MECHANISMS OF MIND–BODY THERAPIES

In the field of Western medicine, we still do not fully grasp how and why many pain conditions develop—why a scanner gun dropped on a foot caused complex regional pain syndrome (CRPS) or why an imaging study failed to show structural evidence of lumbar pain. We also do not fully grasp why some develop a pain condition and others do not—surely many scanner guns have been dropped on many feet without the development of CRPS, and there exist many lumbar imaging studies that show deformation with no experienced pain condition.

There remains much that we do not know about many pain conditions, suggesting that there are portions of our explanatory medical model that are either not adequate or not yet clarified. The expanding interest and research findings in mind–body therapies speak to some of the gaps in the model of Western medicine.

To its credit, inductive experimentalism has yielded quite a number of cures and treatments. But the cost of this advancement was a necessary split in conceptualizing body as separate from the mind. In the scientific age, the mind has been considered a source of error for empirical studies, that is, the effects are contaminants to the “real” findings and must be parceled out. But we are beginning to see a reintegration of the mind into experimentalism—the mind as an independent variable in research studies. Whether it is research in the modulation of gene expression by psychosocial cues,¹ children learning to voluntarily increase oxygen perfusion in tissue,² or knowledge of how state-bound memories and experiences manifest somatically,^3,4 it is clear that mind–body therapies represent something real and progressive, even if not completely understood.

In this chapter, we examine some current mind–body therapies that are being used in the treatment of chronic pain. Some are well researched in terms of their efficacy and effects; some are hardly understood in their mechanisms of action. They mark a departure from the norm of medical treatments, and it may be for this reason that they are becoming increasingly popular. More and more, patients are rejecting modern pharmacologic approaches in favor of naturalistic treatments. They are seeking therapies that are holistic and self-empowering.

MIND–BODY THERAPY DEFINED

The National Center for Complementary and Alternative Medicine (NCCAM) defines mind and body medicine as focusing on the interaction among the mind, body, brain, and behavior, with the intent of using the mind to help establish health. Here we are concerned with therapies that can be used to help deal with pain conditions, including hypnosis, biofeedback, meditation, and relaxation, as well as some Eastern therapies such as Tai Chi and Qi Gong.

AVENUES OF ACTION

Mind–body therapies are thought to produce effect in a number of ways. Here we classify three main groupings for understanding the mechanism of dealing with pain: (1) analgesia, (2) psychological healing, and (3) physical healing. We will consider each in turn.

Analgesia

Analgesia is probably the most used and recognized method of dealing with pain in the mind–body approach. The ultimate goal is to decrease sensations of pain. Whatever structural abnormalities that might perpetuate the pain problem will remain, but the task in the therapy is to alter conscious perception in some way or another.

One way this can be accomplished is through the psychological process of dissociation, or splitting off, of streams of consciousness. Hilgard and colleagues^5–7 in a series of interesting hypnosis studies discovered the existence of a “hidden observer” in his subjects. When hypnotized and given suggestions of analgesia, there remained a nonconscious pain-experiencing aspect that could be communicated with. So although the conscious aspect of the individual reported analgesia, the nonconscious part indicated a pain level. This finding also correlated with the physical body showing signs of distress when pain was applied, such as increased heart rate.

Another avenue of decreasing pain sensation is what happens in various forms of relaxation. By inducing a general state of relaxation—a “good” feeling—the organism is less susceptible to the experience of pain. Another way of stating this is that whereas positive states decrease pain perception, negative mood states increase pain perception. Neuroanatomically, this ability is related to descending inhibitory tracts from brainstem to spinal junctures, modulated by serotonin and noradrenaline. This is the “pain gate”; in terms of “mind–body,” it is the “body” part.

Psychological Healing

This area deals with pain caused by what are called psychosomatic issues. Freud called it conversion; others call it somatization. Regardless of the name, in this section, we are concerned with how emotions, stress, and conflicts have been transduced into physical symptoms of pain. Here we will refer to it as psychosomatic.

