Current Diagnosis & Treatment of Pain, 1st Edition

5. Psychological Interventions

Dennis C. Turk PhD

Tasha Burwinkle PsyD, PhD

Kati Thieme PhD

Essential Criteria

  • Patients with ongoing, persistent pain.
  • Patients for whom standard medical care has been unsuccessful or only moderately successful.
  • Patients with comorbid mood disorders (anxiety, depression).
  • Patients who have consulted numerous medical professionals in search of pain relief.
  • Patients whose pain has resulted in social and occupational difficulties (eg, social isolation, job loss).
  • Patients considering surgery or other invasive procedures to treat chronic pain.
  • Patients being considered for long-term opioid therapy.

General Considerations

A number of psychological interventions have been developed for people with chronic pain, with a large body of research supporting their efficacy. Before reviewing the approaches with the greatest empiric support, it is important to consider the plight of the chronic pain sufferer, the role of psychological factors, and the mechanisms involved in the experience of chronic pain because these serve as the basis for the development of treatment modalities.

The Plight of the Person with Chronic Pain

People with chronic and recurrent acute pain (eg, migraine) often become frustrated and irritated and lose faith when the medical system, which may initially create expectations for cure, turns its back on them when treatments prove to be ineffective.

Although those with acute pain can often receive relief from primary health care providers, people with persistent pain become enmeshed in the medical community as they trek from doctor to doctor, laboratory test to laboratory test, and imaging procedure to imaging procedure in a frustrating search to have their pain diagnosed and successfully treated. In addition, at the same time that returning to work and earning a full income becomes less of a possibility, medical bills for unsuccessful treatments abound. This experience of “medical limbo”-the presence of a painful condition that eludes diagnosis and carries the implication of either psychiatric causation or malingering on the one hand, or an undiagnosed life-threatening disease on the other-is itself a source of stress that can initiate psychological distress or aggravate a premorbid psychiatric condition.

The person who has a chronic pain condition resides in a complex and costly world that is populated not only by the large number of other sufferers but also by their family members, health care providers, employers, and third-party payers. Family members feel increasingly hopeless and distressed as medical costs, disability, and emotional suffering increase while income and available treatment options decrease. Health care providers grow increasingly frustrated as available medical treatment options are exhausted while the pain condition worsens. Employers, who are already resentful of growing workers' compensation costs, pay higher costs while productivity suffers because the employee frequently calls in sick or is unable to perform at his or her usual level. Third-party payers watch as health care costs soar with repeated diagnostic testing for the same chronic pain condition. In time, the legitimacy of the person's reports of pain may be questioned, since a medical etiology often fails to substantiate the complaint.

People with chronic pain may begin to feel that their physicians, employers, and even family members are blaming them when their condition does not respond to treatment. Some may suggest that the individual is complaining in an attempt to receive attention, avoid undesirable activities, or seek disability compensation. Others may suggest that the pain is not real and is simply psychological. Third-party payers may even suggest that the individual is exaggerating the pain in order to receive financial gain. As a result, pain sufferers may withdraw from society, lose their jobs, alienate family and friends, and become more and more isolated.

Given the background provided, it is hardly surprising that the consequences of chronic pain can include demoralization leading to depression, frustration, anger,

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anxiety, self-preoccupation, and isolation. This emotional distress, however, can be exacerbated by a variety of other factors, including fear, inadequate or maladaptive support systems, inadequate personal and material coping resources, treatment-induced (iatrogenic) complications, overuse of potent drugs, inability to work, financial difficulties, prolonged litigation, disruption of usual activities, and sleep disturbance.

Fear of pain or movement and reinjury is an important contributor to disability associated with several chronic pain disorders, including back pain and fibromyalgia syndrome. People with chronic pain often anticipate that certain activities will increase their pain or induce further injury. These fears may contribute to avoidance of activity and subsequently greater physical deconditioning and greater disability. Their failure to engage in activities prevents them from obtaining any corrective feedback about the associations among activity, pain, and injury. For example, even if their pain does increase with activity, this does not necessarily indicate that hurt and harm are equivalent.

In addition to fear of movement, people with persistent pain may be anxious about the meaning of their symptoms for the future-will their pain increase, will their physical capacity diminish, will they have progressive disability where they ultimately end up in a wheelchair or bedridden? In addition to these sources of fear, pain sufferers may fear that people will not believe that they are suffering and they may be told that they are beyond help and will “just have to learn to live with it.” Such fears can contribute to additional emotional distress and to increased muscle tension and physiologic arousal that may exacerbate and maintain pain. 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, and employers to provide support.

We want to draw attention to an important point; throughout this chapter we refer to the person with chronic pain, not the chronic pain patient. Our goal is to sensitize clinicians to the fact that a patient is someone who is being cared for in a clinic, hospital, or practitioner's office; the patient role is only part of the life of the person with chronic pain. As we will note, it is important to consider the prior history and current circumstances of a person with chronic pain and not just the patient with pain ascribed to a problem in some isolated body part.

Despite advances in knowledge of the neurophysiology of pain and the development of new pharmacologic agents with analgesic properties, sophisticated surgical interventions, and the use of advanced technologies (eg, spinal cord stimulation, implantable drug delivery systems), cure of pain has eluded the best efforts of health care providers. Regardless of the treatment, the amount of pain reduction averages only about 33% and less than 50% of patients treated with these interventions obtain even this result.

