Benjamin Rowlands, Nicole Hofstein, Nicklas Parks and Ross Kilpatrick

Marker's comments here....

This investigation was inspired by studies within the Journal of the National Cancer Institute that suggests that women who spend 15 minutes learning or participating in hypnosis before breast cancer surgery experienced less pain, anxiety, nausea, fatigue and will spend less time in surgery thus minimising the need for anesthetics. Dr. Timothy Johnson, the ABC News Medical Editor from Healthy life Now interviews Dr. Woodson Merrell, Executive director for the Continuum Control for Health and Healing to discuss the power of hypnosis.

In this ABC News broadcast interview, Merrell articulates the idea of hypnosis being a positive tool for modern medicine, publicising the use of hypnosis as a medical alternative to anesthetic agents during breast surgery biopsies. He claims it “not only showed improvement in the treatment, but there was a saving of about 1000 dollars per patient”. However when Merrell is asked to clarify how hypnosis translates into physiological changes as the study suggests, he didn't fully address the question. When asked again, he only spoke of the notions of “power”, “control” and “accessibility of mind”.

It was collectively felt by the peers of this group that this media item was indicative of the popularised media surrounding hypnosis today. Much is said about the effects and implications of hypnosis, but the underlying physiological and neurological aspects concerning pain inhibition in particular, are either dismissed or overlooked. If medical experts can not discern the phenomenon of hypnosis, then were does this leave us in terms of improvement? How much is actually known about the possibilities of hypnosis? Do we know less about hypnosis than the medical world would lead us to believe? These are the burning questions which drive this group's motivation to investigate hypnosis as a possible means of improving the quality of life for pain sufferers.

Neuroscientific Context:

Hypnosis Background:

Father of Hypnosis

The idea of hypnosis has existed for hundreds of years, Franz Mesmer being the first to highlight its significance in the medical world through his animal magnetism technique mesmerism. However, it wasn’t until 1843 that the phenomenon was coined ‘hypnosis’ by James Braid in his book Neurypnology (Donald Roberts on 2009). Eventually it was accepted as a proper medical technique in 1958, by the Council of Mental Health of the American Medical Association (Jon Rhodes 2002).

Contemporary hypnosis is defined as a "state of inner absorption, concentration and focused attention" (American Society of Clinical Hypnosis, 2010), similar to being awake or in a trance state (Castaglioni et al., 2009). Hypnosis has long been correlated with being able to inhibit pain, which for the purposes of this discussion will be defined in accordance with the International Association of the Study of Pain (2011) as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage’.

Until recently with the development of non-invasive imaging techniques, the underlying physiological and neurological mechanisms for which hypnosis inhibits pain perception have been ignored by the medical world. Our group will focus our attention towards the underlying physiological pain pathways that allow for pain perception, and then evaluate evidence of hypnotic effects using the latest imaging technology to determine causality or indeed the inability for current technologies to deduce a clear relationship between hypnosis and pain inhibition.

Pain Pathways
The Underlying Physiological Mechanisms for Pain Perception.

Pain starts as a response in nociceptive neurons that travel up the spinal cord to the thalamus (Tracey and Mantyh, 2007). After its ascent the signals are distributed to the two pain systems of the brain, collectively termed the pain matrix
(Legrain et al. 2011; Tracey and Mantyh, 2007), shown basically in figure 1 (adapted from Bie, Brown and Naguib, 2011).

The lateral pain system has projections from the thalamus to the primary and secondary somatosensory cortices and the insula (Pogatzki-Kahn et al. 2010). The perceptual experience of pain involves these many structures in the brain firing together in distinct temporal patterns (Jamieson(ed), 2007; Pogatzki-Zahn et al. 2010; Tracey and Mantyh, 2007).

The medial pain system involves neurons that project from the thalamus to the cingulate cortex, insula, frontal cortex and hippocampus.
Figure 1. Basic pathway of nociception to pain matrix

The Lateral Pain System
The structures of the lateral pain system encode the sensory discriminative aspects of pain (Pogatzki-Zahn et al. 2010).

