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Emotional Dysregulation, Trauma, and Paths to Recovery Mel Pohl MD


Disclosure • Nothing to Disclose


Learning Objectives • Describe fundamentals of pain and suffering • Review the neurobiology of pain and trauma • List non-medication treatments for chronic pain


Emotional Abandonment Abandonment When you have to hide a part of who you are in order to be acceptable/ to protect self. When you have to hide: —Your mistakes/ vulnerabilities — Your feelings — Your needs — Your accomplishments/ success


Emotional Abandonment -- cannot live up to expectations -- attack whole being, worth, and value versus action -- you are to be an extension of another’s dreams. -- you are responsible for another’s feelings, thoughts, and behaviors. -- parents’ esteem is derived through child’s behavior. -- children are treated as peers with no parent child distinction.


Damaged Inadequate Damaged goods

SHAME

Dirty

Stupid Not good enough

Less than


Trauma “stress that causes physical or emotional harm from which you cannot remove yourself� Larke Huang (SAMHSA)


Greater trauma

=

Greater likelihood of addiction


Greater number of Traumas

=

Greater likelihood of multiple addictions


Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: Adverse Childhood Experiences (ACE) Study --Childhood abuse, neglect, and exposure to other traumatic stressors = ACE Almost two-thirds of study participants reported at least one ACE more than one in five reported three or more ACEs. short and long-term outcomes of these childhood exposures ďƒ  health and social problems. CDC and Kaiser Permanente, San Diego


As the number of ACEs increase, the risk for the following health problems increases in a strong and graded fashion: • Alcoholism & alcohol abuse • Chronic obstructive pulmonary disease (COPD) • Depression • Fetal death • Health-related quality of life • Illicit drug use • Ischemic heart disease (IHD)

• Liver disease • Risk for intimate partner violence • Multiple sexual partners • STDs & HIV • Early initiation of smoking • Suicide attempts • Unintended pregnancies

Finally, as the number of ACEs increases, the number of co-occurring or “co-morbid” conditions increases.


Pain Switchboard GENETICS N O C I C E P T I O N

COMT

TRAUMA

P A I N


Patient with Pain Pain

‘Injury’


Patient with Pain Suffering Pain

‘Injury’


“…When touched with a feeling of pain, the ordinary uninstructed person sorrows, grieves, and laments, beats his breast, becomes distraught. So he feels two pains, physical and mental. Just as if they were to shoot a man with an arrow and, right afterward, were to shoot him with another one, so that he would feel the pains of two arrows…” The Buddha


Emotional Intensifiers • • • • •

Guilt Anger – Resentments Loneliness Helplessness Fear


Cycle of Uncontrolled Pain and Fear Avoidance Behaviors Pain

Decreased Mobility FEAR

FEAR

Social Limitations

Diminished SelfEfficacy

Altered Functional Status


Reversal of Cycle of Fear and Pain

Exercise Pain

Increased Mobility

Less Pain

Improved Function

Enhanced SelfEfficacy


Pain Pearls • Conditioning Increases Pain. • Pain Patients Are A Pain. • Secondary Gain Prevents Getting Well.


Trauma Pain Addictions


Trauma Addictions Pain


Trauma Addictions New Trauma Pain Addiction Worsens Pain Worsens


emotional abuse

4

12

19

typhoon

Birth

Vietnam combat

physical abuse

Today


Birth

emotional abuse

4

12

19

typhoon

physical abuse

Vietnam combat

Alcohol

Today


Birth

emotional abuse

4

12

19

Opioids

Pain typhoon

physical abuse

Vietnam combat

Alcohol

Today


Addiction Trauma Pain Medications Addiction Worsens Pain Worsens


Pain Recovery – Develop Balance • • • •

Mental Emotional Physical Spiritual

RESULTING CHANGES – Relationships – Positive actions and behaviors


Non-Medication Treatments at LVRC • • • • • • • • • •

Exercise – Physical Therapy Chiropractic Treatments Therapeutic Massage Reiki Acupuncture EMDR Equine therapy Mindfulness-Based Stress Reduction (Kabat-Zinn) Yoga - Chi Gong Individual + group therapy


Research confirms that drugs give the same benefits as yoga !!!


