"Pain and Suffering”

Recent Advances in Research and Therapy

the K.U.Leuven Center of Excellence ‘Generalization Research

in Ill health and Psychopathology’ (GRIPP*TT)

Pain and suffering: recent

advances in research and therapy

Geert Crombez

Imagine Georges, 47 yrs old, happily married

and three children… He suffers from chronic

severe back pain.….He is on longterm

sickleave… Medical specialists found

nothing “seriously wrong” in his back. He is

however not convinced... He is afraid that his

back problem will worsen, and avoids back

straining activities. He tried several

treatments, but none completely succesful….

What now? As times passes, he starts to

worry about his future. He had a great job, he

was social and sportive, and loved to travel

with wife and children. All have become

impossible because of his pain. He feels

stuck, and uncertain about the future….

However, he won’t give up…

A clinical case

Overview

1. Setting the stage

• Some epidemiological data

• A short history of key constructs

2. Pain and suffering: a multilayered analysis

Pain

Pain-related

fear

Suffering

• Pain: signal of bodily threat

• Pain-related fear: learning

about pain

• Suffering: a threat to identity

Top 10 of most prevalent chronic health problems

Males

(all age groups)

Females

(all age groups)

Back problems 15% Back problems 19%

Allergy 12% Arthrosis 17%

High blood pressure 11% Allergy 14%

Arthrosis 9% High blood pressure 14%

Neck problems 7% Neck problems 12%

Permanently injured by

accident

6% Severe headache 12%

Severe headache 4% Rheumatoid arthritis 8%

Rheumatoid arthritis 4% Depression 6%

Astma 4% Osteoporosis 6%

Chronic pulmonary problems 4% Thyroid gland problems 6%

(Health Interview Survey in Belgium, 2008)

(Health Interview Survey in Belgium, 1997, 2008)

7 days 4 weeks 7 weeks 12 weeks

80%

26%

17%13% 8%

6 months

Based on Spitzer et al. (1987)

Costs

Natural history of non-specific back

problems

Pain DisabilityTissue

Damage

A specificity model of pain

Natural history of back pain

pain after one year in patients with recent onset pain

(Von Korff et al., 1992, 1993)

%

Tissue

Damage Pain

Disability

(Gordon Waddell, 1993)

-

The Gate Control Theory

(Melzack & Wall,1965)

Thermal grill illusion

• Grill with only warm bars (40°C)

• Grill with only cold bars (20°C)

• Grill interlaced with warm and

cold bars

(Thunberg, 1896; Craig & Bushnell, 1994)

Warmth

Coolness

Burning pain

IASP, Subcommittee on pain terms, 1986

Definition of pain

An unpleasant sensory and emotional experience

associated with actual or potential tissue damage,

or described in terms of such damage

Tissue

Damage Pain

Disability

Operant view on pain behavior

• “Pain behavior” instead of “pain” should be the focus of management of chronic pain

• Assumption– Biomedical findings do not eliminate the possibility that psychological

or social factors contribute to the level of pain disability.

– The factors that maintain the pain problem can be different from those that initiated it.

• Application of operant learning principles to problemsof chronic pain– Positive and negative reinforcement of pain behavior

– Avoidance behavior

– Graded activity: reinforcment of well behaviour

(Fordyce ,1976)

“Pain is to disability

as spaghetti to a

brick”

(Fordyce, 1998)

Biopsychosocial perspective

Pain DisabilityTissue

Damage

Disuse

Catastrophizing

Jobsatisfaction

Coping

Socioeconomic status

Central sensitisation

Social Support

Doctor

Shopping

Genetics

Stress

AvoidanceDepression

Pain and suffering: a multilayered

analysis

1. Pain: signal of bodily threat

2. Pain-related fear: learning

about pain

3. Suffering: a threat to identity

Pain

Pain-related

fear

Suffering

• Pain interrupts behaviour,

captures attention & urges escape

• Affective-motivational and not

perceptual characteristics

• Attention to pain is result of

• pain-related characteristics

• other environmental demands

(Eccleston & Crombez, 1999; Crombez, 2006;

Van Damme et al., 2010; Legrain et al., 2009, 2011)

Ss are instructed to ignore pain to complete

an attentionally demanding task. Retardation

and error in task performance are used as

measures of attentional interference by pain.

