Pain/health Flashcards
What is pain
- unpleasant sensory and emotional experience associated with, or resembling that of actual or potential tissue damage
- Old view pain V new view pain - now subjective experience
Pain and the mind
Issue muscle damage healed 3-6months
Persistent pain - What’s maintaining it then?
Pain is a construct of the mind…doesn’t make it not real
- E.g phantom limb, a friend who tore muscles but didn’t feel it while saving her baby
- Mirror box therapy: think it’s your left hand there so you associate it moving without pain so doesn’t need to always be in pain
Somatic symptom criteria
1+6month somatic symptoms that are distressing or result in significant disruption of daily life
- Excessive thoughts, feelings (anxiety) or behaviours (time + energy) related to the somatic symptoms or associated health concerns
Illness anxiety
- high level of anxiety about health
- Preoccupation with having or acquiring a serious illness
- Somatic symptoms are not present, or, if present, are only mild
- The individual performs excessive health-related behaviours (e.g. repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g. avoids doctor appointments)
Specify: Care seeking type OR care avoidant type
Care-seeking subtype: Go to the doctor
Care-avoidant subtype: Avoid doctor in case they tell them something they don’t want to hear, have a fear
[IF NOT MILD THEN CAN BE SOMATIC ANXIETY
OR IF ACTUAL MEDICAL PROBLEM]
Somatic vs illness
Somatic Symptom Disorder there is generally a somatic expression of the complaint (e.g., back pain), whereas in Illness Anxiety Disorder, it is dominated by anxiety about having or acquiring a serious medical illness.
Conversion Disorder
+ what test to tell if real
- One or more symptoms of altered voluntary motor or sensory function
- incompatibility between the symptom and recognised medical conditions.
Specify: with paralysis/swallowing/speech/seizures etc
Tests you do to tell
- Trimmer test
Factitious Disorder:
Factitious disorder imposed on self or other:
- Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception
- Presenting oneself/or another (victim) as ill, impaired, or injured.
- The deceptive behavior is evident even in the absence of obvious external rewards.
Factitious vs malingering
Malingering requires intentional, voluntary, external incentive (escape work)
Differentials
- General Medical Condition
- Panic vs health
- both fear physical or mental catastrophe
- Diff = time frame, health-anxious = fearing catastrophe in the future, panic disorder = immediate catastrophe.
- Depression: often accompanied by somatic symptoms (Depression often secondary to chronic pain)
- Psychosis: SSD- the worry is not of delusional proportions and not bizarre (e.g. I’ve been infected with a Martian disease) & IAD can acknowledge that worries are out of proportion to reality
- GAD: Worry about a lot of things vs. only about health
- OCD: Somatic symptom – less intrusive and linked to their somatic symptoms, IAD - concerned about (already) having a disease or a predisposition to a disease, OCD - concerned getting a disease
Adjustment disorder- in practice this is the most commonly diagnosed disorder for chronic pain
Assessment
- Physical – medical tests
o Early stages of disease can look like somatic disease, can have problem with both medical and psychological - Understanding of their pain (do they still have medical beliefs around it or hurt = harm beliefs)
- How they cope with pain (eg avoidance)
- Impact of their pain, including check current activity levels eg typical day (are they engaging in pain-contingent patterns - stop when experience pain, boom and bust patterns - push through then flare up and need long time to recover)
- Risk.
- Personal expectations for treatment of chronic pain.
- Comorbidities eg anxiety/mood.
- Background e.g. trauma if relevant.
- Social system: how do they respond?
- Lengthy medical history
- ‘Doctor shopping’ and strained doctor-patient relationships
- History of serious illnesses
- Disease in a family member
Psychometrics
- Pain Catastrophising Scale
Illness Anxiety psychometrics:
● IAS: Illness Attitude Scales (Kelner)
Theories
gate control
Neuromatric
Operant behavioural
Nocebo
Gate control theroy
Sensory messages travel from stimulated nerves to the spinal cord. The messages are sent to the brain through open ‘gates’. Once the messages reach the brain, the sensory info is processed in the context of the individual’s current mood, state of attention, and prior experiences.
If the brain continues to consider the pain as dangerous, the pain gates remain open (get info), if not, the pain gates are closed and pain is reduced. In chronic pain the danger messages continue to be sent from the brain and the gates remain open.
Treatments used to close the ‘gate’ include a range of self-management strategies including relaxation, improving mood, distraction and involvement in other activities. Pain relief has limited impact on chronic pain.
The Neuromatrix in the brain
- The gate opening will be influenced by cognitive factors, culture learning, past experiences, personality, etc.
Operant-behavioural treatment
- How kind partner is changes level of pain more kind = more pain
Nocebo:
- Verbal suggestions of symptoms worsening, patient expects to feel worse and eventually will
Causes / risk factors
- Historic serious illness, disease with family member
- Reading or hearing about disease
- Trauma will increase chance of pain due to active alarm system
- personality: being high harm avoidance person
Maintaining
- Reward/positive reinforcement: Attention and care from others
- Focusing attention on the body
- For some super situations thinking “if I think about illness I will get it”
- Metacognitive “If I don’t worry about my health something will go wrong”
- checking and scanning the body for possible signs, checking can lead to body changes (etc soreness) providing evidence for illness + arousal which can be interpreted as signs of disease
- Reassurance seeking – unnecessary tests and interventions, ambitious information (can be rewarding in short term)
- Selective attention and confirmation bias
Models
Fear Avoidance Model of Chronic Pain:
Cognitive-Behavioural Model of Hypochondriasis (PIC)
Fear Avoidance Model of Chronic Pain:
Injury > pain experience > low fear >confrontation > recovery
Injury > pain experience > catastrophize > fear of pain > pain anxiety > avoidance > disability
(feed back into pain experience)
Cognitive-Behavioural Model of Hypochondriasis (Ambramowitz & Deakin): Vulnerability of developing Illness Anxiety arises when erroneous health-related beliefs lead to misinterpreting physical signs and symptoms as suggestive of a serious illness.
