Hypnosis, Placebo, and Suggestion in the Treatment of Warts

N. SPANOS et al.al. (13) gave hypnotic suggestions for wartremission to 17 subjects and no treatmentto seven others. At the end of 3 months,53% of the hypnotic subjects, but none ofthe controls, had lost at least some of theirwarts. The findings of these two controlledstudies certainly suggest the operation ofa psychological treatment effect. Nevertheless,given the somewhat counterintuitivenature of the findings, the wide between-subjectvariability found in rates ofspontaneous remission for warts (e.g., 11),and the small number of control subjectstested by Surman et al (13), replication ofthese findings is called for. The presentstudy includes two controlled experimentsaimed at replicating and extendingprevious findings concerning the role ofpsychological factors in wart remission.HYPNOSIS, IMAGERY,AND PLACEBOSOne potentially important differencebetween hypnotic and placebo treatmentsconcerns the psychological orientations thatsubjects develop toward these procedures.Both procedures attempt to instill expectationsof treatment success. However,hypnotic subjects are encouraged to seethemselves as engaged in cognitive activitythat will bring about their own recovery.For example, suggestions for wartregression encourage subjects to becomeinvolved in vividly imagining their wartsas tingling, shrinking, disappearing, andso on. Placebo procedures, on the otherhand, tacitly define subjects as the passiverecipients of a therapeutic procedure. Subjectsgiven a placebo are not asked to imagineanything or to view themselves as activelyinvolved in bringing about their ownrecovery. Instead, they are instructed tosimply wait for therapeutic effects to occur,or to look for indications that sucheffects are in progress (e.g., to notice anytingling around the wart). One purpose ofour first experiment was to compare wartregression in subjects assigned to a hypnotic,placebo, or no treatment controlcondition.Several investigators (14, 15) have arguedthat the important therapeutic componentin hypnotic treatments is the imageryencouraged by the suggestions forwart regression. According to this hypothesis,subjects who generate the most vividsuggested imagery are the most likely toexhibit wart regression. In order to examinethis hypothesis, we assessed thevividness that our hypnotic subjects attributedto their suggested imagery. We alsoexamined relationships between the reportingof suggested sensations and treatmentefficacy in both the hypnotic and placebotreatments.Hypnotizability and Wart RemissionSubjects vary substantially in their levelof responsiveness to hypnotic suggestions(i.e., hypnotizability), and a number ofstandardized scales for the assessment ofhypnotizability are available (e.g., 16).Three studies (6,17,18) reported that highlyhypnotizable subjects given a hypnotictreatment were more likely to lose wartsthan low hypnotizables. On the other hand,one study (9) reported that none of 20 highlyhypnotizable subjects treated with hypnosisexhibited wart regression, and anotherstudy (13) found no relationship betweenhypnotizability and wart loss inhypnotically treated subjects.Unfortunately, most studies in this areadid not use standardized scales to assesshypnotizability, and the psychometric246 Psychosomatic Medicine 50:245-260 (1988)

HYPNOSIS IN WART TREATMENTproperties of the assessment proceduresthat were used are unknown. Furthermore,in these studies hypnotizability wasassessed before the hypnotic wart treatment.Consequently, subjects' knowledgethat they were hypnotizable or unhypnotizablemay have influenced the mannerin which they responded to subsequentsuggestions for wart regression. For example,some evidence (19, 20) indicatesthat hypnotizability correlates with suggestedanalgesia when hypnotizability isassessed before analgesia testing and whensubjects conceptually link their hypnotizabilitywith the analgesia test situation.However, when hypnotiability is assessedafter analgesia testing,or if low hypnotizablesare assured that they can exhibit suggestedanalgesia despite their low hypnotizability,then the significant correlationbetween hypnotizability and suggestedanalgesia often disappears. In other words,hypnotizability testing can create potentexpectations concerning how subjects arelikely to respond to forthcoming suggestions.For example, as a consequence ofhaving previously tested low in hypnotizability,some subjects may come to believethat they are unable to generate the imagerycalled for by the suggestion for wartremission. Therefore these subjects maymake no attempt, or only a half-heartedattempt, to generate such imagery. In thepresent experiments we eliminated potentialinterpretive problems of this kind byassessing hypnotizability at the end of the6-week assessment period that followedtreatment administration.Some investigators (21) have suggestedthat hypnotizability should predict wartregression following psychological interventionregardless of whether the psychologicaltreatment involves administrationof an hypnotic induction procedure. Totest this possibility we assessed subjectsin all treatments for hypnotizability at theend of their follow-up period.Specificity EffectsPerhaps the most dramatic finding inthis research area concerns the idea thatsuggestions can exert a selective effect onwart regression. In one study (18), highlyhypnotizable subjects, all of whom hadwarts on both sides of their body, weregiven the hypnotic suggestion that theywould lose only the warts on one side. Thesuggestion was always aimed toward theside of the body with the largest numberof warts. Nine out of the ten highly hypnotizablesubjects lost warts only on thetreated side, while the remaining subjectlost warts bilaterally.Five subsequent studies (7-9, 13, 22)have reported failures to replicate this sidespecific treatment effect. However, most ofthese replication failures have had methodologicaldifficulties. For instance, in twoof these studies (9, 22), so few subjects lostwarts on either side that no conclusionsabout a side-specific effect were possible.Two other studies (7, 8) failed to find aside-specific effect when using a placeboas the treatment. Unfortunately, neitherstudy employed hypnotic suggestion.Surman et al. (13) unambiguously failedto replicate the side-specific treatment effect.In that study, ten subjects with bilateralwarts lost warts following a hypnoticsuggestion directed at one side of the body.In nine out of the ten cases, however, wartloss was bilateral rather than treatmentsidespecific.In order to further explore the side-specificeffect, subjects in both of our experimentswith bilateral warts were given atreatment directed to only one side of theirPsychosomatic Medicine 50:245-260 (1988) 247

