The Relationship of Cognitive Impairment to Hypnotic Susceptibility in a Sample of Elderly: A Pilot Study

doi:10.4236/psych.2012.31010

Paper Menu >>

Journal Menu >>

Psychology

2012. Vol.3, No.1, 62-64

Published Online January 2012 in SciRes (http://www.SciRP.org/journal/psych) http://dx.doi.org/10.4236/psych.2012.31010

The Relationship of Cognitive Impairment to Hypnotic

Susceptibility in a Sample of Elderly: A Pilot Study

James R. Hall1,2*, Melissa Pennington1, Erica Swicegood1, A. Scott Winter1

1Department of Psychiatry, University of North Texas Health Science Center at Fort Worth, Fort Worth, USA

2Institute of Aging and Alzheimer’s Disease Research, University of North Texas Health Science

Center at Fort Worth, Fort Worth, USA

Email: *[email protected]

Received October 6th, 2011; revised November 14th, 2011; accepted December 15th, 2011

The relationship between cognitive impairment and hypnotic susceptibility in elderly individuals was in-

vestigated. The Stanford Hypnotic Suggestibility Scale (SHSS; Form C Modified) was administered to 30

volunteers between the ages of 65 - 87 who had been evaluated for cognitive impairment. The sample

consisted of 14 normal controls, 8 subjects with mild Alzheimer’s disease, and 8 subjects with mild cog-

nitive impairment. No significant differences between groups were found on performance on the SHSS.

Results suggest that that hypnosis may be a useful adjunct to enhance the effectiveness of therapeutic in-

terventions for elderly patients with mild dementia.

Keywords: Hypnotic Suggestibility; Normal Aging; Alzheimer’s Disease; Mild Cognitive Impairment

Introduction

As the population ages and requires higher levels of medical

care including surgery and invasive procedures, there is an

increased need for adjunctive approaches that don’t have the

negative side-effects of many medications, analgesics, and

anesthesia. Hypnosis is a viable non-pharmacological interven-

tion with few if any negative side effects. Although there have

been a few controlled trials studying hypnosis with the elderly,

there is evidence supporting the utility of hypnosis with older

adults for a number of medical conditions and treatments.

Beneficial effects for the use of hypnosis with older adults have

been reported for the control of chronic pain (Morone & Greco,

2007), the control of osteoarthritis pain (Gay, Philippot, & Lu-

minet, 2002), the treatment of obesity (Cherniack, 2008), the

use during invasive medical procedures (Lutgendorf, et al.,

2007), and as an adjunct during colonoscopy (Elkins, et al.,

2006).

A number of issues have been raised regarding the use of

hypnosis with the elderly. It has been argued that older adults

are not as capable of being hypnotized as younger people

(Luskin, et al., 2000). The effectiveness of hypnosis has been

related to the hypnotizability of the subject (Hilgard, 1965;

Braffman & Kirsch, 1999; Montgomery, DuHamel, & Redd,

2000; Milling, Coursen, Shores, & Waszkiewicz, 2010). Re-

search on age and hypnotizability has suggested that hypnotic

susceptibility is a trait that does not vary significantly as indi-

viduals age (Piccone, Hilgard, & Zimbardo, 1989). Page and

Green (2007) found that hypnotic suggestibility scores decrease

from age 17 - 40 and then tend to increase and stabilize as a

person ages. Lutgendorf, et al. found that increasing age did not

affect hypnotizability nor diminish the utility of hypnosis dur-

ing invasive medical procedures. Taken together these findings

indicate that aging is not a significant determinant of hypno-

tizability.

In addition to the concern with age as a factor in hypnotiza-

bility there are questions about the use of hypnosis with elderly

who have cognitive impairment. The hypnotic process has been

described as “attentive receptive concentration” (Spiegel &

Spiegel, 1987) that requires intact cognitive functioning. Recent

neurophysiological evidence supports the importance of atten-

tional mechanisms in hypnotizability (Raz, Fan, & Posner,

2006). The anterior cingulate and right frontal and parietal areas

(Faymonville, Boly, & Laureys, 2006) are areas posited to be

involved in the attentional network. Dementia, especially Alz-

heimer’s disease (AD), is marked by deficits in the functioning

of these areas. This raises questions about the utility of hypno-

sis in seniors who may have neurocognitive deficits. Another

type of cognitive impairment found in the elderly, Mild Cogni-

tive Impairment (MCI), is well-established as a precursor to

dementia (Petersen, 2004) and is seen as a neuropathological

progression between normal aging and patients with Alz-

heimer’s disease (AD) (Braak & Braak, 1995). A recent study

(Redel, et al., 2010) found that selective attention, which was

related to fronto-parietal networks, was significantly reduced in

MCI patients and further impaired in AD. This neurophysi-

ological evidence suggests that individuals with even mild cog-

nitive deficits may have impaired attentional processes that may

limit their ability to be hypnotized.

