Transcript Pain Management A Biopsychosocial Approach

Psychological Assessment and
Treatment of Pain
Matthew Bailly, Ph.D., C.Psych.
Department of Clinical Health Psychology
University of Manitoba School of Medicine
Acute Pain
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Characterized by intense, temporary noxious
sensations and is related to tissue damage
For patients that do not experience adequate
analgesia, can lead to chronic pain
Important to provide effective pharmacological
analgesia as soon as possible during, or even
before, an acute pain episode
Acute Pain
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Pain can be accompanied by anxiety, stress, and
physical tension, which can exacerbate and/or
prolong the acute pain episode
These additional factors should also be
addressed as soon as possible
A number of psychological strategies can be
used to help patients cope with these, as well as
thoughts and emotions that may increase
physiological arousal and reduce the patients’
sense of control
Pain Education
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Patients should be given as much information as
possible about care provided, if possible before
any procedures
Patients should also be educated in using their
analgesics appropriately
An emphasis should be placed on taking
medications as scheduled, not only when pain
emerges, and patients’ concerns regarding side
effects, including any addiction potential, should
be addressed
Diaphragmatic Breathing
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Inform patients that physiological arousal can increase
pain signals, and that relaxation strategies can reduce
this arousal
Ask patients to assume a comfortable position and to
place one hand over their abdomen
Instruct patients to inhale deeply through their nose,
bringing air into the bottom of their lungs, then to
exhale through their mouth
Repeat this for two or three breaths, then request that
they practice this regularly, for three to five minutes at a
time
Distraction
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Tell patients that although strong, pain signals are one
of many possible sensations that they may notice at any
given moment, and that actively distracting from the
signal may provide some relief
Ask patients to gently guide their attention to another
stimulus, such as television, music, reading, simple
puzzles, or conversations with supportive
family/friends
Encourage patients to imagine a preferred place or
situation where they feel calm and relaxed, in as much
detail as possible, pulling in all of their senses, including
sights, sounds, smells, touch, and taste
Self-Coaching
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Discuss the role of thoughts on patients’ sense
of coping with pain, and their relationship to
physiological arousal
Encourage patients to generate and practice
positive self-talk that emphasizes their ability to
cope with the pain
Patients should also be reassured that the pain
episode is of limited duration, and that they can
remind themselves that it will pass
Definition of Chronic Pain
(International Association for the Study of Pain)
An unpleasant sensory or emotional
experience resulting from actual or
potential tissue damage lasting beyond the
usual course of the acute disease or
expected time of healing
Elements of Chronic Pain
(Fordyce, 1988)
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Nociception – mechanical, thermal, or chemical energy
impinging on specialized nerve endings that signal
aversion to the CNS
Pain – sensation arising from stimulation of perceived
nociception
Suffering – affective or emotional response triggered by
nociception or other aversive events
Pain behaviour – responses made to pain and suffering
Biopsychosocial Model
(Gatchel & Turk, 2002)
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Unfortunately, many patients still view pain in
terms of physical disease
Sees chronic pain as not just disease, but as an
“illness”
Pain seen as an ongoing, multifactorial process
Relative weighting of the contributions of
physical, psychological, and social factors change
over time
Biopsychosocial Model
(Gatchel & Turk, 2002)
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Sociocultural factors include illness beliefs,
expectations, healthcare seeking and availability
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Involves social and operant learning
Cognitive factors include thoughts about
controllability of pain, self-efficacy, cognitive
errors, and coping ability
Affective factors include levels of depression,
anxiety, anger
Biopsychosocial Model
(Gatchel & Turk, 2002)
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Personality factors include interpersonal sensitivity,
fearful appraisals of bodily sensations, bodily
preoccupation and catastrophic thinking
The above factors act indirectly on pain and disability
by reducing physical activity, muscle flexibility, tone, and
strength, and physical endurance
Direct effects include increased sympathetic nervous
system arousal, endogenous opioid production, and
elevated levels of muscle tension
Consequences for the Individual and Others
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Vocational
Financial
Health care use
“Systems” issues
Functional impairment
Interpersonal
dysfunction
Mood and anxiety
disturbance
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Increased responsibility
for family members
Health care provider
frustration
Increased health care
costs
Increased social service
costs
Reduced work
productivity
Factors Complicating Chronic Pain
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Substance abuse
