UK: Improving Access to Psychological Therapies (IAPT) articles, blogs and discussion

http://www.cbtwatch.com/focus-on-the-chief-psychological-complaint-and-miss-the-boat/

 

Thanks Joan. re this bit:

Do you know how good the science underpinning claims about central sensitisation really is? I'm concerned by some of the examples I've seen, where there seem to be some problems and hype. To me, it looks like some are hoping to take ME/CFS the central sensitisation route too, and I'm not sure how good that will be for patients.

 

The central sensitisation model is well understood and studied in chronic pain and fibromyalgia. It's understood and taught on pain management programmes as a nerve and brain disorder / dysfunction. We don't know why some people develop central sensitisation and others do, often after fairly trivial injuries. It's rare in my NHS clinic that I'll assess a patient who has had a major injury pre chronic pain. Sometimes it is routine surgery that triggers the chronic pain. And often the onset is quite slow over time too.

CS can be seen clearly (as in black and white) with different physiological responses to pain. i. e. Clear abnormal response via fMRI to a light pain stimuli. And QEEG seems to be straightforward too - I'm looking into this. Also, csf abnormalities eg raised glutamate and substance P are well documented (not specific to chronic pain). None of this is done routinely in primary or secondary care. FMRI is used in research. Spinal taps would I suspect be seen as too high risk routinely though I am sure patients would be willing to be investigated. Plus about a third of chronic pain patients have NHS defined low thyroid function. That's really noticeable. The Physios I work with identify and can see CS response during their objective and subjective assessments.

As for ME and CS I haven't seen much research on this. I think it would help to understand pwME and chronic pain but not necessarily ME itself. This would need to be studied in pwME with and without pain. Over time many PwME develop pain. As do many people with rheumatoid arthritis even when they are stable on treatment for that. Ie inflammation markers low/normal.

Some people think that psychological distress is what causes CS. There is some low quality evidence in support of this. However, that has largely been studied using cross sectional design. This cannot define cause or effect only that a relationship exists. When the development of chronic pain is studied via prospective studies - no link between stress, trauma and chronic illness and pain exists. The cross sectional results can easily be explained by the psychological phenomenon of mood congruent recall. E. G. When you are in pain and distressed (and being in chronic pain is traumatic and distressing - seems obvious to state this but it can pass some people by) then you will have more availability in memory for previous upsetting and traumatic, painful experiences. It's how the brain works - it is doing a good job via perceptual matching linking pervious times when you felt the same or similar distress in the past. So, looking back over your life when you are frightened and in pain, people asked via a survey will recall all sorts of upsets which they probably would not recall or find of lesser significance if they were not in pain. I hope I've explained that well. Patients relate to this as they have much more recall of previous upsetting incidents in their lives that they thought they had forgotten when they get ill and are in pain. It explains some of the general distress of getting ill. Once it can be explained as a normal process then patients can try and reduce the interference and significance of this which can be helpful in itself.

Moreover, only about a third to a half of patients I assess in pain clinic have history of trauma with about a quarter or less meeting criteria for PTSD using SCID. When these patients receive trauma focused psychotherapy and move on well from this (this us where there is strong evidence for efficacy for trauma focused cbt) it makes no difference to their chronic pain. It does not alter this one jot.I f chronic pain was caused by chronic or acute psychological trauma then it would have some impact on the pain....

What psychological therapy can help with is to move on from trauma (if that is relevant) and skill the patient to cope well and manage their pain well. Then the pains interference in everyday life is reduced but not the pain itself. Knowledge of the pain science is one part of this.

I hope that makes sense
Bw Joan Crawford
Counselling Psychologist

 

What does this mean?

 

Hi, so essentially the impact / distess of the chronic pain on their functioning across the board (relationships, social life, work and so forth) is reduced by the patient adapting and adjusting to living well despite being in pain. It's often about re evaluating what is important for the patient and then deciding to do things that are achievable even though they are in pain. It's about adjustment not rehabilitation / recovery.

As people are by in large loss averse they will continue to persist with activities and interests which they can no longer do due to pain, so they become pissed off and demoralised. If they persist and endure through the pain in the hope that they will recover then they will endlessly feel let down. Sometimes they persist so much they can be in so much pain they become suicidal.

One large reason that the CBT/GET MUS approach is so unhelpful as this is what patients have already been trying to do often for years without success. It has often worsened their pain and mood. And alienated them from people around them too.

In essence pain management is about adapting and adjusting as best one can. And this is honestly the limit of medical and psychological support at this time. It's IMHO important to be honest about this and not over reach weak evidence.

On the other hand, Wessely school CBTGET MUS is about seductively telling patients to just keep trying and if you do that you will get better. There is no objective evidence for this. It's unhelpful and insulting to patients and causes increased distress.

