TREATMENT OF SPECIFIC ANXIETY-BASED PROBLEMS

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Psychosomatic and physical disorders

 It has been known for centuries that psychological/emotional factors are related to many physical illnesses--some emotional reactions cause problems and some psychological circumstances or techniques help us feel better. Emotional trauma can cause physical problems. A recent study reported that women who experience trauma--domestic violence--have 50% to 70% more neurological, gynecological, and stress-based physical problems than women who have never been abused (Johns Hopkins School of Nursing, 2002, Archives of Internal Medicine). Of course, the reverse is true too: having a physical problem may cause us distress and sadness while good health contributes to happiness. Usually there is a two-way relationship between the psychological and physical aspects. An entire issue of the Journal of Consulting and Clinical Psychology (July, 2002) documents well the role of psychology in the management of many specific physical problems and diseases. Negative emotions influence our hormones and lower our immunity to several diseases. Depression, anger, and social isolation contribute to heart disease; psychology can and should be part of the treatment (see heart section below). Different behaviors contribute to healthy and to unhealthy aging. Stress affects asthma, digestive track disorders and many other physical ailments; psychological techniques can help one relax. Behavioral control methods are, of course, related to maintaining the all important healthy diet and exercise program. Behavioral self-regulation is at the crux of weight control...diabetes management...of pain and headache management...of somataform disorders...and of many other problems that are commonly seen as "physical."

 Hundreds of magazines and books (Borysenko, 1988; Barsky, 1988) tell us over and over that stress causes or worsens illness. But, do we listen? Specific experimental psychological treatments have been developed for a variety of ailments: heart disease, tension headaches, migraine headaches, pain, hypertension, ulcers, insomnia, asthma, skin conditions, hives, tics, and many others (Knapp & Peterson, 1976). Yet, as sufferers, we still look for physical causes and physical-drug cures. The truth is, however, that we should also be looking for psychological causes, i.e. sources of frustration, helpless feelings, and, most importantly, interpersonal conflicts and disappointments. Relationships are where a therapist will look first for stress. You should, too (of course, you need a careful "physical" as well). Look for ways to reduce these tensions (Benson, 1975 or 1984; Domar, 1996).

 Heart disease. In 1628, William Harvey described the heart and noted it was affected by emotions. Nearly 200 years later, William Osler, the father of internal medicine, observed that the heart attack patient was frequently an ambitious man going full speed through life. In the 1950's, cardiologists Friedman and Rosenman researched the connection between heart disease and the Type A personality, i.e. one who is prone to do two things at the same time, anxious, impatient, and bubbling hostility. So there has long been an awareness that psychology and emotions are intimately related to diseases of the heart.

 This is a serious topic. Heart disease, the #1 killer in the US, begins in the mind! To have healthy hearts, Americans have to change their diets and their cynical, mistrusting thoughts, and hostile emotions. These aren't comments by psychologists; they are statements by a heart specialist (Williams, 1989). We want and expect a pill or a diet to prevent a heart attack. But now Williams, an internist, says we must and can change our thoughts, our attitudes, and our emotions in 12 steps: (1) keep a journal of the things that make you mad (record events, note your thoughts and attitudes that produce anger and mistrust), (2) reveal to others your hopes of changing your temper and negative attitudes, (3) use thought stopping (chapter 11) against cynical, anger-producing thoughts, (4) challenge irrational thoughts (chapter 14) that lead to feeling suspicious ("they are trying to screw me over"), angry ("they are really stupid"), and punitive ("they should be severely punished--I'd like to do it myself"), (5) practice empathy frequently and develop understanding (chapter 13), (6) lighten up, the universe doesn't revolve around you, laugh at your self-centeredness, (7) relax frequently (chapter 12) and use a cue-word, like "relax," to reduce your irritation and anger, (8) practice trusting and being tolerant of others, (9) and (10) learn active listening, "I" statements, and assertiveness skills (chapter 13), (11) tell yourself that getting riled up and criticizing others can kill you, so it is better to replace your anger with optimistic, tolerant understanding before the heart attack occurs rather than after it, and (12) forgive those (method #4 in chapter 14) who have angered you and, thereby, free yourself from resentment and wanting to get even--and from heart disease. What a smorgasbord of self-help techniques! Undertaking these be-kind-to-your-heart treatment efforts would surely bring more happiness to you and more kindness to others and, therefore, lighten your mood as well.

