University of EdinburghUniversity of Edinburgh

Lothian Chronic Pain ServiceLothian Chronic Pain Service

Dr. David GillandersDr. David Gillanders University of EdinburghUniversity of Edinburgh NHS Lothian Chronic Pain ServiceNHS Lothian Chronic Pain Service

Living Successfully with Chronic Living Successfully with Chronic Pain: Pain:

Appraisals, Acceptance, Catastrophising & Appraisals, Acceptance, Catastrophising & FunctioningFunctioning

AcknowledgementsAcknowledgements

Dr. Sujata Bose 26/10/1979 – 26/06/2007

Dr Tammy Spencer NHS Tayside

OverviewOverview

• The impact of chronic pain

• Disability

• Emotional dysfunction

• Beliefs and appraisals

• Catastrophising

• Acceptance & Commitment Therapy

• A cross sectional study of chronic pain patients

• Results

• Discussion

BackgroundBackground• Chronic pain is pain that persists beyond 6

months or continues after the normal time of healing

• Complex multifactorial causes, both physiological and psychological

• Survey of 46,394 people in 15 European countries19% of adults of working age had moderate to severe chronic pain

(Brevik et al, 2006)

BackgroundBackground

• Theories suggesting psychogenic causation have not been supported by empirical evidence

• Behavioural and Cognitive understandings have fit the data better, have been influential in understanding pain and helpful to clinicians in treating pain

(McCracken & Turk, 2002)

Psychological understandingsPsychological understandings

• Fear & Avoidance(Vlaeyen, Kole-Snijders, Boeren et al., 1995; McCracken & Gross, 1993)

• Beliefs are more disabling than pain itself(Crombez, Vlaeyen, Heuts et al., 1999; Vlaeyen & Linton, 2000)

• Catastrophising(Sullivan, Bishop & Pivik, 1995)

Illness PerceptionsIllness Perceptions

• ‘The Common Sense Self-Regulatory Model’(Leventhal et al., 1980; 1992; 1997; Weinman & Petrie, 1997; Rankin & Holtum, 2003)

• People make appraisals of symptoms and signs

• Appraisals influence self regulatory behaviour

• Influential model in many health states (rheumatoid arthritis, COPD, psoriasis, asthma, MI, diabetes, epilepsy, headache, & chronic pain)

Illness PerceptionsIllness Perceptions

• Dimensions:

IdentityTimelineCauseConsequencesCure / ControllabilityEmotional representations

CatastrophisingCatastrophising• An exaggerated mental set

• Rumination on pain sensations & consequences

• Magnification of seriousness of condition

• Perceptions of self as helpless

• Current and future orientated(Sullivan et al., 2001)

CatastrophisingCatastrophising• Stable dispositional trait

(Sullivan et al, 1995; Keefe, Brown, Wallston et al., 1989; Turner, Mancl & Aaron, 2004; Ellis & D’Eon, 2002; however Dixon et al, 2004 found less stable)

• Strong relationships between catastrophising and most indices of functioning:Pain intensity, disabilty and distress (Severeijins et al., 2001)

Quality of life (Lame et al., 2005)

Depression (Geisser et al, 1994; Jensen et al, 1991; Turner et al, 2000)

Observable pain behaviour & spousal responses(Sullivan et al, 2004; Boothby et al, 2004; Keefe et al, 2000)

Coping FrameworkCoping Framework• Strong evidence that coping behaviour is related to

pain intensity, emotional and physical functioning(Keefe et al, 1997; 2004; Jensen et al, 1991; Haythornthwaite et al, 1998)

• Coping means behaving in certain ways and thinking in certain ways in an effort to minimise pain, minimise distress and maintain function

• Variability in types of coping and their effectiveness(Haythorthwaite et al, 1998)

AcceptanceAcceptance• Coping frameworks offer an incomplete model

• Efforts at minimising pain and emotion may paradoxically reduce function

(McCracken, 1988; McCracken et al, 2004; McCracken and Eccleston, 2003; 2006; McCracken and Samuel, 2006)

• Pain control / coping can be viewed as a form of avoidance behaviour

• Avoidance of stimuli enhances their aversive properties(McCracken 1998)

AcceptanceAcceptance• Acceptance based treatment aims to reduce

efforts to control or minimise pain & distress

• Mindfulness and willingness experiential techniques are used to promote willingness to have pain

• In order that people make direct contact with values and value linked goals that give life meaning and purpose

AcceptanceAcceptance• Defusion techniques are used to de-literalise and

decenter from distress and thoughts that are associated with distress, in an effort to change the function of these experiences in cueing avoidant behaviour

• Preliminary evidence suggests ACT based treatments for pain are effective

(McCRacken et al., 2005; Vowles & McCracken, 2008; Dahl, Wilson & Nilsson, 2004; Wicksell, Dahl, Magnusson & Olsson, 2005)

AcceptanceAcceptance• Many cross sectional, prospective, experimental

and mediational studies support the finding that acceptance based approaches and understandings provide a fuller understanding of adjustment in chronic pain

(Wicksell et al., 2008; McCracken, Vowles & Gauntlet-Gilbert, 2007; McCracken and Vowles, 2007; 2008; McCracken, Gauntlett-Gilbert & Vowles, 2007; Vowles,

McCracken and Eccleston, 2007; Paez-Blarina, Luciano et al., 2008; McMullen, Barnes-Holmes et al., 2008; McCracken & Yang, 2006; Hates et al, 1999; Masedo &

Esteve; 2007; Gutierrez, Luciano et al., 2004)

SummarySummary• Pain patients’ behavioural functioning is

compromised

• Pain patients’ emotional functioning is also affected

• Beliefs & appraisals are strongly associated with behavioural and emotional functioning

• Acceptance also appears to play an important role in emotional and behavioural functioning.

