СИНДРОМ ХРОНИЧЕСКОЙ БОЛИ-CHRONIC PAIN SYNDROME

Психогенные абдоминальные боли, т.е. боли в животе, обычно появляются под влиянием невротических расстройств у людей с демонстративным радикалом. Боли нередко сопровождаются желудочно-кишечными расстройствами – спазмом пищевода, кардиоспазмом, дисфагией, анорексией, невротической рвотой, гастралгией. Причинами возникновения могут быть стрессы, психотравмирующие ситуации, эмоциональное напряжение, депрессия , тревога; особенности личности, такие как эгоцентричность, мнительность, стремление к привлечению внимания, тревожность, неустойчивость психики; ситуации конфликта в семье и в коллективе, разрывы отношений, колебания самооценки и др.

В лечении результативно используется психотерапия, т.к. боль появляется вследствие определенной психотравмирующей ситуации и находится под влиянием эмоционально-аффективных факторов. Установлено, что от приема пищи данные расстройства не зависят.

Let us look at the so-called ‘store-front window of the pain supermarket’ to see the range of individual treatments, their advantages, disadvantages and factors which would prevent their use as well as their approximate costs and where these treatments can be obtained.

Take for example, Mary, 33, an ex-kindergarten sister, who had exhaustively sought relief for a chronic back pain problem.

‘Mismanagement by the medical profession has made my life miserable with unbearable pain for the past five years!’ was how she angrily described her problem.

Mary had a long history of lower back pain which had involved two operations in which the individual vertebrae or spinal bones were fused together. Despite the operations on her lower back she was dissatisfied about the continuing level of pain and how it was disrupting her life.

She also complained of severe pain in the neck and shoulders. Her misery was made complete by deterioration of the cartilage at the back of both kneecaps known as chondromalacia patellae.

When admitted to hospital, her pain symptoms were related to her long-term orthopaedic problems and what she described as ‘the lousy cards life’s dealt me’.

After her surgery things had gone spectacularly wrong, with numerous post-operative complications including wound infection. When her knees began to fail, she began swimming to relieve the-pain. But the swimming brought on a painful condition of both shoulders — ‘frozen shoulder’.

She was then re-admitted to hospital where she was told that her original fusion operation was a failure. The second fusion operation was carried out in an attempt to correct the pain in her lower back.

This was as unsuccessful as the first operation in relieving her pain and she was then referred to a psychiatrist. Shortly after this she became acutely suicidal with homicidal thoughts towards her child.

Mary was transferred from a private hospital to the in-patient pain programme with a three-month history of depressive symptoms including persistent lowering of mood, tearfulness, difficulty in getting to sleep, waking early, loss of energy, poor appetite, a weight loss of seven kilos and loss of interest in everything, including physical activity. She had also ‘frightened off her treating psychiatrists — so difficult was she to

manage. b

Initially, Mary was very prickly, with a caustic tongue, very difficult to manage and very defensive, suspicious and hostile towards doctors after her past experiences.

After her first week in the pain program she was still difficult but coming around to the viewpoint that she might as well try any last resort to climb out of the depths that she had fallen into due to her chronic pain experience.

The breakthrough for Mary came with one of the main features of the pain program — patients being given the opportunity to experience a number of different techniques including laser acupuncture.

Within the first few sessions she noticed an improvement in her pain levels. She reported that her pain was becoming more and more acceptable and within the four weeks of the pain program she had minimal levels of pain.

Now, instead of depressing everyone, Mary was a general inspiration for new in-patients. On discharge, she was having weekly treatment. After six months, she had progressed to having treatment monthly.

Today she has continued to improve. Her previous constant demands for pain medication and treatment became far less and her relationship with her husband and son are greatly improved.

She is still taking medication but it has fallen to controllable levels. She is very happy with the results of the treatment and has now gone back to being involved in a kindergarten part-time.

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Migraine headaches are classically described as ‘excruciating’. In many cases, these are thought to be an allergic reaction to some types of food such as citrus fruit, cheeses, peanuts and red wine.

Acute migraines are sometimes accompanied by nausea and double vision and are usually described as being ‘a high intensity, throbbing sensation’.

They are normally experienced on one side of the head, usually the same side during each attack. Some experience what is known as ‘prodromal symptoms’. That is, flashing lights, nausea and sometimes tingling in parts of the body before the beginning of the actual head pain.

