This article was downloaded by: [University of Strathclyde] On: 10 October 2014, At: 07:56 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
International Journal of Clinical and Experimental Hypnosis Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/nhyp20
The use of hypnosis and biofeedback procedures for essential hypertension a
Howard Friedman & Harvey A. Taub
a
a
Syracuse Veterans Administration Hospital and State University of New York Upstate Medical Center , Syracuse Published online: 31 Jan 2008.
To cite this article: Howard Friedman & Harvey A. Taub (1977) The use of hypnosis and biofeedback procedures for essential hypertension, International Journal of Clinical and Experimental Hypnosis, 25:4, 335-347, DOI: 10.1080/00207147708415989 To link to this article: http://dx.doi.org/10.1080/00207147708415989
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
The Idernutwnal Journal of Clinical and Experimental Hypnosis 1977, Vol. XXV. No. 4, 335-347
THE USE OF HYPNOSIS AND BIOFEEDBACK PROCEDURES FOR ESSENTIAL HYPERTENSION’ HOWARD FRIEDMAN AND HARVEY A. TAUB2
Downloaded by [University of Strathclyde] at 07:56 10 October 2014
Syracuse Veterans Administration Hospital and State University of New York Upstate Medical Center at Syracuse
Abstract: In an attempt to evaluate a procedure combining 2 techniques, hypnosis and biofeedback, which might effect significant changes in diastolic blood pressure in essential hypertensives, Ss were placed in 1of 4 groups: hypnosis only, biofeedback only, hypnosis and biofeedback combined, or measurement only. The first phase-training sessions and brief follow-ups (1 week and 1 month)-of the long-term study with 6 monthly follow-up periods, was evaluated. Hypnosis only and biofeedback only procedures were both capable of providing significant lowering of diastolic pressure. However, in intergroup comparisons, the hypnosis only procedure showed the most impressive effect. Unexpectedly, the procedure of combining hypnosis and biofeedback into one technique was as ineffective as the measurement only procedure.
Since the early work in the use of operant conditioning techniques
to produce changes in glandular and visceral responses (DiCara & Miller, 1968; Miller, 19691,there has been a growing and widespread interest in various psychological procedures which might provide pragmatically sound applications for clinical usage. Essential hypertension, because of its commonly considered high incidence in the human population, has attracted a number of investigators who have applied biofeedback techniques in attempts to alter blood pressure. In a critical review of biofeedback applications, Blanchard and Young (1974) noted that though such procedures “can&avebeneficial effects on elevated [blood pressure] BP [p. 5841,” the “demonstration of clinical effects [p. 5871” is open to question. T h e problem of transfer of training beyond the laboratory situation has been emphasized by other reviewers (Shapiro, Schwartz, & Benson, 1974), who offered, as one approach, combining biofeedback with other behavioral proceManuscript submitted October 26,1976; final revision received March 14,1977. The research reported in this article was supported by the Medical Research Service of the Veterans Administration. * Reprint requests should be addressed to Howard Friedman, Chief, Psychology Service, Veterans Administration Hospital, Irving Avenue and University Place, . , Syracuse, New York 13210. 335
Downloaded by [University of Strathclyde] at 07:56 10 October 2014
336
HYPNOSIS, BIOFEEDBACK, AND HYPERTENSION
dures. In a review of biofeedback as a therapeutic modality, Schwartz (1973) was pessimistic about its value used alone when applied to chronic physical disease. Redmond, Gaylor, McDonald, and Shapiro (1974) have called into question the assumption that feedback per se is the crucial agent in effecting blood-pressure changes. They were able to demonstrate predictable directional changes simply in response to forceful, verbal instructions. Relaxation, in one form or another, has been found effective in altering blood pressure since the earliest work of Jacobson (1939)with progressive, muscular relaxation. In two studies, Benson, Rosner, Marzetta, and Klemchuk (1974a, 1974b) used the technique of Transcendental Meditation to elicit the “relaxation response” and obtained some alterations in systolic and diastolic pressures in pharmacologically treated hypertensive patients and in borderline hypertensive Ss. The changes -greater in systolic than in diastolic pressures, and though too small to be clinically significant-persisted beyond the laboratory training periods. Shoemaker and Tasto (1975) compared the effects of muscle relaxation and biofeedback upon both systolic and diastolic blood pressures. They concluded that muscle relaxation effected a lowering of both pressures as Ss progressed from pretreatment to posttreatment measures, with biofeedback showing a reduction, to a smaller degree, in diastolic pressure. Stone and De Leo (1976) have reported a simple psychological-relaxation method which provided effective blood pressure reduction in a selected group of mild to moderate hypertensives over a period of 6 months. The broad spectrum of strategies related to relaxation, including Yogic practices (Datey, Deshmukh, Dalvi, & Vinekar, 1969; Patel, 1973, 1975; Patel & North, 19751, metronome-conditioned relaxation (Brady, Luborsky, & Kron, 19741, and autogenic therapy (Luthe, 19721, have all laid claim to effecting alterations in blood pressure. However, in many of these cases, the investigators have cautioned against extrapolation of techniques in their simplest forms into the clinical setting. Investigations into altering blood pressure using hypnosis alone, or in combination with other procedures are surprisingly sparse. Deabler, Fidel, Dillenkoffer, and Elder (1973) subjected medicated and m e d i c a t e d hypertensive patients to hypnosis combined with skeletal-muscular relaxation or to no experimental procedure for eight sessions over a 4-day period. They found the combined hypnosis-andmuscular-relaxation procedure to be particularly effective in lowering both systolic and diastolic pressures and reported one case in which decreased pressures were apparent on two follow-up sessions, 12 and 13 days posttreatment.
