IS THERE AN EFFECTIVE TRETMENT FOR CHRONIC PSYCHOGENIC PAIN?

presented @ACEP by Gregory J. Nicosia, Ph.D.

May 5, 2018

Most chronic pain is managed with limited success, using opioid analgesics, physical therapy, surgery,

and a host of medical interventions, for example, trigger point injections, Prolotherapy, Platelet

Replacement Therapy to name a few. Many, if not most of these chronic pain patients, have suffered an

injury or traumatic event that leaves them in pain long after the normal physical healing process is

completed. Most often the pain is “unanatomical” in distribution, although clearly evidencing

measurable physiological abnormalities such as, sensory and motor deficits, tenderness, ischemia, and

other autonomic dysfunction. For both patients and health care practitioners the pain appears to arise

from peripheral locations on the body and most therapeutic effort is directed to these areas and effects

little or only transient relief of the pain.

This type of chronic pain is accompanied by autonomic and physical changes that is most likely

psychogenic in origin and its effective treatment must consider its complex nature to be effective in its

remediation.

Today we will explore the relationship between trauma and chronic pain. First with a conceptual

background overview, followed by a less rigorous explanation of the salient factors that cause and

maintain chronic pain and move on to how to more successfully treat chronic pain.

Scientific Overview

Complex Psychogenic Pain (CPP), Rudin (2007) is seen to be centrally encoded during an event where

fear or rage is experienced along with the pain while the individual is constrained from responding to

the circumstances. In addition, a dissociative response to the pain occurs such that subsequent

subconscious stimuli that recreate a similar emotional, somatosensory, or cognitive state, centrally

activates a re-perception of the traumatic pain engaging various vasomotor processes. This trauma

based Complex Psychogenic Pain appears to be encoded in the amygdala in such a manner as to

preclude simple forgetting. Inhibiting reconsolidation of the dually encoded trauma can alleviate the

pain.

EP offers several related methods, e.g. TFT, EFT, that can block the reconsolidation of the emotional

response and simultaneously block the outflow from the amygdala’s nucleus that modulates pain.

Combining an abbreviated form of EMDR focusing on somatic experience, or the “felt sense” of body

memory of the traumatic event activates somatosensory stimuli subconsciously associated with the

event, and can often bring these into conscious awareness. Paired with EP treatment in which sensory

stimulation of bio-energetic pathways inhibits the noradrenergic release of norepinephrine and disrupts

the reconsolidation of the memory of the pain of the traumatic event. Similarly, the affect activation

accomplished by employing conscious conditioned stimuli is paired with EP and inhibits re-consolidation

of the pathway connecting the thought of the traumatic event with the remembered emotion and

results in decreased cortisol levels and can effect a cure of the chronic pain disorder.

Historical Background

Is Complex Psychogenic Pain Real? You bet “ya”. It really hurts.

But if there is no lesion or peripheral cause where does the pain come from?

THE MIND.

Early explorers of subconscious stimuli in the experience of pain including Charcot, Freud and Breuer,

called this painful condition caused by the mind Hysteria.

In1961 Walters defined psychogenic regional pain as chronic pain that is associated with an emotional

or psychological stimulus when the clinician could not find a physical or peripheral cause for the pain.

The location of these psychogenic pains were most commonly in the back, neck, head and limbs and

appeared “unanatomical.” This type of chronic pain is not just an acute pain that is prolonged beyond

the normal healing time, but it has measurable neurologic and autonomic deficits that responded poorly

to treatment. Sarno over many years found that location of the chronic pain occurs at site of previous

injury and that this psychosomatic psychogenic pain is caused by a centrally mediated vasoconstriction

that produces ischemia in tendons and nerves.

Scaer (2001) finds that chronic psychogenic pain can be the results of previous painful injury during a

fearful episode where escape was impossible and a state of tonic immobility was produced. This is the

last part of Fight or flight called FREEZE and is concomitant with fright. Fight, flight or Freeze. Like Sarno,

he believes that the autonomic changes in the body are encoded centrally during the event in what was

termed procedural memory.

So there it is Complex Psychogenic Pain. It’s characterized by unrelenting pain often at a site of a

previous injury, for which a physical cause cannot be found, is largely unresponsive to treatment. It is

“unanatomical” in distribution that doesn’t conform to known pathways, evidences somatosensory

changes and is associated with psychological problems.

