Biofeedback and Hypnosis in Pain Management
Total Page：16
File Type：pdf, Size：1020Kb
SPECIAL TOPICS Biofeedback and Hypnosis in Pain Management Eric K. Willmarth, PhD,1 and Kevin J. Willmarth, MA2 1Michigan Behavioral Consultants, Grand Rapids, MI, and 2Xavier University, Cincinnati, OH Keywords: biofeedback, neurofeedback, hypnosis, pain management, self-regulation Biofeedback and hypnosis have distinctly different histo- pain. In almost all cases this should occur within the con- ries and yet share substantial common ground as pillars text of a setting that includes medical and psychological of self-regulation. Applied to the experience of pain, each support and education. modality permits a clinician to address both the source of perceived pain and the perception of pain itself. This paper Choosing the Target will review some of the data supporting the use of Before one can begin using hypnosis or biofeedback for biofeedback and hypnosis for pain management and dis- pain management, the properties of the pain itself must cuss the theory, neurophysiology, and psychophysiology be considered. Rich Sherman (2004) in his excellent new underlying the use of these approaches. book, Pain Assessment and Intervention from a Psychophysiological Perspective, points out that the Introduction: Pain Is Real if You Feel It simplest classification considers pain as either inflamma- “Why am I being sent to a psychologist? Does my doctor tory or neuropathic. This system focuses primarily on think this pain is all in my head?” These are not uncom- identifying the underlying cause of the pain. No one can mon questions from patients who have been referred for argue that identifying the source of pain is not a won- behavioral medicine services connected to a pain manage- derful achievement. Unfortunately in the real world of ment program. The questions underscore the distinction pain management, two obstacles appear. First, in spite of that physicians and patients alike sometimes make that numerous new diagnostic imaging and assessment tools, suggests that pain only exists if tissue damage or some we still often fail to identify the “cause” of pain. Second, physical problem can be identified. In the absence of an often when we do identify the problem generating the organic cause, the pain is deemed psychosomatic—under- pain, there is nothing that can be done to directly “fix” stood by many people to mean “not real.” The following the problem. Damage to the thoracic spine, for example, limerick is a humorous testament to the existence of these may generate a great deal of pain, but corrective surgery misguided beliefs: is unlikely due to the risk of paralysis. An alternative approach for the clinical consideration There was a good doctor from Deal, of pain management is to assess whether treatment will Who said “although pain isn’t real, address the cause of the pain (pain generator), if known, If I sit on a pin, and it punctures my skin, or the perception of the pain. In the example above, I dislike what I fancy I feel. although surgery and correction of the damage may not be an option, a nerve block or oral analgesic may provide Pain is “an unpleasant sensory and emotional experi- relief from the perception of pain. Treatment with hyp- ence associated with actual or potential tissue damage, or nosis and biofeedback can be considered for both aspects described in terms of such damage.” This definition of of pain management. pain put forth by the International Association for the Study of Pain (Merskey & Bogduk, 1994, p. 210) clearly Before Chemical Analgesia, There Was dismisses this distinction of real versus imaginary pain. Hypnosis It is the perception of pain and the individual’s physical Although Anton Mesmer and other physicians reported and emotional reaction to the pain perception that give on the use of “animal magnetism” for pain relief in the us the opportunity to create treatment approaches that 1700s, the era of hypnoanesthesia began as early as can provide relief. Both biofeedback (including neuro- 1821. Cloquet performed a breast amputation using Biofeedback feedback in this term) and hypnosis provide tools that mesmerism in a demonstration to the French Academy ⎪ patients can learn to use to decrease their experience of of Medicine in 1829, but it was a Scottish surgeon, James Spring 2005 20 Willmarth, Willmarth Esdaile, who became most famous for the use of hypno- most direct statement, “you will feel no pain!” Although sis as a surgical anesthesia (Esdaile, 1847; Kroger, 1963). very dramatic in its effect, only recently have electroen- Esdaile reported on hundreds of painless operations per- cephalograms (EEGs) and positron emission tomogra- formed with mesmerism between 1840 and 1850. In the phy (PET) allowed us to begin to understand how this preface to his book Mesmerism in India (1847), Esdaile works. The answer appears to be in the changes observed wrote that “painless surgical operations and other med- in the brain itself. Faymonville et al. (2000) and Pierre ical advantages” were the “natural birthright” that mes- Rainville (Rainville, Bushnell, & Duncan, 