How do you treat individuals with pain when there is no organic cause?
Today we answer a challenging question submitted by Anne, who writes:
I’m currently studying counselling/psychotherapy in the UK. Last month I discovered your podcast, then read your book Feeling Good, and it was the first thing that really lit up my eyes and got me obsessively studying! Everything about your TEAM-CBT model is so compelling and inspiring and first I just wanted to thank you for taking the time to share it with all of us.
I also have a specific question which I’d love to hear you answer in one of your “Ask David” episodes. My ambition is to specialize in treating patients who have chronic pain with no clear physical cause. I’ve had that problem myself for several years, so I’d love to hear your thoughts on psychological treatments for pain. How do you apply the TEAM CBT model to those patients? Any wisdom you could share would have me on the edge of my seat!
Thanks so much for listening
Thanks, Anne, for your terrific question on one of my favorite topics. In this podcast devoted to pain and depression, I describe research on the relationship between physical pain and negative emotions such as depression, anxiety, and anger. Does pain cause depression? Or does depression cause or amplify pain?
And what can we do to help patients with physical pain and intense negative emotions?
In addition, why do so many individuals struggle with somatic problems, such as physical pain, dizziness, or fatigue, when there is no apparent organic cause for the pain? Is there any hope?
I think you will enjoy the show, Anne, at least I hope you do! I really enjoyed answering your question on one of my favorite topics!
Another great podcast. I look forward to them weekly. Thank you both! I’ve found the hidden emotion technique incredibly useful when treating somatic complaints. The focus can be so much on the symptoms that the negative thoughts, feelings, and events can be lost. I imagine it’s rather easy for the therapist to experience what you call “reverse hypnosis” when treating chronic pain.
Thanks Tyler, good point, and you are absolutely right! Physicians get caught up in “reverse hypnosis” as well, ordering lots of lab tests and such for the somatic complaint. As many as 35% of patients seeking medical treatment for pain, dizziness, fatigue and so forth have no medical problems that cause the symptoms, but rather human problems. The late Dr. Alan Barbour’s classic book, Caring for Patients, is on this very topic. He has one of my professors when I was a Stanford medical student, and I learned about this from him! David
Hi David, thanks so much for answering my question! It was so good to hear your thoughts. I’ll try to get hold of the book you mention above, it sounds like essential reading. Just echoing what the previous commenter said, I do understand why physicians get so caught up in trying to find a medical cause for their patients’ problems. It must feel, to them, like they’re doing the right thing. And I’ve witnessed their egos struggling with failure (a challenge to the notion that they are genius healers who can fix anyone!) Also, the patient may be pressuring and reverse-hypnotising them into action, as you say. But for me the saddest thing is that so many chronic pain patients are actually harmed by all their needless investigative procedures and operations, which leave them with real problems (infections, periods of disability etc) that they didn’t need to have. I’ve met a lot of people in that situation. Thankfully, the NHS is pretty reticent to do any procedure it doesn’t consider 100% necessary so it tends not to go too far. But there are still a few scalpel-happy physicians out there, and it would be so much safer for patients if they were referred on to psychological treatments sooner. But of course so many patients consider that a slap in the face. As you said in the podcast, I can see that agenda setting would be so vital here… some way of helping patients see that being told “your problem is human, not medical,” is not a put-down, but rather the best and most empowering news they could get!
Thank you for your thoughtful comment, Anne. Let me know if you like Dr. Barbour’s book, Caring for Patients! All the best, david
Thanks for this podcast! I’m quite interested in the treatment of chronic and acute pain, since I’m a practicing physical therapist and obviously treat chronic/acute pain. I’ve had the same experience with patients as what you describe, which is that mental health can play a significant role in a patient’s perceived pain.
I was wondering if you can link any of the research studies that you mentioned regarding the link between depression/anxiety and perceived pain (or add any additional ones that might be relevant!). I personally feel that mental health is often overlooked as a pain generator in the health field, and would love to pass on this research, as well as read more about it myself!
No, I did not attempt to publish the studies, I just did the analyses of data at hand because I was curious. There ere three data bases, but I can only recall two of them. One was data from froups I wass running in an inpatient psychiatric unit that included patients with chronic pain, and I measured pain intensity and multiple negative emotioans at the start and end of the daily cognitive therapy gorups. A second data base was given to me on a group of about one thousand arthritis patients fromm a medical center in San Francisco. They had data on pain intensity and negative feelings yearly over a ten year period. Thanks! In both data bases, I used non-recursive structural equation model to estimate the simultaneous causal effects of negative feelings on pain intensity, and the reverse causal effects of pain on the intensity of negative feelings. In both data sets, there was a strong causal effect of negative feeling intensity (depression, anxiety, anger) on pain that accounted for roughly 50% of the pain. Also, in the inpatient CBT groups, I saw the practical impact that over the course of an hour and a half CBT group, there was a 50% reduction (on average) in the patients’ report of pain intensity, along with a comparable reduction in severity of negative feelings.
In both groups, there was also a small but significant causal effect of pain on negative feelings. I have personally experienced this magnification of pain by negative emotions, as well as the (in my case) dramatic reduction in pain when there is a sudden reduction in negative feelings.
These causal effects were similar in patients with organic causality for their pain (the arthritis group) and those without any known organic cause of their pain (the inpatient psychiatric grroup.)
Hope that helps!
Do you have a link to the study demonstrating an average of a 50% reduction in pain with CBT treatment? I can’t seem to find it on my own!