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Chronic pain patients: Psychos?

Chronic pain patients: Psychos?. Liesbet Goubert , Ph.D . Introduction: Conceptualization of pain. Biological processes. Psychological processes. Social processes. Psychological processes of pain. Biological processes. Psychological processes. Social processes.

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Chronic pain patients: Psychos?

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  1. Chronic pain patients: Psychos? LiesbetGoubert, Ph.D. 24th International Winter Symposium, January 2009, Leuven

  2. Introduction: Conceptualization of pain Biological processes Psychological processes Social processes 24th International Winter Symposium, January 2009, Leuven

  3. Psychological processes of pain Biological processes Psychological processes Social processes 24th International Winter Symposium, January 2009, Leuven

  4. Psychological processes: an overview • Introduction: some important concepts • Fear-avoidance model • Coping with chronic pain: misdirected problem solving • Dual-process model of coping • Conclusions 24th International Winter Symposium, January 2009, Leuven

  5. Natural history of sick leave Based on Spitzer et al. (1987) 80% 26% 17% 13% 8% 6 months 7 days 4 weeks 7 weeks 12 weeks Subacute pain Chronic pain Acute pain 24th International Winter Symposium, January 2009, Leuven

  6. Natural history of low back pain (Von Korff et al., 1992, 1993) % 24th International Winter Symposium, January 2009, Leuven

  7. Tissue Damage Pain Disability (Waddell et al., 1993) 24th International Winter Symposium, January 2009, Leuven

  8. Fear of pain is more disabling than pain itself Gordon Waddell, 1993 24th International Winter Symposium, January 2009, Leuven

  9. Avoidance Hypervigilance Fear-avoidance model Injury Disuse Disability Depression Recovery Confrontation Pain Fear of movement, pain, (re)injury Nofear Catastrophizing Leeuw et al., 2007; Vlaeyen et al., 1995 24th International Winter Symposium, January 2009, Leuven

  10. A lot of evidence, but… • Fear of injury may be only tip of the ice berg • Fear of injury and catastrophizing about pain may be part of misdirected problem solving • Problem definition: injury is cause of all pain problems (low quality of life, distress) • Patients persevere in trying to solve an insoluble problem • Stuck in (problem solving) coping with pain (Eccleston & Crombez, 2007; Van Damme et al., 2008) 24th International Winter Symposium, January 2009, Leuven

  11. “I need to concentrate on getting rid of my pain.” “It’s important to keep fighting this pain” 91% 95% Patient Attitudes from Bath (N=103) Agree 24th International Winter Symposium, January 2009, Leuven

  12. Ageing literature Quality of life increases despite increase in impairments Assimilative coping mode Active coping, solving the problem/situation Accommodative coping mode Passive coping, adjustment of personal preferences/goals to constraints Dual process model (Brandtstädter & Renner, 1990) 24th International Winter Symposium, January 2009, Leuven

  13. Dual Process model + Evaluation of the situation Situation satisfactory? Low corrective tendency - Appraisal ASSIMIL Corrective action + Personal control? ACCOM enhancement - Improvement possible? + - - External support External support & resources? + Disorganization Identity crisis disorientation Accommodative reappraisal restabilization 24th International Winter Symposium, January 2009, Leuven

  14. Dual Process model & Chronic Pain + Evaluation of the situation Situation satisfactory? Low corrective tendency - Appraisal ASSIMIL Bed rest Avoidancebehaviour Medicationmisuse Riskyinterventions Corrective action + Personal control? enhancement - Improvement possible? + - External support External support & resources? + (Eccleston & Crombez, 2007; Van Damme et al., 2008) 24th International Winter Symposium, January 2009, Leuven

  15. Empirical findings:Attempts to control… • …heighten attention to chronic pain (Crombez et al., 2008a) • …at the expense of other goals (Crombez et al., 2008b) • …result in lower quality of life and more distress (De Vlieger et al., 2006) • Catastrophizers persevere in problem solving despite low belief in solution!! →Accepting pain as an insoluble problem leads to decreased hypervigilance and better mental wellbeing (Viane et al., 2002, 2004) 24th International Winter Symposium, January 2009, Leuven

  16. Coping with chronic pain: acceptance of pain and flexible goal adjustment 24th International Winter Symposium, January 2009, Leuven

  17. Patient is active problem solving agent Patients persevere in solving an insoluble problem Coping with pain: mission impossible Perseverance leads to frustration, distress, hypervigilance, disability Conclusion 24th International Winter Symposium, January 2009, Leuven

  18. Social processes of pain Biological processes Psychological processes Social processes 24th International Winter Symposium, January 2009, Leuven

  19. Social-communicative model of pain(adapted from Hadjistavropolous & Craig, 2002) Internal pain experience Intrapersonal and contextual determinants Encoding in expressive behaviour Decoding Action Pain stimulus SENDER PERCEIVER 24th International Winter Symposium, January 2009, Leuven

  20. Pain catastrophizing Social context Social-communicative model of pain(adapted from Hadjistavropolous & Craig, 2002) Internal pain experience Intrapersonal and contextual determinants Encoding in expressive behaviour Decoding Action Pain stimulus SENDER PERCEIVER 24th International Winter Symposium, January 2009, Leuven

  21. Social-communicative model of pain(adapted from Hadjistavropolous & Craig, 2002) Internal pain experience Intrapersonal and contextual determinants Encoding in expressive behaviour Decoding Action Pain stimulus SENDER PERCEIVER 24th International Winter Symposium, January 2009, Leuven

