Guest Lecture Flashcards
1
Q
What are the key psychological models of pain?
A
- Psychodynamic models (1915)
- Behavioral models (1930s)
- Cognitive-behavioral models (1960s-80s)
- These models have influenced pain assessment and treatment.
2
Q
What are the key ideas behind psychodynamic models of pain?
A
- Popularized by Freud (1915/1957)
- Chronic pain results from unconscious “conflicts”
- Suppression of negative memories/emotions
- Anecdotal/clinical descriptions of “pain-prone” patients
- Engel (1959) influenced by Freud & psychosomatic medicine
- Personality predispositions to develop chronic pain / psychogenic pain
3
Q
What are the core principles of behavioral models of pain?
A
- Skinner (1930s): Focused on observable behaviors
- Pioneered the extension of operant principles to chronic pain
- Core principle: Behaviors are influenced by their consequences
- Fordyce (1976): Pain behaviors maintained by positive consequences (e.g., support)
4
Q
What are the fundamental concepts of cognitive-behavioral models of pain?
A
- Cognitions influence how people feel & behave
- Patients can learn maladaptive ways of thinking, feeling, and behaving
- Turk (1983): Cognitions play a key role in pain perception and adjustment
- People are active processors of information
Cognitive-behavioral perspective has had a major influence on psychological assessment & treatment.
5
Q
How do cognitions and emotions influence pain?
A
- Immediate evaluation of whether the pain sensation is “threatening”
- If appraised as threatening: attentional focus is directed toward pain
- Cognitive evaluation affects response
- Emotional states such as fear and anxiety can be experienced
- Beliefs about control over pain and ability to cope
- Self-efficacy beliefs: beliefs about one’s ability to function despite pain
6
Q
What are primary and secondary pain appraisals?
A
- Primary appraisals: Expectations about pain and pain treatment
- Secondary appraisals: Negative pain-related beliefs are associated with:
- ↓ use of coping strategies
- ↑ clinical pain intensity
- ↑ pain-related disability
7
Q
What is pain catastrophizing, and what are its three dimensions?
A
- Pain catastrophizing includes elements of primary & secondary appraisals
- It has 3 dimensions:
- Rumination: Focus on pain symptoms
- Magnification: Exaggerating the threat value of pain
- Helplessness: Feeling unable to reduce pain intensity
8
Q
What are fear-avoidance beliefs, and how do they impact chronic pain?
A
- Fear-avoidance beliefs: Pain is harmful, and activity should be avoided
- This leads to:
- Avoidance of physical activities → ↑ pain-related disability
- Decreased muscle strength
- Many patients with chronic back pain are passive/sedentary due to fear-avoidance beliefs.
9
Q
How does perceived injustice contribute to chronic pain?
A
- Chronic pain can contribute to feelings of injustice due to its persistence
- Perceived injustice can be directed toward:
- The cause(s) of pain
- Someone else’s negligence
- Employers, insurers, clinicians, or the healthcare system
- 2 main dimensions:
- Blame/Unfairness: (“Nothing will ever make up for all I’ve gone through.”)
- Severity/Irreparability of loss: (“People don’t understand how severe my condition is.”)
- Associated with:
- ↑ pain intensity and ↑ pain-related disability
- Anger and depressive symptoms
10
Q
What is the relationship between chronic pain and mental disorders?
A
- Pain is known to cause psychological distress
- Many patients with pain meet diagnostic criteria for 1 or more mental disorders
- Psychological distress becomes clinically significant when it interferes with function
- Common mental disorders among pain patients:
- Depressive disorders
- Anxiety disorders
- Trauma- and stressor-related disorders
- Personality disorders
- Substance use disorders
11
Q
What are the key features of depressive disorders associated with chronic pain?
A
- Low mood │ Loss of pleasure (anhedonia)
- Hopelessness, guilt, suicidal thoughts
- Major Depressive Disorder │ Persistent Depressive Disorder (Dysthymia)
- Associated with ↑ pain intensity and pain-related disability
12
Q
How does anxiety interact with chronic pain?
A
- High prevalence of anxiety symptoms among pain patients
- Pain is often accompanied by multiple stressors:
o Finances/work
o Access to care
o Implications of pain and limitations - Generalized Anxiety Disorder
- Panic attacks │ Panic disorder
- Associated with ↑ pain intensity and pain-related disability
13
Q
What is the relationship between trauma and chronic pain?
A
- High prevalence of PTSD among chronic pain patients
- Veterans with pain have a high rate of PTSD
- High prevalence of traumas (physical, sexual) among persons with chronic pain
- Common causes of trauma: Car accidents, abuse
- PTSD is associated with ↑ pain intensity and pain-related disability
14
Q
What are the main components of the nervous system involved in pain perception?
A
- Peripheral nervous system: Nociceptors │ Ascending pathways
- Central nervous system (Spinal cord): Processes nociceptive signals
- Central nervous system (Brain): Integration/interpretation of nociceptive signals
- Perception of pain is influenced by psychological factors
15
Q
How does the brain contribute to pain perception?
