Role of Psychology with Patients Experiencing Chronic Pain

Anneliese Corcoran, Psy.D.Licensed Clinical Psychologist

Water’s Edge Pain Clinic

What we will cover today-

• Prevalence of chronic pain, depression, anxiety, substance use disorders• Reasons for involving “psychology" with chronic pain patients• Interaction between emotional functioning and pain• Psychobehavioral treatments for chronic pain• Depression/chronic pain and the primary care provider• Working together- messages we can consistently give patients

experiencing chronic pain

Stats Related to Prevalence

• Depressive Disorders are ranked third in terms of disease burden as defined by the World Health Organization (WHO, 2014)• Depression is the leading cause of disability world wide (WHO, 2012)• Estimates for rates of depression for people with chronic pain-

between 30% and 54% (Banks & Kerns, 1996)• Estimates for rates of anxiety for people with chronic pain- between

20% and 40% (Asmundson & Katz, 2009)

Stats Related to Prevalence

• 116 million American adults experience some form of chronic pain (Jensen, et al., 2014)• A review of the data- chronic pain more prevalent than heart disease,

diabetes, and cancer combined (Jensen, et al., 2014)• Chronic pain in adults over 65- between 47%-63% (Tsuag et al.)• Institute of Medicine estimated cost to U.S. economy $560-$630

annually (Institute of Medicine 2011)

This is a medical issue right? Why involve a psychologist?• We have the luxury of time• Disease related education for both the patient and the family-

understand connection between their pain and emotional functioning• Identify relationship between behaviors, thoughts, and mood, and

how impacts pain• Assist in learning new skills to address depression, anxiety sx’s, stress

management skills, sleep hygiene

Why Involve a Psychologist?

• Assist in identifying and making recommendations for individuals with high-risk factors for opiate use• Assessment for pain pump and stimulators• Teach specific strategies for fears related to procedures• Identify and refer for specific treatments if necessary (psychiatric

care, sleep specialist)• Attend and participate in interdisciplinary treatment team meetings

Reasons for a Referral to the Water’s Edge PsychologistConcern Noted by WE Provider Assessment Requested by WE Provider

Sadness, or other depressive symptomsOpioid Risk Assessment

Anxiety Stimulator

Multiple Unmanaged Stressors

Lifestyle choices impacting health Pump

Lack of coping skills/lack of social supports

Substance use

Adjustment concerns

Noncompliance with care

Health Psychology

• Biopsychosocial model

health or illness= + ++ +

• Health psychology both theoretical (research based) and applied (clinical)• Connect how emotional factors are impacting health, contribute to illness• Seeks to use psychological knowledge (research based) to positively impact

health through psychosocial education, techniques of behavioral change, psychotherapy

biological factors

(e.g. genetic predisposition)

behavioral factors

(e.g. lifestyle, stress, health

beliefs)

social factors(e.g. cultural influences,

social supports)

Biopsychosocial Model of Pain

(Gatchel, R., McGeary, D, McGeary, C., Lippe, B., & 2014)

Bio• Medication• Exercise• Surgery• Sleep

Psycho• Cognitions• Emotions• Behaviors• Attention

Social• Health

Care• Family • work

Depression

• Patients with depression and chronic pain:• Tend to have higher pain scores• Report feeling less in control of their lives• Use passive-avoidant coping strategies• Adhere less to treatment plans• Have greater interference from pain, including more pain behaviors• Respond less well to pain treatment unless the depression is addressed(Substance Abuse and Mental Health Services Administration, 2012)• Jarvik, J. et al. 2005- Greatest predictor of back pain 3 years after initial

imaging study- depression at baseline- 2.3 times more likely to have back pain

Suicide

• In patients with chronic pain suicidal risk “appeared to be at least doubled” (Tang & Crane, 2006)• People with chronic pain more likely to attempt and commit suicide,

not explained by co-occurring substance abuse disorders or mental disorders (Braden & Sullivan, 2008)

Anxiety

• Common with patients experiencing chronic pain• Often co-occurs with depression (2/3 of anxiety disorders also have co-existing mood disorder

present), but anxiety can present without depression• Patients with chronic pain and trauma, have increased rates of both anxiety and anxiety disorders