Chronic pain is by definition incurable; it is a chronic disease much like diabetes. Unlike diabetes, however, those with chronic pain constantly confront noxious sensations and other aversive symptoms. Thus, persons with chronic pain are faced with managing their symptoms on their own. Faced with this task, the common response is “How?“

It is important to consider the prior history and current circumstances of a person with chronic pain. The importance of this whole-person approach is addressed by Bonica who emphasizes the relationship between psychological and environmental factors and the experience of pain. He asserts that the pain cycle is subject to the influence of the “mind.”

Based on the overview provided, two conclusions should be obvious:

  1. Psychological factors play a significant role in the experience, maintenance, and exacerbation, if not the cause, of pain.
  2. Since there are no cures for chronic pain and some level of pain will persist in most pain sufferers regardless of treatment, psychological approaches may be useful complements to more traditional medical and surgical approaches.

Bonica JJ. Preface. In: Bonica JJ, Loeser JD, Chapman CR, Fordyce WE, eds. The Management of Pain. 2nd ed. Philadelphia: Lea & Febiger; 1990. Turk DC. Clinical effectiveness and cost effectiveness of treatments for chronic pain patients. Clin J Pain. 2002;18:355.

Vlaeyen JWS et al. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85:317.

Psychological Formulations of Chronic Pain

A number of different psychological perspectives on the chronic pain sufferer have evolved. It is important to briefly consider these because psychological treatments are based on different and at times competing psychological principles.

  1. Psychogenic View

Psychodynamic perspectives of chronic pain were first described in the 1960s, when people with pain were viewed as having compulsive and masochistic tendencies, inhibited aggressive needs, and feelings of guilt- “pain-prone personalities.” It was commonly believed

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that people with pain had childhood histories fraught with emotional abuse, family dysfunction (eg, 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 patients with chronic pain is directed toward identifying the psychopathologic tendencies that instigate and maintain pain. Although the evidence to support this model is scarce, The American Psychiatric Association has created a psychiatric diagnosis, somatoform pain disorder. Diagnosis of a pain disorder requires the following:

  1. The patient's report of pain must be inconsistent with the anatomic distribution of the nervous system.
  2. If the pain mimics a known disease entity, organic pathology does not account for the pain.

Even in the presence of a medical condition that may cause pain, psychological factors may be implicated, and thus, the patient may receive a psychiatric diagnosis of pain disorder associated with both psychological factors and a general medical condition.

  1. Behavioral Formulations

According to the classic or respondent conditioning model, if a painful stimulus is repeatedly paired with a neutral stimulus, the neutral stimulus will come to elicit a pain response. For example, a person who experienced pain after performing a treadmill exercise may become conditioned to experience a negative emotional response to the presence of the treadmill and to any stimulus associated with it (eg, physical therapist, gym). The negative emotional reaction may instigate muscle tensing, thereby exacerbating pain and further reinforcing the association between the stimulus and pain. Based on this conditioned correlation, people with chronic pain may avoid activities previously associated with pain onset or exacerbation.

In 1976, psychologist Wilbert Fordyce introduced an extension of operant conditioning to the thinking about chronic pain. This view proposes that acute pain behaviors (such as avoidance of activity to protect a painful area from additional pain) may come under the control of external contingencies of reinforcement (responses increase or decrease as a function of their reinforcing consequences) and thus develop into a chronic pain problem.

Overt pain behaviors include the following:

  1. Verbal reports.
  2. Paralinguistic vocalizations (eg, sighs, moans).
  3. Motor activity.
  4. Facial expressions.
  5. Body postures and gesturing (eg, limping, rubbing a painful body part).
  6. Functional limitations (reclining for extensive periods of time, inactivity).
  7. Behaviors designed to reduce pain (eg, taking medication, use of the health care system).

These behaviors may be positively reinforced directly; for example, patients may receive attention from a spouse or health care provider or monetary compensation or they may be able to avoid an 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” (eg, activity, working) may not be positively reinforcing and the more rewarding pain behaviors may, therefore, be maintained.

The development and maintenance of pain behaviors can also occur by means of observational learning. That is, people can acquire responses that were not previously in their behavioral repertoire by the observation of others performing these activities. Expectancies and actual behavioral responses to nociceptive stimulation are based, at least partially, on prior social learning history. Complicating the issue is that cultural factors may influence how patients interpret, respond to, and cope with illness. This may contribute to the marked variability in response to objectively similar degrees of physical pathology noted by health care providers.

The operant conditioning model does not concern itself with the initial cause of pain. Rather, it considers pain an internal subjective experience that can be directly assessed and may be maintained even after an initial physical basis of pain has resolved. The pain behavior originally elicited by organic factors caused by injury or disease may come to occur, totally or in part, in response to reinforcing environmental events.

It is important, however, not to make the mistake of viewing pain behaviors as being synonymous with malingering. Malingering involves consciously and purposely faking a symptom such as pain for some gain, usually financial. 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.

