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Moderator: Welcome to WebMD Live's World Watch and Health News Auditorium. Today we are discussing "The Mind-Body-Pain Connection: How Does It Work?" with Brenda Bursch, Ph.D., Michael Joseph, M.D., and Lonnie Zeltzer, M.D.
Brenda Bursch, Ph.D., is the Associate Director of the Pediatric Pain Program, Co-Director of Pediatric Chronic Pain Clinical Service and Assistant Clinical Professor of Psychiatry & Biobehavioral Sciences at UCLA Department of Pediatrics in the School of Medicine. She has written about asthma, developmental & behavioral pediatrics, emergency medicine, AIDS education and prevention, chronic digestive diseases and pediatric bowel disorders. She has membership in the American Pain Society, American Psychological Association, Munchausen Syndrome by Proxy Network, and the UCLA Center for the Study of Organizational and Group Dynamics.
Michael Henry Joseph, MD, is an assistant professor of pediatrics and co-director of Chronic Pain Services at the University of California at Los Angeles Children's Hospital. He is a recipient of the Golden Apple Award for Excellence in Teaching.
Lonnie Zeltzer, M.D., is an expert in the field of pediatric pain. She is a former president of the Society for Adolescent Medicine and member of the National Institute of Health?s Human Development Study Section. She is currently a Professor of Pediatrics and Anesthesiology at the UCLA School of Medicine. She is Director of the UCLA Pediatric Pain Program and Associate Director of the Patients & Survivors Section, Cancer Prevention and Control Research Branch of the UCLA Jonsson Comprehensive Cancer Center. She has well over one hundred scientific publications, reviews and chapters in medical journals, and has lectured internationally.
Moderator: Doctors, welcome back to WebMD Live.
Dr. Bursch: Thank you.
Dr. Joseph: Thank you.
Dr. Zeltzer: Thank you.
Dr. Zeltzer: As you know, the mind-body pain connection is the basis upon which our pediatric pain program at UCLA operates, both in terms of how it conceptually views pain and its approach to treatment. I would like to begin by discussing the physiology that is underlying a lot of our functional definitions of pain and our basic philosophy and our mind-body connection model.
Dr. Joseph: I'd like to say the differentiation into components is a fallacy. Your brain and nervous system communicate with the rest of your body just like all other organ systems. All work together. Pain is not a simple entity in which it's like pulling on a string and ringing a little bell in your head. It's more dynamic than that, in which you do have nerve input from fingers and toes and organs that goes to spinal column and then to your brain. You also have nerve pathways that are coming from your brain down your spinal column. There are many factors that change the way we actually perceive pain and can make pain more intense or less intense depending on the situation. This is also true for other symptoms. This connection between your central nervous system and your brain communicates with your peripheral nervous system so nerves coming from organs, arms and legs, and all symptoms that you may be feeling can be altered by your nervous system either increased or decreased. That's true of nausea or difficulty breathing or any symptom you might be feeling. In fact, it's true of all of your senses. Your sense of hearing, smell, taste, vision are also all interpreted perceptions. Different factors that can alter your perception specifically when it comes to pain include how much attention you pay to the symptom, what the meaning of the symptom is. For some people, pain is a good thing such as when you've been working out and you're waiting to feel that burn and the burn has a good context, as opposed to if you pull a muscle, you may have exactly the same amount of tissue damage but the way you perceive the pain is very different. Memory can affect perception of pain. When we are awake, it takes much less stimulus to cause pain than when we are asleep. If we were in a coma, it would take even more, possibly we don't even experience pain.
Dr. Bursch: As Dr. Joseph just described, the nature of perception of pain, each individual is different not only in pre-existing neurology but also in their experiences that would contribute to their memories of pain, to their arousal, due to circumstances and their experiences and the meanings they attribute. Also, there are different points at which they would become distressed by the signaling. From a physiologic standpoint, people have different levels at which sensory nerves that carry pain information will send those signals. Some people have the ability to have a lot of stimulation before the signals are sent, and some people are very sensitive and a very little stimulation sends the signal. People with irritable bowel syndrome are known through many studies to have a very low threshold for sensory info sent from their intestine to their brain.
Dr. Zeltzer: People can learn different coping skills and ways of blocking out the sensation so they experience them, but it doesn't have to distress them. Since you describe the physiologic basis for how pain becomes pain -- how different tissue injury turns into pain -- maybe you can talk about the body's natural pain control system, from a mind-body perspective?
