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Psychosocial and Psychiatric Aspects of Chronic Pain
Introduction
When a patient presents to a healthcare provider with a symptom of pain, the initial focus is on the patient’s medical history and the underlying pathology—a search to identify the “broken body part” that once identified is treated to eliminate the symptom. When pain is not easily alleviated and becomes chronic, it can cause a patient (provider and significant others) significant distress with many other ongoing difficulties that compromise all aspects of their lives. Living with chronic pain requires considerable emotional resilience as it depletes people’s emotional reserves; the continuing quest for relief often remains elusive, leading to feelings of demoralization, helplessness, and hopelessness.
Historically, the amount of pain a person reported was expected to be related to the amount of tissue damage—“somatogenic.” When the presence and extent of pain report was not adequately explained by any identifiable pathology, pain was considered “functional” or “psychogenic.” Psychological factors were then considered to be playing a causal role. However, over the past four decades, research has consistently demonstrated that pain is not unidimensional; it is instead a complex biopsychosocial phenomenon. A range of cognitive, affective, behavioral, and sociocultural factors, in addition to physical and other biomedical factors, all contribute to the chronic pain experience. Treating individuals with chronic pain requires a comprehensive approach customized to each patient’s unique characteristics and needs.
Advances in the knowledge of the neurophysiology of pain have resulted in the development and evolution of pharmacologic agents, surgical interventions, innovative technologies (e.g. spinal cord stimulation, implantable drug delivery systems), and nonpharmacologic treatments (e.g. neurofeedback, cognitive-behavioral therapy) for the treatment of patients with chronic pain. However, despite these developments, the amount of pain reduction averages only about 35%, and fewer than 50% achieved this result. Therefore many people with persistent pain shuttle from healthcare provider to healthcare provider, diagnostic test to diagnostic test, in a frustrating and prolonged quest to achieve relief. This experience of “medical limbo”—the presence of a painful condition that, in the absence of acceptable pathology, is either attributed to psychiatric causation or malingering on the one hand, or an undiagnosed but potentially progressive and untreatable disease on the other—is itself a source of significant and ongoing stress that can initiate high levels of emotional distress or aggravate a premorbid psychiatric condition.
The person who has chronic pain resides in a complex world populated not only by them but also by their significant others, including family healthcare providers, employers, and third-party payers. Family members feel increasingly hopeless and distressed as medical costs, disability, and emotional suffering mount while available treatment options and income decline. Healthcare providers grow increasingly frustrated and ineffective and defeated as available treatment options are exhausted, while the pain condition remains a mystery and with no end in sight. Providers may come to question the veracity of their patients and their complaints. Employers, who are already resentful of growing worker’s compensation benefits, pay higher costs while productivity declines because the employee frequently calls out sick or cannot perform at his or her usual level (“presenteeism”), often with coworkers having to pick up the slack. Third-party payers watch as healthcare expenditures soar with repeated diagnostic testing, often with inconclusive results. In time, the legitimacy of the individual’s report of pain may be questioned since often a physical etiology fails to substantiate the cause of the symptoms.
People with chronic pain may feel that their healthcare providers, employers, and even family members are skeptical, blaming them when their condition fails to respond to treatment as expected. Some may suggest that the individual is complaining excessively in an attempt to obtain prescriptions for centrally acting and reinforcing medications (e.g. opioids, mood altering), receive attention, benefit financially (i.e. obtain disability compensation), avoid undesirable activities, or be relieved from onerous obligations (e.g. gainful employment, household chores). Others may suggest that the pain reported is not real, that they are feigning or exaggerating their symptoms, and it is “all in their head.” Often, the ensuring result is an unfortunate, inappropriate, and detrimental adversarial relationship between patients, their healthcare providers and employees.
As a result of these attitudes, and in the absence of a cure or even substantial pain relief, individuals experiencing chronic pain may withdraw from contacts, lose their sources of income, alienate family, friends, and coworkers, and become more and more isolated, despondent, and depressed. They may become angry and frustrated as their bodies, the healthcare system, legal system, and their significant other have all let them down; they may feel they have even let themselves down as they relinquish their usual activities and responsibilities because of symptoms that are intractable, yet often inscrutable when not directly observable or validated by objective pathologic findings. This emotional distress can be exacerbated by a variety of other factors, including fear of disease progression and their vulnerability to escalating sets of symptoms and disabilities, insufficient or maladaptive support systems, inadequate personal and material coping resources, treatment-induced (iatrogenic) complications, including overuse of potent drugs with significant adverse effects, disruption of usual activities and sleep disturbance, inability to work, financial difficulties, and prolonged litigation. Living with persistent pain conditions requires considerable emotional resilience and tends to deplete people’s emotional reserves, taxing not only the individual sufferer but also the capacity of family, friends, coworkers, employers, and society to provide support.
