Transcript EMDR-AND-PAIN-INTRODUCTION

EMDR treatment of Chronic Pain
Mark Grant, MA
London, 2-3 November, 2012
Sponsored by EMDR Association of UK
Mark & Ana Grant
Aims of this workshop
1. To understand the nature of pain and the contribution
of trauma, personality factors and injury to pain.
2. To develop assessment skills regarding the contribution
of these factors to pain.
3. To learn how to resolve and/or manage pain (both
traumatic and ‘medical’ pain) using EMDR.
4. To learn how to reduce impact of pain on clients
identity and self-esteem.
5. To learn how and when to integrate EMDR with other
treatment modalities.
6. To enjoy this learning experience.
Mark Grant
Trauma and pain
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Axel Munthe
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Pierre Janet
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Sigmund Freud
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Trauma and pain
“..result of exposure to an inescapably stressful event
that overwhelms a person's coping mechanisms…
The trauma response involves hyper-reactivity to
stimuli and traumatic reexperiencing [as well as]
psychic numbing, avoidance, amnesia and
anhedonia.
- Van der Kolk, 1994
“Somatization disorder is primarily one of
autonomic/physiological trauma memory.”
- Colin Ross
Mark Grant MA
Pain
‘nociception + emotion’
- Price, 2000
“an altered brain state in which there may be
altered functional connections or systems and
… degenerative aspects of the CNS.”
- Borsook et al., 2007
Mark Grant MA
DSM Categorization of pain
1. Pain disorder associated with psychological
factors (eg; PTSD, depression)
2. Pain disorder associated with both
psychological factors and a medical condition
(eg; some types headache pain, vaginismus)
3. Pain disorder associated with a medical
condition only (eg; cancer pain, arthritis)
Mark Grant MA
Pain disorders associated with
psychological factors
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Conversion disorder
Somatization Disorder
Pain Disorder
Hypochondriasis
Body Dysmorphic Disorder
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Conversion disorder
• Motor symptoms;
Paralysis or weakness. Balance problems,
problems, lump in throat
swallowing
• Sensory symptoms;
Visual problems, deafness, altered pain or touch sensations
• Seizures or convulsions;
Like epileptic fits
• Mixed presentation
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Trauma-related disorders
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Acute Stress Disorder (ASD)
Post Traumatic Stress Disorder (PTSD)
Complex PTSD
Borderline Personality Disorder
Dissociative Disorders (DID, DDNOS)
Somatoform Disorders (somatization disorder,
conversion disorder)
- Van der Hart, Nijenhuis & Steele (2006)
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Pain and PTSD
Traumatised Refugees
Abuse Survivor
Chronic Pain
Combat Veterans
PTSD
General Population
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20
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60
80
% of population who experience
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Types of Trauma associated with Pain
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Work accidents, MVA’s
Abuse/Neglect
Attachment problems
Complicated bereavement
Diagnosis of a life-threatening illness,
Childbirth, abortion,
Combat trauma,
Exposure to political violence
Mark Grant MA
Types of pain associated with trauma
(Diseases of Stress)
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Immune system disorders
Pelvic pain
Abdominal pain
Myofacial pain
Chronic Regional Pain Syndrome (CRPS)
Fibromyalgia
TMJ
Chronic Fatigue Syndrome (CFS)
Headaches
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2 main types of pain
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Nociceptive Pain
Neuropathic pain
(tissue damage)
(CNS dysfunction)
Postoperative pain
Mechanical low back pain
Arthritis
Cancer pain
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Postherpetic neuralgia
Neuropathic low back pain
Trigeminal neuralgia
Chronic Regional Pain Syndrome
(CRPS)
• Fibromyalgia
Mark Grant MA
Mechanisms
• Psychological:
Insufficient safety and support ( < emotional distress )
Dissociation
Affect regulation problems
• Neurological:
Central sensitization
Biochemical imbalances
• Hereditary:
Genetic factors
• Physiological:
Tissue damage
CNS disorders
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Trauma-related symptoms
• PTSD symptoms (eg; flashbacks,
hypervigilance)
• Dissociative symptoms
• Affect regulation problems
• Somatization
• Depression
• Relationship problems
• Identity issues
- van der Kolk (1996)
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Traditional view of ANS
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Porges view of ANS
Para-sympathetic
MYLENATED
(social engagement system)
‘SAFE’
ventral vagal system
Sympathetic adrenal system
(Freeze response)
Muscle tone +
UNMYLENATED
(shut down)
Dorsal vagal system
Muscle tone -
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‘DANGEROUS’
‘LIFETHREATENING’
Insufficient safety &/or support
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Increased likelihood of unhealthy behaviors.
