7.12 Behavioural and Psychosocial Interventions for pain management

Question 1

1. What % of those with advanced illness will experience pain?
2. List 3 complications of pain in patients living with advanced illness

Answer 1

1. Studies suggest that > 50% of patients with advanced disease experience pain.
2. Higher levels of pain are associated with:
   - worse functional well being
   - higher # depressive symptoms
   - increased mortality

Question 2

Treatment of pain in patients with advanced illness is often suboptimal.

List 3 types of barriers to effective pain management.

Answer 2

1. Provider related:
   - restricting focus of pain assessment/treatment to biomedical factors
2. Patient related:
   -hesitation to discuss pain due to fear of being perceived as complaining/drug seeking or anxiety that pain = dz progression
3. Caregiver related:
   - hold back on discussing pain with patient so as not to burden them

Question 3

As an expanded model of Dame Cicely Saunder’s term “total pain”, list 4 overlapping elements

Give an example of each element

Answer 3

Figure 7.12.1
1. Biological factors:
- nociception
- neuropathy

2. Psychological factors:
   - anxiety, depression
3. Social factors:
   - social support, communication
4. Spiritual:
   - meaning and purpose in life

Question 4

1. Give an example of how dysregulation of each the 4 elements in the biopsychosocial-spiritual model could exacerbate a patient’s pain.
2. Give examples of approaches to improve patient’s biopsychosocial-spiritual pain management.

Answer 4

Pt with painful swallowing due to inflammatory changes (biological factor) from radiation Rx

When pain is severe, pt ruminates about his poor prognosis and feels anxious/depressed (psychological factor)

He doesn’t want to burden wife with his negative emotions, so withdraws (social factor) which reduces his access to social support

His social withdrawal leads to less engagement in activities (medidating, time with family) that make his life meaningful (spiritual factor).

Motivation to remain active declines, more time in bed, fewer distractions from pain = inc suffering, intolerable pain.

Bio: pain meds

Psycho: Address unhelpful thinking patterns (the rumination)

Social: Address maladaptive coping efforts (social withdrawal)

Spiritual: To help patient reconnect with the most meaningful aspects of his life

Question 5

1. Describe the gate control theory by Melzack and Wall (1965)
2. How was this theory updated in 1999?
3. Name one tech advancement that has helped us better understand pain

Answer 5

1. Pain is a complex experience with sensory, affective, motivational, and cognitive components. Noxious inputs from periphery can be modulated in the brain via non-noxious inputs from periphery + descending inputs to gating system in spinal cord.
2. NEUROMATRIX theory - there are multiple inputs (somatic, sensory, emotional, cognitive, stress) to the neuronal networks responsible for the perception of pain
3. Research with functional and structural MRI has helped with understanding neural pain circuitry and role of neuroinflammation

FS
- there is a nerve “gate” in the dorsal horn of spinal cord - noxious inputs from 1st order neurons (Ad and C fibers) open gate, non-noxious inputs from 1st order neurons (Ab fibers) close the gate, descending inputs can also close the gate (eg release of endorphin)

Question 6

List 3 types of psychological factors that can influence pain in advanced disease - give 1 example of each.

Answer 6

1. Cognitive factors:
   - overly negative thoughts and beliefs
2. Emotional factors:
   - depression, anxiety, anger, and guilt
3. Behavioural factors:
   - holding back on pain communication
   - withdrawal from social interactions

FS: think CBT triangle

Question 7

A meta-analysis of diagnostic interviews in pall care settings revealed 29% of patients had a diagnosable mood disorder

1. List 2 aspects of pain that can be affected by a mood disorder.
2. Why is it important to assess psychological functioning in the above case?

Answer 7

Pain and psychological distress are often comorbid and can exacerbate one another.

1. Patients with advanced cancer and more depressive/anxiety symptoms were more likely to:
   i) report higher levels of pain (SEVERITY)
   ii) report pain that freq interfered with social relationships and general function (IMPACT)
2. Poorly controlled pain that interferes with functioning is a risk factor for suicide in terminally ill patients.

Question 8

Name 2 ways pain can worsen patients’ spiritual distress

Answer 8

1. The meaning of pain - an increase in pain is a reminder of disease, loss of control, or death
2. For some patients, meaning of pain is test of faith/punishment - leads to feeling of sadness and guilt.

Question 9

Patients with higher level of satisfaction with their social support are more likely to experience better symptom control and improved health-related QOL.

List 3 types of social support that can improve pain

Answer 9

1. practical support - increased help with ADL’s/IADL’s
2. emotional support - willingness of caregiver to discuss serious illness/pain
3. informational support - info about strategies for managing pain

Question 10

It is common for patients to withdraw from social interactions (fear of being burden). This can reduce distress in short term, but exacerbates distress over time.