N. SPANOSetal.body. To test for the specificity effect, thedata from the two experiments were combined.Consequently, these findings arediscussed at the end of Experiment 2.METHOD (EXPERIMENT 1)SubjectsSixty-four individuals with warts on one or bothhands (29 males, 35 females, ages 10-74 years) weresolicited for participation in a study of warts throughadvertisements placed on posters around the CarletonUniversity campus, in local newspapers, and onthe radio. Subjects were informed that several treatmentsfor warts were being compared and that somesubjects would be assigned to a placebo treatment.Subjects were asked to abstain from any other warttreatment for the duration of the study. All were paid$15 for their participation.ProcedureSubjects were randomly assigned to a hypnoticsuggestion (N = 22), cold laser placebo (N = 24), orno treatment control condition (N = 17). All subjectswere seen individually by a research assistant, whocounted the warts on each of their hands and recordedtheir age and their estimates of the durationof their warts (in months). Subjects were then escortedto the treatment room and introduced to themale therapist, who conducted both the hypnoticand placebo treatments. Hypnotic and placebo subjectswere administered their respective treatmentsand scheduled to return in six weeks for follow-upevaluation. Control subjects were informed that theywere on a waiting list and were asked to return in 6weeks to receive treatment. At the 6 weeks followupsession, subjects again had their warts countedby a research assistant and were then tested for hypnotizabilityusing the Carleton University Responsivenessto Suggestion Scale (CURSS; 13). This scaleyields an objective (CURSS: 0) score that reflects thenumber of suggestions to which subjects made theappropriate behavioral response, and a subjective score(CURSS: S) that reflects the intensity of their subjectiveresponses to the suggestions. At this time, subjectswere also assessed on a modification of the Bettsvividness of imagery questionnaire (23). The researchassistant who counted subjects' warts in the baselineand follow-up sessions was blind to subjects' treatmentassignment.Hypnotic Treatment.Eleven of the 22 subjects in this group had wartson both hands. In these 11 cases, one hand was chosenat random as the target hand, and all treatmentsuggestions were referred exclusively to the targethand. After being comfortably seated and asked toclose their eyes, subjects were orally administered a5-min hypnotic induction procedure (modified from24). Following the induction procedure, and withouta break in continuity, subjects were administered asuggestion for wart elimination that was 2 min induration. The suggestion asked subjects to attend tothe sensations in their target hand and informed themrepeatedly that the skin around their warts was beginningto tingle and grow warm. The suggestion alsoinformed subjects that their warts would shrink andfall off and asked them to vividly imagine their wartsshrinking in size and dissolving away. Following thesuggestion, subjects opened their eyes and rated thevividness with which they had imagined their wartsshrinking and disappearing on a 7-point scale withalternatives that ranged from "No image present"(scored 0) to "Extremely vivid; as vivid as though itwas actually happening" (scored 6). Next, subjectsrated the intensity with which they experienced sixsensations around their warts (tingling, warmth,throbbing, numbness, shrinking, prickling). Eachsensation was rated on a 7-point scale that rangedfrom "not at all" (scored 0) to "strongly" (scored 6).The six items were totaled to yield a single sensationscore for each subject.Following their sensation ratings, subjects wereasked to again close their eyes and were readministeredthe same 2-min suggestion. Finally, subjectswere "awakened," instructed to count their warts everyday, and after each counting to close their eyes andspend 3 to 4 min imagining the warts on their targethand disappearing.Placebo TreatmentThese subjects were informed that they would betreated with a relatively new technique known as a"cold laser." They were given a few minutes to readan article from Life Magazine (May 1982) on the medicaluse of lasers, and afterwards they read a briefbut technical account of laser action. This technicalaccount included an explanation in terms of "differentialtissue density" of how the cold laser wouldkill their warts without effecting surrounding healthytissue. Subjects with bilateral warts (N = 12) wereinformed that only one hand would be treated at that248 Psychosomatic Medicine 50:245-260 (1988)