  22. Effects on the perceiver: EMPATHY EMPATHY = “A sense of knowing the personal experience of another person, with cognitive, affective and behavioural components” “mind-reading” (Ickes, 1993) 24th International Winter Symposium, January 2009, Leuven

  23. CONTEXTUAL INFLUENCES (e.g. type of relationship, affinity, attachment patterns,..) TOP-DOWN INFLUENCES - observer’s learning experiences - shared knowledge - observer’s pain catastrophizing SENSE OF KNOWING THE EXPERIENCE OF ANOTHER PERSON IN PAIN AFFECTIVE RESPONSES - Self-oriented - Other-oriented BEHAVIOURAL RESPONSES - providing comfort - reassurance - withdrawal - … BOTTOM-UP INFLUENCES - observed person’s (facial/verbal) pain expressions Empathy in the context of pain Goubert et al., Pain, 2005 24th International Winter Symposium, January 2009, Leuven

  24. Impact of observer and patient characteristics upon observers’ estimations of pain • Pediatric pain: the impact of parental catastrophizing about their children’s pain (Goubert et al., in press) • Method: • 53 school children (mean age=11.74 years; SD=1.73) participated in an experimental pain test (pressure pain; varying levels of pressure applied by means of algometer) • Parents estimated children’s pain • Results: • Parents generally underestimated children’s pain • Tendency toward less parent-child incongruence in pain ratings when child showed more facial pain expressions • Higher parental catastrophizing related to less parent-child incongruence in pain ratings 24th International Winter Symposium, January 2009, Leuven

  25. Impact of observer and patient characteristics upon observers’ estimations of pain • Adult pain: the impact of expertise (Cheng et al., 2007) • Method: • 28 femaleparticipants; 2 groups: • Expert group: 14 physicianswithexperience in acupuncturefor at least 2 years • Matchedcontrolgroup (noexperience) • Observation of dynamicvisual stimuli depicting body parts in bothnon-painful and (potentiallypainful) acupuncturesituations 24th International Winter Symposium, January 2009, Leuven

  26. Impact of observer and patient characteristics upon observers’ estimations of pain • Adult pain: the impact of expertise (Cheng et al., 2007) • Results: 24th International Winter Symposium, January 2009, Leuven

  27. Impact of observer and patient characteristics upon observers’ emotional and behavioural reactions • Pediatric pain: the impact of parental catastrophizing about their children’s pain (Goubert et al., in preparation) • Participants: • Participants: 36 adolescents with chronic pain (mean age=15.74 years; SD=1.82) recruited from the Bath Pain Management Unit, UK, and one of their parents (32 mothers; 4 fathers) • Pain test: • Speeded walking test during assessment before chronic pain programme • Video is shown to one of the parents 24th International Winter Symposium, January 2009, Leuven

  28. Impact of observer and patient characteristics upon observers’ emotional and behavioural reactions CONTEXTUAL INFLUENCES (e.g. type of relationship, affinity, attachment patterns,..) TOP-DOWN INFLUENCES Parental catastrophizing about their child’s pain (state version of PCS-P; Goubert et al., 2006) SENSE OF KNOWING THE EXPERIENCE OF ANOTHER PERSON IN PAIN PARENTS’ DISTRESS RESPONSES (Adjectives; NRS 0-10) BEHAVIOURAL RESPONSES: Tendency to stop the child • BOTTOM-UP INFLUENCES • - Child’s facial pain expression • Child’s verbalization of pain • Child’s protective pain behaviour 24th International Winter Symposium, January 2009, Leuven

  29. Impact of observer and patient characteristics upon observers’ emotional and behavioural reactions • Adult (non-specific low back) pain: the impact of health care providers’ biomedical versus biopsychosocial orientation upon treatment recommendations (Bishop et al., 2008) • Method: • 2000 general practitioners and 2000 physiotherapists answered questionaires measuring biomedical versus biopsychosocial orientation and treatment recommendation for patient described in vignette • Results: • Higher biomedical and lower biopsychosocial orientation associated with advice to remain off work. 24th International Winter Symposium, January 2009, Leuven

  30. Social-communicative model of pain(adapted from Hadjistavropolous & Craig, 2002) Internal pain experience Intrapersonal and contextual determinants Encoding in expressive behaviour Decoding Action Pain stimulus SENDER PERCEIVER 24th International Winter Symposium, January 2009, Leuven

  31. Impact of observers’ responses upon patient • Health care providers’ recommendations to rest and stay off work in case of non-specific low back pain are likely to result in prolonged disability (Bishop et al., 2008) • Parental catastrophizing about their children’s pain is related to higher disability and less school attendance in children with chronic musculoskeletal pain (Goubert et al., 2006) • Some helping or treatment behaviours which are generally considered as helpful may in fact have deleterious or mixed effects: e.g. reassurance (McMurtry et al., 2006; Linton et al., 2008) 24th International Winter Symposium, January 2009, Leuven

  32. CONCLUSION: ARE CHRONIC PAIN PATIENTS PSYCHOS? NO! 24th International Winter Symposium, January 2009, Leuven

  33. CONCLUSIONS: • A combination of biological, psychological, and social factors contribute to the pain experience and disability of a particular patient • This means that, in general, prolonged pain problems cannot be attributed to a patient’s (deviant) personality structure!! • Interventions for chronic pain patients should therefore always be multidisciplinary, targeting the particular biological, psychological and social processes that contribute to a patient’s pain problems 24th International Winter Symposium, January 2009, Leuven

  34. Thank you! Liesbet.Goubert@Ugent.Be 24th International Winter Symposium, January 2009, Leuven

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