I just had a surprising conversation with my class today-my last time meeting with first-year students at the university-about globalization, ASEAN, and their role as future leaders of Thailand. They were intelligent, cogent, engaged, and thougtful! I felt that maybe perhaps our conversation may in some way be one tiny wiggle toward social progress. Teaching this class (Global Society and Living) in the context of a country where a sizable portion of the "developed world" procures cheap labor has been thought-provoking in many ways. It has been fun to pose and examine questions pertaining to the true meaning of development," but when I move to kindergarten next week, can I inspire the same sorts of dialogue through fingerpaint and nap times?
Perhaps my friend is right-I need a juice box to think it over.
Wednesday, April 25, 2012
Sunday, June 17, 2007
Friday, May 25, 2007
It's almost finished!
I couldn't waste this. I had to distil the soul from my paper, and I'm left with several thoughts that I would feel bad just tossing--it would be like what happened to those tasty tortillas that wound up in the Trader Jo's dumpster...
well, here's my thought for the day!
The secret of our cognition is the heart of all that is transcendent and mysterious in our universe. Throughout the course of history, the study of the mind has often left us more dazzled. The more we search for the very threads that tie our existence together, the more tangled we find the knot to be. Although complexity may be married to the essence of existence, the core of human nature can never cease in its attempts to explore and understand.
well, here's my thought for the day!
The secret of our cognition is the heart of all that is transcendent and mysterious in our universe. Throughout the course of history, the study of the mind has often left us more dazzled. The more we search for the very threads that tie our existence together, the more tangled we find the knot to be. Although complexity may be married to the essence of existence, the core of human nature can never cease in its attempts to explore and understand.
Friday, May 11, 2007
Part II
Physiology of chronic pain
After a lifetime of experiencing pain, and over a year of studying, contemplating, and reading about pain, I am afraid that I can speak of all that is involved in this phenomenon about as well as a baby can make babbling sounds in an attempt to speak its native language. The historically held specificity theory of pain is straightforward: a noxious stimulus evokes a threshold potential in a nociceptor, or pain cell, which then sends the signal of pain to the brain by way of the spinal cord. The signal is processed in the pain center, and voila, the organism is enlightened with a perception of pain! The organism is now equipped to react accordingly.
In real life, pain cannot be understood this simply. Elements of one’s surrounding environment, state of mind, level of physiological arousal, and history of injury are just a few examples of how the experience of pain can be affected. Imagine that on a sunny afternoon you are playing an intense game of Ultimate Frisbee and you are guarding an opponent who is on the offensive team. While you are intent on keeping the Frisbee away from her, you watch the disk sail straight for your head. In your excitement for keeping it away from the enemy, you barely notice the impact. The next morning you see the tender, bulging welt on your forehead and you can only faintly remember the heroic maneuvers that resulted in this mark. Now consider an instance when you are walking outside with one of your friends on a cold and dreary evening. You are deeply engaged in an important conversation when a Frisbee flies out of the periphery and smacks you in the forehead. The rest of the evening, you are plagued with a splitting headache, and you do not stop whining about the bump on your head for a week. The injury is the same in both situations, but the perception of the pain in each is dramatically different. The intervening variables that affect the perception of pain in these two situations are fairly obvious, but what exactly lies at the root of such a difference? The former examples are illuminating enough to realize that there is much more to pain than the specificity theory can explain.
Yet, it is important to have a basic knowledge of the physiology behind pain in order to understand how hypnosis might be effective in providing relief. In their work, The Challenge of Pain, Ronald Melzack and Patrick Wall continually discourage the reader from holding a simplistic theory of pain sensation and perception. They write, “…we have learned to recognize that chronic pain rarely has not a single cause but is instead the result of multiple, interacting causes (1983).” This theme of complexity resonates through their entire work and becomes amplified throughout the vast, global research body addressing pain. From the seemingly endless investigations into complex second-messenger and signaling mechanisms which cause an overwhelmingly and insufficiently understood array of effects at the cellular level (Purves, 2004) to the theorizing about overarching, cognitive psychological constructs, understanding the mechanisms of pain becomes less and less simplistic with each new day of scientific progress.