  1. Gate Control Model

Although not a psychological formulation itself, the Gate Control model was the first to popularize the importance of central, psychological factors in pain perception. This model contradicts the notion that pain is either somatic or psychogenic. Instead, it postulates that both factors have potentiating and moderating effects. According to this model, both the central and peripheral nervous systems interact to contribute to the experience of pain. It is not only these physical factors that guide the brain's

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interpretation of painful stimuli that is at the center of this model but also that psychological factors (eg, thoughts, beliefs, emotions) also play a role in determining the pain experience resulting from painful stimuli.

Prior to the Melzack and Wall formulation of the Gate Control theory, psychological processes were largely dismissed as reactions to pain. Although the physiologic details of the Gate Control model have been challenged, it has had a substantial impact on basic research and in generating treatment modalities.

  1. Cognitive-Behavioral Perspective

The cognitive-behavioral model, perhaps the most commonly accepted model for the psychological treatment of persons with chronic pain, suggests that behaviors and emotions are influenced by interpretations of events and emphasis is placed on how persons' beliefs and attitudes interact with physical, affective, and behavioral factors. The cognitive-behavioral view suggests that conditioned reactions are largely activated by learned expectations rather than being automatically evoked. In other words, it is the person's information processing that results in anticipatory anxiety and avoidance. The critical factor, therefore, is that people learn to anticipate and predict events and to express appropriate reactions.

A number of studies have attempted to identify cognitive factors that contribute to pain and disability. These studies have consistently demonstrated that a person's attitudes, beliefs, and coping strategies as well as his or her expectations about the health care system affect reports of pain, activity, disability, and response to treatment. For example, persons respond to medical conditions in part based on their subjective ideas about illness and their symptoms. When pain is interpreted as signifying ongoing tissue damage or a progressive disease, it is likely to produce considerably more suffering and behavioral dysfunction than if it is viewed as being the result of a stable problem that is expected to improve.

Once beliefs and expectancies are formed, they become stable and rigid and relatively impervious to modification. Pain sufferers tend to avoid experiences that could invalidate their beliefs (disconfirmations) and guide their behavior in accordance with these beliefs, even in situations where these beliefs are no longer valid. Therefore, it is essential for persons with chronic pain to develop adaptive beliefs about the relationships between impairment, pain, suffering, and disability and to deemphasize the role of experienced pain in their regulation of functioning.

Self-efficacy, a personal expectation that one can successfully perform a behavior to produce a desired outcome, is particularly important among persons with chronic pain. Given sufficient motivation to engage in a behavior, it is a person's self-efficacy beliefs that determine the choice of activities that he or she will initiate, the amount of effort that will be expended, and how long he or she will persist in the face of obstacles and aversive experiences. In this way, self-efficacy plays an important role in therapeutic change.

Distorted thinking can also contribute to the maintenance and exacerbation of pain. A particularly potent and pernicious thinking style that has been observed among persons with chronic pain is catastrophizing (holding negative thoughts about one's situation and interpreting even minor problems as major catastrophes). Research has indicated that people who spontaneously use more catastrophizing thoughts report more pain than those who do not catastrophize.

Coping strategies, or a person's specific ways of adjusting to or minimizing pain and distress, act to alter both the perception of pain intensity and the ability to manage or tolerate pain and continue everyday activities. Overt behavioral coping strategies include rest, medication, and use of relaxation, among others. Covert coping strategies include various means of distracting oneself from pain, reassuring oneself that the pain will diminish, seeking information, and problem solving, to list some of the most prominent.

Studies have found that active coping strategies (efforts to function in spite of pain or to distract oneself from pain) are associated with adaptive functioning, while passive coping strategies (depending on others for help with pain control, avoiding activities because of fear of pain and injury, self-medication, alcohol) are associated with greater pain and depression. Regardless of the type of coping strategy, if persons with chronic pain are instructed in the use of adaptive coping strategies, their rating of pain intensity decreases and pain tolerance increases.

  1. Biopsychosocial Model

Although the Gate Control model introduced the role of psychological factors in the maintenance of pain symptoms, it focused primarily on the basic anatomy and physiology of pain. The biopsychosocial model, which expands the cognitive-behavioral model of pain, views illness as a dynamic and reciprocal interaction between biologic, psychological, and sociocultural variables that shape the person's response to pain.

This model is unique because it takes into consideration the influence of higher order cognitions, including perception and appraisal. It accepts that persons are active processors of information and that behavior, emotions, and even physiology are influenced by interpretations of events, rather than solely by physiologic factors. Persons with chronic pain may therefore have negative expectations about their own ability and responsibility to exert any control over their pain. Moreover, pain sufferers' behaviors elicit responses from significant others that can reinforce both adaptive and maladaptive modes of thinking, feeling, and behaving.

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The biopsychosocial model presumes some form of physical pathology or at least physical changes in the muscles, joints, or nerves that generate nociceptive input to the brain. At the periphery, nociceptive fibers transmit sensations that may or may not be interpreted as pain. Such sensation is not yet considered pain until subjected to higher order psychological and mental processing that involves perception, appraisal, and behavior. Perception involves the interpretation of nociceptive input and identifies the type of pain (ie, sharp, burning, and punishing). Appraisal involves the meaning that is attributed to the pain and influences subsequent behaviors. A person may choose to ignore the pain and continue working, walking, socializing, and engaging in previous levels of activity or may choose to leave work, refrain from all activity, and assume the sick role. In turn, this interpersonal role is shaped by responses from significant others that may promote either the healthy response or the sick-role. The biopsychosocial model has been instrumental in the development of cognitive-behavioral treatment approaches for chronic pain, including assessment and intervention.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Revision. Washington, DC: APA Press; 2000.

