Psychology

Chronic pain as psychiatric disorder


For years I’ve taken a stance that chronic pain is not a psychiatric disorder. Yes, it’s associated with depression, anxiety and a host of other problems, but in itself it’s not primarily a mental health problem. I was taken to task for this the other day. The argument went like this:

“Pain disorder”: chronic pain…thought to be caused by psychological stress.  I argued that I didn’t like the label, and have met more people with psychological problems after they’ve developed chronic pain, rather than chronic pain initiated through psychological stress. The International Association for the Study of Pain notes accompanying the definition of pain states:

“Many people report pain in the absence of tissue damage or any likely pathophysiological cause; usually this happens for psychological reasons…. pain most often has a proximate physical cause (http://www.iasp-pain.org/Taxonomy?navItemNumber=576).”

Some people argue that this set of statements doesn’t consider central sensitisation (it was written before there were ways to examine living brain function) – but the end result was, as intended, to equate the experience of pain with only the experience of pain, rather than nociception or tissue damage. The person who disagreed with me suggested I was denigrating those with a mental health diagnosis – I hope I’m not, because illness affects people whether it’s so-called “physical” or “mental”.

Studies have shown that some people do develop chronic pain after being exposed to workplace stress – but haven’t been able to demonstrate that this is a direct stress —> pain relationship. Instead there could be any number of mediating and moderating factors, such as genetic predisposition to chronic pain, tendency to respond to stress with fatigue and increased risk of making errors, response from within the workplace system, working faster and harder because of stress, limited attention to recovery and so on. To show a direct relationship between stress and developing chronic pain, we’d need to see clear evidence of an impact on biological systems that are involved with both stress and pain, and we’d need to see a dose-response relationship and so on. There’s some suggestion that chronic stress may influence the HPA axis, particularly during childhood development, but the main hypothesis about stress and cortisol and neuroinflammation (the glucocorticoid cascade hypothesis) doesn’t appear to have translated well from animal studies to humans (Frodl & O’Keane, 2013).  Quintner and colleagues have suggested fibromyalgia may be the outcome of long-term adaptation to stress, but this hypothesis has not yet been rigorously tested (Lyon, Cohen & Quintner, 2011).

My stance on stress and chronic pain is that having chronic pain is extremely stressful. When a person experiences pain it disrupts and interferes with usual bodily experience during movement and rest. Being unable to do what’s important in life is frustrating, and can lead to social rejection – social rejection itself activates a number of neural pathways that are very similar to those active in chronic pain (MacDonald & Leary, 2005). There’s no doubt that for some people, the demoralising effect of trying time after time for a diagnosis, and the search for effective treatment is stressful enough to produce depression and/or anxiety, and certainly a sense of hopelessness and helplessness. If you happen to be vulnerable to mood problems, or to the effects of stress on a sensitive nervous system, then I’m certain there is a relationship between the two. But not in every case, and not all the time. And the jury is still out on which came first: the mood problem or the chronic pain.

Whatever, I have other reasons for not wanting chronic pain to be labelled a psychiatric disorder. Like it or not, mental health problems are not as well accepted socially as say, breaking a leg or having the flu. Despite the vigorous efforts of many people to raise awareness about depression and anxiety, it’s not anywhere near as easy to announce to people “I’ve got depression” than it is to say “I’ve got the flu”. It’s more difficult if you have chronic pain. Not only is there a really strong belief in the general community that pain should be associated with some sort of visible tissue insult, this belief carries through to many health professionals. Hopefully that’s changing, but far too slowly. What’s worse, many insurers and much compensation law identifies that if there’s no tissue damage, or the problem can’t be imaged, then pain is not a compensable condition. This places the person experiencing pain in an incredibly difficult position – how to demonstrate to people around them that they have a problem that isn’t imaginary and can’t be shrugged off.

Now add another layer of complexity to the argument. By labeling chronic pain a psychiatric disorder, the person being thus labelled experiences a double-whammy. Their pain may be real but not acknowledged, their suffering may be acknowledged but labelled a psychiatric problem. And very often treatment for psychiatric conditions is poorly funded, with limited attention to a biopsychosocial model or to an interdisciplinary approach.

A person given a diagnosis of “somatic symptom and related disorder” (according to DSM 5) is meant to mean they have “somatic symptoms associated with significant distress and impairment.”  The diagnosis is to be made “on the basis of positive symptoms and signs (distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to these symptoms) rather than the absence of a medical explanation for somatic complaints.” (See DSM-5, p. 309.)

I wonder, what are “abnormal” thoughts, feelings and behaviours in response to pain?  How is this judged? Who does the judging? What’s normal? Simply having pain that no-one can explain is, in itself, distressing. I’d have thought this was a pretty normal response.

The American Psychiatric Association states that the DSM 5 Pain Disorder diagnosis “takes a different approach to the important clinical realm of individuals with pain”. They go on to say “In DSM-IV, the pain disorder diagnoses assume that some pains are associated solely with psychological factors, some with medical diseases or injuries, and some with both. There is a lack of evidence that such distinctions can be made with reliability and validity, and a large body of research has demonstrated that psychological factors influence all forms of pain. Most individuals with chronic pain attribute their pain to a combination of factors, including somatic, psychological, and environmental influences. In DSM-5, some individuals with chronic pain would be appropriately diagnosed as having somatic symptom disorder, with predominant pain. For others, psychological factors affecting other medical conditions or an adjustment disorder would be more appropriate.”(click here for the document)

By acknowledging that it’s not possible to distinguish between pain associated with psychological, medical, injury or both, I think this category is a catch-all. I think it’s acknowledging that chronic pain is a problem that many people with mental health problems experience, and it recognises that clinicians working with those who have mental health problems need a box to tick to enable them to address the issues and be paid for it. This isn’t attacking those clinicians who use DSM V to justify their involvement with people who experience chronic pain. But I think it’s a clumsy way of addressing the underlying issue that means insurers and legislators STILL believe there has to be tissue damage, or something we can “see” before a person can have real pain.

 

Frodl, Thomas, & O’Keane, Veronica. (2013). How does the brain deal with cumulative stress? A review with focus on developmental stress, HPA axis function and hippocampal structure in humans. Neurobiology of Disease, 52(0), 24-37. doi: http://dx.doi.org/10.1016/j.nbd.2012.03.012

Lyon, Pamela, Cohen, Milton, & Quintner, John. (2011). An evolutionary stress-response hypothesis for chronic widespread pain (fibromyalgia syndrome). Pain Medicine, 12(8), 1167-1178.

