Pain

05/18/08

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Psychological Aspects of Pain

“O poeta é um fingidor.
Finge tão completament
Que chega a fingir que é dor
A dor que deveras sente.”
Fernando Pessoa
POESIAS, Auto-psicografia, 1932.

           Healers have been relying on psychological insight to help suffering patients since long before the advent of modern medicine.  Shamanism, a collection of insights and techniques in use for well over 20,000 years and which is arguably the antecedent of the scientific method and of allopathic medicine – as well as of psychotherapy – is remarkably successful in relieving a wide range of ailments, often through manipulation of the patient’s  mental set, states of consciousness and belief systems (Krippner, 2000).  While the modern clinician has an impressive array of pain medications at her disposal, we do our patients and ourselves a great disservice if we ignore the crucial aspects of suffering that occur in the mind of the patient – and must therefore be addressed with psychological sophistication.  Pain is much more than a stimulus-response interaction involving the nervous system; pain is a complex interaction involving personality structure, sensations, thoughts, feelings, beliefs and emotions.  Each of these facets of the patient needs to be considered in designing an appropriate treatment protocol.  In the first edition of Bonica’s classic work on the management of pain (1953), he emphasized the importance of psychological considerations and the danger in over-reliance upon a mechanistic model of pain:
The crucial role of psychological and environmental factors in causing pain in a significant number of patients only recently received attention.  As a consequence, there has emerged a sketch plan of pain apparatus with its receptors, conducting fibers, and its standard function, which is to be applicable to all circumstances.  But … in so doing, medicine has overlooked the fact that the activity of this apparatus is subject to a constantly changing influence of the mind.
 
Note the last word of this passage.  In using mind rather than brain, Bonica reaffirms his point that it is the personality of the patient which is crucial to both the experience of pain and its treatment (in part II of this chapter, we will discuss the importance of the physician’s personality in pain treatment).  Indeed, one of the more frustrating aspects of pain treatment is the frequency with which a patient’s suffering appears to have no organic physiological source whatsoever.  In such cases, many physicians are at a loss to explain or relieve this all-too-real suffering.  The purpose of this chapter is to offer some introductory guidance to physicians who find themselves faced with such cases and to provoke some consideration of many fascinating, yet generally ignored, components of successful pain management.
 
 
You never identify yourself with the shadow cast by your body, or with its reflection, or with the body you see in a dream or in your imagination.  Therefore, you should not identify yourself with this living body, either.
 
--SHANKARA (A.D. 788-820), Viveka Chudamani (Vedic scriptures)
 