Loeser and Melzack (1999) explain that there are four components of pain. The first is known as “nociception,” or the detection of tissue damage that is transmitted as a nerve impulse by nociceptors to the central nervous system. The second component is the perception of pain which is often the result of injury. However perception of pain is not necessarily preceded by nociception, as is the case with many patients who suffer from chronic pain. Additionally, some amputees experience excruciating phantom limb pain despite the obvious lack of pain--sensing cells that were once on the missing limb. The third component of pain is the negative, affective response which is known as “suffering”. This occurs in conjunction with a threat to one’s physiological or psychological state of balance due to the pain. Finally pain behaviors constitute the fourth aspect of pain. These can be described as any behavior demonstrated as a response to the injurious stimulus. While example of the Frisbee injury involves these four components of pain, it only covers two of the three types of pain specified by Loeser and Melzack. In this instance, transient, or the short-lived pain intended to warn, occurs as the Frisbee hits your head. Such acute pain is the result of tissue damage and continues as the body heals—the pain from the nasty bruise on your forehead would be classified as acute pain. Although such commonplace instances of pain are helpful in providing an overall understanding of the subject, they represent a limited view of how complex the problem of pain, especially chronic pain can be.
In the 1960s Melzack and Wall began developing the gate-control theory of pain answer to the commonly held and overly simplistic specificity theory of pain. “Basically,” they explain, “the theory proposes that a neural mechanism in the dorsal horns of the spinal cord acts like a gate which can increase or decrease the flow of nerve impulses from peripheral fibres to the central nervous system. Somatic input is therefore subjected to the modulating influence of the gate before it evokes pain perception and response (1982).” In other words, in this model of pain, inhibitory and excitatory impulses from an array of neurons, of variable axon width and degrees of myelination, stemming from the injured site summate in the dorsal horns of the spinal cord. The neurons that converge at this theoretical gate proceed not only from the site of injury, but also from efferent pathways running from the brain. Upon reaching or exceeding a threshold, the neurons in the dorsal horn activate the chain of events, called the “action system,” concurrent with tissue damage. Aware of how complex cases of pain can be, Melzack and Wall (1982) are careful to describe this system as follows: “Pain, as we have seen, does not consist of a single ring of the appropriate central bell, but is an ongoing process comprising a sequence of responses by the action system, beginning with a series of reflex responses and continuing with complex strategies to terminate the pain.” It is through this understanding of pain signal propagation that there can be theoretical room for the modulation of the signal in any number of ways before it becomes a perception of pain.
It is now widely understood that discriminative pain information, “location, intensity, and quality,” ascends to the brain by way of the anterolateral system (Fig. 1) (Purves, 2004). This pathway begins in the dorsal horns of the spinal cord (at Melzack and Wall’s pain gate) and projects to brain structures that are involved in pain sensation such as the thalamus and the primary somatic sensory cortex. The affective-motivational pain pathway sends pain signals along a similar route as the anterolateral system. However, the affective-motivational pain pathway targets structures such as the reticular formation, amygdala, and hypothalamus which are involved in evoking an aversive perception of the pain. Additionally, it is known that structures in the brain such as the somatic sensory cortex, amygdala, hypothalamus, and other mid to lower brain ganglia can send modulatory signals to the afferent pain pathways (Purves, 9.7, Fig. 2?).
Over the last half century, the gate-control theory of pain served its purpose very well. Melzack and Wall (1982) write:
The major impact of the gate-control theory, initially, was to free the field of pain from the straitjacket of specificity theory...Psychologists suddenly found a model which placed psychological observations and techniques in the mainstream of pain research. Physiologists began to explore regions of the spinal cord and brain that were previously held to play no role in pain and discovered complex mechanisms and relationships that were hitherto unsuspected. The transmission of pain signals to the brain was no longer restricted to a single pathway and it became possible to speculate on the functional relations among different ascending and descending systems.
The authors of Neuroscience confirm the success of the gate theory, stating that it “stimulated a great deal of work on pain modulation and has emphasized the importance of synaptic interactions within the dorsal horn for modulating the perception of pain intensity. (Purves, 2004)” Even a standard anatomy and physiology book pays homage to the theory: “it fostered a generation of valuable research (Marieb, 2004).”
