Tracking Psychological Processes Involved in Self-Management of Chronic Pain Measures of Psychological Flexibility

Transcription

1 Tracking Psychological Processes Involved in Self-Management of Chronic Pain Measures of Psychological Flexibility INPUT Pain Management Unit Lucie Knight, Counselling Psychologist (on behalf of Prof Lance McCracken)

2 Focus of Presentation Measures used at INPUT to assess the psychological underpinnings of chronic pain. Processes involved in adjusting and living with chronic pain and their assessment. Developing new measures: the Committed Action Questionnaire and the Cognitive Fusion Questionnaire.

3 INPUT Measures Main outcome measures: SF-36 Patient Health Questionnaire (PHQ-9) EQ-5D-5L; Brief Pain Inventory Health care visits, medication use, work status Process measures based on ACT: Chronic Pain Acceptance Questionnaire (CPAQ) Acceptance and Action Questionnaire (AAQ-II) Experiences Questionnaire (EQ) Cognitive Fusion Questionnaire (CFQ) Committed Action Questionnaire (CAQ)

4 ACT A form of cognitive behavioral therapy with the following features: Focuses on behaviour change Includes a primary process called psychological flexibility Recognizes that suffering is a normal part of the human condition Does not aim to eliminate pain, but offers skills to respond flexibly, in ways that enables people to follow their values in the face of challenges. Relies heavily on experiential exercises and metaphorical or paradoxical uses of language Is emotionally intensive Follows a philosophy called functional contextualism Has a direct association with Relational Frame Theory, a program of basic behavioral science.

5 ACT Treatment Processes Contact with the Present Moment Acceptance Values Psychological Flexibility Cognitive Defusion Committed Action Self as Context Mindfulness

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7 Work stress Randomized Trials of ACT in Problem Area Physical Health Authors Bond & Bunce, 2000 Flaxman & Bond, 2010 Brinkborg et al., 2011 Pain and stress Dahl et al., 2004 Drug refractory epilepsy Lundgren et al., 2006 Diabetes Gregg et al., 2007 Chronic pain Wicksell et al., 2008 Johnston et al Wetherell et al Thorsell et al., 2011 Pediatric chronic pain Wicksell et al., 2009

8 Randomized Trials of ACT- Continued Promotion of physical activity Butryn et al., 2011 Headache Dindo et al., 2012 Mo tamedi et al, 2012 Multiple sclerosis Nordin et al., 2012 Tinnitus Hesser et al., 2012 Cancer Rost et al., 2012

9 ACT for Chronic Pain (N = 16 Studies) o Dahl et al o McCracken et al o McCracken et al o Vowles & McCracken, 2008 o Wicksell et al o Vowles et al o Johnston et al o Wetherell et al o Thorsell et al o McCracken & Gutierrez- Martinez, 2011 o McCracken & Jones, 2012 o Wicksell et al., 2013 o Burhman et al., 2013 o McCracken et al., 2013 o Steiner & Bigati, 2013 o Luciano et al., 2014 Green = RCT

10 Measures: Psychological Flexibility Process Measure Publications* Acceptance Cognitive defusion Acceptance and Action Questionnaire-II Chronic Pain Acceptance Questionnaire Experiences Questionnaire Cognitive Fusion Questionnaire Drexel Defusion Scale Contact with the present Self-as-observer Mindful Attention Awareness Scale (most mindfulness measures) Experiences Questionnaire 23 (364) 0 Values-based action Committed action Valued Living Question Chronic Pain Values Inventory Bulls Eye Engaged Living Scale Committed Action Questionnaire Engaged Living Scale 3 42 * Keyword Search: chronic pain + process term; Medline, Psychinfo, EMBASE; 8 November 2013.

11 ACT measures used at INPUT Chronic Pain acceptance Questionnaire CPAQ (McCracken et al, 2004; Vowels et al, 2008): 2 factors: activity engagement and pain willingness Acceptance and Action Questionnaire - AAQ (Hayes et al 2004; Bond et al 2011): measure of psychological acceptance / experiential avoidance. General measure of psychological flexibility. AAQ II includes 7 items Experiences Questionnaire EQ (Fresco et al, 2007; McCracken et al, 2014): De-centering and rumination Committed action questionnaire CAQ: newly developed Cognitive Fusion Questionniare CFQ (Gillanders et al 2013): recently validated in chronic pain

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13 Creating a Measure N = 216 consecutive adults with chronic pain at INPUT. 62.5% women. Mean age years of education. Primary pain 88.3% back. Mdn pain duration 104 months.

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15 Factor Analysis of CAQ

16 Correlations Including the Committed Action Questionnaire SF-36 Pain Acceptance Pain (0-10) Depression (PHQ-9) Phys Soc Mental Health Vital Gen Health Committed Action (CAQ) Pain Acceptance (CPAQ).49*** ***.20***.40***.58***.33***.37*** ***.17*.31***.39***.24***.30*** * p <.05; ** p <.01; *** p <.001.

