8. Dissecting Pain: Measurement to Management

Question 1

L-8 Health Tips?

Answer 1

1. Pain is in your head (but that doesn’t mean it isn’t real).
2. Take Tylenol for a broken heart.
3. To treat a patient’s pain, treat their social network.

Question 2

Why focus on pain?

Answer 2

Pain is the symptom of greatest concern to patients.
-> And the most likely to lead them to use health services.
Pain is also heavily influenced by psychosocial processes. (pain is inherently psychological in nature)

Question 3

Pain serves a purpose?

Answer 3

Warns self or others of tissue damage/injury/disease; evokes care.

Question 4

Even though pain serves a purpose it also leads to…? + which model?

Answer 4

◦ Poor health behaviours.
◦ Loss of employment/income.
◦ Depression, fear, anxiety.
◦ Social isolation.
◦ Sleep disorders.
◦ Marital and family dysfunction

Biopsychosocial model
- Biology
- Psychology
- Social Factors

This model is even more necessary than when considering stress.

Question 5

Our understanding of pain is still evolving…

Case in point: Fish DO feel pain!

Answer 5

More and more people are willing to accept the facts. Fish do feel pain. It’s likely different from what humans feel, but it is still a kind of pain.

Question 6

Specificity Theory of Pain (Descartes, 1664)?

Answer 6

Pain is directly proportional to the amount of tissue damage. A 1:1 correspondence.

1. Upon injury, pain messages originate in nerves associated with damaged tissue and travel to the spinal cord.
2. A signal is then sent to
   (a) a motor nerve, and
   (b) the brain, where pain is perceived.

This perspective still persist in the medical field today.

Question 7

Specificity Theory of Pain is A Purely Biomedical Approach…?

Answer 7

• Assumption of one-to-one correspondence to injury/disease.
• Unfortunate practices (e.g., blaming the patient, assuming psychiatric disorder or intentional faking of symptoms).
• Men are more likely to be taken seriously (“brave men” vs. “emotional women”) ex. men are more likely to be prescribed pain medication and women wait much longer to receive adequate diagnosis.
• Focus on pharmacological, surgical, or other medical interventions to control pain. -> problematic in chronic pain conditions this will usually never be sufficient long-term. Essential to address psycho social factors!

Question 8

Gate-Control Theory?
(Melzack & Wall, 1965) Canadain scientist, most influential in pain reserch.

Answer 8

Pain is NOT directly proportional to tissue damage. We do not even see small correlations!

A neural pain gate in the spinal cord opens or closes to modulate pain signals to the brain.

Involves inhibitor and projector neurons that respond to sensory input and send certain signals to the brain.

Question 9

Gate-Control Theory - Physical

What opens and closes the gate?

Answer 9

What Opens the Gate? Amplifies pain
- Extent of injury
- Inappropriate activity level; inactivity

What Closes the Gate? Modifies pain
- Medication
- Counter stimulation (massage, heat)

Question 10

Gate-Control Theory - Emotional

What opens and closes the gate?

Answer 10

What Opens the Gate? Amplifies pain
- Anxiety or worry
- Tension
- Depression
- Relationship problems

What Closes the Gate? Modifies pain
- Positive emotions
- Relaxation
- Social support

Question 11

Gate-Control Theory - Cognitive

What opens and closes the gate?

Answer 11

What Opens the Gate? Amplifies pain
- Focusing on pain
- Boredom

What Closes the Gate? Modifies pain
- Distraction
- Concentration
- Involvement and interest in activities

Question 12

Gate-Control Theory brought up the important notion that?

Answer 12

Multiple types of factors influence the pain gate!

Question 13

Pain without (Known) Pathology?

Answer 13

In studies of multiple pain conditions, objective findings have no clinically significant correlation to pain levels.

American Medical Association (2001) – “In up to 85% of individuals who report back pain, no pain-producing pathology can be identified.”

