Download Psychological Considerations in Pain

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 Center
Clinical Director of Psychiatry Consultation Liaison Service at Riley Hospital for Children
Department of Psychiatry – Riley Child and Adolescent Psychiatry Clinic
Indiana University School of Medicine – Indiana University Health Physicians
705 Riley Hospital Drive, Suite 4300
1
Indianapolis, IN 46202
*No Disclosures
The Pain Experience
• Pain Scale – YouTube
• Pain
– Subjective experience
• Nociception
– Nerve transmission
• Nociceptors
http://www.cerebromente.org.br/n16/history/mind-history_i.html
Modulation of Pain
Cognition, Attention,
Emotion, Coping
Inhibitory
Processes
Facilitation
Processes
Exercise
Sunburn
PAIN
Noxious Input
3
Physiological pathway for
supraspinal influences on pain
1.
Psychological variables
(Emotion, Attention, Cognition, Coping)

2.
PAG -> RVM -> Dorsal Horn
Conditioned Pain Modulation
(Diffuse Noxious Inhibitory Controls)
• Noxious stimulus -> ventrolateral
quadrant of spinal cord ->
Subnucleus Reticularis Dorsalis->
Dorsal Lateral Funiculus -> Dorsal
Horn
4
Conditioned Pain Modulation
+
5
CPM in 7-12 year-old girls with IBS
n = 21
n = 22
6
PSYCHOLOGICAL FACTORS
Emotion
Pain Report
Nociceptive Blink Reflex
Depressed mood
Anxiety
Somatization
Fear
Anger/Frustration
9
Operant Conditioning
Behavior
Consequence
Take tylenol for
a headache
headache goes
away
Outcome
more likely to
take tylenol
Add Something
Remove Something
Increase Behavior
+ reinforcement
- reinforcement
Decrease Behavior
+ punishment
- punishment
10
Operant Conditioning
Behavior
Consequence
Outcome
Positive Reinforcement
• Social attention
Pain Behavior
Well Behavior
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)
Increased
Pain and
Pain
Behaviors
Positive Punishment
• Increased pain
• Social ridicule
• Interpersonal stress
Negative Punishment
• Loss of social attention
• Loss of resources (disability)
11
Catastrophizing
Children who catastrophize
have more pain disability
In children who
catastrophize, parents can
help reduce their pain
disability by promoting
coping
12
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.
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
13
Distraction
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.
repetitive, pleasant,
engaging
Anterior Cingulate
Cortex
14
Physiological Arousal
• Hypothalamus – ANS
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.
15
Sleep
 Psychological and behavioral factors can lead
to sleep deprivation
Sleep deprivation
Increased pain
– Impaired pain inhibitory processes?
– Mediated by prostaglandins?
Positively associated with symptoms and functioning
16
17
What does this have to do with
my patients?
Psychological Conceptualization of the patient in pain
18
Conceptualization
• 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
19
Conceptualization:
Pain and Disability
• 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
20
Conceptualization:
Acute vs. Chronic Pain
• Acute Pain
– Adaptive Response
• Withdraw and protect from injury
• Rest & avoid things that can
exacerbate pain
• Parental attention &
accommodation
21
Conceptualization:
Acute vs. Chronic Pain
• 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
22
Conceptualization
Patient 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
23
STRATEGIES WITHIN THE PHYSICIAN
OFFICE
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.”
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
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
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?”
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
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
30
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
31
ACUTE/PROCEDURAL PAIN
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
33
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
34
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
35
References
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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.
Schurman, J., Friesen, C., Dai, H., Danda, C., Hyman, P., & Cocjin, J. (2012). Sleep problems and functional disability in children with functional gastrointestinal
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https://www.youtube.com/watch?v=dH4HiSQd3bE#t=57
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