MacDonald, Geoff, & Leary, Mark R. (2005). Why does social exclusion hurt? The relationship between social and physical pain. Psychological bulletin, 131(2), 202.

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Stepping out of the glue: How to generate goals


Chronic pain has been called one of the “most powerful and insidious disruptors” of routine, habit and wellbeing (Karoly, Okun, Enders & Tennen, 2014).  When a person experiences pain, a whole range of mechanisms come into play and work together to use thinking and processing space, and especially those areas we use when we’re developing and achieving goals.  When people are first trying to make sense of their situation, they can find it hard to think about future goals and plans, and instead focus on trying to solve the problem of pain – many people call this time like being in limbo (McGowan, Luker, Creed & Chew-Graham, 2007).

It’s not surprising, then, that when clinicians begin to work with someone who has had pain for a very long time, it can be very difficult for them to think of a “goal”. After all, not everyone sets goals anyway (I heard somewhere that it’s about 3% of people – but I can’t find the research to support it). But in pain management, funders often ask clinicians to work with the client to “set goals” for therapy from the first day as a way to ensure a client-centred programme, increase motivation, and monitor outcomes. This can be a problem in a couple of ways: first of all, if the person doesn’t have goals because they’ve been in “limbo land” for a long time, and feel pretty demoralised or their goal relates to “getting rid of the pain”; secondly, if the person has vague ideas that are difficult to set into the typical “SMART” formula (incidentally, I really don’t like that acronym!); thirdly, if the person doesn’t have strong ideas about what they want from therapy, the clinician can set the goals for them, and perhaps not those the client is really all that interested in; and finally, it’s hard to set goals without having spent some time listening to and collaborating with the client.

Pain can be experienced as a major obstacle to motivation for setting goals. Negative mood associated with pain can reduce motivation to think ahead, to dream. Morning pain in particular can make it more difficult to want to do things, unless those activities are important, there are relatively structured ways to pursue them, and they don’t need much planning.  This can influence whether a person gets out of bed to go to work, or the gym, or take the kids to school. In a daily diary study, Karoly, Okun, Mooris, Enders and Tennen (2014) found that people with relatively high overall pain over a two-week period, but not necessarily just in the morning, and who have chosen to stay working, often also carry out their “lifestyle” goals in the afternoon. They suggest this could be because goals that are further out in time, and the positive feelings associated with achieving work goals keep them motivated. But they also found that even then, on the days people had more than their usual pain in the morning, they were less inclined to do as much.

The implication of this finding by Karoly and colleagues is that people who experience a “high pain” morning might need some reminders of the pleasure they get when they achieve goals – perhaps to pay attending to people and places that support their goal achievement. Helping people develop goal planning skills might also be useful – do the thinking when you’re feeling a bit more positive and can see beyond “now”, then when pain is higher, the cognitive demanding work is already done and the reminders help to generate positive emotions to encourage doing them.

OK, so we know some ways of helping people keep motivated, but what do we do to help people set them in the first place?

People are motivated by both push and pull factors. We want to move towards things we experience as good, and away from things we don’t enjoy. When pain is present, not only does it become hard to think straight, it doesn’t feel like it will ever change. So we need to help people dream a little. One way I do this is ask “What would you be doing if pain wasn’t such a problem for you?” Note that I’m not saying pain isn’t there – but that it’s less of a problem. Sometimes I’ll use a plastic magic wand and hand it to the person, asking them to dream a little. Other times I’ll add in “What gives you joy and pleasure? What makes you lose your sense of time and place? What gives you a sense of satisfaction when it’s done?”

These questions begin to identify activities in which a person might experience “flow” – Mihaly Czikszentmihalyi.

Another way is to ask the person what they need to, or want to do, perhaps using the occupational therapy broad groups of “productivity/work”, “leisure/fun”, and “self care” as prompts.

I’ve also found that by asking “what’s important in your life” can be a good way to generate personal goals. Importance indicates that the person places value on it. Values are important and lasting beliefs or ideals shared by people about what is good or bad and desirable or undesirable. Values underpin ACT (Acceptance and Commitment Therapy), because instead of setting goals, which can be achieved, values are like a compass – things we do (actions) allow us to move closer towards important values, and we never completely achieve them. They’re directional and aspirational, and allow us to do difficult things that have short-term negative consequences, just so we can move towards a better long-term consequence (van Huet, Innes & Stancliffe, 2013).

How can you use this in therapy?

Well, if a person really values family, and being a good Dad, anything that Dad does to enable him to be a better Dad will be motivational. So you can ask “What could you do today that would take you one step closer to being a great Dad?” And use whatever that might be as the foundation for a goal. Then you can go on and use all the other great goal-setting strategies like specific, measurable, achievable, relevant, and so on.

This doesn’t mean that doing that thing will be easy – far from it! But it will make achieving it more relevant, powerful and motivating. Working with the challenges is why you are a therapist.

 

Karoly, Paul, Okun, Morris A., Enders, Craig, & Tennen, Howard. (2014). Effects of Pain Intensity on Goal Schemas and Goal Pursuit: A Daily Diary Study. Health Psychology, 33(9), 968-976.

McGowan, Linda, Luker, Karen, Creed, Francis, & Chew-Graham, Carolyn A. (2007). ‘How do you explain a pain that can’t be seen?’: The narratives of women with chronic pelvic pain and their disengagement with the diagnostic cycle. British Journal of Health Psychology, 12(2), 261-274.

van Huet, Helen, Innes, Ev, & Stancliffe, Roger. (2013). Occupational therapists perspectives of factors influencing chronic pain management. Australian Occupational Therapy Journal, 60(1), 56-65.

…but I thought a new knee would fix my pain!


ResearchBlogging.org
Working in an orthopaedic surgery department is quite enlightening. Along with discussions about ceramic vs metal implants and cartilage regeneration (I work with a team of researchers looking at how to create replacement cartilage), the topic of what counts as a surgical success in knee surgery also comes up from time to time. Knee joint replacement isn’t as successful as hip joint replacement for a number of reasons including the complex nature of the joint, the way the joint capsule is disrupted during surgery, and the knee can apparently feel quite different from the original knee.

What this means is there can be quite a mismatch of expectations for people who believe very strongly that there should be no pain and they should have a completely normal knee joint after surgery. In fact, in the NZ National Joint Registry, the main reason recorded for knee joint revision is pain.