Despite the fecundity of the gate control theory Melzack is perhaps the first to agree that recent discoveries, birthed out of the very climate of pain research brought about by this theory, warrant yet another reviion of our pain model. Melzack courageously writes, “…as historians of science have pointed out, good theories are instrumental in producing facts that eventually require a new theory to incorporate them. And this is what has happened (Melzack, 2005).” From this statement, Melzack continues to propose his “neuromatrix” theory of pain which attempts to incorporate the knowledge we now have regarding the workings of the brain while keeping in mind the gate theory and what we already understand about pain processing in the periphery and spinal cord.
We understand that patients, such as amputees, can perceive pain despite the absence of a stimulus where the pain is “felt”. It therefore follows that there is a mechanism in the brain itself that can independently account for the perception of pain. The neuromatrix theory suggests that the circuitry of our brain is such that our brains have an individual electrochemical pattern that arises from a network of circularly interconnected brain structures. Melzack (2004)
After a lifetime of experiencing pain, and over a year of studying, contemplating, and reading about pain, I am afraid that I can speak of all that is involved in this phenomenon about as well as a baby can make babbling sounds in an attempt to speak its native language. The historically held specificity theory of pain is straightforward: a noxious stimulus evokes a threshold potential in a nociceptor, or pain cell, which then sends the signal of pain to the brain by way of the spinal cord. The signal is processed in the pain center, and voila, the organism is enlightened with a perception of pain! The organism is now equipped to react accordingly.
In real life, pain cannot be understood this simply. Elements of one’s surrounding environment, state of mind, level of physiological arousal, and history of injury are just a few examples of how the experience of pain can be affected. Imagine that on a sunny afternoon you are playing an intense game of Ultimate Frisbee and you are guarding an opponent who is on the offensive team. While you are intent on keeping the Frisbee away from her, you watch the disk sail straight for your head. In your excitement for keeping it away from the enemy, you barely notice the impact. The next morning you see the tender, bulging welt on your forehead and you can only faintly remember the heroic maneuvers that resulted in this mark. Now consider an instance when you are walking outside with one of your friends on a cold and dreary evening. You are deeply engaged in an important conversation when a Frisbee flies out of the periphery and smacks you in the forehead. The rest of the evening, you are plagued with a splitting headache, and you do not stop whining about the bump on your head for a week. The injury is the same in both situations, but the perception of the pain in each is dramatically different. The intervening variables that affect the perception of pain in these two situations are fairly obvious, but what exactly lies at the root of such a difference? The former examples are illuminating enough to realize that there is much more to pain than the specificity theory can explain.
Yet, it is important to have a basic knowledge of the physiology behind pain in order to understand how hypnosis might be effective in providing relief. In their work, The Challenge of Pain, Ronald Melzack and Patrick Wall continually discourage the reader from holding a simplistic theory of pain sensation and perception. They write, “…we have learned to recognize that chronic pain rarely has not a single cause but is instead the result of multiple, interacting causes (1983).” This theme of complexity resonates through their entire work and becomes amplified throughout the vast, global research body addressing pain. From the seemingly endless investigations into complex second-messenger and signaling mechanisms which cause an overwhelmingly and insufficiently understood array of effects at the cellular level (Purves, 2004) to the theorizing about overarching, cognitive psychological constructs, understanding the mechanisms of pain becomes less and less simplistic with each new day of scientific progress.
Loeser and Melzack (1999) explain that there are four components of pain. The first is known as “nociception,” or the detection of tissue damage that is transmitted as a nerve impulse by nociceptors to the central nervous system. The second component is the perception of pain which is often the result of injury. However perception of pain is not necessarily preceded by nociception, as is the case with many patients who suffer from chronic pain. Additionally, some amputees experience excruciating phantom limb pain despite the obvious lack of pain--sensing cells that were once on the missing limb. The third component of pain is the negative, affective response which is known as “suffering”. This occurs in conjunction with a threat to one’s physiological or psychological state of balance due to the pain. Finally pain behaviors constitute the fourth aspect of pain. These can be described as any behavior demonstrated as a response to the injurious stimulus. While example of the Frisbee injury involves these four components of pain, it only covers two of the three types of pain specified by Loeser and Melzack. In this instance, transient, or the short-lived pain intended to warn, occurs as the Frisbee hits your head. Such acute pain is the result of tissue damage and continues as the body heals—the pain from the nasty bruise on your forehead would be classified as acute pain. Although such commonplace instances of pain are helpful in providing an overall understanding of the subject, they represent a limited view of how complex the problem of pain, especially chronic pain can be.
