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Topical Session 01 HIDDEN DRIVERS OF PAIN: PSYCHOLOGICAL / PSYCHIATRIC PERSPECTIVES CARL GRAHAM Fremantle Hospital, WA NEWMAN L. HARRIS Royal North Shore.

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Presentation on theme: "Topical Session 01 HIDDEN DRIVERS OF PAIN: PSYCHOLOGICAL / PSYCHIATRIC PERSPECTIVES CARL GRAHAM Fremantle Hospital, WA NEWMAN L. HARRIS Royal North Shore."— Presentation transcript:

1 Topical Session 01 HIDDEN DRIVERS OF PAIN: PSYCHOLOGICAL / PSYCHIATRIC PERSPECTIVES CARL GRAHAM Fremantle Hospital, WA NEWMAN L. HARRIS Royal North Shore Hospital, NSW

2 THIS PRESENTATION MAY MAKE REFERENCE TO SOME “OFF-LABEL” USES OF MEDICATIONS WHICH ARE INCLUDED ONLY FOR ACADEMIC COMPLETENESS. ATTENDEES SHOULD NOT INFER ANY ENCOURAGEMENT TO BREECH PRESCRIBING REGULATIONS.

3 DISCLOSURES Speakers Bureau Boehringer Ingelheim Eli Lilly GlaxoSmithKline Medtronics Pfizer Solvay Wyeth Advisory Boards Boehringer Ingelheim Eli Lilly Pfizer Conference Sponsorship Boehringer Ingelheim Eli Lilly GlaxoSmithKline Pfizer Wyeth

4 What about the 10% who cost us 90% -

5 What about the 10% who cost us 90% - Another hedgehog maybe?

6 Return to Work After Lumbar Discectomy ( Schade et al 1999 ) Correlates with depression and workplace stress, not with indices of organicity.

7 Biopsychosocial consideration Parsons (1951) – The Sick Role Mechanic (1961) – Illness Behaviour Pilowsky (1969) - Abnormal Illness Behaviour Engel (1977) – “Biopsychosocial”

8 WHAT IS PAIN ? “An unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” (IASP 1979) Pain is always subjective Definition doesn’t tie pain to a stimulus Nociception is NOT equivalent to pain

9 The Multidisciplinary Approach (Presley and Cousins 1992) Holistic biopsychosocial assessment Rationalised organic treatment plan Psychological and social interventions A paradigm shift from traditional medical approach is required.

10 INTERACTIONS WITH ENVIRONMENT PAIN BEHAVIOURS SUFFERING COGNITIONS ATTITUDES BELIEFS PAIN PERCEPTION NOCICEPTION NEUROPATHY Fordyce and Loeser’s formulation

11 Descending Pathway Ascending Pathway Descending Pathway Theoretical Representation

12 Dr M K Nicholas, PM&RC

13 Psychiatric Disorder in the Pain Clinic 90% of pain clinic attendees suffer at least one psychiatric disorder (Large 1980) Over 60% satisfy criteria for more than one (Fishbain et al 1986)

14 Psychiatric Disorder in the Pain Clinic Anxiety Disorders Depression Somatoform Disorders Substance Problems Psychotic Illness

15 Comorbid Mood Disorder in Primary Care Setting : – 34% of Joint & Limb Pain – 38% of Back Pain – 40% of Headache – 46% of Chest pain – 43% of Abdo Pain Kroenke & Price 1993

16 Depression – Higher levels of pain reported – More pronounced pain behaviour – Pain settles with Rx of mood – Depression implicated in transition to chronicity along with somatisation & distress

17 Risk of Suicide in Depression & Chronic Abdominal Pain Magni et al. Pain 1998.

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19 Yellow Flags Attitudes and Beliefs Belief that pain is harmful or disabling resulting in fear- avoidance behaviour Belief all pain must be abolished before return to work or normal activity Catastrophising, thinking the worst, misinterpreting bodily symptoms Behaviours Use of extended rest, disproportionate downtime Reduced activity, significant withdrawal from activities of daily living Report of extremely high intensity of pain on VAS Sleep quality reduced since onset of back pain https://www.cebp.nl/media/m24.pdf

