PSYCHOSOCIAL ASPECTS OF PAIN

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PSYCHOSOCIAL ASPECTS OF PAIN

• Baylor University Medical Center
• Richard C. Robinson, Ph.D.

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The Significance of Pain

• Obvious significance
• Pain hurts and so it disrupts our lives
• Pain is critical for survival
• Minor pains provide low-level feedback
• Shift posture, uncross legs
• Roll over when asleep
• Medical consequences
• Pain is the symptom most likely to lead an
  individual to seek treatment

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Scope of the Problem

• Chronic pain 2-40 median point prevalence of
  15 (Verhaak et al., 1998)
• 17 of patients seen in primary care report
  persistent pain (Gureje, 1998)

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Cartesian Dualism
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Gate Control Theory of Pain
Melzack and Wall (1965)
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Biopsychosocial Approach

• Biomedical Model
• Biopsychosocial Approach
• George Engel
• Disease - objective
• Illness - subjective

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The Elusive Nature of PainOverview

• Pain is a psychological experience
• Interpretation of the pain influences
• The degree to which it is felt
• How incapacitating it is
• Beechers study of WWII injuries
• To soldiers, pain means, Im alive
• Pain is influenced by
• Context, culture, and gender

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Pain Pathways
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Mental Health Disorders

• Polatin et al. (1993), Katon et al. (1985)
• 59 met current diagnostic criteria for a
  psychiatric disorder
• Current substance disorder 15 to 28
• 77 met lifetime diagnostic criteria for a
  psychiatric disorder
• 51 personality disorder
• Of those who met criteria for lifetime diagnosis
• 54 Major Depression
• 95 Anxiety Disorder
• Lifetime substance disorder 23 to 41
• 94 of the chronic pain patients with lifetime
  substance use disorder experienced the onset
  before development of pain

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Mental Health Disorders

• Depression and Pain
• 34-54 Depression (Polatin et al. 1993 Fishbain
  et al. 1996)
• 77 met lifetime diagnosis criteria of
  psychiatric disturbance (Polatin, 1993)
• Pain and Physical/Sexual Abuse
• 61 sexual/physical abuse (Bailey, et al. 2003)

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Stress Response
Hypothalamus
Stressor/Pain
CRH
Pituitary
ACTH
ACTH
LC-NE
Adrenal Cortex
Corticosteroids (Cortisol)
Sympathetic
Adrenal Medulla
Epinephrine Norepinephrine
Gatchel, Buam Krantz (1989)
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Stress Response Continues

• Immune system suppressed
• Limbic system activated (amygdala, hippocampus,
  etc.)
• Endogenous opioids released

Melzack (1999)
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Prolonged Stress

• Elevated Cortisol
• Immune system suppression
• To ensure enough glucose, breaks down the protein
  in muscle and inhibits the ongoing replacement of
  calcium bone
• Breakdown of bone
• Muscle tissue loss
• Neural tissue loss
• Marked negative impact on hippocampus
• Hippocampus also acts as brake for cortisol
• Deleterious to brain-derived neurotrophic factor
  (BDNF) keeps brain cells healthy and sprouting

Melzack (1999)
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Prolonged Stress

• Cortisol modulated by sympathetic nervous system
  and endogenous opioids
• Dysregulation of feedback-hypocortisolism/hypercor
  tisolism

Melzack (1999)
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Depression and Stress

• Nemeroff (1999)
• Greater ACTH response to stress if removed from
  mother at early age
• Heim et al. (2000)
• Greater ACTH response to lab stressors

Holden (2003)
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Estimated marginal means of cortisol variability.
Gatchel et al.
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Chronic Pain

• Gatchel (1991)
• Pain (hurtharm)
• Stage 1 Initial psychological distress
• Stage 2 Development or exacerbation of
  psychological problems
• Stage 3 Acceptance of sick role and
  consolidation of abnormal illness behavior
• Physical and Mental deconditioning overlay

