23-10-23 - Psychology of chronic pain Flashcards
Learning outcomes
- Define pain and chronic pain
- Describe the burden associated with chronic pain for the individual, society, and health care system
- Describe the interrelationship among our thoughts (cognitions), emotions (affect) and behaviours relevant to the experience and management of chronic pain
- Identify methods of assessment and management of pain
What is pain?
What type of experience is pain?
What are 3 characteristics of pain?
- Pain is a subjective experience – there is no “pain thermometer
- Pain is an almost universal experience but there is little consensus on its definitions
- 3 characteristics of pain:
1) Time continuum (acute – brief, subacute – months, chronic – years)
2) Episodic, i.e. recurrent acute pain (e.g. migraines) - unique category
3) Pain associated with malignancies
Describe the definition and management of acute and chronic pain
- Acute pain
- An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described by the patient in terms of such damage
- Managed by addressing the cause of pain
- Chronic pain
- Pain which has persisted beyond normal tissue healing time
- Managed by addressing the effects of pain and finding ways to maximise function and quality of life
Prevalence of chronic pain in Scotland – estimates (in picture)
Describe the 4 levels to the burden of chronic pain
- 4 levels to the burden of chronic pain:
1) Patients with chronic pain continuing quest for relief → feelings of helplessness, hopelessness and depression
2) Significant others/family Share frustration of their loved ones → chronic stress and worry
3) Healthcare providers Share frustration with the patients as their pain reports continue
4) Society Lost productivity and disability benefits
What 5 factors influence chronic pain?
- 5 Factors influence chronic pain:
1) Attention
2) Anxiety
3) Prior learning history
4) The meaning of the situations
5) Other physiological and environmental factors and physical pathology
What are the 3 prominent theories/approaches to chronic pain?
- 3 prominent theories/approaches to chronic pain:
1) Gate Control Theory
2) Biopsychosocial
3) Cognitive-Behavioural perspective
Gate Control Theory (Melzack & Wall, 1982).
What inputs are involved in pain?
Where is there a ‘gating’ mechanism for pain?
What 4 factors can open the gate?
What 4 factors can close the gate?
- Gate Control Theory (Melzack & Wall, 1982)
- Both ascending physiological inputs and descending psychological inputs are involved in pain
- ‘Gating’ mechanism in the dorsal horn of the spinal cord that ‘opens’ (permits) or ‘closes’ (inhibits) the transmission of pain impulses.
- 4 Factors that open the gate:
1) Inactivity/poor fitness (physical)
2) Poor pacing (behavioural)
3) Anxiety/depression/hopelessness (emotional)
4) Catastrophizing, worrying about the pain (cognitive) - 4 factors can close the gate:
1) Appropriate use of medication
2) Massage; heat/cold
3) Positive coping strategies
4) Relaxation; exercise
What are 2 pros of the Gate Control Theory?
What are 3 cons of the gate control theory?
- 2 pros of the Gate Control Theory:
1) Provides a physiological explanation for how psychological factors affect pain perception.
2) Moving away from ‘sensation’ to ‘perception’.
- Cons of the gate control theory:
1) Evidence is mixed.
2) Large amount of evidence showing the impacts of psychological factors on pain experience, but physiological evidence is mixed.
3) Lack of direct evidence of a ‘gate’.
What 3 components of pain does the Biopsychosocial Model include?
What does the Biopsychosocial Model view illness as?
What are affective disorders described as?
Describe the Biopsychosocial Model (in picture)
- 3 components of pain does the Biopsychosocial Model include:
1) Cognitive
2) Affective
3) Behavioural - The Biopsychosocial Model views illness as a dynamic and reciprocal interaction among biological, psychological and sociocultural variables that shape person’s response to pain
- Mood disorders or affective disorders are described by marked disruptions in emotions (severe lows called depression or highs called hypomania or mania).
- Biopsychosocial Model (in picture)
Describe the diagram for the diagram for the cognitive behavioural perspective of pain (in picture).
What 4 things does does the Cognitive-Behavioural perspective place emphasis on in the formation of pain perceptions?
