[Case Study] Managing Unconscious Resistance in a Patient with Trigeminal Neuralgia Chronic Pain with Clinical Hypnosis

Written By Dr Anand Chandrasegaran - 10 June 2022

1. Introduction

One issue with traditional pain assessment methods (Karoly & Jensen, 1987) is that clinicians 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 in regard to pain assessment.

This is a case of a 32-year-old gentleman who presented to me with facial pain for 2 years. He has been diagnosed with Trigeminal Neuralgia of unknown origin. Trigeminal neuralgia is sudden and severe facial pain, which this patient described as sharp shooting pain, or like having an electric shock in the jaw, teeth, or gums. The patient described the pain attacks as short and unpredictable, lasting just a few seconds. The attacks stop as suddenly as they start.

He is on Trileptal and Neurotin (both are anti-epileptic medicines which can be used in chronic pain management, especially for neuropathic pain) and Ultracet (a mild opioid). All three medications were taken three times a day for almost 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 with regard to 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 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 consulted a dental specialist for further assessment. After a routine dental assessment, it was determined that the problem that he presented with was not from the oral cavity (he had 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 for pain relief. Before starting on medications, his pain score ranged from VAS (Visual Analogue Scale) 9-10/10. With medications, his VAS pain score was 2-4/10, more intense when there were 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 help him manage his pain.

3. Challenges faced with this patient during the hypnosis session

After a careful explanation, all myths and issues surrounding hypnosis were explained. The patient was then 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 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, there was 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 for his feedback. He reported that he was not able to practise 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 to be no changes in pain score and the patient’s pain perception over the facial region.

In this case, the challenge that the author 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 strained the patient.

4. Solutions

In view of 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 the following strategies:

I. Unconscious Exploration to Enhance Insight or Resolve Conflict

Here, the patient was engaged by further assessing his inability to relax. With a series of questions, the unconscious process involving the reasons behind the patient's inability to relax was identified.

For this patient, the inability to relax was a psychological process that he had developed during his days in college. He took over his family’s financial burden, and from a young age, he started working hard. He would constantly stress himself out, as he had to meet his financial commitments to his family. And this cognitive structure continued even after he had stabilised 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 kept 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 the patient had the inability to relax consciously, the induction method used involved: Interspersal Technique and the use of metaphors, which the patient could relate to his 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.

Once the patient was relaxed, he 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

• Unconscious Exploration of Function or Meaning of Pain

• The Inner Adviser Technique (to explore the meaning and triggers of pain)

• Reinterpretation of Sensations: pain associated with facial muscle strain/stress as a means to induce a relaxed state.

• Increasing Pain Tolerance: Mental Rehearsal of Coping with Triggers and Pain

II. Creating Anaesthesia or Analgesia

• Glove Anaesthesia method

5. Results

Immediately after the second session, the patient was able to relax.

The VAS before the session for relaxation was 8-9/10. At the end of the second session, the VAS for relaxation was 2-3/10. He felt his face and neck and shoulder muscles were more at ease and relaxed. The patient reported that this was the first time in many years that he felt his upper body muscles were at ease.

The patient also reported that he was 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 is now able to practise the self-hypnosis relaxation methods.

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 is able to sleep more relaxedly at night.

Generally, the patient was satisfied and the author managed to achieve the patient’s expectation, which was to achieve a state where he had a sense of relaxation over his shoulder, neck and facial muscle. The patient is optimistic that, with more self-practise and working on his deep-seated issues, he will get better soon.

Discussion

As physicians treating pain, we must adopt a pragmatic framework regarding the position of hypnosis. 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 clearly helpful but are in need of 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.

It is imperative for physicians to evaluate more than the biophysical features of pain. Especially with chronic pain patients, a 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 hypothesise that this may particularly be the case when the cause of the pain is unknown and cannot be causally related to any pathophysiologic process, where the pain seems more intense than would ordinarily be anticipated, and/or when pain lasts longer than is appropriate.

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References

1. 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 hypnotic-analgesia 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 toward pain. Journal of Psychosomatic Research, 31(3), 393-400. https://doi.org/10.1016/0022-3999(87)90060-2

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Authored: Dr Anand Chandrasegaran Anaesthesiologist & Critical Care Medicine Consultant, Columbia Asia Klang Hospital Clinical Hypnosis Pain Specialist Contact: mbbsum@gmail.com