consciousness, pain, sleep & associated disorders
TRANSCRIPT
Consciousness, Pain, sleep & associated disorders
Dr.Harim Mohsin
Consciousness & Altered states of consciousness
Definition of consciousness
For the purpose of descriptive clinical psychopathology, consciousness can be simply defined as
-- a state of awareness of the self and the environment
(Fish, 1967)
Architecture of consciousness
Stages of consciousness
Four aspects of self-awareness
the existence and ACTIVITY of the self
being a unity(SINGLENESS) at any given point of time
Continuity of IDENTITY over a period of time
being separate from the environment ( awareness of eg BOUNDARIES/DEFINITION)
Fifth dimension of ego vitality(Scharfetter,1981,1995) Previously this characteristic was incorporated within the awareness of activity, Which subsumed ‘being’ and existing with other principles.
Consciousness
Individual awareness of one’s unique thoughts, memories, feelings, sensations and environment.
Continuum of Consciousness wide range of experiences from being aware and alert to being
unaware and unresponsive.
1. Controlled Processes Full awareness, alertness, and concentration
2. Automatic Processes Little awareness and take minimal attention
3. Daydreaming
Low level of awareness
Often occurs during automatic processes
Involves fantasizing/dreaming while awake
4. The Unconscious
“It contains all sorts of significant and disturbing material which we need to keep out of awareness because they are too threatening to acknowledge fully” –
Process of Free Association - a method of exploring a person's unconscious by eliciting words and thoughts with meaningful associations .
Dream Interpretation - the process of assigning meaning to dreams
Continuum of Consciousness5. Unconsciousness
Total unawareness and loss of responsiveness to one’s environment
6. Altered States
Awareness that differs from normal consciousness
Results from using any procedures: meditation, hypnosis, or psychoactive drugs
Continuum of Consciousness
7. Sleep and Dreams
Sleep – involves different levels of consciousness and psychological arousal, which occurs in 5 stages.
Dreams – astonishing visual, auditory and tactile images in sleep, which occurs in the REM stage.
Altered States
A. Meditation
The practice of focusing attention
To enhance awareness and gain more control of physical and mental processes
Increased alpha & theta rhythm – Feeling deeply relaxed and free from being stressed
B. Hypnosis
Trance-like state
A procedure that opens people to the power of suggestion
Altered StatesC. Psychoactive Drugs
A chemical substance that acts primarily upon the central nervous system where it alters brain function, resulting in temporary changes in perception, mood, consciousness and behavior
a. Stimulants: drugs that stimulate the central nervous system.
b. Sedatives: drugs that slow down the central nervous system
c. Narcotics: also called opiates; drugs that can relieve pain
d. Hallucinogens: drugs that cause sensory and perceptual distortions
Freud’s model of consciousness
The Defenses role in consciousness
The defense mechanisms
Sleep Sleep Architecture - represents the cyclical pattern of sleep as it
shifts between the different stages
Dreams
Impulses and desires of the id are suppressed by the superego.
Because the guards are down during sleep, the unconscious has the opportunity to act out and express the hidden desires of the id.
However, the desires of the id can, at times, be so disturbing and even psychologically harmful that a "censor" comes into play and translates the id's disturbing content into a more acceptable symbolic form.
Disorders of consciousness—psychopathological aspects
Disorders of consciousness
Disorders of consciousness are associated with disorders of perception, attention, attitudes, thinking, registration and orientation
Three dimensions of consciousness and unconsciousness
Vigilance(wakefulness)-----drowsiness(sleep) axis
Lucidity ----clouding axis
Consciousness of self
Normal state of consciousness----- death(in a person suffering from serious brain disease)
Full wakefulness-----to deep sleep( in a person who is sleep)
Full vigilance ------total unawareness(in an alert and healthy person
The organic state of brain, as for instance, demonstrated by EEG, is utterly different in these three situations
Classification of Disorders of consciousness(Sims)
Quantitative lowering of consciousness
Qualitative change of consciousness
Normal (alert, vigilant, lucid)
Clouding
Drowsiness
Stupor
Coma
Death
Delirium
Fluctuations
Confusion
What is the Pain?“Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.”
