Psychological Assessment and Treatment of Pain

1. Psychological Assessment and Treatment of Pain Matthew Bailly, Ph.D., C.Psych. Department of Clinical Health Psychology University of Manitoba School of Medicine

2. Acute Pain • Characterized by intense, temporary noxious sensations and is related to tissue damage • For patients that do not experience adequate analgesia, can lead to chronic pain • Important to provide effective pharmacological analgesia as soon as possible during, or even before, an acute pain episode

3. Acute Pain • Pain can be accompanied by anxiety, stress, and physical tension, which can exacerbate and/or prolong the acute pain episode • These additional factors should also be addressed as soon as possible • A number of psychological strategies can be used to help patients cope with these, as well as thoughts and emotions that may increase physiological arousal and reduce the patients’ sense of control

4. Pain Education • Patients should be given as much information as possible about care provided, if possible before any procedures • Patients should also be educated in using their analgesics appropriately • An emphasis should be placed on taking medications as scheduled, not only when pain emerges, and patients’ concerns regarding side effects, including any addiction potential, should be addressed

5. Diaphragmatic Breathing • Inform patients that physiological arousal can increase pain signals, and that relaxation strategies can reduce this arousal • Ask patients to assume a comfortable position and to place one hand over their abdomen • Instruct patients to inhale deeply through their nose, bringing air into the bottom of their lungs, then to exhale through their mouth • Repeat this for two or three breaths, then request that they practice this regularly, for three to five minutes at a time

6. Distraction • Tell patients that although strong, pain signals are one of many possible sensations that they may notice at any given moment, and that actively distracting from the signal may provide some relief • Ask patients to gently guide their attention to another stimulus, such as television, music, reading, simple puzzles, or conversations with supportive family/friends • Encourage patients to imagine a preferred place or situation where they feel calm and relaxed, in as much detail as possible, pulling in all of their senses, including sights, sounds, smells, touch, and taste

7. Self-Coaching • Discuss the role of thoughts on patients’ sense of coping with pain, and their relationship to physiological arousal • Encourage patients to generate and practice positive self-talk that emphasizes their ability to cope with the pain • Patients should also be reassured that the pain episode is of limited duration, and that they can remind themselves that it will pass

8. Definition of Chronic Pain(International Association for the Study of Pain) An unpleasant sensory or emotional experience resulting from actual or potential tissue damage lasting beyond the usual course of the acute disease or expected time of healing

9. Elements of Chronic Pain(Fordyce, 1988) • Nociception – mechanical, thermal, or chemical energy impinging on specialized nerve endings that signal aversion to the CNS • Pain – sensation arising from stimulation of perceived nociception • Suffering – affective or emotional response triggered by nociception or other aversive events • Pain behaviour – responses made to pain and suffering

10. Biopsychosocial Model(Gatchel & Turk, 2002) • Unfortunately, many patients still view pain in terms of physical disease • Sees chronic pain as not just disease, but as an “illness” • Pain seen as an ongoing, multifactorial process • Relative weighting of the contributions of physical, psychological, and social factors change over time

11. Biopsychosocial Model(Gatchel & Turk, 2002) • Sociocultural factors include illness beliefs, expectations, healthcare seeking and availability • Involves social and operant learning • Cognitive factors include thoughts about controllability of pain, self-efficacy, cognitive errors, and coping ability • Affective factors include levels of depression, anxiety, anger

12. Biopsychosocial Model(Gatchel & Turk, 2002) • Personality factors include interpersonal sensitivity, fearful appraisals of bodily sensations, bodily preoccupation and catastrophic thinking • The above factors act indirectly on pain and disability by reducing physical activity, muscle flexibility, tone, and strength, and physical endurance • Direct effects include increased sympathetic nervous system arousal, endogenous opioid production, and elevated levels of muscle tension

13. Vocational Financial Health care use “Systems” issues Functional impairment Interpersonal dysfunction Mood and anxiety disturbance Increased responsibility for family members Health care provider frustration Increased health care costs Increased social service costs Reduced work productivity Consequences for the Individual and Others

14. Factors Complicating Chronic Pain • Substance abuse • History of mental disorder • Trauma • Chronic illness • Family discord • Grief • Systems issues • Legal concerns • Financial issues • Multicultural issues

