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COGNITIVE BEHAVIOURAL INTERVENTION IN A CASE OF PSYCHOGENIC CEPHALALGIA

Autor: Viorel Lupu Izabela Ramona Todiriţă
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ABSTRACT: 

The article presents the cognitive behavioural hypnotherapy in a case of psychogenic cephalalgia at an adolescent of 15 years old which lasted for approximately 3 months. The intervention was made in a number of 4 sessions of hypnosis combined with sessions of self-hypnosis. The results were favourable and they persisted in time at follow-up at 1 month, 2 months, 3 months, 6 month and 1 year from the last session. In conclusion hypnotherapy was effective in this case of psychogenic cephalalgia where usual medication did not have any results. Hypnotherapy is a very valuable alternative in pain therapy which appears rather frequently in psychosomatic diseases in the case of children and adolescents.

 


 

Sporadic cephalalgia affects approximately 70% of the population in developed countries while chronic cephalalgia affects 7%. Functional headaches may be diagnosed as vascular or tensional headaches. Tensional cephalalgia is present during straining of the shoulder and backhead muscles which leads to the extension of the ache to all the cephalic extremities. (Luban-Plozza and colab., 2000). It may be due to:

  • Emotional reactions to severe trauma or to an acute conflict;
  • Impaired emotional adjustment;
  • Psychosomatic personalities;
  • Psychosomatic symptoms in endogen psychosis.

“Mihai” is a 15 year old adolescent, who lives in an urban environment. He is in the 9th grade of a high school, studying Mathematics and Physics. He sought specialized help due to a persistent cephalalgia localized in the frontal and occipital area and because his school performance decreased dramatically.

The problems had started 3 months before coming to the clinic. He had changed classmates, having problems of adaptation to the new environment. He had been investigated in some clinics before: ophthalmology, neurology and paediatrics.

None of the investigations signalled pathological modifications. All medication against pain remained without results, the pain persisting almost all the time.

As psycho type, his mother described him as being highly emotional, very attached to his family, with constitutional anxiety and low tolerance to pain. His parents were high school graduates and got along well, but his mother had followed therapy for generalized anxiety disorder.

His IQ was 110, Mihai having very good results in school (being among the first students in primary and middle school).

During the first evaluation, he completed HADS questionnaire obtaining 17 points for anxiety (over 11 points being considered pathological values), and 7 points for depression.

He was asked to evaluate the intensity of his headache on a scale from 0 – 10 (0=lack of pain and 10=the most intense pain). He said his pain was at level 9. Taking into account the psychogenic context and the absence of a somatic cause, the diagnostic was: “Psychogenic pain due to stressful situations” and “Adaptation Disorder”.

We started with hypnotherapy in order to reduce and eliminate cephalalgia. At the same time, we aimed at reducing his anxiety too, both by changing catastrophic cognitions connected to his adaptation to the new environment and by strengthening his self-esteem.

There have been 4 sessions of hypnotherapy and in all we alternated it with exercises of self-hypnosis which were learnt by the adolescent during the hetero-hypnosis.

During the first session, the hypnotic induction was made with the progressive muscular relaxation method (Jacobson) and the deepening of the trance was obtained counting from 0 to 20. For the cephalalgia we used “the blackboard exercise” in the following form: “Imagine a blackboard on which you write letter A with a white chalk, you look at it and get calm…, then you take the sponge and wipe the letter slowly and get more and more relaxed… more and more… more and more… Then you write letter B…etc.” (You follow the same procedure with letters C, D).

Mihai was told to continue with the other letters by himself, starting with letter E and wiping each letter after he finished writing it and then, with each written letter he would get more and more relaxed… more and more… After 5 minutes the boy was told to wipe the blackboard with the sponge, to take the chalk and write the following words, one under the other:

SICKNESS

FEAR

DISBELIEF

UNADAPTABILLITY

HEADACHE

LOW PERFORMANCE

He had to contemplate them and then wipe them slowly from the blackboard, … while getting more and more relaxed. Then, we suggested him to take the chalk again and to write, one by one, the following words which will stay on the blackboard forever:

HEALTH

WELLBEING

TRUST

ADJUSTMENT

HIGH PERFORMANCE

WITH THE HELP OF GOD I WILL SUCCEED,

I WILL SUCCEED…I WILL SUCCEED

“You will do the blackboard’s exercise each day and this will help you solve your problems.” Then we got him out of the trance counting from 1 to 10. At waking up from the trance, we applied again HADS and the scores were: 10 for anxiety (compared with 17 points before the exercise) and 5 for depression (compared with 7 points before the exercise). Also, there was a decreasing of the pain from 9 to 7 after the first session of hypnosis. We explained to Mihai that it was normal to see the 9th grade as a difficult life experience and why anxiety and cephalalgia had contributed to a decreased school performance in comparison to his performance in the 6th and 7th grades and in spite of the fact that he was among the best students. We recommended that, in the following 4 days, he should make the self-hypnosis exercise of the “blackboard”.