International Association for the Study of Pain, 1979
• Site(s)
• Quality
• Severity
• Date of onset
• Duration
• What makes it better/worse
• Impact on sleep, mood,
activity
• Effectiveness of previous medication
Patient Pain History
PQRST mnemonic:
• P: Precipitating and palliating factors
• Q: Quality
• R: Region and radiation
• S: Severity
• T: Time
Psychiatric Disorders with Pain
Psychiatric disorders with pain• The typical finding is an increased occurrence of psychiatric
disorders among persons with a specific pain condition when compared with persons with no pain.
Depression
Anxiety
Chronic Pain
Somatoform disorders
PTSD
Types of Pain
1. Acute (<6 months)
2. Chronic (6 months <)
Acute pain:
• lasts less than 6 months, subsides once the healing process is accomplished.
Presentation of Pain
AcuteChronic• Often obvious distress
• Can be sharp, dull, shock-like, tingling, shooting, radiation, fluctuating in intensity, and varying in location
• (occur in timely relationship to noxious stimuli)
• Comorbid conditions not usually present
• May see HTN, increased HR, diaphoresis, pallor…
• Can appear to have no noticeable suffering
• Can be sharp, dull, shock-like, tingling, shooting, radiation, fluctuating in intensity, and varying in location (do NOT occur in timely relationship to noxious stimuli)
• Symptoms may change over time
• Usually NO obvious signs
Acute Pain (Nociceptive)
• Somatic• Superficial (nociceptors of skin)
• Deep [body wall (muscle, bone)]
• Visceral • (sympathetic system; may refer to superficial structures of
same spinal nerve)
PHYSIOLOGY OF PAIN
(Yoneda, Hata, Nakanishi, Nagae, Nagayama, Wakabayashi, and Hiraga, 2011).
Acute Pain• Travels into the spinal cord along the
appropriate nerve root.
• Nerve root -> front division and a back division and carries pain sensation to the CNS (spinal cord and brain).
• Passed to a short tract of nerve cells (interneurons), which in turn synapse with a nerve tract that runs to the brain .
• Sent out to the rest of the brain, connecting with thinking and emotional centers.
• A modifier pathway from the brain modifies pain at the synapses in the back part of the spinal cord (acute pain is decreased rapidly after tissue injury).
Chronic pain:
• Complex processes & pathology. • Usually altered anatomy & neural pathways.
• Constant & prolonged, > 6 months, sometimes for life.• “Lasting longer than expected time frame”
Altered Neural Structure
• Chronic pain accompanied by: • Cortical Reorganization
• Brain Atrophy
Chronic Pain
1. Malignant (cancer)
2. Nonmalignant
• Neuropathic (nerve injury)
• Inflammatory (musculoskeletal)
• Mixed or unspecified
• Psychogenic
Chronic Pain• Neuropathic:
• Severe pain disorder that results from damage to the central and peripheral nervous systems.
• Inflammatory:
• Results from the effects of inflammatory mediators.
• Neuralgia• an extremely painful condition consisting of recurrent episodes of intense shooting or
stabbing pain along the course of the nerve.
• Causalgia• recurrent episodes of severe burning pain.
• Phantom limb pain
• feelings of pain in a limb that is no longer there and has no functioning nerves.
Peripheral Nerve Fibers Involved in Pain Perception
• A-delta fibers–small, myelinated fibers that transmit sharp pain
• C-fibers–small unmyelinated nerve fibers that transmit dull or aching pain.
Biopsychosocial ModelBIOLOGICAL
NociceptionTissue DamageDisease Process
PSYCHOLOGICAL
Pain beliefsLocus of control
Lack of self-efficacyLimited coping
Emotions
SOCIAL
Cultural influencesLearning mechanisms
social learningreward/punishment
classical conditioning
PSYCHOLOGICAL FACTORS
1. LOCUS OF CONTROL:
Rotter (1996) stated that there were “internal” and “external” Locus of control.
The “internals” (believe that their own actions significantly influence their health)
The “externals”(believe that they don't have much control over their health)
Persons who believe that the prognosis for their pain is influenced mainly by luck or fate (external) are engage in maladaptive coping strategies such as wishful thinking or catastrophizing.
