Module C „Basic Clinical Problems“
topic No 2 PAIN
1. Pathophysiological and psychological aspects of pain in adults and
children
1.1. Pathophysiology and psychophysiology of pain (doc. Yamamotová)
General introduction
definition of pain, biological role of pain, reasons for the study of pain
Terminology used in pain physiology
nocicepor (nocisensor), nociceptive stimulus,
pain threshold, pain tolerance
acute and chronic pain
protophatic pain and epicritic pain
referred pain, phantom pain, central pain, anaesthesia dolorosa, neurogenic pain, causalgia, neuralgia,
allodynia, dysesthesia, hyperalgesia, hyperesthaesia, hypoalgesia, neuritis, paraesthesia
Peripheral mechanisms of pain
Classification of free nervous endings, polymodal nociceptors, “silent” nociceptors
pain provoking substances
stimulating nociceptors (prostaglandins, leucotriens)
sensitizing nociceptors (bradykinin, serotonin, histamine, potassium ions etc.)
Nociceptive afferents (cutaneous, muscle, visceral, C and A fibers)
Central mechanisms of pain
neospinothalamic and paleospinothalamic pathways
spinal cord pain mechanisms
the gate control theory of pain mechanism (role of substantia gelatinosa Roladni, role of presynaptic
inhibition)
medullary and midbrain mechanisms of pain
thalamic mechanisms of pain (ventrobasal complex, intralaminar nuclei)
cortical mechanisms of pain (role of frontal and cingular coretex in pain perception)
Central pain inhibitory mechanism, its neuroanatomical substrates and neurotransmitter systems
periaqueductal gray, ncl. raphe magnus
substance P, glutamate (EAA), GABA, serotonin, endogenous opioids
opioid vs. non-opioid analgesia (brain stimulation-produced analgesia, stress-induced analgesia)
mechanisms of non-opioid analgesia (role of NMDA receptors)
Classification of opioid receptors () and their distribution in CNS
ascending and descending pain pathways
hypothalamic-pituitary axes
nigrostrial and mesolimibic dopaminegic system
Measurement of pain
pain thresholdand pain tolerance, direct scaling techniques, psychophysiological correlates of pain
1.2. Psychological approaches to pain (doc. Balcar)
1
Pain as a psychological phenomenon:
1.1 Perceptual quality of pain: sensory threshold of pain, affective component of pain, and their psychological
determinants and properties.
1.2 Meaning quality of pain: perceiving, feeling, understanding and appraising the origin of, present meaning of,
and future outlook on the experienced pain.
1.3 Psychological role of pain: its diagnostic and motivational functions generally as well as specifically as to its
kind, to the meaning attributed to it, to the psychosocial specificity of the patient (especially as to the age, social
role, education, culture, etc.).
1.4 Reasons for causing pain, for allowing, alleviating, or eliminating it in medical care and the meaning thereof
for the patient, for his/her experiencing, understanding, and acting.
2
Psychological factors influencing the rise and course of pain and reactions to it:
2.1 Pain tolerance, its permanent and actual psychological sources.
2.2 Somatogenic pain and psychological factors: influence of expectations, attention, memory (linking pain
experiences to specific situations, states and activities), volition and behavior, interpersonal situation, and
ongoing events
2.3 Psychogenic pain and possible mental causes of pain:
2.3.1 Acute, short-term pain: influence of the mental state, e. g., fatigue, tension, stress brought by outer events
or inner (experiential) processes (esp. by conscious and unconscious conflicts) upon the pain evoking somatic
peripheral (e. g., muscle and vessel tensions) and central (nervous) processes as well as upon the rise of pain
without apparent somatic background.
2.3.2 Chronic, lasting pain: influence of learning (model learning, respondent and operant conditioning,
cognitive learning) in situations of experiencing pain of a primarily different, origin.
3
Indication and application of psychological (counseling and psychotherapeutic) approaches in pain
control:
3.1 Suggestive, placebo, and hypnotherapeutic pain control.
3.2 Autoregulative pain control through imagination, relaxation procedures, and biofeedback techniques.
3.3 Rational and cognitive-behavioral methods of changing attitudes and behaviors that contribute to pain
experience.
