NATURE OF PAIN
The exact nature of pain as well as the various mechanisms underlying the modulation of pain sensation are extremely complex and, at present, inadequately explained. One investigator has stated that there is no such thing as a pain fiber or even a pain neuron in the peripheral nervous system.4 Pain is not a primary sensory modality, like seeing or hearing, but rather is, in part, an emotionally charged percept influenced to an astonishing degree by psychological factors. Moreover, allowing for variations in responses in humans, the pain threshold is more dependent on physiological factors,7 whereas pain tolerance is influenced largely by psychological ones.30
The author has described elsewhere in this book how the pain tolerance is raised by various types of suggestive and/or hypnotic procedures per se in major and minor surgical operations, obstetrical conditions, and other problems such as headache, backache and pelvic pain. Therefore, the thrust of this chapter will be to explain some of the common denominators for hypnoanesthesia and acupunctural analgesia (A.A.). It is no mere coincidence that both of these valuable technics are ancient methodologies which are as yet poorly understood. However, even if A.A. turns out to be another form of the nonspecific placebo response, it does work—particularly for the Chinese—for the reasons mentioned below.
REASONS FOR EFFECTIVENESS OF HYPNOSIS AND ACUPUNCTURE
Both hypnosis and A.A. may have a similar neural basis and, therefore, may be opposite sides of the same coin. Hypnoanesthesia, like A.A., can be produced by different sensory inputs. As is the case with hysterical analgesia, the anesthesized areas follow no known segmental nervous distribution.
Clinically, A.A. would be better understood if it were realized that objective signs of hypnosis and a formal induction procedure are not necessarily required to induce analgesia and anesthesia.1 Furthermore, few American scientist-observers of A.A have had training or exposure to disguised or covert hypnotic induction technics for production of anesthesia. One might speculate as to what the acceptance of A.A. might be if the method had not received so much ballyhoo in recent years.
Empirically, the reasons for the clinical effectiveness of acupuncture in medical disorders have been discussed in numerous publications. Dimond succinctly summed it up when he stated, “A great deal of it is plain psychotherapy for psychosomatic complaints.”6 Melzack and Wall, whose gate theory has been used to explain the effectiveness of acupuncture, recognized the role of emotions in the perception of pain.23 They state that “… relaxants, tranquilizers, sedatives, suggestion, placebos, and hypnosis exert a profound influence on pain. … These methods deserve more attention than they have received.”
Other methods whereby pain can be obtunded employ counterirritation, such as heat (ignipuncture or moxibustion); acupressure and cupping; and transcutaneous electrical stimulation (by needles, electrodes, or static electricity). These methods, based on the distraction principle, work by diverting the attention to a stimulus other than the pain. The anxiety that ordinarily accompanies pain also is minimized by A.A., thus reducing fear and tension to raise the pain tolerance automatically.11
OPIATE RECEPTOR SYSTEM: ROLE OF ENDORPHINS IN PAIN
A dramatic breakthrough was made that may help to explain how pain tolerance can be increased by hypnosis and A.A. It has been discovered that the rat brain is equipped with specific opiate receptors.26 Two different peptides have been isolated from pig brains, which were named methionine enkephalin and leucine enkephalin, respectively.10 Subsequently, a compound named a-endorphin was isolated.9 Both the enkephalins and a-endorphin manifested morphine-like activity which could be reversed by naloxone hydrochloride. It was suggested that all the opiate substances be referred to as endorphins.8 As a class, the endorphins are similar to fragments of the pituitary hormone beta-lipoprotein and, like morphine, act as an analgesic. Some of these compounds may be inhibitory neurotransmitters of specific neuronal systems involved in pain perception. Like other pituitary polypeptides, the endorphins also act as hormones on distant organs.
Pomeranz suspected a hormonal mechanism to explain acupuncture and hypnosis before the endorphins were known to exist.27 He and his co-workers tested A.A. on mice and compared the responses of intact, hypophysectomized, and sham-operated mice. The hypophysectomized group showed no analgesic effect; the others did. Pain blockade persisted for more than an hour. These researchers found that the opiate antagonist naloxone completely blocked A.A. in mice; saline-injected controls responded normally.