“Psychosomatic” has acquired something of a pejorative tone in medicine, probably because it is poorly understood as an entity. Psychosomatic pain is no less real (to the experiencer) than pain of physical deformation, neuropathology, or inflammation. But in psychosomatic cases, the “pain generator” is not viewable through any of our current imaging technologies, which makes it difficult to diagnose. In addition, there is somehow less nobility attached to pain that is rooted in psychological conflict. Finally, patients are often resentful if a professional suggests that the pain may have psychological origins; it is easily interpreted as “it’s all in your head.” Yet it is nonetheless real as a pain experience.

Case 1 Jeremy presented with a lack of mobility bilaterally in his arms, in concert with generalized pain and episodic worsening, seemingly at random. Jeremy also had posttraumatic stress. Two years earlier, the crane he operated had tipped over; the outriggers failed while the crane boom was extended with load. In relaxation training, he noticed the pain increasing in his arms and was encouraged to attend to it. As he paid more attention to the specific sensations, he went back in time to the actual moments of the fall and crash. He recalled raising his arms to block his fall as the crane tipped. After the relaxation, he remembered his bracing against a part of the cab. He realized how his apparently random worsening of the pain was connected with stress and fears surrounding the incident. Remaining therapy consisted of working through unprocessed emotions connected to his pain. For example, his loss of bowel control during the incident did not fit with the “strong” culture of crane operators. With his memory brought to consciousness and the education that loss of bowel and bladder control was a common reaction in trauma, he was able to regain some of his mobility and to find relief from his pain.

For Jeremy, his pain was inextricably bound within a physiological state connected with the extreme of the trauma situation. In such instances, the memories are encoded within the state itself; the biological milieu is the memory and the state. Rossi explains how state-bound memories—memories and experiences encoded in a particular physiological state—exert influence in a number of ways, including pain. Because these state-dependent memories exist in an environment that is not the same as the conscious mind in everyday life, they therefore cannot ordinarily be addressed by the conscious mind. Mind–body therapies can provide access to such states, thereby opening a door for healing.

Physical Changes

A growing body of evidence supports the idea that actual physical healing occurs from the mind and that changes in consciousness make alterations at the physical level. The most basic route includes making outward behavioral changes such as exercising, doing yoga, or changing one’s diet. Stress often equates with negative health behaviors, such as increased alcohol and drug intake, decreased exercise, and so on. This is a behavioral level of mind–body healing. Although dismissed by many, engaging in such behaviors is very important in patients with chronic pain who suffer from the stress of loss of autonomy, loss of efficacy, depression, and so on. Making positive change—that is, getting better sleep, exercise, making healthier choices, and so on—is related to immunologic changes.⁸

At a more intricate level than basic behavioral changes, making physiological changes includes skeletal muscle relaxation, peripheral vasodilation, or reductions in blood pressure. These are frequently done in the mind–body therapies of biofeedback and relaxation training. They also can occur in hypnosis through suggestion and metaphor, as well as in meditation, yoga, and Tai Chi.

The most involved level of mind–body healing (at the current state of our knowledge) is exemplified by remarkable healing case studies such as Norman Cousins self-healing from ankylosing spondylitis⁹ or Klopfer’s 1957 account of the case of Mr. Wright. This account describes a man diagnosed with terminal lymphosarcoma and tumor masses the size of oranges. In an incredible account, after injection of an inert substance, the masses “melted” within days, and he became ambulatory and energetic.

We recognize these changes in a phenotypical manner, and it may seem that the morphologic changes themselves are the “miracle.” But the real miracle—the basis of such changes—occurs in a genotypical fashion: at the molecular and genetic levels.

