In this post, I will continue the conversation with Sarah Nelson, PhD, pain psychologist. Previously we talked about common psychological issues associated with headache, issues that affect coping and functioning for patients with chronic headache, dealing with resistance to accepting psychological help and barriers to care.
What are the best screening measures to use in primary care to assess levels of psychological distress and challenge?
SN: Screening for psychological distress and challenge will be most effectively done in collaboration with a trained psychologist or counselor. However, if you suspect issues with anxiety or depression, a general guideline that we like to use is to ask if the symptoms are “getting in the way.” Do these thoughts or feelings preoccupy you? Cause you to miss out on things? Keep you up at night? Using the level of impairment or disruption that these symptoms may cause can be a helpful way to gauge whether higher level of intervention is required.
- There are a number of validated screening tools available. Check out this document, Mental Health Screening and Assessment Tools for Primary Care: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Documents/MH_ScreeningChart.pdf
What types of psychological supports are helpful for patients with headaches?
SN: As mentioned previously, the most important aspect of psychological support is the relationship built between therapist and client. However, research does show that the most effective type of therapy is cognitive-behavioral therapy.
Cognitive behavioral therapy (CBT) is a form of psychological treatment that has been demonstrated to be effective for a range of problems including depression, anxiety disorders, pain and many other psychological issues. Numerous research studies suggest that CBT leads to significant improvement in functioning and quality of life, and has been shown to be at least as effective as other forms of psychological therapy or psychiatric medications, with ample scientific evidence to back this up. CBT is quite effective for both children and teenagers.
CBT specifically focuses on addressing those unhelpful thoughts (e.g., pain getting in the way, etc.) and behaviors (e.g., avoiding school or physical activity because of pain) through teaching skills and strategies that patients can continue using for the rest of their lives.
CBT strategies include:
- Learning to recognize distortions in thinking that are create problems, and then to reevaluate them in light of reality.
- Gaining a better understanding of the behavior and motivation of others.
- Using problem-solving skills to cope with difficult situations.
- Learning to develop a greater sense of confidence is one’s own abilities.
CBT treatment also usually involves efforts to change behavioral patterns and may include:
- Facing your fears instead of avoiding them.
- Using role playing to prepare for potentially problematic interactions with others.
- Learning to calm your mind and relax your body.
Biofeedback can also be helpful for many patients. This involves learning how to address aspects of nervous system excitability (e.g., blood pressure, heart rate, respiration) in a very concrete way so decrease stress and pain.
What are appropriate resources for PCPs to be aware of, in the case of patients challenged by chronic headache?
SN: First and foremost, PCP’s should be vigilant about what language they use when recommending treatment for headaches. Conveying to the patient that headaches can be treated solely by psychotherapy may be appropriate at times (e.g., to learn coping and address underlying tension/stress and nervous system overexcitement). However, using the wrong language can severely undercut the reasoning/logic behind the treatment and lead to damaged rapport and aversion to psychotherapy.
When recommending psychotherapy, it would be most beneficial to highlight the skills-based nature of psychotherapy and that often, the best outcomes for headache come from the non-pharmacologic treatment options. Facilitating psychological support could come in the form of providing resources for help and education on what they can expect (e.g., skills-based, learn pain coping, short-term, focused, etc.). Using the description of ‘learning skills and strategies to manage pain’ is often more acceptable to adolescents and families, as opposed to standard supportive therapy.
PCPs are a valuable resource for families, because they usually know what the resources in the community are available and appropriate. The family’s insurance carrier can also be a valuable resource on finding an in-network provider. The Psychology Today website has a search function that is quite extensive as well (www.psychologytoday.com). Instruct them to search by their zip code, and then narrow the search down to child/adolescent, and CBT.
So there you have it. Thank you Sarah, for sharing your knowledge and expertise on the world of pain psychology.
HeadFirst PNP 