Chapter 8 Pain management and cognitive behavioural therapy

Introduction

Cognitive behavioural interventions are psychologically based therapies that aim to reduce distress. In the context of health conditions such as chronic pain these interventions enable people to develop psychological and physical strategies that help them to manage the condition and its physical and psychological consequences (Moorey & Greer 2002, Quarmby et al 2006, Hutton 2008). They are one of the most effective interventions for reducing the impact of chronic pain (Morley et al 1999).

This chapter will discuss why people with pain suffer; why cognitive behavioural interventions are important in chronic pain; describe the content of these interventions and address some issues that need to be considered when working with people with joint hypermobility syndrome (JHS) or fibromyalgia (FM).

Why people with pain suffer

Chronic pain is defined as pain that has lasted for more than 3 months (The International Association for the Study of Pain 2003). When pain is long term the secondary biological, psychological and social effects of the condition can begin to play a significant role in the increase and maintenance of many difficulties (Turk & Monarch 2002). These difficulties can be extremely wide ranging:

• Distress relating to their experience of the healthcare system

– Have been told different things by different people about the cause of their pain

– Have been offered a variety of treatments; some of which may have helped but many have not helped

• Lack of understanding about their pain

– Confusion about its cause

– Concerns about increasing damage

– Not knowing the best way forward for them and their pain

• Medication

– Tried many different types, many of which only take the edge off the pain

– Experienced many side effects

• Fitness

– Reduction in fitness

– Weak muscles

– Stiff joints (despite being hypermobile)

• Friends and family

– Reduction in social life

– Loss of contact with friends

– Increased isolation

– Difficulties in sex life due to pain, fatigue, worry, misunderstandings

• Work

– Difficult to fulfil role at work due to pain

– Experience that managers/colleagues do not understand

– Reduction on working hours or stopped working

• Sleep and fatigue

– Hard to initiate sleep

– Wake during the night

– Feeling tired and fatigued throughout the day

– Sleep during the day, but unable to sleep at night

The history of chronic pain models

To understand the complexity of chronic pain and its effects one needs to look beyond the original models of pain such as that proposed by Descartes in the 17^th century. This was a dualistic model suggesting that pain perception was purely physical and did not involve psychological factors. The model proposed that a direct, unbroken pathway exists between peripheral pain receptors and specific brain centres and that pain is always a result of damage. The intensity of pain is considered proportional to the amount of damage and psychological processes are not involved in this pathway or in pain perception.

This dualistic model of pain was used until developments in scientific research and clinical observations gathered evidence to refute its reality. Some of the evidence lies in the following observations:

• Pain can continue to be experienced if the pain ‘pathway’ is cut. For example, people can experience phantom limb pain following the amputation of a painful limb.

• The physical changes that are seen on X-rays and scans are not proportional to the pain experienced. The results of X-rays and scans of people who report pain can be normal. Conversely, people who do not report pain can have abnormal X-rays and scans.

• Reports of pain are influenced by cognitive and psychological processes such as attention, emotions and beliefs about pain.

Developments in psychophysical and functional magnetic resonance imaging (fMRI) research have helped increase our understanding of the neural correlates of the pain experience and the role of psychological processes in the experience of pain. Imaging studies have shown that despite giving identical external noxious stimuli to a range of participants their reports of pain intensity varied (Coghill et al 2003). fMRI results show that reports of pain intensity do not correlate with stimulus intensity but with the degree of cortical activation in several brain regions that are not only important in pain processing but also cognitive processes. Participants who rated the noxious stimuli as very painful showed greater and more frequent activation of the following areas:

• Primary somatosensory cortex (thought to be involved in pain localization processing)

• Anterior cingulate cortex (thought to be involved in motivation and goal-oriented cognitive processes)

• Prefrontal cortex (associated with the affective component of pain and contributes to providing the negative emotional valence to the pain experience).