AN EXPANDED VIEW OF MIND–BODY HEALING

At present, we do not understand such mechanisms of mind–body healing well enough to know how to reproduce them at will (from intention to manifestation), but we are beginning to understand them, some in rough outline form and others in more detail. Much work has been done in the area of psychoneuroimmunology (PNI), for example. Studies of the effects of “allostatic load”—the cumulative effects of long-term exposure to stress, along with the body’s ability to respond—demonstrate changes in hypothalamic–pituitary–adrenal (HPA) axis and immune functioning.¹⁰ Negative emotions, such as stress, anxiety, and depression, can up- or downregulate the production of proinflammatory cytokines implicated in chronic pain conditions such as arthritis.^11,12 In addition, this dysregulation then further inhibits immune responses. The loop feeds on itself, so disrupting such cycles is important for the pain practitioner and patient.

Going beyond PNI, Ernest Rossi,⁴ in The Psychobiology of Mind-Body Healing, outlines routes of mind–body healing, including the autonomic nervous system, endocrine system, and neuropeptide system. He emphasizes that all of these are avenues of information transfer, and although some of it is via nervous system, all of it involves messenger molecules such as neurotransmitters, hormones, cytokines, or peptides. In other words, according to this paradigm, all biologic, psychological, and physiological processes are essentially information processing systems, interacting with and influencing the others (Table 21-1).

The importance of these findings is that collectively they present the picture that psychology and physiology are tightly bound together, and the dividing line is less clear than was once thought. Event perception and meaning is traceable on the path through the HPA axis, distress or depression regulates production of cytokines, and emotions and stress are expressed through changes in gene regulation.^4,13 More than ever before, the picture that begins to emerge—and this is one of the highlights of mind–body therapies—is that there is much that can be done of personal accord, which has significant health effects.

HYPNOSIS (TABLE 21-2)

Case 2 Lydia’s search for medical relief of her pelvic pain of 12 years’ duration had left her bitter and resentful. In the initial interview, she was suspicious of the pain psychologist and answered few questions herself, letting her husband field most of them. She was depressed and anxious, stayed inside most of the day, and had no friends. Her only pain relief was her husband massaging her perineal area for 30 minutes every night. Many physicians had tried to help her with her pain, but the outcome was always the same. Lydia was introduced to hypnosis through basic relaxation methods, a cautious approach. In this way, she developed a skill of being able to find hypnotic trance easily. Her hypnotic treatment included posthypnotic suggestions, as well as ideomotor signaling. Soon she brought into treatment her realization of the beginning of her pelvic pain: after a prior relationship in which she had been anally raped on a repeated basis. She had accepted this abuse in exchange for financial security for herself and her son. She was able to exit the relationship and moved across the country in order to begin again. However, the move was disruptive for her son, and he took up drugs; left behind the idea of responsibility; and blamed her, her past relationship, and the cross-country move. As she brought up these conscious realizations, her talking through this helped her to recognize the no-win situation she was in and the connection between her trauma and her pain. She also acknowledged her guilt for moving, which (she believed) caused her son’s difficulties. Over a period of weeks, her pain began to subside. Not long after, when she terminated therapy, she was getting involved in community activities, making new friends, and considering returning to work.

In the clinical vignette, Lydia was first trained in methods of relaxation, and she became adept at developing deep relaxation. Because of this, her attention, or focus, could be guided fairly easily through metaphors and suggestions. Building the relationship over time and going slow allowed her to build trust in the therapist, which meant that she no longer felt the excessive need to defend through suspicion (judging and monitoring). Still, prior abusive experiences were never directly asked about but were indirectly referenced through posthypnotic suggestions as something that might be helpful in therapy. In this way, she was able to develop a sense of control (the root of her problem) yet was also able to bring it up for the necessary processing.

Common Elements of Hypnosis

Hypnosis is a unique mind–body therapy in that it can provide a route for the therapist to communicate with deeper, unconscious structures of the mind of the patient. Although there exists great debate about exactly what hypnosis is, for purposes of the current discussion we adhere to the following common elements reported by Don Price:¹⁴