 
            You are dreaming.  In your dream, you are walking barefoot through a field of red, blue and yellow wildflowers.  You can feel the soft breeze on your face, the warm earth beneath your feet, the cool grass between your toes.  Suddenly there is a sharp pain in your right foot!  You look down and see a snake with its fangs set deep into the flesh of your foot, hot, red blood flowing over your skin.
To what extent is this experience real?  Most of us would agree that the field, flowers and snake are not real in any objective sense; they exist only in your mind.  But what of the terror you felt when the snakeattacked?  Clearly, your body responded as if your fear were real: your heart rate increased, adrenaline rushed into your bloodstream, you may have called out in your sleep, etc.  Indeed, you may well have experienced some or all of these physiological responses in just reading this paragraph.  It seems clear that although there was no actual danger to the physical body presented by the dream, the experience of fear was quite real.  We might say that fear belongs to that class of phenomena that exist in the world of experience alone.  That is, fear exists inasmuch as it is felt – regardless of the validity of the supposed danger.  The same may be said of pain.  Where there is suffering, there is pain.  So, in what way – if any – is imagined pain qualitatively different from real pain? 
Physicians familiar with cases of phantom limb pain know that it is not even necessary to have the corresponding neurological structures in the body to feel pain and/or other sensations in an appendage which does not physically exist.  That this phenomenon is not always attributable to trauma or neurological damage is confirmed by the fact that children born without a given limb can experience phantom limb sensation at that site (Ramachandran, 1994; 1996).  Similarly, patients under hypnosis often display physiological responses to non-existent stimuli  (e.g., developing blisters in response to being “burned” with a pencil) as well as an ability to ignore stimuli which would be considered extremely painful under normal circumstances (Hilgard & Hilgard, 1983).  The body often responds more to what we believe has happened than to what may actually have occurred.  Apparently – and not only in dreams – we can and do feel a symbolic body that is not our actual physiological body.
As these examples suggest, saying that the pain is all in the mind can be both true and untrue.  It can be true in the sense that the pain may indeed by psychogenici, but it is untrue in the implication that the pain is therefore somehow unreal. In other words, in the context of pain treatment, physicians may need to rethink their ideas concerning malingering patients.  Given the complexity and inscrutability of the symbolic symphony at play in any personality, it is virtually impossible – not to say unethical – to assert that any pain, with or without tissue damage, is somehow not real.  Just as a patient suffering from chills on a hot day is not reminded of the ambient temperature and sent home, we should avoid further pathologizing the patient’s all-too-real suffering by doubting its authenticity.  As we will be discussing in detail below, pain is often an expression of non-physical issues – what we might call psychological trauma – and is sometimes best seen as an attempt by the subconscious to call attention to (or, conversely, to obscure) a source of psychological suffering.  While not wishing to bore the reader with a long philosophical discussion of the nature of reality, we would simply like to remind him that philosophers have been attempting to demonstrated that there exists some objective reality at all outside of our perceptual framework for millennia.  None has yet been successful.  We are reminded of this humbling paradox each night by the urgency, vividness, and profound – if transitory – reality of our dreams.