In the 1960s Melzack and Wall began developing the gate-control theory of pain answer to the commonly held and overly simplistic specificity theory of pain. “Basically,” they explain, “the theory proposes that a neural mechanism in the dorsal horns of the spinal cord acts like a gate which can increase or decrease the flow of nerve impulses from peripheral fibres to the central nervous system. Somatic input is therefore subjected to the modulating influence of the gate before it evokes pain perception and response (1982).” In other words, in this model of pain, inhibitory and excitatory impulses from an array of neurons, of variable axon width and degrees of myelination, stemming from the injured site summate in the dorsal horns of the spinal cord. The neurons that converge at this theoretical gate proceed not only from the site of injury, but also from efferent pathways running from the brain. Upon reaching or exceeding a threshold, the neurons in the dorsal horn activate the chain of events, called the “action system,” concurrent with tissue damage. Aware of how complex cases of pain can be, Melzack and Wall (1982) are careful to describe this system as follows: “Pain, as we have seen, does not consist of a single ring of the appropriate central bell, but is an ongoing process comprising a sequence of responses by the action system, beginning with a series of reflex responses and continuing with complex strategies to terminate the pain.” It is through this understanding of pain signal propagation that there can be theoretical room for the modulation of the signal in any number of ways before it becomes a perception of pain.
It is now widely understood that discriminative pain information, “location, intensity, and quality,” ascends to the brain by way of the anterolateral system (Fig. 1) (Purves, 2004). This pathway begins in the dorsal horns of the spinal cord (at Melzack and Wall’s pain gate) and projects to brain structures that are involved in pain sensation such as the thalamus and the primary somatic sensory cortex. The affective-motivational pain pathway sends pain signals along a similar route as the anterolateral system. However, the affective-motivational pain pathway targets structures such as the reticular formation, amygdala, and hypothalamus which are involved in evoking an aversive perception of the pain. Additionally, it is known that structures in the brain such as the somatic sensory cortex, amygdala, hypothalamus, and other mid to lower brain ganglia can send modulatory signals to the afferent pain pathways (Purves, 9.7, Fig. 2?).
Over the last half century, the gate-control theory of pain served its purpose very well. Melzack and Wall (1982) write:
The major impact of the gate-control theory, initially, was to free the field of pain from the straitjacket of specificity theory...Psychologists suddenly found a model which placed psychological observations and techniques in the mainstream of pain research. Physiologists began to explore regions of the spinal cord and brain that were previously held to play no role in pain and discovered complex mechanisms and relationships that were hitherto unsuspected. The transmission of pain signals to the brain was no longer restricted to a single pathway and it became possible to speculate on the functional relations among different ascending and descending systems.
The authors of Neuroscience confirm the success of the gate theory, stating that it “stimulated a great deal of work on pain modulation and has emphasized the importance of synaptic interactions within the dorsal horn for modulating the perception of pain intensity. (Purves, 2004)” Even a standard anatomy and physiology book pays homage to the theory: “it fostered a generation of valuable research (Marieb, 2004).”
Despite the fecundity of the gate control theory Melzack is perhaps the first to agree that recent discoveries, birthed out of the very climate of pain research brought about by this theory, warrant yet another reviion of our pain model. Melzack courageously writes, “…as historians of science have pointed out, good theories are instrumental in producing facts that eventually require a new theory to incorporate them. And this is what has happened (Melzack, 2005).” From this statement, Melzack continues to propose his “neuromatrix” theory of pain which attempts to incorporate the knowledge we now have regarding the workings of the brain while keeping in mind the gate theory and what we already understand about pain processing in the periphery and spinal cord.
We understand that patients, such as amputees, can perceive pain despite the absence of a stimulus where the pain is “felt”. It therefore follows that there is a mechanism in the brain itself that can independently account for the perception of pain. The neuromatrix theory suggests that the circuitry of our brain is such that our brains have an individual electrochemical pattern that arises from a network of circularly interconnected brain structures. Melzack (2004)
the first installment
I wonder how much I can post!
