Anesth Prog 36:127-139 1989 Gerschman 131

7. Corah NL. Development of a dental anxiety scale. JDent Res 1969;48:496.

8. Corah NL, Pantera RE. Controlled study of psychologicstress in a dental procedure. J Dent Res 1968;47:154-157.

9. Scott DS, Hirschman R. Psychological aspects of dentalanxiety in adults. JADA 1982;104:27-31.

10. Sheehan DV. Panic and phobic disorders: Current con-cepts in psychiatry. New Engl J Med 1982;307:156-168.

11. Sheehan DV. The efficient treatment of phobic disord-ers. In: Manschreck T (ed): Psychiatric Medicine Update Series.Amsterdam, Elsevier-Holland, 1979, pp 189-204.

12. Sheehan DV, Sheehan K. The classification of anxietyand hysterical disorder. I. Historical review and empiricaldelineation. J Clin Psychopharmacol 1982;2(14):235-244.

13. Sheehan DV, Sheehan K. The classification of anxietyand hysterical disorder. II. Towards a more heuristic classi-fication. J Clin Psychopharmacol 1982;2(16):386-393.

14. Sheehan DV, Sheehan K. The classification of phobicdisorders. Int J Psychiatr Med 1982;12(4):243-256.

15. Sheehan DV, Sheehan K. Diagnostic classification ofanxiety and phobic disorders. Psychopharmacol Bull 1982;18(4):35-44.

16. Sheehan DV, Ballenger J, Jacobson G. The treatment ofendogenous anxiety with phobic, hysterical and hypochondria-cal symptoms. Arch Gen Psychiatr 1980;37:51-59.

17. Sheehan DV, Sheehan K, Minichiello WE. Age of onsetof phobic disorder: A reevaluation study. Compr Psychiatry1981;22:544-553.

18. Weiner AA. The theory and management of phobicdisorders as they relate to the dental visit. Int J Analgesia1980;3(2):5-13.

19. Weiner AA, Sheehan DV, Jones KJ. Dental anxiety-the development of a measurement model. Acta PsychiatrScand 1986;73:559-565.

Hypnoiability and Dental Phobic DisordersJack A. Gerschman, BDSc, LDS, PhD

Oro-facial Pain Clinic,Department of Dental Medicine & Surgery,

School of Dental Science, University of MelbourneMelbourne, Australia

Anxiety and fear are significant determinants of bothattendance patterns and behavior during dental

treatment. Despite the development of many new proce-dures these factors are still issues of major concern tomany dental patients.There is both a lack of agreement as to the nature of

the syndrome or the condition from which these individu-als suffer' as well as the importance of the separate social,psychological and physiological phenomena that underlieand maintain these problems.2 The need for furtherresearch into these areas is pertinent, with the continuinglow percentage of regular dental attenders, as shown byrecent American,3 British,4 Swedish,5 and Australian6 sur-veys. Fear motivated dental avoidance in these studiesranged from 8% to 16%, which is considerably higherthan the often quoted estimates of 5-6% of some twodecades ago.6'7

Behavioral psychotherapy techniques, relaxation andhypnotherapy have in recent years assumed increasing

This study formed part of a Ph.D. dissertation carried out in theDepartments of Dental Medicine and Surgery and Psychiatry, Univer-sity of Melboume.Received January 1, 1989; accepted for publication January 27, 1989.Address correspondence to Dr. Gerschman, Department of Dental

Medicine and Surgery, University of Melboume, Melboume, Australia.

C) 1989 by J.A. Gerschman

prominence as effective treatment regimes. Dentists haveused a number of methods in the management of dentalphobic disorders through hypnosis.89 They have treatedthe anxiety directly and symptomatically, relying largelyon relaxation. Behavioral techniques have also beenfound to combine effectively within the hypnotic frame-work. Hypnosis has also been found to be useful in moresophisticated uncovering techniques of age-regressionand hypnoanalysis as part of more analytical insight-oriented psychotherapies.