3.4 Psychodynamic work with inner sources of pain inducing tension (frustration and conflict resolution, etc.).
3.5 Working with family and other social relationships of the pain suffering patient.
Reading assignments:
Sarafino, E. P.: Health psychology. New York: Wiley and Sons 1994, 1998 (chapters 11, 12).
1.3. Aspects of pain in children (MUDr. Palyzová)
1.
Pathophysiological and psychological aspects of pain in children
a) Development of knowledge and opinions about the quality and quantity of the pain in childhood
according the maturity of structures of CNS (history: the theses of the limited sense of pain in the youngest
children, insufficient memory of the pain).
b) The specialties of the early postnatal period: the pain experiences of full-term and immature neonates
and their manifestation of the pain
c) The delivery and early postnatal period as a source of the pain in physiological newborns and specially
in sick babies (in the Intensive Care Unite)
2.
Pain measurement in children in regard of the age
a) Models of the behaviour of painful child with the acute or chronic pain: non-verbal communication in
newborns and infants, the starting verbalisation (toddlers), verbal communication with predominant form of
concrete thinking (pre-school age) and with the developmental abstract form of thinking (school children
and adolescents)
b) Neurochemistry of pain: the releasing of catecholamines, cortisol, renin, vasopressin, beta endorphins as
an answer for the painful stimuli
c) Vegetative reactions as the answer to the pain: the changes of heart and breath rates, and sweating in
connection with the painful stimulus
3.
Contact with the child with acute and chronic pain: as a source of information (the intensity of pain
and the possibility of its measurement)
a) The pain as an indirectly measured category
b) Newborns, infants and toddlers: the main sign of the pain is the scream, mimic reaction, common
painful behaviour with increased tension and tendency to the defensive reaction
c) Pre-school age: the using of testing aids
d) School-age and adolescents: visual scale combined with conversation (aimed to the quality and quantity
of pain)
4.
Non-pharmacological approach to the pain in children
a) The influence of environment: the test (experiment) to eliminate some stressful stimuli and their
substitution by relaxed conditions (music, room decoration)
b) Personal influence (the behaviour of staff)
c) The influence of the formulas of painful behaviour in family
d) The psychological preparation: the child must be adequately informed of the investigation in the
connection with following positive experience
e) Distraction attention from painful procedures
f)
Music, painting, modeling as a way of therapy of pain
g) Play as a treatment of painful process
h) Individual and group psychotherapy
i)
Hypnosis
2. Pharmacology of pain (prof. Kršiak)
A/ Schedule of teaching:
1. hour:
2. hour:
3. hour:
4. hour:
Opioid analgesics
(Lecture)
Nonopioid analgesics
(Lecture)
Determining of exemplary case studies (about 1 – 3) (Seminar)
Schedule of pharmacotherapeutical design
(Seminar)
(Problem, selection of drug group, concrete drug, drug form, doses,
risks, individualization, economical aspects, further control)
5. a 6. hours:
Individual elaboration of appropriate case studies
(Individual work and/or in small groups)
7. hour: Evaluation of elaborated designs of appropriate case studies
– correction suggestions
(Seminar, “workshop”)
8. hour: Corrections. Summary. Credits.
(Seminar)
B/ Brief characteristic of problematic of “Pharmacology of Pain”
1. Introduction: Short reminding of pathophysiological mechanisms of pain (see “Patophysiological aspects of
pain” – prof. Rokyta)
Basic drug groups used for pain release – categorizing of drugs considering their mechanisms of action.
