Psychology of chronic pain Flashcards
What is the definition of Pain?
Pain is an almost universal experience but there is a little consensus on its definitions;
- Pain is a subjective experience - there is no “pan thermometer”
Has multiple characteristics;
- time continuum (acute - brief, subacute - months, chronic - years)
- episodic - i.e recurrent acute pain (e.g migraines)
- unique category - pain associated with malignancies
What is the definition of Acute Pain?
Acute Pain
An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described by the patient in terms of such damage
What is the definition of Chronic Pain?
Chronic Pain
Pain which has persisted beyond normal tissue healing time. Pain longer than normal tissue time, usually longer 3 months
How do you Manage Acute Pain?
Manage Acute Pain;
- Addressing the cause of pain
How do you Manage Chronic Pain?
Manage Chronic Pain;
- Addressing the effects of pain and finding ways to maximise function and quality of life
What is the Burden of Chronic Pain?
Burden of Chronic Pain - Multilevelled
1). Patients with chronic pain;
- Continuing quest for relief -> feelings of helplessness and depression
2). Significant others/family;
- Share frustration of their loved ones -> chronic stress and worry
3). Healthcare providers;
- Share frustration with the patients as their pan reports continue
4). Society;
- Lost productivity and disability benefits
What activities and aspect of life does chronic pain affect?
Less able;
- 56% sleep
- 50% exercise
- 49% lifting
- 42% household chores
- 40% walking
- 34% attending social activities
- 29% working outside home
- 24% maintaining an independent lifestyle
- 24% having sexual relations
- 24% driving
- 22% maintaining relationships with family and friends
No longer able;
- 32% working outside home
- 23% driving
- 23% exercise
- 23% lifting
- 19% having sexual relations
- 14% attending social activities
- 12% household chores
- 9% sleep
- 7% walking
- 6% maintaining an independent lifestyle
- 5% maintaining relationships with family and friends
Further effects;
- 21% are diagnosed with depression
- 19% lost job
- 16% changed job responsibilities
- 13% changed jobs entirely
What are the 3 different theories of chronic pan?
- Gate control theory
- Biopsychosocial
- Cognitive-Behaviooural perspective
What is the Gate Control Theory ?
Gate Control Theory;
- Pain is multidimensional and subjective experience of perception
- Both ascending physiological inputs and descending psychological inputs are involved
- ‘Gating’ mechanisms is the dorsal horn of the spinal cord that ‘opens’ (permits) or ‘closes’ (inhibits) the transmission of pain impulses
- What ‘opens’ the gate? -> e.g inactivity / poor fitness (physical); poor pacing (behavioural); anxiety / depression / hopelessness (emotional) catasrophising, worrying about the pain (cognitive)
- What ‘closes’ the gate? -> e.g appropriate use of medication; massage; heat/cold; positive coping strategies; relaxation; exercise
E.g putting cold on pain uses other pathway to overcome pain
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’
It does not explain why the same event can be interpreted by different people as more or less painful
What is the Biopsychosocial Model?
Biopsychosocial Model;
- Includes cognitive, affective and behavioural components of pain
- Views illness as a dynamic and reciprocal interaction among biological, psychological and sociocultural variables that shape person’s response to pain
- Makes your own unique experience of pain
Biological;
- Genetics
- Neurochemistry
- Physiology
- Tissue damage
Social;
- Identity
- Support network
- Socio-economic
- Pain meaning
- Prior experience & condition
Psychological;
- Anxiety
- Depression
- Self-efficacy
- Beliefs & memories
- Catastrophising
What are the features of “Cognitive-Behavioural Perspective”
Cognitive-Behavioural Perspective;
Pain perception can be influenced by the following;
- Attention
- Self-efficacy
- Patterns of thinking and beliefs
Emphasis on peoples idiosyncratic beliefs, appraisals and coping repertoires, as well as sensory, affective and behavioural contributions, in the formation of pain perceptions
- If a person interprets pain as a significant life threatening illness then they will focus on pain (attention); Catastrophising - These patients are More likely to experience High Pain
- If a person interprets pain as the result of a minor injury then they will focus on other things; Realistic appraisal - These patents are Less likely to experience High Pain
CBT can shift from left person to right to reduce pain
What are the tools involved in the Pain Assessment ?