For a more in-depth discussion about psychological factors and pain the reader is directed to Chapter 3 and also Wall (2000) and Melzack (2001). Suggesting that psychological factors influence our experience of and responses to pain is not the same as saying that pain is psychological; rather it is the recognition that physical and psychological factors play a role in the processing and perception of physical symptoms.

In addition to biological and psychological factors influencing pain perception, it is now understood that social factors also play a role (Morris 1993, Frank 1997, Carr et al 2005). We do not live in isolation but within systems such as the family, work, healthcare, friendships and society. A variety of beliefs, messages, rules, stories and narratives exist within these systems, all of which influence our own beliefs and behaviour. The messages and information that we hear about illness and coping play a significant role in the perception of illness and the way in which the illness impacts on our lives.

Using the dualistic model to understand health conditions is now considered to be outdated and unhelpful (Sharpe & Williams 2002). It can result in patients’ pain being unhelpfully labelled as psychogenic or even if they are not told this explicitly patients are very sensitive to the possibility that a clinician believes that someone’s pain is psychological. Many of those suffering from JHS or FM have had this experience. This results in anger, frustration and a feeling of being disbelieved (Gurley-Green 2001) (see Prologue).

Those who have moved away from using the dualistic model now use a biopsychosocial framework (Engel 1977) to help them and the patient understand their condition and the effects that it is having on them and their lives.

The biopyschosocial model highlights the dynamic interaction between biological, psychological and social factors in all health conditions for everyone. The degree to which each of these factors plays a role will differ between individuals but this is seen as normal rather than pathological. This model has been applied to pain (Main & Williams 2002, Waddell 2004) and has placed psychological and social factors firmly in the realm of pain research and practice (Linton 2000).

Cognitive behavioural therapy

Medical interventions can be helpful for some but not all people with chronic pain. Research has suggested that even if these interventions reduce the pain by 30% this does not necessarily result in an improvement in the quality of people’s lives because the secondary psychological and physical effects of pain remain (Dworkin et al 2003). The absence of a cure for everyone with chronic pain has led to the development of psychologically based interventions. The cognitive behavioural model is a psychological model that is used to understand and address people’s distress. It was developed by Beck (1976) and its application to a range of difficulties is now supported by the National Institute for Health and Clinical Excellence (NICE) (2007).

The central tenet of the model is that our thoughts, emotions, behaviour and bodily sensations influence one another (Fig. 8.1).

Fig. 8.1 Thoughts, emotions, behaviour and bodily sensations influence one another

The model hypothesizes that it is our interpretation of the situations that we are in that is one of the main precursors of distress. If a number of people are in the same situation it is very likely that they will have different thoughts about the situation and therefore experience different emotions and will respond to the situation in different ways. People’s interpretations of situations are based on many factors. Some of these, accompanied by examples relating to pain include:

• Past experiences (e.g. having coped well with a previous experience of pain)

• Family beliefs (e.g. must remain stoical in the face of illness)

• Past observations (e.g. seeing someone with the same condition who is coping well)

• Messages and stories told by influential people (e.g. a doctor telling someone that they will end up in a wheelchair)

• Memories (e.g. a parent with a disabling condition who did not cope well)

• Current and past mood (e.g. depression, anxiety).

Cognitive behavioural theory does not deny the reality of peoples’ pain and distress. It recognizes that people have a pain condition but that their beliefs and thoughts about their pain and situation influence their response to their pain and their level of distress. It is essential that the reader and the patient understand that the model is not suggesting that pain is caused by psychological factors and if only someone thought differently then all their troubles would be over.

As the diagrammatic form of the cognitive model suggests, the influence between thoughts, feeling, behaviour and the body is not linear but cyclical. One can influence another which can influence another and another and so the cycle continues. If these influences are unhelpful, over time the detrimental impact of the pain can become wide ranging. Figure 8.2 outlines a typical situation that can occur over a few months or years.

Fig. 8.2 A typical situation that can occur over a few months or years

Cognitive behavioural interventions aim to help people recognize their unhelpful cognitive and behavioural responses to pain, re-evaluate them and replace them with more helpful alternatives that will reduce distress and disability. This brief description does not do justice to the intricacies of this intervention and the skills required in its implementation. The application of this model requires the therapist to undergo appropriate training and to be supervised in their clinical practice.

