Effects of Combining a Brief Cognitive Intervention with Transcranial Direct Current Stimulation on Pain Tolerance: A Randomized Controlled Pilot Study.

Objective: Cognitive behavioral therapy has been shown to be effective for treating chronic pain, and a growing literature shows the potential analgesic effects of minimally invasive brain stimulation. However, few studies have systematically investigated the potential benefits associated with combining approaches. The goal of this pilot laboratory study was to investigate the combination of a brief cognitive restructuring intervention and transcranial direct current stimulation (tDCS) over the left dorsolateral prefrontal cortex in affecting pain tolerance. Design: Randomized, double-blind, placebo-controlled laboratory pilot. Setting: Medical University of South Carolina. Subjects: A total of 79 healthy adult volunteers. Methods: Subjects were randomized into one of six groups: 1) anodal tDCS plus a brief cognitive intervention (BCI); 2) anodal tDCS plus pain education; 3) cathodal tDCS plus BCI; 4) cathodal tDCS plus pain education; 5) sham tDCS plus BCI; and 6) sham tDCS plus pain education. Participants underwent thermal pain tolerance testing pre- and postintervention using the Method of Limits. Results: A significant main effect for time (pre-post intervention) was found, as well as for baseline thermal pain tolerance (covariate) in the model. A significant time × group interaction effect was found on thermal pain tolerance. Each of the five groups that received at least one active intervention outperformed the group receiving sham tDCS and pain education only (i.e., control group), with the exception of the anodal tDCS + education-only group. Cathodal tDCS combined with the BCI produced the largest analgesic effect. Conclusions: Combining cathodal tDCS with BCI yielded the largest analgesic effect of all the conditions tested. Future research might find stronger interactive effects of combined tDCS and a cognitive intervention with larger doses of each intervention. Because this controlled laboratory pilot employed an acute pain analogue and the cognitive intervention did not authentically represent cognitive behavioral therapy per se, the implications of the findings on chronic pain management remain unclear.

Functional neuroimaging of personally-relevant stimuli in a paediatric case of impaired awareness.

BACKGROUND: Functional neuroimaging studies have observed preserved neural activation to personally relevant stimuli in patients within the disorders of consciousness (DOC) spectrum. As the majority of studies have focused on adult DOC patients, little is known about preserved activation in the developing brain of children with impaired consciousness. CASE STUDY: The aim of this study is to use fMRI to measure preserved neural activation to personally relevant stimuli (subject's own name and familiar voice) in a paediatric patient who sustained a traumatic brain injury and anoxic-ischaemia following a motor vehicle accident at 18 months of age rendering her probable for minimally conscious state. Contrasts revealed activation in the right middle frontal gyrus when hearing the subject's own name and the anterior supramarginal gyrus when hearing a familiar voice. CONCLUSION: This study provides preliminary support for fMRI as a method to measure preserved cognitive functioning in paediatric DOC patients.

Simulation modelling analysis for small sets of single-subject data collected over time.

The behavioural data yielded by single subjects in naturalistic and controlled settings likely contain valuable information to scientists and practitioners alike. Although some of the properties unique to this data complicate statistical analysis, progress has been made in developing specialised techniques for rigorous data evaluation. There are no perfect tests currently available to analyse short autocorrelated data streams, but there are some promising approaches that warrant further development. Although many approaches have been proposed, and some appear better than others, they all have some limitations. When data sets are large enough (∼30 data points per phase), the researcher has a reasonably rich pallet of statistical tools from which to choose. However, when the data set is sparse, the analytical options dwindle. Simulation modelling analysis (SMA; described in this article) is a relatively new technique that appears to offer acceptable Type-I and Type-II error rate control with short streams of autocorrelated data. However, at this point, it is probably too early to endorse any specific statistical approaches for short, autocorrelated time-series data streams. While SMA shows promise, more work is needed to verify that it is capable of reliable Type-I and Type-II error performance with short serially dependent streams of data.

Examining the potential impact of a family session in therapeutic assessment: a single-case experiment.

Most clinicians concede the benefits of conceptualizing children in systemic terms. Yet, many child assessments involve parents only on a limited basis. The Therapeutic Assessment model for children and families (TA-C) emphasizes parental involvement and family-driven collaboration throughout the intervention. Child TA has shown promise as an effective brief intervention (e.g., Smith, Handler, & Nash, 2010; Tharinger et al., 2009). Family intervention sessions (Finn, 2007; Tharinger, Finn, Austin, et al., 2008) are an integral component of the child TA model in facilitating familial changes. However, TA-C research has yet to empirically examine the potential impact of a family session on treatment trajectory. This case study includes an extended presentation of the development and execution of a family session. The authors use a daily measures time-series experiment to empirically examine the clinical effectiveness of the TA-C and the hypothesis that the family session was a tipping point in the trajectory of improvement.

