stress

What happens when you can’t do what you want to?


Intendus interruptus, or ‘I want to but I can’t do it’

There is no doubt that having chronic pain stops many people from working towards things they want in their life.  At least for some of the time, especially during the early phases of their experience, people tend to focus on obtaining a diagnosis, then either a cure or some form of pain reduction.  Comments from people during this time are ‘I put my life on hold’, ‘I’m just focusing on getting through each day’.

What we then see, as chronic pain persists, is a gradual reduction of engagement in firstly leisure activities, then work activities (however you construe this), and finally self care activities. Over time, as Paul Karoly puts it, they develop ‘… a self-defeating reappraisal of one’s everyday goals and aspirations in light of the unabating discomfort and pain.’ (Karoly & Reuhlman, 1996) We see this as deactivation, demoralisation and reducing levels of function. (more…)

Distress and wellbeing – two sides of the same coin?


ResearchBlogging.org

Predictors of psychological distress and well-being in women with chronic musculoskeletal pain: Two sides of the same coin?
Alexa Hubera, Anna Lisa Sumana, Giovanni Biasib, Giancarlo Carlia

This is an interesting article on the concepts of wellbeing and distress. Distress is often considered a key element in whether someone has ‘good quality of life’ (see my post from a day or so ago), but in this article, the relationship between psychological distress and well-being was explored, and the predictors of both in patients with chronic nonmalignant pain are identified.

Why would we be bothered about distress and how is it measured? Distress is not a particularly well-defined concept, but is often referred to in the same breath as ‘eustress’ and ‘distress’ (see this entry in Wikipedia for an exploration of several theories relevant to stress and coping). If its used in this way, it often refers to suffering (which is about negative judgements of a situation or event), and is distinct from depression. Using Loeser’s onion rings model of pain, it’s the emotional judgement of pain that negatively impact on the individual.

In this article, however, the authors refer to two traditions and the impact these traditions have on our ideas about wellbeing. To quote ‘[the] hedonic approach focuses on happiness, while the eudaimonic approach defines well-being in terms of the degree to which a person is fully functioning, which may or may not be accompanied by feeling good.’
This reminds me of the traditional WHO definition of health – which is not simply the absence of disease!

One of the reasons I was drawn to this study was the statement by the authors that ‘To date, few studies on well-being in patients suffering from chronic pain have been published’. (Of course I’d argue that experiencing chronic pain may be mandatory, but ‘suffering’ is optional!) This is precisely the point I’ve been trying to make for some time in that most of our knowledge about people experiencing chronic pain is drawn from people who are seeking treatment. People who live well despite having chronic pain are not studied often and hence we know relatively little about them.

So, getting down to the nuts and bolts of this study: 69 women recruited from a University Hospital Rheumatology centre. The majority of them met criteria for fibromyalgia, while the remainder had widespread pain, and many of them also experienced other conditions associated with central sensitisation syndrome (e.g. psoriasis, irritable bowel syndrome, headache, fatigue).
They all completed a raft of measures, but the ones I want to focus on are those assessing distress:
The Symptom Check List-90 (SCL-90) measures psychiatric symptoms and psychological distress and has been used often in this type of research.
The State–Trait Anxiety Inventory Form Y (STAI-Y) consists of two scales measuring state (STAT-Y1) and trait anxiety (STAT-Y2), respectively. It’s been used in many studies of anxiety in different patient and community groups.


The Multidimensional Affect and Pain Survey (MAPS)was used to measure pain-related emotional suffering and well-being. It consists of 101 descriptors within 30 clusters, grouped into three scales.
1.
The Somatosensory Pain scale measures somatosensory pain sensations, and its results weren’t considered in this study.
2.
The Emotional Pain scale (EP) measures pain-related emotional suffering within eight areas: Physical Illness, Depressed Mood, Self-Blame, Anger, Anxiety, Fear, Apathy, and Fatigue.
3.
The Well-Being scale (WB) measures aspects of wellbeing in five clusters. The first two clusters—Mentally Engaged (e.g.,“interested”) and Physically Active (e.g., “vigorous”)— measure healthy activities and follow the eudaimonic tradition (which defines well-being in terms of functioning, not happiness).
The third and fourth clusters—Affiliative Feelings (e.g.,“sympathetic”) and Positive Affect (e.g., “happy”)—measure happy thoughts and really within the hedonic tradition. The fifth cluster, Treatable Illness, measures to what extent the patient believes that his/her illness is “curable” or “manageable” and represents a separate dimension of well-being.