Naturally, the problem of pain after surgery is something surgeons and researchers are also interested in. Many studies have shown psychological factors such as catastrophising (thinking the worst) and low mood are associated with poorer outcomes (Riddle, Wade. Jiranek, & Kong, 2010; Roth, Tripp, Harrison, Sullivan & Carson, 2007; Shelby, Somers, Keefe, Pells, Dixon & Blumenthal, 2008).  The outcomes looked at so far include length of stay in hospital at the time of surgery, analgesia use during surgery, increased disability after surgery and revision rates.

Now, one solution to this problem could be simply not performing joint replacement surgery in people who are depressed and tend to think the worst. The problem is that two of the strongest predictors for looking for treatment are – you guessed it: low mood and catastrophising (and disability). Another solution is to provide intervention after surgery to target the people who tend to become fearful – perhaps an enhanced level of physiotherapy for this group, while the less vulnerable may even require less. Some studies have also looked at giving better education about what the surgery entails and the expected outcomes, and doing this before the person undergoes surgery, while another study has looked at providing a pain coping skills training course prior to surgery (Riddle, Wade, Jiranek & Kong, 2011). The outcomes from this last approach were promising, although it was a very small sample size, and the follow-up was for only two months.

There are a number of problems with implementing any of these approaches in clinical practice, at least in the system I’m most familiar with (NZ):

  1. Many orthopaedic surgeons still discount the importance of psychological factors, and consider the information they provide completely adequate for presurgical preparation
  2. It’s difficult to give someone different or special treatment based on psychological factors within a usual clinical setting without also inadvertently giving people a label that may change how they are responded to
  3. Any additional intervention will have an up-front cost (not good for cost accountants!)
  4. These treatments need specially trained clinicians who understand the measures being used, the rationale for treatment, and the type of treatment needed – and because these are psychological factors and surgery is conducted in a “physical” hospital, this is unfamiliar territory for many
  5. Patients may not be very comfortable with a treatment that focuses on thoughts, emotions and pain

It seems to me, and from the results from a recent study looking at analgesic use after surgery, that an argument simply based on the cost of failing to go ahead with effective management of psychosocial factors would make sense. Here’s the detail:

Fuzier, Serres, Bourrel, Palmaro, Montastruc and Lapeyre-Mestre (2014) conducted a large study of patients in the Midi-Pyrenees region of France. They examined the medical records of all 1939 patients who had knee arthroplasty, and compared the drug use (what was dispensed) at four times – 12 months before surgery, 2 months before surgery, and 10 months before and after the knee surgery.  What they found was an increase in analgesic, antineuropathic and opioid drug use in the 12 months after surgery. The actual percentage of patients requiring more medication is astonishing: 47% of people needed more analgesia, 8.6% needed more antineuropathic medications, and 5.6% needed more opioids. That’s a whole lot of drugs!

These researchers also analysed a number of other variables associated with the medication changes, and made some more understandable findings:

  • people having total knee replacement surgery were at a greater risk of using more medication than those having unicompartmental surgery (half a joint)
  • people with high levels of preoperative pain along with “psychiatric vulnerability” were at greater risk of having increased neuropathic medications prescribed
  • but older people were less likely to be prescribed additional medications

Unfortunately, this study didn’t identify the particular “psychiatric vulnerabilities” of the patients who participated – from the paper it looks like data was extracted from clinical records, so psychiatric disorders such as depression, anxiety and so on are the likely culprits. We don’t therefore know whether catastrophising contributed to the medication use – but given the results from at least 20 studies I have in my database, I think it’s probably likely.

Medications are not cheap. While they’re quick to prescribe, dispense and take, they cost not only in fiscal terms (which is a serious consideration, nevertheless), but also in side effects – and more importantly, in loss of personal locus of control. What I mean by this is that these are people who haven’t been given the opportunity to develop pain self management skills. They will continue to catastrophise, and perhaps even more so after surgery because their fears have been confirmed. Maybe it’s cheaper and more humane to bite the bullet and begin giving people appropriate psychosocial treatment before, during and after surgery.

Fuzier, R., Serres, I., Bourrel, R., Palmaro, A., Montastruc, J., & Lapeyre-Mestre, M. (2014). Analgesic drug consumption increases after knee arthroplasty: A pharmacoepidemiological study investigating postoperative pain PAIN®, 155 (7), 1339-1345 DOI: 10.1016/j.pain.2014.04.010

Riddle, D. L., Keefe, F. J., Nay, W. T., McKee, D., Attarian, D. E., & Jensen, M. P. (2011). Pain coping skills training for patients with elevated pain catastrophizing who are scheduled for knee arthroplasty: a quasi-experimental study. Archives of Physical Medicine & Rehabilitation, 92(6), 859-865.

Riddle, D. L., Wade, J. B., Jiranek, W. A., & Kong, X. (2010). Preoperative pain catastrophizing predicts pain outcome after knee arthroplasty. Clinical Orthopaedics & Related Research, 468(3), 798-806.

Roth, M. L., Tripp, D. A., Harrison, M. H., Sullivan, M., & Carson, P. (2007). Demographic and psychosocial predictors of acute perioperative pain for total knee arthroplasty. Pain Research & Management, 12(3), 185-194.

Shelby, Rebecca A., Somers, Tamara J., Keefe, Francis J., Pells, Jennifer J., Dixon, Kim E., & Blumenthal, James A. (2008). Domain specific self-efficacy mediates the impact of pain catastrophizing on pain and disability in overweight and obese osteoarthritis patients. Journal of Pain, 9(10), 912-919.

Widespread pain, aka fibromyalgia – does it really belong in rheumatology?


ResearchBlogging.org
I’ve asked it before, and I’ll probably ask it again, but does widespread pain really belong with the rheumatologists? I think the answer is rapidly becoming “No”.
The “so what” question begs: does it really matter who looks after people with widespread pain? I think the answer is “yes”, only because it’s becoming clear that helping unravel the problem of fibromyalgia (widespread pain) is going to take a different tack from looking at peripheral mechanisms alone. In fact, it could be that peripheral mechanisms are by and large irrelevant to this enigmatic disorder.

What is fibromyalgia?