Introduction
Mrs. E suffered from terminal breast cancer that had metastasized into the bone of her right arm and hand. She described the pain in her arm as “terrible,” and reported that on most days the pain forced her to take codeine every three to four hours, and it was then only effective in taking off the edge. Her constant pain was a perpetual reminder of her terminal illness. Left in this state, Mrs. E was unable to truly live during what she knew to be her last months of life. She was depressed and unable to enjoy even the simple things that had previously filled her life, like her family and friends, reading, or relaxing at the beach.
Mrs. E was referred to Dr. Ernest Hilgard for therapy involving hypnosis. Once induced into a state of hypnosis using imagery related to her positive experiences at the ocean, she was able to use the suggested analgesic technique to completely remove the pain in her arm. Before being instructed to wake from hypnosis, Mrs. E was told that she would retain a mild discomfort in her right arm—just enough to serve as a warning not to overdo any activity. In addition, she was instructed that she would retain the freeing and pleasant feelings associated with her idyllic time at the beach.
For the remainder of that day, she reported not needing any more codeine; in fact, after this point, an overall reduction in usage of pain medication continued. As treatment continued, Mrs. E was also taught a suggestion technique that helped her sleep through the night. Although Mrs. E eventually passed away, her therapy not only helped to reduce the pain in her arm, it greatly improved her overall quality of life.
Dr. Ernest Hilgard (1975) writes about Mrs. E:
At the time of the first contact, Mrs. E was clearly depressed not only by her pain but also by anxiety over the implications of her illness. Anxiety and pain are inextricably woven together in the problems faced by such a patient; at times the anxiety can be more severe than the pain of the disease itself…The patient was seen a total of seven times during a month. On each occasion, suggestions of relaxation and comfort of mind were stressed: how valuable it was to be able to exert more control over a part of her life, over the pain, and over the insomnia. Judging from the patient’s statements, from her cheerfulness, and from a positive shift in the tests of her mood at the laboratory, her mental state had improved markedly. She spent less time thinking of herself, and instead spent more time reading and enjoying the company of family members and friends.
Hilgard and Hilgard (1975) discussed the use of hypnosis in the clinical setting and the promise of experimental research. They write, “Our hope is that because we have preserved scientific integrity and caution, members of the medical and psychological profession…will find a considered statement of the role of hypnosis in relation to pain” (viii-ix). Our culture demands empirical evidence. Therefore, considering the 30-year-old contributions from researchers such as Hilgard, I wonder why it is that the general populous remains only familiar, by and large, with the sensational use of hypnosis as an entertaining novelty.
Stories and rumors surrounding the practice of hypnosis commonly induce curiosity and skepticism, but I have heard of observed hypnosis as a viable option for clinical therapy. My previous exposure to the practice of “hypnotherapy” was limited to neon signs advertising “licensed” hypnotherapists who worked in the same seedy buildings as the local Tarot card reader. Skepticism about hypnosis may be inherent to any sort of study peering into the depths of our mind. The secret of our cognition is the heart of all that is transcendent and mysterious in our universe. Throughout the course of history, the study of the mind has often left us more dazzled. The more we search for the very threads that tie our existence together, the more tangled we find the knot to be. Although complexity may be married to the essence of existence, the core of human nature can never cease in its attempts to explore and understand.
This never-ending puzzle, whereby an increase in complexity evokes more curiosity, which in turn uncovers more complexity, may seem antithetical toward reaching any sort of answers. It is foolish to ignore complexity in an attempt to achieve parsimony, yet it is just as disastrous to refuse grounding in perspective by wallowing in an overwhelming web of detail and intricacy. The problem of pain is no exception to this epistemic conundrum. On one hand, the nature of pain is extremely complicated. In any given painful experience, even if the cause of pain can be determined, the pain cannot be considered as an isolated event. The experience and implications of even simplest of all painful experiences, imagine a paper cut for instance, is affected by the surrounding circumstances. The function of pain is widely known to be of survival value. Pain is therefore necessarily…painful—it relentlessly grabs all of our attention with an unwavering grip and will not let us rest without relief. It is no wonder that psychological intervention may be necessary for treating patients who are chronically impaired by this mechanism designed for survival. Skidmore (2004) writes, “It has been my experience that pain chronicity—the longer a patient has to struggle with pain—increases the likelihood that a patient may require psychological services to assist with emotional distress and relationship problems, and/or readjustment to work and life goals.” As we have seen with Mrs. E, the pain served as a woeful reminder of her cancer and fueled her depression. Yet it is this extremely overwhelming tangled mess of comorbid physical and psychological issues around pain control that begs for answers, cures, and relief. If we stop our attempts to untie the knot of pain, we tie the noose on hope.
