Cognitive Behavioural Management of Chronic Edited 31by Meena Hariharan G. Padmaja Meera Padhy Publish by Global Vision Publishing House

Transcription

1 Trauma and Pain Biopsychosocial Perspectives Cognitive Behavioural Management of Chronic Edited 31by Meena Hariharan G. Padmaja Meera Padhy Publish by Global Vision Publishing House COGNITIVE BEHAVIOURAL MANAGEMENT OF CHRONIC DAILY HEADACHES Manju Mehta & Anubha Dhal Every head has its own headache Chronic daily headache is among the leading reasons for which persons seek consultation in numerous healthcare settings such as medicine and neurology out patient departments. This type of headache often presents as a global, tension type headache with mild to moderate intensity with symptoms worsening as the day progresses (Carson, Zeman, Myles, & Sharpe, 2008). Patients suffering from this type of headaches often report a prior history of migraines and a prolonged exposure to analgesics (Bahra, Walsh & Menon, 2008; Carson et al., 2008). The association of stress and emotional distress, particularly depression with this type of headache has been increasingly reported in the recent literature (Mitsikostas & Thomas, 1999; Carson et al., 2008). However, a cause-effect relationship has not been firmly Manju Mehta Professor & Head of Child and Adolescent Psychiatry Clinic and Clinical Psychology at AIIMS, New Delhi. Anubha Dhal: Research Scholar (Clinical Psychology) at the Department of Psychiatry, AIIMS, Delhi

2 32 Trauma and Pain: Biopsychosocial Perspective established. This along with a failure to withdraw from analgesics sheds light on the need to address symptoms through psychological approaches such as cognitive behavior therapy (Kronke & Swindle, 2000). This approach is based on the inter-relationships between our thoughts, emotions and behaviour (Beck, 1995). It emphasizes the role of negative thoughts and increased emotional distress in increasing maladaptive behavioral responses such as headaches. It employs a range of cognitive and behavioral techniques such as relaxation, cognitive restructuring and problem solving to reduce symptomatic distress (Lipchik, Holroyd & Nash, 2002). Goals of Cognitive Behaviour Therapy The common goals of cognitive behavioural interventions targeted at managing somatic symptoms such as headaches usually fall into the following categories: (1) psycho-education, (2) addressing the lifestyle and personality factors associated with vulnerability to developing somatic illness, (3) provision of alternative, noncatastrophic interpretation of symptoms in cognitive behavioral terminology, (4) challenging catastrophic thoughts related to somatic symptoms, (5) modification of the dysfunctional beliefs associated with symptoms through behavioral experiments, (6) reversal of avoidance and maladaptive coping behaviors, (7) inculcating behavioral coping skills, and (8) instilling problem solving skills (Brown, 2007). Cognitive Behavioural Conceptualization Cognitive Behavioural Therapy focuses on understanding the physiological, emotional, behavioural, cognitive as well as social factors involved in the precipitation and maintenance of symptoms, distress and disability experienced by a person. The cognitive behavioural conceptualization in understanding symptomatic distress arising from various symptoms can be understood in the light of the models provided by Sharpe, Peveler and Mayou (1992) and Brown (2004). These posit that the chronicity of symptoms follows from persistent misinterpretation of physical symptoms as a form of organic pathology as well as maladaptive coping strategies that develop from such misinterpretation (Brown, 2007; Chandler, 2001). The negative

