pain psychology: theory and practice
TRANSCRIPT
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Pain Psychology:Theory and Practice
John T. Mullen, Ph.D., L.P.
Courage Kenny Pain ClinicAllina Health Services
Introduction
Philosophy - definitions and distinctions
Cognitive-behavioral model of chronic
Behavioral strategies for chronic pain management
Applications of pain psychology
Acute Pain vs. Chronic Pain
Acute Pain Chronic Pain
Duration < 3 months > 3 months
Location Body Body and Mind
Source Physiology Multiple:Psychophysiology
Course Linear Cyclic
Treatment Goal Cure, Fix Manage, Stabilize
Intervention Target Pain Contributing Factors
Provider Role Do to and Do for Guide, Educate, Support
Patient Role Passive (Wait) Active (Do and Learn)
Treatment Relationship Directive Collaborative
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Biopsychosocial
Biopsychosocial Model
•Broad framework for organizing information• multifaceted nature of chronic health conditions
•Captures a range of potential variables• pain condition and physical status• unique individual factors• history, context, and circumstance
Biopsychosocial Model
Biology PsychologySocial/
Environment
Medication Thoughts Family
Procedures Emotions Community
Rehabilitation Behaviors Work
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Biopsychosocial Model
•Central role of the individual:•active processor of information• thoughts-feelings-behaviors in context•behavior is influenced by person and situation• capacity to learn adaptive skills and strategies• involvement of individual in treatment process
•Person vs. broken body part•Pain vs. impact of the pain
Biomedical vs. Biopsychosocial
Biomedical Biopsychosocial
Relationship Directive Collaborative(compassion, empathy: trust, hope)
Patient Role Passive Active
Perspective Impersonal Individualized
Scope Specific / Narrow Holistic / Broad
Condition Acute Chronic
Objective Cure / Fix Stability / Management
Cognitive Behavior Therapy
• Learning-based intervention• knowledge – new perspectives• skills – new abilities
•Active self-management• active – passive• self – other• management – fix/cure/eliminate
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Motivational interviewing (MI)
• Stages of change• Precontemplation
• Contemplation - ambivalence
• Action
• Maintenance
•Address importance and confidence regarding change• Differential interest (medication, rehabilitation, psychology)
• Identify initial objectives, incentives, and obstacles
Treatment Goals
•Increase adaptive activity
•Use chemicals safely and effectively
•Manage pain and stress/distress
•Increase independence
•Improve quality of life
Illness behavior
• Actions and statements that reflect pain and suffering, often beyond the physical experience
• Idiosyncratic patterns of illness experience, adjustment, and accommodation
• Influenced by history, expectation, beliefs…
• Represents efforts to manage the pain and related challenges
• Actions can be effective but not adaptive
Address the chronic pain condition
and manage the illness behavior pattern
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Habit
“an acquired pattern of thought or behavior, that through repetition, has become nearly or completely involuntary”
Cognitive-Behavioral Model
Sensations
Automatic Thoughts
Actions
Emotions
Results:
Short term - Long term
Benefits - Costs
Outcome short-term long-term
benefits
costs
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Pain Experience =
Pain condition + deconditioning + distress + sleep disturbance +
negative thoughts + impairment + family concerns + mood +
muscle tension + frustration + etc…
Target: overall pain experience, not pain per sei.e., address the contributing factors
Pain
Tension
Emotion
Fatigue
Distress
Disruption
Dysregulation
Cycle of Chronicity
Cognitive-Behavioral Model
Sensations
Automatic Thoughts
Actions
Emotions
Results:
Short term - Long term
Benefits - Costs
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Sensations
•Psychophysiology• Autonomic nervous system activation
• Defensive / protective response
• Sympathetic / Parasympathetic balance• Ability to self-regulate
• Sensations perceived as harm or threat
Sensations
Automatic Thoughts
Actions
Emotions
Sensations
