#acl 3608E,3613E,3966D:read,write Default = Hypnosis: physiological processes and how it affects pain and anxiety = <> == Introduction == Hypnosis is a state of altered consciousness where suggestions and commands are much more effective with a high focusing on attention and responsiveness. It is usually artificially induced. Its first representative scientifically is considered to be [[https://en.wikipedia.org/wiki/Franz_Mesmer|Franz Mesmer]], a German physician of the 18th century who used this method in the treatment of some patients with magnets, hence “mesmerising". The origin of the words hypnosis and hypnotism comes from the Greek “hypnos” which means “sleep”. The term is coined in the middle of the 19th century by the English physician [[https://en.wikipedia.org/wiki/James_Braid_(surgeon)|James Braid]] to represent the God of Sleep Hypnos when he studied the phenomenon. Today hypnosis is used in the treatment of pain, anxiety, depression, psychosomatic, post-traumatic, and dissociative disorders. Research in this field is really important and interesting because hypnotic interventions are easy and inexpensive to provide. There are only few negative side effects. It could prove to be really helpful even during brain surgery for example by communicating with the patient to know whether the doctor is touching or cutting important parts. Different kinds of hypnosis exist nowadays, such as cognitive hypnosis, Ericksonian hypnosis, Hypno-psychotherapy, hypnoanalysis, past life regression, time line therapy, self-hypnosis. Cognitive hypnosis is a young approach that combines techniques from a variety of available therapies. The core of cognitive hypnotherapy is neuro-linguistic programming (NLP) and hypnosis. Ericksonian hypnosis has been developed by the principles of [[https://en.wikipedia.org/wiki/Milton_H._Erickson|Dr. Milton Erickson]] . This form of hypnosis is even more efficient on people skeptical of hypnosis as it uses metaphors instead of direct suggestions. The brain is stimulated to think creatively and reach conclusions that may not be achieved by more traditional hypnosis. Self-hypnosis helps patient relax and to reach a hypnotic state by themselves. The person makes their own suggestions and commands. Audio recordings can also be used as a guide. == Physiology of Hypnosis == No exact models have shown particularly the physiological background of the hypnotism, however many studies have been carried out. To see a general view of the effects of hypnotism, we should focus on several experiences and not only one. Ensuing are some studies about different factors which would affect people’s sensitivity of hypnotisability and the different changes happening during hypnotic state. === Study 1 === 47 healthy participants have been selected from colleges and universities for hypnotisability using total scores on the Harvard Group Scale for Hypnotic Susceptibility. First, an hypnotic induction is done followed by a series of instructions given in attend to degrade sensory, motor, and volitional function. 36 highs and 21 lows have scored consistently high or low on both measures. Four conditions have been applied in counterbalanced order: *Hypnotic happiness (hypnotic emotion condition) *Hypnotic vacation (hypnotic memory condition) *Resting state *Memory condition Patients with low hypnotisability focus on everyday concerns when the ones with high experience imagery or positive experiences (Cardena et al. 2013). Hypnotisability is linked to the level of [[https://en.wikipedia.org/wiki/Dopamine|dopamine]] metabolite homovanilic acid in the [[https://en.wikipedia.org/wiki/Cerebrospinal_fluid|Cerebrospinal fluid (CSF)]]. High level of [[https://en.wikipedia.org/wiki/Homovanillic_acid|homovanilic acid]] in the brain would be a factor of higher hypnotisability (Jiang, 2017). Functional activity between the [[https://en.wikipedia.org/wiki/Dorsolateral_prefrontal_cortex|dorsolateral prefrontal cortex (DLPFC)]] which is rich in dopamine and the [[https://en.wikipedia.org/wiki/Anterior_cingulate_cortex|dorsal anterior cingulate cortex (dACC)]] increases during the hypnotic state. The ACC surrounds the [[https://en.wikipedia.org/wiki/Corpus_callosum|Corpus Callosum]] and contains the [[https://en.wikipedia.org/wiki/Brodmann_area|Brodmann areas]] 24, 32 and 33. The DLPFC is responsible for the “control of behaviour” (Mars, 2007). Sensation of pain during hypnotic state: *If someone is telling to the patient “You will feel pain”, DLPFC, dACC and insular activation occurs. *If someone is telling to the patient “The pain will not affect you”, The activity of dACC decreases and hypnotic Analgesia will happened. Hypnotic analgesia is the decrease or disappearance of noxious sensation perception due to hypnotism. What can be concluded is that the activation of dACC is task dependant. dACC is associated to appraisal and the expression of fear and pain. It also plays a role in the will of perseverance and the sense of personal agency. People who felt the most hypnotised show the greatest connectivity between the left DLPFC and left insula. The insula can be divided into regions describing their function. The regions are a sensorimotor region, a