Transcript Cognitive & Behavioural Changes in MS

MULTIPLE SCLEROSIS AND
NEUROPSYCHOLOGICAL FUNCTIONING:
MANAGING COGNITIVE DEFICITS
Dr. Lesley Ritchie, C.Psych.
Ms. Jodie Gawryluk, B.A.
Department of Clinical Health Psychology
University of Manitoba
OVERVIEW
1.
2.
3.
4.
5.
6.
7.
Introduction to the brain
Understanding MS
The treatment team
What is neuropsychology?
Neuropsychological assessment
 Cognitive domains
Neuropsychological profile of MS
Managing neuropsychological deficits
 Specific strategies
 Special considerations
OVERVIEW
1.
2.
3.
4.
5.
6.
7.
Introduction to the brain
Understanding MS
The treatment team
What is neuropsychology?
Neuropsychological assessment
 Cognitive domains
Neuropsychological profile of MS
Managing neuropsychological deficits
 Specific strategies
 Special considerations
INTRODUCTION TO THE BRAIN

The brain monitors and controls nearly everything
that we do from our breathing and heart beats to
our senses (e.g., vision, hearing), to our
movements, speech, and personality
INTRODUCTION TO THE BRAIN
• The brain is divided into left and right cerebral hemispheres
Left Hemisphere
is important for:
• language
(thinks in words)
• math
• logical abilities
• movement of the right
side of the body
Right Hemisphere
is important for:
• visual information
(thinks in pictures)
• organization
• creativity
• movement of the left
side of the body
INTRODUCTION TO THE BRAIN
Frontal Lobes
• Movement
• Speaking
• Planning
• Organizing
• Reasoning
• Decision making
• Judgment
• Personality
INTRODUCTION TO THE BRAIN
Temporal Lobes
• Memory
• Recognition Hearing
• Understanding Language
• Emotions
INTRODUCTION TO THE BRAIN
Parietal Lobes
• Sensations
• Reading and Writing
• Ability to use Numbers
• Spatial Reasoning
• Perception
Occipital Lobes
• Seeing objects
• Locating objects in
space
• Recognizing the
things we see
INTRODUCTION TO THE BRAIN
Cerebellum
• Maintaining balance
• Coordination of
movement
• Timing of movement
INTRODUCTION TO THE BRAIN
Brain Stem
• Connection between
brain and body
• Breathing
• Blood pressure
• Swallowing
• Appetite
• Body temperature
• Digestion
• Sleeping
INTRODUCTION TO THE BRAIN
Brain Anatomy
 The brain is made up of two types of tissue:
 Grey matter (where information is processed)
 White matter (the highways that take information to the
processing stations)
White matter
Grey matter
INTRODUCTION TO THE BRAIN
Functional Analogy
OVERVIEW
1.
2.
3.
4.
5.
6.
7.
Introduction to the brain
Understanding MS
The treatment team
What is neuropsychology?
Neuropsychological assessment
 Cognitive domains
Neuropsychological profile of MS
Managing neuropsychological deficits
 Specific strategies
 Special considerations
MULTIPLE SCLEROSIS




Multiple = more than one
Sclerosis = area of stiffening/damage
Autoimmune disorder
Immune system attacks the CNS


Demyelination
White matter tissue is white because of myelin, a fatty covering that helps information travel to
brain areas quickly
MULTIPLE SCLEROSIS



Symptom onset btwn
20 – 40 years of age
2-3x more common in
women
Increased prevalence
in northern latitudes
MULTIPLE SCLEROSIS

Affects brain and
spinal cord


Altered motor, sensory,
and cognitive
functioning
Common presenting
symptoms
Symptoms vary
according to disease
course
(Olek 2005)

Symptom
Frequency (%)
Sensory disturbance
- limbs
30.7
Visual loss
15.9
Motor disturbance
(subacute)
8.9
Diplopia
6.8
Gait disturbance
4.8
Motor (acute)
4.3
Balance problems
2.9
Sensory disturbance
(face)
2.8
MULTIPLE SCLEROSIS

