Psychological Considerations in Painfiles.academyofosteopathy.org/convo/2016/Handouts/... ·...
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Psychological Considerations in Pain
Supraspinal Pain Modulation and Implications for Optimal Treatment of the Patient in Pain
Amy E. Williams, PhD*Assistant Professor
Director of Riley Pain CenterClinical Director of Psychiatry Consultation Liaison Service at Riley Hospital for Children
Department of Psychiatry – Riley Child and Adolescent Psychiatry ClinicIndiana University School of Medicine – Indiana University Health Physicians
705 Riley Hospital Drive, Suite 4300Indianapolis, IN 46202 1
*No Disclosures
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The Pain Experience
• Pain Scale – YouTube
• Pain
– Subjective experience
• Nociception
– Nerve transmission
• Nociceptors
http://www.cerebromente.org.br/n16/history/mind-history_i.html
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Modulation of Pain
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PAIN
Facilitation
Processes
Inhibitory
Processes
Noxious Input
SunburnExercise
Cognition, Attention,
Emotion, Coping
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Physiological pathway for supraspinal influences on pain
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1. Psychological variables
(Emotion, Attention, Cognition, Coping)
PAG -> RVM -> Dorsal Horn
2. Conditioned Pain Modulation
(Diffuse Noxious Inhibitory Controls)
• Noxious stimulus -> ventrolateral quadrant of spinal cord -> Subnucleus Reticularis Dorsalis-> Dorsal Lateral Funiculus -> Dorsal Horn
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Conditioned Pain Modulation
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+
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CPM in 7-12 year-old girls with IBS
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n = 22n = 21
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PSYCHOLOGICAL FACTORS
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Emotion
Pain Report
Nociceptive Blink Reflex
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Depressed moodAnxietySomatizationFear Anger/Frustration
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Operant Conditioning
Add Something Remove Something
Increase Behavior + reinforcement - reinforcement
Decrease Behavior + punishment - punishment
Behavior Consequence Outcome
Take tylenol for headache goes more likely to a headache away take tylenol
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Operant Conditioning
Pain Behavior
Positive Reinforcement• Social attention
Negative Reinforcement (escape/avoidance conditioning)• Temporary reduction in pain• Avoidance of dis-liked tasks or
situations (like school, chores, work)• Temporary reduction in worry (after
seeking reassurance from physician)
Well Behavior
Positive Punishment• Increased pain• Social ridicule• Interpersonal stress
Negative Punishment• Loss of social attention• Loss of resources (disability)
Increased Pain and
Pain Behaviors
Behavior Consequence Outcome
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CatastrophizingChildren who catastrophize have more pain disability
In children who catastrophize, parents can help reduce their pain disability by promoting coping
Vervoort, T. T., Huguet, A. A., Verhoeven, K. K., & Goubert, L. L. (2011). Mothers’ and fathers’ responses to their child’s pain moderate the relationship between the child’s pain catastrophizing and disability. Pain, 152(4), 786-793.
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Reinforcement: Caregiver Empathy
• Responding with reassurance, apologies, and empathy actually increases pain
– Tells patient that caregiver is worried
– Reinforces pain behavior by temporarily reducing distress
– Gives permission to express distress – which increases their experience of pain
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Distraction
Walker, LS, Williams, SE, Smith, CA, Garber, J, Van Slyke, DA. (2006). Parent attention versus distraction: Impact on symptom complaints by children with and without chronic functional abdominal pain. Pain, 122(1-2), 43-52.
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Distraction
• repetitive, pleasant, engaging
• Anterior Cingulate Cortex
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Physiological Arousal
• Hypothalamus –ANS
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Pain During Relaxed Breathing
Park E, Oh H, Kim T. (2013). The effects of relaxation breathing on procedural pain and anxiety during burn care. Burns 39: 1101-1106.
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Sleep
Psychological and behavioral factors can lead to sleep deprivation
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Increased pain
– Impaired pain inhibitory processes?
– Mediated by prostaglandins?
Positively associated with symptoms and functioning
Sleep deprivation
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What does this have to do with my patients?
