Transcript Chronic Pain and PTSD: Developing an Integrated Treatment

Chronic Pain and PTSD:
Developing an Integrated
Treatment Approach
John D. Otis, Ph.D.
VA Boston Healthcare System
Boston, MA
Presentation Overview
• Overview: Chronic Pain and OEF/OIF
Veterans
• The co-morbidity of Chronic Pain and
PTSD
• Development of an Integrated Treatment
for Chronic Pain and PTSD
• Questions & Ideas
Images of Pain
What is Chronic Pain?
• Pain is defined as an unpleasant sensory
and emotional experience associated with
actual or potential tissue damage, or
described in terms of such damage.
• Chronic pain = Pain with a duration of 3
months or greater that is often associated
with functional, psychological and social
problems that can negatively impact a
person’s life.
The Problem of Pain
• Pain is one of the most common complaints made by
patients to primary care providers in the VA
healthcare system (approximately 50% of patients).
• In a study of 1,800 OEF/OIF Veterans, 46.5%
reported some pain, with 59% of those exceeding
the VA clinical threshold of ≥ 4 (0 to 10 scale)
(Gironda et al., 2006).
• Pain is typically an adaptive reaction to an injury and
gradually decreases over time with conservative
treatment.
• However, for some people pain persists past the
point where it is considered adaptive and contributes
to negative mood, disability, and increased use of
healthcare system resources.
The Pain Cycle
Muscle atrophy &
weakness
Weight loss/gain
Pain
Disability
Negative self-talk
Poor sleep
Missing work
Distress
Less active
Decreased motivation
Increased isolation
The Challenge of Pain
• Over time, negative thoughts and beliefs
about pain, and behaviors related to pain
can become very resistant to change.
Thoughts
Behaviors
• My pain is going to kill me
• Staying in bed all day
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• Sleeping all day
• Staying away from friends
• Decreasing activities that
have the potential to
increase pain
• Taking more medication
than prescribed
This is never going to end
I'm worthless to my family
I’m disabled
There is nothing I can do
for myself
• I'm a bad father, husband,
and provider
Cognitive Behavioral Therapy
for Pain Management
• Research supports the efficacy of CBT for the
treatment of chronic pain (Morley et al., 1999)
• Components of CBT for pain include:
– Identifying inaccurate beliefs about pain
– Reconceptualizing pain as subject to personal
control through the influence of thoughts, feelings
and behaviors
– Teaching cognitive and behavioral coping skills
(e.g., cognitive restructuring, activity pacing, etc.)
– Practice and consolidation of coping skills through
imagery, rehearsal, and reinforcement of their
appropriate use
• Pain often results from injuries related to
events such as occupational injuries, motor
vehicle accidents, or military combat.
• This has led to a growing interest in the
interaction between pain and Posttraumatic
Stress Disorder (PTSD), as research and
clinical practice indicate that they frequently
co-occur and can interact in such a way to
negatively impact the course of treatment for
either disorder.
The Co-morbidity of Chronic
Pain and PTSD
• The prevalence of PTSD has been estimated
to be between 20 to 34% in patients referred
for the treatment of pain.
• The prevalence of pain has been estimated
to be between 45 to 87% in patients referred
for the treatment of PTSD.
• Question: Data obtained from VA Boston
Psychology Pain Management indicate that
50 % of patients assessed met criteria for
PTSD based on PTSD Checklist (PCL)
scores (n=65).
The Interaction between
Chronic Pain and PTSD
• Patients with co-morbid pain and PTSD
experience more intense pain, more
emotional distress, higher levels of life
interference, and greater disability than
pain patients without PTSD.
• Due to the interaction of these
conditions, these patients can also be
more complex and challenging to treat.
Clinical Examples
• “When ever I'm laying in bed at night and my
shoulder starts hurting, I start having thoughts
of when I was shot.”
• “When I think about the day my vehicle was
hit I can feel the pain in my back flare up right
where I was hurt.”
• “I tried my PT exercises but the pain started
increasing and I started thinking about what I
saw and heard in Vietnam so I just said the
heck with it and called it quits for the day.”
Potential Mechanisms
• Anxiety Sensitivity – a fear of arousal-related
sensations arising from the belief that they will
have harmful consequences.
• Catastrophizing – exaggerated beliefs and
expectations that events will lead to negative
outcomes.
