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.
24
Acutely Disturbed Sleep Impairs an Indirect Measure of the Endogenous Opioid System
Smith et al., Sleep, 2007, 30:494.
25
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!