central-olfactogustatory region, a socio-emotional region and a cognitive anterior-dorsal region (Uddin, 2017). When certain factors are applied to the patient the connectivity between the left DLPFC and the left insula increases during hypnosis. Executive control network (ECN) is a region of the brain containing DLPFC and superior parietal cortices (See Figure 1). The ECN is active during “focused attention and working memory tasks” (Jiang, 2017). [[https://en.wikipedia.org/wiki/Salience_network|Salience network (SN)]] region is linked to attention control and is activated by challenge or anxiety (Jiang et al, 2017). || {{attachment:5.jpg||width="600"}} || ||'''Figure 1''' ''Areas of activity of hypnosis (self drawn)'' || For highly hypnotisable people : *Activity of dACC decreases *Connectivity between ECN regions increases *Connectivity in regions of brain which mediate the self-referential processing decreases The medial prefrontal cortex (mPFC) and the posterior cingulate cortex (PCC), representing the middle brain structures and activating during rumination and rest, make part of the Default Mode Network. The DFC is a network of different brain regions stimulated during awake and resting state of a person. Its activity decreases during hypnosis. These informations show that the hypnosis is a state of awareness different from the resting state (Jiang et al, 2017). === Study 2 === The goal of the second review was to identify the main biological, psychological, and social factors that play a role in the response to hypnotic suggestions and also to assess the relative importance of each factor (See Figure 2). Researchers wanted to check if multiple factors emerge that tend to indicate a weaker or more moderate associations to hypnotic responding. [[https://en.wikipedia.org/wiki/Alpha_wave|Alpha waves]] ( 8–13 Hz ) tend to occur in posterior regions and are associated with feelings of relaxation, as well as a lack of sensory input. [[https://en.wikipedia.org/wiki/Beta_wave|Beta waves]] (13–30 Hz) tend to occur more frontally and are associated with feeling alert, active and anxious. [[https://en.wikipedia.org/wiki/Gamma_wave|Gamma waves]] (38 + Hz) occur during memory tracing and recall and are also associated with cross-modal sensory processing like the senses for the sights, smells and touch of an object or experience. [[https://en.wikipedia.org/wiki/Theta_wave|Theta waves]] (4–8 Hz) are associated with drowsiness, focused attention and memory functions. High hypnotisable people show a greater level of theta activity than lows (Jensen et al, 2015). Hypnotic analgesia suggestions have been shown to reduce the inflammatory processes associated with heat injury and increased sensitivity to pain in the periphery (Jensen et al, 2015). When effective, a decrease of the activity in the thalamus, sensory cortices, insula, anterior cingulate cortex, and prefrontal cortex is observed (Jensen et al, 2015). An ability-aptitude model put in evidence the importance of 2 factors leading to hypnotic responding: A latent cognitive ability for hypnotic responding meaning that this ability is not activated The belief of the patient about the existence of a hypothetically hypnotic response (Benham et al, 2006). || {{attachment:3.jpg||width="600"}} || ||'''Figure 2''' ''Biological, physiological and social factors affecting the hypnosis of patients and the degree of hypnotisability (self drawn)'' || [[https://en.wikipedia.org/wiki/Positron_emission_tomography|PET]] (Positron Emission Topography), [[https://en.wikipedia.org/wiki/Functional_magnetic_resonance_imaging|fMRI]] (functional Magnetic Resonance Imaging) measure the blood flow in certain areas, so with this indication, the activity of the central nervous system can be deduced. MEG (Magnetoencephalography) records the magnetic fields produced by the electrical activity of neurones in the brain. All of them can reproduce three-dimensional images of brain. === Study 3 === A study from the University of Zurich has been conducted on 50 healthy people who are familiar with hypnosis. The research was done on the brain activation connectivity patterns attached to hypnosis. FMRI was used as the imaging tool. Characteristics seen which make a difference in neurobiological bases of hypnosis can be: *Heterogeneity regarding hypnotic induction procedures *Insufficient statistical power *Mono-Modality Hypnotic states are compared to the control states as a reference. Two steps are required to enter a hypnotic state: first an induction which lead patients into first hypnotic state and a hypnotic deepening which lead to very deep hypnotic state for 10 minutes. During that time a fMRI was performed. Control state corresponds to text representing induction and very deep hypnotic state. Each of these states will last for 10 min during which, like previously, fMRI is performed. Three changes have been observed. The first being differences in resting state functional connectivity and the second differences in heart rate and respiratory frequencies between the four conditions (Mike Bruegger, 2018). Functional connectivity is the link between the different brain regions which share a specific function. Resting state