Psych and psychiatric interventions for pain

Question 1

Multidimensional model of pain in terminal illness

Answer 1

• interaction of cognitive, emotional, socioenvironmental factors with nociceptive pain
• Somatic therapies treat nocicpetive pain
• Psychosocial therapies treat cognitive, emotions, socioenvironmental factors

Question 2

Psychological factors of pain

Answer 2

• impaired ADLs
• unpredictable painful episodes
• negative thoughts about personal or social competence
• worries about cause of pain
• anxiety
• depression
• existential concerns

all associated with more pain

Question 3

Variable affecting pain related quality of life

Answer 3

1. Physical well being
2. Psychological well being
3. Interpersonal well being

Question 4

Psychiatric disorders and pain

Answer 4

• psychiatric disorders associated with chronic pain
• adjustment, depression, anxiety
• advanced disease has high prev of depression and delirium

Question 5

Pain and suicide

Answer 5

• uncontrolled pain major risk factor
• suicidal thoughts common
• rare to complete
• pain associated with desire for MAID

Question 6

Psychotherapy for pain

Answer 6

Goals:

1. Support
2. Knowledge
3. Skills (relaxation, coping, infor about analgesics)

Can be group, indivual or family

Question 7

Cognitive behaviour therapy for pain

Answer 7

1. Psychoeducation
   - self monitoring, pain journal, etc
2. Relaxation
   - passive breathing
   - progressive muscle relaxation
3. Distraction
4. Combined techniques
   - meditation, hypnosis, biofeedback, music therapy
5. Cognitive therapies
6. Behavioural therapies
   - modelling
   - graded task management
   - contingency management

Question 8

Cognitive therapies

Answer 8

• focused intervention to change maladaptive techniques
• dysfunctional attitudes
• Collaborative process
• teaching to interrupt automatic, destructive, fatalistic thoughts wiht more productive views

Question 9

Operant pain

Answer 9

• Operant conditioning
• pain behaviour reinforced or amplified or continues because of secondary gain (attention, caring)
• can become indepdendent of original pain

Question 10

Respondent pain

Answer 10

• Respondent pain results from respondent learning/conditioning
• stimuli from prior painful experiences can elicit increased pain and avoidance
• Pavlovian response

Question 11

Cognitive restructuring

Answer 11

• redefinition of some or all aspects of pain
• Requires:
  
  • Identification of dysfunctional automatic thoughts
  • Challenging them
  • Interrupting them when they occur and replacing with more appropriate not distorted thought

Question 12

Graded task assignments for pain

Answer 12

• hierarchy of tasks
• broken down and performed sequentially in more manageable steps to acheive a goal
• useful for patients whose pain is overwhelming or difficilty completing tasks

Question 13

Systematic desensitization

Answer 13

• exposure therapy
• relaxation and distraction and then exposure slowly to anxiety provoking stimuli
• empowerment to manage anticipatory anxiety

Question 14

Ideal candidates for CBT…

Answer 14

• mild-moderate pain
• capacity to engage in therapy (no confusion)

Question 15

Hypnosis

Answer 15

• A state of inner absorption, concentration and focused attention used to manipulate perception of pain
• 1/3 people not able to be hypnotized
• Use self hypnosis
• relax
• Mental filter to ease the pain

Question 16

Biofeedback

Answer 16

• behavioural therapy
• teaches patients to gain awareness and control over physiological functions
• eg use of a pulse oximeter as feedback to alter thinking, emotions.

Question 17

Music, aromatherapy, art therapy

Answer 17

Music

• well beingm reduces stress, distracts patients
• physiological effects through ANS
• decreased need for pain medicine?

Aromatherapy

• no evidence

Art Therapy

• enhanve well being
• vehicle to explore issues
• use for children or less verbal people

Question 18

SSRIs for pain

Answer 18

• first line for depression, anxiety
• paroxetine, fluoxetine, citalopram

Question 19

SNRI

Answer 19

• Inhibits reuptake of serotonin and NE
• venlafaxine, duloxetine
• Duloxetine best evidence for neuropathic pain
• also mood, and anxiety

Question 20

TCAs for pain

Answer 20

• inhibuit reuptake serotonin and NE
• variable efficacy
• more side effects
• ACh
• previousl first line, now after SNRIs

Question 21

MAOIS

Answer 21

• inhibit monoamine oxidase
• significant se and toxicity
• rarely used
• refractory depression
• no evidence for pain

Question 22

Mirtazapine

Answer 22

• Antagonist of presynaptic alpha2 receptors on noradrenergic neurons
• Increased appetite
• sedating at low dose, less at high doses
• antinausea effect
• no evidence for pain

Question 23

Buproprion

Answer 23

• Enhances NE and dopamine
• depression, smoking, ADHD
• Activating
• fewer sexual SE
• lowers seizure threshold
• little evidence for analgesic

Question 24

Trazadone

Answer 24

• Serotonin antagonist
• Depression and anxiety
• Sedating
• used for insomnia
• no evidence for pain

Question 25

Gabapentin

Answer 25

• first line for neuropathic pain

Question 26

Anxiolytics

Answer 26

• clonazepam used for pain sometimes
• limited evidence
• maybe for anxiety and neuropathic pain

Question 27

Antipsychotics

Answer 27

• no evidence for pain
• Methotrimeprazine weak evidence as adjuvant
• olanzapine, seroquel, risperdone can be useful for nausea and delirium