Psychological factors affecting physical disorders: Part 2

Author(s): Armando S. Miciano, MD

Originally published:09/20/2014

Last updated:09/20/2014

1. DISEASE/DISORDER:

See Part 1.

2. ESSENTIALS OF ASSESSMENT

See Part 1.

3. REHABILITATION MANAGEMENT AND TREATMENTS

Available or current treatment guidelines

The co-occurrence of chronic pain and psychological disorders (e.g., depression, anxiety, posttraumatic stress disorder [PTSD]) necessitate the use of evidence-based interventions that address both the psychological distress and decreased function of chronic pain patients. Treatment of these complex patients is best accomplished when multiple providers concomitantly offer their services. These services often include rehabilitation through physical therapy, occupational therapy, medication management, complementary and alternative medicine approaches, psychological therapies, and limited use of interventional pain procedures. In a multidisciplinary approach, a number of providers independently offer treatments within their specialty. However, with an interdisciplinary team, providers from varying backgrounds join to co-treat the patient. Within the interdisciplinary team model, there is significantly greater understanding between providers as to what each specialty brings and how an integration of these multiple fields will contribute to the rehabilitation of patients. Interdisciplinary approaches requires that the rehabilitation physician also possess a greater understanding of the other disciplines co-treating patients. This article topic will provide the rehabilitation physician and other members of the rehabilitation team with a greater understanding of the approaches available for the psychological components of chronic pain patients.

Commonly utilized psychological interventions include cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT). These evidence-based models of treatment, whether delivered through individual or group therapy modalities, target patients’ appraisals of pain and their resulting behavioral responses.1-3 Given the large body of empirical support, CBT is currently considered the criterion standard of psychological treatments for chronic pain by the American Psychological Association Division 12 Task Force. This therapy aims to restructure patients’ maladaptive and catastrophic cognitions. Given that frequent catastrophizing is associated with unfavorable treatment outcomes, CBT is particularly beneficial in reducing psychological distress and pain-related disability in catastrophizing patients.1,4

CBT also encourages skill mastery and behavioral activation through the use of realistic, goal-directed physical activities. In order to prevent chronic pain patients from failing to meet their physical goals, patients are encouraged to set small, attainable goals as they work toward larger goals. The encouragement of physical activities can be especially helpful for chronic pain patients with comorbid anxiety who also demonstrate a consistent fear of movement and reinjury.4Known as kinesiophobia, this fear of movement leads to avoidance of any physical activity that is perceived to contribute to further pain or nerve damage. Given that kinesiophobia is strongly associated with functional limitations and self-reported physical disability, more so than pain severity, the successful attainment of realistic behavioral goals, as practiced through CBT, is particularly important for such patients. Overall, CBT, in conjunction with interdisciplinary chronic pain treatments, is effective in reducing maladaptive pain-related cognitions, increasing functionality, and decreasing psychological distress among chronic pain patients presenting with depression, anxiety, PTSD, and hypochondriasis.1,3,5-7

Another cognitive behavioral model of psychotherapy that is beginning to gain empirical support is ACT. This therapy examines how pain-related cognitions impact the functioning of chronic pain patients and how the experience of pain promotes psychological suffering. ACT aims to disentangle patients from their threatening pain-related cognitions, foster acceptance of the chronic nature of their pain, and encourage commitment of values-based action. Doing so allows chronic pain patients to experience less depression and pain-related anxiety, reduce their health care use, and increase their functionality.8

Treatment outcomes studies suggest that patients living with chronic pain and certain psychological disorders (eg, depression, anxiety, PTSD) benefit from increased self-efficacy and perceived control over their pain experience, which often lead to more adaptive coping of their chronic condition. Psychopharmacology is frequently used utilized along with psychological treatments. Some medications, such as serotonin-norepinephrine reuptake inhibitors (SSRIs) (eg, venlafaxine, desvenlafaxine, duloxetine, milnacipran, levomilnacipran) can treat both depression and pain. However, multiple medications are often combined. When doing so, the prescriber should be aware of possible complications, especially in patients who do not take their medications as prescribed or who are at increased risk of intentional overdose. Two major conditions to be aware of are central nervous system depression and serotonin syndrome (triad of mental status changes, autonomic hyperactivity, and neuromuscular abnormalities). Serotonin syndrome occurs in approximately 14% to 16% of persons who overdose on SSRIs, but it can also occur from standard doses.9

