By Guy Odishaw, RBCST
A brief holistic (integral) look at chronic pain.
Integral Theory based on Wilberian Philosophy breaks the world up into 4 categories based on language.
Here are some examples of Chronic Pain factors plugged into the Integral model.
In a holistic approach we must honor each quadrant equally. One quadrant is not more ‘real’ than another.
An integral treatment plan would include at least one modality from each quadrant.
An integrally informed practitioner would have at least a basic understanding of how the patient’s
needs are reflected in each category and what modalities would address those needs.
#1) The problem with pain:
Pain is a subjective experience.
It can not be weighed, measured, scanned, palpated or otherwise perceived by an other.
#2) Because of #1 people with chronic pain are subject to doubt, marginalization and shaming from healthcare providers, employers, friends and family. In most cases this serves to increase their pain.
#3) Pain is a bio-psycho-socio-cultural phenomenon and must be treated as such. It is not merely a physical condition.
#4) The experience of pain can be learned. That’s the easy part, unlearning pain can be difficult. Do not grin and bear it.
#5) Neuroplasticity – the brain’s ability to rewire its self – can work against you in chronic pain by increasing the neurons registering your pain.
#6) The state of your mental health plays an important role in your susceptibility to and recovery from chronic pain.
#7) Complimentary & Alternative Medicine (CAM) modalities can be very effective in the treatment of chronic pain.
#8) 100 Million Americans suffer from chronic pain. More than the top 3 health conditions combined.
#9) Chronic pain costs our economy an estimated $550 Billion a year.
#10) Chronic pain is the #1 Public Health epidemic at nearly 4 times the rate of #2 Diabetes.
For those who would like a little more….
#1) The definition of pain, “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage….Pain is always subjective….It is unquestionably a sensation in a part or parts of the body, but it is also always unpleasant and therefore also an emotional experience.” – SOURCE: IASP, 1994.
“Most chronic diseases involve multiple physical, cognitive, and emotional factors. While chronic pain shares many attributes with other chronic diseases, it also has distinct characteristics. For example, pain, especially chronic pain, can lack reliable “objective” measures, and it has strong cultural, religious, and philosophical meanings that affect (and serve as context for) a person’s pain experience. Because all people experience some degree of pain at some time, moreover, they often do not realize how chronic sever pain differs in its character and effects from the relatively mild and easily treated pain with which they are familiar.
The IASP definition emphasizes that pain is a subjective experience. Other people cannot detect a person’s pain through their own senses: it cannot be seen, like bleeding; it cannot be felt, like a lump; it cannot be heard, like a heart arrhythmia; it has no taste or odor; and it often is not confirmed by x-ray or more sophisticated imaging procedures. No current clinical tests for pain are analogous to temperature, blood pressure, or cholesterol measurements. Clinical findings that can be seen—a broken bone on an x-ray, for example—do not necessarily correlate well with the severity of pain the patient perceives. People afflicted by pain may find the rough tools of language inadequate to convey the character and intensity of their experience and its significance to them. This can be a substantial barrier to obtaining adequate treatment (Werner and Malterud, 2003).” – Source 2010 IOM Relieving Pain In America
I agree with their definition and the commentary on it from the IOM but I still think they have kept the definition too narrow. There is too much emphasis on the body as the origin of the pain or the place it manifests. This does not allow for the emotional self or the mental self to be the origins of pain and the site of manifestation. I have clients how say their mind hurts, when asked to locate it they will often indicate their head. But give permission to express a location without reference to their bodies they indicate a nonphysical reference point for their pain. This makes perfect sense to me with my background and training but I can see how conventionally trained healthcare providers could struggle with this.
#2) “‘Stigma’ was documented by Goffman in the 1960s and has since been widely applied to groups suffering from a variety of physical and mental conditions including chronic illness [58]. Although chronic back pain is not itself visible, its behavioural manifestations, including help-seeking, can be perceived in everyday life through interaction with others. But as previous authors have noted, it is the very invisibility of pain that brings about most of the problems of being ‘discredited’ [59]. The stigmatisation of those with chronic pain is evident in 20th Century literature which sought to identify the ’pain-prone personality’ [60] and attribute pain complaints to secondary gain [61]. As a result, those with ‘chronic pain syndrome’ are subject to disbelief by the lay public as well as professionals who label these patients as psychologically damaged or deviant. Resistance of these stigma appeared to lead some of our participants to engage in activities, such as helping others, likely to exacerbate their pain.