3 Cognitive Behavioural Management of Chronic 33 affect and emotional arousal that result from the misinterpretation may lead to the person experiencing further bodily sensations. The misinterpretation associated with symptoms may lead to the person adopting coping behaviors which may maintain the symptoms experienced, by generating more sensations, leading to heightened symptom focus as well as continuing with the misattributions assigned by the person to the symptoms experienced. These behaviors further make the individual vulnerable to social factors which may reinforce focus on symptoms, illness appraisal and maladaptive coping methods. The factors central to conceptualizing a case suffering from headaches can be discussed under the following heads (Brown, 2007; Mehta, 1992): (a) Predisposing factors: These factors include: Childhood trauma: This constitutes physical, emotional or sexual abuse by parents or caregivers as well as neglect or lack of care. Persons with a history of trauma in childhood are thought to focus on bodily symptoms as a means of avoiding the cognitive and emotional processing associated with the traumatic experiences. Childhood experience of illness: The children with a history of physical illness in childhood that is reinforced by anxious parents may increase the focus on bodily symptoms, anxiety and illness behaviour in adulthood as well as resorting to maladaptive coping behaviours. Personality: Negative affectivity or neuroticism personality factors have been found to be associated with somatic preoccupation, illness behaviour as well as symptom misinterpretation in persons with somatic complaints. (b) Precipitating factors: These factors include: Physical illness: Recent physical illness may increase anxiety related to health, which may precipitate development of multiple somatic complaints such as recurrent headaches. Life events: Somatic symptoms such as headaches may be preceded by life events such as trauma, interpersonal difficulties or financial problems. This relationship between

4 34 Trauma and Pain: Biopsychosocial Perspective life events and development of somatic illness may be mediated by factors such as anxiety or depression or body focus to avoid unwanted cognitive and emotional processes associated with those life events. (c) Maintaining factors: These factors include: Illness beliefs: Some beliefs about physical health and illness have been found to be associated with maintaining somatic complaints such as headaches. Example of such beliefs include those involving beliefs about inability to tolerate stress or having vulnerability to illness, beliefs about importance of maintenance of vigilance about symptoms, cost of illness or death, danger of anxiety as well as all or none beliefs about personal competence. Illness behaviours: Certain illness behaviours such as avoidance of certain stimuli or physical exercise, compensatory behaviours, repeated medical consultations and body check-ups may maintain somatic illness or symptomatic distress. Cognitive factors: Excessive rumination or worry about causes, implications and treatment of symptoms and physical health often maintain somatic complaints experienced by persons. A selective attribution bias for information confirming symptoms has been found to be associated with maintenance of somatic symptoms. Affective factors: Emotional distress such as anxiety and depression has been associated with increase in rumination, catastrophizing and worrying about the somatic symptoms as well as increase in illness behavior and increase in other somatic symptoms. Social factors: Excessive reassurance/care-seeking from significant others may increase somatic preoccupation. The stigma associated with emotional distress and psychological illness by others may reinforce assigning physical causes to symptoms and also increase illness behaviour. Increase in visits to doctors may at times increase misattributions

5 Cognitive Behavioural Management of Chronic 35 regarding symptoms especially if causal factors associated with somatic symptoms are explained in an ambiguous way to the patient. Physiological factors: Certain physiological factors such as sleep and appetite changes, organic illness, and medication overuse can maintain the illness behaviour, associated emotional distress as well as cognitive misattributions and hence, exacerbate somatic symptoms. Assessment of Headache and Associated Factors The cognitive behavioural conceptualization as well as treatment plan is aided by assessment of certain factors. The goals of assessment include: firstly, to establish whether possibility of any physical disease has been ruled out; Secondly, to engage the patient in a therapeutic process; Thirdly, to gain information regarding cognitive behavioural formulation of the presenting complaints; Lastly, to understand the medical and psychological conditions that the person is suffering from. The following case vignette illustrates the process of assessment. Case Vignette A 34 year old female belonging to middle socio-economic status nuclear family, educated up to graduation, housewife with no family history of psychiatric illness presented with complaints of daily headaches of moderate intensity lasting 4-6 hours since the past three years. She also started complaining of increased irritability and getting into frequent arguments with her husband due to decrease in interest in household activities. Due to this, she was referred to the psychiatry Out Patient Department (OPD). Before starting any treatment, the following assessments were undertaken. 1. Headache Symptoms and Medical History: The assessment of somatic symptoms such as headache started with collaborating with physicians or neurologists so as to exclude any organic pathology to the same. The investigations involved certain neurological investigations such as MRI or CT scans,

