Psychological Treatment for Chronic Pain: What Does the Evidence Say

Psychological Treatments for Chronic Pain: What Does the Evidence Say? Jennifer A. Haythornthwaite, Ph.D. Department of Psychiatry & Behavioral Sciences Johns Hopkins University School of Medicine Baltimore, MD

May 16, 2011

Disclosure ď Ž

Nothing to Disclose

1

Individual Differences:

↑ Activation of ACC, SI, and PFC in Individuals with High Pain Sensitivity

Coghill et al., PNAS, 2003 2

Learning Objectives 





Describe the contributions of psychological factors to chronic pain and pain-related adjustment Cite different psychological approaches to pain management List current findings regarding the efficacy of cognitive-behavioral treatments for chronic pain

Psychological factors will… 

Modify the perception of pain, and…



modulate the experience of pain, but…



rarely cause of pain

Objectives #1: Describe the contributions of psychological factors to chronic pain and pain-related adjustment 

Anxiety and depressive symptoms



Pain-related catastrophizing



Sleep disturbance

Objectives #1: Understand the contributions of psychological factors to chronic pain and pain-related adjustment 

Anxiety and depressive symptoms



Pain-related catastrophizing



Sleep disturbance

Acute to Chronic Pain Trajectory Anxiety Depression

Acute Pain

Acute to Chronic Pain Trajectory

X

Anxiety Depression

Pain Free

Acute Pain

Acute to Chronic Pain Trajectory Anxiety Depression

Acute Pain

Persistent Pain

Anxiety and Depression Pain 1 Year Following Knee Replacement Anxiety Depression

Acute Pain

Persistent Pain

Brander et al., Clin Orthoped Related Res, 2003, 146: 97

Pre-op anxiety and depression predict knee pain ratings 1 yr post knee replacement Anxiety r = 0.38

Depression r = 0.43

Brander et al., Clin Orthoped Related Res, 2003, 146: 97

Acute to Chronic Pain Trajectory‌..Consider Function

Acute Pain

Persistent Pain

Poor Function

It’s not just pain…..but also function

3 months post injury

→ → → → 0.31

pain

0.20 (p<0.01) 0.23 (p<0.01) 6 Month Anxious Distress Overall Function

12 months post injury pain

6 Month Depressive Distress 0.54 (p<0.01)

0.55 (p<0.01)

0.31

Overall Function

Wegener et al., Psychological distress mediates the effect of pain on function. Pain, 2011

Acute to Chronic Pain Trajectory

Anxiety Depression

Acute Pain

Persistent Pain

Anxiety Depression

Poor Function

% summed pain intensity difference

High Negative Affect is associated with reduced opioid analgesia in CLBP

60

(59.3%) 50

(49.3%) 40

(37.3%)

30 20 10 0

Low

Mod

High

Composite Negative Affect Score Wasan et al., The association between negative affect and opioid analgesia…Pain, 117:450-461

Objectives #1: Describe the contributions of psychological factors to chronic pain and pain-related adjustment – Anxiety and depressive symptoms – Pain-related catastrophizing – Sleep disturbance

Pain is a stressor that activates pain-related catastrophizing and heightens painâ&#x20AC;Ś

Acute Pain

Acute Pain Pain Catastrophizing

↑ Temporal summation

Situational catastrophizing and pain modulation

N=38 healthy women, 49o C stimulus Edwards et al., Pain-related catastrophizing… Clin J Pain, 2006, 22, 730-737

↓ Diffuse Noxious Inhibitory Controls DNIC

-

Catastrophizing

+

Pain ratings

N= 35 healthy men and women Goodin, et al., Associations between catastrophizing…J of Pain, 2009, 10, 180-190

Individual Differences in Catastrophizingâ&#x20AC;Ś.

TMJ Pain on Palpation TMJ patients

Pain Clinic patients

• over three weeks following resolution of acute pulpitis pain (top) • following total knee surgery (bottom) • scores do decline with psychological treatment

TKA: Edwards et al., Pain Res Manage, 2009, 14: 307.