 Williams (1989) and Williams & Williams (1993), who believe hostility is the villain, aren't the only ones to treat heart disease successfully using psychology. Volumes of research over 20 years have studied the relationship between Type A personality and heart disease. Type A's are not just angry, they are tense, hurried, pressured, impatient, competitive, and irritable. They are twice as likely to get heart disease as less anxious persons. Several recent studies have clearly shown that extensive (40+ hours spread over 1 to 3 years) treatment can cut Type A's risk of a second heart attack nearly in half (Blanchard, 1994). That's impressive. What treatment works? Stress management skills to change the core personality: relaxation training, self-observation to help recognize and reduce emotional over-reactions, communication skills training, cognitive therapy (see the several methods above), and training in problem-solving, including determining values and goals. In short, the Type A's were taught self-help skills and, thus, changed. Why isn't the medical establishment encouraging this treatment?

 Recent research has continued to confirm the role of psychological factors in heart disease. John Hopkins University(Archives of Internal Medicine, April, 2002) has confirmed that medical students who (a) expressed or concealed their anger, (b) were irritable, and (3) griped a lot were 3 times more likely to develop early heart disease and 5 times more likely to have a heart attack than their calmer class mates. Likewise, another study at University of North Carolina (Williams, 2001) found that people with high anger scores (quick tempered with frequent, intense rages and urges to hit people, etc.) were three times more likely to have a heart attack or cardiac death. Early measures of hostility (mistrust, aggression, cynicism) are good predictors years later of heart disease so early intervention is possible. High stress reactions have been shown to trigger a heart attack. Depression increases the likelihood of death from heart disease. It seems likely that heart patients might benefit from anger, depression, and/or stress management. Several publications have already suggested that more complete psychoeducational programs would be beneficial and a couple of major studies of extensive psychological treatment are now underway (Research to the Heart of the Matter). It seems likely that self-help efforts to reduce the major emotions of Anxiety, Depression, and Anger could have significant impact on your future health. And don't forget exercise, a healthy diet, no smoking, and a good social life.

 A psychologist, David Abrams, testified before Congress (May 16, 2002) that good stress management and lifestyle changes, such as healthy dieting and smoking cessation, can reduce the deaths from heart disease by 34%! One must think in terms of life-long heart-healthy programs, not just dieting after blockage of an artery has been found by an angiogram. Psychologists have shown that working long hours (over 40 or 50 hours a week), working weekends, getting little sleep (less than 6 hours a night) doubles or triples the risk of heart attacks. Anger combined with exhaustion is quite dangerous. Apparently, psychological stress increases the risk of death during a heart attack in complex ways, including actually interfering with the flow of blood to the heart just as plaque, cholesterol, and arteriosclerosis might do.

 The amount of fatigue you feel at work is a complex matter. For men and women, fatigue is greater when you are not able to organize your own work and when colleagues are not supportive. For many men, high emotional and physical demands, plus demanding bosses, lead to feeling tired on the job within one year. For women, demanding work and interpersonal conflicts are the more likely causes of fatigue. As you might guess, men who have professional jobs run less risk of heart disease and death compared to men with less authority, less education and lower income. Yet, women in demanding positions with high authority were 3 times more likely to develop heart disease than women in less demanding jobs (this tendency was not related, according to these researchers, to having "two jobs--one at work and one at home" or to higher levels of emotions, like anger, depression, or tension.) Men in non-traditional roles, such as being househusbands or living alone, had greater risk of death. You pay a price for being different.

 For a timely and detailed review of the many mechanisms (specific physiological pathways) by which environmental stress, emotions, and personality characteristics affect various aspects of Coronary disease, see Smith & Ruiz (2002). Understanding the specific heart disease processes is complex, involving medicine, physiology, psychology and other disciplines. The quality and precision of this research has increased greatly in the last decade or two. Anyone realistically dealing with the psychology-heart connections must learn about these relationships. I can only summarize for you a few basic psychological findings: several emotions are repeatedly shown to be related to chronic heart disease--anger (open expression) and hostility (cynicism and distrust), social dominance (controlling behaviors), negative emotions (depression, anxiety, lack of energy), interpersonal isolation and conflict (including marital strain), and job stress (high demand, low control). Much more study is needed but this area of research is and will likely be at the cutting edge of mind-body research for a while.

