Il dolore cronico nella malattia avanzata: aspetti cognitivi ed emozionali

Il dolore cronico nella malattia avanzata: aspetti cognitivi ed emozionali PowerPoint PPT Presentation


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direct pathways from the thalamusto the amygdala and related structures. . . Aspetti multidimensionali del dolore e del suo trattamento. L'ipotesi patogenetica bio-psico-socialenella clinica del dolore. Bio-psycho-social hypothesis. Multidimensional Concept of Pain. Torta e Lacerenza, 2002. Tradizional vs.biopsychosocial models of pain.

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Il dolore cronico nella malattia avanzata: aspetti cognitivi ed emozionali

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5. …in wich brain, body, and environment influence one another and several therapeutic approaches (such as psychopharmacology or psychotherapy or social interventions) should concur to the symptomatological improvement…in wich brain, body, and environment influence one another and several therapeutic approaches (such as psychopharmacology or psychotherapy or social interventions) should concur to the symptomatological improvement

6. Multidimensional Concept of Pain The interactions of cognitive, emotional, socio-environmental and physical aspect of pain provides a model for a multimodal intervention. Psychosocial therapies indeed demonstrate a profound impact on nociception, while somatic therapies, directed on nociception, have also beneficial effect on the psychological aspect of pain. The augmentation coming from the simultaneous use of somatic and psychosocial therapies can be a must in the multidisciplinary approach to pain management The interactions of cognitive, emotional, socio-environmental and physical aspect of pain provides a model for a multimodal intervention. Psychosocial therapies indeed demonstrate a profound impact on nociception, while somatic therapies, directed on nociception, have also beneficial effect on the psychological aspect of pain. The augmentation coming from the simultaneous use of somatic and psychosocial therapies can be a must in the multidisciplinary approach to pain management

7. Tradizional vs.biopsychosocial models of pain In traditional medical model of pain management, pain is seen as a signal of an underlying disease. In the biopsychosocial perspective, pain is viewed as an experience with biological, psychological and social derivatives. In the first model only the physician is active, while the patient is passive. In the second model the treatment need to the patient participation. In the traditional medical model the goal is only a relief from pain, in the biopsychosocial model the pain improvement must be associated with emotional well-being and a quality of life improvement. So the focus of the treatment will be on the person rather than on the disorder.In traditional medical model of pain management, pain is seen as a signal of an underlying disease. In the biopsychosocial perspective, pain is viewed as an experience with biological, psychological and social derivatives. In the first model only the physician is active, while the patient is passive. In the second model the treatment need to the patient participation. In the traditional medical model the goal is only a relief from pain, in the biopsychosocial model the pain improvement must be associated with emotional well-being and a quality of life improvement. So the focus of the treatment will be on the person rather than on the disorder.

8. Components of the pain history Somatic aspects Onset Location Quality Quantity Duration Aggravating-alleviating factors

11. VAS Visual Analog Pain Scale (Scott et al. 1976) Single 10-cm line Self-evaluation Anchors of “no pain” (=0) and “pain as bad as it could be” Pain assessment instruments are useful adjuncts to the evaluation of the pain patient that allow the examiner to ascertain the severity and intensity of pain experiences. The most commonly used pain scales involve single-dimension ratings of pain intensity. Such scales are easy to administrate and evaluate, but have been criticized for oversimplifying pain evaluation, ignoring emotional and cognitive factors that contribute to exacerbate the pain experience. The VAS (visual analogue scale) consists of a 10-cm line with anchors at 0 and 10. The patient is asked to draw an X along the line that best denotes his or her level of pain.Pain assessment instruments are useful adjuncts to the evaluation of the pain patient that allow the examiner to ascertain the severity and intensity of pain experiences. The most commonly used pain scales involve single-dimension ratings of pain intensity. Such scales are easy to administrate and evaluate, but have been criticized for oversimplifying pain evaluation, ignoring emotional and cognitive factors that contribute to exacerbate the pain experience. The VAS (visual analogue scale) consists of a 10-cm line with anchors at 0 and 10. The patient is asked to draw an X along the line that best denotes his or her level of pain.