Young & Healthy: Edwards et al., Pain, 2004, 111: 335; Acute Pulpitis: Edwards et al., J of Pain, 2004, 3:164;

Men

Women

Acute pain

Pain resolved

5 4 3

ns

p =.05

2 1 0

Young & Healthy

CSQ Catastrophizing

Trait catastrophizing scores are quite STABLE

Catastrophizing Score

6

8 7 6 5 4 3 2 1 0

Pre-Surg

Acute Pulpitis

1 Month 3 Month 6 Month 12 Month

Catastrophizing predicts persistence of pain1,2 Time 1 Pain

Catastrophizing

→→→→

Time 2 Pain

Design: Randomized, crossover clinical trial (N=68 PHN patients) with pain measured at 2 drug-free baselines

Result: Catastrophizing at Time 1 predicted pain at 8 weeks (Time 2), beyond the effects of pain at Time 1.

1Haythornthwaite 2

et al. Pain coping strategies play a role in the persistence of pain in PHN. Pain, 2003, 106:453.

Keefe et al., Coping with rheumatoid arthritis pain: Catastrophizing as a maladaptive strategy. Pain, 1989, 37: 51

• There is some indication that catastrophizing scores increase with clinical severity •Is this related to duration of pain: does catastrophizing increase as pain endures?

Score on Catastrophizing

• Sex differences in catastrophizing occur in some clinical samples, but not consistently

ns ns p<.05

ns

ns

•Is this a selection process: do patients with more catastrophizing fail treatment?

SSc: Edwards et al., Clin J Pain, 2006, 22: 639; CPP& LBP: Heinberg et al., Pain, 2004, 108:88; PHN: Haythornthwaite et al., Pain, 2003, 106: 453; Pain Center: Buenaver et al., Pain, 2007, 127: 34 TMJ: R01 DE13906 (NIH/NIDCR)

Objectives #1: Describe the contributions of psychological factors to chronic pain and pain-related adjustment – Anxiety and depressive symptoms – Pain-related catastrophizing – Sleep disturbance

Sleep, 2009, 32:779.

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Acutely Disturbed Sleep Impairs an Indirect Measure of the Endogenous Opioid System

Smith et al., Sleep, 2007, 30:494.

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Pain is a stressor that disturbs sleep and may contribute over time to persistent painâ&#x20AC;Ś

Sleep Disturbance Acute Pain

Acute Pain

Sleep Disturbance

Persistent Pain

Objectives #1: Understand the contributions of psychological factors to chronic pain and pain-related adjustment #2: Cite different psychological approaches to pain management #3: Describe current findings regarding the efficacy of cognitive-behavioral treatments for chronic pain

Biofeedback: Intervention •

Learning to influence physiological parameter •

electromyography (EMG)

•

galvanometry (electrodermal)

•

temperature

•

Shaping of behavior

•

Typically includes training in relaxation techniques

Biofeedback: What happens?

Biofeedback: Outcomes •

There is very good evidence that the vast majority of people can learn to modulate physiological parameters such as muscle tension, skin temperature, peripheral blood flow, heart rate, etc.

•

Reduction in tension and migraine headaches, Raynaud’s, LBP, IBS

Cognitive-Behavioral Treatment: Model 





Integrates Behavioral/operant and Biofeedback interventions Adds focus on cognitive structures and cognitive processes Adds additional focus on affective factors 5/3/10

Cognitive-Behavioral Treatment: Model ď Ž

ď Ž

Cognitive Aspects: affect and behavior are largely determined by cognitive processes (beliefs, attitudes, thoughts) Behavior results from a complex interaction between environmental input, cognitive structures (e.g., beliefs), cognitive processes (e.g., automatic thoughts), and the resulting intrapersonal and interpersonal consequences

Cognitive-Behavioral Treatment: Overview 

Emphasis on Self-Management



Share 4 common components     5/3/10

education skills acquisition cognitive and behavioral rehearsal generalization and maintenance

Cognitive-Behavioral Treatment: Intervention

 Education Gate Control theory of pain - influence of cognitive and affective factors on the experience of pain  Acute vs. chronic pain  Deconditioning and activity-rest cycles 

Cognitive-Behavioral Treatment: Intervention

Skills Training and Development  

Relaxation Strategies Pain Coping Strategies    



distraction - pleasant activity scheduling coping self-statements social support activity pacing

Identifying and challenging maladaptive thoughts

Cognitive-Behavioral Treatment: Changing Cognitions 

How do you stop catastrophizing??

