Cognitive Behavioral Protocols for Medical Settings

A Clinician’s Guide

Jennifer Labuda, Bradley Axelrod, James Windell, Bradley N Axelrod

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9781315282398
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

This book offers specific evidence-based behavioral treatment plans for the most commonly observed symptoms seen in medical and clinical settings. It will address the needs of therapists who work in fast-paced clinics and are often mandated to provide time-limited and effective treatment. Intended for early career clinicians as well as experienced psychotherapists, clear goal-directed protocols are outlined in a specific manner to assist the clinician in treating frequently reported pain complaints, somatic illnesses, anxiety, sleep difficulties, panic, agitation, anger management, and more. A brief review of symptoms is followed by specific cognitive behavioral treatment strategies, quantitative treatment tracking tools, and methods to address obstacles and facilitate progress. This clinician-friendly manual will guide research based interventions and documentation needs, while also showing how the intervention can best be used to avoid common pitfalls in treatment.

Part I
General Principles and Evidence-Based Treatment

Chapter 1
Common Conditions Significant in Medical Settings

If you are a psychologist or a clinician in a hospital or medical clinic, there are a number of physical conditions and symptoms which you will likely encounter with surprising regularity. In this book, we have selected nine of these common physical conditions because these are the ones most often seen by clinicians.

In this initial chapter, those nine conditions and symptoms will be described in detail. While the core of this book will provide treatment protocols for each of the nine conditions, this chapter may be regarded as the background you will need prior to beginning treatment. Each condition or symptom will be described in terms of epidemiology, prevalence, symptoms, interrelationship with other symptoms, misdiagnosis, assessment, treatment, and relapse potential. In later chapters, the recommended treatment, based on the research and evidence, will be presented.

The conditions and symptoms covered in this chapter and in this book are:

• pain
• sleep difficulties
• depression
• anger dysregulation
• anxiety about the medical setting and treatment
• illness anxiety
• “anxiety attacks” (panic)
• agitation (confusion)
• pragmatic difficulties.

Pain

Of all the physical conditions and symptoms, pain affects more Americans than any other disease, symptom, or condition. According to the American Academy of Pain Medicine, more people in this country are affected by pain than by diabetes, heart disease, and cancer combined.

Pain is commonly defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (International Association for the Study of Pain, 2015). Acute pain is often associated directly with underlying tissue damage; it fades as tissues heal. Most often, acute pain is associated with an identified cause (such as injury or disease), and usually responds well to treatment. Pain becomes chronic if it continues after the expected healing time. The cause of the pain may not be identifiable in chronic pain, and usually persists despite treatment. Pain is generally classified as “chronic” if it persists more than 3 months after the identifiable medical event (Smith et al., 2001).

There may be as many as 116 million Americans who suffer from chronic pain (Jensen and Turk, 2014). The risk of pain increases with age, with some estimates suggesting that 25 percent or more of people older than 50 years experience chronic pain at any one time (Johannes et al., 2010). Although pervasive, certain groups report more difficulties with pain. For instance, women are more likely than men to have chronic pain, as are older adults, Caucasians, people who did not graduate from high school, as are adults who are obese, who describe their overall health as fair or poor, and who have been hospitalized in the past year (Kennedy et al., 2014).

A survey conducted by the National Institute of Health Statistics indicated that lower back pain was the most common pain (27 percent), followed by severe headache or migraine pain (15 percent), neck pain (15 percent), and facial ache or pain (4 percent) (American Academy of Pain Medicine, 2016). Importantly, when an individual’s movements are limited by their discomfort, their ability to work, perform daily tasks around the home, and engage socially can all be disrupted. Consequently, their lives can become more restricted both in terms of the way they spend their time as well as their financial stability in light of reduced income from changes in employment. Whether pain is acute or chronic, pain robs people of their productivity, their well-being, and, some individuals suffering from extended illness, their very lives. The financial toll of what might be labeled as an epidemic is tremendous. A report funded by the Institute of Medicine pegs the cost in the neighborhood of $600 billion a year (Gaskin and Richards, 2011). This cost does not even begin to take into account the challenges one person’s pain presents to family, friends, and health care providers who often offer comfort to that individual.

