Dynamic Psychotherapy for the Patient with Persistent PainDr Stephanie OakLiaison Psychiatry

What is Psychotherapy?the talking cureconversations with a listener who is trained to help you make sense of, and try to change, things that are troubling youPatient as active participantOver 200 varietiesBehaviouralCognitivePerson-centred / humanisticSystemsPsychoanalytic / psychodynamic

What is dynamic psychotherapy?Started with the discoveries of Freud over 100 years agoConcerned with the meaning of experience and behaviourCrystallises out of shared exploration between therapist and patientLooks beyond what we know and remember to what is buried and secret (unconscious)Leads us to a fuller sense of our motivations, intentions, feelings, how we act & the way we areNot just for the sake of creating psychological explanations but to help dismantle the obstacles that stop us resolving issues or moving on in our lives.

Does dynamic psychotherapy work?5 RCT psychodynamic therapy superior to TAU control conditions inIBS (Svedlund, 1983; Guthrie, 1991)Functional dyspepsia (Hamilton et al, 2000)Somatoform pain disorder (Monsen & Monsen, 2000)Urethral syndrome (Baldoni et al, 1995)Reduction in pain and other physical symptoms, reduced health utilisation and reduction in psychological symptoms.

Pain as a focus for psychotherapySurprisingly little psychoanalytic literature on the subject of chronic painIf Irmas pains had an organic basis, I could not be held responsible for curing them; my treatment only set out to get rid of hysterical pains (Freud, 1900)Engel (1959) the pain prone patient encouraged widespread adoption of concept of psychogenic pain.

The pain prone patientFocused on psychodynamic factors involved in pain pathogenesisAn unconscious need to sufferA response to a real, threatened or fantasised lossConflicts or guilt over intense aggressive or forbidden sexual impulsesHighlighted link between chronic pain and a history of distressing life experiencesSaw pain as a subjective experience, like an affect or emotion, which, once represented mentally, no longer needs peripheral stimulation to be provoked.

Pain in therapyPsychological vulnerabilities to pain (which are largely unconscious), can be embedded in the neuromatrix waiting to be activated by some life event.How are psychological processes operating to determine the ultimate character of the pain experience of the patient and its manner of communication to the physician?Identify and explore these unconscious vulnerabilities, and through resolution of conflicts, alleviate symptoms.

Why patients with persistent pain are difficult to engageThe typical pain patientDifficult to establish a rapportAsking them to make an extreme conceptual shiftTaking away their accustomed way of coping (before you take away the pain)

Who is likely to benefit from dynamic therapy?Accept the concept of an unconscious mindBe aware of mental painBe ready to receive helpHave reasonable verbal skillsIBSOne site of painshorter durationPresence of anxiety/depression at intakeAbsence of constant pain

Short term dynamic therapies for persistent pain

Mrs A (Whale, 1992)Pain Clinic Addenbrookes Hospital, Cambridge, UKPatient questionnaireExclusion criteriaAll offered 1.5 hr psychodynamic assessmentIdentified an early memory + any clear focus of unresolved psychological conflict which might be influencing the pain4 therapy sessions, 50 minsF/U 6 mths and 1 year

Mr B (Stern, 2003)St Marks Hospital, Middlesex, UKEmploys a psychoanalytic psychotherapist9 sessions, initially sporadically then 6 weeks in a rowOnset of symptoms and their link with issues surrounding loss, sexuality, unacknowledged murderous impulses and guilt

Mrs C (Monsen & Monsen, 2000)Employees of a large Norwegian office companyFulfilled criteria for Pain Disorder (DSM IV)Pain not associated with work-related injuries33 sessions of psychodynamic body therapyExplore affect experienceLook at how certain maladaptive experiencing or expressive patterns are linked to other people and to their representations of significant othersBodily interventions include massage grips & specific exercises to accelerate the psychotherapeutic process by making affects accessible to conscious awareness