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Group treatment for pain and discomfort
167
Patient Education and Counseling, 20 (1993) 167-175
Elsevier Scientific Publishers Ireland Ltd.
Group Treatment for Pain and Discomfort Heinz-Dieter
Basler
Institute for Medical Psychology, Bunsenstrasse 3, W-3550 Marburg (Germany)
Abstract Rheumatic patients very often sufferfrom chronic pain and impairment and show psychological reactions as a consequence of their physical condition. These reactions may vary from psychophysiological symptoms to anger, anxiety, or depression. We developed a cognitive-behavioral treatment programme in a group setting format with components of relaxation, cognitive restructuring, and the promotion of well-being. Subjects included in the study were given diagnoses of low back pain, tension headache, rheumatoid arthritis, and ankylosing spondylitis. Treatment effects in different diagnostic groups were compared to each other, supporting the assumption that pain reduction is greatest in low back pain and least in ankylosing spondylitis. Subjects with inflammatory rheumatic diseases showed some improvement in self-reported physical complaints and in their feelings of well-being.
Key words: Chronic pain; Cognitive behavioral therapy; Effect size; Group treatment.
Conceptualisations of Rheumatic Diseases in Behavioral Medicine In behavioral medicine, there is a focus on a line of research that conceptualises rheumatic diseases as stressful life-events. From the view of the patients, pain and impairment is their most prominent burden. There is a controversy about which of both imposes more strain upon the patients, continuous pain on
one hand (Gibson and Clark, 1983, or progressive functional impairment on the other hand (Cornelissen et al., 1988). With regard to ankylosing spondylitis (AS), for example, Keitl et al. (1980) found that about half of their subjects had to face a constant progression of their illness despite continuous medical care. As a consequence, the patients became psychologically impaired through feelings of anxiety and depression. In a study of 170 AS patients, Urbanek et al. (1984) reported that more than half of the patients had become labeled as physically impaired and had retired from nearly any kind of physical activity. Furthermore, they suffered from loneliness, family conflicts and financial worries, and some of them contemplated suicide. Chamberlain’s findings (198 1) corroborate the clinical experience that AS patients are disabled in many aspects of their daily life, such as shopping, recreational activities, physical exercise or engaging in vocational activities. Both men and women reported restrictions on their sexual activities (Elst et al., 1984). Findings with regard to anxiety in rheumatoid arthritis subjects (RA) were reported by Welter-Enderlin (1989). Fears of the patients focused on the anticipated consequences of the disease, such as being confined to a wheelchair, being dependent on a nursing home, being operated upon the joints, and loosing the spouse or the job. Between 20 and 40% of RA subjects show depression scores equivalent to patients in
0738-3991/93/$06.00 0 1993 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
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medical treatment for depressive disorders (Raspe and Rehfisch, 1990). There is a controversial discussion as to the interpretation of the conjunction between depressive and rheumatic disorders with a focus on chronic pain as a mediative link. Pain as a stressful experience might impose excessive demands on the coping resources of the pain sufferer. On the other hand, correlations between pain intensity and depression seldom exceed 0.4. Consequently, only about 20% of the variation in depression scores is accounted for by pain ratings. Rudy et al. (1988) proposed cognitive factors as mediating links between pain and depression, suggesting that pain only leads to depression if inadequate cognitive coping styles are used such as feelings of hopelessness in conjunction with destructive thoughts. Recently, Brown (1990) found evidence that future depressive states may be predicted by present pain, whereas future pain is not predicted by present depressive mood. Consequently, depression may be a consequence of pain, not its cause. Findings of Raspe and Rehlisch (1990), indicating a relationship between depression scores and somatic variables, such as the number of inflamed joints, may be used to support this assumption, although the correlation scores are not impressive, and only 20% of the variance of depression can be explained by the medical status of the patients. Strategies for the promotion of coping with pain are based on behavioral, psychophysiological, and cognitive principles. In the behavioral model, operant conditioning is used to accomplish two major aims (Fordyce, 1976): to decrease the frequency of pain behavior and to increase the frequency of well behavior. Pain behavior includes descriptions of pain, reductions in activity, avoidance of responsibilities at home or at work, and reliance on pain medication, as well as adoption of body postures and facial expressions that are indicative of pain. Well behavior is incompatible with pain behavior and comprises all those activities that either add to a
feeling of well-being or that are indicative of pleasurable experiences. Pain and well behavior may be modified by learning. A chronic pain sufferer may learn, for example, that complaints of pain are followed by reinforcing consequences, such as attention from a solicitous spouse, delivery of a habit-forming narcotic drug, or avoidance of unwanted social, family, or occupational responsibilities. As a result, pain behavior may get more and more stabilised, and well behavior more and more discouraged. This process may finally end up in a complete loss of pleasant feelings and in an increased awareness of pain, anxiety, and depression. For this reason, the main objective of behavioral programmes is a reconditioning of the patient suffering from pain. All kinds of pleasant activities are strongly encouraged, and pain behavior is disregarded during treatment. Physiological concepts focus on the vicious cycle of pain and muscular tension (Flor, 1991). According to this concept, an initial, pain-eliciting event triggers reflexive muscle spasms accompanied by vasoconstriction, the release of pain-producing substances, and by increased pain. As time passes, an individual may attempt to minimise pain by restricting movement. Such an attempt leads to a deconditioning of the muscles, which predisposes additional spasms and additional pain. This cycle may be reinforced by stressful lifeevents, which may further add to tension in predisposed people. The concept of relating stress to pain has been labeled the “diathesisstress-model” (Flor, 1984). There is evidence that subjects, on the basis of a diathesis or predisposition, display a specific pattern of muscular spasm when exposed to significant stressors. The most common feature of programmes based on the physiological model is the implementation of relaxation techniques in order to reduce excessive muscular reactivity in targeted muscles. The cognitive approach underlines the effects of information-processing on pain expe-
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rience. It conceptualises pain as a perceptual event, which is the result of the integration and interpretation of both sensory and psychological stimuli. According to Turk and Rudy (1988), the cognitive approach takes into account the psychological aspects of information processing without neglecting the importance of environmental factors underscored by the operant approach. Special emphasis is placed upon the interaction of distorted thinking, feelings of anger, depression, guilt, fear, anxiety, and pain experience. The distorted thinking of individuals may be the consequence of their beliefs that there is nothing they can do to manage their pain, that their situation is hopeless, and that they are useless to themselves and to others. Turk and Rudy (1988) recently summarised the objectives of cognitive-behavioral interventions for enhancing self-control of chronic pain as follows: (1) Combat demoralisation. Chronic pain patients usually conceptualise their problems in terms of an acute illness model, which includes feelings of victimisation and helplessness which, in turn, finally leads to demoralisation. Now they are taught to reconceptualise their problems from overwhelming to manageable.
