Applications of Hypnosis: Pain Management

1. Applications of Hypnosis: Pain Management • Linda Thomson, APRN, ABMH • Hypnovations III - Intermediate Workshop • Burlington, VT • April 2010

2. Objectives • Identify two hypnotic strategies that can be used in both acute and chronic pain • Restate the precautions for using hypnotic pain relief

3. Pain is an experience in the soul of the patient • Plato

4. Pain . . . “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” • Merskey, Bugduk, 1994

5. Pain is private and personal. It is subjectively experienced and includes both mental and emotional suffering and distressing physical sensations. • Kuttner

6. Pain Theories • Von Frey – Specificity Theory • Goldscheider – Pattern Theory • Melzack and Wall – Gate Control • Theory

7. PainNociception • Mechanical, thermal or chemical energy impinging on specialized nerve endings • Signals the CNS about the occurrence of an aversive event • Pain is the sensation that arises from nociception

8. Types of Pain • Nociceptive • Inflammatory • Neuropathic • Functional

9. Components of Pain • Sensory Pain – actual way the individual feels the pain • Suffering – amount of unpleasantness that occurs as a result of sensory pain

11. Pain, Suffering, Pain Behavior • Pain • Sensation that can arise from nociception • Suffering • Affective response to pain • Disruptions in work, relationships, activities, QOL • Pain Behavior • Actions that communicate suffering • Independent of nociception

12. Legal Definition – A Triad of Distress • Sensory Pain • Suffering • Mental Anguish – the global feeling of sadness, frustration and dependency which results

13. Pain FactsNUPRIN Pain Report, Sternbach (1986) • 75 Million Severe Pain • 50 Million Chronic • 25 Million Acute Injury • 45% Pop. Seek Care • 4 Billion Work Days Lost • 79 Billion Dollars in Lost Wages • Most Common Complaint to Health Providers

14. Hypnotic interventions for pain control began when the first mother kissed her child’s booboo and made it all better. • Franz Baumann

15. Humans have limited amount of conscious attention available • When involved in a hypnotic trance experience there are less cognitive resources available to devote to evaluation of nociceptive pain

16. There is an interplay of thoughts, beliefs, emotions and attitudes with the sensations occurring in the body that create the sensation of pain • This same interaction of mind and body enables us to increase or decrease pain

17. It is not simply mind over matter, but it is clear that mind matters. • David Spiegel • JAMA, 1999

18. Each component of pain can be modified by • The Hypnotic Experience • Rapport • Language • Responsivity • Heightened psychophysiologic control • Positive Expectancy is an essential ingredient

19. Factors affecting pain perception • Age and developmental stage • Previous experience with pain • Context of symptom, emotional significance of pain • Physical and emotional state • Culture • Gender and individual differences • Candy Erickson

20. Factors Affecting Efficacy of Hypnosis • Age and developmental stage • Previous experience with pain • Previous experience with hypnosis • Context of symptom, emotional significance of pain • Physical and emotional state • Culture • Gender and individual differences

21. Factors Affecting Efficacy of Hypnosis • Coping style – attender or avoider • Acceptability of hypnosis • Medication • Hypnotic susceptibility

22. Other Factors Affecting Efficacy of Hypnosis • Attitude of family toward symptom and hypnosis • Attitude of medical staff toward symptom and hypnosis • Therapist’s attitude toward symptom, belief in hypnosis, and skill

23. Physiologic markers of pain appear to persist even when a person feels no pain or decreased pain after hypnotic suggestionPerhaps pain is not being processed by cognitiveprocesses during hypnosis

24. Mechanism of Hypnotic Analgesia • Poorly understood • Pain activates the anterior cingulate cortex • Anger activates the anterior cingulate cortex • Hypnosis activates the anterior cingulate cortex • The same structure may both respond to pain and participate in pain control

25. “The evidence supporting the effectiveness of hypnosis in alleviating chronic pain is strong. In addition, hypnosis is effective for chronic pain in other conditions such as IBS and tension headache.” • NIH Technology Assessment Conference • JAMA 276:313 1996

26. Hypnosis for Pain Control • 1994 – IASP includes hypnosis in its curriculum for pain • 1996 – NIH acknowledges hypnosis as a viable and effective intervention for alleviating pain from cancer and other chronic pain

