Pain Psychology: Disclosure Slide. Learning Objectives. Bio-psychosocial Model 8/12/2014. What we won t cover (today) What influences chronic pain?

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1 Disclosure Slide Pain Psychology: No commercial interests to disclose Screening for distress and maladaptive attitudes and beliefs Paul Taenzer PhD, CPsych Learning Objectives At the end of the session, participants will be able to: Recognize the 'Yellow Flags' risk factors for chronicity Identify brief screening strategies for distress, maladaptive attitudes, and beliefs Utilize office-based strategies and referral options for psychosocial issues What we won t cover (today) Relevant psychosocial history Psychosocial strengths: coping and support Screening for other co-morbid factors or impacts: sleep, social, occupational, existential concerns Bio-psychosocial Model What influences chronic pain? Main & Williams,

2 Psychology and chronic pain /story25i1.gif What are psychosocial factors? Attitudes: catastrophizing Beliefs: fear-avoidance Mood states: anxiety and depression Stressors: financial, personal Social factors: family and social support Occupational: job satisfaction, support Behaviors: care seeking, bed rest, avoiding Psychosocial Yellow Flags (Kendall, Linton and Main,1997) Derived from research on psychosocial predictors of chronicity of back pain Early attempt at secondary prevention Contains both health and occupational elements What are the yellow flags? Belief that back pain is harmful or potentially severely disabling Fear-avoidance behaviour and reduced activity levels Psychology in practice Low mood and social withdrawal Expecting passive treatments (rather than active participation) to help 2

3 Mary s Case Mary is a 32 year old married elementary school teacher with 4 and 7 year old sons that has had wide spread muscle aches, insomnia, fatigue and forgetfulness after a minor MVA a year ago that is now effecting her performance and her joie de vivre. What is Mary s emotional experience likely to be? Fear What s wrong with me? Is this a serious illness? Do I have cancer or MS? Worry What if it gets worse? Can I keep working? Will my husband stay? Frustration It s getting worse even though I ve been doing everything I know to take care of myself. I not getting my work done. The house is a mess. Life isn t fun anymore. I got a horrible feeling that the doctor thought it was mental Hellstrom O, et al. A phenomenological study of fibromyalgia. Patient perspectives. Scand J Prim Health Care 1999;17: Your goal Insure that Mary knows that you are taking her seriously and believe her: Face her and establish eye contact Ask about the impacts of symptoms Acknowledge feelings Summarize what you ve heard Explain what diseases you ve ruled out and why It is a relief to know that one, doesn t have MS Explain why you ve ordered or not ordered lab tests and imaging Use lay language 3

4 Significant Emotional Distress Screen for Ψsocial risk factors Significant emotional distress The belief that they have a serious problem Significant disruption of usual activities (work, household and leisure) Passive coping Inappropriate treatment expectations When it hurts and one has pain and no energy, then one gets sad and this gets on one s nerves Screen for: Depression (PHQ-2) Over the past 2 weeks, how often have you been bothered by: Little interest or pleasure in doing things? Feeling down, depressed or hopeless? Anxiety (GAD-2) Over the past 2 weeks, how often have you been bothered by the following problems Feeling nervous, anxious or on edge? Not being able to stop or control worrying? PTSD (PC-PTSD) In your life, have you ever had any experience that was so frightening, horrible or upsetting that, in the past month, you: Have nightmares about it or thought about it when you did not want to Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? Were constantly on guard, watchful, or easily startled? Felt numb or detached from others, activities, or your surroundings? The belief that they have a serious problem What did you think may be the cause of your [ ] pain? Are there illnesses that you are afraid might be causing these symptom? What do other people in your life think the problem may be? Setting the stage for positive coping Passive coping What are you doing to cope when your pain is at it s worst? Inappropriate treatment expectations What do you think will help you get better? Explain the diagnosis: The evidence for the diagnosis in their case What diagnoses you considered and dismissed What the diagnosis means for them: Prognosis: e.g. potential for good symptom management and improvement over time but no curative Tx at this time The importance of partnership with you and others in managing the condition as a chronic illness The importance of their active engagement in selfmanagement 4

5 Actions: Correct misconceptions/ misinformation Consider referral to community based education and self-management programs For severe cases consider referring to a multidisciplinary pain clinic, if available Schedule a follow-up visits to monitor outcomes of therapies and progress with self-management and improved function Reinforce optimism Focus on function as well as symptom control Summary Chronic pain is associated with psychosocial sequelae There are simple office-based techniques for detecting and possibly remediating Ψsocial issues Thank you Questions? Comments? Contact info: Paul Taenzer PhD, CPsych ptaenzer@gmail.com References Hellstrom O, et al. A phenomenological study of fibromyalgia. Patient perspectives. Scand J Prim Health Care 1999;17: Kendall, N A S, Linton, S J & Main, C J (1997). Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain: Risk Factors for Long-Term Disability and Work Loss. Accident Rehabilitation & Compensation Insurance Corporation of New Zealand and the National Health Committee. Wellington, NZ. Hill JC, Whitehurst DGT et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 2011; 378: Kroenke K, Spitzer RL, Williams JBW. The Patient Health Questionnaire- 2: validity of a two-item depression screener. Med Care 2003; 41: Kroenke K, Spitzer RL, Williams JBW, Monahan PO, Löwe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med 2007;146: Van Dam D, Ehring T, Vedel E, Emmelkamp PM. Validation of the Primary Care Posttraumatic Stress Disorder screening questionnaire (PC-PTSD) in civilian substance use disorder patients. J Subst Abuse Treat Sep;39(2):