Chronic pain – Psychology and management

Harpreet Singh Dhillon; Shibu Sasidharan

doi:10.4103/jrap.jrap_11_21

COMMENTARY

Year : 2021 | Volume : 7 | Issue : 2 | Page : 55-58

Chronic pain – Psychology and management

Harpreet Singh Dhillon¹, Shibu Sasidharan²
¹ Department of Psychiatry, Military Hospital, Jammu, Jammu and Kashmir, India
² Department of Anaesthesiology and Critical Care, Level III Hospital, Goma, Democratic Republic of the Congo

Date of Submission	19-Jul-2021
Date of Acceptance	24-Dec-2021
Date of Web Publication	08-Mar-2023

Correspondence Address:
Harpreet Singh Dhillon
Department of Psychiatry, Military Hospital, Jammu
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jrap.jrap_11_21

How to cite this article:
Dhillon HS, Sasidharan S. Chronic pain – Psychology and management. J Recent Adv Pain 2021;7:55-8

How to cite this URL:
Dhillon HS, Sasidharan S. Chronic pain – Psychology and management. J Recent Adv Pain [serial online] 2021 [cited 2023 Mar 31];7:55-8. Available from: http://www.jorapain.com/text.asp?2021/7/2/55/371248

Introduction

Chronic pain (CP) (persistent or frequent recurring) has a significant debilitating impact on an individual's life. Pain is labeled chronic when it persists for more than 03 months along with significant emotional distress and/or functional disability.^[1] CP is a highly prevalent condition with an estimated 20% of worldwide population suffering from it and is responsible for 15% to 20% of visits to physician.^[2],[3] In an international survey (18 countries, 42,249 respondents), the 12-month prevalence of CP was found to be 37% in developed countries and 41% in developing countries.^[4] CP has a significantly negative impact on psychological state, physical health, and social functioning.^[5]

In an attempt to systematically classify, CP has been coded into the international classification of diseases (ICD), 11^th revision as chronic primary pain, chronic widespread pain, chronic primary visceral pain, chronic primary musculoskeletal pain, chronic primary headache or orofacial pain, and complex regional pain syndrome.^[6]

Historically, pain was essentially viewed as a medical symptom, which should respond to physical treatment (pharmacological, surgical management). However, due to inadequate response to conventional treatments, there was a shift in perspective, and a biopsychosocial effects and causes model was proposed.^[7] The experience of CP is designed by a multitude of biological, psychosocial (e.g., patients' beliefs, affective state, and expectations), and behavioral factors (e.g., circumstances and behavior of significant others). CP impacts all ages and sociodemographic groups in a multi-dimensional manner, and hence, the management of CP entails a multi-disciplinary approach.^[8],[9] In this article, the authors have tried to understand the magnitude, psychology, implications, and management of CP with emphasis on cognitive behavior therapy (CBT).

Psychology of Chronic Pain

There are various psychological models, which have been applied to advance our understanding on causation, perpetuation, and management of CP.

As per the operant model, the frequency of any behavior is contingent upon the response that it elicits from the environment. A favorable response (affection, sympathy, support, and sanctioned time out) increases the frequency of particular behaviors while unfavorable (neglect/aversion/punishment) responses reduce the frequency. Pain behaviors tend to sustain or even increase in frequency when they elicit favorable responses. However, if such favorable responses can be substituted with alternate behaviors (or better known as “well behaviors”), it can lead to reduction in frequency of pain behaviors. These “well behavior” includes graded physical exercise, active lifestyle, activity tolerance, focus on self-efficacy, and independent functioning despite CP. On the other hand, maladaptive pain behaviors contribute to maintenance of pain and prolonged disability. Hence, the management of CP as per operant model involves identification of factors, which precipitates, perpetuate and relieve pain with the final aim to reduce the reinforcing behaviors and boost the “well behaviors”. It involves educating the patient as well as significant others to identify and practice the well behaviors while ignoring the reinforcing behaviors.^[10]

The peripheral muscle relaxation-training model with the help of biofeedback was initially advocated for the treatment of stress and anxiety disorders. However, certain CP conditions (chronic low backache and tension type headache) are also attributable to persistent and excessive muscle tension. Hence, it is worthwhile to educate CP patients that they can regulate their autonomic nervous system through relaxation training and biofeedback. Relaxation training coupled with biofeedback thus forms an important component of multidisciplinary CP management.^[11]

Table 1: Overview of cognitive-behavioral therapy techniques

Click here to view

The cognitive and coping model argues that the pain behaviors of an individual can be better predicted and influenced when his cognitions (beliefs, motivation, attribution, intentions, etc.) are taken into account. Thus, during the management of CP, patients are educated to become more aware of their thoughts accompanying the pain, maintain a log, and identify the adaptive/maladaptive thoughts based on their overall helpfulness/unhelpfulness. They are then instructed to focus and strengthen the adaptive thoughts and avoid/ignore the unhelpful ones. There is extensive literature supporting the efficacy of cognitive behavioral therapy (CBT) in reducing CP and improving overall physical and psychological function.^[12]

Assessment

An inherent problem in assessing pain is that there are currently no objective measures to determine/validate the extent of an individual's pain except the subjective self-reporting by the patient. However, CP affects not only the patient but also the significant others (partners, friends, relatives, employers, and co-workers) around him and thus necessitates the evaluation of a comprehensive biopsychosocial profile of the patient including physical, psychological, and financial implications. The health-care providers need to conduct thorough clinical examination and diagnostic investigations to locate any biological etiology of pain, while concurrently assessing the patient's cognitions and coping, emotional impact and dysregulation, expectations, responses of significant others (caregiver burden), and functional as well as financial disability.^[13]

The psychosocial and behavioral factors can be screened with the acronym “ACT-UP” (activity, coping, think, upset, and people's responses) that can be used as a guide for a brief screening interview for clinicians. This can be summarized as follows.

