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Psychological techniques in chronic pain
Understanding pain Pain can mean different things to the person experiencing it and to the doctor whom they consult. Pain tends to interrupt thoughts and action, to dominate attention and to demand answers to the questions “What is this?” and “What should I do about it?”.
The patient’s viewThe patient who expects pain, for example a patient well prepared for postoperative pain, and who feels able to control it, with or without the help of healthcare professionals, can answer these questions satisfactorily and execute the required actions with minimal anxiety, doubt or delay. However, many patients have insufficient or unhelpful information about what the pain is, and/or perceive it as a serious threat, and are therefore unable to deal with the pain or its implications, with or without help. Patients who feel that the doctor does not understand their pain, or has not appreciated their problems, are less likely to accept and adhere to treatment that they feel is not addressing their particular problems. Their attempts to cope will be repeatedly undermined by concern that they may be making their condition worse.
The clinician’s view
The clinician asks “What does this pain indicate?”, usually delaying decisions about treatment until a diagnosis can be made. However, pain is a dysfunction of the central nervous system and not a simple response to a lesion or pathology, although they may be present. Changes in inhibitory and excitatory mechanisms at spinal cord level, and more complex changes in representation and processing in the brain, produce the complete experience of pain. When assessing a patient, it is useful to ask about current, average and worst pain intensity, current and average pain distress, and the extent to which pain interferes with daily activity (Figure 1). A simple question about pain combines these in a way that obscures valuable information. Attention to the pain, as well as to the search for its cause, conveys concern to the patient.
Focus of treatment
The doctor consulted by a patient with persistent or recurrent pain, or very disrupting acute pain, has to decide whether to:
pursue investigation and treatment of the presumed cause
abandon that search and focus on medical and physical pain-control techniques of the sort offered by pain clinics
pursue rehabilitation, despite continuing pain, using the methods in Figure 2.
The decision is influenced by previous treatment and its outcome. Patients may present, as new or significantly worse, a pain that has, in the doctor’s opinion, already exhausted available resources to no effect.
Discussing the anxieties and privations the pain causes, and how the patient imagines the future, will probably raise issues of concern to the patient. These may be dealt with immediately or in repeat planned consultations with the doctor or with non-medical colleagues with the required skills. The patient who feels heard and understood is usually interested in aiming towards self-management. The patient who feels disbelieved or dismissed construes self-management as abandonment by the medical profession.
Pain and fear
Pain threatens physical integrity because it often signals damage, and leaves the patient anxiously searching for a cause. The most credible and authoritative source of information about the cause is the doctor to whom the patient presents. The consultation provides a valuable, but often missed, opportunity to equip the patient with understanding that resolves the anxiety. Patients who fear that the pain indicates undetected damage are reluctant to use analgesics because they think that by doing so they are obscuring an important warning. Often these patients return, reporting good analgesia, but no recovery of function as a result.
Fear generates avoidance of cues and situations associated with fear. Over the long term, the fearful patient withdraws from many activities that increase the pain or impinge on their capacity to cope (e.g. social situations in which behaviour is constrained). For example, the person with head pain who feels that the only way to manage it is to lie in a quiet, dark room may not venture far from home. Studies in industrial settings show that patients with back strain, who believe that pain implies damage and that standing or lifting are destructive, generally fail to return to work over the natural recovery period of 6–12 weeks and become disabled by chronic pain. Simple information about back care in the early days after injury can promote return to work.
In musculoskeletal pain, fears about the cause of pain tend to focus on degeneration and destruction of joints, bone and muscles. In visceral pain, the fear is more often of an undetected tumour or cardiac problem. Visceral pain can lead to repeated consultations in an attempt to achieve certainty that there is no pathology. However, without a satisfactory alternative explanation, the anxieties recur with the pain. Patients do not necessarily report fears, particularly if they are avoiding all the feared situations, but sensitive questions about what they think might be wrong can lead to their elaboration.