6 36 Trauma and Pain: Biopsychosocial Perspective which revealed no abnormality. After obtaining a consultation with physicians and neurologists, the patient was asked about her past and current medical history. It was found that she had developed headache three years back after she had a miscarriage. The headache would last for several hours a day and occurred daily. She would usually take analgesics to relieve the headache or she would sleep. Due to distress caused by repeated headache, she started avoiding her daily chores as she found them to increase the headache. This led to further arguments with her spouse. Her pre morbid temperament was found to be well adjusted and no history of past psychiatric or physical illness was elicited. This was followed by obtaining information regarding previous experiences of illness as well as a list of the current and previous medications and other treatments, intake of caffeine, diet and sleep patterns (Brown, 2007). She had sought consultation from the medicine OPD and was started on 25mg of amitriptiline which was build up subsequently to 75mg. Her caffeine intake as well as sleep and appetite were found to be normal. Short form of McGill Pain Questionnaire (Melzack, 1987) was used to estimate the intensity and description of the nature of headaches experienced by the patient. She had a total score of 30 with the type of pain usually experienced being sharp, throbbing, tiring and cruel/punishing. 2. Pain Beliefs and Assumptions: The thoughts or beliefs associated with headaches were elicited through the headache diary which helps to monitor the situational triggers as well as the intensity of pain experienced and the associated pain beliefs. Certain questions were also asked to elicit pain or illness beliefs. These included: (i) When you experience pain, what goes through your mind? (ii) (iii) What went through your mind when you noticed that your headache was worse? What do you think is the cause of your problem?

7 Cognitive Behavioural Management of Chronic 37 (iv) When your symptoms are at their worse, what do you think is the worse thing that can happen? (v) What is your worst fear about your symptoms? These helped to elicit the negative automatic thoughts experienced by the person. It was noted that the patient experienced negative thoughts such as I will never get better, I might have a brain tumor. 3. Illness Behaviours and Coping Strategies: Maintaining an activity diary helped to identify illness behaviour such as excessive rest or avoidance, which the patient engaged in while she experienced recurrent headaches. Information pertaining to pre-morbid behaviour and levels of activity were also elicited and it was reported that she would usually use excessive rest as a means of coping with past stressful events and would not engage in physical activity often. Certain questions were also asked to elicit safety, reassurance seeking or avoidance activities (Brown, 2007). These included - (i) If you did not have headaches then what would be different about your life? (ii) Are there certain things which you try to do when you get a headache? (iii) When your headaches bother you, are there certain things that you do which make you feel better? 4. Mood and Affect: The affect associated with occurrence of headache was assessed through the headache/abc diary the patient had been asked to maintain. This was corroborated by asking the informants regarding the patient s predominant mood states (Brown, 2007). It was found that the patient reported having a predominantly irritable mood that would at times turn into anger while experiencing headaches. Certain standardized measures such as the Hospital Anxiety and Depression Scale (HADS) can also be used to assess the anxiety and depression associated with the headaches experienced by the person (Zigmond & Snaith, 1983).

8 38 Trauma and Pain: Biopsychosocial Perspective 5. Social and Environmental Factors: The patient s history can help delineate the social and environmental factors such as trauma, interpersonal conflict that may precipitate or maintain somatic symptoms. The intake interview was focused on eliciting information about the person s family relationships and whether any form of interpersonal communication might have reinforced headache symptoms. This includes family members or significant others showing excessive concern, having a history of somatic symptoms in the family which the patient may emulate or instances of reinforcing avoidance behaviour in the patient (Brown, 2007). It was noted that her mother used to suffer from constant headaches, which may have been a model for the patient to emulate. Her husband would usually press her forehead or prepare tea or refreshments when she would have severe headaches. This was found to be a form of secondary gain, which she may have been receiving as these were the only few times when she perceived her husband to actually care for her. Cognitive Behavioural Management Cognitive behaviour management of headache is based on principles of agenda setting, guided discovery and collaborative empiricism. The steps or techniques involved in the cognitive behavioral management of headache can be elucidated as below with the help of the earlier vignette in which the patient underwent six sessions of cognitive behaviour therapy with one session per week lasting for 45 minutes each. (a) Socialization: The first session was focused on forming a working therapeutic alliance with the patient and psychoeducating the patient regarding the nature and course of chronic headaches as well as the role of stress and other psychological factors in precipitating and maintaining the illness. The patient was made aware of what cognitive behavioral therapy entails. She was also provided with an individually tailored cognitive behavioral conceptualization. The second session involved explaining the ABC model of

