States of consciousness

1. Consciousness, Pain, sleep &
associated disorders
Dr.Harim Mohsin

2. Consciousness
& Altered states of consciousness

3. Definition of consciousness
 For the purpose of descriptive
clinical psychopathology,
consciousness can be simply
defined as
-- a state of awareness of the
self and the environment
(Fish, 1967)

4. Architecture of consciousness

5. Stages of consciousness

6. Four aspects of self-awareness
 the existence and ACTIVITY of the self
 being a unity(SINGLENESS) at any given point of time
 Continuity of IDENTITY over a period of time
 being separate from the environment ( awareness of eg
BOUNDARIES/DEFINITION)
 Fifth dimension of ego vitality(Scharfetter,1981,1995) Previously this characteristic was
incorporated within the awareness of activity, Which subsumed ‘being’ and
existing with other principles.

8. Consciousness
 Individual awareness of one’s unique thoughts, memories, feelings,
sensations and environment.
Continuum of Consciousness
 wide range of experiences from being aware and alert to being
unaware and unresponsive.
1. Controlled Processes
 Full awareness, alertness, and concentration
2. Automatic Processes
 Little awareness and take minimal attention

9. 3. Daydreaming
 Low level of awareness
 Often occurs during automatic processes
 Involves fantasizing/dreaming while awake
4. The Unconscious
 “It contains all sorts of significant and disturbing material which we need to
keep out of awareness because they are too threatening to acknowledge
fully” –
 Process of Free Association - a method of exploring a person's unconscious by
eliciting words and thoughts with meaningful associations .
 Dream Interpretation - the process of assigning meaning to dreams

10. Continuum of Consciousness
5. Unconsciousness
 Total unawareness and loss of responsiveness to one’s environment
6. Altered States
 Awareness that differs from normal consciousness
 Results from using any procedures: meditation, hypnosis, or
psychoactive drugs

11. Continuum of Consciousness
7. Sleep and Dreams
 Sleep – involves different levels of consciousness and psychological
arousal, which occurs in 5 stages.
 Dreams – astonishing visual, auditory and tactile images in sleep,
which occurs in the REM stage.

12. Altered States
A. Meditation
 The practice of focusing attention
 To enhance awareness and gain more control of physical and
mental processes
 Increased alpha & theta rhythm – Feeling deeply relaxed and free
from being stressed
B. Hypnosis
 Trance-like state
 A procedure that opens people to the power of suggestion

13. Altered States
C. Psychoactive Drugs
 A chemical substance that acts primarily upon the central
nervous system where it alters brain function, resulting in
temporary changes in perception, mood, consciousness and
behavior
a. Stimulants: drugs that stimulate the central nervous system.
b. Sedatives: drugs that slow down the central nervous system
c. Narcotics: also called opiates; drugs that can relieve pain
d. Hallucinogens: drugs that cause sensory and perceptual
distortions

15. Freud’s model of consciousness

16. The Defenses role in consciousness

17. The defense mechanisms

18. Sleep
 Sleep Architecture - represents the cyclical pattern of sleep as it
shifts between the different stages

20. Dreams
 Impulses and desires of the id are
suppressed by the superego.
 Because the guards are down during
sleep, the unconscious has the
opportunity to act out and express the
hidden desires of the id.
 However, the desires of the id can, at
times, be so disturbing and even
psychologically harmful that a "censor"
comes into play and translates the id's
disturbing content into a more
acceptable symbolic form.

21. Disorders of consciousness—
psychopathological aspects

22. Disorders of consciousness
 Disorders of consciousness are associated with disorders of
perception, attention, attitudes, thinking, registration and
orientation

23. Three dimensions of consciousness and
unconsciousness
 Vigilance(wakefulness)-----
drowsiness(sleep) axis
 Lucidity ----clouding axis
 Consciousness of self
 Normal state of consciousness----- death(in a
person suffering from serious brain disease)
 Full wakefulness-----to deep sleep( in a person
who is sleep)
 Full vigilance ------total unawareness(in an alert
and healthy person
 The organic state of brain, as for instance,
demonstrated by EEG, is utterly different in
these three situations

24. Quantitative lowering
of consciousness
Qualitative change of
consciousness
 Normal (alert, vigilant, lucid)
 Clouding
 Drowsiness
 Stupor
 Coma
 Death
 Delirium
 Fluctuations
 Confusion
Classification of Disorders of
consciousness(Sims)

