Self-hypnosis and the use of metaphors are useful complementary techniques to help patients manage their pain, highlighting the importance of holistic and personalized pain management in modern medicine.
What is pain?
Pain is a universal and individual experience, purely subjective with no real reliable witness apart from evaluation scales, in which the patient is always his own witness because it is impossible to compare his level of perception of pain to that of other humans, as inter-individual variations are significant.
It presents in multiple facets: mild or intense, acute or chronic, with or without after-effects. The repercussions on life, daily activities and mental well-being both on an individual and societal level can have a very negative impact.
With the DMS-5 (Diagnostic and Statistical Manual of Mental Disorders ), a new category was specifically created to describe people in whom pain or physical symptoms occupy an abnormal place in their lives. People who fall into this category have a bothersome somatic symptom such as pain for a period of more than six months and any of the following symptoms:
- Disproportionate and persistent thoughts about the severity of symptoms
- High and persistent anxiety about illness, health, or pain
- Excessive expenditure of time and energy related to pain or concerns about health.
In 1968, Melizac and Casey defined four components of pain that the High Authority of Health will take up in France:
- Cognitive: it includes the mental processes that influence painful perception as well as behavioral reactions,
- Affective-emotional: it affects the painful perception of an unpleasant character which can lead to anxiety or depression. The subject's history and personal experience influence this emotional dimension,
- Sensori-discriminative: it allows the analysis of a nociceptive stimulus (nature, intensity, duration and location), in order to design an adapted response,
- Behavioral: it corresponds to the way in which the patient expresses his pain. It includes physiological reactions (muscular, neurovegetative), motor reactions (mimicry, prostration), and verbal reactions (cries, moans).
Acute pain and chronic pain
It is important to understand the distinction between acute and chronic pain and to take the time to explain it to patients.
Acute pain or “pain symptom” alerts by its acute intensity or by its unexpected occurrence: a bit like a clap of thunder in a calm sky. For the French Society for the Study and Treatment of Pain , acute pain lasts less than three months. As with acute stress, it is a powerful wake-up call to the body as a complex and high-functioning system. This is an unpleasant perception that attracts attention. It warns the body of the lesions it is suffering from and thus allows it to protect itself from its destruction by reacting as best as possible and as quickly as possible to stimuli of various mechanical, thermal or chemical natures. Just like fear, acute pain can be extremely useful for living things to react quickly to danger. We are thus genetically programmed to avoid pain and get closer to what is good for our survival. Seeking to avoid physical pain is a normal physiological response. Conversely, people who feel no or very little nociceptive stimuli due to a genetic deficiency of central pain receptors very often put their lives in danger. Far from being an opportunity for them, it is on the contrary a sort of curse in the sense that this deprivation of sensory sensors makes them much more vulnerable to their environment.
R Danziger who devoted a book to these patients and talks about a defect in bodily homeostasis. In the absence of symptoms, the body system functions wonderfully independently, ensuring major physiological functions: digestion, breathing, blood circulation... It's a bit as if the body always knows what it has to do! The famous “silence of the organs” symbolizes homeostasis or the natural balance of the body system .
Illness is defined in relation to health. Health is a state of good functioning of the body and illness, on the contrary, is an alteration of health. Illness, according to Claire Marin, philosopher, is an experience of premature old age. The same goes for chronic pain which leads to an unexpected experience of limitation and even mutilation with the body. The impact on self-image is considerable. Chronic pain is typically pain that lasts more than 3 months and for some even 6 months, beyond the normal healing period.
It is no longer considered as an alarm signal, but rather as a real pathology in itself. We then speak of “pain-disease” or “pain syndrome”. Pain “disease” can have significant psychosocial consequences and constitutes a complex pathology in which causes and effects are often closely intertwined. For the American Medical Association (AMA) chronic pain syndrome is persistent or recurring pain, not relieved by drug treatment alone. This results in a regression of functional and relational status in daily activities. Chronic pain may be the patient's only complaint or one of their dominant symptoms which alone will require special attention from the caregiver.
Thus, chronic pain in fibromyalgia, musculoskeletal tensions or chronic back pain is not simply one symptom among others and dominates the clinical picture of these pathologies. This pain “disease” is common and according to the first European multicenter survey carried out in 2006: Pain In Europe (PIE): nearly 75 million Europeans are affected. In women, its prevalence is greater than in men (mainly pain of musculoskeletal origin). In France, the High Authority for Health considers that 30 to 35% of the general population is affected by this type of problem. Fibromyalgia and diffuse polyalgia syndrome are the best known pathologies but we also find algodystrophy, endometriosis, cervico-brachial neuralgia, pudendal neuralgia, inflammatory or functional diseases of the digestive tract, and certain neuropathies.