A
- Advances in neuroscience and brain imaging have revealed differences in brain structure and function in chronic pain patients vs. healthy individuals
- Multiple brain regions/networks are involved in pain perception:
- Sensory dimension
- Cognitive-evaluative dimension
- Affective/emotional dimension
- Behavioral/motor dimension
- Pain is a “multidimensional” experience
16
Q
How do psychological factors influence brain processing of pain?
A
- Psychological states (e.g., anxiety, depression, catastrophizing) affect pain processing
- Experimental manipulations:
- Cognitions: Attention/distraction, expectations, cognitive reappraisals
- Affect: Hypnosis, mindfulness meditation
17
Q
What is Quantitative Sensory Testing (QST), and how do psychological factors affect it?
A
- QST: A set of psychophysiological procedures used to evaluate alterations in nervous system function
- Common pain induction modalities:
- Thermal
- Mechanical
- Electrical
- Endogenous pain modulation (e.g., temporal summation, conditioned pain modulation)
- Psychological factors influence QST measures such as pain thresholds & pain tolerance
18
Q
What social and contextual factors influence pain perception?
A
- Work-related demands
- Disability benefits/litigation
- Wait lists for treatment
- Cultural differences in coping and pain management
- Income: Impact on access to care │ Insurance coverage
- Ethnic disparities: Minority groups receive lower quality pain care
- Pain among minority groups tends to be undertreated
- Disparities in pain care can contribute to emotional distress, pain, and disability
19
Q
How do social interactions impact pain behaviors?
A
- Pain is often experienced in a social context
- Pain behaviors communicate pain and suffering to others
- Support is useful, especially during acute pain
- Pain behaviors may be reinforced and maintained over time by empathy/social support
- Repeated expressions of pain can lead to:
- Distress among partners
- Marital problems
- Partners’ solicitous responses to pain behaviors are significant predictors of disability
20
Q
What are the possible negative social consequences of expressing pain?
A
- Chronic pain & pain expression can elicit negative judgments from others
- Accusations of exaggeration/faking or secondary gains
- Patients perceived as less likable
- Psychological consequences: Identity, self-esteem, mental health
- Perceptions of stigma
21
Q
What dimensions do physicians typically assess in chronic pain patients?
A
- Pain, function/disability
- Benefits and harms of medications
- Whether psychological factors might contribute to pain and disability
22
Q
What are the challenges in psychological interventions for chronic pain?
A
- Psychologists are frequently involved in chronic pain assessment & treatment
- Many patients are reluctant to admit that psychological factors might influence their pain
- Medical interventions remain the central component of chronic pain management
- Psychological interventions are complementary
23
Q
What are the primary objectives of psychological interventions for chronic pain?
A
- Improve patients’ adjustment to chronic pain
- Improve patients’ pain
- Help patients play a more active role in managing their condition
- Improve patients’ mental health, function, and quality of life
24
Q
What are the 2 primary psychological approaches for pain management?
A
- Cognitive-Behavioral Therapy (CBT)
- Focuses on cognitions, emotions, and behaviors
- Cognitive restructuring, coping skills training, exposure therapy - Acceptance and Commitment Therapy (ACT)
- Focuses on openness, acceptance, and values-based living
25
What are the key components of Cognitive-Behavioral Therapy (CBT) for pain?
* Education about pain and the cognitive-behavioral perspective
* Cognitive restructuring: Identify & challenge:
* Maladaptive beliefs
* Cognitive distortions
* Coping skills training
* Improve mood & increase self-confidence
* Recognize how emotions influence pain & behaviors
26
How do CBT homework assignments help chronic pain patients?
* Help patients become more active/functional
* Use of paper diaries
* Smartphones to track pain and coping strategies
27
Q: What behavioral interventions are used for chronic pain?
1. Reinforcement of adaptive behaviors
- Encourage engagement in daily activities/movements
- Establish a structured schedule of activities
2. Graded activity
- Increase activity levels gradually to improve function
3. Graded exposure │ In vivo exposure
- Gradually expose patients to previously avoided movements/activities
- Leads to a decrease in fear
28
What are the key assumptions and principles of ACT for chronic pain?
* Patients with chronic pain spend considerable effort "fighting" pain
* This can be demoralizing and directs patients away from living a meaningful life
29
What are the 3 core processes of ACT?
1) Openness / Acceptance
- Patients are encouraged to accept the persistence of pain and its limitations
2) Awareness
- State of "non-judgmental" awareness
- Observing thoughts and feelings as they are
3) Engagement / Committed Action
- Patients are encouraged to redefine personally meaningful values
- Patients are encouraged to derive meaning from life despite chronic pain
30
How do mental disorders complicate pain management?
