THE PSYCHOLOGY OF PAIN
Dr. G. Moore-Groarke, Chartered Health Psychologist
Clinical Hypnosis as a Therapeutic Technique
A study of hypnosis in the relief of pain
ICHP Post Graduate Training Programme, P27-37
“Perhaps the most universal form of stress encountered is pain”… Anonymous.
What is the relationship between pain and the mind? What is the difference between the emotional and behavioural responses to pain? How do we measure pain and what is the relationship between stress/tension in our pain intensity ratings? What are the different ways we can think about pain? What is meant by the cognitive behavioural approach to pain management? What does goal setting and pacing mean in relation to pain management?
Pain is a most complex and distressing psychological experience. It is the most common reason people seek medical attention. Chronic pain as you learned in the previous chapter can last for anytime from a year to indefinitely, despite treatment. Often there is no clear explanation why the pain is continuing. Most people with chronic pain have had an injury (or a series of injuries) and at some stage and for some reason, the pain associated with that injury has never really gone away. The reason for this is not fully understood.
PAIN AND THE MIND
Most patients however, tend to want to focus on their physical symptoms of pain, in an attempt to find the ultimate and absolute “cure”. It is imperative that the psychosocial factors regarding pain must be evaluated. The pain is usually felt in a part or parts of the body that they can see. Many patients with severe and prolonged symptoms of physical pain express psychological effects of the pain in terms of the physical part of the body. The mental anguish and emotional distress that accompanies chronic pain can often produce even more suffering than the pain itself.
There are two types of psychological reaction to pain – emotional reaction and behavioural reaction. Such reactions are important in acute pain situations but in chronic pain, patients feel they may be the only important features. There is considerable misunderstanding about the psychological aspects of pain by many patients including their doctors. It is as, if these emotional responses and changes in behaviour somehow intrude upon, and distort the picture portrayed by the patient who is having pain, and the one perceived by the doctor. This makes diagnosis very difficult and often leads to inappropriate management through under-treatment or over-treatment with mood altering drugs.
Your doctor must be fully aware of the key role of those psychological reactions to pain and provide early and effective treatment. Otherwise treatable acute pain could progress to a chronic type and may be very difficult to treat. It must also be said that when a psychologist enters the treatment scene, often the patient will react with hostility, because they feel that the medical practitioner is discussing their pain as “all in the mind”. This is not the case as you will learn throughout this book, but such a reaction is not uncommon.
EMOTIONAL RESPONSES
Pain is never without an emotional response. All patients, whatever their age or circumstances, experience some distress when they are in pain. Feelings of fear and helplessness go hand in hand with pain. The greatest fear is that your pain means something is seriously wrong with your body, consequently patients themselves often request several M.R.I. scans etc… Fear leads us to imagine the worst; for example you might see your pain as a symptom of cancer, or you might think it could lead to paralysis or a permanent disability.
When fear becomes dreaded, pain usually progressively worsens. Hence many patients report feeling sick with fear. Helplessness comes from the feeling that you no longer own or can take charge of your own body and your pain is now dominating all of your feelings and activities, preventing you from being yourself and living your own life. No matter how hard you try the pain is always there. It is as if you are standing still at a cross-roads wondering which road out of that cross-roads will provide you with some relief. Your sense of well-being becomes a thing of the past, there is little ahead to look forward to and very little to comfort you.
These emotional reactions usually increase the sensitivity of the injured tissues and your pain worsens. Your pain then feeds on your anxiety which in turn feeds on your pain. The more distressed you become the more you will become depressed. Depression adds to your mental anguish, often both pain-relieving and anxiety relieving medication will be administered.
Chronic pain goes hand in hand with complex emotional responses. Depression, negative morbid thought patterns even suicidal thoughts lead to a semi-vegetative or sedentary life-style in many patients. Activity decreases to minimal levels and patients soon loose interest in themselves and their surroundings. Weight gain is usual which further exacerbates depression and inactivity. The disease then becomes chronic pain. Because of such symptoms advice from a dietician is often required for appropriate patient care.
BEHAVIOURAL RESPONSES
The behavioural responses to pain are the movements, postures and body expressions we use when we are re-experiencing pain. These are the features your doctor and physiotherapist observes and uses to assess the severity of your pain, appropriate to a diagnosis and as a guide to planned therapy intervention. Such interventions will be discussed in later chapters.
