Transcript Pat Davis The How and the What of Behavioral Health

6th Annual Montana Pain Initiative Conference
University of Montana
5/31/2014
Patrick Davis, PhD
Montana Spine & Pain Center
Providence Health and Services St. Patrick Hospital
Missoula, MT
Patrick Davis, Ph.D.
Has no real or apparent
conflicts of interest to report.
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Jenson & Turk (2014)
 Inadequacy of purely biomedical treatments
 Demonstrated efficacy of behavioral health
interventions
 Behavioral health intervention for chronic pain is a
model for behavioral health intervention for other
chronic health conditions
Specialty Mental Health Professional
or
Primary Care Behavioral Health Consultant
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Resources
 The Primary Care Consultant: The Next Frontier for Psychologists in Hospitals
and Clinics – James & Folen (Eds.)
 American Psychologist Special Issues
▪ Chronic Pain and Psychology (2014) ,Vol 69, No. 2
▪ Primary Care and Psychology (2014), Vol 69, No. 4
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Continuing Education
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Treatment Team Meetings
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Rules: Abbreviations, Content consistent with procedure and diagnostic coding
Timely, Legible, Brevity
Action Oriented
Balance of patient privacy and team need to know (minimum necessary rule)
Flexibility
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Stay above the fray - Don’t form alliances
Documentation
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A & P, etc.
Schedule
Practice habits
Ethical Differences
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Multiple relationships
Patient autonomy v. Paternalism/non-maleficence
1. GOMERS DON'T DIE.
2. GOMERS GO TO GROUND
3. AT A CARDIAC ARREST, THE FIRST PROCEDURE IS TO TAKE
YOUR OWN PULSE.
4. THE PATIENT IS THE ONE WITH THE DISEASE.
5. PLACEMENT COMES FIRST.
6. THERE IS NO BODY CAVITY THAT CANNOT BE REACHED
WITH A #14G NEEDLE AND A GOOD STRONG ARM.
7. AGE + BUN = LASIX DOSE.
8. THEY CAN ALWAYS HURT YOU MORE.
9. THE ONLY GOOD ADMISSION IS A DEAD ADMISSION.
10. IF YOU DON'T TAKE A TEMPERATURE, YOU CAN'T FIND A FEVER.
11. SHOW ME A BMS (Best Medical Student, a student at the Best Medical School) WHO
ONLY TRIPLES MY WORK AND I WILL KISS HIS FEET.
12. IF THE RADIOLOGY RESIDENT AND THE MEDICAL STUDENT BOTH SEE A LESION
ON THE CHEST X-RAY, THERE CAN BE NO LESION THERE.
13. THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS
POSSIBLE.
1.
Schedules are merely guidelines and aspirational.
2.
Notes need to be completed on the same day that the service is provided
whenever possible and no later than the following business day
3.
You may have to provide referring providers with the language they need to ask
you meaningful questions
4.
If it takes more than one minute to read or explain your clinical impressions you
will lose your audience
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Be prepared for the warm handoff
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Learn to translate medical jargon to street speak for patients
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Ask the patient if they understand what the physical medicine provider told them
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Clarify misconceptions
Report of the Interorganizational Work Group on
Competencies for
Primary Care Psychology Practice
March 2013
6 broad core competency domains
Science
Systems
Professionalism
Relationships
Application
Education
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Who is eligible to use these codes?
 Psychologists, nurses, licensed clinical social workers, and other
non-physician health care clinicians whose scope of practice
permits can bill the codes. Physicians performing similar
services should use Evaluation and Management codes.
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Focus of assessment not on mental health but rather on
biopsychosocial factors important to physical health
problems and treatment
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Focus of intervention is to improve the patient’s health
and well-being utilizing cognitive, behavioral, social,
and/or psychophysiological procedures designed to
ameliorate specific disease-related problems
96150
Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations,
psychophysiological monitoring, health-oriented questionnaires, each 15 minutes face-to-face
with the patient; initial assessment.
96151
Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations,
psychophysiological monitoring, health-oriented questionnaires, each 15 minutes face-to-face
with the patient; re-assessment.
96152
Health and behavior intervention, each 15 minutes, face-to-face; individual.
96153
Health and behavior intervention, each 15 minutes, face-to-face; group (2 or more patients).
96154
Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient
present).
96155
Health and behavior intervention, each 15 minutes, face-to-face; family (without the patient
present).
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Childhood Sexual Abuse
Adverse Childhood Experience (ACE) Study
Suboptimal Attachment Dynamics
Adverse Adult Experience
Pain Behavior
Attentional Bias/Somatic Focus
Anxiety
Depression
Affective Distress in Response to Pain
Catastrophizing
Fear/Avoidance
Low Self Efficacy
Irrational Pain-Related Beliefs
Characterological Negative Affectivity/Type D Personality
Psychosocial Stress
Deficient or Maladaptive Coping Strategies
Tobacco Dependency
Suboptimal Sleep
Neuroplastic Change
Posture
Muscle Tension
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Norms in the general population
 15-25% of females and 5-15% of males
▪ Finkelhor (1994)
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Wurtele et al (1990)
 39% of women & 7% of men seeking services for chronic pain
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Finestone et al (2000)
 69% of women in group therapy for survivors of childhood sexual abuse v.