HYPNOSIS IN WART TREATMENTtime and that the other hand would be treated in 6weeks. The target hand was chosen randomly.The "laser" was housed in a sound-attenuatedchamber. It was a metal devise with numerous dialsand buttons and an opening in which subjects placedtheir target hand. When the "laser" was switched on,it made a whirring sound, and a sweeping pink lightcould be seen in the opening. Subjects donned "protectivegoggles" and placed their hand in the openingfor the first of two 4-min "laser doses." They weretold that they might experience some tingling, prickling,and warmth in their hand during the treatmentbut not to be alarmed at these sensations. Followingthat first "laser dose," subjects completed the samesensation questionnaire given to the hypnotic subjects,and then placed their hand back in the "laser"for their second dose. Following the placebo treatment,subjects were instructed to count their wartsevery day and at these times to notice whether theyexperienced any sensations in their warts.No Treatment ControlsAfter their warts were counted, these subjects wereinformed that they were on a waiting list and wouldbe administered a treatment for their warts in 6 week'stime.RESULTSTable 1 shows the number of warts atbaseline for subjects in the three conditions.A one way analysis of variance {AN-OVA) indicated no significant differencesamong conditions in number of baselinewarts, F(2,61) < 1. Separate ANOVAs alsoindicated no significant differences betweenconditions in subjects' ages or intheir estimates of wart duration.Unfortunately, there is no ideal way toquantify wart loss. In the present study thenumber of warts possessed by subjects atbaseline ranged from one to 60. Almost athird of the subjects (N = 20) had onlyone wart at baseline, and slightly more thanhalf the subjects (N = 33) had three or fewerwarts at baseline. Subjects with a smallnumber of baseline warts could show onlysmall decreases in absolute number ofwarts, even when they lost all of their warts.On the other hand, a measure of percentageloss also has difficulties. For example,a subject who loses her only wart gets ahigher percentage loss score (100%) thana subject who loses 25 of his 50 warts (50%).We dealt with the measurement issue byusing both a continuous and a dichotomousindex of wart loss. The continuousindex was percentage of wart loss frombaseline, and the dichotomous index waswhether or not a subject lost any (one ormore) warts.Treatment EffectsTable 1 shows that subjects in the threeconditions differed significantly in percentageof warts lost (F (2,61) = 7.17,p < 0.01). Post hoc analyses indicated thatTABLE 1. Means for Number of Warts at Baseline, Percent Wart Loss, Age and Estimated Duration ofWarts in Hypnotic, Placebo, and No Treatment Control ConditionsBaselinePercent lossAgeDurationHypnosisMSD7.32"14.9233.68 a 41.4829.45 a11.1377.83 a 97.31PlaceboMSD7.21 a10.769.08 6 22.2528.33 a13.4064.04 a 43.70Within rows, means sharing the same letter superscript fail to differ significantly at a = .05.Estimated duration is in months.ControlMSD5.35 a6.112.06 b6.3929.06 a14.0478.00 a 52.95Psychosomatic Medicine 50:245-260 (1988) 249

N. SPANOS et al.TABLE 2. Number of Subjects Who LostOne or More Warts or Who Did Not LoseAny Warts in Hypnosis, Placebo, and NoTreatment Control ConditionLostDid not loseHypnosis Placebo Controlhypnotic subjects lost a greater percentageof warts than subjects in either the placeboor control group. The latter two groupsfailed to differ significantly in this regard.Table 2 shows the number of subjectsin each condition who lost at least onewart and the number who lost no warts.The three conditions differed significantlyin this respect, (X 2 (2) = 7.35, p < 0.05).Further analysis indicated that significantlymore hypnotic subjects than controlslost warts (X 2 (lj = 6.45, p < 0.01).Hypnotic subjects were also marginallymore likely than placebo subjects to losewarts, (X 2 (l) = 3.43, p = 0.06). However,placebo and control subjects failed to differin this regard, (X 2 (1) = 0.98).Recall that subjects in both the hypnoticand placebo conditions rated the vividnesswith which they imagined the sensationssuggested to them. Hypnotic subjects[M = 20.86; SD = 13.00) rated theirsuggested sensations as significantly morevivid than did placebo subjects (M = 6.42,SD = 7.01, t [44] = 4.75, p < 0.01).Warts at BaselineSubjects in both the hypnotic and placeboconditions were divided into thosewho lost warts and those who did not. Theresultant four groups were compared onnumber of warts at baseline with a 2 x 2hypnosis/placebo x lost/did not lose between-subjectsANOVA. Subjects who lostwarts (M = 12.94, SD = 18.27) had significantlymore warts at baseline than thosewho did not lose warts [M = 3.97,SD = 3.90, F [1.42] = 6.66, p < 0.01). Noother effects achieved significance.Table 3 shows the number of hypnoticand placebo subjects who had either onewart at baseline or more than one wart atbaseline. In both conditions, subjects wholost warts tended to have multiple wartsrather than a single wart at baseline. Whenthe conditions were combined, subjectswho lost warts were significantly morelikely than those who did not to have multiplewarts at baseline (X 2 (1) = 4.98,P < 0.05).Gender EffectsTo examine gender effects, subjects inthe hypnotic and placebo groups were againcombined. Males in the combined treatment(M = 6.68, SD = 11.02) did not differin number of baseline warts from females(M = 7.75, SD = 13.32).Nevertheless, females in the combinedtreatments (M = 34.21, SD = 41.70) losta significantly greater percentage of theirwarts than did males (M = 6.27,SD = 16.19, F [1,44] = 8.86, p < 0.01).Table 4 shows that females in the com-TABLC 3. Number of Subjects with OneBaseline Wart or Multiple Baseline WartsWho Lost or Did Not Lose Warts in theHypnosis and Placebo Conditions1 Baseline wart 1 Baseline wartHypnosisLostDid not losePlaceboLostDid not loseCombinedLostDid not lose2607213956111516250 Psychosomatic Medicine 50:245-260 (1988)

