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Topical Session 01 HIDDEN DRIVERS OF PAIN: PSYCHOLOGICAL / PSYCHIATRIC PERSPECTIVES CARL GRAHAM

Topical Session 01 HIDDEN DRIVERS OF PAIN: PSYCHOLOGICAL / PSYCHIATRIC PERSPECTIVES CARL GRAHAM Fremantle Hospital, WA NEWMAN L. HARRIS Royal North Shore Hospital, NSW.

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Topical Session 01 HIDDEN DRIVERS OF PAIN: PSYCHOLOGICAL / PSYCHIATRIC PERSPECTIVES CARL GRAHAM

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  1. Topical Session 01 HIDDEN DRIVERS OF PAIN: PSYCHOLOGICAL / PSYCHIATRIC PERSPECTIVES CARL GRAHAM Fremantle Hospital, WA NEWMAN L. HARRIS Royal North Shore Hospital, NSW

  2. This presentation may make reference to some “off-label” uses of medications which are included only for academic completeness. Attendees should not infer any encouragement to breech prescribing regulations.

  3. Speakers Bureau Boehringer Ingelheim Eli Lilly GlaxoSmithKline Medtronics Pfizer Solvay Wyeth Advisory Boards Boehringer Ingelheim Eli Lilly Pfizer Conference Sponsorship Boehringer Ingelheim Eli Lilly GlaxoSmithKline Pfizer Wyeth DISCLOSURES

  4. What about the 10% who cost us 90% -

  5. What about the 10% who cost us 90% - Another hedgehog maybe?

  6. Return to Work After Lumbar Discectomy (Schade et al 1999) • Correlates with depression and workplace stress, • not with indices of organicity.

  7. Biopsychosocial consideration Parsons (1951) – The Sick Role Mechanic (1961) – Illness Behaviour Pilowsky (1969) - Abnormal Illness Behaviour Engel (1977) – “Biopsychosocial”

  8. WHAT IS PAIN ? • “An unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” (IASP 1979) • Pain is always subjective • Definition doesn’t tie pain to a stimulus • Nociception is NOT equivalent to pain

  9. The Multidisciplinary Approach (Presley and Cousins 1992) • Holistic biopsychosocial assessment • Rationalised organic treatment plan • Psychological and social interventions A paradigm shift from traditional medical approach is required.

  10. INTERACTIONS WITH ENVIRONMENT PAIN BEHAVIOURS SUFFERING COGNITIONS ATTITUDES BELIEFS PAIN PERCEPTION NOCICEPTION NEUROPATHY Fordyce and Loeser’s formulation

  11. Descending Pathway Descending Pathway Ascending Pathway Theoretical Representation

  12. Dr M K Nicholas, PM&RC

  13. Psychiatric Disorder in the Pain Clinic • 90% of pain clinic attendees suffer at least one psychiatric disorder (Large 1980) • Over 60% satisfy criteria for more than one (Fishbain et al 1986)

  14. Psychiatric Disorder in the Pain Clinic • Anxiety Disorders • Depression • Somatoform Disorders • Substance Problems • Psychotic Illness

  15. Comorbid Mood Disorder in Primary Care Setting : • 34% of Joint & Limb Pain • 38% of Back Pain • 40% of Headache • 46% of Chest pain • 43% of Abdo Pain Kroenke & Price 1993

  16. Depression • Higher levels of pain reported • More pronounced pain behaviour • Pain settles with Rx of mood • Depression implicated in transition to chronicity along with somatisation & distress

  17. Risk of Suicide in Depression & Chronic Abdominal Pain Magni et al. Pain 1998.

  18. Yellow Flags Attitudes and Beliefs • Belief that pain is harmful or disabling resulting in fear-avoidance behaviour • Belief all pain must be abolished before return to work or normal activity • Catastrophising, thinking the worst, misinterpreting bodily symptoms Behaviours • Use of extended rest, disproportionate downtime • Reduced activity, significant withdrawal from activities of daily living • Report of extremely high intensity of pain on VAS • Sleep quality reduced since onset of back pain https://www.cebp.nl/media/m24.pdf

