Tuesday, 4 December 2018

Emotional Awareness for Pain

Integrative Medicine (Fourth Edition) 2018, Pages 963-970.e2 Chapter 102 - Emotional Awareness for Pain Author links open overlay panelHowardSchubinerMD Available online 28 April 2017. Get rights and content Introduction There is an epidemic of chronic pain and related disorders in the United States and around the world.1, 2, 3 It is estimated that there are more than 100 million individuals with chronic pain in the United States, and this number is increasing.4, 5, 6 Back pain, neck pain, fibromyalgia (FM), tension and migraine headaches, temporomandibular joint (TMJ) syndrome, and abdominal and pelvic pain syndromes are among the most common diagnoses made in primary care and consume a significant proportion of medical costs.7 In addition to these disorders associated with chronic pain, there are a variety of commonly associated disorders such as chronic fatigue, irritable bowel syndrome (IBS), interstitial cystitis (IC), and postural orthostatic tachycardia syndrome (POTS) that are frequently seen by both traditional and integrative practitioners.8 The traditional biomedical model attempts to identify an underlying local and structural cause for pain. However, evidence of pathological conditions in this group of disorders has been elusive. Furthermore, treatment of these conditions has proven to be difficult,9, 10 as becomes clear when one considers the number of people who chronically suffer from these conditions. For example, the vast majority of individuals diagnosed with headaches, abdominal and pelvic pain syndromes, and FM have no clear evidence of peripheral nociceptive inputs generating pain. Chronic back pain often occurs in the absence of radicular pain corresponding to an observed nerve root lesion or evidence of nerve root compression, such as altered muscle strength, deep tendon reflexes, or sensation. In these patients, magnetic resonance imaging (MRI) evidence of degenerative disk disease, bulging or herniated disks, spinal stenosis, and other syndromes are assumed to be the cause of pain. However, studies comparing MRI findings of individuals with and without pain show similar findings.11, 12 The assumption that commonly seen MRI findings are the cause of pain in those without objective evidence of structural abnormalities often leads to overtreatment and the resulting increased costs and complications.13, 14 Whiplash is another example of a chronic pain syndrome that has been shown to be unrelated to ongoing injury or a specific disease process in the neck.15 Formany pain syndromes the etiology is complex with no simple cause and effect. When the mind suffers, the body sympathizes. This chapter addresses this powerful effect. While central nervous system (CNS) transmitters have been found to be associated with FM and migraine headaches,16 it is not clear whether they are the cause of these disorders or the result. There are genetic predispositions toward some of these conditions, such as migraine, anxiety, and depression.17 However, studies have shown that life events are required to trigger these conditions, that is, to cause expression of underlying genetic predispositions.18 In fact, one study showed that a particular genotype for depression can be activated by a stressful childhood (thus increasing risk for depression) and can be deactivated by an emotionally supportive childhood (thus decreasing depression risk).19 Because of the inability to identify and treat the underlying cause for most chronic pain conditions, attention has shifted to pain management. However, biomedical approaches to pain management, including pain medications (including opiates), injection techniques, and surgical and chemical ablations, have also not been shown to be efficacious.9, 10, 13, 14, 15, 20 There is clearly a need for a new understanding and approach to these disorders. Please note that the disorders considered in this article exclude those with objective evidence of structural pathology, such as cancer, fractures, and inflammatory and infectious conditions. This chapter describes a mind-body model in which these disorders are conceptualized to be related to individual reactions to stressful events and unresolved emotions. Their Pain is Real Neuroscientists have identified areas of the brain that process, accentuate, and reduce pain.21, 22, 23, 24 To appropriately diagnose and treat chronic pain, it is necessary to develop a more nuanced view of the relationship between pain and the brain. Physical injuries do not always result in the experience of pain; and pain (even severe pain) can result in the absence of a physical injury.25 There is clear evidence that pain can originate in the absence of a tissue disorder in the area where the pain