Pain,addiction, and psychiatry

The first lesson of clinical medicine is to observe.  Listen.  Smell. Only then does one even consider touching or palpitation.

Pain is classified first and foremeonst into acute and chronic.  Then one considers if this is original or recurrent.  All this critical information is gained by asking the right questions and observing.  When did the pain begin.  What is the quality of the pain.  What it it’s nature.  Is it sharp or dull.  Crescendoing or steady.  What makes it worse? What makes it better?  Where is it on the body.  Show me.  Tell me.  Where does it begin. Does it radiate or move from that place. Has it changed?

With acute paint the response might be exactly the opposite to chronic or recurrent pain.  Acute back pain requires rest whereas chronic back pain requires excercise or at least stretching.  

Palpation begains as very gently hardly touching the area any more than as a feather might then moving deeper.  The examination elicits pain and is meant to especially to discover ‘rebound abdominal pain’ a diagnostic symptom elicited by deep pressure.  

The patient today seems to have watched too television or simple misinformation and nonsnese. They want instant relief but don’t even know that a good clinician can’t treat pain unless they have a diagnosis.  With appendicitis the pain migrates around the abdominun and the ‘movement and direction’ of the pain make the diagnosis.

Patients commonly think that there’s a ‘magic’ pain killer like a magic bullet, Even opiates which are the ultimate pain medication don’t work well in all cases.  NSAIDS and ASA are better for certain musculosketal conditions than opiates.  Placebo or mind over matter bedside intervention can reduce pain by up to 80%..  Bleech in the last ccntury showed that anxiety alone could account for 30% of acute pain,

When the pain is maximum the mind shuts off.  The body shuts off.  Torture is limited by this.  The Torturer has to keep waking the patient.  

The sense of aloneness that comes with pain is also coupled with a feeling of uniqueness.  Some people even think they are more sensitive that others and are making a case against themselves in the midst of pain.   All the platitudes, hope, faith make pain less. They work.  Too often warmth and fluid are needed more than pain medication,  For some pain warmth and fluid make pain worse.

The problem with ‘pain’ medication is that it interacts with other medications.  So knowing what a person has taken in that last 24 hours is critical.  Substances that are abused like alcohol or marijuana are ‘medications’ to the body and influence reactions of the medications given for pain.

Do no harm is critical in medicine.  

Be calm.  Use one’s mind to calm thee panic.  FMRI’s studies show that people indeed can consciously ‘calm’, still the breathing, stop moving.  Be patient.  It’s all counterintuitive when the body is shouting ‘flee’, “fight’, and thanks to Dr. Google and years of misinformation from Dr. Zuckerberg and social media, the immediate care givers are actually knowledgeable and trying to help you despite fearing the medical team is Dr. Joseph Mengele.

Chronic pain is commonly note to have more volume and excitement.  Acute pain is the most painful.  Chronic pain is often noted by ‘anger’ in the tone of despair.  In Acute Pain there is desperation more than accusation.  Recurrent pain is a different kettle of fish and is a specific kind of chronic pain.  Given that there is recurrence the examiner is vurious as to what is causing this pain which should have been treated the first time. Why has the pain returned. What is the nature of the condition that it is continuing.  Diagnosis becomes very important as important if not more important than with acute pain,.

There is also acute on chronic pain,.  This ‘new’ pain might signal some development which could be most significant.

Pain is a symptom as in acute pain but it can be a diagnosis and a disorder as in ‘phantom limb pain’.  Pain disorders are forms of ‘chronic pain’ and can reflect brain changes over time.

Patients with addiction histories, such as alcoholics or those who have used opiates or cocaine or marijuana, are very different in their presentation because their pain centres may be under responsive or over responsive.  Anaesthetism might need to give them 5 x the normal anesthesia pre surgery because of tolearnacce or they may be very sensitive and go into respiratory arrest with the normal dosage. They are especially difficult to treat as chronic pain patients because ‘acute’ on ‘chronic pain’ is often a problem with these patients.

Chronic pain is commonly associated with depression and anxiety and treating the depression or anxiety is often more effective than using ‘pain killers’.  

The pain ‘team’ has for decades included an internists, anesthetist and psychiatrist which indicates the importance of the mind in regards to the body.  

