|Year : 2008 | Volume
| Issue : 6 | Page : 777
Psychosocial Aspects of Pain Management
Professor, Dept.of Anesthesiology, Christian Medical College Hospital, Vellore-632004, India
|Date of Acceptance||20-Sep-2008|
|Date of Web Publication||19-Mar-2010|
Dept.of Anesthesiology, Christian Medical College Hospital, Vellore-632004, Tamil Nadu,
Source of Support: None, Conflict of Interest: None
Pain and psychological disorders with associated disability still remains a major issue in management of chronic pain. The subjective nature and reliance on self-report makes pain the most challenging of all symptoms to treat. Mental and physical functions are not separate from each other, they are interrelated - the 'mind-body' concept. Pain causes significant suffering and distress, is feared by patients, is often poorly understood, and hence poorly managed by clinicians. Philosophy of mind deals with mentality and its properties and understanding this is important not only for the pain relievers but for all those interested in understanding pain. This article is a brief review on what we know regarding these so far, the social and psychological implications and their impact on adult pain management.
Keywords: Acute pain, Chronic pain, Interventional pain management, Psychology and pain, Philosophy of mind, Pain and Hurt, Social factors in pain.
|How to cite this article:|
Korula M. Psychosocial Aspects of Pain Management. Indian J Anaesth 2008;52:777
| Introduction|| |
Rene Descartes (1664) described human pain as 'Fast moving particles of fire ... the disturbance passes along the nerve filament until it reaches the brain  . Is that why 'more or less' similar patients with 'more or less' similar diagnoses, given 'more or less' similar treatments, manifest different effects? To understand this, we need to know not only the pathophysiology of pain but also the philosophy of the mind. This comprises epistemology (the way we explain things), ontology (the way we think the world is), phenomenology (the way we think we experience things). And these are all intricately linked  . That is why despite all the advancements in medicine and technology, we still cannot explain fully "Why pain hurts!"
As early as in 400 - 300 BC, Hippocrates suggested that mind could influence body  . With the Renaissance period, this theory was regarded unscientific. In the 1980's and 1990's, the mind/body relationship was reestablished and now many adopt the other extreme approaches of psychosocial, psychological or functional to the extent of leaving the 'bio' part out from the biopsychosocial approach  .
In the early days, pain treatment focused on specific anatomy, physiology and neurochemistry to alter nociception. We have now come to recognize that biological, psychological, social and emotional factors interact with health and illness to contribute to the experience of pain. We have enough evidence that multimodal interventions including cognitive-behavioral therapy is not only beneficial but also cost-effective in long-term management of pain ,.
According to Descartes, human body is composed of two irreducible entities, mind and body and there cannot be a difference in one without a corresponding difference in the other - 'pahysicalism / materialism'  . Consciousness is the main feature of mentality and without this we cannot experience the world as we do. Pain perception cannot be explained by changes in brain alone because brain matter changes in accordance with the intentional consequences of these sensory perceptions. The most difficult challenge is to explain this conscious and individual experience which is 'the hurt of pain' , .
We have many definitions for human pain ,,, . We all now tend to agree with McCaffrey that "pain is whatever the patient defines it to be at whatever moment in time".
| Psychological effects of Pain|| |
Acute pain is almost always a warning mechanism for avoidal  . This response is sometimes also the cause for continuing pain and disability. It's a vicious cycle of loss of fitness, confidence& increasing disability as seen in chronic musculoskeletal pain and 'complex regional pain syndrome'.
The fact that chronic pain patients present with a wide range of associated emotions and manifest various levels of psychosocial distress is well recognized and sometimes over emphasized. Many of these patients are diagnosed with reactive disorders including depression, anxiety, somatisation, personality disorders and other non-specific issues like emotion, anger and loss of self-esteem  . Even though well recognized, they are still poorly understood. Psychological issues can influence diagnosis, prognosis and outcome. So psychological abnormalities, diagnosis and management has become an integral part especially in interventional pain management. But these should not be confused with psychogenic pain  .