Disease course
1. Relapsing and remitting MS (RRMS):
–
–
2.
Secondary progressive MS (SPMS):
–
3.
80% with initial RRMS show declines between attacks w/o periods
of remission; most common
Primary progressive MS (PPMS):
–
–
–
4.
Clearly defined attacks and periods of remission
Triggers: warm weather, infections, stress
10% who do not have period of remission following 1st attack
Continuous decline
Older at onset
Progressive relapsing MS (PRMS):
–
steady decline with attacks
Bobholz & Gremley (2011)
OVERVIEW
1.
2.
3.
4.
5.
6.
7.
Introduction to the brain
Understanding MS
The treatment team
What is neuropsychology?
Neuropsychological assessment
 Cognitive domains
Neuropsychological profile of MS
Managing neuropsychological deficits
 Specific strategies
 Special considerations
TREATMENT TEAM
GP: manages all medical concerns
 Neurologist: manages concerns about MS or
other brain conditions
 Radiologist: collects images of the brain
 Neuropsychologist

OVERVIEW
1.
2.
3.
4.
5.
6.
7.
Introduction to the brain
Understanding MS
The treatment team
What is neuropsychology?
Neuropsychological assessment
 Cognitive domains
Neuropsychological profile of MS
Managing neuropsychological deficits
 Specific strategies
 Special considerations
CLINICAL NEUROPSYCHOLOGY
… is an applied science concerned with
the behavioural expression of brain
dysfunction (Lezak, 1995)
Normal Distribution - Test Interpretation
Average
AVERAGE
Low
average
Low
Ave
Borderline
Impaired 2.14%
13.59%
0.13%
0.13%
Z -3
-2
-1
34.13%
34.13%
13.59%
X
0
High
Ave
High
average
1
2
Superior
2.14%
3
V. Superior
0.13%
Normal Distribution - Test Interpretation
Average
AVERAGE
Low
average
Low
Ave
Borderline
Impaired 2.14%
13.59%
0.13%
0.13%
Z -3
-2
-1
34.13%
34.13%
13.59%
XX
0
High
Ave
High
average
1
2
Superior
2.14%
3
V. Superior
0.13%
Normal Distribution - Test Interpretation
Average
AVERAGE
Low
average
Low
Ave
Borderline
Impaired 2.14%
13.59%
0.13%
0.13%
Z -3
-2
-1
34.13%
34.13%
13.59%
XX
0
High
Ave
High
average
1
2
Superior
2.14%
X
3
V. Superior
0.13%
CLINICAL NEUROPSYCHOLOGY
What neural mechanisms underlie various
cognitive abilities and different emotional
states?
 How do these mechanisms work ?
 What are the effects of brain damage on
behaviour ?
 Application of appropriate intervention strategies

OVERVIEW
1.
2.
3.
4.
5.
6.
7.
Introduction to the brain
Understanding MS
The treatment team
What is neuropsychology?
Neuropsychological assessment
 Cognitive domains
Neuropsychological profile of MS
Managing neuropsychological deficits
 Specific strategies
 Special considerations
CLINICAL NEUROPSYCHOLOGY

Neuropsychological Assessment
 Specific nature of the injury
 Pre-injury history  strengths / weaknesses
 Specific situation demands of life / work
 Supports available
 Personality factors
 Emotional response to injury & limitations
 Adaptive & coping skills
 Beliefs / expectations of client & family
 Psychometrics
CLINICAL NEUROPSYCHOLOGY

All neuropsychological tests are developed
through research

Administered in a standardized manner

Results are compared to normative data
CLINICAL NEUROPSYCHOLOGY

Cognitive domains
 Estimated premorbid ability
 General Intellectual ability
 Attention
 Speed of information processing
 Sensory – motor function
 Language
 Visual Perception & Construction
 Executive functions
 Memory
 Mood / Psychopathology / Personality
 Validity & Effort
OVERVIEW
1.
2.
3.
4.
5.
6.
7.
Introduction to the brain
Understanding MS
The treatment team
What is neuropsychology?
Neuropsychological assessment
 Cognitive domains
Neuropsychological profile of MS
Managing neuropsychological deficits
 Specific strategies
 Special considerations
NEUROPSYCHOLOGICAL PROFILE OF MS






45-65% of people with MS have cognitive symptoms
80% of those are mildly affected
Even mild problems can interfere with everyday
activities
Cognitive deficits increase with prolonged disease
duration
20-30% of patients develop more severe impairments,
such as dementia
Cognitive deficits don’t tend to fluctuate

Greater deficits associated with
 Progressive
disease courses (PPMS, SPMS)
 Duration of disease
 Increased prevalence of cognitive decline in men
 Quantity of MR abnormalities
COGNITIVE IMPAIRMENT IN MS