43% of combined control groups (psychiatric outpatients & nurses) reported
chronic pain
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Raphael & Widom (2011)
 Childhood abuse/neglect is associated with future chronic pain only when
PTSD is also present. Recommendation for assessment to “focus on PTSD
rather than broad inquires into past history of childhood abuse or neglect”
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Schofferman et al (1992)
 85% of patients reporting 3/5 types of childhood trauma
had surgery failure v. 5% of those reporting 0/5
▪ Sexual, physical, and/or emotional abuse, abandonment, and
parental substance abuse
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ACE Study
 Emotional abuse, physical abuse, sexual abuse, emotional
neglect, physical neglect, parental separation, domestic
violence, substance abuse, mental illness, prison
▪ http://acestudy.org/
▪ http://www.cdc.gov/ace/index.htm
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Insecure Attachment
 Elevated prevalence of chronic widespread pain
▪ Davies, Macfarlane, McBeth, Morriss, & Dickens, 2009)
 Increased pain reporting and pain-related suffering among
individuals with chronic pain
▪ McDonald & Kingsbury, 2006; McWilliams, Cox, & Enns, 2000;
Meredith, Strong, & Feeney, 2007
 Higher health care utilization among chronic pain patients
▪ Ciechanowski, Sullivan, Jensen, Romano, & Summers, 2003
 Associated with a proclivity to catastrophize about pain
▪ Kratz, Davis, & Zautra, 2011
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Trauma
 66%-88% comorbid chronic pain in war veterans with PTSD
▪ Poundia et al (2006); Shipherd et al, (2007)
 As much as 75% of torture victims develop chronic pain
▪ Olsen et al (2007)
 Trauma
Onset FMS, RA
▪ Hauser et al (2013): PTSD/FMS
▪ Boscarino et al (2010): PTSD/RA
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Stress
▪ Khasar et al (2009): Cortisol and epinephrine cause intracellular signal
pathway changes in primary afferent nociceptor resulting in enhanced
nociceptive signaling
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Verbal: expressions of hurting; moaning, sighing, etc.
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Non-verbal: limping, rubbing, grimacing, use of a cane, etc.
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General activity level
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Consumption of medications and use of other devices to
control pain
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Fordyce, W.E. (1976). Behavioral methods for chronic pain and illness. St. Louis, MO: Mosby
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Sanders, S.H. (2002). Operant conditioning with chronic pain: back to basics. In D.C. Turk & R.J. Gatchel (Eds.),
Psychological approaches to pain management: a practitioner’s handbook. (pp. 128-137) New York: Guilford
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Attentional Bias/Somatic Focus
Anxiety
Depression
Affective Distress in Response to Pain
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Provides a partial review of the literature
demonstrating the impact of attention and
mood on pain perception
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MRI findings suggest that separate neuromodulatory circuits underlie emotional and
attentional modulation of pain
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Seminowicz & Davis (2005)
 Cites studies finding an impact of catastrophizing
on pain intensity, disability, difficulty disengaging
from pain, and predicting post-surgical pain levels
 fMRI results demonstrated negative correlation
between catastrophizing scores and activity of
prefrontal cortical regions implicated in top down
modulation of pain
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Vllaeyen & Linton (2012)
 Fear-avoidance model of chronic musculoskeletal
pain: 12 years on, PAIN, 153 (2012) 1144–1147
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Bandura (1977)
 Efficacy expectations determine how much effort people will expend
and how long they will persist in the face of obstacles and aversive
experiences
 A ‘‘resilient self belief system’’ whereby ‘‘people who believe they can
exercise control over potential threats do not conjure up apprehensive
cognitions and, hence, are not perturbed by them’’
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Nicholas (2007)
 Brief summary of pain literature relevant to construct of self-efficacy
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Treatment dropout
Pain behaviors
Work status
Medication use
Pain interference in daily behaviors
 Author of the Pain Self-Efficacy Questionnaire (PSEQ)
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People are helpless to do anything about their pain
People should not have to experience pain
Pain is unacceptable
The healthcare system can and should eliminate pain
Pain makes it impossible to have a decent quality of life
Life will just have to be on hold until pain goes away
People who experience pain and physical limitations are worthless
Pain always means the body is being damaged
Pain means that it is not safe to exercise
Increasing physical activity will cause increased pain
Stress and emotions have nothing to do with pain
Medication is the only effective treatment for pain
Medication is the most effective treatment for pain
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Cook & DeGood (2006): Cognitive Risk Profile for Pain (CRPP)
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A tendency to experience negative emotions
(e.g., anger, anxiety, sadness) across time and
situations
 Barnett et al (2009) Type D personality and chronic
pain: construct and concurrent validity of the DS14
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Melzack & Wall (1982). The Challenge of Pain
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Janssen (2002) Negative affect and sensitization
to pain
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Negative emotions are associated with increased activation in the
amygdala, anterior cingulate cortex, and anterior insula
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These brain structures not only mediate the processing of
emotions, but are also important nodes of the pain neuromatrix
that tune attention toward pain, intensify pain unpleasantness,
and amplify interoception (the sense of the physical condition of
the body).