Primary task paradigm

(Crombez et al., 1994; Eccleston et al., 1994)

(Eccleston, 1995)

Intense chronic pain demands

attention

Thre

High pitch tone

Low pitch tone

(Crombez et al., 1998)

ms

Catastrophizing about pain: students

Summary of findings

(Van Damme et al., 2010; Legrain et. al., 2011; Moriarty et al., 2011)

• Factors amplifying interruption by pain• Pain intensity

• Abrupt onset

• Unpredictability

• Threat value of pain

• Pain catastrophizing

• Pain related fear

• Brain structures involved• Largely multimodal system

Insula, ACC, MCC, (amgydala)

• Saliency (threat) detection system

• Urges action (Moureaux et al., in press)

Clinical implications: a cognitive analysis

• Cognitive control over pain

• Directing attention away from pain is part of many cognitive-

behavioural programs

(Turk & Meichenbaum, 1989; Morley et al., 2004)

• Distraction works,… but when and how…

• Challenges

• Which characteristics of distraction task?

• Attentional set (Van Ryckeghem et al., in preparation)

• Goal value (Verhoeven et al., 2010)

• Works less when pain is intense, novel and threatening,…

(Heyneman et al., 2000; Hadjistravopoulos et al., 2000; Verhoeven

et al., 2010)

• Does not change threat value of pain

Pain and suffering: a multilayered

analysis

1. Pain: signal of bodily threat

2. Pain-related fear: learning

about pain

3. Suffering: a threat to identity

Pain

Pain-related

fear

Suffering

(Gordon Waddell, 1993)

“Fear of pain is more

disabling than pain

itself”

KINESIOPHOBIA

An excessive, irrational and

debilitating fear of physical

movement and activity

resulting from a feeling of

vulnerability to painful injury or

reinjury

(Kori et al., 1990)

Pain Confrontation

Recovery

Disuse

Disability

Depresssion

No fear

Fear of movement,

pain, (re)injury

Catastrophizing

Hypervigilance

Avoidance

Fear-avoidance & kinesiophobia

Injury

(Vlaeyen et al., 1995;Leeuw et al., 2007)

(Crombez et al., 1998)

* **

Hypervigilance for (signals of) pain

(Crombez et al., 2005)

Avoidance behaviour

(Crombez et al., 1996, 1998, 1999)

(Pfingsten et al. 2001; Trost, 2008, in press )

Movement 1 Movement 2Counterbalanced

AABB or BBAA

(Crombez et al., 2002; Goubert et al., 2002; Trost et al., 2008)

Clinical implications: a learning

psychology perspective

• Exposure is clinical analogue of extinction

– Reluctance to generalise corrective experiences

– Overgeneralisation of negative experiences

• Graded exposure (Vlaeyen et al., 2004)

– Idenfication of fearful situations/movements

– Fear hierarchy

– Gradual exposure to movments

• Disconfirming that back pain=injury

• Exposure works

– Reduces the threat value of pain and disability

Challenges

• Psychopathology vs culturally endorsed beliefs

• “Rational” phobia

• Misconceptions about pain also in painfree

• Misconceptions about pain also in health care providers

• “Recovery” does not mean “pain-free”

• Physical movements may remain painful

• Chronic pain may become a threat to identity

• Pain interferes with valued goals

• Pain causes “biographic rupture”

• Pain causes uncertainty about the future

Pain and suffering: a multilayered

analysis

1. Pain: signal of bodily threat

2. Pain-related fear: learning

about pain

3. Suffering: a threat to identity

Pain

Pain-related

fear

Suffering

Suffering: when chronic pain becomes a

threat to identity

action

change

present

state

present

state

present

state

present

state

anticip.

state anticip.

state anticip.

state

anticip.

state

be a good

father

ideal

selfPlay with son

Pick up

ball

system

conceptprinciple program sequence

"be" goals "do" goals motor control goalsgeneral guidelines

(Carver & Scheier, 1998)

Fear-avoidance model is tip of the

iceberg

Fear-avoidance model better

conceptualized as part of

misdirected coping with

disability & suffering

• Classification of coping strategies• Problem focused vs emotion focused (Lazarus & Folkman, 1984)

