Cognitive and Behavioral Pain Management

Judith B. Chapman, Ph.D., ABPP

Behavioral Medicine

Program

Traditional disease model of pain

Psychological and social factors viewed as reactions to disease and trauma

View of pain conditions as either organic or psychogenic in etiology

How to explain…

For up to 80% of persons complaining of low back pain, no physical basis can be identified (Deyo, 1986)

Expression of pain symptoms, related psychological distress, and extent of disability are at best only moderately correlated with observable pathophysiology (Waddell & Main, 1984).

Biopsychosocial Model

Biological factors – initiate, maintain, modulate physical changes

Psychological factors – influence appraisal, perception of internal physical signs

Social factors –shape the behavioral responses of patients to the perception of physical changes

Which psychological factors influence pain?

Cognitive (Pain Beliefs, Cognitive Errors, Self

Efficacy, Coping)

Affective

Personality

Pain Beliefs

Anxiety SensitivitySome patients may be hypersensitive and experience a lower threshold for labeling stimuli as noxious (Asmundson, Bonin, Fromback, & Norton, 2000)

Learned ExpectationAbout 83% of patients with LBP were unable to complete a movement sequence because of anticipated pain, 5% unable because of lack of ability (Council, Ahern, Follick, & Cline, 1988).

Pain Beliefs

Patients’ beliefs about pain or disability are better predictors of ultimate level of disability than are physician ratings of disease severity

Self Efficacy

- a personal conviction that one can complete a course of action to produce a desired outcome

Low self efficacy ratings of pain control are related to low pain tolerance (Dolce, Crocker, Moletteire, & Doleys, 1986)

The Efficacious Person…

Experiences less anxiety and physiological arousal when experiencing pain

Is better able to use distraction

Can persist in the face of noxious stimuli (stoicism)

Cognitive Errors

a negatively distorted belief about oneself or one’s situation

Examples: Catastrophizing, overgeneralization,

selective abstraction

Consequences of catastrophizing

Among postsurgical patients, those with a greater frequency of catastrophizing thoughts had a greater number of pain complaints and required significantly more pain medications (Butler, et al., 1989).

Coping Style

Active coping (distraction, reinterpreting sensations, stoicism) is associated with greater activity and better mood

Passive coping (wishful thinking, relying on others) is correlated with greater perceived pain and depression

Affective Factors

40-50% of chronic pain patients experience depression

About half report feelings of anger, irritability Both are associated with perception of

increased pain severity, greater pain interference, lower activity level

How do personality disorders fit in?

No specific personality disorder is associated with poorer coping with pain

However, the presence of any personality disorder predicts less adaptive coping

Palo Alto Pain Clinic Demographics

Average age 56 years (range 20-87) 88% male 87% Caucasian (6% African American, Hispanic; >1%

Asian, Native American)

61% Predominantly Musculoskeletal Pain

(30% neuropathic, 3% visceral, 7% other)

Palo Alto Pain Clinic Data

75% depressed 33% report active suicidal thoughts 48% report a history of trauma 19% meet criteria for PTSD

Pain Clinic Follow-up Data

At two and six month follow-up, patients reported a significant decrease in pain severity and a significant decrease in pain interference

Changes seen across diagnostic and demographic groups (age, type of pain, presence of significant mental disorder)

No significant overall change in mood, sleep, or activity level

Older patients

Reported significantly less pain severity than young

Less pain interference Better overall sleep Less depression

Aging and Pain

Changes in visceral sensations with age Increased prevalence of post-herpetic

neuralgias Nonlinear relationship between joint pain and

age

Cognitive-behavioral Treatment

Enhancing motivation Relaxation exercises Education about Sleep Management Hypnosis and Imagery Cognitive Therapy Family Interventions

Principles of Motivational Enhancement Therapy

Expressing empathy Developing discrepancy Avoiding arguments Rolling with resistance Supporting self efficacy

Relaxation Strategies

Progressive muscle relaxation Deep (diaphragmatic) breathing Biofeedback Autogenic training

Caveats and contraindications

Psychotic patients Relaxation-induced anxiety Panic attacks

Hypnosis

A state of highly focused attention in which there is an alteration of sensations, awareness, and perceptions

Reduces pain through attention control and distraction

Essential Components of Hypnosis

Physical relaxation Deepening exercise Pleasant imagery Suggestion Post-hypnotic suggestion Gradual return to alertness

Sleep and Pain

Pain severity and opioid use does not predict sleep problems; depression does

Sleep medications seem to have no impact on depression or pain severity

Sleep med use was highly correlated with poorer sleep quality, poorer sleep duration, and poorer sleep efficiency (Chapman, Lehman, Elliott, and Clark, In Press).

Sleep Management Guidelines

Go to bed when sleepy Do not remain in bed if not sleeping Bed as cue for sleep Have regular wake-up time Avoid evening use of ETOH, caffeine,smoking Exercise in AM, rather than at night Arrange relaxing nighttime routine

Cognitive Therapy

Identify and monitor pain-relevant cognitions Notice emotional consequences of negative

cognitions Learn how to challenge maladaptive cognitions

or consider probability bad events may occur Assertiveness training Value of self reinforcement

Goals of Family interventions

Recognition of operant principles as they relate to pain behaviors

Altering patterns of pain-relevant communication Increase time spent in non-pain related conversation Increase frequency of pleasurable family activities Recognition/treatment of depression in other family

members

Who doesn’t benefit from CBT for pain?

Cognitively disorganized Patients with little- no motivation to use

strategies Severe anxiety or depressive disorder Active substance abusers

Pain may be inevitable, but misery is optional

Greatest Limitation of CBT for Pain

- Compliance with

successful strategies decreases over time

- No benefit when not practicing

Best Recommendation

Relapse Prevention should be part of the therapy

Encourage booster sessions 6-12 months after therapy ends