is being felt, as seen in phantom limb syndrome.26 A study by Derbyshire et al. confirmed that pain initiated by the brain is identical to pain originating in peripheral tissues.27 This implies that pain is a function of the brain, with inputs from peripheral nociceptors as well as from pain generating/processing centers in the brain and that the resultant pain experiences are indistinguishable. This understanding is important for reassuring patients that all pain is real and will be taken seriously. The anterior cingulate cortex (ACC) is a key area within the brain that, when activated, augments pain.22, 24Pain also activates the amygdala and the autonomic nervous system (ANS).28, 29 Emotional memories are stored in the amygdala, and individuals with adverse childhood experiences are more likely to develop migraine, FM, IC, IBS, and chronic pelvic pain.30, 31, 32, 33, 34, 35, 36 Evidence also indicates that the amygdala, the ACC, and the ANS are activated when emotions are experienced.37, 38 To summarize, these areas are involved in the activation of pain pathways, and these pathways are strongly influenced by thoughts and emotions.22, 23, 24 Learned pain pathways can develop after an injury (even a mild one) or can be created during times of significant stress and emotional reactions. While most injuries heal within a reasonable amount of time, pain pathways can persist (become “wired”), thus creating intermittent or chronic pain that may be refractory to medical therapies. These pain pathways are often very specific and can involve discrete or large areas of the body. A veteran told me that he was injured in the Vietnam war during an ambush that led to a dangerous Med-evac escape. He had shrapnel wounds to his left leg, resulting in pain and limping. Within a few months, both of these symptoms had completely resolved. Interestingly, he had a recurrence of the pain and limping 20 years later when a helicopter flew overhead. There are also built in central mechanisms for reducing pain. Notably, activation of the dorsolateral prefrontal cortex (DLPFC) area results in diminished pain.23 Positive emotional states and reductions in pain are correlated with activation of the DLPFC39 (Fig. 102.1). Download full-size image FIG. 102.1. The neurology of psychophysiologic disorders (thick solid line, activating; dashed line, deactivating). ACC, anterior cingulate cortex; ANS, autonomic nervous system; DLPFC, dorsolateral prefrontal cortex; GI/GU, gastrointestinal/genitourinary; MBS, mind-body syndrome. The Psychology of Pain There are two major components of the mind: conscious and subconscious. We are consciously aware of many of our actions, decisions, thoughts, and feelings. However, the majority of our thoughts and emotions are actually derived from subconscious processes.40, 41 In addition, these subconscious processes are typically the basis for most of our actions. Thus many of our activities are routine and programmed by our subconscious minds, such as walking, talking, eating, driving, as well as reactions to people, places smells, and situations. These activities and reactions are carried out via sets of learned neural pathways. Another function of the subconscious mind is to protect us from physical threats, and therefore we continuously monitor our environment for stimuli that might be “dangerous” in some way.38 Innate neural pathways cause our bodies to react very quickly to a snake, a thrown object, or other physical threats. Our reactions to these threats are immediate and do not involve conscious processing (i.e., we are aware of them after they occur).38, 41 The subconscious mind also notices emotional threats and causes our bodies to react to them in a similar fashion. In fact, Kross and colleagues demonstrated that the same regions of the brain were activated by both peripheral nociceptive stimulation and emotional stimulation.42 We are all aware that our bodies react to stress with a variety of reactions, including facial flushing, tight stomach muscles, sweaty palms, voice changes, and others. Given the previous, it should not be surprising that during times of significant tension and stress, our bodies can develop physical reactions in a myriad of ways, such as the development of neck or back pain, headache, gastrointestinal or genitourinary symptoms, and many other symptoms. The danger or alarm pathways (fight/flight and freeze/submit) are centered in the amygdala and are necessarily sensitive to relatively small stimuli that are potentially harmful for protective purposes.38, 43 Auseful question to ask is, “Where do you carry stress in your body?” This often gives insight into how we can learn from these subconscious pathways. Individuals subjected to adverse childhood events develop a