Psychology of Chronic Pain* Flashcards
Describe the biopsychosocial model.
Biological, psychological, and social factors interact to determine health.
Define pain.
An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described by the patient in terms of such damage.
Define chronic pain.
Pain which has persisted beyond normal tissue healing time.
What are some ways to distinguish between acute, and chronic pain ?
TIMELINE
Acute to chronic pain: 12-week duration (but that is arbitrary)
MANAGEMENT
Acute: Addressing cause of pain
Chronic: Addressing the effects of pain and finding ways to maximise function and quality of life
How many adults in the UK are affected by chronic pain ? What proportion of the adult population ?
35-51.3%
~28 million adults
What is the prevalence of chronic pain in 18-25 yo ? >75 yo ?
18-25: 14.3%
>75: 62%
Identify some burdens associated with chronic pain, by order of least to most frequent.
- Maintaining relationships with friends and family
- Driving
- Sexual relations
- Living independent lifestle
- Working outsid ehome
- Attending social activities
- Walking
- Household chores
- Lifting
- Exercising
- Sleeping
ALSO
- Depression
- Changes jobs, job responsibilities, lost job (consequences on finances)
What proportion of adults with chronic pain saw 2-6 doctors ?
54%
Identify reasons why patients with chronic pain saw more than one doctor.
- Previous doctor said could do no more for the pain
- Friend/relationship recommended
- Previous doctor unable to control pain
- Not satisfied with treatment
- Went to pain specialist
- Primary doctor referred
- Went to specialist for medical condition
- Primary doctor is general/family doctor
What proportion of chronic pain sufferers have co-morbid depression ? What proportion of have other chronic illnesses ? What are the most common ones ?
20-50%
• 88% of patients with chronic pain have other chronic illnesses.
Most common ones: cardiovascular disease and depression.
To what extent is severe chronic pain associated with increased 10 year mortality ?
Severe chronic pain was associated with increased 10 year mortality’
Particularly from heart disease and respiratory disease. Exact mechanisms need to be investigated.
Which kind of doctor is the majority of chronic pain patient managed by ?
Family doctor (GP)
How much more do chronic pain patients visit their GP than those without chronic pain ? Why ?
Twice
Higher level of use of emergency and unscheduled care
Identify theories of pain.
Specificity theory: Direct causal relationship between pain stimulus and pain experience
Pattern theory: Stimulation of pain receptors produces a pattern of impulses and only if they pass a certain threshold they are transmitted to the cortex which leads to pain perception
Gate control theory
Describe the gate control theory of pain.
• Pain is multidimensional and subjective experience of perception.
• Both ascending physiological inputs and descending psychological
inputs are involved.
• ‘Gating’ mechanism in the dorsal horn of the spinal cord that ‘opens’ (permits) or ‘closes’ (inhibits) the transmission of pain impulses.
• What ‘opens’ the gate? inactivity/poor fitness (physical); poor pacing (behavioural); anxiety/depression/hopelessness (emotional) catastrophizing, worrying about the pain (cognitive)
• What ‘closes’ the gate? appropriate use of medication; massage; heat/cold; positive coping strategies; relaxation; exercise
What are the pros, and cons of the gate control theory ?
PROS
-providing a physiological explanation for how psychological factors affect pain perception (moving away from sensation to perception)
CONS
- Evidence is mixed (large amount of evidence showing the impacts of psychological factors on pain experience, but physiological evidence is mixed)
- Lack of direct evidence of a gate
Identify psychosocial aspects of pain.
- Anxiety
- Previous experience and conditioning
- Self-efficacy
- Fear
- Secondary gains
- Meaning
- Pain behaviour
What does cognition have to do with pain ?
Our thoughts, beliefs, the way we think impact on our experience of pain, specifically:
- Attention
- Self-efficacy (belief in your own ability to do something)
- Patterns of thinking and beliefs
How does attention affect pain ?
• Increased attention to pain has been associated with increased pain perception (BUT don’t know enough about how distraction works in those with chronic pain)
-This explains why patients suffering from back pain who take to their beds take longer to recover than those who carry on working and engaging with their lives (i.e. bred rest no longer main treatment option)
Identify a kind of pain which has “meaning”.
Childbirth
Identify a negative pattern of thinking linked to pain, and describe its main components.
CATASTROPHIZING
3 components:
• Rumination: focus on internal and external info. E.g., “I can feel my neck click every time I move”
• Magnification: overestimating the extent of threat. E.g., “The bones are crumbling and I will become paralysed”
• Helplessness: underestimating resources. E.g., “Nobody understands how to fix the problem and I just can’t bear any more pain”
Identify the main emotions/affects which may affect pain.
- Anxiety
- Depression
- Fear
Describe how anxiety may affect pain.
• Acute pain: Anxiety increases acute pain but when acute pain is treated the anxiety drops and that further leads to reduction in pain.
- Cycle of pain reduction
• Chronic pain, different story:
Tx has little impact on chronic pain which leads to increased anxiety which then leads to increased pain
- Cycle of pain increase
Describe how depression may affect pain.
- Common to have hopelessness, helplessness, and despair.
- Direction of the relationship between pain and depression is not always clear cut. It’s more likely that depression is an outcome of chronic pain rather than cause of it.
Describe how fear may affect pain.
- Extensive fear of increased pain or pain reoccurring is v common.
- This can lead to avoidance of a range of activities, i.e. fear-avoidance model of pain:
The fear of pain –> amplified perception (hypervigilance) –> pain avoidance behaviours –> disability and disuse –> higher pain
Describe the psychological vicious cycle of pain.
Pain Anger, Anxiety, Fear, Distress Impoverished mood Depression Increased perception of pain
Describe the physiological vicious cycle of pain.