  19. Yellow Flags Compensation Issues • Lack of financial incentive to return to work • Delay in accessing income support and treatment cost, disputes over eligibility • History of extended time off work due to injury or other pain problem Diagnosis and Treatment • Experience of conflicting diagnoses or explanations for back pain • Dramatisation of back pain by HP's, dependency on treatments, passive treatment • Expectation of a techno-fix, eg, requests to treat as if body were a machine https://www.cebp.nl/media/m24.pdf

  20. Yellow Flags Emotions • Fear of increased pain with activity or work • Depression (especially long-term low mood), loss of sense of enjoyment • Anxiety about and heightened awareness of body sensations (includes sympathetic nervous system arousal) • Feeling under stress and unable to maintain sense of control Family • Over-protective or solicitous partner, emphasising fear of harm or catastrophising • Socially punitive responses from spouse (eg ignoring, expressing frustration) • Extent to which family members support any attempt to return to work • Lack of support person to talk to about problems https://www.cebp.nl/media/m24.pdf

  21. Yellow Flags Work • Frequent job changes, stress at work, job dissatisfaction, • Poor relationships with peers or supervisors... • Belief that work is harmful; that it will do damage or be dangerous • Unsupportive or unhappy current work environment https://www.cebp.nl/media/m24.pdf

  22. Yellow Flags Why would psychosocial variables influence pain and disability? • Catastrophising directly influences pain intensity & pain-related disability (Turner, et al (2002) Pain; 98, 127-134) • Psychological or social variables which function as threats, or are experienced as a loss of control, access standard sickness responses resulting in increased inflammation (Brydon, et al (2009)Brain, Behavior & Immunity 23; 217-224) • Inflammatory proteins can have an exacerbatory role in pain (Wieseler-Frank, Maier, Watkins (2005) Neurosignals;14:166–174) • Cycle - Cognitive & emotional responses during the experience of pain shaped pro-inflammatory immune system responses via interleukin-6 (Edwards, et al (2008) Pain; 140, 135-144)

  23. Mayer, et al 2009

  24. Remaining at Work • 20 public health workers at risk for developing chronic pain (taking sick days for pain probs) • 10 TAU vs 10 CBT (4 x 1 hrs ACT) • Dahl, Nilsson & Wilson, Behavior Therapy, 2004

  25. Cohen’s d at follow-up = 1.00

  26. Case 1: TIM 44 y.o. software genius Referred by Rehabilitation Physician In context of escalating workplace pressue, gradual onset of neck, bilat. shoulder and arm (RSI-like) pain Pain began in context of escalating workplace stressors Workplace critical / unsupportive 20 months on WorkCover

  27. Over prior 18 months he had been off work, receiving 1:1 physiotherapy input 1:1 exercise physiologist instruction 1:1 generalist psychology input

  28. Investigations C. Spine MRI Brain MRI L Shoulder MRI Bilat nerve conductions Rheumatological screen Bone scan

  29. Reason for referral: Failure to progress: Tolerances / capacities unchanged Rigid pain focus entrenched

  30. Findings of Team Assessment Nil organic aetiology identified Marked physical deconditioning Exaggerated somatic preoccupation a/writualised safety behaviours High depression and anxiety scores Marked obsessionality Fear avoidance Poor self efficacy Oversolicitous partner Substances - 2 different benzos, 2 OTC analgesics, 2 types anti-inflammatory& EtOH

  31. Recommendations from Team Assessment Reassurance Substance rationalisation Self-help text “Manage Your Pain” 1:1 psychology and physiotherapy – 3 sessions of each over 6 weeks

  32. Progress Liked the book – he understood and felt inspired – but couldn’t progress Psychiatric assessment requested.

  33. Psychiatry assessment • Ritualised safety behaviours – • gyration of shoulder girdles • multiple pillows / braces • Melancholia (EMW, anhedonia, ruminations, low energy, cognitive poor, anorexia) • Controlling / demanding / obsessional • 2 different benzos, 2 OTC analgesics, 2 types anti-inflammatory • 60 g EtoH

