Psychological Interventions in the Management of Arthritis

1
Psychological Interventions in the Management of
Arthritis

• Frank McDonald
• Consultation-Liaison Psychologist
• The Townsville Hospital
• www.fmcdonald.com
• April 4 2003

2
Overview

• Psychological challenges of arthritis
• Psychological interventions
• Your professions your personal input
• Self-management strategies
• Specific psychological strategies
• Resources references

3
Psychological challenges

• Anxiety of facing an incurable disease. May
  change life expectancy. Initial Whats going to
  happen to me? reaction
• Arbitrary nature course of disease
  unpredictable / can come go
• Pain - ranging from minor to incapacitating
• Restricted activities limitations imposed on
  simple things used to do

4
Psychological challenges

• Altered self-esteem / sense of self. We like to
  feel in control of our selves / health. When
  disease strikes everyone feels some loss here. We
  dislike dependency
• Sexuality affected impaired abilities
  concerns about attractiveness
• Dealing with pain, stress, sadness possible
  depression, anger frustration

5
Psychological challenges

• A chief side-effect of RA is sense of
  helplessness over inability to control the
  disease and the pain it causes1,2
• Isolation at home, socially on the job
• So problem is not just disease (biomedical
  aspects) but pressure to cope
• Everyone with chronic illness suffers
  psychologically degree depends on number
  intensity of challenges faced

6
Psychological interventions

• How can we help patients meet these psychological
  needs?
• 3 levels
• your professional personal input
• encouraging supporting self-management
• specific psychological strategies shown to
  alleviate condition associated problems

7
Psych Interventions Professional Personal
input

• Professional contributions can significantly
  improve patients psychological state
• Patients sense of control esteem can be
  heightened by progress improvements with
  physical therapy, exercise, occupational therapy
  medications

8
Psych Interventions Professional Personal
input

• Patients benefit from attentions of concerted
  professional team approach e.g. primary care
  physicians nurse educators
• Appreciate being able to discuss manage their
  various concerns with appropriate range of
  specialists

9
Psych Interventions Professional Personal
input

• Personal contributions also can significantly
  improve patients psychological state
• Patients do better with professionals whom they
  say
• generally are able to empathise communicate a
  sense of how difficult things must be
• are willing to listen my answer questions
  without judging me allowing me to be more
  informed knowledgeable about my illness

10
Psych Interventions Professional Personal
input

• see me as a whole person - not a disease. They
  see me not just from the perspective of their
  profession
• enquire about common problem areas associated
  with my illness so might ask This illness may
  affect the things you feel you are capable of
  doing in turn your self-esteem. How are going
  in that area?

11
Psych Interventions Professional Personal
input

• are willing to bring up issues I may be
  reluctant to like sexuality or the anger /
  why me ? stuff I was half-denying
• give a sense of hope to recently diagnosed pts
  about the promise of new therapies treatments.
  They understand the importance of conveying a
  positive attitude

12
Psych Interventions Professional Personal
input

• enquire about degree of support understanding
  from partner, family, friends or boss
• refer to other professionals, like psychiatrists
  or psychologists, when they do not have the time
  or skills to get into things - without implying
  youre not coping with this as well as you
  should

13
Psych Interventions Self-management strategies

• Patients who adopt a self-management approach, to
  augment professional management, fare better with
  their condition3
• Subjective experiences like degree of
  suffering/emotional components of pain diminish

14
Psych Interventions Self-management strategies

• Self-management skills can include
• Self-education. Learning as much as possible
  about condition. Becoming expert at
  understanding managing pain e.g. appropriate
  use of medication
• Adopting an internal locus of control attitude.
  Open, experimental I control me not it
  (pain) or they (doctors) attitude
• Extending coping/self-care skills Balancing
  relaxation (mental, physical, behavioural skills)
  with activity (? pacing ? movement ?
  occupation)

15
Psych Interventions Self-management strategies

• Following slide graphically illustrates the
  important place of self-management3
• Higher-level treatments tend to be less effective
  if there are problems at lower levels

16
(No Transcript)
17
Psych Interventions General Psychological
Strategies

• Broad aims
• Assessment of full range of relevant variables
  (most important step in management of chronic
  conditions)
• Reducing stress - seems to exacerbate the
  disease. Immune system appears to be link between
  stress its aggravation. RA pts immune systems
  more sensitive to stress than comparison
  groups4,5,6,7,8 e.g. reducing stress from
  disturbances in personal relationships. Several
  investigations suggest this form may contribute
  to development of disease9,10 and / or its
  course11,12

18
Psych Interventions General Psychological
Strategies

• Providing a range of cognitive-behavioural
  strategies directed to
• Pain-coping skills8 e.g. relaxation training
• Coping with symptoms of disease8 e.g. self-talk
  therapy
• Increasing self-efficacy (opposite of
  helplessness) optimism13
• Reducing cognitive distortions that can aggravate
  depression other emotional responses to
  arthritis14
• Relapse prevention to preserve behavioural
  attitudinal gains15

19
Psych Interventions General Psychological
Strategies

• Results of a meta-analysis published in June 2002
  Arthritis Rheumatism (pp. 291-302)16 supplement
  show psychological therapies can have significant
  positive effect on several aspects of RA
• Specifically
• levels of pain
• feelings of helplessness
• ability to function
• depression
• coping (largest most consistent finding)
• joint tenderness last 3 most enduring (gt8.5
  months)

20
Psych Interventions Specific Psychological
Strategies

• As yet do not know which therapies or
  combinations work to produce above results
• Studies meeting quality inclusion criteria for
  meta-analysis trialled these other treatments
• Relaxation training
• Progressive muscle relaxation
• EMG Thermal Biofeedback Autogenic training
• Stress Management (within support group
  framework)
• Cognitive therapy (modifying attitudes beliefs)
• Social Support sessions with family friends
  active listening by leaders

21
Psych Interventions Specific Psychological
Strategies

• ROM Dance Program (Tai Chi, relaxation,
  biofeedback, stress discussions)
• Guided imagery
• Disclosure therapy writing/talking about most
  stressful or traumatic life events
• Non-directive/client-centred group therapy
• Information
• Active coping
• Coping with depression
• Rational thinking (e.g. decatastrophising)

22
Psych Interventions Specific Psychological
Strategies

• Improving communication with health care
  professionals
• Attention re-focussing (stimuli outside body, on
  to activity)
• Dissociation (self-hypnosis/meditation) /
  relabelling
• Self-encouragement
• Communication skills training/assertiveness
  training
• Self-efficacy enhancement
• Groups for maintenance of treatment gains

23
Psych Interventions Specific Psychological
Strategies

• Other strategies incorporated in other arthritis
  programs and as suggested by general chronic pain
  literature17
• Increasing either mastery or pleasure activities
  to at least one per day to counter self-esteem
  mood problems
• Problem-solving (anti-worry) strategies
• Teaching principles of activity pacing
• Increasing appropriate movement walking,
  swimming, physio exercises
• Teaching significant others to reinforce positive
  pain behaviour (e.g. self-massage) ignore
  negative (e.g. groaning)

24
Resources and References

• www.fmcdonald.com for a copy of this presentation
  related material
• e.g. on pain management (self-management
  guidelines, activity pacing principles
  diaries), sleep enhancement, activity scheduling
  for depression, adjustment to chronic illness
  advice stress management booklets
• http//www.arthritis.org.au for information,
  services links
• References available from author