Good question: there are clear diagnostic criteria for the disorder, but developed mainly for research purposes. In clinical terms, fibromyalgia is a little more tricky. Essentially, if a person says “I hurt all over”, and they also report unrefreshing sleep, foggy thinking, fatigue and sensitivity to multiple sensory modalities, chances are the person has fibromyalgia, especially if the usual diagnostic tests fail to show anything else out of order. The American College of Rheumatology released revised criteria in 2010 (Wolfe, Clauw, Fitzcharles, et al., 2010) and now doesn’t require the presence of tender points.

And this is why I don’t think it’s necessary for people to be diagnosed by a rheumatologist: there are too many people who experience this range of symptoms for diagnosis to remain the province of a single specialty. At the same time, it seems quite evident that hunting for mysterious explanations for the problem by undertaking multiple investigations is also not the answer – instead, a GP using good clinical techniques can make a diagnosis and then focus on helping the person to manage his or her symptoms quickly and without fuss.

A recent paper by Fitzcharles, Ste-Marie & Pereira (2013) argues this point, saying that “the diagnosis is made on the basis of a composite of symptoms, centred on chronic widespread pain and absence of physical findings that would indicate another condition”, and “a physical examination is required for all patients, and findings may be completely within normal limits”, and “only limited laboratory testing should be conducted for most patients” (p. E646).

What about the neurobiology?

Here’s where the situation gets a little murky, and it’s going to take a while before we really begin to understand the problem.

Neurophysiologic studies show abnormal pain processing at various levels of the nervous system, and no single unique change associated with fibromyalgia. I use the term “pain” advisedly here, because while nociception may be involved, it is not obligatory, so what we are left with is the experience of pain and some really weird abnormalities that are associated with the experience. Remember, people have pain, it’s an experience, it’s formed by the interaction of biological, psychological and social elements, and we only know about it because people do something about it – look for help.

Studies show peripheral sensitisation of the primary somatosensory neuron, central sensitisation at the dorsal horn, changes at the thalamus and gray matter of the brain, impairment or reduced functioning of the descending noxious inhibitory control mechanisms, not to mention alteration of endogenous opioid uptake. Treatments are, therefore, focused primarily on reducing the ascending information and increasing the descending inhibitory mechanisms, or working to alter the way this information is managed or prioritised by the cortex.

This means that for most people with this kind of pain, some sort of neuromodulatory drug is part of the mix – something to reduce the “reactivity” of the neural circuitry involved in processing this kind of information.  Anticonvulsants such as gabapentin or pregabalin seem to do something useful, while tricyclic antidepressants or SNRI’s are also helpful, together or separately from the anticonvulsants. BUT medications really don’t alter the pain terribly much for many people with FM. I’m one of those who fail to respond to medications. What I, and many others with fibromyalgia are left with, is learning to use the most powerful of mechanisms in the world – our fabulous cortex.

A teeny bit more neurobiology

In a paper that is in preprint right now, a group of Spanish researchers have been l0oking not just at one part of the brain, but more at the connectivity and subtle interplay between various parts of the brain while a person with fibromyalgia experiences pain. The usual culprits involved in processing nociception such as the periaqueductal gray, anterior insula, pariental operculum/secondary somatosensory cortex (SII), and the primary somatosensory cortext.

Normally, there is activity between the perietal operculum/SII and the various sensory cortices such as the auditory, visual, primary somatosensory cortex and posteria insula. This is called the “default mode” and seems to provide support for Melzack’s “neuromatrix” theory where this network is assumed to monitor and maintain “normal representation” of the body. In people with fibromyalgia, there is reduced functional connectivity between these regions.  Interestingly, there were increased functional connections between the parietal operculum/SII and the posterior cingulate cortext, precuneus, ventral putamen and ventral insula. Subjective pain ratings were positively correlated with measures of functional connectivity between the parietal operculum and PCC, ACC, left angular gyrus (also parts of the default mode network), and the left prefrontal cortex.

The authors conclude that “Overall the data suggest a strong association of clinical pain with a general weakening of sensory integration in fibromyalgia.” They point out that the amgydala and the insula are two major parts of the descending limbic input to the PAG – suggesting down-regulation of the cerebral influence on the PAG. Normally the PAG provides a “brake” on ascending sensory information – if, in people with FM, this is not working properly, it provides some explanation for the poor sensory filtering in people with fibromyalgia.

What the authors argue is that because non-nociceptive information is downregulated, it provides an opportunity for more nociceptive information to reach various parts of the brain – and this occurs not just in pain, but also in other sensory modalities such as scent, sound and vision. A bit like migraineurs perhaps? Anyway, these researchers argue that “spontaneous pain may be a consequence of partial damage in the nociceptive system with a subsequent nociceptive system hyperexcitability and a secondary inhibition of the transmission of tactile signals.”

What does this mean for treatment?

Some treatments are based on providing competing information between nociceptive and non-nociceptive input – things like peripheral nerve stimulation, whole-body vibration therapy, heated water body stimulation – and probably far closer to my heart, whole body movement, body awareness and cognitive behavioural therapy. These provide opportunities for people with FM to develop (refine, enhance) discrimination between various body states and sensory inputs. By learning to be more aware of what is really happening in the body, paying mindful attention to what is, rather than what has happened or might happen, and by carefully structuring these experiences to grade the complexity and psychosocial variables associated with them including the emotions associated with them, people with FM may begin to “retune” the out of sync central mechanisms involved in sensory processing.

To me this means we need to go beyond a biomedical approach to managing fibromyalgia, or widespread pain. We need to incorporate occupational therapists, who have specific training in analysing occupations (activities) and can grade the complexity of these occupations to titrate the level of input to where the individual needs it. We need physiotherapists to guide movements and grade complexity of movement patterns. We need to work as a team to help people understand and reconceptualise their role in managing fibromyalgia – and overall, we need to help people with FM learn to live well despite their pain. My question is: should this be the province of a single speciality in medicine? I don’t think so, I think it belongs to us all, and especially to people living with the problem.

Fitzcharles, Mary-Ann, Ste-Marie, Peter A., Pereira, John X., & Iglar, Karl. (2013). Fibromyalgia: evolving concepts over the past 2 decades. Canadian Medical Association Journal. doi: 10.1503/cmaj.121414

Pujol, J., Macià, D., Garcia-Fontanals, A., Blanco-Hinojo, L., López-Solà, M., Garcia-Blanco, S., Poca-Dias, V., Harrison, B., Contreras-Rodríguez, O., Monfort, J., Garcia-Fructuoso, F., & Deus, J. (2014). The contribution of sensory system functional connectivity reduction to clinical pain in fibromyalgia PAIN® DOI: 10.1016/j.pain.2014.04.028

Wolfe, F., Clauw, DJ., Fitzcharles, M-A., et al. (2010). The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity. Arthritis Care Research (Hoboken), 62, 600-610.

