville P ,

Hofbauer

RK , Bushnell

MC , Duncan GH ,

Price

DD .

Hypnosis modulates activity in brain structures involved in the regulation

of consciousness

. J Cogn Neurosci 2002 ; 14 : 887 –

901 .

(11) Faymonville

ME , Laureys

S , Degueldre

C , DelFiore

G ,

Luxen A ,

Franck G , et al

. Neural mechanisms of antinociceptive effects of hyp-

nosis . Anesthesiology 2000 ; 92 : 1257 –

67 .

(12) Spiegel

D , Bierre P , Rootenberg

J .

Hypnotic alteration of somatosensory

perception . Am J Psychiatry

1989 ; 146 : 749 –

54 .

(13) Rainville P , Carrier

B , Hofbauer

RK , Bushnell MC , Duncan GH . Dis-

sociation of sensory and affective dimensions of pain using hypnotic

modulation . Pain 1999 ; 82 : 159 –

71 .

(14) Kosslyn SM , Thompson WL , Costantini-Ferrando MF , Alpert NM ,

Spiegel

D .

Hypnotic visual illusion alters color processing in the brain

Am J Psychiatry

2000 ; 157 : 1279 –

84 .

(15) McGlashan

TH , Evans

FJ , Orne MT . The nature of hypnotic analgesia and

placebo response to experimental pain

. Psychosom Med

1969 ; 31 : 227 – 46 .

(16) Raz

A , Fan J , Posner

MI . Hypnotic suggestion reduces conﬂ ict in the

human brain

. Proc Natl Acad Sci USA

2005 ; 102 : 9978 –

83 .

(17) Spiegel

D , Kraemer

H , Carlson R . Is the placebo powerless?

N Engl

J Med 2001 ; 345 : 1276; author reply

(18) Wager

TD , Scott DJ , Zubieta JK . Placebo effects on human {micro}-

opioid activity during pain

. Proc Natl Acad Sci USA

2007

; 104 : 11056 – 61 .

(19) Spiegel

D , Albert

L .

Naloxone fails to reverse hypnotic alleviation of

chronic pain

. Psychopharmacology

1983 ; 81 : 140 –

3 .

(20) Spiegel

D , King

R . Hypnotizability and CSF HVA levels among psychiat-

ric patients . Biol Psychiatry

1992 ; 31 : 95

– 8 .

(21) Raz

A . Attention and hypnosis: neural substrates and genetic associations

of two converging processes

. Int J Clin Exp Hypn

2005 ; 53 : 237 – 58 .

(22) Lichtenberg

P , Bachner-Melman R , Gritsenko I , Ebstein RP . Exploratory

association study between catechol-O-methyltransferase (COMT) high/

low enzyme activity polymorphism and hypnotizability

. Am J Med Genet

2000 ; 96 : 771

– 4 .