• Importance: • Distinguish pain from somatic reactions and guarding behaviors• Recognize somatic and psychophysiological reactions
• Tension
• Fatigue• Weakness
• Process:• Relaxation, meditation, stillness, awareness• Radar vs spotlight
• Goal:• Reduce somatic vigilance and reactivity • “non-judgmental, present moment awareness”• neutrality
Sensations
Automatic Thoughts
Actions
Emotions
Automatic Thoughts
• Content – what a person thinks• Irrational thoughts
• Implicit beliefs
• Unrealistic expectations
• Process – how a person thinks• Emotional biases
• Catastrophic thinking• Preoccupation, magnification, helplessness
Sensations
Automatic Thoughts
Actions
Emotions
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Automatic Thoughts
• Memories• Cause and course of pain condition
• Frustrations and failures
• Beliefs• Self, others, pain and illness beliefs
• “old rules” vs “new rules”
• Expectations• Apprehension, outcomes, changes
Sensations
Automatic Thoughts
Actions
Emotions
Automatic Thoughts
• Myths of chronic pain• “pain is a reliable signal of damage or harm”
• “a pill for every ill, when in doubt cut it out”
• “pain is a signal to stop moving”
• “if doctors have told you they have ‘done all they can,’ your situation is hopeless”
Sensations
Automatic Thoughts
Actions
Emotions
The Pain Survival Guide:
How to Reclaim Your Life
DC Turk and F Winter
Pain Beliefs
• Nociception – pain experience
• Hurt – harm
• Pain - danger
• Can’t – won’t
• Active – passive
• Reactive – deliberate
• Caution – ambition
Sensations
Automatic Thoughts
Actions
Emotions
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Ambition
Caution
Automatic Thoughts
• Objective: • Increase awareness of maladaptive patterns
• Process:• Thought record: situation-emotion-thought
• Goal:• Establish realistic expectations
• Reframing – create adaptive and alternate perspectives
• Reduce impact of negative thoughts upon pain and coping patterns
Sensations
Automatic Thoughts
Actions
Emotions
situationphysical
sensationthought emotion action outcome
2 3 4 1 5 6Where was I?Who was I with?What was happening?What was I doing?When did this happen?
What did I notice in my body?What was changing?
What was I thinking?What was I expecting?What was I paying attention to?
How was I feeling?How intense was the feeling?
What did I do?What did I not do?
What happened?Did I feel different?What did I learn?
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Pain Acceptance
Adjustment
Accommodation
Acknowledgment
Adaptation
Compromise
Critical aspects: Pain willingness
Activity engagement
Sensations
Automatic Thoughts
Actions
Emotions
MIND
BODY
Memories
Beliefs
Images
Expectations
Ability
Capacity
Restrictions
Limitations
sports/orthopedic
rehabilitationreturn to prior ability
pain
rehabilitationadapt to current ability
reasonable
realistic
sustainable
(compromise)
DoDifferently
ThinkDifferently
Psychological Flexibility
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Emotional Experience
• Negative emotions• Anger / frustration / irritability
• Anxiety / fear / worry / apprehension
• Depression / sadness / loss / hopelessness
• Positive emotions• Pleasure / joy / contentment
Sensations
Automatic Thoughts
Actions
Emotions
Emotional Experience
• Importance: • Recognize judgments and evaluations related to pain experience
• Process:• Thought record, review of difficult situations
• Goal: • Reduce negative affect
• Reduce linkage between sensation, thought, emotion, and action
• Link thoughts to actions, connect actions to goals
Sensations
Automatic Thoughts
Actions
Emotions
Cognitive-Behavioral Model
Sensations
Automatic Thoughts
Actions
Emotions
Results:
Short term - Long term
Benefits - Costs
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Pain Behavior
• Efforts to manage pain, distress, fear, tension, frustration
• Evidenced in daily activity pattern, routines
• Excesses (rest, chemicals) and deficits (productive activity)
Sensations
Automatic Thoughts
Actions
Emotions
Outcome short-term long-term
benefits
costs
Pain Behavior
• Importance: • Understand the activity pattern and decisions regarding daily engagement
• Process: • Self-monitoring – activity record• Sleep/wake cycle• Reactivation
• Pleasurable engagement – create positive an enjoyable experiences• Productive engagement – create successes and accomplishments