Processing speed
Attention/concentration
Sustained
 Complex

Abstract reasoning
 Problem-solving




Language
Verbal fluency
 Naming
Memory (40-60%)
Episodic/recent memory
 Working memory
Executive functioning (EF)



Visuospatial skills
Table 20.3; Bobholz & Gremley (2011)
PROCESSING SPEED



Speed of mental
activity
Most common
Underlying factor


Memory
Working memory
http://www.mountsinai.on.ca/
care/ebffrc/ms
ATTENTION
Attention = vigilance, capacity for information,
switching attention, selective attention
 20-25% of MS patients
 Deficits in rapid and complex info processing

 Working
memory
 Attentional switching
 Rapid visual scanning

Intact attention span
INFORMATION ABOUT ATTENTION
Focused Attention is the ability to focus on something
in the moment.
For example, focused attention can be for things you
see, such as watching television or for things you hear,
such as listening to the radio.
INFORMATION ABOUT ATTENTION
Sustained Attention allows you to
focus on something over a long period
of time
For example, watching a movie or
reading a book.
INFORMATION ABOUT ATTENTION
Selecting Attention allows you to pick out
important information from unimportant or
distracting information
For example, listening to a conversation in a
noisy cafeteria.
INFORMATION ABOUT ATTENTION
Shifting Attention allows you to switch back and forth
between two different tasks.
For example, when you are cooking you may need to
shift your attention back and forth between watching for
a pot boil and preparing vegetables to put in the pot.
INFORMATION ABOUT ATTENTION
TYPES OF ATTENTION
Divided Attention allows you to work on two different
tasks at the same time, and is sometimes referred to as
multi-tasking.
For example, singing along to the radio while driving
home.
INFORMATION ABOUT ATTENTION
Symptoms of Attention Difficulties
• Becoming easily distracted
• Having trouble keeping track of what is being said and
done or have trouble making sense of things
• Having trouble focusing on one person, thing or
conversation in crowded environments
• Having trouble keeping track of more than one thing at a time
• Having difficulty doing more than one task at a time
• Having difficulty learning and remembering information
• Becoming easily frustrated with yourself and
others
• Feeling confused and overwhelmed
• Avoiding contact with care givers, friends and
family
MEMORY

Ability to learn and recall information about
previous experiences.
 E.g.,

favorite song and the look of our home
Different types of memory are stored in
different places in the brain.
Verbal information
(such as words) are
typically stored on
the left side of the
brain
Visual information
(such as pictures) are
typically stored on the
right side of the brain
FACTS ABOUT MEMORY
TYPES OF MEMORY
 Different types of memory based on time.
 Short term memory, Working memory,
 Recent memory, and Long term memory
FACTS ABOUT MEMORY
SHORT TERM MEMORY
•This is the ability to remember
something in the moment or that
you only need to remember for a
few minutes
•Remembering a phone number
you have just been told
•Short term memory is often
impaired after a brain injury
FACTS ABOUT MEMORY
WORKING MEMORY
• This is the ability to remember in the moment or for a
few minutes while you focus on something else or are
distracted
• An example is keeping a phone
number in mind while looking for a pen
and paper to write it down.
• Working memory is often affected by
brain injury
FACTS ABOUT MEMORY
HOW ARE MEMORIES MADE?
1. Attention
You must pay attention
to what you are learning
2. Recording
Your brain needs to 'take in'
and record information
The 3 R’s
of Memory
3. Retain
The information needs to
be stored in the right spot
4. Retrieve
Information needs to be
recalled when it is needed again
If problems occur anywhere
in these steps, then
memory difficulties will
occur
EXECUTIVE FUNCTIONING

Cognitive abilities
required to complete
goal-directed
behaviors that are
not automatic,
overlearned, or
routine (Sohlberg & Mateer,
2001).
EXECUTIVE FUNCTIONING








Initiation
Inhibition
Set-switching
Judgment/Reasoning
Goal identification
Working memory
Speed of processing
Cognitive flexibility/problemsolving








Sequential processing
Planning
Self-Monitoring
Perseveration
Prioritizing
Multi-tasking
Emotional control
Insight/Awareness
EXECUTIVE FUNCTIONING

15-20% of patients with MS exhibit executive
dysfunction
 Impaired goal-directed behavior
 Verbal disinhibition
 Poor self-monitoring (e.g., tangential speech)
 Reduced insight
 Deficits in planning and prioritizing
 Problems with abstraction and conceptualization
LANGUAGE AND VISUOSPATIAL