Other researchers have demonstrated that naloxone does not block hypnotically induced analgesia in humans, suggesting that another mechanism was involved.27 Pomeranz believes that “hypnosis is ruled out by our anesthetized cats and by sham acupuncture.”27 It was postulated that acupuncture was driving the pituitary to release its endorphins. Another acupuncture-endorphin link was suggested by Goldstein, who noted that when specific brain areas in the rat were stimulated, pain tolerance was rapidly induced, with concomitant release of endorphins from their storage site in the brain. Apparently, the brain appears to compensate for the increased demand by synthesizing more peptides than usual.
While these exciting studies sound convincing with reference to the acupuncture-hypnosis controversy, one must consider that it is extremely difficult to extrapolate results from animal experiments to humans; in the latter, pain, as mentioned above, is mediated by complex psychological factors.
NEUROPHYSIOLOGY OF PAIN IN HYPNOSIS
Wykert has discussed the relationship of pain and hypnosis.34 He posits that the activity of the rostroreticular system is dampened by hypnosis. The principal site of action is the lower (caudal) part of the reticular formation. It is here that pain impulses are blocked at the periphery, so that there is no central reception of pain. This is similar to the saturation threshold hypothesis advanced in Chapter 28, and also is in accord with Pavlov's internal inhibition—the neural mechanism postulated for hypnosis.
EXPLANATION OF ACUPUNCTURE IN TERMS OF CONDITIONING THEORY
Despite the spate of articles on acupuncture, the author still adheres to his published explanations of A.A.14,19 He believes that A.A. can best be understood in terms of a conditioning theory paradigm which often includes the preoperative use of Schultz's rehearsal method,29* desensitization, and “waking hypnosis.” A comprehensive explanation of how A.A. works in “natural surgery,” which the author was among the first to propose, includes the following significant variables: (1) a 5,000-year-old belief system; (2) the suggestive effects of the impressive charts, mannikins, and models with their meridians and spots; (3) Mao's words and exhortations on the subject, accepted as gospel; (4) the ideological fervor and evangelical zeal of the masses, resulting in patriotic adherence to Maoist doctrine; and (5) the characteristic stoicism of the Chinese.
Additional variables include (1) strong rapport; (2) motivation; (3) the conviction that A.A. would work; (4) the idea that the doctor must serve the patient (therefore, because he is convinced of the efficacy of A.A., his suggestions, either by words or actions, tend to reinforce the patient's suggestibility); (5) the knowledge that the State has done so much for the people that it knows what is best for them (A.A., like hypnoanesthesia, is a praiseworthy method as it markedly reduces the need for analgesia and anesthesia); (6) the special selection of patients, and wherever possible the mock rehearsal, of the various steps of the operation before surgery, in and out of the operating room by the same surgical team; (7) the training of patients in groups, which induces an “emotional contagion” and desire to please the doctor or group leader; (8) the mobilization of competitiveness which takes place in a group; (9) the use of preoperative analgesic agents and Novocain, which are nearly always employed singly or in combination during surgery; (10) the ritualistic placement of the needles; (11) the twirling of the needles, which produces distraction and acts as a powerful diversion; and (12) the teaching of yogic breathing and other relaxing exercises, where possible, for induction of calmness.
Some of the above-mentioned variables, though known to hypnotherapists, were apparently overlooked by the first Western scientists who reported on A.A. For instance, pricking the Ho-ku points results in soreness and heaviness of the hand, and often the arm. This convinces the patient that the acupuncturist has the ability to produce even greater effects.25 Hypnotists achieve the same effects when they insert large needles through the skin—which can readily be done at nonhypnotic levels—to impress the patient and, as a result, achieve a favorable mind-set. This prior indoctrination maneuver, like the “needling test” in A.A., is important for a successful outcome.
Chavez and Barber have advanced a six-factor theory similar to the author's explanations of A.A.3 As usual they avoid the term hypnosis as they feel there is no need to explain A.A. by a term which at present cannot be defined. MacIntosh has remarked, “If someone will explain hypnosis to me, I am confident that the secret of acupuncture will be revealed at the same time.”21 However, it has been noted that those who responded well to acupuncture were the same persons who were good hypnotic subjects.12
The author has performed numerous major and minor surgical procedures without analgesia or anesthesia simply by using the rehearsal technic and hypnosis.18 For want of a better name, I called the method “hypnosis,” albeit the term is a misnomer. The patients reacted and looked like those shown in the official films made in the People's Republic of China.
