THE PSYCHOLOGY OF CHRONIC PAIN

Transcription

1 THE PSYCHOLOGY OF CHRONIC PAIN Nomita Sonty, Ph.D, M.Phil Associate Professor of Medical CUMC Depts. of Anesthesiology &Psychiatry College of Physicians & Surgeons Columbia University New York, NY Mark Collen, NYT 2008

2 I have no conflicts of interest

3 To: 1.Understand a biopsychosocial model of pain 2. Understand differences in pain presentation 3. identify psychological factors in pain assessment

4 Burden of chronic pain in the US Mayday Fund Report 2009, Tsang, 2008 Society Productivity- 50 million lost workdays/yr Economic loss billion annually Increased cost on healthcare system Family Increased stress & responsibility Loss of support Loss of plans & hopes for the future Individual Adds unpredictability to life Loss of friends, family, work Loss of control and identity 116 million U.S. adult chronic pain sufferers

5 Just as my pain belongs in a unique way only to me, so I am utterly alone with it. I cannot share it. I have no doubt about the reality of the pain experience, but I cannot tell anybody what I have experienced Ivan Illich, 1976 Pain is personal

6 Ecological model for chronic pain & dysfunction (Dworkin & Sherman, 2001) DYSFUNCTIONAL Neglect Delay Denial Reduction Insensitivity FUNCTIONAL Social Roles Behavior Appraisal Perception Nociception DYSFUNCTIONAL Chronic sick role Pain behaviors Catastrophizing Augmentation Hypersensitivity

7 Development of the pain cycle Sources: Pain Center, Columbia Hospital, Milwaukee; Center for Pain Studies, Rehabilitation Institute of Chicago

8 Your patient with pain Mind Body Environment Unpleasant bodily sensations Interpretations of these sensations Fears, depression, Uncertainties Personal reserves Diverse education, race, SES, stress, & social support Current presentation

9 Pain Perception Pain is not always measurable in terms of stimulus intensity. Emotional states can augment the perceptual impact, and that it is a dynamic process that is constantly being tuned to the needs of the individual from moment to moment. -Dr. William Livingston 1947

10 The Psyche in Pain there has emerged a sketch plan of the pain apparatus with its receptors, conducting fibers, and its standard function which is to be applicable to all circumstances. But.in so doing, medicine sometimes overlooks the fact that the activity of this apparatus is subject to a constantly changing influence of the mind John Bonica, MD (1954)

11 Pain is Emotional Pain is Emotional There are times when my pain medication stops working and the horrible nerve pain takes over, ripping through my innocent leg. I lay on my bed trapped, trapped by pain. I feel fear, afraid the pain will never cease, afraid I'll go insane. I cry out to God begging for mercy. What have I done to deserve this fate? I feel like an innocent man condemned. I am trapped in a cage of pain, a cage made of rebar. I cannot tolerate it another second. I try a desperate escape by pushing my face through the bars, but I can go no further. I'm trapped in hell. --Mark Collen New York times, 2008

12 Emotions Positive Emotions Negative Emotions

13 Catastrophization Magnification Rumination Helplessness

14 Threat appraisal in the fear- avoidance model Injury Dysfunction Depression Pain Avoidance Vigilance Threat Catastrophizing No threat Fear Confronting pain Recovery -Vlaeyan & Linton, 2000

15 4 Stage Model for Pain Processing Stage 1: Recognize pain location, type of pain sensation & intensity Stage 2: Immediately appraise it in terms of unpleasantness & threat Stage 3: Respond or react to pain Stage 4: Based on stages I-III level of illness behavior manifested -Wade & Price, 2000

16 Pain beliefs: A cognitive schemata about pain Greater Self reported pain Pain constancy Pain Permanence Greater Anxiety Greater depressive symptoms Self blame Pain mystery Greater overall distress Williams et al., 1994

17 Fordyce s model of Pain behaviors More pain behaviors Pain Reinforcers Pain behaviors More pain behaviors Reinforcers

18 Pain behaviors Behaviors that communicate to others nonverbally that pain is being experienced -(Fordyce, 1976). Guarding Bracing Rubbing Grimacing Sighing Reliance on others

19 Pain assessment is complicated by. As pain assessors, we are co-participants, not merely observers and, therefore,..we acknowledge that we are jointly engaged in creating the pain dimensions we seek to measure. Karoly & Jensen, 1987

20 Pain measurement: Unidimensional & Multidimensional scales NAME TYPE DESCRIPTION NUMERIC RATING UNI 0-10 SCALE SCALE VISUAL ANALOGUE SCALE UNI MARK ON A 10 CM LINE THE INTENSITY OF PAIN FACES SCALE UNI A SERIES OF FACES SHOWING VARIOUS LEVELS OF DISCOMFORT PAIN INVENTORIES MULTI INTENSITY, LOCATION, HISTORY, ADLS, TX. PAIN QUESTIONNAIRES MULTI SENSORY, AFFECTIVE & EVALUATIVE BEHAVIORAL OBS MULTI VISIBLE SIGNS OF DISCOMFORT

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22 Pain Diagrams

23 Pain description & image New York Times 2008

24 Comorbidities with chronic pain Psychiatric disorders: (Proctor et al., 2013; Rosen et. al 2008) Anxiety:30% Depression: 44% PTSD: 29% Substance abuse: Opioids Marijuana Sleep disorders: Insomnia Intermittent sleep disturbance

25 Pain Beliefs Hurt is harm Medicines will make me an addict Need to find a cure for my pain Being active will increase my pain Rest is the best medicine A good Dr. can cure me

26 Cognition Cognitive functions: Elevated pain interferes with attention, concentration & memory Awareness & responsiveness: Related to magnitude of sensation Amount of information coming from the environment Feedback Vigilance: Hyper-vigilance: A heightened state of arousal which leads to a more keen attention to bodily sensations.

27 Chronic pain research has been disease focused Positive focused Disease focused

28 Risk & resilience in adaptation to chronic pain Sturgeon & Zautra, 2010

29 Psychological flexibility in adaptation to chronic pain McCracken L., 2014

30 Readiness for change & treatment adherence Contemplation Relapse Preparation Readiness for change Maintenance Action

31 Triggers for Psychological Evaluation High levels of pain behavior and functional impairment despite receiving appropriate medical treatment Psychological distress: anxious/sad/angry/suicidal & psychiatric co-morbidities Overuse of healthcare services, medications and/or other substances. Analgesic overuse Disability Skills training Treatment adherence issues Special evaluations: Pre-surgical evaluations Readiness for return to work

32 Psychological Treatment Modalities for pain Individual Psychotherapy Psycho education Biofeedback Group therapy

33 Summary Pain is a personal experience but is expressed in an interpersonal domain There are Individual differences in response to apparently similar stimuli. Distress is associated with actual pain and or anticipation of pain Pain is mediated by cognitive, perceptual, emotional & social factors. Readiness for change should be matched with treatments offered and will affect treatment adherence.