A model for assessment in chronic pain

Dr Tayyeb Tahir

Dr Scott Hall

Workshop Outline

• Introduction to “the model” (guided discussion)

• Group case formulation

• Small group case formulation

• Feedback

1 minute - individually

• In your initial assessment of a “typical” patient presenting with chronic pain

• What are your three main objectives?

Engel’s Model (summary)

• Biological changes in disease are not always reciprocated in illness

• Presence/absence of disease does not necessarily shed light on the meaning of symptoms

• Psychosocial determinants of illness are of fundamental importance in assessment and symptom expression

• The sick role/illness behaviour is not necessarily associated with disease

• Success (or failure) of biological treatments is influenced by psychosocial factors (&vice-versa)

• Dr/P relationship influences outcomes• Patients are profoundly influenced by the way in which

they are studied (&vice-versa)

Translation of the BPS model to clinical practice

• Relationship between mental/physical aspects of health

• Paying “lip service” to participatory relationship• Self-awareness• Cultivation of trust• Empathic curiosity• Recognising bias• Using informed intuition• Communicating clinical evidence

Clinical Formulation

• A map to help us understand the terrain of an individuals narrative

• An attempt to explain why a person is experiencing symptoms in a particular way at a particular point in time.

• Moving beyond description into explanation

Models and Reality

• Don’t mistake models for reality!

The Four P Model

• An attempt to provide an explanatory overview of a presenting problem / problems

• Not based in any one psychiatric / psychological model

• Evidence based

• Forces you to consider relevant factors

Predisposing Factors

• Things that make the person vulnerable to developing the current presentation

• Examples could include:– Early trauma (e.g. abuse, bullying, parental

separation).– Physical health problems.– Family history of mental ill health.

• Think – What happened in the past?

Precipitating Factors

• ‘The Final Straw”• Things that happened in the person’s life that

seemed to trigger an episode of illness • Examples could include

– a bereavement – loss of a job or – other significant life change.– drug use

• Think – What was the final straw?

Perpetuating Factors

• Things that seem to be keeping the person in their current state of distress.

• Examples include – pervasive negative thinking. – lack of a close confiding relationship– lack of adherence to medication

• Think – Why are they not getting better?

Protective Factors

• Things which seem to help keep the person well and which need to be strengthened in order to decrease the likelihood of the problem reoccurring

• Examples include – a strong relationship, – a particular skill in a specific area – a psychological feature such as a good sense of

humour

• Think – What are their strengths? What’s good in their life?

Iatrogenic Factors

• Iatrogenic factors relate to treatments that worsen the patient’s condition

• These are not part of the formulation but can have a massive impact on treatment.

• Tend to be associated with drug treatment but all treatments are potentially iatrogenic.

The Four P Model

Predisposing Precipitating ‘Symptoms’

Perpetuating

ProtectiveIatrogenic

Biological Psychological Social

Predisposing

Precipitating

Perpetuating

Protective

Iatrogenic

Putting it together: An integrative aetiological formulationNB : First we need a collaborative understanding of the presenting complaint!

Biological Psychological Social

Short term

Medium term

Long term

Management