List 4 clinical outcomes of decrease in a patient’s perceived social support/increased social isolation.

Answer 10

1. Increased pain severity and pain interference
2. higher levels of depressive symptoms
3. greater cognitive decline
4. increased mortality

Question 11

List 3 adverse effects of a patient’s poorly controlled pain on their caregivers

Answer 11

1. High levels of burnout, fatigue
2. Psychological distress, worse mood
3. Caregiver is at increased risk of early mortality

Question 12

1. Describe spirituality
2. Define religiosity
3. How does spirituality differ from religiosity?

Answer 12

1. How individual’s pursue and express PURPOSE& MEANING IN LIFE, as well as, experience a connection to the present, to the self, others, and to the significant or sacred.
2. Religiosity is institutionally formalized activities and beliefs of a specific faith.
3. Spirituality may or may not be connected to religiosity. It is a broader construct, sense of meaning/purpose not associated with a specific faith.

Question 13

List 3 mechanisms by which spirituality can influence pain experience positively *

Answer 13

1. Distraction
2. Relaxation
3. Social support
4. Turning toward beliefs to cope with pain experience (i.e. afterlife without pain)
5. Turning toward spiritual practices (prayer, meditation) to cope with pain experience

FS
1. Relaxation (prayer, meditation)
2. Coping beliefs (afterlife)
3. Social support

Question 14

What is maladaptive vs. adaptive religious and spiritual pain coping?

Answer 14

1. Maladaptive (viewing pain as punishment or abandonment from a higher power):
2. Adaptive (thinking of life as part of a larger spiritual force):

Question 15

Poorly controlled pain can substantially impact a patient’s spiritual wellbeing.

Research shows which 4 possible clinical outcomes of reduced spiritual well being in palliative & EOL care settings.

Answer 15

1. Increased pain
2. Distress
3. Hopelessness
4. A strong desire for hastened death and requests for physician-assisted death

Question 16

Advanced illness and pain can disrupt a central facet of spirituality - sense that life has meaning.

Maintaining meaning may be the most critical aspect of spirituality for those with advanced illness.

List 4 symptoms that were less reported by patients expressing a greater sense of meaning in life.

Answer 16

1. Less pain
2. Lower levels of sleep disturbance
3. Fewer cognitive complaints
4. Less fatigue

Question 17

List 5 interventions designed to address psychological and social factors contributing to pain in advanced illness.

IMPORTANT SLIDE

Answer 17

Table 7.12.1:
1. pain coping skills
2. mindfullness meditation
3. acceptance and commitment therapy
4. hypnosis
5. meaning-centred psychotherapy

Skills MAM hypno

Question 18

1. How does the CBT framework approach pain?
2. What is the evidence supporting CBT-based interventions for persistent pain?

Answer 18

1. Patient’s beliefs, thoughts, expectations, feelings, and behaviours affect adjustment to pain and perceptions of pain.
2. Meta-analysis of RCTs with cancer patients showed that behavioural and psychosocial interventions produced medium sized reductions in pain.

Question 19

1. What is pain coping skills training?
2. What are the 3 steps involved?

Answer 19

1. Most widely used cognitive/behavioural approach to pain.
   Focuses on understanding + enhancing pain coping strategies through systematic training
   Protocols vary:
   - 3 to 12 sessions
   - individual vs group vs pt-caregiver dyad
   - in person, phone, video, internet based
2. 3 steps:

i) Patients learn RATIONALE for how thoughts, emotions, and behaviours can affect pain
(gate control theory/pain neuromatrix)

ii) Learn SKILLS to enhance ability to cope with pain

iii) Learn how to APPLY coping skills to challenging situations (pain flares, painful ADLs) & how to overcome obstacles to pain coping efforts

Question 20

List 7 skills taught in pain coping skills training

IMPORTANT SLIDE

Answer 20

Table 7.12.2:
1. Progressive muscle relaxation
2. Brief relaxation practice
3. Guided imagery
4. Pleasant activity scheduling
5. Activity-rest cycles
6. Goal setting
7. Cognitive restructuring

Good peanut butter goal CAP

Question 21

Muscle relaxation training is a key skill in pain coping skills training.

Describe the process and the rationale behind it.

Answer 21

Taught using “progressive” muscle relaxation

Building and releasing tension in sequential muscle groups in order to decrease:
- muscle tension
- autonomic arousal
- psychological distress

Exercises may need to be modified due to physical limitations (i.e. passive muscle relaxation vs. tensing)

Question 22

Once patients are proficient in progressive muscle relaxation, they can be instructed in brief relaxation practice.