20 Yellow Flags Compensation Issues Lack of financial incentive to return to work Delay in accessing income support and treatment cost, disputes over eligibility History of extended time off work due to injury or other pain problem Diagnosis and Treatment Experience of conflicting diagnoses or explanations for back pain Dramatisation of back pain by HP's, dependency on treatments, passive treatment Expectation of a techno-fix, eg, requests to treat as if body were a machine https://www.cebp.nl/media/m24.pdf

21 Yellow Flags Emotions Fear of increased pain with activity or work Depression (especially long-term low mood), loss of sense of enjoyment Anxiety about and heightened awareness of body sensations (includes sympathetic nervous system arousal) Feeling under stress and unable to maintain sense of control Family Over-protective or solicitous partner, emphasising fear of harm or catastrophising Socially punitive responses from spouse (eg ignoring, expressing frustration) Extent to which family members support any attempt to return to work Lack of support person to talk to about pr oblems https://www.cebp.nl/media/m24.pdf

22 Yellow Flags Work Frequent job changes, stress at work, job dissatisfaction, Poor relationships with peers or supervisors... Belief that work is harmful; that it will do damage or be dangerous Unsupportive or unhappy current work environment https://www.cebp.nl/media/m24.pdf

23 Yellow Flags Why would psychosocial variables influence pain and disability? Catastrophising directly influences pain intensity & pain-related disability (Turner, et al (2002) Pain; 98, ) Psychological or social variables which function as threats, or are experienced as a loss of control, access standard sickness responses resulting in increased inflammation (Brydon, et al (2009)Brain, Behavior & Immunity 23; ) Inflammatory proteins can have an exacerbatory role in pain (Wieseler-Frank, Maier, Watkins (2005) Neurosignals;14:166–174) Cycle - Cognitive & emotional responses during the experience of pain shaped pro-inflammatory immune system responses via interleukin-6 (Edwards, et al (2008) Pain; 140, )

24 4/10/10 Mayer, et al 2009

25 Remaining at Work 20 public health workers at risk for developing chronic pain (taking sick days for pain probs) 10 TAU vs 10 CBT (4 x 1 hrs ACT) Dahl, Nilsson & Wilson, Behavior Therapy, 2004 Dahl, Nilsson & Wilson, Behavior Therapy, 2004

26 Cohen’s d at follow-up = 1.00

27 Case 1: TIM 44 y.o. software genius Referred by Rehabilitation Physician In context of escalating workplace pressue, gradual onset of neck, bilat. shoulder and arm (RSI-like) pain Pain began in context of escalating workplace stressors Workplace critical / unsupportive 20 months on WorkCover

28 Over prior 18 months he had been off work, receiving 1:1 physiotherapy input 1:1 exercise physiologist instruction 1:1 generalist psychology input

29 Investigations C. Spine MRI Brain MRI L Shoulder MRI Bilat nerve conductions Rheumatological screen Bone scan

30 Reason for referral: Failure to progress: Tolerances / capacities unchanged Rigid pain focus entrenched

31 Findings of Team Assessment Nil organic aetiology identified Marked physical deconditioning Exaggerated somatic preoccupation a/w ritualised safety behaviours High depression and anxiety scores Marked obsessionality Fear avoidance Poor self efficacy Oversolicitous partner Substances - 2 different benzos, 2 OTC analgesics, 2 types anti-inflammatory & EtOH

32 Recommendations from Team Assessment Reassurance Substance rationalisation Self-help text “Manage Your Pain” 1:1 psychology and physiotherapy – 3 sessions of each over 6 weeks

33 Progress Liked the book – he understood and felt inspired – but couldn’t progress Psychiatric assessment requested.

34 Psychiatry assessment Ritualised safety behaviours –  gyration of shoulder girdles  multiple pillows / braces Melancholia (EMW, anhedonia, ruminations, low energy, cognitive poor, anorexia) Controlling / demanding / obsessional 2 different benzos, 2 OTC analgesics, 2 types anti-inflammatory 60 g EtoH

