Pain Psychology Flashcards
Criteria for Major Depressive Disorder?
- symptoms present for most of day for most days for greater than 2 weeks
- 5 of 9 but must include either low mood or anhedonia:
SIGECAPS (sleep, interest, guilt, energy, concentration, appetite, psychomotor retardation, suicide) - can’t be attributed to substances or other medical condition
- must result in clinically significant distress or impairment
Criteria for Somatic Symptom Disorder?
A. one or more somatic symptoms that are distressing or lead to significant daily disruption
B. Excessive thoughts, feeling or behaviours related to somatic symptom manifested by one or more of:
- persistent thoughts about seriousness of symptom
- persistent high level of anxiety about symptom
- excessive time and energy devoted to these symptoms or health concerns
C. Persistent symptoms (usually greater than 6 months)
specifiers a) with predominant pain; b) persistent
c) mild (only one of B), moderate (2 or more of B) or severe (2 or more of B plus multiple complaints or severe somatic symptom)
Criteria for Generalized Anxiety Disorder?
A. 3 of 6 of MRFISC (muscle tension, restlessness, fatigue, irritability, sleep disturbance, concentration difficulties)
B. Difficulty controlling worry
C. 6 months or greater of excessive anxiety and worry about a number of events or activities
D. can’t be attributed to substances or other medical condition
E. must result in clinically significant distress or impairment
Criteria for Substance Use Disorders?
2 or more of the following over 12m period leading to clinically significant distress or impairment:
Compulsive use (4)
- larger amounts and over longer periods (loss of control)
- unsuccessful cutting down
- excessive time spent in obtaining substance
- craving
Things given up (2)
- failure to fulfill major role obligations
- activities (social, occupational and recreational) given up due to use
Use despite negative consequences (3)
- recurrent use in physically hazardous situations
- continued use despite social and interpersonal problems
- continued use recurrent physical and psychological problems caused by substance
Biological adaptations (2)
- tolerance
- withdrawal
4 main categories in the Criteria for PTSD?
A. Exposure actual or threatened death, serious injury or sexual violence a traumatic near death experience
B. Re-experiencing of event (ie. nightmares or flashbacks)
C. Avoidance behaviours of stimuli associated with the trauma
D. Negative alterations in mood and cognitions (ie. memory loss of event or significant guilt or persistent negative emotional state (anger, irritability)
E. Increased arousal state and reactivity (hypervigilance)
F. Symptoms > 1 month post trauma
G. can’t be attributed to substances or other medical condition
H. must result in clinically significant distress or impairment
What are the stages of CBT?
Wall & Melzack: 1. Assessment stage 2. Cognitive stage 3. Behavioural stage 4. Learning stage Alternatively: 1. Assessment 2. collaborative reconceptualization of patient’s view of pain 3. acquisition of skills 4. consolidation of skills, including cognitive and behavioral rehearsal 5. generalization, maintenance, and relapse prevention 6. booster sessions and follow-up
Compare and contrast CBT and mindfulness based therapy
CBT
- targets cognition distortions
- attempt to reframe or change automatic thoughts;
- uses behavioral activation;
- directive;
- structured;
- homework involved
-
MBSR
- acknowledge the thought or emotion but does not attempt to change the thought or emotion;
- focuses on the present;
- does not address underlying core beliefs;
- empowering and accepting;
- teaches to notice and accept problem events
- changes relationship to the thoughts, sees them as passing events
Compare and contrast MBSR and MBCT
MBSR:
- focused on noticing and acceptance
MBCT:
- Paying attention in a particular way on purpose, in the present moment, non-judementally
- focused awareness, attention regulation
- open monitoring (emotional regulation, emotional non-reactivity, non-judgemental, acceptance)
Indications for hypnosis?
- Headache
- labour pain
- procedure induced pain
- cancer (bone marrow transplant, lumbar punctures)
- pain from chemotherapy and radiation
- arthritis
- sickle-cell
- dental,
- post-surgical pain
- burns (debridement, dressing change)
What is the mechanism of action of hypnosis?
- decrease pain-related affect (limbic ACC)
- decrease pain sensation (SS1; prevent awareness)
- inhibit spinal-level processing (DHC)
Stages of hypnosis?
- deep relaxation
- absorbed/ focused
- no judging, monitoring, censoring
- time distortion
- automaticity (action before thought)
What are examples of psychological self-regulation techniques for pain management?
- Relaxation therapy
- Biofeedback
- Guided imagery
- Autogenic therapy
- Verbal induction
- Mindfulness techniques
What brain area is associated these functions?
- amygdala
- PFC
- DLPFC (dorsolateral prefrontal cortex)
- ACC
- insula
- somatosensory cortex
- thalamus
- PAG/RVM
- amygdala - emotional component of pain experience
- PFC - inhibitory control of amydala
- DLPFC (dorsolateral prefrontal cortex) - executive function and ability to inhibit
- ACC - emotional and motivational component
- insula - emotional component
- somatosensory cortex - location and intensity of painful stimulus
- thalamus - location and intensity of painful stimulus
- PAG/RVM - descending feedback system
What are 4 skills used to enhance self-efficacy in Stanford pain self-management program?
- skills mastery
- modelling
- reinterpretation of physiological symptoms
- persuasion
What are the five stages of readiness to change?
Pre-contemplative Contemplative Preparation Action Maintenance
Motivational interviewing skills?
OARS
- open ended questions
- affirmations
- reframing
- summarizing
What are the 5 principles of Motivational interviewing?