E.g., non-specific low back pain

There is no 1:1 correlation between pain and tissue damage!!

Question 14

Neuropathic Pain?

Answer 14

Results from current or past disease/damage in peripheral nerves; people experience pain in absence of noxious stimulus (something that clearly should be causing pain).

Neuropathy = damage to the nervous system.

Question 15

Neuropathic Pain - Neuralgia?

Answer 15

An extremely painful syndrome in which the patient experiences recurrent episodes of intense shooting or stabbing pain along a nerve; often follows infection.

Question 16

Neuropathic Pain - Causalgia? (“complex regional pain syndrome”)

Answer 16

Involves recurrent episodes of severe burning pain that are often triggered by minor stimuli (e.g., clothing resting on the area).

Question 17

Phantom Limb Pain?(+classified as what kind of pain)

Answer 17

Phantom limb pain is pain experienced in an amputated limb; classified as neuropathic pain.

80-100% of people who have limb removed report feeling some sensation, mainly pain. Generally these disappear over time.

Question 18

Neuromatrix Theory (Melzack, 1990, 2001)
An extension of the gate control theory of pain…?

Answer 18

A widespread network of neurons (distributed throughout the brain and spinal cord) generates a pattern that is felt as a whole body possessing a sense of self.
-> the ‘body-self neuromatrix’

Question 19

Neuromatrix Theory (Melzack, 1990, 2001)

This network is responsible for generating…?
- Pain can occur in the absence of…..
- Various parts of the nervous system work together to….
- Each sensation, including pain, is marked by a unique….

Other theories that the brain was just….?

Answer 19

bodily sensations, including pain. (Pain is produced in the central nervous system.)

• Pain can occur in the absence of signals from sensory nerves.
• Various parts of the nervous system work together to respond to stimuli from the body and/or environment to create the experience of pain.
• Each sensation, including pain, is marked by a unique neurosignature or pattern of activation of the neuromatrix.

Other theories that the brain was just passively perceiving the pain, but this theory indicates that the brain plays an active role in producing the subjective pain response.

Question 20

Current State of the Research

Phantom limb pain may be triggered by…?

Answer 20

other types of input, lack of normal sensory input (which may cause a unique pain neurosignature), or incongruence between types of input due to lack of limb.

A lot of empirical support for the gate control theory of pain and the neuromatrix of pain.

Question 21

How do we define pain?

Answer 21

An unpleasant sensory and emotional experience (it is always a subjective internal experience) associated with actual or potential tissue damage, or described in terms of such damage (psychological experience).

Question 22

Pain is ALWAYS subjective?

Answer 22

It is impossible to definitively know whether another creature’s subjective experience is like our own.

Pain is whatever the person says it is and exists whenever the person says it does…

Self-Report Measures of Pain

Question 23

Pain Rating Scales

Answer 23

Self-Report Measures of Pain

Graphic rating scales, numerical rating scales, verbal rating scales (using adjectives), etc. have been found to be valid and reliable methods for assessing pain.

Question 24

Wong-Baker FACES Pain Rating Scale?

Answer 24

A valid tool for assessing pain in young people (ages 4 to 16).

Question 25

Nonverbal Measures of Pain?

The inability to communicate verbally…

Answer 25

Pain behaviours are observable behaviours that occur in response to pain.
* Facial and audible expression of distress.
* Distortions in posture or gait.
* Negative affect (mood, anxiety, depression).
* Avoidance of activity.

The inability to communicate verbally in no way negates the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment.

Question 26

Neonatal Facial Coding Scale

(No need to memorize all of these!)

Answer 26

-Brow Lower
- Eye Squeeze
- Squint
- Blink
- Flared nostril
- Nose Wrinkler
- Nasolabial Furrow
- Cheek Raiser
- Open Lips
- Upper Lip Raiser
- Lip Corner Puller Horizontal Mouth Stretch - Vertical Mouth Stretch

Question 27

Coding Pain in Mice

Answer 27

Coding of facial expressions of pain in the laboratory mouse.