(Just a comment – I’m not sure of the relationship between this measure and measures of acceptance such as those being studied by McCracken and others).
The other variables included in this study were ‘general epidemiological–anamnestic questionnaire, six measures of physical symptoms (tender point count, pain area, pain intensity, fatigue, stiffness, and physical disability).

Now for some statistics – not particularly challenging ones, so don’t panic!
Pearson correlation coefficients were used to assess the relationships between measures of well-being and psychological distress, applying Bonferroni adjusted α levels.

These showed only three physical symptoms—pain intensity (VAS), number of positive tender points, and physical disability (FIQ)— showed meaningful correlations with psychological distress and/or well-being.

A hierarchical multiple regression analysis was carried out to separately predict each of the six measures of well-being (WB-4 and each of the five WB clusters) and three measures of psychological distress (MAPS EP, STAI-Y2, and SCL-90 GSI).  ‘Predictors were entered in the following order in five steps: (a) age; (b) pain duration (i.e., time passed since the onset of pain symptoms); (c) pain intensity; (d) number of positive tender points; and (e) physical disability.‘ Just so you know, several of these were mathematically transformed to make the stats assumptions work (which may affect the rigour of the results), but at least they told you about it!

Ok, results.
Well, almost half the participants reached the cut-off score for trait anxiety, and many of them also reached the score for high distress.  They sound fairly like the people that get referred to Burwood Pain Management Centre.

In terms of psychological distress, higher age and more physical disability emerged as the two most important predictors of psychological distress, each making unique contributions.

‘Both Pearson correlations (and multiple regression demonstrated that wellbeing (as measured by WB-4) was significantly predicted from low physical disability alone, and was independent of age, pain duration, pain intensity, and tender point count.’

What does this actually mean?
The results really show that the relationship between psychological distress and pain-related symptoms, may be mediated by the patient’s limitations in the capacity to perform daily household chores (ie disability).

We know that disability is influenced by a whole range of factors including the responses of significant others – and the cognitive interpretation of the meaning of those limitations, such as the disparity between what the person believes is expected of them as compared with what they believe they are capable of.  It’s not simply about pain intensity.

Wellbeing, on the other hand, decreased with higher disability but, in contrast to psychological distress, was independent of age, pain intensity, and tender point count.

Now the finding that well-being was independent of pain intensity is an important result of this study.

Yesterday I quoted from Katz where it was assumed that if pain intensity alone was reduced, ‘quality of life’ would improve. I wouldn’t want to equate ‘quality of life’ with ‘wellbeing’ – but the dimensions are similar, and suggest that it’s simply not enough to reduce pain without simultaneously addressing other issues that are important to the individual.

As the authors state ‘Our findings suggest that, in patients with chronic musculoskeletal pain, well-being is related to aspects of physical disability that are not directly linked with pain. The results are in line with the literature demonstrating that the negative impact of chronic pain on physical functioning and work status is moderated by cognitive and psychosocial factors, such as pain catastrophizing and pain-related fear of movement.’

They add ‘Results are consistent with the view that pain behavior, rather than pain per se, should be the target of treatment’. Not news to many of us, but perhaps to those clinicians with a somewhat simplistic (or perhaps simply a biomedical) viewpoint, it may be surprising.

I’m also keen to support their contention that psychological wellbeing should be measured as an outcome quite distinct from a reduction in psychological distress. It’s a new concept for health care – to think that along with ways to reduce distress, clinicians could also consider ways to enhance wellbeing – and that this can occur in the absence of a focus on pain reduction.

