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Structurally diverse agents have been employed for their sedative-hypnotic properties, including paraldehyde, chloral hydrate, ethchlorvynol, glutethimide, methyprylon, ethinamate, and meprobamate. With the exception of meprobamate, the pharmacological actions of these drugs generally resemble those of the barbiturates they all are general CNS depressants that can produce profound hypnosis with little or no analgesia their effects on the stages of sleep are similar to those of the barbiturates their therapeutic index is limited, and acute intoxication, which produces respiratory depression and hypotension, is managed similarly to barbiturate poisoning their chronic use can result in tolerance and physical dependence and the syndrome after chronic use can be severe and life-threatening. The use of these drugs is limited.
Some groups of drugs, e.g., anti-infectives, are undergoing a process of continual development. In contrast, the local anesthetics that are indispensable to attain freedom from pain in diagnostic and therapeutic interventions tend to be a rather quiescent group. Compared to general anesthetics, there are major regional differences in their proportional share in anesthetic techniques that vary between 5 and 70 . Despite the introduction of medical hypnosis, dental medicine is absolutely dependent on local anesthetics. Temporary abolition of pain sensation by chemical substances was achieved thanks to the Vienna ophthalmologist Karl Koller, who experimented with cocaine at the suggestion of Sigmund Freud.
Pain clinics in the United States frequently utilize mindful therapies (MT) for patients with pain because they have been found experientially to be beneficial. Frequently, nurses or psychologists receive training in one or more of these therapies and teach the patients to utilize them on a regular basis, for both prevention of pain and to manage pain flares. These therapies include relaxation breathing, meditation, mindfulness-based stress reduction (MBSR), self-hypnosis, guided imagery, autogenic training, and progressive muscle relaxation (PMR).79
Hypnotherapy guided imagery Mindfulness meditation Patient-centered communication Tramadol Tropisetron Vegetarian diet Whole-body heat therapy Written emotional disclosure Cognitive behavioral therapy (CBT) The German FMS guideline group reviewed 14 RCT on CBT. Most studies lasted between 6 and 15 weeks, and most therapies comprised 6-30 hours of intervention. Twelve of the 14 studies found a superiority of CBT in most outcomes at the end of the therapy. Nine of the 14 studies performed follow-ups and 5 9 studies reported a persistant reduction of FMS symptoms after 6-24 months 69 . Twenty-two out of 33 relevant studies investigating 1209 subjects could be meta-ana-lyzed. CBT had large effects on pain, self-efficacy and disability only at follow-up. Hypnotherapy has a large effect on the improvement of self-efficacy pain and a medium effect on the improvement of pain post treatment and at follow-up 77 .
On balneo- and spa therapy, two studies on homeopathy, five studies on hypnotherapy guided imagery, three studies on patient-centered communication, two RCT on vegetarian diet, three RCT on whole-body heat therapy, two on written emotional disclosure, three on tropisetron, and three on tramadol (one in combination with acetaminophen), fulfilling the criteria defined above 24, 65, 66, 68, 69 . Since December 2006 further RCT on pharmacologic, psychotherapeutic and physical treatment have been published which support the efficacy of the interventions mentioned above.
Non-pharmacologic options for trauma patients include transcutaneous electrical nerve stimulation (TENS), acupuncture, and relaxation techniques. In general, these therapies tend to be most useful as adjuncts to either nerve blocks or pharmacotherapy or in patients with mild pain. Relaxation techniques such as guided imagery, self-hypnosis, and biofeedback are most beneficial in patients with high anxiety levels, whereas the best candidates for eye movement desensitization and reprocessing (EMDR) and cognitive-behavioral therapies are cognitively intact patients willing to take an active role in treatment. The treatment of coexisting psychopathology is critical to optimizing pain treatment outcomes and should not be underestimated. In fact, long-standing anxiety from poorly managed pain has been associated with depression and posttraumatic stress disorder.
