Psychological Approaches in Pain Management

Plight of Individuals With Chronic Pain

People with chronic pain and recurrent, episodic acute pain (e.g. migraine, trigeminal neuralgia) often feel rejected by the very elements of the society that exist to serve them. They typically begin their healthcare journey expecting that there is some physical cause of their pain, that the pathology causing their pain will be identified by a healthcare provider, and that their pain will be eliminated by treatments prescribed by their providers and in a reasonable time interval. In this scenario, the “patient” with chronic pain remains a passive recipient awaiting a “cure” provided by healthcare providers. However, for many of these individuals, the journey becomes an arduous one as they shuttle from one healthcare provider to another, to increasingly invasive laboratory testing, to imaging procedures, to other specialists, and yet more diagnostic tests, all in the quest for an eventual cure. Usual life roles are altered, family and social interactions are impaired, gainful employment may become increasingly difficult, conflicts with third-party payers escalate, and medical expenses for unsuccessful treatments accumulate. They are often informed at various times that no specific pathology can be identified to account for the pain they report and, eventually, that all treatment options are exhausted (“there is nothing else I can do for you”). The perpetual experience of being in the “medical limbo” taxes their patience and perseverance. A frustrated person with chronic pain may lose their faith in health care and feel helpless; psychological distress compounds the difficulty of having to live with chronic pain and disability.

A vicious cycle is initiated when an equally frustrated physician, with no ways to explain the persistence of pain reported and no new treatment options are in sight, may implicitly or explicitly suggest that the pain is caused by “psychological issues.” Once optimistic, family members also experience pervasive frustration that adversely affects the family dynamics. Over time, the legitimacy of the pain may be questioned by significant others, employers, and third-party payers, as diagnostic and therapeutic efforts fail despite the sophisticated biomedical technologies. Many individuals with chronic pain feel disbelieved, dismissed, and stigmatized by their situation, which further exacerbates their distress. It is hardly surprising to see the increasing emotional distress that accompanies these people’s quest to finding relief.

To place the situation for an individual experiencing chronic pain in context, consider that chronic pain affects over 20% of the adult United States population (50 million), with over 8% reporting high impact chronic pain (limited life or work activities on most days or every day during the past six months). If we extend our view to the impact of chronic pain on families and friends, many more people in our society are affected directly or indirectly by chronic pain. Pain has societal consequences beyond those of the individuals affected. Pain is expensive; health care and indirect costs associated with disability, lost tax revenues, retraining, unemployment or under employment, and legal fees exceed $550 billion annually. These astronomical figures do not incorporate the incalculable human suffering attended to chronic pain. To put it bluntly, pain hurts the individual with the symptoms, people around the person, and society as a whole. The Institute of Medicine aptly labeled the current situation of chronic pain as a “crisis.”

Despite an increased understanding of the pathophysiology of pain, technologic advancements, and pharmacotherapeutic innovations, a cure for chronic pain has eluded the best efforts and intentions of researchers and healthcare providers. Regardless of the treatment modality, the pain reduction averages only about 35%, and fewer than half of persons treated obtain this outcome. The extent of improvement in emotional, physical, and social functioning is often below this level.

People with chronic pain continually confront noxious symptoms and experiences that affect every aspect of their lives. Thus those with chronic pain face a dire need to manage their symptoms. Recall Bonica’s comment in the preface of the first edition of his seminal work The Management of Pain over 60 years ago:

“The crucial role of psychological and environmental factors in causing pain in a significant number of patients only recently received attention. As a consequence, there has emerged a sketch plan of pain apparatus with its receptors, conducting fibers, and its standard function, which is to be applicable to all circumstances. But …in so doing, medicine has overlooked the fact that the activity of this apparatus is subject to a constantly changing influence of the mind.” (p. 11)

It should be evident that psychological, social, and contextual factors play significant and contributory roles in the experience, maintenance, and exacerbation of pain. The neurophysiology does not exist apart from psychology and the context in which pain occurs. Instead, what we do, how we think, and how we feel constantly send feedback to the brain to modulate the neurophysiologic system. Psychological processes such as emotional states, thoughts about pain, and attitudes in response to pain may impact on, and be affected by, how an individual interprets, perceives, and manages his or her pain.

With the advent of innovative research, we have become aware that psychological factors are interconnected with brain regions implicated in the perception, attention, and modulation of pain. ^, In this sense, research has shown that it is not the pain itself but rather the interpretation of the pain that predicts how an individual behaves in response to it. How others respond to people with pain can affect the experience of pain, adaptation, and disability. These observations are the basis for the emergence of interest in using psychological approaches to assist individuals in managing their pain and lives despite pain.

Psychological Formations of Chronic Pain

To many healthcare providers, “psychological treatment” is a generic term. However, various psychological interventions form the basis for a diversity of psychological treatments based on their tenets. Although all psychological treatments have a fundamental commonality, emphasizing the whole person affected and self-management rather than cure, they do have essential differences. A brief review of the history of the area is warranted to provide a better understanding of the current practices of psychological interventions with individuals experiencing chronic pain. This is important for non-mental health professionals for their treatment planning and making referral requests about which psychological treatment to select from among those available. Since there are different emphases among the various treatments, providers need to identify and select a treatment approach that best fits each of their specific patient’s current state, most pressing problems, and personal characteristics. However, depending on resources, there may be limitations and constraints on the options available.

