H&S - Pain - ICBT - 04.pptx (1) PDF

Pain Malika Guruge BSc Psychology and Counselling MSc Clinical and Health Psychology Table of contents 01 Introduction to Pain 02 Early Pain Theories Gate control Theory of 03 Pain 04 Treatment 05 Measuring Pain Diﬀerent Perspectives of 06 Pain Objectives What is pain? Early pain theories – pain as a sensation The gate control theory of pain – pain as a perception The role of psychosocial factors in pain perception The role of psychology in pain treatment Measuring pain 01 Introduction What is Pain? Pain is a complex and subjective experience that is typically associated with actual or potential tissue damage (Taylor, 2017). It is an unpleasant sensory and emotional perception that serves as a protective mechanism. Pain provide information about the functioning of our bodily systems. The symptoms experienced due to pain will likely lead a person to seek treatment. Complaints of often lead to mental and physical disorders, complicating diagnosis and treatment (Taylor, 2017). Refer- https://youtu.be/I7wfDenj6CQ What is Pain? Cont. Pain can vary widely in its intensity, duration, and characteristics and can be inﬂuenced by psychological, social, and cultural factors. Key Aspects of Pain include: ○ Perception- This interpretation is inﬂuenced by various factors, including past experiences, emotions, and cognitive processes (Taylor, 2017). ○ Sensory and Emotional Components- This relates to the intensity location, and quality of the pain, while the emotional component encompasses the emotional response to the pain, such as fear, anxiety, or distress. ○ Subjectivity- Two people experiencing the same type of injury may report different levels of pain based on their personal thresholds, experiences, and emotional states (Taylor, 2017). What is Pain? Cont. ○ Acute vs. Chronic Pain: Acute pain is typically short-term and serves as a warning signal of injury or disease. Chronic pain, on the other hand, persists over an extended period and may be associated with a chronic medical condition (Taylor, 2017). ○ Management- involves addressing the underlying cause of pain (when possible) and alleviating the perception of pain using, medication, physical therapy, psychological interventions, and lifestyle modiﬁcations. Diﬀerent Perspectives of Pain Pain is a complex and subjective experience which can be approached by various perspectives reﬂecting the interdisciplinary nature of pain: ○ Biological Perspective It examines the physiological processes underlying pain which involves the studying nerve pathways, neurotransmitters, and the role of the nervous system in detecting and transmitting pain signals (Taylor, 2017). ○ Psychological Perspective It examines the factors inﬂuencing the perception and experience of pain. It examines the impact of stress, anxiety, depression, and coping strategies on the experience of pain while considering the role of emotions, cognition, attention and individual differences. Diﬀerent Perspectives of Pain Cont. ○ Behavioural Perspective It examines the impact of pain and it’s inﬂuence on behaviours, movement, and activity levels in individuals. It is also involved with the assessment of pain-related behaviours in clinical settings and the development of behavioural interventions for pain management. ○ Sociocultural Perspective It examines how social support, cultural beliefs, and societal attitudes towards pain impact the perception and management of pain in the social context, relationships and the cultural norms (Taylor, 2017). Pain is Complex Chronic and Acute Pain Acute Pain ○ Acute pain is typically short-term and has a sudden onset. It usually only lasts for less than 6 months (Mills et al., 2019). ○ It is often a response to a speciﬁc injury, surgery, illness, or trauma, often with a sharp or severe pain (Mills et al., 2019). ○ Acute pain disappears when the tissue damage is repaired. Chronic Pain ○ Chronic pain persists over an extended period, typically lasting more than 6 months. (Mills et al., 2019). ○ It is usually is a ongoing and persistent, often becoming a condition in its own right (Mills et al., 2019). ○ It is often described as more persistent, dull, aching, or burning. It can be associated with ongoing conditions such as arthritis, ﬁbromyalgia, or neuropathy. Refer- https://youtu.be/-yVXUvP0CwA Chronic and Acute Pain Cont. Chronic Pain ○ Chronic Pain is of two types. 1. Chronic Benign Pain Chronic benign pain could refer to long-term pain that is not associated with a life-threatening condition and may not progressively worsen over time. It persists for 6 months or longer. E.g. Chronic low back pain. 2. Chronic Progressive Pain It is when persistent pain that worsens over time or is associated with a progressive underlying conditions which persists longer than 6 months and increases in severity over time (Mills et al., 2019). E.g. arthritis, neurodegenerative disorders, or certain cancers. Models of Pain Early pain theories described pain within biomedical framework as an automatic response to an external stimulus or factor. The earliest Models of pain in health psychology utilised the biomedical model, which attributed pain to physiological factors & treated it as a symptom of an underlying medical condition. 