Nonpharmacological Pain Management — CBT for Chronic Pain

Nonpharmacological Pain Management
Dr. Dawn-Elise Snipes, PhD, LPC-MHSP, LMHC
Executive Director: AllCEUs Counselor Education
Host: Counselor Toolbox Podcast
Objectives
~ Types of pain
~ Impact of pain on sleep, HPA-Axis and mood
~ Treatment options for chronic pain
~ CBT Interventions

Types and Locations of Pain
~ Chronic pain
~ Lasts more than 3 months
~ May have a known or unknown cause
~ Persists beyond expected healing time or despite treatment
~ Best conceptualized as a condition to be managed rather than cured

Types of Pain
~ Nocioceptive Pain
~ Pain that is caused by damage to body tissue and is based on input by specialized nerves called nociceptors
~ Most nociceptive pain is musculoskeletal, and is often described as aching or deep
~ Examples
~ Back and neck pain
~ Arthritis/Gout
~ Tendonitis
~ Bursitis
~ Pelvic floor disorders
Types of Pain
~ Neuropathic Pain
~ Occurs when there is nerve damage that typically involves either the peripheral or central nerves
~ It is often described as burning, shooting, tingling, or electric
~ Examples
~ Radicular pain—radiates along a nerve (sciatica)
~ Phantom limb
~ Fibromyalgia
~ Peripheral neuropathy
~ Spinal tap/epidural
~ Carpal tunnel
Types of Pain
~ Headache Pain
~ Tension (15 days/month for at least 6 months)
~ Cluster (15-180 minutes every other day to 8x/day)
~ Migraine (2-72 hours)
~ TBI (may last 6 or more months)
~ Cervicogenic (referred pain from the neck/cervical spondylosis or fracture)
~ Medication Overuse/Rebound Headaches
Treatment Options
~ TENS units
~ Massage
~ Physical Therapy
~ Stretching
~ Ergonomics
~ Heat/cold
~ Chiropractics
~ Acupuncture/Acupressure
~ Yoga/Tai-Chi

Treatment Options
~ Biofeedback: Noticing HPA-Axis activation and responding with relaxation exercises
~ Relaxation Training
~ Mindfulness
~ Behavioral Therapy. Observable behaviors such as grimacing, sighing, or limping are often socially reinforced and can lead to increased self-perceptions of pain
~ Cognitive Behavioral Therapy (CBT) addresses thoughts, behaviors and emotions associated with pain
~ Acceptance and Commitment Therapy (ACT) aims to develop greater psychological flexibility and learn to “live in the and.”
~ Hypnotherapy
CBT-CP Theoretical Components
Factors Maintaining Pain
Psychological Factors Associated with Pain
~ Pain Cognitions. Negative cognitions and beliefs about pain can lead to maladaptive coping, exacerbation of pain, increased suffering, and greater disability
~ Catastrophizing. Catastrophic thoughts contribute to increased pain intensity, distress, and failure to utilize adaptive coping techniques. Examples “my pain will never stop” or “nothing can be done to improve my pain.”
~ Hurt versus Harm. When pain is interpreted as evidence of further damage to tissue rather than an ongoing stable problem that may improve, individuals with chronic pain will report higher pain intensity regardless of whether damage is occurring (Smith, Gracely, & Safer, 1998).
Psychological Factors Associated with Pain
~ Negative Affect. The relationship between pain and negative affect is complex and bidirectional.
~ Answer-Seeking. Failing to accept the offered cause of pain or being unwilling to accept that a source of pain cannot be determined can lead to increased distress and pain intensity
~ Pain Self-efficacy is the level of confidence that some degree of control can be exerted over the pain.
Social Factors Associated with Pain
~ Solicitous significant other who is highly responsive to an individual’s pain or to expressions of behavior indicative of pain results in increased reports of pain.
~ Social interactions that focus the individual’s attention away from pain and onto different topics or activities.
~ Punishing responses involve either angry or ignoring responses, each aimed at limiting expression of pain
~ Potential consequences of punishing responses include dramatic (loud) expressions of one’s pain experience in an effort to be “heard” or, alternately, inability to express emotions about pain can lead to stoicism and resignation.
Behavioral Factors Associated with Pain
~ Guarding
~ Resting/under-activity
~ Overactivity (ignoring the pain)

Impact of Pain
~ Emotionally
~ Cognitively
~ Physically
~ HPA-Axis
~ Secondary problems
~ ADLs
~ Interpersonally
~ Occupationally

