Case study: A Multidimensional Assessment in Managing Trigeminal Neuralgia Chronic Pain with Clinical Hypnosis.
By Dr. Anand Chandrasegaran
One issue with traditional pain assessment methods (Karoly & Jensen, 1987) is that they overlook the potential role of unconscious variables as a possible source of a pain problem.
This case write-up is to illustrate this point, namely the importance of considering the unconscious process regarding pain assessment.
This is a case of a 32 years old gentleman, who presented to me with facial pain for 2 years. He has been diagnosed with Trigeminal Neuralgia of unknown origin. The patient described the pain attacks would be short, and unpredictable attacks that can last just a few seconds. The attacks stop as suddenly as they start.
Trigeminal neuralgia is sudden and severe facial pain, which this patient described as sharp shooting pain, similar to having an electric shock in the jaw, teeth or gums.
He is on Trileptal and Neurotin (both are antiepileptic medicine which can be used in chronic pain management, especially for neuropathic pain and Ultracet (mild opioid). All 3 medications for 3 times a day, for 2 years.
He is under follow-up with a neurologist and a dental specialist. He was also referred to a psychiatrist to help him manage his anxiety about this facial pain. However, he did not go for the psychiatrist follow-ups for fear of the social stigma associated with seeing a psychiatrist.
Despite being compliant with the above medications, his symptoms never improved. He was referred for hypnotherapy sessions to help him with his pain management. The patient was very optimistic about being able to get a resolution to his pain with hypnotherapy.
2. Background of the case
Before the intense facial pain, the patient initially had a sharp toothache, which he described as shooting pain only on chewing. He got a dental specialist for further assessment. After a routine dental assessment, it was determined that the problem that he presented with, is not from the oral cavity (he has normal dental findings).
He was referred to a neurologist for further assessment. The patient, had extensive MRI scans done to determine the cause of his trigeminal neuralgia. There was no evidence to indicate cranial nerve lesions or any obvious pathology to explain the origin of this neuropathic pain.
He was diagnosed as having idiopathic trigeminal neuralgia (unknown aetiology) and started on medications. He is dependent on these medications as pain relief. Before starting on medications his pain score ranges from VAS ( Visual Analogue Scale) 9-10/10. With medications, his VAS pain score was 2-4/10. More intense when there are facial muscle movements ( smiling, talking, chewing).
After 1 year on medication, it was observed that his medication dosage needed to be increased to manage the pain better (medication tolerance). The patient was advised by the neurologist that he needed to learn relaxation skills and look into reducing his work-related stress.
The patient is an IT manager. As a team leader, he faced various forms of stress and pressure from work-related matters. He is constantly working despite being at home. The patient was referred to the author, for a non-pharmacological approach to helping the patient to manage his pain.
3. Challenges for you with this client
After a careful explanation and the necessary pre-talks, all myths and issues surrounding hypnosis explained, the patient was introduced to relaxation hypnosis. This was followed by hypnotic pain control strategies and techniques which included “glove anaesthesia” and Imagery Modification ( which involved the Dial reduction method ).
During this, the patient has elicited the appropriate hypnotic phenomenon, namely, lightness and numbness of the arms. during the hypnotic trance. The patient was asked to have a future projection of comfort around the facial region during eating and talking. The patient responded well during this process.
However, after the waking-up stage, the patient was asked about his experience. He reported that he was consciously following the suggestions delivered, and still feeling tense and had muscle spasm-like feelings around his neck, shoulder and scalp. As for the facial pain, no reduction at all. The patient was taught relaxation techniques and self-hypnosis.
In the following follow-up session, one week later, the patient was asked about his feedback. He reported that he was not able to practice self-hypnosis at home, and he was not able to relax. He kept saying that, he was not able to relax and felt strain over the shoulders and neck region. On further assessment, there seemed no changes in pain score and patient’s pain perception over the facial region.
In this case, the challenge faced was identified. There was the element of unconscious resistance to relaxation ( inability to relax ). In the first session, the patient was given suggestions for relaxation and being calm was repeatedly used. However, the patient later reported that he had to actively respond to the suggestions. He found himself not able to relax comfortably. The effort to try to consciously relax was very tiring and stressful for the patient.
4. Solutions (which techniques)
Given the possibility of unconscious resistance for the patient to relax via the progressive muscle relaxation approach, the patient was offered a different approach. Instead of jumping straight into hypnosis scripts by inducing relaxation, the author approached this patient with strategies as below:
I. Unconscious Exploration to Enhance Insight or Resolve Conflict
a. Here the patient was engaged by further assessing the inability of the patient to relax.
b. With a series of questions, the unconscious process involving the reasons behind the inability of the patient to relax was identified.
c. For this patient, the inability to relax, was a psychological process that he developed during his days in college. He took over his family’s financial burden and from a young age, he started working hard. Constantly he would stress himself up, as he had to meet his financial commitment to his family. And this cognitive structure continued even after he had stabilized his financial commitment, done well at his job, and had a family of his own.
