Psychological Aspects of Pain

Psychogenic Aspects

Acute pain: response to a noxious stimulus designed to protect the body; leads to mental state of heightened awareness, allowing you to fix what’s wrong

Chronic pain: leads to mental state of depression which leads to worsening of the pain, more depression, etc.

Variables in pain perception:

attention

social situation: wartime or sports injuries are often percieved as less painful at the time

cultural influences: i.e. Mediterranean cultures tend to be vocal about pain, Westerners tend to be more stoic

past pain experiences: how pain was treated when you were young influences how you see it as an adult

Doctor-patient disagreement regarding severity: because there are no concrete tests to quantify pain, doctors tend to underestimate and undertreat patients with chronic pain; this tendency is potentiated by a doctor’s fear of causing an addiction to pain meds; take patient’s pain at face value until proven otherwise

Pain description: usually done through analogy; difficult for patients to describe because it is a subjective experience often with emotional components

Psychogenic Pain: complaints of pain without adequate physical findings and with evidence of psychological factors

pain/pleasure principle: helps explain why create psychogenic pain if it is by definition painful; physical pain may be relative pleasure if it relieves other feelings such as guilt, anxiety, etc.

Diagnosis: does depression cause pain or pain cause depression?; hypochondriasis, somatization disorder, disability syndromes, malingering

Psychological Aspects

Pain Modulating Factors

mood: depression and pain are interrelated; other symptoms of depression related pain include: sleep disturbance, loss of interest in activities and social interaction; sleep deprivation is important because it can often mimic depression or worsen its symptoms

environmental context: pain is often reinforced by the environment; i.e. pain complaints elicit attention, allow patient to skip work/school; patient may not be aware of the effect of these reinforcements

cognitive: pain is modulated by patient’s beliefs; i.e. what they think the underlying process is may make the pain worse, expectations of pain medication, etc.

psychosocial: family environment is very important in modulating pain through reinforcement

personality: may modulate pain; patient with certain personalities inherently make them more difficult to treat (i.e. borderline)

Abnormal pain behavior: incidence of malingering is low, but suspicion is high; patient complaints should be taken at face value until proven otherwise

Addiction and medication abuse: narcotics are becoming more accepted as a form of long-term therapy within guidelines:

no prior history of addiction or abuse
meds administered on a regular schedule rather than as needed
meds should improve pain, rather than reinforce pain behavior

Psychological evaluation of pain should include:

function of the pain for the patient: litigation, potential benefit of pain for patient
situations that cause fluctuation of pain (i.e. is it just during the work week?)
how it is expressed, how others respond, behavioral manifestations
assessment of mood: see above

Treatment

meds: regular dose rather than prn; eliminate narcotics when appropriate; medication masking when appropriate (try different doses, meds blinded to patient with their permission)

non-pharm: heat/cold, exercise (doesn’t relieve pain, but makes patient more functional); desensitization (particularly useful in reflex sympathetic dystrophy); train patient not to modulate activity so as not to over/under do it; train patient in self-management (very important pain management to have patient look internally for relief)