Chronic Pain Cycle
The Chronic Pain Experience
~ Those who struggle with chronic pain and associated functional impairments may feel frustrated and disappointed that they have not received the answers regarding the cause of their pain, or effective treatments.
~ They often feel as if they have not been “heard” and complain that doctors have not taken the time to listen and understand.
~ Some people also feel that they have been treated as if they are “crazy,” and that the pain is all in their head.
~ Others may feel that they have been unjustly labeled as “drug seeking” when they are only looking for a way to feel better.
~ Factors such as these may cause those with chronic pain to present at the initial session with doubts that anything will help.
~ Remember the pain is emotional and physical
Chronic Pain Experience–Issues
~ Many people expect to rely on passive treatment, often that provide rapid relief
~ Surgery
~ Injection
~ Chiropractics
~ Massage
~ Emphasize the benefits of self-managed, active approaches. A chiropractor is not going to be available at 2am.

Chronic Pain Experience–Issues
~ Develop a list of active approaches the person can use:
~ Stretching
~ Relaxation
~ Hot/cold
~ Guided Imagery
~ Alternate focus
~ TENS

Chronic Pain Experience–Issues
~ Changing or Vague Complaints
~ Some people are more comfortable focusing on somatic rather than emotional complaints
~ As treatment progresses, complaints may change
~ When back pain is lessened, the person may notice other pain issues more. (Embrace the dialectic)
~ They may also complain of fatigue or malaise.

Chronic Pain Experience–Issues
~ When the location of the pain shifts
~ Get new pain evaluated by a medical provider
~ Redirect to the primary pain and notice the improvements
~ Remind the person of strategies to manage original pain and apply them to new pain
~ Identify cognitive, emotional or behavioral issues contributing to that and effective solutions
~ “What has changed that is causing to feel more tired/sick?”

Chronic Pain Experience–Issues
~ When complaints are vague it may be countertherapeutic to focus on them
~ You can also consider using a transdiagnostic approach and identifying possible neurotransmitter/HPA-Axis related issues
~ I feel achy
~ I am fatigued
~ Difficulty concentrating

CBT-CP
~ Assessment and Interview
~ Pain Rating: Frequency, intensity and duration
~ Pain Catastrophizing Scale (Sullivan, Bishop, & Pivik, 1995) Assesses tendency to ruminate, magnify, & feel helpless about pain
~ Assess interference of pain in various areas such as socialization, work, daily activities, and relationships with others including family/marital
~ Assess the existence and severity of depression and anxiety symptoms, which have a high co-occurrence with pain
~ Assess perception of quality of life regarding: physical health, mental health, relationships, and environment
~ Gather treatment plans from medical providers

CBT-CP
~ Assessment and Interview cont…
~ Identify times when the pain is better (increase)
~ Identify strategies that help reduce pain (increase)
~ Identify triggers/exacerbators of pain (mitigate/decrease)
~ Goal Setting (Specific, Measurable, Achievable, Relevant, Time Limited)
~ Reduce the negative impact of pain on daily life (AEB)
~ Improve physical and emotional functioning (AEB)
~ Increase effective coping for pain (AEB)
~ Reduce pain intensity (AEB)

CBT-CP
~ Physical Activation and Pacing
~ Importance of movement and thoughtful approach to activities (Spring clean on a “good day”)
~ Use tracking logs for activity, duration, intensity, pain before, immediately after, and before bed
~ Increasing motivation for implementation of PT plan
~ Decisional Balance
~ Avoiding activity increases pain over time because of decreased flexibility and stamina, increased weakness and fatigue, spasms from tight muscles
~ These things cause increased risk of injury and weight gain (adding strain to the body) as well as feelings of sadness, guilt, frustration, or boredom, which encourages withdrawal
CBT-CP– Pacing cont…
CBT-CP
~ Relaxation
~ Techniques
~ Deep breathing (triggers relaxation response)
~ Progressive muscular relaxation
~ Guided imagery
~ Laughter
~ Pair relaxation with daily activities
~ Use a relaxation “app”
~ Add relaxation minutes to prevent muscle tension buildup
~ Obstacles
~ I’m in too much pain to relax (Bidirectional pain scale)
~ I have to keep moving (Danger of overdoing it)
~ I relax all the time (Relaxing is different than resting/lounging)
CBT-CP
~ Pleasant Activities
~ Educate about the benefits of pleasant activities: Distraction, improved mood, socialization, enhanced direction and efficacy
~ Make a list of pleasant activities
~ Encourage daily engagement to make life worth living despite pain
~ Encourage positive journaling
~ Sleep
~ Educate about the importance of sleep for mood and pain
~ Discuss sleep hygiene and make a sleep plan
~ Youtube.com/AllCEUseducation Effect of Sleep on Mood
CBT-CP
~ Cognitive Strategies
~ Identifying, understanding, monitoring and addressing automatic negative thoughts (ANTs) and how they impact pain experience
~ About the problem
~ About the functional impact of their problem
~ About their ability to impact pain levels

