Treating Co-occurring PTSD and Chronic Pain

using an Acceptance-Based Approach

Dr. Pamela L. Holens, C. Psych.

University of Manitoba

What we know about pain acute vs chronic

What we know about PTSD a chronic “pain” response

The overlap between chronic pain and PTSD

Acceptance-based approaches

Outline

What We Know About Pain

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

Official Definition (International Association for the Study of Pain)

Historical Understandings of the Pain Response

Descartes’ (1664) Model of Pain - Pain as an Alarm System

Melzack and Wall’s Gate Control Theory (1965)

Melzack’s Neuromatrix Theory (2001)

Three Components of Pain

Sensory

(“Ouch!”)

Affective

(“It’s horrible. Get rid of it!”)

Cognitive

(“Why me? What will this do to me, to my life?”)

MEDICATIONS PRIMARILY HELP HERE

PSYCHOTHERAPY PRIMARILY HELPS HERE

The actual, physical pain sensation is an adaptive reflex. It serves the function of alerting us to danger, tissue damage, or threats of such damage.

The noxious sensation of pain is critical for our survival.

The Pain Sensation

Signals injury or disease and produces actions to stop it or treat the causes, eg. Chest pains may signal heart disease and may force us to seek medical help

Memories of earlier pain and suffering warn us to avoid potentially dangerous situations

After serious injury or disease, pain makes us rest, promoting the body’s healing processes

Survival Functions of Pain (Melzack, 2005)

What is the value of phantom limb pain?

Many aches and pains (backaches, headaches, muscle pains, nerve pains, pelvic pains, facial pains) serve no discernible purpose, are difficult to treat, and are horrendous for the people who suffer them.

Chronic pain is not a warning to prevent physical injury or disease. It is the disease – the result of neural mechanisms gone awry.

Pain is valuable, but . . . . (Melzack, 2005)

Chronic Pain (AKA persistent pain):

Pain that persists beyond the usual course of an acute illness or healing time of an injury (usually beyond three to six months), associated with a pattern or recurrence over months or years or associated with a chronic pathological process. It is often accompanied by emotional (depressive) symptoms but objective physiological signs are sometimes absent (p. 3).

Pain Assessment and Management Clinical Practice Guidelines (WRHA, April 2012)

An alarm system working overtime

Chronic Pain is . . .

Causal and maintaining factors may be unclear

Efforts to reduce or eliminate the pain may be unsuccessful

Continuing attempts to control pain may be maladaptive, especially if they cause unwanted side effects or prevent participation in valued activities such as those involving work, family, or community

When pain is chronic . . . (McCracken et al., 2004).

Recommendation 17: Opioids (p. 12)

Opioids are not indicated in all chronic pain conditions, and medication alone is often insufficient to manage chronic pain. Other effective pharmacologic and non-pharmacologic treatments should also be considered.

Chronic Pain and Opioids (WRHA, 2012)

Non-Pharmacological Management (Recommendation 24: p. 16)

Superficial heat and cold

Massage

Relaxation

Imagery

Prayer/spiritual practices

Pressure/vibration

Music

Cognitive Behavioural Therapy (CBT)

Child/infant specific practices

Selection of non-pharmacological methods should be based on individual preference, and may include strategies such as:

Pain Catastrophizing (Turner & Aaron, 2001)

Fear Avoidance (Vlaeyen & Linton , 2000)

Low self-efficacy and Lack of perceived control (Arnstein et al., 1999; Litt, 1988)

Passive Pain Coping (McCracken & Eccleston, 2003) These factors are addressed in Cognitive Behavioural Therapy (CBT) for chronic pain

Psychological Factors Associated with Pain Severity and Disability

The development of avoidant behaviours motivated by fear of feeling pain.

Fear Avoidance

Excessive pain behaviours* in the service of decreasing physical activity and leading to physical deconditioning and increased risk for the development of worsening pain and other medical comorbidities (e.g., obesity) (Verbunt et al., 2003).

• e.g., grunting, sighing, frequently talking about

the pain, facial expressions, guarded movements,

restriction of movements

Disuse Syndrome

What We Know about PTSD

1) Exposure to a threat to well-being (traumatic event)

2) Symptoms, for longer than one month, of:

i) Re-experiencing

ii) Avoidance

iii) Hyperarousal

Posttraumatic Stress Disorder (PTSD)

An alarm system working overtime

Posttraumatic Stress Disorder is . . .

Avoidance of trauma-related thoughts and situations may work in the short-run, but in the long-run it prolongs posttrauma reactions and prevents individuals from getting over their trauma-related difficulties.

(Rothbaum, Foa, Hembree, 2007)

Avoidance maintains PTSD symptoms

“The world is an extremely dangerous place”

“I am incompetent/unable to cope”

Unhelpful thoughts and beliefs maintain PTSD symptoms

Combination of the following techniques:

1. Psychoeducation

2. Anxiety management

3. Cognitive restructuring

4. Exposure exercises

Recommended therapeutic strategies for treating PTSD

Foa, 1999

Demystify symptoms

Normalize and validate reactions

Reinforce personal effectiveness and hope

Psychoeducation

Relaxation Techniques are taught:

Slow breathing

Muscle relaxation

Anxiety management

Assumptions:

It’s not the situation itself that creates distress, but one’s perception of the situation

The most effective way to diminish/modify emotions is to change one’s perception

Cognitive restructuring

Clients are helped to confront safe but anxiety-arousing situations in order to decrease their excessive fear and anxiety.