13. Some individuals claim that they are very sensitive to pain, whereas others say that they tolerate pain well. Using VAS to define pain sensitivity and functional magnetic resonance imaging to assess brain activity, Coghill and collegues found that highly sensitive individuals exhibited a more robust pain-induced activation of the primary somatosensory cortex, anterior cingulate cortex, and prefrontal cortex than did insensitive individuals. Some individuals claim that they are very sensitive to pain, whereas others say that they tolerate pain well. Using VAS to define pain sensitivity and functional magnetic resonance imaging to assess brain activity, Coghill and collegues found that highly sensitive individuals exhibited a more robust pain-induced activation of the primary somatosensory cortex, anterior cingulate cortex, and prefrontal cortex than did insensitive individuals.

14. MPQ McGill Pain Questionnaire (Melzack, 1995) 20 gruppi ognuno di 6 parole che descrivono il dolore; Autovalutativo; Valutate quantita’ e qualita’ del dolore; Aree indagate: 1. Dimensione sensoriale-discriminativa del dolore; 2. Dimensione motivazionale-affettiva; 3. Dimensione cognitiva-valutativa; 4. Mista. Recentemente validato il QUID (Questionario Italiano del Dolore, DeBenedittis et al. 1994) che propone una scelta fra 42 termini, secondo un principio analogo al MPQ Il dolore, sensazione di sofferenza come risposta soggetiva a uno stimolo avvertito dall’organismo come nocivo, riduttivo del benessere, e’ una variabile fondamentale nell’approccio globale del pz.Il dolore, sensazione di sofferenza come risposta soggetiva a uno stimolo avvertito dall’organismo come nocivo, riduttivo del benessere, e’ una variabile fondamentale nell’approccio globale del pz.

16. 16 It is well known that a serotoninergic and noradrenergic dysregulation can be present both in depression and pain But the role of these neurotransmitters in the pathogenesis of anxiety was until now not so well defined. It is well known that a serotoninergic and noradrenergic dysregulation can be present both in depression and pain But the role of these neurotransmitters in the pathogenesis of anxiety was until now not so well defined.

18. In the spinal cord NE and 5HT directly inhibit the spino-thalamic tract, as well as opiates do, and, at the same time, reduce the synthesis and release of pain-promoting neurotransmitters (such as substance P and glutamate).In the spinal cord NE and 5HT directly inhibit the spino-thalamic tract, as well as opiates do, and, at the same time, reduce the synthesis and release of pain-promoting neurotransmitters (such as substance P and glutamate).

25. Another example, is neuropatic pain, in which allodinia, hyperalgesia and wind up can be substained by a reduction of descending inhibitor mechanisms that are potentiated by glutamate and inhibited by 5HT,NE and GABA. So drugs that enhance these latter such as ADs and BDZs and drugs that inhibits glutamate such as several AEDs can contribute to the neuropatic pain control Another example, is neuropatic pain, in which allodinia, hyperalgesia and wind up can be substained by a reduction of descending inhibitor mechanisms that are potentiated by glutamate and inhibited by 5HT,NE and GABA. So drugs that enhance these latter such as ADs and BDZs and drugs that inhibits glutamate such as several AEDs can contribute to the neuropatic pain control

26. Antidepressants and pain

28. The first antalgic effect of ADs can be indipendent from antidepressant activity. This first antalgic effect is reached with low doses and demonstrates a rapid onset. The following antalgic effect, that appears later, is also related to mood improvement. The first antalgic effect of ADs can be indipendent from antidepressant activity. This first antalgic effect is reached with low doses and demonstrates a rapid onset. The following antalgic effect, that appears later, is also related to mood improvement.

32. Evaluation of emotional and cognitive neurotoxicity in course of chemotherapy for cancer: preliminary data from a multicenter study Caldera P, Berra C.,Amodeo L, Malabaila Torta R, Mussa A. Psycho-Oncology , 2006

33. Antiepilettici e dolore Gli AED sono dotati di proprietà stabilizzanti di membrana (attività gabaergica e azione di blocco dei canali del sodio) e sono in grado di influenzare la soglia di scarica neuronale e inibire i foci ectopici che si possono creare nelle lesioni del nervo pariferico e del SNC. Gli AED sono dotati di proprietà stabilizzanti di membrana (attività gabaergica e azione di blocco dei canali del sodio) e sono in grado di influenzare la soglia di scarica neuronale e inibire i foci ectopici che si possono creare nelle lesioni del nervo pariferico e del SNC.