These participants were at the point of entry into a service that is often regarded by those with chronic pain as their ‘last resort’. However, as Eccleston et al [28] documented, the beliefs of patients and health professionals may be diametrically opposed – patients seeking biomechanical explanations and medical treatments, and professionals offering psychological explanations and interventions. Patients attending pain clinics are often confronted by mixed messages. The sign over one such clinic reads ‘Pain Relief Clinic’, indicative of an environment that encourages the sick role [59, 12]. The chronic pain treatment model has only recently changed to one of self-management, rather than cure [62, 63]. No wonder patients may feel confused and dismayed by their interactions with health care professionals [28]. “– source The stigmatisation of people with chronic back pain. Immy Holloway a, Beatrice Sofaer-Bennett b, Jan Walker c, In press in Disability and Rehabilitation
#3) “Research has identified a particular style of thinking—“pain catastrophizing”—as a common maladaptive cognitive response to the experience of pain, particularly chronic pain. When people “catastrophize” their pain—that is, when they tend to ruminate about their pain, magnify pain sensations, and feel helpless about their ability to manage it (in other words, when they believe pain will lead to far worse outcomes than it will)—they not only increase their pain and dysfunction but also slow their recovery and adjustment. Therefore, these catastrophic beliefs must be assessed and addressed (Sullivan et al., 2001; Keefe et al., 2009). Pain catastrophizing interacts closely with the pain-avoidance fears…” – Source 2010 IOM Relieving Pain In America
Pain is not merely a physical event. Pain may be caused by and certainly mediated by:
• Emotional state • Mental state • Social status
• Cultural beliefs and bias’s • Physiology • Brain chemistry
• Sleeploss • Memory • Time
• Intensity • Placebo/nocebo effect
| Factor | Negative Impact | Positive Impact |
| Emotional State | Fear increases pain | Joy decreases pain |
| Mental State | Pessimistic increases Pain | Optimistic decreases pain |
| Social Status | Poor or minority increases pain | Privileged decreases pain |
| Cultural Beliefs | ‘Doctors are bad’ increases pain | ‘Doctors are good’ decreases pain |
| Provider Bias | Racist/classist increases pain | Egalitarian decreases pain |
| Physiology | Hyperinflamitory increases pain | Balanced decreases pain |
| Brain Chemistry | +/- serotonin increase pain | Balanced decrease pain |
What you don’t know you know can help you or hurt you.
The Placebo and Nocebo effects:
Most of us are familiar with the placebo effect, you take a sugar pill and feel better because you believed you were taking something that was going to help you.
The nocebo effect has had much less press and much less research but in some ways more is known about this phenomena. The nocebo effect is the opposite of the placebo effect. You have a negative experience because you believe you should. A great example of this is pharmaceuticals. Before a drug is advertized on TV it will have a certain incident of reported side effects once TV advertizing begins side effects increase proportional to the region and amount of advertizing. Side effects most frequently reported are the ones listed in the commercial.
Another place this shows up is informed consent, when your healthcare provider tells you all the things that could go wrong in your treatment. You are more likely to suffer one of those outcomes for no reason other than you were told it was possible. Do you still want to be informed? This is a current and ongoing debate within medicine today. There are many astounding research based examples of the nocebo effect at work.
For example: “In 1987, a team of doctors in Ontario, Canada, suspected that medical consent forms might actually cause harm. Using the chance occurrence of two different consent forms being used for the same drug trial, they compared patient reactions to the wording of the forms. The trial pitted aspirin against sulfinpyrazone, a medicine already approved to treat gout, as a treatment for chest pain. Patients at two of the three centers hosting the trial were informed that “side effects are not anticipated beyond occasional gastrointestinal irritation and, rarely, skin rash.” At the third center, patients’ consent forms did not mention gastrointestinal effects. Seventy-six patients out of 399 (19 percent) given the first consent form that mentioned GI irritation withdrew from the study, citing GI issues, compared to just 5 out of 156 (3 percent) who received the second form.” – source Worried Sick By Megan Scudellari. M.G. Myers et al., “The consent form as a possible cause of side effects,” 42:250-53, 1987.
#4 & #5) “Functional neuroimaging also has yielded information about the brain regions involved in the cognitive and emotional factors that modulate pain, including attention (Petrovic et al., 2000), anticipation (Koyama et al., 2005), fear/anxiety (Ochsner et al., 2006), empathy, reward (Ochsner et al., 2008), placebo, and direct control (Younger et al., 2010a). Such studies have demonstrated that pain evokes a response in multiple areas of the brain—a “distributed network”— consistent with the variety of physical, affective, cognitive, and reflexive reactions to pain that people experience. Additionally, the involvement of multiple brain areas and their independent, parallel organization for transmission of nociceptive information are “quantitatively related to subjects’ perceptions of pain intensity” (Coghill et al., 1999, p. 1939). These same brain regions also have been observed to undergo plastic changes as a consequence of chronic pain, changes that are visible only now because of these new technologies.
Researchers also have used structural neuroimaging to characterize anatomical changes in the brains of people with chronic pain. Although structural imaging yields no direct information about neural function, it provides indirect information about how chronic pain affects central plasticity and identifies the anatomical differences between people with chronic pain and those who are healthy. For instance, researchers have demonstrated abnormal gray matter changes in the brains of people with chronic low back pain, fibromyalgia, and temporomandibular disorders (Apkarian et al., 2004; Kuchinad et al., 2007; Younger et al., 2010b). Structural imaging can be used to track longitudinal changes due to disease severity and progression and can characterize changes following treatment.