There are three important components that mediate, recognise and localise pain, being the primary and secondary somatosensory cortex, and the Insula
The primary somatosensory cortex receives somatotopically organised nociceptive input and is involved in localising painful stimuli, including it's intensity and duration (Chudler et al. 1990; Schnitzler and Ploner, 2000). Alongside this, the secondary somatosensory system plays a role pain recognition (Shnitzler and Ploner, 2000). Lastly,the Insula is involved in mediating the physiological conditions of pain and temperature (Shnitzler and Polner, 2000).

The Medial Pain System
The medial pain system works to encode the affective components of pain (Pogatzki-Khan et al. 2010).

There is considerable evidence to suggest that the anterior cingulate cortex (ACC) is involved in the affective responses to pain, immediate behavioural reactions to pain and the suppression of pain affect (Rainville et al. 1997; Schnitzler and Ploner, 2000; Bie, Brown and Naguib, 2011; Harte, Spuz and Borszcz, 2011; Shackman et al. 2011; Jamieson (Ed.), 2007). Integrating 192 studies on cingulated cortex activation, Shackman and colleagues (2011) identified consistent
Figure 2. Downward modulation of pain

crosstalk in the activation of specific areas of the cingulate cortex during the evocation of negative affect, pain or cognitive control. The frontal cortex is thought to be involved in attention towards a painful stimulus, descending control of pain, and modulating the response (Gruzelier and Warren, 1993; Tracey and Mantyh, 2007; Jamieson (Ed.), 2007). The hippocampus has been strongly associated with driving the aversion of painful stimuli (Liu et al. 2011; Zhao et al. 2009).

It has been suggested that the analgesic effects observed are a result of dissociation between the sensory and affective components of pain. Subjects under hypnotic analgesia, even though experiencing a decrease in pain affect can still report the intensity and location of a painful stimulus (Castaglioni et al. 2009; Jamieson (Ed.), 2007; Rainville et al, 1997).

Pharmacological studies (Yang, Shih and Shyu, 2006; Harte, Spuz and Borszcz, 2011) support the idea that agonistic activation of the ACC evokes the release of endogenous opioids into the the midbrain. This then triggers antinociceptive projections to the medulla and spinal cord dorsal horn (Figure 2, adapted from Tracey and Mantyh, 2007), suppressing the throughput of nociception to the forebrain sites involved in pain perception, thus decreasing pain affect (Harte, Spuz and Borszcz, 2011).

Hypnotic analgesia has consistently shown decreases in cortical activity and an increase in the functional connectivity between the ACC and other brain regions of the pain matrix during hypnosis (Gruzelier and Warren, 1993; Jamieson (Ed.), 2007; Pykaa et al. 2011), providing evidence of possible top-down modulation of pain during hypnotic analgesia.

Neurological Imaging and Hypnosis
Where do we stand in terms of understanding?
Figure 3. Difference in activation levels within the contralateral thalamus, bilateral striatum and anterior cingulate (ACC) during painful stimulus.

Until recently, the effects of hypnosis on pain have been largely modelled using behavioural techniques (Craig et al., 2001). However current technological advancements in neuroimaging have allowed for analysis of the brain's localised activation during hypnosis (Raz., et al 2002). Studies have been conducted to try and coordinate the extensive neuronal networks in hopes to invite new understanding into how hypnosis prevents pain perception (Feymonville et al., 2000). The utilization of Positron Emission Tomography (PET) has allowed for the establishment of a clear link between the functional activity of the ACC with the, insula, perigenual cortex, pre-supplementary motor cortex, superior frontal gyrus, right thalamus, right caudate nucleus and midbrain/brainstem (Chen., 2009). These localized areas are functionally correlated with pain modulation (Tracey and Mantyh, 2007), showing connections that exist in the thalamus, hippocampus, septum, amygdala and ACC (Castaglioni et al. 2009). A study using functional Magnetic resonance Imaging (fMRI) on activation levels of specific cortical region identified modulation of upper cortical representation based on the strength of neuronal signals sent via pain pathways during hypnosis (Pykaa et al., 2011). This study consolidates much of the past research, providing further validation for the effects of hypnosis on pain inhibition.

