1. A model for assessment in chronic pain
Dr Tayyeb Tahir
Dr Scott Hall

2. Workshop Outline Introduction to “the model” (guided discussion)
Group case formulation
Small group case formulation
Feedback

3. 1 minute - individually
In your initial assessment of a “typical” patient presenting with chronic pain
What are your three main objectives?

5. Engel’s Model (summary)
Biological changes in disease are not always reciprocated in illness
Presence/absence of disease does not necessarily shed light on the meaning of symptoms
Psychosocial determinants of illness are of fundamental importance in assessment and symptom expression
The sick role/illness behaviour is not necessarily associated with disease
Success (or failure) of biological treatments is influenced by psychosocial factors (&vice-versa)
Dr/P relationship influences outcomes
Patients are profoundly influenced by the way in which they are studied (&vice-versa)

6. Translation of the BPS model to clinical practice
Relationship between mental/physical aspects of health
Paying “lip service” to participatory relationship
Self-awareness
Cultivation of trust
Empathic curiosity
Recognising bias
Using informed intuition
Communicating clinical evidence

7. Clinical Formulation
A map to help us understand the terrain of an individuals narrative
An attempt to explain why a person is experiencing symptoms in a particular way at a particular point in time.
Moving beyond description into explanation

8. Models and Reality
Don’t mistake models for reality!

10. The Four P Model
An attempt to provide an explanatory overview of a presenting problem / problems
Not based in any one psychiatric / psychological model
Evidence based
Forces you to consider relevant factors

11. Predisposing Factors
Things that make the person vulnerable to developing the current presentation
Examples could include:
Early trauma (e.g. abuse, bullying, parental separation).
Physical health problems.
Family history of mental ill health.
Think – What happened in the past?

12. Precipitating Factors
‘The Final Straw”
Things that happened in the person’s life that seemed to trigger an episode of illness
Examples could include
a bereavement
loss of a job or
other significant life change.
drug use
Think – What was the final straw?

13. Perpetuating Factors
Things that seem to be keeping the person in their current state of distress.
Examples include
pervasive negative thinking.
lack of a close confiding relationship
lack of adherence to medication
Think – Why are they not getting better?

14. Protective Factors
Things which seem to help keep the person well and which need to be strengthened in order to decrease the likelihood of the problem reoccurring
Examples include
a strong relationship,
a particular skill in a specific area
a psychological feature such as a good sense of humour
Think – What are their strengths? What’s good in their life?

15. Iatrogenic Factors
Iatrogenic factors relate to treatments that worsen the patient’s condition
These are not part of the formulation but can have a massive impact on treatment.
Tend to be associated with drug treatment but all treatments are potentially iatrogenic.

16. The Four P Model Iatrogenic Protective Predisposing Precipitating
‘Symptoms’
Perpetuating

17. Putting it together: An integrative aetiological formulation
NB : First we need a collaborative understanding of the presenting complaint!
Biological
Psychological
Social
Predisposing
Precipitating
Perpetuating
Protective
Iatrogenic

18. Management Biological Psychological Social Short term Medium term
Long term