Behavioral Medicine Approaches to Chronic Pain

1. Behavioral Medicine Approaches to Chronic Pain STOP PAIN McGrady 2012

2. Chronic Pain • - “a demoralizing situation that confronts the individual sufferer not only with the stress created by the pain, but with many other ongoing stressors that compromise all aspects of his or her life.” Gatchel & Turk (1996). Psychological Approaches to Pain Management; page 3. McGrady 2012

3. Disease vs. Illness in Chronic Pain • Disease – disruption of normal function, confirmed by anatomical, physiological or biochemical changes. • Illness – subjective experience of being sick, only loosely related to pathophysiology. McGrady 2012

4. Additives to the pain itself • Psychological suffering, sleep disorders • Anxiety and depression (Arnow et al., 2006; Roy-Byrne, Davidson, Kessler, Gordon, Asmundson, Goodwin, et al., 2008). McGrady 2012

5. Models of Chronic Pain • Biomedical • Most appropriate for acute pain. • Focuses on physical disease • Relies on medical management • Biopsychosocial • Nocioception pain experience. • Perceptions of illness and illness behavior are more important than biology. McGrady 2012

6. Transformation of Acute Pain to Chronic Pain • Strong reinforcement of pain behaviors • Weak reinforcement of well behaviors McGrady 2012

7. What Whiplash? McGrady 2012

8. Study of Pain in Demolition Derby Drivers and Other Drivers • Few derby drivers developed chronic neck pain • Higher percent of ordinary drivers develop whiplash after one accident McGrady 2012

9. The Vicious Pain Cycle Injury Pain Decreased Pain tolerance Increased attention to pain Rest Analgesic use Isolation Depression De-conditioning McGrady 2012

10. Psychological Factors Influencing the Pain Experience • Learning • Operant conditioning • Social - copying others’ behaviors • Cognitive • Attention • Beliefs • Errors McGrady 2012

11. Psychodynamic Factors • Pain lets one receive care • Pain is a punishment for being bad • Pain intensifies due to past (actual) experience McGrady 2012

12. Perceptions and Pain Tolerance • High tolerance: • pain is a controllable challenge • action can help manage pain Low tolerance • pain is an ordeal that can’t be controlled • action orientation is low McGrady 2012

13. Maintenance Factors in Chronic Pain • Secondary gain • Overuse of medication • Poor coping • Depression, anxiety, anger McGrady 2012

14. Personality and Pain • Neuroticism (anxious, depressed, hostile, high arousal, emotionality). • May mediate physiological responses to nocioceptive stimuli. • Higher scores on neuroticism scales correlated with greater pain sensitivity (Charles, Gatz, Kato, & Pedersen, 2008). McGrady 2012

15. Personality, Fear and Painthe Fear Avoidance Model • Anxious fear affects the experience of pain and the patient’s decisions when experiencing pain. (Vlaeyen & Linton, 2000). Patients tend to catastrophize even small problems. • Imagining negative consequences of activity, increases the likelihood that moving the body will be avoided or that actions will be stiff and guarded. Those with higher anxiety expect more pain and stop movement sooner than they are actually physically capable of doing (Strigo, Simmons, Mathews, Craig, & Paulus, 2008). McGrady 2012

16. Evaluation of the Chronic Pain Patient by the Behavioral Medicine Provider • Detailed history (past experience with pain) • Assessment (diagnostic evaluation for emotional illness) DSM-IV • Psychological testing (BDI-II, BAI), (MBHI, MMPI) • Family interview • Daily pain log McGrady 2012

17. Common Diagnoses in Chronic Pain Patients • Dysthymia • Major Depressive Disorder • Generalized Anxiety Disorder • Somatoform Pain Disorder McGrady 2012

18. Medical versus Self Management of Chronic Pain • Medical management: • Responsibility placed on provider. • Emphasis on procedures and medicine • Most effective with acute injuries McGrady 2012

19. Self-Management Goals • Divert attention away from pain. • Improve overall physical condition. • Modulate schedule of daily activities. • Foster positive emotions • Use complementary therapies • Have a plan for flare-ups McGrady 2012

20. Behavioral Medicine Treatment Approaches • Biofeedback and relaxation • Guided imagery • Hypnosis • Psychotherapy • Self management • Motivational interviewing McGrady 2012