HYPNOTIC RESPONSIVENESS AND NONHYPNOTIC SUGGESTIBILITY: DISPARATE, SIMILAR, OR THE SAME?

This study examined if participants respond to different types of suggestions, including hypnosis, uniquely or similarly. This study used 9 suggestibility measures and hypothesized a 3-factor model. It was hypothesized that hypnosis, Chevreul's pendulum, and body-sway would load on the first factor; the odor test, progressive weights, and placebo on the second factor; and conformity, persuasibility, and interrogative suggestibility would load on the third factor. The study comprised 110 college students. Factor analyses failed to result in three factors. Additional attempts at two and three-factor models were also rejected. Hypnosis had no strong relationship with the various suggestibility measures. Thus, no clearly delineated factor structure of suggestibility emerged, indicating that the domain of suggestibility seems to be neither a single attribute, trait, or group of related abilities. Implications are discussed.

Testing the effectiveness of family therapeutic assessment: a case study using a time-series design.

We describe a family Therapeutic Assessment (TA) case study employing 2 assessors, 2 assessment rooms, and a video link. In the study, we employed a daily measures time-series design with a pretreatment baseline and follow-up period to examine the family TA treatment model. In addition to being an illustrative addition to a number of clinical reports suggesting the efficacy of family TA, this study is the first to apply a case-based time-series design to test whether family TA leads to clinical improvement and also illustrates when that improvement occurs. Results support the trajectory of change proposed by Finn (2007), the TA model's creator, who posits that benefits continue beyond the formal treatment itself.

Moving and Reflective Functioning Under Stress.

According to mentalization theory, reflective functioning is a core feature of healthy affect regulation which involves interactions among implicit and explicit processes across multiple systems of the individual in relation with others. Mother-infant interactions point to the role of whole body movement as a feature of developing affect regulation, promoting self-organization. Using behavioral imaging technology, we examined the legacy of whole body movement in adults undergoing an interpersonal stress task (Trier Social Stress Test; TSST). Movement was assessed as a multidimensional system over time, allowing for examination of rigid recurrence and self-organized determinism in movement dynamics (Multidimensional Recurrence Quantification Analysis). Reflective functioning was assessed using an automated analysis of transcripts. We found flexible yet self-organized movement uniquely predicted reflective function. Self-reported personality organization, assessed at least one week prior, showed some bivariate relationship with indices of movement dynamics, while self-reported attachment styles did not. Using novel methodology, this study demonstrated the cooccurrence of reflective functioning and specific movement dynamics. The authors suggest theoretical approaches from phenomenology to understand these findings and call for further research.

Clinical practice as natural laboratory for psychotherapy research: a guide to case-based time-series analysis.

Both researchers and practitioners need to know more about how laboratory treatment protocols translate to real-world practice settings and how clinical innovations can be systematically tested and communicated to a skeptical scientific community. The single-case time-series study is well suited to opening a productive discourse between practice and laboratory. The appeal of case-based time-series studies, with multiple observations both before and after treatment, is that they enrich our design palette by providing the discipline another way to expand its empirical reach to practice settings and its subject matter to the contingencies of individual change. This article is a user's guide to conducting empirically respectable case-based time-series studies in a clinical practice or laboratory setting.

A parametric control chart adjustment for handling serial dependence in health care quality data.

Numerous tools are available to health care quality managers geared toward helping them make data-based inferences about quality processes. Recently, in this journal, Tukey's control chart technique was promoted as a good option for handling short streams of time series data when the assumption of data normality cannot be confirmed. Although this technique does not appear to perform well with serially dependent (or autocorrelated) data, an autocorrelation-corrected version of the technique is now available. However, when managers wish to capitalize on the superior power of parametric control charts (ie, when data sets are large and normality can be confirmed), there are currently few options available in the way of statistical process control techniques that appropriately handle autocorrelated data. In this article, the authors report the empirical false-positive rates and power performance of the mean-sigma (X-S) control chart technique under various levels of autocorrelation. Results indicate that this popular technique offers poor false-positive control with autocorrelated data. Next, the authors describe a method for autocorrelation correction and finally compare the autocorrelation-corrected X-S chart with the original X-S technique. The autocorrelation-corrected X-S chart demonstrates better type I error control with similar power to the original chart and may offer quality managers an important tool for appropriately handling autocorrelated quality data.