How occupational engagement might work in pain management


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Intuitively, most of us know that when we’re actively involved in doing something we either enjoy or is sufficiently complex enough to need attention, we can lose awareness of things like hunger, thirst – or pain.  In the very early years of occupational therapy, this “distracting” factor of occupation was employed to good effect to while away the time needed to recover from serious trauma following the World Wars.  Over the years following, the positive effects of being involved in occupation were somehow overlo0ked in the desire to get scientific about the serious business of rehabilitation. Frivolous things like occupation for occupation’s sake was often left behind.

More recently we’ve begun to learn more about how occupation might be a good thing.  First came the cumulative findings that being in work was not only economically healthy, but also maintained physical and mental wellbeing.

Then we found that through positive psychology studies that the state of  “flow” popularised by Mihaly Csikszentmihalyi could bring about not only positive emotions (afterwards, not specifically during because during flow the focus is almost entirely on the doing rather than any emotion) but also greater creativity and integrated physical/emotional/mental performance.

Now studies are emerging to demonstrate how occupational engagement (not necessarily even flow experiences) may work in pain management.  This is interesting to me for several reasons – firstly there have been some inconsistent findings with respect to the usefulness of distraction per se, where in one study people experienced an increase in pain after being engaged in a distraction activity (Goubert, Crombez, Eccleston & Devulder, 2004).  Secondly, most of the research into coping with chronic pain has occurred without specific attention to the valued goals of the individual.

Let me explain: usually it’s recommended to maintain a consistent level of activity.  Sometimes this is called activity pacing.  Yet there are times when it’s appropriate to suspend the use of pacing – when there is a special event like Christmas, or when dealing with an important deadline (writing an exam over two hours).  We accommodate these events by varying the kind of strategy employed, maybe drawing on the use of additional relaxation in the day following Christmas, or using coping self statements during the exam.

Schrooten, VanDamme, Crombez, Peters, Vogt and Vlaeyen explored whether bias to attend to pain is impaired when an individual is engaged in a competing activity.  Participants in this experimental study with people who do not usually have pain, were given a spatial cueing task with pain cues and neutral cues.  Their attention bias towards pain was measured in terms of the speed with which they were able to identify whether a cue matched a stimulus.  Two different colours were used, one of which had been associated with a painful stimulus.  Usually, people respond more quickly to the stimulus that has been associated with pain than to a neutral stimulus because pain is a threat and our brains work hard to make sure we notice anything that might threaten our wellbeing.

To make this a little more exciting (well, for the researchers anyway!), half of the participants were also presented with a letter in the middle of the screen (the cues were randomly placed to either left or right of the screen) and asked to say the letter out loud.  If they got the letter correct, they were told they would be rewarded with money depending on the number of correct responses they made.  This was the “nonpain task goal”, or activity/occupation.

The results showed that when participants were distracted by the activity that might earn them money, they were slower at responding to the painful cue than when they were not distracted.  In other words, they were not as quick to respond to things that they had previously viewed as a potential threat.

This is a really interesting finding – while it’s a far cry from the kind of naturally rewarding activity we usually engage in when in the real world, the very structured and controlled nature of this experiment was able to demonstrate that there are measurable effects on how quickly our brains attend to things that we have learned might be a threat.

Another similar study using a different experimental study is by Bradshaw, Chapman, Jacobson and Donaldson (2012) in which music was used.  Their findings were that “engaging activities may prevent pain by creating competing constructions of reality that draw on the same processing resources as pain. ”

It looks like occupational therapists need to seriously get involved in the psychophysiological studies of why and how occupational engagement might work in pain management.

Schrooten, M., Van Damme, S., Crombez, G., Peters, M., Vogt, J., & Vlaeyen, J. (2012). Nonpain goal pursuit inhibits attentional bias to pain PAIN DOI: 10.1016/j.pain.2012.01.025

Goubert, L., Crombez, G., Eccleston, C., & Devulder, J. (2004). Distraction from chronic pain during a pain-inducing activity is associated with greater post-activity pain. Pain, 110(1-2), 220-227.

Bradshaw, D.,Chapman, CR., Jacobson, RC.,  and Donaldson, G. (epub ahead of print). Effects of Music Engagement on Responses to Painful Stimulation. Clinical Journal of Pain.

When patients think their problem is mysterious


ResearchBlogging.orgThis post is sparked off by a Facebook discussion where someone (you know who you are!) asked what to do when patients hold entrenched beliefs about the uniqueness or mysteriousness of their situation.  They might say things like “I don’t think anyone know what to do with me”, or “I think because my situation is atypical, I don’t expect to respond normally”, or “herniated discs don’t usually shoot ALL the way to the foot”.  Does anyone else recognise this pattern?

The person who asked about this said the main problem was in trying to tell the person that his or her symptoms are not unique or weird, without taking away their “specialness”.  Sometimes, in trying to give accurate information, and pointing out that others have similar symptoms, the person can react as if they’re offended.  On the one hand, this person said, we are all unique and deserve to be treated as individuals and on the other hand there is a commonness in suffering that we should take comfort in.

In musing about this, I thought about some of the reasons people seek treatment.  While it’s almost a given that people are looking for alleviation of their suffering, there are a complex range of reasons that people come in to see a health provider, and not all of the reasons are evident even to the patient!

As an aside, I think it’s incredibly difficult to help some clinicians see that people think they’re logical and know the reasons for their actions, when in fact we are all influenced by an array of factors that are implicit and thus we’re not aware of their effect – more on this later.

Why do people seek treatment?

In a meta-analytic study by Ferreira, Machado, Latimer et al. (2010), the main determinants of care-seeking in back pain were

  • being female (OR: 1.67; 95% CI: 1.49, 1.88),
  • having had a bout of back pain before(OR: 1.45; 95% CI: 1.12, 1.86),
  • having higher levels of disability (OR: 1.92; 95% CI: 1.33, 2.78),
  • externalized beliefs regarding pain management (OR: 3.6; 95% CI: 2.1–6.0),
  • fear of future job impairment (OR: 3.07; 95% CI: 2.33, 4.04),
  • limited social functioning (OR: 3.07; 95% CI: 2.33, 4.04),
  • or those engaged in sports activities (OR: 1.3; 95% CI: 1.0, 1.7)

What does this tell us?