The rest of this article will examine the phenomenon of pain from several different perspectives.  In Part I, we will examine the three psychological tools mentioned previously in the context of shamanism: mental set, belief system and states of consciousness.  Each of these time-tested approaches offers many opportunities for a modern physician to relieve the suffering of her patient.  Part II will offer a brief overview of pain from an evolutionary perspective, asking: why and how did our experience of pain develop?  Following this, we will briefly explore some of the implications for the physician or nurse who works in a pain-control unit.  We are particularly passionate about this last subject because there is very little discussion of the experience of the health care professional in the medical literature.  Knowing how to protect oneself must always be the first consideration in any helping profession and – given the clear psychological dangers of extended exposure to a constant stream of suffering patients – we feel strongly that this point receives far less attention in the medical literature and in medical education than it merits.
 
 
Part I.
Mental Set, Belief System and States of Consciousness
 
Pain as conversion symptom
 
Most psychologists and psychiatrists have a complicated relationship with the work of SigmundFreud.  That he is both revered and ridiculed, loved and hated, feared and disdained seems fitting.  But whatever history decides about Freud’s work in general, his recognition of conversion symptoms is of paramount importance.  Building upon this insight, psychologists have shown that many seemingly physical conditions are in fact psychological distress being converted to bodily expression.  Most of the research relating repressed emotions to pain has focused on perceived emotions such as fear, anxiety, anger or sadness (some of this research is discussed below).  But we should keep in mind that unconscious feelings can also be involved in pain conditions – particularly those involving chronic pain – as well as other conditions with unclear origin (see below).  In the Freudian interpretation, these conditions arise to distract attention away from the real problem.  If a patient suffering from obsessive-compulsive disorder has to wash his hands exactly fifty times per day -- always at ten minute intervals -- he will have little time or energy to think about deeper issues.  Similarly, pain can often serve to deflect attention away from deep-seated conflicts that remain unresolved in the psyche (Wickramasekera, 1998).  While this pain can sometimes be relieved with drugs or placebos, the symptom is likely to either return when the drug is withdrawn or to manifest in some other symptom (Sarno, 1998).  The clear lesson here is that psychogenic symptoms are not only frustrating and mysterious; they have a purpose.  Pain is a message.  The message may involve tissue damage or some difficulty in the psyche, but if the message is ignored or silenced without resolution, we have achieved only a short-term, symptomatic cure – and may well be inadvertently breaking the first Hippocratic oath: to do no harm.  In cases where the origins of the pain are unclear – or the characteristics of the pain are not clearly understood by the physician, a psychological/psychiatric consultation can be an invaluable help.  Indeed, we strongly believe that a psychiatrist and/or psychologist is an essential part of any well-equipped pain-control unit.  Without the sort of insight that only a well-trained mental health professional can offer to these conditions, misdiagnosis is extremely likely.  For example, many highly respected physicians have suggested that all chronic back pain should be assumed to be psychogenic until proven otherwise (e.g., Sarno, 1981, 1998; Weil, 1990).  The same might be said of a long list of disorders including but not limited to, fibromyalgia, temporomandibular joint syndrome, carpal tunnel syndrome, many cases of chronic pain, many dermatological disorders, irritable bowel syndrome, chronic fatigue syndrome, eating disorders, insomnia, sexual dysfunction, and so on.
 
