PAIN: PSYCHOLOGICAL
PARADIGMS AND PRACTICE



INTRODUCTION



Inexplicable pain and suffering have long been of interest to clinical psychologists. The goal of Freud and the psychoanalytic pioneers was to reduce phenomenological experience and constructs to their underlying biological mechanisms and processes. In the 1930's, active efforts were undertaken to correlate physical and emotional experience. This led to the development of psychosomatic approaches. An understanding of the historical significance of the psychosomatic approach is helpful in evaluating current psychological approaches to the treatment and evaluation of pain.

The search to meaningfully link physical and psychological experience had to first overcome a 200-year scientific paradigm that separated mind and body, i.e. Cartesian Dualism. The separation of the body from the mind (and soul) had allowed early medical practitioners to investigate the workings of the human organism in both its diseased (and less often) healthy state. The pioneers of psychosomatic research shifted their emphasis to the psyche. Early theories hypothesized that specific intrapsychic conflicts were reflected in pathological physical processes. The longstanding psychoanalytic interest in conversion disorders served as a foundation for this thinking. Treatment strategies to treat so-called psychosomatic disorders (ulcers, low back pain, asthma) were postulated on the need to discover unconscious conflicts that would be physiologically expressed via specific symptom paths. As an example, oral dependent conflicts would be the cause of asthma, anal expressive conflicts led to low back pain. These formulations were abandoned by all but the most orthodox psychoanalytic practitioners by the early 1960's. Analogous thinking, however, continues to inform the more psychodynamically-oriented practitioners of psychotherapy. Treatment strategies based on these formulations have never demonstrated significant success in the treatment of pain related conditions and chronic pain syndrome. Psychodynamic approaches have been supplanted by behavior orientations which are discussed next.

At the same time that psychoanalytic pioneers were developing their psychosomatic approaches, academic psychologists in the United States were following in the footsteps of John Watson to develop a psychology based on scientific principles derived from the higher sciences, particularly physics. This led to the development of behaviorism and a study of the mechanisms of human and animal learning. Foremost among the practitioners of behaviorism was the Harvard psychologist B.F. Skinner. By the 1940's and early 1950's, psychologists began to utilize principles derived from Skinner's theory to change human behavior. It is important to note that the conceptualization involved in these efforts were to "change behavior" rather than to "cure disease." Such approaches laid the genesis for behavioral medicine, health psychology, and the psychotherapy now termed cognitive therapy. This paradigm and the practices based upon it form the foundation for the modern evaluation and treatment of pain experiences and pain behavior by psychologists. Operating independently or as part of a team, psychologists strive to examine pain behavior and the experience of pain from a biopsychosocial perspective. Such an approach departs from the longstanding disease model, which focuses on a search for fixed physical causes of pain and mechanical or chemical palliatives. Recognizing that the medical/mechanical model is useful in the diagnosis and treatment of the narrow spectrum of acute pain, psychologists have attended in a more systematic fashion to the broad spectrum of chronic pain. The remainder of this paper will examine the psychological, biological, and social factors frequently addressed by psychologists in the management of chronic pain conditions.


BIOLOGICAL CONSIDERATIONS


NOCICEPTION refers to the actual physiological event that we label pain. This event involves the activation of particular fibers. It is a biochemical event. PAIN is a subjective experience. It can occur in the absence of nociception and paradoxically, nociception can occur without the experience/report of pain. SUFFERING is the emotional response to a combination of nociception and a variety of other central nervous system inputs. People vary not only in their thresholds for pain and suffering, but in their thresholds for nociceptive responses as well. Many non-biological factors can affect pain. The western reductionistic tradition emphasizes nociception as the cause of suffering. Most of us (especially when we are suffering pain) strive to define pain as a biological event. With this orientation, biological (surgery, manipulation, chemical intervention, etc.) are the remedies most frequently sought. An exclusive reliance on a biological explanation for pain can lead to an inappropriate reliance on biologically-based therapeutics. This, in turn, can lead to dependency on chemical agents and dependency on health-care providers. In the absence of rapid remission (the desire of every pain patient), deconditioning frequently occurs. This will result in decreased stamina and increased fatigue. There is good reason to believe that this translates into actual biochemical events exacerbating pain and further complicating treatment efforts that depend on biological interventions alone. The foregoing factors have provided the impetus for the development of cognitive/behavioral strategies to manage pain. These factors are discussed next.