Atkinson et al, and Asmundson et al have shown 31% - 50% chronic pain patients had associated anxiety disorder and phobic disorders ,. Fishbain, Van Korff and Simon, Rush et al have studied the influence of depression on pain and have reported that if pain is alleviated, the depression also improves , . Pennix et al, Rush et al, have also found association between degree of physical activity and presence or absence of depression , . Flor et al postulated that patients with depression associated with poor coping resources are at an increased risk of developing excessive muscle tension responses to pain  . Depressed patients showed high levels of bilateral trapezius muscle tension when exposed to stressors. Manchikanti et al, have claimed that for chronic low back, pain and depression may precede or follow onset of pain  . Whether their occurence is casual, coincidental, mutually exacerbating or synergistic is not clear. The risk for major depression seems higher with chronic pain than with other medical conditions. Waddel et al have reported that patients with low back pain who show expressive distress tend to receive more treatment interventions but with lesser success rates  . Breslau& Davis have shown that 20 - 30% patients suffering from migraine have major depression or have increased risk of major depression and vice versa too  .
Stress is commonly seen in chronic pain patients as in war victims or motor vehicle injuries or childhood abuse. Patients react to stress in different ways like anxiety, depression and anger. Distress is the abnormal stress response  . Three types of stress history include physical or sexual abuse and post-traumatic stress syndrome  . Depression is the most common disorder, followed by general anxiety disorder, somatisation disorder and drug dependence. Psychogenic pain seems to the least prevalent of all these. The autonomic arousal created by post-traumatic stress disorder (PTSD) have shown to influence physical symptoms and pain. However reduction in PTSD or other stress did not always result in pain reduction. Alterations in brain functions and neurochemical activity in pain patients with PTSD have been demonstrated ,. Chronic pain patients tend to demonstrate a cluster of symptoms that may be actually 'low grade PTSD'.
Depressive disorders are commonly associated with chronic pain. Reactive form of depression is when the patient experiences poor sleep and concentration and lack of enjoyment along with chronic pain. Many people believe chronic pain as a form of marked depression. Patients with multiple pain complaints are more likely to be depressed. Major depression is characterized by change in weight, sleep disturbances, psychomotor agitation, fatigue, guilty rumminations, difficulty in thinking or concentrating or recurrent thoughts of death or suicide .
Anxiety and worry often accompany pain but this is not synonymous with general anxiety disorder. Panic disorder is most commonly associated with headaches, chest pain and abdominal pain. Anxiety symptoms are feeling-tense, wound-up or on edge. Physical signs include tachycardia, sweating, dry mouth& tremor, difficulty in concentration, anger etc. but may not amount to anxiety neurosis or hypochondriasis  . Many patients become distressed about seeing doctors and are angry and frustrated when told their pain is imaginary or 'in their heads', leading to non-compliance.
Somatization is different from Somatization disorder (Briquettes syndrome), a more complex and controversial psychiatric diagnosis  . Lipowski defined it as 'tendency to experience and communicate somatic distress and symptoms unaccounted by pathological findings, to attribute them to physical illness and seek medical care for them'  . This is often seen with fibromyalgia and myofascial pain syndromes. Somatization can also be a process within the pain disorder itself. The tendency begins in childhood and presents as chronic pain, irritable bowel syndrome, worry or chronic migraine. It can be associated with physical diseases especially chronic pain. About 60 - 80% of physically healthy people experience somatic symptoms in a week  . They have higher risk of iatrogenic complications, hence limiting investigations and treatment in these patients may avoid unnecessary interventions and decrease side-effects.