priming of the brain’s danger pathways along with a corresponding emotional memory for specific types of threats.44 These children may develop stomachaches, insomnia, anxiety, headaches, and other disorders.30, 31 Later in life, if new emotional or physical threats occur (especially if they are similar to those that occurred in childhood), neural pathways can be activated causing new symptoms to develop, with musculoskeletal or visceral pain syndromes being the most common.45 In a typical history, a girl who grows up with an emotionally abusive and controlling parent may develop migraine headaches as a teen when she is subjected to a jealous and controlling boyfriend. If she marries an abusive husband in her twenties, she may develop abdominal or pelvic pain. In her thirties, when subjected to a threatening work situation or a motor vehicle accident, she may develop widespread pain that will often be diagnosed as FM, as well as anxiety and/or depression. These symptoms prompt medical attention that usually leads to symptom-based pharmaceutical or physical interventions. If these treatments are ineffective, the persistence of symptoms activates fear, which leads to increases in the danger signal and resulting increases in symptoms. This vicious cycle is common and can explain the fact that pain syndromes often worsen over time in terms of the location, frequency, and severity of pain. These physical reactions are real, and the pain they cause is real. The source of pain, whether due to nociceptive inputs or created by neural pathways, cannot be distinguished by the quality or severity of pain. Since neural pathways are physiological, rather than pathological, responses (i.e., they do not involve tissue destruction), they can be reversed. These symptoms are created by the subconscious mind in an attempt to warn us or protect us from some threat (for example, a controlling boss, an abusive husband, or an overwhelming set of responsibilities). In essence, pain and other symptoms serve as a “danger” message from the brain. In the case of an arm fracture, the message is “rest and get a cast,” while in the situation of stressful life events causing headaches or neck pain, the message should be “you are feeling threatened, take action to alter the situation or respond to it.” We are currently using the term “psychophysiologic disorders” (PPDs) to describe these neural pathway symptoms, but they have also been termed psychosomatic or functional disorders, medically unexplained illnesses,46 tension myositis syndrome,47 stress-related illness,48 and mind-body syndrome.45 Psychophysiologic disorders (PPD) is the current term being used to describe this process. Another observation commonly made about those who develop psychophysiologic reactions is that they tend to have a highly developed conscience.45, 47 Individuals who are affected by this group of disorders (Table 102.1) typically exhibit the following characteristics: being selfless, highly responsible, or self-critical; feeling excessive guilt; lacking assertiveness; being perfectionists; holding themselves to very high standards; caring what others think of them; holding emotions in; and neglecting their own needs. Large international studies have shown that women are more likely than men to display these characteristics (possibly due to higher rates of childhood and adult victimization and gender-based socialization).49, 50 These personality factors may play a role in the higher rates of chronic pain and other PPDs among women. TABLE 102.1. Personality Traits Common to Those With Psychophysiologic Disorders (PPDs) Would you describe yourself as: 1. Having low self-esteem _______ 2. Being a perfectionist _______ 3. Having high expectations of yourself _______ 4. Wanting to be good and/or be liked _______ 5. Frequently feeling guilt _______ 6. Feeling dependent on others _______ 7. Being conscientious _______ 8. Being hard on yourself _______ 9. Being overly responsible _______ 10. Taking on responsibility for others _______ 11. Often worrying _______ 12. Having difficulty making decisions _______ 13. Following rules strictly _______ 14. Having difficulty letting go _______ 15. Feeling cautious, shy, or reserved _______ 16. Tending to hold thoughts and feelings in _______ 17. Tending to harbor rage or resentment _______ 18. Not standing up for yourself _______ Diagnosis of Psychophysiologic Disorders PPD should be suspected in patients who present with symptoms of one or more of the common PPD diagnoses (Table 102.2) and for whom a specific structural condition is not identified. If it is understood that PPD can cause a wide variety of symptoms, the practitioner can suspect it from the beginning of an encounter. There are several clues in a medical history that