PSYCHOLOGICAL CONSIDERATIONS



Reductionistic models of pain conditions often assume an underlying structural defect or ongoing tissue damage. In the chronic stages of pain, however, barriers to improvement include psychological and social factors. Psychological approaches to the management of chronic pain refrain from posing the question: "Why does this person have pain?" and instead focus on contexts which are accompanied by pain, behaviors that communicate pain, and internal beliefs that maintain pain behavior. Common cognitions which can intensify the experience and report of pain include the tendency to personalize events, overgeneralization, catastrophization and the selective abstracting of negative events from the flow of experience. Cognitive therapy is employed with pain patients to aid them in identifying these cognitive distortions and substituting more accurate reality percepts. Pain, no matter what its origin or intensity, can adversely affect attention and information processing. Psychologists engaged in cognitive therapy with pain patients must make efforts to ensure that patients adequately attend to processing information provided in the course of the therapy hour. Psychologists frequently design recording templates for pain patients to record the occurrence, intensity, and circumstances proceeding and following events reported as painful. Psychologists employ these charting mechanisms not only to determine baselines and changes in pain behavior, but also to provide patients with an experience that they can exercise control over their behavior.

The so-called locus of control dimension has been systematically investigated by research health psychologists. It is assumed that persons who believe that they cannot control circumstances in their environment are more prone to pain behaviors and less likely to follow treatment recommendations because they believe that their pain is caused exclusively or predominantly by factors beyond their control. Experimental evidence (Smith, et al., 1994) supports this point of view. Smith's work also underscores the confounding effects of depression on pain (see below). Jensen and Karoly (1991) investigated the effects of control beliefs and coping efforts in the adjustment to chronic pain. Their findings indicated that the employment of positive coping self-statements, adoption of an internal locus of control, ignoring pain or diverting attention from pain could positively affect activity levels for low and moderately severe pain. This effect, however, was not noted with severe pain. This is a second confounding variable that must be taken into consideration when treating pain patients. Although the level of reported pain may be subjective, actual levels of pain may have differential effects on high pain level patients when they are compared to patients whose pain level is less severe. The subjective nature of this appraisal is regrettably most obvious and particularly vexing in forensic contexts. Secondary evidence that severe levels of pain may be less amenable to cognitive intervention stems from the work of Christensen, et al. (1991) who researched the health and locus of control beliefs of 96 hemodialysis patients. Patients with internal locus of control orientation more often hold the belief that health is a controllable experience and report less depression than persons with an external locus of control. This, however, was not true following receipt of information that a renal transplant had failed. Again, the nature of the pain context will affect psychological buffers.

Cause and effect dilemmas which bewitched early psychosomatic researchers are revisited when we examine the question of chronic pain and depression. Many theorists have long held that chronic pain syndrome (particularly low back pain) is simply a depressive equivalent. This question has been researched with mixed outcomes. Katon, et al. (1985) identified a sub-set of patients whose chronic pain syndromes were preceded by significant histories of depression and/or substance abuse. These subjects could be viewed as suffering from a chronic psychological pain syndrome which may be related to a somataform disorder (see the appendix). For these patients, chronic pain syndrome is most likely a depressive equivalent. In evaluating pain patients to determine the role played by depression, it is essential to differentiate between so-called endogenous and reactive depressions. Pain, be it acute or chronic, is invariably accompanied by some degree of depression. Persons who have a biological propensity to depression (so-called endogenous depression) will more likely be difficult to treat. A detailed history (see below) is essential for addressing this issue.

A complete and relevant history is essential for the treatment and forensic evaluation of pain patients. Every patient's experience of pain reflects that person's developmental history. Pain is often developmentally linked with themes of solace, punishment, aggression, loss, and sexuality (Blackwell, 1989). Appraisals and beliefs play an important role in the coping process. The patient's beliefs about the control, management and meaning of pain are essential in understanding so-called pain behaviors. Pain is a communicating experience, it is a symbol and it is a metaphor. No matter how rigorous the behavioral orientation, an appreciation of these dynamic factors is essential if the therapist is to make a successful and meaningful therapeutic intervention. Pain history will determine the relationship of stress to pain onset, pain maintenance and pain intensity. A pain history (including the responses of the patient's family of origin to sickness, trauma and pain) is vital. An adequate history will help the psychologist determine the role of state and trait factors as they influence pain. A skilled history taking, combined with adequate psychological testing (see below) will assist the clinician in differentiating the effects and outcomes of pain on personality from the pre-existing traits of character that influence the form of pain behavior expressed by the patient. It is essential to make this differentiation so as not to confuse cause with consequence.

