11 February 2018
There are two key components to chronic pain, the body sensations and the associated emotions. How someone reacts to body sensations, whether that is pain, tension, impaired movement or other physical issues, depends on many factors. Their personality, whether introvert or extrovert, their locus of control, whether optimistic or pessimistic and any personality disorders, will also influence how they cope with pain.
Research, particularly in the field of placebo analgesia, has some interesting perspectives for hypnotists and hypnotherapists, particularly relating to the influence of personality on an individual’s experience of pain. When considering some of the placebo analgesia research, it may be that when we are using pain management approaches with our clients, that it could be more effective to address emotional and personality aspects first.
Placebo and placebo analgesia
There are varied definitions for ‘placebo’, in this context it relates to something given to an individual with the intention of psychological benefit, rather than intending a purely physiological effect. Thus, working with the mind, rather than directly on the functioning of the body. The ‘placebo effect’ works on influencing the perceptions and expectations of the recipient. Whether the substance or process is perceived as helpful or damaging, it can generate a corresponding response in the mind and body, as if it were an active substance or process. Hypnosis researcher Irving Kirsch (Kirsch), suggested that the effects come from belief that there will be a difference.
Placebo analgesia is the use of the placebo effect to reduce pain. This has two components. Firstly, is the change in the individual’s perception of pain, and secondly is the placebo effect creating the release of endorphins. These are the painkillers that the brain can naturally produce. The naturally created opioid effect blocks pain, slows breathing and has a generally calming and anti-depressing influence. It is interesting that placebo analgesia even has an effect on painkilling medication. When people know they are receiving analgesics, they were found to be more effective than when they didn’t know (Price).
From a hypnosis and hypnotherapy perspective, placebo has a significant element of suggestion. Whether that is the individual suggesting to themselves that something inactive is actually active, or accepting and acting upon that suggestion from an external source. Hypnosis and hypnotherapy makes great use of suggestion. However, hypnotherapy has a vast range of approaches, methods and practices which enable the therapist to work with the individual as an individual, rather than simply in response to a named condition or symptom. This means that we can address the topic of pain management from a broader perspective, than simply symptom management. What may be interesting, is the order or strategy we employ in which to help our pain management clients.
Emotions around pain can be related to the past, such as anger or self-blame, the present, such as sadness for a loss of health, and potentially worries or anxiety about the future. Furthermore, individuals with certain traits and personality disorders may continue to worry and ruminate about their symptoms long after the tissue pathology has resolved. All of this, the hypnotherapist is well-equipped to address as part of an overall pain management strategy.
Emotional engagement can be either helpful or unhelpful to the experience of pain. Where there is a positive mindset, the individual can have stronger coping skills and greater confidence in self-management. A negative mindset, can add to the complexity of working with pain. Some studies (Schwartz) suggest that the greater the emotional distress, the higher the experience of pain. Other studies (Carrlson) found that patients with chronic pain tended to have had more negative childhood experiences, and had less inhibition of aggression than those without chronic pain. As hypnotherapists working with pain management we are able to help clients address past experiences and develop greater self-control.
People who are able to regulate their emotions, may also have greater ability to regulate their experience of pain. Emotional regulation is trainable skill. Hypnotherapists are able to employ a wide range of behavioural, cognitive and analytical strategies to help clients regulate how they experience and express their emotions, and to cope more effectively with managing their pain. Helping clients to gain greater emotional regulation, such as working with anger management, can influence changes in the opioid receptor system, resulting in stronger placebo effect and potentially greater acceptance of hypnotic suggestions.
Personality and emotion
Our emotional response, to anything, is influenced by our personality. When considering placebo analgesia, research suggests that positive personality traits can have positive effects. Whilst less desirable personality traits, can have adverse effects. This may be no surprise to the hypnotherapist, as the same will apply to our client’s engagement and work within the therapy process. They suggest personality traits explain a significant proportion of the variance in placebo analgesic response, activation in endogenous opioid neurotransmission and cortisol plasma levels. Whilst we are unlikely to effect polar opposites in our client’s personality, helping the client develop their positive traits can have benefits even more broadly than simply addressing their pain management.
Positive emotions and traits
A whole host of positive emotions and traits, such as optimism (Geers) and low state anxiety (Morton) have been researched and found to be positive predictors for placebo analgesia. It has been found (Pecina) that individuals who are altruistic (associated with selflessness), resilient and more straightforward in their interactions, tend to have greater activity in the brain regions that are associated with reward, and are more likely to experience pain relief when a placebo is administered during a painful experience.
Response to the placebo effect is linked to personality traits associated with self-control (such as agreeableness and ego-resiliency). Ego resilience indicates the ability to react to stress and adversity. A client with higher ego resilience is likely to be much more able to adapt their level of self-expression to suit the occasion and demonstrate flexibility in their self-control. This flexibility is significant. Neither rigid over-control (stiff, reserved), nor weak under-control (chaotic, unfocused) is beneficial. Rather it is the ability to inhibit impulses when they choose, and still retain the ability to be spontaneous and uninhibited at the right moment. Strong ego resilience is associated with positive emotions and adaptive changes in the reward and emotional processing areas of the brain. Interestingly, straightforwardness is associated with agreeableness, and high agreeableness, cooperation and concern for others are all considered positive interpersonal traits and predictors for strong responses to placebo. Straightforwardness is also related to effortful self-control and the ability to control anger (Robinson).
Placebo can have strong analgesic effects with activity in the brain region (nucleus accumbens) associated with reward and pleasure. It is recognised that placebo analgesia may partly occur because positive expectations of pain relief (reward) generate a spike in dopamine in the brain, stimulating release of mu-opioids (endogenous painkillers). Whilst studies (Scott) found that expectation alone was not sufficient for placebo-induced pain response, it was found that those with low levels of ‘angry hostility’ were more likely to experience placebo-induced analgesia. These individuals also had decreased cortisol levels.