 
Whatever the source of the patient’s suffering, his mental set, belief system and state(s) of consciousness will be important considerations in choosing the best treatment protocol.  Indeed, if the pain in question is psychogenic in origin, these considerations are of paramount importance; physiological approaches will be fruitless, at best; they may be potentially harmful, at worst.  Just as with non-psychogenic pain, masking the symptom without a full understanding of the message of the pain can easily lead to further damage.
Even if the pain is not psychogenic, the patient’s experience of his pain will certainly be affected – generally amplified – by these factors, and this experience is therefore open to modification via the same psychological factors.  In a recent book exploring developments in cancer treatments (Lerner, 1998), for example, we read that, “there is no question in the minds of many clinicians who work with cancer pain that many of the psychological approaches… routinely diminish, or sometimes even erase, cancer pain” (p. 482).  The author goes on to divide these psychological approaches to the treatment of cancer pain into the following five categories:
1.     Psychotherapy, based upon the assumption that the perception of pain occurs within a personal and interpersonal context.  The general assumption is that dealing with critical intra- and interpersonal issues will reduce the impact of pain.
2.     Hypnosis.
3.     Relaxation techniques and biofeedback.  Relaxation techniques include several types of yoga, meditation, progressive muscle relaxation, as well as autogenic relaxation techniques that use suggestions that the body is getting heavy, warm, or relaxed.  Biofeedback uses instruments to increase awareness of bodily states (blood pressure, heart rate, skin temperature, brain wave activity, and so on).
4.     Cognitive approaches, including assessment of beliefs, expectations and fears.
5.     Behavioral techniques focusing on the role of environmental reinforcement of pain.
Each of these techniques can be equally valuable for treating pain that is not related to cancer.
In looking over this list of techniques one might use in designing a treatment protocol, it becomes apparent how important belief structures become in the patient’s understanding and experience of his pain.  Indeed, suffering is perhaps best defined as the narrative structure and meaning we give to pain.  Sometimes, that narrative can profoundly alter the experience of pain.  One widely cited example of this phenomenon are the studies of wounded American soldiers in Korea and Vietnam.  Soldiers who had minor wounds that could be treated locally consistently reported worse pain than those who had been injured more severely, and were being sent back to the United States for treatment.  Seemingly, the meaning of the wound increased the pain for those who were being sent back into the war and lessened it for those who were being sent home – regardless of the actual severity of the wounds.  A study of patients suffering from chronic pain (Riley, et al., 1988) found that, independent of the pain levels reported, those who believed pain should inhibit their movement were the most inhibited.  In other words, the belief that pain implies disability was more determinant of disability than the pain itself.  Patients can often attribute maladaptive meaning to their experience of pain.  They can interpret the pain as retribution for their own failings in life, or they can see themselves as innocent victims of a cruel world.  They can link the pain (consciously or unconsciously) to rage against a parent, sibling or spouse.  These sorts of narratives impede the patient’s ability to respond to intervention or rehabilitation.  Psychological counseling is essential in recognizing and addressing these sorts of self-destructive interpretations.
Not all factors influencing the patient’s suffering are strictly internal, however.  One novel study, reported in Science (Ulrich, 1984), examined how pain sensitivity may be modulated by other types of sensory input.  In this retrospective study, ten years of records at a suburban hospital were examined, noting how much pain medication was  requested by patients recovering from gallbladder surgery.  Patients who were in rooms with a view of trees from their windows requested significantly less pain medication that those whose windows had no view of trees.  Other well-known studies have shown that psychological variables such as having a sense of control over treatment also dramatically alters the amount of pain medication requested (e.g., Jully and Sibbald, 1981; Citron, et al., 1986; Chapman and Hill, 1989).  In the United States, many hospitals provide televisions with several different 24-hour comedy channels in response to research showing that laughter decreases reported pain severity in patients, just as a sense of hopelessness increases such severity (DeVillis and Blalock, 1992).  Given the fact that feelings such as sadness, fear, anxiety and boredom tend to adversely affect the patient’s experience of pain, one wonders at the influence of the hospital setting itself on the patient’s prognosis.  Few places are more marked by these very emotions.  With this in mind, it seems clear that as soon as medically possible, pain considerations would suggest that moving the patient to an out-patient basis is generally advisable.
However, moving the patient to his home environment may introduce a new set of psychological issues to consider.  If the pain is in some way related to problematic relations among family members, a negative feedback loop is likely to develop in which the patient’s suffering is seen as a burden or indictment by the other family members (very complex dialogues can take place on a subconscious level without any of the participants ever becoming fully aware of what is being communicated) – who respond by defensively trivializing the patient’s experience.  This trivialization, in turn, may tend to provoke an increase in the severity of chronic condition(s) and/or an increase in the frequency of acute attacks.  When the physician becomes aware of this type of dynamic among family members, a psychological consultation is urgently called for.
To further complicate matters, we cannot discuss the psychological aspects of pain without considering the role of gender.  It is well-known that men and women experience pain (and practically everything else) very differently from each other.  Whether these differences are primarily biological or cultural in origin, it is common knowledge that women tend to have higher pain thresholds than men.  Men may also tend to find the role of being a patient more problematic, in that the vulnerability inherent in such a role is often a feeling quite unfamiliar and threatening to many men.  Similarly, men may attempt to mask or underreport the severity of their pain, for fear of seeming less masculine.  Ironically, this fear may actually be amplifying the pain they are attempting to hide!  Along with sensitivity to gender issues, we should attempt to be aware of the fact that in an increasingly heterogeneous world, cultural and ethnic differences in our patients may significantly alter the process of psychological assessment and treatment as well as the patient’s experience of pain (Turner and Romano, 2001).
 