(2) Enhance outcome efficacy. Aiming at motivating active cooperation, much effort is directed at persuading the patients that the treatment will meet their needs and, with their cooperation, improve their condition. The patient’s belief that the treatment is effective is supposed to be a prerequisite of an active participation in the treatment. (3) Foster self-efficacy. Patients learn to reconceptualise their views of themselves from passive, reactive and helpless to active, resourceful, and competent. They are encouraged to believe in their power to control their pain and to be efficacious in initiating changes.
(4) Break up automatic maladaptive patterns. Patients are taught how to monitor and
become aware of thoughts, feelings, and behavior which interact with pain experience. (5) Skills training. Patients are taught a range of adaptive responses to their problems and circumstances. (6) Self-attribution. Patients learn to view themselves as active agents of change. They attribute success to their own efforts, not to external factors. (7) Facilitate maintenance. Patients are taught to anticipate problems and to discuss them, as well as ways to cope with them in order to maintain long-term success. Thus, the cognitive-behavioral approach relies heavily on active patient participation, which extends not only to the treatment sessions but also to homework assignments. Homework usually includes self-assessments of pain-related thoughts, feelings, and behavior, as well as the application of acquired skills in the natural environment. Cognitive treatments for pain are usually administered to groups of patients, thus taking advantage of self-help activities and peer counselling, which are important adjuncts to professional guidance. A Cognitive-Behavioral Treatment Programme for Chronic Pain During the past years, we have developed and published a cognitive-behavioral treatment programme for chronic pain patients (Rehtisch et al., 1989). The programme consists of 12 weekly 90-minute sessions and has been conducted by members of our study group. The programme is based on cognitivebehavioral principles and uses behavioral, psychophysiological, and cognitive methods for the self-management of pain. It consists of several components. Education
The
educational
elements
of the
pro-
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gramme aim primarily at a reconceptualisation of the patients’ pain experience according to the rationale of the programme. Patients are encouraged to take an active part in the treatment by obtaining thorough explanations about why the acute illness model is not beneficial to their present problems. They receive information about the vicious circle of pain, muscular tension, and demoralisation and about how different treatment methods would contribute to gradually gaining selfcontrol over thoughts, feelings, and behavior. Active participation in the treatment by engaging in group discussions and by performing the homework tasks are strongly reinforced. Furthermore, patients are informed about kinds and effects of pain medication, but are not encouraged to change medication without consulting their physician. Relaxation
After an introduction into the rationale of the programme, the patients first learn how to control their physical responses to pain as a stressor, such as increased muscle tension and psychophysiological arousal, with the aid of progressive muscle relaxation according to Jacobson (1938). A relaxation tape for home practice is provided. By gradually abbreviating the relaxation instructions and by applying relaxation to real life situations, an attempt is made to make the stress-reducing relaxation response available in everyday life. As a second step the patients are taught how to use imagery techniques and visualisation in order to distract themselves from pain and to further improve their relaxation skills. Modifving thoughts and feelings
Keefe et al. (1989) found evidence that catastrophizing is a maladaptive coping strategy in pain patients. In our programme, maladaptive thinking associated with increases in psychological distress is identified by means of self-observational records and is replaced by alternative, rational coping thoughts. Following Keefe et al. (1986),
coping cards were completed by each patient with his or her maladaptive thoughts on one side and coping thoughts on the reverse. The conjunctions between negative emotions such as fear, depression or anger and irrational thinking are explained to the patients. Pleasant activity scheduling
In order to reduce depression and suffering, patients are encouraged to use distraction techniques. In order to shift the focus of attention from activities from which they are restricted to those which they can enjoy, guidelines for pleasant activities such as “Find your own way to enjoy yourself”, “Focus your attention completely on what you are doing while you are engaged in pleasant activities”, or “Only do one thing at a time” are introduced. Moreover, in order to demonstrate that the feeling of pleasure is bound to our sensual experiences and that one’s senses can be trained, different olfactoral sensations, such as those caused by oranges, fresh leaves, perfumes, etc. are encouraged. Patients are asked to touch and smell each of these, to describe the odours, and to recall pictures and images which have been associated with similar experiences before. For homework, patients are asked to look for different kinds of smells in their environment. Activity goals are scheduled, and pleasant activities are reinforced in subsequent sessions. Methods Computation of effect sizes
The programme was tested both in a primary care setting and in the format of the German Rheumatism League, which is a physician-supported, self-help association for individuals with rheumatic diseases. The treatments were conducted in accordance with the manual by therapists who hold a long history of experience in chronic pain management. In order to compare treatment effects in different diagnostic groups, we used an ap-
