Chronic Pain Management with Cognitive Behavioral Therapy

Definition of Chronic PainChronic pain is often defined as any pain lasting more than 12

weeks. Whereas acute pain is a normal sensation that alerts us to

possible injury, chronic pain is very different. Chronic pain persists—often for months or even longer.

Statistics As of 2012, about half of all adults—117 million people—have one or more

chronic health conditions. One of four adults has two or more chronic health conditions.

Arthritis is the most common cause of disability (27%). In the United States each year 600,000 ppl develop pain from arthritis for the first time

Other debilitating painful conditions are osteoporosis (21%), diabetes (17%), COPD and allied conditions (15%), cancer (11%), and stroke (11%). More than 22 million say it causes them to have trouble with their usual activities.

Low back pain disables approximately 7 million people and accounts for 8 million doctors visits

According to the American Pain Foundation, about 32 million people in the U.S. report having pain lasting longer than one year.

From one-quarter to more than half of the population that complains of pain to their doctors are depressed.

On average, 65% of depressed people also complain of pain

Pain StudyPercent of adults age 20 years and

over reporting pain lasting 24 hours or more in the month prior to interview: Total 25.8%, Men 24.4%, Women 27.1%(NHANES 1999-2002)

Duration of pain among adults reporting pain in the month prior to interview: Less than 1 month 32.0%, 1 month to less than 3 months 12.3%, 3 months to less than 1 year 13.7%, more than 1 year 42.0%(NHANES 1999-2002)

Diagnostic CriteriaPain disorder is now classified as Somatic symptom disorder (SSD) in DSM V. SSD is characterized by somatic symptoms that are either very distressing or result in significant disruption of functioning, as well as excessive and disproportionate thoughts, feelings and behaviors regarding those symptoms. To be diagnosed with SSD, the individual must be persistently symptomatic (typically at least for 6 months).

Changes from DSM IV to DSM V

Several important changes have been made from previous editions of DSM. The DSM-IV disorders of somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder have been removed, and many, but not all, of the individuals diagnosed with one of these disorders could now be diagnosed with SSD.

Another key change in the DSM-5 criteria is that

while medically unexplained symptoms were a key feature in the DSM IV it is not a key feature in an SSD diagnosis; symptoms may or may not be associated with another medical condition.

Reason for Changes in the DSM VOverlapping previous diagnosesDifficult for non

psychiatric physicians to applyReduction of stigmaPotential for mind body dualismImplication that symptoms were 

not “real”

DSM-5 looks at pain and psychological factors conjointly . Based on research psychological factor influence all forms of pain. Most individuals with chronic pain attribute their pain to a combination of factors, including somatic, psychological, and environmental influences.

Pain and Psychological Factors

Pain Cycle

When a patient presents pain it is important that the therapist or healthcare professional accepts the reality of the patient. Any attempt to determine whether pain is in excess of what might be expected may negate psychosocial factors that influence the clinical pain experience.

Accept the reality of the pain for the patient

It is very tempting but dangerous to resort to concepts such as “exaggerated pain” or “psychogenic pain” in patients which does not correlate between their pain reports and the physical findings.

EducateElicit how patients feel about their pain. What is

their knowledge and attitude about pain and its treatment.

Provide psychoeducation◦ The physiology of pain: Pain results from a signal sent

from nerves to your brain. It can serve as an alarm, a warning -- that you're stepping on a nail or touching a hot stove. But sometimes the signals keep firing, and the pain continues. That’s when it becomes chronic.

◦ Medical contradiction ( know what leads to increased harm not just increased pain {talk to family doctor}) pain response and signals aren’t always a sign of danger

AssessIdentify history and nature of

persistent pain◦Frequency, intensity, duration, location◦Pain intensity scale

Identify the impact of pain on daily life ◦Pain diary◦Pain assessment checklist

Compile a list of all medical dx, treatments, meds, doctors

Assessing Problems and ConcernsProblem lists. These are a common

and useful strategy for identifying the psychological, social, occupational, and financial difficulties faced by patients.

Therapists who used problem lists typically elicit a list of five to 10 difficulties from the patient during the first part of session 1. Problems are best identified using open-ended questions

Problem Frequency Severity ImpactSocially Isolated

Stay at home out of 7 days

Limited social contacts; moderate-to-severe isolation

Highly distressing; socially debilitating; estranged family/friends

Pain Experience pain each hour

Pain intensity is when present

Pain leading to decreased activity level, inability to work

Feelings of Worthlessness

Occur days 3 out of 7

Very intense when present; sometimes involves suicidal Thoughts

Highly distressing; work, social, and relationships influences intimate

Fatigue Occurs almost Constantly

Fatigue not intense buttroublesome

Decreased activity level, frequent naps, inability to complete daily tasks

Define the Problem

Devise Long Term Goals

Experience decreased feelings of intensity and/or duration of pain episodes

Obtain needed skills to better manage pain

Better cope with pain to increase ability to complete daily tasks and engage in social activities