suggest a PPD. An injury, particularly a mild one, that doesn’t follow the usual pattern of gradual diminution of pain over time is likely to be due to PPD. This diagnosis should be considered when symptoms vary significantly with regard to time and place, such as pain that goes away when on vacation or when doing certain activities or pain that occurs only when sitting in some chairs but not in other chairs. Similarly, pain that shifts from one location to another within the body is often due to PPD. I saw a patient who had wrist and hand pain while keyboarding at her job, forcing her to be unable to work. Rest and antiinflammatory medications had not been effective. Her doctors assumed that this was simply a repetitive strain injury. However, further history revealed that the pain also regularly occurred on Sunday evenings when she hadn’t done any keyboarding. This suggested that her brain was activating pain in anticipation of stress during the workweek. She had a complete recovery after treatment for a PPD. Of course, a medical workup should be conducted to rule out any structural conditions such as tumors, fractures, infections, or vascular or inflammatory conditions. A physical exam to rule out evidence of nerve root compression is mandatory as those findings would preclude a diagnosis of PPD. Imaging studies of the neck and back are likely to demonstrate degenerative changes because asymptomatic individuals have high rates of such MRI findings. A study from Finland showed that degenerative disk disease and bulging disks were identified in 50% and 25%, respectively, in healthy 21-year-olds.51 As mentioned, similar degenerative MRI findings are found in the majority of middle-aged adults,11, 12 and physicians should be cautious in attributing back pain to these findings. Similar studies document the presence of abnormal MRI findings of the hips, shoulders, and knees in healthy individuals without pain.52, 53, 54, 55 TABLE 102.2. Syndromes That Are Commonly Caused by Psychophysiologic Disorders (PPDs) Chronic Pain Syndromes Tension headaches Migraine headaches Back pain Neck pain Whiplash Fibromyalgia Temporomandibular joint (TMJ) syndrome Chronic abdominal and pelvic pain syndromes Chronic tendonitis Vulvodynia Piriformis syndrome Sciatic pain syndrome Repetitive stress injury Foot pain syndromes Myofascial pain syndrome Autonomic Nervous System-Related Disorders Irritable bowel syndrome Interstitial cystitis (irritable bladder syndrome) Postural orthostatic tachycardia syndrome Inappropriate sinus tachycardia Reflex sympathetic dystrophy (chronic regional pain disorder) Functional dyspepsia Other Syndromes Insomnia Chronic fatigue syndrome Paresthesias (numbness, tingling, burning) Tinnitus Dizziness Spasmodic dysphonia Chronic hives Anxiety Depression Obsessive-compulsive disorder Posttraumatic stress disorder Once this is accomplished, the topic of PPD should be broached with the patient. Talking with patients about PPD should be done in a way that emphasizes that their symptoms are real and with empathy toward their situation and frustration in not getting better. The clinician should explain that real symptoms, including severe and chronic pain, can frequently occur in the absence of structural disease processes, and one can use phantom limb syndrome as an example of this phenomenon.26 Introducing the concept of learned neural pathways helps patients to connect their symptoms to a CNS processes. The practitioner should state that learned neural pathways are simply sets of nerve connections that have developed through experiences, such as the pathways that allow us to ride a bicycle, throw a ball, walk, and talk a certain way. Pain and other symptoms are easily learned, and once these pathways are established, they can continue for several years and can be reactivated after many years. Reassure the patient that there is no physical and structural disease process and offer hope that the real condition that they suffer from can be reversed. Whether or not a physical injury occurs, stressful situations and powerful subconscious emotions are universal triggers of pain pathways in PPD. These pathways become engrained in the presence of situations and emotions that remain unresolved. In addition, chronic pain frequently leads to frustration about ongoing pain and fear about an underlying physical disease. These reactions further activate pain pathways in the brain by activation of the amygdala, ANS, and ACC.56, 57 This educational process is extremely important to allay fears of a disease process, explain the reason for the symptoms, and offer hope and the expectation that these symptoms can be resolved. Treatment for PPD in the absence of understanding and accepting the above is typically not effective. The