Psychological Psychological Assessment and Assessment and

Treatment of PainTreatment of Pain

Matthew Bailly, Ph.D., C.Psych.Matthew Bailly, Ph.D., C.Psych.

Department of Clinical Health Department of Clinical Health PsychologyPsychology

University of Manitoba School of University of Manitoba School of MedicineMedicine

Acute PainAcute Pain

Characterized by intense, temporary Characterized by intense, temporary noxious sensations and is related to noxious sensations and is related to tissue damagetissue damage

For patients that do not experience For patients that do not experience adequate analgesia, can lead to chronic adequate analgesia, can lead to chronic painpain

Important to provide effective Important to provide effective pharmacological analgesia as soon as pharmacological analgesia as soon as possible during, or even before, an acute possible during, or even before, an acute pain episodepain episode

Acute PainAcute Pain

Pain can be accompanied by anxiety, Pain can be accompanied by anxiety, stress, and physical tension, which can stress, and physical tension, which can exacerbate and/or prolong the acute pain exacerbate and/or prolong the acute pain episodeepisode

These additional factors should also be These additional factors should also be addressed as soon as possibleaddressed as soon as possible

A number of psychological strategies can A number of psychological strategies can be used to help patients cope with these, be used to help patients cope with these, as well as thoughts and emotions that as well as thoughts and emotions that may increase physiological arousal and may increase physiological arousal and reduce the patients’ sense of controlreduce the patients’ sense of control

Pain EducationPain Education

Patients should be given as much Patients should be given as much information as possible about care information as possible about care providedprovided, if possible before any , if possible before any proceduresprocedures

Patients should also be educated in Patients should also be educated in using their analgesics appropriatelyusing their analgesics appropriately

An emphasis should be placed on taking An emphasis should be placed on taking medications as scheduled, not only when medications as scheduled, not only when pain emerges, and patients’ concerns pain emerges, and patients’ concerns regarding side effects, including any regarding side effects, including any addiction potential, should be addressedaddiction potential, should be addressed

Diaphragmatic BreathingDiaphragmatic Breathing

Inform patients that physiological arousal can Inform patients that physiological arousal can increase pain signals, and that relaxation increase pain signals, and that relaxation strategies can reduce this arousalstrategies can reduce this arousal

Ask patients to assume a comfortable Ask patients to assume a comfortable position and to place one hand over their position and to place one hand over their abdomenabdomen

Instruct patients to inhale deeply through Instruct patients to inhale deeply through their nose, bringing air into the bottom of their nose, bringing air into the bottom of their lungs, then to exhale through their their lungs, then to exhale through their mouthmouth

Repeat this for two or three breaths, then Repeat this for two or three breaths, then request that they practice this regularly, for request that they practice this regularly, for three to five minutes at a timethree to five minutes at a time

DistractionDistraction

Tell patients that although strong, pain signals Tell patients that although strong, pain signals are one of many possible sensations that they are one of many possible sensations that they may notice at any given moment, and that may notice at any given moment, and that actively distracting from the signal may provide actively distracting from the signal may provide some reliefsome relief

Ask patients to gently guide their attention to Ask patients to gently guide their attention to another stimulus, such as television, music, another stimulus, such as television, music, reading, simple puzzles, or conversations with reading, simple puzzles, or conversations with supportive family/friendssupportive family/friends

Encourage patients to imagine a preferred place Encourage patients to imagine a preferred place or situation where they feel calm and relaxed, in or situation where they feel calm and relaxed, in as much detail as possible, pulling in all of their as much detail as possible, pulling in all of their senses, including sights, sounds, smells, touch, senses, including sights, sounds, smells, touch, and tasteand taste

Self-CoachingSelf-Coaching

Discuss the role of thoughts on patients’ Discuss the role of thoughts on patients’ sense of coping with pain, and their sense of coping with pain, and their relationship to physiological arousalrelationship to physiological arousal

Encourage patients to generate and Encourage patients to generate and practice positive self-talk that emphasizes practice positive self-talk that emphasizes their ability to cope with the paintheir ability to cope with the pain

Patients should also be reassured that the Patients should also be reassured that the pain episode is of limited duration, and pain episode is of limited duration, and that they can remind themselves that it that they can remind themselves that it will passwill pass