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preach that has gained widespread acceptance in meta-analytic research. Meta-analyses consist of the integration and synthesis of research through statistical analysis of individual studies. Perhaps the most innovative aspect of meta-analytic applications is that they afford the use of inferential statistics in a domain where conclusions were formerly tested on simple summation and opinion and thereby did not control for the subjective interpretation of the reviewer. The procedure takes means and standard deviations of experimental and control subjects at different assessments into account, using a mathematical formula for the conversion of this information into an index. This index is called effect size and represents the strength of the relationship between treatment procedure and treatment outcome in different target areas (Malone and Strube, 1988). The effect size of a treatment is calculated by relating post treatment differences between mean values in experimental (Xe) and control groups (Xc) to the post treatment standard deviation in the control group (S.D.c) according to the following formula: Effect Size =
Xe - Xc
(1)
SDc Computations based on this formula result in the determination of the effects of treatment in standard deviation units. Thus, for example, an effect size of 0.50 reveals that one treatment condition exceeded another by one half of a standard deviation. This result can be interpreted as a specific treatment performing one half of a standard deviation better than an alternate treatment or a no treatment. According to Flor et al. (1992), a valuable feature of the computed effect size is that it is comparable to a standardized Z-score and thus can be converted to percent improvement. Thus, according to the Z-score distribution, an effect size of 0.50 for a treatment indicates that the average treated patient fared better than 69.15% of the untreated patients.
Assessment instruments Several published, self-report measures with well-established psychometric properties were administered to our subjects at each assessment period before and after treatment and at a 6-month follow-up. (1) A pain diary was completed over 14 days. On a scale between one (no pain) and six (very intense pain), subjects rated the intensity of their pain three times a day. The kind and quantity of pain medication were recorded. (2) The trait form of the State-TraitAnxiety Inventory in a German version adapted by Laux et al. (1981). The scale contains 20 items that ask patients to rate the frequency of certain feelings using a four-point scale with 1 = ‘almost never’ and 4 = ‘nearly always’. Items included: “I get tired easily”, “I feel nervous and tense when I think of my present problems”, “I lack self-confidence”, and so forth. The internal consistency of the scale (Cronbach’s) is 0.90. (3) The Von Zerssen Depression Scale (DS’, von Zerssen, 1976). This 16-item scale assesses how often depressive symptoms occur including the report of general dysphoric mood (“I can’t help crying.“), behavior (“I sleep badly at night.“), and suicidal ideation (“I contemplate suicide.“), using a four-point scale in which 1 = ‘not at all true’ and 4 = ‘absolutely true’. The internal consistency of the scale (Cronbach’s) is 0.81. (4) A checklist of bodily symptoms (Brahler and Scheer, 1983). It contains 57 items (nausea, tiredness, trembling, exhaustion, etc.) which ask patients to rate the extent to which they suffer from these symptoms using a scale between 1 (“not at all”) and 5 (“extremely”). The internal consistency of the scale (Cronbath’s) is 0.90. Samples Studies included in our analysis comprise patients with low back pain (Kaluza and Basler, 1986), back pain and tension headache (Basler and Rehfisch, 1990) RA-patients (Rehfisch, 1988), and AS-patients (Basler and Rehlisch, 1991).
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The first two studies mentioned above were conducted in a primary care setting format, the subsequent studies in a setting of the German Rheumatism League. In the primary care format, the patients were selected from the charts by their physicians, in the Rheumatism League format, there was a self-selection of the participants after an introductory lecture.
Fig. 1. data.
In every study, the patients had to sign informed consent, and subsequently, were randomly assigned to an immediate treatment and a waiting-list control condition. Controls were offered a psychological treatment after termination of the treatment in the study group. All of the patients were chronic pain sufferers with a duration of pain of more than 10 years. In all the studies, more than 80% of the participants were female, with an exception of the AS-study, showing an equal distribution of both sexes.
0.21
Table 1 presents the number of patients (drop-outs not included) in each study with complete data sets at each assessment before and after treatment. Drop-out rates were high in primary care and low in a self-help setting of the Rheumatism League. Results
To start with, in neither study a significant reduction of the number of days with pain medication could be demonstrated in the diary. Figure intensity
1 represents the effect sizes of pain measured in the pain diary after
Table 1. Diagnoses
Effect sizes of pain intensity-pain
diary
Effect Size 1.2
i
II 0.8 0.6 0.41
0f
4 LBP
TH
Post Treatment
W
1.08
Follow-Up
3,
0.91
RA
/
AS 0.91
0.31
0.06
0.75
0.48
0.06
treatment and at the 6-month follow-up assessment. The effect sizes are highest in back pain and headache subjects and lowest in inflammatory rheumatic diseases. AS patients seem to have little benefit from the treatment applied as far as pain reduction is concerned. There is only an insignificant decline of the effect sizes at the follow-up assessment. For the sake of data reduction, we calculated mean effect sizes including the symptom check list, and the anxiety and depression scale. This may be called a well-being index. The result is presented in Fig. 2. Again, the effect sizes in low back patients are most pronounced. However, contrary to pain intensity, AS patients demonstrate beneficial effects with regard to their well-being. This effect is maintained over a period of half a year. Data not yet published show that a longterm outcome is associated with long-term adherence. Those patients who still practised re-
and sample size. Drop-outs are not included in sample size.
