Zimmerman, E. M., Jensen, K. M., Ackley, R., Epstein, P. S., & Konopka, L. M.

Presented at the Second Croatian Congress on Prevention and Rehabilitation in Psychiatry

10.2.2012

Pain management using a person-

centered approach

Previous approach to chronic pain treatment:Biologically focusedPeripheral CNS involvement

Other components often ignored:Higher CNS pain processingPsychological interpretation of painSocial isolation Spiritual doubt

Growing recognition of need for multidimensional approach (Wachholtz, Pearce, & Koenig, 2007)

Treatment of chronic pain

Bio-Psycho-Social-Spiritual (Engel 1977, 1992; Sulmasy, 2002)

MultidimensionalBidirectional Individual

Person-centered approach

51 year old, Mexican-American male Married to American 2 children, 2 grandchildren

Raised in Mexico Mexican Army

Moved to US Several manufacturing jobs Multiple on-the-job injuries

Left knee Right knee/ankle Second-degree burn (18-20% of body)

The patient

Chronic pain: burn Itching Swelling Anhidrosis Pain consistently between 5 – 8 (out of 10)

Chronic pain: knees and ankleMedications

Celebrex (1/day; pain) Cymbalta (3/day; anti-depressant/anti-anxiety) Lyrica (3/day; anti-seizure) Oxycontin (3/day; pain) Metformin (3/day; diabetes)

Presenting issues

Weight: 319 lbs, BMI: 40HypertensionDiabetes Mellitus Type II

Neuroimaging: MRI, PET, and qEEG

Biological

Positron Emission Tomography: Areas of significant subcortical and cortical hypo- and hyper-

activity: Contralateral thalamic hypometabolic activity Cingulate hypometabolic activity

biological

Quantitative EEG Excess slow and fast frequencies Small amplitude evoked potentials (auditory and visual stimuli)

Standard EEG acquired during ligand distribution: Subseizure activity: right frontal lobes

biological

Reported symptoms Pain Sleep difficulties Fear of driving Withdrawal Irritability

Neuropsychological findings (frontal lobe) Attention difficulties to

visual/auditory continuous performance task (anxiety)

Poor decision-making and planning

psychological

Attributions and motivation: (see Valente et al., 2009) Interpretation of pain (threatening v. tolerable) Self-efficacy (low v. high)

Individual habits and skills Avoidance v. acceptance Pain-contingent rest v. activity Guarding v. openness

Mood Depression and Anxiety: well-established link to chronic pain

(Miro, Nieto, & Huguet, 2008) Negative feelings increase pain intensity (Keogh, MacCracken, &

Eccleston, 2006)

psychological

IsolationWithdrawalDisinterest in family/friendsLoss of connections with

community

social

Social support High: less pain intensity, lower utilization of passive coping

strategies (Lopez-Martinez, Esteve, & Ramirez-Maestre, 2008). Low: higher levels of depression, poorer pain adjustment

(Campbell, Clauw, & Keefe, 2003)Cultural approach to pain

Differences in pain treatment and response based on culture US greater emotional/behavioral disruptions, more use of meds (Carron,

DeGood, & Tait, 1985)

Gender roles: pain response and culturally-based expectations Tolerance (Pool, Schwegler, Theodore & Fuchs, 2007) Coping Strategies (Ramirez-Maestre, Lopez-Martinez, Esteve,

2004)

Social

Lack of faith: “Why?”Lack of community: isolationRefusal to prayAnger

spiritual

spiritual

Image from Wachholtz, Pearce, & Koenig, 2007

Spiritual beliefs and practices may influence emotions/thoughts and thus biology to reduce pain experience (Rippentrop et al., 2005) Serotonin and spiritual proclivity (Borg et al., 2003) Enhanced treatment outcomes when incorporated (Tix & Frazier,

1998)Higher tolerance (Bush et al., 1999): able to continue

functioning in daily lives Positive R/S: problem solving with God, helping others, spiritual

support from community Negative R/S: deferring responsibility to God, feeling abandoned,

blaming Punishing v. Absent God

Spiritual/religious > meditation alone (Wachholtz & Pargament, 2005)

spiritual

Interdependence of biopsychosocial-spiritual features of patient care and requirement for individualized approach (Velente et al. 2008)

summary

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Bush,E. G., Rye, M. S., Brant, C. R., Emery, E., Pargament, K. I., & Riessinger, C. A. (1999). Religious coping with chronic pain. Applied Psychophysiology And Biofeedback, 24(4), 249-260. doi:10.1023/A:1022234913899

Campbell, L. C., Clauw, D. J., & Keefe, F. J. (2003). Persistent pain and depression: A biopsychosocial perspective. Biological Psychiatry, 54(3), 399-409. doi:10.1016/S0006-3223(03)00545-6

Carron, H., DeGood, D. E., & Tait, R. (1985). A comparison of low back pain patients in the United States and New Zealand: Psychosocial and economic factors affecting severity of disability. Pain, 21(1), 77-89. doi:10.1016/0304-3959(85)90079-X

Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196, 129-136.

Engel, G. L. (1992). How much longer must medicine's science be bound by a seventeenth century world view?. Family Systems Medicine, 10(3), 333-346. doi:10.1037/h0089296

Keogh, E., McCracken, L. M., & Eccleston, C. (2006). Gender moderates the association between depression and disability in chronic pain patients. European Journal Of Pain, 10(5), 413-422. doi:10.1016/j.ejpain.2005.05.007

López-Martínez, A. E., Esteve-Zarazaga, R., & Ramírez-Maestre, C. (2008). Perceived social support and coping responses are independent variables explaining pain adjustment among chronic pain patients. The Journal Of Pain, 9(4), 373-379. doi:10.1016/j.jpain.2007.12.002

references

Miro, J., Nieto, R., & Huguet, A. (2008). Predictive factors of chronic pain and disability in whiplash: A Delphi poll. European Journal of Pain, 12, 30-47.

Pool, G. J. Schwegler, A. F., Theodore, B. R. & Fuchs, P. N. (2007). Role of gender norms and group identification on hypothetical and experimental pain tolerance. Pain, 129, 122-129.

Ramirez-Maestre, C., Lopez Martinez, A. E., Esteve Zarazaga, R. (2004). Personality characteristics as differential varaibles of the pain experience. Journal of Behavioral Medicine, 27(2), 147-165.

Rippentrop, E. A., Almaier, E. M., Chen, J. J., Found, E. M., & Keffala, V. J. (2005). The relationship between religion/spirituality and physical health, mental health, and pain in a chronic pain population. Pain, 116, 311-321.

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Wachholtz, A. B., Pearce, M. J., & Koenig, H. (2007). Exploring the relationship between spirituality, coping, and pain. Journal of Behavioral Medicine, 30, 311-318.

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