Chronic pain and disability are closely related. Evidence supporting the role of the central nervous system (cortical and limbic system), as opposed to peripheral, nociceptive processes, in the development and maintenance of chronic pain is reviewed. This includes the phenomenon of central sensitization, relevant limbic-cortical processes, and psychiatric diagnoses often co-morbid with chronic pain. Psychological and socioeconomic `red flags' for a poor return to work prognosis are delineated. The critical importance of cognitive beliefs and, therefore, physician statements to patients concerning their medical condition, resulting restrictions, and limitations is emphasized. The relationship between motivation, performance, and patients' beliefs about what they can do (self-efficacy) and what will happen when they return to work is discussed. The need for a comprehensive interdisciplinary approach oriented towards functional restoration to enable patients with chronic pain to reach maximum medical improvement (MMI) is reviewed. It is argued that psychiatry, with a bio-psychosocial perspective is uniquely qualified to evaluate and treat chronic pain.
Recent neuroimaging studies have used hypnotic suggestion to distinguish the brain structures most associated with the sensory and affective dimensions of pain. This paper reviews studies that delineate the overlapping brain circuits involved in the processing of pain and emotions, and their relationship to autonomic arousal. Also examined are the replicated findings of reliable changes in the activation of specific brain structures and the deactivation of others associated with the induction of hypnosis. These differ from those parts of the brain involved in response to hypnotic suggestions. It is proposed that the activation of a portion of the prefrontal cortex in response to both hypnotic suggestions for decreased pain and to positive emotional experience might indicate a more general underlying mechanism. Great potential exists for further research to clarify the relationships among individual differences in reactivity to pain, emotion, and stress, and the possible role of such differences in the development of chronic pain.
Ericksonian therapy can be viewed as an active approach which is individually tailored to each patient and in which insight is not viewed as necessary for change. Implicit in Erickson's work is a positive notion of the unconscious as a resource to utilize and a view of change best elaborated by general systems theory. It is argued that the processes of change described by theorists working in different areas or within different schools of therapy correspond to the processes of primaryand secondary-order change delineated by general systems theory. Assessing and intervening upon multiple systems levels provides the best integrative model for eclectic therapy.In a memorial service for Milton Erickson, Robert Pearson, a physician, colleague, and friend, said that "Milton Erickson had taken on the psychiatric establishment singlehandedly and wonbut they don't know it yet!"Erickson achieved remarkable therapeutic success, quite probably because he broke many of the established rules for the conduct of treatment. In an era when psychoanalysis reigned supreme, Erickson studied-and then discarded-that approach. While the accepted view was that hypnosis was a shallow, or supportive, therapy, a poor alloy that would interfere with the pure gold of
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