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A few vignettes

A few vignettes. The Great Conundrum. Understanding theoretical basis of disease vs Explaining the phenomenon of actually having it. Faith & Hope. Hope = expectation of something desired Faith = belief in things we cannot know as fact Both are beyond the realm of fact and yet...

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A few vignettes

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  1. A few vignettes

  2. The Great Conundrum • Understanding theoretical basis of disease vs • Explaining the phenomenon of actually having it

  3. Faith & Hope • Hope = expectation of something desired • Faith = belief in things we cannot know as fact • Both are beyond the realm of fact and yet... we function day to day on basis of both.

  4. Triangle of Life Hopelessness, Demoralisation, Pessimism False hope, Foolish hope, Denial of reality Genuine hope, Realistic hopefulness, Optimism

  5. Core beliefs • Control vs helplessness • Loveability vs fear of rejection • Achievement vs fear of failure

  6. Illness Behaviour, Normal & Abnormal • The sick role • Pillowsky • ‘When patient & physician disagree’

  7. Health Anxiety • Previous illness experience • Dysfunctional assumptions • Critical incident • Activation of dysfunctional assumptions • NAT’s • Health concerns causing anxiety • Behavioural - avoidance • Affective – anxiety, anger, depression • Cognitive – helplessness, preoccupation • Physiological – sleep disturbance, hyperarousal

  8. Anger • Anger-in : suppression of feelings • Anger-out : aggressive behavioural expression • Passive-aggressive: covert behavioural • Procrastination • Noncommunication • Disengagement

  9. C.B.T. • NAT’s & PET’s • pacing

  10. Adjustment to Pain • Cognitive • Negative : catastrophising • Positive : self-efficacy, readiness to change, acceptance • Affective • Negative : depressed mood, anxiety • Positive : stable • Behavioural • Negative : fear avoidance, insomnia • Positive : active coping

  11. Is this ‘Depression’? • or dysphoria • or dysthymia • or demoralisation • or bipolar disorder • or S.A.D

  12. Personality Disorders • MAD (Cluster A) • Paranoid; Shizoid; Schizotypal • BAD (Cluster B) • Antisocial; Borderline; Histrionic; Narcissistic • SAD (Cluster C) • Avoidant; Dependent; Obsessive-Compulsive

  13. Just you, a trait or a disorder? • Persistence • Impairment • Distress

  14. Containment • Harm reduction

  15. History • ‘the difficult questions’ • hearing the unspoken dialogue • reading the body language

  16. Physical Examination • real or unreal signs? • knowing your signs/patterns • challenging the evidence • ‘pain out of proportion to physical evidence’ • putting the ‘bio’ back into BPS

  17. Headache • History to diagnose • Examination to exclude ‘red flags’ • No role for opioids

  18. Diversion • Death • prescription drug OD > ... • MVA & suicide • Oxycodone

  19. Elderly • ‘Forgotten majority’ • Pain as a part of aging (?) • Pain & frailty

  20. Placebo Effect • Change in illness attributable to symbolic import of treatment; therefore a placebo simulates therapy • Factors • Expectation, conditioning • Other issues • Natural history, regression to the mean • Strategies to utilise • Placebo run-in, open-hidden paradigm

  21. ‘Fibro’ • Total body pain and misery • No unambiguous evidence • Need for a name • Same family as TTH, CFS, MCS, IBS, TMJD

  22. Cancer Pain • Total pain Dame Cecily Saunders

  23. Needles • ESI • MBB • RF • SIJ • CLS • SGB • PNB

  24. Neuromatrix • Brain processes provide basis for ‘self’ • integrated • unique = neurosignature • Inputs from body modulate outputs

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