Despite his work and his financial state having improved, he was still worried that something might go wrong. this constant worry keeps him on guard all the time, hence, the stress and strain he felt around his shoulders and neck region.
After the author and the patient managed to understand this unconscious need for the patient to not relax, the author approached the patient with the following strategy (which was done under hypnosis).
Keeping in mind, that patient cannot relax consciously, the induction method used involved: Interspersal Technique 1 and the use of metaphors, which the patient could relate to this work and other aspects of his life. The induction method here involved the usual progressive muscle relaxation techniques. However, instead of using the suggestions to relax, the script was replaced with “inability not to relax’ instead of just “relax”. This is a form of a double negative statement, which induced confusion in his conscious process. The Interspersal technique was crucial in this delivery mode.
When the patient was relaxed, the patient was asked to respond via Ideomotor Signalling. When the author and the patient were both satisfied with the patient’s relaxed state, the following strategy was used:
I. Cognitive-Perceptual Alteration of Pain:
a. Unconscious Exploration of Function or Meaning of Pain
b. The Inner Adviser Technique (to explore meaning and triggers of pain)
c. Reinterpretation of Sensations: pain associated with facial muscle strain/stress as a means to induce a relaxed state.
d. Increasing Pain Tolerance: Mental Rehearsal of Coping with Triggers and Pain
II. Creating Anaesthesia or Analgesia: Glove Anaesthesia method
Immediately after the second session, the patient was able to relax.
VAS before the session for relaxation was 8-9/10. At end of the second session, VAS for relaxation was 2-3/10. The patient reported, that, this is the first time in many years, that he felt his upper body muscles, facial and neck muscles were at ease. The patient also reported that he is not consciously (actively) inducing relaxation. He felt he was able to relax passively and felt like the suggestions during the trance were more natural compared to his experience during the first session.
The patient’s facial pain reduced from VAS 3/10 to 1/10. On follow-ups via phone calls, the patient reported that he can practise the self-hypnosis relaxation methods now.
Currently, at the writing of this report, 1 month after the 2 sessions. The patient reported that his facial pain intensity has improved. He is experiencing less frequent shooting pain every time he speaks or chews his food. His sleep has improved, as he can sleep more relaxingly at night.
Generally, the patient is satisfied and the author managed to achieve the patient’s expectation, which was to achieve a state where his shoulder, neck and facial muscle has perception of relaxation. The patient is optimistic that, with more self-practice and working on his deep-seated issues, he will get better soon. Currently, he can cope with his pain intensity and this gives a sense of confidence to him.
As physicians treating pain, we must adopt a framework regarding the utilization of hypnosis in pain management. Hypnosis is like any other medical or psychological approach: it is not enough for every patient. Some patients obtain excellent pain relief with hypnosis; others find it helpful but need still other methods of relief; some find that it reduces the affective components of pain (Barber, 1977), making the sensory pain more bearable; and some patients receive no benefit from hypnosis.
Physicians must evaluate more than the biophysical features of pain. Especially with chronic pain patients, multidimensional assessment is recommended (Hammond 2005), taking into account the physical-sensory, behavioural, affective, interpersonal-environmental, and cognitive (and adaptive function) components of the pain experience.
There are occasions when a pain problem, or part of a pain problem, may be associated with past trauma or serve unconscious purposes (e. g, for self-punishment). We may conclude this when the source of the pain is unexplained and cannot be associated with any clinical pathophysiologic process.
6. The interspersal hypnotic technique for symptom correction and pain control.
Am J Clin Hypn;1966 Jan;8(3):198-209.doi: 10.1080/00029157.1966.10402492.
2. Barber, J., & Mayer, D. (1977). Evaluation of the efficacy and neural mechanism of a hypnoticanalgesia procedure in experimental and clinical dental pain. Pain, 4, 41–48.
3. Defining Hypnosis: An Integrative, Multi-Factor Conceptualization October 2005; Hammond. The American journal of clinical hypnosis 48(2-3):131-5
4. Jensen,M.P. , Karoly.P&Huger R. (1987). The development and preliminary validation of an instrument to assess patients’ attitudes towards pain. Journal of Psychosomatic Research, 31(3), 393-400.
Dr Anand Chandrasegaran
Anaesthesiologist & Critical Care Medicine Consultant
Columbia Asia Klang Hospital
Clinical Hypnosis Pain Specialist