Hypnotizability (also termed hypnotic responsivity orhypnotic susceptibility) has been found to be a relativelystable characteristic of the individual. Approximately 20%of the population is highly susceptible, 20% is unrespon-sive and the remaining 60% is moderately susceptible tovarying degrees.10l" Hypnofizability has been relatedpositively to the degree of improvement in chronic painproblems'0 asthma, and various dermatological condi-tions. 13 Recent studies indicate that some specific clinicalpopulations are characterized as more hypnotizable thanthe general population.

Frankel12 was the first to report this relationship. Hefound that 58% of a group of 24 phobic patients washighly responsive to hypnosis when evaluated on theHarvard group scale of Hypnotic Susceptibility, Form A(HGSHS:A; Shor and Ome 1962). The phobic group

132 Hypnotizability and Dental Phobic Disorders

was also found to be significantly more hypnotizable thana control group of patients wishing to stop smoking. Hefurther suggested that there was a relationship betweenhypnotizability and the aetiology of phobias. Furthersupporting data was presented by Frankel and Orne'3and Frankel." 1̀6Gerschman et al'7 obtained similar results with dental

phobics-48% of the sample of 40 patients scored withinthe high susceptible range of hypnotizability on theDiagnostic Rating Procedure (DRP, Orne and O'Connell(1967). 18

In a further study, Foenander et al'9 reported similarfindings for a group of 33 mixed phobic patients, 45.5%were highly susceptible on the HGSHS:A.Rodney et al20 using the HGSH:A found that 55% of a

sample of 20 patients who were phobic to snakes, spidersor rats were highly responsive to hypnosis.

Kelly21 comparing 112 patients with a variety of com-plaints with 22 phobic patients, using the HypnoticInduction Profile (H.I.P. Spiegel 1970) and the StanfordHypnotic Clinical Scale (SHCS Morgan and Hilgard1975) found that the phobic patients were higher inhypnotic responsivity than are the population in generaland non phobic patients seeking hypnosis in particular.

Although five cited studies have found an increasedlevel of hypnotizability in phobics, only one study byFrischolz et a122 using the Hypnotic Induction Profilefound no statistical differences in the mean hypnotiza-bility of 95 phobics, 226 smokers, and 65 chronic painsufferers.The aim of the present study was to further investigate

the relationship between hypnotizability and dental pho-bic disorders using a larger sample size, additional mea-sures of phobic behavior and a more stringent method-ology.

MATERIALS AND METHODS

In 1974 a multidisciplinary outpatient clinic (The Oro-facial Pain Clinic) was established conjointly by theDepartment of Dental Medicine and Surgery in the RoyalDental Hospital of Melbourne and the Department ofPsychiatry of the University of Melbourne. The clinicteam has focused on a number of research areas; chronicoro-facial pain,2324 comparison of patients with pain orfear of pain,25 the determinants of dental phobic disor-ders27 and, in this particular study, hypnotizability anddental phobic disorders. Clinic team members includeddentists, nurses, psychiatrists, psychologists, and a socialworker. Other specialists were involved when their exper-tise was required.

Patients were referred to the clinic with previouslyunmanageable dental phobic disorders. All patients ini-

tially received intensive medical, dental, and psychiatricassessment.

Psychometric assessment included objective and sub-jective rating scales and questionnaires. These consistedof a social and demographic profile (e.g., age, sex,occupation, marital status, ethnicity, etc.); visual ana-logue scales of pain, discomfort, anxiety and depressionmodified from Aitken,27 the Hamilton rating scales ofdepression28 and anxiety;-9 a rapid symptom check list;30the Esyenck Personality Inventory (E.P.I. form B).31 Hyp-notizability was assessed by the Diagnostic Rating Proce-dure. 18

Dental fear ratings were measured by a visual analoguefear rating scale (The Fear Thermometer),32 the DentalAnxiety Scale,33 the Fear Survey Schedule,34 a DentalFear Scale7 and a positive reaction to dentistry scale.7