Hypnotizability and somatic complaints: a gender-specific phenomenon.

The relationship between hypnotizability and somatic illness was measured in 45 college students. Several weeks after completing the Waterloo-Stanford Group C Scale (WSGC), participants filled out a somatic-complaint checklist and measures of psychopathology. Results indicated a positive correlation between hypnotizability and somatic illness, and the relationship was stronger for female participants. In contrast to the quadratic model proposed by Wickramasekera, the current data demonstrated a linear relationship between hypnotizability and somatic complaint. Further analyses showed that somatic complaints were associated with hallucination and imagery items, corresponding to the perceptual-cognitive factor identified in Woody, Barnier, and McConkey's (2005) factor analysis of the Stanford Hypnotic Susceptibility Scale, Form C. The results call into question some claims that high hypnotizability is an adaptive and healthy trait.

Is Primary-Process Cognition a Feature of Hypnosis?

The division of cognition into primary and secondary processes is an important part of contemporary psychoanalytic metapsychology. Whereas primary processes are most characteristic of unconscious thought and loose associations, secondary processes generally govern conscious thought and logical reasoning. It has been theorized that an induction into hypnosis is accompanied by a predomination of primary-process cognition over secondary-process cognition. The authors hypothesized that highly hypnotizable individuals would demonstrate more primary-process cognition as measured by a recently developed cognitive-perceptual task. This hypothesis was not supported. In fact, low hypnotizable participants demonstrated higher levels of primary-process cognition. Exploratory analyses suggested a more specific effect: felt connectedness to the hypnotist seemed to promote secondary-process cognition among low hypnotizable participants.

Expect the unexpected: ability, attitude, and responsiveness to hypnosis.

Participants' expectancies and hypnotic performance throughout the course of a standardized, individually administered hypnotic protocol were analyzed with a structural equation model that integrated underlying ability, expectancy, and hypnotic response. The model examined expectancies and ability as simultaneous predictors of hypnotic responses as well as hypnotic responses as an influence on subsequent expectancies. Results of the proposed model, which fit very well, supported each of the 4 major hypothesized effects: Expectancies showed significant stability across the course of the hypnosis protocol; expectancies influenced subsequent hypnotic responses, controlling for latent ability; hypnotic responses, in turn, affected subsequent expectancies; and a latent trait underlay hypnotic responses, controlling for expectancies. Although expectancies had a significant effect on hypnotic responsiveness, there was an abundance of variance in hypnotic performance unexplained by the direct or indirect influence of expectation and compatible with the presence of an underlying cognitive ability.

An autocorrelation-corrected nonparametric control chart technique for health care quality applications.

Recently, Alemi proposed a nonparametric control chart technique (Tukey's control chart) for quality management applications when few data points are available and when data do not conform to the assumptions of traditional control chart techniques. Borckardt et al then published an empirical evaluation of the technique and concluded that the presence of autocorrelation in control-chart data negatively impacted the technique's ability to help managers make accurate decisions about the presence of special-cause variation in their data. Thus, there is still a need for control chart techniques that appropriately handle short data streams that do not necessarily conform to the assumptions of traditional control chart techniques but are not negatively impacted by autocorrelation in the data. In this article, the authors empirically evaluate a modified version of the technique presented by Alemi that is designed to account for autocorrelation. Empirical analyses indicate that the modified technique demonstrates superior false-positive performance with very little degradation of power compared with the original technique proposed by Alemi.

Salient findings: identifying the building blocks of hypnotizability, and the neural underpinnings of subjective pain.

Two papers of special interest to the hypnosis community have appeared in the general scientific literatures. One of these papers examines the building blocks of hypnotic response. Using expanded hypnotic protocols and sophisticated multivariate statistical analyses, the authors found evidence for 4 components of hypnotizability: direct motor, motor challenge, perceptual-cognitive, and posthypnotic amnesia. The second paper examines brain correlates of the subjective reality of physically and hypnotically induced pain by tracking regional brain activation across conditions using fMRI. During suggestion-induced pain, the extent to which subjects judged the pain to be real correlated with activity in the rostral and perigenual anterior cingulate cortex and in the medial prefrontal cortex.

Anatomy of a hypnotic response: Self-report estimates, actual behavior, and physiological response to the hypnotic suggestion for arm rigidity.