HYPNOSIS IN WART TREATMENTTABLE 4. Number of Males and Females Losingand Not Losing Warts in the Hypnosis andPlacebo Conditions CombinedLostDid not loseMalesFemalesbined treatments more frequently lost atleast one wart than did males, X 2 (1) = 6.88,p

N. SPANOSetal.lost fewer warts than hypnotic subjects andalso reported less intense experiencing ofsuggested sensations than did hypnoticsubjects. These findings may indicate thathypnotic subjects were more subjectivelyinvolved in their treatment than were placebosubjects and that subjective involvementin the treatment process is helpfulin bringing about wart regression. Thefinding that placebo group subjects failedto differ significantly from controls in wartloss was somewhat surprising given thesignificant placebo effect reported byMemmesheimer and Eisenlohr (12). Perhapsour rather complicated "cold laser"placebo was simply less convincing thansuch relatively simple procedures as havingmedical personnel (instead of psychologists)paint the warts or inject subjectswith innocuous substances definedas powerful wart medications. Futurestudies that employ a range of differentplacebo procedures, and that independentlyassess each procedure for believability,might provide useful information.In hypnotic subjects, wart regressioncorrelated significantly with the reportedvividness of suggested imagery and suggestedsensations. Interestingly, in thesesame subjects wart regression failed to correlatesignificantly with either an attributemeasure of the propensity to imagine vividly(The Betts Questionnaire) or withhypnotizability dimension. These findingsindicate that in the case of wartregression, situation specific indicators ofsubjects' cognitive involvements and motivationsmay be better outcome predictorsthan global indexes of fantasy pronenessand suggestibility. The global indicatorsmay simply be too far removed from theparticular constellation of context specificmotivations, imaginings, and beliefs thatdetermine subjects' responses to the treatmentsuggestions. On the other hand, thesefindings may simply point to limitationsin the particular indexes of imagery andhypnotizability employed in our study. Toexamine this possibility, our second experimentemployed a second standardizedtest of hypnotizability and two differentattribute measures of imaginal activity.Our finding that treatment effects werelarger for females than for males was surprising,because five previous studies (6,12, 13, 17, 22) found no sex differences inwart regression in subjects treated witheither hypnotic suggestion or placebo.Thus, our findings with respect to sex differencesshould be considered highly tentativeuntil replicated.Our finding that subjects with manywarts showed a better treatment responsethan those with only a few is consistentwith the results of at least two earlier studies(12, 22). In one study (22), for example,30% of the 10 subjects with four or morewarts showed wart regression followinghypnotic treatment, while none of the 12subjects with three or fewer warts showedany treatment effect.EXPERIMENT 2A good deal of experimental work indicatesthat hypnotic and motivated nonhypnoticsubjects respond equivalentlywhen given the same suggestions. Equivalentlevels of responding in these twogroups have been found for suggestionsthat call for such varied responses as analgesia,age-regression, hallucination, motoricand sensory alterations, and allergicreactions (for reviews, see 25, 26). Onlyone study (22) compared hypnotic andnonhypnotic subjects given the same suggestionfor wart regression. Unfortunately,the number of subjects per treatment wassmall, a no-treatment control condition was252 Psychosomatic Medicine 50:245-260 (1988)