 Perhaps the most important area of study is "Psychologically what can be done to prevent or reduce heart disease?" These findings have not become clear-cut yet. But, several interventions have been repeatedly shown to be helpful: relaxation training, self-monitoring of Type A behavior, stress management, hostility management, cognitive restructuring, supportive counseling by nurses and counselors, reduction in risky behaviors (smoking, poor diet, over-weight), meditation, exercise, and others. In fact, several researchers have concluded that psychosocial treatments were more effective than the usual medical and surgical interventions, including beta-adrenergic blocking medications, anticoagulants, stents, etc. However, standard medical treatment has recently improved with better beta-blockers, lipid lowering meds, better stents, etc. More research of the psychological treatment is needed but the promise is there.

 I will not try to link you to all the heart relevant self-help methods in this book but there are many self-change techniques that can help you prevent and cope with heart disease. Remember, just stopping smoking reduces the heart patient's mortality risk by 40%. What if you never smoked? Starting an exercise program and losing weight also have known benefits. We know a lot about how to reduce anxiety, depression, anger, loneliness, conflicts, and so on. You have a pretty good idea of what you need to do...so get to it.

As always, your treatment has to be designed to meet your needs. For example, both overly expressive individuals (tense, angry, poorly controlled) and overly inhibited individuals (unable to express anger primarily) are prone to heart attacks. Thus, some people may need to express more feelings (but in moderation, not violently), while angry Type A's need to recognize the  In light of all this data strongly connecting emotions with heart disease, it may surprise you to learn that many cardiologists pay little attention to the role of emotions in causing or in treating lethal heart disease. Even when the heart patient's wife says to the doctor that her husband got enraged and put his fist through the door the other day, the doctor may just shrug his shoulder. Many, perhaps most, cardiologists do not refer their patients to psychologists if they need to gain better emotional control. However, even if referrals were made, many patients wouldn't go because of the stigma of seeing a shrink. Much better prevention and treatment could be provided than it is now, but the professions will have to cooperate and use all the knowledge available to us.

 There are apparently myths in all areas. That includes notions of how to avoid heart trouble. Have you been told that you should express your feelings..."get it out of your system"...that anger will consume you if you don't "let it out?" A lot of people, including counselors, give this advice... sometimes it may be good advice, sometimes bad. Several studies report that having intense anger and venting it is unhealthy. .

 Have you heard over and over that drinking red wine moderately is heart-healthy? A recent study questions whether wine is healthy for you or if healthier people drink wine (July, 2002, American Journal of Clinical Nutrition). These new findings illustrate the fallacy of the single cause (see Rational Thinking in chapter 14). For example, wine drinkers have better diets, exercise more, smoke less, and eat more veggies than non-drinkers. Moreover, wine drinkers smoke less, eat more fiber, less fat and cholesterol than drinkers of other kinds of alcohol. So, maybe good advice is far more complex than "drink red wine for a healthy heart." The body and all life is complex. We need good science to understand the complexities.

 Have you heard of the hoax that circulated through the Internet called "cough self-CPR"--coughing repeatedly and vigorously--if you think you are starting to have a heart attack when alone? Well, according to the American Heart Association, this vigorous coughing every two seconds self-treatment is useless or dangerous advice. AHA says if you are in this tense situation (a) attend to the warning signs (chest or upper body discomfort, shortness of breath, and possibly a cold sweat, nausea...), (b) call 911 immediately, (c) have someone begin CPR (if needed), and, hopefully, (d) have an Automated External Defibrillator nearby.

 Cancer is a serious, scary, not clearly understood disorder where cells grow out of control. Half a million Americans die from cancer each year. One out of every three Americans will have some form of cancer sometime during their life. Lung cancer is the most common cancer and often related to smoking. The risk of malignant melanoma is increased by sun burns. But not much is known about the causes of other common cancers, such as breast, prostate, and colorectal. Cancer strikes many parts of the body. The type of cancer is determined by the organ it started in, the type of cell in that organ it started in, and the general appearance of the cancerous cells. So, different kinds of cancer can start in the same organ, such as your kidney, and each would need a different kind of treatment. Thus far, family history--the genes?--appears to play a moderate role in causing certain cancers but our knowledge about the causes of cancer is limited. We know about 10% of all American women will eventually have breast cancer, the risk increases with age.

 Should you study your own type of cancer? The medical literature can be confusing and disturbing reading. If you are thinking about researching your own cancer, read the pros and cons of doing so on the CancerGuide by Steve Dunn. The medical aspects of cancer are very complex and technical, plus the terminology is difficult for a layman to understand. But, if you have a rare cancer, you might be able to help your physician find helpful information or experts to consult with. Note: Always consult carefully with your physician, don't try to treat cancer on your own. There is a lot of garbage out there. The psychological aspects of coping with cancer are also complex and may also be difficult to understand. However, a few points need to be made.

