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Topical Session 01 HIDDEN DRIVERS OF PAIN: PSYCHOLOGICAL / PSYCHIATRIC PERSPECTIVES CARL GRAHAM

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Topical Session 01 HIDDEN DRIVERS OF PAIN: PSYCHOLOGICAL / PSYCHIATRIC PERSPECTIVES CARL GRAHAM Fremantle Hospital, WA NEWMAN L. HARRIS Royal North Shore Hospital, NSW.

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Topical Session 01

HIDDEN DRIVERS OF PAIN: PSYCHOLOGICAL / PSYCHIATRIC PERSPECTIVES

CARL GRAHAM

Fremantle Hospital, WA

NEWMAN L. HARRIS

Royal North Shore Hospital, NSW

slide2

This presentation may make reference to some “off-label” uses of medications which are included only for academic completeness. Attendees should not infer any encouragement to breech prescribing regulations.

disclosures
Speakers Bureau

Boehringer Ingelheim

Eli Lilly

GlaxoSmithKline

Medtronics

Pfizer

Solvay

Wyeth

Advisory Boards

Boehringer Ingelheim

Eli Lilly

Pfizer

Conference Sponsorship

Boehringer Ingelheim

Eli Lilly

GlaxoSmithKline

Pfizer

Wyeth

DISCLOSURES
slide4

What about the 10%

who cost us 90% -

slide5

What about the 10%

who cost us 90% -

Another hedgehog maybe?

return to work after lumbar discectomy schade et al 1999
Return to Work After Lumbar Discectomy (Schade et al 1999)
  • Correlates with depression and workplace stress,
  • not with indices of organicity.
biopsychosocial consideration

Biopsychosocial consideration

Parsons (1951) – The Sick Role

Mechanic (1961) – Illness Behaviour

Pilowsky (1969) - Abnormal Illness Behaviour

Engel (1977) – “Biopsychosocial”

what is pain
WHAT IS PAIN ?
  • “An unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” (IASP 1979)
  • Pain is always subjective
  • Definition doesn’t tie pain to a stimulus
  • Nociception is NOT equivalent to pain
the multidisciplinary approach presley and cousins 1992
The Multidisciplinary Approach (Presley and Cousins 1992)
  • Holistic biopsychosocial assessment
  • Rationalised organic treatment plan
  • Psychological and social interventions

A paradigm shift from traditional medical approach is required.

slide10

INTERACTIONS WITH ENVIRONMENT

PAIN BEHAVIOURS

SUFFERING

COGNITIONS ATTITUDES BELIEFS

PAIN PERCEPTION

NOCICEPTION NEUROPATHY

Fordyce and Loeser’s

formulation

slide11

Descending Pathway

Descending

Pathway

Ascending

Pathway

Theoretical Representation

psychiatric disorder in the pain clinic
Psychiatric Disorder in the Pain Clinic
  • 90% of pain clinic attendees suffer at least one psychiatric disorder (Large 1980)
  • Over 60% satisfy criteria for more than one (Fishbain et al 1986)
psychiatric disorder in the pain clinic1
Psychiatric Disorder in the Pain Clinic
  • Anxiety Disorders
  • Depression
  • Somatoform Disorders
  • Substance Problems
  • Psychotic Illness
comorbid mood disorder in primary care setting
Comorbid Mood Disorder in Primary Care Setting :
  • 34% of Joint & Limb Pain
  • 38% of Back Pain
  • 40% of Headache
  • 46% of Chest pain
  • 43% of Abdo Pain

Kroenke & Price 1993

depression
Depression
  • Higher levels of pain reported
  • More pronounced pain behaviour
  • Pain settles with Rx of mood
  • Depression implicated in transition to chronicity along with somatisation & distress
slide19
Yellow Flags

Attitudes and Beliefs

• Belief that pain is harmful or disabling resulting in fear-avoidance behaviour

• Belief all pain must be abolished before return to work or normal activity

• Catastrophising, thinking the worst, misinterpreting bodily symptoms

Behaviours

• Use of extended rest, disproportionate downtime

• Reduced activity, significant withdrawal from activities of daily living

• Report of extremely high intensity of pain on VAS

• Sleep quality reduced since onset of back pain

https://www.cebp.nl/media/m24.pdf

slide20
Yellow Flags

Compensation Issues

• Lack of financial incentive to return to work

• Delay in accessing income support and treatment cost, disputes over eligibility