Patients may report somatic symptoms over psychological concerns as the care-givers respond more sympathetically to physical rather than psychological distress and insurance companies also encourage this. So there are concerns as to whether there is a relationship between somatization, secondary gain and pain  . Manchikanti et al found no somatic form disorder in non pain patients and was lesser seen in patients presenting for surgery than for interventional pain therapies. 'Conversion symptoms' have been described with CRPS. Increased bodily awareness is another emotional state .Main's Modified Somatic Perception Questionnaire (MSPQ) is used to assess somatisation along with increased sympathetic activity. 
Personality disorders play an important role in the development and maintenance of chronic pain conditions - 'the pain-prone personality ,, . They interact with biological factors to bring about responses to pain. It is important to differentiate between personality traits and disorders. Influence of personality especially on chronic pain and misconceptions have been widely studied but no one single personality disorder has been proven to the associated with chronic pain. A genetic or familial predisposition to chronic pain has also been implicated  .
Drug dependence, substance abuse, overuse of controlled substances, alcohol abuse are common problems in chronic pain management especially in interventional pain management. Many pain therapists believe opioid analgesics can be the cause of psychological distress, impaired outcome, cognition& poor outcome ,
The very existence of psychogenic pain is disregarded by many pain therapists. It implies pain is unreal or illusional  . Even with modern technology including MRI, we can arrive at a diagnosis only in 15% patients. With the development of minimally invasive interventional technology, an organic cause can be found in about 75% patients. Besides, psychogenic pain will also not yield any compensatory benefits. And this should not be confused with malingering. Kolodny has shown an incidence of 1 in 3000 patients, with physical diagnosis found in 98% of patients labelled psychosomatic  . It must be remembered that neurophysiological studies will not diagnose 85% patients with spinal pain& nearly 100% with sacro-iliac joint pain.
| Psychological aspects of Interventional Pain Therapy|| |
Interventional pain management has developed dramatically thanks to technology. But just because it is freely available doesn't necessarily mean it should be used on all patients. The implication for performing unnecessary surgery or interventions without considering the psychosocial variables should be condemned. They are sometimes considered 'nuisance variables' but as Doleys quotes 'if one were on the other end of the needle, how much importance would you want to give these factors?'  .
Discography and Implantable therapies are common procedures performed by interventionalists. The identification of a 'positive disc' will support the need for other interventional therapies or spine surgery. In one study , those who had no back pain before discography complained of back pain after for even upto one year, so a positive discogram should not be the sole indication for intervention either.
As Michael Cousins puts it 'block-shops' are on the increase  . In interventional therapy like spinal cord stimulation, additional procedures often depend on the patient's report of the effect of previous intervention. It was seen that a variable number of patients recalled different pain levels than reported immediately after the intervention when asked again. Psychological clearance for these procedures should be well-defined.
The 'placebo effect' has also been a controversial issue. There are enough and more studies to prove this effect exists and not , . One should be careful using an acute treatment to predict longterm outcome of a chronic problem. This is especially true of CRPS where psychological distress can co-exist and it is not clear whether this is the cause or consequence of the disorder. These variables can be confounding factors and make interpretation difficult. Differential spinal blocks (DSB) have been used to establish diagnosis of pain of different etiology including 'psychogenic, sympathetic, somatic and central'. There is concern whether hysterical patients are more likely to respond with reports of pain relief to one aspect compared to the others ,.
| Social aspects of pain|| |
Pain patients can be angry, mistrustful, depressed and difficult to treat making clinicians also react with negative emotions like dislike, resentment and frustration especially when treatment doesn't bring the desired responses and this prevents effective dialogue and mistrust between patient and the doctor. Social impact of pain may be described in terms of interruption, interference, and identity , It is important to look for these behavioral mechanisms as treatment can be focussed on each of these [Table 1] .
These processes - interruption, interference and identity will vary across people and the duration of pain. Acute clinical pain will have both interruptive and interference effects of a temporary nature, but it is unlikely to have any impact on a person's identity. Chronic persistent pain or frequent recurrent episodic pain, such as headache, may have profound effects on a person's life. The repeated interference with tasks that are essential to achieve life's various goals and maintain a person's status in society will have an impact on their sense of self or identity .