Therapeutic Hypnosis

I was a family physician in a country medical surgical practice when I first trained and obtained my Certificate of the American Hypnosis Society.  At the time time I was amused by the acronym, CASH, which limitted me from adding it to the list of medical credentials following my name.  I used hypnosis for minor surgery where standard anaesthesia would not be an advantage. The first example of this was a child cut where two sutures were required and using xylocaine freezing would have required me to insert two needles and then do two sutures. It seemed a good place to start using hypnosis. I did and it worked. Often thereafter I would formally hypnotize a person for suturing or other unpleasant medical procedures.  Later I'd do more advanced training with the Ericksonian Foundation. Milton Erickson, MD was the the father of american hypnosis.  Jay Haley, a psychiatrist who studied with psychiatrist Dr. Erickson wrote the book "Uncommon Therapies".  In family therapy the techniques employed in the Erickson method are called 'Strategic Therapy".  Training as a family , group and marital therapies I learned to utilize ideas and techniques which derived from the work of hypnosis.  When Cameron did a review of psychotherapy for the Ontario Medical, Psychiatric Societies and Government to assess which psychotherapies had been proven by 'evidence based research' and hence should be funded the Ericksonian or Strategic Therapy stood alongside Cognitive and Insight Psychotherapies.  It's validity is thus well proven by research but the training is much more exacting and extensive than Cognitive Behavior therapies which have a recipe workbook formulary approach.  The latter lack the elegance and intrigue that are associated with hypnosis but no one can fault their plodding success.  However one shoe doesn't fit all and having a variety of tools in one's tool box certainly helps.
I did 'sodium amital' interviews, which are a chemical 'truth serum' approach and give a somewhat similiar experience to hypnosis. A person can freely associate material that would not otherwise be available to conscious recall. However similiarly the 'learning' of this consciously suppressed or even repressed material doesn't immediately lead to resolution because a person must essentially be 'ready' for change.  Just because one says 'consciously' they want to change doesn"t mean they will change.  Too commonly there is too much overt and covert secondary gain associated with all manner of pathology.  Further change can be frightening as a new journey when the old way of being and behaving have become like comfortable old clothes no matter how much one may complain about them.
Hypnosis induction  begins with a state of relaxation. In classic hypnosis, the person being hypnotised sits comfortably and focusses their attention on the hypnotist then who leads them slowly with words or  other stimuli to what is true and obvious to what is not so.  In this regard, I might say, "You are sitting comfortable, breathing in and out".  The person is sitting comfortably breathing in and out so there is natural agreement.  I will continue to comment on observable phsiological behaviour, then get slightly ahead of the process so that now I'm commenting on what is observed and nudging the person further. "Your eyelids look heavy and I imagine they must feel heavy. They are getting heavier and heavier."  I will then use repetition and ritual to create a situation where the person is following the directions without feeling that this is forced. "Your breathing is becoming slower. Breathe more slowly in and out.  Your eyelids are growing heavier, close your eyes and listen carefully to what I am saying."  When the person is entering what is an observable first stage of trance I will then begin to tell them what I specifically want.  "You are going deeper, deeper into your unconscious. It is like sleep but you are not asleep because you can hear my words and follow what I am saying.."
From there it's just a matter of what you are using the hypnosis for. Sometimes these are combined. Visualization can be used to take a person to a restful calming place.  I used this technique even before I learned hypnosis as it is a common group relaxation therapy which I learned and taught when was doing creative drama and creative dance.  To create anaesthesia I would tell a person that they would feel no pain that their arm was separated from their mind and that while I was working on their arm their mind would be in another place.  When I wanted to do memory work I'd regress a person to the time of trauma and walk around the edges of the experiences carefully. Hypnotherapy was child's play after doing hypnosis for surgery. My original teacher was actually the Anesthetist hypnotist called in on major surgery cases where a patient was allergic to a variety of anesthesia.
Placebo is the term for positive self healing.  All healing might simply be induction of the innate self healing processes.  A neut our Darwinian distant ancestor can regrow tails and most of us most of the time have immunological systems that renew and revitalize us.  Hypnotherapy is often just induction of the placebo reponse (30 % of healing including healing of cancer occurs as 'spontaneous remission').