 As we discussed above, stress and certain emotions can contribute to the development of certain physical problems, like heart problems, but in other disorders stress is not a cause but a result of having certain physical problems. Breast and prostate cancers are cases in point. Being told you have breast cancer or prostate cancer would set off a near panic reaction in most of us. Many people still believe they will die when they are told they have cancer. That is probably a misunderstanding of the diagnosis. During the course of cancer, patients report having continuing emotional distress, fatigue, lack of energy, fears, depression, and interpersonal difficulties, in addition to added financial, health insurance, and employment problems. Can psychology help allay these high stress or depressive reactions? Often, yes.

 Will psychology pro-long your life? Probably not by directly slowing the growth of cancer cells. In the late 1980's, a couple of well publicized studies involved life-threatening cancer and appeared to result in a higher survival rate several years later for those patients who attended a support group than for those who did not get such a treatment. Such a finding gets attention. Unfortunately, the treatment and control groups may not have been well matched. The latest research findings are a bit mixed but generally most scientists would conclude that psychological treatment and/or positive thinking do NOT prolong life (based, in part, on several cancer studies analyzed in 2002 by Dr. Edzard Ernst at the University of Exeter). The earlier studies may have created an exaggerated illusion of control over death. On the other hand, there is clear evidence that psychological intervention, education, and professionally run support groups can "improve the quality of life for many cancer patients," not prolong their lives. Psychologist-led groups can help with anxiety, depression, pessimistic or suicidal thoughts, and family relationships. Behavioral interventions can improve diets, exercising, compliance with doctor's orders, and general health. Oncologists understand the need for these changes and relief from emotional problems but as a profession they tend to think it is someone else's job. In fact, about 20% of oncologists are reportedly uncomfortable treating advanced cancer patients who are dying. Other professionals, hospice workers, nurses, and mostly family members will have to provide the needed support.

 Massive cancer research done during the 1990's produced wonderful improvements in the physical treatment of cancer and generally confirmed that psychological interventions can generally (but not always) increase the quality of life in cancer victims. Much more research is needed, however. Some peer support groups are helpful but some may be harmful. I'd suggest you choose a support group led by a professional--a psychologist or a social worker--experienced with cancer. Several Web sites provide information about cancer: WebMDHealth and American Cancer Society and Cancer.gov. It may also be helpful to read on those sites people's descriptions of their battles with cancer. Taylor & Thompson (2002) share the moving but informative stories of 30 cancer patients.

 If you have cancer, there are two things you should do to understand the psychological aspects better: (1) read a scholarly and detailed review--not just a newspaper article--of the recent psychological research with cancer patients (such as, Anderson, 2002; Email: anderson.1@osu.edu). This gives you a realistic notion of what to expect from psychological treatment. Several types of psychological interventions have been researched--relaxation training, individual therapy, group therapy, cognitive-behavioral therapy, educational classes, training physicians to be warmer and more supportive, peer groups, and peer counseling. In general, these interventions reduce distress in cancer patients. As you know (and as this book tells you over and over) most self-help methods are adaptations of therapy techniques, so you could select self-help methods that would fit you and your situation. Examples: in general, relaxation techniques (see chapter 12) and challenging your upsetting, irrational thoughts (see chapter 14) might help you calm down. In a more specific instance, the radiation treatment of cervical cancer often results in several kinds of significant sexual dysfunctions. Therapists have found that a device, called Eros, is very helpful in gradually restoring sexual functions and pleasures. It consists of a gentle vacuum that is applied to the clitoris. With a prescription and a little advice about how to use the device (costing $395), it could become a self-treatment procedure.

 (2) The second thing I would do is read Holland & Lewis's (2001) book, The Human Side of Cancer. Holland is a physician, a female, who has concentrated for years on the psychological/emotional experiences associated with having cancer. She is a leader in this field. One of her salient points is that the popular self-help literature sometimes does harm to cancer victims by preaching "positive thinking." Some pop psych writers blindly believe and will tell you that having unwavering hope, being positive and inspired, being an aggressive fighter of disease, etc. will help you overcome cancer, almost implying positive thoughts are a cure. Positive thinking can improve the lives of some people in several ways but it can also actually cause harm to others. Holland points out that many people have never had a positive, optimistic, rosy, everything-will-be-wonderful outlook and they aren't going to adopt such an attitude while being diagnosed with cancer, facing sickness and possible death, and enduring painful, draining cancer treatment. Some people cope by being realistic and quietly stoic.

