Psychological assessment for implantable therapies Dr Pete Murphy Consultant Clinical Psychologist Dept. of Pain Managemen...
Is psychological assessment  necessary  for SCS patients? <ul><li>YES - 1998 Consensus statement Task Force of the Europea...
Psychological Assessment of Candidates for Spinal Cord Stimulation for Chronic Pain Management.  Expert Panel Report 2004 ...
Why Assess ? Mental health problems common in Chronic Pain <ul><li>Chronic Pain and anxiety 15% to 50%  (McCracken et al. ...
Psychological factors are associated with poor outcome <ul><li>Depression </li></ul><ul><li>Catastrophising </li></ul><ul>...
psychological factors contd... <ul><li>active psychosis </li></ul><ul><li>somatisation  disorder </li></ul><ul><li>severe ...
Current UK practice  Survey by ACKROYD  et al. 2003 <ul><li>69 Consultants involved in SCS implants contacted -  </li></ul...
 
So for the MDT…  <ul><li>The question is not just are they suitable but also are they  ready? </li></ul>
Psychologist can be involved at: <ul><li>Assessment & preparation </li></ul><ul><li>During the procedure (trial & implant)...
Initial clinical interview  <ul><li>Psychosocial setting ( maintaining factors)‏ </li></ul><ul><li>Family background, curr...
State  vs.  Trait factors <ul><li>Potential for clinicians to: </li></ul><ul><li>overstate  dispositional  factors (neurot...
Facilitate  patient  risk assessment <ul><li>Anxious people may lousy statisticians </li></ul><ul><li>Do they understand t...
Informed consent <ul><li>Agreeing or compliance? </li></ul><ul><li>demand characteristics/ social desirability </li></ul><...
Manage distress <ul><li>Work  on their distress related  or  unrelated to pain, which if left untreated could interfere wi...
Facilitate behavioural change <ul><li>Breaking the  habits  of disability </li></ul><ul><li>Goal setting and pacing </li><...
 
No Psychologist ? Psychometric screening & yellow flags <ul><li>reports pain being constant, no variability despite a rang...
Psychometric questionnaires <ul><li>Beck Depression Inventory-II </li></ul><ul><li>Pain Anxiety Symptoms Scale </li></ul><...
What to look for in the questionnaires <ul><li>Depression   (BDI) – has 2 factors  </li></ul><ul><li>1.  Somatic factor  -...
Catastrophising <ul><li>Pain Catrastrophising Scale  (Sullivan 2001)‏ </li></ul><ul><li>Highly  associated with ongoing an...
Pain Self Efficacy Questionnaire <ul><li>Assesses the patient’s view of their ability to manage their pain </li></ul><ul><...
Pain Anxiety Symptom Scale <ul><li>assesses Fear Avoidance behaviour </li></ul><ul><li>High score can be associated with p...
Refer to a clinical psychologist  and/or PMP ? <ul><li>BDI (Depression)  >24 </li></ul><ul><li>Catastrophising  >35 </li><...
Case example 1 <ul><li>Pt extremely fearful of procedures, fears paralysis </li></ul><ul><li>History of an operation (yrs ...
Case example 2 <ul><li>Pt excellent trial response </li></ul><ul><li>But high anxiety about op for permanent </li></ul><ul...
Case example 3 <ul><li>Significant Psychiatric co-morbid presentation </li></ul><ul><li>Don’t  proceed to trial </li></ul>...
Breakdown of all MDT Recommendations
Result of SCS  Trial:  MDT vs No MDT (success  => 50% pain relief)‏
Permanent  implants - 6 month follow-up <ul><li>90% reported ≥ 50% pain relief for both MDA and  No-MDA pts </li></ul><ul>...
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Psychological Assessment For Implantable Therapies Dr Peter Murphy

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Lecture given to the North British Pain Association on 16th May 2008 by Dr Peter Murphy. In this talk, Dr Murphy discusses the psychological assessment and preparation of patients for implantable therapies including spinal cord stimulation.

www.nbpa.org.uk

Published in: Health & Medicine, Technology
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  • Psychological Assessment For Implantable Therapies Dr Peter Murphy