Attention is a fundamental psychological process that ensures the smooth flow of behaviour. Painful stimuli have immense capacity to capture attention and interrupt ongoing cognitive and behavioral activity. The brief emotional consequences of this are seen in increased ratings of negative mood, particularly frustration  , pain-related fear  , catastrophizing  and health-related anxiety  , which enhance the interruptive consequences of painful stimuli. Chronic pain patients often complain of memory deficits. Griasart and colleagues have shown that pain interrupts memory tasks that require attention while memory that requires automaticity is unaffected by pain .
Interference is most likely when pain becomes chronic and patients have to adjust living with it. If pain is interpreted as a signal of impending harm and danger, the person will tend to avoid engaging in those activities out of fear. Persistent avoidance of activities will eventually lead to disuse and disability
Impact of chronic pain on a person's humanity and sense of self (identity) has long been represented in art and literature.  Thus a younger patient may report that he feels and acts older, the result being a feeling of entrapment by the pain - "the trapped self.". In presence of solicitous partners, patients are known to 'under perform' on behavioural tasks. Similarly, it is argued that expressions of pain are reinforced by a solicitous partner, and this is reflected as increased level of pain in their presence  .
Chronic pain patients may take great pains to avoid displaying pain behaviour in an attempt to appear normal to others and to preserve their own sense of efficacy and social competence. Within the family and close social groups, the need to avoid being seen as a burden appears to be a strong motivation for concealment .
Self-discrepancy theory (SDT) considers three aspects of the self: the actual-self (what I am now), ideal-self (what I would like to be), and ought-self (what I think I ought to be). Acceptance and commitment therapy (ACT) aims to help patients learn new ways to live with pain.  . The term acceptance can be misleading: it does not mean 'putting up with it'. ACT 'focuses on acceptance of thoughts and feelings that have been unhelpful in the past.'  . Acceptance aims to help the sufferer disengage from old, ineffective ways of solving the problem of pain and to begin to accept and live a near full life with the continued presence of pain.
Pain can occur in psychiatric patients just as in the general public. In the older age groups, possibility of dementia and in all groups, substance abuse and alcohol abuse should be considered. Dualistic thinking is dangerous as it has the double hazard of dismissing a patient as crazy or hypochondriac on one hand while clinicians try out all sorts of treatment on them from cutting to overdrugging them.  Past painful experiences could sensitise the individual to later pain problems. Guilt, life's short-comings, sexual abuse are some psychosocial precursors of pain .
| Sex, gender and pain|| |
Women are known to be more sensitive to a pain stimulus compared to men  , probably because of hormonal fluctuations, differences in body size, skin thickness, blood pressure, social expectations, cognitive stimulation, method of stimulation and differences in psychological traits like anxiety and depression. Moulton and colleagues have recently shown by functional imaging a reduced activation in primary sensory cortex, anterior cingulate and prefrontal cortices in females when noxious heat was applied  which was the opposite of the previous studies done by Paulson& Colleagues  .
Descartes explains 'perception is neither an act of vision, nor touch but only an intution of mind'. Rather than reflexly respond to physical information, our experiences can be expressed according to our judgment  . Alterations in the descending inhibitory- pathways may be one cause for this gender difference, the genital organ differences, variations in sex hormones and the cyclical variations may all contribute.