Diagnoses
N 03
N (C)
Follow-up
Drop-outs
LBP (PC) BP & TH (PC) RA (RL) AS (RL)
13 25 31 25
11 20 31 20
6 6 6 6
33% 24% 0% 0%
Months Months Months Months
LBP, Low-back pain; BP, Back pain; TH, Tension headache; RA, Rheumatoid arthritis; AS, ankylozing spondylitis; PC, Primary care format; RL, Rheumatism league format.
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Fig. 2. Mean effect size of symptoms, anxiety and depression (Well-Being Index)-questionnaire data. Effect Size /1 1
0.6 0.6
0.4 0.2 rIaikB& OL LBP
BP&TH
RA
AS
follow-up the exercises at laxation assessments reported more beneficial effects than those who did not. Discussion Ankylosing spondylitis has found little attention in psychological research. On the contrary, several controlled studies have been published with rheumatoid arthritis subjects evaluating the effectiveness of behavioral methods aimed at an improvement of coping with pain and at the management of stress, anxiety, depression and the feeling of helplessness, which often goes along with a chronic disease (Achterberg et al., 1981; Anderson et al., 1985; Bradley et al., 1985; Bradley et al., 1987; Bradley et al., 1988; Cziske et al., 1987; Kiihler, 1982; Parker et al., 1988; Randich, 1982; Shearn and Fireman, 1985; Strauss et al., 1986). In all these studies except that of Strauss et al. (1986), the beneficial effects of a behavioral treatment were supported by selfreport data. Although these studies were conducted in a behavioral context, treatment procedures in the experimental groups and interventions in the control group differed widely, and some studies focussed on stress management (Sheam and Fireman, 1985; Spilberg, 1984), other studies on pain management techniques (Appelbaum et al., 1988; Bradley et al., 1988; Cziske et al., 1987; KGhler, 1982; O’Leary et al., 1988). Control conditions included treatment as usual
(Cziske et al., 1987; KGhler, 1982; Randich, 1982), supportive discussions (Bradley et al., 1988; Shearn and Fireman, 1985), keeping a pain diary (Appelbaum et al., 1988), assertive training (Strauss et al., 1986), or attention placebo (Parker et al., 1988). Only a few studies reported a significant reduction of pain intensity after the treatment (Appelbaum et al., 1988; Bradley et al., 1988; Cziske et al., 1987), long-term effects on pain intensity could not be demonstrated at all. On the other hand, well-being of the subjects improved considerably even at the follow-up assessments. There was a marked decrease in depression scores and anxiety (Bradley, 1989; Kiihler, 1982). Some authors even found a reduction in the number of inflamed joints (Shearn and Fireman, 1985), and a reduction of the rheumatism factor as a result of the treatment (Bradley et al., 1988). These results are in line with our findings. The effectiveness of the treatment in RA subjects as well as in AS subjects seems to pertain more to emotional stabilization than to pain reduction. This is also confirmed by statements of the patients during the final interviews, e.g. when they said that “Pain still exists, but it doesn’t interfere with my life as much as it did before”, or “I learned that there are much more things of importance in my life besides my pain”, or “For me it is most essential to relax in spite of my constant pain”. Further confirmation of the beneficial emotional effects of the treatment on RA and AS subjects could be obtained by the ratings of the outcome on different target areas indicating most success in relaxation and wellbeing and least improvement in pain reduction. This finding could be confounded by the different drop-out ratios in the different treatment settings. In order to receive more information about the motives of the drop-outs in the primary care setting format, these patients were also interviewed in the follow-up assessments. Compared to those who completed, drop-outs felt less accepted in the
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groups, felt less supported by their family and reported more unrealistic initial expectations of therapy success. They became especially disillusioned when they realized that they were expected to make a consistent effort performing exercises on a daily basis and participating in the sessions and the homework in an active manner. On the basis of this finding, the assumption seems to be justified that the influence of the different drop-out ratios on the outcome may be insignificant. In both formats, there was a drop-out of demotivated patients at different times of the study. In the self-help format, the selection process took place before the beginning of the treatment, in the primary care format during the treatment. To come to a conclusion: our meta-analytic approach to comparing treatment effects in different diagnostic groups supports the assumption that a cognitive-behavioral treatment has beneticial effects on subjects with inflammatory rheumatic diseases especially with regard to emotional stabilization. On the other hand, the magnitude of the effect in ASand RA-patients is lesser than that of back pain patients. Further research is needed to test the stability of our findings. Finally, we wish to discuss the practical implications of the study. Those expecting a significant reduction of pain intensity in patients with rheumatic diseases as a consequence of a cognitive-behavioral treatment, may feel disappointed. On the other hand, the treatment seems to exert a remarkable influence on measures indicating an improvement of physical complaints and emotional stabilization. For this reason, we feel encouraged to recommend cognitive-behavioral therapy as an adjunct to medical treatment. Psychological therapy has beneficial effects on the wellbeing of rheumatic patients, and thereby may support a pharmaceutical treatment of pain, but it is unlikely to replace it. References Achterberg, J., McGraw, P. and Lawis, G.F. (1981). Rheumatoid arthritis: a study of relaxation and temperature biofeed-
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Correspondence to: Prof. Dr. Heinz-Dieter Medical Psychology, Bunsenstrasse 3, Germany.