2. Opioid analgesics
history
2.1. Basic pharmacology of the opioid analgesics
- pharmacokinetics – absorption, metabolism, excretion
- pharmacodynamics - mechanisms of action, endorphins, opioid
- receptors, receptor types and distribution
- neurobiological mechanisms of tolerance and dependence
- central nervous system effects
- peripheral effects
2.2. Clinical pharmacology of the opioid analgesics
- clinical use – indications, mode of use
- toxicity and adverse reactions, interactions
- Basic Agents – categorizing of analgesics considering intensity of their analgesic effects
and mechanism of the effects
- Strong agonists
Morphine, Methadone, Meperidine, Fentanyl, Levorphanol
- Mild to moderate agonists
Codeine, Propoxyphene
- Mixed agonist/ antagonists of opioid receptors
Nalbuphine, Buprenorphine, Butorphanol, Pentazocine, Dezocine
2.3. Opioid antagonists – pharmacokinetics, pharmacodynamics, clinical use
Basic Agents
Naloxone, Naltrexone
3. Nonopioid analgesics
- Categorizing of drugs considering their mechanism of actions
3.1. Nonoipioid analgesics without anti-inflammatory effect
- Basic Agents, pharmacokinetics, indication, adverse reactions
Paracetamol
3.2. Anti-inflammatory drugs – categorizing of drugs considering their mechanisms of action, basics of
pathophysiology of inflammation
3.2.1. nonsteroidal anti-inflammatory drugs
- pharmacokinetics - absorption, metabolism, excretion
- pharmacodynamics – mechanisms of action, types of action
- clinical use
- adverse reactions – drug forms, mode of applications, interactions
- Basic Agents – categorizing, basic characteristics, indications
Aspirin, Ibuprofen, Flurbiprofen, Ketoprofen, Indomethacin, Diclofenac, Piroxicam,
Diflunisal, Meclofenamic acid, (Phenylbutazone)
3.2.2. slow-acting anti-inflammatory drugs
- categorizing, mechanisms of action
- clinical use (antirevmatics)
- adverse reactions
- Basic Agents – characteristics, indications
Antimalarial drugs (Chloroquine), Gold, Penicillamine, Methotrexate, Levamisole
and further immunosuppressive drugs
3.2.3.
Drugs used in gout- characteristics, pharmacotherapeutic approach
- adverse reactions
- Basic Agents
nonsteroidal anti-inflammatory drugs in treatment of the gout
Colchicine
Uricosurics – Probenecid, Sulfinpyrazon
Allopurinol
3.3 Steroidal anti-inflammatory drugs - glucocorticoids
- pharmacokinetics – mode of administrations
- pharmacodynamikcs – mechanisms of action
- clinical use
- adverse reactions – drug forms, mode of administrations, interactions
- Basic Agents – examples, characteristics, indications
Hydrocortisone, Prednisone, Triamcinolone, Betamethasone, Dexamethasone etc.
4. Other possibilities in pharmacotherapheutical approaches to pain release - examples
3.3.
3.4.
Local Anesthetics – reminding of mechanisms of action, use, basic agents
Drugs with CNS-depressant effects – Sedative–Hypnotics, Central Myorelaxans, Neuroleptics
–mechanisms of action, potenciation of action of analgetics– combination with analgetics,
algosedation
- clinical use, adverse reaction
- basic agents – examples
5. Recommended literature:
Katzung BG et al.: Basic and Clinical Pharmacology, A Lange medical book, 1998
Rang HP et al.: Pharmacology, Churchil Livingstone, 1997
Harvey RA et al.: Lippincott’s Illustrated Reviews Pharmacology, Lippincott-Raven, 1997
PC-Databases – AISLP (in English) , Drugdex, Martindale, PDR, British National Formulary etc. …….in the
PC-net of seminary room of Pharmacology No 523 (Ruska 87, Prague 10)
3. Pharmacological and surgical treatment of pain
3.1. Neurosurgery (prof. Haninec)
A. Surgery of pain
1.
2.
3.
4.
5.
6.
7.
Spinothalamic chordotomy - transsection of tractus spinothalamicus lateralis
comissurotomy – transsection of comissura anterior (mediolongitudinal myelotomy)
central myelothermocoagulation – thermal lesion at C1 or Th12 level
thermocoagulation in dorsal root entry zone – exclusion of the secondary pain pathway neuron in the dorsal
roots of spinal cord
electrostimulation methods
stereotaxic methods in thalamic region
intrathecal opiate application – application of opiates into liquor spaces using permanent reservoirs
B. Surgery of neuralgia n.V and n. IX
1.
2.
retroganglionic surgery - chemical or thermal retroganglionic damage of trigeminal pathway
microvascular decompression – decompression from abnormal course of a. cerebelli posterior superior or its
branches in the transition zone of n.V of posterior cranial fossa.
Literature:
Kunz Z.: Neurochirurgie, Avicenum, Praha, 1983.
Šourek K.: Chirurgie bolesti, Avicenum, Praha, 1981.
3.2. Anaesthesiological care and postsurgical pain (doc. Málek)
Anaesthesiological methods in pain therapy
Treatment of acute and chronic pain is an essential part of anaesthesiology. The main fields of interest are
organisation of acute pain service, mainly in postoperative care, participation in obstetric analgesia and some
special methods of treatment of chronic and malignant pain. In fact the concept of pain treatment originated in
anaesthesiology and the first pain clinic was founded in 1964 by the anaesthetist dr. Bonica.