To our knowledge, no studies have looked specifically at the

relationship between the level of cognitive functioning and

hypnotic susceptibility in the elderly. The present study inves-

tigates hypnotic susceptibility in individuals with mild Alz-

heimer’s disease, mild cognitive impairment and cognitively

normal elderly. Understanding these associations may have an

impact on the clinical use of hypnosis with elderly individuals

with cognitive impairment.

Method

Setting: The study was conducted at a large urban health sci-

*Corresponding author.

J. R. HALL ET AL.

ence center. The sample for the study was drawn from indi-

viduals who had attended a university based geriatric medicine

clinic and had been assessed as having either normal cognition,

mild cognitive impairment, or mild dementia by consensus

diagnosis. This evaluation was based on clinical diagnoses and

neurocognitive testing. Individuals scoring within the normal

range on a standard battery of neuropsychological tests includ-

ing tests of memory (WMS-III) and executive functions (Clock

Drawing and Trail Making Tests A & B) were classified as

normal. Individuals were diagnosed with Mild Cognitive Im-

pairment (MCI) if they scored within the impaired range (1.5 sd

below norms for age and education) on at least one neurocogni-

tive test of the standard battery and had subjective reports of

cognitive change without the presence of significant impair-

ment in everyday functioning. Individuals were diagnosed with

dementia if they met DSM-IV criteria for dementia. The final

pool of possible participants was composed of 120 individuals

who had attended the clinic within the past 12 months and had

been diagnosed as cognitively intact, MCI or having dementia

and had a Clinical Dementia Rating (CDR) global score of 0, .5

or 1.0 (Morris, 1997). The CDR is a global assessment instru-

ment that yields a score between 0 and 3 that is regularly used

in clinical and research settings to stage dementia severity

(Morris, 1997).These individuals (58 normal; 20 MCI and 42

with a dementia diagnosis) were contacted by a member of the

research team and asked if they were interested in participating

in research on hypnosis. The nature of the study was com-

pletely explained to each person and those agreeing to partici-

pate were consented and seen in the geriatric psychiatry clinic.

Participants: The final sample consisted of 30 individuals: 14

normal controls (NC), 8 with mild cognitive impairment (MCI),

and 8 with mild dementia. The NC group was composed of 14

volunteers without a history of cognitive impairment and who

had been clinically assessed as cognitively intact during the

past year. To determine if change in cognitive functioning had

occurred in the Normal Controls since the initial evaluation, the

Mini-Mental Status Exam (MMSE) (Folstein, Folstein,

McHugh, & Fanjiang, 2001) was administered at the time of

their appointment. The MMSE is one of the most widely used

brief screening instruments of general cognitive functioning

and provides a total score. Those scoring within normal range

for age and education were assigned to the Normal Control

group. The MCI group consisted of 8 individuals diagnosed

with Mild Cognitive Impairment and had a CDR score of ≤ 0.5.

The Mild Dementia group consisted of 7 individuals diagnosed

with Alzheimer’s disease and one diagnosed with a mixed Alz-

heimer’s and Vascular Dementia who had a global CDR score

of ≤1.0.

Procedures: All individuals who consented to participate

were seen in single individual appointments lasting between 60

and 90 minutes. Participants were administered the Stanford

Hypnotic Suggestibility Scale (SHSS Form C Modifed). The

hypnotic suggestions included in the study (see Table 1.) were

those that have been shown to be non-duplicative and excluded

the mosquito hallucination and the anosmia hallucination (Nar-

ing, Hoogduin, & Keijser, 2004). Standard procedures were

followed although all items were administered to every subject.

The SHSS-C was administered by two senior psychiatry resi-

dents (authors M.P & E.S.) who had received extensive training

in hypnosis and the administration of the scale. The study was

approved by the Institutional Review Committee and all par-

ticipants provided written informed consent. Patients in the

Table 1.

Hypnotic suggestions.

