Monday, 28 January 2013

Pain management & Hypnotherapy

I recently attended a fascinating course on pain management, run by Hypnotherapist Clem Turner as part of my CPD (Continued Professional Development). This has lead me to investigate and read further on the subject.

Imagine the chain of events. You are in the street and someone sells you a charity badge, which (with clumsy fingers) they helpfully pin to your Jacket. Unfortunately as they work their clumsy fingers, they push the pin into your flesh. You experience pain.

“Bluggerax!” you shriek pushing them away.

What is pain? This sensation that has caused you to react so instantly?

In your flesh there are lots of little detectors, or nociceptors as they are known, and when stimulated by the pin they these send a signal at high speed along the neural pathway to the spinal chord. The signal is relayed up the spinal chord to a point in the thalamus, which is in the midbrain. Here the signal is processed and sent to an area at the top of the brain in the sensory cortex. This part of the brain defines the sensation as PAIN! And sends a signal to motor cortex which is conveniently close by. This part of the brain generates a signal that is sent back to the body and results in a response that is aimed at stopping that sensation. 

You push them away with sudden hand movements and shriek at them:

“Bluggerax! – Get off me you clummock!”

Further examination of the situation will show us that there are two types of nerve fibre involved. A and C Nerve fibres.

The A fibres are divided into three types , and . If the level of stimulation only activates the and you feel no pain. If, however the level of stimulation rises to a point when it activates the then Yabbles! That hurts! The stimulation of these nerves causes what we describe as sharp acute pain. If the C cell fibres are also stimulated you will experience a duller longer pain.

There are a bewildering number of ways that pain is measured. It’s difficult because of course there is an element of subjectivity about it all.

However there are a lot of ways of asking someone how much it hurts.

Maybe the most simple is the visual analogue scale:

As in please make a mark on the line that indicates the level of pain you are experiencing:
No pain------------------------------------------------------------------Worst possible pain

Or with numbers

As in please circle the number that corresponds to level of pain you are experiencing:
No pain   1  2  3  4  5   Worst possible pain.

Or circle a word that describes your pain:
None Moderate Severe Unbearable

However these methods of measuring pain don’t tell you an awful lot about the quality of the pain and are clearly subjective.

We all use words to describe pain such as “It’s a shooting pain” or It’s a “sharp” pain.
The marvelously named “Brief Pain Inventory” measures both the intensity of the pain and the way it interacts with a person’s whole life. For example how it interferes with work or mood. Originally it was developed by a group focusing on cancer pain, but now the BPI a commonly used pain assessment tool.

The multidimensional affect and pain survey (or MAPS) uses a staggering number of descriptors that describe the qualities of pain in a more nuanced way. These descriptions of pain are grouped into 30 “sub clusters” which are themselves grouped into three big groups called “super clusters”. (Someone enjoyed this form organization too much!)

The big super clusters are:
Sensory pain (includes descriptions like “burning”),

Emotional pain (Descriptions such as “depressed”),

Well being (descriptors like “calm”).

Interestingly using this tool it can be seen that people who anticipate greater pain and emotional distress before an operation actually consume more morphine postoperatively. This aspect of anticipated pain is clearly of great interest to me, as it can be acted on within hypnotherapy sessions.

As a research tool into pain some people were asked to keep a “pain diary”. How reliable are patients’ reports of past pain? In this research it has been seen that your memory of pain may not be very accurate. The memory of past pain, is in fact influenced by any present pain. However even more interestingly for me, as a Hypnotherapist, is the fact that memory of past pain is also influenced by present worry, anxiety, stress, and fear. This in turn may become a lens through which any future pain is anticipated. Thus making it terrifying to visit a dentist, or go to a doctor. 

One particular model of pain interests me a great deal: the  so called “three dimensions” of pain, described by In 1968 Ronald Melzack and Kenneth Casey. This model of pain proposes the following three aspects of pain:

“Sensory – discriminative” In other words the intensity, location and duration

“Affective – motivational” The unpleasantness – the power of the urge to get rid of the sensation.

“Cognitive – evaluative” Formed by an appraisal of the pain,  the cultural values and context surrounding the sensations.

You can see that these categories are very similar to the ones used by the MAPS as Super clusters.

What is interesting to me is that certainly the Cognitive / Evaluative aspects of pain can be influenced by hypnotherapy. 

To an extent it is also possible to lessen the Affective / Motivational dimension (the unpleasantness) of a sensation by using your mind to transform the sensation into another sensation; simply imagining that an ache is a hot sensation instead of an ache for example. 

With regard to the actual physical transmission of the sensation of pain (the sensory / discriminative) along the nerves to the brain there are many approaches within hypnotherapy that suggest that you can induce numbness; mostly well known of these approaches being so called “glove anesthesia” in which the clients hand becomes numb and may then be placed against another part of the body – a jaw for example, to lessen the sensation of tooth ache.