While there is great interest in understanding the function and structure of individual brain regions, researchers increasingly are appreciating that the manner in which these brain regions are connected (i.e., networked) may be more important in understanding pain. For example, a growing body of research is focused on examining resting state functional connectivity changes in the human brain. The theory is that the brain defaults to an intrinsic pattern of brain networks when at wakeful rest. Several abnormal resting state brain networks have been identified in various chronic pain conditions, such as fibromyalgia and diabetic neuropathic pain (Cauda et al., 2009a, b, 2010; Napadow et al., 2010).” – Source 2010 IOM Relieving Pain In America
#6) “Many people suffer from both persistent pain and a broader mental health disorder. An estimated 40 to 50 percent of people with chronic pain have mood disorders, but the direction of causality is not completely clear and can, in some instances, go either way. Most studies suggest that depressive disorders, for example, tend to occur after chronic pain begins (Fishbain et al., 1997); however, many people so affected have a prior history of depression. In one study of people with chronic disabling occupational spinal cord disorders, some 65 percent were found to have at least one current psychiatric disorder, and 56 percent had a major depressive disorder (Dersh et al., 2006).
One factor that has been suggested as breaking the link between depression and chronic pain is the belief that one can exert some control over the pain. (The latter findings are consistent with research findings on stress in general: that it is not stressful events, per se, that produce ill effects, but the individual’s judgments or appraisals of those events, particularly a perceived lack of control [McEwen, 1998].) The neurotransmitter serotonin is associated with both pain and depression, and some researchers have theorized that a common genetic trait or susceptibility is linked to pain and both depression and anxiety.” – Source 2010 IOM Relieving Pain In America
This tends to be a difficult fact to take in, people seem quite opposed to even the gentlest hint that they should take a look at their mental health. There are very few good reasons for this and many not so good reasons. But when it comes to relief from chronic pain all cards should be on the table. This includes a sincere consideration of ones mental health. You simply can not take a holistic approach if there is a hole in your whole. Leaving out mental health creates a big hole.
#7) “Definitions of CAM differ. For example, a study of CAM in hospices identified practices as diverse as massage therapy, supportive group therapy, music therapy, pet therapy, and guided imagery or relaxation, not all of which are usually associated with CAM (Bercovitz et al., 2011). Acupuncture, chiropractic spinal manipulation, magnets, massage therapy, and yoga often are considered CAM pain treatments. According to the National Institutes of Health’s (NIH) National Center for Complementary and Alternative Medicine, additional CAM therapies used for pain include dietary supplements, such as glucosamine and chondroitin intended to improve joint health; various herbs; acupuncture; and mindbody approaches, such as meditation and yoga (NIH and NCCAM, 2010).
CAM holds special appeal for many people with pain for several reasons:
• deficits in the way that many physicians treat pain, using only single modalities without attempting to track their effectiveness for a particular person over time or to coordinate diverse approaches;
• the higher preponderance of pain in women (see Chapter 2), given that “women are more likely than men to seek CAM treatments” (IOM, 2005, p. 10); and
• a welcoming, less reserved attitude toward people with pain on the part of CAM practitioners and an apparent willingness to listen to the story of a patient’s pain journey.
Whatever the reasons, pain is a common complaint presented to CAM practitioners (NIH and NCCAM, 2010). In 2007, 44 percent of people with pain or neurologic conditions sought help from CAM practitioners (Wells et al., 2010). In 2002, three-fifths of people who turned to CAM for relief of back pain found a “great deal” of benefit as a result (Kanodia et al., 2010). The National Center for Complementary and Alternative Medicine’s strategic plan, released in February 2011, supports the development of better strategies for managing back pain, in particular.
However, a single CAM practice, like a single type of medical treatment, may not be as beneficial as an integrated approach. It is unclear which types of patients—defined on the basis of pain condition, attitude, or other characteristics—stand to benefit most from CAM treatments for pain.” – Source 2010 IOM Relieving Pain In America
There is no one holistic treatment and no one provider is a holistic provider. The best we can hope for is an “integrally informed’ provider working from a holistic perspective. Having a broad network of trusted referral partners with whom patient care may be coordinated. No two patients are the same, no set of symptoms are the same. For this reason a consultation with a broadly educated healthcare provider is the best course of action. Find out what CAM therapies are best for you.
Guy Odishaw is an Integrally Informed practitioner at the Bhakti Wellness Center. Founder and co-owner of the Bhakti Wellness Center, an Integrative CAM clinic in Edina, Minnesota. www.bhakticlinic.com , godishaw@mac.com, 612-859-7709