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EMDR treatment of Chronic Pain

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1 EMDR treatment of Chronic Pain
Mark Grant, MA London, 2-3 November, 2012 Sponsored by EMDR Association of UK Mark & Ana Grant

2 Aims of this workshop To understand the nature of pain and the contribution of trauma, personality factors and injury to pain. To develop assessment skills regarding the contribution of these factors to pain. To learn how to resolve and/or manage pain (both traumatic and ‘medical’ pain) using EMDR. To learn how to reduce impact of pain on clients identity and self-esteem. To learn how and when to integrate EMDR with other treatment modalities. To enjoy this learning experience. Mark Grant

3 Trauma and pain Mark Grant

4 Axel Munthe Mark Grant

5 Pierre Janet Mark Grant

6 Sigmund Freud Mark Grant

7 Trauma and pain “..result of exposure to an inescapably stressful event that overwhelms a person's coping mechanisms… The trauma response involves hyper-reactivity to stimuli and traumatic reexperiencing [as well as] psychic numbing, avoidance, amnesia and anhedonia. - Van der Kolk, 1994 “Somatization disorder is primarily one of autonomic/physiological trauma memory.” - Colin Ross Mark Grant MA

8 Pain ‘nociception + emotion’ - Price, 2000 “an altered brain state in which there may be altered functional connections or systems and … degenerative aspects of the CNS.” - Borsook et al., 2007 Mark Grant MA

9 DSM Categorization of pain
Pain disorder associated with psychological factors (eg; PTSD, depression) Pain disorder associated with both psychological factors and a medical condition (eg; some types headache pain, vaginismus) Pain disorder associated with a medical condition only (eg; cancer pain, arthritis) Source – DSM IV-TR Mark Grant MA

10 Pain disorders associated with psychological factors
Conversion disorder Somatization Disorder Pain Disorder Hypochondriasis Body Dysmorphic Disorder Mark Grant

11 Conversion disorder Motor symptoms;
Paralysis or weakness. Balance problems, swallowing problems, lump in throat Sensory symptoms; Visual problems, deafness, altered pain or touch sensations Seizures or convulsions; Like epileptic fits Mixed presentation Mark Grant

12 Trauma-related disorders
Acute Stress Disorder (ASD) Post Traumatic Stress Disorder (PTSD) Complex PTSD Borderline Personality Disorder Dissociative Disorders (DID, DDNOS) Somatoform Disorders (somatization disorder, conversion disorder) - Van der Hart, Nijenhuis & Steele (2006) New slide Mark Grant

13 Pain and PTSD Pribor = ref for 90% chronic pain in abuse survivors Kessler = PTSD 10% ref NVVRS Vets, 1993 Abuse survivors Perry, 1999 Mark Grant MA

14 Types of Trauma associated with Pain
Work accidents, MVA’s Abuse/Neglect Attachment problems Complicated bereavement Diagnosis of a life-threatening illness, Childbirth, abortion, Combat trauma, Exposure to political violence Tell the Michener story as simple example of how trauma can cause pain Heart attack – 1 in 8 ptsd Mark Grant MA

15 Types of pain associated with trauma (Diseases of Stress)
Immune system disorders Pelvic pain Abdominal pain Myofacial pain Chronic Regional Pain Syndrome (CRPS) Fibromyalgia TMJ Chronic Fatigue Syndrome (CFS) Headaches Chronic pain is one of the most studied symptoms associated with prior history of severe trauma – Scaer 2001 Mark Grant

16 2 main types of pain Nociceptive Pain (tissue damage)
Postoperative pain Mechanical low back pain Arthritis Cancer pain Neuropathic pain (CNS dysfunction) Postherpetic neuralgia Neuropathic low back pain Trigeminal neuralgia Chronic Regional Pain Syndrome (CRPS) Fibromyalgia Mark Grant MA

17 Mechanisms Psychological:
Insufficient safety and support ( < emotional distress ) Dissociation Affect regulation problems Neurological: Central sensitization Biochemical imbalances Hereditary: Genetic factors Physiological: Tissue damage CNS disorders Changed to incorporate van der kolks spectrum of trauma symptoms Mark Grant

18 Trauma-related symptoms
PTSD symptoms (eg; flashbacks, hypervigilance) Dissociative symptoms Affect regulation problems Somatization Depression Relationship problems Identity issues - van der Kolk (1996) New slide Mark Grant

