1. www.eslinger.net1 The Pain Brain Connection The H.A.V.E. E. (TM) Model for Pain Management Ron Eslinger CRNA, MA, APN, BCH, CMI www.eslinger.net

2. 2 Objectives 1. Understand how the brain functions in chronic pain. 2. Understand the role of Cortisol. 3.Review methods in glove analgesia/anesthesia 4.Learn how to develop a treatment plan for chronic pain 5.Be introduced to the Sarno Mind Body Prescription for chronic pain 6.Tweaking the Friedberg eye movement technique 7.Discuss hypnosis for chronic pain. When does it end?

3. www.eslinger.net3 Perception of Pain the Friend

4. www.eslinger.net4 If Pain Perception is Misinterpreted What if the Brain does not understand the signal and sends back the wrong message? This can result in Chronic Pain that does not respond to conventional treatment.

5. www.eslinger.net5 When Pain Perception is Modified Pain can be modified by TENS, Massage, Acupuncture, and Hypnosis.

6. www.eslinger.net6 Neurotransmitters  Chemical substances within each cell of the nerve tract  They either pass the pain message on or stop it  Act as either pain killers or pain producers  Pain killers are — Serotonin — Endorphins — Melatonin People produce different amounts of these neurotransmitters, which explains why some experience more pain than others.

7. www.eslinger.net7 The Gate Control Theory  The Gate Control Theory proposes that a sufficient amount of stimuli can close the gate to the pain sensation.  “A” fibers transmit milder pain sensations or pressure faster than the slower “C” fibers so the simple act of rubbing an area that is hurting closes the gate to the pain.

8. www.eslinger.net8 Limbic System Parts & Location

9. www.eslinger.net9 Limbic System Functions  sets the emotional tone of the mind  filters external events through internal states (emotional coloring)  tags events as internally important  stores highly charged emotional memories  modulates motivation  controls appetite and sleep cycles  promotes bonding  directly processes the sense of smell  modulates libido

10. www.eslinger.net10 Limbic System Problems  moodiness, irritability, clinical depression  increased negative thinking  perceive events in a negative way  decreased motivation  flood of negative emotions  appetite and sleep problems  decreased or increased sexual responsiveness  social isolation

11. www.eslinger.net11 The Amygdala Remember by One Word FEAR Input - Sensory input that signals danger –Perception is truth –Response is to the perception real or not Out put - Must be able to control the Autonomic nervous system –Fight or flight It is involved with mood and the conscious emotional response to an event - Neg or Pos

12. www.eslinger.net12 The Hippocampus MemoryRemember by One Word Memory Three types of Memory –The first is short term is working memory – The second is Long-term or declarative memory –The third is procedural Memory

13. www.eslinger.net13 Working Memory Like the RAM of a computer –Adding numbers –Composing sentences –Following directions It does not become permanent memory

14. www.eslinger.net14 Declarative Memory Like the hard drive of the computer –composed of all the facts, figures, and names you have ever learned –All of our experiences and conscious memory are of this type Hippocampus is necessary to file away all this memory It is not know where memories are stored

15. www.eslinger.net15 Procedural Memory Probably the most durable form of memory –actions, habits, or skills that are learned simply by repetition The hippocampus is critical in laying down declarative memory –is not necessary for working memory –procedural memory –memory storage

16. www.eslinger.net16 Hypothalamus concerned with homeostasis Homeostasis is the process of returning something to some “set point.” It works like a thermostat So why is the Hypothalamus important to hypnotists?

17. www.eslinger.net17 Hypothalamus The hypothalamus is responsible for regulating your hunger, thirst, response to pain, levels of pleasure, sexual satisfaction, anger and aggressive behavior, and more. It also regulates the functioning of the parasympathetic and sympathetic nervous systems, which in turn means it regulates things like pulse, blood pressure, breathing, and arousal in response to emotional circumstances.