Based on what we describe above about the plight of the person with chronic pain, two conclusions are obvious: (1) psychosocial and behavioral factors play a significant role in the experience, maintenance, and exacerbation of pain and potentially even the cause, and (2) since some level of pain persists in the majority of people with chronic pain regardless of treatment, self-management is an important complement to biomedical approaches. In this chapter, we will emphasize a set of important psychological constructs, including dispositional, cognitive, affective, behavioral, and contextual factors. We discuss them individually for ease of explication. However, it is important to note that although we will describe these separately, there is considerable overlap and interaction among them. We will conclude with a discussion of integrative models and treatments for people with chronic pain.
Historical Models
Biomedical Model of Chronic Pain
The traditional biomedical model of pain—which dates back to the ancient Greeks and was inculcated into medical thinking and practice by Descartes in the 17th century—assumes that people’s symptoms result from a specific disease state represented by disordered anatomy and pathophysiology. The diagnosis is confirmed by data from objective tests of physical pathology and impairments, and medical interventions are specifically directed toward correcting the organic dysfunction and organic source of pathology.
Healthcare providers often undertake Herculean efforts (often at great expense to the patient or third-party payer) attempting to establish the specific link between objective indications of tissue pathology and the reported presence and severity of pain. The expectation is that once the physical cause has been identified, appropriate treatment will follow. Treatment will then focus on eliminating or blocking the putative cause(s) of the pain, chemically (e.g. oral medication, regional anesthesia, implantable drug delivery systems), surgically (e.g. laminectomy, spinal fusion), or physically (e.g. spinal cord stimulation, transcutaneous electrical nerve stimulation [TENS]) on the pain pathways.
Several perplexing features of chronic pain do not fit neatly within the traditional biomedical model, suggesting an isomorphic relationship between pathology and symptoms. For example, pain may be reported even in the absence of identified pathologic process. It is estimated that one-third to one-half of all visits to primary care physicians are prompted by symptoms for which no biomedical causes can be detected. In up to 86% of the cases, the cause of back pain is unknown despite the performance of sophisticated imaging. Conversely, imaging studies using computed tomography scans and magnetic resonance imaging (MRIs) have noted the presence of significant pathology in up to 35% of asymptomatic people. , Yet, they do not appear to experience any pain. Thus those who report severe pain with no identifiable pathology and those with demonstrable pathology may not complain of or even experience any pain. Moreover, the nature of patients’ responses to treatment often has little to do with their objective physical condition.
Several different psychological perspectives on chronic pain have evolved because of the multiple psychosocial factors involved in the onset and maintenance of chronic pain. Many of the psychological treatments for chronic pain are based on different psychological principles, which differ and complete from one another. Thus it is important to consider the varying perspectives.
Psychogenic Perspective of Chronic Pain
As often happens in medicine, when a biologic explanation for symptoms seems inadequate or is disproportionate to objective physical pathology, the pain reports are attributed to a psychological etiology and thus are “psychogenic.” The psychogenic perspective is the opposite of the biomedical model. When a patient’s report of pain occurs in the absence of demonstrable pathology, it may be viewed as a psychiatric diagnosis within the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-V): Pain disorder associated with psychological factors or even a pain disorder associated with psychological factors and a general medical condition.
A psychodynamic perspective on chronic pain was first described systematically in the 1960s. During this time, people with pain were viewed as having compulsive and masochistic tendencies, inhibited aggressive needs, and feelings of guilt—“pain-prone personalities.” It was commonly held that people with pain had childhood histories fraught with emotional abuse, family dysfunction (e.g. parental quarrels, separation, divorce), illness or death of a parent, early responsibilities, and high orientation toward achievement. Some current research has reported associations between chronic pain and childhood trauma, although the research is not consistent. Based on the psychogenic perspective, assessment of persons with chronic pain is directed toward identifying the psychopathologic tendencies that instigate and maintain pain. It is assumed that reports of pain will cease once the psychogenic mechanisms are resolved. Treatment is geared toward helping patients gain “insight” into the underlying maladaptive psychological contributors. ,
Although the psychogenic pain notion is ubiquitous, empirical evidence supporting it is scarce. A substantial number of chronic pain patients do not exhibit significant psychopathology. Moreover, studies suggest that in most cases, the emotional distress observed in these patients occurs in response to the persistence of pain and not as a causal agent , and may resolve once the pain is adequately treated. Furthermore, insight-oriented psychotherapy has not been shown to be effective in reducing symptoms for the majority of patients with chronic pain. Studies suggest that the emotional distress observed in patients with chronic pain more typically occurs in response to the persistence of pain and not as a causal agent, , and may resolve once the pain is adequately treated. The psychogenic model has thus come under critical scrutiny and may be flawed in its view of chronic pain.