Patients were also grouped according to the type ofphobia (single or multiple) on the basis of their pre-dominating symptom present. Clinical and psychometricdata was recorded in a standardized form suitable forstatistical analysis. Treatment consisted of behavior ther-apy and cognitive therapy in association with hypnother-apy. Patients were seen individually at two to four weeklyintervals.Outcome of treatment was assessed in the following

ways:1 change in presenting symptoms,2 subjective re-ports of improvement,3 changes in functional impair-ment, i.e., manipulative behavior, social activities, workperformance,4 change in psychological status. Patientassessment was made by the clinic team to minimize anypossible bias on the part of the primary therapist.

Follow-up was carried out by assessment of all patientsat the clinic and by means of a standard postal question-naire. The following features were recorded: 1) thenature of the original complaint, 2) the period of follow-up, 3) the state of the patient with respect to the originalproblem, 4) whether the patient had sought furthertreatment from other health professionals.

DATA ANALYSIS

There were two broad questions addressed by the pres-ent study. The first concemed the characteristics of thepatients. The analysis of these data involved the calcula-tion of descriptive statistics on proporfions of cases fallinginto various categories and, when appropriate, meanscores on continuous variables.The second set of questions concemed the relation-

ships between hypnotizability and various characteristicsof the patients and their response to treatment. Bothunivariate and multivariate statistics were used.35 Uni-variate analyses were used to compare the data withFrankel's original data. However, the commonly adopted

Anesth Prog 36:127-139 1989

Anesth Prog 36:127-139 1989

strategy of evaluating all possible correlations betweenpatient variables and outcome is unsatisfactory; if no

adjustment is made for the large number of tests con-

ducted many spuriously significant results may be ob-tained. Appropriate adjustments have thus been made bymeans of the Bonferroni inequality adjustments.The strategy of statistical analysis adopted was a

three-stage one. The first stage consisted of data reduc-tion by means of principal components analysis. Theobject of this stage was to achieve an economical descrip-tion of the original variables in terms of a small number ofcombinations of variables which could be interpreted intheoretically interesting ways. To this end, principal com-ponents analyses were performed within the fear mea-

sures and outcome variables.The second stage of the analysis consisted of the

exploration of correlations between the factors emergingfrom the principal components analyses. Because of thedata reduction achieved by the principal componentsanalysis a comparatively small number of significancetests were conducted with an appropriate Bonferroniadjustment.The third stage of the analysis examined relationships

between groups of factors and outcome. This was carriedout to examine the possibility that combinations ofpsychosocial and fear variables might be better predic-tors, of outcome than individual psychological and fearfactors. The method chosen was multiple regression.

RESULTS

Descriptive Data

The study of the population consisted of 130 patients,these being 50% random sample of consecutive patientspresenting to the clinic over an 8-year period.

There were 88 women (67.7%) and 42 men (32.3%)with a mean age of 27.2 years (range 5-60 years). Themean duration of symptoms was 134.7 months (range8-630 months) with the mean time elapsed since theprevious dental visit being 69.5 months (range 2-88months).Most patients presented with a combination of dental

fears. The most common fears were fear of not being ableto express or cope with feelings of helplessness anddefenselessness (87.7%), fear of pain (86.2%), fear ofinjections (84.6%), generalized dental anxiety (78.5%),fear of drilling (76.9%) and fear of extractions (63.8%).The majority of patients, 108 (83.1%), had other

phobic symptoms besides their dental phobia, i.e., multi-ple phobias.

