Topical Session 01 HIDDEN DRIVERS OF PAIN: PSYCHOLOGICAL / PSYCHIATRIC PERSPECTIVES CARL GRAHAM Fremantle Hospital, WA NEWMAN L. HARRIS Royal North Shore Hospital, NSW.
Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.
Topical Session 01
HIDDEN DRIVERS OF PAIN: PSYCHOLOGICAL / PSYCHIATRIC PERSPECTIVES
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.
What about the 10%
who cost us 90% -
What about the 10%
who cost us 90% -
Another hedgehog maybe?
Parsons (1951) – The Sick Role
Mechanic (1961) – Illness Behaviour
Pilowsky (1969) - Abnormal Illness Behaviour
Engel (1977) – “Biopsychosocial”
A paradigm shift from traditional medical approach is required.
INTERACTIONS WITH ENVIRONMENT
COGNITIONS ATTITUDES BELIEFS
Fordyce and Loeser’s
Kroenke & Price 1993
Magni et al. Pain 1998.
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
• 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
• 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
• 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
• 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
• 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
Why would psychosocial variables influence pain and disability?
Mayer, et al 2009
Remaining at Work
Cohen’s d at follow-up = 1.00
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
1:1 physiotherapy input
1:1 exercise physiologist instruction
1:1 generalist psychology input
C. Spine MRI
L Shoulder MRI
Bilat nerve conductions
Reason for referral:
Failure to progress:
Tolerances / capacities unchanged
Rigid pain focus entrenched
Findings of Team Assessment
Nil organic aetiology identified
Marked physical deconditioning
Exaggerated somatic preoccupation a/writualised safety behaviours
High depression and anxiety scores
Poor self efficacy
Substances - 2 different benzos, 2 OTC analgesics, 2 types anti-inflammatory& EtOH
Recommendations from Team Assessment
Self-help text “Manage Your Pain”
1:1 psychology and physiotherapy –
3 sessions of each over 6 weeks
Liked the book – he understood and felt inspired – but couldn’t progress
Psychiatric assessment requested.
Fishbainet al. Pain Pract. 2009 Nov-Dec;9(6):449-67
Morphine sulphate SR 20 mg bd
Diazepam 2.5 – 5 mg up to qid
Procedures / “blocks” every 6-12 weeks
….and of course herself too!
fear of losing job.
- Couldn’t focus