Joan Crawford
Counselling Psychologist

 

Trudie Chalder for one appears to be changing tack and advocating ACT for a lot of things (including post-covid), although not admitting that their original approach with CBT was in any way wrong.
But, from what I have read, the basics of ACT is largely what chronically ill people have to do anyway, without the intervention of therapists.
As the two approaches seem to be the pole opposite of each other, it seems like a therapy for therapy sake.

 

That's interesting that TC is advocating ACT. It totally opposite to WS. ACT is adapting and adjusting to living well with and many patients will do this on their own. Therapy is only a help if people are struggling to do this.

One reason why NICE WS CBT GET is unhelpful is that it advocates therapy for ALL when resources are better served with those who are struggling and are open to psychological support. Also the message that everyone with ME 'needs' therapy undermines natural coping and gives the impression within the medical community that ME is largely Psychosocial in nature, which it isn't.

 

I am a bit sceptical about this to be honest, @Joan Crawford.

We know that people with chronic pain report more pain than would be expected from a structural examination of their painful areas. So in that sense they are operationally sensitised, and yes there is good reason to think the problem is central. But as far as I am aware, and I have been close to this field for decades, there is precious little known about why this is or the mechanism. There are animal models, but they do not look to me to be very relevant. There is algodystrophy, where one can see major neurovascular and dystrophic changes but that is probably unrelated to the commoner forms of chronic pain. Different appearances on fMRI are quite consistent with the fact that you are studying someone in distress rather than a normal control. In a sense fMRI is too far in to the cognitive process to help. It tells us nothing about mechanism as far as I can see. You mention glutamate, but not specifically related to pain so I am not sure where that fits in.

I worry that when people say this is a scientifically based clinical concept what is meant is that it is a clinical concept to which some scientific speculation has been attached. Science involves such speculation but most people think of things being scientifically based if there is evidence for a mechanism. I may be out of date but colleagues at UCL have been saying they understand CS since the 1980s but I have never been convinced there is much to go on.

 

I know someone who is struggling with this at the moment. They will hopefully be switching to some a different type of medication soon which will help manage, but not cure.

Several members of my extended family live with constant pain. Sometimes, when the underlying condition worsens, it becomes severe. To them, this approach is deeply depressing. They know what exacerbates their pain. Sometimes, like with an ME patient, it will be worth the payback, often it won't. The most distressing thing is they are in pain all of the time, so management is about the degree of pain.

They would rather have attention focussed on better pain relief, or better drugs to manage the condition causing the pain, or a cure then just accepting it. In their eyes, they've already accepted it - they've had no choice.

I'm not trying to have a go here @Joan Crawford, I appreciate your input. This is just something that has come up many times in my family so something I have a particular interest in.

 

Doubly ironic is that acceptance and commitment are basically "giving in" to the "sick role" within the BPS model, the origin of it all, the foundational assumptions that formed the first 2 decades of self-promotion.

In reality it's much more nuanced than this but those are two self-contradictory ideas that both exist simultaneously or as is required for convenience of explanation. Basically they contradict themselves entirely while pretending they are the same ideas. Zero accountability for blatant contradictions. PACE is "proof" that ME is psychological even though a pragmatic trial cannot be used to ascribe a cause, all because GET is shown to "work", but no one does PACE-style GET anymore. Nothing matters. Facts are fluid based on the audience. There are no underlying principles, just basic sales-and-BS tactics of con artists. It's a particle. It's a wave. It's both. It's quantum medicine. In the macro world. Don't bother about this not making any damn sense it's all just the magical powers of the mind, or whatever.

 

So much of what you say here resonates with me @Joan Crawford.

When my spine started causing significant pain in my thirties, I was keen to continue doing most of the things that I had previously been able to do. If I had accepted that I needed help with certain physical things sooner it would have been much less stressful.

As I have a spinal deformity, which has always been clear on X-rays and is now visibly obvious I have not had the doubt from professionals about my pain being of a physical origin.

It literally took me about 15 years to accept that my health meant that it was unreasonable to expect that I could do regular, paid, even part-time work.
Sometimes I am a very slow learner.

 

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Hi Marge, You made me smile - I don't think you are a slow learner - I think you are human It can take a long time and a lot of courage to adjust.

I'm not a massive fan of the word accept. This can be foisted upon people rather cruelly. And, from day to day the resources people with pain and debility have to 'accept' their condition and impacts varies widely. It's my view that no one 100% accepts - who does? - and it's on a sliding scale day to day. And the more awareness we have of our need to take care of ourselves the more likely we are to stop and think - even on those low and painful days - to make good decisions in line with our values and more in tune with our needs. It's a work in progress. And hard work at that. Well done you

 

"They would rather have attention focussed on better pain relief, or better drugs to manage the condition causing the pain, or a cure then just accepting it. In their eyes, they've already accepted it - they've had no choice."