Hypnotizability was assessed for 120 out of the 130patients. The others were selected out because their

Table 1. Distribution of Hypnotizability Scores on theDiagnostic Rating Procedure

HypnotizabilityFrequencies Low Medium High

Observed 6 57 57 120Expected 24 72 24 120

x2= 62.00, 2 df p < 0.001

psychiatric problems, including schizophrenia and severedepressive illness, was a contra-indication for the use ofhypnosis. No patients were unhypnotizable, 6 (5.0%)were low, 57 (47.5%) were medium and 57 (47.5%)were high (Table 1). Other descriptive details have beendetailed elsewhere.2Assessment of outcome of treatment showed that there

was no response in 5 (4.2%), a poor response in 16(13.3%), a fair response in 24 (20.0%), a good responsein 40 (33.3%) and an excellent response in 35 patients(29.2%). The mean period of follow up was 35.1 months(range 0-72). The majority of patients (74.2%) main-tained their level of improvement.

STATISTICAL ANALYSISUnivariate Analysis1. Distribution of Hypnotizability Scores on the Diagnos-tic Ratings Procedure. Patients were classified as low,medium or highly hypnotizable according to their scoreson this scale. A Chi-square analysis was carried out inorder to compare the distribution of these scores fromthat expected in the normal population. The expectedfrequencies were calculated on the basis that in thenormal population 20% are low in hypnotizability, 60%are medium and 20% are highly hypnotizable.A further Chi-square analysis compared the distribu-

tion of phobic patients with chronic facial pain patientsbeing investigated in the clinic for whom hypnosis wasbeing used. There were 35 pain patients with a mean ageof 35.4 years and a sex distribution of 75% female and25% male.The Chi-square analysis (Table 1) showed that the

distribution of the scores of phobic dental patients weresignificantly different from that expected in the normalpopulation (X2 = 62.0, df = 2 p < 0.001) and from thechronic pain patients, Table 2 (X2 = 46, df = 2 p <0.001).

Patients with dental phobic disorders were thus signif-icantly more hypnotizable than chronic pain patients andthe normal population.

Gerschman 133

134 Hypnotizability and Dental Phobic Disorders

Table 2. Comparison of Hypnotizability Scores on theDiagnostic Rating Procedure Between Patients with DentalPhobic Disorders and with Chronic Facial Pain

Hypnotizability

Frequencies Low Medium High

Dental Phobic Disorders 6 57 57 120Chronic Facial Pain 19 13 3 35x2= 49.00, 2 dfp < 0.001

2. The Distribution of Hypnotizability According to theType ofPhobia Patients were divided into those reportingmultiple phobias and those complaining of only a singlephobia (dental phobia).A Chi-square analysis demonstrated that there was a

significant relationship between Hypnotizability and thetype of phobia (single or multiple) (X2 = 85.92, df = 2 p

< 0.001) (Table 3).Patients with multiple phobias were significanfly more

hypnotizable than those with single phobias.

MULTIVARIATE ANALYSIS

The principal components analysis of the Fear Measuresproduced three interpretable factors accounting for 73%of the variance in the original variables. The first factorwas a measure of the fearfulness of individual stimuli. Thesecond factor was a measure- of global dental anxiety.The third factor reflected the origins of dental fear.The principal components analysis of the outcome

variables produced three factors accounting for 78% ofthe variance. The first factor was a measure of changes invarious aspects of dental fear, such as change in pre-

senting symptom, co-operation during treatment etc. Thesecond factor was a measure of improvement in generalsocial functioning. The third factor was a measure ofwhether further treatment had been sought with anotherdentist.The only correlations reported are those tested for

significance after the Bonferroni correction has been usedto account for the number of tests performed.There was a weak relationship between hypnotizability

and global dental anxiety (first fear measure factor) (r =0.19, p 0.001).There was a positive relationship between hypnotiza-

bility and outcome of treatment as measured by changesin various aspects of dental fear (second outcome factor)r = 0.54, p 0.001).A stepwise multiple regression of social factors and

hypnotizability on fear measures showed that hypnotiza-bility accounted for 20% of the variance.