DEARS
- develop discrepancy
- emotional empathy
- avoid arguments
- rolling with resistance
- supporting self-efficacy
Name six factors that underlie the placebo response?
- biases
- regression to the mean
- spontaneous remission
- detection ambiguity
- unidentified co-interventions
- psychosocial/psychobiological factors
When to refer to a psychiatrist?
- Major personality disorder
- PTSD
- Active substance use disorder
- High level of distress
- psychosis
- high scores on depression or anxiety screening scales
- any suicidal ideation
What are examples of yellow flags for back pain (when to refer to multidisciplinary team due to psycho-behavioral issues) ?
- catastrophization
- depression
- anxiety
- poor coping
- fear avoidance
- kinesophobia
- oversolicitous spouse
- maladaptive behaviors
- maladaptive cognitions or beliefs
- low self-efficacy
- high external locus of control
- secondary gain (litigation, compensation)
What are blue flags (perception of occupational)?
- not working
- poor work satisfaction
- fear of re-injury
- work related stress
Black flags (actual work conditions)?
- poor work conditions
- manual work
- unsociable hours
What are the mechanisms behind placebo response?
Psychological:
- conditioning (conscious or unconscious)
- expectancy (information, cognitive)
- desire/motivation
Biological:
- Endogenous opioid system (endorphin, enkaphalins, dynorphins)
- dopamine
- cortical networks
Mechanism – Brain :
- During anticipation: increase DLPFC (cognitive control)
PAG, orbitofrontal (evaluative/reward processing), rACC
- During treatment: decrease in ACC, Thalamus, insular cortex (*pain matrix)
Mechanism - Opioid vs. Non-opioid system:
- Naloxone sensitive: expectation, endogenous
opioid system, can be regional (somatotopic)
- Naloxone in-sensitive: conditioning (classical), growth
hormone, 5-HT, CCK (associated with negative verbal
suggestion or expectancy)
What is the neurological mechanism underlying mirror image pain ie. Allochiria?
-Ipsi injury induced, CL peripheral neurite loss
What are 2 mechanisms of remote hyperalgesia?
- Injury induced of unmasking of previously ineffective synaptic connections
- Cross system, viscero-visceral interactions w/in the CNS
What is the most appropriate, accurate and acceptable diagnosis for people who are overly concerned about their pain, other than SSD?
Adjustment Disorder
List 5 negative consequences relating to pain with the new DSM 5 SSD Diagnostic category that Frances and Chapman had?
- Stigma
- Risk parent w/ child with chronic illness being Dx’d w/ SSD
- Encouraging sick role behaviour of child
- Overlooked Dx
- Further marginalization of women in the HC system
- Increased risk inappropriate psych med prescription
Compare and contrast current SSD Dx with recommended revised SSD. (Brackets - indicated current SSD)
Revised:
- ALL 3 symptoms of excessive thoughts, feelings, & behaviours relating to their somatic symptom (vs. 1/3)
- Significant Functional impairment (not a req)
- Present x >=6m (not req’d)
- Symptoms grossly in excess to nature of medical condition
List components of CBT Rx for chronic pain (10)?
Education
-Education on pain + prognosis
Self Mx & Physical Action Oriented
- Goal setting
- Graded Exercise
- Problem Solving
- Relaxation &/or Biofeedback
CBT/Therapist Guided (CABO)
- Attention Mx (Use Distraction/imagery control techniques)
- Cognitive Restructuring
- Behavioural Experiments
- Operant Principles
Learning
-Generalization & Maintenance Strategies
What are the 5 self Mx concepts that one would want to incorporate into their therapy
- Personalized pain education + prognosis
- Plan for dealing with exacerbations + knowing when to reconsult
- Plan for graded activity, and return to usual function
- Increase support networks
- Analgesic maintenance or reduction
What are some areas of CBT development and challenges identified?
• Implementing/incorporating technology
• Personalizing or tailoring Rx
• Mx of Iatrogenic Problems
Eg. Opioids, LT risks
• Trauma related pain
Eg. PTSD
• Language and cultureWhat are the 3 broad categories Morley suggests on how the pain experience affects the normal processes.
- Interruption of : Attention & Behaviour Processes
- Interference: on tasks & roles
- Identity Loss/changes: Personal + social identity maintenance challenges
Name 5 examples of Adverse Childhood Experiences (ACE)?
- sexual and physical abuse
- poor emotional relationship with parents
- lack of physical affection
- witnessed parental conflict
- substance use disorder in mother
- separation
- poor financial situation < 7 yo
What is one treatment for pain catastrophizing?
Progressive goal attainment program
What are the components of treatment for Kinesophobia?
- Education, reassurance and activity encouragement
- Graded exposure
- Activity monitoring, progressive goal attainment and graded activity
- CBT techniques
What outcomes are improved by a Pain Self-Management Program?
- pain severity
- dependency on others
- vitality
- aspects of role functioning
- self-efficacy
Define: Anxiety, Catastrophizing, Fear Avoidance
- Anxiety - dispositional tendency for pts to be fearful of arousal or somatic related sensation based on belief that the sensation themselves may have or reflect harmful consequences
- Catastrophizing - Tendency to magnify potential threat of an experience and to have limited confidence in one’s ability to tolerate it
- Fear Avoidance - Concept which pts believe that the experience of pain reflect physical damage is occuring esp during physical activity or exercise. aka. Kinesiophobia
