Pain: Psychological Correlates 3
By Dr.Thilini Rajapakse, Dr. Dilani Wijeratne
and Dr. Ranjith Pallegama
Psychosocial Aspects of Chronic Pain
The association of psychosocial issues
Involvement of psychosocial conditions with chronic pain can be viewed mainly from three aspects as briefly mentioned in the previous section. In patients who are suffering from chronic pain conditions with an organic cause of pain, there can be a considerable amount of psychosocial modulation such as attention seeking, anticipation, mood changes, anxiety and catastrophizing. This explains why certain patients with trigeminal neuralgia (TN) report a cure or an episode of no-pain even after an irrelevant treatment procedure such as extraction of a tooth close to the site of pain. In this case patients presume and expect that the extraction will cure the condition. The modulation through this expectation will alleviate symptoms for a while and known as the “expectation-induced placebo effect”, but, inevitably the symptoms will recur after a short lapse as root cause of the pain condition has not been eliminated. In the current literature, pain related catastrophizing, i.e., extreme negative appraisal of pain, has been identified as a major risk factor for chronic pain and thought to account for 7% to 31% of variation in pain experience. Investigations point to the fact that pain related catastrophizing appears to amplify CNS processing of noxious input. Pain-related fear is one of the most potent predictors of observable performance in chronic pain patients and is highly correlated to self-reported disability levels. It is reported that fear of pain is more disabling than the pain itself.
There can also be psychological reactions to chronic pain conditions with an underlying organic cause. Frustration, suffering and eventually development of more serious states such as depression are considered as such psychological reactions. But rarely, in some patients, chronic pain conditions with psychological origin (psychogenic pain) can be found. In the ‘classification of chronic pain’ published by International Association for the Study of Pain, different types of pain conditions of purely psychological origin are described. But it is important to remember that prevalence of these conditions is very low and hence, careful examination and exclusion of all above conditions are necessary before confirming that a particular patient has a psychogenic pain condition.
Multidimensional assessment of chronic pain conditions: case formulation
In multidisciplinary pain management, multidimensional perspective should be the guiding principle in assessment of chronic pain conditions. Initial assessment should identify the main presenting problem and the factors contributing in physiological, demographic, social or environmental, psychological domains. The assessment should include, pain quality, mood (especially anxiety and depression), interference in daily activities due to pain (disability), pain behaviors (limping, etc.), cognition and beliefs (e.g., locus of control, acceptance of pain, catastrophizing, belief about the link between pain and injury), use of pain coping strategies (avoidance, taking drugs, resting etc.) and pain severity assessed on pictorial, numerical or visual analogue scale. Psychometric tools such as Multi-Dimensional Pain Inventory (MPI), Medical Outcome Study (36 items short health survey) (SF-36), McGill Pain Questionnaire as general measures and Pain Catastrophizing Scale (PCS), State Trait and Anxiety Inventory (STAI), and Hospital Anxiety and Depression Scale (HADS) as specific measures can also be used.
In the ‘case formulation’, which is much more than diagnosis, the other contributing factors to the patients’ condition is identified. These identified factors will be targets for intervention in the management process. For example, a patient with TN will be discriminated from a patient with TN and higher degree of catastrophizing and then approach for management should be planned in a multidisciplinary basis.
Psychosocial approaches to pain management
In addition to the conventional treatment modalities in chronic pain management, multidisciplinary customized self-management programs should be introduced based on the case formulation. These may include procedures such as cognitive behavioral management programs alongside the medical treatments, reassurance -verbal /feedback, education and graded physical activity combined with physiotherapy. Currently used psychosocial approaches in chronic pain managements include:
Cognitive Behavioral Therapy
Emotional Disclosure Interventions
Hypnosis Acceptance Based Treatments
Partner Based Treatments
The role of family and the society is highly significant and cannot be ignored in managing patients with chronic pain. Especially the role that should be played by a “significant other” (e.g., a partner or any other close person to the patient whose care, attention and relationship is significant to the patient) is placed at a very high level by modern research for the success in managing chronic pain patients. For example, partner assisted coping skills can be mentioned. Further, the potential role of the entire family and society such as the environment of the working place are considered of paramount importance in managing chronic pain patients. Many familial and social factors, such as conflicts and financial constraints, have been identified to predispose, exacerbate and maintain chronic pain conditions. Readers are referred to more advance text for further details on these techniques.
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