Psychology of Persistent Pain Putting Pain in Perspective

Pain defined “ An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” International Association for the Study of Pain , 1994

Subjectivity of Pain Pain is always a subjective experience Everyone learns the meaning of “pain” through experiences usually related to injuries in early life

Dimensions of Chronic Pain Loneliness Hostility Social Factors Depression Anxiety TIME Psychological Factors Pathological Process Physical Factors A.G. Lipman, Cancer Nursing, 2:39, 1980

Is pain a learned behavior? William Fordyce - Operant conditioning model Pain behaviour is rewarded by solicitous attention not having to work access to drugs To treat need to: ignore pain behavior, reward non-pain behavior (e.g. physical activity) Fordyce WE. Behavioral methods in chronic pain and illness. St. Louis: Mosby; 1976.

Biobehavioral Model Cultural and spiritual factors Physiological/pathological Tissue injury Pre-dispositional Factors Pain perceptions Behavioral factors Social factors Neuroplasticity/central sensitization Psychological factors Functional outcomes

Fear Avoidance Model

Fear of Pain and Re-injury Fear of pain, movement, or re-injury thought to lead to avoidance behaviors and hyper-vigilance to pain Disability

Social & Environmental Factors Environmental responses to pain behaviors can inadvertently reinforce pain & disability. There are several examples of reinforcements: Attention and affection from partner/caregivers Attention from health care provider(s) Pain medication Financial incentives/disincentives

Cognitive Factors Beliefs about Pain Readiness to Change Self-Efficacy Cognitive Coping Skills Cognitive Errors

Cognitive Errors Catastrophizing Dichotomous Thinking Overgeneralization:

Cognitive Errors Selective Abstraction “Should” statements Entitlement Fallacy

Personality Styles High needs for Perfectionism, Control, and/or Approval from others Intolerance of Uncertainty Extroversion is associated with higher pain thresholds External Locus of Control vs. Internal Experiential Avoidance Psychological Inflexibility A Heightened Sense of Entitlement

Comorbidities and pain Anxiety/Fear (25%-50%) Anger and Frustration (50%-80%) Insomnia (50%-80%) Medication Misuse Sexual Dysfunction Family Dysfunction

Depression and Pain Depression is common in patients who experience persistent pain Degree of depression is also greater in patients who rate their pain higher Fishbain, D. A., Cutler, R., Rosomoff, H. L., & Rosomoff, R. S. (1997). Chronic pain-associated depression: antecedent or consequence of chronic pain? A review. Clin.J Pain 13, 116-137.

OR Depression Pain Depression Pain Fishbain, D. A., Cutler, R., Rosomoff, H. L., & Rosomoff, R. S. (1997). Chronic pain-associated depression: antecedent or consequence of chronic pain? A review. Clin.J Pain 13, 116-137.

Treatment – Psychological Approach

Cognitive Behavioral Treatment (CBT) Mindful Meditation Education/Motivational Enhancement Goal Setting (Realistic Expectations) Relaxation/Imagery Hypnosis/Distraction Biofeedback Correcting Cognitive Errors Graded Activity Exposure (Behavioural Activation)

Mindfulness Defined “The awareness that emerges through paying attention on purpose, in the present moment, and non-judgmentally to the unfolding of experience moment to moment.” Kabat-Zinn, 2003.

The clinical use of mindfulness meditation for the self-regulation of chronic pain. Kabat-Zinn J, Lipworth L, Burney R. Ninety chronic pain patients were trained in mindfulness meditation in a 10-week Stress Reduction and Relaxation Program. Statistically significant reductions were observed in measures of present-moment pain, negative body image, inhibition of activity by pain, symptoms, mood disturbance, and psychological symptomatology, including anxiety and depression. Pain-related drug utilization decreased and activity levels and feelings of self-esteem increased. Improvement appeared to be independent of gender, source of referral, and type of pain. A comparison group of pain patients did not show significant improvement on these measures after traditional treatment protocols. At follow-up, the improvements observed during the meditation training were maintained up to 15 months post-meditation training for all measures except present-moment pain. The majority of subjects reported continued high compliance with the meditation practice as part of their daily lives. The relationship of mindfulness meditation to other psychological methods for chronic pain control is discussed. J Behav Med. 1985 Jun;8(2):163-90.

Being Mindful - Jon Kabat-Zinn Mindfulness creates space around our pain, allowing us to work with it without being overwhelmed.

Mindfully Working with Pain 3 Basic Strategies for Working with Pain: focusing on the pain focusing on the mental and emotional reactions to the pain focusing away from the pain onto something soothing and pleasant

Mindfully Working with Pain Methods: Free-Floating with the Discomfort Breath Pleasure Relaxing with Out Breath Pleasure of O2 Entering the Body

Acute exacerbation of pain- CBT management Provide information Relaxation Techniques including Breathing PMR (progressive muscle relaxation) Imagery Hypnosis Cognitive (i.e., Positive Coping Self- Statements, Distraction, Sensory Focus)

Relaxation video – Guided Imagery http://www.healingchronicpain.org/content/relax/default.asp Guided Imagery Progressive Relaxation

CBT – Chronic Pain Management Teach Activity-Rest Cycling (Pacing) Patients learn that activity causes pain Pain and suffering increase over time Activity decreases over time pattern of high activity followed by a period of deactivation lead to Pacing Problems

CBT – Chronic Pain Management Time-Contingent Medication Use Relapse Prevention Acceptance (e.g., Mindfulness Meditation) Couples/Family Communication Therapy Treat Co-morbid Conditions

Motivate Self management Maintain Respect for the Dignity of the Patient Defuse Myths about Chronic Pain Avoid “Psychologizing” the Problem “Listen” and Avoid Power Struggles Communicate Understanding in the Reality of Pain Experience

Motivating Self management Introduce a Model (eg., Gate Control) Encourage Realistic Expectations (eg., 50% pain reduction, improved daily function, etc.) Get a Commitment from the Patient Collaborate With the Patient Against “it”

Avoid these messages to the client Let pain be your guide The pain is being caused by psychological factors The pain is not real – there is no reason for your pain

Messages to Give Clients Pain can cause suffering Can’t always change pain, but you can reduce suffering Reducing suffering and pain behavior can lead to reduced pain

“Pain may be inevitable but misery is optional” Dee Malchow, RN, amputee