Secondary Gain Perspective on Chronic Pain
The secondary gain (motivational) perspective is a variant of the psychogenic model frequently invoked within the legal system. From this perspective, reports of pain in the absence of or in excess of physical pathology are attributed to the desire of the patient to obtain some benefit such as time off from undesirable activities, financial compensation, or acquisition of mood altering drugs— secondary gains. In contrast to the psychogenic model, in the secondary gain view, the assumption is that the patient is consciously attempting to acquire a desirable outcome. The complaint of pain in the absence of pathologic process, thus, is regarded as fraudulent.
Behavioral Formulations
Pain is an unavoidable part of human life. No learning is required to activate nociceptive receptors. However, pain is a potent and salient experience. Beyond mere reflexive actions, people must learn to avoid, escape, modify, or cope with noxious sensations. Three major behavioral learning principles can help us understand the acquisition of adaptive versus dysfunctional responses associated with pain: classical (respondent) conditioning, operant conditioning, and observational (social) learning.
Classical (Pavlovian, Respondent) Conditioning
According to the classical (Pavlovian, respondent) conditioning model, if a painful stimulus is repeatedly paired with a neutral stimulus, the neutral stimulus will elicit a pain response. The influence of classical conditioning (i.e. the result of a stimulus followed by a response) can be observed in pain patients. Consider physical therapy, a mainstay of treatments for chronic pain patients, where treatment may evoke a conditioned fear response in patients. A patient who experienced pain after performing a treadmill exercise, based on the frequent pairing of exercise followed by pain, may become “conditioned” to experience a negative emotional response to the presence of the treadmill and any stimulus and any contextual cues associated with the nociceptive stimulus (e.g. physical therapist, gym). The negative emotional reaction may instigate muscle tensing, thereby exacerbating pain and further reinforcing and thereby strengthening the association between the stimulus and response (pain). People with chronic pain may avoid and attempt to escape from activities previously associated with pain onset or exacerbation.
Once a pain problem persists, fear of motor activities may become increasingly connected (i.e. conditioned), resulting in avoidance of activity in anticipation of avoidance of pain. Avoidance of pain is a powerful rationale for the reduction of activity, where muscle soreness associated with exercise functions as a justification for further avoidance. Thus although it may be useful to reduce movement in the acute pain stage, limitation of activities can be maintained not only by pain but also by anticipatory fear that has been acquired through the mechanism of classical conditioning. Thus cognitive processes may intervene with pure conditioning. The anticipation motivates a conscious decision to avoid or seek to escape from specific behaviors or stimuli.
In chronic pain, many activities that were initially neutral or even pleasurable may come to elicit or exacerbate pain. So they are experienced as aversive and actively avoided. Over time, a greater number of stimuli (e.g. activities) may be expected to elicit or exacerbate pain and will be avoided. This process is called stimulus generalization. Thus the anticipatory fear of pain and restriction of activity, and not just the actual nociception, may contribute to disability. Anticipatory fear also can elicit physiologic reactivity (e.g. increased muscle tension) that may aggravate pain. As a consequence, conditioning may directly increase nociceptive stimulation and, subsequently, the perception of pain.
The conviction that patients hold that they should remain inactive is challenging to modify, as long as activity-avoidance succeeds in preventing aggravation of pain. By contrast, repeatedly engaging in behavior— exposure —that produces progressively less pain than was predicted (corrective feedback) will be followed by reductions in anticipatory fear and anxiety associated with the activity. Such transformations add support to the importance of a quota-based physical exercise program, with patients gradually and progressively increasing their activity levels despite fear of injury and discomfort associated with the use of deconditioned muscles. This exposure, in the absence of anticipated pain, provides the corrective feedback that should be positively reinforcing and increase the likelihood of continuation of previously avoided activities.
Operant Conditioning
The effect of environmental factors in shaping the experience of people with pain was acknowledged long ago. However, a new era in thinking about pain began with Fordyce’s extension of operant conditioning to chronic pain. The fundamental principle is that if the consequence of a given behavior is rewarding, its occurrence increases, whereas if the consequence is aversive, the likelihood of its occurrence decreases. The key in this model is the role of consequences. The main focus of operant learning is modification in the frequency of a given behavior—increasing desirable behaviors and extinction of maladaptive behaviors. When a person is exposed to a stimulus that causes tissue damage, the immediate behavioral response is withdrawal in an attempt to escape from noxious sensations. Such reflexive behaviors are adaptive and appropriate. However, in chronic pain, avoidance may be maladaptive as it may lead to reductions in strength, flexibility, and endurance, all of which contribute to increasing disability. The principles of learning suggest that through a process of learning, responses that receive positive consequences (positive reinforcement), especially repeated desirable consequences, will more likely be maintained; behaviors that fail to activate positive consequences, or that receive negative consequences (punishment), will be less likely to occur and thus reduced (i.e. extinguished) or avoided. Behaviors may also be maintained by the escape from undesirable events, in the case of pain, by the use of analgesic drugs, rest, or the avoidance of undesirable activities.