Many investigators contend that A.A. is not due to any kind of hypnosis, because A.A. is used on a variety of animals. Ignored is an extensive literature on the “immobility reflex” (or I.R.), erroneously called “animal hypnosis.”13 Many animals develop the I.R. when held in restraint; they can be operated upon relatively painlessly. Therefore, the argument that animals can undergo surgery under A.A. does not invalidate the hypnosis hypothesis.
Those who cite that infants respond to A.A. and, therefore, are not amenable to hypnosis or
Maoist teachings are not aware that swaddling or restraint produces the “still reaction”33; this raises the pain threshold.
Observations by others largely support the author's formulations about A.A.2,12,19,31 Mann stated that “suggestion may be integral to A.A.”21 He demonstrated that the patient's belief in the effectiveness of acupuncture is crucial to its success. Acupuncture failed to produce analgesia to deep pin pricks in 90 per cent of subjects who were not told that it would be effective. Lee and co-workers found that it did not matter whether the needles were placed in the traditional meridian locations or in arbitrary fixed points.20 Melzack states “every culture on every continent has developed its own type of acupuncture.”23 Thus the explanation for the Chinese puzzle falls into the realm of conviction phenomena—a sort of “tribal medicine.”
SUMMARY
This presentation is not intended as a criticism of A.A. In the environment in which it is being applied, it is obviously the method of choice and should not be denigrated. The author's purpose is solely to clarify its modus operandi and to reconcile the mutually contradictory theories and the variegated formulations in an attempt to explain its scientific rationale. It is no mere coincidence that A.A. works as the sole analgesic agent in approximately the same number of patients (about 10-20%) as hypnoanesthesia, and for similar surgical conditions. Moreover, the indications, contraindications, limitations, and advantages are identical. It appears that mesmerism, the precursor of hypnotism, has been replaced by “needleism”!
The following conclusions may be drawn: (1) very responsive subjects are selected for A.A.; (2) “waking responsiveness” to suggestions is higher in such persons than commonly assumed; (3) the prestige of the doctor and acupuncturist makes it clear to patients that a high degree of responsiveness is desired and expected; and (4) the cultural setting facilitates or enhances suggestibility. This last factor is the crucial variable, and, therefore, requires a fuller understanding. Thus we should evaluate the sociocultural and demand characteristics (expectations, roles and subliminal cues) as they appear in a regimented society such as China with the demand characteristics as they exist in the Occidental world. This accounts not only for variations in hypnotic phenomena, but also applies in relation to the broad spectrum of psychologic experiences which have to do not only with well-known placebo responses, but also with more basic aspects of psychobiologic functions, such as attention, concentration, and perceptual awareness.
In a regimented society, the demand characteristics function in such a way as to bring about compliant behavior without the necessity of overt cooperation or motivational involvement. In a nonregimented society, there is much less evidence that compliance will be obtained unless cooperative behavior is elicited via strong interpersonal relationships or reward inducements, as designated in Mao Tse Tung's New Thought Directives. Thus the whole concept of acupuncture relates not only to hypnosis, but also to the whole aspect of behavioral shaping, in keeping with some of Skinner's contributions for one, and decidedly within the realm of the forming and shaping of adaptive behavior.*
The Chinese philosopher Lao-tse wrote 2,400 years ago, “When the water is muddy, who can settle things? Only wait, and it will become clear.”
REFERENCES
1. Barber, T.X.: A Scientific Approach to Hypnosis. New York, Van Nostrand, 1969.
2. Buser, P., and Viala, G.: A study on hypnosis in the rabbit. In Chertok, L. (ed.): Psychophysiological Mechanisms of Hypnosis. New York, Springer-Verlag, 1969.