More detailed analysis of the various Principal Com-ponents Analysis and other correlations are describedelsewhere.2

DISCUSSION

The present study is the sixth major study to find arelationship between hypnotizability and phobic behav-ior, and the third study confirming the association ofhypnotizability and dental phobic disorders.The data of Frankel, who first proposed the relation-

ship between hypnotizability and phobic behavior, wassuggestive of such a relationship, but only weakly. Histest was not very powerful because both variables werecategorical (three levels of the Stanford Hypnotic suscep-tibility scale and two levels of phobic behavior, i.e., singleand multiple phobias). The other cited studies except forthose from our own group have only measured hypnotiz-ability.The analysis used in this study, using principal com-

ponents analysis, and the correlation of scores on theprincipal components with hypnotizability provides amore powerful test and a quantitative index of strength ofrelationship. For the purposes of comparing Frankel'sresults and the results of this study, the data was alsoreported in categorical form and subjected to univariateanalysis. The distribution of hypnotizability in the dentalphobic population was compared with population normsand the patients with chronic oro-facial pain havinghypnosis.The results of the various analyses strengthened the

support for the hypothesis that there is a relationshipbetween hypnotizability and phobic behavior.The correlation of scores on the principal components

with hypnotizability indicated that there was a weakrelationship between hypnotizability and global dentalanxiety (r = 0.19, p < 0.001). There was a strongerrelationship between hypnotizability and successful out-

Table 3. The Distribution of Hypnotizability on theDiagnostic Rating Procedure According to Type of Phobia(Single or Multiple)

Hypnotizability

Frequencies Low Medium High

Multiple phobia 1 46 56 113Single phobia 5 11 1 7

6 57 57 120X2 = 85.922,2 df p < 0.001

Anesth Prog 36:127-139 1989

Anesth Prog 36:127-139 1989

come of treatment (r = 0.54, p < 0.001). Hypnotizabilityalso accounted for 20% of the variance of the fearmeasures.

Frankel's method of determining the relationship be-tween hypnotizability and the severity of phobia was tocompare the hypnotizability scores of patients with multi-ple or single phobias. He found that the multiple phobicgroup had a significantly higher mean hypnotizabilityscore than the single phobic group.Comparison of hypnotizability scores of patients with

multiple phobias and single phobias (ie. only dental) inthe present study also demonstrated that there was asignificant relationship between hypnotizability and theseverity of the phobic disorder (X2 = 85.92, p < 0.001),viz. patients with multiple phobias were significantly morehypnotizable than patients with a single phobia,

Frankel'3 further investigated the hypnotizability of 24patients complaining of phobic symptoms by comparingthem with the rating of an equal number of smokers keento quit smoking through hypnosis. He found that thephobic pafients were significantly more hypnotizable thanthe smokers (X2 = 5.73, p < 0.015). He emphasized that30% of the smokers were essentially non-responsive, anumber resembling the occurrence of low hypnotic re-sponsiveness in the general population, while not a singlephobic patient was found to be unresponsive.

In the present study a Chi-square analysis similarlydemonstrated that the distribution of scores of hypnotiza-bility of phobic dental patients was significantly differentfrom that expected in the normal population (X2 = 62.0,df = 2, p < 0.001) and from a group of chronic facialpain patients (X2 = 46, df = 2, p < 0.001) receivinghypnosis.

Frankel's findings that none of his group of 24 phobicpatients receiving hypnosis were non hypnotizable and asimilar finding in a group of 30 phobic patients16 wascorroborated in the present study. No patients wereconsidered non hypnotizable in the 120 patients investi-gated. The finding of five out of six cited studies similarlyfound that in both undifferentiated and multiple phobicpopulations the level of hypnotizability was higher thanexpected in the general population.The implication of these findings has significance for

both the genesis of dental phobic disorders as well as fortheir management.

Frankell2'14"15 has postulated that phobic patients showa tendency to the same kind of mental functioning that isinvolved in responding to hypnotic induction and thatthese patients must also have the capacity to manifest thekind of cognitive functioning that characterizes the hyp-notized individual.