(Worsham, 2006)
2. CATASTROPHIZING COGNITIONS:
Pain catastrophizing is characterized by the tendency to magnify the threat value of pain stimulus and to feel helpless in the context of pain, and by a relative inability to inhibit pain-related thoughts in anticipation of, during or following a painful encounter.
A “Neurophysiological Model” of catastrophizing proposes that:
Cont…
In a research study pain catastrophizing was assessed pre-surgery.
The results showed significant variance in postsurgical pain ratings, narcotic usage, depression, pain-related activity interference and disability levels.
Another study by Edwards, suggested that pain catastrophizing was related to increased suicidal ideation in a large sample of chronic pain patients.
SELF-EFFICACY AND EFFECTIVE COPING:
In a Research study low levels of self-efficacy was found to be associated with a lower levels of pain tolerance and higher levels of pain intensity in samples of people with chronic pain.
Those who alleviate their pain are likely to mobilize whatever skills they have learned to preserve themselves.
The higher the perceived self-efficacy the longer pain can be tolerated and less medications are required.
Individuals who experience pain may develops two types of coping.
Adaptive coping: active coping strategies are considered to be adaptive in which patient is an active participant and assumes self management responsibilities.
Maladaptive coping: these are passive coping strategies in which patient withdraw from activities and shows dependency on others for pain relief. (Placebo)
Studies have found that active coping strategies decreases the pain intensity and increases pain tolerance.
However, passive coping is associated with greater pain and related depression.
Coping
PAIN AND EMOTIONS:
The typical emotional reaction to pain includes anxiety, fear, anger, guilt, frustration, and depression.
According to FAM (Fear-avoidance model) “Fear of pain” is the most important emotional factor in perception of pain.
A fear response to pain leaves an individual with two options:
Confrontation (Menstrual pain)
Avoidance (Fracture pain and hygiene care)
The “Confronter” is more likely to view pain as temporary , is motivated to return to normal work, social and leisure activities, and is prepare to confront their personal pain barriers.
Cont… The pain “Avoider” is motivated by fear and avoid both pain experience
(cognitive component) and painful activities (behavioral component). Thus, this avoidance leads to more pain and is harmful to the recovery
process. Certain other negative emotions such as anger, hostility and depressed
mood can also influence pain perception. Negative emotional states registers in the brain in a manner that strikes
brain pathways which are responsible for enhancing pain. The expression of anger and hostility are often used as defensiveness and
can seriously compromise the therapeutic relationship between nurse-patient, which further deteriorates patient’s condition.
NEUROTICISM EXTRAVERSION (Eysenk’s personality theory): High neuroticism is the result of cortical arousal which increases sensitivity and contributes to emotional instability. Such individuals are more likely to worry about physical symptoms like (pain).
(Eysenk’s personality theory): Extraversions have low cortical arousal, requiring more frequent and stronger stimulation to acquire satisfactory levels of arousal. As a result, extravert exhibit diminished pain sensitivity and higher pain threshold.
These individuals generally do not cope well with stress and perceive painful stimulus as threatening and distressful.
Extraversion is also associated with use of active and strong coping strategies that lead to better adaption to painful stimulus. (For example, being optimistic)
certain dimension of neuroticism negatively correlates with pain (experiment):1.Negative mood decreases pain tolerance time.2.Emotional vulnerability increases pain intensity and unpleasantness.
Extroversion is positively associated with general health perception. Individual both healthy and with self-reported medical problems feel good about themselves and try to mobilize all their resources to maintain this state of health.
Neuroticism is significantly high in patients with lower back pain, joint pain and cancer pain etc.