 Dr. Holland describes cancer cases in which the patient feels especially hopeless because they just can't get optimistic, even though their cancer treatment is going well or has been successful. Because the self-help books say you must be positive, they feel afraid and worried because they don't have the "right" attitude. Sadness and fear do not make tumors grow. No one is going to die because they can't keep a positive attitude. Self-help book writers should realize their positive message, while helpful in some cases, can also encourage blaming the victim. Some people are so into the positive thinking thing that they actually blame people for having a brain tumor or cancer of some internal organ. That is stupid and cruel. But humans, always hoping they have a solution, are prone to think this way, e.g. before bacterial infections were found to be responsible for tuberculosis and for ulcers, it was thought that personality traits and high stress were the causes. Cancer can't be caused or controlled by your positive or negative thoughts, but optimism can perhaps help you cope with the growing cells.

 Back in the late 1970's a popular treatment for cancer, advanced by medical doctors, involved having the patient visualize their healthy cells attacking and killing the cancer cells. Well, that treatment has been discarded, but we still have the self-help books saying "you have to be positive," "you need to imagine being cured of cancer," "you have to eat specific foods," and so on to get well. We must separate the nonsense from the truth. Of course, being cooperative and conscientious about carrying out your treatment and maintaining your general health are important.

 General health, according to popular and interesting but spiritual books by Siegel (1989), is related to peace (acceptance of ourselves and the world), love, hope, taking responsibility for oneself, self-body talk, openness to joy, reaching out to others, relaxing, self-acceptance, expression of feelings, visualization of healing, having a fighting spirit, spiritual faith, and other factors. For health we certainly need to talk to and listen to our feelings--our inner selves.

 And for health we may need a protective, nurturing system of care, something far warmer, more available, and more personal than our current medical/psychological services. Shelley Taylor (2002) has pulled together the evidence for "tending and befriending" tendencies (see Anxiety section above) and for the critical importance of having a caring social environment throughout life, but particularly from loving parents in childhood. In her book, The Tending Instinct, she also reminds us that the radical collapse of economic/social/political/health care systems, such as when the Communist block crumbled, resulted in "the system" and people being less able to help each other. The death rates in these countries during the 1990's increased (life expectancy went from the 70's to the early 60's, especially for men), the marriage and birth rates decreased, heart disease, cancer, and accidents increased as the caring/tending aspects of the culture and within the families declined. Apparently, having social support by relatives, close friends, coworkers, by social and church groups...and by the health care system, plays a major role in keeping us healthy. .

 Does Prayer Improve Health?. This is not an easy question to answer. Most people are told "yes" in church. Many people pray for sick relatives and friends. There are also many studies that say "yes, prayer helps." One such article was reported recently by a respected Ob-Gyn specialist at Columbia University (Lobo, 2001, in Journal of Reproductive Medicine). Half of 200 Korean women wanting to get pregnant were secretly prayed for by North American and Australian prayer groups. Those prayed for reportedly got pregnant twice as often. Similarly, a group of physicians at Duke (Krucoff, 2001, in American Heart Journal) studied the effects on angioplasty of both relaxation techniques and prayer groups located around the world...the results: patients prayed for had "fewer complications." This is strange stuff and it gets even more spooky in other studies where prayer reportedly affects bacteria, enzyme cells, animals, and plants. No one knows the mechanisms, if any, behind this power of prayer. It is mind-boggling. Here is my current belief--just like a caring Mom and Dad keep an infant or child safe and healthy, just like mature teenagers look out for each other and help each other be reasonable and safe, so an openly concerned, nurturing, warmly "tending and befriending" church or support group or family would give good advice and support one another to be healthy. On the other hand, I have serious doubts about the effectiveness of any totally secret (unknown to the sick person and his/her doctor), mystical, scientifically inexplicable prayer curing human disease, improving the results of any physical treatment, helping sperm enter an egg, or helping plants grow better. However, a friend, minister, or loved one sitting down with you and holding your hands as they lovingly express concern and affection (or pray) may be psychologically very comforting and, thus, physically helpful..

