Pain-related Distress: Recognition and Appropriate Interventions Tamar Pincus Professor in psychology Royal Holloway University of London
Remit (and limitations) of presentation Mostly, research in low back pain Tasters from a plethora of research. An opinionated, rather than objective, approach
Prevalence In chronic pain patients, the prevalence of depression is estimated at around 30% (conservatively). In Fibromyalgia, prevalence can be as high as 56%; Anxiety even higher (71%). (Arnold et al., 2007)
Differences in prevalence: Current measures Include of somatic items Difficulty sleeping Loss/gain weight Lack of libido Fatigue Exclusion of positive response items I look forward to things I feel connected / supported Majority developed in populations with mental disorders. 4
The experience of pain Life strain: disturbed sleep, strain on relationships, impaired quality of life, etc. Emotional distress is appropriate, including worry, fear and low mood. When these interfere with recovery, they are classified as Yellow Flags. When they are extreme, affect quality of life beyond pain, they might be Orange Flags.
The concept of flags Flagging up a concern Not a diagnosis Red flags: be vigilant for physical pathology Yellow flags: be vigilant for psychosocial barriers to recovery Orange flags: be vigilant for mental pathology.
Depression in groups with chronic pain Normal response? Yellow flag? Orange flag?
Un-packing depression in pain Psychiatric diagnosis is probably inappropriate and unhelpful for many patients Most measurements are contaminated with somatic items Many clinicians prefer to avoid the emotional baggage in patients presenting for a physiological problem Many patients are angered by the implication that their pain might be influenced by psychology
Orange flags The psychiatric equivalent of red flags. Require consideration of referral for specialist assessment. Arguably, individuals are not suitable for biopsychosocial management of their pain, without specifically addressing their mental problem. For example, a major and pervasive depressive illness, schizophrenia, bi-polar disorder.
Appropriate Distress Loss Justified anxiety about the future Recognising problems Change Adjustment It just breaks my heart that I can t run anymore I honestly don t know how we re going to manage financially Acknowledge Discuss Problem solving
Unhelpful Distress Magnification Generalisation Non-specific anger and resistance to help My whole life is destroyed and no-body seems to care yes, BUT Cognitive Behavioural Approach Refer to Multidisciplinary Team ASAP
Depression Self-hate Guilt Shame Extreme Hopelessness Helplessness It s all my fault, I always ruin everything I m just so useless, there s no point trying Refer to Clinical Psychologist or Psychiatrist Gently explore suicidal / self-harm tendencies
What is the focus of pain distress? Comparing cognitions between depressed groups and paindepressed groups Depressed: Self as shameful, unlovable, guilty. World as threatening and dangerous. Future as hopeless and bleak. Pain-depressed: Self associated with loss and suffering. World i.e. others don t understand. Should be able to help / cure. Future- optimistic- a cure will be found if I just keep searching. Pessimistic- Who will I be in future if I can t be who I used to be?
Unhelpful beliefs in pain patients Black & White thinking: I can t run anymore, I m therefore less lovable / worthy. Negative future thinking: I m going to end up in a wheel chair Positive as chance or transient: I had no pain this morning BUT Emotion-led reasoning: I just know its something serious Generalization: All doctors are Projecting: people think I m a loser Should and self-punishment: I should vanish You should cure me
The self Who am I now compared to who I used to be? Loss is realistic But often misattributed to pain Reality slaps hurt Who will I be if the pain won t go away? Reduced options Reduced goals
Evidence: memory bias (Pincus et al., 1995) Compared a surprise memory test of a list of adjectives previously judged as describes me, or describes my best friend. The words includes depression related (i.e. unlovable, shameful); neutral (tall, polite); and health related (aching; disabled). Depressed pain patients show a significant bias towards negative health words, not depression related words. BUT only in self-reference.
Self-Enmeshment Theory (Pincus & Morley, 2001) Proposed three separate domains: Self, Pain and Illness. Illness Pain Pain Self Self Illness
This gives us some ideas for interventions If we can t change the pain Pain Self
Cognitive-Behavioural treatment in chronic pain In general, moderately effective (Morley et al 1999; Eccleston update, 2009) But tends not to focus on depression, rather on healthy behaviour and coping. Almost no trials targeting depression in the context of chronic pain! But much prescribing of anti-depressants.
The assumptions underlying CBT That people have unhelpful beliefs That their perceptions are not accurate Sometimes referred to as dysfunctional cognitions BUT Although they may hold unhelpful beliefs and have attention and recall bias, the fundamental belief that pain is here to stay is accurate.
Activities inherent in CBT approach interventions for pain Pacing Setting achievable (physical) goals Becoming aware of automatic thoughts about pain Understanding pain better
Other options ACT / Mindfulness approaches Get up and do?
Enhanced Transtheoretical Model Intervention (ETMI) in CLBP Ben Ami et al., in press JOSPT Targeted low motivation and low self-efficacy to engage with physical recreational activity. Matched stage of change in patients. Enhanced communication skills. Standard statements about the value of PA Allowed choice of PA In vivo exposure if fear of walking reported.
Mean change from baseline against physiotherapy as usual at 12 months N = 94 N = 95 Mean difference P-value RMDQ 6.7 (5.4-8.0) 4.0 (2.7-5.2) 2.7 (0.9-4.5) 0.004* Severe Pain 2.9 (2.0-3.7) 1.7 (0.9-2.5) 1.2 (0.05-2.3) 0.04* Average Pain 2.6 (1.9-3.3) 1.7 (1.1-2.4) 0.9 (-0.03-1.8) 0.06 BPAQ 0.8 (0.4-1.3) 0.1 (-0.3-0.6) 0.7 (0.07-1.3) 0.02*
In summary We still tend to diagnose and treat depression as if it was a separate problem from the pain syndrome. We sometimes tend to measure and treat this depression as a psychiatric disorder, and prescribing antidepressants is common. Yet much of the evidence suggests that it is qualitatively different from clinical depression, and highly related to pain and disability.
Take home message It is extremely important to elicit information on low mood and its impact on life. Practitioners should try to explore whether mood preceded pain, or is intrinsically linked with pain. For those with long term mood problems, a referral is indicated: Some patients respond to anti-depressants, so consider these. CBT is as effective as anti-depressants. Where depression is closely linked to pain, pain management might help. Consider CBT and ACT, if available. Always consider the resilience and non-pain aspects of the patients life- can we support/ nurture these?
Thank you!