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1 THE PSYCHOLOGY OF RESILIENCE AND THE ASSOCIATIONS WITH CHRONIC PAIN Toby Newton-John PhD Clinical Psychologist & Senior Lecturer Graduate School of Health UTS, Sydney Australia UTS CRICOS PROVIDER CODE: 00099F

2 AGENDA 1. Chronic pain current models and understanding 2. Resilience definitions and approaches 3. Combining the concepts resilience in relation to living with chronic pain 4. Innate vs learned: is resilience something you are born with, or can you become resilient over time?

3 DEFINITION OF PAIN I An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (IASP International Association for the Study of Pain)

4 PAIN THERE IS A LOT OF IT ABOUT 80% of Western world experience back pain at some point (Briggs & Buchbinder MJA, 2009) Prevalence of chronic pain in NSW: 17.1% males; 20.0% females Increases with age: 30% prevalence in 65 years+ (Blyth et al. Pain, 2001) Costs: $34.3 billion per annum in treatment & lost productivity (Access Economics, 2007) 40% of all early retirements due to back pain and arthritis (Schofield et al. Health Economics 2012) BUT: Of the 20% with chronic pain, only around 7-10% become disabled by it

5 DEFINING PAIN II Acute pain: * short-term (seconds-days) * usually associated with obvious (peripheral) tissue damage/lesion * resolves with healing/treatment Chronic pain: * long-term (> 3-6 months) * often associated with non-obvious (central) changes * persists beyond expected healing time Also: * Sub-acute pain (>4 weeks < 12 weeks) * Chronic-recurring pain (migraine headaches) Essentially time-based definitions, but evidence of different mechanisms as well.

6 NEUROBIOLOGY OF PAIN

7 TRANSDUCTION BUT NO PAIN!

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10 NEUROBIOLOGY OF PAIN II DESCENDING INHIBITION

11 Tracey & Mantyh 2007

12 So, we know a fair amount about how acute pain works what about chronic pain?

13 TREATMENTS FOR PAIN Acute pain follows the healing process +/- medications, medical interventions, physical therapies etc. overwhelmingly, acute pain resolves Chronic pain - many treatments, not so positive outcomes

14 NO TREATMENT OFFERS LASTING RELIEF OF CHRONIC PAIN: E.G., CHRONIC LOW BACK PAIN Machado et al. Rheumatology 2009; 48: 520-7

15 NO TREATMENT OFFERS LASTING RELIEF OF CHRONIC PAIN: E.G., CHRONIC LOW BACK PAIN Machado et al. Rheumatology 2009; 48: Conclusion all treatments had minimal effects on long term pain relief.

16 CAUTION: MEDICATIONS MIGHT NOT JUST HAVE HAVE SHORT-TERM SIDE-EFFECTS

17 WHEN CHRONIC PAIN BECOMES A PROBLEM REDUCED ACTIVITY CHRONIC PAIN UNHELPFUL BELIEFS & THOUGHTS REPEATED TREATMENT FAILURES LONG-TERM USE OF ANALGESIC, SEDATIVE DRUGS CHANGES IN CNS WITH PERSISTENT PAIN LOSS OF JOB, FINANCIAL DIFFICULTIES, FAMILY STRESS M K Nicholas PhD Pain Management & Research Centre Royal North Shore Hospital St Leonards NSW 2065 AUSTRALIA

18 WHEN CHRONIC PAIN BECOMES A PROBLEM CHRONIC PAIN REDUCED ACTIVITY UNHELPFUL BELIEFS & THOUGHTS REPEATED TREATMENT FAILURES PHYSICAL DETERIORATION (eg. muscle wasting, joint stiffness) FEELINGS OF DEPRESSION, HELPLESSNESS, IRRITABILITY CHANGES IN CNS WITH PERSISTENT PAIN LONG-TERM USE OF ANALGESIC, SEDATIVE DRUGS LOSS OF JOB, FINANCIAL DIFFICULTIES, FAMILY STRESS SIDE EFFECTS (eg. cognitive impairments, constipation, dependence) M K Nicholas PhD Pain Management & Research Centre Royal North Shore Hospital St Leonards NSW 2065 AUSTRALIA