Think about the chronic pain patients you have seen Is it possible to treat?

THE QEEG OF EMDR

QEEG Normalized in Delta and Theta Frequencies

• Pre EMDR

• Post EMDR

Is it possible to treat? CASE STUDY

CLINICAN STATEMENT, Gregory Nicosia, Ph.D.

Nancy, a 50 year old caucasian female was first seen by me upon the referral of her neuropsychiatrist,

Dr. Marilyn Krauss post 5 back surgeries in December 1997 that were followed by severe infection for

which she was antibiotics for 2 1/2 months. Her history was significant for an aortic valve replacement

in April 1998 that had resulted in seizures and coma that left her with moderate neuropsychological

impairment for which she had undergone Occupational Therapy. Nancy presented with severe

unremitting back pain associated with nonhealing fractures and was uncontrolled with multiple

medications. She was severely depressed and had become hopeless expressing suicidal ideation and

frequent panic attacks. Nancy’s memories were evoked using an abbreviated form of EMDR and these

memories were treated with TEST, a form of Thought Field Therapy.

She obtained a substantial reduction in pain after her first treatment decreasing from 10 to 3 SUDS. Her

anxiety reduced from 9 to 2 Suds and her depression from a rating of 9 to 7 Suds. She was taught to

perform her customized treatment and used this therapy at home many times each day.

Nancy took her last pain medication on 6/12/98, only eight days after her initial treatment. Her

depression and panic, and numerous symptoms of PTSD including insomnia and flashbacks also

responded to her treatment that targeted many events related to her multiple surgeries and sudden

total disability. By the end of August, Nancy no longer displayed symptoms of depression, she was

optimistic about her recovery. Se had no significant pain and had not had a panic attack for many weeks

and she was able to use her TEST treatment protocol to quell her anxiety during ongoing medical

testing. Her other medications were also reduced. Nancy then began cognitive rehabilitation. Ten years

later Nancy still uses her Energy Psychology procedures that have helped her cope with a debilitating

fall and problems associated with diabetes. Nancy continues to be an optimistic person and is an

inspiration to her friends and family.

PATIENT STATEMENT:

Nancy Schaub

My experience with TFT and pain:

Going from eight to ten narcotic pills a day down to none, allowing me to live a half normal life not

dealing 24 hours a day controlled by the pain. I started in the hospital around the middle of December

on morphine. After 5 back surgeries. I was in constant pain on the medication at home for about 7

months and was able to get off all the pain medication in 3 to 4 weeks using the Thought Field Therapy

prescription

In December, a year after my last back surgery, and 6 months since my last X-rays that was right before I

started coming here. They took new X-rays and when I went to see my surgeon he had them. He was

literally dumbfounded by the amount of bone mass that had been created in the spine where I had had

the surgeries. That was where I had my pain was. He literally could not believe it. That was where I had

rods , pins and plates put in and taken out. They finally determined that I had been allergic to the metal.

They sent me home with an open incision from my waist up. I was on home IVs for over 3 months with

visiting nurses. Then I started having pain on the other side, and that is how I ended up here at

Advanced Diagnostics (Dr. Nicosia). My neuropsychiatrist knew that I was literally on the verge of

committing suicide. I could not stand the pain it was 24 hours a day, it gave me no peace, no life. It

consumed every bit of energy I had. There had to be some other way. The pain pills were not working

anymore. So fortunately, my neuropsychiatrist knew about the work you were doing here and that’s

how I ended up here. I got rid of my pain. Yes, I did tap a lot. I tapped until I thought my hands were

going to fall off. I tapped maybe ten or twelve times a day because it felt so good to be rid of that pain.

It just felt wonderful because it hade just been months dealing with that pain, you know you’re not a

person anymore when you have that pain, you become a monster. All I could think about was that pain.

