Transcript The Anxiety Disorders Some Practical Questions & Answers

The Chronic Pain
Patient
Ten Practical Psychiatric Perspectives
A Presentation for SOMC Medical Education
Kendall L. Stewart, MD, MBA, DFAPA
October 15, 2010
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These are among the most frustrating patients you will encounter.
to the conventional wisdom, they can also be among your most grateful and gratifying patients.
2Contrary
Why is this important?1
• This is a huge medical problem.
• Chronic pain is among the most
common reasons patients visit
physicians.
• This is the third largest health
care problem in the world.
• More than 60 million Americans
suffer from chronic pain.
• And its treatment leads to all
kinds of other problems.
• You will see many of these
patients, and they will frustrate
you enormously.
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• After listening to this
presentation, you will be able to
answer the following questions:
– Why is this issue so important?
– What practical psychiatric
perspectives will assist you in
managing these challenging
patients?
– How can you implement these
perspectives in your clinical
practice?
– What are some of the treatment
challenges?1
• Your ability to integrate these
practical perspectives in your
clinical practice will enhance
your effectiveness.
Click on the hyperlinks in the presentation for additional information.
What are some practical psychiatric
perspectives on managing chronic pain?
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Ask whether the patient is confident that
nothing has been missed.
2. Remember the “soma to psyche”
connection.
3. Leave the drug management to the
experts—unless you are one.
4. Suggest regular visits.
5. Monitor drug usage carefully.
6. Recommend appropriate daily exercise.
7. Encourage healthy distractions.
8. Teach progressive relaxation.
9. Suggest sensory override techniques
10. Encourage positive addictions.
Ask whether the patient is confident that
nothing has been missed.
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So long as your patient believes
something has been missed, you
cannot begin working on the goal of
living with the pain.
Many of our patients like to go to
the Cleveland Clinic for a second
opinion.
You will be humbled by the number
of times consultants will find
something significant that you have
missed.
New findings rarely produce a cure.
But a comprehensive examination
often provides an enabling sense of
closure.
A local surgeon diagnosed diverticulitis and recommended surgery.
Remember the “soma to psyche”
connection.
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Begin with the genuine
acknowledgement that the patient
is suffering.
Remind them that you are there to
help them “live with” their pain.
After you have convinced the
patient that you believe the pain is
real, begin to tentatively explore
the painful emotions that may be
contributing to the pain experience.
When your conversations are
confined mostly to the psychic pain,
avoid going back to the physical
symptoms except to briefly
document the intensity of the pain.
An elderly woman came in with the complaint that her head was burning.
Leave the drug management to the
experts—unless you are one.
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This complex medical management is
best left to one physician.
Clarify your role up front.1,2,3
Invite the patient to make an
informed decision.
Make a commitment to the
prescribing physician that you will
not prescribe.
Then inform the patient of your
commitment.
When they test you—and they will—
remind them of this commitment and
their previous agreement.
Do this before you get frustrated and resentful.
colleague of mine promised to call his patient every evening.
3Then he moved away and left the patient to me.
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Suggest regular visits.
• These patients often feel their
physicians don’t take them
seriously.
• They feel shunted to other
specialists.
• They want a physicians they can
depend on.1,2,3
• Seeing the doctor too frequently
often becomes their positive
addiction.
• Their visits to the doctor are often
their principal social outlets.
I routinely now ask my patients when they would like to return.
change the frequency depending on what is going on in their lives.
3I reassure them that they can always call.
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Monitor drug usage carefully.
• Ask your patients to keep a
medication diary.
• Ask to see this at every visit.
• Inquire about side effects.
• Communication about what you
learn and observe with the other
physicians on the team.
• This patients will sometimes ask
you not to communicate with
their other physicians.
• Don’t agree to this condition.1,2
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Never, ever agree to confidentiality beforehand.
borderline patient once asked me to keep her pill stash for her.
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Recommend appropriate daily
exercise.
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This remains a hard sell, but we
must keep selling it.
Those physicians who exercise
regularly themselves are more likely
to recommend exercise to their
patients, and they are more credible
persuaders.
People with chronic back pain are
very likely to overdo exercise at
times.
Daily exercise works best.
Combining exercise with some other
enjoyable activity is critical.1,2
I exercise two hours every day.
combine exercise with thinking, classical music, reading my Kindle, and watching the news.