Postoperative pain
Insufficiently or incorrectly treated postoperative pain results in many adverse complications: increased tone of
sympathetic nerve system with increased consumption of oxygen and increased demands on myocardium,
catabolism, pulmonary dysfunction, trombembolism.
Possibilities
-preemtive analgesia, e.g. blocking of nociception before surgery. Often used in painful preoperative conditions,
before amputation etc.
-psychological methods as a part of pre-operative evaluation
-physical methods (TENS) are based on the gate theory of pain, usually used in combination with other methods
-analgesics antipyretics and NSAID are used for monotherapy only in minor procedures, more often in
combination with opioids
-systemic administration of opioids: i.m., i.v., s.c., s.l., continual infusion i.v. or s.c., patient controlled analgesia
(PCA) i.v., s.c., intranasal (less often)
-regional anaesthesia: infiltration of surgical wounds, nerve blocks (ilioinguinal and iliohypogastric nerves
blocks in hernia repair, penile block, intercostal nerve blocks), interpleural analgesia, single shot or continual
block of nerve plexus, continual subarachnoid (less often) or epidural analgesia with local anaesthetics, opioids
or combination of both either as a bolus or continual method or using PCA.
The crucial condition for success are: a) individual approach to patients, b) good knowledge of pharmacology of
drugs used, c) an adequate monitoration of effect (visual analogue scale or other), d) monitopration of side and
adverse effects of the method used and their appropriate therapy and e) assessment of satisfaction of the patient.
Audits of acute pain therapy should be held regularly to evaluate results, improve therapy and make standard
protocols.
Postoperative pain in children is a speciel field, which is often underestimated. It has been proved, that even
newborn has reaction to pain and it means that analgesia must be performed. Because of inmaturity of
ventilatory centre, which can cause ventilatory depression after many drugs including opioids, locoregional
methods, analgesic antipyretics and NSAID are often prefered.
Chronic and malignant pain
Anaesthesiological methods are used in less than 1% of patients, mainly in cases, where systemic analgesics and
adjuvant therapy are not sufficient to suppress pain or is accompanied with high incidence of adverse effects.
Main anaesthetic techniques are temporary nerve blocks or permanent blocks (neurolysis). Blocks can be divided
into diagnostic blocks when the origin of pain is not clear, prognostic blocks before neurolysis and therapeutic
blocks. Indications of anaesthetic techniques are ischemic and phantom pains of lower limbs, pain caused by
tumours of pelvis, abdomen and thorax, pain caused by nerve root compression (caudal pressure blocks), Bier´s
blocks for complex regional pain syndromes, blocks of ganglion stellatum and ganglion coeliacum. The blocks
are sometimes performed under sciascope or with neurostimulator. Catheters are often tunnelised or
subcutaneous port is used.
The drugs used are local anaesthetics, opioids, steroids, alpha2 mimetics, ketamine and other less common
drugs. Adjuvant therapy is any case essential part of treatment.
Obstetric analgesia
The available methods are psychological, physical, systemic administration of opioids, inhalational analgesia,
infiltration anaesthesia, paracervical block, caudal block and epidural continual analgesia, which is the most
commoly used by anaesthetists. Except of general contraindications special condicions of labour and demands of
obstetricians must be accepted. The main advantage of epidural analgesia is comfort of the patient, suppression
of sympathetic response to labour and improvement of uteroplacentar perfussion.
Epidural analgesia is the method of choice in noncolaborating patients and in preecclapmsia and ecclampsia. The
most dangerous complication is hypotension because of compression of vena cava inf. by uterus. Prevention is
an appropriate choice of concentration and dose of local anaesthetic, prehydratation of the patient and left lateral
tilt position. Other side effects include longer labour and increased use of forceps for delivery.
4. Therapy of pain in neurology (prof. Kalvach)
Acute and chronic pain
Two clinical entities
Acute pain – up to three months – is associated with a sympathetic pattern of changes (pulse
acceleration, blood pressure, hyperventilation, mydriasis, increased pulse volume). The dominant emotion is
anxiety. Analgesics should be administered in an adequate amount, to estimate probability of chronification.
