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elective - pain y3 > psychological interventions > Flashcards

psychological interventions Flashcards

1
Q

what is pain-related fear and anxiety?

A

= the fear that emerges when stimuli that are related to pain are perceived as a main threat

the fear and anxiety response comprises of:
1. psychophysiological elements - e.g. heightened muscle reactivity
2. behavioral elements - e.g. escape and avoidance behavior
3. cognitive elements - e.g. catastrophizing thoughts

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2
Q

fear-avoidance model of pain

what is the fear-avoidance model of pain?

A

a cognitive-behavioral model of chronic low back pain (CLBP)

provides an explanation of why CLBP problems and associated disability develop in a minority of those experiencing acute LBP

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3
Q

fear-avoidance model of pain

what are the 2 pathways resulting from different interpretations of pain?

A

acute pain is perceived as non-threatening → patients are likely to maintain engagement in daily activities
* functional recovery is promoted

pain is catastrophically (mis)interpreted → a vicious circle may be initiated
* leads to pain-related fear, and associated safety seeking behaviors (e.g. avoidance/escape and hypervigilance)
* can be adaptive in the acute pain stage, but worsen the problem in the case of long-lasting pain
* long-term consequences (e.g. disability and disuse) in turn may lower the threshold at which subsequent pain will be experienced

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4
Q

fear-avoidance model of pain

evidence for the components of the model - pain severity

A

pain severity: high pain intensity is in itself a threatening experience that drives escape and avoidance
* numerous studies shown that pain intensity has a considerable contribution in explaining disability
* the association between pain and disability both during the acute and chronic stages of pain may be more important than previously suggested

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5
Q

fear-avoidance model of pain

evidence for the components of the model - pain catastrophizing

A

pain catastrophizing = the cognitive element of the fear network - refers to the process during which pain is interpreted as being extremely threatening
* has consistently been associated with pain disability in pain patients, as well as in the general population
* study: p’s who were led to believe that a cold metal bar was hot, rated it as more painful and ascribed more damaging properties to it than p’s who were led to believe that the same bar was cold
* shown that initial pain catastrophizing is related to higher pain intensity in a variety of situations
* some evidence that pain catastrophizing may be considered as a precursor of pain related fear

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6
Q

fear-avoidance model of pain

evidence for the components of the model - attention to pain

A

attention to pain: pain that is intense, or that is perceived as threatening, demands attention and may interrupt ongoing activities
* excessive attention to pain is dependent upon the presence of pain-related fear
* excessive attention to pain mediates the relationship between pain-related fear and increased pain intensities (little evidence)
* attentional disruption by pain-related info is not the result of an initial shift of attention to the pain stimuli - rather stems from difficulties in disengaging attention from these stimuli

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7
Q

fear-avoidance model of pain

evidence for the components of the model - escape/avoidance behavior

A

avoidance = behaviour aimed at postponing or preventing an aversive situation from occurring
* chronic pain: not possible to avoid but possible to avoid perceived threat → activities that are assumed to increase pain or injury
* study: fearful CLBP patients performed less well on behavioral performance tasks → possible withdrawal, and thus avoidance, from these tasks

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8
Q

fear-avoidance model of pain

evidence for the components of the model - disability

A

disability = refers to problems in executing daily life tasks and activities, in the home as well as the work situation
* avoidance and hypervigilance contribute to disability
* selective attention to pain-related stimuli, and the associated difficulty with disengaging from these stimuli, might occur at the cost of vigilance to the usual tasks of daily life
* found that CLBP patients with heightened levels of pain-related fear report increased disability

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9
Q

fear-avoidance model of pain

evidence for the components of the model - disuse

A

disuse syndrome = the physiological and psychological effects of a reduced level of physical activity in daily life
* generally, the physical fitness of CLBP patients is found to be either lower or equal to that of healthy subjects
* changes in musculoskeletal functioning and flexion may be important for the understanding of how pain may interfere with daily life functioning
* lower physical activity levels or physical consequences of long-term avoidance are not clearly confirmed