HYPNOSIS IN WART TREATMENTnot employed, and very few subjects ineither treatment lost warts. Consequently,the results were ambiguous.The major components in hypnotictreatments for wart regression usually includethe definition of the situation ashypnosis, the administration of an inductionprocedure that emphasises relaxation,and suggestions to imagine the warts disappearing.In order to determine whetherdefining the situation as hypnosis or relaxationfacilitated any wart regression effectsproduced by the suggestion alone, wecompared the following four conditions;a) hypnotic induction plus suggestion, b)the same suggestion preceeded by nonhypnoticrelaxation instructions, c) thesuggestion alone, and d) a no-treatmentcontrol condition. Each subject was administeredtheir treatment twice separatedby a 1-week interval. Following each treatmentsession, subjects rated the vividnesswith which they imagined the sensationssuggested to them their degree of relaxation,and the extent to which they experiencedgeneralized alterations in consciousness(e.g., "I felt dazed," "time stoodstill"). A number of investigators (e.g., 27)have emphasized the importance of subjects'expectations of treatment success inbringing about wart regression. In fact, ithas been argued (27) that expectation isthe only important psychological mediatorof wart regression. Supposedly, otherpsychological variables (such as engagingin the suggested imagery) are importantonly to the extent that they bolster subjects'expectations of treatment success.Alternatively, other investigators havesuggested that subjects' expectations arelargely unrelated to treatment outcome andhave reported successful treatment inhighly skeptical subjects (e.g., 28, 29). Unfortunately,no studies have systematicallyassessed the relationship betweenexpectations and treatment outcome. Inorder to examine this issue, subjects in eachof our treatments estimated how effectivethey believed their treatment would be atremoving their warts.At the end of the 6-week follow-up period,all subjects were tested on two differenthypnotizability scales and were administeredTellegen and Atkinson's (30)questionnaire measure of absorption inimaginative activities, as well as the versionof the Betts' imagery questionnaireused in Experiment 1 (23).METHODSubjectsForty-five males and 31 females (ages 15-66 years)with warts on one or both hands were recruited forparticipation in a study on the psychological treatmentof warts in the same manner as in Experiment1.ProcedureSubjects were randomly assigned to four conditionswith 19 subjects in each condition. The fourconditions were a) the same hypnotic induction procedureplus wart remission suggestion used in Experiment1, b) the wart remission suggestion preceededby relaxation instructions in place of thehypnotic induction, c) the suggestion alone withoutpreliminary hypnotic or relaxation instructions, andd) no treatment control.The relaxation instructions were modelled afterthe hypnotic instructions used in Experiment 1. Theywere the same length as the hypnotic instructions.However, they defined the situation as relaxationrather than hypnosis, and all references to drowsiness,sleep, and hypnosis were replaced with referencesto relaxation and comfort.Subjects in the three treatment groups were administeredtheir respective treatment procedurestwice, with a week separating the two administrations.Within each treatment, 11 subjects were administeredthe procedures by a male experimenter,and eight were administered them by a female experimenter.Subjects in all conditions returned forfollow-up evaluation 6 weeks after their initial ses-Psychosomatic Medicine 50:245-260 (1988) 253

N. SPANOS et al.sion. In the first session, and again at the 6-weekfollow-up, subjects' warts were counted by a technicianwho was blind to subjects' treatment assignment.In-session QuestionnairesImmediately after each treatment procedure, subjectswere administered the following questionnaires.Intensity of Imagined Sensations. Subjects ratedthe extent to which they experienced each of the foursensations (i.e., tingling, warmth, shrinking, prickling)described in the suggestion. Each sensation wasrated on a 7-point scale, and the four sensation itemswere totaled to yield a single suggested vividnessscore.Expectation of Treatment Success. Subjects respondedto the following item: "How effective do youthink this treatment will be at removing your warts?"Alternatives ranged from "not at all effective" (scored0) through "moderately effective" (scored 5) to "extremelyeffective" (scored 10).Altered Experience. Field (31) constructed a scaleto assess alterations in experience frequently associatedwith hypnotic induction (e.g., "I felt dazed").We modified the scale by eliminating all items thatmade explicit reference to sleep or hypnosis. Thirtythreeitems remained that tapped a range of alterationsin body image, relaxation, and sensory experiences.All items were scored dichotomously andtotaled to yield a single altered experience score.Relaxation. Subjects rated their degree of relaxationon a six-item scale that was anchored with thedescriptors "very tense" (scored 1) at one end to "veryrelaxed" (scored 6) at the other end.Measures Taken at Follow-upAfter their warts had been counted at the 6-weekfollow-up, subjects were assessed for hypnotizabilityboth on the CURSS and on a 10-item version of theStanford Hypnotic Susceptibility Scale, Form C(SHSS : C) (32). This version of the SHSS :C has beenmodified in our laboratory to yield both an objectivemeasure (SHSS : C/O) and a subjective measure(SHSS : C/S) of hypnotizability (33). The CURSS andSHSS : C were administered at least 1 day apart incounterbalanced order. Before CURSS administrationsubjects completed the version of the Betts imageryscale used in Experiment 1. Before SHSS : Cadministration they completed Tellegen and Atkinson's(30) questionnaire measure of absorption. Thisquestionnaire assesses subjects' propensities for involvementin everyday fantasy (e.g., reading novels).RESULTSThere were no significant treatmentdifferences in number of warts at baseline,F (3, 68) < 1. There were also nosignificant treatment differences in subjects'ages or in the estimated duration oftheir warts. The means involved in theseanalyses are given in Table 6.Slightly more than half the subjects inthis experiment had only one wart at baseline(N = 39, 51.3%), and the large majorityhad three or fewer warts at baseline(N = 64, 84.2%). Because the number ofwarts at baseline was so severely skewedtoward the low end, we measured wartloss exclusively in terms of our dichotomouslost one or more/lost none index.Treatment EffectsTable 7 shows the number of subjectsin each condition who lost and who didnot lose warts. The four conditions differedsignificantly in this regard (X 2(3) = 7.92, p < 0.05). Further analyses indicatedthat the three treated groups failedto differ significantly from one another.Furthermore, subjects in the three treatedgroups combined more frequently lost wartsthan did controls, X 2 (1) = 4.75, p < 0.05.Hypnotic subjects taken alone more frequentlylost warts than did controls, X 2(1) = 4.47, p < 0.05; and suggestion onlysubjects taken alone also more frequentlylost warts than did controls (X 2 (1) = 7.12,p < 0.01). However, relaxation-plus-suggestionsubjects failed to differ significantlyfrom controls in this respect (X 2(1) = 2.11).254 Psychosomatic Medicine 50:245-260 (1988)

