Understanding Pain: Chronic vs. Acute

• Pain is an unpleasant sensory and emotional experience linked to actual or potential tissue damage.

Chronic Pain and Mental Health

• 39% have comorbid depression.
• 40% have comorbid anxiety
• Adults are more likely to experience depression and anxiety compared to pain-free individuals.
  • They are 3x more likely to have depression.
  • They are 4.5x more likely to have anxiety.

Chronic vs. Acute Pain

• Acute Pain:
  • Usually involves obvious tissue damage.
  • Has a distinct onset and short, well-characterized duration.
  • Resolves with healing and serves a protective function.
  • Effective therapy options exist.
• Chronic Pain:
  • Has multiple causes, including malignancy and benign conditions.
  • Can have a gradual or distinct onset.
  • Persists for 3-6 months or longer.
  • It can be a symptom or a diagnosis.
  • Serves no adaptive purpose.
  • May be refractory to treatment.

Factors Important to Patients

• Synthesis of qualitative research from 195 studies identified four major themes.

Biopsychosocial Model of Chronic Pain

• Biological factors include disease severity, nociception, inflammation, and brain function.
• Psychological factors include mood/affect, catastrophizing, stress, and coping mechanisms.
• Social factors include cultural factors, social environment, economic factors, and social support.

Gate Control Theory of Pain

• Spinal nerve gate open results in more suffering, a closed gate results in less suffering.

Loeser's Conceptual Model of Pain

• Consists of nociception, pain, suffering, and pain behavior.

Fear-Avoidance Model of Pain

• Injury leads to pain experience, pain catastrophizing, pain-related fear, and avoidance.

• Central sensitization is a pathophysiologic process in which the CNS undergoes changes that alter its processing of pain and other sensory stimuli.

  • Includes hyperalgesia, allodynia and global sensory hyperresponsiveness

• Pain does not equal tissue damage; hurt does not necessarily equal harm.

• Predictive coding and chronic pain suggests we see the world as we believe it to be.

CBT for Chronic Pain

• Includes psychoeducation, relaxation strategies, activity pacing, pleasant activity scheduling, cognitive restructuring, and assertive communication.
• Targets pain catastrophizing, pain invalidation, kinesiophobia, and poor self-efficacy.

New Psychological Interventions

• Central sensitization treatment targets central mechanisms.
• Some interventions target peripheral mechanisms.

Pain Reprocessing Theory (PRT)

• Highlights that the brain actively constructs chronic pain without tissue damage.
  • The goalis to reappraise the causes and threat value of pain to reduce or eliminate it.
  • Letting go involves addressing fear of pain, fixating on pain, and frustration with pain.
• Emotional awareness and expression therapy targets trauma, stress, and relationship problems common in chronic pain.
• Sleep stages include awake, REM, N1, N2, and N3.

DSM-5 Criteria for Insomnia

• Dissatisfaction with sleep quantity or quality.
  • Difficulty initiating sleep.
  • Difficulty maintaining sleep.
  • Early morning awakening.
• Sleep difficulty occurs at least 3 nights per week for at least 3 months.

Insomnia and Mental Health

• Major depressive disorder, GAD, PTSD, and bipolar disorder can include sleep disturbance as a symptom.

CBT for Insomnia

• Includes psychoeducation, sleep restriction, stimulus control, and cognitive restructuring.

Two-Process Model of Sleep

• Homeostatic process (Process S) increases the pressure to sleep with time.
• Circadian process (Process C) involves an internal biological clock.
• Clinical application: napping in the afternoon may cause trouble sleeping at night.

3-P Model of Insomnia

• Predisposing factors include hyperarousal/hyperactivity and worry/tendency to ruminate.
• Precipitating factors include medical illness and acute stress or psychiatric illness.
• Perpetuating factors include spending excessive time in bed awake and an increase in non-sleep-related behaviors in bed.

Behavioral Sleep Interventions

• Stimulus control.
• Sleep restriction.
• Sleep hygiene.

Stimulus Control

• Rationale: insomnia occurs when the bed or bedroom ceases to be paired with sleep and becomes paired with other activities.
• Goal: reestablish the association between the bed and successful sleep.
• Good stimulus control: bedroom, bedtime, and sleep.
• Stimulus dyscontrol: eating/reading/watching TV/working/worrying in bed, cleaning the bedroom.
• Recommendations: go to bed only when sleepy, eliminate sleep-incompatible behaviors, leave the bedroom when awake for more than 15 minutes, return to bed only when sleepy, and set a standard wake time.

Sleep Restriction

• Spending excessive time in bed can lead to fragmented sleep.
• Restricting time in bed can consolidate sleep and improve sleep quality.
• Goal is to induce sleep deprivation to increase homeostatic pressure and decrease wakefulness.

Sleep Hygiene

• Goal is to maximize sleep-promoting behaviors and minimize sleep-interfering behaviors.
• Recommendations include managing substance use, diet, exercise, daytime napping, and the bedroom environment.

CBT-I: Cognitive Restructuring

• Rationale: dysfunctional beliefs about sleep can maintain or exacerbate insomnia.
• Goal: identify and reframe dysfunctional beliefs about sleep.

Nightmares

• DARC (Distress, Arousal, Reactivity, and Cognition).
• Involve dream, awakening, remembering, and clinically significant distress.
• Nightmare theories include activation synthesis hypothesis, continuity hypothesis of dreaming, and trauma processing.

Image Rehearsal Therapy

• Involves writing out the nightmare, identifying themes, and rescripting the nightmare.
• Nightmare themes include safety, trust, esteem, intimacy, and power/control.

