Psychiatry - December 2008 - (Page 26)

broken down into small steps. Cognitive techniques can be utilized such as first predicting how uncomfortable or difficult a particular bit of exertion will be, then doing it, and finally observing how difficult it actually was as well as how it made them feel. This practice of breaking activities into manageable steps and realizing they can accomplish more than they thought they could allows them to gradually re-engage in life alongside their pain. Case example: taking things one step at a time. Psychiatrist: How did your homework go? Patient: It was challenging. Psychiatrist: Tell me about it. Patient: Well, like we talked about, I made a schedule for what I needed to do before I could go to the party. important. So what came next? Patient: I laid down flat on my back for awhile. I was afraid I would get up all stiff, so I only rested for 20 minutes. Psychiatrist: How did that work? Patient: I was really tempted to lie there longer and just forget about going out, but I reminded myself of my promise to my husband, and I got up. Psychiatrist: (nodding) Nice! How did you feel? Patient: Oh man, I was in so much pain… (Initially, she appeared weary. Then, she spoke with apparent anger) I thought this homework was no good, that you were pushing me too hard! Psychiatrist: (nodding again, waiting) Patient: Then I remembered I was the one who chose it… Psychiatrist: (still waiting) Psychiatrist: Remember how sometimes we make ourselves feel even worse than the situation already is, by criticizing ourselves harshly? Patient: I do that all the time. Psychiatrist: What could you have said to yourself instead? Patient: (tentatively) That even though I really hate this, I’m an intelligent woman and I can do this? Psychiatrist: You certainly are and you certainly can! This situation is very difficult and you suffer a lot, but you still keep on going. PRACTICE POINT: NEVER GIVE UP Working with patients who are always in pain is challenging and can be draining at times, almost as if by sharing a space with them, you affectively register the heaviness of their burden. They feel demoralized and hopeless, and you as their psychiatrist must recognize the shared affect and move past it. This recognition allows you to be truly empathic in your responses to them, and helps you not to feel demoralized and helpless yourself. The patient needs to know you are strong enough to handle his or her pain, his or her anger and frustration, and not be submerged by it nor abandon him or her.26 By accepting the challenge of therapy with a chronic pain patient, you too become more flexible and more capable. [The] practice of breaking activities into manageable steps and realizing [patients with chronic pain] can accomplish more than they thought they could allows them to gradually re-engage in life alongside their pain. Psychiatrist: Let’s look at it together. Patient: (bringing out a notebook) Well, first I had to shower. I thought it would be exhausting, an 8 out of 10. Psychiatrist: How exhausting was it? Patient: I decided to not wash my hair since I had done that the day before, so it didn’t take nearly as much energy as I thought it would. I actually felt a little bit better afterward, even though I was tired. Psychiatrist: Those were important things to do and to notice: First you let yourself off the hook and gave yourself permission to do a little less than you usually do. Then you took note of the fact that you handled the shower without being so worn out. Patient: I guess I did. Psychiatrist: Both are really 26 Psychiatry 2008 [ V O L U M E 5, NUMBER Patient: (sheepishly) Then I felt angry at myself and the whole situation again…I was getting worked up into a major pity party. Psychiatrist: But something changed? Patient: I got the idea, “I’ll show her…I’ll go through with it and be so much worse I’ll be in pain for a week after this.” Psychiatrist: So you used your anger to motivate yourself. Patient: You could say that I guess. Anyway, I did the schedule like we worked out. I just put on my underwear, and then I sat until I was ready. That wasn’t so bad. Then I put on my shirt and just sat there again…then the anger came back I felt like a child, like a dope doing it this way. Psychiatrist: Were you able to respond to that automatic thought? Patient: (looking quizzically) 12, DECEMBER] REFERENCES 1. Yutzy SH, Parish BS. Pain disorder. In: Tasman A, Kay J, Lieberman JA, et al (eds). Psychiatry, Third Edition. West Sussex, England: John Wiley & Sons, Ltd., 2008:1530–1534. Baron R. Complex regional pain syndromes. In: McMahon SB, Koltzenburg M (eds). Wall and Melzack’s Textbook of Pain, Fifth Edition. Philadelphia: Elsevier Limited, 2006:1011-1027. Meyer RA, Ringkamp MR, Campbell JN, et al. Peripheral mechanisms of cutaneous nociception. In: McMahon SB, Koltzenburg M (eds). Wall and Melzack’s Textbook of Pain, Fifth Edition. Philadelphia: Elsevier 2. 3.

Table of Contents Feed for the Digital Edition of Psychiatry - December 2008

Psychiatry - December 2008 Editor’s Message Contents Editorial Advisory Board Antidepressant Prescribing by Specialty and Treatment of Premenstrual Dysmorphic Disorder Pain, Pain, Go Away: Antidepressants and Pain Management Why Psychotherapy Helps the Patient in Chronic Pain General Medical Drugs Associated with Depression Katatonia: A New Conceptual Understanding of Catatonia and a New Rating Scale Thermoregulation and the Role of Calcium Signalling in Neurotransmission Cognition and Schizophrenia: Is There a Role for Cognitive Assessments in Diagnosis and Treatment? Journal Watch Information for Authors

Psychiatry - December 2008

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