    1. 1. Psychological assessment for implantable therapies Dr Pete Murphy Consultant Clinical Psychologist Dept. of Pain Management Walton Centre
    2. 2. Is psychological assessment necessary for SCS patients? <ul><li>YES - 1998 Consensus statement Task Force of the European Federation of IASP Chapters (EFIC) - Gybels et al. (1998)‏ </li></ul><ul><li>YES – 2004 Pain Society Guidelines </li></ul><ul><li>“ data from the literature shows that a careful psychological screening leads to a significantly better outcome for SCS procedures” </li></ul>
    3. 3. Psychological Assessment of Candidates for Spinal Cord Stimulation for Chronic Pain Management. Expert Panel Report 2004 ( Beltrutti … North, Turk, Melzack & others) Pain Practice vol. 4 Sept. 2004 ) <ul><li>Found </li></ul><ul><li>Personality per se is not predictive of outcome </li></ul><ul><li>evidence supports psychological assessment, but it’s based on single centre studies, with different methodologies and small numbers therefore meta-analyses difficult </li></ul><ul><li>recommend a brief battery with clinical interview </li></ul>
    4. 4. Why Assess ? Mental health problems common in Chronic Pain <ul><li>Chronic Pain and anxiety 15% to 50% (McCracken et al. 1999) </li></ul><ul><li>Chronic Pain & depression 30% to 100% (Fishbain et al. 1997)‏ </li></ul><ul><li>Chronic Pain and somatoform disorder ? </li></ul><ul><li>(Bankier et al. 2000)‏ </li></ul>
    5. 5. Psychological factors are associated with poor outcome <ul><li>Depression </li></ul><ul><li>Catastrophising </li></ul><ul><li>Anxiety </li></ul><ul><li>are strongest predictors of disability at 2 yr follow-up </li></ul><ul><li>Significantly better than pain or current level of disability (Sullivan 2001)‏ </li></ul>
    6. 6. psychological factors contd... <ul><li>active psychosis </li></ul><ul><li>somatisation disorder </li></ul><ul><li>severe sleep disturbances </li></ul><ul><li>serious drug or alcohol addiction </li></ul><ul><li>lack of social support </li></ul><ul><li>major cognitive deficits </li></ul><ul><li>unresolved compensation </li></ul><ul><li>unrealistic outcome expectations </li></ul><ul><li>(Gureje et al. 1998; Macfarlane et al. 1999)‏ </li></ul>
    7. 7. Current UK practice Survey by ACKROYD et al. 2003 <ul><li>69 Consultants involved in SCS implants contacted - </li></ul><ul><li> 44 responded </li></ul><ul><li>41 respondents work in MDT setting </li></ul><ul><li>38 had a Clinical Psychologist in the team </li></ul><ul><li>24 worked with developed guidelines </li></ul>
    8. 9. So for the MDT… <ul><li>The question is not just are they suitable but also are they ready? </li></ul>
    9. 10. Psychologist can be involved at: <ul><li>Assessment & preparation </li></ul><ul><li>During the procedure (trial & implant)‏ </li></ul><ul><li>Post trial </li></ul><ul><li>Post implant </li></ul>
    10. 11. Initial clinical interview <ul><li>Psychosocial setting ( maintaining factors)‏ </li></ul><ul><li>Family background, current stressors </li></ul><ul><li>Significant others </li></ul><ul><li>Beliefs </li></ul><ul><li>Check for understanding & possible misunderstandings </li></ul><ul><li>Expectations </li></ul><ul><li>Do they have a plan B if SCS doesn’t work? </li></ul>
    11. 12. State vs. Trait factors <ul><li>Potential for clinicians to: </li></ul><ul><li>overstate dispositional factors (neuroticism) and </li></ul><ul><li> underplay situational factors </li></ul><ul><li>Watch for psychopathologising a miserable situation </li></ul><ul><li>Poor outcome could be reflection of poor management – not the patient’s fault ! </li></ul>
    12. 13. Facilitate patient risk assessment <ul><li>Anxious people may lousy statisticians </li></ul><ul><li>Do they understand the odds? </li></ul><ul><li>How is the information framed ? </li></ul><ul><li>Get them to contemplate their own possible response to various outcomes </li></ul><ul><li>black & white or graded ? </li></ul>