There are many tools and scales for pain assessments. They can be split into;
1). Pain intensity self-report
- Most commonly used scales for pain assessment
2). Pain intensity by Observational Scales
- Focus on behavioural aspects, e.g facial expressions, guarding and limping important when working with infants, or people with advanced dementia
3). Pain distress
- Pain may vary other time, thus important to access distress in addition to intensity
Other aspects to access: Mood and emotional state; Cognitive processing; Physical function and disability
What are the different Pain Intensity self report methods and brief features?
Verbal rating scale (VRS)
- Rank-ordered set of descriptors (often no pain, mild pain, moderate pain, severe pain, very severe pain)
Numerical rating scal (NRS)
- Numbered scales (usually 0 - 10) with descriptors at each end and presumed ration properties
Visual analogue scale (VAS)
- Line of set length with descriptors at the ends but no intermediate words or markers, on which 3the patient marks pain as a spatial analogue
- Happy face, sad face etc
McGill Pain Questionnaire (MPQ)
- Most widely known
- 78 items in 20 groups: sensory, affective, evaluative dimensions
- Sensory: throbbing, crushing, quivering
- Affective: exhausting, fearful
- Evaluative: annoying, miserable
- Cons - Time confusing for patients and scores (Often asks person to do at home, but can change answers over week etc)
What are the limitations of Self-report measures ?
- They tend to be long measures so limed use during consultation but the patient may be asked to bring it back
- Verbal skills (More so languages and cultural backgrounds as pain in different cultures varies)
- Limited use of psychological scales when it comes to people whose first language s not English, those who come from diverse cultural backgrounds, people with communication difficulties -> visual analogue scale may be more appropriate
- Misrepresentation of pain; exaggeration or downplay of pain
- Chronic pain is difficult to capture using verbal and numerical scales
How should we manage Chronic Pain?
Using Scottish Model !
4 different levels;
Level 1 - Self Management;
- Combination of activity and relaxation, non-opioid painkillers, support from 3rd sector organisations (E.g Pain Association Scotland, Pain Concern)
Level 2 - Primary Care;
- GP, Physiotherapist or Pharmacist provide help through assessing pain, providing advice, medication, exercise programmes, links to self-management, alternative therapies (e.g acupuncture)
Level 3 - Secondary Care;
- Hospital based pain clinics or services
- Have multidisciplinary teams (MDT), which usually includes Consultants trained in chronic pain, Nurses, Physiotherapists, Psychologists, Pharmacists, Occupational Therapists and Psychiatrists
Level 4 - Tertiary Care;
- Highly specialised services - intensive PMP’s are conducted by Scottish National Residential Pan Management Program (SNRPMP) in Glasgow
- Can do very specialised things like kill pain neurons
What does Behavioural management/ Pacing involve ?
Based on principles of operant-behavioural conditioning
- Pacing to break the ‘overacivity-rest’
If person has a good day they wake up feeling good, the chances are they had a list of things in their mind they didn’t do and spend the whole day catching up on things (overactivity), next morning wake up and have bad day extremely tired or in pain, can be weeks of time to get back to good day. Frustration, disappointment, then good day and cycle happens again.
May only have 2 good days in a month
Pacing asks the person to do not do a 10 on that day do a 3 or 4 then chances the next day aren’t fatigues or in pain and can do a 3 or 4 etc then increase after. Might never get to a 10 eventually but chances are can eventually get an average of an 8 or 9
What does CBT aim to do?
CBT / Cognitive Behavioural Therapy aims to alter the intensity, frequency or form of maladaptive or unhelpful thinking styles, emotional responses and coping patterns to improve pain-related functioning
Looks at patents;
- Thoughts (cognitions)
- Emotions
- Behaviours
As psychiatry is limited in NHS his self help things online