1. The Biomedical Model ○ This model focused on physical aspects of pain, attributing pain to be solely to physiological dysfunction or damage in the body. 2. The Biopsychosocial Model (George Engel in 1977) ○ This model recognises the interplay between biological, psychological, and social factors leading to pain. Theories of Pain 1. Cartesian Dualistic Theory ○ Put forward by Rene Descartes, who proposed the philosophical framework that separates the mind from the body. ○ This theory hypothesized that pain was a mutually exclusive phenomenon (Trachsel, 2023). 2. Speciﬁcity Theory of Pain ○ Developed by Von Frey (1895), states that the brain has a separate area and system for perceiving pain, similar to vision and hearing. ○ He mentioned that there are speciﬁc sensory receptors which transmit cold, pain, heat, and touch, and that each receptor was sensitive to speciﬁc stimulation. ○ Frey also mentioned that the brain is a complex structure with various components (Trachsel, 2023). Theories of Pain 3. Pattern Theory ○ Goldschneider (1920), indicated that there are no separate receptors for each of the four sensory modalities. ○ Instead, he suggested that each nerve impulse relays a speciﬁc pattern or sequence of signals to the brain which decipers the information. Thus, the degree of pain is generated. ○ It suggests that pain is not the result of speciﬁc receptors and pathways but is instead determined by the pattern of neural activity across various types of sensory nerve ﬁbers. Common Features of the Three Theories 1. Tissue damage causes the sensation of pain (Trachsel, 2023). 2. Psychology is involved in these models of pain only as a consequence of pain (e.g. anxiety, fear, depression). Psychology has no causal inﬂuence. 3. Pain is an automatic response to an external stimulus. There is no place for interpretation or moderation. 4. The pain sensation has a single cause (Trachsel, 2023). 5. Pain was categorized into being either psychogenic pain or organic pain. a. Psychogenic pain was considered to be ‘all in the patient’s mind’ and was a label given to pain when no organic basis could be found. b. Organic pain was regarded as being ‘real pain’ and was the label given to pain when some clear injury could be seen (Trachsel, 2023). Incorporation of Psychology in Theories of Pain The early simple models of pain did not consider the inﬂuence of psychology. However, over the course of the twentieth century, psychology began to play a crucial role in comprehending pain. Initially, it was noticed that medical interventions like drugs and surgery were predominantly effective for addressing short-term pain (acute pain). These approaches demonstrated limited efficacy in managing prolonged pain (chronic pain). Incorporation of Psychology in Theories of Pain Cont. It was noted that individuals experiencing identical levels of tissue damage exhibited variations in their descriptions of pain and responses to pain. A third notable observation pertained to phantom limb pain, where a signiﬁcant number of amputees reported feeling pain in a limb that was no longer present. Intriguingly, this phantom pain could intensify post-amputation and persist even after the affected area had fully healed. These observations strongly imply individual differences, hinting at a potential role for psychology in understanding and interpreting pain experiences. Consequently, these observations indicate signiﬁcant variability among individuals. This variability may suggest a potential involvement of psychology in understanding and interpreting these diverse responses to pain. The Gate Control Theory of Pain The gate control theory of pain (GCT), was proposed by Ronald Melzack and Patrick Wall in 1965, the GCT acknowledges that pain perception is not solely determined by the extent of tissue damage or nociceptive input. Instead, it introduces the idea that psychological factors, such as cognitive processes, emotions, and attention, play a crucial role in modulating the perception of pain (Trachsel, 2023). Key Principles of the GCT of Pain: 1. Central Control Mechanism The theory suggests that there is a "gate" located in the spinal cord that can either facilitate or inhibit the transmission of pain signals to the brain. This gate is inﬂuenced by a balance between signals from large-diameter nerve ﬁbers (which inhibit pain) and small-diameter nerve ﬁbers (which facilitate pain). Once the gate is open, the signal can travel to the brain where it is processed, and the individual proceeds to feel pain (Trachsel, 2023). 