Chronic Pain Management with Cognitive Behavioral Therapy

1. Chronic Pain Management with Cognitive Behavioral Therapy

2. Definition of Chronic Pain Chronic pain is often defined as any pain lasting more than 12 weeks. Whereas acute pain is a normal sensation that alerts us to possible injury, chronic pain is very different. Chronic pain persists—often for months or even longer.

3. Statistics • As of 2012, about half of all adults—117 million people—have one or more chronic health conditions. One of four adults has two or more chronic health conditions. • Arthritis is the most common cause of disability (27%). In the United States each year 600,000 ppl develop pain from arthritis for the first time • Other debilitating painful conditions are osteoporosis (21%), diabetes (17%), COPD and allied conditions (15%), cancer (11%), and stroke (11%). More than 22 million say it causes them to have trouble with their usual activities. • Low back pain disables approximately 7 million people and accounts for 8 million doctors visits • According to the American Pain Foundation, about 32 million people in the U.S. report having pain lasting longer than one year. • From one-quarter to more than half of the population that complains of pain to their doctors are depressed. • On average, 65% of depressed people also complain of pain

4. Pain Study • Percent of adults age 20 years and over reporting pain lasting 24 hours or more in the month prior to interview:Total 25.8%, Men 24.4%, Women 27.1%(NHANES 1999-2002) • Duration of pain among adults reporting pain in the month prior to interview: Less than 1 month 32.0%, 1 month to less than 3 months 12.3%, 3 months to less than 1 year 13.7%, more than 1 year 42.0%(NHANES 1999-2002)

5. Diagnostic Criteria Pain disorder is now classified as Somatic symptom disorder (SSD) in DSM V. SSD is characterized by somatic symptoms that are either very distressing or result in significant disruption of functioning, as well as excessive and disproportionate thoughts, feelings and behaviors regarding those symptoms. To be diagnosed with SSD, the individual must be persistently symptomatic (typically at least for 6 months).

6. Changes from DSM IV to DSM V • Several important changes have been made from previous editions of DSM. The DSM-IV disorders of somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder have been removed, and many, but not all, of the individuals diagnosed with one of these disorders could now be diagnosed with SSD. • Another key change in the DSM-5 criteria is that while medically unexplained symptoms were a key feature in the DSM IV it is not a key feature in an SSD diagnosis; symptoms may or may not be associated with another medical condition.

7. Reason for Changes in the DSM V • Overlapping previous diagnoses • Difficult for non psychiatric physicians to apply • Reduction of stigma • Potential for mind body dualism • Implication that symptoms were not “real”

8. Pain and Psychological Factors DSM-5 looks at pain and psychological factors conjointly . Based on research psychological factor influence all forms of pain. Most individuals with chronic pain attribute their pain to a combination of factors, including somatic, psychological, and environmental influences.

9. Pain Cycle

10. Accept the reality of the pain for the patient When a patient presents pain it is important that the therapist or healthcare professional accepts the reality of the patient. Any attempt to determine whether pain is in excess of what might be expected may negate psychosocial factors that influence the clinical pain experience. It is very tempting but dangerous to resort to concepts such as “exaggerated pain” or “psychogenic pain” in patients which does not correlate between their pain reports and the physical findings.

11. Educate • Elicit how patients feel about their pain. What is their knowledge and attitude about pain and its treatment. • Provide psychoeducation • The physiology of pain: Pain results from a signal sent from nerves to your brain. It can serve as an alarm, a warning -- that you're stepping on a nail or touching a hot stove. But sometimes the signals keep firing, and the pain continues. That’s when it becomes chronic. • Medical contradiction ( know what leads to increased harm not just increased pain {talk to family doctor}) pain response and signals aren’t always a sign of danger

12. Assess • Identify history and nature of persistent pain • Frequency, intensity, duration, location • Pain intensity scale • Identify the impact of pain on daily life • Pain diary • Pain assessment checklist • Compile a list of all medical dx, treatments, meds, doctors

13. Assessing Problems and Concerns • Problem lists. These are a common and useful strategy for identifying the psychological, social, occupational, and financial difficulties faced by patients. • Therapists who used problem lists typically elicit a list of five to 10 difficulties from the patient during the first part of session 1. Problems are best identified using open-ended questions

14. Define the Problem

16. Devise Long Term Goals • Experience decreased feelings of intensity and/or duration of pain episodes • Obtain needed skills to better manage pain • Better cope with pain to increase ability to complete daily tasks and engage in social activities • Find a new sense of empowerment in ability to manage pain

17. Devise Short Term Objectives • Identify and monitor particular pain triggers • Learn and implement somatic skills • Identify negative pain related thoughts and replace them with positive coping related thoughts • Increase level and range of activity by identifying and engaging in activities