CBT-CP
~ Cognitive Strategies
~ Catastrophizing.
~ “It is a tumor” “This will end my career and I will be unemployable.”
~ Emotional Reasoning
~ “I am scared about what is causing the pain, so it must be bad”
~ Overgeneralization
~ “I cannot play ball with my son anymore so I am a terrible parent”
~ All or Nothing
~ “If I have pain, my life is miserable”
~ “I am always in pain”
~ “I am never comfortable”

CBT-CP
~ Cognitive Strategies
~ Minimization of the positive
~ “Yeah, my back is feeling better, but I’m sure it won’t last”
~ Mind Reading
~ “My kids hate me because I can’t do the things with them that I used to.”
~ Jumping to Conclusions
~ “If I have pain now, I will always have pain.”
~ Mental Filter
~ “Nobody understands.
~ Control Fallacies
~ “I have no control over my pain or the way it impacts my life”
~ “If I just _____ then the pain will go away”

CBT-CP Automatic Negative Pain Thoughts
~ Have participants list their Automatic Negative Thoughts (ANTs) as they relate to
~ Their pain
~ Their relationships (because of their pain)
~ The probability of treatment success
~ Their quality of life (because of their pain)
CBT-CP—Cognitive Distortions Worksheet
CBT-CP—Cognitive Distortions Log
CBT-CP
~ Cognitive Strategies
~ Challenge the negative thought by asking
~ Is this 100% true and factual?
~ Am I using automatic negative thoughts (ANTs)?
~ Is there a different way to look at this issue?
~ What would I tell a close friend if they had this thought?
~ Is this thought helpful to me?
~ Is there evidence that I am not taking into account?

CBT-CP
~ Cognitive Strategies
~ Motivational Enhancement
~ Feedback
~ Responsibility
~ Advice
~ Menu of Options
~ Empathy
~ Support

Summary
~ Cognitive Behavioral Therapy addresses both thoughts and behaviors
~ Help people learn
~ About their body and pain
~ How over or under activity can make their pain worse
~ About sleep hygiene and the importance of sleep
~ What aspects of their pain they can control
~ How pain impacts mood and vice versa
~ Relaxation strategies
~ Alternate, nonpharmacological, methods to address their pain
~ Identify cognitive distortions and help people develop alternate helpful thoughts

Impact of Drugs
~ Serotonin
~ High or low serotonin can cause agitation, restlessness, anxiety, irritability
~ Low serotonin is associated with lower pain threshold
~ Norepinephrine
~ High norepinephrine can cause agitation, restlessness, anxiety, irritability
~ Reduces GABA
~ GABA
~ Enhances serotonin
Treatment Options
~ NSAIDS
~ Opioids
~ Tramadol/Ultram
~ Narcotic
~ Blocks pain receptors
~ Releases serotonin and norepinephrine
~ Topical analgesics
~ Muscle relaxants

Treatment Options
~ Adjuvant analgesics
~ Antidepressants increase serotonin and norepinephrine: duloxetine/Cymbalta; venlafaxine/Effexor; nortriptyline/Pamelor
~ Anticonvulsants (increase GABA), primarily used to relieve neuropathic pain, include gabapentin, pregabalin/Lyrica, topiramate, and lamotrigine
~ Headache Analgesics.
~ Preventative (e.g., Propranolol (beta blocker), topiramate (GABA))
~ Abortive (e.g., Sumatriptan (Serotonin))
~ Rescue (butalbital(GABA)/acetaminophen/caffeine).
~ Rebound headaches, may occur when excessive analgesics are taken for headache relief, leading to chronic daily headaches of a different type.
Treatment Options
~ Nerve blocks
~ Trigger point injections
~ Radiofrequency ablation—High heat that destroys nerves ability to transmit pain
~ Botox (exp. For migraines)
~ Spinal cord stimulator