17 Regression Results Block Predictors ΔR 2 β (final) Depression (PHQ-9) Adjusted R 2 1 Pain (0-10).064**.22** 2 Committed action (CAQ).15*** -.39***.20*** 1 Pain (0-10).064**.20** 2 Pain acceptance (CPAQ).15*** Committed action.17*** -.48***.37*** Physical Functioning (SF-36) 1 Pain (0-10).080** -.27** 2 Committed action (CAQ).033*.18*.097** 1 Pain (0-10).080** -.27** 2 Pain acceptance (CPAQ) Committed action (CAQ) **

18 Block Predictors ΔR 2 β (final) Social Functioning (SF-36) Adjusted R 2 1 Pain (0-10).081** -.26** 2 Committed action (CAQ).15***.38***.21*** 1 Pain (0-10).081** -.25** 2 Pain acceptance (CPAQ).077**.12 3 Committed action.080**.32***.22*** Mental Health (SF-36) 1 Pain (0-10) Committed action (CAQ).32***.57***.34*** 1 Pain (0-10) Pain acceptance (CPAQ).14***.13 3 Committed action (CAQ).20***.51***.35***

19 Block Predictors ΔR 2 β (final) Vitality (SF-36) Adjusted R 2 1 Pain (0-10).036* Committed action (CAQ).10***.32***.12*** 1 Pain (0-10).036* Pain acceptance (CPAQ).046* Committed action (CAQ).062**.29**.12*** General Health (SF-36) 1 Pain (0-10) Committed action (CAQ).13***.37***.12*** 1 Pain (0-10) Pain acceptance (CPAQ).089**.16 3 Committed action (CAQ).065**.29**.13***

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21 A Preliminary Study of Cognitive Fusion N = 326 people seeking treatment for chronic pain. 67.8% women Mean age 47.4 years (sd = 11.8) Participants completed an interim 13-item version of the Cognitive Fusion Questionnaire (Gillanders et al., 2013) as part of a treatment outcome assessment process.

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23 Correlations SF-36 AAQ-II CPAQ PHQ-9 Phys Ment Soc Vital GH Cog Fusion (CFQ) Pain Accept (CPAQ).78*** -.53***.59*** *** -.41*** -.35*** -.34*** -.54*** -.51***.16**.39***.37***.29***.30*** ** p <.01; *** p <.001.

24 Regression Model for Depression

25 Regression Model for Mental Health

26 INPUT Outcomes Measures Pretreatment mean (SD) Posttreatment mean (SD) 9-month mean (SD) F p Cohens d (prepost) Cohens d (pre- 9month) PHQ (N=138) (6.34) 9.83 (6.41) (7.19) AAQ (N=142) (10.97) (11.28) (12.70) CFQ (N=140) (13.79) (15.68) (15.28) CPAQ (N=128) (19.13) (18.65) (19.42) Physical functioning SF-36 (N=146) (3.65) (4.57) (4.64) Social functioning SF-36 (N=147) 4.88 (1.86) 6.52 (2.00) 5.87 (2.33)

27 Outcomes for the two week pre- Neuromodulation programme N = 174 in a two-week treatment course. All participants being considered for a neuromodulation procedure. Neuromodulation means a spinal cord stimulator implantation for pain relief. Question: Can people actively seeking other treatment benefit from an ACTbased treatment?

28 Selected Results Post Treatment Pre M (SD) Post M (SD) t d Physical (3.97) (4.51) 6.58**.38 Social 5.04 (1.85) 6.34 (1.99) 8.22**.70 Mental Health (5.80) (4.87) 10.96**.70 Depression (6.86) (6.02) 9.53**.62 Acceptance (18.17) (18.96) 3.02*.56 Physical, Social, and Mental Health scores are raw scores from SF-36, depression score is from PHQ-9. * p <.01, ** p <.001.

29 Empirical Studies from INPUT since 2013 McCracken, L. M. (2013). Committed action: An application of the psychological flexibility model to activity patterns in chronic pain. The Journal of Pain, 14, Barker, E, & McCracken, L. M. (in press). From traditional Cognitive Behavioral Therapy to Acceptance and Commitment Therapy for chronic pain: A mixed method study of staff experiences of change. British Journal of Pain. McCracken, L. M., DaSilva, P., Skillicorn, B., Doherty, R. (in press). The Cognitive Fusion Questionnaire: a preliminary study of psychometric properties and prediction of functioning in chronic pain. The Clinical Journal of Pain. McCracken, L. M., Barker, E., Chilcot, J. (in press). Decentering, rumination, cognitive defusion, and psychological flexibility in people with chronic pain. Journal of Behavioral Medicine. McCracken, L. M., Chilcot, J. & Notron, S. (in press). Further development in the assessment of psychological flexibility: A shortened Committed Action Questionnaire (CAQ-8). European Journal of Pain.

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31 Conclusions A number of new measures have been developed and validated to support the assessment of psychological processes involved in adjusting to chronic pain. These complement outcome measures and provide insight into how people adjust or what impedes progress. The CAQ and CFQ, assessing two key ACT processes of the psychological flexibility model, Committed Action and Cognitive Fusion, have been tested and been shown to have good psychometric properties. Both committed action and cognitive fusion explain significant proportions of the variance in depression, mental health and social functioning. Shorter forms of the scales are being developed and there are plans to create further new measures, e.g. to assess self as observer.