More recently, the cost of pain has been directly associated with the a rising opioid abuse epidemic in the United States. Many opioid abusers are introduced to narcotics in their doctor’s office, as treatment for chronic pain. In fact, opioids are now the most commonly prescribed medication in the United States for pain (National Institute on Drug Abuse, 2015). Prescription opioid misuse is the fastest growing form of drug misuse, and is now the leading cause of accidental overdoses and mortality in the United States (American Society of Addiction Medicine, 2016).

Chronic pain is often associated with comorbid mental health conditions. Typically, as pain gets worse, depression, anxiety, and posttraumatic stress disorder (PTSD) symptoms may worsen. Conversely, as mental health conditions worsen, pain also worsens, along with increased emotional distress. It is estimated that the overlap between depression and pain is as much as 66 percent, and for PTSD, there is a high co-occurrence as well (Bair et al., 2003). More recently, associations between chronic pain and mental health disorders in general have been found, especially concerning PTSD (Bosco et al., 2013). One of the most frequently reported symptoms of U.S. service members returning from operations in Iraq and Afghanistan is pain. Along with pain, many servicemen returning from these two countries report persistent post-concussive syndromes, and PTSD or posttraumatic symptoms (Bosco et al., 2013).

As simple as it sounds, pain is anything but simple. Pain is a multidimensional perceptual experience that includes not only the physical injury but also consequences that are not physiologic at all. Think about the last time you hurt yourself—not only did you feel the sensory (ouch!), but you also had a behavioral reaction (maybe you moved away from something), you had a thought (“I can’t believe I did that.”), an image or memory (the last time you did it), an emotion (anxiety, irritation), and a social experience (sympathy). Each one of these is like a river that feeds into the pool of pain. Because there are so many channels, people’s experience of pain is unique to them—and those who appear to have identical injuries or illnesses can have very different pain experiences! We have all heard emergency room stories about people with terrible injuries (like a knife still in the body) and felt nothing (how can this be?), or conversely had small injuries (ever had a paper cut?) that caused big pain. A person’s experience of pain is determined by sensory, emotional, cognitive, behavioral, and social factors.

The multifactorial presentation of a pain experience can make the diagnosis and assessment of pain especially challenging. Acute pain—associated with tissue damage or disease—is typically assessed in a primary care medical or hospital setting. Comprehensive medical evaluations (including imaging, blood work, physical examination, symptom review) are conducted in order to find the cause of pain. When the cause is identified, it can be treated, healing occurs, and the pain abates.

Chronic pain, in contrast, occurs long after tissue healing has ended. It is dissociated from acute damage and often not linked to an identifiable cause. It is instead maintained by the nervous system. The assessment focus is therefore targeted at factors that impact the nervous system, the subjective magnitude of the pain, and the daily consequences of pain.

Assessment of Chronic Pain

Comprehensive pain assessment must include both unidimensional and multidimensional tools, as well as a review of the patient’s pain and medical history. A comprehensive assessment should include an individual’s unique pain story.

Unidimensional tools are accurate, simple, quick, and both easy to use and easy to understand, and are commonly used for both acute and postoperative pain assessment. Measuring pain allows the clinician to assess the degree of a patient’s pain, and, according to Melzack and Katz (2013), it is a patient’s selfreport of his or her pain that provides the most valid measurement of the pain experience. Unidimensional pain intensity scales used most often in the clinical setting are Pain Numeric Rating Scale (PNRS), also known as the Numerical Pain Intensity Scale (NPIS); Visual Analog Scale (VAS); Subjective Units of Distress Scale (SUDS), and Verbal Descriptor Scale (VDS).

There are multidimensional pain assessment tools which are also available. These tools help identify the many factors that have an effect on the subjective pain experience (Herr et al., 2006). Multidimensional instruments look at the emotional responses to the pain, how the person thinks about the pain, activity levels, subjective pain descriptors, and behavioral history. The most common multidimensional assessment tools include the McGill Pain Questionnaire, Brief Pain Inventory, and the Memorial Pain Assessment Card.

Treatments for Pain

The treatments for pain are as diverse as the causes. The many approaches to pain range from over-the-counter and prescription drugs to mind/body techniques to acupuncture. However, no single approach or technique is guaranteed to produce complete pain relief. As many patients discover, relief may be found only by using a combination of treatment methods.