15. Psychological Treatment • Currently no treatment that consistently and permanently alleviates pain for all patients • Management of chronic pain often depends on the readiness and abilities of the client • Primary goal is to improve function rather than alleviate pain • Effective management is achieved most readily using a multidisciplinary approach (Turk and Stieg, 1987) • Should be customized to the patient (Turk, 1990) • Treatment varies, but is usually planned for about 10 to 12 sessions

16. Psychological Treatment • An active, time-limited treatment, with patients guiding their own progress rather than passively receiving care • For patients that are not candidates for treatment, a consultative resource to facilitate existing treatment • Assessment and treatment emphasizes a biopsychosocial model

17. Patients Likely to Benefit from Psychological Treatment • Pain is considered to be the chief concern • Patient understands what psychology can offer, and agrees to pursue assessment and/or treatment • Patient is assumed to be motivated and capable of maintaining regular involvement with appointments and skill acquisition

18. Patients Unlikely to Benefit from Psychological Treatment • Psychological factors are obviously a primary concern • Patient understands what psychology can offer, but maintains a unidimensional view of pain • Patient is unmotivated/resistant, or experiencing too much distress (relationship distress, substance abuse) to maintain regular involvement with treatment

19. Typical Patient • It is not understood what degree psychological factors play a role • Patient agrees to pursue assessment and/or treatment, but may need more education regarding what psychology can provide • Patient may or may not receive treatment, depending on the assessment

20. Diagnostic Interview • Typically uses one or two 1-hour sessions • Includes obtaining a history of the presenting problem and a brief medical and psychological history, followed by an assessment of functioning within the following domains… • Educational and vocational • Social and recreational • Family, including brief developmental history • Mental status and current psychological functioning

21. Formal Assessment • Not always needed, but dependent on referral question and presenting problem • Typically involves administration of instruments measuring personality, impact of illness, coping, beliefs and expectations about pain and injury, and psychological distress • May be completed in one or two 1-hour testing sessions

22. Psychological Treatment • Currently no treatment that consistently and permanently alleviates pain for all patients • Management of chronic pain often depends on the readiness and abilities of the client (Jensen et al., 2003) • Primary goal is to improve function rather than alleviate pain • Effective management is achieved most readily using a multidisciplinary approach (Turk and Stieg, 1987) • Should be customized to the patient (Turk, 1990) • Treatment varies, but is usually planned for about 10 to 12 sessions

23. Psychological Treatment(Turk, 2002) • Problem-oriented • Educational • Collaborative • Uses clinic and home practice for skill-building • Encourages expression and management of feelings that impair rehabilitation • Addresses relationships among thoughts, feelings, behaviour, and physiology • Anticipates setbacks and teaches clients how to manage these

24. Psychological Treatment • Involves evaluating and correcting maladaptive beliefs, appraisals, and schemas to alleviate mood symptoms and increase coping behaviour • Training in relaxation techniques, such as abdominal breathing, visualization, and progressive muscle relaxation to reduce anxiety that typically magnifies pain signals • Treatment attempts to increase behaviours associated with pain self-management, such as adaptive coping, exercise program participation, and improved communication with providers • Focuses on increasing self-efficacy

25. References • Fordyce, W. (1988). Pain and suffering: a reappraisal. American Psychologist, 43, 276-283. • Jensen, M., Nielson, W., Turner, J., Romano, J., and Hill, M. (2003). Readiness to self-manage pain is associated with coping and with psychological and physical functioning among patients with chronic pain. Pain, 104, 529-537. • Turk, D. (2002). A cognitive-behavioral perspective on treatment of chronic pain patients. In Gatchel, R. & Turk, D. (Eds.) Psychological Approaches to Pain Management: A Practitioners Handbook. New York, The Guilford Press.

26. References • Turk, D. & Monarch, E. (2002). Biopsychosocial perspective on chronic pain. In Gatchel, R. & Turk, D. (Eds.) Psychological Approaches to Pain Management: A Practitioners Handbook. New York: The Guilford Press. • Turk, D. (1990). Customizing treatment for chronic pain patients: who, what, and why. Clinical Journal of Pain, 6, 255-270. • Turk, D., & Stieg, (1987). Chronic pain: the necessity of interdisciplinary communication. The Clinical Journal of Pain, 3, 163-167.