It makes me think that the emerging field of positive psychology is something that pain management clinicians could well start to view more seriously. My post from the other day on counting blessings comes to mind. And for those of us working in the field for the long term – it might make our work just a little lighter and more fun!

HUBER, A., SUMAN, A., BIASI, G., CARLI, G. (2008). Predictors of psychological distress and well-being in women with chronic musculoskeletal pain: Two sides of the same coin?. Journal of Psychosomatic Research, 64(2), 169-175. DOI: 10.1016/j.jpsychores.2007.09.005

Pain, disability and psychosocial factors


ResearchBlogging.org

Something that can really get my goat is when people think that because someone has high disability, and they have pain, it must be the pain that ’causes’ the disability – therefore reduce the pain, and you will inevitably reduce the disability.

This can lead to over-treatment of pain with medication (to reduce the pain, often in response to the person saying that their pain is ‘getting worse’, and limited attention to the factors that are associated with the person seeking treatment or having difficulty reducing their disability. What’s worse is that while a pain reduction treatment initially reduces pain, it doesn’t address the factors that lead to a person seeking treatment or those that contribute to disability.

Now I know that I have a bias towards psychosocial factors, but to disregard these factors and to treat only the pain using pain reduction can leave some people over-treated with pain reduction interventions, but continuing to experience distress and disability because those psychosocial factors are not addressed.

I’ve come across this paper by Truchon, Cote, Fillion, Arsenault & Dionne (2007), which nicely integrates psychosocial factors associated with low back pain disability into a ‘stress process model’.

The stress process model ‘attempts to explain how individuals react to life events that are generally associated with substantial adaptations.’ While this model doesn’t attempt to explain why some people experience low back pain, it does attempt to explain low back disability. They are not the same.

From this study, using some very well-known assessment tools, the authors crunched numbers and were able to form a structural model that demonstrates what some of us have seen in our clinical work: life events and injury cognitive appraisal had a direct influence on emotional distress. The indirect contribution of life events to explain disability through emotional distress is consistent with the literature on the stress process model.

The link between cognitive appraisal in terms of harm and lack of control and emotional distress has received considerable empirical validation in the stress literature, but less so in the low back pain literature. The perception of physical activity as harmful to back health and a perceived lack of control over pain were likely to lead to the use of physical-activity-avoidance strategies.

This is critical where an individual has received a pain reduction intervention but continues to perceive that ‘structural weakness’ in the back is present. What may happen is that any fluctuation in pain intensity (after surgery or with medication), particularly any increase after a period of time when the pain has reduced, can be perceived as confirmation that ‘things are not right’, leading to activity avoidance. Alternatively, unregulated activity levels can lead to times when over-activity is then followed by under-activity dependent on pain levels. Pain levels increase after over-activity possibly because of lack of conditioning for the specific tasks…

Finally, and probably most importantly, emotional distress was directly linked to coping strategies. This signifies that the more an individual feels distress, the more he or she tends to avoid physical activity. These results suggest that addressing cognitions and distress in clinical settings [my emphasis] could increase compliance with staying active.

And finally, the combination of emotional distress and coping strategies contributed to explaining over half the variance of functional disability in the subacute stage, as measured by the Roland–Morris questionnaire.

What makes this study unusual is the inclusion of life events that may influence the general coping quality of an individual experiencing low back pain. Some of the most stressful life events include pregnancy and birth, loss of a job, relationship changes, as well as numerous ‘life hassle’s that have a cumulative effect. Maybe it’s time we assessed for life events around the time of the onset of acute low back pain, to establish whether more attention than usual should be paid to helping someone cope more effectively with back pain, rather than merely providing pain relief.

TRUCHON, M. (2007). Low-back-pain related disability: An integration of psychological risk factors into the stress process model. Pain DOI: 10.1016/j.pain.2007.10.019

Chronic Pain’s Favourite Tools


Teamwork and working with thoughts and beliefs.