Chronic pain – no sympathetic changes; usually a number of vegetative and psychosocial disturbances
are present (algogenic psychosyndrom): sleep disorders, loss of appetite, decreased tolerance to pain, depression,
hostility, hypochondria, abnormal pain behaviour.
The chronic pain has a treatable form – a recurrent attacks of acute pain and a less treatable
form – permanent perception of pain, psychically modified; this special syndrome needs a
different, complex multidisciplinary approach. The treatment program should be oriented
according to the somatic affective and social role in the image of the suffering. Search for a
correlation of subjective feelings and the objective findings is important.
The chain perception according to Loester: nociception (somatic), pain reception (sensory), reaction to
pain – suffering (affective component) and change in behaviour (behavioural component).
Most frequent causes for an unsurpressable pain: neuralgia, radicular pains (low back syndrome),
myofascial syndrome, tunnel syndromes, reflex syndromes, phantom pains. Psychiatric and psychosomatic
diseases, rent neurosis and some other task related phenomena.
In the treatment strategy of psychosocially modified pains analgesics should be avoided as soon as
possible, antidepressive agents, psychotherapy, physical therapy, ergotherapy, hypnosis, biofeedback,
acupuncture should be employed. Collaboration of the family is important. The aim is a resocialisation of the
patient.
Headache
The international classification of headache (1988) is based on etiologic factors.
Primary headache:
migraine
tension type headache and related syndromes
cluster headache and related syndromes
Migraine: paroxysmal disorder, predominantly one-sided (hemicrania). More in women. In its pathogenesis the
main role is believed to be in the interaction of serotonin and the trigeminovascular complex.
Common migraine – no aura.
Classical migraine – a visual, or acoustic, or sensitive, or motor aura precedes.
Basilar migraine with brain stem symptoms.
Opthalmoplegic migraine with occular paresis.
A complicated migraine should always be well examined (suspicion of another etiology – vascular
malformation, tumor etc.).
Tension type headache: the most frequent headache, non-paroxysmal, both sided, either episodic or chronic.
Psychogenic factors in its provocation are frequent.
Cluster headache: cyclic cephalea, more rare, more in men. One-sided attacks of headache are located in the
orbit and surroundings. The conjunctiva and the nose mucosa react with increased secretion.
Cranial neuralgias:
Secondary headache due to another cranial or extracranial disease.
The basic disease may be dangerous; sometimes urgent diagnostics are needed. Most conspicuous are pains,
which arose suddenly, or changed its previous character. Abnormal neurologic findings, changes in behaviour,
fever, meningeal syndrome, disturbed consciousness are warning signs. The same is true in case of a headache,
which appeared only after 50.
Pains of Vertebral Column
One of the most frequent reasons for neurological check up in the outpatient as well as in the inpatient service.
Two main categories:
vertebrogenic (spondylogenic) pain
radicular (neurogenic) pain
Vertebrogenic (spondylogenic) pain arises in pathological strains exerted on osseous, chondrous and fascial
components of vertebral column. It arises also in abnormal exertion of muscular bends.
a)
pain of vertebral bodies – degenerative processes – osteomyelitis, spondylitis, deffects of vertebral
body plates – Schmorl’s bundles, trauma.
b) discogenic pain – trauma, anular tears, disc bulging and prolapses
c)
facette pain (intervertebral joints) in extreme mobility of intervertebral joints, or with their
degenerative changes
d) ligamentous pain – most often posterior and anterior longitudinale ligament in disc bulging,
intervertebral ligaments in postural and dynamic disturbances (scoliosis, olisthesis)
e)
muscular pain in abnormal muscular efforts and exertion
Radicular (neurogenic) pain – compression of neural root, spinal ganglion or spinal nerve in their passage
through the intervertebral foramen, neural sleeve or extreme lateral disc bulging. The most frequent cause is a
protrusion or prolaps of the intervertebral disc. The medial variant of protrusion sticks out against the dural sack,
the lateral variant against the deviating root, the extreme lateral variant against the spinal nerve. A characteristic
feature of the radicular pain is its irradiation according the topography of radicular areas.
The radicular syndrome manifests itself primarily by pain, later a sensitive loss in a given segment appears, the
segmental reflex drops down or disappears and finally a paresis followed by atrophy may arise.
