Tuesday, 20 May 2014

Medical contributions to psycho-genic pain

Further to my first blog on reading The Hidden Psychology of Pain by Dr James Alexander, I thought I'd add some more thoughts. I thoroughly agree with his contention that the medical establishment contributes in no small part to the perpetuation of the notion that pain can only have a physical cause. The idea that emotions can cause pain is dismissed in the main, especially since both physician and patient make the mistake of thinking that this means the pain is 'all in the mind' and therefore not real!. Psychogenic pain is completely real - it has a physical manifestation - which can be due to lack of oxygen supply to the tissues or over-contraction (spasm) but the over-riding cause is an emotional memory which has not been released and continues to replay the motor action that was in place at the time that the encoding traumatic event first occurred. So, in simple language the body holds the trauma in memory and, as this is never discharged, chronic pain ensues.. This may take the form of back pain, shoulder pain or in very severe cases, fibromyalgia and other chronic fatigue-related syndromes. There is usually complex childhood trauma at the heart of these syndromes.

The brain is able to create physical symptoms via the combination of limbic system (deep brain) which triggers the Hypothalamus, Pituitary, Adrenal (HPA) axis mediated by the autonomic nervous system; the body is flooded with stress chemicals (mostly cortisol from the adrenal glands) and the stress cycle begins. Cortisol will cause most of the symptoms seen, especially if it is released continuously.

Unfortunately, when a person is misdiagnosed with a physical cause of this (via increasingly sophisticated technological scans which reveal 'pathology' of the various tissues), the belief that there is indeed something physically 'wrong' is corroborated. What you are not told is that many people who are not in pain have the same 'pathology', but since they do not consult their doctors, this is rarely appreciated. However, there are many reliable studies that have confirmed this, it just does not fit the current model. If the pain was caused by the structural abnormalities then why doesn't everyone who has these abnormalities have pain? It just doesn't make sense.

With some chronic pain/fatigue syndromes like CFS/ME the symptoms are so varied that it is hard to see how they relate at all. They can range from cognitive disorders, digestive issues, cold hands and feet, postural hyptension (low blood pressure when standing up), etc, etc. The brain lies at the heart of all of these symptoms via, as we have said, the HPA axis and excess cortisol but for someone suffering it is hard to believe this.

I recently had  a client tell me that she has finally got a diagnosis of Menieres disease, a disorder of the inner ear that affects hearing and balance. It causes sudden attacks of vertigo (a spinning sensation), tinnitus (a loud ringing in the ears), and a temporary loss of hearing. She seemed relieved that at last there is an explanation for the very disabling symptoms she has been experiencing. However, I am not convinced that this 'disease' is not simply another manifestation of the autonomic nervous system imbalance. Sadly, it is hard to contradict the medical view as it is so supported in our culture, and, for someone in pain, they need to have an explanation or they fear that people will think they are making it up or 'swinging the lead' as it used to be called. Being told by a doctor that you have 'x disease' and then, worse, being told it is bad enough to merit investigation, usually by tests (in this case MRI), further traumatises the patient and ensures the symptoms will continue and usually get worse. For traumatisation to occur requires that the person be helpless. There is nothing like being subject to medical investigation with complex interventions by 'experts' to make a person feel helpless. They are totally disempowered from their bodies, their self-determination and become stuck in the anxiety loop.

Unless they are able to work with a trusted holistic/mindbody practitioner who can demonstrate the real meaning of these symptoms and give them tools to alleviate the stress, the likely prognosis is poor. We have seen people die from these chronic fatigue related diseases, and most live a thoroughly reduced quality of life. It takes a lot of courage to break free of the medical model, with its round of tests and specialists who each corroborate the view that this is lifelong and nothing much can be done. And the social care model, that only pays disability payments to those with defined conditions simply adds to the burden that these people feel. If they then get better does that mean they never had it in the first place?? how will they live while they are recovering but are still not well enough to work? This places such a pressure on people that they are unlikely to step outside the system, especially since this means losing the little certainty they had.

It is a very challenging field in which to work. But I have no doubt medical science and psychology will eventually unite and prove that this psycho-genic model is the correct one. We will in the future be able to understand our emotional fallibility without blame - and have a collaborative healthcare team to work with us to re-write the programme and release us from pain.

Saturday, 17 May 2014

Ruminations on The hidden Psychology of Pain

Top of my reading list at the moment is The hidden psychology of pain by Dr James Alexander who's ideas support and further develop the ideas of Dr John Sarno re the origins of chronic pain. Sarno's ideas were that a lot of chronic back pain and pain syndromes like Chronic Fatigue Sydrome/ME are a psychologically driven response to unresolved emotions. Sarno's ideas are revolutionary and challenging to current medical thinking but as he is an MD and has treated a lot of people using his protocol, there are many clinicians who are beginning to take him seriously. John Alexander is one of them but he differs in that he is a psychologist so has, perhaps more of an idea on the psychological determinants of this. he has suggested that our response to pain is determined by our thinking about it - i.e. whether it dominates our lives, we catastrophise it, and interpret its meaning as one of 'things getting worse'. Certainly in my clinical practice I have noticed this tendency in the clients who fail to get better and I remember my own experience here too. I think I belong to that category or 'ruminators'. He refers to a couple of Pain Questionnaires1 that help determine these responses and therefore allow us to rate our contribution to pain and therefore suggest ways of re-training the mind (via hypnotherapy, psycho-sensory techniques such as EFT, etc).
My contribution to this debate is that trauma may be at the heart of this 'sensitisation' of the mind. I am coming to believe that all of us have traumatic memory - some small, some large but that the cumulative effect of these poorly processed emotions is one of priming the autonomic nervous system (the fight and flight mechanism) to one of hypervigilance - and the end result of that is that when challenging events do occur in later life (like accidents, viral infection, etc) our system (especially the adrenals) are so severely compromised that the immune system is depressed and we end up in a cycle of pain and worrying about pain...

This then becomes our focus and we start our journey to find external solutions, whether it be conventional or alternative. We fight the notion that the answer is in us as that seems like blaming ourselves for our pain when we feel innocent (which is correct - we are). But we need to take responsibility and begin to explore the old hurts (without endlessly recounting them) so that we can heal. I recommend Eye Movement Desensisation and Reprogramming (EMDR) for this as it heals the hurt without retriggering. It is quite profound.

I myself and having (EMDR) therapy so that
i/ I know what it feels like and
ii/ I can be cleared of my triggers to get my mental attic cleared
Both of these help me to be clearer when helping my clients.

I started by looking at my blood phobia which is something that limits me and makes me embarrassed (I feel faint if I even look at it). This seemed simple enough. But within a couple of sessions other images and ideas popped into my head unbidden and these have to do with my grandmother and mother and certain panic feeling they had. I have no doubt for myself that I have trauma from my early years (ages 2-3) which I don't remember but seems to keep me forever looking out for failure and disaster. This inner exploration is very interesting and has had the useful corollary of reducing my Reynaud's symptoms (white finger) and generally my anxiety levels.

So, I look forward to a day when I am free of these things and hope to be able to use my learning to help clients in pain - those who are willing to go beyond the external search anyway..

1 The Pain Catastrophizing Scale by
Michael JL Sullivan, PhD