19 Traditional view of ANS
Mark Grant

20 (social engagement system) Sympathetic adrenal system
Porges view of ANS Para-sympathetic MYLENATED (social engagement system) ventral vagal system Sympathetic adrenal system (Freeze response) Muscle tone + UNMYLENATED (shut down) Dorsal vagal system Muscle tone - ‘SAFE’ ‘DANGEROUS’ ‘LIFE-THREATENING’ Mark Grant

21 Insufficient safety &/or support
Increased likelihood of unhealthy behaviors. Poor self-care. Increased stress reactivity, and Decreased healing capacity. Mark Grant

22 Dissociation “..a traumatic event whose completion is truncated by lack of spontaneous resolution of a freeze/immobility response … is associated with a complex set of somatic pathologic events characterized by cyclical autonomic dysregulation, and an evolving state of vagal dominance involving primarily the dorsal vagal nucleus. The experimental model of kindling is intrinsic to the self-perpetuation of this pathologic process, driven by internal cues derived from unresolved procedural memory of threat, and enhanced by endorphinergic mechanisms inherent to both the initial response to threat, and subsequent freeze/dissociation.” ` Robert Scaer, 2001 Mark Grant

23 Dissociation “Endpoint of chronically experiencing catastrophic states of relational trauma in early life: progressive impairment of ability to adjust, take defensive action, or act on one’s own behalf, and a blocking of the capacity to register affect and pain, all critical to survival. - Shore, 1993 “..the younger a person is when flooded by trauma, the more likely that person will be to dread affective experience, leading affects to be mostly somaticized, poorly verbalized and poorly differentiated. - Krystal, 1974 Second quote not in orig handout Mark Grant

24 Dissociation “Pathology results when unprocessed experiences are … unable to link up with anything adaptive.” - Shapiro, 2007 “there is a sense of being cut off … from embodied existence… a fragmentation of the self… In dissociation the hemispheres are more than usually disengaged” - McGilchrist, 2009 Mark Grant

25 Mark Grant

26 Central sensitization
“Stressors have destructive effects on muscle, skeletal and hippocampal neural tissue, which may become the immediate basis of pain, or provide a basis for the devastating effects of later minor injuries in which the severity of pain is disproportionately far greater than would be expected from the injury.” - Melzack, 1999 Although most people tend to think of pain as a physical event, which should respond to physical treatments (drugs, surgery) we know its not Mark Grant

27 Pain in the brain The regions of the brain involved in memory processing that are implicated in PTSD include the hippocampus, amygdala and frontal cortex. While the heightened stress response is likely to involve the thalamus, hypothalamus and locus coeruleus. ACC “gates” the amygdala. PTSD = Also increased activity in insula. Reduced activity in PFC Deactivation of PFC Increased activity of emotional brain (amygdala, ACC, right insula) IBS linked to left-handedness Dancey et al, 2005 Increased reactivity in amygdala Mark Grant

28 Neurological changes Biochemical changes;
eg; reduced neurotransmitter levels, reduced BDNF Structural changes; eg; decreased grey matter in Fibromyalgia sufferers (x3 times normal ageing), reduced hippocampal volume Functional changes; eg; homeostasis problems, reduced communication between hemispheres, increased activity in dorsal horn area etc. Schema/body-map Altered body-image Mark Grant MA

29 Biochemical changes (from stress to pain)
Stress = increased cortisol. Cortisol breaks down the priotiens in muscle, to ensure high level of glucose, but this inhibits on-going replacement of caaalcium in bone = increased risk of fractures. Mark Grant MA

30 Genetic factors Needam:56 broken bones, 2 x broken back, shot x 1 – NO PAIN. Woman – fell as entering tube – CHRONIC PAIN 2 yrs + pain killers, physio etc. Worst singe acc = broken back. Punctured lung, 6 broken ribs, lost 3 teeth. Mark Grant

31 Genetic factors (PTSD)
Dysregulation of HPA axis Serotonin Dopamine GABA 5HT Heart rate variability memory problems NPY BDNF GR Physiology of hyperarousal axis Mark Grant MA

32 Genetic factors (pain)
PTSD Dysregulation of HPA axis Serotonin Dopamine GABA 5HT Heart rate variability memory problems NPY BDNF GR Physiology of hyperarousal axis Mark Grant MA

