Dr Robert London

Helping Patients Beat Chronic Pain

Clinical Psychiatry News - Volume 32, Issue 4, Page 19 (April 2004)

Last month, I explored the value of controlling chronic pain patterns with psychodynamic psychotherapy. We defined a chronic  pain pattern as an illness that, in a short period of time, can seriously alter a person's lifestyle and lead to depression, isolation, irritability, and despair.

Whether the pain pattern is from physical or emotional causes (or a combination of both), many of our nonpsychiatric colleagues—such as neurosurgeons, orthopedists, neurologists, and rheumatologists—offer procedures and medications that alleviate pain. I mention this so that we always keep in mind that pain is a physical response that can be an indicator of a more serious medical or surgical problem. Therefore, self-referred chronic pain patients need a full medical examination from their general physicians to rule out medical or surgical illness. But when chronic pain continues despite the best efforts of those physicians, we in psychiatry have specific, effective techniques to offer.

An important aspect of these techniques is their short-term nature. Most chronic pain control strategies can be successfully demonstrated, practiced, and transferred within two or three 1-hour sessions. As reinforcement for the transfer of strategies, a tape of the sessions is made and sent home for the patient to use as a resource. The psychiatrist thereby puts the strategy in the patient's hands for use as needed.

Over the years, I have used three main techniques to reduce chronic pain. All three make use of a person's physiologic and psychological capacity to produce physical and mental sensations through imagery. They are the cold/warm technique, the glove-anesthesia technique, and the screen technique.
The Cold/Warm Technique
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A 40-year-old woman referred by her gynecologist was experiencing acute migraine/tension headaches accompanied by nausea during the week before her period. She also suffered from severe anxiety in anticipation of the headaches. The episodes affected her work and family life. She had missed a significant amount of time at work and was much distressed by her inability to control her irritable, angry outbursts at her husband and children. There were no secondary gains surrounding this headache pattern. Medications were either ineffective or caused unacceptable side effects, such as drowsiness.

The patient was taught some deep-breathing relaxation exercises. Then the use of imagery began: In the first of a series of suggestions, the patient was told to imagine an ice-cold motorcycle or football helmet on her head. It was then suggested that she feel the ice of the helmet cool her head and numb her forehead and temples, easing the pain. Finally, she was told to imagine breathing in the cold air from the helmet to create a cooling sensation in her esophagus and stomach, thus relieving the nausea. This process was practiced many times over several visits.

Once the patient understood the technique (after several practice sessions), the psychotherapeutic treatment was over. The patient was given a cassette tape of the sessions and was taught to practice at home, modifying the technique to suit her lifestyle and preparing for the week when the headaches were expected to start.

In this patient's case, the strategy was successful. The therapeutic technique of using cold or warm imagery is also a good choice for musculoskeletal pain in which case the image of an ice pack or heating pad is introduced.
The Glove-Anesthesia Technique
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A 28-year-old man was referred to me after successful orthopedic surgery failed to relieve the chronic pain pattern he had experienced since he injured his knee playing tennis.

Although his knee had been repaired, the patient could not play tennis or golf—his favorite sports—without severe pain. I used the glove-anesthesia technique to help this patient.

Again, therapy began with the patient being taught a simple relaxation technique. The patient was then asked to imagine carrying a bag loaded with free weights. It was then suggested that the bag was becoming heavier and that as the weight increased, the patient was grasping the bag handle more and more tightly. The patient was then guided to imagine feeling numbness in the hand that was grasping the bag handle. When numbness was achieved, the patient was instructed to touch the painful knee and to imagine the numb sensation flowing into the knee and relieving the pain.

With practice, the patient achieved about a 50% reduction in pain. He was able to resume doing sports comfortably. This procedure has been used by many clinicians over the years and works quite well.
The Screen Technique
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Another patient was referred with chronic back pain from tension and muscle spasms. After being taught the initial relaxation exercise, the patient was instructed to project himself and his pain onto a giant movie screen. It was then suggested that the patient watch the projection of himself and his pain in a detached manner as though he were watching a movie. As the patient mentally isolated the pain onto the screen, he could actually feel the pain reduction.

With practice, the patient could not only project his pain onto the screen, but could also change the imaginary channel to a pleasant scene, thus removing himself one level further from the pain.

I found this to be an excellent technique for treating muscle spasms caused by structural problems and by muscle tension/stress.

We can learn, develop, and refine these techniques to provide alternative medical psychiatric approaches to certain types of chronic pain. As psychiatrists, we can be clinically active in pain control. Be our involvement psychodynamic or behavioral, let's give it a try.

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© 2004 International Medical News Group. Published by Elsevier Inc. All rights reserved.