Chapter 16 PAIN

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Chapter 16PAIN

• D.F.Marks, M.Murray,
• B.Evans, C.Willig, C.Woodall
• C.M. Sykes (2005)
• Health Psychology Theory, Research Practice
• (2nd edition). London Sage.
• Starred authors feature in video-clips

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PAIN

• Introduction
• Theories of pain
• Psychological aspects of pain
• Socio-cultural influences on pain
• Assessment
• Management
• Summary

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INTRODUCTION

• Pain is a uniquely personal human experience,
  which has been defined in many ways
• An aversive, personal, subjective experience,
  influenced by cultural learning, the meaning of
  the situation, attention and other psychological
  variables, which disrupts ongoing behaviour and
  motivates the individual to attempt to stop the
  pain (Melzack and Wall, 1988)
• Whatever the person experiencing it says it is,
  existing whenever the experiencing person says it
  does (McCaffery and Thorpe, 1988).
• It is an unpleasant sensory and emotional
  experience associated with actual or potential
  tissue damage, or described in terms of such
  damage (Merskey, 1996).

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Terminologies in pain research

• Acute pain is a useful biological response
  provoked by injury or disease, which is of
  limited duration (IASP, 1992).
• Chronic pain is described as pain persisting for
  six months or more and tends not to respond to
  pharmacological treatment.
• Malignant is associated with progressive illness
  (e.g. cancer)
• Benign is not associated with progressive illness
  (e.g. lower back pain)
• Progressive means becoming worse overtime (e.g.
  arthritis)
• Intractable means resistant to treatment (e.g.
  lower back pain)
• Intermittent is pain that fluctuates over time
  and in intensity (e.g. fibromyalgia)
• Recurrent is acute pain occurring periodically
  (e.g. migraine)
• Organic involves observable tissue damage (e.g.
  arthritis)
• Psychogenic means absence of demonstrable
  pathology (e.g. fibromyalgia)
• Referred is pain originating in one body area
  which is perceived as originating from another
  (e.g. perceiving an earache that in fact
  originates from a bad tooth).

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Components of Pain
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The Cost of Pain

• Pain inflicts significant costs on individuals,
  their families, the health services and society
  in general.
• The economic costs are very high due to extended
  hospital stays, lost working days and increased
  take-up of benefits.
• The cost of pain in terms of human suffering is
  also high.
• It is often the most distressing and debilitating
  aspect of chronic illness.
• Its effects on quality of life can be devastating
  to the individual and their significant others.
• The emotional toll of severe chronic pain should
  not be underestimated
• It is estimated that around 50 of severe
  chronic pain patients
• consider suicide.

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THEORIES OF PAIN

• In this lecture, we will consider three theories
  of pain
• Specificity Theory
• Pattern Theory
• Gate Control Theory

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Specificity Theory (Von Frey, 1894)

• This theory describes a direct causal
  relationship between pain stimulus and pain
  experience.

• Stimulation of specific pain receptors
  (nociceptors) throughout the body, sends impulses
  along specific pain pathways (A-delta fibres and
  C-fibres) through the spinal cord to specific
  areas of the sensory cortex of the brain.
• Stimulus intensity correlates with pain
  intensity higher stimulus intensity and pain
  pathway activation resulting in a more intense
  pain experience.
• Failure to identify a specific cortical location
  for pain, realisation that pain fibres do not
  respond exclusively to pain but also to pressure
  and temperature, and the disproportional
  relationship between stimulus intensity and
  reported pain intensity.

BRAIN
Spinal cord
NOCICEPTORS
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Pattern Theory

• Pattern theorists proposed stimulation of
  nociceptors produces a pattern of impulses that
  are summated in the dorsal horn of the spinal
  cord.
• Only if the level of the summated output exceeds
  a certain threshold is pain information
  transmitted onwards to the cortex resulting in
  pain perception.
• Evidence of deferred pain perception raised
  questions concerning the comprehensiveness of
  pattern theories
• Soldiers not perceiving pain until the battle is
  over
• Phantom limb
• Injury without pain perception
• There was growing evidence for a mediating role
  for psychosocial factors in the experience of
  pain, including cross-cultural differences in
  pain perception and expression.