Definition of Chronic PainDefinition of Chronic Pain(International Association for the Study (International Association for the Study of Pain)of Pain)

An unpleasant sensory or An unpleasant sensory or emotional experience resulting emotional experience resulting from actual or potential tissue from actual or potential tissue damage lasting beyond the usual damage lasting beyond the usual course of the acute disease or course of the acute disease or expected time of healingexpected time of healing

Elements of Chronic PainElements of Chronic Pain(Fordyce, 1988)(Fordyce, 1988)

Nociception – mechanical, thermal, or chemical Nociception – mechanical, thermal, or chemical energy impinging on specialized nerve endings energy impinging on specialized nerve endings that signal aversion to the CNSthat signal aversion to the CNS

Pain – sensation arising from stimulation of Pain – sensation arising from stimulation of perceived nociceptionperceived nociception

Suffering – affective or emotional response Suffering – affective or emotional response triggered by nociception or other aversive triggered by nociception or other aversive eventsevents

Pain behaviour – responses made to pain and Pain behaviour – responses made to pain and sufferingsuffering

Biopsychosocial ModelBiopsychosocial Model(Gatchel & Turk, 2002)(Gatchel & Turk, 2002)

Unfortunately, many patients still view Unfortunately, many patients still view pain in terms of physical diseasepain in terms of physical disease

Sees chronic pain as not just disease, Sees chronic pain as not just disease, but as an “illness”but as an “illness”

Pain seen as an ongoing, multifactorial Pain seen as an ongoing, multifactorial processprocess

Relative weighting of the contributions Relative weighting of the contributions of physical, psychological, and social of physical, psychological, and social factors change over timefactors change over time

Biopsychosocial ModelBiopsychosocial Model(Gatchel & Turk, 2002)(Gatchel & Turk, 2002)

Sociocultural factors include illness Sociocultural factors include illness beliefs, expectations, healthcare seeking beliefs, expectations, healthcare seeking and availabilityand availability Involves social and operant learningInvolves social and operant learning

Cognitive factors include thoughts about Cognitive factors include thoughts about controllability of pain, self-efficacy, controllability of pain, self-efficacy, cognitive errors, and coping abilitycognitive errors, and coping ability

Affective factors include levels of Affective factors include levels of depression, anxiety, angerdepression, anxiety, anger

Biopsychosocial ModelBiopsychosocial Model(Gatchel & Turk, 2002)(Gatchel & Turk, 2002)

Personality factors include interpersonal Personality factors include interpersonal sensitivity, fearful appraisals of bodily sensations, sensitivity, fearful appraisals of bodily sensations, bodily preoccupation and catastrophic thinkingbodily preoccupation and catastrophic thinking

The above factors act indirectly on pain and The above factors act indirectly on pain and disability by reducing physical activity, muscle disability by reducing physical activity, muscle flexibility, tone, and strength, and physical flexibility, tone, and strength, and physical enduranceendurance

Direct effects include increased sympathetic Direct effects include increased sympathetic nervous system arousal, endogenous opioid nervous system arousal, endogenous opioid production, and elevated levels of muscle tensionproduction, and elevated levels of muscle tension

Consequences for the Individual Consequences for the Individual and Othersand Others

VocationalVocational FinancialFinancial Health care useHealth care use ““Systems” issuesSystems” issues Functional Functional

impairmentimpairment Interpersonal Interpersonal

dysfunctiondysfunction Mood and anxiety Mood and anxiety

disturbancedisturbance

Increased Increased responsibility for responsibility for family membersfamily members

Health care Health care provider frustrationprovider frustration

Increased health Increased health care costscare costs

Increased social Increased social service costsservice costs

Reduced work Reduced work productivityproductivity

Factors Complicating Factors Complicating Chronic PainChronic Pain Substance abuseSubstance abuse History of mental disorderHistory of mental disorder TraumaTrauma Chronic illnessChronic illness Family discordFamily discord GriefGrief Systems issuesSystems issues Legal concernsLegal concerns Financial issuesFinancial issues Multicultural issuesMulticultural issues