The authors suggest that “individuals seek care based on an interaction that includes their predisposition to use health care, the available resources and their recognition for the need of care”.  They add “disability, and not pain, is the strongest determinant of care-seeking behavior in people with back pain”, and suggest that interventions need to aim at matching expectations and reducing disability rather than focusing on reducing pain.

So, what to do when a person says their pain is mysterious.

If we consider that people who seek treatment are inclined to do so as part of their belief that treatment is important, as well as tendency to look for treatment (almost like a habit), maybe we need to look at what health providers (us!) do to maintain this habit.

By saying “my pain is different”, the person may well be doing what he or she has learned before – maybe they haven’t responded as expected with another provider, and been told their pain is “different”. Maybe they’re worried that you won’t be able to help them either.  Remember that intermittent reinforcement has a powerful training effect and may be influencing the expectancy of this person – they’re anxious to let you know they are hanging hopes on doing “something”.

I suggested reflecting the “meta-message” the person is telling you. What about saying “It sounds like you’ve had some trouble getting help with your pain. From all the things people have told you about what’s going on, what do you make of it? What’s your theory?”.  At this time it’s also helpful to ask them “what does that mean for you? Where does that leave you?”.

If the person describes a belief that doesn’t sound plausible, or has some catastrophic interpretation of what might be going on (like the “herniated discs don’t usually shoot all the way to the foot”), I’d ask if it’s OK to tell them what I understand might be happening.  I then ask the person if they’d be prepared to work with me on a series of mini experiments to help us work out what is going on.

It’s worth checking in with our beliefs about why people seek help for their pain.  And establishing whether there are things we can do to help people remain active and engaged with their own health management.

Ferreira, Machado, Latimer et al (2010) concluded that “values and attitudes that individuals have about health and the use of health services can be viewed as the bridge between social structure and the perceived need for health care; it is how the status of a person in the community, or the individual’s ability to cope with presenting problems, can modify his or her perception for the need to seek care.”
Ferreira, M., Machado, G., Latimer, J., Maher, C., Ferreira, P., & Smeets, R. (2010). Factors defining care-seeking in low back pain – A meta-analysis of population based surveys European Journal of Pain, 14 (7), 7470-2147483647 DOI: 10.1016/j.ejpain.2009.11.005

Which comes first: Doing or knowing?


ResearchBlogging.orgReceived wisdom in cognitive behavioural therapy says that to change behaviour, a person must first change his or her thinking.  This has created a tension between those clinicians who emphasise the cognitive aspects of pain management – and those who focus on helping people with pain do more.  Should we educate and target cognitions, particularly those sticky core beliefs – or can we use behaviour change as a way to help the person make gains?

The answer is, as you’d have guessed, not black and white.  In fact, as several authors and researchers have pointed out (see the references below for just two), not only is the cognitive behavioural approach to chronic pain management a mixed bag of strategies, there is very little information on the process of change that occurs during treatment.

Here’s what I’ve seen clinically – while some people are ready to change, others are not.  I need to work with this second group using motivational interviewing approaches to help them identify their own reasons for doing things differently.

This might mean creating a sense of dilemma – identifying where they are now in terms of goals and satisfaction with life, and creating awareness both of the possibility that life might be different, and what that might look like.  This helps people recognise their “stuckness” and creates momentum for change.  From there, it’s far easier to help them develop goals and start to problem-solve what needs to happen to reach them.

Another group of people are those who are relatively inflexible in their thinking and behaviour – they’re stuck not because of a dilemma, but because they’re continuing to use strategies that have worked for them in the past, but are not working now.  It’s like they have trouble working out another way of approaching problems.

A good example of this is a man who has always been fit and before his pain began was a representative sportsman. His approach was always to do more than what was required. He was stuck because doing this when he had pain created a “boom and bust” approach to activity.   For this kind of person, I like to use what Steven Hayes (ACT) likes to call “creative hopelessness” – pointing out that it’s not the methods the person is using, but their purpose. I use experiential methods to do this – gettng the person to monitor what has happened over the week, and asking him to establish what he believes: his mind and what it tells him? or his experience and whether it works.

Cognitive change doesn’t necessarily occur before behaviour change
It’s strange, but true, that despite our best efforts, twelve months after people have completed a pain management programme, few are still using the strategies we help them develop.  While some are goal setting, or using relaxation, or exercising, or even checking in with their thinking – the majority are simply getting on with life (Curran, Williams  & Potts,  2009 – doi: 10.1016/j.pain.2005.09.004). And even more strange – people who start making behavioural changes early in a pain management programme seem to do best, while those who actually complete between-session activities also seem to do best (Heapy, Otis, Marcus, et al., 2005).

Persuasion, challenging core beliefs, and education have their place – for the right reasons, at the right time, for the right person – but they don’t alter the fundamental issue alone. 

 What is that issue? It’s about an attitude shift towards “sitting with” uncomfortable thoughts and sensations, and working towards valued goals despite those thoughts and sensations.  It’s about a spirit of gentleness and willingness to recognise those thoughts and sensations as the mind’s way of solving problems – and at the same time, accepting that it’s entirely possible to do what is important despite the presence of these thoughts and sensations.

Morley, S., & Keefe, F. (2007). Getting a handle on process and change in CBT for chronic pain Pain, 127 (3), 197-198 DOI: 10.1016/j.pain.2006.10.025
Morley, S. (2004). Process and change in cognitive behaviour therapy for chronic pain Pain, 109 (3), 205-206 DOI: 10.1016/j.pain.2004.02.008

Curran, C., Williams, A. C. d. C., & Potts, H. W. W. (2009). Cognitive-behavioral therapy for persistent pain: Does adherence after treatment affect outcome? European Journal of Pain, 13(2), 178-188.

Around and around and around we go – or…back to the beginning again


ResearchBlogging.orgIn the early days of non-medical chronic pain management, operant models of behavioural learning were used by Prof W Fordyce.  At the time, this was a revolutionary approach to helping people with chronic pain reduce their disability, distress and depression by altering the reinforcement schedules operating on pain behaviour.  It was such an innovation because it moved the focus from pain intensity to disability associated with pain, and in doing so, it offered hope to the many people who were otherwise thought unlikely to ever “get better”.