19 WHEN CHRONIC PAIN BECOMES A PROBLEM REDUCED ACTIVITY PHYSICAL DETERIORATION (eg. muscle wasting, joint stiffness) UNHELPFUL BELIEFS & THOUGHTS CHRONIC PAIN REPEATED TREATMENT FAILURES FEELINGS OF DEPRESSION, HELPLESSNESS, IRRITABILITY EXCESSIVE SUFFERING CHANGES IN CNS WITH PERSISTENT PAIN LONG-TERM USE OF ANALGESIC, SEDATIVE DRUGS LOSS OF JOB, FINANCIAL DIFFICULTIES, FAMILY STRESS SIDE EFFECTS (eg. cognitive impairments, constipation, dependence) M K Nicholas PhD Pain Management & Research Centre Royal North Shore Hospital St Leonards NSW 2065 AUSTRALIA

20 REMEMBER Approximately 20% of adults in the Western world have some form of chronic pain, but only 7-10% become disabled by it?... Are the 10-13% with pain, but without pain-related disability, demonstrating resilience??

21 RESILIENCE DEFINED Originally from developmental literature on chronic adversity and search for causes of adult psychopathology Poverty, parental bereavement, war, natural disasters On many occasions, no mental illness develops! Synonymous with terms: positive adaptation, adjustment, emergent resilience

22 RESILIENCE IS Developmental perspective: A relatively positive psychological outcome in spite of exposure to severe risk experiences (Rutter, 2006) Adult, binary, diagnostic perspective (in response to potentially traumatic experiences): resilience as the absence of diagnosed psychopathology akin to defining health as the absence of disease (Bonanno & Diminich, 2013)

23 RESILIENCE IS Resilience is usually understood as the ability to resist or to bounce back from adversity (Bonanno et al., 2010; Tedeschi & Calhoun, 1995) Bending without breaking

24 RESILIENCE IS Resilience is not the same as recovery. To recover, you must have been sick/ill/lost normal functions for a period of time By contrast, resilience reflects the ability to maintain a stable equilibrium.

25 TRAJECTORIES AFTER TRAUMATIC EVENTS

26 RESILIENT TO WHAT? Responses to: Potentially Traumatic Event/s (PTEs) Single incident, time limited events vs chronic, unending adversity Personal crises (e.g. illness) vs. pervasive, mass casualty trauma (e.g. war)

27 GOOD NEWS In response to single incident trauma, most people demonstrate high resilience: the stress reaction is usually relatively mild, transient, and typically does not impact the ability to continue normal levels of functioning For example: six months after 9/11, a large survey of NY residents found: Clear majority (65%) experienced only one or no trauma symptoms during this period, and had almost no depression; even for those who were inside WTC at time of attacks (Bonanno et al. 2006)

28 NOT SO GOOD NEWS In response to ongoing mass casualty stressors (e.g. war), significant anxiety and depression are seen in almost all of the population initially. However, when surveyed over 12 months, 3 groups emerged for PTSD: a) moderate-improving (73% moderate symptoms at baseline, improving over time), b) severe-chronic (23.2% severe and elevated symptoms over the entire year); and c) severe-improving (3.5% severe symptoms at baseline and marked improvement over time). (Hobfoll et al. 2011)

29 NOT SO GOOD NEWS Similar proportions for depression thus approximately 25% of people do not demonstrate a resilient response to chronic adversity/mass casualty stress (Hobfoll et al. 2011)

30 RESILIENCE Self esteem Social supports Optimism Coping strategies Condly, 2006

31 CHRONIC PAIN AND RESILIENCE Single incident pain associated with traumatic injury pain associated with surgery/disease Chronic adversity pain of repeated flare-ups pain of ongoing treatments losses financial, status, identity, etc.

32 RESILIENCE AND CHRONIC PAIN 2011

33 MEASURING RESILIENCE

34 Greater resilience associated with less pain-related disability, less fear of pain, and less pain intensity Greater resilience associated with more social supports and work engagement However, resilience did not add to our prediction of good adjustment to chronic pain beyond the usual predictors (pain beliefs, confidence, fear of pain)

35 CONCLUSIONS 1. Adults are generally very good at bouncing back from a one-off stressful/ traumatic event suggests high resilience 2. Ongoing stressors/adversities are associated with poorer mental health in 25% of individuals 3. Chronic pain is a stressor which can test resilience in terms of initial injury response ( bouncing back ) and the ongoing experience of pain (chronic adversity) 4. Evidence is that chronic pain patients do demonstrate resilience, particularly those with stronger social networks 5. Resilience is the sum of multiple factors, each of which can be learned and fostered.

36 Thank you very much for your attention!