• Active vs passive coping (Brown & Nicassio, 1987)

• Assumption• Active & problem focused coping = adaptive

• Passive & emotion focused = maladaptive

• Problems• Descriptive but no functional approach of coping (e.g. medication

use)

• Content overlap between coping items and outcome

• Active & problem focused coping, may become part of the

problem

Coping with adversity

(Brandstadter & Renner, 1991;Skinner et al., 2005)

• Ageing literature

• Quality of life increases despite increase in impairments

• Assimilative coping mode

• Goal pursuit

• Solving the obstacle/problem in order to continue

• Accommodative coping mode

• Goal adjustment

• Adjusting personal preferences/goals to

constraints/limitations

Dual process model of coping

(Brandstadter & Renner, 1991; Brandstädter & Rothermund, 2002)

Misdirected problem solving

• No deficit in general problem solving skills

• Problem definition is wrong, or at least too narrow

• Problem: injury=pain, pain=disability

• Search for solution dominated by a tenacious

search for cure/pain relief• Avoidance behavior & bed rest

• Doctor shopping

• Pain medication (e.g. Medication Overuse Headache)

• Invasive techniques with risk of iatrogenic effects

(e.g. Failed Back Surgery Syndrome)

(Aldrich et al., 2000;Vlieger et al., 2006a; 2006b; Lauwerier et al., in press)

Interference by pain

Problem solving

behaviour

Hypervigilance

Worry

Biomedical

Problem

Frame

Problem Solved

Acute pain

Findings in acute pain

• Try to get rid of pain

• Can not accept that pain is insoluble

• Belief that there is a solution

• Meaningful life despite pain

Problem

unsolved

(Eccleston & Crombez, 2007; Brandstadter & Renner, 1990)

(Jamison, 2011)

Interference by pain

Problem solving

behaviour

Hypervigilance

Worry

Biomedical

Problem

Frame

Chronic painMisdirected

problem-solving

Findings in chronic pain

• Try to get rid of pain =

• Can not accept that pain is insoluble =

• Belief that there is a solution ↓

• Meaningful life despite pain ↓

• Distress ↑

• Worrying ↑

• Hypervigilance ↑

Problem

unsolved Perseverance

loop

Pain catastrophizers persevere in

misdirected problem solving…• Solving pain, r=.37***

• Meaningfulness of life despite pain, r=-.46***

• Acceptance of insolubility of pain, r=-.32***

• Belief in a solution, r=-.11*

• Solving pain is necessary to continue with life goals, r=.40**

at the expense of other valued life goals• There are more important things in life than pain, r=-.44***

• I will only be satisfied when I have no pain, r=.45***

• Reassurance

• Communicating bad/good news

• Cognitive behavioural therapy (Turner et al., 2007)

• Δ pain = disability ↓

• Δ pain = injury ↓

• Δ Catastrophizing ↓

• Goal adjustment and acceptance

• Disengage from struggle against pain

• Adapt goals/aspirations to constraints and limitations

• Reengage in valued goals

• Acceptance and committment therapy (McCracken, 2004)

Clinical implications: A self regulation

perspective

Concluding remarks

• Chronic pain is a prototype of chronic illness

• Disability and suffering <> Disease, Illness

• Model of (dis)ability and suffering

• Health psychology model

• “Individuals in abnormal situations” instead of “abnormal

individuals”

• “Medically explained” and “medically unexplained” complaints

• Challenges

• When does search for cure/control becomes too costly

• How to avoid “medicalisation”, but also “psychologisation”

• How to live with chronic illness in a world of healthy

Thank you for your attention

Liesbet Goubert

Stefaan Van Damme

Tine Vervoort

Valéry Legrain

Lies Notebaert

Marieke Dewitte

Chris Eccleston

Ken Craig

Paul Karoly

Stephen Morley

Charles Spence

Johan Vlaeyen

Katrien VerhoevenEmelien Lauwerier

Annabelle CasierDimitri van Ryckeghem

Line CaesKim Helsen

Lies De RuddereSofie Vandenbroucke

Ilse Viane

Acknowledgements