Step 1: Recognize when you’re catastrophizing  Step 2: Identify the consequences  Step 3: Examine the evidence that your catastrophic thoughts are true  Step 4: Practice new ways of developing more balanced thinking  Worksheets and Diaries are used throughout 36 5/3/10 

Cognitive-Behavioral Treatment: Intervention

 Cognitive and Behavioral Rehearsal 

In session   



Homework assignments   

5/3/10

practice of new skills weekly goals cognitive restructuring home practice of relaxation pacing challenging maladaptive thoughts

Objectives #1: Understand the contributions of psychological factors to chronic pain and pain-related adjustment #2: Describe different psychological approaches to pain management #3: List current findings regarding the efficacy of cognitivebehavioral treatments for chronic pain

Cognitive-Behavioral Treatment: Outcomes     

↓ pain intensity ↓ pain-related disability and pain behaviors control and self-efficacy, ↓ helplessness improve emotional state active coping, ↓ passive coping (e.g., catastrophizing)

 RA: ↓ biological markers (joint swelling)

Effects (average effect size) of psychosocial interventions in arthritis

Dixon et al., Psychological interventions for arthritisâ&#x20AC;ŚHealth Psychology, 2007, 26: 241.

Cognitive-Behavioral Treatment: Outcomes  



Gains often increase following treatment Gains observed in the context of ongoing medical management Gains often include reductions in health care utilization

CBT in early RA: reduced depression and disability

Percent Possibly Depressed

SC

Sharpe et al., Long-term efficacy of CBTâ&#x20AC;Ś, Rheumatology, 2001, 42:435.

CBT

Mindfulness and Acceptance treatment 

Newer Acceptance-based therapies 





Emphasize mindfulness and present-moment focus Minimize the meaning and significance of negative thoughts – they are just thoughts Focus on behaving in a way that is consistent with personal, positive goals and values

Vowles et al., Processes of change in treatment of chronic pain: The contributions of pain, acceptance, and catastrophizing. Eur J Pain, 2007, 11:779.

Mindfulness and Acceptance treatment 

Acceptance-based CBT  



Reduces catastrophizing Increases acceptance

These changes appear to contribute to reduced suffering  

reduced distress, pain anxiety, avoidance reduced physical and psychosocial disability

Vowles et al., Processes of change in treatment of chronic pain…Eur J Pain, 2007, 11:779.

• ACT and CBT were comparable in outcomes on pain interference, depression, and pain-related anxiety.

• CBT group had higher expectations for outcomes • ACT group reported higher satisfaction at the end of treatment

Wetherall et al.: A RCT of acceptance and Commitment therapy and CBT for chronic pain.

Pain, 2011.

45

Working with the patient…Use self-help  We know that generally we have effective

behavioral and psychological treatments

– These treatments typically are provided to a highly select subgroup of the larger group that needs them, often late in the course of illness, and usually after a broad range of medical/surgical treatments have failed.

Working with the patientâ&#x20AC;ŚUse self-help Despite these challenges, these treatments generally reduce pain, disability, improve mood, increase perceptions of control and self-efficacy, and reduce health care utilization So they need to be: #1: implemented earlyâ&#x20AC;Ś..

Working with the patientâ&#x20AC;ŚUse self-help

Andâ&#x20AC;Ś#2: patients need to develop the right framework, have access to the right materials, and get guidance and support from providers

Promote Self-Management …

Margaret Caudill: Managing Pain Before It Manages You

Advantages: • workbook format • inexpensive • allows “stepped care

Recommend online cognitive therapy for depression: http://moodgym.anu.edu.au/

Self-help materials for your patients Managing Your Pain Before it Manages You by Margaret Caudhill, M.D.  Pain Survival Guide by Dennis Turk, Ph.D.  Cognitive Therapy for Chronic Pain: A Step-by-

Step Guide by Beverly Thorn, Ph.D. Managing Chronic Pain by John Otis, Ph.D.  Internet sites for depression: 5/3/10

http://moodgym.anu.edu.au/

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Learning Objectives 





Describe the contributions of psychological factors to chronic pain and pain-related adjustment Cite different psychological approaches to pain management List current findings regarding the efficacy of cognitive-behavioral treatments for chronic pain

Thank you!