Psychological TreatmentPsychological Treatment

Currently no treatment that consistently and Currently no treatment that consistently and permanently alleviates pain for all patientspermanently alleviates pain for all patients

Management of chronic pain often depends on Management of chronic pain often depends on the readiness and abilities of the clientthe readiness and abilities of the client

Primary goal is to improve function rather Primary goal is to improve function rather than alleviate painthan alleviate pain

Effective management is achieved most Effective management is achieved most readily using a multidisciplinary approach readily using a multidisciplinary approach (Turk and Stieg, 1987)(Turk and Stieg, 1987)

Should be customized to the patient (Turk, Should be customized to the patient (Turk, 1990)1990)

Treatment varies, but is usually planned for Treatment varies, but is usually planned for about 10 to 12 sessionsabout 10 to 12 sessions

Psychological TreatmentPsychological Treatment

An active, time-limited treatment, with An active, time-limited treatment, with patients guiding their own progress patients guiding their own progress rather than passively receiving care rather than passively receiving care

For patients that are not candidates for For patients that are not candidates for treatment, a consultative resource to treatment, a consultative resource to facilitate existing treatmentfacilitate existing treatment

Assessment and treatment emphasizes Assessment and treatment emphasizes a biopsychosocial modela biopsychosocial model

Patients Likely to Benefit Patients Likely to Benefit from Psychological from Psychological TreatmentTreatment Pain is considered to be the chief Pain is considered to be the chief

concernconcern Patient understands what psychology Patient understands what psychology

can offer, and agrees to pursue can offer, and agrees to pursue assessment and/or treatment assessment and/or treatment

Patient is assumed to be motivated Patient is assumed to be motivated and capable of maintaining regular and capable of maintaining regular involvement with appointments and involvement with appointments and skill acquisitionskill acquisition

Patients Unlikely to Benefit Patients Unlikely to Benefit from Psychological from Psychological TreatmentTreatment Psychological factors are obviously a Psychological factors are obviously a

primary concernprimary concern Patient understands what psychology Patient understands what psychology

can offer, but maintains a can offer, but maintains a unidimensional view of painunidimensional view of pain

Patient is unmotivated/resistant, or Patient is unmotivated/resistant, or experiencing too much distress experiencing too much distress (relationship distress, substance abuse) (relationship distress, substance abuse) to maintain regular involvement with to maintain regular involvement with treatmenttreatment

Typical PatientTypical Patient

It is not understood what degree It is not understood what degree psychological factors play a rolepsychological factors play a role

Patient agrees to pursue assessment Patient agrees to pursue assessment and/or treatment, but may need and/or treatment, but may need more education regarding what more education regarding what psychology can provide psychology can provide

Patient may or may not receive Patient may or may not receive treatment, depending on the treatment, depending on the assessmentassessment

Diagnostic InterviewDiagnostic Interview

Typically uses one or two 1-hour sessionsTypically uses one or two 1-hour sessions Includes obtaining a history of the Includes obtaining a history of the

presenting problem and a brief medical presenting problem and a brief medical and psychological history, followed by an and psychological history, followed by an assessment of functioning within the assessment of functioning within the following domains…following domains…

•Educational and vocationalEducational and vocational•Social and recreationalSocial and recreational•Family, including brief developmental historyFamily, including brief developmental history•Mental status and current psychological functioningMental status and current psychological functioning

Formal AssessmentFormal Assessment

Not always needed, but dependent on Not always needed, but dependent on referral question and presenting referral question and presenting problem problem

Typically involves administration of Typically involves administration of instruments measuring personality, instruments measuring personality, impact of illness, coping, beliefs and impact of illness, coping, beliefs and expectations about pain and injury, and expectations about pain and injury, and psychological distresspsychological distress

May be completed in one or two 1-hour May be completed in one or two 1-hour testing sessions testing sessions

Psychological TreatmentPsychological Treatment

Currently no treatment that consistently and Currently no treatment that consistently and permanently alleviates pain for all patientspermanently alleviates pain for all patients

Management of chronic pain often depends on Management of chronic pain often depends on the readiness and abilities of the client (Jensen the readiness and abilities of the client (Jensen et al., 2003)et al., 2003)

Primary goal is to improve function rather than Primary goal is to improve function rather than alleviate painalleviate pain

