Page 27 - 2018_04

Attachment theory in chronic pain clinics Fábio Monteiro da Silva1; Joana Varandas2; Ernesto Silva3; Sara Moreira4
1 – Interno de Formação Específica de Psiquiatria, Hospital de Magalhães Lemos, Porto, Portugal
2 – Interna de Formação Específica de Anestesiologia, Serviço de Anestesiologia do Centro Hospitalar do Porto, Porto, Portugal
3 - Assistente Graduado de Anestesiologia, Serviço de Anestesiologia do Centro Hospitalar do Porto, Porto, Portugal - Unidade Funcional de Dor Crónica
4 - Assistente Graduada de Psiquiatria, Serviço de Psiquiatria e Saúde Mental do Centro Hospitalar do Porto, Porto, Portugal - Unidade Funcional de Dor Crónica
The therapeutic relationship (TR) lies at the center of the clinical practice in chronic pain clinics - without it, it would not be possible to make diagnosis or negotiate treatments. In patients with chronic low back pain, the quality of the TR predicts clinical outcomes. However, physicians frequently find it difficult to build trusting relationships with their patients. Attachment theory us a useful framework to understand difficult TRs in medical settings.
Attachment theory, developed by Bowlby, explains lifelong patterns of interpersonal relating as a result of early experiences of parent-infant interactions in situations of perceived danger or threat, which are internalized as internal working models of others and self. In the Bartholomew and Horowitz model of adult attachment, individuals can view themselves and others either positively or negatively, resulting in a four-quadrant model with four attachment styles (Fig. 1). Secure attachment is characterized by a positive view of self and others. Individuals who view themselves and/or others negatively have insecure attachment styles – further classified as preoccupied, dismissing and fearful. Preoccupied attachment results in dependency and clinginess. Dismissing attachment results in self-reliance and independency. Fearful attachment results in both dependency and hostility towards others.
The present case report illustrates how a disrupting TR with a patient with chronic low back pain was managed in the light of attachment theory, highlighting the role of psychiatry in the multidisciplinary management of patients with chronic pain.
Introduction
Case report
Fig. 1 – Adult attachment styles
G.D. is a 43-year-old woman who was referred to a chronic pain clinic by her neurosurgeon because of a multifocal, multifactorial, refractory and incapacitating chronic low back pain, for which she operated twice. At her first appointment with two chronic pain physicians, the patient was outright hostile, demanding, anxious and reluctant to accept suggested pharmacologic and non-pharmacologic interventions.
Given the incomprehensible behavior of the patient and the difficulty in delivering care, the case was discussed in a monthly multidisciplinary team that includes a psychiatrist and a psychologist.
Later, in psychiatric consultations, a life history of physical and emotional abuse/neglect was identified. Antidepressant medication for symptomatic treatment of anxiety and support psychotherapy improved the patient’s behavior and her relationship with the team, ultimately allowing her to accept new treatments.
jan/2011
jan/2017 fev/2017
mar/2017 mai/2017 jul/2017
History of low back pain since 30 years old, with periods sciatica L4-L5 Discectomy
S1 Root Decompression
First medical appointment in chronic pain clinic
• Low back pain but no sciatica
• Parcial pain control with pregabalin, tapentadol and paracetamol
• Reluctant to be further medicated
• Intervention: Psychoeducations and prescription of non-pharmacologic measures (physiotherapy and swimming pool) • During interview and examination: hostile, demanding, anxious, non-compliant
Multidisciplinary evaluation
• Incomprehensibility of the patient's hostile attitude
• “She was about to beat me, I can not understand why..."
Psychiatric evaluation
• Historyofadversechildhoodevents:poverty,physicalabuse,physicalandemotionalneglet,fatherwithalcoholusedisorder • Intervention:supportpsychotherapy+pharmacotherapyforanxietysymptoms
Re-evaluation
• Thepatientismuchmorecooperative,lessanxiousandwillingtotrynewtreatments • Intervention:proposedtoElectricalTranscutaneousNeurolestimulation
Fig. 2 – Case report chronogram
Discussion
This patient behaved in a paradoxical way - while asking for help, she was hostile and devaluing towards her physicians, as if she needed help but could not receive it. Attachment theory can be used to understand the patient’s behavior in the context of the TR (Fig. 3). The pattern of interpersonal behavior demonstrated by the patient in this situation of vulnerability is typical of patients with fearful- avoidant attachment style, who frequently have antecedents of serioua childhood adverse events. This interpersonal behavior in helping relationships is the result of perceiving others simultaneously as a source of help and danger. Fearfully attached individuals think that they are unworthy of care and that others are not trustworthy for giving appropriate care. All caregiving is viewed as potentially threatening or hostile. People with this attachment style will most likely be inconsistent with any mode of medical treatment. While other insecure attachment styles may be managed by physicians with simple strategies, some authors stress the need of psychiatric liaison in the management of patients with fearful attachment styles.
Attachment style Patients’ behavior
Risk
Health care team strategy
Secure
Cooperative
No special risk
Treatment as usual
Preocuppied
Compulsive help-seeking
Iatrogenic harm
Short but regular appointments
Dismissing
Compulsive self-reliance
Non-compliace
Respect patients’ desire for autonomy Motivational interview
Fearful
Demandng but non-compliant
Conflits wihtin the team
Multidisciplinary management
Fig. 3 – Attachment styles in clinical practice
Learning points
Attachment theory is a useful framework to understand and manage difficult TRs. Besides diagnosing and treating psychiatric comorbidities, the role of psychiatrists in multidisciplinary chronic pain clinics could be to cooperate with other physicians in understanding and dealing with difficult patients.
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 The authors declare no conflicts of interest
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