(Dersh et al., 2002)• n=85,088, 17 countries-

• Back or neck pain 2-3x’s more likely to be diagnosed past 12 mo. With panic disorder, agoraphobia, or social anxiety disorder

• 3x’s more likely to have been diagnosed with Generalized Anxiety Disorder or PTSD

• Women with fibromyalgia 4-5x’s more likely to have a dx of OCD, PTSD, or Generalized Anxiety Disorder during their lifetime

• Anxiety impacts functioning and may make patients less able to participate in pain management treatment

(Substance Abuse and Mental Health Services Administration, 2012)

Post-Traumatic Stress Disorder

• Chronic Pain and PTSD frequently co-occur• Pain one of the most commonly reported symptoms of patient’s with

PTSD• PTSD symptoms are especially common in patients who have • chronic pain and• high pain scores and• high pain affect and• high pain interference Asmundson (et al., 2002)

Impact of Abuse (Both Sexual and Physical)• Research has not consistently distinguished between physical and sexual

abuse (Hart-Johnson, et al. 2012)• Abuse history is more prevalent with individuals with chronic pain (Davis

et al. 2005)• Individuals with chronic pain and an abuse history also have poorer-

• Adjustment to pain• Higher health service usage• More psychiatric diagnoses (Bailey et al., 2003; Fergusson, D.M. et al. 2002)

• Women more likely to disclose abuse early in their relationship with a physician. Men more likely to wait much longer- even years into the relationship to disclose (Hooper & Warwick, 2006)

Chronic Pain and Substance Use Disorder• 32% of patients with chronic pain may have addictive disorders

(Chelminski et al., 2005)• 29-60% of people with opioid addiction report chronic pain

(Substance Abuse and Mental Health Services Administration, 2012)

Both pain and substance addiction are…• not static conditions• fluctuate in intensity over time and different circumstances• require ongoing management• both neurobiological conditions with evidence of disordered CNS function• mediated by genetics and environment• may have serious harmful consequences if not treated• can require a multifaceted treatment

• Treatment for one condition can support or conflict with treatment for the other.(Substance Abuse and Mental Health Services Administration, 2012)

Pain/Emotional Response Cycle and Substance Abuse Risk

Chronic Pain Emotional

Response-sleeplessness

-anxiety-depression

More Pain

Exacerbating Factors-physical inactivity

-overuse of sedating drugs-lack of engagement with life

Increased risk for self-medicating substance

use

Treatment…

• “The goals of chronic pain treatment most often include, along with reduction of pain relief of associated symptoms such as anxiety, depression, or sleep disturbance and increased function in valued social, vocational/avocational, creative and recreational roles.”

(Savage, et al. 2008)

Psychobehavioral Treatment

• Overlap between modalities• Cognitive behavioral therapy (CBT) has incorporated other techniques

from other models

Cognitive Behavioral Therapy (CBT) for Treatment of Chronic Pain• Considered “strong research support” for CBT for treatment of

chronic pain by the American Psychological Association – highest grade possible• Includes strong research support for…• fibromyalgia• low back pain• rheumatologic pain • headaches

CBT Basics

• Originally designed and used as a treatment for depression- now research supports use for a variety of reasons and conditions• Utilizes psychoeducational approach• All CBT approaches view-

• People as “active processors of information”• People are able to gain control over their thoughts, feelings and behaviors, and

even sometimes their physiology• Interrelationships exist between thoughts, feeling and behaviors (Jensen M., et al. 2014)

• The premise of CBT- cognitive triangle- thoughts, feelings and behaviors are all connected

• Want to see changes in mood, anxiety? Focusing on feelings is the most difficult place to illicit change, instead CBT focuses on thoughts and behaviors maintaining the symptoms• Focusing on behaviors means lifestyle changes that impact mood sx’s,

anxiety, and even chronic pain (diet, exercise, sleep hygiene)

The thoughts part of the triangle…

• Focusing on thoughts, means recognizing negative, maladaptive thinking, “cognitive distortions”, sometimes called cognitive errors. • Some of the types of cognitive distortions: black and white thinking,

labeling, overgeneralization, discounting the positive, mind reading, magnification, emotional reasoning and catastrophizing