Psychogenic View

As is often the case in medicine, when physical explanations seem inadequate and no treatments seem to provide consistent outcomes, individuals’ reports of pain are often attributed to a psychological origin (i.e. psychogenic). This unfortunate trend in medicine has a long history but was first systematically articulated in the 1960s when people with persistent pain were viewed as having compulsive and masochistic traits, inhibited aggressive needs, and feelings of unresolved guilt—“pain-prone personalities.” It was commonly believed that people reporting persistent pain had histories of troubled childhoods, including emotional abuse, family dysfunction, loss of parents, and pressure to attain unreasonably high goals for themselves. Some have insinuated the psychogenesis of pain from the psychological “wounds” by linking childhood trauma to adulthood chronic pain, although the findings to support this contention are not consistent and remain controversial. ^,

The psychogenic model has focused clinicians’ efforts toward identifying the etiologic and historical psychopathologic processes involved. Addressing the maladaptive psychological needs that allegedly caused pain was common in the early days of pain medicine. ^,

Although the incidence of depression and anxiety are common in people with chronic pain, and how could they not be given the description of the plight of the person with chronic pain outlined, attempts to establish the causal link have been inconsistent. To address the gap, the American Psychiatric Association formulated a psychiatric diagnosis, “Somatoform Pain Disorder,” in their 4th edition of the Diagnostic and Statistical Manual of Mental Disorders . The diagnosis of Somatoform Pain Disorder was made by default when persistent pain could not be explained biomedically, and the pain was associated with excessive thoughts, feelings, or behaviors about the symptoms. This diagnostic category was highly criticized for the questionable meaning of “medically unexplained” pain and appropriateness of the assumption that poorly defined “excessive distress” has an etiologic role in pain. The classification was deleted from the latest version of the diagnostic manual and replaced by a new designation, Somatic Symptom Disorder. Notably, in this new iteration, pain is no longer required to be “medically unexplained.” Nevertheless, it remains unclear how the diagnosis leads to appropriate treatment plans, and it continues to risk misdiagnosing a medical condition as a psychiatric illness. For the most part, the psychogenic model has thus come under appropriate scrutiny and has fallen out of favor.

Behavioral Formulations

Learning principles play an important role in dysfunctions associated with chronic pain. Three behavioral principles can influence people with chronic pain individually and interactively. Through experiential learning based upon the classical (Pavlovian) conditioning model, a painful experience can lead to an emotional association between contextual factors and activity with fear of pain. For example, for a person who tries to vacuum rugs and then experiences a pain flare, the co-occurrence of vacuuming the floor and the resulting pain becomes conditioned to pain-related fear. Avoidance is a natural response to feared activity. Pain-related fear-based conditioning is ubiquitous in chronic pain, leading to further deconditioning and loss of function. The Fear-Avoidance Model has incorporated the conditioned fear and avoidance into a vicious circle of pain, avoidance of activity, and subsequent deconditioning and the resulting disability. Several studies have shown the significant association between pain-related fear-avoidance and disability.

Another contribution of the learning principles to pain comes from the operant conditioning model, pioneered by Fordyce at the University of Washington in the 1970s. The operant conditioning model posits that the likelihood of particular behavior recurring depends upon the immediate consequence of the behavior. For example, imagine that a man grimaces and complains of his back pain while arguing with his wife. The wife immediately stops arguing, brings him a cold beer, tells him to take it easy, and rubs his back. Here, the likelihood of grimacing and complaining reoccurring will increase because of immediate consequences of (1) negative reinforcement (removal of the aversive situation) and (2) positive reinforcement (attaining something positive: beer, sympathy), and a back rub. Fordyce posited that over time, various pain-related behaviors (e.g. sighing, moaning, bracing, limping, guarding, medication taking) could be reinforced through operant conditioning and, consequently, shaping and maintaining the person’s chronic pain experience.

From the operant perspective, the central features of pain behaviors are that behavior is (1) a source of communication and (2) observable. People express their pain in different ways. Their significant others respond to those expressive behaviors in different ways. However, the principles of operant conditioning apply to all behavioral communications. Maladaptive behavioral patterns that are reinforced could lead to significant disability and increased healthcare utilization. Consequently, identifying maladaptive patterns of reinforcement and replacing them with adaptive patterns to reinforce “well behaviors” (e.g. activity, reduced time reclining) is a critical focal point of behavioral treatment of individuals with chronic pain.

Fordyce’s operant conditioning model does not concern itself with the initial cause of pain. It also does not directly address pain per se, which is a subjective and perceptive experience. Instead, it focuses on observable behaviors presumably related to the communication of pain and subsequent reinforcement. Observable behaviors help people with chronic pain communicate with the world around them, but they can lead to greater dysfunctionality if maladaptive behaviors are continually reinforced and maintained.

