Pain & Psychosocial Adaptation: Chronic Illness and Disability

Biopsychosocial Model of Pain

• Multidimensional, dynamic interaction among physiological, psychological, and social factors that reciprocally influence each other, resulting in chronic and complex pain syndromes

• Sensory and affective experience

Fear Avoidance Model of Pain

Effect of Psychosocial Constructs and Processes on Pain-Related Outcomes

Psychosocial Factors Influencing Pain-Related Outcomes - Contribute to painintensity, long term outcomes such as physical disability, health care cost, mortality and suicide

• Depression, anxiety, negative affect

Premorbid psychological dysfunction represents a risk for?

future development of chronic pain conditions

___________ were associated with more post-surgical pain and impairment

Higher presurgical emotional distress

Emotional distress and psychosocial stress have been shown to increase the likelihood of transitioning from ____ to ______

acute to chronic musculoskeletal pain

__________ improves pain intensity through reducing pain catastrophizing

Dispositional optimism

Childhood physical, sexual and psychological abuse are reported to be risk factors for adult development of pain syndromes such as

FM, irritable bowel syndrome, chronic pelvic pain, TMJ disorders

Presence of past trauma was associated with 2-3 fold increase in __________

subsequent development of chronic widespread pain

Reports of child abuse conferred 97% increase in risk for having _______

painful somatic syndrome

______ has been identified as a risk factor for chronic pain, transition from acute to chronic pain and elevated severity of pain and disability in abuse victims

PTSD

In patients with acquired amputation, ________ were less likely to develop persistent phantom limb pain

positive general social support

________ is strongly related to the development of children's persistent pain after a major surgery and is significantly related to the child's disability

Parental catastrophizing

_________________ may provide specific pathways by which parental catastrophizing amplifies a child's pain experience and behavior

Parental attention to pain and solicitousness behavior that encourage children to avoid regular activities

2 Crucial Interpersonal Factors for Psychotherapy Process

1. Stimulating the patient's expectations that treatment will help

2. Establishing a sound therapeutic relationship

Active vs Passive Coping

VActive coping - strategies that control pain or function despite pain • Passive coping - relinquishing control of pain to others

comprised of negative cognitive emotional processes such as helplessness, pessimism, rumination about pain and magnification of pain reports

Catastrophizing

refers to an individual's belief that his or her own ability to perform a certain behavior to achieve a desired outcome

Self-Efficacy

_________________ is related to increased feelings of control, use of more active coping strategies and better functional outcomes

Generalized positive outcome expectancy or dispositional optimism

True/False: Both patient and provider expectations for treatment success were strong predictors of respones

True

Medical Model of Disability

Social Model of Disability

Impairments

• Concerned with abnormalities of body structure and appearance and with organ or system function

• Any loss or abnormality of psychological, physiological or anatomic structure or function

• Disturbance at organ level

Disability

• Reflects the consequence of impairment in terms of functional performance and activity

• Disturbance at the level of person

• Inability to walk and perform ADL

Handicap

• Disadvantage which prevents from performing a role

• Reflect interaction with and adaptation to the individual's surroundings

• Societal level

• Immobility, dependence

Some persons with disability die up to ___ years earlier than those without disabilities

20

Persons with disabilities have twice the risk of developing conditions such as?

depression, asthma, diabetes, stroke, obesity or poor oral health

Statistics on Chronic Illness and Disability

• Approximately 54M Americans (1 in 5) have physical, sensory, psychiatric or cognitive disabilities that interfere with daily living

• > 9M Americans with disabilities are unable to work or attend school

• Costs of annual income support and medical care provided by US government is about $60B

• Disabilities are higher among older people, minorities and lower socioeconomic groups

• 8 of the 10 most common causes of death in US are associated with chronic illness

Factor that Create a Profound Effect on the Life of the Individuals with Chronic Illness and Disability

• Degree of functional limitations

• Interference with ability to perform daily activities and life roles

• Uncertain prognosis

• Prolonged course of medical treatment and rehabilitation

• Psychosocial stress associated with the incurred trauma or disease process itself

• Impact on family and friends

• Sustained financial losses

Dynamics to the Psychosocial Adaptation to CID - Stress

• Increased frequency and severity of stressful situations • Need to cope with daily threats

  • One's life and well being

  • Body integrity

  • Independence and autonomy

  • Fulfillment of familial, social and vocational roles • Future goals and plans

  • Economic stability

Dynamics to the Psychosocial Adaptation to CID - Crisis

• Sudden onset, life-threatening, loss of valued functions

• Although crisis is time limited, during its presence life is affected by disturbed psychological, behavioral and social equilibrium