2. Nerve Fiber Types Large-Diameter Nerve Fibers (Aδ ﬁbers): These ﬁbers transmit non-painful sensations, such as touch or pressure. Small-Diameter Nerve Fibers (C ﬁbers): These ﬁbers transmit pain signals. The Gate Control Theory of Pain Cont. 3. Opening and Closing the Gate When non-painful sensory signals (e.g., touch) are activated, they stimulate the large-diameter nerve ﬁbers, closing the gate and inhibiting the transmission of pain signals to the brain (Trachsel, 2023). In contrast, when pain signals are dominant, they activate the small-diameter nerve ﬁbers, opening the gate and allowing pain signals to reach the brain. The Gate Control Theory of Pain marked a shift from a purely biomedical model to a more comprehensive understanding that considers the interaction of sensory, emotional, and cognitive factors in pain perception (Trachsel, 2023). Refer- https://youtu.be/M-rL8XdHo6Q In more recent times, researchers have postulated that these cortical control centers are responsible for the effects of cognitive and emotional factors on the pain experienced. E.g. somebody who is depressed has a “gate” that is open more often, allowing more signals to get through, increasing the probability that an individual will experience pain from an otherwise normal stimuli (Trachsel, 2023). Diﬀerences Between the Gate Control Theory and Earlier Models of Pain 1. Biomedical vs. Multidimensional Approach ○ Earlier Models emphasized a predominantly biomedical approach, focusing on the direct relationship between tissue damage and the experience of pain (Trachsel, 2023). ○ GCT emphasized that pain is not solely determined by the extent of tissue damage but is also inﬂuenced by cognitive, emotional, and attentional processes. 2. Role of Central Nervous System Processing ○ Earlier Models often viewed pain as a straightforward transmission of signals from the periphery to the brain (Trachsel, 2023). ○ GCT highlighted the signiﬁcance of central nervous system processing, introducing the concept of a "gate" in the spinal cord. 3. Incorporation of Psychological Factors ○ Earlier Models generally overlooked or downplayed the role of psychological factors in pain perception. ○ GCT integrated psychological factors, recognizing that cognitive processes, emotions, and attention can inﬂuence the perception of pain (Trachsel, 2023). 4. Subjectivity of Pain ○ Earlier Models often treated pain as a straightforward response to a speciﬁc stimulus, assuming a uniform experience across individuals. ○ GCT emphasized the subjective nature of pain perception, acknowledging that individual differences, psychological states, and context can signiﬁcantly impact how pain is experienced. What Factors Inﬂuence the Opening and Closing of the Gate 1. Opening the Gate ○ Physical Factors- an injury or activation of the small ﬁbres (Ropero Peláez & Taniguchi, 2016). ○ Emotional Factors- Experiencing negative emotions such as stress, anxiety, fear, or sadness can sensitize the nervous system making the gate more permeable to pain signals. ○ Behavioural Factors- Directing attention speciﬁcally to the pain sensation or dwelling on the pain ampliﬁes the signal transmission opening the gate. 2. Closing the Gate ○ Physical Factors- stimulation of large-diameter nerve ﬁbres through gentle touch, massage, or pressure inhibits the transmission of pain signals by closing the gate. ○ Emotional Factors- happiness, relaxation and optimistic emotional states, feelings of happiness contributes to closure of the gates (Ropero Peláez & Taniguchi, 2016). ○ Behavioural Factors- Focusing attention on non-painful activities, concentrating on a task, or engaging in distracting activities contributing to close the gate by diverting attention away from pain signals, reducing the perception of pain. Criticisms of the Gate Control Theory 1. Oversimplify the complex nature of pain perception by focusing primarily on spinal cord mechanisms. 2. Some experimental ﬁndings have not consistently supported all aspects of the GCT. 3. Downplay of the critical role of the brain regions including the cortex, play a signiﬁcant role in the interpretation and modulation of pain signals. 4. Oversimplify the role of neurotransmitters in pain processing. 5. The GCT was initially developed to explain acute pain, it offer a less comprehensive explanation for chronic pain conditions. 6. GCT suggests some integration or interaction between mind and body, it still sees them as separate processes. Understanding Pain 1. Pain serves as the brain's mechanism to draw attention to potential threats to the body. 2. The intensity of pain is heightened by the brain in correlation with its perception of the level of threat. 3. The brain considers various factors in determining the magnitude of pain, such as stress, which can amplify pain sensations. 