Language
 Mild confrontation naming deficits
 Speech abnormalities (dysarthria, hypophonia)
 Poor verbal fluency (retrieval deficit/speed)


20-25%
Visuospatial
 Angle matching
 Face recognition
 impact of changes in vision/diplopia
 Visual miscalculations
OVERVIEW
1.
2.
3.
4.
5.
6.
7.
Introduction to the brain
Understanding MS
The treatment team
What is neuropsychology?
Neuropsychological assessment
 Cognitive domains
Neuropsychological profile of MS
Managing neuropsychological deficits
 Specific strategies
 Special considerations
MANAGING NEUROPSYCHOLOGICAL
DEFICITS
MANAGING NEUROPSYCHOLOGICAL
DEFICITS

Neuropsychological rehabilitation
 Interventions aiming to enhance or support
cognitive abilities following brain injury, with an
emphasis on achieving functional changes (Sohlberg &
Mateer, 2001)


Target: reductions in cognitive, emotional,
psychological functioning that encumber everyday
functioning
Goal: increase independent functioning by means of
enhanced knowledge and skill, behavior change, or
implementation of compensatory strategies
MANAGING NEUROPSYCHOLOGICAL
DEFICITS

Foundation of cognitive intervention
 Tx
based on current level of function
 Build on strengths to support weaknesses
 Collaborative
 Goal-oriented
 Education
SPECIFIC STRATEGIES
Processing speed
 Attention
 Memory
 Executive functioning
 Language

PROCESSING SPEED




Complete one activity
at a time
Schedule more time to
complete tasks
Limit distractions
Record information for
later review
SPECIFIC STRATEGIES
Processing speed
 Attention
 Memory
 Executive functioning
 Language

ATTENTION

Orienting procedures
 “What
am I doing?”
 Minimizes gaps in attention

Pacing
 Realistic
expectations
 Elongated performance times
 Minimize frustration
 Vary according to time of day
 Schedule adequate rest
ATTENTION




Environmental modification
 Work in a quiet environment
 Reduce clutter
 Limit distractions
 Refer to checklists to complete tasks
 Set timers to prevent going overtime
Work on one task at a time
Double/triple check work to minimize errors
Have a significant other check work
ATTENTION

Top Ten tips to help you manage attention
difficulties:










Practice
Check in
Modify your environment
Pace yourself.
Take care of yourself.
Monitor your mood.
Double check
Break tasks down
Do difficult tasks at your best time of day.
Use your family and friends for support.
Take care of yourself.
Fatigue, hunger, and/or thirst all
adversely affect your attention.
Taking care of yourself will help maintain
optimum attention.
SPECIFIC STRATEGIES
Processing speed
 Attention
 Memory
 Executive functioning
 Language