• Its consequences are long lasting and may evolve into pathological disorders

Dynamics to the Psychosocial Adaptation to CID - Loss and grief

• Triggers a mourning process for the lost body part or function

• Constant reminder of the permanency of the condition

• Daily triggering events act to remind of the permanent disparity between past and present or future situations

Dynamics to the Psychosocial Adaptation to CID - Mourning

1. Non-acceptance of the facts

2. Erupting Emotions

3. Parting with the former

4. Finding a new self as well as new perspectives for one’s future

Dynamics to the Psychosocial Adaptation to CID - Body image

• Unconscious mental representation or schema of one's own body

• Evolves gradually and reflects interactive forces exerted by sensory (visual, auditory, kinesthetic), interpersonal (attitudinal), environmental (physical conditions) and temporal factors

• CID alters and distorts own's body image and self-concept

Successful psychosocial adaptation to CID is said to reflect the integration of

physical and sensory changes into a transformed body image and self- perception

Dynamics to the Psychosocial Adaptation to CID - Self - concept

• Linked to body image and often seen as conscious, social derivatives of it

• Self-identity (sense of self) is privately owned and outwardly presented

  • May be denied in social interactions with others who respond to the person as disabled first = lost sense of real self

  • Self-esteem gradually becomes eroded and negative self-perceptions follow

Dynamics to the Psychosocial Adaptation to CID - Stigma

• Negative set of beliefs about people with specific characteristics

• Increased life stress, reduced self-esteem and withdrawal from social encounters, including treatment and rehabilitation

• Structural Stigma

• Public Stigma

• Self-Stigma

Stigma - Social avoidance

• left out of social activities, circle may be more distant, people hesitant to make eye contact or start conversation

Stigma - Stereotyping

• presumed helpless, unable to care for self, unable to make decisions

Stigma - Discrimination

• Jobs, housing, opportunities

Stigma - Condescension

• coddles or over-protected due to perceptions of helplessness

Stigma - Blaming

Accused of using disability for unfair gains

Stigma - Internalization

Person himself feel ashamed or embarassed

How Disability Stigma Affect Your Relationship with Patients? - Concealment

Reluctant to use assistive device or disclose their diagnosis

How Disability Stigma Affect Your Relationship with Patients? - Disability Pride

• Some express pride and positive identity to counteract stigma

• Join groups with same disability

• May opt against medical treatment because they have developed an identity around the disability

How Disability Stigma Affect Your Relationship with Patients? - Social Integration

Choose t o make a disability more evident to improve their options for social participation (using a wheelchair instead of walker to travel with family without fatigue)

How Disability Stigma Affect Your Relationship with Patients? - Need for Respect

• Build a collaborative partnership with patient built on trust and respect communicates your support for the patient as a whole person

Dynamics to the Psychosocial Adaptation to CID - Uncertainty and Unpredictability

• Stable or predictable - amputation, cerebral palsy

• Unstable and unpredictable - epilepsy, cancer, DM, MS

  • Exacerbation and remissions

  • Unpredictable complications

  • Experiences of pain and loss of consciousness • Alternating pace of gradual deterioration

Dynamics to the Psychosocial Adaptation to CID - Perceived uncertainty in illness

uncertainty, or inability to structure personal meaning, results if the individual is unable to form a cognitive schema of illness-associated events

Dynamics to the Psychosocial Adaptation to CID - Quality of Life Domains

• Intrapersonal (health, perceptions of life satisfaction, feelings of well being)

• Interpersonal (family life, social activities)

• Extrapersonal (work activities, housing, schooling or learning and recreational)

QOL is linked to a more positive ____________

positive self-concept and body image, increased sense of control over CID

QOL is negatively associated with?

perceived stress and feelings of loss and grief

CID Triggered Responses - early

• Shock

• Anxiety

• Denial

CID Triggered Responses - Intermediate

• Depression

• Anger / hostility

CID Triggered Responses - late reactions

• adjustments (reintegration, acceptance)

CID Triggered Responses - Shock

• Short-lived reaction

• Marks the initial experience following the onset of a traumatic or sudden injury or diagnosis of a life threatening or chronic and debilitating disease

• "psychic numbness"

Psychic Numbness

Cognitive disorganization and dramatically decreased or disrupted mobility and speech

CID Triggered Responses - Anxiety

• Characterized by panic-like feature on initial sensing of the nature and magnitude of the traumatic event

