Dr. C. L.

Narayan MD, FIPS, FIAPP

 Affects

the whole life emotionally and socially. Enduring changes on self esteem Becomes the source of a variety of psychosocial stressors. Pain Stress cycle Pain tends to amplify stress and stress magnifies the subjective experience of suffering associated with pain. Stress-reactivity - - a continuum of the degree to which any individual reacts to external and internal stressors. Psychiatric co-morbidity is very common.

 The

pain of the mind is worse than the pain of the body A prime expression of a muted depressive state May be suggestive of adjustment difficulties. Becomes the conscious source and focus of patients distress. Pain and Depression Very commonly associated, chicken and egg Major Depressive Disorder or Dysthymic Disorder . Psychopathology not invariable- many of chronic pain are quite well adjusted.

Apparently may not actually include pain! Many complainants do not fit the criteria. 50% have no identifiable precipitant. Pain is not proportional to any identifiable precipitant. There is no objective independent measure of pain. A clinical diagnosis i.e. no consistent abnormalities on investigation There is no agreement as to causal mechanism. Probably it may be an idiosyncratic response to or consequence of some initiating event that generates the condition.
Regional? Pain? Syndrome
G Schott Pract Neurol 2007 Chronic?

 Reflex

sympathetic dystrophy: A common clinical avenue for somatoform expression

Ochoa and Verdugo 1995

At

present satisfactory data are not available to foretell which individuals are likely to develop CRPS they often seem to have led a psychologically unremarkable life before the condition developed.
G D Schott Pract Neurol (2007) 7: 145-157

 The

presence of physical symptoms that suggest a general medical condition (hence the term somatoform) and are not fully explained by a general medical condition, by the direct effects of a substance or by another mental disorder (e.g. Panic Disorder). The symptoms must cause clinically significant distress or impairment in social, occupational or other areas of functioning. Somatization represents the symbolic displacement of intra-psychic conflicts into somatic sphere in an unconscious attempt to avoid distressing affects. Primary and Secondary Somatization.

Somatization Disorder Poly-symptomatic onset before 30 years, ongoing, threshold of complaints. Undifferentiated Somatoform Disorder: Below threshold for Somatization Disorder. Conversion Disorder: Unexplained symptoms (usually neurological) Psychological factors judged to be associated. Pain Disorder: Pain is the predominant focus of clinical attention. Psychological factors judged important. Hypochondriasis: Preoccupation with fear of having serious disease Body Dysmorphic Disorder: Preoccupation with imagined bodily defect Somatoform Disorder Not Otherwise Specified.

 Chronic

Fatigue Syndrome Fibromyalgia Irritable Bowel Syndrome Da Costas Syndrome. Premenstrual Syndrome

Related Disorder
Factitious

Disorder Hospital Addiction Syndrome, Munchausen Syndrome Malingering

Pain is the predominant focus of the clinical presentation and sufficient severity to warrant clinical attention. Pain causes significant distress or impairment in social, occupational or other important areas of functioning. Psychological factors are judged to have an important role in the onset, severity, exacerbation or maintenance of the pain. The symptom or deficit is not intentionally produced or feigned. The pain is not better accounted for by Mood, Anxiety or Psychotic Disorders. Acute: less than 6 months Chronic: more than 6 months

Five axes I. anatomical region II. organ system III. temporal characteristics and pattern IV. patients statement of intensity V. aetiology Psychological components can be coded under II (as a mental disorder) or V (can be psychophysiological or psychological)

The predominant complaint is of persistent, severe and distressing pain, which cannot be explained fully by a physiological process or a physical disorder. Pain occurs in association with emotional conflict or psychosocial problems that are sufficient to allow the conclusion that they are the main causative influences. The result is usually a marked increase in support and attention, either personal or medical. To be differentiated from the histrionic elaboration of organically caused pain for which definite physical diagnosis not reached.

The patterns of behavior that people adopt when they are ill or injured or when they believe that they are Symptoms may be differently perceived, evaluated and acted (or not acted) upon by different kinds of persons. To be well is not the same as to feel well A range from making light and shrugging off to responding to the slightest twitches of pain by quickly seeking medical advice One of the prime functions of public health programs is to teach populations to accept and behave in accordance with the definitions made by the medical profession

 Cultural,

ethnic and family background, religious denomination, social class, personality, personal experience and psycho-social circumstances
- all determine how a person responds to illness or injury
M. Zborowski 1952

Cultural components in response to pain

 Some

can be just as enthusiastic about illness as are their patients to whom even small injuries require a great deal of medical attention. If the pain from a minor injury is to be substantially prolonged, it is indispensable to have a doctor on side.
A.