 
As our Freudian dream illustrates, the configuration of consciousness is vitally important in how and whether any given stimulus will be experienced as pain – or experienced at all.  While allopathic medicine makes little use of the profound relationship between sensation and consciousness, the linkage is evident in many other contexts.  Virtually every known religious/spiritual tradition incorporates some pain-defying rituals – from the self-flagellation, fasting and kneeling on cold stone floors for extended periods common to Judeo-Christian and Muslim traditions to lesser-known rituals such as the Sun Dance (where the flesh is pierced and followers dance for hours or days without stopping) or sweat lodge ceremonies (where temperatures can reach 100O C for brief periods of time) of the plains tribes in the United States (see Weil, 1980).  In the Buddhist traditions, there are many examples of ceremonies in which the modification of consciousness is demonstrated and/or facilitated  by withstanding extremes of cold or heat, as well as maintaining difficult positions for extended periods (see Murphy, 1992 for an excellent review of these practices).  Martial Arts training typically involves learning various techniques for overcoming pain by restructuring the meaning of the pain.  Even body-builders attempt to reframe the meaning of pain with the expression: “No pain, no gain.”  In the world of sexuality, many people associate either their own experience of pain (masochism) – or that of others (sadism) – with extreme pleasure.
On November 16th, 1895, the editors of the Journal of the American Medical Association wrote what they thought was the obituary for medical hypnosis.  “Before many years the medical profession will drop hypnotism as a therapeutic agent,” they wrote (JAMA, 1895;25:867-868).  Luckily, they were wrong about the future of therapeutic hypnosis.  Hilgard (1979) compiled the following list of surgical procedures performed between 1955 and 1974 during which hypnotic pain reduction was used without chemical analgesics or anesthetics:
·      Appendectomy (Tinterow, 1960)
·      Caesarean section (Kroger & DeLee, 1957; Taugher, 1958; and Tinterow, 1960)
·      Gastrostomy (Bonilla et al., 1961)
·      Mammaplasty (Mason, 1955)
·      Breast tumor excision (Kroger, 1963)
·      Breast tissue excision (Van Dyke, 1970)
·      Skin grafting, debridement, etc. (Crasilneck et al., 1956; Tinterow, 1960; and Finer & Nylen, 1961)
·      Cardiac surgery (Marmer, 1959; and Tinterow, 1960)
·      Cardiac excision (Ruiz & Fernandez, 1960)
·      Fractures and dislocations (Goldie, 1956; and Bernstein, 1965)
·      Cervical radium implantation (Crasilneck & Jenkins, 1958)
·      Curettage for endometritis (Taugher, 1958)
·      Vaginal hysterectomy (Tinterow, 1960)
·      Circumcision where phimosis present (Chong, 1964)
·      Prostate resection (Schwarcz, 1965)
·      Transurethral resection (Bowen, 1973)
·      Oophorectomy (Bartlett, 1971)
·      Hemorrhoidectomy (Tinterow, 1960)
·      Facial nerve repair (Crasilneck & Jenkins, 1958)
·      Thyroidectomy (Kroger, 1959; Chong, 1964; and Patton, 1969)
·      Ligation and stripping (Tinterow, 1960)
In addition to these documented cases, there is a large clinical literature about hypnotic analgesia in childbirth.  American physician R. V. August, for example, reported that 58 percent of 850 deliveries for which he was responsible required no medication at all, while 38 percent required only mild analgesics such as Demerol, and only 4 percent (36 of the 850) required a local or general anesthetic (August, 1961).  In a survey of 210 childbirths reported in the British Medical Journal, women taught autohypnosis suffered significantly less pain during labor than women who were taught relaxation and controlled breathing or given no training at all (Davidson, 1962).  More recent studies have come to the same conclusions.  A recent study by a panel of experts convened by the National Institutes of Health (U.S.A.) found “strong evidence for the use of relaxation techniques as well as hypnosis” (Richmond et al., 1996).
Because its mechanism(s) of action remain unclear, many physicians are hesitant to refer patients for hypnotically-facilitated psychotherapy, despite the complete absence of any potentially harmful secondary effects associated with these techniques.  While this seems to be a logical reaction to a somewhat mysterious phenomenon, we should not forget that we have an incomplete understanding of many of the medications we use regularly.  The mechanisms of even the most common pain-relief medication on earth (aspirin) was not fully understood until more than half a century after its use became widespread!  While Prozac remains one of the best-selling drugs of all time, neurologists continue to learn more about how it works.  In fact, many accepted medical procedures are receiving renewed scrutiny as Evidence Based Medicine (E. B. M.) gains popularity.  The results suggest that misunderstanding the mechanism of action is more a problem than not understanding it at all.  That is to say, the discomfort many physicians feel toward hypnosis may be due more to the fact that there is no popularly-accepted hypothesis for how it works, rather than to the absence of hard data supporting this hypothesis. In truth, we probably don’t understand as much as we think we do concerning many medical procedures. According to a recent article in the journal Patient Care, ‘‘Some experts estimate that only 20 percent of medical practices are based on rigorous research evidence’’ (Flaherty, et al., 2001).  The same article presents evidence contradicting the validity of many procedures and beliefs thought to be well-documented (e.g., do not give analgesics to patients suffering from abdominal pain, efficacy of bed rest for acute low back pain, immobilization for uncomplicated ankle sprains, antibiotic treatment for acute bacterial sinusitis, and so on).
Despite all that we do not know about hypnosis, there are a few things we do know.  For example, it seems that hypnotic effects are not due to endorphin release.  Hilgard and his associates administered naloxone, an endorphin-blocker to subjects given suggestions for pain reduction.  Because their subjects’ analgesia was not significantly altered by the drug, it seems that hypnotic suggestion is mediated by mechanisms other than endorphins.  Further experiments confirmed these results (Goldstein & Hilgard, 1975; and Spiegel & Leonard, 1983).  We also know that hypnotic effects are highly dependent upon the hypnotic ability of the patient – which may be another cause for physician discomfort.  Hypnotic ability can be easily assessed by any properly-trained psychologist or psychiatrist before attempting the techniques.  So, while there may be controversy and mystery concerning how hypnosis works, that it often does work has been clearly demonstrated repeatedly for well over a century.
 