Catastrophizing and Pain

• Research has looked at the relationship between catastrophizing thoughts and pain for the past 50 years• Characterized by feelings of helplessness, rumination, and

magnification of pain • Often seen with depression and chronic pain• Affects pain coping behavior • Studies show that pain catastrophizing is an independent risk factor

for predicting chronicity of pain and poorer prognosis

Everyone experiences painful situations at some point in their lives. Such experiences may include headaches, tooth pain, joint or muscle pain. People are often exposed to situations that may cause pain such as illness, injury, dental procedures or surgery. • We are interested in the types of thoughts and feelings that you have when you are in pain. Listed below are thirteen statements describing different

thoughts and feelings that may be associated with pain. Using the following scale, please indicate the degree to which you have these thoughts and feelings when you are experiencing pain.

• 0 – not at all 1 – to a slight degree 2 – to a moderate degree 3 – to a great degree 4 – all the time • When I’m in pain … • 1 I worry all the time about whether the pain will end. ☐• 2 I feel I can’t go on. ☐• 3 It’s terrible and I think it’s never going to get any better. ☐• 4 It’s awful and I feel that it overwhelms me. ☐• 5 I feel I can’t stand it anymore. ☐• 6 I become afraid that the pain will get worse. ☐• 7 I keep thinking of other painful events. ☐• 8 I anxiously want the pain to go away. ☐• 9 I can’t seem to keep it out of my mind. ☐• 10 I keep thinking about how much it hurts. ☐• 11 I keep thinking about how badly I want the pain to stop. ☐• 12 There’s nothing I can do to reduce the intensity of the pain. ☐• 13 I wonder whether something serious may happen. ☐• …Total Updated 11/11

CBT Techniques for Chronic Pain

• Recognizing cognitive triggers, limiting beliefs, cognitive distortions, learning to reframe and restructure• Problem solving• Psychoeducation related to pain, mechanics of depression and anxiety• Relaxation techniques (Breathing, Progressive Relaxation, Autogenics,

Imagery etc.)• Understand cognitive triangle and behavior part of equation,

specifically behavioral activation (lifestyle factors- movement, smoking, nutrition, sleep, social outlets, etc.)

CBT Techniques for Chronic Pain

• Address lifestyle (behavior) may use charting, homework, psychoeducation r/t process of behavior change and roadblocks etc.• Activity Pacing• Mindfulness • Will employ other techniques including biofeedback and hypnosis

States of Mind

Core Belief Filter

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+ +

+

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-+

+

Mindfulness

Mindfulness

• Basis thousands of years old• Selective attention• Can use while breathing, in the moment, for an event, eating, etc.• Regular practice of mindfulness can significantly impact pain

tolerance and reduced sensitivity (Grant et at, 2011)• In a mindfulness exercise for pain could notice breathing, notice

sensations of pain, notice thoughts related to pain- without judgment, sitting with the pain

(Fancher, J. 2012)

Mindfulness

Brief Demonstration…Really This Won’t Take Long

Acceptance and Commitment Therapy (ACT)

Acceptance and Commitment Therapy (ACT)• Like traditional CBT, also rated as “strong” for research support by the

American Psychological Association in general- “regardless of pain location, diagnosis or source” (Bailey, et al., 2015)• “Third Wave” of CBT• In the CBT family• Mindfulness- how you think about pain and emotions vs. CBT what

you think about emotions ”(McCraken, L. & Vowles, K, 2014)• Importance of “psychological flexibility”(McCraken, L. & Vowles, K,

2014)• Important component acceptance

Biofeedback

Evidence Supports Use of Biofeedback as a Nonpharmcological Therapy with:• Chronic pain• Chronic Low back pain• Chronic headaches including chronic migraines• fibromyalgia• Musculoskeletal pain

• Useful with a wider range of patients, do not have to be psychologically minded to benefit

Chronic Pain, Emotional Distress and Primary Care• Over 50% of people with mental health needs go to their PCP (Kessler

et al., 2007)Baik et al., (2013)- • Recent study showed even once a diagnosis of depression had been

made, physicians sometimes had to “sell" their diagnosis and then the treatment, trying to convince the pt.• After “selling” the patient then treatment options could be

considered• Relationship important “interactional familiarity”