At different disease stages

The high rates of comorbidity between chronic pain and psychological disorders and the impact of psychological distress on pain prognoses highlight the importance of using mental health screeners. Although interdisciplinary teams may rely on their psychologists for the administration and interpretation of sophisticated psychological assessments, patients who are being following by one provider or co-located providers may not have opportunities to receive mental health screenings. Brief screening tools can help to identify patients who are in need of psychological interventions.

After such patients have been identified, the trajectory and severity of their psychopathology should undergo further consideration. For example, although mild-to-moderate depression may respond to outpatient psychotherapy and psychopharmacology, severe depression and suicidal ideation that is accompanied by intent and plan often warrant more intensive treatment and, at times, inpatient psychiatric care. When treating patients with any kind of severe psychopathology, pain-related psychological interventions are often secondary to the stabilization of the patient through intensive psychotherapy and psychopharmacology. Similarly, other psychological comorbidities, such as PTSD and ongoing substance use (including alcohol, marijuana, tobacco, caffeine, prescription medications, and illicit drugs) often warrant specialized and additional mental health treatments.10The initial assessment and ongoing monitoring will help determine if these other conditions are better treated prior to continuing with the pain team.

In addition to assessing the severity of patients’ psychopathology, psychosocial stressors (e.g., lack of housing, financial hardship) should be considered. According to Maslow’s hierarchy of needs,11all humans have basic needs (e.g., food, shelter, security). When these needs are not readily fulfilled, higher-order psychologic interventions cannot be successfully implemented. Therefore, patients who are in need of housing, for example, may benefit more from resources provided from social work before being able to fully participate in psychological interventions.

Coordination of care

The interdependent relationship between chronic pain, psychological distress, and decreased function warrants comprehensive, interdisciplinary assessment and treatment.4Because ofits pervasive influence on patients’ lives, chronic pain often does not respond favorably to unidisciplinary approaches. On the other hand, interdisciplinary care of chronic pain patients reduces psychological distress, improves physical functioning, and decreases medication use in a cost-effective manner.1,12This team should not only includes the providers previouslylisted, but it also could include pain pharmacy, social work, nursing, vocational rehabilitation, and recreation therapy. Finally, case management can be a critical component of the team, helping the patient navigate thepotential complexity of the treatment plan.Also, the case manager becomes a single point of contact when the patient experiences the expected change in symptoms as they progress in their treatment.In addition to improving treatment outcomes, coordination of care can help providers identify patients with other psychological issues (e.g., Munchausen syndrome, fictitious disorders).13From a mental health perspective, interdisciplinaryteams that include social workers and psychiatrists in addition to psychologists may help address complicated psychological concerns of chronic pain patients, some of which have been previously mentioned.

Patient & family education

Educating patients about commonly observed emotional and behavioral reactions to chronic pain is an important aspect of most pain-related psychological interventions.14Pain education allows psychologists, along with other providers, to normalize patients’ experience of pain while introducing adaptive coping skills. This type of subtle intervention is associated with pain-related cognitive modifications and increased physical activity.3Given the widespread influence of chronic pain, family members and caretakers of patients may also benefit from attending pain education sessions. At times, family members unknowingly reinforce patients’ pain behaviors and, therefore, contribute to the maintenance of the patients’ poor coping and lack of acceptance about the chronic nature of their pain.