- Higher pain intensity and increased pain-related disability
- Decreased treatment efficacy
- Concurrent clinical problems (ex: substance use problems)
31
What complexity does chronic pain represent?
Chronic pain is a multi-dimensional disease, involving physical, emotional, psychological, and social factors
32
What is the moral and ethical issue surrounding pain treatment according to McGee et al., 2011?
Under-treatment of pain is essentially a moral issue. Treating pain is an ethical obligation embedded in the relationship between provider and patient, and between the healing professions and society
33
List physician-related barriers to effective pain management
* Believing patients always report pain
* Lack of training/knowledge
* Fear of regulatory scrutiny
* Concerns about addiction and side effects
* Time-consuming nature of management
* Prioritizing disease management over pain
* Viewing pain as a symptom, not a disease
* Failing to define goals and expectations
34
List patient-related barriers to effective pain management
* Belief that pain is normal
* Unwillingness to report pain
* Fear of side effects and addiction
* Belief that therapy may hinder control of future severe pain
* Cognitive impairment, depression
* Passive coping strategies
35
List system-related barriers to effective pain management
* Failure to recognize the magnitude of the problem
* Lack of resources
* Misuse of existing resources
* Insufficient education
* Permissive compensatory systems
36
Name major categories of Chronic Non-Cancer Pain (CNCP)
* Primary pain (ex: fibromyalgia)
* Post-traumatic pain
* Post-surgical pain
* Headache
* Orofacial pain
* Musculoskeletal pain
* Can be nociceptive, neuropathic, visceral, or idiopathic
37
Define neuropathic pain according to IASP
Pain caused by a lesion or disease of the somatosensory nervous system
VS
Pain initiated or caused by a primary lesion, dysfunction or transitory perturbation of the peripheral or central nervous system
38
What is the first step in treating CNCP?
Define therapeutic goals, focusing on palliation and rehabilitation
39
Common goals in chronic pain management include:
* Decrease pain
* Recuperate sleep
* Increase activity
* Improve mood
* Enhance quality of life
40
What are the 4 main categories of palliative therapy for CNCP?
1. Pharmacotherapy
2. Invasive interventions
3. Behavioral therapy
4. Complementary & alternative medicine
41
Pharmacotherapy for CNCP involves which drug categories?
* Non-opioids (acetaminophen, NSAIDs)
* Opioids
* Adjuvants: antispasmodics, anticonvulsants, antidepressants, antiarrhythmics, alpha-2 agonists, local anesthetics, cannabinoids
* “The administration of medication is always a risk benefit calculation” (Agency of Health Care Policy and Research, 1994)
42
What routes can analgesics be administered through?
- Oral
- Rectal
- IV
- Subcutaneous
- Cutaneous
- Spinal
- Nasal
43
What factors should analgesic selection be based on?
* Onset
* Provocation/palliation
* Quality
* Region and radiation
* Severity
* Time
44
Key considerations for opioids/cannabis in CNCP management:
* Are they useful in resistant pain?
* Which type to choose?
* In what populations?
* When/how to start and maintain treatment?
* When to stop?
45
Name invasive measures used for CNCP
* Trigger point injections
* Nerve blocks
* Spinal axis interventions
* Super-invasive: peripheral nerve, spinal cord, and brain stimulation, implanted spinal pumps
46
What is the evidence for invasive interventions in CNCP?
* Not enough evidence justifying nerve block therapy for chronic LBP
* Most high-quality studies show minimal long-term benefits for spine interventions
47
What is complementary & alternative medicine in CNCP care?
Treatment approaches outside conventional medicine, underutilized due to lack of evidence and funding
48
What were the outcomes from CNCP community studies?
* 4-year community study1:
* Increased pain prevalence (45.5% → 53.8%)
* 79% still reported pain after 4 years
* Retrospective study of patients with CRPS2:
* None had recovered
* In most: only modest symptom improvement
* Improvement not necessarily associated with therapy
49
What major lesson can CNCP management learn from cancer medicine?
Focus on prevention, early identification, and risk-factor modification rather than palliation alone
50
Similarities between cancer and CNCP:
* High prevalence
* Multi-factorial causes
* Variety of palliative approaches
* Current therapies fail to meaningfully alter outcomes
51
What is the future direction for CNCP management?
* Phenotype and genotype patients at risk
* Identify environmental contributions
* Explore preventive analgesia
* Prevention of CNCP
52
Describe an example of successful CNCP prevention (immunization against CNCP)
- Post-herpetic neuralgia
- ~40,000 people > 60 years old
- Median follow up time of >3 years
- Early vaccination resulted in:
- Reduced incidence of HZ by 51.3%
- Reduced burden of illness by 61.1%
- Reduced incidence of PHN by 66.5%
53
Can patients control their own pain perception (self pain control)?
- Yes
- Via fMRI-guided training, patients learned to control activation of the rostral ACC
- In chronic pain patients: one day training resulted in a significant pain reduction (64% MPQ, 44% VAS)
