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Psychological Assessment and Management of Chronic Pain
In a recent seminar on chronic pain held in Toronto, Dr. Dennis Turk, a psychologist and well-respected figure in the field of pain, reported that 80-85 percent of chronic pain patients have no identifiable organic pathology that would adequately account for their reported symptoms.
Most of these patients are a puzzle to their medical health providers. Many of them would be erroneously seen as complainers, unmotivated, or, worst still, malingerers. Others would be thought of as having serious psychological problems or poor personality integration. Rarely are psychological factors the cause of their pain.
Pain is a subjectively-experienced event brought about by the dynamic interaction of biological, psychological, and social variables. Since pain is experienced differently by different individuals, it becomes important to assess not only physical causes that might account for its presence, but also personal variables that may contribute to it. This includes cognitive, affective, and behavioural factors which the individual brings into the situation.
Human beings try to make sense of their experiences. They search for information, they generate inferences about personal and environmental events, and they develop schemas around which they organize their experiences. Beliefs about pain and its significance, conceptualizations about its causes, appraisals about one’s ability to manage the discomfort, and errors in processing information (self-defeating styles of thinking) can all affect one’s experience of pain. Chronic pain patients who tend to catastrophize, or who show pessimistic styles of thinking, for instance, are likely to show higher levels of physical and emotional distress than those individuals who show less self-defeating styles of thinking.
The role of thinking processes in one’s experience of pain is further demonstrated by the results of an experiment which showed that the EMG recordings of back muscles in chronic low back pain sufferers showed elevated recordings when subjects thought of their pain; such elevations being greater than those produced by laboratory-induced stressful situations. It is well-recognized that, with the failure of medical/physical intervention to relieve pain and associated limitations following an injury, pain sufferers can become anxious, or worried about their pain, and that, with continued suffering, they may well develop a sense of helplessness and become depressed.
Sympathetic nervous system arousal associated with high levels of anxiety leads to increased muscle tension, and, thus, to an increase in discomfort, through a paintension-pain cycle. It is likely also to lead to disrupted sleep, and, thus, to a disruption in restorative mechanisms which may then make a chronic pain sufferer’s day much more challenging. Chronic pain sufferers who are also clinically depressed tend to report higher levels of pain intensity and higher interference with life activities and life satisfaction as a result of pain, relative to those sufferers who are not depressed. When one considers that about 40-60% of participants in chronic pain management programmes are depressed, one can further appreciate the challenges faced by chronic pain sufferers in the management of their discomfort.
From a behavioural standpoint, psychologists assess the presence of pain behaviours and of passive or avoidance strategies associated with pain. Operant conditioning models suggest that pain behaviours can be reinforced by the social environment and are, thus, more likely to recur. They are also more likely to recur if they lead to the avoidance or elimination of some aversive circumstance in the life of the patient. Pain behaviours can result in a variety of consequences. They can lead to an increase in attention or sympathy from others, but they can also lead to others moving away from the sufferer.
It is not uncommon for chronic pain sufferers to develop avoidance strategies in managing their pain. They do so, in part, to avoid an increase in discomfort. They may also do so for fear that an increase in pain is an indication that they are causing more harm to their body. While passive or avoidance strategies are appropriate in the management of acute pain, they become counterproductive in the management of chronic pain, since they lead to physical de-conditioning, and thus facilitate the perpetuation of pain.
Cognitive-behavioural therapy (CBT), based on the assumption that if chronic pain sufferers can develop appropriate coping strategies they can alter their experience of pain, has assumed a prominent role in the management of chronic pain. CBT focuses on the physical sensations of pain, as well as on the cognitive, affective, and behavioural factors that may maintain or affect its presence. It assists sufferers in the development of strategies that facilitate more of a sense of control over their experience and lower their sense of helplessness and general emotional distress. Included in cognitive-behavioural pain management programmes are:
- education on the dynamic interaction among physical, cognitive, affective, and behavioural variables • the teaching of specific strategies with which to monitor and modify one’s physical and emotional distress
- relaxation training components that allow individuals to gain a sense of awareness over physiological states and to achieve a sense of physical and mental relaxation • cognitive restructuring approaches that facilitate the elimination of self-defeating patterns of thinking and the development of more adaptive ones
- anxiety and depression management techniques focus on pain behaviour
- self-monitoring and pacing components • structured daily plans to ensure the presence of pleasant experiences during the day
- assertion training to facilitate productive interaction with treatment personnel and with significant others
Psychological therapy-based programmes of this nature are not suited to those individuals whose goal is the elimination of pain, but they can be quite helpful to those who have reached the point of having to learn to manage their discomfort and to live productive and rewarding lives in spite of the presence of pain.
Caudill,M.A. Managing Pain Before it Manages You. New York: The Guilford Press, 1995.
Gatchel, R.J. and Turk, D.C. Psychological Approaches To Pain Management: A Practitioner’s Handbook. New York: The Guilford Press, 1996. International Association for the Study of Pain www.iasp-pain.org