This implies the kind of mental process where imagesand fantasies can become sufficiently vivid and real as tobe confused with the world outside, incongruities cease to

be troublesome, logic can become temporarily superflu-ous, present experience takes precedence over the pastand future, and a sense of time ceases to be important.This kind of mental process is common to the event ofhypnosis and the phobic experience. In highly hypnotiza-ble persons, the process can and does occur spontane-ously. The observation that phobic patients with multiplephobias were more highly hypnotizable than those with asingle phobia reinforces the hypothesis that the capacityfor spontaneous trance-like occurrences is related to theorigin of phobic symptoms. Thus, the individual whoalready has a propensity for phobic symptoms, who ismore hypnotizable, appears to be at greater risk ofacquiring several symptoms than those phobic individu-als of less hypnotic ability.

Frankel further argued that a useful treatment strategyoffers itself once one recognizes that the phobic patient'spropensity for spontaneously occurring trance phenom-ena may provide the context for the symptoms toemerge. In such an individual, the hypnotic experiencecan provide the means of helping the patient learn tounderstand more about the special mode of functioningthat represents one of his assets as well as one of hisliabilities. Therapeutically, the approach becomes neitherone of suggesting away the symptoms nor one primarilybased on using hypnosis to look for the specific dynamicfactors embodied in symptom formation. Instead hypno-sis is utilized to facilitate the patient's understanding of hisspecial mode of mental functioning. The state of hypnosiscan provide the context in which to conduct an acceler-ated program of imaginal desensitization or it may beused to produce an analogous symptom in the surgery,that closely resembles the psychologic abnormalities mosttroublesome to the individual. If one can produce thesymptom and guide the patient to a degree of familiaritywith and mastery over this experimentally induced situa-tion, he begins to leam something about the shift infunctioning that is involved in causing and in controllinghis own psychopathological manifestations. At times thetrance process can help the patient to experience feelingspreviously seen as frightening and ego alien, as familiar,under his control, and perhaps even as comfortable.

Furthermore the careful integration of self hypnosisinto the strategy reinforces the patients' conviction thatthey can exert effective control. This method also articu-lates well with the procedures involved in counter-con-ditioning implosion and shaping behavior.The role of hypnotizability as a possible facilitator in the

acquisition of dental phobias should be recognized. Therecognifion and management of spontaneous trancestates particularly in children deserve special attention.

Children have been considered as being parficularlyhypnotizable36 and the association of trance states withactual or perceived dental trauma warrants careful con-

Gerschman 135

136 Hypnotizability and Dental Phobic Disorders Anesth Prog 36:127-139 1989

sideration. Studies of hypnotizability particularly in pho-bic children may add further evidence as to the involve-ment of hypnotic responsivity in the development ofdental phobias.The results and foregoing discussion would suggest

that hypnosis would be eminently suitable in the man-agement of dental phobias. The literature is replete withaccounts of techniques and a multitude of applications ofhypnotic techniques to dentistry. Hypnosis has in fact hadvarying periods of popularity followed by its rejection andappears to warrant far wider use than it receives. Thismay be related in the past to the lack of undergrad-uate training, misinformation, superstition, exaggeratedclaims, and the re-introduction of conscious sedationtechniques.

In more recent times, the attempts to relate hypnoticresponsivity to the production of dental analgesia haveranged from the excellent work and more or less ex-pected findings of Gottfredson36 who found a moderaterelationship between hypnotizability and pain reductionand the remarkable claims of Barber,37 who found thathypnosis was effective in pain reduction in virtually allcases and was not related to hypnotizability.

This study adds further support to a growing body ofevidence relating hypnotizability to both the acquisitionand management of phobic disorders. The dental situa-tion in particular lends itself to carefully controlled investi-gation providing further evidence to support a robusttheory.

REFERENCES

1. Molin C, Seeman K: Disproportionate dental anxietyclinical and nosological considerations. Acta Odontol Scand1970;28: 197-212.

