Psychological aspects of the biopsychosocial model.

[quark]

The general question is how, specifically, to deal with psychological aspects of the biopsychosocial model.

This is in the context of my wife, who has chronic hip pain radiating down her right leg. She's familiar with the biopsychosocial model, trains regularly (which does not cause additional pain), has been evaluated for structural problems (MRI was normal for someone her age), but has pain pretty much all of the time (sitting, walking, etc.), although intensity varies. She's had injections and radiofrequency denervation in lumbar nerves and felt better (research suggests this is placebo effect, but at least the intensity of the pain is lower). Anxiety or other psychological stress causes the pain to increase. For example, we'll be walking and a dog will bark at her or jump at her and pain will immediately spike.

The recommendations I see most often under the biopsychosocial model are (1) familiarity with the model, especially the realization that pain does not necessarily mean ongoing tissue damage, (2) graduated exposure to movement and (3) dealing with psychological issues. The first two are ongoing, the question is how best to deal with psychological issues.

Are there specific treatment protocols you recommend? For example, I frequently see CBT recommended, but I rarely see any specifics. Perhaps reading https://www.amazon.com/CBT-Chronic-P...818/ref=sr_1_1 would help? Sometimes seeing a psychiatrist or psychologist is recommended, but we're not sure how to find one who is competent in pain science.

I've had a number of very helpful responses from Austin on her condition generally, but this part remains unclear to me.

[Michael Ray]

Hey, thanks for the inquiry.
Psychological issues that may impact how someone deals with persistent/recurrent pain are anxiety, depression, catastrophizing, and self-efficacy.
CBT is a common cornerstone when dealing with patients with persistent/recurrent pain. In essence the process involves reframing the issue to something that is less worrisome and empowers the person they can handle the issue on their own while altering learned behavioral responses. When consulting in clinic we typically screen for a history of these issues and then assess our ability to manage them as it relates to their pain experience. If the person displays underlying psychological issues that have not been diagnosed prior to visiting our clinic and seem to greatly influence the prognosis of the case, then we refer out to a psychologist for management as this is out of our scope. I've managed cases previously in conjunction with psychologist and overall the knowledge of pain isn't typically up to date with what we are currently seeing in the research, but honestly that's not too different than the rest of the fields in healthcare. Ideally if you all think the best route is consultation with psychologist/psychiatrist or she's been recommended by a healthcare provider to seek consult, you can certainly screen providers and see if it is a good fit. I have no idea if you are seeking insurance reimbursement for such consultation, which would likely influence the availability of the provider. We do have data on how family (inclusive of significant others) influence a person's ability to manage persistent/recurrent pain. The ideal goal is patience, understanding, and support without being enabling (as part of the issue with castrophizing is learned helplessness - see Sullivan 2001). I've not read the book you reference and can't weigh-in on its validity. Ultimately, this is a process and changing beliefs and behavioral responses take time and do not happen quickly. Happy to discuss more.

[quark]

Would it be reasonable to start with self-administered CBT? If so, are there any CBT resources you'd recommend?

Most of her issues are associated with the chronic pain in her hip and leg. For example, it doesn't seem unreasonable after a year or more of pain to believe that the pain will continue long-term, to believe that it will affect her life in a negative way (it certainly cuts down on visiting museums, gardens and foreign lands if walking is painful). and to be unhappy about that. Biomechanical treatment (lumbar injections and radiofrequency denervation) helped smooth out spikes, but no more, and graduated exposure to movement seems to have reached a limit. Knowledge of the biopsychosocial model helps on an intellectual level.

[Michael Ray]

Hey!
It can be difficult to self-administer CBT because often our current "normal" seems like that's all there is and will be. It often takes an outside source to step-in and educate about how things can be different and this is a process. If someone has been dealing with persistent/recurrent pain for years then the process can take a while to adjust beliefs and learned responses. The framing should be pain is a part of life (to a point) and acceptance is the first step towards instilling new beliefs and creating new responses for how to deal with the pain. People often can feel secluded and alone, as if no one else understands them or can relate. It's paramount to be empathetic while instilling self-efficacy and internal locus of control without stigmatizing the person. A great article that recently came out that may help elucidate the issue: https://journals.lww.com/pain/Fullte...elf___a.6.aspx.

[quark]

Am I reading correctly, the practical advice is that some sort of process with a psychologist/psychiatrist might be helpful, providing a competent one can be found, although their "overall the knowledge of pain isn't typically up to date with what we are currently seeing in the research"?

That plus the aforementioned graduated exposure to movement (e.g., weight training and walking) and familiarity with the biopsychosocial model and related research, which she has been doing.

I'd add she's much more likely to follow some prescribed course (read materials and do a defined program) than go to a therapist who may or may not be useful, which is one reason I'm pushing this line of inquiry.

[Austin Baraki]

One resource that I’m trying out with a few patients at the moment, in addition to direct contact with them for education, is a phone app called Curable. Might be worth a shot.

[quark]

The free version appears to be a good description of pain science and the biopsychosocial model, ending with the message to retrain your brain by better awareness of what stressors are associated with pain and a suggestion to subscribe to the paid version for more information. Seems worthwhile.

Reviews for both the Android and iOS versions look good. https://www.curablehealth.com/

Austin, I believe you've previously mentioned that there are some web resources you've explored. Is this the one you currently recommend?