Describe “brief relaxation practice” as a pain coping skill - the process, when to do it, and how often.

Answer 22

Patient to imagine a wave of relaxation flowing from the top of their head to their feet, releasing any tension that may be present.

Conduct brief practices frequently throughout day

Use internal cues (inc pain, anxiety) or external cues (having meal, convo) as reminder to do brief relaxation

Start with 5 per day and gradually work up to 20 per day.
Once at 20, it becomes a habit, easier to maintain.

Question 23

Describe the practice of guided imagery as a pain coping skill

Answer 23

Patients are asked to focus on a pleasant and relaxing scene.

Scene that holds special meaning, pt felt at peace or connected to (meaningful memories)

Spend 1-2 minutes focusing on 5 senses in that scene (i.e. what does patient see, hear, etc)

After session, discuss bodily responses, thoughts, emotions

Question 24

Describe pleasant activity scheduling and its rationale as a pain coping skill

Answer 24

Decrease in patient activity may be necessary in declining health, but cutting back in all valued activities = inc in psychological distress

Identify valued activities that are pleasant and enjoyable and doable for patient
(i.e. watching a sunset rather than going camping)

Schedule time in day for pleasant activities and note how they feel before, during, after experience

Question 25

Describe goal setting as a pain coping skill

Answer 25

Support patients in setting realistic goals aligned with their personal values (family relations, recreation, spirituality)

Discuss goals as concrete steps toward an aspirational value

(ie. attending grandchild’s sporting event as a goal for patient who identifies family relationships as a primary value)

Question 26

Describe activity-rest cycle as a coping skill.
What are the 3 steps involved?

Answer 26

Helps patients learn to pace their activities and avoid overexertion –> latter leads to freq severe pain episodes and more resting over time.

1. Help patient identify activity they commonly overdo (i.e. sitting up too long)
2. Collaboratively set time limits for being active and for resting (ie. sitting up 40 min then 10 min of reclining)
3. Pt instructed to repeat cycle frequently and keep track of how many times they use it each day

Question 27

List the 4 steps involved in cognitive restructuring.

List 3 ways it can help patients.

Answer 27

A.
1. Patients learn to identify thoughts that may be exacerbating their pain & other symptoms:

Focus on unhelpful thoughts that are likely working against them (usually about self):
- I can’t handle this
- No one cares for me anymore
- I will never be able to do any of the things I like to do

2. Write down thoughts they have and how these relate to their feelings and behaviours
3. Learn to challenge and refute the thoughts that work against them :
   - Is this thought true?
   - Am I being too hard on myself
4. Learn to replace unhelpful thoughts with more adaptive thoughts that enhance coping with pain:
   Replace:
   “No one wants to be around me when I’m in pain”
   with
   “My friends want to spend time with me, and I don’t notice my pain as much when I’m with them”

B. Restructuring of cognition can:

i) improve emotional responses (reduce anger, fear, sadness) to difficult situations
ii) decrease symptom interference
iii) increase involvement in valued activities

Question 28

1. Define mindfulness.
2. What is the goal of mindfulness meditation
3. Research shows mindful meditation can help terminally ill patients in which 3 ways?
4. What is the most well-studied approach?

Answer 28

1. An intentional present-moment awareness that is non-judgemental
2. Goal is to increase awareness of the present moment with a non-judgemental attitude
3. improve stress management
   reduce anxiety/depressive symptoms
   reduce pain interference and disability in chronic pain
4. Mindfulness-based stress reduction (MBSR)
   - targets stress management through relaxation training and meditation

Question 29

1. What is the theory behind Acceptance and Commitment Therapy?
2. How is ACT delivered?
3. What is the central goal in ACT?
4. What is the evidence for ACT?

Answer 29

1. That suffering is ubiquitous but can be managed through psychological flexibility:
   - being fully present
   - non-defensive
   - engaged in behaviours that align with values
   And that symptoms are made worse by avoidance
2. Group or individual
   - Focus on openness, awareness, engagement using stories/metaphors/experiential exercises
   - Mindful based meditation to confront symptoms
   - Assess if behaviours align with values
   - Cognitive defusion
3. To help patients improve their acceptance of their illness and symptoms while living a life that is congruent with their values
4. Evidence is in chronic pain (is being adapted to terminal illnesses):

ACT produces significant, sustained improvement in:
- pain intensity
- pain interference
- depressive sx
- anxiety
- disability

Question 30

1. Define hypnosis
2. What is the evidence for hypnosis in pain management? List 2 positive outcomes
3. How do we think it works for pain?