• History of extended time off work due to injury or other pain problem

Diagnosis and Treatment

• Experience of conflicting diagnoses or explanations for back pain

• Dramatisation of back pain by HP\'s, dependency on treatments, passive treatment

• Expectation of a techno-fix, eg, requests to treat as if body were a machine

https://www.cebp.nl/media/m24.pdf

slide21
Yellow Flags

Emotions

• Fear of increased pain with activity or work

• Depression (especially long-term low mood), loss of sense of enjoyment

• Anxiety about and heightened awareness of body sensations (includes sympathetic nervous system arousal)

• Feeling under stress and unable to maintain sense of control

Family

• Over-protective or solicitous partner, emphasising fear of harm or catastrophising

• Socially punitive responses from spouse (eg ignoring, expressing frustration)

• Extent to which family members support any attempt to return to work

• Lack of support person to talk to about problems

https://www.cebp.nl/media/m24.pdf

slide22
Yellow Flags

Work

• Frequent job changes, stress at work, job dissatisfaction,

• Poor relationships with peers or supervisors...

• Belief that work is harmful; that it will do damage or be dangerous

• Unsupportive or unhappy current work environment

https://www.cebp.nl/media/m24.pdf

yellow flags
Yellow Flags

Why would psychosocial variables influence pain and disability?

  • Catastrophising directly influences pain intensity & pain-related disability (Turner, et al (2002) Pain; 98, 127-134)
  • Psychological or social variables which function as threats, or are experienced as a loss of control, access standard sickness responses resulting in increased inflammation (Brydon, et al (2009)Brain, Behavior & Immunity 23; 217-224)
  • Inflammatory proteins can have an exacerbatory role in pain (Wieseler-Frank, Maier, Watkins (2005) Neurosignals;14:166–174)
  • Cycle - Cognitive & emotional responses during the experience of pain shaped pro-inflammatory immune system responses via interleukin-6 (Edwards, et al (2008) Pain; 140, 135-144)
slide25

Remaining at Work

  • 20 public health workers at risk for developing chronic pain (taking sick days for pain probs)
  • 10 TAU vs 10 CBT (4 x 1 hrs ACT)
  • Dahl, Nilsson & Wilson, Behavior Therapy, 2004
case 1 tim 44 y o software genius

Case 1: TIM 44 y.o. software genius

Referred by Rehabilitation Physician

In context of escalating workplace pressue, gradual onset of neck, bilat. shoulder and arm (RSI-like) pain

Pain began in context of escalating workplace stressors

Workplace critical / unsupportive

20 months on WorkCover

over prior 18 months he had been off work receiving

Over prior 18 months he had been off work, receiving

1:1 physiotherapy input

1:1 exercise physiologist instruction

1:1 generalist psychology input

investigations

Investigations

C. Spine MRI

Brain MRI

L Shoulder MRI

Bilat nerve conductions

Rheumatological screen

Bone scan

reason for referral

Reason for referral:

Failure to progress:

Tolerances / capacities unchanged

Rigid pain focus entrenched

findings of team assessment

Findings of Team Assessment

Nil organic aetiology identified

Marked physical deconditioning

Exaggerated somatic preoccupation a/writualised safety behaviours

High depression and anxiety scores

Marked obsessionality

Fear avoidance

Poor self efficacy

Oversolicitous partner

Substances - 2 different benzos, 2 OTC analgesics, 2 types anti-inflammatory& EtOH

recommendations from team assessment

Recommendations from Team Assessment

Reassurance

Substance rationalisation

Self-help text “Manage Your Pain”

1:1 psychology and physiotherapy –

3 sessions of each over 6 weeks

progress

Progress

Liked the book – he understood and felt inspired – but couldn’t progress

Psychiatric assessment requested.

psychiatry assessment
Psychiatry assessment
  • Ritualised safety behaviours –
      • gyration of shoulder girdles
      • multiple pillows / braces
  • Melancholia (EMW, anhedonia, ruminations, low energy, cognitive poor, anorexia)
  • Controlling / demanding / obsessional
  • 2 different benzos, 2 OTC analgesics, 2 types anti-inflammatory
  • 60 g EtoH
what next
What next?
  • Education re integrated activity of limbic and other brain centres with pain circuitry
  • Discussion re neuroplastic exacerbatory processes
  • Discouraged benzos
  • Offered SNRI - declined
  • Pregabalin commenced
case 2 somatisation
Case 2 : Somatisation
  • Long history of complaints
  • High utilisers of health services
  • Biomedical focus
  • Excessive illness behaviour c.f. pathology
  • Outcome issues - poor prognosis
is chronic pain associated with somatization hypochondriasis
Is chronic pain associated with somatization/hypochondriasis.
  • An evidence-based structured review (57 studies)
  • Somatisation and hypochondriasis were both consistently associated with chronic pain
  • Study evidence indicated a correlation between pain intensity and presence of somatisation and hypochondriasis
  • Pain treatment improved somatisation and hypochondriasis