Commonly these headaches last from one to several hours and respond to sleep and appropriate and early treatment.

Less common variants can last for up to several days at a time. In some sufferers the headache can be experienced on both sides of the head. The headache may be accompanied by severe disturbances of bodily sensation — numbness and tingling — and even paralysis.

Parts of the vision of the affected eye may be lost causing partial vision in the affected patient. In some the nausea can be extreme with nothing able to be held down.

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Knowledge gaps about pain sensation, and its severity, existed until only recently. To a large extent, this was because most of the research was done on experimental animals rather than on actual chronic pain patients. There was thus no deep understanding of the difference between acute and chronic pain. (See Chapter 3 for a more detailed explanation.) There was also an over emphasis on pain’s physical and mechanical causes based on the widespread, but wrong, assumption that pain is purely a sensory experience. The emotional and psychological factors involved in pain were relegated to secondary importance.

Different definitions

Even specialists from different fields of pain management and research define pain in different ways. A recent international conference of pain specialists provided a fascinating range of definitions of the word ‘pain’.

1. Neurophysiologists understand ‘pain’ as being the appropriate response of specific pathways within a nervous system.

2. To experimental psychologists ‘pain’ is a behaviourial response to a stimulus.

3. Neurologists understand that ‘pain’ means the patient has perceived just that experience.

4. Clinical psychologists believe that an individual may complain of pain whether or not a physiological stimulus is identified.

5. Psychiatrists understand that ‘pain’ means a patient is in distress, which is expressed as a disagreeable somatic (body) sensation.

6. Acupuncturists usually define ‘pain’ as a complaint of a disagreeable sensation. The word pain is used to describe a subjective perception of distress. It is not a simple sensation like a primary sensation. Accompanied by a greater emotional response than any of these, pain is complex and subject to individual interpretation.

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T he word pain comes from the Latin word poena or the French word peine. It is important to realise there are many different types of pain. For example:

Jill’s trigeminal neuralgia

Jill had trigeminal neuralgia a lightning-like pain in the face and mouth, which is so severe that it makes some sufferers feel as though they want to kill themselves. ‘My pain feels like someone is jabbing my face with a red-hot electric needle. The worst thing about the pain is that it’s so unpredictable. I never know what’s going to set it off— swallowing, laughing, or talking. Even the smallest thing can set it off. I try to stay home and go out as little as possible.’I don’t use make-up. I don’t wash my face. I don’t even brush my teeth. Sometimes I don’t have any pain for days.Then I find myself starting to worry about when it may start up again.’

Mary’s post-operative pain

‘After surgery to remove the gallstones, I felt miserable. The pain near the incision was sharp. It seemed to spread all over my body. The nurses gave me some pills which took the edge off the pain and by about three days after the operation, the pain was mostly gone.’

Rudl with terminal cancer

‘At first, I didn’t mind the thought of dying, so long as it wasn’t too painful. But, then I began to worry about all those drugs they were giving me. They were making me groggy and confused. I couldn’t think properly or even feel like I was alive. There were times when I didn’t take the pills because I wanted to be alert for whatever was left of my life.’

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A current trend is to discuss holistic medicine as if it were something new, invented by alternative practitioners of the Seventies and later. Some people even seem to think that holistic medicine is a new approach, in comparison with orthodox medicine, which is deemed dry, mechanical and unrelated to real life.

In fact, nothing could be further from the truth. Orthodox medical doctors have known for a long time that your genetic make-up, your working environment, your marriage, your hobbies, the chemicals with which you’re in contact, your thoughts and your concerns, in fact, your whole lifestyle, are all intimately bound up with whether you feel well or ill. Holistic, in terms of medicine, means caring for the whole person – mind, body and spirit. It is not the form of medicine that is holistic, but the attitudes and views of the practitioner – orthodox, alternative or otherwise.

This point is very important, especially for headache sufferers. Good orthodox medicine is holistic, too. It’s all about treating the whole person, not just little bits of him. You don’t have a headache in isolation. You are a person with a headache, and in order to understand and treat that headache we need to look at the whole of you, not just the bit from the neck up. Orthodox and complementary treatments all have their place in assessing and treating that headache.