• Goal:• Create consistent routine• Improve level and pattern of activity• Balance: Demands – Abilities – Self-care
Sensations
Automatic Thoughts
Actions
Emotions
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Intensity
Consistency
Pain
Tension
Emotion
Fatigue
Distress
Disruption
Dysregulation
Cycle of Chronicity
Sleep management – CBT-I
• Importance: • Contribution of sleep disruption to the chronic pain experience
• Process: • Sleep hygiene
• Sleep restriction
• Reactivation
• Goal:• Create consistent diurnal pattern
• Reduce “down time”
• Improve ability, activity, engagement, energy
Sensations
Automatic Thoughts
Actions
Emotions
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Coping Patterns
Behavior Emotion Cognition
Passive / Dependent
resigned,withdrawn
discouraged,depressed
hopeless, helpless
Avoidant reactive anxious, fearful
threat,danger
Persistent over-active, determined
angry, frustrated
strength,independence
Adaptive accommodating,adjusting
even,stable
acceptance,accommodation
Biopsychosocial Model
Biology PsychologySocial/
Environment
Medication Thoughts Family
Procedures Emotions Community
Rehabilitation Behaviors Work
BiopsychoSOCIAL
• Interpersonal context• family, friends, work, school, community
• Punishing - critical / demanding• “work harder” “do more” “get stronger”
• Solicitous – “too” helpful• “be careful” “let me do that”
• Distracting – encouraging, supportive• “let’s try together” “I’ll help”
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BiopsychoSOCIAL
•Communication and collaboration
• Clarify ability to others• Inform them that symptoms vary• Limit pain talk• Ask for and accept assistance• Assertiveness skills
Interdisciplinary pain management
•Coordinated and integrated services• Medical care
• Rehabilitation services
• Pain psychology
• Alternative and complementary services
• Strong research support
Spinal cord stimulator evaluation
• Biopsychosocial perspective• Pain as an integrative phenomenon• Peripheral and central factors, history and circumstance• Coping patterns• Demonstrated impact on outcome – pain, activity, adjustment
• Pain psychology evaluation• NOT – pass/fail – use of the device is a medical decision• Identify obstacles to optimal outcome
• Clinical evaluation• Review of medical records• Psychometric assessment
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MMPI-2-RF
• Validated psychometric instrument
• 338 true-false questions
• Validity scales• Orientation toward the test
• Self-report – possible misrepresentation
• Clinical scales• Symptom patterns
• Behavioral patterns
SCS Evaluation
• Areas of concern:• Somatization and pain preoccupation/amplification
• Mood or anxiety disorders
• Passive and avoidant coping
• Recommendations:• Comprehensive pain services
• Mental health or chemical dependency services
• Goal:• Increase the likelihood of a successful outcome
Perioperative interventions
•Reduce post-operative and persistent pain • Identify high-risk patients
• e.g. mood and anxiety disorders, catastrophic thought patterns
• Provide pre-operative interdisciplinary intervention• Psychology – emphasis on self-care skills
• Brief educational and information intervention
• Evidence of impact:• Reduced opioid use
• Reduced pain interference
• Improved mood
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CBT for Chronic Pain - Limitations
•Training demands
•Technical experience
•Provider interest
•Efficacy vs. Effectiveness (Ideal, controlled settings vs “real world”)
• Select patient groups• Limited duration of studies• Modest outcomes
CBT for Chronic Pain - Remedies
• Acceptance and Commitment Therapy (ACT)• Psychological flexibility• Activity engagement – focus on function
• Patient matching • Diagnostic groups• Cardinal features• Motivational level • Coping patterns
• Mechanisms of change• “active” components of treatment• Catastrophic thinking• Reactivation• Hopelessness
• Integrated and comprehensive care• Physical therapy models• Interdisciplinary services
CBT for Chronic Pain
• Behavioral management • Components• Processes
• Recognition of the idiosyncratic pattern• Disposition / history• Circumstances
• Behavior change via awareness and learning• Establish new habits and patterns• Improved adjustment and pain management• Pain acceptance• Illness accommodation
•Quality of life