Halasana Excellent for back pain and insomnia.


Balasana Position that brings the sensation of peace and calm.


Savasana Position of total relaxation.


References • • • • • • • • • • • •

American Academy of Pain Management Pain Outcome Profile (POP) American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000 Ballantyne, J, Fleisher, L, Ethical issues in opioid prescribing for chronic pain. PAIN, 2010;148:365-367. Ballantyne & Mao, Opioid Therapy for Chronic Pain, NEJM, Nov 2003 Bantick, S., Wise, R, et al., Imaging how attention modulates pain in humans using functional MRI,. Brain 2002;125:310-319 Baron, MJ, McDonald PW. Significant pain reduction in chronic pain patients after detoxification from high-dose opioids. Journal of Opioid Management, 2006: 2(5): 277-282 Bohnert,A., Valenstein,M., et.al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA, 2011: 305 (13) 1315-1321. Bruera E, et al. Recent developments in palliative cancer care. Acta Oncologica. 1998;37:749-757. Bulfari, L, Aprile, T., et.al. Empathy for pain and touch in the human somatosensory cortex. Cerebral Cortex 2007. 17(11) 2553-2561. Burns, JW. Do changes in cognitive factors influence outcome following multidisciplinary treatment for chronic pain? A cross-lagged panel analysis. Journal of Consulting and Clinical Psychology, 71(1), pp.81-91 Busch AJ, Barber KA, Overend TJ, Peloso PM, Schachter CL. Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev. 2007 Oct. 17;(4):CD003786. Ciccone DS, Just N, Bandilla EB et al. (2000), Psychological correlates of opioid use in patients with chronic nonmalignant pain: a preliminary test of the downhill spiral hypothesis. J Pain Symptom Management 20(3):180192. Chabal C, et al. Prescription opiate abuse in chronic pain patients: clinical criteria, incidence, and predictors. Clin J Pain. 1997;13:150-155.


References •

• • • • • • • • • • • •

Clark ME, Young RW, Cole BE. Opioid therapy for chronic noncancer pain: Cautions, concerns, misconceptions and potential myths, in Boswell MV and Cole BE (Eds.), Weiner’s Pain Management: A Practical Guide for Clinicians, 7th Edition. CRC Press, Taylor and Francis Group, Boca Raton, FL, 2006, pp. 141-162 Daniell HW. Opioid endocrinopathy in women consuming prescribed sustained-action opioids for control of nonmalignant pain. J Pain. 2008;9(1):28-36. Diatchenko, L, et al. Genetic basis for individual variations in pain perception and the development of a chronic pain condition. Human Molecular Genetics, 2005;14(1):135-143. Eriksen, J, Sjogren,P et.al. Critical issues on opioids in chronic non-cancer pain: An epidemiological study. PAIN, 2006; 172-179. Fishbain DA, et al. Drug Abuse, Dependence, and Addiction in Chronic Pain Patients Clin J Pain. 1992;8:77-85. Flor, H. et al., Conditioning: Learning that Pain Can Elicit Reward, 2003. Society for Neuroscience Annual Meeting. Flor, H. New Developments in the understanding and management of persistent pain Curr Opin Psychiatry 2012; 25 (2):109-113. Gourlay et.al. Universal Precautions in Pain Medicine: A Rational Approach to the Treatment of Chronic Pain. PAIN Medicine 2005. 6,2;107-112 Grady, D., Berkowitz, S. and Katz, M. Opioids for chronic pain. Arch Intern Med. 2011; 171 (16): 1426-1427. Graham AW. Screening for alcoholism by life-style risk assessment in a community hospital. Arch Intern Med. 1991;151:958-964. Heinemann AW, Donohue R, Keen M, et al : Alcohol use by persons with recent spinal cord injury. Arch Phys Med Rehabil 1988; 69:619-624 Hoffman HG, et al. Prevalence of abuse and dependency in chronic pain patients. Int J Addict. 1995;30:919-927. Honkanen R, et al. The role of alcohol in accidental falls. J Stud Alcohol. 1983;44:231-245.