Operant models gradually fell out of favour as cognitive behavioural approaches for managing pain became popular over the 1990’s and later.  Refinements to behavioural approaches have been incorporated into ACT (Acceptance and Commitment Therapy) and graded exposure treatments for pain-related anxiety and avoidance – but this hasn’t been extended to operant conditioning.

What exactly is operant conditioning? The simplest way to think of it is to remember “operant” conditioning “operates” on the environment with behaviour maintained by what occurs afterward – so we need to think about rewards, punishments, and positive and negative conditioning.  In other words, the chance I’ll reach for a certain brand of chocolate bar will go UP if I receive some sort of reward for doing so, while the chance of my watching the Rugby World Cup will go DOWN if the people around me groan in unison whenever a game comes on the TV.  But this depends on whether I want the reward offered by the chocolate manufacturer – or I’m bothered by people groaning when I have the TV on!

In a really interesting study by researchers from Eastern Michigan University and University of Washington (Seattle), three hypotheses were tested: fear-avoidance, operant, and pain models, and their ability to predict activity levels.

To recap, the so-called fear-avoidant (pain-related anxiety and avoidance) model involves anticipatory anxiety, or specific fear of movement/reinjury and the resultant avoidance of activity and is usually associated with a classical conditioning process.  A person moves and simultaneously experiences pain or the fear of pain/reinjury, and therefore movement becomes associated with pain.  It doesn’t take long before the person avoids movement because it hurts, and because of the meaning of the hurt.

The operant model involves the person’s behaviour “operating on” the environment (usually involving people’s responses to the behaviour) which serves to increase or reduce the likelihood the person will do that particular behaviour again.  Think of someone coming home with a headache, looking poorly, maybe lying down, and the partner offering comfort – chances are, if the person liked this response, he or she will do the same thing next time a headache comes to visit!

In the pain model, it’s believed that the experience of pain itself dictates the degree of disability an individual has.  So, the person may have a neurobiological vulnerability leading to a greater sensitivity to painful input, and an augmented experience of pain.

In this experiment, 20 patients with chronic low back pain attending a tertiary pain management centre were asked to complete a range of questionnaires, and then were tested with a pressure algometer to determine the pressure at which they experienced pain.  This is thought to help identify the degree of “pain sensitivity” people may have and in this experiment was used to test the pain model.

Then patients were asked to wear an accelerometer to determine their activity level over five days – except when in water (showering, bathing, swimming).

Working some awesome statistical analyses (that, as usual, I won’t go into! Read the paper itself for more details), the researchers found that “the operant model emerged as the only model accounting for a statistically significant amount of the variance in physical activity”.  While the other two models were also relevant, and did contribute to the level of activity people carried out, family and/or spouse responses that were less solicitous, less punishing, and more distracting predicted higher activity levels.

The researchers concluded that“significant others’ responses account for a significant amount of the variance in physical activity, confirming that reinforcement of behavior is a powerful mechanism for behavior change”.  In a sense, this is not news – the response of family and others has always been thought to be important.  What is news is that when the other two models were tested concurrently, the factor that had the most impact on activity level was that of family and partners.

Here’s a question: how often do we

(a) assess the responses of these important people in behavioural terms?  While we might ask about the impact of pain on relationships, I think we need to examine what people do when the person is experiencing pain, and we also need to know how the person demonstrates or displays their pain – what the significant other is responding to, and

(b) specifically address how the person with pain can manage the responses of other people to their pain behaviour? Do we tell the person to communicate effectively about their pain to help them let other people know what they would like them to do when they’re sore?  It can be a very delicate process to negotiate how to ask the partner not to take over the activities the person with pain is beginning to do again! and finally

(c) include the family and partner in our treatments, goal setting and pain “education” so they are more fully informed about what their family member is trying to do, and so they can know what their best options for offering support might be?

It’s almost like deja vu – operant conditioning is coming back in from the cold.  I’d love to know your take on how we can do this within our usual practice. 

Alschuler, K., Hoodin, F., Murphy, S., Rice, J., & Geisser, M. (2011). Factors contributing to physical activity in a chronic low back pain clinical sample: A comprehensive analysis using continuous ambulatory monitoring PAIN DOI: 10.1016/j.pain.2011.07.017

Education or a cognitive behavioural approach?


ResearchBlogging.orgThere is a reasonable amount of evidence suggesting that self management of chronic pain is only moderately effective.  Some of the factors thought to influence outcomes include the “one size fits all” approach – people with chronic pain may not all equally benefit from the same aspects of a programme; that programmes are usually delivered within a university-based, middle-class, North American setting and that there may be moderating or mediating factors that influence the who and what actually works within a programme.

I was interested to read about an RCT of “education” and “cognitive behavioural approach” conducted by Day, Thorn and Kapoor.   Dr Bev Thorn has written many books and research papers on a structured cognitive behavioural approach for pain that specifically addresses the appraisals people make of their pain.   In this approach, people are taken through a process of firstly identifying their appraisals, then learning how to challenge and restructure their thoughts about pain, while at the same time learning to do activities that they may have avoided for some time.  One feature of a CBT approach is using  “home learning” activities to bridge between sessions and help generalise the learning.

By comparison, an educational approach provides accurate information on aspects of pain and coping strategies, but doesn’t include the “home learning” and doesn’t directly address ways to identify and restructure thinking about pain.

One of the problems with many cognitive behavioural programmes for pain management is that they demand a lot from their participants – and particularly, they require literacy.  There can be, if not carefully structured, a lot of writing.  For people who don’t do writing or pen and paper activities, this can be really off-putting.  The sessions are also somewhat “talky” – again, this can be off-putting for people who prefer action and doing.

In this study by Day, Thorn & Kapoor, the two approaches were used with a group of people from a rural area, with relatively low socio-economic status, and a reading grade level of about 8.  Both groups received a group-based programme of 10 sessions of 90 minutes.  They both received a workbook and additional reading material.  The CBT group had home-learning and also participated in behavioural activities such as relaxation in-session, while the education group did not.

Interestingly, this study presents qualitative information on how participants experienced the sessions, rather than outcomes measures, so it’s difficult to establish whether pain, disability, mood or acceptance were influenced.  Instead it presents thematic analysis from in-depth interviews of the participants.

What this analysis found was that while the CBT group participants initially found it difficult to “get into” the process, they spontaneously identified many of the CBT elements that were meaningful to them such as intermediate beliefs, the ability to “redirect” thinking, and integrating activity management strategies such as pacing and task perseverance.