4. Learning from experiences and being shaped by pain memories, the brain adapts its response to pain. 5. In cases of persistent pain, the primary issue often lies in the nervous system rather than the speciﬁc body part where the pain is localized. Group Exercise Share your thoughts on what pain feels like to you and what activities are impacted upon receiving pain, and the impact it had on your lives. Also, explore the ways you utilised to mitigate the experience of pain during the time you were experiencing it. Persistent Pain is Real Pain Persistent pain, refers to discomfort or pain that persists beyond the expected time for healing or recovery (Gureje et al., 1998). This can have a wide range of effects on various aspects of an individual’s life, impacting physical, psychological, and social well-being. The effects of persistent pain include: ○ Physical Impairment- persistent pain limits the mobility and the physical functioning, affecting individuals daily activities. ○ Emotional Impact- persistent pain can contribute to emotional challenges, including depression, anxiety, and stress. ○ Sleep Disturbance- persistent pain experience disruptions in sleep patterns, including difficulty falling asleep, staying asleep, or achieving restorative sleep. ○ Cognitive Impairment- Persistent pain can affect cognitive function, leading to difficulties with concentration, memory, and decision-making. ○ Financial Strain- The cost of medical treatments, medications, and potential loss of income. The Role of Psychosocial Factors in Pain Perception The interaction between psychological and social elements can inﬂuence the intensity, duration, and impact of pain. 1. Cognitive Factors- Beliefs and expectations about pain, illness, and recovery, as well as expectations regarding the effectiveness of treatments, can inﬂuence the perception of pain (e.g. Catastrophizing). 2. Emotional Factors- High levels of stress and anxiety can heighten pain perception. The body's stress response can sensitize the nervous system, making individuals more susceptible to pain. 3. Social Factors- social isolation or lack of understanding from others may exacerbate the emotional and cognitive aspects of pain [cultural beliefs and norms regarding pain expression, tolerance, and treatment.] 4. Behavioral Factors- Adaptive or maladaptive coping strategies can inﬂuence the management of pain. Avoidance of activities due to fear of pain can lead to physical deconditioning. 5. Personality Factors- personality traits, such as neuroticism or resilience, can impact the way individuals perceive and cope with pain. The Role of Learning Pain Learning, through classical and operant conditioning, can signiﬁcantly inﬂuence the perception, expression, and management of pain. 1. Classical Conditioning Pain experiences can become associated with various stimuli, environments, or activities. E.g. if an individual consistently experiences pain in a speciﬁc context, such as during a medical procedure, that context can become a conditioned stimulus that triggers anxiety or pain anticipation (Sandkühler, 2000). 2. Operant Conditioning Pain behaviors, such as grimacing, vocalizations, or avoidance of certain activities, can be inﬂuenced by reinforcement or punishment. E.g. if a person receives attention and care when expressing pain (positive reinforcement), they may be more likely to exhibit pain behaviors in the future (Sandkühler, 2000). 3. Placebo and Nocebo Effects Positive expectations about a treatment can lead to pain relief (placebo effect), while negative expectations can intensify pain (nocebo effect). These effects are inﬂuenced by prior experiences and learned associations (Sandkühler, 2000). Role of Fear & Anxiety on Pain Fear and anxiety play signiﬁcant roles in the experience and perception of pain. 1. Ampliﬁcation of Pain Perception Emotional states like anxiety heighten the body's stress response, leading to increased muscle tension, heightened sensitivity to pain, and a lower pain threshold (Rhudy & Meagher, 1999). 2. Anticipation and Apprehension Anticipating pain or experiencing apprehension about potential pain-inducing situations can contribute to increased anxiety (Rhudy & Meagher, 1999). 3. Fear-Avoidance Fear of pain can lead to avoidance of activities or movements perceived as painful. While this avoidance may provide short-term relief, it can contribute to physical deconditioning, increased disability, and heightened pain sensitivity in the long run (Rhudy & Meagher, 1999). The Role of Cognition in Pain Cognition, or the mental processes related to acquiring knowledge and understanding, plays a crucial role in the experience of pain. Refer- https://youtu.be/uT_R2k2Qnz8 1. Catastrophizing Catastrophizing can amplify the experience of pain by heightened emotional distress, increased attention to pain sensations, and a diminished ability to cope effectively (Khera & Rangasamy, 2021). 2. Meaning The meaning individuals attach to their pain can inﬂuence their emotional and behavioral responses (Khera & Rangasamy, 2021). 3. Self-efficacy High self-efficacy is associated with better pain management and functional outcomes. Individuals with high self-efficacy are more likely to engage in active coping strategies, adhere to treatment plans, and persist in the face of pain 4. Attention Focusing excessively on pain sensations or catastrophizing thoughts can amplify the pain experience. Cognitive-behavioral interventions often include attention-shifting strategies. Measuring Pain Measuring pain is a complex task due to its subjective nature—pain is a personal experience that cannot be directly observed or measured objectively. 