 So how do the results I just called spooky happen? Well, if there are lots of these studies (and there are), 5% or 10% will show "statistically significant" effects just by chance. Studies finding "Prayer Heals" would get the attention of the press, but not the studies that suggest prayer is powerless or even harmful (i.e. the 5% to 10% of results that are significantly negative by chance). There are other possibilities: mistakes made while gathering data, having employees handling the data who have biases that unconsciously distort the data, and just plain intentional fraud. Chance results are the most likely explanations of spooky results, mistakes and biased but innocent distortion of the data are next, and very rarely is it intentional distortion, but it occurs..

 If your religious beliefs and practices relieve stress and calm you down, they almost certainly contribute to your health. But what is at work here, religious beliefs or stress reduction? Is religion any better at reducing stress than many, many other ways? That answer surely differs from person to person. It needs to be studied. Reading the literature, thus far, doesn't help much to answer these questions. As I have indicated many "studies" have been interpreted by the authors to mean that being religious yields health benefits. Yet, scientists (Sloan & Bagiella, 2002), carefully reviewing all the religion-health studies published in 2000, conclude there are virtually no scientific grounds for believing religious beliefs alone improve health. They actually found that 83% of the published 266 medical articles in 2000 were irrelevant to the question or had serious methodological flaws. Many other scientists have come over the years to the same skeptical general conclusion. One has to wonder why so many poor research designs were published by highly scientific medical journals. There is intense emotional investment in this issue, much like the 150 year controversy over evolution. Strong needs distort our thinking..

 When thinking about the supposed power of prayer, keep in mind that it is obvious that being religious and praying are not all-powerful cure-alls; these actions don't deliver health to all good people; indeed, if religion has any influence at all, overall it is weak. Why would an all powerful God choose to be weak? As in other areas, I believe it would not be wise to put much faith in the results of researchers who are "believers" of the religion being studied, just as one can't totally believe scientists (or lawyers) employed by the company making the drug being evaluated, or a therapist evaluating a type of psychotherapy or a self-help method he/she has developed. Expect to see a lot more "religion improves your health" articles because religion is impossibly confounded with stress reduction, positive expectations, wishful thinking, self-acceptance, a sense of mastery, and so on. Human warmth heals people but undisclosed spiritual prayer probably doesn't. However, face to face praying is human warmth.

 Hypochondriacs seek help from physicians four times as often as the ordinary person, costing them distress and costing all of us millions of dollars. The continuous fear of having a serious illness can be overcome by exposure therapy or by a cognitive-behavioral course which explains our expectation of a serious illness (Avia, et al, 1996). Shouldn't psychological causes be investigated more? Yes. Don't we need to know why we assume a health problem is physical much more often than we think it is a psychological problem? Yes. And we need to learn how to prevent feeling "sick and tired" all the time (Donoghue & Siegel, 1996) but, as Swedo & Leonard (1996) point out, "it's not always all in your head." We cannot forget biology; cancer is not a psychological disorder, although it's influenced by psychological factors. Tiredness will also be discussed in the Depression chapter.

 Allergies have many causes, some psychological but many in food, in pollen, cleaning products, fabrics, medications, cosmetics, dust and other aspects of the work and home environment (Faelten, 1987). Stress often makes the reaction to irritants worse.

 Pain afflicts close to 30% of all Americans! It is the most common medical symptom and the second most common psychological symptom. It interferes with work, with relationships, with enjoying life, and it costs a lot of money. Headaches (15% of men; 25% of women) and backaches are the most common and debilitating pains; both are frequently associated with stress, but the physical mechanisms are not well understood. Over the last ten or 15 years, the picture of how headaches are caused has become more and more complex--not clearer. This is because science is finding some of the pieces of the pain puzzle. It seems that genes, neurotransmitters, hormones, muscle tension (even botox helps some), various parts of the brain, blood vessels, and other parts sometimes play a role in a headache. It is an amazing process. Several new drugs, such as sumatriptan for migraine, have been developed that are effective on certain types of headaches but some are very expensive, others loose their strength, some have damaging side effects. We still have a long way to go. However, if I had frequent serious headaches, I'd seek help from a medical specialist, even though there are many psychological aspects, which we will discuss below.

 For many individuals, stress seems to exacerbate pain in specific parts of the body. So, it isn't surprising that there is a connection between headaches and mental/emotional disorders. For instance, Migraine sufferers have poorer coping strategies (wishful thinking and excessive self-criticism) and have more panic attacks than people without headaches. Likewise, fibromyalgia patients (88%) have more psychological disorders than other sufferers with equal pain, like arthritic patients (30%). Fibromyalgia patients, who's pain pathways in the brain respond strongly to just moderate pressure, are also more likely to have been abused as children and physically assaulted as adults than arthritis sufferers. Thousands of factual tidbits are coming together, such as the frequency of migraine headaches has almost doubled between 1981 and 1989 (a diagnostic fad?) and women have more migraines than men (for women consider the time of the month). Given enough information, the scientific understanding of pain will become clear. That doesn't mean we will be able to stop all pain.