What is the aim of CBT surrounding pain?
- Diagram for the diagram for the cognitive behavioural perspective of pain (in picture)
- 4 things the Cognitive-Behavioural perspective place emphasis on in the formation of pain perceptions
1) Idiosyncratic (individual) beliefs
2) Appraisals
3) Coping repertoires
4) Sensory, affective and behavioural contributions, in the formation of pain perceptions. - The aim of CBT surrounding pain is to change patient perspectives from:
1) Pain interpreted as significant lifethreatening illness
2) Focus on pain (attention)
3) Catastrophising
To:
1) Pain interpreted as the result of minor injury
2) Focus on other things
3) Realistic appraisal
What are the 3 categories of pain assessment tools/scales?
What are 3 other aspects to access in pain assessment?
- 3 categories of pain assessment tools/scales:
1) Pain intensity
* Self-report most commonly used scales for pain assessment
2) Pain intensity
* By Observational Scales focus on behavioural aspects, e.g. facial expressions, guarding and limping important when working with infants, or people with advanced dementia
3) Pain distress
* Pain may vary other time, thus important to access distress in addition to intensity
- 3 other aspects to access in pain assessment:
1) Mood and emotional state
2) Cognitive processing
3) Physical function and disability
What are 4 scales/questionnaires for intensity self-report in pain assessment?
- 4 scales/questionnaires for intensity self-report in pain assessment?
1) Verbal rating scale (VRS)
* Rank-ordered set of descriptors (often no pain, mild pain, moderate pain, severe pain, very severe pain)
2) Numerical rating scale (NRS)
* Numbered scale (usually 0 to 10) with descriptors at each end and presumed ration properties
3) Visual analogue scale (VAS)
* Line of set length with descriptors at the ends but no intermediate words or markers, on which the patient marks pain as a spatial analogue
4) McGill pain questionnaire (MPQ, Melzack, 1975)
* Most widely known
* 78 items in 20 groups: sensory, affective, evaluative dimensions
* E.g., sensory: throbbing; crushing; quivering
* E.g., affective: exhausting; fearful
* E.g., evaluative: annoying; miserable
* Con: time consuming for patients and scorers
What are 4 Limitations of Self-report Measures?
- 4 Limitations of Self-report Measures:
1) They tend to be long measures so limited use during a consultation but the patient may be asked to bring it back
2) Verbal skills
3) Limited use of psychological scales when it comes to people whose first language is not English, those who come from diverse cultural backgrounds, people with communication difficulties → Visual analogue scales may be more appropriate.
4) Misrepresentation of pain: exaggeration or downplay of pain
* Chronic pain is difficult to capture using verbal and numerical scales.
What are the 4 levels of the Chronic Pain Scottish Model?
- 4 levels of the Chronic Pain Scottish Model:
1) Level 1 – Self-management
* Combination of activity and relaxation, non-opioid painkillers, support from 3rd sector organisation (e.g. Pain Association Scotland, Pain Concern)
2) Level 2 – Primary Care
* GP, Physiotherapist or Pharmacist provide help through assessing pain, providing advice, medication, exercise programmes, links to self-management, alternative therapies(e.g. acupuncture)
* Some NHS Boards have specialist pain services provided in primary care
3) Level 3 – Secondary care
* Hospital based pain clinics or services
* Have multidisciplinary teams (MDT), which usually include Consultants trained in chronic pain, Nurses, Physiotherapists, Psychologists, Pharmacists, Occupational Therapists and Psychiatrists
4) Level 4 – Tertiary care
* Highly specialised services – intensive PMPs are conducted by the Scottish National Residential Pain Management Programme (SNRPMP) in Glasgow
* Can conduct invasic procedures to reduce pain e.g killing neurons
Describe 3 different approaches to chronic pain management (in picture)
What is the aim of Cognitive behavioural therapy (CBT)?
- The aim of Cognitive behavioural therapy (CBT) is to alter the intensity, frequency or form of maladaptive or unhelpful thinking styles, emotional responses and coping patterns to improve pain-related functioning