Part II—The Evolution of Pain
 
Why Pain?
 
In the case of tissue damage, the function of pain is clear.  People suffering from pain asymbolia – who are unable to feel pain as such – rarely live beyond 30 years of age, due to joint degradation and other problems.  It is impossible to monitor the state and functioning of one’s body without the type of feedback that pain represents.  But as the previous section of this article makes clear, pain can be far more than a simple a warning of damage to the physical body.  Many things that harm the body are not painful at all – alcoholic drinks, smoking tobacco, extended periods without physical exercise, and so on.  And we all know of healthy activities that can be somewhat painful.  So physical pain -- seemingly much simpler than psychogenic pain – may not be so simple, either.
 
 
[I]t is not a little remarkable that sympathy with the distress of others should excite tears more freely than our own distress; and this is certainly the case.  Many a man, from whose eyes no suffering of his own could wring a tear, has shed tears at the sufferings of a beloved friend.
--- Charles Darwin, “The Expression of the Emotions in Man and Animals” (1872, p. 216)
 
 
Beginning with Charles Darwin, the question of compassion has been a problem for evolutionary scientists (see Ridley, 1996 for a full discussion of the problem).  What is the evolutionary advantage of feeling another’s pain?  Each of us has plenty of pain – both physical and emotional – in our own life; why add other’s pain to our own burden?  Various explanations have been offered over the years, but none has been conclusive.  The question remains open and highly perplexing to those who look for consistent rationality in human design.  Whatever the origins and purpose of compassion may be, that it exists is certain.   One of the best places to find it is in hospitals.
In Europe, students who want to earn a lot of money generally don’t study medicine.  Here, the study and practice of medicine are not likely to lead to significant wealth.  The struggle is the same: long years of uninterrupted study, demanding professors, intense competition among students for limited spots in specialty training, sleepless nights, and so on.  But the list of possible rewards is unlikely to include the five-car garage, indoor swimming pool and 10-bedroom house many American medical students bring to mind when they need motivation to keep working.  So what kind of person decides to subject themselves to so much pressure and stress to become a doctor in Europe?
Think of the people you work with, the people you studied with in medical school.  What were they like?  Are there any characteristics that are common to most of them?  In our experience, physicians in general – and European physicians especially – tend to be people who are highly motivated by compassion.  They choose medicine as a career because they want to help other people in a meaningful way.  Whatever the origins of this mysterious emotion may be, it is one that most physicians feel profoundly.
Of course, empathy for your fellow man is not enough to get you through medical school andresidency!  You have to be focused, serious, responsible, self-sacrificing, and highly intelligent as well.  You have to respect authority and learn to absorb vast quantities of information without wasting too much time or effort questioning the source.  You need to have a great deal of faith in science.  And, perhaps most importantly, you need to have a great deal of faith in yourself and your abilities in order to confront life-or-death situations.  Your patients trust you in ways they trust no-one else, and this implies a great deal of responsibility.
These are all highly admirable qualities – but they come at a price.  If we can say that there is a certain personality profile common to many physicians – and we believe there is – then this profile certainly contains empathy as one of its central elements.  Empathy is essential in putting patients at ease, necessary to getting a complete medical history, and vital to the fine art of diagnosis.  But empathy can also be crippling to a physician.  The suffering of patients can seep into our own personal lives and become our own suffering.  As Darwin noted long ago, this sharing of other’s suffering is – mysteriously but unmistakably – a basic part of human nature.