2. Gerschman JA, Hall W, Burrows GD, Reade PC: Deter-minants of Dental Phobic Disorders. In Press.

3. Gatchel RJ, Ingersoll BD, Bowman L, Robertson M,Walker C: The prevalence of dental fear and avoidance: arecent study. J Am Dent Assoc 1983;107:609-610.

4. Todd JE, Walker AM and Dodd P: Adult Dental Health.United Kingdom, London HMSO, 1982.

5. Seeman K, Molin C: Psychopathology with disproporfio-nate dental anxiety. Acta Psychiat Scand 1976;54:81-91.

6. Victorian Survey of atffitudes to dentists, 1980. AustralianDental Association.

7. Kleinknecht RA, Klepac RK, Alexander LD: Origins andCharacteristics of fear of dentistry. J Am Dent Assoc1973;86:842-846.

8. Gerschman JA, Burrows GD, Reade PC: Hypnosis inDentistry. In Handbook of Hypnosis and Psychosomatic Medi-cine. Ed. G Burrows and L Dennerstein. Elsevier/North Hol-land, Biomedical Press, Amsterdam, pp 443-479, 1980.

9. Thompson KF: A rationale for suggestions in dentistry.Am J Clinic Hypnosis 1963;5:181-185.

10. Hilgard ER: The alleviation of pain by hypnosis. Pain1975;1:213-231.

11. Perry C, Gelfand R, Marcovitch P: The relevance ofhypnotic susceptibility in the clinical context. J Abn Psychology1979;88:592-603.

12. Frankel FM: Trance capacity and the genesis of phobicbehaviour. Arch Gen Psychiat 1974;31:261-263.

13. Frankel FH, Ome MT: Hypnotizability and phobic beha-viour. Arch of Gen Psychiat 1976;33:1259-1261.

14. Frankel FH: Hypnosis. Trance as a coping mechanism.Plenum Publishing Co., New York, 1926.

15. Frankel FH: Hypnotic responsiveness-clinically amixed blessing. Aust J Clinic Exp Hypnosis 1979;7(2):117-123.

16. Frankel FH: Phobic disorders and hypnosis. In Hand-book of Hypnosis and Psychosomatic Medicine, Burrows GDand Dennerstein, L eds. Elsevier/North Holland BiomedicalPress, 171-181, 1980.

17. Gerschman JA, Burrows GD, Reade PC, Foenander G:Hypnotizability and the treatment of Dental Phobic Illness. InHypnosis 1979. Eds. GD Burrows, DR Collison and L Denner-stein. Elsevier/North Holland Biomedical Press, 33-39, 1979.

18. Ome MT, O'Connel: Diagnostic ratings of Hypnotiza-bility. J Clin Exp Hypnosis 14:125-133.

19. Foenander G, Burrows GD, Gerschman JA, Home DT,det: Phobic behavior and hypnotic susceptibility. Aust J ClinExp Hypnosis 1980;8:41-48.

20. Rodney J, Hollander B, Perry C: Hypnotizability andPhobic Behaviour, Further Supporting Data. J Abn Psych1983;92:390-392.

21. Kelly S: Measured hypnotic response and phobic beha-viour. A brief communication. Int J Clinical Ex Hypnosis1984;32: 1-5.

22. Frischolz EJ, Spiegel D, Spiegel H, Balma DL, MarkellCJ: Differential hypnotic responsitivity to smokers, phobics andchronic pain control patients: A failure to replicate. J Abn Psych1982;91:269-272.

23. Gerschman JA, Burrows GD, Reade PC: Oro-facialPain. Aust Fam Physician 1977;6: 1219-1233.

24. Gerchman JA, Burrows GD, Reade PC: Oro-facialChronic Oro-Facial Pain. In Advances in Pain Research andTherapy, Vol. 3. Ed. JJ Bonica, Raven Press, N.Y. 1979;317-323.

