Transcript Folie 1 - International Pain School

International Pain School
Psychological aspects
of managing pain
Theoretical issues and clinical implications
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Objectives
• Provide brief history of pain concepts
• Overview basic principles of psychological variables
involved in acute and chronic pain
• Present clinical implications of psychological
assessment and intervention in treatment outcome for
acute and chronic pain
• Provide applicable psychological interventions
Simplistic and holistic concepts
of pain perception
©2008 by American Physiological Society
Bingel, U. , Tracey, I. (2008). Imaging CNS modulation of pain in humans. Physiology, 23, 371-380.
Acute Pain
First Part
Content
• Definition
• Neurophysiological basic principles of pain experience
and psychological modulation of pain perception
• Case report: post-operative pain
• Psychological mechanisms of pain maintenance
• Assessment of psychosocial risk factors
• Psychological interventions
Pain experience
• IASP Definition: pain is an unpleasant sensory
and emotional experience associated with actual
or potential tissue damage or described in terms
of such damage
• Acute pain has a warning protective function
for the organism
Dimensions of pain perception
• Pain perception integrates following dimensions:
– sensory - discriminative:
where in the body and what characteristics?
– affective - motivational:
pain is unpleasant emotion, move or rest?
– cognitive - evaluative:
which protecting actions or strategies to be taken?
Central nervous system control of pain
experience - ascending pain pathway
Control of sensory dimension and
bodily sensations:
touch, temperature, pressure
e.g. „pain has pulsing characteristic“
(SI, SII, somatosensory cortex)
Control of affective dimension and
emotional response:
e.g. „pain is cruel feeling“
(ACC, anterior cingulate cortex)
Control of cognitive dimension:
beliefs, evaluations, decision-making:
e.g. „“pain is unbearable“
(PFC, prefrontal cortex)
Schweinhardt, P. & Bushnell, M. C. (2010). Pain imaging in health and disease
— how far have we come? Journal of Clinical Investigation, 120, 3788–3797.
Central nervous system control of pain
experience- descending pain pathway
Brain areas underlying
emotional (ACC, anterior cingulate cortex,
amygdala) and cognitive processing
(PFC, prefrontal cortex) send modulating
impulses to
Brainstem, which than modulates
nociceptive input at
Spinal cord
Tracey, I., & Mantyh, P. W. (2007). The cerebral signature for pain perception
and its modulation. Neuron, 55, 377-391.
Modulation of pain experience by
psychological factors
• Following factors decrease pain intensity
– Expectation that stimulus will not hurt
– Placebo, expecting that treatment will reduce pain
– Distraction, focusing away during anticipation of
painful stimulation or during stimulation itself
– Sense of control over situation “I can do something”
– Elevated mood, positive emotions, feeling satisfied
– Hypnotic suggestions about low intensity or low
unpleasantness of painful stimulus: hypnoanalgesia
Modulation of pain experience by
psychological factors
• Following factors increase pain intensity:
– Expectation that stimulus will hurt
– Nocebo, contrary to placebo, expecting that
treatment will hurt
– Attention and hypervigilance to painful stimulus
– Loss of sense of control over pain “I can’t do
anything against pain”
– Catastrophising, exaggerated expectation that the
worst will happen
– Fear from pain, feeling helpless, anxiety, depressive
mood, or anger
Excursus: Common neuroanatomical
basis of physical and social pain input
• Brain research shows that:
• Social exclusion and rejection triggers activity of
pain-processing brain areas
• Social pain “hurts” similarly to physical pain
Eisenberger, N.I. & Lieberman, M.D. (2004). Why rejection hurts: a common neural
alarm system for physical and social pain. Trends in Cogivitive Sciences, 8, 294–300.
Case report
post-operative pain
• Ms. L. 34 years old, professional dancer
• Sudden strong pain in left meniscus, then surgery
• Fear of surgery and of remaining
“handicapped for the rest of life”.
• Fear losing job and not finding new one if she “can’t
move a leg”.