Hand lowering Age regression

Moving hands apart Arm immobilization

Taste hallucination Auditory hallucination

Arm Rigidity Negative visual hallucination

Dream Posthypnotic amnesia

Mild Cognitive Impairment and Mild Dementia group were

determined from interview and neuropsychological testing to

have the capacity to understand the written information in the

consent form and to have the capacity to give informed consent.

Analysis: Chi-Square was used to assess differences on cate-

gorical data and ANOVA were conducted to determine differ-

ences between the groups on continuous variables. Level of

significance was set at p ≤ .05 for all analyses.

Results

There were 11 males and 19 females in our sample with a

mean age of 74.30 years and an average of 13.93 years of edu-

cation. Due to the small sample size the power of the study was

low and the likelihood of making a Type II error was increased.

The characteristics of the sample and score on the Stanford

Hypnotic Suggestibility Scale are presented in Table 2. The

groups did not differ on gender (Chi-square (df = 1) = 2.133, p

= .144); age (F = .972, 2.27), p = .391) or education (F = .462,

(df 2.27) p = .635). ANOVA revealed no significant differences

between the diagnostic groups on total score (F = 1.642 (df

2/27) p = .212).

Discussion

The current study found that there were no significant dif-

ferences on hypnotic susceptibility as measured by the Stanford

Hypnotic Suggestibility Scale between normal elderly, elderly

with Mild Cognitive Impairment or elderly with Mild Dementia.

While other studies have evaluated the link between aging and

hypnotic susceptibility, this is the first study to separate par-

ticipants by level of cognitive functioning. The results of the

current need to be interpreted with caution due to the small

sample size which increases the likelihood of making a Type II

error. With this caveat the results of the current study can be

seen as offering initial support for hypnosis as a useful adjunct

to enhance the effectiveness of therapeutic interventions for

elderly patients with mild dementia. If further research supports

the use of hypnosis with this population then hypnosis has the

potential for treating a number of disorders without the risks

related to medication use in the geriatric population.

Our findings suggest that at least in our sample, individuals

with relatively mild cognitive impairment (MCI and mild AD)

retain adequate attentional processing ability to allow the ap-

plication of hypnosis. The SHSS has no norms specifically for

the elderly or elderly with cognitive impairments. Without

comparative norms it is difficult to evaluate the relationship

between the scores on SHSS and expected response to hypnosis

in this population. Exploratory post hoc analysis of the items

found that suggestions for auditory and visual hallucinations

were unsuccessful across all grndicate that oups. This may i

J. R. HALL ET AL.

Table 2.

Mean and standard deviation of age, education, and stanford hypnotic suggestibility scale—Form C (SHSS-C) total score.

Mean (SD) Normal Controls N = 14 Mild Cognitive Impairment N = 8 Mild Dementia N = 8

Age 74.21 (6.55) 72.00 (7.13) 76.75 (6.99)

Education 14.21 (1.97) 14.00 (2.20) 13.93 (1.77)

SHSS C Total Score 4.53 (1.90) 3.81 (3.55) 5.30 (1.58)

response to these suggestions is rare in older individuals and

that they these items may have little value in assessing suscep-

tibility in the elderly. There are a number of limitations that

impact the generalizability of our findings. Most notable is the

small size and homogeneity of our sample. All the patients

were Caucasian and attended the same clinic. The sample was

middle class and relatively well educated. Five of the partici-

pants were referred by psychiatrists, and as such carried diag-

noses such as Major Depressive Disorder or Generalized Anxi-

ety Disorder, which could arguably affect attention and concen-

tration and thus could skew results although there were no dif-

ferences between these participants and others on total score.

This pilot study opens the door for future studies involving a

larger sample size of patients with different ethnic origins,

educational backgrounds, and absence of psychiatric diagnoses.

The current research can not speak to the specific uses of hyp-

nosis with the mildly impaired elderly but the findings suggest

that hypnosis may be a useful tool even with elderly who have

been diagnosed with mild levels of cognitive impairment.

REFERENCES

Braak, H., & Braak, E. (1995). Staging of Alzheimer’s disease-related

neurofibrillary changes. Neurobiology of Aging, 16 , 271-278.

doi:10.1016/0197-4580(95)00021-6

Braffman, W., & Kirsch, I. (1999). Imaginative suggestibility and hyp-

notizability: An empirical analysis. Journal of Personality and Social

Psychology, 77, 578-587. doi:10.1037/0022-3514.77.3.578

Cherniack, E. P. (2008). Potential applications for alternative medicine

to treat obesity in an aging population. Alternative Medicine Review,

13, 34-42.