Pain Activity Avoidance Progressive deconditioning Pain with decreasing activity Further activity avoidance Further deconditioning
Explain the relation of classical, and operant conditioning with pain.
CLASSICAL CONDITIONING
• We might associate certain environment with the experience of pain. Anxiety plays a role too.
An association of pain with going to dentist –> enhanced pain perception
OPERANT CONDITIONING
We may show ‘pain behaviours’ in response to pain stimuli
e.g., grimacing, limping –> positively reinforced by those around us by giving sympathy and attention.
Identify examples of pain behaviors. Why may these be reinforced ? What is the result of such a reinforcement ?
- Facial or audible expression (e.g., clenched teeth and moaning)
- Distorted posture or movement (e.g., limping, protecting the pain area)
- Negative emotions (e.g., irritability, depression)
- Avoidance of activity (e.g., not going to work, lying down)
- Pain behaviours are reinforced (doesn’t mean ‘caused’) through attention and acknowledgement they receive (e.g., being let off tasks)
- Pain behaviours can lead to lack of activity and disuse through muscle wastage, reduced social contact.
True or False: Good Social Support is Essential in Pain.
TRUE
Identify features of good social support in pain.
• Discouraging avoidance of physical and social activities, offering assistance by generating multiple solutions to problems, and providing emotional support (e.g., sharing sad and pleasant events) (can lead to less pain and better physical functioning)
Describe assessment of pain. What is the aim of pain assessment ?
- Concise history
- Examination
- Biopsychosocial assessment
- Identifying pain type (neuropathic/nociceptive/mixed), severity, functional impact, and context
These will all inform selection of treatment options most likely to be effective (e.g. drugs specifically effective for neuropathic pain are ineffective for nociceptive pain, and vice versa)
Identify examples of self-report measures of pain.
MCGILL PAIN QUESTIONNAIRE
78 items in 20 groups: sensory, affective, evaluative, miscellaneous
E.g., sensory: throbbing; chrushing; quivering
E.g., affective: exhausting; fearful
E.g., evaluative: annoying; miserable
VERBAL RATING, BOX AND VISUAL ANALOG SCALES
E.g. mark the word that best describes your present level of pain (mild, moderate, severe, excruciating)
STaRT BACK TOOL
Screening tool
BEHAVIORAL ASSESSMENT
Often not included in self-report measures
May include:
-Verbal/Vocalisation (moans, complaints)
-Motor (grimacing, distorted gait)
-Seek help/reduce pain (take med, visit doctor)
-Functional limitation (resting, reduced activity)
Identify limitations of self-report measures of pain.
• They tend to be long measures so limited use during a consultation but the patient may be asked to bring it back (e.g. McGill Questionnaire)
• Verbal skills
• 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.
• Misrepresentation of pain: exaggeration or downplay of pain
Chronic pain is difficult to capture using verbal and numerical scales.
• Subjective (someone’s 8 can be someone else’s 4)
Identify a limitation of behavioral assessment of pain.
-Direct observations are also subject to bias: Setting (clinical vs home), the purpose of assessment (benefit claim vs treatment assessment), the assessor characteristics can influence the assessment.
Distinguished between learned pain behaviors and malingering.
Malingering: conscious and purposeful faking of a symptom to achieve some benefit, usually financial
Learn pain behavior, no suggestion of conscious deception, behaviors are unintended and can result from nociceptive input or environmental reinforcement. Most patients who display this are not aware of doing so, nor are they consciously motivated to obtain positive reinforcements with the behaviors.
Describe management of chronic pain, including the goals of chronic pain management.
MANAGEMENT MUST BE MULTIDIMENSIONAL
• Pain management programmes cover pharmacological AND psychological interventions (must also have social, occupational dimensions)
• Aims of these revolve around:
-Improving physical and lifestyle functioning: e.g., improving muscle tone, self-esteem, addressing pain behaviours and secondary gains
-Decreasing reliance on drugs
-Increasing social support and family life
Identify components of psychological management of pain.
Cognitive methods
Respondent methods
Behavioral methods
Describe behavioral strategies for pain.
-Based on principles of operant conditioning: pacing to break the overactivity-react cycle (Someone with chronic pain may have good days when pain is manageable, in which they feel they need to do anything they couldn’t when feeling bad, so overactivity, leading to fatigue/pain next day, leading to rest and frustration, then easing of the symptoms, and again overactivity etc.)
What is the aim of cognitive methods in pain ?
To help individual identify and understand their thoughts/beliefs about pain and modify their ‘cognitions’ that may be exacerbating their pain experience.
Identify examples of cognitive methods in pain.
Cognitive restructuring: identifying and challenging thoughts through Socratic questioning (“What evidence do you have to support your thoughts?”)
Distraction (may have limited use in those with chronic pain); positive self-talk; pain acceptance
CBT: relies on interaction between emotions, thoughts (cognitions) and behaviors
What is the aim of respondent methods in pain ?
To modify the physiological system directly by reducing muscle tension.
Identify examples of respondent methods in pain.
- Decreasing stress and anxiety and therefore decreasing pain.
- Progressive muscle relaxation (e.g. from head to toe focusing on different parts of body)
- Biofeedback
Why should healthcare professionals referring patients for psychological assessment attempt to assess and address any concern the patients may have about such a referral ?
Because oftentimes chronic pain patients may think “it’s all in their head” if referred for psychological referral, so helpful to explicitly state the aims of the referral (i.e. increasing coping and improve QOL)
True or False: Clinicians should be aware of the possibility that their own behaviour and the clinical environment can impact on reinforcement of unhelpful responses.
TRUE
Is the “all in the mind” approach to pain helpful ? Why ?
NOT HELPFUL
Patients need help understanding what role pain management plays in chronic pain.