That pain just overtook my life. I think it is a vicious circle when you hurt, then your mind starts to hurt

and then your body starts top hurt worse. It’s terrible and you do start to think that the only way out of

this pain is suicide. After having the back surgeries and being therein the hospital for 5 weeks, I’ll tell you

that if I could have picked up the chair I my room, I can be truthful and tell you that I would have thrown

it out the window, I would have jumped out., because I simply couldn’t take it anymore, I couldn’t.. By

end of the summer I didn’t have any pain to deal with. I look at my life now like a person who has a

second chance. When I had the stroke and the seizures, I was given one chance in a hundred to live. I

was in a coma for a week. They had told my family that I wasn’t going to make it. I made it. So to me

what could I possibly be unhappy about. My husband had a heart transplant. So we are two people in

one house that both have a second chance. But when I had the pain, I never thought about my life. All I

could think about was that pain. Thank you Dr. Nicosia. Thank you for your treatment here. It literally

saved my life. I could not take that pain anymore and my neuropsychiatrist knew we were at an end.

Now she says you look so good. She is so excited about this. Thank you. Thank you.

Sincerely, Nancy Schaub, 2001.

To understand how to treat CPP, we must know where does it come from.

IT COMES FROM THE MIND. It arises out of a traumatic experience of fear and defensive rage (Cannon,

1929). When fight or flight, the natural responses cannot be carried out – death and/or pain can be

perceived as imminent—right here right now-OMG I’m going to die! I’m helpless, perhaps terrified. This

is the memory that is stored, encoded. And if this memory is encoded in a person with prior traumatic

experience the result is a dissociative memory of the pain. Thus, CPP can be considered a dissociative

disorder where the pain memories are split off from the experience and stored in the subconscious.

Traumatic memory of the event traumatic dissociation of the pain are important processes of the mind.

The conscious memory serves to remember what happened so that you can avoid it in the future; while,

traumatic dissociation of the pain protects us against the terror and pain that paralyzes us. Intense

emotions can permanently store events but also cause dissociation such that the incoming traumatic

sensations are not integrated in our conscious awareness. Thus, our memories or a consciously

associated conditioned stimulus can produce a cognitive- emotional state without re-experiencing the

pain that has been dissociated and does not respond to this stimulus.

LET’S CHECK OUT YOUR MEMORY. Did you ever have a really bad pain, perhaps an accident, maybe

childbirth? Go ahead and think about it. Describe the pain. Was it hot, stabbing, searing, throbbing?

Think about it for a moment. Now as you were remembering this pain, did it hurt? Did you re-

experience the pain? Usually we don’t feel the pain, but we remember what happened because that is

adaptive. We want to avoid a repeat, right? Normally, we consolidate our day’s memory at night during

sleep. We transfer the adaptive , helpful information into a more permanent form and the rest is drops

out of the system. That’s the way it is supposed to work. The more adrenaline in the system, the more

norepinephrine in the brain the more important and memorable the information, up to a point! Beyond

this point too much norepinephrine shut down the processing and the memory stays in a less processed

state closer to the sensations we experienced. If some of you re-experienced the pain to some degree,

then the processing never got fully completed. Here is where EMDR can help you finish the information

processing of these memories of pain that were not dissociated from your conscious experience. But

when the pain memories are dissociated they can be triggered by emotional, cognitive or

somatosensory stimuli that only subconsciously relate to the trauma. And when associated emotions of

anger and anxiety occurring from everyday life have enough of a subconscious associative overlap, they

too can trigger the pain memory and the re-experience of pain and the associated physiologic symptoms

that are not traceable to the conscious memory of the trauma. So, here it is, at last, a mechanism

whereby the persistent triggering of stimuli subconsciously associated with the traumatic experience

underlies the CPP. As the traumatic event is encoded, these subconscious stimuli that are not cognitively

related to the traumatic event enter the amygdala, activate the nociceptive portion of the central

nucleus and produce the pain. Later, when we encounter these subconscious stimuli, research shows

that they can indeed activate the physiological processes (Milders & Perrett, 1993) and the result here

is chronic pain that does not appear to be related to any triggering event.

How then can we treat these CPP symptoms such as migraines, low back pain, head and neck pain,

sciatica, RSD, somatization disorders, phantom limb pain?

The part of the event that has access to conscious awareness is dependent on previous traumas,

inherent psychological disorder and the current landscape of the brain; these can be treated by

conventional psychotherapies and EP methods that can block reconsolidation of the emotional response

and block the outflow from the amygdale that modulates pain.