i/ii/ii/iHYPNOSIS IN WART TREATMENTTABLE 6.Baseline wartsAgeEstimated durationMeans for Number of Warts at Baseline, Age, and Estimated Wart DurationM3.9723.3741.64H -5.196.8828.24M4.1125.1290.36c7.0611.67116.28M3.0523.2660.00R + SS5.459.9563.48M3.0521.6861.32CS5.464.6784.96Estimated duration is in months.Abbreviations for conditions: H + S, hypnosis and suggestion; S, suggestion alone; R + S, relaxation and suggestion;C, control.Gender EffectsMales [M = 3.54, SD = 5.52] and females(M = 3.43, SD = 6.20) did not differsignificantly in the number of wartsthey possessed at baseline. In the threetreated groups combined, eight out of 33males (24%) and four out of 24 females(17%) lost one or more of their warts. Thissex difference was not significant.In-session QuestionnairesRecall that each treated subject was administeredtheir respective treatment twiceand, therefore, responded twice to each insessionquestionnaire. The correspondingquestionnaires for the two sessions weretotaled to yield a single in-session questionnairescore for each treated subject.Subjects in the three treatment groupswere combined and divided into those wholost warts and those who did not. TheTABLE 7.LostDid not loseNumber of Subjects Who Lost and DidNot Lose WartsH + S S R + S C4 615 13217019Abbreviations for conditions: H + S, hypnosis and suggestion;S, suggestion alone; R + S, relaxation and suggestion;C, control.means for these two groups on the in-sessionvariables are given in the upper portionof Table 8. Subjects who lost wartsreported significantly more vivid suggestedsensations than did those not losingwarts (F (1, 50) = 4.81, p < 0.05). Thesegroups failed to differ significantly on anyof the remaining in-session variables.Despite a nonsignificant mean difference,examination of the raw data indicatedthat subjects who lost warts and thosewho did not differed in their expectationsfor treatment success. Among the 12 treatedsubjects who lost warts, three (25%) reportedhigh expectations for success (scoresTABLE 8. Means for in-Session and Follow-upVariables for Treated Subjects Who Lost and DidNot Lose WartsIn sessionSensation vividnessAltered experienceRelaxationExpectationFollow-upCURSS:OCURSS:SSHSS:C/OSHSS:C/SBetts ImageryAbsorptionM41.7035.809.7713.603.1310.005.8813.6372.2528.25LostSD6.228.781.893.062.807.352.104.5313.187.61Did not loseM35.5729.4810.2911.262.746.034.7911.5070.5327.62SD8.2712.311.154.532.354.873.147.7914.966.31Psychosomatic Medicine 50:245-260 (1988) 255

N. SPANOS et al.of 8 or above) in at least one treatmentsession, and nine (75%) reported moderateexpectations (scores of 4-7). None of thesesubjects reported low expectations of successin either session (scores below 4). Onthe other hand, among the 45 treated subjectswho failed to lose warts, the correspondingfigures were 14 (31%) with highexpectations, 16 (36%) with with moderateexpectations, and 15 (33%) with lowexpectations. In other words, subjects wholost warts and those who did not lose wartswere about equally likely to hold high expectationsfor treatment success. However,subjects who held very low expectationsfor treatment success never lost anywarts. This pattern of findings may indicatethat suggestion-induced wart regressionis likely to occur only when subjectshold moderate-to-high expectations fortreatment success. However, positive expectations,in and of themselves, provideno assurance that a treatment effect willoccur.This pattern of findings is consistent withthe following hypothesis. Cognitive involvementin the suggested strategies facilitatesphysiological processes that leadto wart regression. Subjects with low expectationsfor treatment success are unlikelyto initiate or become involved in thesuggested strategies, and consequently, areunlikely to lose warts. Subjects who develophigh expectations for treatment successtend to lose warts if their high expectationslead them to become involvedin the suggested strategies. However, subjectswho cannot or will not develop suchinvolvements are unlikely to exhibit wartregression even when they hold relativelypositive expectations for treatment success.In order to test these ideas, we selectedthose subjects who held moderateor high expectations for treatment successbut did not lose warts (N = 30). Thesesubjects (M = 35.93, SD = 7.71) reportedsignificantly less vivid imagined sensationsthan did the 12 subjects who lost allwarts (all of whom reported moderate orhigh expectations and whose vividnessscores are given in Table 8 (t (40) = 1.93,p < 0.02 one-tailed). In other words, whensubjects who lost and did not lose wartswere equated for expectations, those wholost warts indicated higher involvement inthe suggestion (reported more vivid suggestedimagery) than those who did notlose warts.Post-follow-up VariablesThe bottom portion of Table 8 shows themeans on hypnotizability measures, Bettsimagery, and absorption for subjects wholost and did not lose warts. None of thesevariables differed significantly between thelost/did not lose groups.Side-specific Treatment EffectsRecall that in both experiments, subjectswith bilateral warts were given atreatment aimed at the warts on only onehand. In order to examine any selectiveeffect of the treatment on the target hand,we combined subjects from the two experimentswho a) had bilateral warts, b)received a treatment, and c) lost at leastone wart from either hand. Fifteen subjectsmet all of these criteria. Twelve of thesesubjects (seven hypnotic, five placebo) werefrom Experiment 1, and three subjects (twohypnotic, one suggestion only) were fromExperiment 2.Table 9 shows the number of warts eachof these subjects possessed at baseline onboth their treated and untreated hands, thenumber of warts lost from each hand, andthe percentage of warts lost from each hand.It is clear from this table that subjects tended256 Psychosomatic Medicine 50:245-260 (1988)