Poor self-care.
Increased stress reactivity, and
Decreased healing capacity.
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Dissociation
“..a traumatic event whose completion is truncated by lack of
spontaneous resolution of a freeze/immobility response … is
associated with a complex set of somatic pathologic events
characterized by cyclical autonomic dysregulation, and an
evolving state of vagal dominance involving primarily the dorsal
vagal nucleus.
The experimental model of kindling is intrinsic to the selfperpetuation of this pathologic process, driven by internal cues
derived from unresolved procedural memory of threat, and
enhanced by endorphinergic mechanisms inherent to both the
initial response to threat, and subsequent freeze/dissociation.”
`
Robert Scaer, 2001
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Dissociation
“Endpoint of chronically experiencing catastrophic states of
relational trauma in early life: progressive impairment of
ability to adjust, take defensive action, or act on one’s own
behalf, and a blocking of the capacity to register affect and
pain, all critical to survival.
- Shore, 1993
“..the younger a person is when flooded by trauma, the
more likely that person will be to dread affective experience,
leading affects to be mostly somaticized, poorly verbalized
and poorly differentiated.
- Krystal, 1974
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Dissociation
“Pathology results when unprocessed
experiences are … unable to link up with
anything adaptive.”
- Shapiro, 2007
“there is a sense of being cut off … from
embodied existence… a fragmentation of the
self… In dissociation the hemispheres are
more than usually disengaged”
- McGilchrist, 2009
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Mark Grant
Central sensitization
• “Stressors have destructive effects on muscle,
skeletal and hippocampal neural tissue, which
may become the immediate basis of pain, or
provide a basis for the devastating effects of
later minor injuries in which the severity of
pain is disproportionately far greater than
would be expected from the injury.”
- Melzack, 1999
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Pain in the brain
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Neurological changes
• Biochemical changes;
eg; reduced neurotransmitter levels, reduced BDNF
• Structural changes;
eg; decreased grey matter in Fibromyalgia sufferers
(x3 times normal ageing), reduced hippocampal volume
• Functional changes;
eg; homeostasis problems, reduced communication between
hemispheres, increased activity in dorsal horn area etc.
• Schema/body-map
Altered body-image
Mark Grant MA
Biochemical changes (from stress to pain)
Mark Grant MA
Genetic factors
Mark Grant
Genetic factors (PTSD)
Dysregulation
of HPA axis
PTSD
Physiology of
hyperarousal
axis
Heart rate
variability
memory
problems
Mark Grant MA
Serotonin
Dopamine
GABA
5HT
NPY
BDNF
GR
Genetic factors (pain)
Dysregulation
of HPA axis
PTSD
Physiology of
hyperarousal
axis
Heart rate
variability
memory
problems
Mark Grant MA
Serotonin
Dopamine
GABA
5HT
NPY
BDNF
GR
Implications
Mark Grant MA
AIP model (EMDR)
• “Pathology results when unprocessed experiences
are … unable to link up with anything adaptive.”
• “The stored memories contain within them the
emotional and physical sensations of the frightening
events.”
• “Present situations are viewed as triggers for past,
unprocessed events.”
- Shapiro, 2007.
Mark Grant
AIP model and pain
‘As with traumatic memories, chronic pain
may be a result of unassimilated
neurobiologically stored memories related to
the source of the pain itself (accident, onset of
illness, and so on), the long-standing state of
pain, medical procedures or other unresolved
distressing events.’