Answer 30

1. The use of suggestions during a state of focused awareness in order to change unwanted sensations, thoughts, emotions, and/or behaviours
2. RCTs support efficacy of hypnosis for persistent pain. It can improve:
   - pain severity
   - pain interference
   - emotional wellbeing
   - physical wellbeing
3. Mechanism similar to guided imagery and other relaxation techniques

Brain imaging studies suggest hypnosis affects neuronal networks in processing of pain

Question 31

What are the 3 distinct phases of hypnosis?

Answer 31

1. Induction
   - start with relaxation techniques
2. Deepening
   - suggestions to become increasingly relaxed
3. Post-hypnotic suggestions
   - once a hypnotic state achieved, suggestions to target pain, for example:

• global sense of calmness
  (to reduce sympathetic arousal)
• imagining painful areas engulfed in anesthesia
  (reduced peripheral sensation)
• changing the meaning of pain
  (reducing prefrontal cortex activation)

Question 32

1. What is the goal of meaning-centered psychotherapy?
2. What is the evidence for its efficacy with pain? List 3 ways in which it’s shown to help patients.
3. List 3 techniques used by clinicians in meaning-centered psychotherapy.

Answer 32

1. Helps patients find ways to identify/maintain meaning in context of serious illness
2. Does not directly address pain, but can reduce distress related to physical symptoms

RCTs support efficacy in:
-increasing meaning in life
-improved overall spiritual well-being
-reduce depressive symptoms, hopelessness, DHD

3. i) psychotherapeutic (active listening, probing Q’s)
   ii) patient education
   iii) experiential exercises (think about identity - how it has not changed due to illness; legacy work)

Question 33

List 4 primary sources of meaning that patients learn in meaning-centered psychotherapy to use as resources during times of pain.

Answer 33

1. Historical ( meaning from family hx, current life, legacy one will leave)
2. Attitudinal (meaning through choosing one’s response to suffering)
3. Creative (meaning through accomplishments, roles, work)
4. Experential (meaning through relationships, experiencing beauty, humour, nature)

Question 34

List 3 ways you would deal with patients who are reluctant to report pain, but whose caregivers are concerned about the severity and impact of pain?

Answer 34

To determine accuracy of pain reporting, ask patient to complete:
- pain rating scale
- shade in areas of pain on body diagram

Careful listening and empathetic responses to understand why communicating that pain to others is challenging.

Behavioural approaches (communication skills training) to enhance pt/caregiver ability to talk about pain

Question 35

List 1 way HCP could introduce behavioural and psychosocial pain treatments to patients?

Answer 35

1. pamphlets, flyers, posters describing B & P approaches in various languages
2. Introduce B&P approaches as part of a menu of treatment options to address the multiple ways pain can impact their livers
   (i.e. alongside medical, surg etc)*
3. Presence of interdisciplinary team can send msg about need for comprehensive approach to pain
4. Reassure pt that behavioural methods would not mask/ignore problem that needs to be addressed (i.e. mind-body connection will help distinguish familiar pain vs pain changing in quality/character)

Question 36

List 2 ways of combining medication and behavioural approaches to pain

Answer 36

1. Scheduling regular analgesics during day & using sedating meds at night (to optimize pain and minimize sedation for ADLs during day and maximize sleep)
2. If on optimal pain medication but preparing for physically demanding goal that could increase (breakthrough) pain, use pain coping skills:
   - activity-rest cycle to prevent overexertion
   - relaxation to reduce anticipatory anxiety about pain

Question 37

List a communicate technique HCP can employ to encourage the patient’s use of behavioural and psychosocial approaches to pain

Answer 37

Use motivational interviewing:

• empathic listening
• identifying differences between behavior & values
• avoid arguments
• maintaining rapport even when resistance
• support patient autonomy & self-efficacy

Question 38

1. List 3 contributors to HCP burnout when treating patients with persistent pain.
2. List 3 behavioural and psychosocial skills that have a role in managing the stress experienced by providers?

Answer 38

1.
- dealing with issues of death and dying
- emotional suffering of patients and families
- heavy workload
- managing pain crises
- sense of loss of control over one’s time

2. HCP may benefit from training in same skills patients are taught. For example:
   - relaxation techniques
   - cognitive restructuring
   - value-based goal setting
   - mindfulness

Question 39

List 5 research limitations in the area of behavioural and psychosocial approaches to pain in life-limiting illnesses

Answer 39

1. More RCTs needed to specifically test efficacy in advanced illness population
2. Precise mechanism of pain reduction is not known
3. Which patients with advanced disease benefit the most (demographics, psychological factors, disease-related symptoms, prognosis, etc)
4. What is the optimum dose that would allow for cost-effective treatment
5. What are ways to improve access to B&P treatments (mobile, virtual etc)