Downloaded by [University of Strathclyde] at 07:56 10 October 2014
FREDMAN AND TAUB
337
"he present study is concerned with exploring the possibility of combining two procedures, biofeedback and hypnosis, into a technique which would enhance the clinical effectiveness of psychological procedures in dealing with essential hypertension. Diastolic pressure was selected as the significant dependent variable inasmuch as there is general agreement (Gantt,1972; Merrill, 1966) about the greater clinical significance of diastolic pressure and since, as Miller (1975) and Shapiro (1974) have indicated in reports from their own laboratories, most of the previously mentioned studies have been less successful in dealing with diastolic pressure. Although planned as a longterm study, this report limits itself to the evaluation of the training phase and limited follow-up periods wherein there is minimal confounding by drop-outs due to medication changes or simple failure to return.
METHOD Subjects Volunteer Ss were obtained through a hypertension-screening clinic at the Upstate Medical Center or by contacting former Syracuse Veterans Administration Hospital patients. In all cases, Ss had, in addition to the hospital or screening-clinic diagnosis of essential hypertension, the same diagnosis by their own physicians. Initial contact consisted of a letter in which the prospective S was asked if he were interested in volunteering for a research project which was evaluating various new psychological methods which could be used to lower blood pressure without the use of additional medication. It was pointed out that all the methods involved relaxation procedures, had been reported as being potentially effective, were safe without any negative or undesirable side effects, and could be used in addition to any medication currently being taken. Only those Ss demonstrating a minimal diastolic pressure of 85 millimeters of mercury during the baseline procedures were accepted for the study. This resulted in a total of 48 medicated and unmedicated Ss who were able to complete at least all training and a minimum of one follow-up session, and who were unchanged in medication during the study. For the 1-month follow-up period, one S was lost from the measurement only (MO) group. Table 1 provides relevant descriptive data about Ss in each of the four groups. Two descriptions of the single MO group are provided because the overall data analysis for the training and 1-week follow-up periods was able to use one more S than the analysis for the training and both followup periods. By simple analysis of variance (ANOVA), there were no
338
HYPNOSIS, BIOFEEDBACK, AND HYPERTENSION
TABLE 1 Ss' AGE, SEX,BASELINEDIASTOLICPRESSURE, PERCENT MEDICATED, AND
HYPNOTIC
SUSCEPTIBILITY Ace
SHSS: A Score
Mean of
Downloaded by [University of Strathclyde] at 07:56 10 October 2014
..._ -. . .
HB (N = 101 HO (N = 13) BO (N = 13) MO.to 1-week follow-up (N = 12) M O to l-month follow-up (N = 11)
" HB
=
62%
8-12 7-12 1-9
10.3 9.8 4.1
94.1
15%
0-8
3.6
95.1
13%
0-8
3.3
60% 69%
10
91.8 93.1 95.8
48.3
10
48.1
9
32-53 23-60 29-54
48.2 41.1
8 11
41.2
31-59 31-59
Hypnosis and biofeedback, I10 = Hypnosis only, BO = Biofeedback only, and M O = Measurement
only. The Ss in all four groups reported being medicated with the followingantihypertensive agents: Propranolol, Hydralazine Hydrochloride. Hydrochlomthiazide, Triamterene, and Methyldopa. In addition, the BO and MO groups had one S each on Spironlaetone and another on Reserpine. Fluorosemide and Chlorthiazide were being used by one S each in the BO group.
significant differences between the groups in mean age or in the mean of median-baseline-diastolicpressures (3' =
International Journal of Clinical and Experimental Hypnosis Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/nhyp20
The use of hypnosis and biofeedback procedures for essential hypertension a
Howard Friedman & Harvey A. Taub
a
a
Syracuse Veterans Administration Hospital and State University of New York Upstate Medical Center , Syracuse Published online: 31 Jan 2008.