9 Cognitive Behavioural Management of Chronic 39 cognitive behavior therapy using an example. The patient was first explained the ABC model of cognitive behaviour therapy by delineating how Affect (A), Behaviour (B) and Cognition (C) are inter related. This further involved making the patient aware of how physical symptoms can be maintained or worsened through certain thoughts and behaviour patterns. These if modified can help to manage the symptomatic distress better. A simple experiment to make the person understand the link between symptoms, thoughts and their behaviour was conducted. In this she was asked to tighten her fists and feel the differences in two situations - one in which she was focusing on the fist alone and the other in which she was engaged in a conversation. She was then asked to tell which of the situations was more uncomfortable? This helped to make her understand that over focusing on one s symptoms may be a maladaptive coping strategy and may foster negative thoughts as compared to using distraction technique which helps to cope better with the symptomatic distress. The relationship between A (Affect or emotions experienced), B (Behaviours) and C (Cognition or thoughts) was illustrated through an example that when a person experiences headaches, she may have a lot of accompanying negative thoughts such as I can t handle it, it is going to get worse and she may thus feel irritable, which may further increase her headache. After explaining the model, she was asked to maintain a headache diary in which she was asked to note down the situations which triggered her headache, the intensity of headache experienced (0 = no headache, 100 = unbearable headache), thoughts and emotions experienced as well as what she did to decrease the headache. (b) Goal setting: The treatment goals identified prior to therapy included objective and realistic goals. A contract regarding number of sessions was negotiated at this stage with the patient as per the goals delineated. The common goals were- (i) a consistent approach to activity

10 40 Trauma and Pain: Biopsychosocial Perspective (ii) reduction in reassurance seeking and repeated discussion of symptoms which can interfere with a person s sociooccupational functioning (iii) engaging a family member as a co-therapist so as to minimize negative reinforcement of illness behaviour (iv) reduction in symptomatic distress (headache, anxiety/ depression) (c) Cognitive and Behavioural Interventions: Certain behavioural interventions can be used in management of headache. These include relaxation exercises (abdominal breathing, tensing and relaxing muscle groups progressively), distraction techniques, activity scheduling, graded activities, incorporation of pleasurable activities in daily routine, use of behavioural experiments as well as increase in physical exercise/activity. Use of assertiveness and communication skills as well as problem solving may help the patient to learn more adaptive ways of coping (Brown, 2007; Chandler, 2001). Use of disputation techniques and cognitive restructuring helps in challenging the negative automatic thoughts associated with headache symptoms. Behavioural experiments can also be used here to test predictions that persons suffering from headache attribute to their symptoms. Attention training method can also be used to take the attention away from symptoms and re-focus it on more adaptive thoughts and behaviour (Brown, 2007). Table 1: An example of pain diary Situation Head ache Thought Emotions Consequences (0=No Headache; 100=Ubearable headache) Fight with 80 I can t deal Irritattion & Shouted & Husband with this anger threw the plate Cleaning 85 I can t do Irritation Left work & the kitchen anything went to sleep

11 Cognitive Behavioural Management of Chronic 41 The use of cognitive and behavioural interventions in therapy can be illustrated as follows: The third session comprised of reviewing the headache diary and teaching her relaxation exercises (abdominal breathing for 5-10 minutes) followed by imagery technique in which she was asked to visualize a pleasant scene paying attention to the colors, sounds and tactile sensations. While reviewing her diary, it was noticed that she experienced headaches after verbal arguments with her husband and while she was doing work in the kitchen. Till the next session, it was planned that she would avoid confrontations with her husband, practice relaxation twice a day and maintain the diary. The fourth session involved reviewing the headache diary and helping the patient recognize maladaptive cognitions such as I can t do anything, I can t deal with it. She was then taught how these thoughts can be restructured as I am able to do some things, I can manage and reduce the pain. The fifth session involved helping the patient identify maladaptive patterns of coping with the pain and instilling more adaptive ways of coping with the pain and interpersonal problems. By reviewing the diary, she was made aware that her response to pain involved crying excessively, going to sleep or shouting at her husband. She was explained that these comprised of passive ways of coping, in which she was not solving the problems at hand and was avoiding them. Through an interactive discussion, she was taught how there can be various alternatives to cope with a problem at hand. With the example of getting irritated with doing kitchen work and resorting to sleeping or arguing with her husband, she was encouraged to come up with alternative ways of coping with the situation such as taking a small break between tasks, listening to music she liked while working and dividing chores with her husband. In this session, on her insistence and the consent of the patient s husband, the session was taken jointly with both of them. He was acquiescent of helping her with the household work and avoiding confrontation. She was asked to practice the problem solving