Rescription Instructions

• Change any part of the nightmare as long as it targets an identified theme.
• Keep a link between the nightmare and rescription.
• Write in present tense, first person, and incorporate all the senses.
• Evidence shows significant improvements in nightmare frequency and sleep quality.

Disorders

• Unipolar Depression: Yearly prevalence includes 8% severe cases and 5% mild forms while lifetime prevalence is 26% for women and 12% for men, with an average onset at 19 years.
• Symptoms of depression.
  • Emotional, motivational, behavioral, physical, and cognitive symptoms.
  • The symptoms vary.

Diagnosing Unipolar Depression

• Involves using DSM-5-TR criteria for depressive disorders like major depressive disorder, persistent depressive disorder, and premenstrual dysphoric disorder.

Diagnostic Criteria

• For a major depressive episode, a person displays an increase in depressed mood for the majority of each day and/or a decrease in enjoyment in most activities for at least a two week period.
• Experiencing at least 3/4 symptoms which consist of weight/appetite change, insomnia/hypersomnia, agitation, fatigue, feelings of worthlessness including a significant level of distress.
• Major Depressive Disorder: presence of a major depressive episode with no history of mania or hypomania.
• Persistent Depressive Disorder: person experiences the symptoms of major or mild depression for at least 2 years.

Stress-related and Biological Factors:

• Stressful events may trigger the disorder.
• K inds of depression include reactive (exogenous) and endogenous.
• The biological model involves genetic factors, biochemical factors, brain circuits, and immune functioning.
• Antidepressant drugs are around 65% effective for patients who are depressed per published studied.

Bipolar

• Individuals experience lows of depression and highs of mania.
• Shifts between extreme moods.
• The average onset is in individuals aged 14-44.
• About 1-2.8% of adults have bipolar disorders.

Manic Episode Criteria

• Last one-week where irregular moods, heightened energy, and activity levels are displayed.
• Grandiosity, reduced sleep need, increased talkativeness, rapidly shifting ideas are all symptoms.
• Significant distress or impairment.

Diagnosing Bipolar

• Bipolar I disorder exhibits at least one manic episode.
• Bipolar II disorder exhibits at least one hypomanic and major depressive episode.

Etiology of Bipolar Disorders

• Neurotransmitter activity, ion activity, brain structure and genetic factors.

Medications

• Common medications include lithium, antiseizure drugs, and antipsychotic drugs.
• May be combined with antidepressants, but is less effective for depressive symptoms.
• Adjunctive Psychotherapy: doubles likelihood of medication adherence, helps reduce hospitalizations, improves social functioning, and increases ability to obtain and hold a job.

Suicide and Crisis

• One of the leading causes of death, causes 1 million suicide deaths worldwide annually.
• Approximately 46,000 individuals commit suicide in the US annually.
• Suicide is usually a result of internal factors.

Factors Linked to Suicide Attempts

• Competition for jobs, colleges, and athletic honors, weakening family ties, availability of alcohol/drugs, and modeling of suicides by teenagers and mass media.
• Suicide in older adults.

Models of Depression

• Behavioral activation includes reintroduction to pleasurable activities, identifying unhelpful automatic thoughts, and challenging unhelpful automatic thoughts.
• Sociocultural model: depression is influenced by social context and often triggered by outside stressors, including family-social and multicultural perspectives.

Multicultural: Gender and Depression

• Women are 2x likely to be diagnoses with depression.
• Theories: artifact, hormone, life, body dissatisfaction, rumination.

Eating Disorders

• Exam Prep Case Study:
  • Diagnoses: acute stress disorder, insomnia, trauma response(nightmares)
  • Overaccommodation is determined based on Mark’s thoughts.

What Does Mark Need?

• It is recommended to look at one’s habits before going to sleep.
• Also, only be in bed to sleep, delay until you're tired and can fall asleep once in bed.
• Image rehearsal therapy is recommended for nightmares.

Anorexia Nervosa

• Purposely takes in too little nourishment, resulting in low body-weight.

Eating Disorders

• Individual is very fearful of gaining weight, repeatedly seeks to prevent weight gain despite low body weight, and has a distorted body perception.
• Incidence: 75% of reported cases of anorexia nervosa and occurs in women and girls between 14-20.
• Person with average to slightly above average weight has been on a diet.
• Escalation toward anorexia nervosa may follow a stressful event.

Other Factors

• Driving motivation is fear, thinking is distorted, and patients have a low opinion of themselves.

Trauma and Stress

• Extraordinary stress and trauma can play a central role in certain psychological disorders.

Diagnostic and Statistical Manual of Mental Disorders (DSM)

• Includes acute stress disorder and PTSD.

Fight or Flight Response

• The two brain-body routes by which these systems produce arousal are Sympathetic nervous system and HPA Axis.

Post Traumatic Disorder (PTSD)

• Includes traumatic exposure, intrusion symptoms, negative alterations in cognitions and mood, alterations in arousal and reactivity, duration, clinically significant distress or impairment, and not due to other causes.

Goals for PTSD

• End stress reaction, gain perspective and improve functioning.
• Dissociative amnesia is triggered by trauma or stressful event causing the affected individual to neglect memory functions.

Goal of Eye Movement Desensitization and Reprocessing (EMDR)

• EMDR helps patients process upsetting memories, thoughts, and feelings related to trauma.
  • Involves identifying a target memory.
  • Goal: 1.Psychoeducation 2.Desensitization 3.Installing positive cognition.
  • Also involves body scans and reevaluation.