21. Rationale for Treatment • Repeated practice makes the relaxation response more automatic • Imagery of pleasant scenes gives the mind a break from focusing on pain • Hypnosis facilitates numbing or re-locating the pain • CBT retrains maladaptive thinking McGrady 2012

22. Motivational Enhancement • Enhance motivation: reasons why client wants to control pain • Strengthen commitment to change: explore options for change • Follow through strategies: reinforce positive changes and self efficacy. McGrady 2012

23. Emotional Factors • Maintain relative emotional stability by avoiding excess or inappropiate anger depression,fear and anxiety. • Managing tension through rest breaks and time out relaxation ecxercises. • Positive emotions such a love and compassion joy humor and laughter, and optimism. McGrady 2012

24. Mental Factors • Distraction away from pain • Increased involvement and interest in life activities and social interaction. • Positive attitude toward oneself, other people and the future. McGrady 2012

25. Cognitive Behavioral Treatment in Chronic Pain • Individuals are active processors of information. • Thoughts can elicit or modulate affect and physiology; conversely, affect and physiology and behavior can instigate or influence thoughts. • Behavior is reciprocally determined by the person and the environment. McGrady 2012

26. Actions • Maintaining physical activity. • Balance work, recreational, social activities. • Regular physical exercise, healthy eating patterns • Avoid unhealthy habits McGrady 2012

27. Detailed Plan for Flare-ups of Pain 1. Do my back stretches 2. Regain control: “I can deal with this” 3. Use relaxation technique 4. Take extra dose of pain medicine 5. Watch a funny video 6. Call a friend 7. Ask spouse to massage my back McGrady 2012

28. Functional Behavioral Analysis Systematic analysis of overt behaviors and their controlled antecedent (discriminative) and consequent (reinforcing or punishing) stimulus conditions McGrady 2012

29. Headache • One year prevalence of episodic headache is about 38% • Chronic TTH, at least 15 days per month of pain, is 2-3%. • Migraine headache is diagnosed in 12-14% of the US population. McGrady 2012

30. Pain and Sleep (details in sleep section) • Fewer hours of restorative, deep sleep, fatigue and low energy when awake. • Sleep deprivation increases pain sensitivity (Roehrs, Hyde, Blaisdell, Greenwalk, & Roth, 2006). • Multiple awakenings increase spontaneous pain and decrease the ability to inhibit pain signals, potentially through impaired pain inhibitory pathways (Smith, Edwards, McCann, & Haythornthwaite, 2007). McGrady 2012

31. Migraine • Unilateral, throbbing pain located in the temporal or frontotemporal areas. • Onset (prodrome), pain phase and postdrome symptoms: GI, autonomic, and sensory disturbances. • Aura (visual distortions, zigzag lines, holes in the visual field (scotoma), tingling of the skin, hemiparesis (one sided transient paralysis) ) may precede pain (Headache Classification Committee, 1988). McGrady 2012

32. Tension-Type Headaches • Bilateral, located across the forehead, along the back of the head and neck, not pulsatingalthough the pain may be as severe as that of migraine (Headache Classification Committee, 1988). • TTH may initially occur several times a week for a few hours, but over time, the episodic tension headache pattern can convert to the chronic form (Chen, 2009; Vanderheede & Schoenen, 2002). McGrady 2012

33. Chronic Tension-Type Headache • Exaggerated chronic pericranial muscle tenderness during palpation. • Tenderness could be due to abnormal central pain modulation (Neufeld, Holroyd, & Lipchik, 2000). • Over time, central sensitization and hyperalgesia develop (Bezov, Ashina, Jensen & Bendtsen, 2011); these changes may result from frequent overactivation of stress responses coupled with weak coping resources (Lee, Zambreanu, Menon, & Tracey, 2008). McGrady 2012

34. Case of Melinda • Melinda (Mandy) was a 19 year old female with migraine since age 12 and chronic daily headaches for the past three years. The daily pain was described as varying in intensity, all over her head, with no nausea or other gastrointestinal symptoms. The migraines occurred monthly at the time of her period. McGrady 2012