- Bergmann, 1998; Flor, 2002,
Schneider et al, 2007)
Mark Grant
AIP model and pain.
“Except for organic damage or lack of
information, inadequately processed or
inappropriately stored memories are the
basis of all clinical pathology”
Shapiro, 2009
Mark & Ana Grant
Implications from Neuroscience
• “ Decreases in stress and manipulation of the HPA component of the
stress system are likelier to produce pain relief … than traditional lines of
therapy.”
Kozin, 1993
• “ In order to produce lasting effects, psychotherapy should restructure
neural networks, particularly in the subcortical-limbic system which is
responsible for unconscious emotional motivations and dispositions.
‘Insight’ or ‘appeal’ reach only corticohippocampal structures, which
correspond to conscious memory and cognition, but have only very
limited effects on the motivational system.”
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Fuchs, 2004
Mark Grant MA
Why EMDR?
• [EMDR is] Consistent with new theories of pain (eg; Neuromatrix, LAPs)
incorporating memory, perception, central sensory dysfunction, and role
of limbic system in augmenting pain intensity & suffering.
- Ray & Zbik, 2001
• Similarities and overlap between trauma and pain (physical, psychological
& neurological)
- Grant, 1998, 2002
• Emphasis on affect (‘bottom-up’ approach)
• Research (over 10 published studies)
• Limitations of existing approaches
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Mark Grant MA
EMDR rx pain
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Fibromyalgia
Conversion disorder
Chronic Regional Pain Syndrome
Chronic Low Back Pain
Chronic Fatigue Disorder
Psycho-physiological dizziness syndrome
Capsulitis
Vaginissmus
Phantom Limb pain
Burn pain
Mark Grant
EMDR treatment of pain research
• de Roos CJAM, Veenstra, AC, den Holllander-Gijsman, ME, van der Wee,
NJA, de Jongh, A, Zitman, FG, van Rood, RY. (2006) Eye Movement
Desensitization and Reprocessing (EMDR) for Chronic Phantom Limb Pain
(PLP): A preliminary study of 10 cases. Pain (In press)
• Grant, M (2000) EMDR: a new treatment for trauma and chronic pain.
Complimentary Therapies in Nursing & Midwifery, 6, 91-94 Harcourt.
• Grant, M. & Threlfo, C. (2002). EMDR in the treatment of chronic
pain. Journal of Clinical Psychology, 58(12), 1505-1520.
• Hassard (1993) Investigation of Eye Movement Desensitization and
reprocessing in Pain Clinic patients. Behavioral and Cognitive
Psychotherapy Journal. 23. 177-185.
• Hekmat, H. Groth, S. & Rogers, D. (1994) Pain ameliorating effects of eye
movement desensitization. Journal of Behavior Therapy and Experimental
Psychiatry, 25, 121-130.
Mark Grant
EMDR treatment of pain research
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Mazzola, Alexandra, Calcagno, Marea, Lujon, Goicochea, et al., (2009) EMDR in the
treatment of Chronic Pain. (2009) Journal of EMDR Practice and Research. 3(2) 6679.
McCann, D.L. (1992) Posttraumatic stress disorder due to devastating burns
overcome by a single session of eye-movement desensitization. Journal of
Behavior Therapy and Experimental Psychiatry, 23, 319-323.
Ray, P., & Page, A. C. (2002). A single session of hypnosis and eye movement
desensitisation and reprocessing (EMDR) in the treatment of chronic pain.
Australian Journal of Clinical and Experimental Hypnosis,
30, 170–178.
Schneider, Jens, Hofman, Arne, Rost, Christine, Shapiro, Francine. (2006) EMDR in
the Treatment of Chronic Phantom Limb Pain. Pain Medicine (In press)
Wilson S.A., Tinker, R., Becker, L.A., Hofman, A. & Cole, J (2000 September). EMDR
treatment of phantom limb pain with brain imaging (MEG). Paper presented at
thee annual meeting of the EMDR Association, Toronto, Canada.
Mark Grant
Mazzola et al, 2009
Mark Grant MA
Mark Grant