See similar facial patterns to the pain response.

Question 28

Psychosocial Factors in Pain

Answer 28

Won’t talk a lot about ways to manage pain. If you have time, look this up a little in the reading. Won’t test in detail

Question 29

Organic pain?

Answer 29

Pain that has clearly identifiable phys.

Question 30

Psychogenic pain?

Answer 30

Pain resulting from psych.

Question 31

Scientists used to consider “organic” and “psychogenic” pain to be separate entities.

Today?

Answer 31

Today, scientists recognize that virtually all pain
experiences involve an interplay of both physiological and psychosocial factors.

It is a continuum, not either or. Some have a clear organic cause, others a psychogenic.

Although, you may see some variation in the literature especially within other fields where there is still some disagreement.

Question 32

Emotions and Pain?

Answer 32

Positive emotions (e.g., laughter) appear to reduce

Negative emotions tend to worsen (and result from) pain..
- Most people with chronic pain experience high levels of depression , anxiety , and/or. anger high levels of these emotions are associated with high levels of subsequent pain/disability.

Bidirectional relationship; A cycle, these negative emotions can then make the pain worse.

Question 33

Emotions can also obscure the
memory of pain?

Answer 33

Research has found that high
anxiety patients’ memories of pain are determined more by what they expect than by what they actually feel.

Those who have a lot of anxiety and worry about the pain, that has a larger effect on the experience and memory of pain than the pain itself.

Question 34

Pain and stress are intimately linked… (2)?

Answer 34

(1)
Pain is stressful (partly due to lack of perceived control, chromic pain -> over time can lead to helplessness)
(2)
stress can produce pain (e.g., headache pain)
…in addition to worsening the pain experience.

E.g., Migraine and muscle contraction headaches tend to occur after periods of heightened stress; this link is pronounced for
depressed individuals.

Question 35

The Meaning of Pain?

Answer 35

Pain can be more or less intense depending on the meaning of the pain or underlying injury.

The appraisal of the pain experience.

E.g., enjoyment of pain during sex (masochism).
E.g., relief and optimism following injury in war (vs. civilian surgery, they are correlating the pain experience with returning home with is a positive experience). -> the meaning they assign to pain over time.

Classical conditioning can be one means by which the meaning of pain changes.

Question 36

Based on what we’ve learned so far,
what are some likely adaptive
strategies for coping with pain? And
what are some maladaptive
strategies?

Answer 36

Emotion-focused coping, managing the stress and anxiety.
- Positive reappraisal, adaptive across the variety of situations

Question 37

Coping with Pain - Maladaptive Coping

Answer 37

Destructive thinking; helplessness.

Catastrophizing: Frequent, magnified negative thoughts about pain; magnification, rumination, helplessness

Question 38

Appraisal Model of Pain Catastrophizing?
+ Link with chronic pain?

Answer 38

Primary Appraisal: Focusing on and exaggerating the threat value of pain -> Magnification

Secondary Appraisal: Appraisals of helplessness and of inability to cope

Catastrophizing increases with pain intensity and seems to play a major role in the transition from acute to chronic pain.
- For people that experience some kind of injury, those who catastrophie are more likely to develop chronic pain after that injury than those who don’t engage in catastrophizing.

Question 39

Coping with Pain - Adaptive Coping?

Answer 39

Relaxation; distraction; redefinition of pain
(reappraisal); readiness to change, taking an active role.

Acceptance: (one of the most adpative responses)
Being inclined to engage in activities (of daily living) despite the pain and disinclined to control or avoid the pain.
- When people continue trying to control the pain without success they experience more negative affact because they can not do anything about it -> frustration, anxiety, depression, helplessness

People with high levels of pain acceptance
pay less attention to their pain, have greater self-efficacy for performing daily tasks, function
better, and use less pain medication than those with low pain acceptance.