Davis DA, Luecken LJ, Zautra AJ. Are reports of childhood abuse related to the experience of chronic pain in adulthood? A meta-analytic review of the literature. Clin J Pain. 2005;21:398.

Dickenson AH. Gate control theory of pain stands the test of time. Br J Anaesth. 2002;88:755.

Engel GL. Psychogenic pain and the pain-prone patient. Am J Med. 1959;26:899.

Fordyce WE. Behavioral Methods for Chronic Pain and Illness. St. Louis: Mosby; 1976.

Frischenschlager O et al. Psychological management of pain. Disabil Rehabil. 2002;24:416.

Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965;50:971.

Morley S et al. Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain. 1999;80:1.

Sullivan MJL et al. Catastrophizing, depression and expectancies for pain and emotional distress. Pain. 2001;91:147.

Thieme K et al. Predictors of pain behaviors in fibromyalgia patients. Arthritis Rheum. 2005;53:343.

Turk DC. Cognitive-behavioral approach to the treatment of chronic pain patients. Reg Anesth Pain Med. 2003;6:573.

Turk DC. Understanding pain sufferers: The role of cognitive processes. Spine J. 2004;4:1.

Turk DC et al. Psychological factors in chronic pain: evolution and revolution. J Consult Clin Psychol. 2002;70:678.

Assessment & Evaluation

In order to understand and appropriately treat a person whose primary symptom is pain, clinicians must begin with a comprehensive history and physical examination. Physical examination procedures and sophisticated laboratory and imaging techniques are readily available for use in detecting organic pathology. Physical and laboratory abnormalities, however, correlate poorly with pain complaints, and it is often not possible to make any precise pathologic diagnosis or even to identify an adequate anatomic origin for the pain. Thus, an adequate pain assessment also requires clinical interviews, observation, and use of pain assessment tools to assist in the evaluation of the myriad psychosocial and behavioral factors that influence the subjective report (see Chapter 2).

Because there is no tool that can provide an objective quantification of the amount or severity of pain experienced by a person, it can only be assessed indirectly based on a pain sufferer's verbal and behavioral communication. Patients are usually asked to describe the characteristics (for example, stabbing, burning), location, and severity of their pain. However, even a person's communications make pain assessment difficult, since pain is a complex, subjective phenomenon composed of a range of factors and is uniquely experienced by each individual. Wide variability in pain severity, quality, and impact may be noted in reports of people with pain as they attempt to describe what appear to be objectively identical phenomena. People's descriptions of pain are also affected by cultural and sociologic influences.

  1. Interview

Topics that can be covered in an assessment interview are listed in Table 5-1. A functional assessment of the patient's pain can also be used. Patients can be asked about their current level of pain or pain over the past week or month, or they can maintain regular diaries of pain intensity with ratings recorded several times each day for several days or weeks. Asking about the characteristics of pain, while necessary, is not sufficient. The use of diaries can provide more information than just the varying pain intensity. A clinician can use information about pain obtained during the interview and diaries to identify patterns in behavior, including potential antecedents and consequences to pain exacerbation.

Pain sufferers' beliefs about the cause of symptoms, their trajectory, and beneficial treatments will have important influences on coping with pain and adherence to therapeutic interventions. Thus, when conducting a patient interview, attention should focus on the individual's specific thoughts, behaviors, emotions, and physiologic responses that precede, accompany, and follow pain episodes or exacerbations, including environmental and temporal conditions and consequences

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associated with the patient's responses (cognitive, emotional, and behavioral, including frequency and specificity/generality across situations). Any patterns of maladaptive thoughts should be noted, since they may contribute to a sense of hopelessness, dysphoria, and unwillingness to engage in activity.

Table 5-1. Areas Covered in Clinical Interviews.

   – Patient's perception about the cause of pain
   – Patient's experience of pain (how often and when it occurs) and related symptoms
   – Treatments received and currently receiving
   – Impact of pain on daily activities
   – Impact of pain on interpersonal relationships
   – Level and nature of emotional distress
   – Current stressors and areas of conflict
   – Methods used to cope with symptoms
   – Alcohol and substance abuse history and current use
   – Behaviors used to let others know pain is present
   – Responses by significant others
   – Social history
   – Education and vocational history
   – Receiving or seeking compensation and involvement in litigation
   – Concerns and expectations

Determining the patient's (and family's) expectations and goals of therapy is important. For example, an expectation that pain will be eliminated completely may be unrealistic and should be addressed to prevent discouragement if this outcome does not occur. In addition, formulating treatment goals (including symptom reduction; reduced emotional distress; improved physical, social, and vocational functioning; reduction of inappropriate use of the health care system) is helpful in returning someone to optimal functioning given their age, sex, education, and presence of physical impairments.