Fordyce underscored the fact that since there is no objective way to measure pain—no pain thermometer that can accurately measure the amount of pain a person feels or should be experiencing—the only way we can know of anyone’s pain is by their behavior, whether verbal or nonverbal expressions labeled pain behaviors. The pain behavior originally elicited by organic factors caused by injury or disease may later occur, totally or in part, in response to reinforcing environmental events.
Although pain behaviors include verbal reports, paralinguistic vocalizations (sighs, moans), motor activity, facial expressions, body postures and gesturing (limping, rubbing a painful body part, grimacing), functional limitations (reclining for extensive periods, inactivity), and behaviors designed to reduce pain (taking medication, use of the healthcare system).
The central features of pain behaviors are that they are (1) sources of communication and (2) observable. Observable behaviors are capable of eliciting a response, and the consequences of behavior will influence subsequent behavior. According to Fordyce, these pain behaviors can become subjected to the principles of operant conditioning. That is, since these behaviors are observable, they are capable of evoking responses, and it is the consequences following the behavior that are particularly important as they can serve to maintain or diminish the likelihood of the behavior recurring.
Pain behaviors may be positively reinforced directly (e.g. attention from a spouse or healthcare provider, monetary compensation, avoidance of undesirable activity). Pain behaviors may also be maintained by the escape from noxious stimulation through the use of drugs or rest or the avoidance of undesirable activities such as work. In addition, “well behaviors” (e.g. activity, working) may not be positively reinforcing, and the more rewarding pain behaviors may be maintained.
Table 14.1 summarizes basic operant principles of conditioning. The operant learning paradigm does not explain the etiology of pain or initiation of the behavior but rather focuses primarily on the maintenance of pain behaviors and deficiency in well behaviors. Adjustment of reinforcement schedules will likely modify the probability of recurrence of pain behaviors and well behaviors.
TABLE 14.1
Operant Schedules of Reinforcement
| Schedule | Consequences | Probability of the Behavior Recurring |
|---|---|---|
| Positive Reinforcement | Reward the behavior | More likely |
| Negative Reinforcement | Prevent or withdraw aversive results | More likely |
| Punishment | Punish the behavior | Less likely |
| Neglect | Prevent or withdraw positive results | Less likely |
It is important not to make the mistake of viewing pain behaviors as being synonymous with malingering. Malingering involves the patient consciously and purposely faking a symptom such as pain for some gain, often financial (secondary gain). There is no suggestion of conscious deception in the case of pain behaviors but rather the unintended performance of pain behaviors resulting from environmental reinforcement contingencies. Contrary to the beliefs of many third-party payers, there is little support for the contention that outright faking of pain for financial gain is prevalent.
There is some support for the operant model. For example, Romano et al. videotaped patients and spouses in a series of cooperative household activities and recorded patients’ pain behaviors. Sequential analyses showed that spouses’ solicitous responses were more to precede and follow pain behaviors in patients than pain-free controls. At least a subset of patients demonstrate high levels of pain behaviors and benefit from treatment targeting these behaviors.
Observational (Social) Learning Processes
The social (observational) learning perspective emphasizes the point that behavior can be learned not only by actual reinforcement of an individual’s behavior but also by observation of how others respond and the consequences following responses— observational learning and modeling processes. That is, people can acquire behavioral responses that were not previously in their repertoire by the observation of others, particularly others whom they view as similar to themselves. For example, a middle-aged man might learn what to expect by observing how other middle-aged men with similar medical problems are treated. This is a powerful way of learning, especially when the others being observed are judged to be similar to the observer.
Expectancies and actual behavioral responses to nociceptive stimulation are based, at least partially, on prior social learning history. The culturally acquired perception and interpretation of symptoms determine how people deal with disease states. The observation of others in pain is an event that captivates attention. This attention may have survival value, may help to avoid experiencing more pain, and may help to learn what to do about acute pain.
Observed models can influence the expression, localization, and methods of coping with pain. Physiologic responses may even be conditioned during observation of others in pain. Expectancies and actual behavioral responses to nociceptive stimulation are based, at least partially, on prior experience, either direct or from observation of others. This may contribute to the marked variability in response to objectively similar degrees of physical pathology observed.
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