MEMORY
Repetition - Repeat the
information over and over
and over again.
•Looking at something one
time is never enough.
•For example, if you are
trying to learn someone’s
name, repeating it over and
over to yourself can help
you remember it.
MEMORY
Multimodal learning –
It helps to learn the same information in
different ways.
For example, to learn a new recipe, it
helps to read over the steps in the recipe,
listen to someone telling you the steps,
and practice the recipe by doing it.
See it, hear it, do it!
MEMORY
Break it down - Break up what
you want to remember into
smaller steps. If you have
something really tough to learn,
try to break it down into small
bits and then learn one bit at a
time.
MEMORY
Write it down - When something is important to remember, write it
down, and keep it in a safe place. Remember to check your notes
regularly.
Writing information down also allows for repeated exposure to the
information (Hear, Write, Read – 3x exposure)
• Calendar
• Daytimer
• PDA or cell phone
• Notebook
MEMORY
Learn it right the first time - New skills are easier to remember if
you learn them the right way (mistakes are hard to correct later)
Helpful Hints for Errorless Learning
1. Break the task down into smaller steps.
2. Learn each step at a time and avoid making errors that may confuse you later .
3. Complete the task you are trying to learn together with someone who has
done it before. Ask this person to talk through the steps as you learn the
task (this will help you to avoid errors)
4. Use hints that will help you remember the steps (you can ask someone for
hints or make up notes for yourself that guide you to the next step)
5. Only try to do the new skill when you are sure you know the steps and can do it error-free
MEMORY
Elaboration – This is a technique that you can use to
make information more meaningful and easier to
remember. Information can be easier to remember if
you think through all of the details. Here are some
questions to help you elaborate:
 Can you link this with anything or anyone you know?
 Do you link this with any feelings?
 Is there anything about it that is unique or special?
 Can you link this with things in your daily life?
 How does it look?
 How does it feel?
 How does it sound?
 How does it smell?
 How does it taste?
MEMORY
Space out your attempts to retrieve information - Try to recall
new information several times in a row. If you can recall it correctly,
then gradually increase the time (from minutes to hours) between
attempts.
For example, recall information the first time after 20 seconds, then
space out your attempts to recall – 30 sec, 1 minute, 5 minutes, 10
minutes, 30 minutes, 1 hour, 4 hours, later that day, and the next
day.
Set up a Routine - Follow a daily or weekly routine to help you remember
events and times to get regular tasks done each day.
SPACED RETRIEVAL
Brooke Smith
BACKWARD CHAINING
355-2941
355-294_
355-29_ _
355-2_ _ _
WHO IS THIS?
MEMORY
External Aides (portable memory)
• Labels on the outside of boxes, drawers, and cupboards to help you
find things.
• Post-it notes to leave yourself reminders in places around your home.
• A notepad beside the phone to write down messages and reminders
• Checklists or shopping lists.
• Diary for storing and planning
• Alarm clock, or timer to help you remember when you are supposed
to do something
• A calendar to keep track of appointments
• A tape recorder to leave messages for yourself
• A pill reminder box to keep track of medications
MEMORY
Get Organized – It is easier to remember where things are if they are kept
in one place. For example, if you are constantly losing your wallet, you will
find it faster if you always leave it in the same spot.
Make A 'To Do' List – Making a list of things that you need to do can help
you remember all that you need to get done. For example, you can make a
list of chores to remind yourself of what needs to be done.
MEMORY

Mnemonics
 Consciously
leaned
 Require considerable effort
 Verbal or visual

Richard of York gives battle in vain
 Red,

orange, yellow, green, blue, indigo, violet
My very elderly mother just sat upon a new pin
 Mercury,
Venus, Earth, Mars, Jupiter, Saturn,
Uranus, Neptune, Pluto
SPECIFIC STRATEGIES
Processing speed
 Attention
 Memory
 Executive functioning
 Language

EXECUTIVE FUNCTIONING









Structure and Routine!
 Do things that require the most initiation in the morning or after a
rest
 Set a small number of goals for each day
Set up (with assistance) organizational practices
Large family calendar
Online bill payment
Use labels
Schedules
Simplify activities
Prioritize
Checklists
EXECUTIVE FUNCTIONING
Meta-cognitive strategies
 To
regulate behavior and increase goaloriented behavior
Self-talk
Tracking
behaviors
Self-monitoring

Tracking errors and attention lapses
Goal
Management Training
GOAL MANAGEMENT TRAINING


Maintaining intentions in
goal-directed behavior is
reliant on intact
executive functioning
GMT based on theory of
goal neglect resulting in
disorganized behavior
following frontal lobe
injury
Levine et al. (2000).
SPECIFIC STRATEGIES
Processing speed
 Attention
 Memory
 Executive functioning
 Language

LANGUAGE

Language
 Communication
skills training
 Group interventions
 Modeling
and generalization
 Building
social networks
 In MS, many language deficits are due to physical
changes (i.e., dysphagia) and reduced speed of
processing.
 Allow
more time for communication
CAVEAT
Neuropsychological interventions should be
person-specific
 Different presentations

Attention
Processes
Selective Attention
Executive
Processes
Memory
Processes
Working Memory
Divided Attention
Prospective Memory
Alternating Attention
Awareness
Task Performance
Solberg & Mateer (2001), Figure 8.3
SPECIAL CONSIDERATIONS

Common symptoms of MS
 Emotional
and psychological difficulties
 Depression
 Fatigue
 Pain
EMOTIONAL DIFFICULTIES

Can impact neuropsychological functioning
Healthy Brain
25%
50%
25%
Nurse Cells
Life Support
Cognitive
EMOTIONAL DIFFICULTIES
Brain Injury
17%
25%
33%
25%
Nurse Cells
Cognitive
Life Support
Brain Injury
EMOTIONAL DIFFICULTIES
Brain Injury + Stress/Anxiety
11%
25%
17%
25%
22%
Nurse Cells
Brain Injury
Life Support
Stress/Anxiety
Cognitive
DEPRESSION

Patients with MS have a 50% lifetime risk for
depression

Higher prevalence than the general population and
higher than in other brain disorders

Depression is treatable!