25. What is the Pain?
“Pain is an unpleasant sensory and emotional experience associated
with actual or potential tissue damage.”
International Association for the Study of Pain, 1979

26. • Site(s)
• Quality
• Severity
• Date of onset
• Duration
• What makes it
better/worse
• Impact on sleep, mood,
activity
• Effectiveness of previous
medication
Patient Pain History

27. PQRST mnemonic:
• P: Precipitating and palliating factors
• Q: Quality
• R: Region and radiation
• S: Severity
• T: Time

29. Psychiatric Disorders with Pain

30. Psychiatric disorders with pain
• The typical finding is an increased occurrence of psychiatric
disorders among persons with a specific pain condition when
compared with persons with no pain.
 Depression
 Anxiety
 Chronic Pain
 Somatoform disorders
 PTSD

31. Types of Pain
1. Acute (<6 months)
2. Chronic (6 months <)

32. Acute pain:
• lasts less than 6 months, subsides once the healing process
is accomplished.

33. Presentation of Pain
Chronic Acute
• Often obvious distress
• Can be sharp, dull, shock-like,
tingling, shooting, radiation,
fluctuating in intensity, and varying
in location
• (occur in timely relationship to
noxious stimuli)
• Comorbid conditions not usually
present
• May see HTN, increased HR,
diaphoresis, pallor…
• Can appear to have no
noticeable suffering
• Can be sharp, dull, shock-like,
tingling, shooting, radiation,
fluctuating in intensity, and varying
in location (do NOT occur in timely
relationship to noxious stimuli)
• Symptoms may change over time
• Usually NO obvious signs

34. Acute Pain (Nociceptive)
• Somatic
• Superficial (nociceptors of skin)
• Deep [body wall (muscle, bone)]
• Visceral
• (sympathetic system; may refer to superficial structures of
same spinal nerve)

35. PHYSIOLOGY OF PAIN
(Yoneda, Hata, Nakanishi, Nagae, Nagayama, Wakabayashi, and Hiraga,
2011).

36. Acute Pain
• Travels into the spinal cord along the
appropriate nerve root.
• Nerve root -> front division and a back division
and carries pain sensation to the CNS (spinal
cord and brain).
• Passed to a short tract of nerve cells
(interneurons), which in turn synapse with a
nerve tract that runs to the brain .
• Sent out to the rest of the brain, connecting
with thinking and emotional centers.
• A modifier pathway from the brain modifies
pain at the synapses in the back part of the
spinal cord (acute pain is decreased rapidly
after tissue injury).

38. Chronic pain:
• Complex processes & pathology.
• Usually altered anatomy & neural pathways.
• Constant & prolonged, > 6 months, sometimes for life.
• “Lasting longer than expected time frame”

39. Altered Neural Structure
• Chronic pain accompanied by:
• Cortical Reorganization
• Brain Atrophy

40. Chronic Pain
1. Malignant (cancer)
2. Nonmalignant
• Neuropathic (nerve injury)
• Inflammatory (musculoskeletal)
• Mixed or unspecified
• Psychogenic

41. Chronic Pain
• Neuropathic:
• Severe pain disorder that results from damage to the central and peripheral nervous
systems.
• Inflammatory:
• Results from the effects of inflammatory mediators.
• Neuralgia
• an extremely painful condition consisting of recurrent episodes of intense shooting or
stabbing pain along the course of the nerve.
• Causalgia
• recurrent episodes of severe burning pain.
• Phantom limb pain
• feelings of pain in a limb that is no longer there and has no functioning nerves.

42. Peripheral Nerve Fibers Involved in
Pain Perception
• A-delta fibers–small, myelinated fibers that transmit sharp
pain
• C-fibers–small unmyelinated nerve fibers that transmit dull
or aching pain.