Facial expression, or other ‘pain body language’ such as a guarded or hunched posture, sitting or standing with a noticeable stiffness, or holding or grabbing the pain area are also behavioural responses to pain. Such responses are a way of letting others know how much pain you are having. Much research has shown that medical personnel usually respond to such signs by administering pain-relieving medication. However, relying on these behavioural expressions alone is not enough. Ironically the so called ‘difficult patient’ who verbally moans and groans the most about his/her pain will be most likely to receive prompt attention and be given relief.
MEASURING PAIN
Although pain is basically a subjective experience it can be measured, but with some difficulty and within limits. Week one of our pain management programme shows patients how to record their pain and to find out how and why it varies at different times. The first task is to spend a week recording the amount of pain you feel over the day. This does not mean dwelling on your pain but rather estimating how much it hurts at different times. Patients rate their pain on a 5 point scale. 0 is when the patient is experiencing no pain and 5 is classified as excruciating pain or the worst possible pain you can imagine.
Example of Week 1 Pain Rating Diary (using a 5 point scale)
WHAT RECORDING CAN TELL YOU
Most patients we meet at the clinic insist that there is no variation to their pain, it just hurts all the time. But when they record it in this sort of detail over the day they are surprised to find that the pain intensity is generally higher as the day goes on. For many people pain increases throughout the day with a high point at about 8pm, as can be seen in some of the graphs.
It is also important to record tension ratings and its consequent effects on pain. Tension is best defined as a feeling of emotional strain and a general disturbance in one’s sense of well being. Generally the higher the tension ratings the greater the pain intensity. Tension is also rated on a 5 point scale where 0 is no tension and 5 is unbearable tension.
Contributing factors to tension are assessed by asking the patient what he/she is doing at the time of recording the pain and tension. They are also asked to record what they are thinking, to assess any negative thought patterns which may in fact be contributing to increased pain/tension ratings. There is generally a strong correlation between high pain intensity ratings and high tension recordings. Again, as in pain intensity ratings tension levels usually increase and peak throughout the latter part of the day. The example shown is from a patient whose young family are very dependant on her regarding domestic duties. It is obvious that when her children return from school that her tension increases. This is quite common in patients suffering from chronic pain. The desire to opt out of family life is all too tempting as you can see from what this lady is thinking when recording her pain and tension.
| SAMPLE PAIN AND TENSION RECORD | ||||
| Time | (0-5) Pain rating | (0-5) Tension | What am I doing? | What am I thinking? |
| 9am | 2.3 | 2 | Having breakfast | Busy day ahead, housework, shopping etc… |
| 1pm | 2.4 | 2.5 | Preparing dinner | Finding that it is taking so long |
| 5pm | 4 | 3 | Dinner, housework, children have returned from school | Finding the invasion of the family difficult to cope with, everybody making demands |
| 8pm | 4 | 3.2 | Watching TV | Feeling I would love to be alone |
| 10pm | 4.3 | 4.2 | Preparing lunches and setting breakfast table | Fear of unable to sleep once again tonight |
WAYS OF THINKING ABOUT PAIN
Most people with chronic pain feel and experience depression, irritability, despair, frustration, anger, isolation and unfairness to name but a few. It is important to understand that it is not just pain that influences how you feel. The way you see yourself, the past and the future, all play a big part in making you feel the way you do. Negative thinking prevents us from trying increased activity levels. Negative thinking patterns can easily become habitual. Furthermore, like ways of behaving, some ways of thinking can become unhelpful and like all habits, unhelpful thinking patterns take an effort to change.
You may find it hard at first to see how you can change the ways you think and feel. Many people believe that they have no control over their thoughts and feelings and that they are just made like that. Yet in the past you probably changed your mind about something, or kept your temper when you felt angry. Most probably you changed your mind about something after listening to yourself and talking things through with yourself. Worry, anxiety and panic reinforces the pain response so therefore it is important to address ways of coping with negative thought patterns as part of any pain management programme.
At times of difficulty ask yourself – am I being realistic about the risk? For instance, if your pain is increasing, do you find yourself worrying that it is some undiagnosed and serious disease, and start picturing yourself bed-bound, helpless or worse. Alternatively, do you think to yourself about all the other possible less serious reasons for it worsening, and about what you can do.