We applied again the HADS before the second session, at a distance of 4 days from the first session. The scores diminished a lot, getting 8 for anxiety, 4 for depression and 5 for cephalalgia.

During the second session of hypnosis, we insisted on the suggestions of strengthening the self esteem, using the metaphors of “the river” and of “the oak” adapted after Hawkins (1994). We also suggested directly that each day he would get stronger and stronger, more and more self confident, and independent and that he will finally adapt himself to the school better and that his pain will diminish more and more until till it will disappear. After the trance, the scores for HADS were 6 for anxiety, 3 for depression, and 3 for cephalalgia.

We recommended the boy to continue “the blackboard exercise” during the next 4 days.

Before the third session of hypnosis he reached the levels 4 for anxiety, 2 for depression and 2 for cephalalgia. He was also capable to concentrate better at his homework and was able to get better grades at school, 8 and above and his headaches decreased very much.

During the third session we applied “the little stones exercise” (Lupu, 2009):

“Imagine that you are on the shores of a still lake…on a very pleasant summer day…the blue sky is reflecting itself into the water of the lake… On the shore, there are a lot of coloured little stones… you bend yourself in order to lift a greenish stone… you take it in your hands and feel its warmth accumulated in it from the sun…then you throw it into the lake and see how, at the impact with the surface of the lake, the stone generates little concentric waves which propagate slowly, and, as the circles become wider and wider, you become more and more relaxed…. … Then, you follow the stone as it goes down into the water…it gets down among aquatic plants which you can see because the water is very clear… they are greenish-brownish… then the little stone reaches the bottom of the lake… and millions of mud particles rise towards the surface of the lake, blurring the water … but then, these particles settle back slowly to the bottom of the lake… and the water becomes clear and crystalline again and you are more and more calm and relaxed…” (Then, the same procedure is continued with other 4-5 stones of different colours: bluish, maroon, silver, etc …).

After the boy woke up from the trance, the scores at HADS were 3 for anxiety, 3 for depression and 1 for cephalalgia. He was counselled to continue this exercise at home during the following 4 days and, before the fourth session, the scores were 2 for anxiety, 2 for depression and 0,5 for cephalalgia. In this last session we applied “the rainbow exercise combined with the TV exercise” (Lupu, 2009). “Imagine that you sit in a comfortable armchair… And in front of you there is a colour TV… and you have the remote control in your hand … You push a button for channel 1 and the red colour appears … then you see a field with corn poppies which is delightful… Then you push the button for channel 2 … and you see the orange colour… on the screen you see a basket with freshly picked oranges… you can see their green leaves… you feel them and they have a wonderful smell… you feel your mouth watering at the thought of their delightful sweet – sour taste.

… you push the 3rd channel button and see the yellow colour…a field of ripe wheat… it is about the end of July and it is very hot… but a soft wind is blowing slowly, making the wheat to bend and form some concentric circles which develop slowly and, as they propagate, you get calmer and calmer… then you push the 4th channel button and… you see the green colour… and see that next to the field there is soft grass which makes you lay down… it is hot… the grass is soft as moss… and sitting on the grass you feel drowsy… then you push the 5th button… and you see the blue colour… and you are more and more calm… you look through your eyelashes… sitting on the grass… the blue sky… without any clouds… which makes you more and more calm and relaxed… you push the 6th button and there is the indigo colour with violet reflections… you see the sky in the horizon immediately after the sunset… you are more and more relaxed and calm… the old people say in the countryside say that when there is this colour in the sky the next day will be a beautiful and clear day…” This method is very pleasant for children and adolescents, it is named “the rainbows exercise” because the colours evoked are those in the rainbow: Red, Orange, Yellow, Green, Blue, Indigo and Violet. The succession of colours can be easily remembered according to the famous mnemonic formula ROYGBIV: R(ed), O(range), Y(ellow), G(reen), B(lue), I(ndigo) and V(iolet).

After this session the patient reached the following scores: 1 for anxiety, 1 for depression and 0 for cephalagia. His school grades were 9 and 10. The results were favourable and they persisted in time at follow-up sessions, 1 month, 2 months, 3 months, 6 month and 1 year from the last session. In conclusion, hypnotherapy was effective in this case of psychogenic cephalalgia, where usual medication did not have any results. Hypnotherapy is a very valuable alternative in pain therapy which appears rather frequently in psychosomatic diseases in the case of children and adolescents.

 

Bibliography

  1. Luban-Plozza B., Poldinger W., Kroger F. (2000): Psychosomatic disorders in the medical practice, Medical Ed., Bucharest, 94-96.
  2. Lupu V., (2009): Introduction in the hypnotherapy and in the cognitive-behavioral psychotherapy of the child and the adolescent. ASCR Ed., Cluj-Napoca.