18. Pain Triggers • Identify pain triggers by teaching the patient to self-monitor their symptoms • Pain Diary thoughts, feelings, behaviors, people, situations helps the client to identify how pain impacts his/her daily activities social and leisure involvement • Process the journal with the patient to increase insight into the nature of the pain, cognition, behavioral triggers, and the positive or negative effect of the interventions they are currently using

19. Germany – Patient ID15 Pain diary - experiences Tell us how you were feeling at the beginning, during and at the end of the day What impact did your pain have on you today? Impact on daily activities When I woke up I felt… Impact on your mood During the course of the day I felt… Impact on your relationship with others In the evening I felt…

20. Somatic Skills • Teach relaxation techniques as a useful and quick response to high stress or pain levels. This allows patients in many circumstances to reduce stress and pain and thus cope in an adaptive manner with these unpleasant states. • Quantifying pain on a 5 point scale before and after the relaxed state is a useful aid towards showing its effectiveness, where 0 is no pain and 5 is excruciating pain. • Patients are encouraged to keep pain diaries while on the course

21. Negative Pain Related Thoughts • Catastrophizing/Awfulizing – predicting the worst case scenario. • Black and white thinking – forgetting that reality is composed of many shades of gray. • Unrealistic expectations for the world - (should statements). • Mind reading – believing we know what others are thinking about us. • Emotional reasoning - believing our feelings indicate truth. Believing that if we feel worried about our pain that means our pain is causing harm.

22. Altered Mood • Fear of Injury • Anger • Physical Deconditioning • Fatigue • Anxiety • Confused Thinking

23. Increase Activity Levels • PACING: Scheduling activities throughout a period of time to ration energy (energy conservation) • ENERGY CONSERVATION: Doing no more on a good day, no less on a bad day and therefore reducing the learning relationship between pain and activity (time contingent activity) • ACTIVITY PLANNING: Planning activity to ensure a balance of pleasurable and less pleasurable tasks

24. Activity: Working to Quota Working to Quota is used to disrupt the learned relationship between activity and pain levels, an opportunity to (1) reduce inadvertent learned associations and (2) begin to use skills to help confront fear of pain and take control can begin. • Establish a hierarchy of activities from least concerning to most concerning. Identify exactly what the concerns are – do they need to be addressed with information, or do they need to learn from experiencing (testing) what happens if • Establish your baseline, and develop a ‘timetable’ for a week (or any period of time) in collaboration with the person. • Review and reset the activity schedule – maintain or increase activity level at this time

25. Relapse Prevention • Discuss the distinction between a lapse and relapse, associating a lapse with a return of pain or old habits (e.g. having a bad day) vs relapse with a persistent return of pain and previous behavioral habits and cognitions • Identify and rehearse the management of future situations or circumstance in which lapse could occur using the learned strategies for self management

26. Quiz • In DSM IV –TR a patient with high levels of anxiety about having a disease and many associated somatic symptoms would be given the diagnosis of hydrochondriasis. What DSM V diagnosis would apply to the patient? • General anxiety disorder • Somatoform disorder nos • Somatic symptom disorder • What is the leading cause of debility in the United States • COPD • Stroke • Arthritis • What do experiences such as keeping a pain diary reveal about a patient? • Identifies pain triggers • Shows avoidance areas • Reveals the impact pain has at rested periods of the day • Which of the following has been removed from the DSM- IV? • Hypochondrias • Social Anxiety Disorder • Nasopharyngitis • How does working to quota help disrupt the learned relationship between activity and pain • It shows how to reduce activities • Helps develop skills to confront and control pain • Gauges how to manage medication regimen

27. References • psychological factors affecting other medical conditions dsm 5 http://www.ucdmc.ucdavis.edu/psychiatry/calendar/DSM5_presentation_20130816.pdf • Assessment of the Patient With Pain www.medscape.com"lacks specificity" and could cause the mislabelling of a sizeable proportion of the public as mentally ill./viewarticle/78 DSM-5 Somatic Symptom Disorder Debate Rages On http://www.health.am/psy/more/assessment_of_the_patient_with_pain/ • Cognitive Behavioral Therapy for Managing Pain http://www.apa.org/divisions/div12/rev_est/cbt_pain.html • Cognitive behavioral therapy for back pain • http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000415.htm • Managing Chronic Pain: A Cognitive-Behavioral Therapy Approach Workbook (Treatments That Work) John Otis • Managing Chronic Pain 10 min CBT strategies http://www.youtube.com/watch?v=tiuZBndewbE • Cognitive Behavioural Therapy for Treatment of Painhttp://www.youtube.com/watch?v=v6yLIqdLvNk