pph Pain 2013 (1)

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Psychological factors in Pain

Dr Sinead O’[email protected]

mailto:[email protected]

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Learning outcomes

To develop an understanding of the components of psychological care that can be integrated with physical care.

To develop an understanding of the role of psychology in understanding pain

Introduction

The role of psychology in understanding pain

Theoretical perspectivesPsychological processes

involved in painTen guiding principles

relating psychological factors to the management of pain

Measuring pain – optional

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Role of Psychology

The experience of pain is shaped by a host of psychological factors

These factors are not completely understood

The translation of their use in clinical work remains a challenge

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Early pain theories

Early models of pain described pain within a biomedical framework as an automatic response to an external factor Descartes – direct

pathway Von Frey (1895) -

Specificity theory Goldschneider (1920)-

Pattern theory

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Gate control theory of pain

Introduced a role for psychology and described a multidimensional process rather than a simple linear process

Evidence illustrating the mechanisms to increase and decrease pain

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Gate control theory Melzack & Wall

Gate functioning is based in part on descending influences from the brain

1. Cognitive processes

2. Affective processes

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Psychological effects on & of Pain

Emotions

Cognition Behaviour

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Summary of Psychological Processes involved in Pain Linton S J , and Shaw W S PHYS THER 2011;91:700-711

Dr Barbara Coughlan, UCD School of Nursing, Midwifery and Health Sytems

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Helping people cope with pain

The first line of treatment for acute pain is generally some form of pharmacological treatment.

Psychological interventions generally form a second level intervention in the management of acute pain-i.e.... have high levels of anxiety or have incomplete pain relief.

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Guiding Principle Clinical Implication

1. Psychological factors that may affect pain outcomes are not routinely assessed by many treating clinicians

Better methods of screening and early intervention are needed to improve feasibility and utility in usual care settings

Ten Guiding Principles Relating Psychological Factors to the Management of Pain - Assessment

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2. Persistent pain naturally leads to emotional and behavioural consequences for the majority of individuals

Psychological concepts of learning can be useful to provide empathy and support without reinforcing pain behaviour


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3. Clients who are depressed or have a history of depression may have more difficulty dealing with pain

A brief assessment of mood symptoms should be part of routine screening and intake procedures for pain conditions


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4. Persistent pain problems can lead to hypervigilance and avoidance, but simple distraction techniques are not enough to counter these behaviours

Clinicians should avoid inadvertent messages that escape or avoidance from pain is necessary in order to preserve function

Ten Guiding Principles Relating Psychological Factors to the Management of Pain – Treatment Planning

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5. Individuals hold very different attitudes and beliefs about the origins of pain, the seriousness of pain, and how to react to pain

Assessment and treatment planning should take into account individual differences in pain beliefs and attitude


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6. Personal expectations about the course of pain recovery and treatment benefits are associated with pain outcome

Providing realistic expectations (positive, but frank and not overly reassuring) may be a very important aspect of treatment


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7. Catastrophic thinking about pain is an important marker for the development of long-term problems as well as for poor treatment outcomes

Clinicians should listen for expressions of catastrophic thoughts and offer less exaggerated beliefs as an alternative. A brief assessment might be part of routine intake procedures


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8. Personal acceptance and commitment to self- manage pain problems are associated with better pain outcomes

Over-attention to diagnostic details and biomedical explanations may reinforce futile searches for cure and delay pain self management

Ten Guiding Principles Relating Psychological Factors to the Management of Pain – Treatment implementation

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9. Psychosocial aspects of the workplace may represent barriers for returning to work while pain problems linger

Return-to-work planning should include attention to aspects of organizational support, job stress, and workplace communication


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10. With proper instruction and support, psychological interventions can improve pain management outcomes

Psychological approaches can be incorporated into conventional treatment methods but require special training and support


Measuring Pain22

Pain is very difficult to measure due to its’ multifaceted nature. When measuring pain we need to consider the following Can we objectively

measure tissue damage? Can do two people with the

same injury have different experiences of pain?

Multiple words used to describe the experience of pain e.g. throbbing, stinging, dragging, crushing, radiating….