Many physicians are painfully aware of the dangers of their own empathy and respond by walling themselves off from their patients.  Yet too little empathy can create its own set of problems.  It can be perceived by patients as coldness and arrogance, create barriers to open communication, and interfere with accurate diagnosis.  Furthermore, this sort of emotional distance does not solve the basic problem, and as discussed earlier, emotional problems that are ignored or repressed without resolution simply return in other forms.
Physicians working with pain are in a particularly dangerous position in terms of maintaining their own psychological health.  If empathy is basic to human nature, then simply being in the presence of pain is in itself unavoidably painful.  There is no way to deny or alter this aspect of ourselves.  The way this issue is generally handled in medical education is to ignore it completely – or to teach students that empathy is to be cultivated, while sympathy is to be avoided.  But what distinguishes one feeling from the other?  To what extent can we understand a patient’s pain without sharing some aspect of it ourselves?  To what extent can we truly understand the concept of saltiness without having tasted salt – and recalling the experience – ourselves?  This is one area in which the disconnection between psychology and medicine is especially unfortunate.  Doctors – as students and afterwards – are taught to deny and ignore the sometimes traumatic effects the practice of medicine can have onthemselves.  This is similar to the all-too-common situation of the physician who hasn’t slept for days, eats only an occasional sandwich from the hospital cafeteria and steps outside only for a cigarette lecturing her patients about the importance of diet, sleep and exercise!  And when the effects of this stressful, unhealthy life-style begin to take a toll on the physician, she cannot even turn to colleagues for help in many cases because this will then bring the shared secret of the inherent dangers of practicing medicine into the spotlight.
With the hope of offering some support in this very difficult situation, we would like to offer the following observations:
·      It is simply not possible to be unaffected by the suffering of our patients.
·       We can deny that we are affected; we can erect walls between ourselves and our patients, as well as within ourselves – but this is a symptomatic response.  Eventually, this conflict will be expressed – either somatically (e.g., hypertension, heart disease, hair loss, dermatological problems, etc.) or psychologically (e.g., “doctor burn out,” depression, problems with alcohol or other drugs, relationship/sexual problems, insomnia, and so on).
·      Physicians – especially those working with pain – should be aware that they are working in a highly toxic psychological environment.  Like professionals who work around radioactive materials, physicians should constantly monitor themselves for signs of over-exposure and take appropriate action when necessary.
·      We must admit to ourselves that we are not infallible.  If our motivation is to help our patients, we have to accept the fact that our ability to do this is compromised by too much stress, too many hours, too many patients.  Although it may feel counter-intuitive, we do our patients and colleagues a favor by taking some time off.
·      Although we are needed by our patients and colleagues, we are not essential.  Being a little selfish is a necessary part of helping others.
·      We should try to reserve time to cleanse ourselves of the stresses of our professional lives.  Exercise, meditation, guided relaxation and hatha yoga are all excellent ways to take the mind’s focus off our problems for a while.
·      When signs of problems appear, we should not feel ashamed or hesitant about seeking psychological help.  While it is relatively easy to treat our own infections and other minor medical problems, it is not possible to treat our own psychological problems.  An outside perspective is essential.
 