But how does one treat the various components of the event that cause the pain and are unavailable to

the conscious mind? Here an abbreviated form of EMDR is often an excellent method to help reveal the

subconscious relationships between a client’s suffering and their past experience. Once brought into

consciousness these memories can be rapidly “desensitized” with an EP modality. This integration of

psychotherapeutic methods takes advantage of their synergy, accentuating their relative strengths and

avoiding their weaknesses, e.g. rapid desensitization, conscious awareness of repressed memories and

abreaction.

Let’s see how we do it. Fortunately the therapeutic technique is much simpler than the explanation

we’ve just finished.

COMBINING EMDR AND EP

• Identify target problem • Get a picture or other representation • Get a negative cognition • Get a positive cognition • Identify the associated emotion • Identify location • Correct PR(s) here and prn • Use Eye movements (30X) 3 directions To map out the associated events, beliefs… • Use TFTx, EFTx to desensitize • Repeat

Case Study detailed

CLIENT PACKGROUND

• SA is a 44 y.o. female, married 1997 , 4 children ages 6 to 18. She is youngest of 10 children • Recently started counseling private practice • Alcoholic father angry, verbally and physically abusive. Now 83, sober and much nicer now • Sexually abused between 7-13 by her sister-in-law’s younger sister, 12, who suffered Down’s

Syndrome • Suicidal in late teens. Never told anyone till just before her marriage. Mom said nothing. 4 years

ago told brother and spouse they said , “Why now?” • 2005 began Zoloft added Klonopin and Resperidal

PRESENTING PROBLEMS

• Anxiety, depression, difficulty sleeping, chronic often severe pain in neck and shoulders. As a child her limbs would ache.

• 4 years ago en route to first EMDR session had MVA totaled car. Took it as a sign, never returned.

• Been through hell for past 5 years with her daughter, 18. In 2015, she attacked father, police called, Sara and daughter jailed overnight (traumatic). CYF involved, counseling no help, daughter to group home, now lives with BFs mom. Horrible relationship, scared of her.

• Referred by colleague (former client) for EMDR and Energy work about which she knew nothing • AFTER 1ST SESSION SA BRINGS IN TWO DRAWINGS

SA WAS TRAPPED AS CHILD“YOU’RE A DUMB BASTARD”“WORTHLESS”

SA’S TRAPS DURING HER LIFE

SA’S TRAPS DURING HER LIFE

2nd session Brief EMDR then TFTDx

• EMDR setup: picture daughter attacking husband in their bedroom = the problem

NC: I’m not a good momPC: I love my daughterSadness in Chest 9 SUDs =_EM feels the body wants to

breathe +PR1 +EM OMG triggered fear that someone hurt her daughter sexually her fear since 7y.o. very agitated.

TFTDx: PR1 un, ul, eb, e,a, c, e, c 9G SQ. More EMBlocking daughter from going down the stairs but also sees her mother

in the doorway screaming at her as a kid. Repeated above TFTx and added BH 50X, e, c 9G SQ Picture mom getting out of doorway so she’s not trapped anymore. It felt really good to move her-to see a way out + EM Installation of new PC: “I’m not trapped anymore , I’m Free”

3rd Session: TFT Dx

• AFTER SESION SHE DREAMS THERE WERE TWINS AND SOMEONE DIED. SHE AWOKE PERPLEXED HOPEFUL AND CALM (she had a client with a twin that died)

• Noted that she was bothered but not emotionally overwhelmed when daughter called asking for $ for Prom

• Went to church Sunday clenching her jaws thinking about all this. Targeted with TFT Dx 8 Suds PR1 un, eb,e ,a ,c , e, c, lf, c 9G SQ –4 Suds

• PR2 ul, mf, un, e, c, a 9G Sq 0 Suds

She next came in with another picture

ACCENTUATING THE POSITIVEELIMINATING THE NEGATIVE

After 4 more Sessions targeting other issues on her list: TRANSFORMING WORTHLESS TO LOVABLE

WAIT: THAT’S NOT THE END OF THIS STORY

BOTH THE SORST AND BEST ARE YET TO COME.

ATTEND THE WORKSHOP TO SEE THIS UNFOLD!!!