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Pain Management

• Pharmacotherapy is first line-treatment in US for
  pain (Gatchel Okifuji, 2006)
• Data to demonstrate efficacy and tolerability
  based on RCTs with a mean duration of 5 weeks
• 16 weeks longest RCT
• Average pain reduction of 30
• BEWARE Valid reason to hurt.
• Epidural Steroid Injections Limited evidence of
  long-term benefit (Armon, Argoff, Samuels
  Backonja, 2007)
• Average 2-6 weeks
• Limited impact on functioning

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Pain Management

• Surgery spinal fusion one of the most common
  surgeries
• Reviews have found limited evidence for efficacy
  of spinal fusions or decompressions for lumbar
  spondylosis or lumbar stenosis (Gibson, Grant
  Waddell, 1999 van Tulder, Koss Seitsalo
  Malmivaara, 2006)
• Studied conducted in Washington State Workers
  Compensation System
• 68 worse pain after fusion
• 56 no better quality of life
• 64 to 68 disabled after fusion

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Interdisciplinary Pain Management

• American Pain Society Task Force on Comprehensive
  Pain Rehabilitation (Gatchel Okifuji, 2006)
• Evidence of therapeutic efficacy and cost
  effectiveness
• Review of Interdisciplinary Programs (Guzman et
  al., 2001)
• Strong evidence of improving functioning
• Moderate evidence of reducing pain
• Mixed evidence of impact on vocational outcomes

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Interdisciplinary Pain Management

• Multiple disciplines to address biopsychosocial
  nature of pain
• Physician
• Nurse
• Mental Health Professional
• Psychologist
• Psychiatrist (more needed in this field)
• Masters level clinician
• Physical Therapist
• Case Manager
• Regular staff meetings

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Behavioral Medicine

• Techniques (Specific)
• Relaxation Training
• Biofeedback
• Hypnosis

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Intervention

• Relaxation Training
• Aspirin of Behavioral Medicine
• Systematic approach to teaching people to gain
  awareness of their physiological responses and
  achieve both a cognitive and a physiological
  sense of tranquility. Arena and Blanchard

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Intervention

• Relaxation response Benson (reduced oxygen, blood
  pressure and SNA)
• Diaphragmatic breathing
• Progressive muscle relaxation
• Autogenic training
• Guided imagery
• Meditation

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Intervention

• Relaxation Training-All share two components
• Repetitive focus
• Adoption of passive attitude toward intruding
  thoughts

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Intervention

• Relaxation Training
• 31.7 reported use of relaxation technique in
  past 12 months (Eisenberg et al., 1997).
• Carpal Tunnel Syndrome to Paraplegia

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Behavioral Medicine Evidence

• NIH Technology Assessment Panel on Integration of
  Behavioral and Relaxation Approaches Into the
  Treatment of Chronic Pain and Insomnia (1996)

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Behavioral Medicine Evidence

• Relaxation
• Strong
• Alters sympathetic activity as indicated by
  decreased Oxygen consumption, blood pressure,
  etc.
• Alterations in catecholamines

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Intervention

• Biofeedback
• EMG
• EDR
• Thermal
• EEG

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Intervention

• Biofeedback reliably influences
• Responses not ordinarily under voluntary control.
• Responses that ordinarily are easily regulated,
  but for which regulation has broken down.

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Other Considerations

• Provides nice evidence to patient
• Connection between cognitions and physical
  responses
• Can objectively monitor patients progress and
  ability to generalize
• Can be difficult for patients
• Opposite response might occur.

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General B-Med Considerations

• Usually performed in context of CBT
• Patient motivation is critical
• Increasing Self-Efficacy vs. Passive Treatment
• De-Briefing (What worked?)
• Generalization
• Practice
• Conditioning
• Similarity

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Interdisciplinary Treatment
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Success

• Self-Reported Improvement
• Decrease in Distress
• Increase in Physical Functioning
• Decrease in Pain
• Increase in Control

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Success In Two Programs
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1-Year Pain Reduction
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1-Year Hours Resting Improvement