HYPNOSIS IN WART TREATMENTTABLE 9. Number of Warts and Number ofWarts Lost on Treated and Untreated HandsBaseline numberof wartsPost-test—number lost(percent lost)SS Treated Untreated Treated Untreated11238225415512223513122110122212523814 (36.4)2 (10.0)10 (26.3)1 (50)12 (48)7(17)1 (20)2 (40)1 (100)0(—)1 (50)2 (100)1 (33.3)0(—)1 (100)1 (4.5)2 (20)1 (50)0(—)2(100)1 (20)2 (100)2 (66.6)3 (37.5)1 (100)Ss 1-8 had more baseline warts on the treated hand. Ss9-15 had as many or more baseline warts on the untreatedas on the treated hand.to have more baseline warts on the treatedthan on the untreated hands. Consequently,any tendency for subjects to losemore warts on the treated rather than theuntreated hand might be due to baselinedifferences rather than treatment specificity.We addressed this issue by dividingthese 15 subjects into those with morebaseline warts on the treated hand (N = 8)and those with an equal number or fewerbaseline warts on the treated than the untreatedhand (N= 7).Subjects with more baseline warts onthe treated hand lost a significantly greaterpercentage of warts on the treated hand(M = 42.13, SD = 26.37) than on the untreatedhand (M = 9.25, SD = 17.85, F [1,7] = 8.71, p < 0.05). In fact, five of theseeight subjects (62.5%) lost warts exclusivelyon the treated hand, and none lostwarts exclusively on the untreated side.Taken in isolation, these findings wouldsuggest a strong side-specific treatment effect.However, in subjects who had at leastas many baseline warts on the untreatedas on the treated side, the "specificity effect"disappeared. For these seven subjects,there was no significant differencein the percentage of warts lost from thetreated hand (M = 54.76, SD = 45.86) orfrom the untreated hand (M = 60.71,SD = 41.89, F (1, 6) < 1). Moreover, onlyone of these subjects (14%) lost warts exclusivelyfrom the treated hand, while twoof them (28%) lost warts exclusively fromthe untreated hand.DISCUSSIONIn Experiment 2 hypnotic subjects andsubjects given the suggestion alone wereequally likely to lose warts, and more likelyto lose warts, than no-treatment controlsubjects. These findings are consistent witha large body of data that indicates that hypnoticand motivated nonhypnotic subjectsrespond similarly when they are administeredthe same suggestions (25). Morespecifically, these findings indicate thatneither an hypnotic induction procedurenor instructions for relaxation enhance theefficacy of suggestions at inducing wartregression. From a practical perspective,the equivalent outcomes in the hypnoticsuggestionand suggestion-alone conditionsindicate that therapists can offer psychologicaltreatment for warts without expendingthe extra time required to employhypnotic procedures, familiarize patientswith such procedures, divest patients offears and negative attitudes toward hypnosis,and so on.Neither hypnotizability nor attributemeasures of imagery propensity predictedwart regression in either experiment. Ex-Psychosomatic Medicine 50:245-260 (1988) 257

N. SPANOS et al.periment 2 employed two different scalesto assess behavioral and subjective indexesof hypnotizability, and two differentattribute measures of imaginal propensity.Consequently, the failure of these variablesto predict treatment outcome cannotbe attributed to properties or deficienciesunique to one particular index of hypnotizabilityor propensity for imagery. Morelikely, the failure of these indexes to predicttreatment outcome was related to theirlack of relevance to the treatment. Hypnotizabilityand imaginal propensity werealways assessed at the end of the study.Consequently, the constellation of situation-specificattitudes, expectations, andmotivations that influenced subjects' levelsof responding to these postexperimentallyadministered indexes was probablyvery different from the constellation ofmotives and attitudes that determined theirpsychological response to the treatmentsuggestion.Unlike the attribute indexes, subjects'ratings of suggested imagery vividnesscorrelated significantly with wart regression.Interestingly, ratings of relaxation andof general alterations in experiences failedto predict wart regression. Thus, the extentto which subjects employed their imageryskills in the treatment context, for the specificpurpose called for by the suggestion,predicted treatment outcome. On the otherhand, subjects' propensities to imagine incontexts other than the treatment session(indexed by the attribute questionnaires),their propensities to subjectively and behaviorallyenact hypnotic responses in acontext unrelated to the treatment, and theirlikelihood of experiencing psychologicaleffects that were not directly called for bythe suggestion (i.e., relaxation, generalizedalterations in experience), were simply irrelevantto treatment success. The findingthat degree of suggested imagery predictedtreatment outcome is open to at least twointerpretations. On the one hand, it maybe that imaginal processes are, for somereason, particularly important in initiatingor modulating the chain of physiologicalresponses that leads to wart regression. Alternatively,the important psychologicalvariable may not be imagery per se, butinstead subjects' degree of subjective involvementin a process that they considerto be therapeutic. In the present study, thesevariables were confounded. It would be ofinterest in a future study to compare animagery-suggestion treatment to some procedurethat encourages subjects' involvementin a wart-regression treatment thatdoes not involve generating wart-regressionimagery.The finding in Experiment 2, that expectationsfor treatment success failed topredict wart regression, contradicts thehypothesis that expectations of treatmentefficacy are the only important psychologicalfactors in the induction of wart regression(27). On the other hand, our findingthat subjects with low expectations fortreatment success never exhibited wartregression suggests that moderate-to-highexpectations of success may be necessarybut not sufficient for the production ofpsychologically induced wart regression.Psychologically induced wart regressionmay require the occurrence of cognitivefactors that are distinct from expectationsof treatment success, but that are more likelyto occur when subjects hold strong ratherthan weak expectations of success.The combined findings of our two experiments,like most earlier findings, (7-9, 13, 22), provided no evidence for theoccurrence of a side-specific suggestion effectin subjects with bilateral warts. Instead,our findings suggest that the resultsof the one study (18) that reported such aneffect may have been artifactual. In that258 Psychosomatic Medicine 50:245-260 (1988)