History of mental disorder
Trauma
Chronic illness
Family discord
Grief
Systems issues
Legal concerns
Financial issues
Multicultural issues
Psychological Treatment
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Currently no treatment that consistently and
permanently alleviates pain for all patients
Management of chronic pain often depends on the
readiness and abilities of the client
Primary goal is to improve function rather than alleviate
pain
Effective management is achieved most readily using a
multidisciplinary approach (Turk and Stieg, 1987)
Should be customized to the patient (Turk, 1990)
Treatment varies, but is usually planned for about 10 to
12 sessions
Psychological Treatment
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An active, time-limited treatment, with patients
guiding their own progress rather than passively
receiving care
For patients that are not candidates for
treatment, a consultative resource to facilitate
existing treatment
Assessment and treatment emphasizes a
biopsychosocial model
Patients Likely to Benefit from
Psychological Treatment
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Pain is considered to be the chief concern
Patient understands what psychology can offer,
and agrees to pursue assessment and/or
treatment
Patient is assumed to be motivated and capable
of maintaining regular involvement with
appointments and skill acquisition
Patients Unlikely to Benefit from
Psychological Treatment
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Psychological factors are obviously a primary
concern
Patient understands what psychology can offer,
but maintains a unidimensional view of pain
Patient is unmotivated/resistant, or experiencing
too much distress (relationship distress,
substance abuse) to maintain regular
involvement with treatment
Typical Patient
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It is not understood what degree psychological
factors play a role
Patient agrees to pursue assessment and/or
treatment, but may need more education
regarding what psychology can provide
Patient may or may not receive treatment,
depending on the assessment
Diagnostic Interview
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Typically uses one or two 1-hour sessions
Includes obtaining a history of the presenting
problem and a brief medical and psychological
history, followed by an assessment of
functioning within the following domains…
•Educational and vocational
•Social and recreational
•Family, including brief developmental history
•Mental status and current psychological functioning
Formal Assessment
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Not always needed, but dependent on referral
question and presenting problem
Typically involves administration of instruments
measuring personality, impact of illness, coping,
beliefs and expectations about pain and injury,
and psychological distress
May be completed in one or two 1-hour testing
sessions
Psychological Treatment
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Currently no treatment that consistently and
permanently alleviates pain for all patients
Management of chronic pain often depends on the
readiness and abilities of the client (Jensen et al., 2003)
Primary goal is to improve function rather than alleviate
pain
Effective management is achieved most readily using a
multidisciplinary approach (Turk and Stieg, 1987)
Should be customized to the patient (Turk, 1990)
Treatment varies, but is usually planned for about 10 to
12 sessions
Psychological Treatment
(Turk, 2002)
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Problem-oriented
Educational
Collaborative
Uses clinic and home practice for skill-building
Encourages expression and management of feelings
that impair rehabilitation
Addresses relationships among thoughts, feelings,
behaviour, and physiology
Anticipates setbacks and teaches clients how to manage
these
Psychological Treatment
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Involves evaluating and correcting maladaptive beliefs,
appraisals, and schemas to alleviate mood symptoms and
increase coping behaviour
Training in relaxation techniques, such as abdominal
breathing, visualization, and progressive muscle relaxation
to reduce anxiety that typically magnifies pain signals
Treatment attempts to increase behaviours associated with
pain self-management, such as adaptive coping, exercise
program participation, and improved communication with
providers
Focuses on increasing self-efficacy
References
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Fordyce, W. (1988). Pain and suffering: a reappraisal.
American Psychologist, 43, 276-283.
Jensen, M., Nielson, W., Turner, J., Romano, J., and Hill,
M. (2003). Readiness to self-manage pain is associated
with coping and with psychological and physical
functioning among patients with chronic pain. Pain,
104, 529-537.
Turk, D. (2002). A cognitive-behavioral perspective on
treatment of chronic pain patients. In Gatchel, R. &
Turk, D. (Eds.) Psychological Approaches to Pain
Management: A Practitioners Handbook. New York, The
Guilford Press.
References
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Turk, D. & Monarch, E. (2002). Biopsychosocial
perspective on chronic pain. In Gatchel, R. & Turk, D.
(Eds.) Psychological Approaches to Pain Management: A
Practitioners Handbook. New York: The Guilford Press.
Turk, D. (1990). Customizing treatment for chronic
pain patients: who, what, and why. Clinical Journal of
Pain, 6, 255-270.
Turk, D., & Stieg, (1987). Chronic pain: the necessity
of interdisciplinary communication. The Clinical Journal
of Pain, 3, 163-167.