PHQ-9- A Screener and Conversation Starter• Allows providers to quickly identify patients experiencing symptoms of

depression.• Good idea to use a screener for depression• Depressive disorders are common can go unrecognized• May be first professional that informs them about pain and depression-

normalizing and encouraging treatment• Can lead to a conversation, including screening for suicidal ideation• Old data but good reminder-

• Primary care physicians missed depression 30-50% of the time Simon, G.E. et al., 1995)• 40% of patients who completed suicide had seen their primary care physicians the

month before (Luoma J.B., et al., 2002)

Consistency among Health Care Providers when Discussing Chronic Pain and Emotional Functioning

• You are not your pain• Introducing concept of a “person living with pain” vs. pain patient

• Briefly addressing and gently challenging catastrophizing statements• Fear and role of avoidance• Connection between pain, depression, and anxiety• Importance of addressing depression and anxiety for overall quality of

life, but especially if have chronic pain

Consistency among Health Care Providers when Discussing Chronic Pain and Emotional Functioning

• Normalizing and educating related to the use of anti-depressants• Realistic expectations related to opioid use, and other treatments for

pain• Chronic pain= most likely living with some level of pain, even with

treatments to address pain • Minimizing stigma, especially related to mental health. It is ok to get

the appropriate help- seeing a counselor, substance abuse treatment, psychiatric prescriber, etc.

Consistency Among Health Care Providers- You Were Right All Along! We Should All Be Encouraging:

• Role of lifestyle impacting pain and overall functioning• Nutrition• Get moving- Physical activation (helps with depression, anxiety, pain)• Smoking- Pain management another benefit of quitting• Good sleep hygiene

ReferencesAsmundson, G., Coons, M., Taylor, S., & Katz, J. (2002). PTSD and the Experience of Pain: Research and clinical implications of shared vulnerability and mutual maintenance models. Canadian Journal of Psychiatry, 47(10), 930-937.

Asmundson, G., & Katz, J. (2009). Understanding the co-occurrence of anxiety disorders and chronic pain: State-of-the-art. Depression and Anxiety, 26, 888-901.

Baik, S., Crabtree, B., & Gonzales, J. (2013). Primary care clinicians’ recognition and management of depression: a model of depression care in real-world primary care practice. Journal General Internal Medicine, 28(11), 1430-1439.

Bailey B., Freedenfeld R., Kiser, R., & Gatchel, R. (2003). Lifetime physical and sexual abuse in chronic pain patients: Psychosocial correlates and treatment outcomes. Disability Rehabilitation, 25, 331-342.

Banks & Kerns, (1996). Explaining high rates of depression in chronic pain: A diathesis-stress framework. Psychological Bulletin, 119, 95-110.

Braden, J.B., & Sullivan, M.D. (2008). Suicidal thoughts and behavior among adults with self-reported pain conditions in the National Comorbidity Survey Replication. Journal of Pain, 9(12), 1106-1115.

Chelminski, P.R., Ives, T.J., Gelix, K.M. Prakken, S. D., Miller, T.M., & Perhac, J.S. (2005). A primary care, multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden of psychiatric comorbidity. BMC Health Services Research, 5(1),3.

Davis, D.A., Luuecken L.J., & Zautra A.J.,(2005). Are reports of childhood abuse related to the experience of chronic pain in adulthood? A meta-analytic review of the literature. Clinical Journal of Pain, 21, 398-405.

Demyttenaere, K., Bruffaerts, R., & Lee, S. (2005). Mental disorders among persons with chronic back or neck pain: results from the World Mental Health Surveys. Pain, 111:77-83.

Dersh, J., Polatin, P.B., & Gatchel, R.J. (2002). Chronic pain and psychopathology: Research findings and theoretical considerations. Psychosomatic Medicine, 64, 773-786.

Ehde, D., Dillworth, T., & Turner, J. (2014). Cognitive-behavioral therapy for individuals with chronic pain. American Psychologist, 69(2), 153-166.

ReferencesFancher, J. (2012). Master your pain: A comprehensive science-based method to help you live well with chronic pain. Portland, OR: Visceral Books.