  1. Behavioral Observation

A number of different observational procedures have been developed to quantify pain behaviors. Behavioral checklists have been developed to identify the frequency and type of pain behaviors exhibited by a patient. Such checklists can be self-reports or reports by others; for example, behavioral observation scales can be used by significant others, and health care providers can use observational methods to systematically quantify various pain behaviors (eg, observing the patient in the waiting room, while being interviewed, or during a structured series of physical tasks). Noting the type and frequency of pain behaviors can provide detailed information about when someone performs pain behaviors, around whom the behaviors are elicited, and the responses of others to the pain behaviors. Persons with chronic pain tend to per-form more pain behaviors around others who positively reinforce the pain behavior (such as providing soothing statements, physical intimacy, assistance in performing tasks). Obtaining details about what factors increase and decrease (eg, patterns) behavior can be used when developing treatment goals.

  1. Self-Report Questionnaires

A number of assessment instruments designed to evaluate a person's attitudes, beliefs, and expectancies about themselves, their symptoms, and the health care system have been developed. There are many advantages to the use of standardized instruments: they are easy to administer, require minimal time, assess a wide range of behaviors, obtain information about behaviors that may be private (sexual relations) or unobservable (thoughts, emotional arousal), and most importantly, they can be submitted to analyses that permit determination of their reliability and validity. These instruments should not be viewed as alternatives to interviews; rather, they may suggest issues to be addressed in more depth during an interview or investigated with other measures. In addition, they allow comparison among groups of patients with pain and provide valuable information about the functional status of individuals in relation to others with the same condition.

Questionnaires have been developed to assess patients' reports of their abilities to engage in a range of functional activities, such as the ability to walk up stairs, to sit for specific periods of time, the ability to lift specific weights, performance of activities of daily living, as well as the severity of the pain experienced upon the performance of these activities.

A number of psychosocial screening tools have been developed (see Table 6-6) to assess patients with chronic pain for psychological distress; the impact of pain on their lives; feeling of control; coping behaviors; and attitudes about disease, pain, and health care providers as well as his or her plight. It should be noted, however, that patient's responses may be distorted as a function of the pain or the medications that they take. For example, common measures of depression ask people about their appetites, sleep patterns, and fatigue. Since disease status and medication can affect responses to such items, individuals' scores may be elevated, distorting the meaning of the responses. As a result, it is always best to corroborate information gathered from the instruments with other sources, such as interviews with the patient, their significant others, and chart review.

  1. Referral for Psychological Intervention

The health care provider should be alert for red flags that may serve as an impetus for more thorough evaluation by a psychologist who specializes in the treatment of pain.

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Table 5-2 lists questions worthy of asking patients who report persistent or recurring pain. The positive responses to any one or a small number of these questions should not be viewed as sufficient to make a referral for more extensive evaluation, but referral should be considered when several questions are answered positively. In general, a referral for evaluation may be indicated when the following circumstances are present:

  1. Disability greatly exceeds what would be expected based on physical findings alone.
  2. Persons with pain make excessive demands on the health care system.
  3. Persons persist in seeking medical tests and treatments when they are not indicated.
  4. Persons display significant psychological distress (eg, depression or anxiety).
  5. Persons show evidence of addictive behaviors such as continual nonadherence to the prescribed regimen.

Turk DC. Clinical effectiveness and cost effectiveness of treatments for chronic pain patients. Clin J Pain. 2002;18:355.

Turk DC, Burwinkle TM. Assessment of pain sufferers: outcomes measures in clinical trials and clinical practice. Rehab Psychol. 2005;50:56.

Therapeutic Interventions

There are a number of different clinical approaches to the treatment of chronic pain that have been developed based on the models described, including insight-oriented approaches, behavioral approaches, biofeedback, guided imagery, and hypnosis. Perhaps the most commonly used approach, however, is cognitive-behavioral therapy, which incorporates many techniques from other approaches.

  1. Insight-Oriented Therapies

Therapy based on the psychodynamic view and insight-oriented approaches are primarily focused on early relationship experiences that are reconstructed within the context of the therapeutic relationship. The therapeutic relationship is meant to “correct” the person's prior maladaptive experience via reintegrating emotions into symbolic and available mental processes, resulting in improved emotional regulation. This approach is often supplemented by relaxation therapy and long-term involvement in the therapeutic process. It is thus important for the person with pain and his or her therapist to have a supportive and trusting relationship. Although insight-oriented psychotherapy may be useful with selected individuals, this approach has rarely been shown to be

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effective in reducing symptoms for most patients with chronic pain.

Table 5-2. Screening Questions.

Clinical Issues

· Has the pain persisted for 3 months or longer despite appropriate interventions and in the absence of progressive disease?

· Does the patient report nonanatomic changes in sensation (eg, glove anesthesia)?

· Does the patient seem to have unrealistic expectations of the health care provider or treatment offered?

· Does the patient complain vociferously about treatments received from previous health care providers?

· Does the patient have a history of previous painful or disabling medical problems?

· Does the patient have a history of substance abuse?

· Does the patient display many pain behaviors (eg, grimacing, moving in a rigid and guarded fashion), and do they increase when a significant other is present?