Psychological Conceptualization of the patient in pain
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Conceptualization
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• Patients do have pain
– They are not faking and it is not“all in their head”
But…
• Psychosocial factors can alter pain perception, disability, and medical treatment effectiveness
– accounted for 59% of variance in disability following low back injury
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Conceptualization:Pain and Disability
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• Improved pain ≠ improved functioning– Pain intensity does not predict physical activity
– Psychosocial job factors predict return to work independent of injury severity
– Weak relationship between decreased pain and increased functioning or return to work
Patients need to return to activities before pain is gone and may require directed intervention to return to previous activities even
after pain is gone
---
Athlete recovering from injury – rehabilitation approach
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Conceptualization:Acute vs. Chronic Pain
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• Acute Pain
– Adaptive Response
• Withdraw and protect from injury
• Rest & avoid things that can exacerbate pain
• Parental attention & accommodation
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Conceptualization:Acute vs. Chronic Pain
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• Chronic Pain
– Adaptive response
• Acceptance of pain presence
• Maintain normal activities
• Active pain coping strategies
• Reduce factors that exacerbate long-term pain
• Manage pain exacerbations
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ConceptualizationPatient Mindset– Acute pain vs chronic pain mindset
– Identification with illness
Exacerbating Factors– Behaviors/cognitions that enhance or maintain pain and disability
– Negative emotional states that contribute to pain
– Quality and quantity of sleep
Functioning & Disability– General functioning
– Work/school
– Adherence to medical recommendations
Pain Management Strategies– Active vs. passive coping strategies
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STRATEGIES WITHIN THE PHYSICIAN OFFICE
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Acknowledge Symptoms and Promote Coping
• Some empathy is good
– Reflect the patients concerns
• “Sounds like this has been really difficult for you.”
• “Your pain is really interfering with your job lately.”
• Switch to focus on functioning
– “let’s work on developing a plan so you can get back to enjoying your life.”
– “Sounds like you would like to be able to play tennis again. I would like to help you with that goal.”
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Teach the Mind-Body Connection
• Chronic Pain is a nerve mis-fire or faulty signal
• Many factors contribute to pain
– Effective treatment involves multiple approaches
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Manage Reassurance-Seeking
• Excessive reassurance can increase symptoms– Have regular scheduled visits rather than frequent
emergency calls/visits– Avoid un-necessary tests – Provide an explanation for symptoms
• Negative test results rule out specific conditions and point us towards a functional problem rather than a structural problem
– Recognize catastrophizing and somatization and help them reframe• Or refer for psychotherapy
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Focus on Functioning
• Minimize your inquiries about pain– Instead inquire about functioning
• Help caregivers to reduce inquiries about pain• Promote rehabilitation model
– Functioning is not a direct result of pain level– Pain tends to get better after your functioning improves– If we wait until our pain gets better to function we usually
only get worse
• Set functional goals – “After last session you were able to walk for 10 minutes
each day. I recommend we increase that a little this week. How many minutes do you think we should set as your goal this week?”
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Provide a Pain Plan
• Can prevent/reduce
– Frequent phone calls or last-minute appointments
– Frequent use of or over-reliance on pain medications
– Urgent care or ED visits for acute exacerbations
• Algorithm for responding to pain
– Step-wise instructions
– Ex., stretching, gentle exercise, heat/cold, distraction/pleasant activities, relaxation, medications, call doctor
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When to Refer for Psychotherapy
Comorbid mental illness
Functional interference
Exacerbated by psychosocial factors
Medical interventions are not providing expected benefits
Seeking miracle cure
Strong personal identification with illness
Non-adherence to physician recommendations
Assess for barriers to medical/surgical outcomes– Before escalating treatment
– Not seeing expected improvement
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Does CBT Really Help?
• Grey matter changes after CBT for chronic pain – Increased bilateral dorsolateral prefrontal, posterior
parietal, subgenual anterior cingulate/orbitofrontal, and sensorimotor cortices, hippocampus,
– Reduced supplementary motor area
• Decreased pain catastrophizing associated with – increased left dorsolateral prefrontal and ventrolateral
prefrontal cortices, right posterior parietal cortex, somatosensory cortex, and pregenual anterior cingulate cortex
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ACUTE/PROCEDURAL PAIN
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Early Pain Experiences
• Management of procedural pain in infancy childhood is crucial
• Frequent painful procedures in infancy/childhood associated with changes in somatosensory processing related to pain– More pain in future
• How to manage infant pain during injections– The Power of a Parent's Touch
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Needle Pain
• Needle phobias develop around 4-5 years of age after negative needle experience
– # of injections predictive of phobia
– Phobias predict decreased medical treatment seeking throughout life
• How to manage needle pain in childhood
– It Doesn't Have to Hurt
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Acute Pain in Adults
• Some limited opportunity for control
• Relaxation
• Distraction– Non-procedural talk
• Positive self-statements
• Imagery– Pleasant imagery
• Avoid empathic statements
• Avoid apologies
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Vervoort, T. T., Huguet, A. A., Verhoeven, K. K., & Goubert, L. L. (2011). Mothers’ and fathers’ responses to their child’s pain moderate the relationship between the child’s pain catastrophizing and disability. Pain, 152(4), 786-793.
Walker, LS, Williams, SE, Smith, CA, Garber, J, Van Slyke, DA. (2006). Parent attention versus distraction: Impact on symptom complaints by children with and without chronic functional abdominal pain. Pain, 122(1-2), 43-52.
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