35 What next? Education re integrated activity of limbic and other brain centres with pain circuitry Discussion re neuroplastic exacerbatory processes Discouraged benzos Offered SNRI - declined Pregabalin commenced

36 Case 2 : Somatisation Long history of complaints High utilisers of health services Biomedical focus Excessive illness behaviour c.f. pathology Outcome issues - poor prognosis

37 Is chronic pain associated with somatization/hypochondriasis Is chronic pain associated with somatization/hypochondriasis. An evidence-based structured review (57 studies) Somatisation and hypochondriasis were both consistently associated with chronic pain Study evidence indicated a correlation between pain intensity and presence of somatisation and hypochondriasis Pain treatment improved somatisation and hypochondriasis Fishbain et al. Pain Pract Nov-Dec;9(6):449-67

38 Case 2 : Pam 62 yo Referred by Pain Specialist Multiple morbidities including OA in hips, hands, neck and low back, haemochromatosis, osteoporosis (with compression fractures x2), macular degeneration, chronic constipation, stress incontinence, hypertension. Slim and frail-looking

39 - Powerful biomedical focus - Multiple practitioners – 2-3 specialists /12 Pain specialist Rheumatologists x2 Gastroenterologist Ophthalmologist Endocrinologist Dermatologist Physiotherapist Yoga teacher

40 Morphine sulphate SR 20 mg bd “Digesic” Diazepam 2.5 – 5 mg up to qid Aperients Nutritional supplements Procedures / “blocks” every 6-12 weeks

41 Reason for referral: Assistance sought with her distress - as demonstrated through her seeking of advice and reassurance via frequent phone calls (2-3 per week)

42 Background Younger of two daughters from wealthy family Sickly child – multiple hospitalisations for asthma Father was caring but busy Mother was just busy Teen years: Sister strong, successful and popular. Pam polite, unassertive, “a worrier”

43 Lots to worry about : Three adult offspring – 2 unwell (1 Alcoholic) 1 son-in-law unwell (Colitis) Seven grandchildren Very aging mother Fit but aging husband ….and of course herself too!

44 Case 3 : Brian 48 yo Surveyor Previously fit, very active professional man Actively involved with church Perfect family Perfectionist MBA 3 years ago Multiple orthopaedic (and visceral) injuries 6 weeks in hospital and 5 operations 8 weeks inpatient rehabilitation

45 Inpatient treatment Decompression/fusion L2/3 ORIF R. tibia/fibula ORIF R. humerus ORIF L. radius (distal) Repair hepatic laceration and bladder/ureter damage

46 Complaints Pain distracts him – can’t stop ruminating about pain and the idiot who caused it Cranky Impaired workplace function Exacerbation of (premorbid trait of) relative inflexibility. Had become intolerant Always tired Memory impaired

47 Reason for Referral Referred due to persistent pain (and his responses to it) causing disruption to interpersonal and workplace function – fear of losing job.

48 Assessment findings Team assessment identified nociceptive and neuropathic drivers, obsessional personality, excess pain focus, all-or-none behaviour Self damning / catastrophic cognitions Physical deconditioning

49 Not happy to take medication, fearing further compromise. Unable to obtain benefit from 1:1 CBT - Couldn’t focus -Too busy ruminating / distracting -Too sleepy -Neither time nor energy for behavioural tasks

50 Progress Brain MRI NAD ; neuropsych testing equivocal for ABI. Agreed to trial Nortriptilline 10 mg – unable to tolerate – sleep better BUT daytime compromise and exacerbated hesitancy Not making progress after 6 sessions Clin. Psych plus physio. instruction

51 Problems inherent with a big C approach to CBT Don't give more verbal rules to perfectionists! Behavioural change not enhanced significantly by cognitive intervention Jacobson, et al (2000) Journal of Consulting & Clinical Psychology; 64, 2, Longmore, Worrell (2007) Clinical Psychology Review 27; Dimidjian, et al(2006) Journal of Consulting & Clinical Psychology; 74, 4,

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