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 Sensitivity Some patients may be hypersensitive and experience a lower threshold for labeling stimuli as noxious ( Asmundson, Bonin, Fromback, & Norton, 2000) Learned Expectation About 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