References • • • • • • • • • •

• • • • •

Jackson, PL, Meltzoff, A and Decety, J, How do we perceive the pain of others? A Window into the neural processes involved in empathy. Neuroimage. 2005; 24,(3)771-779. Kalso, E, Hearn, L, Williams, A. Reducing the risk of opioid misuse in persistent pain: Commentary on Jamison et al. PAIN 2010; 150:375-376. Kabat-Zinn, J, Full Catastrophe Living, New York: Bantam Doubleday Dell Publishing Group, Inc., 1990 Loeser JD, Melzack R. Pain: an overview. The Lancet. 1999; 353:1607-1609. Mao J. Opioid-induced abnormal pain sensitivity: Implications in clinical opioid therapy. Pain 2002; 100:213–7. Meta-analyses and systematic reviews of psychological treatments for chronic pain: relevance to an evidencebased practice. Health Psychology. 2007;26(1):10-12. Morley et al, Cognitive/behavioral therapies are effective for the treatment of chronic pain. 1999 Pain 80: 1-13. Monsen K, Monsen JT. Chronic pain and psychodynamic body therapy: A controlled outcome study. Psychotherapy: Research, Practice and Training, 37(3). NIDA’s Monitoring the Future (MTF) & Partnership, Conclusions from National Household Survey on Drug Use and Health 2002-2004 Non-Medical Use of Rx Pain Relievers. Passik, Steven D PhD; Kirsh, Kenneth L PhD; Donaghy, Kathleen B PhD; Portenoy, Russell K MD Pain and Aberrant Drug-Related Behaviors in Medically Ill Patients With and Without Histories of Substance Abuse. Clinical Journal of Pain: 2006; 22 (2):173-181. Pohl, M., A Day Without Pain. 2008; Las Vegas: Central Recovery Press. Pohl, M. A Day Without Pain (Revised and Updated). 2011; Las Vegas: Central Recovery Press. Pohl, M and Smith, L, 2011 Chronic Pain Management Using Buprenorphine: Questions and considerations J of Global Drug Policy and Practice. 5(1). Pohl, M. and Smith, L., 2012 Chronic Pain and Addiction: Challenging Co-occurring Disorders Journal of Psychoactive Drugs, 44 (2), 1–6


References • • • • • • • • • • • • • •

Pohl, M., Szabo, F, Hunter, R, Shiode, D, Pain Recovery. 2009; Las Vegas: Central Recovery Press. Pohl, M., Szabo, F, Hunter, R, Shiode, D, Pain Recovery for Families. 2010; Las Vegas: Central Recovery Press. Porro, CA, et al. Does anticipation of pain affect cortical nociceptive systems? Journal of Neuroscience, 2002;22:3206-3214. Regier DA, Meyers JK, Kramer M, et al. The NIMH epidemiologic catchment area program. Arch Gen Psychiatry 41:934--958, 1984. Reyna TM, et al. Alcohol-related trauma: the surgeon's responsibility. Ann Surg. 1985;201:194-197. Salomons T, Johnstone, T, et al., Perceived Controllability Modulates the Neural Response to Pain 2004. J Neurosci 24: 7199-7203 Schiff, G and Galanter, W. Promoting more conservative prescribing. JAMA, 2009:301,8, 865-867. Sullivan, M. and Ballantyne, J. What are we treating with long-term opioid therapy? Arch Intern Med. 2011; 172 (5): 433-434. US Commission on the Evaluation of Pain, 1987 Vanderah T. Pathophysiology of pain. Med Clin N Am. 2007;91:1-12. Vlaeyen et al., 2002. Psychological Approaches to Pain management. (Turk & Gatchel, eds.) Volkow, N. and McLellan, T, Curtailing diversion and abuse of opioid analgesics without jeopardizing pain treatment. JAMA, 2011:305,13, 1346-1347. Von Korff, M., Kolodny, A., Deyo, R., and Chou, R. Long-term opioid therapy reconsidered. Ann Intern Med. 2011; 155 (5): 325-326. Webster LR, Choi Y, Desai H, Webster L, Grant BJB. Sleep-disordered breathing and chronic opioid therapy. Pain Medicine. 2008;9(4):425-432.


Emotional Dysregulation