Some therapists believe cognitive behavioural therapy (CBT) is ‘only’ for psychologists. Well, I’m not one of them. Frankly, if you are hoping to change ‘what people do’, you are using CBT…whether you’re doing it well or not – that’s another thing! (uhh.. that proviso holds for psychologists also)

What does it involve? It primarily involves identifying thoughts and beliefs, checking out the consequences of holding those beliefs, and providing the person you are working with some information about the implications of those beliefs. After this – it’s about doing something different to cement any belief change into place.

So, how does it all fit together? Well, in chronic pain it could work something like this…Anna attends her pain service. At intake, she is seen by three professionals – medical, functional and psychosocial (including work). She completes a set of questionnaires. At the end of the assessment, all her team sit together to discuss the aspects of her presentation that they feel are important. Using a common model of pain (biopsychosocial), her team review her questionnaires and develop a preliminary explanation (or hypothesis) for the development and maintenance of her current problems with pain. The team explains this model to Anna, who is able to confirm whether their findings ‘fit’ with her experience. She and the team agree that her main concerns are

  • poor sleep,
  • avoiding certain activities
  • low activity level

She starts with the medical person to begin new medications, and then returns to see whether these have helped.

On this occasion she also sees the occupational therapist and psychologist to review (together) a model of chronic pain, and the impact on her life. Anna specifies her main concerns about her sleep, and it is hypothesised that she is not doing very much during the day, and she is very worried about her future. Her general fitness level is low and she is fearful of increasing her activity level.

The working hypothesis for the team is: Anna has chronic pain, she has developed anxiety about her pain, and is avoiding activities that she believes will increase her pain. As a result of this she is not doing very much, and her body is quite ‘wound up’. She is both deactivated (and has lost fitness), and has poor sleep (because she has not exercise much, and lies awake worrying).

Once her medications have been stabilised, Anna starts to see the occupational therapist, psychologist and physiotherapist to begin working on her functional goals.

The occupational therapist is interested in Anna’s daily activity pattern and the activities she most wants to pursue, including work; the physiotherapist is keen to establish a fitness programme to increase her cardiovascular fitness; while the psychologist intends to help Anna become aware of how her worrying has become a habit prior to going to sleep.

As a team they all agree that Anna is anxious about experiencing pain, is worried that when she has pain she ‘won’t cope’ (but is not fully aware of what she means by not coping), and has developed avoidance patterns and engages in safety behaviours that she has inadvertently developed to ‘keep herself safe’.

The physiotherapist encounters Anna’s automatic thought that ‘this is going to be too much for me’ when she starts to get on the bicycle. The physio gently encourages Anna to define what ‘too much’ would be – and reassures her that Anna has the skills to cope even when she is sore. At the same time, the physio starts teaching Anna diaphragmatic breathing, using a the word ‘relax’ as a cue word on the out breath. After the session the physio talks to the occupational therapist who sees Anna next about Anna’s concerns about coping.

The OT starts the session by developing a hierarchy of activities that Anna has been avoiding, going from ‘least concerned about’ to ‘most concerned about’. While doing this, she encourages Anna to identify what her automatic thoughts are, and what she thinks those thoughts mean. She encourages Anna to continue with a daily walk or cycle, and ends the session with a few minutes of diaphragmatic breathing using the cue word ‘relax’, and a posture-based relaxation. She gives Anna a notebook to record her walking or cycling, relaxation, and a copy of the posture-based relaxation.

Anna sees the psychologist last, and discusses the goals for the week. She and the psychologist talk through the meaning of anxiety and stress, and discuss the fight/flight/freeze response. The psychologist gives Anna a worksheet containing sentence stems about chronic pain, advises Anna on basic sleep hygiene and asks her to record her sleep in the diary. The psychologist also enquires about Anna’s exercise plan, and encourages Anna to work to get her heart rate to the target level.
In this example it’s hard to work out where the ‘psychology’ part begins and ends – and similarly where the OT and physio aspects begin and end.

This is teamwork, this is interdisciplinary, this is trust – and this is seamless service delivery.

Who benefits? Anna.