Transcript Cognitive and Behavioral Pain Management Interventions

Cognitive and Behavioral Pain
Management
Judith B. Chapman,
Ph.D., ABPP
Behavioral Medicine
Program
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
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).
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
Which psychological factors
influence pain?

Cognitive (Pain Beliefs, Cognitive Errors, Self
Efficacy, Coping)

Affective

Personality
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).
Pain Beliefs
Patients’ beliefs about pain or disability are better
predictors of ultimate level of disability than are
physician ratings of disease severity
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)
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)
Cognitive Errors
a negatively distorted belief about oneself or
one’s situation
Examples: Catastrophizing, overgeneralization,
selective abstraction
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).
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
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
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
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)
Palo Alto Pain Clinic Data




75% depressed
33% report active suicidal thoughts
48% report a history of trauma
19% meet criteria for PTSD
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
Older patients




Reported significantly less pain severity than
young
Less pain interference
Better overall sleep
Less depression
Aging and Pain



Changes in visceral sensations with age
Increased prevalence of post-herpetic
neuralgias
Nonlinear relationship between joint pain and
age
Cognitive-behavioral Treatment






Enhancing motivation
Relaxation exercises
Education about Sleep Management
Hypnosis and Imagery
Cognitive Therapy
Family Interventions
Principles of Motivational
Enhancement Therapy





Expressing empathy
Developing discrepancy
Avoiding arguments
Rolling with resistance
Supporting self efficacy
Relaxation Strategies




Progressive muscle relaxation
Deep (diaphragmatic) breathing
Biofeedback
Autogenic training
Caveats and contraindications



Psychotic patients
Relaxation-induced anxiety
Panic attacks
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
Essential Components of Hypnosis






Physical relaxation
Deepening exercise
Pleasant imagery
Suggestion
Post-hypnotic suggestion
Gradual return to alertness
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).
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
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
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
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
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