Diagnostic Interview Many practitioners are not trained, nor do they have the time, to conduct an in-depth psychological interview that begins in childhood and attempts to elicit the key psychological factors that have created psychophysiologic disorders. However, the author has published a template for this type of assessment that can be used by patients and/or practitioners.45 A brief description of this interview is provided herein. As previously mentioned, before diagnosing a form of PPD, the practitioner should rule out a pathological medical condition so that the practitioner and patient are comfortable that they are dealing with a form of PPD. Prior to the interview, it is helpful to have the patient complete a checklist of symptoms and syndromes that are commonly caused by PPD (Table 102.3). Five questions form the basis of this interview (Table 102.4). TABLE 102.3. Common Symptoms of Psychophysiologic Disorders (PPDs) 1. Heartburn, acid reflux ___________ 2. Abdominal pains _______________ 3. Irritable bowel syndrome _________ 4. Tension headaches ______________ 5. Migraine headaches _____________ 6. Unexplained rashes _____________ 7. Anxiety and/or panic attacks ______ 8. Depression _____________________ 9. Obsessive-compulsive thought patterns ____________ 10. Eating disorders ________________ 11. Insomnia or trouble sleeping ______ 12. Fibromyalgia __________________ 13. Back pain _____________________ 14. Neck pain _____________________ 15. Shoulder pain __________________ 16. Repetitive stress injury ___________ 17. Carpal tunnel syndrome __________ 18. Reflex sympathetic dystrophy (RSD) _______ 19. Temporomandibular joint syndrome (TMJ) _____ 20. Chronic tendonitis _______________ 21. Facial pain _____________________ 22. Numbness, tingling sensations __________ 23. Fatigue or chronic fatigue syndrome ______ 24. Palpitations ____________________ 25. Chest pain _____________________ 26. Hyperventilation ________________ 27. Interstitial cystitis/spastic bladder (irritable bladder syndrome) _______ 28. Pelvic pain _____________________ 29. Muscle tenderness _______________ 30. Postural orthostatic tachycardia syndrome (POTS) _________ 31. Tinnitus ________________ 32. Dizziness _______________ 33. PTSD __________________ TABLE 102.4. Five Questions to Rule in a Psychophysiologic Disorder (PPD) 1. Did you have a stressful childhood? Did you experience neglect, abandonment, loss, criticism, or conditional love? 2. Did you experience traumatic events, such as physical or sexual abuse? 3. How many symptoms/syndromes have you had in your lifetime? See Table 102.2 for a checklist. 4. Were stressful life events occurring at the time of the onset of the symptoms? 5. Do you have several of the personality traits commonly associated with PPD? (See Table 3 for a description.) Begin the interview by gathering data on the patient’s family of origin and ask probing questions about their parents, siblings, and any other important individuals in their childhood. Gently inquire about episodes or patterns of emotional, physical, or sexual abuse; of criticism, taunting, teasing, blame, humiliation, or judging; and of overly high expectations or conditional love. Ask about parental alcohol or drug abuse, divorce or extramarital affairs, unequal treatment of siblings, and psychological and physical illnesses among family members. Inquire about sibling relationships with special regard to episodes of cruel behaviors, psychological or physical illness, or acting out behaviors. Synthesize the patient’s childhood experiences and reactions to them in an attempt to understand the effects that their upbringing had on their personality and development. Most people with PPD develop a set of personality traits that include having an overly developed conscience (heightened sense of responsibility) and a lack in self-esteem, self-worth, and assertiveness (see Table 102.1). Typically, one finds a set of events and responses that create a priming of the ANS that sets the stage for the development of PPD later in life. Some of the common patterns are those of loss, abandonment, fear, guilt, resentment, and anger. In many instances, people with PPD have very healthy childhoods, and when they are exposed to stressful situations later in life that belie the values that they learned in childhood, PPD symptoms can develop. I often explain to patients that since they are human, they have a mind and a body, and since those are intimately connected, it is not surprising that physical symptoms occur at times of stress; in fact, it probably happens to most people at some points in their lives. The next phase of the interview consists of an evaluation of the events that trigger PPD syndromes. A simple approach is to inquire about