1. Self-Report Scales Numeric rating scale where patients rate their pain intensity on a scale. Patients use verbal descriptors such as "no pain," "mild pain," "moderate pain," and "severe pain" to categorize their pain intensity (Fordyce et al., 1983). 2. Pain Diaries and Journals Patients record their pain experiences over time, noting the intensity, duration, and any factors that may inﬂuence pain (Fordyce et al., 1983) 3. Pain Questionnaires and Inventories McGill Pain Questionnaire which is used to assesses the sensory and affective dimensions of pain using a comprehensive set of descriptive words. 4. Functional Magnetic Resonance Imaging (fMRI) and Brain Imaging Examines brain activity associated with pain perception (Fordyce et al., 1983). Refer- https://youtu.be/Gwp_MCz9MnY Treatment & Management of Pain The management of pain typically involves a multidisciplinary approach that combines various methods and treatments. 1. Medications Non-prescription- acetaminophen, ibuprofen, and aspirin to relieve mild to moderate pain. Prescription- Stronger medications, including opioids, muscle relaxants, and anti-seizure drugs, may be prescribed for more severe pain (Świeboda et al., 2013), 2. Physical Therapy Programs to improve strength, ﬂexibility, and range of motion. 3. Psychological Approaches Cognitive-Behavioral Therapy (CBT) assists individuals identify and modify negative thought patterns and behaviors related to pain. 4. Mind-Body Practices/Relaxation Techniques Mindfulness Meditation, Tai Chi, and Yoga. 5. Acupuncture 6. Surgery Surgical procedures such as joint replacement (Świeboda et al., 2013). Refer- https://youtu.be/jPtKpIeoRcQ , https://youtu.be/nyuZMFXzzvo Cognitive Behavioural Therapy CBT is based upon the premise that pain is inﬂuenced by four sources of information: 1. Cognitive sources such as the meaning of the pain (‘it will prevent me from working’); 2. Emotional sources such as the emotions associated with the pain (‘I am anxious that it will never go away’) 3. Physiological sources such as the impulses sent from the site of physical damage and 4. Behavioural sources such as pain behaviour that may either increase the pain (such as not doing any exercise) or decrease the pain (such as doing sufficient exercise) (Taylor, 2017). Refer- https://youtu.be/tiuZBndewbE The Management & Acceptance of Pain Acceptance of pain involves eight factors (According to research done on experience of pain) ○ Taking Control- Empowers individuals to actively participate in their pain management. ○ Living Day-by-Day- Promotes mindfulness and present-moment awareness. ○ Acknowledging Limitations- Involves acknowledging and working within the boundaries of one's limitations without judgment. ○ Empowerment- Involves actively engaging in activities that bring a sense of achievement and mastery (Taylor, 2017). ○ Accepting Loss of Self- Involves recognizing that self-worth is not solely deﬁned by physical abilities (Taylor, 2017). ○ Belief in More to Life than Pain- Cultivates a broader perspective on life, emphasizing values, relationships, and meaningful activities beyond pain. ○ Spiritual Strength- May involve drawing on spiritual beliefs and practices for comfort, guidance, and resilience. References Finnerup, N. B., Sindrup, S. H., & Jensen, T. S. (2010). The evidence for pharmacological treatment of neuropathic pain. PAIN, 150(3), 573-581. https://doi.org/10.1016/j.pain.2010.06.019 Gureje, O., Von Korff, M., Simon, G. E., & Gater, R. (1998). Persistent pain and well-being. JAMA, 280(2), 147. https://doi.org/10.1001/jama.280.2.147 Taylor, S. E. (2017). Health Psychology. Khera, T., & Rangasamy, V. (2021). Cognition and Pain: A Review. Frontiers in Psychology, 12, 673962. https://doi.org/10.3389/fpsyg.2021.673962 Mills, E. E., Nicolson, K. P., & Smith, B. H. (2019). Chronic pain: A review of its epidemiology and associated factors in population-based studies. BJA: British Journal of Anaesthesia, 123(2), e273. https://doi.org/10.1016/j.bja.2019.03.023 Rhudy, J. L., & Meagher, M. W. (1999). Fear and anxiety: Divergent effects on human pain thresholds. Pain, 84(1), 65-75. https://doi.org/10.1016/S0304-3959(99)00183-9 Ropero Peláez, F. J., & Taniguchi, S. (2016). The Gate Theory of Pain Revisited: Modeling Different Pain Conditions with a Parsimonious Neurocomputational Model. Neural Plasticity, 2016. https://doi.org/10.1155/2016/4131395 Sandkühler, J. (2000). Learning and memory in pain pathways. Pain, 88(2), 113-118. https://doi.org/10.1016/S0304-3959(00)00424-3 Świeboda, P., Filip, R., Prystupa, A., & Drozd, M. (2013). Assessment of pain: types, mechanism and treatment. Pain, 2(7). https://www.researchgate.net/publication/263543237 Trachsel, L. A. (2023, April 17). Pain theory. StatPearls - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK545194/ Thanks! Do you have any questions? [email protected]

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