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Gate Control Theory
Melzack Wall (1982)
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PSYCHOLOGICAL ASPECTS OF PAIN

• Many psychosocial factors have been investigated
  in relation to pain and these appear to exert
  independent effects on the experience of pain.
• In this lecture, we will discuss eight of these
  factors
• Cognitions
• Self-efficacy
• Perceived control
• Prior experience and conditioning
• Secondary gains
• Personality
• Mood
• Stress

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Cognitions

• Cognitions influence the experience of pain,
  particularly the appraisal of situations for
  their significance and meaning.
• Aspects of cognition that have received attention
  related to pain are
• Attention
• Increased attention to pain has been associated
  with increased pain perception. This may explain
  why distraction techniques are useful in
  combating pain.
• Dysfunctional thinking
• Dysfunctional thoughts, attitudes and beliefs
  about pain are automatic patterns of thinking
  that block the attainment of an individuals
  goals.
• Coping styles
• These are strategies an individual uses to
  attempt to deal with their pain. In general,
  active coping styles (e.g. keeping oneself busy)
  have been found to be associated with improved
  coping, reduced pain intensity and improved
  recovery rates.

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Self-efficacy

• Self-efficacy beliefs refers to an individuals
  beliefs about how well they can handle a given
  situation (Bandura, 1977).
• There is a relationship between an individuals
  self-efficacy beliefs and about their ability to
  manage pain (Brekke et al., 2003).
• Selfefficacy beliefs may also relate to a second
  cognitive component that has been associated with
  pain - perceived control.

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Perceived control

• Bowers (1968) showed that individuals endure more
  pain when they control the pain-stimulus on/off
  switch than when it is controlled by someone
  else.
• This concept relates to the development of
  patient controlled analgesia (PCA), in the
  management of post-operative pain and in
  palliative care.
• PCA resulted in patients administering less
  analgesic morphine than when it was controlled
  and administered by nurses or through continuous
  infusion.
• PCA appears to result in better pain management,
  less opiate use and earlier discharge from
  hospital than intramuscular therapy (Royal
  College of Surgeons Anaesthetists, 1990).

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Previous Experience and Conditioning

• Both classical and operant conditioning have been
  implicated in the aetiology of chronic pain via
  the association of behaviour and pain.
• In classical conditioning theory a particular
  situation or environment may become associated
  with pain and therefore provoke increased anxiety
  and pain perception.
• In operant conditioning theory, pain behaviours
  become conditioned responses through positive
  (e.g. attention, medication, time off work) and
  negative (e.g. disapproval
• of others, loss of earnings) reinforcements.

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Secondary Gains

• Secondary gain relates to social rewards accruing
  from the demonstration of pain behaviours.
• These secondary gains are thought to reinforce
  pain behaviours and thus maintain the condition.
• However, this may actually reflect that those in
  receipt of compensation can allow themselves
  appropriate time to recover and says nothing
  about the quality of life of those who returned
  to work earlier.
• For many individuals, pain results in the loss of
  jobs, social contact, leisure activities, valued
  identities, reduced incomes and concomitant
  reduced standard of living.
• Such losses are very real and distressing and are
  often associated with substantial hardships,
  lowered mood and loss of self-esteem, unlikely to
  be outweighed by incidental benefits.

Time off work
Financial benefits
Receiving attention
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Personality

• It has been suggested that there is a pain-prone
  personality (Engel, 1959)
• Features of the pain prone personality include
  continual episodes of varying chronic pain, high
  neurotic symptoms (guilt feelings, anxiety,
  depression and hypochondria)
• Generally, empirical support for the pain-prone
  personality has not been forthcoming and it has
  been suggested that the higher scores for
  particular personality factors (i.e. neurotic
  triad) may be a consequence rather than a cause
  of long-term pain.

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Mood

• There is a relationship between pain and anxiety
• Acute pain increases anxiety. But once pain is
  decreased through treatment, the anxiety also
  decreases, which can cause further decreases in
  the pain, a cycle of pain reduction.
• Chronic pain remains unalleviated by treatment
  and therefore anxiety increases which can further
  increase the pain, creating a cycle of pain
  increase.
• Depression is also commonly associated with pain.
  
• People who experience severe and persistent pain
  often have feelings of hopelessness,
  helplessness and despair.
• While correlations between mood states and pain
  have been found, the causal direction and the
  nature of the relationships remains unclear.

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Stress

• Chronic pain both exacerbates and is exacerbated
  by stress.
• Experiencing persistent high levels of pain can
  itself can be a substantial stressor, possibly
  even the most significant stressor in the lives
  of many individuals.
• It is also often the source of additional life
  stresses, like loss of employment, relationship
  difficulties and financial hardship.
• Individual, stereotypical physiological responses
  to stress (e.g. clenching jaws, migraine
  headaches) can be a direct source of pain and the
  physiological arousal associated with stress may
  lead to increased pain and inhibit effective
  adaptation.
• Stress is such a frequent concomitant of pain
  that stress management techniques are routinely
  included as an integral part of pain management
  programmes.