functional connectivity is the connectivity of individual BOLD time points during resting state. === Study 4: Fast-Fourrier spectral analysis === An [[https://en.wikipedia.org/wiki/Electroencephalography|EEG]], electroencephalography, is the method which record the ion fluctuations in the brain by the way of electrodes. It was used to record monopolarly at frontal, central and posterior derivations during the hypnotic induction of the Stanford Hypnotic Clinical Scale. Induction is a process which establish conditions needed for the hypnosis to occur. It is defined as indicators which assess the degree of hypnosis sensitivity. Waking-rest in eyes-open and eyes-closed condition, early, middle, and late phases of hypnotic induction, rest-hypnosis in eyes closed condition, hypnotic dream and age regression were experimented on a group of 19 people, 9 of which were highly-hypnotisable and 10 had low-hypnotisable scores. During hypnotic dream and age regression, high hypnotisable show a decrease in alpha 1 and alpha 2 amplitudes. This effect was absent for low hypnotisable. Beta 1, beta 2 and beta 3 amplitudes increased in the left hemisphere during age regression for high hypnotisable but a hemispheric balance across imaginative tasks have been observed in low hypnotisable patients. The amount of Beta 3 is higher also in those people and seen the most in left hemisphere.The participants with high hypnotisability have an EEG amplitude of 40Hz compare to the low ones (De Pascalis, 1993). == Chronic Pain == [[https://en.wikipedia.org/wiki/Pain|Pain]] is a widespread phenomenon with many different types, for example chronic pain, acute pain or phantom pain to name a few. However the most common pain treated with hypnosis is chronic pain. Chronic pain is considered as pain that lasts longer than 3 to 6 months or keeps recurring for the same time period (Treede et al, 2015). This type of pain persists past normal healing time (Treede et al, 2015). The Task Force for the Classification of Chronic Pain established by the International Association for the Study of Pain (IASP) with the help of the World Health Organisation has recently created a new classification of chronic pain. The classification is divided into 7 groups. The name of each group indicates the origin of the pain or the cause of the pain. The 7 groups are chronic primary pain, chronic cancer pain, chronic post-traumatic and post-surgical pain, chronic neuropathic pain, chronic headache and orofacial pain, chronic visceral pain and chronic musculoskeletal pain. Currently there are two hypnosis methods used in many different studies that can aid in pain reduction. They are self-hypnosis and hetero-hypnosis. Hetero-hypnosis is done by a professional while self-hypnosis is taught to the patients in order for them to be able to control their pain by themselves (Ardigo et al, 2016). Two studies that used these two types of hypnosis in particular are clinical studies on the treatment of primary headaches with hypnotherapy in paediatric cases and the other was the treatment of pain in geriatric hospital patients. In both cases the data collected indicated that hypnosis significantly decreased the pain that the patients taking part in their respective studies felt. In order to understand the effect of hypnosis on chronic pain better, many different trials using different brain imaging techniques, such as PET, fMRI and EEG, were conducted. With these imaging techniques the researchers were able to show the brain area in which activity took place. The PET scan is used to identify the cortical metabolic activity and the fMRI is used to visualise the changes in blood flow in the central nervous system while the EEG shows the cortical electrical activity and is used to asses brain states (Jensen and Patterson, 2014). With these methods researchers were able to identify that instead of there being a single pain centre in the brain, there are many different areas taking part in pain processing. The cortical areas taking part are the thalamus, the anterior cingulate cortex (ACC), the insular cortex, the primary and secondary cortices and the prefrontal cortex (Jensen and Patterson, 2014). These areas and some other areas in the peripheral nervous system interact and the activity in these areas is connected to pain. The extend of the involvement of each of these areas depends on the type of pain stimulus received. With this knowledge multiple experiments in regards to the effect of hypnosis on pain management were conducted. The results obtained from these studies showed that the before mentioned areas responded to the hypnosis (Jensen and Patterson, 2014). In addition to that it was also shown that hypnosis “influences the processing of aversive stimulation at the level of the spinal cord” (Jensen and Patterson, 2014). Rainville and colleagues (1997) conducted a study which illustrated that in addition to the hypnotic induction, hypnotic suggestion can be directed to specific effects in the activity of the brain. When a subject experiences pain more cortical [[https://en.wikipedia.org/wiki/Beta_motor_neuron|beta neurones]] (frequency 13-30Hz) are firing and less [[https://en.wikipedia.org/wiki/Alpha_motor_neuron|alpha