HYPNOSIS IN WART TREATMENTthe suggestion was directed. These find-ings are consistent with the hypotheses thata) psychological factors induce or facili-tate some set of systemic physiologicalprocesses that lead to wart regression, andb) large clusters of warts are more suscep-tible to the effects of these systemic pro-cesses than is a single or small number ofwarts,study (18), suggestions were always aimedat the side of the body with the most warts,Our subjects lost a significantly greaterpercentage of warts on the treated side whenthe treated side had more warts than theuntreated side to begin with. However,when the treated side had the same numberas or fewer warts than the untreatedside, the percentage of warts lost on eachside was unrelated to the side toward whichREFERENCES1. White DO, Fenner F: Medical Virology. New York, Academic Press, 19862. Allington HV: Review of the psychotherapy of warts. Arch Dermatol Syphilol 66:316-326,19523. Vollmer H: Treatment of warts by suggestion. Psychosom Med 8:138-142, 19464. Zwick KG: Hygiogenisis of warts disappearing without topical medication. Arch Dermatol Syphilol25:508-521, 19325. Ullman M: On the psyche and warts: I. Suggestion and warts, a review and comment. Psychosom Med21:473-488, 19596. Ullman M, Dudek S: On the psyche and warts: II. Hypnotic suggestion and warts. Psychosom Med22:68-76, 19607. Clarke GHV: The charming of warts. J Invest Dermatol 45:15-21, 19658. Stankler L: A critical assessment of the cure of warts by suggestion. Practitioner 198:690-694, 19679. Tenzel JH, Taylor RL: An evaluation of hypnosis and suggestion as treatment for warts. Psychosomatics10:252-257, 196910. Massing AM, Epstein WL: Natural history of warts. Arch Dermatol 87:306-310, 196311. Rulison RH: Warts, a statistical study of 921 cases. Arch Dermatol Syphilol 46:66-81, 194212. Memmesheimer AM, Eisenlohr E: Untersuchungen uber die suggestive behandlung der warzen. DermatolZeitchr 62:63-68, 193113. Surman OS, Gottlieb SK, Hackett TP, Silverberg EL: Hypnosis in the treatment of warts. Arch GenPsychiatry 28:439-441, 197314. Achterberg J: Imagery in healing. Boston, New Science Library, 198515. Barber TX: Changing "unchangeable" bodily processes by (hypnotic) suggestions: A new look at hypnosis,cognitions, imagining, and the mind-body problem. In Sheikh AA (ed), Imagination and Healing.New York, Baywood, 198416. Spanos NP, Radtke HL, Hodgins DC, Stam HJ, Bertrand LD: The Carleton University Responsivenessto Suggestion Scale: Normative data and psychometric properties. Psychol Rep 53:523-535, 198317. Asher R: Respectable hypnosis. Br Med J 1:309-313, 196518. Sinclair-Gieben AHC, Chalmers D: Evaluation of treatment of warts by hypnosis, Lancet 11:480-482,195919. Spanos NP, Hodgins DC, Stam HJ, Gwynn MI: Suffering for science: The effects of implicit socialdemands on response to experimentally induced pain. J Per Soc Psychol 46:1162-1172, 198420. Spanos NP, Kennedy SK, Gwynn MI: The moderating effect of contextual variables on the relationshipbetween hypnotic susceptibility and suggested analgesia. J Abnorm Psychol 53:523-535, 198421. Wadden T, Anderton CH: The clinical use of hypnosis. Psychol Bull 91:215-243, 198222. Johnson RFQ, Barber TX: Hypnosis, suggestion and warts: An experimental investigation implicatingthe importance of "believed in efficacy." Am J Clin Hypn 20:165-174, 1978Psychosomatic Medicine 50:245-260 (1988) 259

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