Psychosocial Treatment of Chronic Pain

1. Psychosocial Treatment of Chronic Pain Dominic Germano Clinical Psychologist North West Shared Care North West Area Mental Health Service

2. Psychosocial Treatment of Chronic Pain • Biopsychological model of chronic pain • Key psychological and behavioural factors that influence the development and perpetuation of pain • Assessment • Treatment Approaches • Case Vignette • Discussion

3. General statistics about chronic pain • Global prevalence of chronic pain is at 20% (Bores-Karpel 2010) • More women than men experience chronic pain • It’s most common in women in the 50-54 age bracket & men in the 55-59 age bracket • Chronic pain is estimated to cost the Australian economy $34.3 billion each year, which equates to $10,847 for each person with the condition (Pain Management Research Institute)

4. Biopsychosocial model of Pain • Built on the gate control theory of pain (Melzack & Wall, 1965) that takes into account the impact of the mind • Pain signals go through a gating mechanism in the spinal cord • Gate can be open or closed • When gate is open pain registers by allowing pain messages through to the brain • Gate can be shut to stop some or all of the messages. • A gate can be opened and closed by emotions (distress), memories, mood and thoughts (attention to pain)

5. Biopsychosocial Model of Pain • More recent research has taken into account not just the biological (physical) but also the importance of psychological and social influences in the etiology and maintenance of chronic physical pain

6. Biopsychosocial model of Pain • Pain is a complex & subjective experience. • Human responses to pain are variable: some have a high tolerance of pain & others don’t

7. Biopsychosocial model of pain • Pain variability can be influenced by a number of factors: - underlying pathophysiology (somatic events) - cognitions (attitudes, beliefs, images, expectations, thoughts, reasoning) affect (depression, anxiety, anger, frustration, guilt, acceptance) - behaviour - sociocultural status - personality (premorbid coping skills)

8. Key psychological & behavioural factors that influence the developmentand perpetuation of pain • Early work looked at personality factors: - predisposition in individuals towards denying emotional and/or interpersonal distress - somatic focus of attention - displaying features associated with a “depression-prone” personality such as pessimism

9. Key Psychological and Behavioural Factors that influence the development and perpetuation of pain More recent work has focused on: • Role of Emotions in determining pain severity, quality and impact In particular role of negative emotions (anxiety, depression and anger)

10. Key psychological and behavioural factors that influence the development &perpetuation of pain • Social Learning i.e. role of social contingencies for overt expressions of behaviour. Examples include - expression of sympathy from family and friends - disability payments - prescription medications

11. Key psychological & behavioural factors that influence the development & perpetuation of pain • Referred to as “pain behaviours” i.e. anything that communicates to another that one is in pain e.g. verbal expressions of pain, visits to doctors, avoidance of work related activities and social activities

12. Key Psychological and Behavioural factors that influence development and perpetuation of pain 3) Cognitive and Behavioural Factors - Catastrophizing - Fear avoidance - Low self efficacy and lack of perceived locus of control i.e see events as being out of one’s control - Passive pain coping through pain avoidance behaviour i.e. behaving in ways that protect you from feeling pain, so everyday activities are avoided just in case they upset the painful condition

13. Assessment A proper pain assessment is central to treatment planning & to tracking treatment progress History: • onset & progression of problem • location, quality & intensity of pain • frequency of pain • duration of pain • aggravating/relieving factors • functional limitations

14. Pain Assessment Tools Routine screening instruments • Pain : Brief Pain Inventory • Psychological Assessment: PHQ-9

15. Psychological Assessment • Self Report is a reliable indicator of the existence and severity of pain • Other indicators include reports by family members & significant others • Consider mental health issues that may affect perception of pain

16. Psychological Assessment i) Depression • Is commonly comorbid with persistent pain • Research suggests a prevalence of 30-65% of chronic pain patients are or will become depressed • They are at increased risk of suicide • Past suicide attempts increase risk of future attempts

17. Psychological Assessment ii) Anxiety • May be a risk factor for the development of chronic pain syndrome • Associated with fear of pain and fear of movement/reinjury • Contributes to an avoidant coping pattern

