1 / 30

It’s Not In Your Head— Or Is It?

It’s Not In Your Head— Or Is It?. Howard P. Levy, M.D., Ph.D. Assistant Professor, Johns Hopkins University August 10-11, 2012 Ehlers Danlos National Foundation 2012 National Learning Conference Cincinnati, OH. Disclosures. No financial disclosures or conflicts of interest.

kemal
Download Presentation

It’s Not In Your Head— Or Is It?

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. It’s Not In Your Head—Or Is It? Howard P. Levy, M.D., Ph.D. Assistant Professor, Johns Hopkins University August 10-11, 2012 Ehlers Danlos National Foundation 2012 National Learning Conference Cincinnati, OH

  2. Disclosures No financial disclosures or conflicts of interest

  3. Learning Objectives • Describe psychological factors that may exacerbate pain in patients with EDS • Discuss the role of psychological approaches in the management of pain

  4. It’s Not In Your Head • Dislocations/Subluxations • Acute & chronic muscle spasm • Neuropathic pain • Degenerative arthritis • and others…

  5. Yes It Is • Pain is a subjective experience • Mood and attitude • Goals and expectations • Fears • Avoidance, disability, isolation • and others…

  6. “And that helps me how?” • Avoid psychologic pain escalation • Learn psychologic pain control • Less pain • Less medication • Fewer side effects

  7. Pain Experience Modifiers • Emotional state • Thoughts • Beliefs • Intentions • Injuries to social relationships • Memories of past injuries • Emotional state of close others Kozlowska et al (2008) Harv Rev Psychiatry 16:136

  8. In Other Words… Psychological distress exacerbates pain Baeza-Velasco et al (2011) Rheumatol Int. 31:1131; Branson et al (2011) Harv Rev Psychiatry 19:259 • Recall a very happy time • Minimal impact of dislocation/subluxation? • Recall a very bad/sad time • Effect of minimal trauma/injury?

  9. Emotional State Common in EDS: • Anxiety & Depression • Low self-confidence • Negative thinking • Hopeless/helpless • Desperation • Low self-efficacy Baeza-Velasco et al (2011) Rheumatol Int. 31:1131; Branson et al (2011) Harv Rev Psychiatry 19:259; Castori et al(2010) Am J Med Genet A. 152A:556; Hagberg et al (2004) OrthodCraniofac Res. 7:178; Rombaut et al (2011) Arthritis Rheum. 63:1979

  10. Thoughts & Beliefs • “Pain will harm me” • Intense self-awareness/hypervigilance • “Waiting for the next shoe to drop” • Amplifies pain experience • Similar to cancer survivors? • Assumption of normal vs. assumption of abnormal Baeza-Velasco et al (2011) Rheumatol Int. 31:1131

  11. Expectation Management(Intentions) • Missing a high bar • Exceeding a low bar • Effect on mood? On pain experience? HIGH BAR ACTUAL EXPERIENCE LOW BAR

  12. Expectation Management High Bar • No pain • No dislocations or subluxations • “Normal” activity tolerance Low Bar • Less pain • Fewer dislocation or subluxations • Improved activity tolerance

  13. Injuries to Social Relationships • Disbelief by friends/relatives • Reduced ability to socialize • Resentment, distrust, hostility between patient/family and health care team • Marginalization, isolation, despair… Baeza-Velasco et al (2011) Rheumatol Int. 31:1131; Branson et al (2011) Harv Rev Psychiatry 19:259

  14. Memories of past injuries • Fear of pain and/or joint instability • Anticipation of negative experience • Avoidance behavior • Exacerbates dysfunction and disability Baeza-Velasco et al (2011) Rheumatol Int. 31:1131; Branson et al (2011) Harv Rev Psychiatry 19:259

  15. Emotional State of Close Others • Fear • Disbelief • Anger • Distrust • Anxiety, depression, etc… • Partners, Parents, Sibs, Children, Extended Family, Friends, Providers…

  16. How/Why? • Probably not completely understood • Pain & emotion co-localize in brain • Endorphins • Induced by emotion & exercise • Modulate pain • “Natural opioids” • Centrally acting meds • Opioids, sedatives, antidepressants

  17. Complicating Factors • PTSD • Resistance to accepting psych etiology • Response to prior misdiagnoses & accusations • “It’s not in my head—it’s real” • Stigma, perceived weakness, “crazy”

  18. Therapy Build/repair relationship with healthcare providers. • Clinician must believe pain and other symptoms are real (validate) • Patient must believe that there are psych components in pain experience and management strategy (trust)

  19. Therapy • Focus on chronic rather than acute pain management • Establish reasonable expectations (exceed a low bar) • Distraction • Hypnosis • Meditation… Branson et al (2011) Harv Rev Psychiatry 19:259

  20. Counseling • For depression, anxiety, PTSD… • For accepting, coping & living with pain, dysfunction & disability • Consider thoughts/feelings of close others • Separate counseling • Group counseling • Work on patient’s response to them. • Requires patient acceptance/willingness

  21. Cognitive Behavioral Therapy • Pain is influenced by cognition, affect and behavior • Goal: manage pain & reduce negative consequences • Focus on thoughts/beliefs re: pain & associated behaviors and avoidances • Can improve pain, disability & mood • Requires active patient participation Baeza-Velasco et al (2011) Rheumatol Int. 31:1131; Eccleston et al (2009) Cochrane Database Syst Rev. 2:CD007407

  22. Unhelpful Thoughts • “Pain means damage; if doing something hurts I should avoid it” • “…it’s hopeless, I should just accept that I’ll end up in a wheelchair” • “I’ve got wear and tear, better not use my joints or they’ll wear out even quicker” • “I need to rest more, if you feel tired it means you’ve been doing too much” • “My pain is a sign of whether I am better, I won’t be better until my pain has gone” Baeza-Velasco et al (2011) Rheumatol Int. 31:1131

  23. Cognitive Behavioral Therapy • Education (and insight) • Self-efficacy, locus of control • Recover function; overcome fears • Distraction • Relaxation (breathing exercises, muscle relaxation, guided imagery) • Biofeedback • Reward positive behaviors Baeza-Velasco et al (2011) Rheumatol Int. 31:1131; Eccleston et al (2009) Cochrane Database Syst Rev. 2:CD007407

  24. Counseling • Work towards positive thinking • Assumption of normal • Control fear • Self-efficacy

  25. Antidepressant Medication • Reduce anxiety & depression • Lessens subjective pain experience • Directly treat pain • Especially neuropathic • Some improve restorative sleep • Less pain

  26. Example Branson et al (2011) Harv Rev Psychiatry 19:259 • Adolescent with EDS & recurrent joint pain • Poorly controlled episodesprogressive escalation in pain and decline in function • Meds didn’t help w/pain, but caused many SE • Hostile relationship w/healthcare teams--abandoned, disengaged, blame (both directions)

  27. Example Problems: • Fear of impending subluxation much more common than actual dislocation • Anxiety, anger & hopelessness • Pain behaviors out of proportion to actual pain • Always rated severity 10/10 • Passivity • Prior care focused on acute rather than chronic pain management

  28. Example Solutions: • Physical rehabilitation & bracing • Education to self-manage non-acute pain • Predictable daily schedule & expectations • Minimize meds, use predictable schedule • Distraction • Avoid directly asking about or discussing pain • Repair medical relationships • Avoid ER/acute pain models • Eventual engagement in counseling

  29. Mind Over Matter • Unchecked psychological distress can amplify pain • A disciplined mind can reduce pain

  30. Summary “90% of the game is half mental”-Yogi Berra

More Related