Several medications have been shown in research studies to be effective. The most effective pain medications include anticonvulsants, which are used to treat trigeminal neuralgia, postherpetic neuralgia, glossopharyngeal neuralgia, and posttraumatic neuralgia (Aiello-Laws et al., 2009). In addition, antidepressants, used in treating neuropathic pain, pain from surgical trauma, postherpetic neuralgia, radiation therapy, chemotherapy, or malignant nerve infiltration, serotonin-norepinephrine reuptake inhibitors (SNRIs), and tramadol are often effective in treating pain (Tauben, 2015).

Some doctors now prescribe exercise as part of the treatment regimen for patients with pain. Since there is a known link between many types of chronic pain and tense, weak muscles, exercise—even light to moderate exercise such as walking or swimming—can contribute to an overall sense of well-being by improving blood and oxygen flow to muscles (Landmark et al., 2013). Just as we know that stress contributes to pain, we also know that exercise, sleep, and relaxation can all help reduce stress, thereby helping to alleviate pain (Mork et al., 2013).

Psychological treatment, however, provides safe, nondrug methods that can treat pain directly by reducing high levels of stress that often aggravate pain. Psychological treatment also helps improve the indirect consequences of pain by helping patients learn how to cope with the many problems associated with pain. Some forms of psychological treatment help establish an internal locus of control about the client’s ability to manage the pain. This leads to the client believing that they have some control over their pain. A large part of psychological treatment for pain is education, which helps patients acquire skills to manage what is a very difficult problem. Education can also assist with increasing and changing movement and activity patterns, which in turn reduces painrelated fear of movement. Cognitive behavioral therapy (CBT) utilizes a wide variety of coping skills and relaxation methods to help clients cope with pain. But, along with CBT, some frequently effective treatments include relaxation techniques, meditation, guided imagery, biofeedback, and hypnosis (National Sleep Foundation, 2016). Relaxation techniques, such as meditation and yoga, have been found to help alleviate discomfort related to chronic pain and to reduce stress-related pain when these techniques are practiced regularly (Kwekkeboom and Gretarsdottir, 2006; Zeidan et al., 2011).

There is little scientific evidence supporting current complementary and alternative medicine approaches to pain that have become popular in recent years. These approaches include acupuncture, massage, chiropractic and osteopathic manipulation therapies, herbal therapies, dietary approaches, and nutritional supplements. Despite the lack of documented support, some methods may nonetheless offer temporary relief for many individuals. However, if these methods—or almost any method—generate no long-term benefit, continuation of such treatments is not justified.

The goal of pain management and most treatment approaches is to improve the patient’s functioning, enabling them to work, attend school, or participate in other day-to-day activities and promote long-term adaptation to pain. While clients and their therapists have a number of options for the treatment of pain, some are more effective than others. In Chapter 3, you can read about research related to the effectiveness of CBT for pain, and in Chapter 4, you can learn about effective treatment protocols for pain.

Sleep Difficulties

Although everyone needs a good night’s sleep, far too many Americans fall short of the 7 or 8 hours of sleep most people need to thrive. It is estimated that 50 to 70 million Americans suffer from a chronic sleep disorder, according to the Institute of Medicine (National Academy of Sciences, 2006). Many adults report at least occasional difficulty sleeping, but the National Institutes of Health reports that chronic and severe forms of insomnia affects one in five (National Institutes of Health, 2011).

Each year, the cost of sleep disorders, sleep deprivation, and sleepiness, according to the National Center for Sleep Disorders Research, is estimated to be $15.9 million in direct costs and $50 to $100 billion a year in indirect and related costs (National Center on Sleep Disorders Research, 2015). And according to the National Highway Traffic Safety Administration, falling asleep while driving is responsible for at least 83,000 crashes, 37,000 injuries, and 886 deaths each year in the United States (National Highway Traffic Safety Administration, 2016).

What Keeps People from Getting All the Sleep They Need?

For most people, the barrier to sound sleep comes down to sleep disorders. Surveys conducted by the National Sleep Foundation reveal that at least 40 million Americans suffer from more than 70 different sleep disorders and 60 percent of adults report having sleep problems a few nights a week or more (American Psychological Association, ...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Introduction
• PART I General Principles and Evidence-Based Treatment
• PART II Treatment Interventions for Symptoms
• Resource Pack
• Index