35. Mandy • As a child, she chewed her nails relentlessly and pulled on her hair. At the time of evaluation, Mandy lived with her mother and father. Dad had coronary artery disease and had suffered two prior heart attacks, one of which occurred in Mandy’s presence when she was 10 years old. • Trials of the Triptan family of drugs produced no benefit. Zoloft™ had a temporary positive effect, but Mandy was subsequently weaned off of this medicine because of the side effects of tingling in the extremities. • Significant worries about her parents. Often, she could not get the thoughts out of her mind, picturing her Dad crumpling to the floor with a heart attack or her Mom crashing her car on her way to work. McGrady 2012

36. Mandy • Mandy was in her first year at a division II college and walked on to the basketball team. She was intelligent, and did extremely well in school. She had made friends in college, particularly other women on the team. The anxiety permeated all activities. McGrady 2012

37. Mandy At the team meals, Mandy was too nervous to eat, as the conversation turned to the next practice or upcoming games. She was concerned about the headaches interfering with her goals of playing and graduating. Sometimes, during competition, Mandy became extremely angry and frustrated with her teammates’ mistakes or her own and these anger episodes caused the coach to bench her. McGrady 2012

38. Conceptualization of the Case • Genetic predisposition intersected with environmental stressors, and an anxious personality type. • Psychophysiological over activation: temp 75 degrees; high sEMG • Mandy was motivated to “get on with life” and she was a cooperative patient. McGrady 2012

39. Personal Response to Stress-Pain Stress is a result of an imbalance between demand and capability. Pain is a type of stressor that causes emotional, mental and body responses It is helpful to identify all the ways that you typically react to stress in order to better manage your reactions. The treatment that we will provide can assist you in learning several relaxation techniques matched to your stress response. These skills will help you manage your pain and the anxiety related to your pain. List the ways in which you generally respond to stressful situations. McGrady 2012

40. Intervention • Breathing exercise • Mindful eating • Direct the conversation to other topics • See the food as self care McGrady 2012

41. Intervention • Progressive relaxation • Use PR before practice and games. • After four weeks, 25% decrease in pain was reported; monthly migraine continued. McGrady 2012

42. Intervention • 20 sessions of biofeedback, relaxation therapy, and cognitive behavioral therapy (CBT). • CBT : thought stopping when catastrophic thinking occurred. • Three months results: daily headaches were decreased by 50% and the negative thinking and worry about her parents was significantly decreased. The monthly migraine continued McGrady 2012

43. Intervention • Perceived need to maintain a “game face” on and off the court. • During training, sEMG decreased significantly. • Technique applied to game breaks. McGrady 2012

44. Intervention • Thermal biofeedback training with warmth imagery resulted in hands at 90 degrees • One year: 75% reduction in daily headaches • Migraine frequency decreased to one every 3-4 months. • 50% decrease in anxious rumination McGrady 2012

45. Research Evidence • Meta-analysis of biofeedback (Nestoriuc Martin, Rief and Andrasik, 2008). Medium to large effect sizes for frequency for adult migraine and TTH; stable for 14 months. • Anxiety, perceived self-efficacy, depression and consumption of medicine were also improved. McGrady 2012

46. Research Evidence (cont.) • Parafunctional activities are non-functional movements of the jaw and mastication muscles; tightening of the jaw muscles and simple tooth contact increases tension and HA severity. • Mandy became aware of her almost constant “game face,” and relaxed her jaw, a substitute for the unwanted behavior (habit reversal) (Glaros, 2008). McGrady 2012

47. Cognitive Factors • Attention increases and distraction decreases brain activation related to pain (Villemure & Bushnell, 2002). • In low back pain patients, higher levels of “anger in” and “anger out” are correlated with greater sensitivity to acute and chronic pain stimuli. (“Anger in” refers to suppressed or internalized anger and “anger out” refers to expressed anger). McGrady 2012

48. Additional Factors Anger results from the experience of being hurt, similarly to the person’s reactions to intended harm by another person (Bruehl, Burns, Chung, & Quartana, 2008). Anger increases pain sensitivity. Anticipation enhances pain, whether the pain is expected or when pain is not explainable by any physiological insult (Bensten, Rustoen, Wahl, & Miaskowski, 2008). McGrady 2012

49. The Case of Max, 55 yrs old Married, on leave from work Severe pain Two surgeries; first did not decrease pain; second was “successful” History of anxiety Current panic attacks Good support from wife and employer McGrady 2012

50. Bereavement – Normal Grief • Bereavement is a normal reaction to loss of a person or other loss • Most resolve with support and positive coping • Person learns to accept the new reality McGrady 2012