Question 40

Coping with Pain: Positive reappraisal
attenuates feelings of pain…

Example?

Answer 40

E.g., Positive self-statements (e.g., “No matter how cold it gets, I can handle it”) reduce pain ratings following cold pressor task IF subjects receive explanation of how self statements can help.

Placebo effect, even if they know it’s a placebo it can have an effect if they are told that it could

Question 41

Social Support & Pain
Social support also attenuates feelings of pain…

Example?

Answer 41

E.g., Verbal support during the cold pressor task more strongly reduced participant pain ratings (in addition to stress) compared to mere presence of other person and being alone

Question 42

Social Factors in Pain?

Answer 42

The social context is of great important to the pain experience, the expression of pain behaviours, and the course of pain-related illness.

It is also a significant source of coping with pain.

Question 43

The Social Communication Model of Pain?

Answer 43

Trauma (physical or perceived)

Two main factors

1. Person in Pain
   -> Personal Experience of Pain
   <-> Expression of Pain (also influence the experience, e.g. catastrophizing).
2. Caregiver
   -> Pain Assessment
   <-> Pain Management (after helping, reassess their pain if management has been effective -> this in turn links back to the personal experience of pain)

All of these stages are affected by Interpersonal Influences (e.g., social context/relationship)

Question 44

Social Communication and Pain:

The social communication model places primacy on the interpersonal context of pain…?

Answer 44

Both the individual in pain and the caregiver (or supportive other) bring to the table unique qualities and characteristics that interact to influence the pain experience.

The dynamic interplay between patient and caregiver continuously influences the pain experience.

Question 45

Social Communication and Pain:

Also considered in this model are important
contextual factors?

Answer 45

E.g., Participants exposed to pain in laboratory adjust their pain responses to match those of others who are present at the time

Question 46

Communal Coping Model of Pain Catastrophizing?(goal)

Answer 46

Social Context & Pain ->

Person in Pain:
Pain Catastrophizing (often to attain help from others)
(As a result, person appears less able to cope
with pain.)
-> But increased attention to pain and pain behaviour still tend to worsen the pain experience.

Caregiver
Provides…
- proximity
- support
- empathy
- assistance

Pain Catastrophizing is not worth it even though it gives you more support, it becomes a netloss because Catastrophizing is so bad!

The goal: To manage distress in a social context rather than an individual one.

Question 47

Catastrophizing and Social Support:

Sullivan (2012) has shown that high catastrophizers display…

&

When individuals receive a supportive response….

Answer 47

High catastrophizers display increased pain behaviour in the presence of another person (and engage in less effective coping).

When individuals receive a supportive response from their spouse, the negative effects of catastrophizing on pain are
significantly reduced.

-> But catastrophizing tends to be harmful nonetheless.

Question 48

Treating the Social Network?

Answer 48

The health and well-being of one’s social network also affects pain outcomes…

E.g., In people with rheumatoid arthritis, spouse depression predicted increasing pain and disability over one year, controlling for their own depression.
- There is a significant lasting effect of emotional factors in one’s network.
- The emotional well-being of one’s loved one’s can have affect on pain experience.

One solution?
Treat the social network, too…

Question 49

What is Social Pain?

Answer 49

The experience of pain as a result of interpersonal rejection or loss, such as rejection from a social group, bullying, or the loss of a loved one.

From an evolutionary perspective, social pain is adaptive -> signals when social relationships are threatened.

Social attachment is responsible for our survival. Used or borrowed the pain response to warn us about threats to social relationships.

Linguistically, we describe social pain and physical pain in similar terms “hurt feelings,” “broken-hearted”.

Question 50

Is social pain the same as “physical” pain? (Neuromatrix appraoch?)