To cite this article: Howard Friedman & Harvey A. Taub (1977) The use of hypnosis and biofeedback procedures for essential hypertension, International Journal of Clinical and Experimental Hypnosis, 25:4, 335-347, DOI: 10.1080/00207147708415989 To link to this article: http://dx.doi.org/10.1080/00207147708415989
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
The Idernutwnal Journal of Clinical and Experimental Hypnosis 1977, Vol. XXV. No. 4, 335-347
THE USE OF HYPNOSIS AND BIOFEEDBACK PROCEDURES FOR ESSENTIAL HYPERTENSION’ HOWARD FRIEDMAN AND HARVEY A. TAUB2
Downloaded by [University of Strathclyde] at 07:56 10 October 2014
Syracuse Veterans Administration Hospital and State University of New York Upstate Medical Center at Syracuse
Abstract: In an attempt to evaluate a procedure combining 2 techniques, hypnosis and biofeedback, which might effect significant changes in diastolic blood pressure in essential hypertensives, Ss were placed in 1of 4 groups: hypnosis only, biofeedback only, hypnosis and biofeedback combined, or measurement only. The first phase-training sessions and brief follow-ups (1 week and 1 month)-of the long-term study with 6 monthly follow-up periods, was evaluated. Hypnosis only and biofeedback only procedures were both capable of providing significant lowering of diastolic pressure. However, in intergroup comparisons, the hypnosis only procedure showed the most impressive effect. Unexpectedly, the procedure of combining hypnosis and biofeedback into one technique was as ineffective as the measurement only procedure.
Since the early work in the use of operant conditioning techniques
to produce changes in glandular and visceral responses (DiCara & Miller, 1968; Miller, 19691,there has been a growing and widespread interest in various psychological procedures which might provide pragmatically sound applications for clinical usage. Essential hypertension, because of its commonly considered high incidence in the human population, has attracted a number of investigators who have applied biofeedback techniques in attempts to alter blood pressure. In a critical review of biofeedback applications, Blanchard and Young (1974) noted that though such procedures “can&avebeneficial effects on elevated [blood pressure] BP [p. 5841,” the “demonstration of clinical effects [p. 5871” is open to question. T h e problem of transfer of training beyond the laboratory situation has been emphasized by other reviewers (Shapiro, Schwartz, & Benson, 1974), who offered, as one approach, combining biofeedback with other behavioral proceManuscript submitted October 26,1976; final revision received March 14,1977. The research reported in this article was supported by the Medical Research Service of the Veterans Administration. * Reprint requests should be addressed to Howard Friedman, Chief, Psychology Service, Veterans Administration Hospital, Irving Avenue and University Place, . , Syracuse, New York 13210. 335
Downloaded by [University of Strathclyde] at 07:56 10 October 2014
336
HYPNOSIS, BIOFEEDBACK, AND HYPERTENSION
dures. In a review of biofeedback as a therapeutic modality, Schwartz (1973) was pessimistic about its value used alone when applied to chronic physical disease. Redmond, Gaylor, McDonald, and Shapiro (1974) have called into question the assumption that feedback per se is the crucial agent in effecting blood-pressure changes. They were able to demonstrate predictable directional changes simply in response to forceful, verbal instructions. Relaxation, in one form or another, has been found effective in altering blood pressure since the earliest work of Jacobson (1939)with progressive, muscular relaxation. In two studies, Benson, Rosner, Marzetta, and Klemchuk (1974a, 1974b) used the technique of Transcendental Meditation to elicit the “relaxation response” and obtained some alterations in systolic and diastolic pressures in pharmacologically treated hypertensive patients and in borderline hypertensive Ss. The changes -greater in systolic than in diastolic pressures, and though too small to be clinically significant-persisted beyond the laboratory training periods. Shoemaker and Tasto (1975) compared the effects of muscle relaxation and biofeedback upon both systolic and diastolic blood pressures. They concluded that muscle relaxation effected a lowering of both pressures as Ss progressed from pretreatment to posttreatment measures, with biofeedback showing a reduction, to a smaller degree, in diastolic pressure. Stone and De Leo (1976) have reported a simple psychological-relaxation method which provided effective blood pressure reduction in a selected group of mild to moderate hypertensives over a period of 6 months. The broad spectrum of strategies related to relaxation, including Yogic practices (Datey, Deshmukh, Dalvi, & Vinekar, 1969; Patel, 1973, 1975; Patel & North, 19751, metronome-conditioned relaxation (Brady, Luborsky, & Kron, 19741, and autogenic therapy (Luthe, 19721, have all laid claim to effecting alterations in blood pressure. However, in many of these cases, the investigators have cautioned against extrapolation of techniques in their simplest forms into the clinical setting. Investigations into altering blood pressure using hypnosis alone, or in combination with other procedures are surprisingly sparse. Deabler, Fidel, Dillenkoffer, and Elder (1973) subjected medicated and m e d i c a t e d hypertensive patients to hypnosis combined with skeletal-muscular relaxation or to no experimental procedure for eight sessions over a 4-day period. They found the combined hypnosis-andmuscular-relaxation procedure to be particularly effective in lowering both systolic and diastolic pressures and reported one case in which decreased pressures were apparent on two follow-up sessions, 12 and 13 days posttreatment.