Focusing on the things you fear such as collapsing, breaking down in public or losing control all increase pain intensity ratings. It is not uncommon for patients with chronic pain to experience severe panic attacks. Your confidence is also important when it comes to dealing with fears and worries about pain. Confidence comes from doing something well, recognising it, remembering it and telling yourself and (other people) about it. Coping with your pain, and carrying on as normal a life as possible despite it, are things you know how to do well. It is more important to ‘cope with’ the pain by recognising your limits than ‘fighting the pain’. Stopping to think and plan instead of panicking is a success in itself. If you expect yourself to manage perfectly, you will be often disappointed.
It is a good idea to think of some situation around your pain and identify your feelings regarding that situation. Secondly identify your negative thoughts about that situation what could you do to change such thoughts.
| Situation | Feelings | Negative thoughts |
| Doctor said ‘you will be in a wheelchair by the time your 50’. |
Despair, anger, resignation. |
What is the point in trying? Why me? It is so unfair? |
Example taken from a patient suffering from chronic pain
for 15 years before joining a pain management programme.
If we look at the above example it is clear that this young man had two choices. Firstly he could have become resigned to the statement that he would end up in a wheelchair, which would have been a negative response. Or secondly a more positive response would be to learn to play a more active role in his own recovery by learning to manage his pain within his ‘own limits’. Once the feelings of anger despair, and resignation are spoken about and dealt with, new coping strategies such as vigilance (i.e. Facing up to the pain) rather than avoidance (based on hoping the problem would disappear and an even more obsessive desire to find the ‘cure’) could be taken on board.
COGNITIVE BEHAVIOURAL THERAPY APPROACH TO PAIN MANAGEMENT
The cognitive behavioural therapy (C.B.T.) approach to pain management is very much a multi-dimensional approach to treatment moving away from the standard medical treatment and treated. Patients entering pain management programmes stress their desires to no longer be treated as a set of walking sympathies. The C.B.T. model looks at not just the physical symptoms but also the emotional, behavioural and cognitive (perceptual) dimensions of a patients’ pain.
C.B.T. is based on five basic assumptions and requires the intervention of a psychologist.
- Patient’s responses to pain are based on their past or learned experiences of pain.
- Stress increases pain and subsequent physiological responses.
- As the pain intensity increases due to psychosomatic (stress related) symptoms a greater need for medical intervention is required.
- Treatment assesses a patient’s environmental factors, their emotions (thoughts and feelings), behaviours, stress levels and physiological response.
- Patients are taught to place an active rather that a passive role in their own recovery.
The goals of the psychologist are
- to help patients become problem solvers,
- to monitor their thought progression such a way that they can overcome helplessness and associated negative thinking, learning new coping skills and learning to adapt to their new limits.
Treatment is based on education not just of the patient but also their families and close significant others. Our pain management programme invites all family members to attend one of our sessions, to share how they feel living with somebody in chronic pain. The session also acts as a forum for the family to open up about their anger and resentment regarding the changes in their lifestyle too and the greater onus often placed upon them.
Relaxation skills training plays a vital role in the C.B.T. model and this will be discussed in detail in a later chapter. Patients are taught to plan for future events and to prepare for setbacks. All the skills taught through C.B.T. have been shown to reduce pain behaviour, disease activity, pain intensity ratings, the need for social support, psychological disability, the need for psychiatric intervention, (including anti-depressant medication) and the rate of reoccurrence of relapse.
Two important elements of the C.B.T. model also include goal setting and pacing.
GOAL SETTING AND PACING
As each person with chronic pain will face different problems, it is important that you should first identify the problems you want to deal with and the goals you want to achieve. Whatever your goals maybe, you are going to have to make some changes in the way you have been living. It is best to start with easy goals and gradually build up your confidence.
The fear of pain and of doing more damage will hold you back. Do not be afraid to look for reassurance from the medical personnel you working with. Do a little to begin with. Goals will take time to achieve, you must be patient with yourself.
- List your reasons for trying
- Record your progress
- Reward yourself
- Do not be afraid to ask for help
Pacing means slowing down in all your activities not just activities that are difficult, and learning to recognise your new physical and mental limitations. While the physiotherapist works through physical goals with the patient, the psychologist focuses on goals of well being. A useful exercise is to set out a hierarchy of goals as a form of commitment to yourself. The following example indicates not only what these goals might be but also a realistic time frame.
Hierarchy of goal setting and pacing
| Level 5: Improved level of relaxation |
| Level 4: Reduction/elimination of anti-depressant medication |
| Level 3: Positive affirmations |
| Level 2: Releasing of negative emotions |
| Level 1: Correct breathing, relaxation |