• Confused thinking, cognitive flooding, multitude of physiological symptoms including rapid heart rates, hyperventilation, excess perspiration and irritable stomach

CID Triggered Responses - Denial

• Defense mechanism mobilized to ward of anxiety and other threatening emotions

• Involves minimization and even complete negation of the chronicity, extent and future implications associated with the condition

• Involves selective attention to one's physical and psychological environments

• Wishful thinking, unrealistic expectations of recovery, or blatant neglect of medical advice and recommendations

CID Triggered Responses - Depression

• Reflect the realization of the permanency, magnitude and future implications associated with loss of body integrity, chronicity of condition, or impending death

• Feelings of despair, helplessness, hopelessness, isolation and distress

CID Triggered Responses - Anger / Hostility

Aggressive acts, abusive accusations, antagonism, passive-aggressive modes of obstructing treatment

Internalized Anger

Self-attributions of responsibility for the condition onset of failure to achieve successful outcomes

Externalized Hostility

Blame others for CID onset or unsuccessful treatment efforts or aspects of the external environment

CID Triggered Responses - Adjustment

Reorganization, reintegration or reorientation

CID Triggered Responses - Adjustment Components

1. Earlier cognitive reconciliation of the condition, its impact, and its chronic or permanent nature

2. An affective acceptance, or internalization, of oneself as a person with CID, including a new or restored sense of self concept, renewed life values and a continued search for new meanings

3. An active pursuit of personal, social, and/or vocational goals

CID Associated Coping Strategies - Coping

• Psychological strategy mobilized to decrease, modify or diffuse the impact of stress-generating life events

• Disengagement coping strategies, Engagement coping strategies

CID Associated Coping Strategies - Disengagement coping strategies

• Seek to deal with stressful events through passive, indirect, even avoidance- oriented activities

• Denial, wish-fulfilling fantasy, self and other blame, resorting to substance abuse

• Associated with higher levels of psychological distress difficulties in accepting one's condition and poor adaptation

CID Associated Coping Strategies - Engagement coping strategies

• Efforts that defuse stressful situations through active, direct and goal-oriented activities such as information seeking, problem solving, planning and seeking social support

• Linked to higher levels of well-being, acceptance of condition and successful adaptation

Psychosocial Reaction-Specific Interventions - Earlier Phases

• Supportive, affective-insightful or psychodynamic in nature are more useful in earlier phases of adaptation

  • Encouraging to vent feelings associated with guilt, shame,, mourning for loss of function

  • Reinforcing social contacts and activities

  • Practicing self-assertiveness, self-determination and independent living skills

Psychosocial Reaction-Specific Interventions - Later Phases

• Active-directive, goal-oriented or cognitive-behavioral in nature may be more beneficial during the later stages

  • Practicing anger expression in socially sanctioned forms

  • Behavior modification techniques to reduce physically and verbally aggressive acts

Global Clinical Interventions

• Provide patient and family with emotional, cognitive and behavioral support

• Equip the patient with adaptive coping skills that could be successfully adopted when facing stressful situations

Global Clinical Intervention - Examples

1. Assisting clients to explore the personal meaning of the CID

   • Vent feelings leading to acceptance of condition permanency, altered body image and realization of decreased functional capacity

2. Providing clients with relevant medical information

3. Providing clients with supportive family and group experiences

4. Teaching clients adaptive coping skills for successful community functioning

   • Assertiveness, interpersonal relations, decision making, problem solving, stigma management and time management skills

QOL - Rehabilitation

Attainment of person-environment congruence, where the person with CID is said to demonstrate better psychosocial adaptation

Establishing Respectful Communication

• speak directly to your patient. Make eye contact

• use ordinary language. "see you later" to a blind or "lets walk to the park" to nonambulatory

• Ask patients with speech impairments how they prefer to communicate

bawal:

• interrupt or rush a patient who communicates slowly

• guess what a patient is trying to say

Respecting Patient Privacy and Autonomy

• provide written materials

• ensure your office and toilets are accessible and they can navigate the space independently

• office practice is accessible (layout, procedures)

• ask a patient the best way to provide physical assistance fi it is needed

bawal: touch, pull or grab patient's body without asking for consent, handle patient's mobility device without consent

Resect Disability Identity and Culture

• respect a patient's choice to downplay or highlight their disability in particular settings

• Introduce your patient to support groups

Bawal:

• use negative words to describe disability (tragedy, suffering, confined to wheelchair)

• "golden rule thinking" - imagining how you would personally feel with a disability as a way to infer how your patients feel