Patients for whom explanation and education do not resolve fears may need guided confrontation of feared and avoided activities in a safe setting. A physiotherapist with understanding of persistent pain psychology may help the patient to find a safe baseline and plan a series of manageable steps to overcome the fear and avoidance. Rushing this process usually results in losing the patient and increasing their fear. Consultation with a psychologist or cognitive behaviour therapist improves the likelihood of a successful treatment.
Pain and depressed mood
Even when patients are reassured about the cause or non-cancerous nature of their persistent pain, they may be extensively limited by it. The person who has difficulties with self-care and domestic activities, who has given up or reduced work demands, who has little energy or inclination for physically undemanding leisure pursuits, who has stopped sports and outdoor activities, and feels a burden on family and a bore in social circles, has lost many of the components of independent and productive adult life to which most people aspire. With this can come a sense of having aged prematurely and of being worthless. At the extreme, this constitutes clinical depression. However, many people with persistent pain may be misdiagnosed as being clinically depressed because as well as being unhappy or dissatisfied with their lives, they have problems that are usually classified as somatic symptoms of depression but which in this case are related to pain (e.g. problems with sleep and energy). Patients who have not internalised a sense of badness or worthlessness need help with their pain rather than a primary focus on their mood.
Increasing involvement in pleasant and rewarding activities is a proven way of treating depressed mood. Patients may need ‘permission’ (from a doctor or therapist) to engage in these before they are able to complete all the duties and chores which they have also abandoned. In addition, help with sleep and with resting at night, by developing a routine that prepares for sleep and by using relaxation techniques, can help improve daytime mood and energy.
Referral to a psychologist or cognitive behaviour therapist helps the patient to challenge an entrenched pattern of negative thinking. Identification of unduly biased perceptions, beliefs and ways of thinking enables the therapist and then the patient to challenge them using a range of techniques. For example, subjecting them to scrutiny for empirical evidence (is it really true that nobody cares about the patient’s pain?), for tendencies to catastrophise (is each effort at recovery really going to end in disaster?), for mind-reading (does the consultant’s comment that nothing shows on a radiograph really mean that he thinks the patient is faking?), overgeneralisation (because one employer rejected the patient at interview, does it really indicate that no employer will ever offer a job?), and so on. The basis of this work is not that the patient is irrational, but that the premises from which he or she starts are incorrect, or that the inferential processes are negatively biased. The purpose is not to persuade the patient that everything is rosy, which is perceived by the patient as profound misunderstanding, but that the situation bears re-examination and reformulation using rational methods.
Changing the pain
Reducing pain intensity is not the primary focus of the pain management methods described above. For many musculoskeletal pains, modified return to activities and increased fitness can reduce everyday pain and the frequency and severity of episodes of worse pain. For many headaches, stress management or the identification and reduction of triggers (among which are many over-the-counter and prescribed analgesics) can reduce frequency. Some pains (e.g. some of neuropathic origin) may be less responsive to behavioural change. In this case, it is worth trying to gain greater control over pain using relaxation and attention-control methods. These usually require referral to a psychologist, or similar therapist, to try a range of techniques using self-suggestion and feedback methods to change the physical and/or mental state in these patients, and in some to achieve an emotional distance from the pain, which is more compatible with continuing worthwhile activities.
Using psychological techniques It would be unrealistic to suggest that all doctors in the pain field have the resources or the inclination to use the psychological techniques described above, but some, such as education, are most effective when used by a doctor, and all should be integrated with continuing medical care, or endorsed by medical authority.
Evidence for cognitive and behavioural techniques is good, whether delivered in single components (where problems are well defined) or in combination (where problems affect many areas of the patient’s life [cognitive-behavioural pain management programmes]). By contrast, evidence is poor for patient-led support (which is comforting while it lasts but does not bring about improved function), and for counselling, where counsellors often feel as mystified and defeated by the pain as is the patient. Liaison with pain clinic nursing, physiotherapy and psychology staff is of value if direct referral is impractical.
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