36. Interventi psicologici e dolore

37. Components of pain and associated psychotherapeutic interventions Given that pain is multidimensional construct, a number of psychotherapeutic and adjunctive techniques can be complementary employed to address the biologic, psychologic and social features associated with pain. So the reduction of the sensory component of pain should be obtained by relaxation training and biofeedback, while on the cognitive component of pain can work the cognitive-behavioral therapy. On the affective component is usefull a dynamically oriented therapy and a supportive psychotherapy. Finally, the psycosocial distress should be reduced by behavior therapy, family therapies and/or vocational training. Given that pain is multidimensional construct, a number of psychotherapeutic and adjunctive techniques can be complementary employed to address the biologic, psychologic and social features associated with pain. So the reduction of the sensory component of pain should be obtained by relaxation training and biofeedback, while on the cognitive component of pain can work the cognitive-behavioral therapy. On the affective component is usefull a dynamically oriented therapy and a supportive psychotherapy. Finally, the psycosocial distress should be reduced by behavior therapy, family therapies and/or vocational training.

38. Fig. 2. The number of new neurons in the granule cell layer (Gcl) of adult rats increases following spatial learning in the Morris water maze. Confocal laser scanning microscopic images of BrdU labeled cells (arrows) reveal a difference in number between control (a) and spatial learning (b) adult rats. The vast majority of BrdU labeled cells (arrows) had the morphology of granule neurons and were immunoreactive for the marker of immature neurons TOAD-64 (c) but not the astroglial marker GFAP (d). GFAP-positive astrocytes that are not BrdU labeled are indicated by arrowheads. New neuron formation during learning Following hippocampus-dependent learning, the majority of new hippocampal cells were located in the granule cell layer and expressed a marker of immature granule neurons (TOAD-64). Gould E, Beylin A, Tanapat P, Reeves A, Shors TJ. Learning enhances adult neurogenesis in the hippocampal formation. Nat Neuro Sci 1999; 2: 260-265. Following hippocampus-dependent learning, the majority of new hippocampal cells were located in the granule cell layer and expressed a marker of immature granule neurons (TOAD-64). Gould E, Beylin A, Tanapat P, Reeves A, Shors TJ. Learning enhances adult neurogenesis in the hippocampal formation. Nat Neuro Sci 1999; 2: 260-265.

40. Very interesting is the fact that adaptive coping styles (such as fighting spirit) increase after only a month of antidepressant treatment, while maladaptive coping styles (such as hopelessness) decrease at the same timeVery interesting is the fact that adaptive coping styles (such as fighting spirit) increase after only a month of antidepressant treatment, while maladaptive coping styles (such as hopelessness) decrease at the same time

42. It is possible to eliminate the placebo (psychosocial) component of an analgesic treatment, free of any psychological contamination. To eliminate the patient’s expectations, the patient is made completely unaware that a medical therapy is being carried out. To do this, drugs are administered through covert infusions by computer-controlled machines. The crucial point here is that the patients do not know that any analgesic is being injected, so that they do not expect anything. In post-operative pain, it was found that a hidden injection of different painkillers, like morphine, buprenorphine, tramadol, etc., in which the patients do not expect any outcome, is significantly less effective than an open one, in which the patients know that a pain reduction will occur. Nevertheless it strongly indicates the important role of the psychosocial component of a therapy and the importance of the patient’s perception that a therapy is being received. This new approach to the identification of the placebo effect might have an important impact on the design of clinical trials It is possible to eliminate the placebo (psychosocial) component of an analgesic treatment, free of any psychological contamination. To eliminate the patient’s expectations, the patient is made completely unaware that a medical therapy is being carried out. To do this, drugs are administered through covert infusions by computer-controlled machines. The crucial point here is that the patients do not know that any analgesic is being injected, so that they do not expect anything. In post-operative pain, it was found that a hidden injection of different painkillers, like morphine, buprenorphine, tramadol, etc., in which the patients do not expect any outcome, is significantly less effective than an open one, in which the patients know that a pain reduction will occur. Nevertheless it strongly indicates the important role of the psychosocial component of a therapy and the importance of the patient’s perception that a therapy is being received. This new approach to the identification of the placebo effect might have an important impact on the design of clinical trials

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