It is from this frame of reference that I set out to explore the empirical efficacy of hypnotherapy, specifically in the context of the treatment of chronic pain. It did not take long to discover that it has indeed met with a fair amount of success within the clinical disciplines. In reference to the previous work of Crasilneck & Hall, Robinson, Crasilneck and Garofalo (2006) write, “hypnosis is a frequently misunderstood technique that has been shown to be safe and effective in addressing a number of physical and psychosocial disorders, including acute pain, chronic pain, smoking cessation, and obesity” (2006). In a clinical study of 30 patients with disabilities, it was found after 10 sessions of hypnotherapy, through the duration of a post-treatment window, the reduction of pain severity was mild to moderate in over half of the patients (Jensen, Hanley and Engel, 2005). In a more recent study reviewing the effects of hypnotherapy, Jensen, McArthur, & Barber did not find a distinct, common effect, but reported that patients experienced “a variety of both symptom-related and nonsymptom-related benefits…including decreased pain, increased perceived control over pain, increased sense of relaxation and well-being, and decreased perceived stress” (2006).
Empirically based acceptance of hypnosis as a clinically proven method of managing pain remains in its relative infancy. After citing the work of Higard and Hilgard from 1975, Patterson and Jensen write, “relatively few randomized clinical studies on hypnotic analgesia have been published, and the extant reviews of this literature, although making important contributions to the understanding of hypnotic analgesia are limited (2003).” In answer to this disappointingly limited body of clinical literature, the researchers proceed to carry out the task of thoroughly and critically examining the few randomized clinical studies that do address the question of efficacy of hypnotic analgesia in both chronic and acute pain arenas. The researchers found hypnosis to be beneficial in reducing pain for patients in both acute and chronic pain conditions. These results are also confirmed by Hawkins (2001). However, while hypnosis was found to be significantly more analgesic than other psychological treatments (such as relaxation techniques and biofeedback) with acute pain, this was not the case for chronic pain (2003).
By no means is hypnosis a miracle cure for pain; its effectiveness is in fact variable from person to person—likely due at least in part to factors such as hypnotic susceptibility and the degree to which a patient predicts the success of the treatment (Patterson & Jenson, 2003). However, there is no doubt that hypnotherapy has proved beneficial in reducing pain for chronic sufferers to at least some extent.
Endless research could be performed in an attempt to pin down a profile for the predicted efficacy of hypnotherapy for patients of varying hypnotic susceptibility indices and degrees of experienced chronic pain, etc. However, since I am satisfied with evidence for the value attributed to hypnosis, I would rather narrow the scope of my research to exploring how hypnosis is effective. Perhaps I am just the glib product of Aristotelian causality, but I cannot help asking what portion of our brain might be responsible for the alleviatory effects of hypnosis on chronic pain. It seems plausible that a neurological mechanism be at hand that would allow a patient in a trance state to interrupt, or at least affect, the pain signal. After all, the perception of pain only exists in one’s mind. Might we capitalize on the ability to trick the mind into stopping this perception? As discussed earlier, relief is not obviously this simple, but I want to better understand why.
Introduction
Mrs. E suffered from terminal breast cancer that had metastasized into the bone of her right arm and hand. She described the pain in her arm as “terrible,” and reported that on most days the pain forced her to take codeine every three to four hours, and it was then only effective in taking off the edge. Her constant pain was a perpetual reminder of her terminal illness. Left in this state, Mrs. E was unable to truly live during what she knew to be her last months of life. She was depressed and unable to enjoy even the simple things that had previously filled her life, like her family and friends, reading, or relaxing at the beach.
Mrs. E was referred to Dr. Ernest Hilgard for therapy involving hypnosis. Once induced into a state of hypnosis using imagery related to her positive experiences at the ocean, she was able to use the suggested analgesic technique to completely remove the pain in her arm. Before being instructed to wake from hypnosis, Mrs. E was told that she would retain a mild discomfort in her right arm—just enough to serve as a warning not to overdo any activity. In addition, she was instructed that she would retain the freeing and pleasant feelings associated with her idyllic time at the beach.