Research QuestionsResearch Questions

• How are these constructs related?

• Which predicts emotional and behavioural functioning better: appraisals or acceptance?

• Are certain appraisals associated with catastrophising and acceptance?

MethodMethod• Cross sectional study

• Standardised Questionnaire measurement

• Clinical sample of heterogenous chronic pain patients

• Recruited from Pain clinics in Tayside and Lothian

MeasuresMeasures• Demographics: age, gender, duration of pain…

• Chronic Pain Acceptance Questionnaire (CPAQ: McCracken et al., 2004)

“I’m getting on with the business of living no matter what my pain is”“Controlling pain is less important than other goals in my life”

• Pain Catastrophising Scale(PCS: Sullivan et al., 1995)

“I worry all the time whether the pain will end”“There’s nothing I can do to reduce the intensity of the pain”

MeasuresMeasures• Illness Perceptions Questionnaire Revised

(IPQ-R: Moss-Morris et al., 2002)

“My pain will last a short time”

“My pain is a mystery to me”“My pain has serious financial consequences”

• McGill Pain Questionnaire – Short Form(MPQ-SF: Melzack, 1987)

• Hospital Anxiety & Depression Scale(HADS: Zigmond and Snaith, 1983)

MeasuresMeasures• Roland & Morris Sickness Impact Profile

(R&MSip: Roland & Morris, 1983)

“I have to lie down and rest more”“I try to get other people to do things for me”“I only walk short distances”“I avoid heavy jobs around the house because of pain”“I try not to kneel or bend”

AnalysisAnalysis

• Path analytic modelling was used(Bramwell, 1996)

• Power analysis indicated a sample size of 109 participants would be needed to detect a medium effect size at alpha 0.05 and power 0.80

(Green, 1991; Cohen, 1992)

Results - ParticipantsResults - Participants• 240 people invited to

participate

• 159 people returned questionnaires (66.3%)

• 153 people included in study

• Mean age 50.8 yrs (SD 13.2)

• 66% female, 44% male

66

44 Female Male

Results - ParticipantsResults - Participants

• Pain intensity: 18/50 McGill (typical of )

• Pain Duration: 10 yrs (SD 8.6 yrs)

Results - CorrelationsResults - CorrelationsVariables 2. 3. 4. 5. 6. 7. 8. 9.

1. Acceptance(CPAQ)

-0.68** -0.37** -0.66** -0.35** 0.32** -0.03 0.18* -0.59**

2.Catastrophising(PCS)

- 0.35** 0.59** 0.36** -0.37** 0.08 -0.32** 0.74**

3. Illness identity(IPQ-R)

- - 0.33** 0.19* 0.02 0.19* 0.08 0.28**

4. Consequences(IPQ-R)

- - - 0.53** -0.23** -0.03 -0.10 0.53**

5. Timeline(IPQ-R)

- - - - -0.37** -0.19* -0.05 0.40**

6. Control(IPQ-R)

- - - - - 0.20* 0.33** -0.30**

7. Cyclical nature(IPQ-R)

- - - - - - -0.01 0.11

8. Illness coherence(IPQ-R)

- - - - - - - -0.41**

9. Emotionalrepresentations(IPQ-R)

- - - - - - - -

* p<0.05 **p<0.01

Results – Path analysisResults – Path analysise = .58

catastrophising

acceptance

emotional function

e = .64

e = .58Identity

Controllability

Consequences

Emotional

-.12* .46** -.25**

-.31**-.36**

.20**

.22**

.40**

Results – Path analysisResults – Path analysise = .58

catastrophising

acceptance

emotional function

e = .64

e = .58Identity

Controllability

Consequences

Emotional

-.12* .46** -.25**

-.31**-.36**

.20**

.22**

.40**

Results – Path analysisResults – Path analysise = .58

catastrophising

acceptance

physical disability

e = .64

e = .72Identity

Controllability

Consequences

Emotional

-.12* .46** -.25**

-.31**-.36**

.14*

.39**

-.36**

Results – Path analysisResults – Path analysise = .58

catastrophising

acceptance

physical disability

e = .64

e = .72Identity

Controllability

Consequences

Emotional

-.12* .46** -.25**

-.31**-.36**

.14*

.39**

-.36**

Summary of findingsSummary of findings

LimitationsLimitations

Clinical ImplicationsClinical Implications

Implications for TheoryImplications for Theory

Future Research / Next StepsFuture Research / Next Steps

Thank you for listening…

david.gillanders@ed.ac.uk