Psych interventions in pain control Flashcards
Multidimensional model of pain in terminal illness
- Interaction of cognitive, emotional, and socioenvionmental factors with nociceptive aspects of pain
Nociception interfaces with:
- Cognition (meaning of the pain)
- Emotion (suffering associated with the pain, loss, etc.)
- Socioenvironmental aspects (social support, etc.)
Somatic therapies can be used to treat the nociceptive aspects of pain, while psychosocial therapies can target cognition, emotion, and socioenvironmental aspects
Psychological factors in the experience of pain
- Women with metastatic breast cancer experience more intense pain if they were depressed and believed the pain represented the cancer spreading
- in ambulatory patients with AIDS, pain associated with depression, functional impairment, disability, and negative pain-related thoughts were associated with greater pain intensity and disability
Higher levels of pain linked to:
- impaired ADLs
- Experience of unpredictable painful episodes
- Negative thoughts about personal or social competence
- Cognitions about the cause of pain
- Greater anxiety or depressed mood
- Existential concerns (fear of future)
Addressing psychological factors is essential to pain management, though medical options for pain control must be explored first with pain control considered a pre-requisite to the assessment and management of other sources of distress.
Variables that affect pain-related quality of life
- Physical well-being
- Psycholgoical wellbeing
- Interpersonal well being
Psychiatric disorders and pain
- Psychiatric disorders are associated with chronic pain in cancer patients
- Most commonly, adjustment disorders, depression, or anxiety
- Advanced disease itself is associated with high prevalence of depression and delirium
Pain and suicide
- Uncontrolled pain is a major factor in suicide and suicidal ideation in the medically ill patients
- Relatively few cancer patients commit suicide, but the are at increased risk
- Suicidal thoughts may be relatively common in advanced illness (“If it gets to bad, there is a way out”), though persistent suicidal thoughts are likely infrequent
- Pain associated with desire for hastened death, particularly when associated with depression and hopelessness
Inadequate pain management
Studies suggest:
- Cancer pain is under treated
- Pain is AIDS is dramatically under treated
- Under treatment may be more likely in women, lower levels of education, history of substance abuse, or those who express patient-related barriers to opioid treatment
- Adjuvant agents (such as antidepressants) underutilised
Causes of inadequate pain management
- Inability to assess pain in all dimensions
- Psychological variables may be ignored
- Psychological variables may be used to explain pain when medical variables have not been adequately addressed
- Lack of physician knowledge re: pharmacologic interventions
- Focus on prolonging life rather than symptom management
- Poor communication between doctor and patient
- Physician anxiety around opioid medications, abuse, diversion, or toxicity
- Limited expectations of patients in achieving pain relief
- Overestimation of opioid risks
Impact of high intensity pain on communication
- Team members may struggle to empathize with high intensity pain
- Clinician ability to assess level of pain becomes unreliable after pain is >7
Impact of active drug use on pain management
Compromised pain management by:
- High tolerance to opioid analgesics
- Drug seeking and manipulative behaviour
- Lack of adherence
- Lack of reliable patient history
- Risk of spreading blood borne infections (e.g. HIV)
Undertreatment is a risk when clinicians expect patients to lie as part of drug-seeking behaviour.
In the context of a terminal stages of illness, appropriate for a clinician to err on the side of believing a patient when they complain of pain and presenting a bias toward treatment, unless there is clear evidence of diversion or self-destructive behaviours.