I totally agree. See my below reply to Marge re my views on acceptance. I don't think anyone just accepts that they are in pain. Adapt and adjust is the best one can do.

I don't see how providing support for those patients who are struggling to cope - via pain management services and pain clinics - often after years of living with chronic pain - detracts form the need to focus on better pain relief / better drugs / cure? I highlight the limitations of current medications and medical interventions (e.g. injections) to patients' GPs and our pain consultants daily. It's for the medics along with researchers to make this a clinical and research priority. I haven't seen much that's in the pipeline re new drug development. I ask the consultant or pharmacist to share this information with pain management groups when they see them in group and individually. That's about hope.

Regarding pain meds: currently there are no good medications for pw Chronic pain - the best pain meds do is they can help to take the edge off. And that needs to be balanced with the impact of side effects.

The majority of meds used in chronic pain were developed for use in acute pain and reduce inflammation e.g. paracetamol, codeine and so forth. However, the driver of the pain when it is chronic is not the same inflammation as in acute pain. So, the drugs help to some extent but they are also not usually prescribed for long term use. This can cause all sorts of side effects (gasto, weight gain, balance issues, debility) along with rebound pain - ie long term use of opiates can make the sensation of pain worse.

The gabas, pregab and amitriptyline can help too but often for a limited time and then the dose gets increased which causes all sorts of side effect and poor tolerablility.

Pain clinic (pharmacist or consultant physician) approach is often to encourage patients to pace so hopefully less flares, maybe manage flares with judicial use of opiates as needed over short time and daily using the lowest risk drug combo that has an effect. And when the daily regime is not working have the patient and GP clued up enough to cycle round and try differing things rather than upping dosage over time of the same thing.

Very occasionally we'll get a pain patient who will be started on Tramadol and who will feel settled and well enough on it to go back to work and report minimal pain. That's happened once in 3 1/2 years.

If patients are struggling to pace and set appropriate goals and are distressed then that's when a referral through to chronic pain management might be helpful. This is particularly important for those patients who have been / are suicidal or may become suicidal due to other life pressures. Intervention can be life saving. Knowing that there is support - even if patients don't access it - can be really helpful here too.

Before being seen the the chronic pain service patients are screened by AMPs (advanced musculoskeletal practitioners - highly trained physiotherapists or the appropriate consultant - neuro / rheumy etc) to rule out malignancies, inflammatory disorders and so forth and be scanned if appropriate (e.g. MRI, neuro screen ) etc. In chronic pain service we see a very small number of patients compared to the musculoskeletal service as a whole.

We defo need to understand more fully what drives the mechanisms that maintain chronic pain. Then newer drugs can be developed to target this or older drugs repurposed. Their is no evidence or known mechanism that psychological distress is driving chronic pain, centrally sensitised mechanism. If this were the case then reducing stress, effective mood management along with pacing would be an effective way to rehabilitate and cure patients. There is no evidence for this. Only support (help patients to identify barriers of effective pacing, effective goal setting etc) and education (pain science, limitation of drugs etc) to help patients to pace and cope and live well despite on-going pain. That's the best medicine (my medical, physiotherapy and pharmacy colleagues agree with me - along with the British Pain Society - their guidelines are what the NHS pain management programs follows) and psychology can do at the moment. I am open with every patient that I am aware that this is not what they ideally want. However, I can only sit in front of someone and be honest.

 

Definitely two approaches which are totally contradictory. There is a lack of awareness of this in the medical world.

Clinicians need to work with the evidence and the limits of it. Currently, that is about pain management - it's the best clinicians (psychologists, medical consultants, pharmacists, and physiotherapists etc ) can do - and that's what is supported within the NHS and by the British Pain Society.

Anything beyond that is oversell and is dishonest and misleading.

WS (CBT/GET) has lost the cure argument in NHS long time ago - which is why they are moving towards MUS and the IAPT system - a lot less knowledge within this system - much easier to manipulate - their BS can and will work within this system - if left unchallenged. I'm working hard to stop this. So, are a lot of my colleagues.

 

and yet we have this:
https://www.s4me.info/threads/kings...l-symptoms-research-and-treatment-unit.14514/

and:
https://www.s4me.info/threads/the-i...ns-and-mus-full-implementation-guidance.6948/

TC version of ACT
https://www.s4me.info/threads/bbc-r...t-therapy-feat-trudie-chalder-nov-2019.12754/

and her lecture on MUS
https://www.s4me.info/threads/13-ma...journey-over-30-years.5576/page-3#post-152193

the PRINCE trial
https://www.s4me.info/threads/proto...-2015-onwards-chalder-moss-morris-et-al.7965/

 

Hi Jonathan,

I agree that there is precious little known about the underlying mechanisms driving chronic centrally sensitised pain. I agree animal models don't seem helpful - without the underlying mechanisms it's be stab in the dark - 'it might look like chronic pain' which is probably not of much value to developing effective treatments.