Fishbainet al. Pain Pract. 2009 Nov-Dec;9(6):449-67

case 2 pam 62 yo
Case 2 : Pam 62 yo
  • Referred by Pain Specialist
  • Multiple morbidities including OA in hips, hands, neck and low back, haemochromatosis, osteoporosis (with compression fractures x2), macular degeneration, chronic constipation, stress incontinence, hypertension.
  • Slim and frail-looking
powerful biomedical focus multiple practitioners 2 3 specialists 12
- Powerful biomedical focus- Multiple practitioners – 2-3 specialists /12
  • Pain specialist
  • Rheumatologists x2
  • Gastroenterologist
  • Ophthalmologist
  • Endocrinologist
  • Dermatologist
  • Physiotherapist
  • Yoga teacher
slide40

Morphine sulphate SR 20 mg bd

“Digesic”

Diazepam 2.5 – 5 mg up to qid

Aperients

Nutritional supplements

Procedures / “blocks” every 6-12 weeks

reason for referral1
Reason for referral:
  • Assistance sought with her distress - as demonstrated through her seeking of advice and reassurance via frequent phone calls (2-3 per week)
background
Background
  • Younger of two daughters from wealthy family
  • Sickly child – multiple hospitalisations for asthma
  • Father was caring but busy
  • Mother was just busy
  • Teen years: Sister strong, successful and popular. Pam polite, unassertive, “a worrier”
lots to worry about
Lots to worry about :
  • Three adult offspring – 2 unwell (1 Alcoholic)
  • 1 son-in-law unwell (Colitis)
  • Seven grandchildren
  • Very aging mother
  • Fit but aging husband

….and of course herself too!

case 3 brian 48 yo surveyor
Case 3 : Brian 48 yo Surveyor
  • Previously fit, very active professional man
  • Actively involved with church
  • Perfect family
  • Perfectionist
  • MBA 3 years ago
  • Multiple orthopaedic (and visceral) injuries
  • 6 weeks in hospital and 5 operations
  • 8 weeks inpatient rehabilitation
inpatient treatment
Inpatient treatment
  • Decompression/fusion L2/3
  • ORIF R. tibia/fibula
  • ORIF R. humerus
  • ORIF L. radius (distal)
  • Repair hepatic laceration and bladder/ureter damage
complaints
Complaints
  • Pain distracts him – can’t stop ruminating about pain and the idiot who caused it
  • Cranky
  • Impaired workplace function
  • Exacerbation of (premorbid trait of) relative inflexibility.
  • Had become intolerant
  • Always tired
  • Memory impaired
reason for referral2
Reason for Referral
  • Referred due to persistent pain (and his responses to it) causing disruption to interpersonal and workplace function –

fear of losing job.

assessment findings
Assessment findings
  • Team assessment identified nociceptive and neuropathic drivers, obsessional personality, excess pain focus, all-or-none behaviour
  • Self damning / catastrophic cognitions
  • Physical deconditioning
slide49

Not happy to take medication, fearing further compromise.

  • Unable to obtain benefit from 1:1 CBT

- Couldn’t focus

    • Too busy ruminating / distracting
    • Too sleepy
    • Neither time nor energy for behavioural tasks
progress1
Progress
  • Brain MRI NAD ; neuropsych testing equivocal for ABI.
  • Agreed to trial Nortriptilline 10 mg – unable to tolerate – sleep better BUT daytime compromise and exacerbated hesitancy
  • Not making progress after 6 sessions Clin. Psych plus physio. instruction
slide51

Problems inherent with a big C approach to CBT

  • Don\'t give more verbal rules to perfectionists!
  • Behavioural change not enhanced significantly by cognitive intervention
  • Jacobson, et al (2000) Journal of Consulting & Clinical Psychology; 64, 2, 295-304
  • Longmore, Worrell (2007) Clinical Psychology Review 27; 173-187
  • Dimidjian, et al(2006) Journal of Consulting & Clinical Psychology; 74, 4, 658-670
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