Psychotherapy for Pain
Goals:
1. Support (provide continuity and supportive care with crisis intervention)
- Knowledge - provide information to both patient and family
- Skills - relaxation, cognitive coping, communication, use of analgesics. Can take the form of group therapy where patients can share experiences and identify helpful coping strategies
Short term supportive psychotherapy for pain
- Focussed on the crisis created by the medical illness
- Therapist provides support, continuity, information, and assists in adaptation
- Focus on emphasising past strengths, supporting previously successful coping strategies, and teaching new coping skills (relaxation training, CBT approaches, self-monitoring, assertiveness, communication skills)
- Provides an opportunity for patients to talk openly about life and experiences, but also to talk or ask questions about death or pain and suffering
Psychotherapy in advanced illness
- Loss of cognitive function or speech deficits may make pyschotherapy challenging
- Support may shift to the family to help balance pain control with sedation, family dynamics around appropriate treatment, and work related to bereavement can begin
Group psychotherapy for advanced illness
May include individual patients, spouses, couples, or family
Goals:
- Share experiences
- Identify successful coping strategies
Limitations:
- Patient physically comfortable enough to participate
- Cognitive capacity to participate
Cognitive Behavioural Techniques for patients with pain
- Psychoeducation
- Preparatory information
- Self monitoring (may include development of a pain journal to identify provoking/palliative factors, etc.) - Relaxation
- Passive breathing
- Progressive muscle relaxation - Distraction
- Focussing
- Mental imagery
- Cognitive distraction
- Behavioural distraction - Combined techniques
- Passive breathing/PMR with mental imagery
- Systematic desensitization
- Meditation
- Hypnosis
- Biofeedback
- Music therapy - Cognitive therapies
- Cognitive distortion
- Cognitive restructuring - Behavioural therapies
- Modelling
- Graded task management
- Contingency management
Behavioural rehearsal
Behavioural therapy for pain
- Use of techniques from experimental analysis of behaviours
Examples:
- Learning and conditioning for the evaluation, prevention, and treatment of physical disease or physiological dysfunction
- e.g. tracking with a pain journal to understand and modify triggers, enhancing behaviours that provide relief or better sense of wellbeing
Cognitive therapy for pain
- A focused intervention targeted at changing maladaptive beliefs and dysfunctional attitudes
- Therapist engages with the patient in a process of collaboration, where underlying beliefs are challenged and corrected
- E.g. targetting automatic thoughts that may worsen the pain experience, like “The intensity of my pain will never diminish.” “I cannot control my pain.” Patients might be taught to identify and interrupt these thoughts with more productive and empowering views
Operant pain - definition
Notion that there are two types of pain behaviour - operant and respondent.
Operant pain behaviours result from operant learning or conditioning. Leads to pain behaviour being reinforced and amplified or continuing because of secondary gain (e.g. increased attention and caring). May evolve to be independent from respondent pain.
E.g. Pain related to cancer is initially respondent, but then may gain an operant component as the patient finds there is secondary gain from the shift in attitude of their family members.
Respondent pain - definition
Notion that there are two types of pain behaviour - operant and respondent.
Respondent pain behaviours result from respondent learning or conditioning. Stimuli associated with prior painful experiences may elicit increased pain and avoidance behaviour.
Often Pavlovian or ‘reflex’ behaviour - e.g. seeing a needle immediately evokes a response. Or - a physiologic response (e.g. pain from bony mets).
Cognitive restructuring for pain
- Redefinition of some or all aspects of the patient’s interpretation of pain
- Negative thoughts about pain can be significantly related to pain intensity, degree of psychological distress, and level of interference in functional activities
Requires:
- Identification of dysfunctional automatic thoughts and underlying beliefs (e.g. I cannot control or improve my pain)
- Challenging these dysfunctional thoughts (e.g. Am I able to take medication that controls the pain? Am I able to alter my activities to mitigate the impact of this pain?)
- Identifying them as they happen and interrupt such thoughts with a more appropriate view (e.g. My pain might be intense now, but I can take my medication to help control it and there will be relief)
Self-monitoring techniques for pain
- Pain diary
- Written (or audiotaped) chronicle that describes specific agreed upon characteristics associated with pain
- Allows physicians to gauge impact of interventions and trajectory of pain over time
- Allows patients to see common triggers or palliating factors
- Provides foundation for more effective management, particularly in the identification of incident pain (pre-medication!), modification of certain activities to better manage pain, and titrating of medication
May also be used in conjunction with cognitive restructuring (e.g. tracking automatic thoughts associated with pain)
Contingency management for pain
Focussing the patient and family responses that either reinforce or inhibit specific behaviours exhibited by the patient.
Method involves reinforcing desired ‘well’ behaviours - e.g. graded exercise, as opposed to treating nociceptive pain.
- Suspect not appropriate for most of our patients - used more commonly in addictions medicine or with patients whose pain behaviour is related to operant behaviour (e.g. secondary gain associated with pain).
- Poor evidence on lit search
Grade task assignments for pain
Creation of a hierarchy of tasks (e.g. physical, cognitive, and behavioural) which are broken down and performed sequentially in more manageable steps to achieve an identified goal
- Useful for patients whose pain creates a sense of overwhelm or difficulty executing/completing tasks
Systematic desensitization for pain
Relaxation and distraction exercises paired with a hierarchy of anxiety-arousing stimuli presented through mental imagery or presented in vivo, resulting in control of fear
- Essentially exposure therapy. Provides patients with tools and empowerment that allows them to better manage anticipatory anxiety that may lead to avoidant behaviours.
Patient selection for CBT interventions for pain
Consider:
- Intensity of the pain
- Mental clarity of the patients
- Level of rapport with patient
Ideal candidates:
- Mild to moderate pain at baseline, or due to effective pharm management
- Capacity to engage in therapy (minimal confusion)