• Fear friends will not want her anymore
• Fear become a burden for the family, “a worthless
invalid”.
Case continued
• Surgery “went fine” but “might experience pain for a
couple of weeks”
• She observes her pain: “it is not going away, it is
becoming worst”, than emotionally distressed.
• Anxiety “something went wrong during that surgery”,
“meniscus is not recovering”
• Avoids movement to not make her pain worst
• Belief “none wants to see me like this”
• Withdraws from friends and colleges.
Psychological signature: transition
from acute to chronic pain
• Acute pain
• Psychological mechanisms increase pain perception at
pain onset (e. g. anxiety before surgery).
• They interfere with top-down inhibition and increase pain
perception.
• Transition from acute to chronic pain
• Psychological mechanisms maintain pain:
• Maladaptive coping: resignation, helpless, “I can do nothing
about my pain”, avoidance behavior and lack of movement
• Mental disorders: anxiety disorder, depression,
posttraumatic stress disorder
The fear-avoidance model
of chronic pain
Asmundson, G.J., Norton, P.J., & Vlaeyen, J.W.S.(2004). Fear-avoidance models of
chronic pain: An overview. In G. J. Asmundson, J.W.S. Vlaeyen, & G. Crombez (Eds.),
Understanding and treating fear of pain (pp.3–24), Oxford: Oxford University Press.
Ms. L.: maladaptive strategies at pain onset
„None wants to see me“
“I am a burden for my family”
Meniscus injury, surgery
No movement
No activity
Observing
„more pain“
„it is not going away, it is getting worst“,
„something went wrong during surgery“
Harm beliefs
„disability“ „handicap“
fear
Assessment of psychosocial risk
factors „yellow flags“
• Attitude: presence of belief that pain is harmful or potentially severely
disabling; catastrophising; expectation that passive treatments rather
than active participation will help
• Behavior: fear-avoidance behavior (avoiding a movement or activity),
withdrawal from social interaction
• Compensation issues: disputes over eligibility
• Diagnosis and treatment - so called “iatrogenic factors”: catastrophising
diagnostic language or confusion by conflicting diagnoses
• Emotion: fear, depressive mood and, anxiety
• Family: over- protective, solicitous or punitive reactions
• Work: work condition, lack of satisfaction, conflicts with
peers or supervisors
Case report continued
Yellow flags for Ms. L.
• Attitude: presence of belief that pain is harmful or
potentially severely disabling; catastrophising
• Behavior: fear-avoidance behaviour (avoiding
movement or activity, withdrawal from social
interaction)
• Emotion: fear, anxiety, depressive mood
How to handle psychosocial
risk factors?
• Address awareness about pain
• Appraise fear
• Advice relaxation techniques
• Advice activity
Psychological interventions
for acute pain
Interventions can be categorized as follows:
1. Information provision
– Provide accurate information about:
– Type of sensation to be experienced
e. g. „stinging“, „sharp“
– Procedure specific to condition
2. Breathing – focused relaxation to reduce arousal
– Instruct deep, slow, patterned breathing - count
breath per minute and / or abdominal breathing
Psychological interventions
for acute pain
3. Cognitive Strategies
• Decatastrophise: educate “catastrophising raises fear
and anxiety”
• Instruct positive self- statements “I can handle this, it
will be over soon”
• Provide distracting stimuli (pictures, music) or mental
tasks (what is the capital of..?)
• Encourage focus on sensation being experienced defocus from emotional aspect of pain
Psychological Interventions by Ms. L.
Interventions
• Provision of information about the applied procedure
• Education about psychological influence on pain
i.e. fear-avoidance model
• Teach relaxation and cognitive techniques,
advise self- practice
• Advice to start gradual physical training, enjoyable
social activity and gradually return to work
Psychological Interventions by Ms. L.
