Cognitive and Behavioral Pain Management

1. Cognitive and Behavioral Pain Management Judith B. Chapman, Ph.D., ABPP Behavioral Medicine Program

2. Traditional disease model of pain Psychological and social factors viewed as reactions to disease and trauma View of pain conditions as either organic or psychogenic in etiology

3. How to explain… • For up to 80% of persons complaining of low back pain, no physical basis can be identified (Deyo, 1986) • Expression of pain symptoms, related psychological distress, and extent of disability are at best only moderately correlated with observable pathophysiology (Waddell & Main, 1984).

4. Biopsychosocial Model • Biological factors – initiate, maintain, modulate physical changes • Psychological factors – influence appraisal, perception of internal physical signs • Social factors –shape the behavioral responses of patients to the perception of physical changes

5. Which psychological factors influence pain? • Cognitive (Pain Beliefs, Cognitive Errors, Self Efficacy, Coping) • Affective • Personality

6. Pain Beliefs Anxiety Sensitivity Some patients may be hypersensitive and experience a lower threshold for labeling stimuli as noxious (Asmundson, Bonin, Fromback, & Norton, 2000) Learned Expectation About 83% of patients with LBP were unable to complete a movement sequence because of anticipated pain, 5% unable because of lack of ability (Council, Ahern, Follick, & Cline, 1988).

7. Pain Beliefs Patients’ beliefs about pain or disability are better predictors of ultimate level of disability than are physician ratings of disease severity

8. Self Efficacy - a personal conviction that one can complete a course of action to produce a desired outcome Low self efficacy ratings of pain control are related to low pain tolerance (Dolce, Crocker, Moletteire, & Doleys, 1986)

9. The Efficacious Person… • Experiences less anxiety and physiological arousal when experiencing pain • Is better able to use distraction • Can persist in the face of noxious stimuli (stoicism)

10. Cognitive Errors a negatively distorted belief about oneself or one’s situation Examples: Catastrophizing, overgeneralization, selective abstraction

11. Consequences of catastrophizing Among postsurgical patients, those with a greater frequency of catastrophizing thoughts had a greater number of pain complaints and required significantly more pain medications (Butler, et al., 1989).

12. Coping Style • Active coping (distraction, reinterpreting sensations, stoicism) is associated with greater activity and better mood • Passive coping (wishful thinking, relying on others) is correlated with greater perceived pain and depression

13. Affective Factors • 40-50% of chronic pain patients experience depression • About half report feelings of anger, irritability • Both are associated with perception of increased pain severity, greater pain interference, lower activity level

14. How do personality disorders fit in? • No specific personality disorder is associated with poorer coping with pain • However, the presence of any personality disorder predicts less adaptive coping

15. Palo Alto Pain Clinic Demographics • Average age 56 years (range 20-87) • 88% male • 87% Caucasian (6% African American, Hispanic; >1% Asian, Native American) • 61% Predominantly Musculoskeletal Pain (30% neuropathic, 3% visceral, 7% other)

16. Palo Alto Pain Clinic Data • 75% depressed • 33% report active suicidal thoughts • 48% report a history of trauma • 19% meet criteria for PTSD

17. Pain Clinic Follow-up Data At two and six month follow-up, patients reported a significant decrease in pain severity and a significant decrease in pain interference Changes seen across diagnostic and demographic groups (age, type of pain, presence of significant mental disorder) No significant overall change in mood, sleep, or activity level

18. Older patients • Reported significantly less pain severity than young • Less pain interference • Better overall sleep • Less depression

19. Aging and Pain • Changes in visceral sensations with age • Increased prevalence of post-herpetic neuralgias • Nonlinear relationship between joint pain and age

20. Cognitive-behavioral Treatment • Enhancing motivation • Relaxation exercises • Education about Sleep Management • Hypnosis and Imagery • Cognitive Therapy • Family Interventions

21. Principles of Motivational Enhancement Therapy • Expressing empathy • Developing discrepancy • Avoiding arguments • Rolling with resistance • Supporting self efficacy

22. Relaxation Strategies • Progressive muscle relaxation • Deep (diaphragmatic) breathing • Biofeedback • Autogenic training

23. Caveats and contraindications • Psychotic patients • Relaxation-induced anxiety • Panic attacks

24. Hypnosis • A state of highly focused attention in which there is an alteration of sensations, awareness, and perceptions • Reduces pain through attention control and distraction

25. Essential Components of Hypnosis • Physical relaxation • Deepening exercise • Pleasant imagery • Suggestion • Post-hypnotic suggestion • Gradual return to alertness

26. Sleep and Pain • Pain severity and opioid use does not predict sleep problems; depression does • Sleep medications seem to have no impact on depression or pain severity • Sleep med use was highly correlated with poorer sleep quality, poorer sleep duration, and poorer sleep efficiency (Chapman, Lehman, Elliott, and Clark, In Press).

27. Sleep Management Guidelines • Go to bed when sleepy • Do not remain in bed if not sleeping • Bed as cue for sleep • Have regular wake-up time • Avoid evening use of ETOH, caffeine,smoking • Exercise in AM, rather than at night • Arrange relaxing nighttime routine

28. Cognitive Therapy • Identify and monitor pain-relevant cognitions • Notice emotional consequences of negative cognitions • Learn how to challenge maladaptive cognitions or consider probability bad events may occur • Assertiveness training • Value of self reinforcement

29. Goals of Family interventions • Recognition of operant principles as they relate to pain behaviors • Altering patterns of pain-relevant communication • Increase time spent in non-pain related conversation • Increase frequency of pleasurable family activities • Recognition/treatment of depression in other family members

30. Who doesn’t benefit from CBT for pain? • Cognitively disorganized • Patients with little- no motivation to use strategies • Severe anxiety or depressive disorder • Active substance abusers

31. Pain may be inevitable, but misery is optional Greatest Limitation of CBT for Pain • Compliance with successful strategies decreases over time - No benefit when not practicing Best Recommendation Relapse Prevention should be part of the therapy Encourage booster sessions 6-12 months after therapy ends