27. Physiology and Hypnosis • Sympathetic Nervous System Reduction • Reduced activity in somatosensory & limbic areas • (Hofbauer et al., 2001; Rainville et al., 1997; Price & Barrell, 2000 • Inhibition of spinal cord fibers • Analgesia suggestions (r) spinal R-III reflex • (Kiernan et al., 1995; Danziger et al., 1998) • Affective and Sensory reductions have been found with hypnosis and wording matters! • (Price et al., 1987; Rainville et al., 1999)

28. Acute Pain

29. Acute Pain • Commands attention • patient is already in a heightened state of awareness / intensely focused • Shocks you into being protective • Causes anxiety • Drains energy • Highly motivated to decrease pain

30. Emergency Room • Keep voice soothing and re-assuring • Talk to the patient even if he seems unconscious • Explain what is happening • Remind patient that the body knows what to do • Explain any puzzling sights or sounds • Minimize other sights and sounds • Wrap-up in a positive manner • Reframe

31. Modify the patient’s experience • REFRAME • Bright red, healthy blood • Beautiful tears • Strong lungs • Captures attention because it is unexpected • Offers positive suggestion about situation and outcome • Separate pain from hurt • Connect to the comforter

32. Modify the patient’s experience • PARADIGM SHIFT • From ‘out of control’ to ‘controlled’ • From ‘scary’ to ‘safe’ • From ‘sick’ to ‘mostly well’

33. Modify the patient’s experience • PACE AND LEAD • Join with the patient • Convey understanding of the situation • Recognize fixed attention • Capture attention

34. Acute Pain • Decreasing anxiety will decrease pain perception • Direct hands on • Quick induction • Suggestions guided by dissociative finger signals

35. Procedural Therapies • Brutaine • restraint by physical force • Narcotics • changes pain sensation • Sedatives • alters perception • Hypnosis • alters patient’s attention to and interpretation of pain

36. Perfect Rx for Procedures • Safe • Rapid Onset • Predictability • Ease of administration • Creates analgesia and amnesia

37. Hypnosis for Procedures • Safe • Ease of administration • Creates analgesia and amnesia • Gives patient skills instead of pills • Promotes self-mastery, self-efficacy and self-esteem

38. The Language of Healing • How you talk is as important as what you say • Acknowledge and ask about pain • “You are in a lot of pain right now and we are going to help you become alot more comfortable” • Having the patient describe the discomfort helps to compartmentalize it • Don’t underestimate the power of listening • Kohen

39. The Language of Healing • As much as possible allow the patient to set the pace • Frame the patient’s discomfort with hope, not doom • Note the parts of the body that aren’t in pain • Avoid words that conjure up fear • Kohen

40. The Language of Healing • Reframe the patient’s distress • Replace pain loaded words • Pain - - discomfort - - bothered • Attack - - episode - - event • Use language that implies positive change • You may be surprised how fast you start feeling better • Kohen

41. I know you want to scream because you can scream as loud as you want till you are all done and don’t need the scream any more and it doesn’t bother you

42. The Language of Healing • Use words of encouragement and reassurance • “You are doing this very well” • When possible let patient know that what they are experiencing is normal, not life-threatening or the result of some terrible disease • Remind patient that pain will come to an end • Kohen

43. Procedural Hypnosis • Pain is usually predictable • Anxiety is enhanced by environmental cues • Identify threat • Determine environmental cues

44. Procedural Hypnosis • Induction with deep relaxation • Anchor suggestions to threatening cues with post-hypnotic suggestion • When you feel _____, then ________

45. Chronic Pain

46. Chronic Pain • Persists beyond its initial useful or protective function • lasts more than 3 - 6 months • More disabling • Negative expectancy • Possibility of secondary gain

47. Conditioning and Chronic Pain

48. Chronic Pain • Anxiety and despair magnify perception of pain • psychological distress in absence of nocioceptive pain • Somatic Preoccupation - becomes part of person’s life • Illness Conviction - hope is replaced by despair and thoughts that it will never go away

49. Chronic Pain • Negative expectancy • when pain starts - it worsens; when it leaves - it returns • Illness Behavior is reinforced • Deactivation - guarding and pacing

50. Some Types of Chronic (non-malignant) Pain • Headache -- migraine, cluster, tension-type • Orofacial Pain -- trigeminal neuralgia, pulpitis, dental pain, atypical facial pain • Anatomic Locational Pain -- neck, shoulder, elbow, chest wall, knee, abdomen • Back Pain • Chronic pelvic pain • Interstitial Cystitis • Arthritis -- OA and RA • Fibromyalgia • Myofascial Pain • Neuropathic Pain • Postherpetic Neuralgia • AIDS-related Pain