Results
• Improved coping mechanisms
• Reduced pain intensity during the next couple of weeks
• Return to work in the next couple of months
• Improved mood and normal social and familiar
functioning
Chronic Pain
Second Part
Content
• Definition
• Biopsychosocial principles
• Chronic pain and associated psychopathology
• Psychological interventions
• Case report: cancer pain
Chronic pain
• IASP definition “pain that extends beyond the expected
period of healing”
• Min. duration: 3-6 Months
• Chronic pain has lost its protective biological role
• Chronic pain is a complex disease per se with impact at
• Biological, psychological and social level of functioning
Categorization
• Nociceptive: chronic pain as result nociceptive
processes such as inflammation, tumor etc.
• Neuropathic: chronic pain as result of injury at nervous
e.g. carpal tunnel syndrome, CRPS, phantom pain etc.
• Somatoform: persistent pain in absence of underlying
tissue damage or injury
Biopsychosocial Model of Pain
Pain is a multidimensional
experience
Biological
Neurophysiological dysregulation
of pain processing
Chronic pain is a disease per se
with multilevel impairment of
Nociceptive:
functioning
Attitudes,
stress, anxiety,
depression,
prior pain memory
or traumatic
experience
Psychological
Mental disorders
PAIN
tissue injury
Neuropathic: NS injury
Somatoform:
absence of organ / tissue
damage
Life events,
cultural beliefs,
work conditions
or
socioeconomical
status
Social
Social role impairment
Components of psychological therapy
for chronic pain
Motivational interviewing
• modify readiness to change and cope with pain,
“acceptance is not resignation”, motivate to engage in
healthy behaviors
Cognitive behavioral therapy
• increase perceived sense of control over pain, decrease
helplessness, modify harm and fear-avoidance beliefs,
gradual exposure to movement.
Emotional and physiological
• reduce helplessness, depressive mood, fear, anxiety etc.;
increase stress and relaxation management competence.
Chronic pain and associated
psychopathology
Assessment of psychopathology is important because:
• Psychopathology delays successful treatment
outcome of pain
• Pain treatment might fail due to comorbid psychopathology
• Psychopathology increases pain intensity and disability
Most common Comorbid mental disorders:
• Depression
• Anxiety disorders
• Addiction
• Somatoform disorder: pain as psychosomatic condition
Cancer pain
Related issues
• Prevalence of cancer pain among
cancer patients: 50 -90%
• Prevalence of untreated cancer pain: 16-91%
• Cancer pain is strongly associated with emotional distress
• Maladaptive psychological mechanisms enhance pain
experience; persistence of such mechanisms can result in
depression or anxiety disorders
• Anxiety and depression are significantly higher among
cancer patients with pain vs. without pain
Cancer pain
Related issues
• Prevalence of depression among cancer patients: 20-58%
• Undiagnosed or untreated depression reduces
compliance, facilitates disease progression and increases
cancer mortality risk
• Depression can be „hidden“ behind symptoms related to
cancer treatment (e.g. cancer fatigue)
• Appropriate treatment of cancer pain requires
appropriate assessment of emotional distress and
mental disorders i.e. depression
Case report: Cancer Pain
• Mr. B. 53 years old
• Four months ago prostate cancer was diagnosed
• The cancer therapy shows progress as expected,
opioids administration shows no complications.
• Patient reports increased fatigability, difficulty to fall
asleep, generalized weakness, loss of energy,
motivation and pleasure in his daily activities, emotional
distress, memory and concentration problems
Case report: Cancer Pain
Assessment
Patient‘s complains:
• increased fatigue, weakness, loss of energy
• sleep disturbance, decreased motivation, emotional
reactivity with sadness
• short-term memory and concentration disturbance
Case report: Cancer Pain
Assessment
Differential diagnosis cancer-related
fatigue vs. depression:
• does sleep or rest have any influence on fatigue? This
would be atypical for cancer fatigue
• is there any diagnosable depression behind these
symptoms? This excludes automatically cancer- related
fatigue.
Case report: Cancer Pain
Assessment of depression
• further diagnostic interview reveals symptoms that
meet the criteria for a major depressive disorder
according to DSM-IV and do not relate to cancer fatigue:
• depressed mood,
• diminished interest and pleasure in everyday activities,
• decrease in appetite,
• feelings of worthlessness, inappropriate guilt of being
sick, recurrent thoughts of death,
• motor agitation
Case report: Cancer Pain
Assessment of patient’s emotional distress
• How he understands his condition?
