9.11 Psychological and psychiatric interventions in pain control Flashcards
Pain is a multifactorial process. List 4 contributors to pain that are not physical in nature
personality, affect, cognition, behaviour, and social relations
What are the differential role of psychological therapies and somatic therapies in the management of pain?
Psychosocial therapies directed primarily at psychological variables may have an impact on pain intensity or distress, while somatic therapies directed at nociception may reduce the adverse psychological aspects of pain.
To manage complex chronic pain problems, both somatic and psychosocial therapies should be used in a multimodality approach
List six contributors to distress that pain can cause
impairment in activities of daily living
the experience of unpredictable painful episodes
negative thoughts about personal or social competence
thoughts about the cause of pain
greater anxiety or depressed mood
more existential concerns such as fears about the future
Describe the relationship between pain and suicidal ideation in patients with advanced illness. What aspect of pain is linked to suicidal ideation?
the majority of suicides involve patients who have severe, inadequately controlled or poorly tolerated pain.
Cancer patients who had significant pain, suicidal ideation was not directly related to pain intensity, but was strongly related to the degree of depression and mood disturbance.
Name three domains that are affected by pain-related quality of life
The variables that affect pain-related quality-of-life may be categorized in three domains:
(1) physical well-being
(2) psychological well-being (consisting of affective factors, cognitive factors, spiritual factors, communication, coping, and meaning of pain or cancer)
(3) interpersonal well-being (focusing on social support or role functioning)
You are asked to provide a psychiatric assessment on a palliative patient with severe pain. The patient is on low dose opioid therapy. What is a prerequisite before your assessment of psychological contributors to this patient’s pain?
Pain assessment and prescription of adequate pain relief
List five risk factors for having inadequately controlled pain in advanced illness
advanced cancer +
- discrepancy between physician and patient in judging the severity of pain
- the presence of pain that physicians did not attribute to cancer
- better performance status
- age of 70 or over
- female sex
diagnosis of AIDS +
- female
- limited education
- substance abuse history
- pain related barriers to opioid treatment
general: lack of knowledge about pharmacological interventions, focus on prolonging life rather than alleviating suffering, lack of communication between doctor and patient, limited expectations of patients to achieve pain relief, patients’ limited capacity to communicate, unavailability of opioid drugs, doctors’ fear of opioid toxicity, and doctors’ fear of amplifying addiction and substance abuse
Describe two ways that inappropriate assessment of psychological aspects of pain can lead to poor pain control
Psychological variables may be ignored, or contrariwise, may be proposed to explain pain when in fact medical factors have not been adequately appreciated
What are the three major types of psychological and psychiatric approaches to pain management? What does response to one of these interventions mean about the etiology of the pain?
psychotherapeutic, cognitive behavioural, and psychopharmacologic interventions, usually in combination.
The mechanisms by which these techniques relieve pain are not known and it widely accepted that a favourable response to a psychological technique should not be viewed as evidence that pain is psychogenic.
What are the three major goals of psychotherapeutic intervention for pain management? Table 9.11.2. Provide an example of how each goal can be achieved
Support - provide continuity
Individuals -supportive/crisis intervention
Knowledge - provide information
Family patient and family are the unit of concern
Skills - relaxation, cognitive coping, communication, use of analgesics
Group - share experiences, identify
successful coping strategies
What is the role of analysis in the psychotherapy utilized in advanced illness?
primarily non-analytical and focuses on current issues, exploration of reactions to illness often involve insights into earlier, more pervasive life issues
Therapy can take place individually or in what two other forms? When are other forms of therapy helpful
Individual, family, group
As the illness progresses, psychotherapy with the individual patient may become limited by cognitive or speech deficits -> focus of supportive psychotherapeutic interventions shifts primarily to the family
Group interventions with individual patients (even in advanced stages of disease), spouses, couples, or families are a powerful means of sharing experiences and identifying successful coping strategies
Negative thoughts about pain are correlated with what 3 findings
pain intensity, degree of psychological distress, and level of interference in functional activities
Patients may be hesitant to utilize cognitive behavioural techniques for pain management due to concerns about their utility and non-pharm nature. What is required before suggesting these therapies? A patient asks how these therapies work, what do you explain about the mechanism?
Best to introduce cognitive behavioural interventions after some rapport has been established with a patient.
it is important to stress that an understanding of the mechanism is not needed for effectiveness and the outcome is most important.
What three contributors to pain make attempts at relaxation useful
Muscular tension, autonomic arousal, and mental distress exacerbate pain
Relaxation techniques are more effective if combined with what? When using imagery, from whom should the images be elicited from
Relaxation is most commonly achieved through the use of a combination of focused breathing and progressive muscle relaxation exercises. Once patients are in a relaxed state, imagery techniques can then be used to induce deeper relaxation and facilitate distraction from or manipulation of a variety of cancer-related symptoms.
Imagery (often referred to as guided imagery) is most effective when the specific image is obtained from the patient.
Match the following therapy descriptions with the technique it describes - table 9.11.13.
a. behavioural therapy
- clinical use of techniques derived from the experimental analysis of behaviour.
b. cognitive therapy
- targeted at changing maladaptive beliefs and dysfunctional attitudes
c. cognitive restructuring
- redefinition of some or all aspects of the patient’s interpretation of the noxious experience.
d. self monitoring/patient diary
- written or audiotaped chronicle that the patient maintains to describe specific agreed upon characteristics associated with pain.
e. contingency management
- focus the pt and family member responses that either reinforce or inhibit specific behaviours exhibited by the patient. Reinforce “well behaviours”
f. grade task assignments
- hierarchy of tasks are compartmentalized and performed sequentially in manageable steps to achieve a goal.
g. systemic desensitization
- relaxation and distraction exercises paired with a hierarchy of anxiety arousing stimuli resulting in control of fear.
List six examples of antidepressants that can be used for depression or anxiety. each from a different class. Must include at least two examples that are effective for pain control and indicate those
Nortriptyline - TCA - pain
Duloxetine - SNRI - pain
Mirtazapine - tetracyclic antidepressant
Buproprion - norepinephrine–dopamine reuptake inhibitor
Citalopram - SSRI
trazodone - serotonin modulator
other MAOI
What is the difference between secondary and tertiary amines for TCAs? Give an example of each
secondary amine - better tolerated, may be less effective
-nortriptyline
Tertiary amine - more side effects (particularly anticholinergic SE), more effective
-amitriptyline
What is the role of psychostimulants in the setting of advanced illness? What is the role for pain?
Treatment of depression, fatigue
No role for pain management
Provide one example of a high potency typical antipsychotic and an atypical antipsychotic. What is the major side effect of each. Provide an example of an antipsychotic that has been used to augment pain management
Typical - Haloperidol - high affinity for D2 receptor- extrapyramidal SE - tardive dyskinesia, acute dystonia, NMS, akathesia, parkinsonism
Atypical - Quetiapine, rispiridone - metabolic side effects, such as glucose intolerance
Methotrimeprazine
List three mood stabilizers that can be used for pain and one that cannot be used for pain
For pain - gabapentinoids, topiratmate, valproic acid, carbamazepine
Not pain - Lithium
Give an example of an anxioltyic used for pain control. In what cirumstances can this be used for pain
clonazepam, when anxiety complicates significant neuropathic pain