18. www.eslinger.net18 Psychoneuroimmunology A study of bi-directional interactions between the mind/brain, nervous system (endocrine system/hormonal release) and immune system. Mind & body are united by messenger molecules, the common communication channel between the emotions, sensations, thoughts, and images of consciousness and the molecular -genetic mechanisms of the Body. (Rossi, 1993, p.22)

19. www.eslinger.net19 The Nature of PNI Organs of the immune system (e.g., thymus, bone marrow, spleen, lymph nodes) are enervated by sympathetic nervous system (SNS), and have catecholamine neurotransmitter receptors Sympathetic nerve endings in these organs make contact with lymphocytes - thus, brain physically connected to immune system. The SNS being involved in mediation of feelings is connected to the immune system through brain and mind.

20. www.eslinger.net20 Cortisol - Stress Hormone It is an essential hormone for survival because it is responsible for producing and maintaining high levels of glucose necessary for the response to stress Can be destructive because –High Levels of glucose breaks down the protein in muscle and inhibits the replacement of calcium –Can contribute to these pain syndromes Fibromyalgia Rheumatoid arthritis Chronic fatigue syndrome Lupus Ronald Melzack & Patric D. Wall Handbook of Pain Management

21. Alpha Change CHANGE THE MIND CHANGE THE BRAIN THANGE THE BEHAVIOR

22. www.eslinger.net22 H.A.V.E.E. Hypnosis Affirmation Visualization Expectation Education

23. Why Hypnosis??  Mind/Body Therapy  Changes Stress Response  Improves Healing  Facilitates Rapid Recovery  Gives the Patient Control  Around since the beginning of time  Simple  It Works!!

24.  20% can reach a light stages of Hypnosis  80% can reach the medium stages of Hypnosis  20% can reach the deeper stages of hypnosis Hypnosis An Altered State of Consciousness

25. Affirmation & Coue’s Law Suggestions only become permanent with repetition Suggestions tend toward dominant effect Law of reverse effect Law of will power vs imagination

26. www.eslinger.net26 Self - Talk Affirmations Must Be Simple Realistic Believable Measurable Positive Present tense Rewardable

27. www.eslinger.net27 Meditate & Affirm I meditate 2 times daily and walk 20 minutes daily so that I am healthy and happy. Positive Affirmations I am relaxed and in control. I feel good. I control how I feel. I feel good.

28. www.eslinger.net28 Visualization Putting the Affirmations into pictures Albert Einstein uses creative day dreaming See yourself as you want to be as if you have already achieved it. Use the Limbic System

29. www.eslinger.net29 Expectations Play a central role in pain experience –Expectations of the hypnotists –Expectations of the Client Directly related to the placebo effect Self fulfilling prophesy How did they get the expectation they have?

30. www.eslinger.net30 Education Client –Pre session knowledge –Personal experience –Pre-talk –Handouts before and after session Hypnotist –Development of treatment plans –Are they prepared –Reading

31. www.eslinger.net31 How do we bring this together?

32. Suggestibility Conscious Analytical Subconscious Literal

33. Suggestibility Conscious Analytical Subconscious Literal

34. Suggestibility in Hypnosis Conscious Analytical Subconscious Literal

35. www.eslinger.net35 Limbic System Parts & Location

36. www.eslinger.net36 Catastrophizing From many practitioners those suffering from chronic pain take on the behaviors of Catastrophizing and Learned Helplessness. These are the people that have basically thrown in the towel and are coming to, or being referred to hypnosis because of the earlier mentioned confounded practitioner. That provider at the time of the referral will be a pivotal point. The provider sets the air of expectation and it can be either a negative (I doubt if it will help but try this) or a positive (this has been very beneficial to many and I think you will do well). Hypnotize yourself out of Pain now, Bruce N. Eimer, Ph. D., ABPP, 2002.

37. www.eslinger.net37 Pain Cycle

38. www.eslinger.net38 Assessment Tools Adult/Verbal Pain Rating Scales (12 y.o. and over) 0 1 2 3 4 5 6 7 8 9 10 No pain Moderate Worst Possible pain ComfortableUncomfortable Numerical Ratings Scale (NRS) - COMMAND CHOICE - Ask the patient to rate his pain on a scale of zero to ten, with zero being no pain and ten being the worst pain he has ever experienced.