Downloaded by [University of Strathclyde] at 07:56 10 October 2014
FREDMAN AND TAUB
337
"he present study is concerned with exploring the possibility of combining two procedures, biofeedback and hypnosis, into a technique which would enhance the clinical effectiveness of psychological procedures in dealing with essential hypertension. Diastolic pressure was selected as the significant dependent variable inasmuch as there is general agreement (Gantt,1972; Merrill, 1966) about the greater clinical significance of diastolic pressure and since, as Miller (1975) and Shapiro (1974) have indicated in reports from their own laboratories, most of the previously mentioned studies have been less successful in dealing with diastolic pressure. Although planned as a longterm study, this report limits itself to the evaluation of the training phase and limited follow-up periods wherein there is minimal confounding by drop-outs due to medication changes or simple failure to return.
METHOD Subjects Volunteer Ss were obtained through a hypertension-screening clinic at the Upstate Medical Center or by contacting former Syracuse Veterans Administration Hospital patients. In all cases, Ss had, in addition to the hospital or screening-clinic diagnosis of essential hypertension, the same diagnosis by their own physicians. Initial contact consisted of a letter in which the prospective S was asked if he were interested in volunteering for a research project which was evaluating various new psychological methods which could be used to lower blood pressure without the use of additional medication. It was pointed out that all the methods involved relaxation procedures, had been reported as being potentially effective, were safe without any negative or undesirable side effects, and could be used in addition to any medication currently being taken. Only those Ss demonstrating a minimal diastolic pressure of 85 millimeters of mercury during the baseline procedures were accepted for the study. This resulted in a total of 48 medicated and unmedicated Ss who were able to complete at least all training and a minimum of one follow-up session, and who were unchanged in medication during the study. For the 1-month follow-up period, one S was lost from the measurement only (MO) group. Table 1 provides relevant descriptive data about Ss in each of the four groups. Two descriptions of the single MO group are provided because the overall data analysis for the training and 1-week follow-up periods was able to use one more S than the analysis for the training and both followup periods. By simple analysis of variance (ANOVA), there were no
338
HYPNOSIS, BIOFEEDBACK, AND HYPERTENSION
TABLE 1 Ss' AGE, SEX,BASELINEDIASTOLICPRESSURE, PERCENT MEDICATED, AND
HYPNOTIC
SUSCEPTIBILITY Ace
SHSS: A Score
Mean of
Downloaded by [University of Strathclyde] at 07:56 10 October 2014
..._ -. . .
HB (N = 101 HO (N = 13) BO (N = 13) MO.to 1-week follow-up (N = 12) M O to l-month follow-up (N = 11)
" HB
=
62%
8-12 7-12 1-9
10.3 9.8 4.1
94.1
15%
0-8
3.6
95.1
13%
0-8
3.3
60% 69%
10
91.8 93.1 95.8
48.3
10
48.1
9
32-53 23-60 29-54
48.2 41.1
8 11
41.2
31-59 31-59
Hypnosis and biofeedback, I10 = Hypnosis only, BO = Biofeedback only, and M O = Measurement
only. The Ss in all four groups reported being medicated with the followingantihypertensive agents: Propranolol, Hydralazine Hydrochloride. Hydrochlomthiazide, Triamterene, and Methyldopa. In addition, the BO and MO groups had one S each on Spironlaetone and another on Reserpine. Fluorosemide and Chlorthiazide were being used by one S each in the BO group.
significant differences between the groups in mean age or in the mean of median-baseline-diastolicpressures (3' =