Elkins, G., White, J., Patel, P., Marcus, J., Perfect, M. M., & Mont-

gomery, G. H. (2006). Hypnosis to manage anxiety and pain associ-

ated with colonoscopy for colorectal cancer screening: Case studies

and possible benefits. International Journal of Clinical and Experi-

mental Hypnosis, 54, 416-431. doi:10.1080/00207140600856780

Faymonville, M. E., Boly, M., & Laureys, S. (2006). Functional neu-

roanatomy of the hypnotic state. Journal of Physiology, Paris, 99,

483-491. doi:10.1016/j.jphysparis.2006.03.018

Folstein, M. F., Folstein, S. E., McHugh, P. R., & Fanjiang, G. (2001).

Mini-mental state examination user’s guide. Odessa, FL: Psycho-

logical Assessment Resources.

Gay, M. C., Philippot, P., & Luminet, O. (2002). Differential effective-

ness of psychological interventions for reducing osteoarthritis pain.

European Journal of Pain, 6, 1-16. doi:10.1053/eujp.2001.0263

Hilgard, E. R. (1965). Hypnosis. Annual Review of Psychology, 16,

157-180. doi:10.1146/annurev.ps.16.020165.001105

Luskin, F. M., Newell, K. A., Griffith, M., Holmes, M., Telles, S.,

DiNucci, E., et al. (2000). A review of mind/body therapies in the

treatment of musculoskeletal disorders with implications for the eld-

erly. Alternative Therapies in Health and Medicine, 6, 46-56.

Lutgendorf, S., Lang, E. V., Berbaum, K. S., Russell, D., Berbaum, M.

L., Logan, H., et al. (2007). Effects of age on responsiveness to ad-

junct hypnotic analgesia during invasive medical procedures. Psy-

chosomatic Medicine, 69, 191-199.

doi:10.1097/PSY.0b013e31803133ea

Milling, L. S., Coursen, E. L., Shores, J. S., & Waszkiewicz, J. A.

(2010). The predictive utility of hypnotizability: The change in sug-

gestibility produced by hypnosis. Journal of Consulting and Clinical

Psychology, 78, 126-130. doi:10.1037/a0017388

Montgomery, G. H., DuHamel, K. N., & Redd, W. H. (2000). A meta-

analysis of hypnotically induced analgesia: How effective is hypno-

sis? International Journal of Clinical and Experimental Hypnosis, 48,

138-153. doi:10.1080/00207140008410045

Morone, N. E. & Greco, C. M. (2007). Mind-body interventions for

chronic pain in older adults: A structured review. Pain Medicine, 8,

359-375. doi:10.1111/j.1526-4637.2007.00312.x

Morris, J. C. (1997). Clinical dementia rating: A reliable and valid

diagnostic and staging measure for dementia of the Alzheimer type.

International Psychogeriatrics, 9, 173-176.

doi:10.1017/S1041610297004870

Naring, G. W., Hoogduin, K. A., & Keijser, C. M. (2004). A rasch

analysis of the Stanford hypnotic susceptibility scale. International

Journal of Clinical and Experimental Hypnosis, 52, 250-259.

doi:10.1080/0020714049052350

Page, R. A., & Green, J. P. (2007). An update on age, hypnotic sug-

gestibility, and gender: A brief Report. American Journal of Clinical

Hypnosis, 49, 283-287.

Petersen, R. C. (2004). Mild cognitive impairment as a diagnostic entity.

Journal of Internal Medicine, 256 , 183-196.

doi:10.1111/j.1365-2796.2004.01388.x

Piccione, C., Hilgard E., & Zimbardo P. (1989). On the degree of sta-

bility of measured hypnotizability over a 25-year period. Journal of

Personality and Social Psychology, 56, 289-295.

doi:10.1037/0022-3514.56.2.289

Raz, A., Fan, J., & Posner, M. (2006). Neuroimaging and genetic asso-

ciations of attentional and hypnotic processes. Journal of Physiology,

Paris, 99, 483-491. doi:10.1016/j.jphysparis.2006.03.003

Redel, P., Bublak, P., Sorg, C., Kurz, A., Forstl, H., Muller, H. J., et al.

(2010). Deficits of spatial and task-related attentional selection in

mild cognitive impairment and Alzheimer’s disease, Neurobiology of

Aging. [Epub ahead of print].

Spiegel, H., & Spiegel, D. (1987). Trance and treatment: Clinical uses

of hypnosis. Washington DC: American Psychiatric Press.