neurones]] (frequency: 8-13Hz) are firing (Jensen and Patterson, 2014). However when the subject is hypnotised this phenomenon is reversed and the number of alpha neurones active increases while the number of beta neurones firing signals decreases. From this information one can deduce that hypnosis does not only “influence pain by altering activity in specific areas” but also “by facilitating shifts in general brain states (Jensen and Patterson, 2014)". All these discoveries have clinical implications such as which area of the brain doctors should target with their hypnotic suggestions to achieve the maximum outcome. In addition to that “hypnosis may be enhanced by focused attention, deep relaxation and disruption of linear thinking (Jensen and Patterson, 2014)". Hypnosis as a form of pain management has many benefits besides pain reduction (Jensen and Patterson, 2014). For example in many cases patients with chronic pain suffer from depression and anxiety as well. Hypnosis is also known to have a positive impact on these conditions. Furthermore hypnosis can improve ones sleep and general well being. On a secondary level when hypnosis is used in pain management the use of addictive drugs such as opioids can be reduced. This has many further implications such as financial benefits and a reduction in time required for patient care. However hypnosis does have some limitations. For example in some cases psychiatric complications can occur. Moreover the expectation of the patient and the reality of hypnosis might not align which might dissatisfy the patient (Lee and Pyun, 2012). == Anxiety == [[https://en.wikipedia.org/wiki/Anxiety|Anxiety]] disorders are the most common diseases diagnosed by psychiatrists. Anxiety is related to specific phobias or stressful situations like social anxiety disorders, panic disorders, agoraphobia, selective mutism and separation anxiety. The anxiety can also be related by medical illness. The use of certain medication can cause an anxiety disorder. Moreover, anxiety can be physical, emotional, cognitive and behavioural, similar to the “fight or fight” response to danger. Some hypothesises link anxiety to the combination of genes, environmental conditions, and changes inside the brain. Anxiety often runs in families and epigenetic markers have been identified. Brain cells play an important role on the anxiety, the “anxiety cells” are where the emotion is stored. For example, researchers at UCSF and Columbia University observed that cells in the hippocampus becomes increasingly active whenever the animal enters an uncomfortable area. The hippocampus is the centre of emotional behaviour and memory, The main symptom of anxiety is [[https://en.wikipedia.org/wiki/Fear|“fear”]]. In the brain the fear’s pathway is called the thalamo-cortico-amygdalien pathway. This pathway is composed of the thalamus, prefrontal cortex, hippocampus, and the amygdala. It can be seen that this pathway is composed of the limbic system responsible of the memory mechanism, and the prefrontal cortex responsible of the emotional control. There is the short and the long fear pathway. The amygdala is one primary structure responsible for fear. It stores the memory of all the stressful situations encountered in ones’ life. When “the memorised stressful/scary situation” reoccurs the individual will react the same way. Some will run away while others will fight, but, this memory and the reflex to deal with it will be remembered for a lifetime, explaining why sometimes, irrational behaviour can occur many times. This phenomenon will be renewed each time the person will have the feeling of being in danger while sometimes it is not even the case. The brain gives one a sense of irrational and insurmountable fear. The situation is perceived as much more dangerous than it really is. In order to avoid these disturbing and destabilising situations, the anxious person will develop a whole range of behavioural patterns to avoid those situations. It was in the 1920s that [[https://en.wikipedia.org/wiki/Classical_conditioning|Pavlov]] demonstrated the conditioning and deconditioning of our negative memories and reprogramming them into positive memories toward the same experience. Hypnosis helps modify our behaviour toward situations perceived as scary or stressful. This is done by interpreting them to their true measure instead of dramatising them. It does not change the events of our past, but the subjective interpretation that we have. Hypnosis can deprogram negative conditioning in patients, as our brain permanently creates connections. However as a result of our neurones’ exceptional plasticity it can also undo them. Indeed, our brain is composed of neurones, which can connect to each other and form a neuronal network. Continuous repetition of the same sentences will lead to nerve cells developing a neural network related to the situation. It is known that when we stop practicing an activity, we lose competence in it. At the level of our neurones, we can now see through medical imaging that the nerve endings are discarded, leading to an impaired neuronal network. The hypnotherapist will use vocabulary and patterns that can act on neurones