There is a second reason why it is so important to consider all aspects of you and your condition – many people don’t have headaches from just one single cause. Usually there are a lot of different reasons, and their effects all multiply together. Perhaps, you’ve identified the cause of your own headache as cervical spondylosis. But, if you look more closely, you’ll find you get other headaches as well – those caused by tension, for example (a common fellow traveller with cervical spondylosis). Maybe you get the odd migraine, too, and of course there’s the pain from that whiplash accident you had ten years ago, to say nothing of the fumes that you get from the old jalopy you drive, and the mid-life crisis you’re currently going through …

It’s vital to emphasise the degree to which all the various causes of headache are interlinked and inter-related. Some are so tightly bound together that its almost impossible to disentangle them; for example, arthritis in the neck is almost inevitably accompanied by reflex muscle spasm, which gives tension headaches.

This is where true holistic medicine comes in, and by this I mean medicine which looks at every single aspect of the individual. In dealing with headaches it’s important to recognise that both orthodox and complementary medicines may have a part to play; that environmental, working and living conditions are important; that psychological, social and spiritual factors are involved.

With a bit of luck, you’ve now worked out what is the main cause for your own headaches. Or, to put it more accurately, you have probably found a number of things that interact, and you’re not yet certain which of them is the real culprit.

The answer, of course, is that you needn’t try to find one culprit; all the various triggers may have an effect on you. You don’t need to worry about whether you’ve mainly got a tension headache or whether there’s a bit of migraine there as well. Instead, accept all these as possible diagnoses and go to work on each of them, one at a time.

Headaches have a nasty habit of not just adding together, but multiplying each other. It’s surprising how often a small problem – such as a worn-out joint in the neck – can have such amazing knock-on effects. Maybe the amount of stress that you’re under wouldn’t normally give you a headache, except that having a worn-out joint multiplies the effects of the tension on your neck muscles, so that even a small amount of stress manifests itself as pain, which in turn will give more spasm, which gives more pain … It’s important to look at each and every one of the possible causes of your headache and try to deal with each of them, however minor each may appear to be.

In some cases, there will be one major cause for your headaches, plus a few minor ones, in which case removing the major cause may clear up the problem entirely. On the other hand, where there is no clear-cut single cause, the best treatment consists of trying to remove or minimise as many of the contributing factors as possible. You will probably find there comes a point where you have reduced the level of insult to your head and neck below the threshold for causing pain, and suddenly your headaches go away – or at least become manageable, which is half the battle.

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Treatment of menopausal symptoms is by replacing the oestrogen. Almost as soon as this is done, any true menopausal symptoms will disappear.

Oestrogens are powerful drugs and, used on their own, they can cause cancer of the womb to develop. But don’t be alarmed, there’s a simple way to get around this. Adding progesterone during the second half of your cycle removes this extra chance that you will get cancer of the womb. If you still have a womb in place, then you will need oestrogen and progesterone; if your womb has been taken away then you only need oestrogen.

What are the benefits and problems associated with hormone replacement? Firstly, the menopausal symptoms go – all the physical and mental symptoms improve and there is often a feeling of well-being where previously there was a vague sense of malaise. Secondly, as the normal drop in oestrogen at the time of the menopause causes the bones to lose calcium, artificially prolonging the time the bones are exposed to oestrogen keeps them stronger for longer, and in later life reduces the chances of developing osteoporosis or of getting a fracture.

Hormone replacement therapy also massively reduces the chance that you will get ovarian cancer and it may also reduce the chance of heart attack.

The drawbacks of HRT are that the periods return again and there is a possibility of an increased chance of breast cancer. Overall, the statistics are in favour of the HRT user. The chances of dying following a fractured hip, from ovarian cancer, or from heart disease are all reduced by a greater factor than the chance of getting breast cancer from having HRT. About five times as many lives will be saved through using HRT by comparison with those lost by HRT.

However, HRT has not been in use long enough for us to be certain that there are no long-term side effects. Although HRT is probably safe for the first five years, and may well be safe for much longer, the statistics are not yet entirely conclusive.

If you would prefer not to be on HRT, but would like treatment for some of the symptoms, the drug clonidine may help with hot flushes; and oestrogen cream applied locally to the vagina may assist with vaginal dryness.

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It’s sometimes very difficult to know just where to draw the line between what is normal and what is abnormal, especially where mental processes occur. For example, tension and stress occur in all of our lives at some point – but although mentally we are wearied by them, the fact that we are tense or stressed doesn’t necessarily mean that our mental processes are abnormal. In fact, some stress is necessary constitutionally to our bodies. Nevertheless, excess tension and stress can make us ill, and if we don’t recognise and deal with it, we can become exhausted mentally or physically.

