Transcript Psychology of Persistent Pain

Psychology of Persistent Pain
Putting Pain in Perspective
Pain defined
• “ An unpleasant
sensory and
emotional
experience
associated with
actual or potential
tissue damage, or
described in terms of
such damage.”
International Association for the Study of Pain , 1994
Subjectivity of Pain
•Pain is always a subjective
experience
•Everyone learns the
meaning of “pain” through
experiences usually related
to injuries in early life
Dimensions of Chronic Pain
Loneliness
Hostility
Social Factors
Anxiety
Depression
Psychological Factors
Pathological Process
Physical Factors
A.G. Lipman, Cancer Nursing, 2:39, 1980
Is pain a learned behavior?
• William Fordyce - Operant conditioning model
• Pain behaviour is rewarded by
– solicitous attention
– not having to work
– access to drugs
• To treat need to: ignore pain behavior, reward
non-pain behavior (e.g. physical activity)
Fordyce WE. Behavioral methods in chronic pain and illness. St. Louis: Mosby; 1976.
Biobehavioral Model
Cultural and spiritual factors
Physiological/pathological
Tissue injury
Pre-dispositional
Factors
Social factors
Pain perceptions
Behavioral factors
Neuroplasticity/central
sensitization
Psychological factors
Functional outcomes
Fear Avoidance Model
Fear of Pain and Re-injury
• Fear of pain, movement, or re-injury thought to lead
to avoidance behaviors and hyper-vigilance to pain
Disability
Social & Environmental Factors
• Environmental responses to pain behaviors
can inadvertently reinforce pain & disability.
• There are several examples of reinforcements:
– Attention and affection from partner/caregivers
– Attention from health care provider(s)
– Pain medication
– Financial incentives/disincentives
Cognitive Factors
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Beliefs about Pain
Readiness to Change
Self-Efficacy
Cognitive Coping Skills
Cognitive Errors
Cognitive Errors
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Catastrophizing
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Dichotomous Thinking
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Overgeneralization:
Cognitive Errors
• Selective Abstraction
• “Should” statements
• Entitlement Fallacy
Personality Styles
• High needs for Perfectionism, Control, and/or
Approval from others
• Intolerance of Uncertainty
• Extroversion is associated with higher pain
thresholds
• External Locus of Control vs. Internal
• Experiential Avoidance
• Psychological Inflexibility
• A Heightened Sense of Entitlement
Comorbidities and pain
• Anxiety/Fear (25%-50%)
• Anger and Frustration
(50%-80%)
• Insomnia (50%-80%)
• Medication Misuse
• Sexual Dysfunction
• Family Dysfunction
Depression and Pain
• Depression is common in patients who
experience persistent pain
• Degree of depression is also greater in
patients who rate their pain higher
Fishbain, D. A., Cutler, R., Rosomoff, H. L., & Rosomoff, R. S. (1997). Chronic
pain-associated depression: antecedent or consequence of chronic pain? A
review. Clin.J Pain 13, 116-137.
OR
Fishbain, D. A., Cutler, R., Rosomoff, H. L., & Rosomoff, R. S. (1997). Chronic painassociated depression: antecedent or consequence of chronic pain? A review. Clin.J
Pain 13, 116-137.
Treatment – Psychological Approach
Cognitive Behavioral Treatment
(CBT)
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Mindful Meditation
Education/Motivational Enhancement
Goal Setting (Realistic Expectations)
Relaxation/Imagery
Hypnosis/Distraction
Biofeedback
Correcting Cognitive Errors
Graded Activity Exposure (Behavioural Activation)
Mindfulness Defined
• “The awareness that emerges through paying
attention on purpose, in the present moment,
and non-judgmentally to the unfolding of
experience moment to moment.”
• Kabat-Zinn, 2003.
The clinical use of mindfulness meditation for the selfregulation of chronic pain.
Kabat-Zinn J, Lipworth L, Burney R.
Ninety chronic pain patients were trained in mindfulness meditation in a 10week Stress Reduction and Relaxation Program. Statistically significant
reductions were observed in measures of present-moment pain, negative
body image, inhibition of activity by pain, symptoms, mood disturbance,
and psychological symptomatology, including anxiety and depression. Painrelated drug utilization decreased and activity levels and feelings of selfesteem increased. Improvement appeared to be independent of gender,
source of referral, and type of pain. A comparison group of pain patients did
not show significant improvement on these measures after traditional
treatment protocols. At follow-up, the improvements observed during the
meditation training were maintained up to 15 months post-meditation
training for all measures except present-moment pain. The majority of
subjects reported continued high compliance with the meditation practice as
part of their daily lives. The relationship of mindfulness meditation to other
psychological methods for chronic pain control is discussed.
J Behav Med. 1985 Jun;8(2):163-90.
Being Mindful - Jon Kabat-Zinn
• Mindfulness creates space around our pain,
allowing us to work with it without being
overwhelmed.
Mindfully Working with Pain
3 Basic Strategies for Working with Pain:
1. focusing on the pain
2. focusing on the mental and emotional reactions to
the pain
3. focusing away from the pain onto something
soothing and pleasant
Mindfully Working with Pain
Methods:
 Free-Floating with the Discomfort
 Breath Pleasure
 Relaxing with Out Breath
 Pleasure of O2 Entering the Body
Acute exacerbation of pain- CBT
management
• Provide information
• Relaxation Techniques including
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Breathing
PMR (progressive muscle relaxation)
Imagery
Hypnosis
• Cognitive (i.e., Positive Coping Self- Statements,
Distraction, Sensory Focus)
Relaxation video – Guided Imagery
http://www.healingchronicpain.org/content/re
lax/default.asp
Progressive
Relaxation
Guided Imagery
CBT – Chronic Pain Management
• Teach Activity-Rest
Cycling (Pacing)
• Patients learn that
activity causes pain
• Pain and suffering
increase over time
• Activity decreases over
time
CBT – Chronic Pain Management
• Time-Contingent Medication Use
• Relapse Prevention
• Acceptance (e.g., Mindfulness Meditation)
• Couples/Family Communication Therapy
• Treat Co-morbid Conditions
Motivate Self management
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Maintain Respect for the Dignity of the Patient
Defuse Myths about Chronic Pain
Avoid “Psychologizing” the Problem
“Listen” and Avoid Power Struggles
Communicate Understanding in the Reality of
Pain Experience
Motivating Self management
• Introduce a Model (eg., Gate Control)
• Encourage Realistic Expectations
– (eg., 50% pain reduction, improved daily function,
etc.)
• Get a Commitment from the Patient
• Collaborate With the Patient Against “it”
Avoid these messages to the client
• Let pain be your guide
• The pain is being caused by psychological
factors
• The pain is not real – there is no reason for
your pain
Messages to Give Clients
• Pain can cause suffering
• Can’t always change pain, but you can reduce
suffering
• Reducing suffering and pain behavior can lead
to reduced pain
“Pain may be inevitable but misery is optional”
Dee Malchow, RN, amputee