Over 40 published randomized controlled trials have assessed the efficacy of cognitive behavioural interventions for chronic pain (Morley 2004). These trials suggest that when compared with waiting list controls, cognitive behavioural interventions are more effective in restoring function, improving mood and reducing disability and unhelpful pain-related behaviours (Morley et al 1999). Compared with a range of heterogeneous interventions (such as those provided by pain clinics, physiotherapy, occupational therapy and educational packages) cognitive behavioural interventions produce significantly greater changes in the pain experience (intensity, unpleasantness and sensation), improved cognitive strategies to manage pain and reduced behavioural expression of pain (Morley et al 1999). McCracken and Turk (2002) support these findings and add that cognitive behavioural interventions lead to an overall decrease in health care costs and an increased chance of returning to work.

The outcome literature suggests that cognitive behavioural interventions help to make a significant impact on improving the physical and psychological function of people with FM (Thieme et al 2006, van Koulil et al 2007, 2008). Clinical outcome measures suggest that people with JHS make significant gains in a pain management programme for people with JHS across a range of physical and psychological measures (Daniel et al 2006). However, to the author’s knowledge there are no studies published on cognitive behavioural interventions for JHS. This may be for the following reasons:

• Those with JHS may be treated in a group of people with many conditions that are associated with chronic pain and therefore are reported as part of a chronic pain cohort in the literature.

• It is known that JHS is under-recognized and neglected in clinical practice (Grahame & Hakim 2008) as are the psychosocial sequelae (Grahame 2001). It is therefore likely that the need for cognitive behavioural interventions for JHS is overlooked.

Aims and content of cognitive behavioural interventions

The wide-ranging effects of chronic pain are reflected in the aims of cognitive behavioural interventions. The overall aim is to help people develop skills to help them manage their pain and reduce the psychological and physical impact on their lives. The specific aims of cognitive behavioural pain management are listed below and then described in more detail in the text. When reading about the intervention it is important to remember than each element of the intervention does not exist in isolation, rather each works in association with the others to:

• Improve understanding of chronic pain

• Reduce pain-related distress

• Improve communication with others, in particular about chronic pain

• Return to valued and enjoyable activities

• Improve physical functioning and reduce disability

• Improve sleep

• Develop ways to manage increases in pain.

Clinical experience suggests that it is helpful if patients and clinicians do not view a reduction in pain as a main aim of these interventions. The research in the effectiveness of cognitive behavioural interventions for chronic pain suggests that a reduction in pain is reported. This may be due to a reduction in the number of days during which the pain increases rather than a reduction in the normal baseline level of pain. If patients focus on pain reduction as their primary aim some may have difficulty focusing on developing self-management skills.

Although cognitive behavioural interventions for chronic pain can be provided by one psychological therapist, those patients whose pain is having a greater physical and psychological impact on their lives may gain more benefit from a multidisciplinary team intervention. The British Pain Society (2007) suggests that the core team should consist of:

• A medically qualified person such as a consultant in pain management or another medical specialist, for example a GP, neurologist, or rheumatologist

• A chartered clinical psychologist or BABCP-registered cognitive behavioural therapist

• A state-registered physiotherapist.

Other members that can provide valuable input are:

• An occupational therapist

• A nurse

• A pharmacist

• An assistant psychologist.

It is essential that all the team members have appropriate training in the application of their professional skills to chronic pain and are supervised in their work.