I don't agree with you that fMRI is consistent with studying someone who is distressed. The majority of people with chronic pain adapt and adjust over time and live with low/healthy range levels of distress. The majority of the patients I see are not clinically depressed or traumatised - they are in the minority - and I see a skewed and biased sample of the most severely affected and those coping the most poorly. A community sample of people largely coping well would not show high levels of distress - certainly there is no more evidence for this than for pw other chronic medical conditions. It's notable the psychological resilience and fortitude that people show in the face of severe challenge -such as living every day in chronic pain.

When patients with chronic pain find it relevant and work and reduce their distress (this may or may not be related to their pain) then they can quite successfully live well with low levels of distress and cope well. They have in essence adapted to living well despite being in pain and perhaps overcome some significant psychological distress from the past. Their levels of pain are largely unaltered.

If you have been convinced that chronic pain is largely a distress issue I would love to hear by what mechanism psychological distress is converted into physical, ongoing chronic pain? And if there is such a mechanism how can it be observed objectively?

I'm not sure what you mean by fMRI is too far into the cognitive process to help?

My physio and medical colleagues teach pain science and are quite clear about the knowledge and the limitations. It's helpful for patients to understand what is going on. And the lack of link between objective findings on MRI scan and their pain. It's a different mechanism from acute pain. Sharing the latest knowledge is helpful - even if an underlying mechanisms are not understood. A parallel might be the helpfulness in sharing with a MS patient about demyelination and how this can impact them and cause their symptoms. Having that knowledge is one part of helping the patient to cope and manage well, reduce fear and helps with the rationale for differing drug regimes and so forth. But it doesn't tell us why a MS patient has developed demyelination and the mechanisms underpinning MS in the first place. We can only share the knowledge that we have.

 

Hello,

I never said it was not going to stop some people from trying Medicine has a long history of psychologising and what it doesn't understand. And few question the lack of robust, objective mechanisms driving distress to disease. The need for that mechanism seems lost on people. Psychological causation gets accepted with a much lower standard of proof - or in the complete absence of proof. Freud's legacy.

Conflating feeling better (as in coping well) and being better (as in cured) uses the psychological trick of substitution (many people just don't notice it due to psychological ease of accepting the premise) that WS /CBT/GET fans have been doing for decades. It is seductive to many in the medical profession (detracts from the failure of research to elucidate mechanisms and develop treatments and so forth) and commissioners of services. MUS is one of it's newest incarnations. It's about empire building - but it has little impact on day to day NHS work across medicine. It's not convinced British Pain Society for example - they tried hard and failed. MUS is making some in roads in NHS services with minimal knowledge - much easier to manipulate if your audience don't understand or care about the nuances/detail.

The psychologisers will keep trying as they genuinely do seem to believe that they can cure people - they have failed in their endeavour to persuade the majority of their profession as they have not provided objective evidence to back up their claims. The best they could do was try and fudge the PACE trial outcomes. Pretty poor.

And if chronic pain, ME and other conditions were largely psychological in nature then successful psychotherapy along with some supportive physio would sort people out in no time. It doesn't work.

X

 

Sorry - Wessely School - CBT/GET cures pwME and FM etc :-( That school of thought.

Health psychology has been around a while. I've not read any specific texts recently but I'd be saddened if that is the focus because it is well beyond the objective evidence. :-(

 

I think you have over interpreted my suggestion that fMRI might be reflecting distress. All I meant is that it may reflect the fact that patients are likely to have different thoughts from controls. fMRI reflects thoughts - cognitive processes. Irrespective of any psychological analysis of the situation we can assume that patients will be thinking different things from controls - it stands to reason. So fMRI is 'too far I to the cognitive process'. After all it can show that someone is thinking about playing tennis. And since nobody has enough idea of exactly the rules of correspondence of fMRI signals to any particular thought content to make any a priori predictions all fMRI can do for us at present is indicate that people are thinking different things as expected.

I shared a department with similar medical and physio colleagues running pain services. You may be very lucky but I had the strong impression that those in my department had strong beliefs that they knew the limitations of their knowledge but didn't. If we do not know what is going on are we sure it is helpful to give the impression we do? I worry that such an assumption gets all too close to the assumption that CBT is good for ME and so on. Sure it is a different mechanism from pain due to something like rheumatoid arthritis, where joints are either inflamed or just damaged, but what mechanism?[/QUOTE]