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10
Q

fear-avoidance model of pain

evidence for the components of the model - vulnerabilities

A
  • fear of pain may be secondary to the fundamental fear ‘anxiety sensitivity’
    (fear of anxiety-related sensations associated with pain)
  • hierarchy: the more general neg affectivity is placed at the top, and the more specific anxiety sensitivity and fear of pain at lower levels
  • individuals with an increased vulnerability to catastrophizing and pain related fear are less changeable in their fear avoidance beliefs
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11
Q

pain-related fear during various stages of LBP

pain-related fear as a maintaining factor of CLBP

A
  • disrupted attentional processes, hypervigilance and avoidance/escape behaviour contribute to maintenance of CLBP
  • when threatening situation is detected → they will either escape from the activity by not performing it at all, or avoid the activity by submaximal performance or the use of safety behaviours
  • prevents them from discovering that the activities are harmless
  • promotes disability and disuse
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12
Q

pain-related fear during various stages of LBP

pain-related fear as a risk factor for the development of chronic LBP

A
  • pain related fear might contribute to the development of a chronic pain problem - due to associations with escape/avoidance behaviour
  • fear avoidance beliefs can influence the transition to CLBP and associated outcomes, such as disability and sick leave
  • shown that initial elevated pain-related fear, fear avoidance beliefs about work or rising levels of pain-related fear in the beginning were predictive of subsequent higher disability
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13
Q

pain-related fear & treatment

A
  • pain-related fear could hamper relationship between patient & therapist - e.g. trigger frustraion
  • fear network might be activated by interactions with healthcare providers - facial expressions, diagnostic labels, etc.
  • fear avoidance beliefs of health care providers can induce or strengthen those of their patients
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14
Q

pain-related fear & treatment

effectiveness of cognitive behavioral programs

A
  • CBT reduces pain-related fear, fear avoidance beliefs, catastrophizing, disability
  • might be that the presence of fear avoidance beliefs may debilitate outcome when usual treatment is applied
  • whereas fear-avoidance based treatments fail to be effective in the absence of pain related fear
  • cognitive behavioural programs, and even brief educational sessions, can effectively diminish disability - might be due to reducing fear avoidance beliefs and pain catastrophizing
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15
Q

pain-related fear & treatment

exposure in vivo

A
  • developed to gradually confront patients with activities they feared and avoided for a long time due to the belief that these might be damaging for the back
  • may provide patients with convincing evidence that expected detrimental consequences of these feared activities are in fact a catastrophic overestimation
  • studies demonstrated the effectiveness of exposure in vivo as compared to graded activity in fearful CLBP patients
  • generalization of in vivo to daily life activities is limited in chronic pain patients

4 components:
1. choice of functional goals
2. education about the paradoxical effects of safety behaviours
3. establishment of fear hierarchy
4. graded exposure to feared activities in the form of behavioural experiments

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16
Q

strategies for regulating pain

what is suppression?

A

= the intentional inhibition of expressive and/or experiential aspects of one’s ongoing affective responses
* inconsistent results - has been shown to decrease, increase or have no effect on emotional experience
* seems to increase pain and distress to pain-inducing stimuli in response to thoughts about or presentation of pain-inducing stimulus
* associated w anxiety & depression
* variable effects depending on context, regulation target and individual differences

17
Q

strategies for regulating pain

what is acceptance

A

= the welcoming of thoughts, emotions, and other experiences in the moment, with non-evaluative judgment
* decreases unpleasant emotional experience, especially under high stress
* associated with decreased anxiety and depressive symptoms over time
* associated with decreased pain and distress to pain-inducing stimuli in response to thoughts about or presentation of pain-inducing stimulus

18
Q

strategies for regulating pain

suppression vs acceptance in regulating responses to pain

A

suppression: should lead to either increases or decreases in unpleasant emotions, and increases in pain
acceptance: should lead to decreases in both unpleasant emotions and pain

study: found that group using suppression to regulate pain showed the lowest tolerance level of pain
- group using an acceptance based strategy exhibited the longest immersion time + reported significantly lower levels of pain and distress than the suppression group

19
Q

The effects of acceptance and suppression on anticipation and receipt of painful stimulation (Braams, 2012)

hypotheses & methods

A

hypotheses:
1. acceptance would lead to the greatest reduction in pain compared to suppression and control - for control we expect no reduction in pain (partial support)
2. acceptance would lead to the greatest reduction in anxiety compared to suppression and control (supported)
3. acceptance would lead to less heart rate reactivity than in either the suppression or control groups (not supported)

method:
* compared differences in pain, anxiety, and associated physiology (i.e., heart rate) between groups in response to experimentally induced pain
* groups: suppression strategy, acceptance strategy or no regulation strategy (control)

20
Q

The effects of acceptance and suppression on anticipation and receipt of painful stimulation (Braams, 2012)

results & discussion

A

results:
* acceptance group showed greater reductions in pain compared to control - however, contrary to hypotheses, suppression was associated with a similar decrease in pain as acceptance
* anxiety was reduced for all groups - in accordance with the hypothesis the reduction for acceptance group was significantly higher
* heart rate defensive responding was reduced in both regulation groups, but not in the control group

discussion:
* results indicated similarities as well as differences between strategies
* both regulation techniques decreased pain, anxiety & heart rate defensive responding → however, anxiety was significantly more reduced for the group using acceptance
* acceptance and suppression may be equally beneficial at reducing pain for short-duration stimuli
* however, for long duration stimuli, suppression may cause paradoxical increases in pain whereas acceptance continues to reduce pain