Answer 50

Negative social experiences rely on the same neural system supporting the affective component of physical pain:
- dorsal anterior cingulate cortex (dACC) (pain, motivation, self-control) and
- anterior insula (AI) (emotional processing)

fMRI research:
dACC is associated with degree of distress; right ventral prefrontal cortex is associated with regulating distress.

The same parts of the pain are involved, in social and physical pain, but it is not the exact same pattern of activation -> They are not identical responses.

Neruomatix approach, different pattern of activation.

Question 51

Social and physical pain… Implications for Treatment?

Answer 51

Acetaminophen (AKA Tylenol) appears to reduce social pain.

Lowers daily self-reported social pain (better than placebo).

fMRI measures of brain activity found that acetaminophen reduced neural responses to social rejection in the dACC and anterior insula, similar to the effects of reducing physical pain.

Overall effect on emotionality -> Acetaminophen has also been shown to reduce empathy

Question 52

Clinical Interventions for Pain?

Answer 52

Surgical interventions

Chemical treatments (pharmacological)
- Peripherally active analgesics (e.g., acetaminophen)
- Centrally acting analgesics / opioids (e.g., morphine)
- Local anaesthetics (e.g., novocaine)

Stimulation therapies
E.g., transcutaneous electrical nerve stimulation (TENS)

Physical therapy & rehabilitation

Question 53

Medical (and especially chemical) methods alone are usually…

Answer 53

… not sufficient for controlling pain, particularly when it is chronic.

Because psychosocial factors play such an important role in the pain experience (see: gate control theory) and in the transition from acute
to chronic pain, treating psychological factors and challenges can be essential.

Nadeau et al. (2021):
But the best approach to treating chronic pain may involve a combination of pharmacological
(e.g., opioids) and non-pharmacological methods.

• A lot of people in terminal care do not receive adequate pain medication because of social norms of opioids.

Question 54

Psychological treatments for pain aim to help clients… (4)?

Answer 54

• reduce their frequency and intensity of pain.
• improve their emotional adjustment to the pain they have.
• increase their social and physical activity.
• reduce their use of analgesic drugs.

Question 55

Common psychological treatments for pain include…? (3)

Answer 55

Fear reduction methods:
Progressive muscle relaxation, meditation, and biofeedback

Cognitive methods:
(distraction, nonpain imagery, redefinition,
promoting acceptance)

Psychotherapy:
(e.g., CBT) help people manage the emotional
difficulties associated with pain

Question 56

A Multidisciplinary Approach to treating pain?

Answer 56

Treating chronic pain with just one method is less likely to succeed than a combined program.

This further underscores the importance
of a biopsychosocial approach…
- biology
- Psychology
- Social Factors

Question 57

What psychosocial interventions
are used to manage chronic illness
and disease?

Answer 57

• Psychopharmacological
• Patient & Family Education
• Individual or Family Therapy
• Stress Management / Relaxation
• Support Groups

Question 58

Cancer Support Groups? People believe

Answer 58

A significant proportion of breast cancer patients attending support groups do so with the belief that they may be extending their lives.

Question 59

Cancer Support Groups? Science says

Answer 59

There is a significant survival benefit from support groups at one year, but not at four years.

• Intervention early on is important (first 6 months to 1 year)!
• Reliability of the effect goes down as a function of time.
• Similar to those who reported decreased depression during the first year.

Question 60

The psychosocial benefits of support
groups?

Answer 60

We’re more certain about the psychosocial benefits of support groups!
* Improved mood
* Reduced uncertainty
* Improved self-esteem
* Enhanced coping skills
* Improved quality of life

Question 61

Informal Caregiving, definition?+ it is condisered being a…

Answer 61

The provision of physical/emotional care to a family member or friend at home.

Being a caregiver is considered a chronic stressor.

Question 62

Caregiving in Canada?

Answer 62

Approximately 1 in 4 Canadians aged 15 and older (over 8 million people) provide care to a family member or friend with a long-term health condition.

