As a clinical psychologist with a specialty in chronic pain management, I am often referred patients with both chronic pain and psychiatric issues. Many of these patients see a psychiatrist and a therapist, and are taking with both psychotropic and pain medications. The referral is often made because there is a sense that psychological issues are complicating the patient’s pain management.
In this article, I’ll describe how psychologists conceptualize the treatment of chronic pain and provide some tips for how you, as a busy prescriber, can leverage some of the successful techniques I use with my patients.
I’ll start by introducing a case of a veteran who is typical of my practice (I have altered the details to preserve confidentiality).
Martin C. is a 37-year-old U.S. veteran who was honorably discharged three years ago after four tours of duty in Iraq and Afghanistan. During his last tour, he sustained multiple injuries after an improvised explosive device detonated in close proximity to his Humvee. Three years later, he suffers from chronic low back pain and shoulder pain, and has been diagnosed with both PTSD and depression. He is taking milnacipran and prazosin for his psychiatric symptoms, and hydrocodone as needed for chronic pain. His referring psychiatrist says that Martin has partially responded to his meds but is still depressed and not very active. I am asked to help Martin learn some cognitive behavioral skills to manage his pain more effectively.
Cognitive behavioral therapy (CBT)
Most of you are probably familiar with basic cognitive behavioral therapy (CBT) concepts. As a reminder, CBT focuses on teaching people ways to identify and change counterproductive automatic thoughts and maladaptive behaviors, and to replace them with more adaptive ones. For example, a typical automatic thought in a patient with depression might be “I’m a failure.” In CBT, we help patients become aware of such cognitions, teach them to examine the evidence that supports the thought, and to generate alternative thoughts that are more balanced and adaptive. If therapy is successful, a patient will be able to recognize automatic thoughts as they occur, and counter them with more realistic thoughts. Over time, the adaptive thoughts become stronger and take the place of those that have been causing distress.
How does CBT work in pain management?
When I meet a new patient, I often start by taking out a sheet of paper and drawing the “Cycle of Pain,” which includes pain, distress, and disability (see figure below). The essence of this vicious cycle is that chronic pain can lead to negative automatic thoughts, insomnia, and isolation, all of which contribute to distress/depression.
Typical examples of maladaptive thoughts in pain patients include “I’m worthless to my family because I can’t work,” “I could have done so much with my life,” “This is never going to get better,” or “I’d better not be too active or I’m going to be in more pain.” Such thoughts lead not only to depression, but also to isolation and inactivity. Patients may isolate themselves to avoid others, in part because they get tired of hearing questions like, “Why aren’t you working? You look fine to me.” Less activity may lead to muscle atrophy and weight gain, both of which can aggravate the original pain condition. The decreased activity and deconditioning lead to more pain.
In my experience, patients with chronic pain will recognize this cycle and will be able to acknowledge that it has affected their lives and worsened their pain.
Returning to Martin, at our first meeting I conducted a typical comprehensive pain assessment assessment: I evaluated the location and quality of his pain, as well as his pain triggers, and took a standard psychiatric history. When I asked him about any strategies he had learned to cope with his pain, Martin responded, “I guess there’s really nothing I do but sit down, rest, and play video games to distract myself.” He used to enjoy fishing and photography, but he felt that his pain made those hobbies impossible to continue. He said he thought that life was passing him by. When I asked Martin, “Have you ever noticed a connection between your mood and pain?” he responded that he had, and that in particular the pain caused him to have a “short fuse” with everyone around him. He also realized that he had lost his motivation to take the steps necessary to return to college and develop a new career.