21
Q

Psychological treatments for fibromyalgia: a meta-analysis (Glombiewski, 2010)

A

Fibromyalgia (FM) = a chronic pain syndrome defined by wide-spread pain
* unclear whether psychological treatments, such as CBT, are effective in reducing symptoms of FM
* hypothesis 1: CBT will be more effective for FM pain than other psychological treatments
* hypothesis 2: CBT and relaxation techniques will be more effective for sleep problems associated with FM than other psychological treatments
* meta-analysis comparing several diff treatments

results:
* hypothesis 1 supported: CBT was significantly better than other psychological treatments in improving FM pain intensity
* hypothesis 2 supported: CBT and relaxation techniques combined are superior to all other psychological treatments in reducing sleep problems in FM patients

discussion
* results demonstrate that psychological treatments provide sustained pain relief for FM patients
* suggest that FM patients should be treated with high-dose CBT + relaxation/biofeedback
* stable long-term effects of psychological interventions for FM = these treatments may be favorable in comparison to other non-psychological treatments that provide only short-term effects

22
Q

The effects of emotion regulation strategies on the pain experience: a structured laboratory investigation (Hampton, 2015)

hypotheses & methods

A

study focuses on relationship between emotional regulation (ER) and pain - 2 ER strategies examined:
1. reappraisal = an antecedent strategy - involves adjusting affect before emotions have been fully activated
2. suppression = a response-focused strategy - requires the inhibition of an ongoing emotion

hypotheses:
* reappraisal would be positively related to pain tolerance and negatively related to self-reported pain, negative affect, and nonverbal expressions
* suppression would be inversely related to pain tolerance and positively related to self-reported pain, negative affect and nonverbal expressions

method:
* 3 conditions: suppression, reappraisal or control
* completed emotion regulation questionnaire
* provided with strategy intructions based on condition to use while given thermal pain
* self report measures of pain, anxiety & tension
* facial expressions, heart rate & galvanic skin response recorded

23
Q

The effects of emotion regulation strategies on the pain experience: a structured laboratory investigation (Hampton, 2015)

results & discussion

A

results:
* pain intensity: both suppression and reappraisal reported significantly lower pain intensity
* unpleasantness: reappraisal reported significantly lower pain unpleasantness
* tension: reappraisal reported significantly lower tension
* facial activity: both reappraisal and suppression expressed less frequent and less intense facial activity
* no relationship between reappraisal and suppression, pain threshold and tolerance

discussion:
* reappraisal: led to a less reactive more adaptive response to the noxious stimulus → suggests that reappraisal impacts both the more cognitively controlled (ie, verbal) and automatic (ie, nonverbal) encoding processes of pain
* = reappraisal may be a valuable strategy in regulating painful experiences
* suppression: led to significantly reduced nonverbal and verbal expressions of pain - but inconsistent findings across literature

24
Q

responses to fear of pain: confrontation vs avoidance

Graded exposure to in vivo in the treatment of pain-related fear (Vlaeyen, 2001)

A

confrontation: if no serious somatic pathology can be identified, confrontation with daily activities despite pain is an adaptive response that may lead to reduction of fear and promotion of recovery

avoidance: leads to maintenance or exacerbation of fear, possibly resulting in condition comparable to a phobia
* results in the reduction of social/physical activities
* leads to physical and psychological consequences augmenting the disability

25
Q

what is kinesiophobia?

Graded exposure to in vivo in the treatment of pain-related fear (Vlaeyen, 2001)

A

a condition in which a patient has an excessive and irrational fear of physical movement and activity resulting from feeling vulnerability to painful injury

26
Q

Graded exposure to in vivo in the treatment of pain-related fear (Vlaeyen, 2001)

aim, hypothesis & method

A

aim: explore the effects of graded exposure in vivo in 4 CLBP patients with substantial fear of movement/(re)injury
- examine the effectiveness in reducing pain-related fears, pain catastrophizing and pain disability

hypotheses:
* significant reductions in average fear levels will be observed during the graded exposure and significantly less during the graded activity
* changes will generalize to increases in pain control and to decreases in levels of disability

method:
* a cognitive behavioural graded exposure in vivo (GEXP) was contrasted with a usual graded activity program (GA)
* either recieved GEXP first then GA or reversed
* pain-related fear, pain catastrophising, pain control and pain disability measured before and after treatment

