1. Dynamic Psychotherapy for the Patient with Persistent Pain Dr Stephanie Oak Liaison Psychiatry

2. What is Psychotherapy? “the talking cure” “conversations with a listener who is trained to help you make sense of, and try to change, things that are troubling you” Patient as active participant Over 200 varieties –Behavioural –Cognitive –Person-centred / humanistic –Systems –Psychoanalytic / psychodynamic

3. What is dynamic psychotherapy? Started with the discoveries of Freud over 100 years ago Concerned with the meaning of experience and behaviour Crystallises out of shared exploration between therapist and patient Looks 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 are Not 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.

4. Does dynamic psychotherapy work? 5 RCT psychodynamic therapy superior to TAU control conditions in –IBS (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.

5. Pain as a focus for psychotherapy Surprisingly little psychoanalytic literature on the subject of chronic pain “If Irma’s 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”.

6. The pain prone patient Focused on psychodynamic factors involved in pain pathogenesis An unconscious need to suffer A response to a real, threatened or fantasised loss Conflicts or guilt over intense aggressive or forbidden sexual impulses Highlighted link between chronic pain and a history of distressing life experiences Saw pain as a subjective experience, like an affect or emotion, which, once represented mentally, no longer needs peripheral stimulation to be provoked.

7. Pain in therapy Psychological 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 it’s manner of communication to the physician? Identify and explore these unconscious vulnerabilities, and through resolution of conflicts, alleviate symptoms.

8. Why patients with persistent pain are difficult to engage The typical pain patient…… Difficult to establish a rapport Asking them to make an extreme conceptual shift Taking away their accustomed way of coping (before you take away the pain)

9. Who is likely to benefit from dynamic therapy? Accept the concept of an unconscious mind Be aware of mental pain Be ready to receive help Have reasonable verbal skills IBS –One site of pain –“shorter duration” –Presence of anxiety/depression at intake –Absence of constant pain

10. Short term dynamic therapies for persistent pain

11. Mrs A (Whale, 1992) Pain Clinic Addenbrooke’s Hospital, Cambridge, UK Patient questionnaire Exclusion criteria All offered 1.5 hr psychodynamic assessment Identified an early memory + any clear focus of unresolved psychological conflict which might be influencing the pain 4 therapy sessions, 50 mins F/U 6 mths and 1 year

12. Mr B (Stern, 2003) St Mark’s Hospital, Middlesex, UK Employs a psychoanalytic psychotherapist 9 sessions, initially sporadically then 6 weeks in a row Onset of symptoms and their link with issues surrounding loss, sexuality, unacknowledged murderous impulses and guilt

13. Mrs C (Monsen & Monsen, 2000) Employees of a large Norwegian office company Fulfilled criteria for Pain Disorder (DSM IV) Pain not associated with work-related injuries 33 sessions of psychodynamic body therapy –Explore affect experience –Look at how certain maladaptive experiencing or expressive patterns are linked to other people and to their representations of significant others –Bodily interventions include massage grips & specific exercises to accelerate the psychotherapeutic process by making affects accessible to conscious awareness