· Does the patient have a history of repeatedly and excessively using the health care system?
Legal and Occupational Issues

· Is litigation pending?

· Is the patient receiving disability compensation?

· Was the patient injured on the job?

· Does the patient have a job to which he or she can return?

· Does the patient have a history of frequently changing jobs?
Psychological Issues

· Does the patient report any major stressful life events just prior to the onset or exacerbation of pain?

· Does the patient demonstrate inappropriate or excessive depressed or elevated mood?

· Has the patient given up many activities (social, recreational, sexual, occupational, physical) because of pain?

· Is there a high level of marital or family conflict?

· Does the patient's significant other provide positive attention to pain behaviors (eg, taking over chores, providing back rubs)?

· Is there anyone in the patient's family who has chronic pain?

· Does the patient fail to use coping efforts, or are the efforts to cope with pain maladaptive or inappropriate?

· Does the patient have plans for increased or renewed activities if pain is reduced?

  1. Respondent-Behavioral Approach

As stated previously, in the classic or respondent conditioning model, if a nociceptive stimulus is repeatedly paired with a neutral stimulus in close temporal proximity, the neutral stimulus will come to elicit a pain response. In chronic pain, many activities that were neutral or even pleasurable may come to elicit or exacerbate pain and are thus experienced as aversive and actively avoided. Over time, a growing number of stimuli (eg, activities and exercises) may be expected to elicit or exacerbate pain and will be avoided (a process known as stimulus generalization). Thus, the anticipatory fear of pain and restriction of activity, and not just the actual nociception, may contribute to disability. Anticipatory fear can also elicit physiologic reactivity that may aggravate pain. Thus, conditioning may directly increase nociceptive stimulation and pain.

As long as activity-avoidance succeeds in preventing pain initiation or exacerbation, the conviction that pain sufferers hold that they remain inactive is difficult to modify. Treatment of pain from the classic conditioning model includes repeatedly engaging in behavior (exposure) that produces progressively less pain than was predicted (corrective feedback), which is then followed by reductions in anticipatory fear and anxiety associated with the activity. Such transformations add support to the importance of quota-based physical exercise programs, with participants progressively increasing their activity levels despite fear of injury and discomfort associated with use of deconditioned muscles.

  1. Operant Approach

Operant approaches focus on the elimination of pain behaviors by withdrawal of attention and increasing well behaviors by positive reinforcement. The operant learning paradigm does not uncover the etiology of pain but focuses primarily on the maintenance of pain behaviors and deficiency in well behaviors. Target pain behaviors are identified, as are their controlling antecedents and consequent reinforcers or punishments, such as helpful, distracting, or ignoring behaviors by a spouse.

Techniques such as extinction (eg, removing the contingent relationship between overt pain behaviors and its consequences) and positive and negative reinforcement are then used to increase desired behaviors and decrease pain-compatible behaviors (eg, with operant behavioral treatment because patients are expected to be active in setting treatment goals and follow through with recommendations). The efficacy of operant treatment has been demonstrated in several studies of patients with various chronic pain disorders, especially low back pain and fibromyalgia syndrome.

  1. Biofeedback

Biofeedback has been used successfully to treat a number of chronic pain states such as headaches and back pain, among others (see Chapter 6). The purpose of biofeedback is to teach a patient to exert control over his or her physiologic processes. When a patient undergoes biofeedback, he or she is connected by electrodes to equipment that records physiologic responses, including skin conductance, respiration, heart rate, skin temperature, and muscle tension. The biofeedback equipment converts the readings of physiologic responses into visual or auditory signals on a monitor that the patient can observe. In this way, the physiologic information is fed back to patients so that they can learn to alter it using their thoughts or breathing.

With practice, most people can learn to voluntarily control important physiologic functions that may be associated directly with pain and stress. Biofeedback generates a state of general relaxation. Typically, patients being treated with biofeedback are instructed to practice relaxing using the methods that have been successful in altering physiologic parameters in the clinic.

The actual mechanisms involved in the success of biofeedback are open to question. The assumption of biofeedback treatment is that the level of pain is maintained or exacerbated by autonomic nervous system parameters believed to be associated with the production of nociceptive stimulation (eg, muscle tension in a person with low back pain). However, in addition to the physiologic changes accompanying biofeedback, patients gain a sense of control over their bodies. Given the high levels of helplessness observed in persons with chronic pain problems, the perception of control may be as important as the actual physiologic changes observed. A general sense of relaxation is also an important feature of biofeedback. Again, it is not clear whether the alterations of specific physiologic parameters putatively associated with pain is the most important ingredient of biofeedback compared with the broader relaxation created.

There are a large number of relaxation techniques that have been used in combination with biofeedback and on their own. The literature is mixed as to whether biofeedback is any more effective than relaxation. The pain condition being treated may differ as far as which of the possible components (relaxation, sense of control, general relaxation) contributes most. Moreover, the components may not be mutually exclusive and may even be synergistic.

  1. Guided Imagery

Guided imagery can be a useful strategy for helping people with pain to relax, achieve a sense of control, and distract themselves from pain (see Chapter 6). Although guided imagery has been advocated as a stand-alone

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intervention to reduce presurgical anxiety and postsurgical pain, it is most often used in conjunction with other treatment interventions such as cognitive-behavioral therapy or relaxation.