25. Gerschman JA, Wright JL, Hall WD, Reade PC, Bur-rows GD, Holwill, BJ: Comparison of Psychological and SocialFactors in Patients with Chronic Oro-facial Pain. In Press, AustDental Journal.

26. Gerschman JA: Diagnosis and Management of OrofacialPain. In The Dental Annual, 1986. John Wright & Sons,79-90.

27. Aitken RCB: Proc Roy Soc Med 1969;62:989-992.28. Hamilton M: A rating scale for depression. J Neurol

Neurosurg Psychiat 1960;23:58.29. Hamilton M: The assessment of anxiety states by rating.

Brit J Med Psych 1959;32:50.30. Parloff MB, Kelman HC, Frank JD: Comfort, Effective-

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description, classification and diagnosis. Br J Psych1964;55:284.

32. Gerschman JA: An investigation of Chronic Orofacialpain and Dental Phobic Illness. Ph.D. Thesis, 1983, MelbourneUniversity.

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Uses of Hypnosis in General PractceJ.M. Auld

General Practice, Inverell,New South Wales, Australia

This presentation is based on the premise that sug-gestion and hypnosis are part of a continuum. It

discusses some of the practical uses of hypnosis for thosewho are as yet inexperienced, and also suggests ways toexpand the usefulness of hypnosis to those who arealready aware. Most of all, this paper's purpose is toarouse curiosity so that one may look at one's totalcommunication with patients.

A BROADER DEFINITION

Hypnosis comprises a range of procedures that can beused to help a patient achieve a psychological state whichwe call a trance. This definition emphasizes that it is thepatient who has control, not the "hypnotist". It is alsoimportant to recognize that the trance state is not alwaysaccompanied by eye closure or even relaxation. Theseare only physical signs. Whereas they do often accom-pany trance states, eye closure or relaxation are onlyindicators of the underlying psychological changes.

Trance has traditionally been divided into light, me-dium, and deep levels, with varying associated psycho-logical and physiological phenomena. Pain control isassociated with deep trance. This level takes time toachieve with traditional hypnotic induction methods, andfor this reason many dentists have been reluctant to usehypnosis. Some excellent rapid hypnotic induction tech-niques have been developed, but they are usually very

Received January 3, 1989; accepted for publication January 27, 1989.Address correspondence to Dr. James Auld, P.O. Box 124, Inverell,

New South Wales, Australia.

e 1989 by J.M. Auld

authoritarian and may not appeal to clinicians or theirpatients.A very convincing demonstration was given by the

Turkish delegates at a recent International HypnosisCongress. "I am going to hypnotize you. When I count tothree you will go into a very deep trance immediately.You will not wake up until I tell you to do so. You will feelno pain, you will be in a very deep trance, and you willnot wake up until I tell you-one, two, three! Go deepasleep!" Apparently, it works for the Turks.The most important part of hypnosis is establishing

communication and rapport with a patient. Rapport, ortrust, is not necessary for trance, but in a clinical situationit makes work much easier. Part of developing a rapportis listening to the patient. Mrs. L. has certain ideas aboutdentistry, and her clinician has a great deal of knowledgeabout dentistry, but it is unlikely that both understandthings in the same way. If the clinician does not learn tolisten carefully, he or she cannot be sure that what is saidis necessarily what is meant.The clinician must also learn to listen to what the

patient is hearing rather than what the clinician thinks heor she is saying to the patient. The difference cansometimes be surprising. For example, if one says to apatient going into surgery, "Would you like to sit in thechair?" what does the patient think? What is meant is"Please sit down," and what could be said is "You can sitdown and relax." This statement is not very objection-able. There is no doubt that the patient can sit down, andby doing so he or she unconsciously accepts the sugges-tion in the second part of the clinician's statement.Communication is not confined to words alone. Facial

expression, eye contact, posture ("body language"), andthe way physical contact is made with the patient all