However, it is important not to mistakenly view pain behavior as synonymous with “malingering.” Malingering is a psychiatric and legal construct that involves consciously and purposefully faking symptoms for personal gain. Operantly conditioned behaviors are neither intentional nor faked, and people do not explicitly use operantly conditioned behaviors—pain behaviors—to obtain something they value and desire.

The third learning principle is encapsulated in the social learning model. The principle of social learning emphasizes that behaviors can be learned not only by actual experiential conditioning but also by observation of what others do, how they are responded to, and how they respond themselves. For example, a middle-aged man might learn how to act when a pain flare occurs by observing how other middle-aged men in similar circumstances act. This type of learning is ubiquitous in our lives, from a baby learning how to react to stress by observing her parents to popular figures and social media shaping cultural norms. Consider the case of the television series, “House.” The central figure, Dr. Gregory House, demonstrates how he responds to his chronic pain—he exclusively and excessively takes analgesic drugs. Thus we can acquire responses that were not previously in our behavioral repertories by observing others. We learn not only observable behaviors but also briefs and attitudes from others. Our response to pain is no exception. Expectations and behavioral responses to nociceptive stimulation are based, at least partially, on one’s social learning history, and expectations play an important role in shaping the pain experience.

Understanding social learning history is clinically important in pain medicine. Children develop attitudes and expectations about health and health care from their parents and other close adults. This lets them learn how to appraise somatic signals and respond to pain. Research has shown that children of parents with chronic pain show greater pain-related behaviors during stressful times than children of healthy parents. ^, It has also been demonstrated that people can acquire physiologic responses to pain by observation.

Gate Control Theory

Though not a psychological formulation itself, the Gate Control Theory (GCT) popularized the importance of central psychological factors in pain perception. The GCT has revolutionized thinking about nociceptive processes and the perception of pain. Melzack and Casey differentiated three systems related to nociceptive processing: sensory-discriminative, motivational-affective, and cognitive-evaluative—all contributing to the eventual experience of pain perception. The GCT contradicts the dualistic notion that pain is either somatic or psychogenic. Instead, it postulates the physiologic basis of the psychological factors modulating the pain experience.

The GCT was the first integrated model of pain. Before this, psychological processes were largely dismissed as a reaction to pain. The GCT specifically points to the psychological factors as significant moderators of pain. Although the physiologic details of the GCT have been challenged, its impact on pain research has been substantial. It also became a source of inspiration for technologic and clinical applications, such as neuromodulation, pharmacotherapy, and multimodal approaches to treating pain.

Cognitive-Behavioral Perspectives

The cognitive-behavioral (CB) perspective is a broad psychological model integrating many of the aforementioned behavioral, emotional, social, and cognitive factors. The model focuses on the cognitive factors as a driver of one’s emotional, context, and behavioral experience, forming a dynamic personal psychosocial environment that interacts with chronic pain experience. It suggests that negative cognitive constructs such as fear appraisals, catastrophizing, beliefs about helplessness, and protective factors such as resilience and self-efficacy can affect the experience of pain. The model posits that cognitive processing is more influential than sensory activity in how individuals perceive, interpret, and manage their pain. ^, Treatments based on the CB perspective are directed not toward a cure but rather toward addressing the negative appraisals and interpretations, encouraging positive beliefs about self-efficacy, fostering resilience, and encouraging adaptive behaviors despite the persistence of pain. A set of techniques, described below, are used to achieve these ends.

To illustrate the potential of cognitive factors, consider the case of a person waking up with abdominal pain. She would make use of her prior experiences and cognitive ability to try making sense of this new sensory experience. If she attributes the pain to her rigorous work out at the gym yesterday versus if she thinks of a family history of colon cancer, her emotional response and the actions she takes would be very different. The thought process often serves as filters that determine the meaning of the experience and the appropriate responses. Thus threatening thought processes will likely lead to negative emotions, a sense of being overwhelmed and distressed, whereas a more benign interpretation might have relatively little impact.

Biopsychosocial Model

The biopsychosocial model integrates and expands both the GCT and CB perspectives of pain, viewing chronic pain as an outcome of dynamic interactions among and within the biologic, psychological, and sociocultural variables. ^, It accepts the idiosyncratic nature of such dynamicity yet provides a conceptual framework to work with a range of people with chronic pain. Initial pain onset may have driven all the systems at first, but then, each system influences other systems reciprocally—maladaptive momentums of how the dynamic interaction lead to further disability and distress. From the biopsychosocial perspective, physiologic, psychological, and social factors each make important contributions throughout the trajectory of pain. However, the relative contributions of each may vary over time, with biologic factors making a larger contribution during the acute phase, the roles of psychological and social factors increase as the presence of pain persists. The biopsychosocial model has become a basis of multimodal approaches in pain medicine, as the model indicates that pain is a multifactorial phenomenon and addressing just one area will likely yield unsatisfactory outcomes.