Within our hypnotherapy approach, ego strengthening in particular can help with developing resilience and can also benefit Locus of Control. Pain nurse and lecturer, Eileen Mann (Mann) suggests that treatments which encourage an internal Locus of Control appear to have greater long-term benefits that treatments which are ‘done to’ the individual.
For hypnotherapists, it would be particularly beneficial to consider the client’s emotional state and work to address underlying emotions which may be contributing to the experience of pain. By doing so before working with pain management strategies, could have several benefits. It could help the client have a more positive perception of the effectiveness of hypnotherapy, develop heightened ego strength and resilience, and may also lead to greater effectiveness of the pain management approaches, reflecting the more positive mindset. It could also reduce the impact that any negative emotions and traits may have upon any aspect of the therapy process.
Negative emotions and traits
Much research evidence makes the connection between physical pain and negative emotions. It has been demonstrated, with neuroimaging studies, that endogenous opioid activity in several brain regions influence the experience of physical pain and negative emotions. Research also demonstrates (Pecina) that negative emotions, like angry hostility, and traits, such as trait anxiety, are negative predictors for placebo analgesia. Another trait example is Neuroticism. Individuals with high levels of neuroticism, tend to notice more physical symptoms, and complain more about muscle tension and headaches, than low neurotics. (Robinson). High neurotics are also reported to cope less well with pain. This could possibly be due to emotional over-reaction. The impact of anger and particularly angry hostility is another unhelpful influence on an individual’s experience of pain. Interestingly, as research (Pecina) links anger to lower opioid receptor system functioning, angry hostility can strongly predict placebo response.
As hypnotherapists, we know that a negatively-focused or hostile client can be less receptive to suggestion, less compliant and engaged in the process, and may be unwilling to engage in self-care. Furthermore, people with a more external locus of control appear to experience more intense pain together with feelings of helplessness, which in itself is a predictor for higher levels of pain (Hadjistavropoulos).
There are many strategies that, as hypnotherapists, we can employ with our clients to optimise the effectiveness of our pain management work and minimise any negative influences. When a client presents for help with managing their pain, it may be appropriate to explore beyond the immediate physical symptoms and consider what underlying influences can impact upon the planned work. It may be tempting, or even necessary, to undertake some symptom management to enable the client to better engage in further therapy. However, for long-lasting and broader effectiveness, taking time to develop the client’s ego strength and resilience would seem to be highly beneficial, as would addressing any strong negative emotions, such as anxiety and hostility. Finally, teaching the client self-care approaches to maintain the gains from therapy will help them strengthen a more internal locus of control and achieve greater empowerment, thus influencing the experience of more positive emotions and mindset.
References & Further Reading
Carlsson, A. M. (1986). Personality characteristics of patients with chronic pain in comparison with normal controls and depressed patients. Pain, 25(3), 373-382.
Gatchel, R. J., & Weisberg, J. N. (2000). Personality characteristics of patients with pain. Washington, DC, US: American Psychological Association.
Massie, M. J. (2001). Personality Characteristics of Patients With Pain. Psychiatric Services, 52(2), 247-247.
Geers, A. L., Wellman, J. A., Fowler, S. L., Helfer, S. G., & France, C. R. (2010). Dispositional optimism predicts placebo analgesia. The Journal of Pain, 11(11), 1165-1171.
Hadjistavropoulos, H., & Shymkiw, J. (2007). Predicting readiness to self-manage pain. The Clinical journal of pain, 23(3), 259-266.
Hodo, D. W. (2002). Personality Characteristics of Patients With Pain. American Journal of Psychiatry, 159(2), 336-336.
Kirsch, I. (1985). Response expectancy as a determinant of experience and behavior. American Psychologist, 40(11), 1189.
Letzring, T. D., Block, J., & Funder, D. C. (2005). Ego-control and ego-resiliency: Generalization of self-report scales based on personality descriptions from acquaintances, clinicians, and the self. Journal of research in personality, 39(4), 395-422.
Mann, E., & Carr, E. (2008). Pain: creative approaches to effective management. Palgrave Macmillan.
Morton, D. L., Watson, A., El-Deredy, W., & Jones, A. K. (2009). Reproducibility of placebo analgesia: Effect of dispositional optimism. Pain, 146(1-2), 194-198.
Peciña, M., Azhar, H., Love, T. M., Lu, T., Fredrickson, B. L., Stohler, C. S., & Zubieta, J. K. (2013). Personality trait predictors of placebo analgesia and neurobiological correlates. Neuropsychopharmacology, 38(4), 639.
Price, D. D., Finniss, D. G., & Benedetti, F. (2008). A comprehensive review of the placebo effect: recent advances and current thought. Annu. Rev. Psychol., 59, 565-590.
Robinson, M. D., Ode, S., Moeller, S. K., & Goetz, P. W. (2007). Neuroticism and affective priming: Evidence for a neuroticism-linked negative schema. Personality and individual differences, 42(7), 1221-1231.
Schwartz, R. A., Greene, C. S., & Laskin, D. M. (1979). Personality characteristics of patients with myofascial pain-dysfunction (MPD) syndrome unresponsive to conventional therapy. Journal of Dental Research, 58(5), 1435-1439.
Scott, D. J., Stohler, C. S., Egnatuk, C. M., Wang, H., Koeppe, R. A., & Zubieta, J. K. (2007). Individual differences in reward responding explain placebo-induced expectations and effects. Neuron, 55(2), 325-336.
We hope this blog on pain management and personalities has been helpful, and if you have any questions relating to this blog, do please get in touch, because we’re always happy to help!
– written by Dr Kate Beaven-Marks