Activities: How is your pain affecting your life (i.e., sleep, appetite, physical activities, and relationships)?
Coping: How do you deal/cope with your pain (what makes it better/worse)?
Think: Do you think your pain will ever get better?
Upset: Have you been feeling worried (anxious)/depressed (down, blue)?
People: How do people respond when you have pain?

The standardized CP assessment tools available to assess the sensory and affective qualities of CP are Numerical Rating Scales; Visual Analog Scales; Faces Scale; Verbal Descriptor Scales; Brief Pain Inventory, Graded CP Scale, McGill Pain Questionnaire; Pain Detect; Neuropathic Pain Scale; Neuropathic Pain Symptom Inventory; Leeds Assessment of Neuropathic Symptoms and Signs, and Douleur Neuropathique-4 Questions. These are easy to use in routine clinical settings.^[14]

Implications of Chronic Pain

CP has a significant association with psychological state and psychiatric disorders. CP poses a greater risk for having depression and also up to 75% of depressed patients reports CP.^[15] The incidence of depression among patients with CP is estimated to be 30%–45% as compared to 5%–7% in the general population.^[16] Furthermore, depressed patients with CP report worse symptoms of sleep disturbances, fatigue, psychomotor retardation, impaired concentration, and poor quality of life compared to people without CP. Moreover, depressed patients with CP respond poorly to antidepressant therapy.^[17]

There has been an increase in the use of opioids for the management of chronic and acute pain because the effect of opioids tends to wear off following prolonged use necessitating increased dosages. There has been a 198% increase in hydrocodone prescriptions, 588% increase in oxycodone prescriptions, and 933% increase in methadone prescriptions from 1997 to 2005.^[18] More than 10 million Americans aged more than 12 years were found to be using opioid analgesics without medical prescription in 2014.^[19] Although opioids are effective for short-term management of acute and cancer pain, but the evidence for long-term management of chronic noncancer pain is lacking.^[20],[21] Second, unregulated long-term use amplifies the risk of addiction and serious side effects. Moreover, patients with existing psychiatric comorbidities (anxiety and depression) tend to experience higher pain intensity, thus demanding higher doses of opioids and increased likelihood of developing opioid dependence.^[22]

Management

The comprehensive management of CP entails addressing the biomedical, psychosocial, and behavioral domains of CP. There is a myriad of pharmacological and nonpharmacological interventions for postsurgical CP which includes analgesics, antiepileptics, antidepressants, capsaicin, epidural steroid injections, local anesthetics, neurotoxins, N-methyl-D-aspartate receptor antagonists, and opioids. The nonpharmacological interventions include acupuncture, graded physical exercise, CBT, magnetic stimulation, relaxation training, biofeedback, and mindfulness-based stress reduction.^[23]

CBT has been primarily utilized in psychiatric disorders such as depression, anxiety, and post-traumatic stress disorder; however, it has been shown to be effective in patients with CP. The principle behind CBT is to identify and change thought patterns accompanying maladaptive behaviors into adaptive ones. The success of CBT techniques in the management of CP is attributable to its ability to alter brain function and connections in nociceptive and nonnociceptive areas of the brain, reduction in posterior cingulate cortex activity, pain-related cognition, and anxiety related to pain.^[24] There have been multiple randomized controlled trials demonstrating that CBT successfully improves CP across a broad spectrum of syndromes including headaches, arthritis, cancer, and fibromyalgia.^[25] The various CBT techniques available for CP are summarized in the following table.

The impact of positive psychological factors (individual adjustment to persistent pain, pain acceptance, hope, and optimism) has been studied in patients with CP. Hope has been associated with reduced CP, functional disability, psychological distress and physical weakening, in patients of multiple sclerosis, and cancer.^[26],[27] Acceptance-based behavioral interventions recommend engaging into meaningful activities despite the pain and has been shown to significantly lower pain levels, pain-associated distress, and disability.^[28]

Recommendations

Clinicians, including (but not limited to) those working in primary care, may lack sufficient teaching and training in relation to the treatment and management of CP. This lack of sufficient teaching and training can result in poor treatment choices.^[29] Coding of CP into ICD-11 has given us an opportunity devise uniform treatment guidelines. Furthermore, the basic assessment, evaluation, and management of CP should be included in the basic medical education teaching curricula.

Conclusion

CP is a significant public health problem utilizing massive health resources, but still, suboptimal outcomes. Psychosocial factors in addition to biological factors play a significant role in patients with CP; therefore, therapeutic interventions must include psychological therapies, especially CBT. CBT has been found to be effective in alleviating CP across a wide spectrum of CP syndromes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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