18. Personality Assessment iii) Personality Disorders • A significant percentage of chronic pain patients are diagnosed with at least one personality disorder (31-51%) • Presence of personality disorders is associated with a poorer prognosis • Personality issues can be exacerbated by chronic stress of persistent pain

19. Assessment iv) Substance Use • Increased prevalence of substance use disorders in chronic pain patient groups • Need for thorough drug and alcohol assessment

20. Psychological Assessment v) Work & Disability Issues • Supporting people through the process of returning to work or making decisions about work related matters

21. Psychological Assessment vi) Contributing Factors & Barriers • Behavioural: Decreased motivation, unrealistic expectations • Social: language/cultural barriers, lack of social support, financial • Sleep: Over half of chronic pain sufferers report sleep disturbance Sleep enhancement strategies are hence important

22. Assessment:Types of Pain 1) Neuropathic Peripheral: pain due to damage or dysfunction of nerves e.g. phantom limb pain, complex regional pain syndrome (pain that develops following a soft tissue injury or immobilisation of an arm or leg) 2) Muscle Pain: Fibromyalgia syndrome, myofacial pain syndrome 3) Inflammatory Pain: Inflammatory arthropathies (rheumatoid arthritis) Infection & postoperative pain Tissue injury Compressed Pain

23. Assessment: Types of Pain 4) Mechanical Pain: Low back pain Neck Pain Musculoskeletal pain- shoulder/elbow Visceral pain These types of pain are not mutually exclusive-patients report having more than one type of pain

24. Assessment • Determine if the pain is acute or chronic • Acute Pain: derives from a condition that builds rapidly to a crisis, such as a sprained ankle, has a predictable beginning, middle & end. • Chronic pain: Longer lasting and more deep seated pain that persists beyond the expected period of healing or resolution of the source of the pain

25. Assessment • Rule out Somatoform Disorders • Conditions in which identifiable physical pathology is absent & psychological factors are judged as important contributors to pain • These require special management requirements

26. Psychological Interventions for Chronic Pain • Four categories: 1) Self Regulatory 2) Behavioural 3) Cognitive Behavioural 4) Acceptance and Commitment Therapy

27. 1) Self Regulatory Approaches • Designed to assist individuals with developing skills to make them active participants in their own care • Often referred to as the mind-body connection • Seek to increase sense of personal control over physiological and emotional states that are commonly believed to be out of one’s control

28. Self Regulatory Approaches • Biofeedback • Relaxation Training • Hypnotherapy • Mindfulness Meditation

29. Biofeedback • Enables an individual to alter aspects of the way his/her body functions • A biofeedback machine contains electrodes that measure aspects of body function • Goal is to develop an awareness of when these processes change 1)Measures muscle tension in the painful area 2)Monitoring local temperature of affected areas 3)Measuring changes in breathing rate

30. Biofeedback • Can train oneself to alter body function, such as blood pressure or heart rate • Plays a prominent role in the treatment of headache pain • Clinical effects have been shown to persist for approximately 15-17 months post treatment for migraine and tension headaches in adults, adolescents and children

31. Relaxation Training • Adjunct method often used in the context of biofeedback training • Also used as a core component of other treatment regimes (e.g cognitive behaviour therapy) • Focuses on identification of states of tension within mind and body • Educate about the relationship between emotional (e.g stress) and physical (e.g muscle tension) states • Aim is to reduce tension and/or to alter the perception of associated physical pain

32. Relaxation Training • Seeks to empower individuals by teaching systematic self control methods for altering physical and emotional states : - diaphragmatic breathing (deep breathing) is likely to ease both pain & stressful feelings - incorporates slow breathing (5 to 8 breaths per minute)

33. Relaxation Training • progressive muscle relaxation-learn to discriminate different forms of muscle tension to achieve a deep state of relaxation with practice

34. Relaxation Training • Guided muscle relaxation (Visualisation/Imagery) Technique allied to meditation Create pleasant images or scenes in your mind to promote general relaxation & ease pain Thought to work because subconscious mind accepts the messages you feed it, whether they are real or imagined Can be used to reduce autonomic arousal and as an effective attention diversion strategy

35. Relaxation • Shown to be effective on a variety of conditions including - migraine pain - musculoskeletal pain - back pain