Health related quality of life measures: include measures of pain


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Short Form-36 Health Survey (SF-36) (Jenkinson & Coulter, 1993).

The SF-36 is a generic, self-completion health status questionnaire with eight distinct dimensions accessing most of the important dimensions of health status including bodily pain. The bodily pain scale has a range of 0 (poor health) to 100 (good health).

The McQill Pain Questionnaire (MPQ)(Melzack, 1975)


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MPQ is one of the most frequently used questionnaires- draws on the fact that we use words to describe pain.

It taps into 3 different aspects of pain by using three dimensions Sensory (e.g. flickering, pulsing, beating) Affective (e.g. punishing, cruel, killing) Evaluative (e.g. annoying, miserable, intense)

Modified Edmonton Symptom Assessment Scale (ESAS) (Bruera et

al. 1991)

Please circle the number that best describes (Patient has to rate the overall severity of symptoms over the last 24 hours)

No pain 0 1 2 3 4 5 6 7 8 9 10 Worst pain

Very satisfied 0 1 2 3 4 5 6 7 8 9 10 Not satisfied

with pain relief with pain relief


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Questions to consider?

How do we measure pain if patient cannot comprehend the question? Young child Patient with dementia Patient Unconscious Patient does not speak English and there is no

interpreter available


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FLACC Scale (0= relaxed & comfortable, 1-3 = mild discomfort, 4-6 moderate pain, 7-10 severe pain

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Psychological Indicators of a poor prognosis

Pain catastrophising

Fear avoidance

Poor expectations for recovery

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Questions or comments

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Breitbart, W. S. Park, J. Katz, A.M. (2010) Pain. In Holland, J. Et al Psycho-Oncology Oxford University Press

Jarrett, C. (2011) Ouch! The different ways people experience pain. The Psychologist 24 (6) 416-420

Linton, S.J., Shaw, W.S (2011) Impact of Psychological Factors in the Experience of Pain Physical Therapy 91 (5) 700-711

http://www.iasp-pain.orghttp://www.ampainsoc.orghttp://pediatric-pain.ca

http://www.iasp-pain.org/

http://www.ampainsoc.org/

http://pediatric-pain.ca/


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Resource text bookMorrison V. & Bennett P. (2006). An Introduction to health

Psychology. Pearson: England (Chapter 16 ) Ogden J. (2007) Health Psychology a Textbook 4th Edition.

Open University Press: England (Chapter 12). Breitbart, W. S. Park, J. Katz, A.M. (2010) Pain. In Holland, J. Et al Psycho-Oncology Oxford University Press

Jarrett, C. (2011) Ouch! The different ways people experience pain. The Psychologist 24 (6) 416-420

Linton, S.J., Shaw, W.S (2011) Impact of Psychological Factors in the Experience of Pain Physical Therapy 91 (5) 700-711

http://www.iasp-pain.org http://www.ampainsoc.org http://pediatric-pain.ca

http://www.iasp-pain.org/

http://www.ampainsoc.org/

http://pediatric-pain.ca/

Resources and references

Bowling, A. (2001) Measuring Disease: A Review of Disease-Specific Quality of Life Measurement Scales, Second Edition. Buckingham: Open University Press.

Bowling, A. (2005) Measuring Health: A review of quality of life measurement scales, Third Edition. Maidenhead: Open University Press.

Eccleston C. (2001) Role of Psychology in pain management. British Journal of Anaesthesia. 87 (1): 144-52

Melzack, R (1975) The McGill Pain Questionnaire: major properties and scoring methods. Pain, 1: 277- 299.

Melzack, R. (1987) The short form Mc Gill Pain Questionnaire, Pain (30): 191-197.

Melzack, R (2005) The Mc Gill Pain Questionnaire – from description to measurement, Anaesthesiology. (103): 199.

Melzack, R. and J. Katz (2001) The McGill Pain Questionnaire: Appraisal and current status, pp 15-34 in D.C. Turk and R. Melzack (eds) Handbook of Pain Measurement, Second Edition. New York: Guilford Press.


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pph Pain 2013 (1)

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