Transcript Slide 1
Mind, body and relationships: treating pain in context Dr Kasia Kozlowska The Department of Psychological Medicine The Children’s Hospital at Westmead The Brain Dynamics Centre, Westmead Hospital The University of Sydney What the talk is about How pain physicians might translate medical information into a psychological formulation The key issues from abstract: • Life events and relationship experiences fine-tune the body’s stress-response system. • Repeated activation of the stressresponse system altered responsiveness • NOT “All in the head” physician psychiatrist Case • Susan • 15yr old girl • Seven year history or recurring left foot pain, recurring whole body pain, headaches, sensory loss in both legs, gastric discomfort and a sensation of having a “floating body”. 72 Heart disease Died from surgical complications of routine surgery 9yrs before Heart disease Died of stroke 16yrs before. Rheumatoid arthritis 47 45 Breast Cancer Died 17m’s before Breast Cancer in remission Mr Stephens Kidney Cancer 7yrs before IgA Nephropathy 4yrs before Steroid Induced Mania 4yrs before Ischemic heart disease 4yrs before Gout 15 10 Susan Pain for 7yrs Home schooling 3m’s Mary Separation anxiety Mrs Stephens What does this medical history alert you to? Susan and her family have been exposed to a large number of cumulative life events. Are any of these life events important? • Is there a temporal relationship between the life events and the pain • Is there a psychological relationship between the life events and the pain (psychological salience) Symptom story Life story Relationship between them Symptom story • 8yrs and 11 months (Yr 2 school) • Painful leg • CRPS Life story Symptom story Life story • 7yrs death grandfather • 8yrs 11 months • Painful leg • CPRS? • 8yrs Aunt diagnosed with Breast Cancer (now in remission) • Father diagnosed with Kidney Cancer surgery complications • “Horrible rental accommodation (Susan’s words) • Susan moves school, fails to make friends and becomes isolated Are any of these life events important? • Is there a temporal relationship between the life events and the pain • Is there a psychological relationship between the life events and the pain (psychological salience) Symptom story Life story • 7yrs death grandfather • 8yrs 11 months • Painful leg • CPRS? • 8yrs Aunt diagnosed with Breast Cancer (now in remission) • Father diagnosed with Kidney Cancer surgery complications • “Horrible rental accommodation (Susan’s words) • Susan moves school, fails to make friends and becomes isolated Symptom story • 10yrs • Recurrent episodes of pain in her foot and hands • 11yrs • Panic attacks needing therapy • No foot symptoms Life story • 10yrs • High levels of family stress 20 to building a new home • Bully at school and “rejected all the time” • 11yrs Susan’s father becomes very ill - Myocardial infarcts - Vomiting - Uncertain Kidney Diagnoses - Steroids hypomania • Brother – separation anxiety • Mother – anxiety needing therapy Symptom story Life story • 12yrs • 4-5 months foot pain • Father given a good prognosis • Family recovers • Susan’s psychological issues remain unresolved • 13yrs Recurrence foot pain and sympathetic changes • Maternal aunt resides in family home whilst having treatment for metastatic lung cancer • • • • 14yrs Stomach aches Head aches Fluctuating foot pain • Aunt dies Symptom story • 15yrs “body breakdown” • • • • Whole body pains Immobility Depression Leg Pain with sympathetic changes • Sensory loss in her lower legs • Floating body • Home schooling loss of friends Life story • Psychological issues remain unresolved. Providing an explanation The explanation needs to resonate with the family and make sense to them Providing an explanation Making a link between the pain and physical and emotional injuries and threats Providing an explanation Susan’s body was manifesting stress symptoms, because her body was unable to manage the sheer number and relentlessness of the stressful life events. Providing an explanation: Medical Jargon • • • • Conversion Disorder Anxiety Disorder Depression CRPS Psychological Organisation – Inhibitory Strategy • Inhibiting subjective awareness of one’s own feelings of pain and distress • Inhibition of body signals of pain and distress – Susan inhibited body expression of pain. • Concomitant use of false positive affect. • Awareness of other’s distress, and caregiving behaviour to alleviate their distress (but not one’s own). Providing an explanation Inhibition of body expression and subjective awareness of feelings The body pays the cost Explaining the Treatment • • • • • • Physiotherapy program Simple analgesia Antidepressant Individual psychological work Family work Attendance at school Outcome takes time • Sick for seven years • Recovery took more than two years of intensive physical and psychological interventions Psychological organisation in a pain cohort • 49 children • 35 girls, 14 boys • Aged 4.25-16.9 years (mean 12.5years) Type B developmental pathway (balanced or secure attachment) • Parent is predictable and comforting • The child signals pain and distress directly and openly • Parents name body signals and make feelings explicit • Children learn to identify, name, and mange positive and negative feelings Type A Developmental pathway : an inhibitory strategy • Inhibition of body signals of pain and negative affect • Silencing of the body • ‘True’ body and emotional state is not seen and is not put into words. • Poor emotional language and lack of emotional skills for negative affects Type C developmental pathway: a coercive strategy • Exaggerated displays of negative affect • Alternated with appeasement displays • Focus on the self • Use of coercion The art of medicine Can we engage them the ‘good’ compliant pain patient (Type A)? And the coercive patient? Complexities of the chronic presentation • • • • • Secondary gain Unhelpful relationship pattens Unhelpful family behaviours Physical deconditioning Loss of hope