Animal studies have shown greater analgesia with opioids in the male rats compared to female rats. Estrogen may be a factor for this response  . Women are known to respond to kappa-agonist pentazocine more than men  . There seems a link with endogenous opioid activity also. Also different neuronal organization and opioid receptor density might account for the different responses  .Cultural differences& difference in social roles of men& women also matter. One explanation can be when women feel overwhelmed by their commitments, they are at a risk from depression and mood changes that can enhance their somatic experience ,, .
| Effect of pain on survival|| |
We now consider pain more of a disease and not just a symptom and have realized treating pain effectively can prolong life by its therapeutic and palliative benefits. For example, post-operative pain not completely treated, would inhibit the patient from engaging in healing activities such as eating or walking which can hasten death. Untreated pain can take on a life of its own, rewire our neurological system, setting the pain alarm 'stuck in the persistent on position' even when the pain generator is silenced - leading to physically damaging stress and psychologically damaging depression, the negative emotions and intensified pain even causing the patient to end life or hasten unassisted death  . Pain and depressed mood are a dangerous combination and vicious cycle, very often antidepressants working quicker against pain than depression.
Unrelieved pain can intensify CAD, sickle cell disease, cancer which becomes refractory to standard treatments and require more stronger interventions or drugs with more side-effects leading to hastening of death , . The depressed mood affects the immune system, the ability to perform daily activities and this may also impact survival.
Spiegel's study on psychotherapy and survival showed an increase in survival rates. Now support therapy& groups especially for cancer pain has become the norm. However by reducing pain alone may not lead to longer survivals as some pain treatments have adverse effect on survival, however, it would be unethical to withold pain treatment to increase life expectancy  .
| Measurement of pain|| |
Pain can be experienced without any obvious clinical signs. Acute, severe pain may be associated with autonomic changes but as yet there is no reliable way of assessing severity or even presence of pain by physical examination or psycho-physiological measurements. There are no psychological tests to distinguish between psychogenic and somatogenic pain. The tests most helpful may be estimation of degree of anxiety or depression and the tendency to somatize distress. Multifactorial assessments include that modelled by the Westhaven/Harvard instrument or Strong's multi-factorial assessment ,. For day to day clinical work, it may be useful to assess pain 'at present, at worst and least severity' to show whether the pain is continuous or intermittent. Modified Somatic Perception Questionnaire (MSPQ) scores, Zung questionnaires (which measures somatic anxiety and depression) have been used as psychological tests to predict relationship with back pain but are found to be inconclusive , .
A combination of intensity of pain, adjectival description (Mcgill Pain Questionnaire) and body drawings of pain may be most useful for measurement of subjective experience of pain . Interpretations of this may be based on personal philosophies and biases but the fact remains there are no objective evaluations in psychological assessment, they are all subjective.
| Treatment options|| |
The subjective nature and reliance on self-report makes pain the most challenging of all symptoms to treat. Most patients cannot help how they react to pain, illness behaviour is involuntary and out of the conscious control of the patient. We are all familiar with the components of pain processing like transduction, transmission, modulation& perception and the total experience of pain is a product of nociception, perception, suffering& pain behaviour. This involves activity at the peripheral nervous system, spinal cord, spino-thalamic tracts and supraspinal areas. So all these have to be considered when treatment is applied  .
Chronic pain is definitely associated with psychosocial problems as part of the 'chronic pain syndrome'. There is still a lot of controversy as to which of these is the cause and which the effect? Change in relationship within family, doctors, anger, depression, loss of integrity and sense of self can lead to ultimate hopelessness, helplessness and even suicide especially when the family and support systems fail at this stage  . Several studies have shown reversal of these trends when pain is treated adequately. Again it should be remembered that repeated, failed attempts at treatment might be even more detrimental for people with chronic pain, and just drugging the patient with strong opioids can only cause more harm. So treatment should be multidisciplinary with emphasis on pain education, increasing activity, cognitive behavioral techniques and appropriate drugs.
Most emotional and psychological changes occur secondary to physical pain and is wrong to assume that pain is psychological if there are no physical findings. They are two sides of the same coin, it is impossible to divide pain into physical or psychological, organic or non-organic, real or imaginary. Manchikanti found that most ordinary patients with back pain have no personality problems  . They do not have a primary psychiatry problem. Terms like hysteria, hypochondria should be discarded altogether while treating these patients.