2000) have led merism provided his patients in Bengal. Esdaile’s work the way in using PET scans to show changes in the ante- overlapped the development of chemical anesthesia with rior cingulate cortex (ACC), the thalamic nuclei, and the first use of nitrous oxide in 1844, ether in 1846, and several somatosensory areas during hypnosis. These chloroform in 1847. By the 1860s, chemical anesthesia findings and others led psychiatrist Peter Bloom (2004) had essentially eliminated the use of hypnoanesthesia, to announce in his keynote address at the recent 16th although dramatic examples of its use are still seen International Congress on Hypnosis and Hypnotherapy, today. “We now have the proof: Words change physiology!” In April of 2000, the International Journal of Clinical Altering the perception of pain can often be accom- and Experimental Hypnosis published a special issue plished by direct or indirect suggestion relating to the entitled “The Status of Hypnosis as an Empirically attributes of pain. Patients can be asked to focus on the Validated Clinical Intervention.” Within this issue, Guy pain and give it size, shape, and color. Suggestions can Montgomery and colleagues presented a meta-analysis then be made to alter these by letting pain grow, shrink, of 18 studies of hypnotically induced analgesia fade, move, or disappear. Another common technique for (Montgomery, DuHamel, & Redd, 2000). As had been chronic intractable pain such as cancer pain is to suggest found in several earlier studies, this report supported distortion of time. Long hours between doses of pain hypnotic analgesia as a valid and reliable phenomena medication may be made to seem “as if only a few with 75% of the clinical and experimental subjects moments have gone by.” Conversely, suggestions can be reporting pain relief. The authors conclude that based on offered that can transform brief periods of sleep into a the criteria set forth by Chambless and Hollon (1998), perception of “a long and refreshing sleep.” Alteration in “hypnotically suggested analgesia should be considered the experience of pain can include changes in affect as a well established treatment” (p. 148). Patterson and well. Willmarth (1998) demonstrated that hypnotic mod- Jenson (2003) supported this position for both acute and ification of mood also resulted in changes in the percep- chronic pain conditions. tion of pain. Although patients often protest that “if you take away my pain I won’t be so depressed,” the reverse How Does It Work? Clinical and seems to be true as well. Neuropsychophysiological Considerations Distraction from pain is almost automatic for minor From a clinical perspective, the use of hypnosis to alter acute pain. We rub a bruised area or turn our attention perception can be applied to the perception of pain in a to something interesting almost without thought. number of effective ways. This is true not only for the Chronic pain often requires more effort, but hypnosis sensation of pain but also for the cognitive and emotion- provides many individuals with a way to experience al factors including attention, attitude, affect, attribution, focused, narrow attention, which redirects attention to and arousal. Although hundreds of creative suggestions thoughts or memories more pleasant than the pain. and metaphors for pain control have been presented in This “hallucination” may itself create physiological the literature, Hilgard and Hilgard (1994) propose three change. Dabney Ewin, a surgeon and gifted hypnotist, general classes of pain management approaches. These notes that if patients with severe burns can be placed include (a) direct suggestion of pain reduction, (b) alter- in trance soon after their injury and can imagine cool ation of the experience of pain, and (c) redirection of or cold conditions on the skin, the course of the injury attention. changes (Ewin, 1986). He notes that much of the dam- Biofeedback Direct suggestion of pain reduction is consistent with age from a burn comes from a secondary process when the more traditional authoritative approach to hypnosis. the body responds to the initial tissue damage. The This may include the suggestion that an area is becom- release of histamines results in blisters and swelling. ⎪ ing numb as if injected with an anesthetic agent, or the Ewin supports his work with dramatic photographs of Spring 2005 21 Biofeedback and Hypnosis in Pain Management burn victims in the hours and days after injury show- pain, and other musculoskeletal and vascular pain syn- ing few blisters and speedy healing. In these cases, he dromes. The forms of biofeedback used and reported suggests that the body responds to the hypnotic hallu- include surface electromyograph (SEMG), electro- cination of cool temperatures, rather than to the burn, encephalograph (EEG), temperature, electrodermal thus avoiding the damaging secondary response to response/galvanic skin response (EDR/GSR), and heart burn. rate variability (HRV). The question of whether biofeed- For all its many advantages, hypnosis has some major back can be considered empirically validated for use with drawbacks.