Circling the Drain: the Case of Milton
Contributing Clinician: Daniel L. Handel, MD
Daniel Handel, MD is currently a member of the Pain and Palliative Care Service, National Institute of Health,
Bethesda, MD. Dr. Handel is the former President and Medical Director of the Center for Pain Management and the Medical Director of the Community Hospice of Texas He is well known for his expertise and creativity in utilizing hypnosis with patients compromised by medical illness. Dr. Handel is an Assistant Professor in Family Practice and Community Medicine at the University of Texas Southwestern Medical Center at Dallas. He is also a Past-President of the American Society of Clinical Hypnosis. Dr. Handel was the Distinguished Lecturer for the 1998 43rd Annual NESCH Workshop.
Referral: Milton E., a 48 year-old medically disabled noncommissioned officer, first presented to me for severe and intractable chest pain. This married father of three self-referred to our pain clinic after seeing a news broadcast about our pain treatment strategies, including hypnosis.
History: In 1993, while stationed in the Pacific, the patient was given a diagnosis of suspected cancer of esophagus ( by biopsy X2). Subsequent radiation therapy to the area of the esophagus, via a thoracic mantle-type port. Also received three cycles of intensive chemotherapy. Multiple endoscopic biopsies thereafter to follow the disease, and no sign of disease found. During treatment, his weight fell from premorbid 185# to a nadir of 95# when he was most ill. His wife was told on two occasions that he would not survive the night. While hospitalized with complications of therapy, he developed sepsis, nausea and vomiting with dehydration, and later, severe strictures of the esophagus. In 1996, he was discharged on medical disability to his home town to be closer to his family of origin. It was thought that he had less than one year to live. During this time he had severe chest pain from radiation esophagitis and esophageal strictures, which he described as constant severe substernal aching and pressure, with movement and exercise-induced spasms of sharp stabbing anterior chest pain. At the time of evaluation, he had regained some weight to 115#.
His wife of 16 years had felt as if something was amiss with his diagnosis. With the help of a military physician his records were pursued and it was discovered that his original diagnosis was in error: he did not have cancer, and had not had cancer at any time His extensive treatments causing his disability and pain were unnecessary.
Functional Assessment: Completely disabled from the service. Living at home with his wife and their third daughter, four years old. He kept to himself in the back of the house in a dark room, yelling at anyone who disturbed him. Frequent complaints of pain which prevented any activities, including household chores or manicuring the lawn (which he had previously greatly enjoyed.)
Unable to eat most solid foods, except during the first week following dilations. In the past the patient had been sustained by feedings through a gastrostomy tube through the abdominal wall into his stomach. Currently was receiving approximately 1,000 calories nightly through this tube.
In the past he had been very gifted athletically, enjoying a stellar high school football career before joining the military to escape Southern poverty and to travel the world. In the service, he had been an instructor before rising through the ranks to manage a motor pool, where he supervised well over one-hundred men and the maintenance of several hundred vehicles. His position involved long hours, high stress, and great responsibility---all of which he very much enjoyed. These years were remembered as the best of his life.
Nuclear Family: Eldest daughter launched, educated, married and with child. Second daughter leaving shortly to attend college on a scholarship. Youngest daughter at home with patient and wife. Describes a very strong and loving relationship with wife. In terms of family structure, he was clearly the family authority. The patient greatly regretted that his medical condition was blocking his active involvement with his youngest daughter.
Morphine: 10-20mg q. 2hrs, as needed for severe pain; averaging 5-6 doses daily.
Methadone elixir: 20 mg every twelve hours for pain.
Prilosec: for history of gastritis.
Desipramine: 30 mg at bedtime for sleep.
Currently receiving dilations of esophagus every 3-6 weeks when his esophagus is dilated from "the size of the lead of a pencil" to approximately "half the diameter of a garden hose." If left longer than 4-6 weeks, his stricture would be severe enough to prevent the swallowing of saliva,leading to drooling.
Pain Score: Current=8/10
Past 24 hr. peak= 10/10
Average over past week= 8/10.
Past Medical History: Achalasia diagnosed in adolescence, required intermittent dilations of the esophagus. Gastritis, by history. No other significant medical history.
Iatrogenic pain syndrome
History of achalasia, which is a predisposing factor for esophageal cancer
Depression- moderate and untreated
Significant anger regarding his preceding management
Discussed with the patient the nature of hypnosis and suggested length of treatment.
Patient agreed to allow videotaping for training purposes ( " to show other health care providers
alternative strategies which are very helpful for pain management.")
Recommended pharmacotherapy for depression. Patient refused antidepressant medication..
Patient's wife---understandingly distrustful of the medical establishment--was invited to be present at each session. It was felt that she could provide an important resource if appropriately involved in her husband's treatment.
Course of Treatment:
Course of Treatment:
Office Visits 1,2:
Transfer of glove anesthesia to involved area.
Progressive relaxation to enable and improve quality of sleep.
Office Visits 3-6:
Amnesia suggestions for episodes between severe pains, and for endoscopic dilation procedures.
Taught "second skin" technique of self-actualization, for imaging weight gain, athleticism, and physical
Began to deal with anger issues, emphasizing control over the process... primarily through the "squeeze technique" for slow release of anger, imagery techniques, and finally the patient engaging and promoting his own imagery unique to his life circumstance... i.e.: the carrying away of all of the harms that had innocently been done to him by his military physicians in a large hot air balloon and basket... watching that disappear into the sky... and then observing the basket "tip" and releasing (like the pamphleting campaign he had previously been witness to in Viet Nam) the documentation back down to earth, informing everyone below of his deserved grievances. This seemed most acceptable to him, he told me, in that he had no wish to "betray" the military, towards which he still felt a powerful sense of loyalty .
Office Visits 7,8: In the final two sessions, Milton enjoyed going into deep levels of trance, displaying dense anesthesia for the camera, and began working on future-oriented issues, such as vocational plans and functional issues. He made plans for vocational reeducation and for an exercise and nutritional plan which would enable (1) reversal (when his weight > 120#) of the gastrostomy tube, which had become a reminder of his disability , (2) enrollment in school, and (3) regular play times with his daughter.
Milton was contacted 18 months after his last visit to me [ February, 1998 --Ed. ]. He is now completely off of morphine, taking only 4mg of methadone once daily and planning to discontinue that shortly, and reporting pain levels of 2-4/10. He exercises with weights four times weekly (in his garage). Milton is half-way through a technical degree which will enable him to return to the workforce. Depression is no longer an issue, although he never received any antidepressant medications. He reports practicing his imagery at least once daily, often twice daily for relaxation and pain control. His dilations have decreased to approximately every 6-8 weeks, and his gastroenterologist reports to him that his esophagus has become more pliant and less fibrotic. Milton is looking forward to becoming employable. Perhaps most importantly, he is now able to derive tremendous pleasure from his family life.