For the remainder of that day, she reported not needing any more codeine; in fact, after this point, an overall reduction in usage of pain medication continued. As treatment continued, Mrs. E was also taught a suggestion technique that helped her sleep through the night. Although Mrs. E eventually passed away, her therapy not only helped to reduce the pain in her arm, it greatly improved her overall quality of life.
Dr. Ernest Hilgard (1975) writes about Mrs. E:
At the time of the first contact, Mrs. E was clearly depressed not only by her pain but also by anxiety over the implications of her illness. Anxiety and pain are inextricably woven together in the problems faced by such a patient; at times the anxiety can be more severe than the pain of the disease itself…The patient was seen a total of seven times during a month. On each occasion, suggestions of relaxation and comfort of mind were stressed: how valuable it was to be able to exert more control over a part of her life, over the pain, and over the insomnia. Judging from the patient’s statements, from her cheerfulness, and from a positive shift in the tests of her mood at the laboratory, her mental state had improved markedly. She spent less time thinking of herself, and instead spent more time reading and enjoying the company of family members and friends.
Hilgard and Hilgard (1975) discussed the use of hypnosis in the clinical setting and the promise of experimental research. They write, “Our hope is that because we have preserved scientific integrity and caution, members of the medical and psychological profession…will find a considered statement of the role of hypnosis in relation to pain” (viii-ix). Our culture demands empirical evidence. Therefore, considering the 30-year-old contributions from researchers such as Hilgard, I wonder why it is that the general populous remains only familiar, by and large, with the sensational use of hypnosis as an entertaining novelty.
Stories and rumors surrounding the practice of hypnosis commonly induce curiosity and skepticism, but I have heard of observed hypnosis as a viable option for clinical therapy. My previous exposure to the practice of “hypnotherapy” was limited to neon signs advertising “licensed” hypnotherapists who worked in the same seedy buildings as the local Tarot card reader. Skepticism about hypnosis may be inherent to any sort of study peering into the depths of our mind. The secret of our cognition is the heart of all that is transcendent and mysterious in our universe. Throughout the course of history, the study of the mind has often left us more dazzled. The more we search for the very threads that tie our existence together, the more tangled we find the knot to be. Although complexity may be married to the essence of existence, the core of human nature can never cease in its attempts to explore and understand.
This never-ending puzzle, whereby an increase in complexity evokes more curiosity, which in turn uncovers more complexity, may seem antithetical toward reaching any sort of answers. It is foolish to ignore complexity in an attempt to achieve parsimony, yet it is just as disastrous to refuse grounding in perspective by wallowing in an overwhelming web of detail and intricacy. The problem of pain is no exception to this epistemic conundrum. On one hand, the nature of pain is extremely complicated. In any given painful experience, even if the cause of pain can be determined, the pain cannot be considered as an isolated event. The experience and implications of even simplest of all painful experiences, imagine a paper cut for instance, is affected by the surrounding circumstances. The function of pain is widely known to be of survival value. Pain is therefore necessarily…painful—it relentlessly grabs all of our attention with an unwavering grip and will not let us rest without relief. It is no wonder that psychological intervention may be necessary for treating patients who are chronically impaired by this mechanism designed for survival. Skidmore (2004) writes, “It has been my experience that pain chronicity—the longer a patient has to struggle with pain—increases the likelihood that a patient may require psychological services to assist with emotional distress and relationship problems, and/or readjustment to work and life goals.” As we have seen with Mrs. E, the pain served as a woeful reminder of her cancer and fueled her depression. Yet it is this extremely overwhelming tangled mess of comorbid physical and psychological issues around pain control that begs for answers, cures, and relief. If we stop our attempts to untie the knot of pain, we tie the noose on hope.
It is from this frame of reference that I set out to explore the empirical efficacy of hypnotherapy, specifically in the context of the treatment of chronic pain. It did not take long to discover that it has indeed met with a fair amount of success within the clinical disciplines. In reference to the previous work of Crasilneck & Hall, Robinson, Crasilneck and Garofalo (2006) write, “hypnosis is a frequently misunderstood technique that has been shown to be safe and effective in addressing a number of physical and psychosocial disorders, including acute pain, chronic pain, smoking cessation, and obesity” (2006). In a clinical study of 30 patients with disabilities, it was found after 10 sessions of hypnotherapy, through the duration of a post-treatment window, the reduction of pain severity was mild to moderate in over half of the patients (Jensen, Hanley and Engel, 2005). In a more recent study reviewing the effects of hypnotherapy, Jensen, McArthur, & Barber did not find a distinct, common effect, but reported that patients experienced “a variety of both symptom-related and nonsymptom-related benefits…including decreased pain, increased perceived control over pain, increased sense of relaxation and well-being, and decreased perceived stress” (2006).