An interesting study using (fMRI) technologies has been used to comparative analysis brain activation of patients who are under hypnosis and those who aren’t (Vanhaudenhuyse et al., 2009). They were able to show differences in neuronal activity, Figure 3, suggesting hypnosis may decrease pain perception by reducing the amount of cortical activation. This study was able to move beyond previous studies as it didn’t just show correlation with specific brain structures and their ability to inhibit pain, but comparatively analysed amounts of activation within these structures.

However, whilst it is clear that our understanding of hypnosis and its effects on pain modulation are improving, there is still no definitive evidence suggesting the underlying mechanisms for how hypnosis causes changes in activation of pain pathways. It is currently believed that further enquiry into the specific neurotransmitters will help deduce the effects of hypnosis on inhibiting pain (Lone Knudsen., et al 2011) but for now we must conclude that although much is known about hypnosis and its ability to inhibit pain, we are unable to discern the exact mechanisms.

Critical Analysis

The video is from the 'Healthy Life' segment of ABC News. The ABC is one of Americas largest commercial broadcasting networks and a subsidiary enterprise of the Walt Disney Corporation. Its involvement in the print media, radio, television and other multimedia demonstrates its wide viewing audience. Due to its diverse demographic, it must present its information in a manner that can be accessible to all. Thus, it sacrifices scientific depth and the language that it uses to describe the concepts, effects, and processes has been simplified. This is evident through Dr Merrel's approach on the subject of hypnosis in which he describes it using vague phrases such as "the power of the mind".
The media item also lacks objectivity as it fails to present any information to criticise or critically evaluate the efficacy of hypnosis in a therapeutic context as it merely refers to a single scientific journal article to support its perspective.
As mentioned above, the lack of scientific information is indicative of its target audience. In addition, it is concerning that the audience is not being informed of the mechanism by which this alternative therapy works. Whilst, there may be clinical evidence to support the effectiveness of hypnosis, the absence of any decent explanation seems to be a discouraging feature for viewers in being able to trust hypnosis and its credibility.

However, whilst the media item is quite hollow in relation to neuroscientific, physiological, or psychological explanations, it does attempt to clarify a prominent misunderstanding about hypnosis or at least promote further investigation into hypnosis. Dr. Merrell does attempt to explain hypnosis or perhaps the experience or state of hypnosis, which is often dramatised in media as participants behaving in outlandish manners or performing ridiculous actions. The item does inform viewers that hypnosis is dependent on the hypnotisability of participants and that effectiveness as a result will vary (Holroyd, 1996). It also proposes that hypnosis is not involuntary and that the participant does have control over themselves and their actions. Another positive element of the media item is that it actually refers to a peer reviewed journal article, albeit only a single paper, there is evidence to support the content. The interviewee is also an accredited hypnotherapist and outlines the corporation that accredits professionals in hypnosis so that viewers may find out more information about providers in their area or any other information they seek to be answered.
Castaglioni et al. (2009) discuss placebo effects in human studies as patients may expect pain relief from therapy. The possibility of a placebo effect was not mentioned by Dr. Merrell, and neither were any limitations in the clinical use of hypnosis. Furthermore, there is no evidence to support Dr. Merrell's belief of hypnosis 'unlocking the subconscious mind' or a person having better control of their mind. This was exemplified in a previous study conducted by Gruzelier and Warren (1993) in which subjects under hypnosis exhibited impaired performance in both verbal letter fluency and finger tapping dexterity.

Appendix: (Research Strategy)

Our group began its research by one of our team members, Ben, creating a facebook group that allowed us to propose our ideas before beginning the project. We all put forward our personal areas of interest ranging from Alzheimer's Disease, the Blue Brain Project, and hypnosis. We than discussed the possibilities of each subject and the information concerning the topic, the availability of media images and what particular topic actually had a viable media project that would enable us to complete a proper analysis of the item itself and its inherent neuro-scientific content. After examining several videos, we managed to narrow our focus to two videos concerning hypnosis and one featuring the Blue Brain Project. However, because the Blue Brain Project didn't seem to contain much debatable content, we decided on hypnosis and its effects on pain perception. We then obtained our media item from youtube and shared it on the facebook group for all our group members to view. We were able to criticize the chosen video and hence, we decided to investigate its claims and scientific content.
From here we began a basic search through google to gain an understanding of basic concepts, but to collect information we used the UNSW library databases to collect our articles.


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