36. Hypnotherapy • Used in the treatment of pain & other medical conditions since the 1700’s • Closely related to relaxation training • Involves both muscle relaxation & perceptual alteration • All hypnotic techniques share common goal of shifting focus to accepting pain rather than fearing pain

37. Hypnotherapy • Altered state of consciousness that is guided by suggestive statements made by hypnotherapist • Hypnotherapist helps the patient to construct a “script” to modify beliefs & feelings hampering him/her • Therapist recites script while person is guided into deep relaxation

38. Hypnotherapy • Designed to focus participants attention in such a way they come to change their own subjective experience of pain • Taught methods of reconnecting with state of hypnotic relaxation at any time by using behavioural cues, such as deep breathing • Good empirical support from relatively low number of controlled studies

39. Mindfulness Meditation • Rooted in principles of Theravada Buddhism • Based on increasing non-judgemental awareness of thoughts (allowing them to come and go without effort) • Goals include the attainment of both relaxation and greater focus of attention • Increased focus on phenomenon that are occurring in the moment, without reference to the past or future • Jon Kabat-Zinn is a pioneer in this field

40. Mindfulness Meditation • Focus on the phenomenon of pain as if one is a detached observer • Thoughts and sensations are registered and observed as they occur, but not focused upon • Separate the experience of pain from the thoughts that are rooted in the past or project to the future • Accepting the pain without the cognitive and emotional connections that make the pain worse • Some evidence to support mindfulness as an effective intervention to cope with a variety of health conditions, including chronic pain

41. 2) Behavioural Approaches • Based largely on operant conditioning model of learning (B.F.Skinner) • Underlying premise is that behaviours that are reinforced tend to increase in frequency, whereas behaviours that are punished or not reinforced tend to decrease in frequency • Behaviours that are targeted through behavioural strategies are referred to as pain behaviours

42. Behavioural Approaches • Pain behaviours targeted include response patterns such as: - excessive verbalisation of pain (grunting, sighing) - frequent discussion about pain - facial expressions - guarded movement - restriction of movement • These behaviours are reinforced through social contingencies, such as responses from other people

43. Behavioural Approaches • Responses from other people can include: - expression of sympathy - relieving the individual of responsibility for even basic activities of daily living - reinforcement of individuals pain symptoms

44. Behavioural Approaches • Reinforcement by such responses serves to increase pain behaviours and contribute to what is referred to as the disuse syndrome • Disuse syndrome: marked by excessive pain behaviours that serve to decrease physical activity, which leads to physical deconditioning and increased risk for the development of worsening pain

45. Behavioural Approaches • Operant Behavioural Therapy - Reduce disability through the alteration of pain behaviours - Uses methods to reduce reinforcing nature of others’ responses to pain behaviours and increase the reinforcement of healthy behaviours - Involves close family members and friends who frequently are responsible for unknowingly contributing to reinforcement of pain behaviours

46. Behavioural Approaches • Operant Behavioural Therapy - Elements of operant behavioural therapy have been incorporated into broader treatment approach of cognitive behavioural therapy for pain - Some evidence that it is a cost effective method for reducing disability and improving physical pain

47. Behavioural Approaches • Fear Avoidance - Refers to development of avoidant behaviours (activity avoidance) that are motivated by fear related to pain - Such individuals seek to avoid contact with the fear provoking stimulus (pain) by engaging in behaviours that allow them to avoid the onset or exacerbation of pain (e.g., inactivity) - This pattern also contributes to disuse syndrome

48. Behavioural Approaches At the core of fear avoidance are: - catastrophic thought patterns related to pain - hypervigilance related to physical symptoms

49. Behavioural Approaches • Fear avoidance - Is often tied to excessive worry about further injury or reinjury if the choice is made to become physically active - This is referred to as kinesiophobia i.e. efforts to avoid physical activity take on a phobic quality for some pain sufferers - Treatment focus is on application of in vivo exposure techniques to decrease fears associated with pain avoidance activity.

50. Behavioural Approaches Goal is to assist with systematically engaging in physical activity: • Using goal setting, activity pacing and activity quotas (engaging in predestined, safe and tolerable levels of activity followed by planned rest) to resume activities • Modifying activities that can still be done • Exploring alternatives to activities that are important but can’t be done any longer.