In contrast nocebo is the negative injuring limitting communication. "You have terminal cancer" is the classic nocebo.  Many doctors and many more 'healers' and all businessmen are great nocebo communicators. I remember learning to sell dancing lessons with the nocebo, "Your life will never be fulfilled if you don't learn to dance like Fred Astaire.'  The sales world is full of nocebo. Politics is worst.  "If you don't elect you me you're going to hell in a hand basket. If you elect the liberals you're going to die. If you elect the conservatives you're going to die too." Religion is a great place for nocebo too. "If you don't come up here and confess your sins before these strangers and let me whack on the head or half down you you will burn in hell."
The concern with hypnosis and hypnotherapy is that a person in this state is suggestable.  That's what makes hypnotherapy potentially more difficult than hypnosis for analgesia.  In hypnotherapy a suggestion can be planted. Interestingly, in contrast to the great stories of Mesmer and Svengali, girls and boys don't fall to having sex wantonly with hypnotists. Every young man courting is trying every possible 'suggestion ' to this end more often than not without success.  The techniques of hypnosis just like the techniques of sales  and elections would make a person willing to have sex more willing. perhaps.  However it's not so far possible to get a person who doesn't want sex to have sex with an unnattractive hypnotist.  Similiarly it's not possible with hypnosis to get someone to kill another.  There is There is this therapeutic protection in this area. The CIA and KGB nonetheless did extensive experiments to utilize hypnosis for their cold war efforts.  Dr. (Lt Colonel) Grossman in "On Killing" reports that the new training of soldiers uses many of the techniques gleaned from hypnosis research to encourage a young man's tendency to kill the enemy.  Dr. Colin Ross who used hypnosis early in the treatment of multiple personality disorders later wrote about CIA experiments in psychiatry.  A fascinating look at State and abuse of power for any of those who are concerned about the stigma of mental illness and interested in how the abuse of mentally ill persists today despite all the efforts at cover up.
I rarely do formal hypnosis in practice these days.  There's no funding to warrant it and it's best for a therapist to have a day or afternoon at least set aside for this form of therapy. Modern psychiatry is just too pressured with prescriptions and emergencies and external interferences and micro management from above and legal economic realities to allow for many of us to give hypnosis the time that is needed for the process. As a result it's more likely these days that counsellors and psychologists often with much less training are more likely to be doing hypnosis.  The greater the training the less like the nocebo.
Hypnosis is a marvellous training tool for observations on human behaviour.  Note above the essence of the hypnotic induction and consider the standard sales approach of shoe salesmen and politicians.  Note how they say, "you want a new pair of shoes" or "you want a good government".  Further they may go on and describe what that is. "The hook though is the switch where the person says "so you will buy these shoes and they will give you happiness."  "So vote for me and I will give you the good government you deserve. "  Televangelists and politicians are always using the techniques of hypnosis.  Hypnotists have the capacity to induce or reduce mass hysteria.  Hitler's techniques of communication coupled with the advent of loud speakers and radios allowed him to come to power in Germany and initially do good before leading that country to disaster.
The Jewish  On Line Internet site called the Nizkor Project encourages society at large to become more aware of these techniques of communication and misinformation as it is the hope of the founders of the Nizkor Project that never again will a Holocaust be possible. For it to occur there had to be a collective ignorance that only education and awareness can protect against.
Frogs into Princes was a delightful and very practical book on hypnosis written by two other students of Dr. Milton Erickson..  Richard Bandler and John Grinder developed Neuro linguistic Programming from hypnosis research.  Not surprisingly their books became instantly popular and sold richly in business psychology where salesman quickly so the value of their ideas.
More often today my own training in hypnosis influences the therapeutic communication that I use.  So many people who persist in having problems and symptons despite the standard listening therapies and passive therapeutic approaches can respond to the active approaches which developped in hypnosis.  Formal induction may not be that helpful.  A person who wants to stop an addiction has an agreed end with the therapist so the therapist can move that person to that end with techniques of hypnosis and strategic therapy coupled with 12 step facilitation and motivation therapy.  Hypnosis whether formal or informal then works best where there is an obvious agreed outcome. It's not 'explorative' like the communication techniques originally developped principally for the neurotic who lacked direction or meaning.