It may become necessary to assist patients who are disappointed over unachieved outcomes, or less than optimal results, after an intervention has been undertaken. Pain relief may be only partial, and there may be residual physical activity limitations that persist after an intervention, necessitating psychiatric follow-up. Strong reactions such as alarm ( Something has gone wrong ), disappointment ( I was hoping I would be better. ), and futility ( Nothing will help. ) may undermine rehabilitative treatment measures and any potentially achievable gains. Adjunctive treatment modalities such as hypnosis, relaxation and imagery, guided imagery, and biofeedback may be helpful in mitigating pain perception and distress in such cases (see also Chapter 6 in this book). Psychotherapeutic measures may be helpful in assisting patients with reframing such reactions to mitigate any potential undermining of rehabilitative endeavors. Ongoing collaborative endeavors between the psychiatrist and...
Ules should be simple to maximize adherence and should be administered in the least invasive manner. Persistent pain requires around-the-clock dosing of analgesics. Certainly psychiatric interventions, including pharmacotherapy and psychotherapy, are prudent in conditions in which there is psychiatric comorbidity. Adjunctive techniques (e.g., hypnosis, relaxation training, bio-
Celiac plexus block has been reported as useful in the treatment of idiopathic abdominal pain.97 Behavioral treatments such as hypnosis, cognitive-behavioral therapy, and supportive psychotherapy have proven valuable, especially if pain is intermittent and there is identified psychiatric disease such as anxiety or depression.87 Swedlund et al.,88 in a prospective, randomized study of 99 patients with the diagnosis of IBS, demonstrated that those patients who received eight psychotherapy sessions (and antispasmotics and bulking agents) had less abdominal pain, better bowel movements, and less psychological distress at both three and 15 months following treatment than similar patients treated only with antispasmotics and bulking agents. Other studies have been less supportive of behavioral treatments.89
The n-nAChRs are thought to have an important presynaptic role in the CNS. There are many cells throughout the CNS that express n-nAChRs both on the soma and on their axonal terminals. Stimulation of these nAChRs results in the presynaptic augmentation of release of glutamate, GABA, dopamine, serotonin, norepinephrine, and ACh itself.28 This increase in release has been shown to augment synaptic transmission in many areas of the CNS, including medial habenula, diagonal band, laterodorsal tegmental nucleus, prefrontal cortex, primary visual cortex, and hippo-campus.32 The behavioral effects of general anesthetics are varied and include hypnosis, amnesia, analgesia, immobility, as well as hemodynamic, gastrointestinal, and thermoregulatory side effects. It is likely that multiple neurophysiologic mechanisms
Many treatments I have seen colleagues endorse, e.g. local injections, TENS, desensitization therapy, continuing search for an effective drug, hypnosis, herbal treatment or other forms of complementary therapy, are not in my armamentarium. I have used spinal cord stimulation with variable success and in relatively young (
Multidisciplinary pain management, psychopharma-cology, opioids, experimental therapies and combinations is the third-line therapy recommended by the APS in cases of persisting symptoms. In cases lacking adaptation to symptoms or persistent restrictions of daily functioning, the German guideline recommended either no therapy or self-management (aerobic exercise, stress management, pool-based exercise), or booster multi-component therapy, or psychotherapy (hypnotherapy, written emotional disclosure), or pharmacologic therapy (duloxetine or fluoxetine or paroxetin or prega-balin, or tramadol with or without acetaminophen), or complementary alternative therapies (homeopathy, vegetarian diet) as third-line therapy. The choice of treatment options should be based on informed patient consent, the patient's preferences and co-morbidities, and the treatment options locally available 24 .
A wide range of chemical structures (e.g., imides, amides, alcohols) can produce sedation and hypnosis resembling those produced by the barbiturates. Despite this apparent structural diversity, the compounds have generally similar structural characteristics and chemical properties a nonpolar portion and a semipolar portion that can participate in
Most barbiturates have antiseizure properties. The discussion below is limited to the two barbiturates that exert maximal antiseizure action at doses below those required for hypnosis, a property that determines their clinical utility as antiseizure agents. The pharmacology of barbiturates is considered in Chapter 16.