 Pain patients who also have certain kinds of psychological problems respond to pain treatment differently. For instance, psychologists (e.g. Turk & Gatchel, 2002) specializing in treating chronic pain patients suggest there may be three subgroups: (1) the "dysfunctional" have severe pain, tend to be depressed and inactive, and feel they have little control over their pain. (2) The "interpersonally unhappy" are in serious pain and feel they are discounted and unsupported by people around them. (3) The "more optimistic copers" have pain but handle life's problems and continue to have hope of controlling their pain. Dr. Turk found that fibromyalgia patients in group (2) did not benefit from standard pain treatment (education, exercise, stress management training), but patients in groups (1) and (3) did benefit. Maybe group (2) needs more help with their interpersonal problems. Indeed, other therapists have found that including others (family or spouse) in the treatment of pain helps the patient...and the relatives (Siri Carpenter, APA Monitor, April, 2002). Pain treatment needs to be individualized, one approach doesn't fit all.

 Perhaps 50 million Americans suffer chronic or frequent pain. Yet, there are great barriers to getting treatment (in addition to our ignorance). (1) Some patients are afraid of being seen as whimps; others worry they may have a serious disorder, like cancer, and don't want to know; some unrealistically fear taking pain-killers, like morphine; others fear the pain is mental or feel their doctor thinks it is. (2) Physicians are not trained in Medical School to handle pain; thus, this isn't their speciality and they are often uncomfortable, especially if the patient doesn't get better. They can get in legal trouble if they over- or under-prescribe. (3) Many managed care and health insurance programs try to avoid paying for expensive pain treatments. Patients may feel better on pain-killers but they often don't go back to work. Thus, there are many reasons people in pain don't get adequate treatment, especially children, the elderly, minorities, and rural groups (Rebecca Clay, APA Monitor, April, 2002). Try to sidestep these barriers if you can.

 Research confirms that psychological treatment--biofeedback, relaxation, and cognitive therapy--can effectively reduce headaches without side effects (Blanchard, 1992). Of course, aspirin, drugs, ice, heat, massage, and hypnosis can reduce pain too. Acupuncture helps some people; even sex relieves a migraine for 15-20% of sufferers. Drugs are effective for many sufferers but they may be depended upon excessively. Hypnosis is surely under used (see chapter 14). There is no magic solution but several techniques may make pain more tolerable: (1) have a hopeful attitude, "I want to...I can...do something about this pain," (2) focus attention away from the pain, perhaps to pleasant memories, exciting plans, socializing, games, TV or music, (3) use relaxation (chapter 12), (4) try self-instructions and stress inoculation (chapters 11 & 12), and (5) if you have a sense of humor, use it now. (6) Much like self-hypnosis, mental imagery can help: (a) imagine that the hurt leaves your body, e.g. "flows out your toes," or is no longer a part of your body, e.g. "the dentist is drilling out the pain," (b) imagine being a popular athlete or war hero who is very tough and has done something great, (c) imagine Novocain being injected into the hurt and the area becoming more and more numb, or (d) imagine studying the pain in great detail, e.g. notice how the pain is sending an important message, it is demanding attention to get me well, the muscle or artery is saying "I'm healthy and trying to help but I need more oxygen," the hurting part is getting what it needs to heal, etc. You have to create your own fantasies; only you can discover how to use fantasy to reduce pain (Kleinke, 1991).

 Clearly, painful disorders, such as low back pain, frequently involve psychological factors; they often have a long history of various physical complaints besides pain, even more alcohol dependency and impaired daily functioning (Bacon, et al., 1994). The best predictor of a bad back at work is job dissatisfaction and stress, not physical strain. Sarno (1994) says back pain is a natural (painful but harmless) reaction to emotions, especially perfectionistic tendencies. The pain distracts us from life's troubles. He suggests that the sufferer concentrate on dealing with his/her life stresses and not on the body pain. The treatment often involves changes in your attitudes and thinking about your emotional problems which result in well planned self-help efforts. The difficult part is convincing yourself to assume the responsibility for your own improvement (not drugs or surgery) and then figuring out what needs to be straightened out in your life. Telling yourself how awful and unbearable the pain is or how weak and helpless you are is harmful, not helpful. By the way, the success of spine surgery is influenced in large part by your psychological health; so, if emotions caused the pain in the first place, don't expect surgery to help.