GEXP: educating the patient, explaining the fear-avoidance model, practice tasks based on graded hierarchy, encouraged to continue exposing in everyday life

GA: patients do activities until pain prevents them from continuing, activity quota is agreed and followed, exercise based on this quota

27
Q

Graded exposure to in vivo in the treatment of pain-related fear (Vlaeyen, 2001)

results & discussion

A

results:
* fear of movement/(re)injury, pain catastrophizing and fear of pain were significantly reduced by GEXP
* improvements in pain catastrophizing and pain fear only occurred during GEXP, and not during GA, irrespective of the treatment order
* increase in pain control is only seen in two patients - change occured during GEXP and not during GA

discussion:
* pain-related fear only reduced by GEXP
* reductions in catastrophizing and pain-related fear correlates to a decrease of self-reported functional disability in daily life
* a possible mediator of the effective treatment effect might be cognitive changes

28
Q

the cognitive behavioral approach to pain management

what are the 5 central assumptions of the cognitive-behavioral perspective?

A
  1. people are active processors of info and not passive reactors
  2. thoughts can elicit and influence mood, affect physiological processes, have social consequences, and also serve as an incentive for behavior (& vice-versa)
  3. behavior is reciprocally determined by both individual and environmental factors
  4. people can learn more adaptive ways of thinking, feeling, and behaving
  5. people should be active collaborators in changing their maladaptive thoughts, feelings, and behavior
29
Q

the cognitive behavioral approach to pain management

phase 1: assessment

A

info obtained from interviweing patients is integrated with biomedical data - used in formulating the components and process of treatment

several functions of assessment - e.g.:
* establish the extent of physical impairment
* identify levels and areas of psychological distress
* provide baseline measures against which the progress and success of treatment can be compared
* examine the role of significant others in the maintenance and exacerbation of maladaptive behavior + determine how they can be positive resources in the change process

30
Q

the cognitive behavioral approach to pain management

phase 2: reconceptualization

A

about restructuring the patient’s beliefs that pain is unmanageable
* focus on identifying maladaptive appraisals
* designed to help patients become aware of the role that thoughts and emotions play in potentiating and maintaining stress and physical symptoms
* therapist encourages patient to challenge the validity of their own beliefs
* identify cognitive errors (e.g. overgeneralization & selective attention) - become target of intervention

31
Q

the cognitive behavioral approach to pain management

phase 3: skills acquisition

A

patients learn self-management strategies and develop a sense of personal control
* therapist discusses the rationale for using a method, they assess whether the skills are in the patient’s repertoires, teach the needed skills, and practice these skills
* skills: problem solving, muscle relaxation, attention diversion, cog coping strategies & assertiveness/communication skills
* imaginal exposure to feared activities
* important to pace their levels of activity through a graded exercise program and learn to rest

32
Q

the cognitive behavioral approach to pain management

phase 4: skills consolidation and application training

A

patients practice and rehearse skills learned in phase 3
* facilitate process using mental rehearsal, role-playing, role reversal, home practice
* homework: active involvement of patients and significant others outside the therapy sessions and the clinic is a major focus
* selection of home assignment should be mutual

33
Q

the cognitive behavioral approach to pain management

phase 5: generalization and maintenance

A

has 3 purposes:
1. encourages patients to anticipate and plan for post-treatment period
2. focuses on the conditions needed for long-term success
3. addresses problems of flare-ups and prevention of relapse

  • therapists focus on cognitive activity of patients as they confront problems throughout treatment
  • patients consider potentially problematic situations and are assisted in generating plans or scripts on how they could handle these difficulties
  • relapse prevention: involves learning to identify and cope with factors that may lead to relapse
34
Q

the cognitive behavioral approach to pain management

phase 6: post-treatment assessment and follow up

A
  • routine follow-ups at 1, 3, and 6 months and every year should be planned - to evaluate progress and reinforce and support patients’ efforts
  • when necessary booster sessions should be considered
  • checking in with the therapist is not viewed as a sign of failure, but rather as an opportunity to re-evaluate progress
35
Q

the cognitive behavioral approach to pain management

effectiveness of the cognitive-behavioral approach

A
  • clinical effectiveness has been demonstrated in many studies with a wide range of pain syndromes
  • suggested that cognitive behavioural and behaviour therapies are most effective when integrated within rehabilitation programs
  • improvements in self-efficacy and physical functioning are maintained at least for 6 months
  • not known whether there are individual differences or situational constraints that limit the efficacy

elective - pain y3 (4 decks)

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