39. www.eslinger.net39 Hypnotic Procedures for Pain Management  Glove anesthesia –o Numbness from local anesthesia –o Cold –o Arm or leg falling asleep  Bouncing ball  Shrinking ball   Erase pain scale (comfort level) as deepen hypnosis  Coloring book or computer graphics  Color  Warm orange colored liquid  Cell memory  Religious and spiritual needs

40. www.eslinger.net40 Why and what do you know about hypnosis What are the Concerns / Expectations The Basics –Gain Rapport today just learn to relax –Suggestibility testing –Explain Hypnosis –Expectations / Goals / Comfort scale / Sleep Scale –What do to me to make me feel like you (Brewer) –What do different if pain 2 points less Progressive Relaxation / CD Ego Strengthening / control / Sleep Home work First Session

41. www.eslinger.net41 Hart BASIC Assessment  Name:___ Date:____  Situation or Problem to be assessed:  What am I currently doing regarding the situation?  What are my emotions related to my behavior?  What Physical symptoms do I have related to my behavior?  How do I imagine myself related to my behavior?  What are my thoughts related to my behavior?

42. www.eslinger.net42 Second Session  Discuss previous session and home work self talk  Answer questions / self talk  Discuss Coue’s law of suggestion  Elman induction to Glove anesthesia  Memory image of dental work  Walk through the process  Remote control

43. www.eslinger.net43 Glove Anesthesia  Returning from the dentist and remembering the numb feeling of the jaw, lips and tongue  Putting ones hand into a cooler of ice reaching for a cold drink until the hand becomes numb  Having the hand or leg go “to sleep” after having the circulation cut off  Imaging putting the hand into a blue thick rubbery paint  The Dave Elman induction creates glove anesthesia without challenging or tasking the client 

44. www.eslinger.net44 Third Session  What do you want me to talk to you about today  Self induction  Warm orange liquid  Imagery, Visualization  TV seeing what is to happen  Block negative / accept Positive

45. www.eslinger.net45 Fourth Session  Self Induction or...  Reinforce  Glove anesthesia  Practice self Hypnosis  DOCUMENTATION

46. www.eslinger.net46 Eye Movement Techniques  From the Book, Eye Movement Technique for Emotional Healing by Fred Friedberg  Great for Calming and Stress Reduction  Eases Pain by dealing with the emotional aspects of pain

47. www.eslinger.net47 Eye Movement Techniques Steps 1. Sitting up focus on stressful feeling, image, or thought ask client to evaluate stress (1-10) 2. Rest hands, palms down own thighs 3. Tap back of hands with index fingers one at a time about 2 times a second 4. Do this for three minutes 5. Reevaluate stress (1-10) Start or continue hypnosis

48. www.eslinger.net48 Releasing Anger and Rage Three potential sources in subconscious 1. That which may have been generated in infancy and childhood and never dissipated. 2. That which results from self-imposed pressure, as in driven, perfectionist or goodist people. 3. That which is a reaction to the real pressures of every day life. James Sarno, Mind Body Prescription

49. www.eslinger.net49 Substitute for Morphine A raisin might not always be a substitute for morphine, but it appears that meditation can help people control their response to pain -- and their outlook on life. "The raisin exercise makes you aware of sights, sounds, scents, and tastes," says Benson. "Now I relax, slow down, and take time to appreciate things around me -- a bird or a cricket, the wind in the trees. Meditation makes my life a little more peaceful. It's made me a better me.

50. www.eslinger.net50 Self-Hypnosis Subliminal Tapes / CDs Can enable you to channel your ability to put your whole brain to work for you when you need it. May help the hypersensitive neurotransmitters and nerve endings to work to the client advantage. The format should aim at banishing negativity or frustration. For extremely analytical clients subliminal tapes can be a way to open the mind to the power of subconscious healing.

51. www.eslinger.net51 Questions????