Psychologists frequently employ tests and survey instruments in order to understand pain behavior and to facilitate the design of intervention plans. Perhaps the most frequently employed is the MMPI-2. The revision of the MMPI has come into common service since 1989. I prefer to employ computer-generated scoring and analysis of the instrument so to cross-check my clinical work and to develop alternative hypothesis. Occasionally, there is an over-reliance on the results of the MMPI, and this is particularly the case in forensic contexts. Utilization of an outside laboratory analysis of test results is of particular importance in the forensic context given the possibility of confirmatory bias. The Beck Depression Inventory is frequently employed in an effort to assay the role depression plays in chronic pain. The Millon Clinical Inventory is also useful as an adjunct to understand personality organization and coping styles. There exist various pain questionnaires and pain inventories that are useful in generating quantified results to compare pain experience pre- and post-intervention.

When interpreting test results, caution about cause and consequence is particularly in order. Nowhere is this more important than interpreting the so-called "V" seen on the MMPI 2. This obtains when the scores on Scale 1 and Scale 3 are higher than the score on Scale 2 (depression) and the conclusion is made that the reported somatic experience has a purely or predominantly psychological origin. Careful analysis of test results and integration with detailed history are essential when analyzing the meaning of the so-called "V."

The MMPI-2 can be useful in evaluating the possible presence of malingering - conscious efforts to exaggerate symptomology for financial gain. A variety of indices are employed to address this possibility. Again, given the possibility of unconscious bias, the computer-scored and analyzed assessment of the MMPI-2 is preferred. The so-called REY test can also be employed when conscious efforts to deceive are suspected. A thorough and detailed life history are essential in addressing the issue of possible malingering or significant exaggeration. The combination of psychological testing and a detailed history will also maximize the possibility for the appropriate diagnosis of somataform disorder as well as factitious disorder.

A discussion of the particular techniques employed by psychologists to treat the psychological aspects of pain behavior is beyond the scope of this paper. An excellent overview of the orientation to the psychological treatment of pain is afforded by Fordyce in his 1988 AMERICAN PSYCHOLOGIST article. The journals PAIN and JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY are excellent sources for descriptions of ongoing research and techniques in the field.



SOCIAL CONSIDERATIONS



A primary contribution of the behavioral approach to the study and treatment of pain behaviors addresses social/contextual influences. These investigations flow from the traditions of operative conditioning as well as social psychology. A guiding principal of this orientation is that behavior which maintains the sick role will ultimately lead to alienation of the patient from others or rejection of the patient by others. Pain behaviors can indirectly reinforce and maintain the sick role. Pain has both symbolic and functional significance in social interactions. If pain behaviors are followed by reinforcing consequences, the rate of pain behaviors will increase over time. This is well-demonstrated in the work of Schwartz, et al. (1994). This work studied persistence in a physically demanding task by chronic pain patients. Schwartz's study showed that stress via personal interactions increased subsequent pain behavior in patients with chronic back pain. The resulting demonstration confirmed what had long been suspected in terms of the social implications of pain behavior. The corollary of this finding is of potential usefulness for couples or family therapy in the treatment of chronic pain. Just as social reinforcements can powerfully affect the rate of exhibited pain behaviors, similar social reinforcement can be used to increase purposeful efforts to positively manage stress and pain.

Pain behaviors can also be negatively reinforced. NEGATIVE REINFORCEMENT is frequently confused with PUNISHMENT (the application of aversive stimuli). Negative reinforcement obtains when an aversive stimulus is removed. The removal of an aversive stimulus can then reinforce (increase the likelihood of elicitation) of the behavior that precedes it. Chronic pain patients who complain often are able to avoid the performance of tasks. The removal of the task demand then reinforces the likelihood that significant others of the pain patient will not demand adaptive behavior. The cycle is then mutually reinforcing and pain behaviors increase, and coping behaviors decrease. Alienation and marital discord then tend to increase, followed by depression with concomitant further increases in pain behavior. The role of family education is important here in that family members often must be made aware that "hurt" and "harm" are not the same.