Both of these factors may increase the fear and
avoidance of activities or thoughts associated with
recovery.
– PAIN: The avoidance of physical activities
– PTSD: The avoidance of feared thoughts/situations
A Need for Research
• Given the high rates of comorbidity
between chronic pain and PTSD, and
evidence suggesting that these two
disorders may interact in some way,
efforts to develop more effective
treatments for this population are
greatly needed.
Efficacy of An Integrated CBT
Approach to Treating Chronic Pain
and PTSD
John D. Otis, Ph.D. and Terence M. Keane Ph.D.
A VA Merit Review funded by the Rehabilitation,
Research & Development Service
Acknowledgements
Terence M. Keane, Ph.D., Co-PI
Co-Investigators
Robert Kerns, Ph.D.
Candice Monson, Ph.D.
Clara Lora, PsyD
Sam Wan, MA
Alex McDonald, MA
Jillian Shipherd, Ph.D.
Barbara Niles, Ph.D.
Purpose
• Evaluate the efficacy of an integrated
CBT approach to the treatment of comorbid chronic pain and PTSD
• Examine potential mechanisms of
action (e.g., catastrophizing, and
anxiety sensitivity) that might serve to
have an impact on treatment outcome
OEF/OIF Veterans
• More co-morbidity with OEF/OIF
veterans when compared with other
veterans because OEF/OIF veterans
are surviving their wounds
• Pain and PTSD more likely to be
associated with the same event
Assessment Measures
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Pain
PTSD
Affective Distress
Physical Functioning/Disability
Catastrophizing & anxiety
sensitivity
12 sessions
Pretreatment
Posttreatment
6-Month
Follow-up
Research Design
• Participants will be 136 veterans with
a co-morbid diagnosis of chronic pain
and PTSD
• Participants will be randomly assigned
to 1 of 4 treatment conditions
1. CBT-Pain
2. CBT-PTSD
3. CBT-PTR
4. Wait-List
Treatment
• CBT-Pain and CBT-PTSD
– Treatment for participants in these conditions will
follow a 12-session, individual, manualized
treatment protocol.
• CBT-PTR
– Treatment will follow a 12-session, individual,
manualized treatment protocol developed for this
research study that will integrate empirically
supported treatment components for both
conditions.
Treatment Components
CBT for Pain
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Education re: pain
Relaxation training
Cognitive restructuring
Stress management
Activity pacing
Pleasant activity
scheduling
• Anger management
• Sleep hygiene
• Relapse prevention
CBT for PTSD
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Education re: PTSD
Cognitive restructuring
Teach coping skills
Social support
Anger management &
sleep
• Exposure therapy
• Reprocessing the
meaning of the event
Study Development Issues
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The assessment/treatment length
Substance use
Relaxation training
Exposure therapy vs. Cognitive
Processing Therapy (CPT)
• Deciding on essential elements of
treatment
Integrated Treatment
• Session 1
• Session 2
• Session 3
• Session 4
• Session 5
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Session 6
Session 7
Session 8
Session 9
Session 10
Session 11
Session 12
Education on Chronic Pain and PTSD
Making Meaning of Pain and PTSD
Thoughts/Feelings related to Pain and PTSD &
Cognitive Errors
Cognitive Restructuring
Diaphragmatic Breathing and Progressive Muscle
Relaxation
Avoidance and Interoceptive Exposure
Pacing and Pleasant Activities
Sleep Hygiene
Safety/Trust
Power/Control/Anger
Esteem/Intimacy
Relapse Prevention and Flare-up Planning
Current Status
• Assessment protocol developed
• All treatment manuals have been
developed and pilot tested
• Actively treating and recruiting study
participants
Questions and Ideas
Otis, J. D., Keane, T. M., & Kerns, R. D. (2003). An Examination of the
relationship between chronic pain and Posttraumatic Stress Disorder.
Journal of Rehabilitation, Research and Development, 40(5), 397-406.
Otis, J. D., Pincus, D. B., & Keane, T. M. (in press). Comorbid Chronic
Pain and Posttraumatic Stress Disorder across the Lifespan: A Review of
Theoretical Models. In Young G., Kane, A., & Nicholson K., (Eds).
Causality: Psychological Knowledge and Evidence in Court. Kluwer
Academic/ Plenum Press.