Guest Lecture 2

Question 1

What are the key psychological models of pain?

Answer 1

• Psychodynamic models (1915)
• Behavioral models (1930s)
• Cognitive-behavioral models (1960s-80s)
• These models have influenced pain assessment and treatment.

Question 2

What are the key ideas behind psychodynamic models of pain?

Answer 2

• 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

Question 3

What are the core principles of behavioral models of pain?

Answer 3

• 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)

Question 4

What are the fundamental concepts of cognitive-behavioral models of pain?

Answer 4

• 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.

Question 5

How do cognitions and emotions influence pain?

Answer 5

• 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

Question 6

What are primary and secondary pain appraisals?

Answer 6

• 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

Question 7

What is pain catastrophizing, and what are its three dimensions?

Answer 7

• 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

Question 8

What are fear-avoidance beliefs, and how do they impact chronic pain?

Answer 8

• 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.

Question 9

How does perceived injustice contribute to chronic pain?

Answer 9

• 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

Question 10

What is the relationship between chronic pain and mental disorders?

Answer 10

• 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

Question 11

What are the key features of depressive disorders associated with chronic pain?

Answer 11

• 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

Question 12

How does anxiety interact with chronic pain?

Answer 12

• 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

Question 13

What is the relationship between trauma and chronic pain?

Answer 13

• 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

Question 14

What are the main components of the nervous system involved in pain perception?

Answer 14

• 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

Question 15

How does the brain contribute to pain perception?

Answer 15

• 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

Question 16

How do psychological factors influence brain processing of pain?

Answer 16

• Psychological states (e.g., anxiety, depression, catastrophizing) affect pain processing
• Experimental manipulations:
• Cognitions: Attention/distraction, expectations, cognitive reappraisals
• Affect: Hypnosis, mindfulness meditation

Question 17

What is Quantitative Sensory Testing (QST), and how do psychological factors affect it?

Answer 17

• 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

Question 18

What social and contextual factors influence pain perception?

Answer 18

• 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

Question 19

How do social interactions impact pain behaviors?

Answer 19

• 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

Question 20

What are the possible negative social consequences of expressing pain?

Answer 20

• 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

Question 21

What dimensions do physicians typically assess in chronic pain patients?

Answer 21

1. Pain, function/disability
2. Benefits and harms of medications
3. Whether psychological factors might contribute to pain and disability

Question 22

What are the challenges in psychological interventions for chronic pain?

Answer 22

• 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

Question 23

What are the primary objectives of psychological interventions for chronic pain?

Answer 23

1. Improve patients’ adjustment to chronic pain
2. Improve patients’ pain
3. Help patients play a more active role in managing their condition
4. Improve patients’ mental health, function, and quality of life

Question 24

What are the 2 primary psychological approaches for pain management?

Answer 24

1. Cognitive-Behavioral Therapy (CBT)
   - Focuses on cognitions, emotions, and behaviors
   - Cognitive restructuring, coping skills training, exposure therapy
2. Acceptance and Commitment Therapy (ACT)
   - Focuses on openness, acceptance, and values-based living

Question 25

What are the key components of Cognitive-Behavioral Therapy (CBT) for pain?

Answer 25

* 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

Question 26

How do CBT homework assignments help chronic pain patients?

Answer 26

* Help patients become more active/functional * Use of paper diaries * Smartphones to track pain and coping strategies

Question 27

Q: What behavioral interventions are used for chronic pain?

Answer 27

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

Question 28

What are the key assumptions and principles of ACT for chronic pain?

Answer 28

* Patients with chronic pain spend considerable effort "fighting" pain * This can be demoralizing and directs patients away from living a meaningful life

Question 29

What are the 3 core processes of ACT?

Answer 29

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

Question 30

How do mental disorders complicate pain management?

Answer 30

- Higher pain intensity and increased pain-related disability - Decreased treatment efficacy - Concurrent clinical problems (ex: substance use problems)