The sick role is quite powerful and often socially supported. Our disability system, including workers' compensation system, often offers significant incentives not only to the pain patient but to the pain patient's family for maintenance of the sick role. The solution to these problems are as much political as psychological and/or medical. (Matranga, 1992).



CONCLUSION



More than a decade ago, Katon (1985) estimated that there were more than eight million visits annually for low back pain. Tens of billions of dollars are expended in medical care, loss productivity and litigation costs regarding chronic pain. There are no real indications that chronic pain (particularly low back pain) is increasing. There are clear indications that social or political factors drive litigation regarding workers' compensation and non-workers' compensation chronic pain issues. The search for certainty remains elusive. Boden (1990) and his colleagues did a systematic investigation on asymptomatic persons using magnetic resonance imaging. Results indicated that organic or structural pathology could be identified in one-third of these individuals and in more than one-third of the individuals over the age of 60. False positive findings are not confined to MRI studies. Likewise, false negative findings have a profoundly negative impact on sufferers of chronic pain. The contributions of psychology to the diagnosis and management of chronic pain have emphasized a shift from a cure to rehabilitation. At the same time, this shift refocuses responsibility from those treating chronic pain patients to the patient themselves. Fordyce (1988) has mentioned that suffering belongs to the person and disability is a legal and social judgment. Psychologists will continue to play an important role in the forensic context. Psychologists bring to this task training and experience in several fields related to the study of chronic pain. These include training in the areas of psychological testing, social psychology, group dynamics, motivation and learning, and clinical pathology. Psychologists will continue to play important roles as members of a comprehensive health team in the treatment of chronic pain. Significant advances in the conceptualization, diagnosis and management of chronic pain have been made in the past 20 years. Continuing advances will demand great measures of courage, compassion and research support.



BIBLIOGRAPHY


Behavioral Sciences and the Law. (1991). Worker's Compensation. Volume 8, No. 4.

Blackwell, Barry. (1989). Chronic Pain. In H. Kaplan and B. Sadock (Eds), Comprehensive Textbook of Psychiatry. Baltimore: Williams and Wilkins, 1264-1271.

Bodon, S., Davis, D., and T. Tina (1990). Abnormal MRI Scans of the Lumbar Spine in Asymptomatic Subjects. Journal of Bone and Joint Surgery, 72-A, 403-408.

Christensen, A., Turner, C. and W. Smith (1991). Health Locus of Control and Depression in End Stage Renal Disease. Journal of Consulting and Clinical Psychology, 59, 3, 419-424.

Diagnostic and Statistical Manual of Mental Disorders - IV Edition. Washington DC. American Psychiatric Press, 1995.

Fordyce, W.E. (1988). Pain and Suffering. American Psychologist, 43, 4, 276-283.

Holroyd, K., Nash, J. and J. Pingel (1990). A Comparison of Pharmacological (Amitriptyline HCL) and Nonpharmacological (Cognitive-Behavioral) Therapies for Chronic Tension Headaches. Journal of Consulting and Clinical Psychology, 59, 3, 387-393.

Jensen, M. and P. Karoly (1991). Control Beliefs, Coping Efforts and Adjustment to Chronic Pain. Journal of Consulting and Clinical Psychology, 59, 3, 431-438.

Katon, W., Egan, K., et al. (1985). Chronic Pain: Lifetime Psychiatric Diagnoses and Family History. American Journal of Psychiatry, 142, 10, 1156-1166.

Matranga, Jeff (1992). The Search to Substantiate Pain and Suffering Perpetuates Pain and Suffering. Augusta: Maine Bar Association.

Patterson, D., et al. (1992). Hypnosis for Treatment of Burn Pain. Journal of Clinical and Consulting Psychology, 60, 5, 713-717.

Schwartz, L., Slater, M., et al. (1994). Interpersonal Stress and Pain Behaviors. Journal of Consulting and Clinical Psychology, 62, 4, 861-864.

Smith, T., O'Keefe, J., et al. (1994). Cognitive Distortion and Depression in Chronic Pain. Journal of Consulting and Clinical Psychology, 62, 1, 95-198.

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