We readily evoke the psychosomatic nature of these symptoms. For Berrube (Berrube, 1991, p. 67) these are “ physical symptoms whose causes are multiple, but where emotional factors play an important role... Physiological manifestations are those which normally accompany certain emotions, but they are more intense and more prolonged. Repressed emotions have a physiological action which, if it is lasting and sufficiently intense, can lead to disruptions in function, or even damage to the organ. The patient is generally not aware of the relationship that exists between his illness and his emotions.
On a physical level, patients suffering from chronic pain very frequently complain of great fatigue and sometimes the slightest physical effort proves particularly painful for them. Some even mention the impression that because of this state, their scope of life is shrinking day by day. Added to this are sleep disorders with difficulty falling asleep because they are no longer able to find a comfortable position. They also complain of unpleasant sensations due to immobilization. In all cases, patients report a loss of quality of their sleep which would no longer be “restorative” and would contribute to reducing the pain tolerance threshold. This is a vicious circle. A study on chronic neuropathic pain showed that 90% of patients had sleep disorders and anxiety. Lack of physical activity, excess alcohol or even taking certain medication treatments that stimulate the nervous system are also important factors that disrupt sleep.
There are significant repercussions on daily life which can cause social isolation. Due to their handicap and sometimes their state of invalidity, the person finds themselves considerably weakened. This results in a significant loss of productivity for her and for the community. She may feel depreciated, disqualified from the societal and/or family game. Patients frequently speak of great relational difficulties. On the family level, it is sometimes the organization and even the structure of the family that is disrupted. The family system no longer functions as it used to. New sources of conflict may appear due to the reduction in physical activity of those who can no longer carry out their daily tasks which were their responsibility until then to participate in family life and in particular household, shopping, supporting children, etc. The person concerned has the feeling of having to be constantly assisted and this makes them more and more irritable towards themselves and those around them or, on the contrary, pushes them to repress their emotions and closes in on itself. In other situations it is the caregiver on whom the person relies completely who himself becomes in great pain, thus revealing the significant collateral damage of illness pain.
The deleterious socio-professional consequences are frequently expressed by patients who quickly feel depreciated, neglected and who are very afraid of losing their job; chronic pain is a source of long-term unemployment. The financial consequences can be very severe and have a considerable impact on social life. Thus problems of assertiveness and social exclusion are particularly frequent. The pain patient often feels a lack of trust in others. Many never dare to express their point of view openly, let alone say “no”. This leads to suffering because they feel misunderstood and despised. They are ashamed of themselves because of “their cowardice” and it is yet another vicious circle of self-devaluation that sets in despite all their attempts at solutions so as not to displease others. This lack of self-esteem is inexorably reinforced with the perpetuation of pain and social exclusion. Many even go so far as to feel a real fear of others, fear of being judged and above all of being definitively rejected from society.
For the Stoic philosophers of antiquity, pain presents moral virtues and, for example, it highlights the virile character of those who endure it without complaining and rely on the will of God. Indeed, in ancient wisdom, resisting pain is one of the fundamental points of Stoic courage. For Seneca, this distancing from the body allows one to achieve tranquility of the soul and happiness, by drawing closer to God. These ancient cultural representations associated with pain have disappeared. They are gradually giving way to a much more technical vision to fight against these evils which tend to dispossess the individual of all control over their own life.
In all human societies the need to relieve pain is at the origin of multiple ways of treating oneself and medicine indeed finds a large and legitimate place in it. In the Western vision, pain very often appears meaningless . “Pain transforms into pure cruelty into endless and reasonless torture” (Le Breton, 1988, p. 134). It becomes a purely medical symptom. Medicine alone must assume all responsibility and guarantee its total disappearance. The doctor is seen as a skilled repairman or technician who is supposed to know how to correct all disorders of bodily functioning. Many patients arrive at the pain center with this type of thinking. Medical competence is lacking in the face of persistent pain. The complexity of chronic pain management for the doctor speaks in favor of a transdisciplinary approach that could be described as integrative global medicine.