Basler, Institute for W-3550 Marburg,
Patient Education and Counseling, 20 (1993) 167-175
Elsevier Scientific Publishers Ireland Ltd.
Group Treatment for Pain and Discomfort Heinz-Dieter
Basler
Institute for Medical Psychology, Bunsenstrasse 3, W-3550 Marburg (Germany)
Abstract Rheumatic patients very often sufferfrom chronic pain and impairment and show psychological reactions as a consequence of their physical condition. These reactions may vary from psychophysiological symptoms to anger, anxiety, or depression. We developed a cognitive-behavioral treatment programme in a group setting format with components of relaxation, cognitive restructuring, and the promotion of well-being. Subjects included in the study were given diagnoses of low back pain, tension headache, rheumatoid arthritis, and ankylosing spondylitis. Treatment effects in different diagnostic groups were compared to each other, supporting the assumption that pain reduction is greatest in low back pain and least in ankylosing spondylitis. Subjects with inflammatory rheumatic diseases showed some improvement in self-reported physical complaints and in their feelings of well-being.
Key words: Chronic pain; Cognitive behavioral therapy; Effect size; Group treatment.
Conceptualisations of Rheumatic Diseases in Behavioral Medicine In behavioral medicine, there is a focus on a line of research that conceptualises rheumatic diseases as stressful life-events. From the view of the patients, pain and impairment is their most prominent burden. There is a controversy about which of both imposes more strain upon the patients, continuous pain on
one hand (Gibson and Clark, 1983, or progressive functional impairment on the other hand (Cornelissen et al., 1988). With regard to ankylosing spondylitis (AS), for example, Keitl et al. (1980) found that about half of their subjects had to face a constant progression of their illness despite continuous medical care. As a consequence, the patients became psychologically impaired through feelings of anxiety and depression. In a study of 170 AS patients, Urbanek et al. (1984) reported that more than half of the patients had become labeled as physically impaired and had retired from nearly any kind of physical activity. Furthermore, they suffered from loneliness, family conflicts and financial worries, and some of them contemplated suicide. Chamberlain’s findings (198 1) corroborate the clinical experience that AS patients are disabled in many aspects of their daily life, such as shopping, recreational activities, physical exercise or engaging in vocational activities. Both men and women reported restrictions on their sexual activities (Elst et al., 1984). Findings with regard to anxiety in rheumatoid arthritis subjects (RA) were reported by Welter-Enderlin (1989). Fears of the patients focused on the anticipated consequences of the disease, such as being confined to a wheelchair, being dependent on a nursing home, being operated upon the joints, and loosing the spouse or the job. Between 20 and 40% of RA subjects show depression scores equivalent to patients in
0738-3991/93/$06.00 0 1993 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
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medical treatment for depressive disorders (Raspe and Rehfisch, 1990). There is a controversial discussion as to the interpretation of the conjunction between depressive and rheumatic disorders with a focus on chronic pain as a mediative link. Pain as a stressful experience might impose excessive demands on the coping resources of the pain sufferer. On the other hand, correlations between pain intensity and depression seldom exceed 0.4. Consequently, only about 20% of the variation in depression scores is accounted for by pain ratings. Rudy et al. (1988) proposed cognitive factors as mediating links between pain and depression, suggesting that pain only leads to depression if inadequate cognitive coping styles are used such as feelings of hopelessness in conjunction with destructive thoughts. Recently, Brown (1990) found evidence that future depressive states may be predicted by present pain, whereas future pain is not predicted by present depressive mood. Consequently, depression may be a consequence of pain, not its cause. Findings of Raspe and Rehlisch (1990), indicating a relationship between depression scores and somatic variables, such as the number of inflamed joints, may be used to support this assumption, although the correlation scores are not impressive, and only 20% of the variance of depression can be explained by the medical status of the patients. Strategies for the promotion of coping with pain are based on behavioral, psychophysiological, and cognitive principles. In the behavioral model, operant conditioning is used to accomplish two major aims (Fordyce, 1976): to decrease the frequency of pain behavior and to increase the frequency of well behavior. Pain behavior includes descriptions of pain, reductions in activity, avoidance of responsibilities at home or at work, and reliance on pain medication, as well as adoption of body postures and facial expressions that are indicative of pain. Well behavior is incompatible with pain behavior and comprises all those activities that either add to a
feeling of well-being or that are indicative of pleasurable experiences. Pain and well behavior may be modified by learning. A chronic pain sufferer may learn, for example, that complaints of pain are followed by reinforcing consequences, such as attention from a solicitous spouse, delivery of a habit-forming narcotic drug, or avoidance of unwanted social, family, or occupational responsibilities. As a result, pain behavior may get more and more stabilised, and well behavior more and more discouraged. This process may finally end up in a complete loss of pleasant feelings and in an increased awareness of pain, anxiety, and depression. For this reason, the main objective of behavioral programmes is a reconditioning of the patient suffering from pain. All kinds of pleasant activities are strongly encouraged, and pain behavior is disregarded during treatment. Physiological concepts focus on the vicious cycle of pain and muscular tension (Flor, 1991). According to this concept, an initial, pain-eliciting event triggers reflexive muscle spasms accompanied by vasoconstriction, the release of pain-producing substances, and by increased pain. As time passes, an individual may attempt to minimise pain by restricting movement. Such an attempt leads to a deconditioning of the muscles, which predisposes additional spasms and additional pain. This cycle may be reinforced by stressful lifeevents, which may further add to tension in predisposed people. The concept of relating stress to pain has been labeled the “diathesisstress-model” (Flor, 1984). There is evidence that subjects, on the basis of a diathesis or predisposition, display a specific pattern of muscular spasm when exposed to significant stressors. The most common feature of programmes based on the physiological model is the implementation of relaxation techniques in order to reduce excessive muscular reactivity in targeted muscles. The cognitive approach underlines the effects of information-processing on pain expe-
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rience. It conceptualises pain as a perceptual event, which is the result of the integration and interpretation of both sensory and psychological stimuli. According to Turk and Rudy (1988), the cognitive approach takes into account the psychological aspects of information processing without neglecting the importance of environmental factors underscored by the operant approach. Special emphasis is placed upon the interaction of distorted thinking, feelings of anger, depression, guilt, fear, anxiety, and pain experience. The distorted thinking of individuals may be the consequence of their beliefs that there is nothing they can do to manage their pain, that their situation is hopeless, and that they are useless to themselves and to others. Turk and Rudy (1988) recently summarised the objectives of cognitive-behavioral interventions for enhancing self-control of chronic pain as follows: (1) Combat demoralisation. Chronic pain patients usually conceptualise their problems in terms of an acute illness model, which includes feelings of victimisation and helplessness which, in turn, finally leads to demoralisation. Now they are taught to reconceptualise their problems from overwhelming to manageable.