 Chronic pain victims are frequently depressed; they tend to be passive and unexpressive of emotions but, in general, pessimistic "awfulizers." If they blame themselves for the pain, they experience less pain. Stressful interactions with others seems to exacerbate the effects of pain (Schwartz, Slater & Birchler, 1994). If their pain is a mystery or someone else's fault, they experience more pain. Interestingly, if they have a good, close system of social support, they also report having more pain. If they can come to understand the causes of their pain and, where appropriate, see their physical pain as a substitute for psychological pain, then they can learn to directly express other feelings and emotions... and learn to relax... and feel better (Miller, 1993; Marcus, 1994).

 Besides dealing with the pain, chronic sufferers must also deal with getting on with life, avoiding searching endlessly for a non-existent total cure, coping with the real disappointments and losses they face, deciding on a middle ground between "silent suffering" and "constant complaining," and working out new and satisfying relationships with the people they love. These are hard problems to solve. Don't wait long to get expert help. There are over 1000 Pain Clinics, some concentrate on medications, some on psychological methods, some on a variety of hands-on techniques to ease pain, such as massage or chiropractic, some more spiritual, and so on. Ask your doctor for a referral or call your local hospital for a referral to a specialized pain center. The problem is that almost anyone can establish a Pain Clinic, so choose one carefully--only physicians (MDs) can prescribe all the available medications but they don't ordinarily do psychological treatment. So, the ideal doctor is hard to find. Therefore, I'd suggest seeing an MD who specializes with your specific kind of pain and who also works closely with a Physical Therapist (more common) or with a psychologist. In most cases, doctors in general practice, psychologists, chiropractors, massage therapists, exercise trainers, health educators/counselors and others are not well trained in the full range of pain control. Even though I believe a skilled hypnotist may have something to offer, I would not see one without first consulting expensively with a pain specialist with a MD and then confirming the credentials of the hypnotist. Finally, knowledge in this area is changing so rapidly and treatments so unreliable (and some are so expensive and long-term), I would strongly urge everyone in pain to do extensive reading in recent publications about his/her specific kind of pain. This is far from an exact science.

 Among the more popular books for back pain are McKenzie (2001) and Sarno (1999), both MDs. Amir (1999) wrote a self-help back pain book based on Sarno. Jemmett (2001), being a Physical Therapist, takes a somewhat different approach called spinal stabilization. Three recent headache books are by MDs: Paulino & Griffith (2001), Buchholz & Reich (2002), and Diamond & Franklin (2001). They all give practical advice to the layman. Also, if you suffer from headaches, write the National Headache Foundation, 428 W. St. James Place, 2nd floor, Chicago, IL 60614 or call 800-843-2256. Other how-to workbooks for pain are by Catalano & Hardin (1996), Caudill (1995), and Chaitow (1993). Several good self-help references are Martin, 1993; Anciano, 1987; Hanson & Gerber, 1989; Catalano, 1987; Melzack & Perry, 1980; Low, 1987; Chaitow, 1990.

 There are a lot of Web sites dealing with various kinds of pain. The directories of major search engines list many of the better ones. See Yahoo! Headaches, Yahoo! Chronic Pain, and Google Neurological Disorders. Many good references about pain in many parts of the body are available at Ask Noah about Pain. Other centers specialize in pain at just one location in the body: Yahoo Back Pain Center and Dr Koop Stomach Pain Center. The Mental Help Net has a section about pain.

 For learning more about professional treatment for a wide variety of physical disorders, see the June, 2002 issue of the Journal of Consulting and Clinical Psychology and Duckro, Richardson & Marshall (1995). As mentioned above, therapy reviews have shown that behavior therapy and cognitive-behavioral therapy work with headaches and irritable bowels (Blanchard, et al., 1980, 1987; Keefe, 1992). Finally, if you have been treated by a MD or a therapist without satisfactory relief from pain, ask for a consultation with a MD or Ph.D. specializing in your kind of pain. If seeing a psychiatrist/psychologist is recommended to you, please don't be offended and go.

Bibliography

 References cited in this chapter are listed in the Bibliography (see link on the book title page). Please note that references are on pages according to the first letter of the senior author's last name (see alphabetical links at the bottom of the main Bibliography page).


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