Transcript TIM 44 y.o. software genius

Topical Session 01
HIDDEN DRIVERS OF PAIN:
PSYCHOLOGICAL / PSYCHIATRIC
PERSPECTIVES
CARL GRAHAM
Fremantle Hospital, WA
NEWMAN L. HARRIS
Royal North Shore Hospital, NSW
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.
DISCLOSURES
Speakers Bureau
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Boehringer Ingelheim
Eli Lilly
GlaxoSmithKline
Medtronics
Pfizer
Solvay
Wyeth
Advisory Boards
• Boehringer Ingelheim
• Eli Lilly
• Pfizer
Conference Sponsorship
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Boehringer Ingelheim
Eli Lilly
GlaxoSmithKline
Pfizer
Wyeth
What about the 10%
who cost us 90% -
What about the 10%
who cost us 90% Another hedgehog
maybe?
Return to Work After Lumbar
Discectomy (Schade et al 1999)
• Correlates with depression and workplace
stress,
• not with indices of organicity.
Biopsychosocial consideration
Parsons (1951) – The Sick Role
Mechanic (1961) – Illness Behaviour
Pilowsky (1969) - Abnormal Illness
Behaviour
Engel (1977) – “Biopsychosocial”
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
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.
INTERACTIONS WITH
ENVIRONMENT
PAIN BEHAVIOURS
SUFFERING
COGNITIONS
ATTITUDES
BELIEFS
PAIN
PERCEPTION
NOCICEPTION
NEUROPATHY
Fordyce and Loeser’s
formulation
Descending Pathway
Descending
Pathway
Ascending
Pathway
Dr M K Nicholas, PM&RC
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)
Psychiatric Disorder in the
Pain Clinic
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Anxiety Disorders
Depression
Somatoform Disorders
Substance Problems
Psychotic Illness
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
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
Risk of Suicide in Depression
& Chronic Abdominal Pain
60%
Wanting to Die
Suicidal Ideation
Suicide Attempt
50%
40%
30%
20%
10%
0%
No Pain or
Depression
(n=3941)
Pain, No
Depression
(n=189)
Depression, No
Pain (n=734)
Magni et al. Pain 1998.
Pain and
Depression
(n=100)
Yellow Flags
• Attitudes and Beliefs
• • Belief that pain is harmful or disabling resulting in fearavoidance 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
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https://www.cebp.nl/media/m24.pdf
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
Yellow Flags
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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 problems
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https://www.cebp.nl/media/m24.pdf
Yellow Flags
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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
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https://www.cebp.nl/media/m24.pdf
Yellow Flags
Why would psychosocial variables influence pain and disability?
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Catastrophising directly influences pain intensity & pain-related disability
(Turner, et al (2002) Pain; 98, 127-134)
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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; 217-224)
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Inflammatory proteins can have an exacerbatory role in pain
(Wieseler-Frank, Maier, Watkins (2005) Neurosignals;14:166–174)
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Cycle - Cognitive & emotional responses during the experience of pain
shaped pro-inflammatory immune system responses via interleukin-6
(Edwards, et al (2008) Pain; 140, 135-144)
6 yellow flags
0.8
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5 yellow flags
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4 yellow flags
3 yellow flags
2 yellow flags
1 yellow flags
0 yellow flags
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Cumulative probability of
remaining unrecovered
1.0
Mayer, et al 2009
Remaining at Work
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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
Cumulative Sick Leave
Average Total # Sick Days
80
70
60
ACT
TAU
50
Cohen’s d at
follow-up =
1.00
40
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20
10
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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
Over prior 18 months he had been
off work, receiving
•1:1 physiotherapy input
•1:1 exercise physiologist instruction
•1:1 generalist psychology input
Investigations
•C. Spine MRI
•Brain MRI
•L Shoulder MRI
•Bilat nerve conductions
•Rheumatological screen
•Bone scan
Reason for referral:
•Failure to progress:
•Tolerances / capacities
unchanged
•Rigid pain focus entrenched
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
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
Progress
Liked the book – he understood and
felt inspired – but couldn’t progress
Psychiatric assessment requested.
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
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
Case 2 : Somatisation
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Long history of complaints
High utilisers of health services
Biomedical focus
Excessive illness behaviour c.f. pathology
• Outcome issues - poor prognosis
Is chronic pain associated with
somatization/hypochondriasis
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• 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. 2009 Nov-Dec;9(6):449-67
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
- Powerful biomedical focus
- Multiple practitioners – 2-3 specialists /12
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Pain specialist
Rheumatologists x2
Gastroenterologist
Ophthalmologist
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Endocrinologist
Dermatologist
Physiotherapist
Yoga teacher
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Morphine sulphate SR 20 mg bd
“Digesic”
Diazepam 2.5 – 5 mg up to qid
Aperients
Nutritional supplements
• Procedures / “blocks” every 6-12 weeks
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)
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”
Lots to worry about :
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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!
Case 3 : Brian 48 yo Surveyor
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Previously fit, very active professional man
Actively involved with church
Perfect family
Perfectionist
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MBA 3 years ago
Multiple orthopaedic (and visceral) injuries
6 weeks in hospital and 5 operations
8 weeks inpatient rehabilitation
Inpatient treatment
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Decompression/fusion L2/3
ORIF R. tibia/fibula
ORIF R. humerus
ORIF L. radius (distal)
Repair hepatic laceration and bladder/ureter
damage
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
Reason for Referral
• Referred due to persistent pain (and his
responses to it) causing disruption to
interpersonal and workplace function –
fear of losing job.
Assessment findings
• Team assessment identified nociceptive and
neuropathic drivers, obsessional personality,
excess pain focus, all-or-none behaviour
• Self damning / catastrophic cognitions
• Physical deconditioning
• Not happy to take medication,
fearing further compromise.
• Unable to obtain benefit from 1:1
CBT
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Couldn’t focus
Too busy ruminating / distracting
Too sleepy
Neither time nor energy for
behavioural tasks
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
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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, 295-304
Longmore, Worrell (2007) Clinical Psychology Review 27; 173-187
Dimidjian, et al(2006) Journal of Consulting & Clinical Psychology; 74, 4, 658-670