Working with patients who are suffering from significant pain – whatever its etiology – carries inherent psychological dangers for the physician.  These dangers must be acknowledged to be guarded against.  An awareness of some of the ways in which psychological distress can manifest in the body and behavior is essential for helping our patients, and for maintaining our own health as well.  Pain may be one of the most difficult conditions to treat, but the opportunity to help alleviate a patient’s suffering is as important and rewarding as it is difficult.
REFERENCES
 
August, R. V.  Hypnosis in obstetrics.  McGraw-Hill, 1961.
 
Bonica, J.  The management of pain. Philadelphia: Lea & Febiger, 1953.
 
Chapman, C. and Hill, H.  Prolonged morphine self-administration and addiction liability: Evaluation of two theories in a bone marrow transplant unit.  Cancer 1989;63: 1636.
 
Citron, M., Johnston-Early, A., Boyer, M., et al. Patient-controlled analgesia for severe cancer pain.  Archives of Internal Medicine 1986;146: 734.
 
Davidson, J. A.  An assessment of the value of hypnosis in pregnancy and labour.  British Medical Journal 1962;4: 951-53.
 
DeVillis, B. E., and Blalock, S. J. Illness attributions and hopelessness depression: The role of hopelessness expectancy.  Journal of Abnormal Psychology 1992;101: 257-264.
 
Flaherty, R. J., Friedland, D. J., and Paauw, D. S.  Medical myths: Today’s perspectives.  Patient Care 2001;17: 34-51.
 
Goldstein, A., and Hilgard, E.  Lack of influence of the morphine antagonist naloxone on hypnotic analgesia.  Proceedings of the National Academy of Sciences 1975; 72: 2041-43.
 
Hilgard, E., & Hilgard, J.  Hypnosis in the relief of pain.  William Kaufmann, 1983.
 
Jully, C., and Sibbald, A.  Control of postoperative pain by interactive demand analgesia.  British Journal of Anaesthesiology  1981;53: 385.
 
Hilgard, J. Personality and hypnosis: A study of imaginative involvement. University of Chicago Press, 1979.
 
Krippner, S. The epistemology and technologies of shamanic states of consciousness. Journal of Consciousness Studies 2000;7: 93-118.
 
Lerner, M.  Choices in healing: Integrating the best of conventional and complementary approaches to cancer. MIT Press, 1998.
 
Loeser, J. (ed.). Bonica’s management of pain. Lippincott Williams & Williams, 2001.
 
Murphy, M. The future of the body: Explorations into the further evolution of human nature. Jeremy P. Tarcher, 1992.
 
Ramachandran, V. S. Phantom limbs, neglect syndromes, repressed memories and Freudian psychology, Int Rev Neurobiol 1994;37: 291-333.
 
Ramachandran, V. S.  What neurological syndromes can tell us about human nature: Some lessons from phantom limbs, Capgras’ syndrome, and anosognosia.  Cold Spring Harbor Symposia 1996;LXI: 115-134.
 
Richmond, J., Berman, B.M., Docherty, J.P., et al. Integration of behavioral and relaxation approaches into the treatment of chronic pain and insomnia. Journal of the
American Medical Association 1996; 276: 313-318.
 
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i The word, psychogenic has come to replace the perfectly adequate term psycho-somatic because of the negative connotations that gathered around the latter term over the years.  As argued in this paper, there is no reason to suppose that a mind-body (psycho-somatic) phenomenon is any less real simply because its etiology and treatment are more complex and less well-understood than other ailments.

 

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