Managing chronic pain in long term conditions

Transcription

1 Managing chronic pain in long term conditions Dr Andrew J. Lucas BSc(Hons) MSc MSc D.Psych. C.Psychol C.Sci AFBPS Consultant Lead Health Psychologist Department of Clinical Health Psychology Royal National Orthopaedic Hospital Stanmore, Middlesex

2 Introduction My role and experience MSK chronic pain

3 Presentation outline Defining Pain Management Psychological sequelae of chronic pain Cognitive behavioural model of chronic pain Pain management at the RNOH PMP key components Focus of psychological intervention Role of cognitive behavioural therapy

4 Defining Pain Management Depends who you ask! Surgical intervention? Therapeutic injections? Medication? Rehabilitation / Self-management?

5 Psychological sequelae of long term health conditions Health related anxiety / frustration Depression Loss of identity and self-esteem Low self-efficacy Hyper vigilance to health status Health seeking behaviour

6 Cognitive-behavioral model DISUSE DISABILITY DEPRESSION INJURY/STRAIN Vlaeyen et al., Pain, 1995 RECOVERY AVOIDANCE BEHAVIOR HYPERVIGILANCE FEAR OF MOVEMENT (RE)INJURY, PAIN PAIN EXPERIENCE EXPOSURE CATASTROPHIZING LOW FEAR

7 Communicative Behaviour Social Response Pain Experience Tissue Damage Protective Behaviour

8 BELIEFS about PAIN and DISABILITY (Main et al,2008) Cultural and social influences Family Media; internet Iatrogenic Most important Beliefs associated with the nature of pain Expectation of outcome Confusing hurting with harming Helplessness and external locus of control

9 KEY MESSAGES All pain behaviour occurs in a social context Symptomatic presentations may be highly idiosyncratic A patient s reaction to the persistence of pain may range from the expression of mild concern, to evidence of significant distress Their pain behaviour may range from display of guarded movements to full-blown chronic pain syndromes Not only the pain stimulus but also Context influence the response to pain

10 TAKE HOME MESSAGE Chronic pain related disability is explained by both physical and psychological factors

11 Residential pain management at the RNOH Admissions are usually for 3 weeks Admissions are from Monday to Friday Each Programme is unique to meet individual needs Each Programme combines group work and individual 1-1 sessions Follow-up sessions will be scheduled over the 12 months post discharge according to individual need

12 RNOH Pain Management and Rehabilitation programmes Admissions usually for 3 weeks Admissions are from Monday to Friday Hotel and Ward options Each programme is individualised and combines group and individual sessions MDT input (Physio, OT, Therapy Techs, Medical, Clinical Health Psychologist) Typically > 70 hours Follow up sessions typically at 3 and 12 months

13 Pharmacology - the experience at the RNOH The magic bullet the need to be fixed How useful? it takes the edge off Competing for misery

14 Polypharmacy and iatrogenics Common to report in excess of 5 different medications for pain Recent case of 26 medications for chronic pain syndrome and associated S/Es Role of interactions known for 2-3 medications but 26? Need for validation or taken seriously

15 PMPs: Key Components (Main & Spanswick,2000; Main, Sullivan,Watson.,2008) Context Major focus on RE-ACTIVATION Optimal Pain Management (including medication) Philosophy: Maximising patient involvement

16 PMPs: Key Components (Main & Spanswick,2000; Main, Sullivan,Watson.,2008) Changing emphasis from passive treatment to: Education (Correcting misunderstandings) Establishing Pain management Skills (Stress reduction; problem solving; pacing) Returning responsibility to the patient

17 PMPs: Key Components (Main & Spanswick,2000; Main, Sullivan,Watson.,2008) Identifying and tackling Obstacles to Recovery Focus on: Thoughts & Beliefs Emotional Reactions Pain Behaviour

18 Focus of Psychological Intervention in Rehabilitation Enhancing overall participation in programme Contextualising emotion & reintroducing the biopsychosocial context of pain and disability Understanding the stress-pain interface

19 Focus of Psychological Intervention in Rehabilitation Teaching basic management of emotions, cognition and pain behavior Defusing anger, hostility and resentment using cognitive re-appraisal Training in stress reduction techniques Cognitive re-structuring (CBT) Developing psychological flexibility (ACT) Changing behaviour using problem solving techniques

20 Focus of Psychological Intervention in Rehabilitation Tackling interpersonal relationships. Assertiveness and Communication The use of role-play as a vehicle for learning about interpersonal behaviour

21 Cognitive Behavioural Therapy (CBT) CBT is a general term for treatment methods using behaviour modification techniques but incorporating procedures for changing maladaptive beliefs. Aim is to change what the patient does and how they think. We all make mistakes in our thinking even you! CBT is about changing cognitive errors or bias CBT explores emotional reactions are there more helpful ways of thinking and reacting to experiences? CBT focuses on appraisal, interpretation and expectancies

22 CBT emphasises reciprocal relationships of what we do, think and feel. Thinking (Cognitive) Feelings (Affective) Doing (Behavioural)

23 The A B C of CBT A = Activating event (image, thought, memory) B = Belief (automatic thoughts and underlying beliefs) C = Consequences (emotions, behaviour, physiology)

24 Problem formulation Outlines the origins and course of problems. The patient provides a personalised account of illness representations and problems. What makes the particular issue a problem for the patient?

25 Socratic Questioning The patient is encouraged to consider the evidence for holding unhelpful beliefs. This is not directly confronting the belief! The patient is guided towards challenging their own beliefs.

26 Examples of questions to explore unhelpful thinking Where is the evidence for my belief? What makes the situation so terrible? Does everyone share my attitude? If not, why not? Am I making a mountain out of a molehill? If I can t stand it what will really happen? Is having this thought or attitude helping me? Does making a mistake make you useless? Are you expecting too much of yourself?

27 Examples of thinking errors All or nothing (I have to always look my best) Should or must statements (my house should always be spotless) Discounting the positive (anyone could cope like I do) Fortune telling (there is no point in taking the medicine) Labelling (I am not fully independent so I am useless)

28 Cost benefit analysis Advantage Disadvantage Current Behaviour Current Belief Desired Behaviour Desired Belief

29 CBT encourages self-acceptance Are weaknesses being used to discount the whole? Just because the patient is unable to do a particular task, does not make them useless. Need to explore expectations of self.

30 Other CBT techniques Homework, practise and consolidation Setback preparation Unhelpful vs. helpful responses Behavioural experiments hypothesis testing of beliefs Relaxation Imagery, Progressive Muscular, Deep Breathing

31 Acceptance and Commitment Therapy / Mindfulness Many people with chronic pain and illness feel that they need to fight it or resist it this contributes to Secondary suffering Acceptance = allowing, letting be, non-resistance Developing psychological flexibility This isn t the same as giving in or resigning yourself to your fate

32 Change relationship to thoughts - Mindfulness Self-awareness adapted from mindfulness meditation A state of being in the present (not on autopilot), accepting things for what they are, i.e. nonjudgementally Accept thoughts rather than fight them, even if you don t like or agree with them Heightens one s experience of the present

33 C B T - should be collaborative - encourages the patient to be responsible for change - aims to modify unhelpful beliefs - emphasises the reciprocal influence of behaviour, thoughts and feelings - develops an active approach to medical self management - must be goal focussed

34 Men are disturbed not by things, but by the view which they take of them. Epictetus the Stoic (c.55 - c.135)

35 Acnowledgements; Professor Chris Main Dr Joseph Cowan Dr Jonathan Berman Professor George Ikkos Dr Roxanah Zarnegar Dr Helen Cohen Thank you