Prevalence of anxiety is 25% - usually associated with
diagnostic uncertainty and decreases over time
DEPRESSION

Common Symptoms
 Feelings of helplessness and hopelessness
 Loss of interest in daily activities.
 Appetite or weight changes
 Sleep changes
 Psychomotor agitation or retardation
 Loss of energy
 Self-loathing
 Concentration problems
DEPRESSION



Self-management strategies
 Schedule in activities each day
 Make plans to see supportive friends/family
 Consider joining a support group
 Try a new hobby
 Try activities that make you think (this will help with
your recovery too!)
 Stay away from drugs/alcohol
 Exercise (e.g., go for a short walk)
Referral to a Clinical Psychologist
Psychotherapy
DEPRESSION
RISK OF SUICIDE
When feelings of depression are severe, it is important for
family members/friends to be aware of suicide risk.
If your family member/friend talks about wanting to end
their life or makes statements such as "It would have been
better if I had died" he/she may be thinking about suicide.
It is important not to ignore these comments and to contact
a member of the healthcare team immediately.
For support from the mental health crisis team (available 24 hours a day all
week) Call 1-877-435-7170 (MANITOBA SUICIDE LINE)
FATIGUE

Why does MS cause fatigue?

The brain has to work harder to
do the same activities it did
before. Because the brain has to
work so hard, it can become
tired more quickly.

The brain may be trying to heal
as you recover from a relapse
and this takes more energy than
usual, which can lead to fatigue.

MS can lead to problems with
sleeping, which can leave you
feeling exhausted.
FATIGUE
When you have fatigue, you may feel suddenly exhausted and lack the energy to do
basic tasks.
Mental Fatigue
Increased forgetfulness
Lack of motivation to plan your day
Lack of interest in things you enjoy
Withdrawal
Slower speech
Giving short answers in a quiet/dull voice
Increased irritability or anxiety
Slurred speech
Difficulty finding words
Poor concentration
Physical Fatigue
Shortness of breath
Slower movement
Withdrawal
Cramps or weak muscles
Poor coordination or balance
Falls
Poor vision
FATIGUE
It can help to figure out what triggers your
fatigue, and how long it takes you to become
fatigued.
Keeping track of these factors can help you
tailor coping strategies to suit you best.
Once you know how fatigue affects you,
there are a number of strategies that can be
used to help you manage the fatigue that so
often results from a brain injury.
What makes fatigue worse?
• Doing too many things.
• Not taking breaks during the day.
• Stress
• Illness
• Too little exercise.
• Poor nutrition, such as eating junk food.
• Alcohol and caffeine
• Feeling depressed or anxious.
• Poor sleep.
FATIGUE
What are some strategies that can make fatigue better?
1. Following a Routine
2. Environmental aids
3. Timing of activities
4. Pace Yourself
5. Sleep
6. Eat properly
7. Exercise your body
8. Exercise your mind
9. Plan ahead
10.Seek support
How to cope with Fatigue
When should you ask for help?
Talk with someone on your health care team if…..
You are having trouble using strategies to cope with fatigue
Your fatigue gets worse over time
You are too fatigued to get out of bed during the day
You have trouble sleeping and aren't functioning properly
You feel sadness and lack of motivation along with fatigue
You are having trouble taking care of yourself
Your ability to think through daily activities is affected by
fatigue
PAIN

Like emotional difficulties, pain can negatively
impact cognitive functioning by:
 Stealing
one’s attention/focus
 Reducing processing speed
 Attention and processing speed deficits can
negatively impact memory
 Exacerbating psychological and
emotional difficulties
PAIN

Coping strategies
 Psychotherapy
 Relaxation
strategies
Abdominal breathing
 Imagery
 Progressive muscle
relaxation

 Cognitive
restructuring
 Behavior management
Planning
 Prioritizing
 Pacing
 Learning how to
communicate about pain

FINAL CONSIDERATIONS

Potential obstacles to successful interventions
 Diminished
insight
 Poor engagement/motivation to change
 Significantly compromised cognitive functioning
 Poor generalization
Sohlberg & Mateer (2001)
FINAL CONSIDERATIONS

-
Solutions
Include significant others
Build generalization into the treatment program.
- Collaborative relationship with the patient and
family
- Homework
- Real world examples
- Work with patient to identify barriers to complete
homework
- Over-learning
- Relapse planning and management
Sohlberg & Mateer (2001)