Pain matters! Implications for acceptance-based interventions with women with co-morbid chronic illnesses

Abbie O. Beacham, Ph.D. Stacy Lorenz, M.A.

Xavier University, Cincinnati, OH USA

Key Collaborators Xavier University ACT Research Team John Forrette, M.A., Desiree Green, B.A., Amy Houston, M.A., Caroline Kelley, M.A., Stacy Lorenz, M.A., Matthew Maley, M.A., Amy Olzmann, M.A. & Stephanie Parazak, M.A.

University of Colorado Denver Dana Brown, M.A. Jessica Geller, M.A., Andrew Herbst, M.A., Carissa Kinman, M.A., & Jessica Payne-Murphy, M.A.

Spalding University Ann Brugh, Psy.D. , Steve Katsikas, Ph.D. , Ken Linfield,Ph.D., Kristen Thacker, Psy.D. & Brooke Threlkeld, Psy.D.

Agenda• Background & Significance

– Challenges of co-morbid chronic illness and pain presentations

• Method – In depth description of sample

• Results • Discussion

– Connect to clinical and research implications

Background & Significance • Non-communicable Diseases/Chronic

Illnesses (CI) – including Chronic Pain – majority of health care costs worldwide

• World Health Organization, 2011

• Empirically supported behavioral assessments and interventions for CI management– Modest-to-good outcomes– Most diagnosis specific

• e.g., diabetes & depression

Background & Significance

• Room for improvement – interventions for chronic illness

management – specialty & primary health care settings

• Acceptance-based interventions – considerable promise in CP populations

• McCracken, Vowles & Eccleston, 2003, 2004, 2005; Vowles, McCracken & Eccleston, 2007; McCracken & Zhao-O’Brien, 2010

– becoming widely applied in patients with co-morbid chronic illnesses

Perceived Illness-related Disability

Functional & Medical

Outcomes

Perceptions of disability

due to illness and symptoms

*Beyond objective

indicators of disability

*Alschuler, Theisen-Goodvich, Haig & Geisser, 2008

Conceptual Model of factors related to Perceived Illness-related Disability(Caveat: Not SEM!)

Perceived Disability

Mindfulness

Experiential Avoidance

CI Acceptance

OUTC

OMES

+/- Affect

“…patients seek care for all of their conditions, not just for a solitary condition. In fact, visits for comorbidities outnumber visits for any single condition…”

– Starfield et al, 2003

Co-morbid chronic illness presentation

Study Questions• In a sample of women, does

concomitant pain matter when among myriad CI symptoms?

• When pain is a primary concern for patients with co-morbid CIs, how might patients “differ” on ACT related variables/constructs?

MethodProcedure: Recruited sample through online CI specific support groups

Yahoo! & Facebook

•“SurveyMonkey” survey •45-60 mins to complete •No incentive for participation

MeasuresPerceived Illness Disability Index

– Adapted from the Pain Disability Index – Pollard, 1984

Mindful Attention & Awareness Scale – Brown & Ryan, 2003

Chronic Illness Acceptance Q’aire– Two-factor structure: Activity Engagement & Willingness

– Beacham, Linfield, Kinman & Payne-Murphy (Under review)

Acceptance & Action Q’aire-II – Bond et al, 2011

Positive & Negative Affect Schedule– Watson, Clark, & Tellegen, 1988

• Diabetes• Hypertension• Heart Disease• COPD• Asthma• Arthritis• Rheumatoid

Arthritis• Fibromyalgia• Multiple Sclerosis

Sample: Recruited CI Support Groups(Most frequently endorsed CI’s)

“Chronic Pain” groups not

targeted

1 Item: “Is chronic/recurring pain a primary concern?”

Yes72%(n=281)

No28%(n=109)

58% of “Yes” Chronic Pain Diagnosis

“Is chronic/recurring pain a primary concern?”

Yes No p value

Age 51.53 54.89 .028

Education (years) 15.25 15.72 ns

Married/Partnered 64.7 54.6 ns

% Caucasian 90.3 86.7 ns

# Chronic Illnesses 2.71 1.55 .000

“Overall, how much pain relief have pain treatments or medications provided?”

0 10 20 30 40 50 60 70 80 90 1000

5

10

15

20

25Mean Relief = 45.7, SD= 24.56

Percent Relief

Perc

ent o

f Sam

ple

Perceived Illness-related Disability “Yes” versus “No”

Total Perceived Disability Score05

10152025303540

p<.001

Yes

No

The short of it: Overall differences “Yes” versus “No” = Pain Matters

Mean SD CIAQ Activity Engagement No 40.49 12.49

Yes 33.52 11.82

CIAQ Willingness No 25.55 11.12Yes 22.75 7.96

MAAS Total No 4.34 0.955Yes 4.00 0.971

PANAS Positive Affect No 29.52 8.09Yes 26.41 7.97

PANAS Negative Affect No 18.43 7.22Yes 21.51 8.25

NOTE: *All p’s < .05

“Is chronic/recurring pain a primary concern?

“Yes” versus “No”

ACT related variablesLegend: Higher scores - Positive outcomes Higher scores - Less Positive Outcomes

The long of it: Upon closer examination

Experiential Avoidance “Yes” versus “No”

AAQ Scores 0

5

10

15

20

25Yes No

p = .007

Negative Affect “Yes” versus “No”

PANAS Negative0

5

10

15

20

25Yes No

p = .003

Mindfulness “Yes” versus “No”

MAAS Scores1

1.52

2.53

3.54

4.55

Yes No

p = .001

Positive Affect “Yes” versus “No”

PANAS Positive0

5

10

15

20

25

30

35Yes No

p = .01

Levels of CI Acceptance “Yes” versus “No”

Activity Engagement Willingness05

1015202530354045

Yes No

p < .05

p <.001

Total Disability Scores by CI Acceptance

Activity Engagement Willingness05

101520253035404550

High Medium Low

p<.001 p<.001

Family/Home Disability Scores by CI Acceptance

Activity Engagement Willingness0123456789

10High Medium Low

p<.001 ns

Recreation Disability Scores by CI Acceptance

Activity Engagement Willingness0123456789

10High Medium Low

p<.001 p <.005

Occupation Disability Scores by CI Acceptance

Activity Engagement Willingness0123456789

10High Medium Low

p<.001 p =.003

% Pain Relief by CI Acceptance

Activity Engagement Willingness0

10

20

30

40

50

60

70High Medium Low

p<.001

ns

LimitationsSample from online support groups

Although online samples not drastically different from clinical samples characteristics

Replication and extension

Retrospective recall of self-identified support group members

Prospective studies next step

Assess objective (i.e., behavioral) and subjective outcomes in multiple domains

Discussion• Patients presenting with co-morbid

CIs may also be struggling with concerns about pain in concert with many other symptoms– Pain concerns may not be reflected in

chart diagnoses

• Lack of assessment of whole picture of complexity could make patients SEEM treatment resistant

Discussion• Transdiagnostic acceptance-

based approaches may have promise for these patients

– Enable a focus on values-based function – committed action within context of the WHOLE symptom picture

– Utility of acceptance subgroups in these approaches?