Empirically based acceptance of hypnosis as a clinically proven method of managing pain remains in its relative infancy. After citing the work of Higard and Hilgard from 1975, Patterson and Jensen write, “relatively few randomized clinical studies on hypnotic analgesia have been published, and the extant reviews of this literature, although making important contributions to the understanding of hypnotic analgesia are limited (2003).” In answer to this disappointingly limited body of clinical literature, the researchers proceed to carry out the task of thoroughly and critically examining the few randomized clinical studies that do address the question of efficacy of hypnotic analgesia in both chronic and acute pain arenas. The researchers found hypnosis to be beneficial in reducing pain for patients in both acute and chronic pain conditions. These results are also confirmed by Hawkins (2001). However, while hypnosis was found to be significantly more analgesic than other psychological treatments (such as relaxation techniques and biofeedback) with acute pain, this was not the case for chronic pain (2003).
By no means is hypnosis a miracle cure for pain; its effectiveness is in fact variable from person to person—likely due at least in part to factors such as hypnotic susceptibility and the degree to which a patient predicts the success of the treatment (Patterson & Jenson, 2003). However, there is no doubt that hypnotherapy has proved beneficial in reducing pain for chronic sufferers to at least some extent.
Endless research could be performed in an attempt to pin down a profile for the predicted efficacy of hypnotherapy for patients of varying hypnotic susceptibility indices and degrees of experienced chronic pain, etc. However, since I am satisfied with evidence for the value attributed to hypnosis, I would rather narrow the scope of my research to exploring how hypnosis is effective. Perhaps I am just the glib product of Aristotelian causality, but I cannot help asking what portion of our brain might be responsible for the alleviatory effects of hypnosis on chronic pain. It seems plausible that a neurological mechanism be at hand that would allow a patient in a trance state to interrupt, or at least affect, the pain signal. After all, the perception of pain only exists in one’s mind. Might we capitalize on the ability to trick the mind into stopping this perception? As discussed earlier, relief is not obviously this simple, but I want to better understand why.
Saturday, April 28, 2007
psychosomatic responses
Why is it that every time I sit down to write, I get really, really tired? I was going to write about pain today, but.....that hasn't worked out. I don't even know where to start! It's such a complex ordeal. On the surface, pain seems like it's just some sensory cells telling the brain that there is an injury. Great! but then when you start studying it, you have to read about how there are various types of these "nociceptors" (pain neurons). Some have myelinated axons with narrow diameters while others have nonmyelinated axons with narrow diameters, and we can't forget the ones with wide axonal diameters. Have you ever noticed how there are multiple sensations of pain--and they are different types of pain--that occur in one incident of injury? There's the initial, ahhh-what's-going-on!!!!-move-your-hand pain, and then there's the throbbing, sentimental, I-told-you-not-to-try-using-the-curling-iron-on-the-cat's-tail pain. It's because the different types of axons send the signals differently! I could spend my lifetime talking about different types of nociceptors and the pain pathways from the stimulus to the brain, but i don't want to! I want to talk about hypnosis as a method of pain management, but i've put so much time in trying to understand what this thing called pain is that I can't waste my work! I think that having an overall understanding of the picture of pain sensation and perception (see, even those two things are completely distinct areas of pain research and inquiry) will be good and perhaps even necessary to talk about how hypnosis could be beneficial. I just have to figure out how....
In the meantime...i really am tired.
In the meantime...i really am tired.
Monday, April 23, 2007
Part I
I emailed "Part I" of my project to my reader last night at 2 am--two weeks later than I was hoping. They say that it isn't helpful to think about that. They are probably right. This portion of my project was an attempt to ground the reader in an understanding of hypnosis as an acceptable method of managing chronic pain. Next, i am going to try to do a runthrough of the basic basic model of pain.
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