Extraversions are more likely to complain about their pain and express their sufferings than individuals high in neuroticism. http://books.google.com.pk/books?id=vwjIskXBbu8C&pg=PA28&dq=pain+and+extraversion+personality&hl=en&sa=X&ei=zRujUcr7JsezhAeayYAY&ved=0CDAQ6AEwAQ#v=onepage&q=pain%20and%20extraversion%20personality&f=false
PHARMACOLOGICAL &
NONPHARMACOLOGICAL MANAGEMENT
Pain Management
Principles of Treatment
• Reduction of Pain:• Behavioral, Meds, Blocks, Surgery, Complementary
• There is no magic bullet, no single cure
• Rehabilitation:
• Reconditioning & Prevention
• Coping:• Management of Residual Pain
Treatment Objectives
• Decrease the frequency and / or severity of the pain
• General sense of feeling better
• Increased level of activity
• Return to work
• Decreased health care utilization
• Elimination or reduction in medication usage
Copyright © 2003 American Society of Anesthesiologists. All rights reserved
Treatment of Pain
1. Non-pharmacologic
2. Medications• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Acetaminophen
• Antidepressants & anticonvulsants
• Adjuvants
• Narcotics
1. Invasive procedures
3. SENSORY CONTROL OF PAIN:
One of the oldest known techniques of pain control is
COUNTER-IRRITATION, a sensory method.
Counterirritation involves inhibiting pain in one part of the body by stimulating or mildly irritating another area.
Overall, sensory control techniques have had some success in reducing the experience of pain. However, their effects are often only short-lived, and they may therefore be appropriate primarily for temporary relief from acute pain.
RELAXATION TECHNIQUES
Rationale for teaching pain patients relaxation techniques, is that it enables them to cope more successfully with stress and anxiety, which may also ameliorate pain.
In relaxation, an individual shifts his or her body into a state of low arousal by progressively relaxing different parts of the body.
HYPNOSIS In 1829, prior to the discovery of anesthetic drugs, a French surgeon,
Dr. Cloquent, performed a remarkable operation on a 64 year old women who suffered from breast cancer and the tumor was being removed without anesthesia through
hypnosis and the lady felt no pain.
First, a state of relaxation is encouraged.
Next, patients are explicitly told that the hypnosis will reduce pain.
In the hypnotic trance, the patient is usually instructed to think about the pain differently
Tools of hypnosis
In acupuncture treatment, long thin needles are inserted into specially designated areas of the body that theoretically influence the areas in which a person is experiencing pain. (Practiced in china for more than 2,000 years).
How acupuncture controls pain is not fully known. But it is possible that acupuncture triggers the release of endorphins, thus reducing the experience of pain.
When Naloxone (an opiate antagonist) is administered to acupuncture patients, the success of acupuncture in reducing pain is reduced.
DISTRACTION Individual who are involved in intense
activities like sports or military maneuvers can be oblivious to pain full injuries due to Distraction
Cont… There are two quite different mental strategies for controlling
discomfort.
To distract oneself by focusing on some other activity.
Focus directly on the events but to reinterpret the experience.
COGNITIVE BEHAVIORAL THERAPY FOR PAIN
ACCEPTANCE AND COMMITMENT THERAPY
AWARNESS AND PERSPECTIVE
MINDFULNESS
COGNITIVE DE-FUSION
WILLINGNESS
COGNITIVE BEHAVIORAL
THERAPY
McCracken, (2005).
COGNITIVE BEHAVIORAL THERAPY FOR PAIN
1. ACCEPTANCE AND COMMITMENT THERAPY:
Aim for ACT is to reduce the feelings of failure (drug dependency) of strategies to control pain.
The therapist creates a collaborative environment in which Patients with pain can review their actual problem and find out their previous way of struggling to solve this problem. This gives a clear understanding of the time duration of persisting problem and range of strategies tried by patient to improve situation.
It helps identifying the actual problem which is not the pain itself, rather the behavior of disregarding oneself for the repeated failures to achieve an effective pain control.
MINDFULNESS:
"the intentional, accepting and non-judgmental focus of one's attention on the emotions, thoughts and sensations occurring in the present moment", which can be trained by meditational practices derived from Buddhist anapanasati.
Non-pharmacologic Pain Management
• Cognitive therapies (relaxation, imagery, hypnosis)
• Biofeedback• Behavior therapy• Psychotherapy• Massage therapy • Art therapy• Music therapy• Aroma therapy
• Neurostimulation
• TENS
• Acupuncture
• Anesthesiology
• Nerve block
• Surgery
• Physical therapy
• Exercise
• Heat/cold
• Psychological approaches
The End