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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


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 uses of medications which are included only for academic completeness.

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


What about the 10% uses of medications which are included only for academic completeness.

who cost us 90% -


What about the 10% uses of medications which are included only for academic completeness.

who cost us 90% -

Another hedgehog maybe?


Return to work after lumbar discectomy schade et al 1999
Return to Work After Lumbar uses of medications which are included only for academic completeness. Discectomy (Schade et al 1999)

  • Correlates with depression and workplace stress,

  • not with indices of organicity.


Biopsychosocial consideration

Biopsychosocial uses of medications which are included only for academic completeness. consideration

Parsons (1951) – The Sick Role

Mechanic (1961) – Illness Behaviour

Pilowsky (1969) - Abnormal Illness Behaviour

Engel (1977) – “Biopsychosocial”


What is pain
WHAT IS PAIN ? uses of medications which are included only for academic completeness.

  • “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 uses of medications which are included only for academic completeness. (Presley and Cousins 1992)

  • Holistic biopsychosocial assessment

  • Rationalised organic treatment plan

  • Psychological and social interventions

    A paradigm shift from traditional medical approach is required.


INTERACTIONS WITH ENVIRONMENT uses of medications which are included only for academic completeness.

PAIN BEHAVIOURS

SUFFERING

COGNITIONS ATTITUDES BELIEFS

PAIN PERCEPTION

NOCICEPTION NEUROPATHY

Fordyce and Loeser’s

formulation


Descending Pathway uses of medications which are included only for academic completeness.

Descending

Pathway

Ascending

Pathway

Theoretical Representation


Dr m k nicholas pm rc
Dr M K Nicholas, PM&RC uses of medications which are included only for academic completeness.


Psychiatric disorder in the pain clinic
Psychiatric Disorder in the uses of medications which are included only for academic completeness. 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 uses of medications which are included only for academic completeness. Pain Clinic

  • Anxiety Disorders

  • Depression

  • Somatoform Disorders

  • Substance Problems

  • Psychotic Illness


Comorbid mood disorder in primary care setting
Comorbid uses of medications which are included only for academic completeness. 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 uses of medications which are included only for academic completeness.

  • 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


Risk of suicide in depression chronic abdominal pain
Risk of Suicide in Depression uses of medications which are included only for academic completeness. & Chronic Abdominal Pain

Magni et al. Pain 1998.


Yellow Flags uses of medications which are included only for academic completeness.

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


Yellow Flags uses of medications which are included only for academic completeness.

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


Yellow Flags uses of medications which are included only for academic completeness.

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


Yellow Flags uses of medications which are included only for academic completeness.

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 uses of medications which are included only for academic completeness.

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)


Mayer, et al 2009 uses of medications which are included only for academic completeness.


Remaining at Work uses of medications which are included only for academic completeness.

  • 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


Cohen’s d at follow-up = 1.00 uses of medications which are included only for academic completeness.


Case 1 tim 44 y o software genius

Case 1: uses of medications which are included only for academic completeness. 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 uses of medications which are included only for academic completeness.

1:1 physiotherapy input

1:1 exercise physiologist instruction

1:1 generalist psychology input


Investigations

Investigations uses of medications which are included only for academic completeness.

C. Spine MRI

Brain MRI

L Shoulder MRI

Bilat nerve conductions

Rheumatological screen

Bone scan


Reason for referral

Reason for referral: uses of medications which are included only for academic completeness.

Failure to progress:

Tolerances / capacities unchanged

Rigid pain focus entrenched


Findings of team assessment

Findings of Team Assessment uses of medications which are included only for academic completeness.

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 uses of medications which are included only for academic completeness.

Reassurance

Substance rationalisation

Self-help text “Manage Your Pain”

1:1 psychology and physiotherapy –

3 sessions of each over 6 weeks


Progress

Progress uses of medications which are included only for academic completeness.

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

Psychiatric assessment requested.


Psychiatry assessment
Psychiatry assessment uses of medications which are included only for academic completeness.

  • 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? uses of medications which are included only for academic completeness.

    • 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 : uses of medications which are included only for academic completeness. 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 uses of medications which are included only for academic completeness. 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 uses of medications which are included only for academic completeness.

    • 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 uses of medications which are included only for academic completeness. - Multiple practitioners – 2-3 specialists /12

    • Pain specialist

    • Rheumatologists x2

    • Gastroenterologist

    • Ophthalmologist

    • Endocrinologist

    • Dermatologist

    • Physiotherapist

    • Yoga teacher


    Morphine sulphate SR 20 mg bd uses of medications which are included only for academic completeness.

    “Digesic”

    Diazepam 2.5 – 5 mg up to qid

    Aperients

    Nutritional supplements

    Procedures / “blocks” every 6-12 weeks


    Reason for referral1
    Reason for referral: uses of medications which are included only for academic completeness.

    • Assistance sought with her distress - as demonstrated through her seeking of advice and reassurance via frequent phone calls (2-3 per week)


    Background
    Background uses of medications which are included only for academic completeness.

    • 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 : uses of medications which are included only for academic completeness.

    • 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 uses of medications which are included only for academic completeness. 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 uses of medications which are included only for academic completeness.

    • Decompression/fusion L2/3

    • ORIF R. tibia/fibula

    • ORIF R. humerus

    • ORIF L. radius (distal)

    • Repair hepatic laceration and bladder/ureter damage


    Complaints
    Complaints uses of medications which are included only for academic completeness.

    • 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 uses of medications which are included only for academic completeness.

    • 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 uses of medications which are included only for academic completeness.

    • Team assessment identified nociceptive and neuropathic drivers, obsessional personality, excess pain focus, all-or-none behaviour

    • Self damning / catastrophic cognitions

    • Physical deconditioning



    Progress1
    Progress uses of medications which are included only for academic completeness.

    • 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


    • Problems inherent with a big C approach to CBT uses of medications which are included only for academic completeness.

    • 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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