Find a new sense of empowerment in ability to manage pain

Devise Short Term Objectives

Identify and monitor particular pain triggers

Learn and implement somatic skills

Identify negative pain related thoughts and replace them with positive coping related thoughts

Increase level and range of activity by identifying and engaging in activities

Pain TriggersIdentify pain triggers by teaching the

patient to self-monitor their symptomsPain Diary thoughts, feelings, behaviors,

people, situations helps the client to identify how pain impacts his/her daily activities social and leisure involvement

Process the journal with the patient to increase insight into the nature of the pain, cognition, behavioral triggers, and the positive or negative effect of the interventions they are currently using

Pain diary - experiencesGermany – Patient ID15

Tell us how you were feeling at the beginning, during and at the end of the day

What impact did your pain have on you today?

When I woke up I felt…

During the course of the day I felt…

In the evening I felt…

Impact on daily activities

Impact on your mood

Impact on your relationship with others

Somatic SkillsTeach relaxation techniques as a useful

and quick response to high stress or pain levels. This allows patients in many circumstances to reduce stress and pain and thus cope in an adaptive manner with these unpleasant states.

Quantifying pain on a 5 point scale before and after the relaxed state is a useful aid towards showing its effectiveness, where 0 is no pain and 5 is excruciating pain.

Patients are encouraged to keep pain diaries while on the course

Negative Pain Related Thoughts

Catastrophizing/Awfulizing – predicting the worst case scenario.

Black and white thinking – forgetting that reality is composed of many shades of gray.

Unrealistic expectations for the world - (should statements).

Mind reading – believing we know what others are thinking about us.

Emotional reasoning - believing our feelings indicate truth. Believing that if we feel worried about our pain that means our pain is causing harm.

Altered Mood

Anger

Anxiety

Confused Thinking

Fatigue

Fear of Injury

Physical Deconditioning

Increase Activity LevelsPACING: Scheduling activities

throughout a period of time to ration energy (energy conservation)

ENERGY CONSERVATION: Doing no more on a good day, no less on a bad day and therefore reducing the learning relationship between pain and activity (time contingent activity)

ACTIVITY PLANNING: Planning activity to ensure a balance of pleasurable and less pleasurable tasks

Activity: Working to Quota

Working to Quota is used to disrupt the learned relationship between activity and pain levels, an opportunity to (1) reduce inadvertent learned associations and (2) begin to use skills to help confront fear of pain and take control can begin.

Establish a hierarchy of activities from least concerning to most concerning. Identify exactly what the concerns are – do they need to be addressed with information, or do they need to learn from experiencing (testing) what happens if

Establish your baseline, and develop a ‘timetable’ for a week (or any period of time) in collaboration with the person.

Review and reset the activity schedule – maintain or increase activity level at this time

Relapse PreventionDiscuss the distinction between a lapse

and relapse, associating a lapse with a return of pain or old habits (e.g. having a bad day) vs relapse with a persistent return of pain and previous behavioral habits and cognitions

Identify and rehearse the management of future situations or circumstance in which lapse could occur using the learned strategies for self management

Quiz In DSM IV –TR a patient with high levels of anxiety about having a disease and many

associated somatic symptoms would be given the diagnosis of hydrochondriasis. What DSM V diagnosis would apply to the patient?◦ General anxiety disorder ◦ Somatoform disorder nos ◦ Somatic symptom disorder

What is the leading cause of debility in the United States◦ COPD◦ Stroke◦ Arthritis

What do experiences such as keeping a pain diary reveal about a patient?◦ Identifies pain triggers◦ Shows avoidance areas ◦ Reveals the impact pain has at rested periods of the day

Which of the following has been removed from the DSM- IV?◦ Hypochondrias ◦ Social Anxiety Disorder◦ Nasopharyngitis

How does working to quota help disrupt the learned relationship between activity and pain⁻ It shows how to reduce activities⁻ Helps develop skills to confront and control pain⁻ Gauges how to manage medication regimen

References psychological factors affecting other medical conditions dsm 5

http://www.ucdmc.ucdavis.edu/psychiatry/calendar/DSM5_presentation_20130816.pdf

Assessment of the Patient With Pain www.medscape.com"lacks specificity" and could cause the mislabelling of a sizeable proportion of the public as mentally ill./viewarticle/78 DSM-5 Somatic Symptom Disorder Debate Rages On http://www.health.am/psy/more/assessment_of_the_patient_with_pain/

Cognitive Behavioral Therapy for Managing Pain http://www.apa.org/divisions/div12/rev_est/cbt_pain.html

Cognitive behavioral therapy for back pain http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000415.htm Managing Chronic Pain: A Cognitive-Behavioral Therapy Approach Workbook

(Treatments That Work) John Otis Managing Chronic Pain 10 min CBT strategies

http://www.youtube.com/watch?v=tiuZBndewbE Cognitive Behavioural Therapy for Treatment of

Painhttp://www.youtube.com/watch?v=v6yLIqdLvNk