(2) Enhance outcome efficacy. Aiming at motivating active cooperation, much effort is directed at persuading the patients that the treatment will meet their needs and, with their cooperation, improve their condition. The patient’s belief that the treatment is effective is supposed to be a prerequisite of an active participation in the treatment. (3) Foster self-efficacy. Patients learn to reconceptualise their views of themselves from passive, reactive and helpless to active, resourceful, and competent. They are encouraged to believe in their power to control their pain and to be efficacious in initiating changes.
(4) Break up automatic maladaptive patterns. Patients are taught how to monitor and
become aware of thoughts, feelings, and behavior which interact with pain experience. (5) Skills training. Patients are taught a range of adaptive responses to their problems and circumstances. (6) Self-attribution. Patients learn to view themselves as active agents of change. They attribute success to their own efforts, not to external factors. (7) Facilitate maintenance. Patients are taught to anticipate problems and to discuss them, as well as ways to cope with them in order to maintain long-term success. Thus, the cognitive-behavioral approach relies heavily on active patient participation, which extends not only to the treatment sessions but also to homework assignments. Homework usually includes self-assessments of pain-related thoughts, feelings, and behavior, as well as the application of acquired skills in the natural environment. Cognitive treatments for pain are usually administered to groups of patients, thus taking advantage of self-help activities and peer counselling, which are important adjuncts to professional guidance. A Cognitive-Behavioral Treatment Programme for Chronic Pain During the past years, we have developed and published a cognitive-behavioral treatment programme for chronic pain patients (Rehtisch et al., 1989). The programme consists of 12 weekly 90-minute sessions and has been conducted by members of our study group. The programme is based on cognitivebehavioral principles and uses behavioral, psychophysiological, and cognitive methods for the self-management of pain. It consists of several components. Education
The
educational
elements
of the
pro-
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gramme aim primarily at a reconceptualisation of the patients’ pain experience according to the rationale of the programme. Patients are encouraged to take an active part in the treatment by obtaining thorough explanations about why the acute illness model is not beneficial to their present problems. They receive information about the vicious circle of pain, muscular tension, and demoralisation and about how different treatment methods would contribute to gradually gaining selfcontrol over thoughts, feelings, and behavior. Active participation in the treatment by engaging in group discussions and by performing the homework tasks are strongly reinforced. Furthermore, patients are informed about kinds and effects of pain medication, but are not encouraged to change medication without consulting their physician. Relaxation
After an introduction into the rationale of the programme, the patients first learn how to control their physical responses to pain as a stressor, such as increased muscle tension and psychophysiological arousal, with the aid of progressive muscle relaxation according to Jacobson (1938). A relaxation tape for home practice is provided. By gradually abbreviating the relaxation instructions and by applying relaxation to real life situations, an attempt is made to make the stress-reducing relaxation response available in everyday life. As a second step the patients are taught how to use imagery techniques and visualisation in order to distract themselves from pain and to further improve their relaxation skills. Modifving thoughts and feelings
Keefe et al. (1989) found evidence that catastrophizing is a maladaptive coping strategy in pain patients. In our programme, maladaptive thinking associated with increases in psychological distress is identified by means of self-observational records and is replaced by alternative, rational coping thoughts. Following Keefe et al. (1986),
coping cards were completed by each patient with his or her maladaptive thoughts on one side and coping thoughts on the reverse. The conjunctions between negative emotions such as fear, depression or anger and irrational thinking are explained to the patients. Pleasant activity scheduling
In order to reduce depression and suffering, patients are encouraged to use distraction techniques. In order to shift the focus of attention from activities from which they are restricted to those which they can enjoy, guidelines for pleasant activities such as “Find your own way to enjoy yourself”, “Focus your attention completely on what you are doing while you are engaged in pleasant activities”, or “Only do one thing at a time” are introduced. Moreover, in order to demonstrate that the feeling of pleasure is bound to our sensual experiences and that one’s senses can be trained, different olfactoral sensations, such as those caused by oranges, fresh leaves, perfumes, etc. are encouraged. Patients are asked to touch and smell each of these, to describe the odours, and to recall pictures and images which have been associated with similar experiences before. For homework, patients are asked to look for different kinds of smells in their environment. Activity goals are scheduled, and pleasant activities are reinforced in subsequent sessions. Methods Computation of effect sizes
The programme was tested both in a primary care setting and in the format of the German Rheumatism League, which is a physician-supported, self-help association for individuals with rheumatic diseases. The treatments were conducted in accordance with the manual by therapists who hold a long history of experience in chronic pain management. In order to compare treatment effects in different diagnostic groups, we used an ap-