in a positive way. For example, when we speak, or act, we think unconsciously and very quickly, thus, our neurones are behind those mechanisms. Moreover, it was scientifically proved that words have a greater positive effect during the hypnotic state than they have during the awaking state. Despite some variability, it was observed that certain zones are always activated like the anterior cingulate cortex, the precuneus, the occipital cortex, the temporal cortex and the areas of the visual cortex that play a key role in attentional processes and cognitive control. These areas are related to the brain's ability to produce mental images. They account for changes in sensory perceptions, the use of memory-associated images, and changes in motor control during a hypnosis session. During the state of hypnosis three major changes were observed in the brain. In the anterior cingulate dorsal region, the activity of the neurones is increased. This region can influence the concentration on solving a problem. This explains why a hypnotised person is so absorbed that they are not paying attention to anything else. Spiegel (2016) said “when you really want to do something, you don’t think about how doing it, you just do it” with hypnosis the dissociation between action and reflexion can lead the patient to do activities suggested by the hypnotherapist without all the conscious/reflexion pathway. Neural exchanges are also more intense between the dorso-lateral prefrontal cortex and the insula, two of the regions that manage cognitive flexibility and self-awareness. It is thought to let the brain have a better control as to what happens in the body. The connectivity between this same dorso-lateral prefrontal cortex and the "default network" is lessened. This default network is activated when the brain is "at rest”. This means that the brain is still active. The weaker connection between these zones explains that the action and consciousness of this action are dissociated in hypnosis. It decreases the activity of structures (lobes in the parietal lobes and the brainstem) related to the distinctions between the body and the external environment. “With hypnosis, patients can look at things differently; they can think and understand situations differently. We do not change what happened, but the perception that the person has.” Nowadays, Hypnosis is not really well understood, but scientists know which part of the brain are activated by this method. They are areas able to influence the perception. The patient under hypnosis is not in an awake state nor in a sleeping state, he is in an intermediate state “default state” allowing the hypnotherapist to act on his perception. The hypnotherapist can use the “suggestion method” more traditionally, under which the patient facing the hypnotist undergoes verbal, visual and body injunctions. The hypnotherapist will subtly suggest better situations, or better outcome. Consequently discarding neural network leading to anxiety. Hypnotherapist will try to alter neuronal network, for example, by making them non logical, adding incoherent suggestion. It was proved scientifically, that the hypnosis is working on anxiety, however, the physiological mechanism is not yet fully understood. == Conclusion == Hypnosis is defined as the state of altered consciousness where suggestions and commands are much more effective with a high focusing on attention and responsiveness. The phenomenon of hypnosis has gained more interest in recent years as it can be used as a therapeutic tool to treat pain and anxiety. With the medical imagining techniques available nowadays, scientists and researcher were able to discover which areas of the brain are activated during hypnosis and what the implications are by the activation of these areas. Overall hypnosis has many benefits to our society but we cannot ignore the limitations that accompany hypnosis. Even though research has lead to incredible advancements in scientific knowledge about hypnosis, there still is much more that has to be discovered. == References == === Scientific Papers === Ardigo, S.; Herrmann, F.R.; Moret, V.; Déramé, L.; Giannelli, S.; Gold. G.; Pautex, S. (2016): Hypnosis can reduce pain in hospitalized older patients: a randomized controlled study. BMC Geriatrics 16: (1) 14 Benham, G.; Woody E.Z.; Wilson, K.S.; Nash M.R. (2006): Expect the unexpected: ability, attitude, and responsiveness to hypnosis. Journal of Personality and Social Psychology 91: (2) 342-50 Braffman, W.; Kirsch, I. 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(2017): Hypnose: que se passe-t-il dans le cerveau. https://theconversation.com/hypnose-que-se-passe-t-il-dans-le-cerveau-76421 Accessed: May 3, 2019 === Figure reference === Figure 1: Areas of activity of hypnosis (self drawn) (M.Roussel) Feilding, A. (2017): Amanda Feilding’s Talk at Horizons 2017. Beckley Foundation Figure 2: Biological, physiological and social factors affecting the hypnosis of patients and the degree of hypnotisability (self drawn). (M.Roussel) Jensen, M.P.; Adachi, T.; Tomé-Pires, C.; Lee, J.; Osman, Z.J.; Miró, J. (2015): Mechanisms of Hypnosis. International Journal of Clinical and Experimental Hypnosis 63: (1) 34-75