Chapter 24 Psychological Interventions for Chronic Pain Flashcards
two emotional states shown to influence the experience of pain
anxiety and depression
Targets for psychological
treatment
(1) reducing pain and pain-related disability; (2) treating comorbid mood disturbances, particularly
depression; (3) increasing perceptions of control
and self-efficacy; (4) increasing health behaviors, such as
appropriate medication use, exercise/activation, sleep
habits; and (5) addressing pain-related psychosocial factors, such as the impact of pain on family functioning and
work life
theoretical basis for behavioral interventions in
persons with chronic pain
Learning theory, incorporating the principles of operant
conditioning (e.g., reinforcement and punishment)
In an operant model of pain, the primary focus of intervention
is the behavior of the patient. These behaviors can include either
verbal expressions of pain (e.g., complaints of pain or requests for medication), gross motor movements that are indicators of pain (e.g., grimacing or limping), or avoidance of potential pain-generating activities
the principles of operant conditioning
which state that a given behavior is highly influenced by the consequences of that
behavior
Reinforcing consequences and
punishing consequences results
Reinforcing consequences increase the likelihood
that a behavior will occur in the future and neutral
or punishing consequences decrease the likelihood that a
behavior will occur
The goal of operant interventions is to
decrease learned pain behavior and replace these maladaptive responses that
are assocaited with the sick role with more adaptive behaviors
Operant programs designed to avoid this negative pattern have three components
- Establish a baseline
- Time-contingent activity
- The level of the behavior is gradually increased
Establish a baseline
A specific target behavior is
identified, such as sitting at a desk. A baseline is
established by measuring for several days the amount of time the individual can sit at the desk before exacerbation of back pain—for instance, an
average 30 min
Time-contingent activity
Rather than having
the individual sit until the pain is intolerable and then stop, an initial goal is set at 70% to 80% of the baseline level, such as 20 to 24 min. The individual
would start by sitting no more than 20 min, thus avoiding the punishment of pain exacerbation and
obtaining the social reinforcement associated with
success
The level of the behavior is gradually increased
The level of the behavior is gradually increased,
usually no more than 5% per week with patients
instructed to use time, not pain, as an indicator for
stopping the activity. Over a period of weeks, the
individual would increase the comfortable duration
of sitting to perhaps 60 min without shifting positions
or standing up
“shaping.”
This process of gradually increasing the nature, frequency, or duration of a behavior
The goal of an intervention is to
increase the adaptive behavior while managing the consequences, which include removing any punishment (e.g., pain) and introducing
reinforcement (e.g., experience of success, social
attention)
The goal for most
relaxation techniques is
nondirected relaxation accomplished through two common components: first, repetitive focus on a word, body sensation, or muscle activity; and second, a passive attitude toward thoughts unrelated to the attentional focus
Common methods used for
teaching relaxation include
systematically tensing and
relaxing specific muscle groups (e.g., progressive muscle relaxation), focusing on breathing and enhancing diaphragmatic breathing, and using guided imagery. A primary goal of relaxation
training is to break the cycle between pain and muscle
tension.
Biofeedback
provides the individual with detailed information about a physiologic process that is typically not within the individual’s awareness. Through this detailed feedback, the individual can learn voluntary control over usually involuntary processes
Biofeedback for pain management usually entails
providing feedback about muscle tension, typically using electromyographic (EMG) feedback from the site of the pain or a standard location such as the frontalis muscles, or feedback about skin temperature, typically using thermistors attached to the fingers.
the efficacy of biofeedback for pain management exists for several specific painful conditions
Raynaud’s phenomenon, tension and migraine headaches, vulvar vestibulitis, and low back pain
cognitive-behavioral theory (CBT)
These interventions typically include components of the behavioral model, particularly relaxation training, and some components of operant conditioning. However, an emphasis is also placed on
cognitive factors, such as attitudes and beliefs that underlie maladaptive emotional and behavioral responses to pain
cognitive-behavioral theory indications
low back pain, rheumatoid
arthritis, and osteoarthritis pain
Primary goals of coping skills training are to
increase perceptions of pain as a controllable experience and decreasing the use of maladaptive coping strategies. In this approach, the emphasis is on skill development
and refinement.
skill development
a new skill is introduced and patients are encouraged to
develop and refine the skill during low pain periods before
attempting to implement the coping skill during an actual
period of pain exacerbation. The skill is shaped over time,
so that the skill is gradually applied to increasingly challenging (i.e., painful) episodes as the individual becomes more proficient in that skill
Cognitive restructuring focuses on the
role of cognitive factors, such as attitudes, thoughts, and beliefs, in determining
emotional and behavioral responses to pain
Catastrophizing
is a particularly maladaptive response to pain that has been
shown to correlate with depression and disability
How does interventions challenge negative self-talk, such as catastrophizing?
(e.g., “I can’t stand the pain anymore”), and replace
these self-statements with more positive statements that
reduce negative affect, emphasize control, and encourage adaptive coping (e.g., “This is a challenge that I have faced before and I can handle it this time.”)
COGNITIVE RESTRUCTURING emphasis is on
balanced thinking, not necessarily positive thinking. This self-monitoring process is supplemented with more in-depth discussions of the underlying attitudes and beliefs contributing to the negative thoughts
Hypnosis
Hypnosis for pain
management usually begins with an induction consisting
of suggestions for focused attention and relaxation. This
is usually followed by specific suggestions to alter how
the pain is viewed or experienced
The goal of using hypnosis when working with people with chronic pain
is to teach them self-hypnosis so they can use the skill
to reduce pain and discomfort outside of the treatment
session
Indications of Hypnosis
reduces chronic pain due to
malignancies, pain due to irritable bowel syndrome, temporomandibular
joint disorders, and tension headaches.
Key elements in self-management include
developing knowledge about the health condition, selfmonitoring progress, acquiring relevant skills, and problem solving
self-management indications
SM interventions have improved outcomes in
many conditions, including rheumatologic diseases, fibromyalgia, and depression.
The decision to pursue admission to an inpatient program is based on
clinical assessment of the patient and his or her environmental circumstances
Inpatient chronic pain
programs offer the advantage of
increased medical attention,
close monitoring of positive and negative health
behaviors, and a structured treatment setting
Inpatient admission maybe appropriate for patients with nonmalignant pain of 6 months or more and
(1) who require detoxification,
(2) have major functional disabilities, (3) need
intensive and extensive psychological or behavioral therapy, (4) need temporary removal from a detrimental home situation to refocus their lives away from the pain, and
(5) have failed conventional methods of treatment.