The present study closely examines subject response to the arm-rigidity item of the HGSHS:A. Subject behavior, subject self-report, and surface EMG of the biceps and triceps muscles were monitored. Two distinct ways of passing the item were observed and verified by EMG recordings: some subjects (tremblers) exerted muscular effort to bend the arm and kept it rigidly straight. Others (nontremblers) passively kept the arm straight without exerting muscular effort to bend, even though they reported exerting effort to bend their arm. These two behaviorally and physiologically different methods of passing the item support the idea of individual differences in hypnotic responding and suggest that subjects may be using different mental processes to pass the item.

An empirical evaluation of Tukey's control chart for use in health care and quality management applications.

Recently in this journal, F. Alemi (Qual Manage Health Care. 2004;13(4):216-221) proposed the use of Tukey's Control Chart because of the unique benefits associated with nonparametric inferential statistics including robust performance with (1) low N sizes, (2) nonnormal data, and (3) the presence of outliers, However, an assumption that applies to virtually all inferential statistical procedures (parametric and nonparametric) is that the observations in question are independent from each other. Unfortunately, there is good reason to suspect violation of this assumption when evaluating quality processes over time (as is often the case in health care settings). In this article, the power (ability to detect real changes in a data process) and type I error (probability of false positives) performance of Tukey's Control Chart technique is empirically evaluated. When observations are not independent, Tukey's Control Chart technique demonstrates unacceptable type I error performance. Additionally, regardless of whether observations are independent, the technique demonstrates low power to detect real effects unless the effects are quite large.

Salient findings: A potentially groundbreaking study on the neuroscience of hypnotizability, a critical review of hypnosis' efficacy, and the neurophysiology of conversion disorder.

Three papers of special interest to researchers and clinicians alike have recently appeared in the general scientific and medical literatures. Two of these papers are original research studies that employ brain-imaging technologies, one using Magnetic Resonance Imaging (MRI), the other position emission tomography (PET). A third paper is a comprehensive review of the empirical findings on the clinical use of hypnosis in pediatric oncology. The research study using MRI technology is extraordinary, because it is the first to document differences in brain morphology between high hypnotizable and low hypnotizable individuals. Arguably, if its findings replicate, the study could be one of the most important developments in scientific hypnosis since the genesis of the Stanford scales 45 years ago. The PET study notes differences in brain activation during intentionally simulated and hypnotically experienced paralysis. The review article examines empirical work addressing the efficacy of hypnosis for procedural pain in pediatric oncology.

The importance of being earnest when crafting definitions: science and scientism are not the same thing.

The APA Division 30 definition of hypnosis is laudable in some respects. For instance, the committee rightly defines the "induction" as nothing more or less than the first suggestion after the introduction. However, the definition stumbles over its nonposition on whether the word hypnosis must be uttered during the procedure. This equivocation invites research designs that preemptively define a hypnotic group and a control group in terms of whether or not the word hypnosis is used in the protocol. These designs represent a backslide into naive operationism; they reveal little new about human nature or hypnosis. The field deserves an optimally heuristic definition that preserves pluralism and is relatively resistant to the teflon shield of preemptive definition. Researchers and practioners require a definition that recognizes the incompleteness of our concepts, generates a level epistemological playing field, and enables hypnosis theories to "reach."

Salient findings: hypnosis in medical settings.

Five papers of special interest to medical researchers and clinicians have recently appeared in the general scientific and medical literatures. Three of these papers are original clinical research studies evaluating whether hypnosis can be useful in treating acute stress disorder, allergic rhinitis, and distress associated with an invasive medical procedure for children. The remaining two articles critically review the empirical literature on whether and how hypnosis might be useful in a number of medical specialties.

The Harvard Group Scale of Hypnotic Susceptibility: accuracy of self-report and the memory for items.

Whereas early studies have found moderately high agreement between self- and observer-rated scores on the Harvard Group Scale of Hypnotic Susceptibility, Form A (HGSHS:A), these studies shared a common confound in that participants were aware of being directly observed. In the present study, confederates made surreptitious observations of group participants' hypnotic responding. Following the hypnotic procedure, participants indicated whether or not they remembered each item and provided self-reports of their hypnotic response. The study assesses the accuracy of participant self-report for hypnosis items when individuals are unaware of being observed. Thirty-two percent of participants failed to recognize at least one item from the hypnosis session, suggesting that the inability to remember items is a common phenomenon. When participants reported not remembering an item, the accuracy of their self-reported response was no better than chance.