the onset of each of the PPD syndromes (Table 102.5). Although the onset may coincide with injury or a viral infection, these events create neural pathways that are usually transient. PPD symptoms can become chronic if the danger signals in the brain are activated. This process occurs in two ways. First, the individual may be in a situation where several of the following circumstances are present: there is an inherently stressful situation; the current events trigger emotional memories of stressful events from childhood; the individual experiences guilt, self-criticism, a strong sense of responsibility, or other issues listed in Table 102.1; the individual is unable to express emotions of fear or anger or is unable to escape feeling trapped in the triggering situation. Second, the symptoms are worrisome or severe, are believed to be due to a disease process, and are labeled by health practitioners as something other than a psychophysiologic process. These beliefs lead the patient to develop a significant amount of fear of the symptoms. This fear activates the danger signal and causes increased symptoms often leading to a vicious cycle of pain-fear-pain. Complete this process with each of the PPD symptoms that have occurred in the lifetime of the patient. You will frequently see clear patterns emerge that will help the patient understand that their symptoms are, in fact, caused by PPD and that they are not crazy, incompetent, or weak, but rather someone who has been exposed to a series of events that have created physical or psychological symptoms in response to a particular combination of stressful life events. When this occurs, the patients can be encouraged to see that they are not to blame for the symptoms, are not physically or psychologically damaged, and have the opportunity to overcome these symptoms. TABLE 102.5. Synthesis of the Diagnosis of Psychophysiologic Disorder (PPD) Chart Age PPD Symptom Potential Triggering Events Emotions That Were Triggered/Core Issues 7 Stomach aches Parents arguing Fear of parents separating/loss 16 Irritable bowel syndrome Parental divorce Loss of father, mother depressed 28 Migraines Husband “cheating” Loss, anger, betrayal 38 Fibromyalgia/fatigue Divorce/difficult boss Loss, fear, powerlessness If it is appropriate, the interview may be concluded with the following messages: “You have a form of PPD, rather than a structural disease process. PPD is caused by learned neural pathways that have been triggered by the particular set of stressors that you have encountered. It is not your fault. Almost everyone gets PPD, and anyone would likely develop these symptoms given the events that occurred. You can get better because learned neural pathways can be reversed. There is a way to unlearn your pain and other PPD symptoms if you are willing to do the work.” Treatment Approach Because PPD is a disorder caused by stress and unresolved emotions, it is possible for everyone with PPD to experience dramatic improvements or remissions. However, it is primarily patient-related factors that determine successful treatment, rather than practitioner-related factors. It is the author’s clinical experience that successful patients are those who are convinced that they have PPD rather than a structural disease process, are confident that they can address the issues that created PPD, are willing and able to devote a significant amount of time for psychological interventions, and have adequate resources as well as a lack of overwhelming obstacles in their lives. It is the practitioner’s job to help the patient develop the first of these attributes, while it is primarily up to the patient to attain the latter ones. Research Support There are two studies that have been conducted documenting the efficacy of the therapeutic approach. The first was a randomized controlled trial for individuals diagnosed with FM.58 In this small trial, at a 6-month follow-up, those who participated in a 3-week intervention had a mean decrease in pain of 2.5 on a 10-point Likert pain scale. In addition, 45% had a decreased pain level of at least 30% and 25% had a decrease of at least 50%. A second study described the outcomes of patients with a variety of musculoskeletal pain syndromes, including FM, back and neck pain, headache, and other syndromes. Patients had a mean duration of pain of 8.8 years and had even better results. After the month-long intervention, 6-month follow-up pain scores showed that 67% had at least a 30% pain reduction and 53% had at least a 50% pain reduction.59 Therapeutic Program Once a biomedical condition has been ruled out, the interview has demonstrated the linkages between priming and triggering events as well as the onset of PPD symptoms, and the patient has been educated and