With guided imagery, patients are asked to identify specific situations that they find pleasant and engaging. In this way, a detailed image that is tailored to the person can be created. When the person with chronic pain is feeling pain or is experiencing pain exacerbation, they can use imagery to redirect their attention away from their pain.

The most successful images tend to be those that involve all of the senses (vision, sound, touch, smell, and taste). Persons with chronic pain are thus encouraged to use images that evoke these senses. Some patients, however, may have difficulty generating a particularly vivid visual image and may find it helpful to listen to a taped description or purchase a poster that they can focus their attention upon as a way of assisting their imagination.

  1. Hypnosis

Hypnosis has been used as a treatment intervention for chronic pain for many years. It has been shown to relieve pain in people with headache, burn injury, arthritis, cancer, and chronic back pain (see Chapter 6). As with imagery, relaxation, and biofeedback, it is rarely used alone; practitioners often use hypnosis concurrently with other treatment interventions. Hypnotic suggestions have been used to instill positive attitudes in patients, facilitate compliance with treatment, foster distraction from negative thoughts or stimuli, alleviate anxiety related to medical procedures, reduce reliance on medication, and promote relaxation and rehearsal of adaptive behaviors.

A meta-analysis suggests an overall benefit of the addition of hypnosis to nonhypnotic pain management strategies, although this may be mediated by a person's level of hypnotic suggestibility. Furthermore, there are discrepancies in the literature with regard to the methods used to induce hypnosis, making it difficult to accurately evaluate the efficacy of this intervention. Finally, it has been suggested that hypnosis has more utility in the treatment of acute pain than chronic pain. Thus, the degree to which hypnosis is effective above and beyond other interventions and for which populations is yet to be determined.

  1. Motivational Interviewing

Most persons with chronic pain adhere to a biomedical model; for example, the nature of their symptoms is closely aligned with physical pathology. As pain persists, some patients may become aware of the role of factors, such as emotional stress, in their experience of pain. This latter group may begin to entertain the possibility that they can learn and use self-management techniques to help them adapt to life with a chronic pain condition. Other chronic pain sufferers have difficulty with this expanded perspective. The stage of acceptance of self-management is important, since those who are not ready for the use of psychological techniques tend to avoid and dismiss such methods. Thus, the clinician needs to be aware of an individual's readiness for self-management. The assessment process should help the health care provider determine the person's motivation for the use of nonphysical approaches.

Motivational interviewing as a treatment intervention was initially developed for populations with substance abuse disorders, although it has been increasingly used with patients who have chronic pain. Specific stages of change have been postulated, and the tasks of intervention are tailored to each stage.

In the precontemplation stage, persons with chronic pain have not yet begun to consider changing from a purely somatic view of pain with the passive role they adopt as they wait for the health care provider to identify and provide the appropriate treatment. The clinician attempts to assist the patient by fostering acknowledgment of risks and problems due to inactivity, such as increased pain and physical deconditioning.

Once persons with chronic pain take responsibility for their prior inactivity, they enter the next of the proposed stages, contemplation. At this stage, the clinical goal is to encourage the patient to conclude that the risks of inactivity outweigh the perceived benefits. When they are ready to become more active (preparation stage), the clinician helps the patient outline appropriate structured physical activities in which the person is willing to participate. Finally, in the action stage, the clinician helps the patient increase their activity. This is followed by maintenance, geared toward the person's ongoing motivation and commitment.

As patients move through the stages, it is important for clinicians to be tolerant. Clinicians can encourage transition to different stages by providing motivational statements, listening with empathy, asking open-ended questions, providing feedback and affirmation, and handling resistance. Because motivational interviewing has only been applied to chronic pain in recent years, the efficacy of this intervention with different chronic pain populations is not well documented. Motivational interviewing is a general framework for preparing patients for treatment and for adhering within the cognitive-behavioral perspective and can be readily used with cognitive-behavioral therapy.

  1. Cognitive-Behavioral Therapy

It is important to make a distinction between the cognitive-behavioral perspective and cognitive and behavioral techniques. The perspective is based on several key assumptions (Table 5-3). The techniques used can

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be drawn from among those described previously as well as more specific ones noted below.

Table 5-3. Assumptions of the Cognitive-Behavioral Perspective.

· Persons are active processors of information and not passive reactors

· Thoughts (eg, appraisals, expectancies, beliefs) can elicit and influence mood, affect physiologic processes, have social consequences and can also serve as an impetus for behavior; conversely, mood, physiology, environmental factors and behavior can influence the nature and content of thought processes

· Behavior is reciprocally determined by both the individual and environmental factors

· Persons can learn more adaptive ways of thinking, feeling, and behaving

· Persons should collaborate actively in changing their thoughts, feelings, behavior, and physiology

Cognitive-behavioral therapy is based on the idea that people hold beliefs that they are unable to function because of their pain and that they are helpless to improve their situation. Thus, treatment goals focus on helping the person with pain to realize that he or she can, in fact, manage their problems as well as provide them with skills to respond in more adaptive ways that can be maintained after treatment has ended.