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preach that has gained widespread acceptance in meta-analytic research. Meta-analyses consist of the integration and synthesis of research through statistical analysis of individual studies. Perhaps the most innovative aspect of meta-analytic applications is that they afford the use of inferential statistics in a domain where conclusions were formerly tested on simple summation and opinion and thereby did not control for the subjective interpretation of the reviewer. The procedure takes means and standard deviations of experimental and control subjects at different assessments into account, using a mathematical formula for the conversion of this information into an index. This index is called effect size and represents the strength of the relationship between treatment procedure and treatment outcome in different target areas (Malone and Strube, 1988). The effect size of a treatment is calculated by relating post treatment differences between mean values in experimental (Xe) and control groups (Xc) to the post treatment standard deviation in the control group (S.D.c) according to the following formula: Effect Size =
Xe - Xc
(1)
SDc Computations based on this formula result in the determination of the effects of treatment in standard deviation units. Thus, for example, an effect size of 0.50 reveals that one treatment condition exceeded another by one half of a standard deviation. This result can be interpreted as a specific treatment performing one half of a standard deviation better than an alternate treatment or a no treatment. According to Flor et al. (1992), a valuable feature of the computed effect size is that it is comparable to a standardized Z-score and thus can be converted to percent improvement. Thus, according to the Z-score distribution, an effect size of 0.50 for a treatment indicates that the average treated patient fared better than 69.15% of the untreated patients.
Assessment instruments Several published, self-report measures with well-established psychometric properties were administered to our subjects at each assessment period before and after treatment and at a 6-month follow-up. (1) A pain diary was completed over 14 days. On a scale between one (no pain) and six (very intense pain), subjects rated the intensity of their pain three times a day. The kind and quantity of pain medication were recorded. (2) The trait form of the State-TraitAnxiety Inventory in a German version adapted by Laux et al. (1981). The scale contains 20 items that ask patients to rate the frequency of certain feelings using a four-point scale with 1 = ‘almost never’ and 4 = ‘nearly always’. Items included: “I get tired easily”, “I feel nervous and tense when I think of my present problems”, “I lack self-confidence”, and so forth. The internal consistency of the scale (Cronbach’s) is 0.90. (3) The Von Zerssen Depression Scale (DS’, von Zerssen, 1976). This 16-item scale assesses how often depressive symptoms occur including the report of general dysphoric mood (“I can’t help crying.“), behavior (“I sleep badly at night.“), and suicidal ideation (“I contemplate suicide.“), using a four-point scale in which 1 = ‘not at all true’ and 4 = ‘absolutely true’. The internal consistency of the scale (Cronbach’s) is 0.81. (4) A checklist of bodily symptoms (Brahler and Scheer, 1983). It contains 57 items (nausea, tiredness, trembling, exhaustion, etc.) which ask patients to rate the extent to which they suffer from these symptoms using a scale between 1 (“not at all”) and 5 (“extremely”). The internal consistency of the scale (Cronbath’s) is 0.90. Samples Studies included in our analysis comprise patients with low back pain (Kaluza and Basler, 1986), back pain and tension headache (Basler and Rehfisch, 1990) RA-patients (Rehfisch, 1988), and AS-patients (Basler and Rehlisch, 1991).
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The first two studies mentioned above were conducted in a primary care setting format, the subsequent studies in a setting of the German Rheumatism League. In the primary care format, the patients were selected from the charts by their physicians, in the Rheumatism League format, there was a self-selection of the participants after an introductory lecture.
Fig. 1. data.
In every study, the patients had to sign informed consent, and subsequently, were randomly assigned to an immediate treatment and a waiting-list control condition. Controls were offered a psychological treatment after termination of the treatment in the study group. All of the patients were chronic pain sufferers with a duration of pain of more than 10 years. In all the studies, more than 80% of the participants were female, with an exception of the AS-study, showing an equal distribution of both sexes.
0.21
Table 1 presents the number of patients (drop-outs not included) in each study with complete data sets at each assessment before and after treatment. Drop-out rates were high in primary care and low in a self-help setting of the Rheumatism League. Results
To start with, in neither study a significant reduction of the number of days with pain medication could be demonstrated in the diary. Figure intensity
1 represents the effect sizes of pain measured in the pain diary after
Table 1. Diagnoses
Effect sizes of pain intensity-pain
diary
Effect Size 1.2
i
II 0.8 0.6 0.41
0f
4 LBP
TH
Post Treatment
W
1.08
Follow-Up
3,
0.91
RA
/
AS 0.91
0.31
0.06
0.75
0.48
0.06
treatment and at the 6-month follow-up assessment. The effect sizes are highest in back pain and headache subjects and lowest in inflammatory rheumatic diseases. AS patients seem to have little benefit from the treatment applied as far as pain reduction is concerned. There is only an insignificant decline of the effect sizes at the follow-up assessment. For the sake of data reduction, we calculated mean effect sizes including the symptom check list, and the anxiety and depression scale. This may be called a well-being index. The result is presented in Fig. 2. Again, the effect sizes in low back patients are most pronounced. However, contrary to pain intensity, AS patients demonstrate beneficial effects with regard to their well-being. This effect is maintained over a period of half a year. Data not yet published show that a longterm outcome is associated with long-term adherence. Those patients who still practised re-
and sample size. Drop-outs are not included in sample size.