Most caregivers (64%) spend less than 10 hours a week on caregiving responsibilities and 21% spend 20+ hours.

Most (~70%) receive some kind of support or assistance for their caregiving duties (from work, family, friends, gov’t programs).

Most caregivers are women (estimated 54%).

Question 63

Caregiving is a Chronic Stressor…

Factors in Caregiver Stress

Insights from 2011 APA report on caregiving, Our Health at Risk?

Answer 63

• Not having time to care for oneself; feeling overwhelmed.
• Engaging in unhealthy behaviours due to lack of time (e.g., overeating, skipping meals, eating unhealthy foods).
• Disrupted or insufficient sleep.
• Poor stress management (e.g., TV) and stress prevention.
• Degrading social relationships and poor support.

Caregivers are also more likely to believe that stress is having a negative impact on their physical health.
- Those who beilive they have an impact on their have tend to have worse helath outcomes. Apprisal matters.

Question 64

Factors in Caregiver Stress

The Economic Burden- Health Costs of Caregiving?

Answer 64

Higher levels of depression and physical health problems in caregivers when compared with non-caregivers.

Biomarker studies comparing caregivers and non-caregivers have found abnormalities in measures of endocrine and immune system function.

Spouse caregivers who reported strain were at risk for premature mortality.

BUT more recent studies suggest that caregivers may live longer, people who tend to take on a caregiver role are more resilient in the first place.

Question 65

Benefits of Caregiving?

Answer 65

Surveys suggest that an overwhelming majority of caregivers consider it a positive experience.

• Providing the best care possible.
• Staying connected or becoming closer.
• Rewarding sense of accomplishment, giving back to someone who has cared for them.
• Sense of meaning and purpose.
• Passing on a tradition of care in family.
• Learning new skills.

Question 66

The Future of Caregiving
Based on Statistics Canada data, it is projected that by 2050…

Answer 66

There will be approx. 120% more older adults using home care support.

There will be approx. 30% fewer close family members (namely, spouses, and adult children) who will be available to provide unpaid care.

Family members (unpaid caregivers) will need to increase their efforts by 40% (some more than others) to keep up with care needs.

Question 67

Managing Terminal Illness - Main Issue of Concern?

Answer 67

Mortality is the main issue of concern to patients in the first few months of being diagnosed with a seriously life-threatening illness.

Question 68

High Mortality Illness?

Answer 68

A high-mortality disease does not typically mean a person will die in a few weeks or months.

Many cancer patients survive for 10 or 20 years before the disease takes their lives, and some are totally cured.

Still, no one can tell for sure what the course of the disease will be, and these individuals and their families must adapt to this uncertainty a source of stress in terminal illness.

In other cases, individuals may be given a terminal diagnosis with only weeks or months to live.

Question 69

Denial in Terminal Illness?

Answer 69

Denial is common in terminal illness, yet it can pose significant challenges for the person and their family.

In some cases, denial can be extreme and persistent.

Question 70

How might such denial be difficult for others (i.e., family and friends of the person dying)?

Answer 70

Class discussion:
- Caring for a person in denial is challenging
- Other may have to play along, ignore sympthoms or medical advice
- Refuse treatment
- Avoid commuicating the seriousness of condition to family and loved ones, others may not learn about the person’s impending death until it’s too late or until there is very little time.

Question 71

Optimism & Hope?

Answer 71

Patients often show optimistic attitudes early on but begin to view their plans for the future more tentatively.

Many patients also hope they will be cured or hope for a miraculous recovery. This can lead patients to choose aggressive care, even if it is futile (care provided even thoough there is very little hope for improvement).
- May comprimse care and quality of life.

Question 72

Denial / Acceptance?

Answer 72

There is evidence that denial is more common early on and acceptance is more common closer to death.

Question 73

Acceptance in Terminal Illness?

Answer 73

Acceptance is important for BOTH patients and their loved ones.
But acceptance means different things to different people.