When a previous pain syndrome reaches a stage of a motor disturbance it becomes an urgent situation for
decision of possible surgical intervention. In plain algic symptoms a possible surgery should be evaluated
according to pain intensity and its duration. The situation considered for surgeryvneeds besides of an x-ray check
up a thorough neuroradiological evaluation by one or two of the following modalities: perimyelography
(instillation of iodine contrast into the dural sack(, CT or MRI. Each of these examinations have other imaging
advantages.
Recommended literature:
Marco Mumenthaler: Neurology. Georg Thieme Verlag, Stuttgart, 1990.
Anne G. Osborn: Diagnostic Neuroradiology. Mosby, St. Louis, Baltimore, Boston, 1994.
5. Pain control in cancer patients (doc. Kovařík)
1. Introduction
Various types of pain in cancer patient – somatic, visceral
Pain characteristics (acute and chronic pain)
2. Pain control
The difference in pain control in cancer patient in comparison with non-cancer patient
a)
surgical therapy of pain (types of surgery)
b) radiation therapy of pain (analgesic radiotherapy using external beam radiotherapy, “half body irradiation”,
brachytherapy using radioactive strontium in therapy of multiple bone involvement
c) painkillers used in cancer patients
the three-level-scale for dosage of analgesics (according to WHO)
prescription rules – the way to establish an optimal interval of application of analgesic
dosge – equianalgetic doses of some opioid analgesics
the rules for use of analgesics-antipyretics
the rules for use spasmolytics
the rules for use of analgesics – anodyns
the rules for use of different drugs (not standard analgesics) in the therapy of pain in cancer patient
hormones in pain control
the role of corticosteroids in the treatment of liver secondaries and brain tumours
the role of androgens, gestagens, and steroid synthesis blockers in metastatic breast cancer
the role of oestrogens and antiandrogens in metastatic prostate cancer
the use of drugs reducing activity of osteoclasts (biphosphonates, calcitonin)
the use of anxiolytics, neuroleptics and antiepileptics
3.
Psychotherapy as a part of complex care of cancer patient in pain
4.
Conclusion – general rules for pain control in cancer patient
6. Psychiatric approach to pain (prof. Libiger)
" Liaison psychiatry of pain"
Psychiatric aspects of pain:
Functional significance of pain: protection, warning, information
Symbolic meaning of pain experience, relationship between culture, emotions and pain (pain inrites of passage,
sacrifices, sex).
Dependence on context in pain experience: emotional value of the pain provoking situation, ethnic and social
differences in experiencing pain.
In practice - a.psychogenic pain - somatoform pain disorder ( ICD 10 category-F45.4)
Psychalgia without detectable or meaningful morphological and /or physiological causes often related to an
emotional conflict.
Mechanisms of dissociation and conversion.
Prevalence, clinical presentation, treatment.
 pain as a sign of acute stress response or disorder of adaptation-expression of an intense distress by means of
conversion or displacement of the original psychological condition.
 pain as an equivalent of a depressive disorder: masked depression. Differential diagnosis from primarily
physical pain symptoms.
 modulation of physically caused pain by anxiety and sadness.
Psychoanalytical models of pain
The influence of developmental psychosocial factors in forming the vulnerability to psychogenic pain.
Pain and pain treatment in the cognitive behavioural therapy
Psychotherapeutic treatment of pain
 relaxation techniques and attention displacement
 suggestion and hypnosis in the treatment of pain
 stress managing techniques
 cognitive behavioural techniques in managing somatoform symptomatology
Presentation of clinical vignettes and training.
Psychopharmacology of pain
Neurotransmitter and hormonal influences on pain perception
Treatment of "masked depression" and somatoform disorder.
Combined analgesic and psychotropic drug treatment
The efficacy of neuroleptic and antidepressant medication in the control of mild pain and additional medication
to analgesics in cases of severe pain.
Problems concerning medication with benzodiazepines (anti-conflict effects turned to symptoms of behavioural
desinhibition)
Case story clinical presentation
Vignette of a patient with persistent psychogenic pain-persistent somatoform disorder.
There are available case stories of two different patients. Both had repeated teeth extractions because of
psychogenic toothache. In one patient the pain was related to an emotional conflict, in the other patient it was a
displacement of depressive symptoms to somatoform ones, within a meaningful context of difficult life
circumstances.
More clinical vignettes will be presented and current patients invited to take part at this seminar, if available.