3. Chavez, J.F., and Barber, T.X.: Needles and knives. Human Behav., 2:19, September 1973.
4. Crue, B.J.: Pain: Research and Treatment. New York, Academic Press, 1975.
5. DeBakey, M.E.: A critical look at acupuncture. Reader's Digest, September 1973, pp. 137-140.
6. Dimond, E.G.: Medical education and care in the People's Republic of China. J.A.M.A., 218:1552, 1971.
7. Gelfand, S.: The relationship of experimental pain tolerance to pain threshold. Can. J. Psychol., 18:36, 1964.
8. Goldstein, A.: Opioid peptides (endorphins) in pituitary and brain. Science, 193:1801, 1976.
9. Guillemin, R., et al.: Endorphins, peptides, d'origine hypothalamique et neurohypophysaire a activité morphineominetique: Isolement et structure moleculaire de l'a-endorphin. C.R. Acad. Sci., 282:783, 1976.
10. Hughes, J., et al.: Identification of two related pentapeptides from the brain with potent opiate agonist activity. Nature, 258:577, 1973.
11. Kaada, B.: Acupuncture analgesia. T. Norske Laegeforen, 94:419, 1974.
12. Katz, R.L.: Pain, acupuncture, hypnosis, In Bonica, J.J. (ed.): Advances in Neurology. New York, Raven Press, 1974.
13. Klemm, W.R.: Use of the immobility reflex (“animal hypnosis”) in neuropharmacological studies. Pharm. Biochem. Behav., 4:85, 1976.
14. Kroger, W.S.: More on hypnosis and acupuncture. Soc. Clin. Exp. Hypn. Newsletter, 13:2, 1972.
15. __________: Hypnotism and acupuncture. J.A.M.A., 220:1012, 1972.
16. __________: Acupunctural analgesia: its explanation by conditioning therapy, autogenic training and hypnosis. Am. J. Psych., 130:855, 1973.
17. __________: A scientific rationale for acupunctural analgesia. J. Psychosom., 14:191, 1973.
18. __________: Current status of acupuncture in surgery, obstetrics and gynecology. In Greenhill, J.P. (ed.): Year Book of Obstetrics and Gynecology. Chicago, Year Book Medical Publishers, 1974.
19. __________: Acupuncture, hypnosis and magic. Science, 180:1002, 1972.
20. Lee, P.K., et al.: Treatment of chronic pain with acupuncture. J.A.M.A., 232:1133, 1975.
21. MacIntosh, R.: Tests of acupuncture. Br. Med. J., 3:454, 1973.
22. Mann, F.: Suggestion may be integral to acupuncture anesthesia. Med. Tribune, May 16, 1973.
23. Melzack, R.: Med. Tribune, Aug. 23, 1973.
24. Melzack, R., and Wall, P.D.: Psychophysiology of pain. Int. Anesth. Con., 8:31, 1970.
25. Paul, G.L.: Physiological effects of relaxation training and hypnotic suggestion. J. Abnorm. Psychol., 74:425, 1969.
26. Pert, C.B., and Snyder, S.H.: Opiate receptors: demonstration in nervous tissue. Science, 179:1011, 1973.
27. Pomeranz, B.H.: Endorphins may explain acupuncture. Med. World News, October 18, 1976, p. 54.
28. Saltoun, D.: Seeking the truth about acupuncture. Med. World News, May 4, 1973.
29. Schultz, J.H.: Some remarks about technics of hypnosis as anesthesia. Br. J. Med. Hypn., 5:23, 1954.
30. Sternbach, R.A.: Pain Patients, Treats and Treatments. New York, Academic Press, 1974.
31. Tarpale, V., and Tarpale, I.: Clinical psychiatry. Arch. Gen Psychiatry, 29:315, 1973.
32. Volgyesi, F.A.: Hypnosis of Man and Animals. Baltimore, Williams & Wilkins, 1966.
33. Wall, P.: The eye on the needle. New Scientist, 53:130, 1972.
34. Wykert, J. (quoting Spiegel, H.): Scientist suggests acupuncture-hypnosis link. Psychiat. News, June 21, 1972.
ADDITIONAL READINGS
Bonilca, J.J.: Acupuncture Anesthesia in the People's Republic of China. J.A.M.A., 229:1317, 1974.
De Jong, R.H.: Acupuncture anesthesia: Pricking the balloon. J.A.M.A., 237:2530, 1977.