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SOCIOCULTURAL INFLUENCES ON PAIN

• Several sociocultural factors have also been
  implicated in the experience of pain.
• Today, we will discuss the role of
• Culture
• Gender
• Age
• Significant others and the family

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Culture

• Pain experience is expressed differently across
  cultural groups.
• Social learning influences pain tolerance levels,
  communication about pain, pain behaviours and the
  meaning of pain.
• Cultural influences may encourage avoidance or
  acceptance of pain, demonstrable pain behaviours
  or stoic concealment.
• It may also affect the treatment received within
  healthcare systems in terms of cultural
  expectations and communication traditions.
• Further research is needed on the influence of
  social factors and discrimination on the
  experience of pain treatment for minority groups.

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Gender

• There is much evidence to suggests that women are
  better at dealing with pain than men.
• Biology, sex hormones, culture, socialization and
  role expectations, psychology, and past
  experience have been offered as explanatory
  variables.
• However, the relationship between pain and gender
  is complex.
• The particular type of pain, when it occurs, and
  the researchers gender are all implicated in
  pain reporting.
• Skevington (1995) argues gender differences may
  have been overemphasized and significant
  similarities exist between the sexes regarding
  pain experiences and actual differences may
  relate to treatment behaviour and pain severity.
  
• Further research is needed to unpack the
  relationship between gender and pain.

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Age

• The experience of pain has been found to vary
  across the lifespan.
• Less is known about pain in children than in
  adults.
• Chronic pain in children appears to be under
  represented in the pain literature, despite the
  reporting of both persistent and recurring
  chronic pain by children.
• For older adults, pain may be a pervasive aspect
  of their lives differing qualitatively from that
  experienced by younger age groups.
• The elderly are also consistently
  under-represented in the pain literature and pain
  in this group is substantially under-diagnosed
  and under-treated.
• Health psychologists should work to improve
  diagnostic techniques and understanding of the
  pain across the lifespan, especially among
  children, older adults and the way it interacts
  with other aspects of their lives.

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Significant others and the family

• A common concept in chronic pain research is that
  subjective pain and pain related behaviour may be
  affected by significant others who are perhaps
  one of the major reinforcers for pain-related
  behaviours and chronicity.
• Spousal solicitousness may inadvertently maintain
  or increase the experience of pain and
  disability.
• Parents are the most significant influence on a
  childs pain perception, modeling behaviours as
  well as reinforcing them.
• Pain within the family is likely to affect all
  family members and the family will affect how
  they all cope.
• Further research is required with measurement
  instruments specifically developed to assess the
  relevant variables in pain populations need to be
  extended to include families and significant
  others.

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ASSESSMENT

• Assessment of pain is difficult and various
  techniques are used singly or in combination.
• These can be grouped under one of four
  categories
• Physiological measures
• e.g. medical examination, EMG, heart rate,
  galvanic skin response, etc.
• Pain questionnaires
• e.g. McGill Pain questionnaire
• Mood assessment questionnaires
• e.g. Becks depression inventory, HADS, etc.
• Observations
• Direct observation
• Self-observation

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Issues in assessment

• Many assessment instruments are insensitive to
  age, disability and culture.
• For example, for groups who have communication
  difficulties, assessment may rely on the reports
  of significant others (e.g. carer, interpreter)
  rather than the individual.
• Research that focuses on pain assessment among
  under represented groups is needed.
• Similarly, more work is required to address
  issues around the impact of situational context
  and assessor characteristics on the assessment
  process.
• Further investigation is needed of the influence
  of assessment, including the impact of
  compensation claim assessments and of the need to
  prove the existence of pain and how it restricts
  the sufferers daily activities.

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MANAGEMENT

• In this section, we will discuss several
  strategies in the management of pain
• Behavioural strategies
• Cognitive strategies
• Cognitive Behavioural Therapy (CBT)
• Pharmacological strategies
• Physical strategies
• Other strategies and approaches
• Palliative care
• Multidisciplinary Pain Management
  Centres/Programmes

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Behavioural strategies

• Most behavioural strategies are based upon
  operant learning processes.
• Conditioning was integral to contingency
  management.
• This was a 2-6 week inpatient program during
  which nursing staff would ignore medication
  requests, reinforce targeted well behaviours,
  introduce increasing exercise quotas, and employ
  a fixed-schedule pain cocktail.
• The pain cocktail delivered medication within a
  strong tasting masking fluid that allowed
  medication dosages to be reduced without the
  patient noticing.
• While such programs have had good (even dramatic)
  short-term results, they have been less
  successful in maintaining such gains, possibly
  due to non-generalisation outside the hospital
  environment.
• It is rare for programmes today to focus solely
  on conditioning methods.