Malleson 2002

Specialist

Clinicians are experts in their own illness and tend to give the benefit of the doubt to this illness

multi disciplinary approach. To encourage the patient towards a healthier psychological adjustment to the pain and resulting limitations. But continued palliation or search for better medical solutions not to be abandoned. Address all the factors that contribute to the patients experience of pain and distress.

 Physician

hopping, repeated disappointment. If pt feels rushed, dismissed, devalued increase in pain behavior & dependency. Effective multidisciplinary therapeutic alliance generates confidence in patient. Reassurance of entire team that pain is being taken seriously & not relegated to status of all in the head. If the pt feels heard, understood & thereby safe, emotional & behavioral antecedents, correlates & precipitants of pain can be discussed.

 Pre-contemplation

stage highly resistant to change, universal tendency to seek medical explanation of each & every ailments. Contemplation stage willingness to consider making behavioral changes, which is reached by offering reasonable alternative explanation of pain experiences. Preparation stage actively considering attempts to change. Action stage- actively engaged in the process of promoting and practicing new set of behaiors. Maintenance stage working to maintain the changes

 Congruence,

Empathy (not simply sympathy) & unconditional positive regard three basic requirement of the therapist. Patient should feel that his/her sufferings are validated and fully appreciated by those who would care for him/her. Psycho-education Assuming an active role in recovery & rehabilitation. Understanding

Stress reactivity & pain-stress cycle. Physiology & psychology of pain Difference between acute & chronic pain Difference between pain and injury, hurt & harm

 If

psychosocial factors appear to contribute in dev & maintenance of chronic pain, supportive & psychodynamic are helpful Pre-morbid psychological factors may contribute to development of pain Focus of therapy is discussion of the patients problems In Supportive Th. - therapist assumes an active role and offers reasonable explanation of various emotional problems faced by the patient. Behavioral, emotional and social impact of pain on patients life are discussed.

 Based

on Freudian and Neo-Freudian Principles. Therapist assume a passive role & pt do much of the talking free association method. Focused on unearthing unresolved & unconscious intra-psychic conflicts. Pain may symbolize and recapitulate unresolved emotional trauma and conflict. Need to recognize & accept the connections between the emotional conflict and the chronic pain.

Conditioning theory Focus on reinforcing role of social & environmental factors in dev & maintenance of chronic pain. Encourage the patient to identify & reinforce wellness behavior, while reduce the reinforcement of illness & behavior. Not limited to the formal psychotherapeutic session, but involves everyone of the team as well as family members & friends of the patient. Treatment approaches applied to a variety of situations of contact with the team like office visits, physical therapy, telephone contacts etc. Specific techniques graded activation & exercise program, de-conditioning, graded exposure, flooding, social reinforcement etc. Patients spouse & family learn how to encourage more adaptive pain management strategy in the patient.

 Aaron

Beck focus on changing maladaptive patterns of behavior preferred therapy for depression & many other. Examining & posing alternative to thoughts, attitudes & beliefs underlying them. Encouraging development of new skills & practices. Threefold approaches Psycho-educational phase Skill building phase relaxation training, activity pacing, distraction strategy, cognitive restructuring, problem solving & goal development. Application phase pts learn to consolidate & generalize the new strategy in >> challenging situations

 Semi-structured

& structured group psychotherapy combine the best element of supportive therapy, psychodynamic therapy, OBT and CBT. Structured group therapy most frequently prescribed interventions in Pain Clinics Time saving. Chances to see others in similar circumstances, experience similar feelings & encounter same problems & frustration. Format of group therapy includes time devoted to dev of group process & sharing of experiences & also formally structured psycho-educational & CBT component.

 Emphasis

not only on reduction of pain but restoration of function. Assisting toward successful limitations depends upon Multidisciplinary appreciation and understanding psychological factors. Establishment of good working alliance with pt. Accurate assessment of pts readiness for change. Application of approaches from a broad spectrum of psychotherapeutic interventions, supported by the entire team.

THANK YOU