accepts the diagnosis, the intervention may proceed. The author has developed a comprehensive program designed to empower the patients and guide them toward healing.45 It consists of a mixture of cognitive-behavioral, mindfulness, and emotional expressive techniques, which is primarily self-guided. It has been shown to increase an internal locus of control, i.e., patients begin to believe that their thoughts and actions are capable of reversing their PPD symptoms.58, 59 Several authors have developed a variety of expressive and therapeutic writing techniques.60, 61 James Pennebaker and others have conducted research on many of these techniques, which has documented beneficial effects on health and well-being.60, 61, 62, 63 The author has incorporated several of these techniques along with others into a program designed to reverse PPD.45 These techniques are summarized in Table 102.6 and discussed in Chapter 98. One of the keys to the efficacy of expressive writing is the ability of the patient to identify, express, and release emotions. The clinician can help patients recognize that their feelings are justified and valid. Encouraging patients to experience and give voice to feelings of anger or resentment, guilt, and grief is often an important process in recovery. A therapeutic model that emphasizes emotional experiences, intensive short-term dynamic psychotherapy, has been shown to have benefit in patients with somatic disorders.64 TABLE 102.6. Expressive and Therapeutic Writing Exercises Free writing: uncensored expressive writing about an emotionally charged topic. Unsent letters: expressing thoughts and feelings fully in a letter format. Dialogues: creating an imaginary conversation between two entities who discuss a relevant issue. Gratitude: writing about things for which one is grateful. Forgiveness: writing to express forgiveness toward oneself or others. Barriers: writing about potential barriers, both internal and external, that may prevent healing. Creating new responses: writing how one chooses to respond to potentially difficult situations. Life narratives: creating an alternative life story that emphasizes overcoming obstacles rather than being victimized. Meditations and visualizations are useful adjuncts in the treatment of PPD. Mindfulness meditation has been shown to reduce reactivity to emotional issues and thus reduce pain;65, 66 guided imagery is an effective tool to create images of health and well-being, which are essential to this therapeutic model.67, 68 The author has created a CD with meditations designed to help patients reverse PPD,45 and Chapters 97 and 100Chapter 97Chapter 100 provide practical advice on using these methods. A key element of the program is to change how one views the symptom and how one responds to it. As mentioned, patients with PPD are often caught in a cycle of pain-fear-pain. To break this cycle, fear of pain must be reduced. Once the symptoms are accepted by the patient as being due to PPD, he or she can begin to stop fearing the pain, separate from it, and take control over it. Consciously choosing to stop monitoring pain and focus more on being active and engaged in living deprives the pain of its fuel, fear. It is remarkable that simple, strong assertions can often reverse pain within minutes when one is convinced of the diagnosis of PPD and of one’s power in overcoming it. However, it can take several months of programmatically ignoring the pain to reprogram learned pain pathways. Box 102.1 offers a script for patients to use. BOX 102.1 Sample Script for Reducing Psychophysiologic Disorder (PPD) Symptoms When pain or other symptoms occur, stop and take a deep breath. Then take a moment to remind yourself that there is nothing seriously wrong with your body. You are healthy, and the mind-body syndrome (MBS) symptoms will subside soon. Tell your mind that you realize that the symptoms are just a way of warning you about underlying feelings of fear, guilt, anger, anxiety, shame, inadequacy, or other emotions. Tell your mind to stop producing the symptoms immediately. Do this with force and conviction, either out loud or silently. Separate from the pain or other neural pathway symptoms and reframe them as sensations that are not harming you. Take a few deep breaths, and focus on things that you need to do in your life. Congratulate yourself on the steps you are taking to bring about recovery, even if symptoms persist for the time being. Another key component in healing is to challenge triggers that maintain symptoms. A trigger can be defined as a stimulus that leads to PPD symptoms, yet would not typically cause a symptom in someone else. Typical examples are weather changes, bright lighting, foods, wine or other alcoholic drinks, family gatherings, visiting