Mindful CAM therapies include relaxation breathing, meditation, mindfulness-based stress reduction, self-hypnosis, guided imagery, autogenic training, and progressive muscle relaxation. Therapeutic touch, healing touch, Reiki, Qi Gong, and shamanic healing are all examples of energy healing therapies. These therapies are based on the construct that energy flow can be manipulated by practitioners and brought into balance to induce healing and pain relief.
The difficulties in obtaining optimal pain relief in CP conditions by pharmacologic intervention emphasize the need for a multidisciplinary approach. Nonpharmacologic treatment regimens including physiotherapy, cognitive and behavioral therapy are often used. Norbrink et al. 59 performed a non-randomized study, in which a multidisciplinary pain program was evaluated in patients with SCI and neuropathic pain. The 10-week program included educational sessions on pain physiology pharmacology, behavioral therapy, relaxation techniques and body awareness training and included 27 patients with SCI. A control group consisting of 11 patients with neuropathic pain was included. At 12-month follow-up no effect was seen on pain intensity, but the level of anxiety and depression decreased. Other methods such as hypnosis may also be useful.
A study of sensory and affective ischemic pain discrimination after inhalation of essential oils led to the conclusion that aromatherapy may not elicit a direct analgesic effect but instead may alter affective appraisal of the experience and consequent retrospective evaluation of treatment-related pain. Hyperbaric oxygenation combined with streptokinase for treatment of arterial thromboembolism of the lower extremity resulted in regression of ischemic pain and prolongation of the survival time of tissues compromised by ischemia. One report suggests that hypnosis may serve as an efficacious adjunct to standard medical care in the management of peripheral arterial occlusive disease.
Applications of cold (to reduce inflammation) or heat (to reduce spasms) to muscles or joints are commonly employed techniques but evidence for an analgesic benefit is mixed. Hypnosis has been shown to reduce pain associated with medical procedures however, it requires specific training and time to administer. Transcutaneous electrical nerve stimulation (TENS) has shown conflicting results in terms of an analgesic benefit in the acute setting, but it has been shown to reduce the need for pharmacologic analgesics. There is limited evidence of benefit in the acute setting from relaxation and guided imagery. Acupuncture and electro-acupuncture have been shown to be of benefit in the acute setting both to improve pain and to reduce common opioid side effects however, they require specific training and time to administer.
The following discussion reviews options for labor analgesia, including nonmedicated and medicated pain relief methods. Nonpharmacologic analgesia techniques include prepared childbirth (LaMaze), aromatherapy, hypnotherapy, acupuncture, and transcutaneous electrical stimulation. Pharmacologic techniques include systemic analgesia, regional analgesia, and nerve blocks.
Clomethiazole has sedative, muscle relaxant, and anticonvulsant properties. It is used outside the U.S. for hypnosis in elderly and institutionalized patients, for preanesthetic sedation, and especially in the management of withdrawal from ethanol. Given alone, its effects on respiration are slight, and the therapeutic index is high. However, deaths from adverse interactions with ethanol are relatively frequent.
As the primary inhibitory neurotransmitter in the central nervous system, y-aminobutyric acid (GABA) is widely distributed throughout the neuraxis. Given its ubiquity, and relatively high concentrations in brain and spinal cord, it is likely that GABA plays a major role in mediating or modulating most, if not all, central nervous system functions. Evidence for this is provided by the fact that GABA receptor agonists and antagonists display a wide variety of pharmacological effects such as anxiolysis, hypnosis, muscle relaxation, amnesia, cognitive enhancement, stimulant, and anti-convulsant activities (Bowery and Enna, 2000 Enna, 1997 Mohler, 2001). Thus, manipulation of GABAergic transmission has proved to be of benefit in the treatment of a host of neurological and psychiatric disorders.