12 42 Trauma and Pain: Biopsychosocial Perspective skills taught during the session at home. In the sixth session, she reported practicing problem solving at home and reported feeling calmer. The patient reported a decrease in frequency of headaches from experiencing them daily to once in a week. (d) Terminating therapy: The patient was encouraged to take more responsibility while ending therapy. The therapist discussed the possibility of minor setbacks involved when terminating therapy. The goals of therapy as well as the process of therapy were reviewed with the patient and practicing the techniques which have proved to be effective for the patient was reinforced by the therapist. She was encouraged to practice the skills taught in therapy sessions and come after a month for booster session. Post Therapy Improvement After a month, she reported having headaches on 3 instances in the past month. She recognized that they were triggered by an argument with her husband on one occasion and not being able to do household work due to feeling low on the other occasions. She also reported getting irritable staying at home all day and not being able to socialize. She blamed her husband for not being available to take her out due to his work commitments. Possible alternatives were explored such as taking a small walk in the neighbourhood every day. Improvement in headaches

13 Cognitive Behavioural Management of Chronic 43 In subsequent months, 2-3 booster sessions were held and therapy was terminated. At the end of therapy, she reported significant improvement in her socio-occupational functioning and frequency and intensity of headaches. It may be concluded that that Cognitive Behaviour Therapy (CBT) for patients with headaches is found effective if applied systematically and scientifically with the goals set clearly and the reviews and termination of therapy planned perfectly. References Bahra, A., Walsh, M., & Menon, S. (2000). Does chronic daily headache arise de novo in association with regular analgesic use? Cephalagia, 20, 294. Beck, J.S. (1995). Cognitive therapy: Basics and Beyond. New York: Guilford Press. Brown, R.J. (2004). The psychological mechanisms of medically unexplained symptoms: An integrative conceptual model. Psychological Bulletin, 130, Brown, R.J. (2007). Medically unexplained symptoms. In N. Tarrier (Ed.), Case formulation in cognitive behavior therapy: The treatment of challenging and complex cases (pp ). New York: Routledge. Carson, A., Zeman, A., Myles, L., & Sharpe, M. (2008). Neurological disorders. In G.G. Lloyd & E. Gutherie (Eds.), Handbook of liaison psychiatry (pp ). New Delhi: Cambridge University Press. Chandler, T. (2001). Cognitive behavior therapy as a treatment for conversion disorders. In P.W. Halligan et al. (Eds.), Contemporary approaches to the study of hysteria: clinical and theoretical perspectives. Oxford: Oxford University Press. Kronke, K., & Swindle, R. (2000). Cognitive behavioral therapy for somatization and symptom syndromes: a critical review of controlled clinical trials. Psychotherapy and Psychosomatics, 69, Lipchik, G.L., Holroyd, K.A., & Nash, J.M. (2002). Cognitive-Behavioral Management of Recurrent Headache Disorders: A Minimal-Therapist- Contact Approach. In D.C. Turk & R.J. Gatchel (Eds.), Psychological approaches to pain management: A practitioner s handbook (pp ). New York: Guilford Press.

14 44 Trauma and Pain: Biopsychosocial Perspective Mehta M. (1992). Biobehavioural intervention in recurrent headache in children. Headache Quarterly: Treatment and Research.4, Mitsikostas, D.D., & Thomas, A.M. (1999). Comorbidity of headache and depressive disorders. Cephalagia, 19, Sharpe, M., Peveler,R. & Mayou, R.(1992). The psychological treatment of patients with functional somatic symptoms: A practical guide. Journal of Psychosomatic Research, 36, Zigmond, A.S., & Snaith, R.P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandanavica, 67,