    13. 14. Informed consent <ul><li>Agreeing or compliance? </li></ul><ul><li>demand characteristics/ social desirability </li></ul><ul><li>( May account for discrepancy between trial and permanent )‏ </li></ul><ul><li>Dissenting for the right reasons? </li></ul><ul><li>How much do they understand? </li></ul>
    14. 15. Manage distress <ul><li>Work on their distress related or unrelated to pain, which if left untreated could interfere with SCS outcome </li></ul><ul><li>Look for strengths in the patient as well as risk </li></ul><ul><li>but watch out for Excessive stoicism </li></ul>
    15. 16. Facilitate behavioural change <ul><li>Breaking the habits of disability </li></ul><ul><li>Goal setting and pacing </li></ul><ul><li>Get them to internalise self-management rather than simply be compliant/ adherent </li></ul>
    16. 18. No Psychologist ? Psychometric screening & yellow flags <ul><li>reports pain being constant, no variability despite a range of interventions ‘ nothing eases it’ </li></ul><ul><li>frequent visits to GP for pain or other issues >12 per year)‏ </li></ul><ul><li>Multiple complaints </li></ul>
    17. 19. Psychometric questionnaires <ul><li>Beck Depression Inventory-II </li></ul><ul><li>Pain Anxiety Symptoms Scale </li></ul><ul><li>Pain Catastrophising Scale </li></ul><ul><li>Pain Self-Efficacy Questionnaire </li></ul><ul><li>Roland & Morris Disability Questionnaire </li></ul><ul><li>Visual Analogue Scale (pain)‏ </li></ul>
    18. 20. What to look for in the questionnaires <ul><li>Depression (BDI) – has 2 factors </li></ul><ul><li>1. Somatic factor - only high on this suggests primarily pain presentation </li></ul><ul><li>2. Cognitive-affective factor - high suggests depression </li></ul><ul><li>If BDI >24 then possibly refer on </li></ul><ul><li>If BDI >30 then always refer on </li></ul>
    19. 21. Catastrophising <ul><li>Pain Catrastrophising Scale (Sullivan 2001)‏ </li></ul><ul><li>Highly associated with ongoing and future disability </li></ul><ul><li>Range 0-52 </li></ul><ul><li>If >35 then possible refer on </li></ul>
    20. 22. Pain Self Efficacy Questionnaire <ul><li>Assesses the patient’s view of their ability to manage their pain </li></ul><ul><li>Range 0 –60 (Higher better)‏ </li></ul><ul><li>If <20 then possible refer on to psychologist </li></ul>
    21. 23. Pain Anxiety Symptom Scale <ul><li>assesses Fear Avoidance behaviour </li></ul><ul><li>High score can be associated with poor adherence to exercise/rehab in long term </li></ul><ul><li>Range 0-200 </li></ul><ul><li>If score >100 consider referring on </li></ul>
    22. 24. Refer to a clinical psychologist and/or PMP ? <ul><li>BDI (Depression) >24 </li></ul><ul><li>Catastrophising >35 </li></ul><ul><li>Pain Anxiety >100 </li></ul><ul><li>Self-efficacy < 20 </li></ul><ul><li>If 2 out of 4 then definite yes </li></ul>
    23. 25. Case example 1 <ul><li>Pt extremely fearful of procedures, fears paralysis </li></ul><ul><li>History of an operation (yrs earlier) going wrong </li></ul><ul><li>Daughter his source of anxiety & guilt </li></ul><ul><li>Involve family & educate </li></ul>
    24. 26. Case example 2 <ul><li>Pt excellent trial response </li></ul><ul><li>But high anxiety about op for permanent </li></ul><ul><li>Turned out source of anxiety was: </li></ul><ul><li>social and economic factors, child care & loss of income </li></ul><ul><li>and </li></ul><ul><li>‘ playing her last card’ </li></ul>
    25. 27. Case example 3 <ul><li>Significant Psychiatric co-morbid presentation </li></ul><ul><li>Don’t proceed to trial </li></ul><ul><li>Liaise with psychiatric services review following CBT intervention </li></ul>
    26. 28. Breakdown of all MDT Recommendations
    27. 29. Result of SCS Trial: MDT vs No MDT (success => 50% pain relief)‏
    28. 30. Permanent implants - 6 month follow-up <ul><li>90% reported ≥ 50% pain relief for both MDA and No-MDA pts </li></ul><ul><li>MDA greatest impact on trial selection </li></ul><ul><li>and allowing more complex patients who may previously have been declined, to be considered for SCS </li></ul><ul><li>Some non-MDA patients have required PMP etc later (observed trend)‏ </li></ul>
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