In 1983 Spiegel and Bloom worked with 54 women with chronic cancer pain from breast carcinoma. They put the women into two support groups. One group was taught self-hypnosis and the other was not. The group using hypnosis used suggestions such as “filtering out” pain by imagining other different sensations competing for supremacy on the sight of the pain. They  were also encouraged to use self hypnosis on their own. The study lasted 12 months. The group that had been taught to use hypnosis demonstrated significantly less pain and suffering than the control group.

In 2004 a similar piece of research was carried out. Elkins et al did a randomized study of 39 advanced-stage (Stage III or IV) cancer patients with malignant bone disease.  Again patients were randomly assigned to receive either weekly sessions of supportive attention,  or a hypnotic intervention. Patients assigned to hypnotherapeutic intervention received four sessions per week in which a hypnotic induction was followed a script. This included suggestions for relaxation, comfort, mental imagery for dissociation and pain control, and instruction in self-hypnosis.
 Thety were also given a recording and asked to listen to this outside the sessions. So it was quite an intense blast of hypnotherapy. The hypnotic group reported far less pain than the control group.

The human mind really is a huge warehouse of resources,

Sunday, 13 January 2013

What Is Anxiety?

What is Anxiety? It’s quite a slippery term. Used by many people in different ways. In general speech we mean unease or nervousness. Sometimes we can attach the feeling to a particular forthcoming event, and sometimes it is a more general feeling that is non specific and falls over us like a cloak. The word itself comes from the Latin anxius to choke, and I guess we have all experienced that particular grade of anxiety which tightens your throat. Very nasty.

Here’s an interesting thing, you can sometimes swap the word “anxious” with “eager”:

“I’m anxious to get to the station”
“I’m eager to get to the station”

“I’m anxious about the speech I have to give next Friday”
I’m eager to make that speech next Friday”

I think this points to the fact that anxiety and excitement are quite closely related emotions. For example stage fright is an interesting combination of anxiety and excitement.

Two people facing the same challenge may fall either side of the dividing line between the concepts. One person may feel principally eager to go on stage, whilst the other may feel principally anxious. In other words we may respond differently to stimuli in our lives. We are obviously meant to experience some anxiety in relation to certain events and occurrences; this is part of our survival system. In the presence of a tiger anxiety is a necessary and appropriate part of our flight or flight system.

Things get more complicated in the modern world as we experience anxiety in relation to things that appear to be threats. The site of your boss, going on a train journey, going to the bank; these may not really contain the level of threat that warrants high levels of anxiety. Nevertheless the mechanisms of the mind may perceive these things as “tigers”.

In fact there are 6 types of anxiety disorder (according to DSM-1V):
Generalised anxiety disorder
Obsessive Compulsive Disorder
Post Traumatic Stress Disorder
Acute Stress Disorder
Panic disorder

As you see, these are quite wide ranging and, from the point of view of a therapist, require quite different approaches. A certain amount of investigation is needed to decide which of these categories they might fall into, and therefore what might be the most appropriate approach for that particular person.

In Generalised Anxiety Disorder or GAD a person may be anxious about almost anything and everything, and this distress is inhibiting to normal life. People suffering from Generalised Anxiety Disorder may experience many symptoms that you might associate with fear; sweating, wanting to go to the loo, heart pumping, a dry mouth and much more.

There are many different ideas about the causes of GAD. What follows is my rather generalised idea of how it may be viewed through the lens of different theories.

Psychoanalytical theory, for example, may put forward the idea that the id and the ego are in conflict. The id is desperately trying to express itself in its sexual or aggressive ways, and the ego is trying to repress this unacceptable expression. This conflict causes anxiety. Remember I’m generalising here.

In Cognitive Behavioural Therapy, it may be proposed that reasons such as the perception of loss of control are at the root of the problem.

Learning theory considers that we learn to associate anxiety with bad things that have happened to us, so the sight of your boss may cause anxiety as your previous experience has shown you that you may be in trouble.

As a Hypnotherapist I might take the view that whatever the cause, the experience may well be linked to certain stimuli in your life. I would hope to try and build new and more suitable associations with that stimuli. Sometimes people may “catastrophise” an event or experience, where they kind of dramatise and magnify their experience. This is not done consciously, it is done at an unconscious lrvrl.

There are many approaches that a Hypnotherapist might take, and the approach will depend very much on the particular character and perceptions of the client.

I’m very interested in working with people with anxiety as I think it is quite a universal experience. In fact it was anxiety that lead me into hypnotherapy in the first place.

Here there is an important thing to say about my experience; I faced some quite horrid surgery, and felt extremely anxious about it. In trying to find answers I went to a Hypnotherapist. The truth is that I was still frightened and it still hurt, but I just had a couple things I could do in my head – even whilst being wheeled into the operating theatre. It really wasn’t a magic bullet, but it did help me deal with the reality I faced.