Effective management is achieved most readily Effective management is achieved most readily using a multidisciplinary approach (Turk and using a multidisciplinary approach (Turk and Stieg, 1987)Stieg, 1987)

Should be customized to the patient (Turk, 1990)Should be customized to the patient (Turk, 1990) Treatment varies, but is usually planned for Treatment varies, but is usually planned for

about 10 to 12 sessionsabout 10 to 12 sessions

Psychological TreatmentPsychological Treatment(Turk, 2002)(Turk, 2002)

Problem-orientedProblem-oriented EducationalEducational CollaborativeCollaborative Uses clinic and home practice for skill-Uses clinic and home practice for skill-

buildingbuilding Encourages expression and management of Encourages expression and management of

feelings that impair rehabilitationfeelings that impair rehabilitation Addresses relationships among thoughts, Addresses relationships among thoughts,

feelings, behaviour, and physiologyfeelings, behaviour, and physiology Anticipates setbacks and teaches clients Anticipates setbacks and teaches clients

how to manage thesehow to manage these

Psychological TreatmentPsychological Treatment

Involves evaluating and correcting maladaptive Involves evaluating and correcting maladaptive beliefs, appraisals, and schemas to alleviate beliefs, appraisals, and schemas to alleviate mood symptoms and increase coping behaviourmood symptoms and increase coping behaviour

Training in relaxation techniques, such as Training in relaxation techniques, such as abdominal breathing, visualization, and abdominal breathing, visualization, and progressive muscle relaxation to reduce anxiety progressive muscle relaxation to reduce anxiety that typically magnifies pain signalsthat typically magnifies pain signals

Treatment attempts to increase behaviours Treatment attempts to increase behaviours associated with pain self-management, such as associated with pain self-management, such as adaptive coping, exercise program participation, adaptive coping, exercise program participation, and improved communication with providersand improved communication with providers

Focuses on increasing self-efficacyFocuses on increasing self-efficacy

ReferencesReferences Fordyce, W. (1988). Pain and suffering: a Fordyce, W. (1988). Pain and suffering: a

reappraisal. reappraisal. American Psychologist, 43,American Psychologist, 43, 276- 276-283.283.

Jensen, M., Nielson, W., Turner, J., Romano, J., Jensen, M., Nielson, W., Turner, J., Romano, J., and Hill, M. (2003). Readiness to self-manage and Hill, M. (2003). Readiness to self-manage pain is associated with coping and with pain is associated with coping and with psychological and physical functioning among psychological and physical functioning among patients with chronic pain. patients with chronic pain. Pain, 104,Pain, 104, 529-537. 529-537.

Turk, D. (2002). A cognitive-behavioral Turk, D. (2002). A cognitive-behavioral perspective on treatment of chronic pain perspective on treatment of chronic pain patients. In Gatchel, R. & Turk, D. (Eds.) patients. In Gatchel, R. & Turk, D. (Eds.) Psychological Approaches to Pain Psychological Approaches to Pain Management: A Practitioners Handbook.Management: A Practitioners Handbook. New New York, The Guilford Press.York, The Guilford Press.

ReferencesReferences

Turk, D. & Monarch, E. (2002). Turk, D. & Monarch, E. (2002). Biopsychosocial perspective on chronic pain. Biopsychosocial perspective on chronic pain. In Gatchel, R. & Turk, D. (Eds.) In Gatchel, R. & Turk, D. (Eds.) Psychological Approaches to Pain Psychological Approaches to Pain Management: A Practitioners Handbook.Management: A Practitioners Handbook. New York: The Guilford Press.New York: The Guilford Press.

Turk, D. (1990). Customizing treatment for Turk, D. (1990). Customizing treatment for chronic pain patients: who, what, and why. chronic pain patients: who, what, and why. Clinical Journal of Pain, 6,Clinical Journal of Pain, 6, 255-270. 255-270.

Turk, D., & Stieg, (1987). Chronic pain: the Turk, D., & Stieg, (1987). Chronic pain: the necessity of interdisciplinary communication. necessity of interdisciplinary communication. The Clinical Journal of Pain, 3,The Clinical Journal of Pain, 3, 163-167. 163-167.