Emerging/unique Interventions

Patient-reported modifications of pain-related cognitions, increased physical functioning, and adaptive coping of general psychological distress often signify a favorable response to treatment.1To objectively measure various aspects of treatment, instruments (e.g., Medical Outcomes Study 36-Item Short-Form Health Survey, Pain Catastrophizing Scale, West Haven-Yale Multidimensional Pain Inventory, Minnesota Multiphasic Personality Inventory) are commonly utilized. However, patients’ expectations of pain treatments are also important predictors of treatment outcome.12For example, patients who are not receptive to psychological interventions or who do not agree with self-management of chronic pain may not benefit from treatment. According to the readiness-for-change model, patients who believe that their pain can only be managed through medical means are often not suitable candidates for psychological interventions.12In order to assess the expectations of patients, providers should facilitate discussions of treatment goals and the time frame in which patients anticipate reaching those goals.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Many psychotherapies improve the functioning of chronic pain patients through self-efficacy enhancing strategies. Group psychotherapies can be especially effective in fostering emotional and behavioral competencies. Group settings allow patients to share their concerns while receiving encouragement from other patients in a therapeutic, nonthreatening environment. Other techniques that can foster self-efficacy include using a variety of strategies (e.g., verbal, written) to convey important information to patients, encouraging self-management of nonacute pain, inquiring about emotional appraisals of pain, and identifying and reinforcing patients’ past and present successes in pain management.

4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

Cutting edge concepts and practice

Biofeedback is a technique that uses monitoring to report a patient’s bodily responses (e.g., skin temperature, heart rate) with the intention that a patient can learn to have more voluntary control over these responses. Although biofeedback has been used since the 1950s, there are continued technologic advances of the machines and physiologic responses that can be measured. For example, the use of real-time functional magnetic resonance imaging to measure and report the activity of specific brain areas related to the perception of pain has demonstrated some effectiveness for decreasing the magnitude of pain for patients with chronic pain in a research study.15However, despite advances in biofeedback machinery, there is evidence that general relaxation training designed to increase patient awareness of physiologic responses can be successful without the use of external devices.16

5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE

Gaps in the evidence-based knowledge

One area of the research that is not well studied or understood is how and why some patients transition from acute pain to chronic pain after an injury or why some people become disabled by chronic pain while others do not. Identifying the psychological factors that contribute to the development of chronic pain after an injury could potentially help with the prevention of more disabling conditions. At this point, however, little is even known about those factors. Additional longitudinal research is needed to better understand patients who recover or cope well with their condition.12In addition, research in pharmacology would provide guidance on how to safely treat co-existing medical and psychological conditions with fewer medications.

REFERENCES

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2. Marks R, Allegrante JP. A review and synthesis of research evidence for self-efficacy enhancing interventions for reducing chronic disability: implications for health education practice (part II).Health Promot Pract. 2005;6:148-156.

3. Moseley GL. Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain.Eur J Pain. 2004;8:39-45.

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5. Barsky AJ, Ahern DK. Cognitive behavior therapy for hypochondriasis. JAMA. 2004;291:1464-1471.

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7. Vowles KE, McCracken LM, Eccleston C. Process of change in treatment for chronic pain: the contributions of pain, acceptance and catastrophizing. Eur J Pain. 2007;11:779-787.

8. Vowles KE, McCracken LM. Acceptance and values-based action in chronic pain: a study of treatment effectiveness and process. J Consult Clin Psychol. 2008;76:397-407.

9. Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. 2005;352:1112-1120.

10. Edlund MJ, Steffick D, Hudson T, Harris KM, Sullivan M. Risk factors for clinically recognized opiod abuse and dependence among veterans using opiods for chronic non cancer pain. Pain. 2007;129:355-360.

11. Maslow AH. A theory of human motivation. Psychol Rev. 1943;50:370-396.

12. Turk DC, Okifuji, A. Psychological factors in chronic pain: evolution and revolution. J Clin Psychol. 2002;70:678-690.

13. Stiles A, Mitrirattanakul S, Sanders B. Munchausen syndrome presenting in patient who has undergone temporomandibular joint surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;91:20-23.

14. Morley S, Eccleston C, Williams A. Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain. 1999;80:1-13.

15. deCharms RC, Maeda F, Glover GH, et al. Control over brain activation and pain learned by using real-time functional MRI. Proc Natl Acad Sci U S A. 2005;102:18626-18631.

16. Arena JG, Blanchard EB. Biofeedback and relaxation therapy for chronic pain disorders. In: Gatchel RJ, Turk, DC, eds. Psychological Approaches to Pain Management: A Practitioner’s Handbook. New York, NY: Guilford Press; 1996:179-230.

Author Disclosure

Armando S. Miciano, MD
Nothing to Disclose

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