Dr. Joseph: The body has a number of ways of controlling pain throughout different organ systems. The most direct is pathways, nerve pathways, that travel from your brain back down your spinal column and they signal directly to those same nerves that are sending pain signals to your brain. They interrupt those pain signals on their way up. These nerve pathways are activated by a number of factors. The easiest one to recognize is fear. A good example of this is, say you're in a dark parking lot and you accidentally shut your finger in the car door. It hurts a lot. You start hearing footsteps behind you. All of a sudden your finger stops hurting. There's no difference in the amount of tissue damage between when you heard the footsteps and when you didn't, but your brain has sent signals to your body that it is time to run away as opposed to time to feel pain. There are subtle ways that your body controls pain, as well. Your brain makes chemicals called endorphins and enkephalins. These molecules are very similar to drugs such as morphine, which everybody recognizes as a pain fighting drug. Interestingly, not only your brain makes these chemicals but also your immune system. B-lymphocytes actually make these chemicals as well. When you have inflamed or infected areas and sending pain signals, even your immune systems can go to those areas, release pain modulating chemicals into that area and decrease the pain right then, if it's something the person needs to have happen at that time. There are many ways pain can be increased or decreased depending on the needs of the individual at each time.
Dr. Bursch: Based on the earlier model that Dr. Joseph presented that delineated the relationship of memory, attention and arousal on the pain system, there are a number of behavioral or cognitive strategies that one can engage in order to impact perception of pain, things as simple as engaging in relaxing activities, using distraction so that you're focusing on something else. It could be using visualization techniques which is similar to distraction technique. You can use your mind and you can use your body in ways that the actual pain perception can be altered if you can alter your arousal or your attention or your memory, or memory you have about the pain. You can change your experience of that symptom.
Dr. Zeltzer: It is always amazing to me how powerful the mind is at having actual physical effects on the body, and it always reconfirms my belief (and that of most clinicians and researchers in pain) that the mind and body are tightly linked. It is always amazing that one can have extreme pain and that thinking about something or having a different emotion, like anxiety, joy and happiness, can alter the experience of that pain, and if one were looking through PET (positron emission tomography) scans at brain metabolic activity or if you looked at the signals of the nervous system, one would see actual physical changes going on during these thinkings and emotional events. Maybe you might want to talk a little bit about the role of some of the complementary therapies focusing on the mind-body connection in treating pain?
Dr. Joseph: I would love to. We do utilize a number of therapies that work specifically on a mind/body connection, the most obvious of which is biofeedback. Biofeedback is a technique in which sensors are placed on the body to measure either the tension in muscles or they can measure skin temperature or heart rate. These measures are displayed for the patient on a screen with lights, sounds and numbers. The patient is then taught ways and taught skills on how to use their mind to alter different physiologic factors within their bodies such as their muscle tension or their pulse rate. They're taught ways to relax and as they do this, the read out on the computer actually shows them how much success they're having which then reinforces ability of the mind to interact and control what the body is doing. Quite often, a number of pain syndromes are reinforced by ongoing muscle tension. Muscle tension may or may not be cause of pain, but it certainly continues the pain for longer periods of time or makes the pain worse. Learning ways to control how your body reacts to the pain and to stress in general assists the patient in learning control and reducing the overall pain signaling. Other therapies that focus on mind/body reaction include hypnotherapy. It involves state of focused concentration in which patient can use their mind to control a host of physiologic factors including perception of nausea, amount of constriction in their lungs if they have asthma and effectively control perception of pain to the extent where they can turn down pain signaling Additionally, therapies such as movement therapy or integration of the body back to the mind can actually work in the reverse direction, whereby getting your body to move in ways that it is not used to sends signals to the brain that improve pain signaling, or can turn down perception of other symptoms as well. Therapies can be targeted brain to body, or body to brain. Again, operating from the direction of altering perception of symptoms, from the position of arousal and attention, individual psychotherapies, group therapy or family therapy can be helpful. At an individual level, distressing events and increased overall body arousal can contribute to ongoing pain as well as other ongoing symptoms, and addressing those distressing things in one's life can lead to less body arousal and less experience of symptoms.
Dr. Bursch: When coping with symptoms and self management of symptoms, this can be addressed through learning of skills focused on relaxation, or how one interprets those signals cognitively, and what they do with the signals once they perceive them. One person might feel body sensations and interpret those as fatal and drive their symptoms higher, or they might understand through education and they might understand the symptoms they're experiencing are really symptoms of panic and they are not going to lead to death. If it is true, rather than having these symptoms lead to catastrophic thinking, it can be a signal for engaging in relaxation techniques. At a family level, parents and siblings can be taught techniques so they don't contribute to arousal or excessive attention to the symptoms. If you are sitting at your computer and very engrossed in a computer game, you might not be paying attention to your abdominal pain. If someone walks into the room and says how is your abdominal pain, your attention will shift from the computer to the abdomen and then you will perceive it and feel pain. Concerned family members often in their attempt to be supportive, contribute to increased perceptions of pain by frequently asking about symptoms. That's an example of how education and changes in behavior can affect pain perception and coping with pain.
Dr. Zeltzer: Brenda, you brought up the neural peptides and the role that they play in pain, especially in the development of chronic pain. I assume you mean examples such as serotonin. Would you like to talk more about that?