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Behavioural Strategies

• Other behaviorual strategies are discussed below
• Graded exercise strategies involve setting a
  starting level of activity that the person can
  manage and then developing a schedule to
  gradually increase the length of time and
  intensity of the exercise.
• Biofeedback and autogenic training teach the
  individual to control aspects of their
  physiology. The individual receives continuous
  feedback through visual and audio signals from a
  machine that monitors their physiology, through
  which they learn to control their response.
• Relaxation probably affects pain perception both
  directly and indirectly, through its positive
  effects on stress and anxiety. This may involve
  progressive muscle relaxation or more simply deep
  rhythmic breathing. This is often used in
  conjunction with meditation or imagery
  techniques.

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Cognitive strategies

• Cognitive strategies aim to help the individual
  identify and understand their cognitions and
  their connection with their experience of pain
  and then change negative cognitions to improve
  it.
• This includes teaching individuals to identify
  and challenge distorted thinking -
• Cognitive restructuring
• an active coping technique that promotes the
• internal attribution of positive changes.

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Cognitive strategies

• Training in cognitive coping skills has generally
  been found to be beneficial to pain patients.
• Distraction and positive self-talk are just two
  examples from the repertoire of coping skills.
• Imagery involves forming and maintaining a
  pleasant, calming or coping image in the mind. In
  guided imagery attention is guided away from an
  undesirable sensation or mood (e.g. pain) by
  another person who verbally describes the image
  while the patient relaxes.
• Meditation also frequently forms part of
  relaxation training and involves the individual
  focusing their attention on a simple stimulus, to
  the exclusion of all other stimuli.

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Cognitive strategies

• Information provision has been shown to reduce
  pain reports and intensity, possibly by
  alleviating the fear and anxiety of not knowing
  what to expect for acute and postoperative pain
  (Williams et al., 2004).
• The widespread interest in self-help literature,
  internet information and support groups may be
  indicative of the desire of people in pain to
  understand their experience, what to expect and
  potential treatment options.

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Cognitive behavioural therapy

• Cognitive behavioural therapy utilises the full
  range of cognitive and behavioural techniques
  already described in individualised programmes
  that emphasise relapse prevention strategies.
• Stress management training is often included due
  to the significant levels of stress implicated in
  the generation and exacerbation of pain.
• The literature on CBT and pain suggests it shows
  considerable promise as an effective treatment
  for pain in adults (Eccleston, et al., 2002).

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Pharmacological strategies

• Various analgesics and anaesthetics are
  prescribed for the treatment of pain.
• Anaesthetics are used to numb the sensation of
  pain.
• However, the associated perceived high risk of
  addiction has resulted in their use being
  restricted.
• Non-opioid analgesics, non-steroidal
  anti-inflamatory drugs (NSAIDs) and drugs that
  control pain indirectly (e.g. antidepressants,
  sedatives) are also commonly used.
• Another aspect relating to drugs is the placebo
  effect.
• In addition to prescribed drug treatments many
  individuals self-medicate with recreational drugs
  like alcohol and cannabis to alleviate their
  pain.
• However, the informal use of cannabis for pain
  control and its interaction with other pain
  control strategies needs further investigation.

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Physical strategies

• Surgical control of pain mainly involved cutting
  the pain fibres to stop pain signal transmission.
  
• However, it provided only short-term results and
  the risks associated with surgery mean it is no
  longer viewed as a viable treatment option
  (Melzack Wall, 1982).
• Physiotherapy may be used to increase mobility
  and correct maladjusted posture, encourage
  exercise and movement and education.
• Other physical strategies include the stimulation
  of nerves under the skin (i.e. transcutaneous
  electrical nerve stimulation/ TENS treatment),
  massage, spinal cord stimulation, etc.