Clients learn that they can tolerate these situations and that nothing bad happens to them.

(Rothbaum, Foa, Hembree, 2007)

Exposure Therapy

The Overlap Between Chronic Pain and PTSD

CHRONIC PAIN

PTSD BOTH

The co-morbid experience of chronic pain and PTSD appears to be associated with more severe presenting symptomatology than either condition alone (Geisser, Roth, Bachman et al., 1996)

Research on Chronic Pain and PTSD

CHRONIC PAIN

PTSD BOTH

Chronic Pain and PTSD frequently co-occur, and similar mechanisms, such as fear avoidance, anxiety sensitivity, and catastrophizing, may exist for maintaining both conditions (Otis, Keane, & Kerns, 2003) .

Research on Chronic Pain and PTSD

Among individuals utilizing an online chronic pain support group:

Fully 50% of participants met criteria for PTSD

For those with PTSD, more severe symptoms were related to lower levels of chronic pain acceptance

Conclusions-> Avoidance may be a mutually maintaining mechanism in chronic pain and PTSD

->Acceptance should be studied as a potential treatment link between the two disorders

Research on Chronic Pain and PTSD

Thomas (2012)

Factors that maintain both chronic pain and PTSD:

1) Attentional biases

2) Anxiety sensitivity

3) Pain acting as a reminder of the traumatic event

4) Avoidance is used for coping

5) Fatigue/lethargy/depression contribute

6) General anxiety contributes

7) Cognitive demands limit use of adaptive coping

The Mutual Maintenance Model Sharp & Harvey, 2001

Acceptance-Based Approaches

When “pain” is “unacceptable”:

Patients are likely to attempt to avoid it at all costs

Patients are likely to seek readily available interventions to reduce or eliminate it

-> These efforts may not be in their best interest if the consequences include no reductions in pain and many missed opportunities for satisfying and productive functioning

Why acceptance? (Kerns, Sellinger & Goodin, 2011)

Some patients may achieve better overall adjustment to chronic pain if they reduce their avoidance and other attempts to control chronic pain, increase their levels of acceptance, and direct their efforts toward goals they can achieve

Why acceptance? (Kerns, Sellinger, Goodin, 2011)

Pain is seen as an inevitable part of living that can be accepted, whereas struggling to avoid inescapable pain causes more suffering.

The more an individual struggles to escape the pain, the more he or she suffers.

An acceptance-based stance

Reports of lower pain intensity

Less pain-related anxiety and avoidance

Less depression

Less physical and psychosocial disability

Greater physical and social ability

Better work status (McCracken, 1998; McCracken & Velleman, 2010; McCracken & Zhao-O’Brien, 2010; Vowles & McCracken, 2008).

Greater acceptance of pain is associated with . . .

Acceptance of pain was found to be a significant predictor of adjustment on several measures of patient function, independent of perceived pain intensity (McCracken, 1998).

Level of acceptance of pain has been shown to be independent of pain intensity (i.e., it is not simply those with less pain who are more willing to accept pain) (McCracken et al., 2004).

Also . . .

With clinical and non-clinical populations alike, acceptance techniques (e.g., observing and accepting thoughts and feelings as they are) produce greater tolerance of acute pain and discomfort than do more traditional techniques of pain control, such as distraction and cognitive restructuring (Gutierrez et al, 2004; Levitt et al., 2004).

Laboratory studies have shown

ACT is a form of CBT that uses acceptance and mindfulness processes, as well as commitment and behaviour change processes, to produce greater psychological flexibility.

This is the treatment approach that we have chosen to use with our clients who have comorbid PTSD and chronic pain

Acceptance and Commitment Therapy (ACT)

ACT is a form of CBT, but it differs from traditional CBT in that rather than trying to teach people to better control their thoughts, feelings, sensations, and memories, ACT emphasizes observing thoughts, feelings, sensations, and memories as they are, without trying to change them, and behaving in ways consistent with valued goals and life direction.

ACT versus traditional CBT

While pain indeed hurts, it is an individual’s struggle with pain that causes suffering (Dahl & Lundgren, 2006).

ACT philosophy as applied to Chronic Pain

Experiential avoidance/Experiential control

Cognitive fusion

Lack of contact with the present moment

Problematic Processes addressed by ACT

Attempts to control, alter, or avoid the following: thoughts, feelings, sensations, or memories

Experiential Avoidance/ Experiential Control

Cognitive Fusion

Lack of contact with the present moment

Acceptance

Defusion

Self as Context

Contact with the Present Moment

Values

Committed Action

Six Core Therapeutic Processes of ACT

Acceptance: an alternative to experiential avoidance

Pain is ruining

my life

Cognitive Defusion

PAIN

Cognitive Defusion

Present Moment Awareness

Chronic Pain and PTSD . . . alarm systems working overtime

Quieting the alarm system

Mindfulness Meditation

Self as Context

Defining Valued Directions

Committed Action

Chronic pain and PTSD frequently co-occur

Both can be viewed as involving an overactive alarm system

Avoidance contributes to the maintenance and worsening of both conditions

Acceptance-based interventions assist with calming the alarm system and reducing avoidance, thereby improving overall functioning and Quality of Life.

In Summary . . .

Thank you!

Questions?

pholens@deerlodge.mb.ca