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Thus, when individuals experience negative emotions like anger or
fear as a result of pain or other emotionally salient stimuli, the
heightened neural processing of threat in affective brain circuits
primes the subsequent perception of pain
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McFarlane (2007)
 Multiplicity of pathways between stress and
musculoskeletal pain
▪ Posttraumatic body memory
▪ Chronic HPA axis activation
▪ Impact on CNS sensitization
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Vachon-Presseau et al (2013)
 The overall portrait is that prolonged pain may constitute
an allostatic load in individuals showing more stress
vulnerability, inducing long-lasting plastic changes that in
turn instigate a spiraling down of the patient’s condition
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Riley & Robinson (1997)
 Revision of the Coping Strategies Questionnaire
(CSQ-R)
 Original CSQ conceived by Rosenstiel and Keefe
 6 Scales
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Distraction
Catastrophizing
Ignoring Pain
Distancing
Cognitive Coping
Praying
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Behrend et al (2013)
 5333 patients with spinal-related pain:
▪ “As a group, those who had continued smoking during
treatment had no clinically important improvement in
reported pain.”
▪ “Compared with patients who had continued to smoke,
those who had quit smoking during the course of care
reported significantly greater improvements in pain.”
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Cooperman et al (1934)
Moldofsky et al (1975 & 1976)
Roehrs et al (2006)
Davies et al (2008)
Okfuji & Hare (2011)
 Sleep deprivation, and particularly lack of Stage 4 and REM sleep results in
▪ Increased pain sensitivity
▪ Increased musculoskeletal tenderness
▪ Reduced pain tolerance
▪ Reduced effectiveness of pain medication
 Better sleep is associated with recovery from chronic widespread pain
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Sleep Apnea – Epworth Sleepiness Scale
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Seminowicz et al (2013)
 An 11-week CBT intervention for coping with chronic pain
resulted in increased GM volume in prefrontal and
somatosensory brain regions, as well as increased dorsolateral
prefrontal volume associated with reduced pain
catastrophizing. These results add to mounting evidence that
CBT can be a valuable treatment option for chronic pain
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Zeidan, F., et al (2012)
 Reviews the growing literature documenting the benefits of
mindfulness meditation for reducing pain
 The data indicate that, like other cognitive factors that
modulate pain, prefrontal and cingulate cortices are intimately
involved the modulation of pain by mindfulness meditation
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Poor posture creates imbalances in the body in which some
muscles are overworking and others are not doing their job
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This creates stress on the joints, excessive tension in some
muscles, deconditioning in other muscles and over time,
leads to pain
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Pretty much a no-brainer, but just for example:
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Klinger et al (2010)
 Classical conditioning model of chronic muscle
tension
 Found that tension-type headache and low back pain
patients demonstrated a higher number of both
conditioned and unconditioned muscle tension
reactions in response to exposure to an aversive
stimulus (electric shock)
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Numerical Analogue Scale (NAS)
 0-10
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McGill Pain Inventory –Short Form
 Sensory and Affective Dimensions
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Multidimensional Pain Inventory
 Pain Severity Subscale
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MMPI-2-RF
Millon Behavioral Medicine Diagnostic
(MBMD)
Pain Patient Profile (P3)
Battery for Health Improvement -2 (BHI-2)
Multidimensional Pain Inventory (MPI)
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Hospital Anxiety and Depression Scale (HADS)
Pain Catastrophizing Scale (PCS)
Tampa Scale of Kinesiophobia (TSK)
Chronic Pain Acceptance Questionnaire (CPAQ)
Psychological Inflexibility in Pain Scale – 12 Item version (PIPS-12)
Pain Stages of Change Questionnaire (PSOCQ)
Pain Self-Efficacy Questionnaire (PSEQ)
Cognitive Risk Profile for Pain (CRPP)
Screener for Opioid Addiction in Pain Patients – Revised (SOAPP-R)
Opioid Risk Tool (ORT)
Epworth Sleepiness Scale and associated Snoring Scale
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4 broad model of behavioral health intervention
 Jensen & Turk (2014)
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Operant Models
Peripheral Physiological Models
Cognitive and Coping Models
Central Nervous System Neurophysiological Models
The Psychodynamic Perspective
▪ Freud
▪ Sarno