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Other strategies and approaches

• There are many other strategies and alternative
  therapies that individuals use in their efforts
  to deal with their pain.
• Acupuncture has been around for centuries and
  while the mechanisms by which it produces
  beneficial effects are not well understood it
  does appear to exert substantial analgesic
  effects (WHO, 2003).
• There is substantial, reliable evidence that
  hypnosis has beneficial effects for the treatment
  of acute (e.g. childbirth) and chronic pain (e.g.
  cancer-related) conditions.
• Individuals frequently use complementary or
  alternative therapies (e.g. aromatherapy, Chinese
  medicine) to combat pain and there is growing
  support that they help chronic pain control (e.g.
  NIH, 1997).
• The widespread use of alternative strategies may
  reflect dissatisfaction with mainstream
  approaches.
• It is important that such strategies are
  evaluated independently and in conjunction with
  traditional approaches

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Palliative care

• Palliative care refers to the alleviation of
  symptoms of illness when there is no cure
  available, particularly concerning terminal
  illness.
• Its aims are to reduce suffering, fear and
  distress, normalise the dying process, maintain
  active participation in life, increase quality of
  life and maintain dignity until death for the
  patient.
• Terminally ill patients are often asked to take
  part in drug trials, even without any expectation
  of the drugs helping them.
• Despite this, effective pain management underpins
  palliative care, including medication, CBT and
  alternative therapies.

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Multidisciplinary Pain Management Centres

• Pain management programmes today tend to be run
  on an outpatient basis in specialist pain
  management centres.
• Multidisciplinary teams may include doctors,
  nurses, physiotherapists, psychologists,
  psychiatrists, occupational therapists and
  counsellors.
• Individual programmes are developed that aim to
  improve the individuals quality of life by
  reducing pain, increasing activity and coping,
  restoring function, promoting self-efficacy and
  self-management.
• The patient receives a full assessment,
  education, skills training, exercise schedules,
  relapse prevention and family work.
• Multidisciplinary rehabilitation programmes
  represent the most comprehensive approach to
  date, by targeting the individuals specific pain
  experience and tailoring appropriate treatment
  combinations.

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Treatment issues

• Pain management can be a particularly
  controversial issue.
• Evidence suggests that in many circumstances pain
  is under-treated due to (Greenwald et al., 1999)
• Inadequate assessment
• Focus on underlying pathologies
• Negative stereotypes and erroneous assumptions
  about certain population groups
• Addiction fears
• The inappropriateness of non-pharmacological
  treatments
• Patients inability to verbalise pain information
  or requests for medication
• It has also been shown that many prejudices and
  misconceptions operate in the treatment of pain
  patients, with various populations being under
  treated for pain (Todd et al., 2000)
• Children, people with communication difficulties
  and the elderly

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Treatment issues

• Pain is sometimes deemed to be psychogenic,
  resulting from emotional, motivational or
  personality problems.
• However, the distinction between organic and
  psychogenic pain may have little practical value.
  
• While psychogenic pain may represent a convenient
  label for cases where underlying pathology has
  not been found, it has a tendency to inherently
  ascribe the problem to the patient and thus
  promote prejudice and injustice.
• Health psychologists must endeavour to promote
  the sensitive and respectful treatment of
  individuals reporting pain, both within the
  discipline and externally, in terms of research,
  intervention development, and treatment.

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Summary

• Early pain theories proposed that pain was a
  sensation that involved a direct line of
  transmission from the pain stimulus to the brain.
  
• However, the growing body of evidence for the
  psychological mediation of pain saw the
  development of the multidimensional gate control
  theory, which acknowledged psychosocial
  influences.
• Many psychological variables that influence the
  pain experience have been examined including
  cognitions, self-efficacy, perceived control,
  prior experience, conditioning, secondary gains,
  personality, mood and stress.
• Similarly sociocultural factors such as culture,
  gender, age, the role of significant others and
  the family have been implicated.
• Particular groups appear to be under represented
  in the pain literature including ethnic
  minorities, children, the elderly, some disabled
  people and people with certain medical conditions.

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Summary (continued)

• Assessment of pain is difficult and various
  techniques are used singly or in combination
  (e.g. medical examinations, observations,
  questionnaires, diaries and logs, and
  interviews).
• A wide variety of pain management strategies
  exist. Currently, the most successful approach
  appears to be programmes that combine cognitive
  behaviour therapies and traditional medical
  therapies.
• The assessment and treatment of pain,
  particularly chronic pain, can be influenced by
  misconceptions about specific patient groups
  including ethnic minorities, children, the
  elderly, some disabled people, and people with
  certain medical conditions (e.g. sickle cell
  disease sufferers assumed to be drug users).
• The body of research suggests that pain is a
  complex and multidimensional phenomenon that
  includes biological, psychological and
  behavioural components.
• Health psychologists can make a significant
  contribution in promoting sensitive and
  respectful research and treatment for people
  experiencing long standing painful conditions.