Fergusson D., Swain-Campbell, N., & Horwood, L. (2002). Does sexual violence contribute to elevated rates of anxiety and depression in females? Psychological Medicine, 32, 991-996.

Fishbain, D.A., Lewis, J.E., Gao, J., Cole, B., & Rosomoff, S.R. (2009). Are chronic low back pain patients who smoke at greater risk for suicide ideation? Pain Medicine, 10 340-346.

Gatchel, R., McGeary, D., McGeary, C., & Lippe, B. (2014). Interdiscipinary chronic pain management. American Psychologist, 69(2) 119-130.

Grant, J.A., Courtemanche, J., & Rainville, P. (2011). A non-elaborative mental stance and decouoling of executive and pain-related cortices predicts low pain sensitivity in Zen mediators. Pain, 152, 150-156.

Hart-Johnson, T., & Green, C. (2012). The impact of sexual or physical abuse history on pain-related outcomes among blacks and whites with chronic pain: gender influence.Pain Medicine, 13, 229-242.

Hooper, C., & Warwick, I. (2006). Gender and the politics of service provision for adults with a history of childhood sexual abuse. Critical Social Policy, 26, 467-479.

Institute of Medicine. (2011). Relieving Pain in America: A blueprint for transforming prevention, care, education, and research. Washington, D.C. National Academic Press.

Jarvik, J., Hollingworth, W., Heagerty, P., Haynor, D., Boyko, E., & Deyo, R. (2005). Three-year Incidence of low back pain in an initially asymptomatic cohort: clinical and imaging risk factors. Spine, 30(13), 1541-1548.

Jensen, M., & Patterson, D. (2014). Hypnotic approaches for chronic pain management. American Psychologist, 69(2), 167-177.

Jensen, M., & Turk, D. (2014).Contributions of psychology to the understanding and treatment of people with chronic pain. American Psychologist, 69(2), 105-118.

Kessler R., Merikangas, K., & Wang, P. (2007). Prevalence, comorbidity, and service utilization for mood disorders in the United States at the beginning of the twenty-first century. Annual Review of Clinical Psychology, 3, 137-158.

References

Linton, S. (2000). A review of psychological risk factors in back and neck pain. Spine, 25(9), 1148-1156.

Luoma J.B., Martin C.E., & Pearson J.L. (2002). Contact with mental health and primary care providers before suicide: a review of the evidence. American Journal of Psychiatry, 159, 909-916.

McCracken, L., & Vowles, K. (2014). Acceptance and Commitment Therapy and Chronic Pain. American Psychologist, 69(2), 178-187.

Raphael K.G., Janal M.N., Nayak S., Schwartz J.E., & Gallagher RM. (2006). Psychiatric comorbidities in a community sample of women with fibromyalgia. Pain, 124, 117-125.

Savage, S., Kirsh,K., & Passick, S. (2008). Challenges in using opioids to treat pain in persons with substance use disorders. Addiction Science & Clinical Practice, June 2008.

Simon G.E., & VonKorff M. (1995). Recognition, management, and outcomes of depression in primary care. Archive Family Medicine, 4, 99-105.

Substance Abuse and Mental Health Services Administration. (2012). Managing chronic pain in adults with or in recovery from substance use disorders: Treatment Improvement Protocol (TIP) Series 54. SAMHSA's National Clearinghouse for Alcohol and Drug Information (NCADI). 1-128.

Tang, N.K., & Crane. (2006). Suicidality in chronic pain: A review of the prevalence, risk factors and psychological links. Psychological Medicine, 36, 575-586.

Tsang, A., Von Korff, M., Lee, S., Alonso, J., Karam, E., Angermeyer, M.C., & Wantabee, M. (2008). Common chronic pain conditions in developed and developing countries: Gender and age differences and comorbidity with depression-anxiety disorders. Journal of Pain, 9(10), 883-891.

WHO. (2014). Global burden of disease (GBD). Retrieved from http://www.who.int/healthinfo/global_burden_disease/gbd/en/

WHO (2012) Depression fact sheet Retrieved from http://www.who.int/mediacentre/factsheets/fs369/en/index.html