Psychological assessment and management of chronic pain

1. Psychological assessment and management of chronic pain Frank McDonald Consultation-Liaison Psychologist The Townsville Hospital May 2002 www.fmcdonald.com

2. Overview 1. Common presenting problems 2. Role of psychologist in management of chronic pain 3. Phases of psychological intervention. Broad assessment methods and issues 4. Models of pain etiology and maintenance 5. Specific behavioural and cognitive-behavioural management approaches

3. Common conditions • Chronic pain – defined as pain lasting > 3 months after normal healing phase passes – Lifetime prevalence estimated >30% of the general population • Common problems • Chronic low back pain • Cervical injury • Fibromyalgia • Myofascial pain • Arthritis

4. Psychologist’s role • General aim is not to eliminate pain • Rather to: • reduce its frequency and severity and its personal and social impact with a variety of psycho-educational methods embedded in a good therapeutic relationship • help the person lead as close to normal a life as possible. Often need to help change view of pain and suffering from overwhelming to manageable

5. Psychologist’s role • Two main pillars: physical conditioning (building stamina) to raise paced activity levels and psychological training

6. Psychologist’s role (cont’d) • Liase with and refer to other treating professionals e.g. GP, Psychiatrist, Physiotherapist, Rehabilitation specialist

7. Intervention phases 1. Initial assessment 2. Reconceptualising pt’s view of pain/education phase 3. Skills acquisition and consolidation including goal setting and cognitive and behavioural rehearsal, generalisation 4. Follow-up

8. Psychological assessment methods and issues • Clinical interviews e.g. to rule out Somatoform Disorders. See following slides on DSM-IV considerations • Routine screening instruments e.g. The Multi-Axial Pain Inventory, BDI, DASS • Pain, activity and exercise diaries • Collateral from significant others • Behavioural tests (e.g. 4 minute walk test) • See www.fmcdonald.com for further discussion (e.g. co-authored book chapter) and examples (e.g. diaries and interview protocols)

9. DSM-IV Somatoform Disorders • Conditions in which identifiable physical pathology is absent and psychological factors are judged as important contributors to pain • Rule these out before applying standard treatments because of their special management requirements

10. DSM-IV Somatoform Disorders (Cont’d) • Somatisation Disorder • Conversion Disorder • Hypochondriasis • Pain Disorder • With Psychological Factors • With Both Psychological Factors and a General Medical Condition • Undifferentiated Somatoform Disorder • Somatoform Disorder Not Otherwise Specified

11. Etiology and maintenance models of the psychophysiology of pain • Linear interactive models • Gate-control theory • Cognitive-behavioural model

12. Circular model of pain problems • Pain can increase tension which in turn adds to pain. Other, more complex, linear models that guide therapeutic targeting abound in the literature Pain Tension

13. Gate-Control Theory • This proposes hypothetical gates which can open to allow pain messages through to the brain, or to shut and stop someor all of the messages. A gate is opened by factors such as attention to pain or distress, and closed by factors such as counterstimulation.A TENS (transcutaneous electrical nerve stimulation) machine provides counterstimulation

14. Cognitive-behavioural and behavioural models • Variables • Independent • Somatic events: pathophysiology • Personality: premorbid coping skills • Environment: socio-economic consequences • Time since pain began: maladaptive behaviour may have set in or pt may have learned to adapt

15. Intervening • Cognitions (attitudes, beliefs, images, expectations, thoughts, fantasies, reasoning) • Affect (depression, anxiety, anger,frustration, guilt, acceptance)

16. Dependent • Nociception (sensory experience) • Pain behaviour (see examples following) • Chronic pain See www.fmcdonald.com for fuller description of both models

17. Pain behaviour • Medication • Activity • Rest • Verbalisation • Guarding • Crying • Relaxation • Withdrawal • Aggression • Alcohol/drugs • Hot/cold packs All can be positive or negative depending on the frequency

18. Pain management strategies • Slow, deep (diaphragmatic) regular breathing • Progressive relaxation • Brief (“cue”) relaxation induction • Peaceful imagery • Self-hypnosis • Meditation • External focusing (stimuli outside body, engage in activity)

19. Pain management strategies • Mental distraction (thoughts, memories, music, mathematics . . .) • Reappraisal of pain (transforming pain, denial, relocating thoughts to non-pain site etc) • Self-talk (e.g. decatastrophising) • Persistence or non-avoidance • Activity pacing • Emotion defusing/problem solving strategies

20. Pain management strategies • Increasing movement – walking, swimming, physio exercises • Direct statement of needs/assertiveness • Clock-based vs p.r.n. medication scheduling • Coaching significant others to reinforce positive pain behaviour and ignore negative • Increasing either mastery or pleasure activities to at least one per day ~