certain people, places, movements, driving, and many others. Triggers become activated by subconscious processes in a similar way that Pavlovian responses develop (i.e., operant conditioning). Therefore, triggers cause symptoms because they activate learned neural pathways, and they can be attenuated by understanding this process and by actively challenging them. Avoiding triggers allows them to exert even greater effects, so patients should be encouraged to seek out these triggers and expose themselves to them in order to overcome them. It requires significant courage to begin to engage in exercise despite pain or the anticipation of pain. See Box 102.2 for a script regarding eliminating triggers. BOX 102.2 Sample Script for Reducing Psychophysiologic Disorder (PPD) Triggers When you notice you are encountering or are about to encounter any triggers to the symptoms or any stressful situations, immediately stop and take a deep breath. Take a moment to remind your mind that this activity or trigger will NOT cause any symptoms or problems any more. For example, if you are lifting an object, remind yourself, “This will not cause any back problems. My back is healthy and strong, and I can do this without worrying about hurting myself.” It is important to have a deep understanding that your body is healthy and that you can get better by using these methods. Keep reminding yourself that you will not be allowing your mind to produce symptoms at these times. Relax and breathe in order to decrease fear. Repeat positive phrases about yourself, your body, and your recovery when you encounter any of your triggers until your brain unlearns unwanted neural pathways. As previously mentioned, many patients with PPD have personality traits of being overly responsible, self-critical, and unassertive. Individuals with PPD often find themselves in situations in which they feel trapped or conflicted. They may be caring for an ailing parent who was abusive, work for a boss who is controlling and manipulative, or have a spouse or child who continually takes advantage of them. In these situations, it is often necessary to take action. Pain is often dramatically reduced when a difficult situation is resolved or ameliorated to a significant degree. It is often necessary to encourage patients and help them find assertive, yet civil, methods for dealing with these situations. Finally, individuals who have endured significant childhood and adult stressors and who have suffered with chronic pain often have a negative view of themselves and low levels of self-esteem and self-efficacy. Therefore, an overarching theme for guiding individuals with PPD to health is the development of love and compassion toward themselves. This can be accomplished by positive affirmations, meditations and visualizations, and encouraging them to stand up for themselves and take time for themselves. There are some excellent resources for helping patients achieve compassion for themselves.69, 70 Conclusion A significant proportion of people with chronic pain do not have a structural cause for this pain and are actually suffering from PPD. Biomedical approaches to PPD often lead to an endless cycle of pain and ineffective interventions. When a biomedical condition is ruled out, a careful interview will usually identify the priming and triggering events leading to the onset of pain. Education about PPD will help the patient discard the biomedical explanation for their pain and empower the patient to take control of their symptoms and their lives. Reversing PPD often takes time and a variety of cognitive, behavioral, and emotional interventions. However, it can be gratifying to help patients realize that their pain, even if it has persisted for many years, can be reversed or reduced. Key Web Resources Unlearn Your Pain: The website of Dr. Howard Schubiner Dr. John Sarno: The official website of John Sarno, MD Stress Illness: The website of Dr. David Clarke Dr. David Schechter: The website of Dr. David Schechter PPD/TMS Peer Network: A participant-oriented information site on psychophysiologic disorders, including a list of practitioners who practice in this area and an active forum RSI-Back Pain: A patient-run information site for people suffering with chronic painful conditions Pain Psychology Center: Counseling center specializing in PPD therapy via phone and Skype Defined Organized Comprehensive Care (DOCC) Project: Website of Dr. David Hanscom, a spine surgeon’s program that incorporates PPD References 1 J.K. Freburger, G.M. Holmes, R.P. Agans, et al. The rising prevalence of chronic low back pain Arch Intern Med, 169 (2009), pp. 251-258 CrossRefView Record in ScopusGoogle Scholar 2 S.A. McClean, D.J. 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