  34. What next? • Education re integrated activity of limbic and other brain centres with pain circuitry • Discussion re neuroplastic exacerbatory processes • Discouraged benzos • Offered SNRI - declined • Pregabalin commenced

  35. Case 2 : Somatisation • Long history of complaints • High utilisers of health services • Biomedical focus • Excessive illness behaviour c.f. pathology • Outcome issues - poor prognosis

  36. Is chronic pain associated with somatization/hypochondriasis. • An evidence-based structured review (57 studies) • Somatisation and hypochondriasis were both consistently associated with chronic pain • Study evidence indicated a correlation between pain intensity and presence of somatisation and hypochondriasis • Pain treatment improved somatisation and hypochondriasis Fishbainet al. Pain Pract. 2009 Nov-Dec;9(6):449-67

  37. Case 2 : Pam 62 yo • Referred by Pain Specialist • Multiple morbidities including OA in hips, hands, neck and low back, haemochromatosis, osteoporosis (with compression fractures x2), macular degeneration, chronic constipation, stress incontinence, hypertension. • Slim and frail-looking

  38. - Powerful biomedical focus- Multiple practitioners – 2-3 specialists /12 • Pain specialist • Rheumatologists x2 • Gastroenterologist • Ophthalmologist • Endocrinologist • Dermatologist • Physiotherapist • Yoga teacher

  39. Morphine sulphate SR 20 mg bd “Digesic” Diazepam 2.5 – 5 mg up to qid Aperients Nutritional supplements Procedures / “blocks” every 6-12 weeks

  40. Reason for referral: • Assistance sought with her distress - as demonstrated through her seeking of advice and reassurance via frequent phone calls (2-3 per week)

  41. Background • Younger of two daughters from wealthy family • Sickly child – multiple hospitalisations for asthma • Father was caring but busy • Mother was just busy • Teen years: Sister strong, successful and popular. Pam polite, unassertive, “a worrier”

  42. Lots to worry about : • Three adult offspring – 2 unwell (1 Alcoholic) • 1 son-in-law unwell (Colitis) • Seven grandchildren • Very aging mother • Fit but aging husband ….and of course herself too!

  43. Case 3 : Brian 48 yo Surveyor • Previously fit, very active professional man • Actively involved with church • Perfect family • Perfectionist • MBA 3 years ago • Multiple orthopaedic (and visceral) injuries • 6 weeks in hospital and 5 operations • 8 weeks inpatient rehabilitation

  44. Inpatient treatment • Decompression/fusion L2/3 • ORIF R. tibia/fibula • ORIF R. humerus • ORIF L. radius (distal) • Repair hepatic laceration and bladder/ureter damage

  45. Complaints • Pain distracts him – can’t stop ruminating about pain and the idiot who caused it • Cranky • Impaired workplace function • Exacerbation of (premorbid trait of) relative inflexibility. • Had become intolerant • Always tired • Memory impaired

  46. Reason for Referral • Referred due to persistent pain (and his responses to it) causing disruption to interpersonal and workplace function – fear of losing job.

  47. Assessment findings • Team assessment identified nociceptive and neuropathic drivers, obsessional personality, excess pain focus, all-or-none behaviour • Self damning / catastrophic cognitions • Physical deconditioning

  48. Not happy to take medication, fearing further compromise. • Unable to obtain benefit from 1:1 CBT - Couldn’t focus • Too busy ruminating / distracting • Too sleepy • Neither time nor energy for behavioural tasks

  49. Progress • Brain MRI NAD ; neuropsych testing equivocal for ABI. • Agreed to trial Nortriptilline 10 mg – unable to tolerate – sleep better BUT daytime compromise and exacerbated hesitancy • Not making progress after 6 sessions Clin. Psych plus physio. instruction

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