Dynamic Psychotherapy for the Patient with Persistent Pain

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Dynamic Psychotherapy for the Patient with
Persistent Pain

• Dr Stephanie Oak
• Liaison Psychiatry

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What is Psychotherapy?

• the talking cure
• conversations with a listener who is trained to
  help you make sense of, and try to change, things
  that are troubling you
• Patient as active participant
• Over 200 varieties
• Behavioural
• Cognitive
• Person-centred / humanistic
• Systems
• Psychoanalytic / psychodynamic

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What is dynamic psychotherapy?

• Started with the discoveries of Freud over 100
  years ago
• Concerned with the meaning of experience and
  behaviour
• Crystallises out of shared exploration between
  therapist and patient
• Looks beyond what we know and remember to what is
  buried and secret (unconscious)
• Leads us to a fuller sense of our motivations,
  intentions, feelings, how we act the way we are
• Not just for the sake of creating psychological
  explanations but to help dismantle the obstacles
  that stop us resolving issues or moving on in our
  lives.

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Does dynamic psychotherapy work?

• 5 RCT psychodynamic therapy superior to TAU
  control conditions in
• IBS (Svedlund, 1983 Guthrie, 1991)
• Functional dyspepsia (Hamilton et al, 2000)
• Somatoform pain disorder (Monsen Monsen, 2000)
• Urethral syndrome (Baldoni et al, 1995)
• Reduction in pain and other physical symptoms,
  reduced health utilisation and reduction in
  psychological symptoms.

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Pain as a focus for psychotherapy

• Surprisingly little psychoanalytic literature on
  the subject of chronic pain
• If Irmas pains had an organic basis, I could
  not be held responsible for curing them my
  treatment only set out to get rid of hysterical
  pains (Freud, 1900)
• Engel (1959) the pain prone patient encouraged
  widespread adoption of concept of psychogenic
  pain.

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The pain prone patient

• Focused on psychodynamic factors involved in pain
  pathogenesis
• An unconscious need to suffer
• A response to a real, threatened or fantasised
  loss
• Conflicts or guilt over intense aggressive or
  forbidden sexual impulses
• Highlighted link between chronic pain and a
  history of distressing life experiences
• Saw pain as a subjective experience, like an
  affect or emotion, which, once represented
  mentally, no longer needs peripheral stimulation
  to be provoked.

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Pain in therapy

• Psychological vulnerabilities to pain (which are
  largely unconscious), can be embedded in the
  neuromatrix waiting to be activated by some life
  event.
• How are psychological processes operating to
  determine the ultimate character of the pain
  experience of the patient and its manner of
  communication to the physician?
• Identify and explore these unconscious
  vulnerabilities, and through resolution of
  conflicts, alleviate symptoms.

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Why patients with persistent pain are difficult
to engage

• The typical pain patient
• Difficult to establish a rapport
• Asking them to make an extreme conceptual shift
• Taking away their accustomed way of coping
  (before you take away the pain)

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Who is likely to benefit from dynamic therapy?

• Accept the concept of an unconscious mind
• Be aware of mental pain
• Be ready to receive help
• Have reasonable verbal skills
• IBS
• One site of pain
• shorter duration
• Presence of anxiety/depression at intake
• Absence of constant pain

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Short term dynamic therapies for persistent pain
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Mrs A (Whale, 1992)

• Pain Clinic Addenbrookes Hospital, Cambridge, UK
• Patient questionnaire
• Exclusion criteria
• All offered 1.5 hr psychodynamic assessment
• Identified an early memory any clear focus of
  unresolved psychological conflict which might be
  influencing the pain
• 4 therapy sessions, 50 mins
• F/U 6 mths and 1 year

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Mr B (Stern, 2003)

• St Marks Hospital, Middlesex, UK
• Employs a psychoanalytic psychotherapist
• 9 sessions, initially sporadically then 6 weeks
  in a row
• Onset of symptoms and their link with issues
  surrounding loss, sexuality, unacknowledged
  murderous impulses and guilt

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Mrs C (Monsen Monsen, 2000)

• Employees of a large Norwegian office company
• Fulfilled criteria for Pain Disorder (DSM IV)
• Pain not associated with work-related injuries
• 33 sessions of psychodynamic body therapy
• Explore affect experience
• Look at how certain maladaptive experiencing or
  expressive patterns are linked to other people
  and to their representations of significant
  others
• Bodily interventions include massage grips
  specific exercises to accelerate the
  psychotherapeutic process by making affects
  accessible to conscious awareness