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Cases of the New England Society...Milton
Number 1.1
March 1998
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.
Current medications:
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.
Assessment:
Iatrogenic pain syndrome
History of achalasia, which is a predisposing factor for
esophageal cancer
Depression- moderate and untreated
Disability issues
Significant anger regarding his preceding management
Treatment:
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:
Glove anesthesia.
Transfer of glove anesthesia to involved area.
Progressive relaxation to enable and improve quality of
sleep.
Office Visits 3-6:
Deepening techniques.
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 control.
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.
Update:
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.
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Last update: October 1, 2002
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