Anxiety is similar – undue anxiety can be an altered way of thinking, in which we get anxious and stressed without any external triggers. At this point anxiety becomes a psychological problem.

In practice, it isn’t easy to define the point at which these processes become part of illness behaviour. Tension headaches can occur in those who, psychologically peaking, are completely normal; in others, they can be part of an anxiety state. Therefore tension, stress, tension headaches, stress management, and relaxation techniques apply both to healthy and to psychologically unwell people. Don’t assume that because you’re stressed you necessarily have a psychological illness -you probably don’t. Nor should you think that because you get tension headaches you’re psychologically unwell; again you may well not be. However, if you are aware that your mental processes aren’t quite what you would like them to be, and that your anxieties or your inner turmoil are such that they, rather than tension itself, are the underlying problem, then read on.

There is a definite group of people who have headaches due primarily to Mychological illnesses. It is a gross misconception to say that these headaches are ‘all in the mind’. It’s all real pain; it’s just produced differently.

Some people have headaches that are entirely caused by muscle spasm from Biental tension, but there is often a mixed cause; any underlying neck injury will magnify, and be magnified by, the excess muscle tension caused through stress.

There is a second psychological cause for headaches, which is much more difficult to understand. This occurs when there is no apparent external source for the pain, and no muscle tension, either. It would be easy to think that pain like this really was all in the mind, but to the sufferer the pain is extremely real, as real as any other type of headache. We’ll come to this subject in more detail later.

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Too much, or too little light can cause headaches. Factors such a the contrast of computer screens and the glare of sunlight are covered elsewhere on this book.

Fluorescent Lighting.

Although fluorescent tubes appear to be giving off a steady shadowless light, in reality they flicker one hundred times per second. Because the retina smooths out these little bursts of light, normally we’re not consciously aware of the flickering. However, this flickering still has a very special and very odd effect. When you switch your gaze from one point to another, the eyes move in a smooth line; however, if the fluorescent light is in its ‘off phase at the time you are about to look at another point in the room, your eyes can’t see it, and will overshoot it slightly. When the light comes on a hundredth of a second later, your brain realises that it’s overshot the mark and starts moving your gaze back again until it gets to the right position.

Therefore, under fluorescent lights your gaze is constantly overshooting and needs constantly to be corrected. Making these extra corrections is tiring on the eyes, and is one of the reasons why so many people find working under fluorescent lights irritating and tension-making.

There is a very quick way to stop this happening – double the frequency of the current in the lights. Then the fluorescent tubes flicker at two hundred cycles per second, which is too fast to allow the eye overshoot to occur. Working under fluorescent lights like this is much more restful, but lamps like this are more expensive than the ordinary sort.

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Headache from fever occurs much more frequently in children, for two reasons. Firstly, an infection in a child usually causes a much higher fever than the same infection would in an adult: a mild viral infection producing a temperature of only 99.5° F (37.4° C) in an adult might produce a fever of 103° F (39.4° C) in a child.

Secondly, the higher the temperature, the more powerful the headache, and children get many more high fevers than adults. As we’ve just seen, part of this is because some illnesses produce high temperatures in children, and not in adults. But there is a second and more important factor at work: children are simply much more vulnerable than adults to being infected by the germs that are present in the community at the time. The reason is quite simple. A person is vulnerable to any illness he hasn’t met before, but once he’s had the infection, he develops immunity to it, so he can’t get it again. This is why (with very few exceptions) it’s only possible to have an illness like mumps once. After the initial infection the body recognises the mumps virus, and on every subsequent occasion that this virus tries to gain entry, the immune system locates and neutralises it.

Lastly, and very importantly, don’t forget meningitis is a cause of fever and headache. Meningitis is more common in children, so get into the habit of checking for a stiff neck every time your child gets a temperature. That way, if it is meningitis, you’ll be giving your child the best possible chance of getting over it. Meningitis in the very young doesn’t always give a stiff neck: a bulging fontanelle (the soft bit at the top of a baby’s head), vomiting, irritability and/or drowsiness, are among the things to look for. And remember that in meningitis immediate medical treatment may save your child’s life.

But meningitis is rare. Don’t get over-anxious about the possibility of your child having it. Just check that neck, routinely, each time he or she gets a temperature.

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