A few vignettes
The Great Conundrum • Understanding theoretical basis of disease vs • Explaining the phenomenon of actually having it
Faith & Hope • Hope = expectation of something desired • Faith = belief in things we cannot know as fact • Both are beyond the realm of fact and yet... we function day to day on basis of both.
Triangle of Life Hopelessness, Demoralisation, Pessimism False hope, Foolish hope, Denial of reality Genuine hope, Realistic hopefulness, Optimism
Core beliefs • Control vs helplessness • Loveability vs fear of rejection • Achievement vs fear of failure
Illness Behaviour, Normal & Abnormal • The sick role • Pillowsky • ‘When patient & physician disagree’
Health Anxiety • Previous illness experience • Dysfunctional assumptions • Critical incident • Activation of dysfunctional assumptions • NAT’s • Health concerns causing anxiety • Behavioural - avoidance • Affective – anxiety, anger, depression • Cognitive – helplessness, preoccupation • Physiological – sleep disturbance, hyperarousal
Anger • Anger-in : suppression of feelings • Anger-out : aggressive behavioural expression • Passive-aggressive: covert behavioural • Procrastination • Noncommunication • Disengagement
C.B.T. • NAT’s & PET’s • pacing
Adjustment to Pain • Cognitive • Negative : catastrophising • Positive : self-efficacy, readiness to change, acceptance • Affective • Negative : depressed mood, anxiety • Positive : stable • Behavioural • Negative : fear avoidance, insomnia • Positive : active coping
Is this ‘Depression’? • or dysphoria • or dysthymia • or demoralisation • or bipolar disorder • or S.A.D
Personality Disorders • MAD (Cluster A) • Paranoid; Shizoid; Schizotypal • BAD (Cluster B) • Antisocial; Borderline; Histrionic; Narcissistic • SAD (Cluster C) • Avoidant; Dependent; Obsessive-Compulsive
Just you, a trait or a disorder? • Persistence • Impairment • Distress
Containment • Harm reduction
History • ‘the difficult questions’ • hearing the unspoken dialogue • reading the body language
Physical Examination • real or unreal signs? • knowing your signs/patterns • challenging the evidence • ‘pain out of proportion to physical evidence’ • putting the ‘bio’ back into BPS
Headache • History to diagnose • Examination to exclude ‘red flags’ • No role for opioids
Diversion • Death • prescription drug OD > ... • MVA & suicide • Oxycodone
Elderly • ‘Forgotten majority’ • Pain as a part of aging (?) • Pain & frailty
Placebo Effect • Change in illness attributable to symbolic import of treatment; therefore a placebo simulates therapy • Factors • Expectation, conditioning • Other issues • Natural history, regression to the mean • Strategies to utilise • Placebo run-in, open-hidden paradigm
‘Fibro’ • Total body pain and misery • No unambiguous evidence • Need for a name • Same family as TTH, CFS, MCS, IBS, TMJD
Cancer Pain • Total pain Dame Cecily Saunders
Needles • ESI • MBB • RF • SIJ • CLS • SGB • PNB
Neuromatrix • Brain processes provide basis for ‘self’ • integrated • unique = neurosignature • Inputs from body modulate outputs