Whenever there is a state of clear depression or anxiety, treatment should be directed specifically towards the disorder in addition to treating the pain. However, many patients continue to experience pain despite the resolution of their depression. And many patients have shown improvement in depression with adequate pain relief. This means not all pain patients require anti-depressants nor should have this as sole treatment.
| Behavioral approach to improve compliance and motivaiton|| |
The fundamental aspect of behavioral medicine is accepting the fact that psychological and behavioral factors reciprocally and dynamically interact with physical health. Linear causalty does not exist in this relationship and treating all three by multimodal therapies will improve pain  . One important requirement for successful rehabilitation of chronic pain is that patients adopt an active, participatory role in their treatment. Patients have to modify lifestyles to include various physical activities, though sustaining this seems to be difficult. Compliance is critical for rehabilitation.
Thoughts can elicit or modulate physiological and affective responses which may influence behaviour or vice-versa. Behaviour is reciprocally determined by both the individual and environment. Just as people are themselves responsible for the development of maladaptive feelings or thoughts, they can be active agents who can change these modes of responses and not become totally helpless  . Behavioral medicine assessment should include standardized self-report, impediments and factors that facilitate rehabilitation must also be sought for, like patient's current mental status, mood functions and any maladaptive behavioral patterns  .
Depressed patients have fewer close friends and family or social support which can make them more isolated and depressed. So just like providing family and other supports after surgery, these should be extended to interventional pain procedures too. It is unfair& unwise to refuse interventional procedures for patients with psychosocial disorders, they should be treated like surgical patients  .
The most commonly used approach is cognitive-behavioral therapy - integration of cognitive, affective and behavioral factors into an overall clinical picture. This includes not only actual responses but also learned responses to evoke appropriate reaction to actual or anticipated events. How a person perceives a situation and what they expect from it are thought to be important  .
Cognitive-behavioral therapy -'self-management of pain'
The 3 components are education, behavioral skill training and cognitive skill training. The differences between acute and chronic pain, hurt vs harm concept and expectations, how these interact with pain can help in behavioral skill training phase. Relaxation, controlled breathing exercises are easy to learn and useful to reduce anxiety and stress responses and improve sleep. These are active processes and simple demonstration to patients that behavior can alter their physiological states  .
Attentional training - diverting patient's attention to non-pain stimuli, using mental imageries unrelated to pain are useful but have not proved consistently successful  . Interpersonal stress is a major aggravating factor for their pain. Basic interpersonal skills, training in areas of communication, assertiveness and problem solving skills may help being down stress levels and manage pain .
| Cognitive skills training|| |
Patients learn to identify factors that induce stress and what they actually experience emotionally, behaviorally and physically when they have pain/stress. Self-regulation of pain depends on the patients specific way of dealing with pain, adjusting to pain, reducing or minimising pain through coping strategies, thus being able to enhance his/her control over pain and associated symptoms and engage in everyday activities. Self efficacy beliefs are influenced by past success / failure in managing pain  .
| Motivation enhancement therapy (MET)|| |
strategies help a patient to get more motivated. Empathy, avoiding judgmental attitudes and not pressurizing the patient to change are most important here , . Therapists should help patients become aware of their own tendency for negative cognitive patterns or emotions like polarizing pattern, overgeneralization, catastrophizing, filtering or emotional reasoning pattern and motivate longterm compliance  .
The worst thing about Pain is that 'it hurts' . When one experiences pain, one becomes conscious of it, so the first order thought of pain becomes a higher order state  . Pain in one person to one stimulus cannot be predicted in another. As Peter Staats quotes 'Treating pain requires the pharmacology of an anesthetist, the comparison of a physician, the technical skills of a surgeon, the diagnostic skills of a radiologist / internist, the rehabilitating skills of a psychiatrist and innovation of a scientist  . Pain cannot be separated from the person experiencing it, accepting and believing their pain will atleast bring us closer to them ,, and may be one day, we will be able to explain 'why pain does hurt!' .
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