The cognitive-behavioral therapy approach combines cognitive and behavioral techniques, including assertiveness, stress management, relaxation training, goal-setting, and pacing of activities. Psychologists assist patients with their concerns about the future, returning to work, and physical limitations. Furthermore, psychologists help patients build their communication skills; gain a sense of control over their pain; and cope with fear of pain, reinjury, or frustrations due to the responses of others (significant others, physicians, insurance companies, employers) toward the patients' pain reports or behaviors. Patients are educated in developing positive coping strategies and are encouraged to increase their activities in a graded fashion. It is expected that patients will gain mastery over their pain, which will then result in improved mood.

Four components of cognitive-behavioral therapy have been postulated: education, skills acquisition, skills consolidation, and generalization and maintenance. The education component is composed of helping the patient challenge his or her negative perceptions regarding abilities to manage pain through a process called cognitive restructuring, which makes the patient aware of the role thoughts and emotions play in potentiating and maintaining stress and physical symptoms.

Steps in cognitive restructuring include the following:

  1. Identifying maladaptive thoughts during problematic situations (eg, during pain exacerbations, stressful events).
  2. Introducing and practicing coping thoughts.
  3. Shifting from self-defeating to coping thoughts.
  4. Introducing and practicing positive or reinforcing thoughts.
  5. Finally, home practice and follow-up.

Using these steps, the therapist encourages the patients to test the adaptiveness (not the so-called rationality) of individual thoughts, beliefs, expectations, and predictions. The crucial element in successful treatment is bringing about a shift in the person's repertoire from well-established, habitual, and automatic but ineffective responses toward systematic problem-solving and planning, control of affect, behavioral persistence, or disengagement when appropriate.

The goals of skills acquisition and skills consolidation are to help patients learn new pain management behaviors and cognitions, including relaxation skills, problem-solving training, distraction skills training, activity pacing, and communication skills. Using role-playing techniques and homework assignments, patients can practice emerging skill sets and evaluate their usefulness in the management of their pain.

Finally, generalization and maintenance is geared toward solidifying skills and preventing relapse. Problems that arise throughout treatment are viewed as opportunities to assist patients with learning how to handle setbacks and lapses that may occur following treatment. In this phase, it is helpful to assist patients in anticipating future problems and high-risk situations so that they can think about and practice the behavioral responses that may be necessary for successful coping. The goal during this phase, then, is to enable patients to develop a problem-solving perspective where they believe that they have the skills and competencies within their repertoires to respond in an appropriate way to problems as they arise. In this manner, attempts are made to help the person learn to anticipate future difficulties, develop plans for adaptive responding, and adjust his or her behavior accordingly.

The efficacy of cognitive-behavioral therapy has been demonstrated in a large number of studies of patients with various chronic pain disorders. There is a wealth of evidence that both individual and group cognitive-behavioral therapy can help restore function and mood as well as reduce pain and disability-related behaviors. Despite the fact that cognitive-behavioral therapy is undoubtedly the most used intervention for patients with chronic pain, there are limitations. For example, although cognitive-behavioral therapy has been found to

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be helpful for a number of individuals, there are some for whom cognitive-behavioral therapy is not beneficial. Researchers are just beginning to explore different aspects of cognitive-behavioral treatment to answer the question “What works for whom?”

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Interdisciplinary Pain Rehabilitation Programs

Although cognitive-behavioral approaches on their own have found strong support in the literature, it is worthwhile to discuss the efficacy of interdisciplinary pain rehabilitation programs (IPRPs) since the cognitive-behavioral perspective and cognitive and behavioral techniques are frequently important ingredients in these programs. The premise underlying the development of IPRPs is that patients with complex pain problems are best served by the collaborative efforts of a team of specialists that often includes physicians, nurses, physical therapists, occupational therapists, vocational counselors, and psychologists. IPRPs operate under the assumption that pain is not just the result of body damage but that pain has psychological and environmental origins as well. In other words, IPRPs treat more than pain: they treat the whole person.

The primary goal of IPRPs is to improve physical performance and coping skills, and to transfer the responsibility for pain management from the health care provider to the individual. This treatment plan is rehabilitative rather than curative, and encourages people to take a more active role in the management of their pain.

IPRPs adopt the biopsychosocial model of chronic pain, which assumes that all human behavior, including the report of pain, reflects a combination of the events occurring within the person's body, the recognition of these events, appraisal of these events, the affective responses to these events, and the influence of the environment. Comprehensive and concurrent treatment interventions may include drug detoxification, psychological treatment (eg, relaxation training, problem solving, coping skills training, functional restoration, and rehabilitation), physical conditioning, acquisition of coping and vocational skills, and education about pain and how the body functions.

There have been a large number of published studies and several meta-analyses supporting the clinical effectiveness of IPRPs. In general, compared with pharmacologic, medical, and surgical alternatives, IPRPs appear to be equally effective in reducing pain and significantly more effective in reducing health care consumption, leading to closure of disability claims, increasing functional activities, and returning patients to work. Even at long-term follow-up, patients who are treated in IPRPs appear to maintain their reductions in pain and emotional distress. An additional benefit of IPRPs is that they cost substantially less per person per year than medications and surgeries, rendering treatment more cost-effective.

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