43. Biopsychosocial Model
BIOLOGICAL
Nociception
Tissue Damage
Disease Process
PSYCHOLOGICAL
Pain beliefs
Locus of control
Lack of self-efficacy
Limited coping
Emotions
SOCIAL
Cultural influences
Learning mechanisms
social learning
reward/punishment
classical conditioning

45. PSYCHOLOGICAL FACTORS
1. LOCUS OF CONTROL:
 Rotter (1996) stated that there were “internal” and “external” Locus
of control.
 The “internals” (believe that their own actions significantly influence
their health)
 The “externals”(believe that they don't have much control over their
health)
 Persons who believe that the prognosis for their pain is influenced
mainly by luck or fate (external) are engage in maladaptive coping
strategies such as wishful thinking or catastrophizing.
(Worsham, 2006)

46. 2. CATASTROPHIZING COGNITIONS:
 Pain catastrophizing is characterized by the tendency to magnify
the threat value of pain stimulus and to feel helpless in the
context of pain, and by a relative inability to inhibit pain-related
thoughts in anticipation of, during or following a painful
encounter.
 A “Neurophysiological Model” of catastrophizing proposes
that:

47. Cont…
 In a research study pain catastrophizing was assessed
pre-surgery.
 The results showed significant variance in
postsurgical pain ratings, narcotic usage, depression,
pain-related activity interference and disability levels.
 Another study by Edwards, suggested that pain
catastrophizing was related to increased suicidal
ideation in a large sample of chronic pain patients.

48. SELF-EFFICACY AND EFFECTIVE COPING:
In a Research study low levels of self-efficacy was found to be
associated with a lower levels of pain tolerance and higher levels of
pain intensity in samples of people with chronic pain.
Those who alleviate their pain are likely to mobilize whatever skills
they have learned to preserve themselves.
The higher the perceived self-efficacy the longer pain can be
tolerated and less medications are required.

49. Coping
 Individuals who experience pain may develops two types of
coping.
 Adaptive coping: active coping strategies are considered to be
adaptive in which patient is an active participant and assumes
self management responsibilities.
 Maladaptive coping: these are passive coping strategies in
which patient withdraw from activities and shows dependency
on others for pain relief. (Placebo)
 Studies have found that active coping strategies decreases the
pain intensity and increases pain tolerance.
 However, passive coping is associated with greater pain and
related depression.

50. PAIN AND EMOTIONS:
 The typical emotional reaction to pain includes anxiety, fear, anger,
guilt, frustration, and depression.
 According to FAM (Fear-avoidance model) “Fear of pain” is the
most important emotional factor in perception of pain.
 A fear response to pain leaves an individual with two options:
 Confrontation (Menstrual pain)
 Avoidance (Fracture pain and hygiene care)
 The “Confronter” is more likely to view pain as temporary , is
motivated to return to normal work, social and leisure activities,
and is prepare to confront their personal pain barriers.

51. Cont…
 The pain “Avoider” is motivated by fear and avoid both pain experience
(cognitive component) and painful activities (behavioral component).
 Thus, this avoidance leads to more pain and is harmful to the recovery
process.
 Certain other negative emotions such as anger, hostility and depressed
mood can also influence pain perception.
 Negative emotional states registers in the brain in a manner that strikes
brain pathways which are responsible for enhancing pain.
 The expression of anger and hostility are often used as defensiveness and
can seriously compromise the therapeutic relationship between nurse-patient,
which further deteriorates patient’s condition.

52. NEUROTICISM EXTRAVERSION
(Eysenk’s personality theory): High neuroticism is
the result of cortical arousal which increases
sensitivity and contributes to emotional instability.
Such individuals are more likely to worry about
physical symptoms like (pain).
(Eysenk’s personality theory): Extraversions have
low cortical arousal, requiring more frequent and
stronger stimulation to acquire satisfactory levels
of arousal. As a result, extravert exhibit diminished
pain sensitivity and higher pain threshold.
These individuals generally do not cope well with
stress and perceive painful stimulus as
threatening and distressful.
Extraversion is also associated with use of active
and strong coping strategies that lead to better
adaption to painful stimulus. (For example, being
optimistic)
certain dimension of neuroticism negatively
correlates with pain (experiment):
1.Negative mood decreases pain tolerance
time.
2.Emotional vulnerability increases pain intensity
and unpleasantness.
Extroversion is positively associated with general
health perception. Individual both healthy and
with self-reported medical problems feel good
about themselves and try to mobilize all their
resources to maintain this state of health.
Neuroticism is significantly high in patients with
Extraversions are more likely to complain about
lower back pain, joint pain and cancer pain etc.
their pain and express their sufferings than
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53. Pain
Management
PHARMACOLOGICAL &
NONPHARMACOLOGICAL MANAGEMENT