Diagnoses
N 03
N (C)
Follow-up
Drop-outs
LBP (PC) BP & TH (PC) RA (RL) AS (RL)
13 25 31 25
11 20 31 20
6 6 6 6
33% 24% 0% 0%
Months Months Months Months
LBP, Low-back pain; BP, Back pain; TH, Tension headache; RA, Rheumatoid arthritis; AS, ankylozing spondylitis; PC, Primary care format; RL, Rheumatism league format.
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Fig. 2. Mean effect size of symptoms, anxiety and depression (Well-Being Index)-questionnaire data. Effect Size /1 1
0.6 0.6
0.4 0.2 rIaikB& OL LBP
BP&TH
RA
AS
follow-up the exercises at laxation assessments reported more beneficial effects than those who did not. Discussion Ankylosing spondylitis has found little attention in psychological research. On the contrary, several controlled studies have been published with rheumatoid arthritis subjects evaluating the effectiveness of behavioral methods aimed at an improvement of coping with pain and at the management of stress, anxiety, depression and the feeling of helplessness, which often goes along with a chronic disease (Achterberg et al., 1981; Anderson et al., 1985; Bradley et al., 1985; Bradley et al., 1987; Bradley et al., 1988; Cziske et al., 1987; Kiihler, 1982; Parker et al., 1988; Randich, 1982; Shearn and Fireman, 1985; Strauss et al., 1986). In all these studies except that of Strauss et al. (1986), the beneficial effects of a behavioral treatment were supported by selfreport data. Although these studies were conducted in a behavioral context, treatment procedures in the experimental groups and interventions in the control group differed widely, and some studies focussed on stress management (Sheam and Fireman, 1985; Spilberg, 1984), other studies on pain management techniques (Appelbaum et al., 1988; Bradley et al., 1988; Cziske et al., 1987; KGhler, 1982; O’Leary et al., 1988). Control conditions included treatment as usual
(Cziske et al., 1987; KGhler, 1982; Randich, 1982), supportive discussions (Bradley et al., 1988; Shearn and Fireman, 1985), keeping a pain diary (Appelbaum et al., 1988), assertive training (Strauss et al., 1986), or attention placebo (Parker et al., 1988). Only a few studies reported a significant reduction of pain intensity after the treatment (Appelbaum et al., 1988; Bradley et al., 1988; Cziske et al., 1987), long-term effects on pain intensity could not be demonstrated at all. On the other hand, well-being of the subjects improved considerably even at the follow-up assessments. There was a marked decrease in depression scores and anxiety (Bradley, 1989; Kiihler, 1982). Some authors even found a reduction in the number of inflamed joints (Shearn and Fireman, 1985), and a reduction of the rheumatism factor as a result of the treatment (Bradley et al., 1988). These results are in line with our findings. The effectiveness of the treatment in RA subjects as well as in AS subjects seems to pertain more to emotional stabilization than to pain reduction. This is also confirmed by statements of the patients during the final interviews, e.g. when they said that “Pain still exists, but it doesn’t interfere with my life as much as it did before”, or “I learned that there are much more things of importance in my life besides my pain”, or “For me it is most essential to relax in spite of my constant pain”. Further confirmation of the beneficial emotional effects of the treatment on RA and AS subjects could be obtained by the ratings of the outcome on different target areas indicating most success in relaxation and wellbeing and least improvement in pain reduction. This finding could be confounded by the different drop-out ratios in the different treatment settings. In order to receive more information about the motives of the drop-outs in the primary care setting format, these patients were also interviewed in the follow-up assessments. Compared to those who completed, drop-outs felt less accepted in the
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groups, felt less supported by their family and reported more unrealistic initial expectations of therapy success. They became especially disillusioned when they realized that they were expected to make a consistent effort performing exercises on a daily basis and participating in the sessions and the homework in an active manner. On the basis of this finding, the assumption seems to be justified that the influence of the different drop-out ratios on the outcome may be insignificant. In both formats, there was a drop-out of demotivated patients at different times of the study. In the self-help format, the selection process took place before the beginning of the treatment, in the primary care format during the treatment. To come to a conclusion: our meta-analytic approach to comparing treatment effects in different diagnostic groups supports the assumption that a cognitive-behavioral treatment has beneticial effects on subjects with inflammatory rheumatic diseases especially with regard to emotional stabilization. On the other hand, the magnitude of the effect in ASand RA-patients is lesser than that of back pain patients. Further research is needed to test the stability of our findings. Finally, we wish to discuss the practical implications of the study. Those expecting a significant reduction of pain intensity in patients with rheumatic diseases as a consequence of a cognitive-behavioral treatment, may feel disappointed. On the other hand, the treatment seems to exert a remarkable influence on measures indicating an improvement of physical complaints and emotional stabilization. For this reason, we feel encouraged to recommend cognitive-behavioral therapy as an adjunct to medical treatment. Psychological therapy has beneficial effects on the wellbeing of rheumatic patients, and thereby may support a pharmaceutical treatment of pain, but it is unlikely to replace it. References Achterberg, J., McGraw, P. and Lawis, G.F. (1981). Rheumatoid arthritis: a study of relaxation and temperature biofeed-
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Correspondence to: Prof. Dr. Heinz-Dieter Medical Psychology, Bunsenstrasse 3, Germany.
Basler, Institute for W-3550 Marburg,