cognitive and behavioral pain management judith b. chapman, ph.d., abpp behavioral medicine program
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Cognitive and Behavioral Pain Management
Judith B. Chapman, Ph.D., ABPP
Behavioral Medicine
Program
Traditional disease model of pain
Psychological and social factors viewed as reactions to disease and trauma
View of pain conditions as either organic or psychogenic in etiology
How to explain…
For up to 80% of persons complaining of low back pain, no physical basis can be identified (Deyo, 1986)
Expression of pain symptoms, related psychological distress, and extent of disability are at best only moderately correlated with observable pathophysiology (Waddell & Main, 1984).
Biopsychosocial Model
Biological factors – initiate, maintain, modulate physical changes
Psychological factors – influence appraisal, perception of internal physical signs
Social factors –shape the behavioral responses of patients to the perception of physical changes
Which psychological factors influence pain?
Cognitive (Pain Beliefs, Cognitive Errors, Self
Efficacy, Coping)
Affective
Personality
Pain Beliefs
Anxiety SensitivitySome patients may be hypersensitive and experience a lower threshold for labeling stimuli as noxious (Asmundson, Bonin, Fromback, & Norton, 2000)
Learned ExpectationAbout 83% of patients with LBP were unable to complete a movement sequence because of anticipated pain, 5% unable because of lack of ability (Council, Ahern, Follick, & Cline, 1988).
Pain Beliefs
Patients’ beliefs about pain or disability are better predictors of ultimate level of disability than are physician ratings of disease severity
Self Efficacy
- a personal conviction that one can complete a course of action to produce a desired outcome
Low self efficacy ratings of pain control are related to low pain tolerance (Dolce, Crocker, Moletteire, & Doleys, 1986)
The Efficacious Person…
Experiences less anxiety and physiological arousal when experiencing pain
Is better able to use distraction
Can persist in the face of noxious stimuli (stoicism)
Cognitive Errors
a negatively distorted belief about oneself or one’s situation
Examples: Catastrophizing, overgeneralization,
selective abstraction
Consequences of catastrophizing
Among postsurgical patients, those with a greater frequency of catastrophizing thoughts had a greater number of pain complaints and required significantly more pain medications (Butler, et al., 1989).
Coping Style
Active coping (distraction, reinterpreting sensations, stoicism) is associated with greater activity and better mood
Passive coping (wishful thinking, relying on others) is correlated with greater perceived pain and depression
Affective Factors
40-50% of chronic pain patients experience depression
About half report feelings of anger, irritability Both are associated with perception of
increased pain severity, greater pain interference, lower activity level
How do personality disorders fit in?
No specific personality disorder is associated with poorer coping with pain
However, the presence of any personality disorder predicts less adaptive coping
Palo Alto Pain Clinic Demographics
Average age 56 years (range 20-87) 88% male 87% Caucasian (6% African American, Hispanic; >1%
Asian, Native American)
61% Predominantly Musculoskeletal Pain
(30% neuropathic, 3% visceral, 7% other)
Palo Alto Pain Clinic Data
75% depressed 33% report active suicidal thoughts 48% report a history of trauma 19% meet criteria for PTSD
Pain Clinic Follow-up Data
At two and six month follow-up, patients reported a significant decrease in pain severity and a significant decrease in pain interference
Changes seen across diagnostic and demographic groups (age, type of pain, presence of significant mental disorder)
No significant overall change in mood, sleep, or activity level
Older patients
Reported significantly less pain severity than young
Less pain interference Better overall sleep Less depression
Aging and Pain
Changes in visceral sensations with age Increased prevalence of post-herpetic
neuralgias Nonlinear relationship between joint pain and
age
Cognitive-behavioral Treatment
Enhancing motivation Relaxation exercises Education about Sleep Management Hypnosis and Imagery Cognitive Therapy Family Interventions
Principles of Motivational Enhancement Therapy
Expressing empathy Developing discrepancy Avoiding arguments Rolling with resistance Supporting self efficacy
Relaxation Strategies
Progressive muscle relaxation Deep (diaphragmatic) breathing Biofeedback Autogenic training
Caveats and contraindications
Psychotic patients Relaxation-induced anxiety Panic attacks
Hypnosis
A state of highly focused attention in which there is an alteration of sensations, awareness, and perceptions
Reduces pain through attention control and distraction
Essential Components of Hypnosis
Physical relaxation Deepening exercise Pleasant imagery Suggestion Post-hypnotic suggestion Gradual return to alertness
Sleep and Pain
Pain severity and opioid use does not predict sleep problems; depression does
Sleep medications seem to have no impact on depression or pain severity
Sleep med use was highly correlated with poorer sleep quality, poorer sleep duration, and poorer sleep efficiency (Chapman, Lehman, Elliott, and Clark, In Press).
Sleep Management Guidelines
Go to bed when sleepy Do not remain in bed if not sleeping Bed as cue for sleep Have regular wake-up time Avoid evening use of ETOH, caffeine,smoking Exercise in AM, rather than at night Arrange relaxing nighttime routine
Cognitive Therapy
Identify and monitor pain-relevant cognitions Notice emotional consequences of negative
cognitions Learn how to challenge maladaptive cognitions
or consider probability bad events may occur Assertiveness training Value of self reinforcement
Goals of Family interventions
Recognition of operant principles as they relate to pain behaviors
Altering patterns of pain-relevant communication Increase time spent in non-pain related conversation Increase frequency of pleasurable family activities Recognition/treatment of depression in other family
members
Who doesn’t benefit from CBT for pain?
Cognitively disorganized Patients with little- no motivation to use
strategies Severe anxiety or depressive disorder Active substance abusers
Pain may be inevitable, but misery is optional
Greatest Limitation of CBT for Pain
- Compliance with
successful strategies decreases over time
- No benefit when not practicing
Best Recommendation
Relapse Prevention should be part of the therapy
Encourage booster sessions 6-12 months after therapy ends
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