The problems that arise in the relief of pain associated with chronic conditions are more complex. Repeated daily administration of opioid analgesics eventually will produce tolerance and some degree of physical dependence. The degree will depend on the particular drug, the frequency of administration, and the quantity administered. The decision to control any chronic symptom, especially pain, by the repeated administration of an opioid must be made carefully. When pain is due to chronic nonmalignant disease, measures other than opioid drugs should be employed if possible. Such measures include the use of NSAIDs, local nerve blocks, antidepressant drugs, electrical stimulation, acupuncture, hypnosis, or behavioral modification. However, highly selected subpopulations of chronic nonmalignant pain patients can be maintained adequately on opioids for extended periods of time.
Her physician advises her to discontinue all of them if possible. What alternative therapies can be recommended This case highlights the importance of CAM in the everyday practice of medicine. Herbal or nutriceutical treatments will most likely be avoided because of the uncertainty of these agents in pregnancy. Acupuncture may also carry at least a theoretical risk of premature labor. Self-management techniques such as biofeedback, yoga, and hypnosis can all be recommended. Osteopathic and chiropractic treatment can be beneficial, particularly if musculoskeletal factors trigger or influence headache. The herbal agent feverfew, which is commonly used in migraine, should be avoided during pregnancy.
Exercises, biofeedback and EMG, hypnosis, relaxation, imagery, ultrasound, phonophoresis and iontophoresis, acupuncture and TENS. It is thought that provision of an ideal occlusion will reduce abnormal muscle activity and so reduce pain. A variety of so-called stabilization splints have been used which are worn at night when it is thought most likely that patients clench and grind their teeth (parafunctional habit). The oral appliances predominantly cover one or other arch either completely or partially. Some attempt to realign the maxillomandibular relationship whereas others do not seek to change the relationship. They can be made of soft plastic but many are rigid and attached to the teeth by clasps. Evidence for their efficacy has not been proven.
There is considerable evidence that preparation for childbirth can significantly modify the pain experience. Fear, fatigue, and anxiety can all enhance pain perception, thus good antenatal education may modify the experience, but it will not lead to painless childbirth. Labor support and relaxation and breathing techniques form the basics for this technique. The continuous presence of a midwife or female support person (doula) has been shown to decrease the severity of pain reported. Relaxation techniques and or self-hypnosis can relieve anxiety and tension and thus modify the pain experience. These techniques should be encouraged for all pregnant women.
Nontraditional approaches to CPP include chiropractic treatment, hypnosis, and acupuncture.18'180 A prospective study on chiropractic treatment in 18 CPP patients demonstrated significant improvement in pain and functioning over a six-week treatment period of flexion distraction and trigger point techniques.180 III A randomized controlled study found a 90 percent improvement in dysmenorrhea with acupuncture compared with only 36 percent in the placebo group.181 II A Cochrane review21 I of acupuncture for pain relief with dysme-norrhea concluded that there was insufficient evidence to determine the effectiveness of acupuncture in reducing dysmenorrhea.
Physical therapy involving massage, manipulation and passive movements may prevent trophic changes and vascular congestion in the stump. Other treatments, such as transcutaneous electrical nerve stimulation, acupuncture, ultrasound and hypnosis, may in some cases have a beneficial effect on stump and phantom pain. At least three studies have examined the effect of transcutaneous electrical nerve stimulation on phantom pain, but the results are not consistent. One study showed an effect of a Farabloc, a metal-threaded sock to be worn over the stump 43 . It has been suggested that visual feedback with a mirror can eliminate painful phantom limb spasms. In a larger clinical trial of 80 amputees, however, Brodie et al. 44 failed to find any significant effect of mirror treatment on phantom limb pain, sensation, and movement. Flor et al. 4 demonstrated that sensory discrimination training obtained by applying stimuli at the stump reduced pain in five upper limb amputees. The...
Using Hypnosis To Achieve Mental Mastery
Hypnosis is a capital instrument for relaxation and alleviating stress. It helps calm down both the brain and body, giving a useful rest. All the same it can be rather costly to hire a clinical hypnotherapist, and we might not always want one around when we would like to destress.