Dr. Bursch: Sure. In my initial discussion of physiology I left out some of the specifics about which neuropeptides and neurotransmitters were involved with chronic pain development. I think that they're interesting for a few reasons, mainly because I think that it's relatively well accepted that neurotransmitters work in your nervous system. Serotonin is involved in pathways that are functional with depression as well as anxiety. There are other neurotransmitters, such as substance P, which is major transmitter of pain, or nociception, which is the nerve signaling portion of pain. I think the truly interesting fact is that many organs other than your nervous system also have receptors for these same neuropeptides, such as substance P not only signals pain but it also causes dilation of blood vessels. That seems somewhat interesting but when you've been injured, not only do you want to tell your brain there's a site of injury but you also want to increase blood flow to that same area because you want the bloods cells that initiate healing to go there. There's the concept that the entire existence of pain evolved to signal the individual that there is some form of tissue injury and you need to stop and begin the healing process. Separate from pain, there are also other neurotransmitters that affect organs. The easiest ones to understand are neurotransmitters such as adrenaline or epinephrine. These signals cause a whole host of both emotional changes as well as physiologic changes. In addition, other neurotransmitters cause various changes in organ function. Quite often when you have different emotional states, that same neuro signaling causes differences in your organ functioning as well. People who are depressed have activated and disregulation in their immune system, as well as alterations in their liver, etc. It's no wonder that quite often chronic physical diseases are also associated with psychological illness, further indications that there is no separation between what we consider the mind and body. Both systems are continually monitoring each other. There is also research that demonstrates that behavioral interventions that increase one's sense of a mastery over a task can improve one's immune functioning. Again, this idea that it works both ways is an important one to remember.
Dr. Zeltzer: Given that certain neurotransmitters play a role in both chronic pain and in other emotional states and conditions such as anxiety and depression, maybe you would like to explain why certain antidepressants that are used for treating both anxiety and depression are also useful in treating chronic pain?
Dr. Joseph: The medications that we have found useful for treating pain, other than the medications such as opioids that we know have been used to treat pain for eons, have been in the realm of anti-anxiety medications or antidepressants. Ones that are useful are medications such as the tricyclic antidepressants. These medications work through a number of neurotransmitters, specifically norepinephrine and epinephrine. These medications make the specific neurotransmitters available to the nerves for longer periods of time. Not only do they help in depression, but they have been found to be very useful in decreasing pain signaling.
Dr. Bursch: Other medications such as Mellaril (thioridazine hydrochloride), which is not an antidepressant but was developed to treat severe anxiety and even psychosis, is active through a different neurotransmitter pathway and is also very effective at decreasing pain signaling, as well as assisting the mind in distracting from the pain and decreasing pain perception. For these reasons, when children come to our pediatric pain clinic with chronic pain, we typically use a variety of treatments that may include medications such as those that Michael described, as well as helping the child and family to change their belief systems about the pain and the controllability of the pain, as well as function, as well as incorporating many alternative and complementary therapies such as biofeedback, acupuncture, massage, and others.
Dr. Zeltzer: Certainly, because of the mind-body connection, when pain becomes chronic, it recruits so many different parts of the body -- the mind, the emotions, and the neurochemistry -- that a multi-modal (meaning many different components) approach is needed to treat the pain and help the child be able to go back to school, sleep, and do other activities.
Dr. Bursch: I would like to emphasize what Dr. Zeltzer presented and underscore the importance of education.
Dr. Zeltzer: Many children coming to us have been placed on drugs, even some of the same drugs we might recommend, but without the other components and because of the mind-body connection, the various components must be addressed, otherwise the drugs alone will not be effective.
Dr. Bursch: Many people who have chronic pain spend much time, money, and energy attempting to find that part of their body that is broken, and while it's reasonable to have a thorough evaluation, often one's pain has been going on for a while. It is very difficult or impossible to find the source of that pain. As we've described, the reason for that is because it is a pain signaling issue that can go on, even if the initial reason for the pain has gone away. If you start to treat your pain without an understanding of this, you could spend a lot of time in search for the cause when you will never find one and, of course, be quite distressed in the meantime which can contribute to the pain itself. If you're spending a lot of time in the diagnostic part of this, then you might not be spending time on treatment and getting better. So cognitively understanding how the various systems interact to help pain continue long after the reason for pain has gone away can actually help somebody get better and refrain from causing themselves more distress and more pain.
Moderator: Doctors, as we near the end of our time, would you care to offer some closing remarks?
Dr. Joseph: I think I would like to reiterate the fact that your mind and your body do communicate with each other on an intimate basis. Your mind is your body and your body is your mind. Those systems are not separate. When we are dealing with chronic illness or chronic pain, what has happened is a discommunication of those normally functioning pathways. Instead of mind and body being one, they become separated and it leads to chronic stress. By learning techniques and reintegrating healthy communication, that communication enables the body and person as a whole to heal and become healthy again.
Dr. Zeltzer: Certainly, I would like to provide the phone number for anybody who has a child with a chronic pain problem and would like further information about our pain clinic: It's UCLA, (310) 825 0731.
Dr. Zeltzer: Thank you, Brenda and Mike, for participating.
Dr. Joseph: Thank you, Dr. Zeltzer, for having us.
Dr. Bursch: Thank you.
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