• “the cancer is getting worst”
• What pain means to the patient and how it
impacts his mood?
• “Condition is progressing”, feelings of helpless
and hopeless, depressive mood
Case report: Cancer Pain
Assessment of patient’s emotional distress
• Which coping strategies is he applying, how do these
impact his relationship?
• Resignation, feeling of senselessness “it is not worth it
participating, i can anyway do nothing against pain,
none can help, i am a burden for my family”, withdrawal
from common pleasant activities.
Case report: Cancer Pain
Assessment of patient’s emotional distress
• Which psychosocial context pre-existed, history, selfconceptions, any emotional distress, familiar or work
conflicts?
• Upon negative self-image of being worthless the patient
employed silent assumption “I am valuable only when I
accomplish”. Self-efficacy and proving for his family
have been essential means to raise self-esteem.
Children grew up and got married a while ago, he felt
“useless”.
Case report: cancer pain
Assessment of patient’s emotional distress
• Since pain onset loss of sense of control, marked feeling
of being worthless.
Assessment supports the diagnosis of depressive
development since pain onset
Case report: cancer pain
Consequences for add-on- treatment strategies
• Treatment of depression with add- on antidepressant
therapy
• Psychological intervention with maladaptive coping:
• Educate about interaction of depression, emotional
distress and with experience
• Enhance patient’s self- care strategies: resting, applying
relaxation exercise, etc.
• Advise activity and cognitive coping: focusing or
distracting, repeat calm self- statement
Case report: Cancer Pain
Results of add- on- strategies
• Patient’s increase of compliance with opioid
and tumor therapy
• Improved emotional distress and appraisal of pain
• Increased sense of control
• Improved quality of life
Conclusions
• Psychological variables influence processes of pain
Modulation, Maintenance and Management
• Assessment and management of psychological
risk factors improves treatment outcome of acute
and chronic pain
• Psychological interventions can be applied in hospital
and ambulant settings for acute and chronic pain
conditions and
• Require low to moderate psychological expertise and
time recourses
This talk was prepared originally by:
Etleva Gjoni
Tirana, Albania / Berlin, Germany
International Pain School
The talks for the Pain School were written by a faculty of volunteers.
Physiology and pathophysiology of pain
Nilesh Patel, PhD, Kenya
Assessment of pain & taking a pain history
Yohannes Woubished, M.D, Addis Ababa,
Ethiopia
Clinical pharmacology of analgesics
and non-pharmacological treatments
Ramani Vijayan, M.D. Kuala Lumpur, Malaysia
Management of postoperative pain – low technology
treatment methods
Dominique Fletcher, M.D, Garches & Xavier
Lassalle, RN, MSF, Paris, France
Management of postoperative pain– high treatment
technology methods
Narinder Rawal, M.D., PhD, FRCA(Hon),
Orebro, Sweden
Cancer pain– low technology treatment methods
Barbara Kleinmann, MD, Freiburg, Germany
Cancer pain– high technology treatment methods
Jamie Laubisch MD, Justin Baker MD, Doralina
Anghelescu MD, Memphis, USA
Palliative Care
Jamie Laubisch MD, Justin Baker MD,
Memphis, USA
Neuropathic pain - low technology treatment methods
Maija Haanpää, MD, Helsinki & Aki Hietaharju,
MD, Tampere, Finland
Neuropathic pain – high technology treatment methods
Maija Haanpää, M.D., Helsinki & Aki Hietaharju,
M.D., Tampere, Finland
Psychological aspects of managing pain
Etleva Gjoni, Germany
Special Management Challenges: Chronic pain, addiction &
dependence, old age and dementia, obstetrics & lactation
Debra Gordon, RN, DNP, FAAN, Seattle, USA
International Pain School
The project is supported by these organizations: