A model for assessment in chronic pain Dr Tayyeb Tahir Dr Scott Hall

Workshop Outline Introduction to “the model” (guided discussion) Group case formulation Small group case formulation Feedback

1 minute - individually In your initial assessment of a “typical” patient presenting with chronic pain What are your three main objectives?

Engel’s Model (summary) Biological changes in disease are not always reciprocated in illness Presence/absence of disease does not necessarily shed light on the meaning of symptoms Psychosocial determinants of illness are of fundamental importance in assessment and symptom expression The sick role/illness behaviour is not necessarily associated with disease Success (or failure) of biological treatments is influenced by psychosocial factors (&vice-versa) Dr/P relationship influences outcomes Patients are profoundly influenced by the way in which they are studied (&vice-versa)

Translation of the BPS model to clinical practice Relationship between mental/physical aspects of health Paying “lip service” to participatory relationship Self-awareness Cultivation of trust Empathic curiosity Recognising bias Using informed intuition Communicating clinical evidence

Clinical Formulation A map to help us understand the terrain of an individuals narrative An attempt to explain why a person is experiencing symptoms in a particular way at a particular point in time. Moving beyond description into explanation

Models and Reality Don’t mistake models for reality!

The Four P Model An attempt to provide an explanatory overview of a presenting problem / problems Not based in any one psychiatric / psychological model Evidence based Forces you to consider relevant factors

Predisposing Factors Things that make the person vulnerable to developing the current presentation Examples could include: Early trauma (e.g. abuse, bullying, parental separation). Physical health problems. Family history of mental ill health. Think – What happened in the past?

Precipitating Factors ‘The Final Straw” Things that happened in the person’s life that seemed to trigger an episode of illness Examples could include a bereavement loss of a job or other significant life change. drug use Think – What was the final straw?

Perpetuating Factors Things that seem to be keeping the person in their current state of distress. Examples include pervasive negative thinking. lack of a close confiding relationship lack of adherence to medication Think – Why are they not getting better?

Protective Factors Things which seem to help keep the person well and which need to be strengthened in order to decrease the likelihood of the problem reoccurring Examples include a strong relationship, a particular skill in a specific area a psychological feature such as a good sense of humour Think – What are their strengths? What’s good in their life?

Iatrogenic Factors Iatrogenic factors relate to treatments that worsen the patient’s condition These are not part of the formulation but can have a massive impact on treatment. Tend to be associated with drug treatment but all treatments are potentially iatrogenic.

The Four P Model Iatrogenic Protective Predisposing Precipitating ‘Symptoms’ Perpetuating

Putting it together: An integrative aetiological formulation NB : First we need a collaborative understanding of the presenting complaint! Biological Psychological Social Predisposing Precipitating Perpetuating Protective Iatrogenic

Management Biological Psychological Social Short term Medium term Long term