Chronic pain and negative trance
The pain would be hypnotic to the extent that it would draw attention away from the outside world and into one's own body. (Delboeuf, 1993). Chronic pain disrupts consciousness and its functioning. It leads to the fixation of attention with a reduction in the subject's sensory and emotional capacities and it is amplified thanks to imagination and memory. It thus contributes to a sort of self-sustained hypnotic confinement. Unlike physiological trance states which occur regularly at all times of the day, there are situations in which perceptions are truly fixed: these are pathological trances in reaction to particular situations. This situation is common in post-traumatic stress but also in phantom limb pain after amputation. More generally, depressive states and chronic pain states are characterized by a state of pathological trance with multiple somatizations and imaginative capacities which diminish over time. For David Lebreton : “Pain is an emotion that grips the living person with such intensity that it imposes itself as a priority on those who experience it. This priority makes it a perceptual experience of attention which almost cannot be detached from the person experiencing it and is therefore one of the most powerful hypnotic inducers there is. Over time, the subject experiences a constant repulsion for a state that he does not accept, which contributes to maintaining this pathological trance.
When we are healthy, we are not aware of our body's limitations. On the other hand, illness produces dissociation within ourselves and leads us to distance ourselves from those parts of our body that cause pain. Our self-presence is modified, it is as if these painful parts become autonomous and gradually resemble foreign bodies totally separated from the rest of the body. This state can lead to great psychological distress and the entire quality of our presence in ourselves and in the world is altered.
Use and effectiveness of hypnosis in chronic pain
Numerous studies have made it possible to objectify and provide concrete evidence on the effectiveness of hypnotherapy in the management of pain. We will not detail all of these studies which are also very well summarized in the 2015 INSERM report (Gueguen, 2015) . The main hypothesis of this work is that a specific and intense focus of attention constitutes an important modulator of pain. Several studies have shown that pain can decrease by 10 to 20% when the patient voluntarily directs their attention towards another source of stimulation (Miron, 1989). Thirteen prospective studies comparing the results of hypnosis in the treatment of chronic pain with reference data were analyzed in a review article. Different types of chronic pain are addressed: arthritis, cancer, back pain, sickle cell anemia, temporomandibular pain and fibromyalgia. The results show a significant reduction in pain under hypnosis. The authors hypothesize that by making analgesia suggestions, we intervene at the cortical level (level of higher mechanisms for integrating painful information) by reducing the unpleasant feeling of pain (Miron, 1989). There is a rearrangement of the responses with modification of the painful information at the cortical level: the pain is still perceived as a signal but its unpleasant nature lessens a little as if the person was observing it from a distance. (Elkins, 2007). Several studies have shown the effectiveness of hypnosis in relieving or preventing migraines with a reduction in the number of attacks, a reduction in intensity, but also a reduction in the anxiety caused by pain (Evans, 2001).
A recent Cochrane meta-analysis looked at the benefit of hypnosis in chronic musculoskeletal or neuropathic pain, taking into account only randomized trials from five large databases. Nine studies were included in this meta-analysis involving a total of 530 patients. The authors conclude that there is a moderate but significant reduction in pain intensity thanks to hypnosis provided that at least 8 sessions are practiced (Langlois, 2022).
Hypnosis is increasingly recognized by the medical community and constitutes an interesting unconventional alternative for patients consulting pain centers. INSERM recommends using it to improve patient comfort, while reducing health costs for the community (reduction in drug treatments, shortening the length of stay, etc. (Gueguen, 2015)
Autohypnosis, defined as “the self-induction of a hypnotic trance with a view to achieving a specific objective” (Virot, 2010) is particularly useful in chronic pain, it allows the patient to induce himself- even trance. The patient practices this practice with the therapist in a few sessions. To enter a trance, he can learn, for example, to concentrate on a fixed point on the wall, or on an object of his choice or simply by focusing only on his own breathing. Other complementary techniques such as anchoring comfort and security through a specific gesture, or comfort autosuggestions, can be taught to the patient. Some very simple works by directly offering mini scripts to read or listen to can also be of great help (Chamy, 2020) . These different types of learning can be very useful to the patient to help them modulate their pain and discomfort when they feel the need.
The use of metaphors can be extremely interesting to support patients. The metaphorical suggestions offered open up access to another perspective and possible solutions. ". Suggestion and autosuggestion, through images and sounds, bring a new representation of a situation experienced, a small step towards change, which induces chain reactions (Kerouac, 2000).
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