Cognitive behavioural interventions for chronic pain are typically delivered in a group format known as pain management programmes (PMPs). This approach works well because the team provides consistent and reinforced messages and because group members can gain a great deal from meeting people with the same condition. A debate exists about whether PMPs should be provided for diagnostic groups rather than chronic pain per se (Turk & Okifuji 2001, Daniel 2005, Daniel et al 2006). Whilst the overriding principles and techniques are the same for all chronic pain regardless of the cause, when the pain is related to a specific condition or syndrome that is associated with other difficulties then groups for specific diagnoses may be beneficial because these difficulties could be addressed to some extent within the group context. In addition it has been recognized that those who feel different from the other group members are more likely to leave the group before the end of the intervention (Coughlan et al 1995). The author’s clinical observations suggest that having one or two people with JHS in a group of people with chronic pain not associated with JHS can lead to group disharmony and the people with JHS feeling dissatisfied with the intervention and misunderstood by the team. Conversely, being in a group specifically for people with JHS can provide a containing and supportive environment for the group to develop self-management techniques.

Improving understanding of chronic pain

Many of the difficulties experienced following the onset of pain are the secondary physical and psychological effects. These arise partly due to a misunderstanding about chronic pain. Many people respond to chronic pain as though it were acute. Acute pain is pain that lasts for less than 3 months and is generally associated with damage. If we believe that our pain is acute, our response is often rest to allow healing to take place, medication to reduce the pain, and protecting the painful areas by restricting movement. Although not always the case, we tend not to worry about acute pain because although it may be unpleasant we believe that any damage will heal and the pain will resolve. However, these responses in the presence of chronic pain can cause more difficulties. In chronic pain the relationship between pain and damage is less clear. Very often there is no damage even if the initial pain began following an injury. It is because of the need to respond differently to acute and chronic pain that education is an important element of cognitive behavioural interventions. Learning about the differences between the physiology of acute and chronic pain helps people to understand chronic pain and the need to change their responses to it.

People who have JHS are more susceptible to injury, dislocation and subluxation (see Chapter 2). Therefore it can be hard, but necessary, for people with JHS to understand the differences between pain that is a result of injury and their long-term chronic pain and to know how to respond to both.

Reducing pain-related distress

Due to the association between thoughts, feelings, behaviour and bodily symptoms it is common for people with chronic pain to experience a range of distressing emotions and those with JHS and FM are no exception (Gurely-Green 2001, Gupta et al 2007, Verbunt 2008). Although research papers allude to JHS being associated with distress, to the author’s knowledge there are no published data on the prevalence of specific psychological difficulties in this population. However, the data collected in a PMP specifically for people with JHS suggest that their distress is similar to those with chronic pain that is not associated with JHS. The types of distress that are commonly reported by people with chronic pain are:

• Low mood or depression due to losses associated with long-term pain

• Frustration because the pain is a barrier to achieving goals

• Anxiety about the nature and cause of the pain

• Fear about the pain increasing, the future and losing independence

• Guilt due to feeling a burden on other people.

The cognitive behavioural pain literature recognizes that people’s beliefs and thoughts about themselves and their pain can contribute to this distress and reinforce unhelpful behaviours which can increase distress further (Crombez et al 1999, Lamé et al 2005). For example, the belief that having chronic pain takes away everything worthwhile may result in low mood which in turn may result in a reluctance to engage in life outside the home, which has the consequence of lowering activity level which in itself results in many unhelpful effects. Common unhelpful meanings and beliefs about chronic pain that can increase distress and unhelpful behaviours include:

• My pain means that something inside me is damaged

• An increase in my pain means I have done something I shouldn’t have

• An increase in my pain means that the damage has become worse

• My pain means that I’ll never live a happy life

• My pain means that I’ll never fulfil any of my dreams

• Having pain means that I won’t have a meaningful future

• I’ll never be able to cope with chronic pain.

Although these thoughts are understandable, they are not helpful and are not necessarily fact. Cognitive behavioural interventions help people to understand the link between thoughts, emotions, behaviour and pain. They are encouraged to become aware of their unhelpful thoughts, particularly in relation to the meaning of the pain and ongoing damage. They learn that thoughts are our own interpretations of a situation and that they tend not to be fact. These interpretations are influenced by normal but often unhelpful biases in the processing of information. Patients are encouraged to consider any biases that may be resulting in an unhelpful interpretation of the situation. These biases include:

• Hypervigilance to physical symptoms

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