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Encourage healthy distractions.
• Healthy distractions
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Television1
Reading
Music
Facebook™
Productive activities
• Unhealthy distractions
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Alcohol
Pain medications
Rumination
Complaining
Eating
Consumptive activities
When my mother’s television went off, her pain increased dramatically.
Teach progressive relaxation.
• This simple exercise is highly
effective.1
• It works best if you make a
recording for your patient the
first time.
• It is easily combined with
meditation and self-hypnosis.
• Some people will become
highly agitated due to a fear of
loss of control.
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This is also a great way to put yourself to sleep.
Suggest sensory override techniques.
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Heating pad
Heating rubs
Local cold compresses
Hot bath
Loud music1
Vigorous exercise
Sex
Deep tissue massage
Other strong sensory experiences
My schizophrenic patients often drown out the voices this way.
Encourage positive addictions.
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Self-help groups can be very helpful—
especially for recovering patients.1
Religious people who worship regularly
clearly lead more healthy, satisfying
lives.
A consuming passion for serving others
is the best positive addiction.
Some demanding hobbies such as coupon
clipping, scrapbooking and genealogy
can serve as positive addictions.
Passions that produce strong negative
emotions such as spectator sports or
politics are not as helpful.
Those who become consumed with helping others are most likely to succeed.
The Psychiatric Interview
A Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process
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Introduce yourself using AIDET1.
Sit down.
Make me comfortable by asking some
routine demographic questions.
Ask me to list all of problems and
concerns.
Using my problem list as a guide, ask me
clarifying questions about my current
illness(es).
Using evidence-based diagnostic criteria,
make accurate preliminary diagnoses.
Ask about my past psychiatric history.
Ask about my family and social histories.
Clarify my pertinent medical history.
Perform an appropriate mental status
examination.
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Review my laboratory data and other
available records.
Tell me what diagnoses you have
made.
Reassure me.
Outline your recommended treatment
plan while making sure that I
understand.
Repeatedly invite my clarifying
questions.
Be patient with me.
Provide me with the appropriate
educational resources.
Invite me to call you with any
additional questions I may have.
Make a follow up appointment.
Communicate with my other
physicians.
Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment.
Explain what is going to happen next. Thank your patients for the opportunity to serve them.
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Where can you learn more?
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American Psychiatric Association, Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition, Text Revision, 2000
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical
Psychiatry, Third Edition, 20081
Flaherty, AH, and Rost, NS, The Massachusetts Handbook of
Neurology, April 20072
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry
Clerkship, Second Edition, March 2005
Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and
Review, Twelfth Edition, March 20093
Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the
Brain, January 2008
Median, John, Brain Rules: 12 Principles for Surviving and Thriving
at Home, Work and School, February 2008
Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous
Patients,” 2000
Jacobson and Jacobson, Psychiatric Secrets, 2nd Edition, 2001
Where can you find evidence-based
information about mental disorders?1
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Explore the site maintained by the organization where evidence-based
medicine began at McMaster University here.
Sign up for the Medscape Best Evidence Newsletters in the specialties
of your choice here.
Subscribe to Evidence-Based Mental Health and search a database at
the National Registry of Evidence-Based Programs and Practices
maintained by the Substance Abuse and Mental Health Services
Administration here.
Explore a limited but useful database of mental health practices that have
been "blessed" as evidence-based by various academic, administrative and
advocacy groups collected by the Iowa Consortium for Mental Health here.
Download this presentation and related presentations and white papers at
www.KendallLStewartMD.com.
Learn more about Southern Ohio Medical Center and the job opportunities
there at www.SOMC.org.
How can you contact me?1
Kendall L. Stewart, M.D.
VPMA and Chief Medical Officer
Southern Ohio Medical Center
Chairman & CEO
The SOMC Medical Care Foundation, Inc.
1805 27th Street
Waller Building
Suite B01
Portsmouth, Ohio 45662
740.356.8153
[email protected]
[email protected]
www.somc.org
www.KendallLStewartMD.com
1Speaking
and consultation fees benefit the SOMC Endowment Fund.
Are there other questions?
Sarah Porter, DO
SOMC FP 2006
www.somc.org
Kevin Kammler, DO
OUCOM 1993
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