Fewer of these themes emerged from the education group, although group process factors similar to that identified in the CBT group were found.  Both groups identified that it was good to know they weren’t alone and that they learned from other members in the group.  Both groups also identified that they felt more confident and in control of their situation, that they could “rise above” their pain.

Where the groups also differed was in their engagement in preferred life activities (occupations).  Participants in the CBT group indicated that they were returning to preferred social activities, sports and leisure activities and that they believed they were able to persist with these despite an increase in pain.  This didn’t occur in participants involved in the education group.

What does this tell me?

Well, a couple of really important things.  While we don’t know which parts of the self management programmes do the hard work for people with chronic pain, it seems that a group approach has some unique benefits irrespective of the type of programme offered.  People with chronic pain often feel isolated and very alone, as if they are the only people with their specific problems.  A group approach provides an opportunity to normalise these experiences.

I also take the idea that information alone doesn’t necessarily initiate change – structured goals seem to help, setting an expectation that learning and engaging in activities between sessions may help, the feedback and problem-solving may help too.  It could also be the process of cognitive therapy – learning to identify thoughts and beliefs, and restructure these may be helpful.

We can’t, from this study at least, determine which of these ‘active ingredients’ is doing the trick.  I rather fancy that although the cognitive aspects certainly play a part, it could be these other aspects – setting expectations, supporting change, problem solving – these could actually be the parts that get people started on doing things differently in their own environment.

Is it time for a different take on self management? Maybe it’s time to embark on a less educational, more occupation-focused approach that incorporates cognitive restructuring in an active and “doing” way as part of problem solving – what do you think?

Day, M., Thorn, B., & Kapoor, S. (2011). A Qualitative Analysis of a Randomized Controlled Trial Comparing a Cognitive-Behavioral Treatment With Education The Journal of Pain DOI: 10.1016/j.jpain.2011.02.354
Miles, C., Pincus, T., Carnes, D., Homer, K., Taylor, S., Bremner, S., Rahman, A., & Underwood, M. (2011). Can we identify how programmes aimed at promoting self-management in musculoskeletal pain work and who benefits? A systematic review of sub-group analysis within RCTs European Journal of Pain DOI: 10.1016/j.ejpain.2011.01.016

Low mood and catastrophising – one is bad, two is worse


ResearchBlogging.orgHaving pain that persists creates a lot of stress, but there are many people who can limit the effect on their life and carry on.  These people seem to return to their everyday activities even if their pain hasn’t settled.  Then there are the other people.  This group have much more trouble managing with their pain.  They have more disability, more distress, seek more treatments and the impact of their pain spreads from the direct effect on their life, to effects on people around them.

If we could identify, then treat the risk factors that can lead to trouble recovering from pain, we might be able to limit the long term effects that chronic pain can have on people and our community.  While maybe 25 years ago the factors were thought to be biomechanical, or things like the extent of tissue damage – and yes, these do have some effect – over time it has become clear that psychosocial factors play an important role.

“Psychosocial factors” were initially quite poorly defined, and covered a multitude of sins! And to be honest, the focus is very often more on the psychological than the social part of that group of factors, but over time the picture is becoming a little clearer.  More on the social factors later – today it’s about low mood and catastrophising.

Firstly, low mood.  It’s unsurprising that people with persistent pain can feel a bit depressed.  Some people feel a lot depressed.  Imagine having trouble sleeping, worrying about your health, your job security, having to go through many different assessments and investigations – and all the while that pain is there.  So it’s not a big shock to find that people with low mood are often more distressed, seek more treatment – and have greater disability than people feeling less depressed.  Low mood in the subacute phase of pain is associated with more disability 12 months later.  This is a finding from many different studies and suggests that treating low mood is really important.

Catastrophising too, has been identified as a risk factor for greater disability and distress.  Catastrophising is the tendency to “think the worst” and has been viewed as an independent risk factor for longterm disability for some time.

In this multi-centre study based in New Zealand, Sweden and Australia, individuals with sub-acute pain (back pain with duration of less than three months) completed several questionnaires.  It’s a little unfortunate that the two groups used different measures, but with some magic by numbers, the measures were thought to be comparable.

The pain catastrophising measures used, were the Pain Catastrophising Scale and Pain Response Self Statements, and have excellent psychometric properties.  In addition to this, participants completed either the Hospital Anxiety and Depression Scale (Swedish sample) or the Depression Anxiety Stress Scale (Australasian sample), both of which are measures of low mood.  The disability measures were selected questions from the Orebro Musculoskeletal Questionnaire (the four ADL questions) in the Swedish group, while the Australasian group completed the Roland-Morris Disability measure.

What the researchers found was that some individuals had only high catastrophising, some had only high depression scores, and some had both high catastrophising and high depression scores. Oh – and some had both low depression scores and low catastrophising.  Make sense?

A relationship between high scores on either catastrophising or depression with greater disability was found – but not only this, there was a relationship between having high scores on both depression and catastrophising and having greater disability.  It seems evident that having both low mood and catastrophising increases the risk of disability.

It’s a little more complex that this – in the group with high catastrophising and low depression, higher levels of disability were found than in the group with high depression scores and low catastrophising.  This suggests that catastrophising may have a greater effect on disability than depression.

While this isn’t really a new finding, it is an important one.  This study shows that irrespective of the measures used to identify catastrophising and low mood in people with chronic pain, there is an increased risk of disability in people who have both problems, and more importantly, this is now shown in three different countries.  While the total number of participants isn’t enormous (in the 100’s rather than 1000’s), it is still a significant finding.  It also shows that having catastrophising is potentially a more problematic issue than simply having low mood.

What should we learn from this?
I think it’s critical that treatment providers working with those who have subacute musculoskeletal problems routinely assess (or at least screen for) the presence of catastrophising.  While low mood is troublesome, it seems to have greater recognition amongst primary care clinicians than catastrophising, so low mood can be identified and treated reasonably readily.  Catastrophising isn’t quite so commonly recognised nor managed – and that makes the risk of long term disability much greater.

Once identified – catastrophising needs to be managed.  I’ve written about this a good deal recently, so I hope this post might encourage readers to consider what steps they can take to identify and treat the problem promptly – or refer on.

Linton, S., Nicholas, M., MacDonald, S., Boersma, K., Bergbom, S., Maher, C., & Refshauge, K. (2011). The role of depression and catastrophizing in musculoskeletal pain European Journal of Pain, 15 (4), 416-422 DOI: 10.1016/j.ejpain.2010.08.009