54. Principles of Treatment
• Reduction of Pain:
• Behavioral, Meds, Blocks, Surgery, Complementary
• There is no magic bullet, no single cure
• Rehabilitation:
• Reconditioning & Prevention
• Coping:
• Management of Residual Pain

55. Treatment Objectives
• Decrease the frequency and / or severity of the pain
• General sense of feeling better
• Increased level of activity
• Return to work
• Decreased health care utilization
• Elimination or reduction in medication usage

56. Treatment of Pain
1. Non-pharmacologic
2. Medications
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Acetaminophen
• Antidepressants & anticonvulsants
• Adjuvants
• Narcotics
1. Invasive procedures
Copyright © 2003 American Society of Anesthesiologists. All rights reserved

57. 3. SENSORY CONTROL OF PAIN:
 One of the oldest known techniques of pain control is
COUNTER-IRRITATION, a sensory method.
 Counterirritation involves inhibiting pain in one part of the body
by stimulating or mildly irritating another area.
 Overall, sensory control techniques have had some success in
reducing the experience of pain. However, their effects are often
only short-lived, and they may therefore be appropriate primarily
for temporary relief from acute pain.

58. RELAXATION TECHNIQUES
 Rationale for teaching pain
patients relaxation techniques,
is that it enables them to cope
more successfully with stress
and anxiety, which may also
ameliorate pain.
 In relaxation, an individual
shifts his or her body into a
state of low arousal by
progressively relaxing different
parts of the body.

59. HYPNOSIS
 In 1829, prior to the discovery of anesthetic drugs, a French surgeon,
Dr. Cloquent, performed a remarkable operation on a 64 year old women who suffered
from breast cancer and the tumor was being removed without anesthesia through
hypnosis and the lady felt no pain.
 First, a state of relaxation is encouraged.
 Next, patients are explicitly told that the hypnosis will reduce pain.
 In the hypnotic trance, the patient is usually instructed to think about the
pain differently

60. Tools of hypnosis

61.  In acupuncture treatment, long thin needles are inserted into
specially designated areas of the body that theoretically
influence the areas in which a person is experiencing pain.
(Practiced in china for more than 2,000 years).
 How acupuncture controls pain is not fully known. But it is
possible that acupuncture triggers the release of endorphins,
thus reducing the experience of pain.
 When Naloxone (an opiate antagonist) is administered to
acupuncture patients, the success of acupuncture in reducing
pain is reduced.

62. DISTRACTION
 Individual who are involved in intense
activities like sports or military
maneuvers can be oblivious to pain full
injuries due to Distraction

63. Cont…
 There are two quite different mental strategies for controlling
discomfort.
To distract oneself by
focusing on some other
activity.
Focus directly on the events but
to reinterpret the experience.

64. COGNITIVE BEHAVIORAL
THERAPY FOR PAIN
ACCEPTANCE AND
COMMITMENT THERAPY
AWARNESS AND
PERSPECTIVE
MINDFULNESS
WILLINGNESS
COGNITIVE
DE-FUSION
COGNITIVE
BEHAVIORAL
THERAPY
McCracken, (2005).

65. COGNITIVE BEHAVIORAL THERAPY FOR
PAIN
1. ACCEPTANCE AND COMMITMENT THERAPY:
 Aim for ACT is to reduce the feelings of failure (drug dependency) of strategies to
control pain.
 The therapist creates a collaborative environment in which Patients with pain can
review their actual problem and find out their previous way of struggling to solve this
problem. This gives a clear understanding of the time duration of persisting problem
and range of strategies tried by patient to improve situation.
 It helps identifying the actual problem which is not the pain itself, rather the behavior
of disregarding oneself for the repeated failures to achieve an effective pain control.

66. MINDFULNESS:
"the intentional, accepting and non-judgmental focus of one's
attention on the emotions, thoughts and sensations occurring in
the present moment", which can be trained by meditational
practices derived from Buddhist anapanasati.

67. Non-pharmacologic Pain Management
• Cognitive therapies (relaxation,
imagery, hypnosis)
• Biofeedback
• Behavior therapy
• Psychotherapy
• Massage therapy
• Art therapy
• Music therapy
• Aroma therapy
• Neurostimulation
• TENS
• Acupuncture
• Anesthesiology
• Nerve block
• Surgery
• Physical therapy
• Exercise
• Heat/cold
• Psychological approaches

68. The End