33 Implications Mark Grant MA

34 AIP model (EMDR) “Pathology results when unprocessed experiences are … unable to link up with anything adaptive.” “The stored memories contain within them the emotional and physical sensations of the frightening events.” “Present situations are viewed as triggers for past, unprocessed events.” - Shapiro, 2007. Mark Grant

35 AIP model and pain ‘As with traumatic memories, chronic pain may be a result of unassimilated neurobiologically stored memories related to the source of the pain itself (accident, onset of illness, and so on), the long-standing state of pain, medical procedures or other unresolved distressing events.’ - Bergmann, 1998; Flor, 2002, Schneider et al, 2007) Mark Grant

36 AIP model and pain. “Except for organic damage or lack of information, inadequately processed or inappropriately stored memories are the basis of all clinical pathology” Shapiro, 2009 Mark & Ana Grant

37 Implications from Neuroscience
“ Decreases in stress and manipulation of the HPA component of the stress system are likelier to produce pain relief … than traditional lines of therapy.” Kozin, 1993 “ In order to produce lasting effects, psychotherapy should restructure neural networks, particularly in the subcortical-limbic system which is responsible for unconscious emotional motivations and dispositions. ‘Insight’ or ‘appeal’ reach only corticohippocampal structures, which correspond to conscious memory and cognition, but have only very limited effects on the motivational system.” Fuchs, 2004 Mark Grant MA

38 Why EMDR? [EMDR is] Consistent with new theories of pain (eg; Neuromatrix, LAPs) incorporating memory, perception, central sensory dysfunction, and role of limbic system in augmenting pain intensity & suffering. - Ray & Zbik, 2001 Similarities and overlap between trauma and pain (physical, psychological & neurological) - Grant, 1998, 2002 Emphasis on affect (‘bottom-up’ approach) Research (over 10 published studies) Limitations of existing approaches Mark Grant MA

39 EMDR rx pain Fibromyalgia Conversion disorder
Chronic Regional Pain Syndrome Chronic Low Back Pain Chronic Fatigue Disorder Psycho-physiological dizziness syndrome Capsulitis Vaginissmus Phantom Limb pain Burn pain Mark Grant

40 EMDR treatment of pain research
de Roos CJAM, Veenstra, AC, den Holllander-Gijsman, ME, van der Wee, NJA, de Jongh, A, Zitman, FG, van Rood, RY. (2006) Eye Movement Desensitization and Reprocessing (EMDR) for Chronic Phantom Limb Pain (PLP): A preliminary study of 10 cases. Pain (In press) Grant, M (2000) EMDR: a new treatment for trauma and chronic pain. Complimentary Therapies in Nursing & Midwifery, 6, Harcourt. Grant, M. & Threlfo, C. (2002). EMDR in the treatment of chronic pain.  Journal of Clinical Psychology, 58(12),   Hassard (1993) Investigation of Eye Movement Desensitization and reprocessing in Pain Clinic patients. Behavioral and Cognitive Psychotherapy Journal Hekmat, H. Groth, S. & Rogers, D. (1994) Pain ameliorating effects of eye movement desensitization. Journal of Behavior Therapy and Experimental Psychiatry, 25,   Mark Grant

41 EMDR treatment of pain research
Mazzola, Alexandra, Calcagno, Marea, Lujon, Goicochea, et al., (2009) EMDR in the treatment of Chronic Pain. (2009) Journal of EMDR Practice and Research. 3(2)   McCann, D.L. (1992) Posttraumatic stress disorder due to devastating burns overcome by a single session of eye-movement desensitization. Journal of Behavior Therapy and Experimental Psychiatry, 23,    Ray, P., & Page, A. C. (2002). A single session of hypnosis and eye movement desensitisation and reprocessing (EMDR) in the treatment of chronic pain. Australian Journal of Clinical and Experimental Hypnosis, 30, 170–178. Schneider, Jens, Hofman, Arne, Rost, Christine, Shapiro, Francine. (2006) EMDR in the Treatment of Chronic Phantom Limb Pain. Pain Medicine (In press) Wilson S.A., Tinker, R., Becker, L.A., Hofman, A. & Cole, J (2000 September). EMDR treatment of phantom limb pain with brain imaging (MEG). Paper presented at thee annual meeting of the EMDR Association, Toronto, Canada. Mark Grant

42 Mazzola et al, 2009 Mark Grant MA

43 Mark Grant

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