The Psychology of Pain: Understanding and Management in

Nursing Care

Group Presentation

SHAHID HUSSAIN

OBJECTIVESAt the end of this session, students will be able to:

1.Define pain.

2.Explain the types of pain.

3.Explain physiological perspective of pain (brief).

4.Discuss psychological perspective of pain (gate-control theory, bio-psychosocial model of pain, etc.).

5.Factors affecting pain perception including psychological, social and biological.

6.Discuss treatment approaches for pain management (recent researches).

7.Discuss the role of nurses in pain management.

DEFINITION OF PAIN • Pain is an unpleasant sensory and emotional

experience associated with the actual and potential tissue damage .

(Fishman, Ballantyne and Rathmell. 2011)

TYPES OF THE PAIN There are several types of the pain. Main types of the pain are listed below.

1.Acute pain

2.Chronic pain

3.Referred pain

4.Phantom pain

ACUTE PAIN:

Acute pain is characterized by injury of body tissues and activation of nociceptive transducer at the site of local tissue damage. Acute pain is severe as compare to the chronic pain .

(Picone, 2012)

CHRONIC PAIN:Chronic pain is characterized by injury or disease that is caused by remote factors. The chronic pain extend for long period of time. It’s represented level of pain is low as compared to acute pain.

(Stannard, Kalso, Ballantyne (Eds.) 2010)

REFERRED PAIN:Referred pain is defined as the perceived pain at a site nearby or even at a distance from the pain’s origin.

(Fishman, Ballantyne and Rathmell. 2011)

PHANTOM PAIN:Phantom pain sensation refers to the perception of a variety of physical feelings in a part of the body that has been removed. Although this is generally associated with limb amputation.

(Flor, Nikolajsen, Jensen, MacIver, Lloyd, Kelly, and Nurmikko, (2010).

PHYSIOLOGY OF PAIN

(Yoneda, Hata, Nakanishi, Nagae, Nagayama, Wakabayashi, and Hiraga, 2011).

SPECIFICITY THEORY• Earliest theory of pain proposed by Rene Descartes in 17th century.• There is a direct relationship between nerve endings and pain spots on our

body.• Pain travels to the brain in only one pathway, which is the same path used

by other sensations. • The Specificity Theory stated that pain is "a specific sensation, with its own

sensory apparatus independent of touch and other senses".• Severity of injury is directly proportional to the level of experienced pain.

CRITICISM: • All nerve fibers in our body are not pain receptors, but there are some

specialized pain receptors in our body.– Example: severely wounded soldiers in battle complain of less pain

contrary to extreme pain in minor injuries.• A single stimulus type (e.g., a blow, electric current) can produce different

sensations depending on the type of nerve stimulated. (Dean, Gwilym, Carr. 2013)

Nerve Fibers For Pain

(http://ucalgary.ca/pip369/mod7/tempain/theories)

Proposed by Ronald Melzack & Patrick David Wall in 1965.

Proposed by Ronald Melzack & Patrick David Wall in 1965.

Pain stimulus on

skin

Pain stimulus on

skin

Nerve impulses transmit

pain to the spinal cord

Nerve impulses transmit

pain to the spinal cord

Gates in spinal cord

Gates in spinal cord

Pain is sensed if gates are

open

Pain is sensed if gates are

open

Pain is not

sensed if gates are

closed

Pain is not

sensed if gates are

closed

• Opening and closing of gates also depends upon numerous factors:

– person’s attention to the pain source, emotion, anxiety, coping ability and physical damage to the body.

• The brain provides information about the psychological state of an individual, including behavioral and emotional states and previous experience of similar stimulus.

(Kandel, Schwartz & Jessel. 2000).

INHIBITORY INTERNEURON

PROJECTION NEURON

Aβ fiber

C fiber

Pain sensed

INHIBITORY INTERNEURON

PROJECTION NEURON

Aβ fiber

C fiber

Pain not sensed

Biopsychosocial Model

BIOLOGICALNociception

Tissue DamageDisease Process

BIOLOGICALNociception

Tissue DamageDisease Process

PSYCHOLOGICALPain beliefs

Locus of controlLack of self-efficacy

Limited copingEmotions

PSYCHOLOGICALPain beliefs

Locus of controlLack of self-efficacy

Limited copingEmotions

SOCIALCultural influences

Learning mechanismssocial learning

reward/punishmentclassical conditioning

SOCIALCultural influences

Learning mechanismssocial learning

reward/punishmentclassical conditioning

PSYCHOLOGICAL FACTORS1. LOCUS OF CONTROL:• Rotter (1996) stated that there were “internal” and “external” Locus

of control.

• The “internals” (believe that their own actions significantly influence their health)

• The “externals”(believe that they don't have much control over their health)

• People with a strong internal LOC believed to have good control over their pain and are able to adapt by effective coping strategies and manage pain better than those with an external LOC.

• Persons who believe that the prognosis for their pain is influenced mainly by luck or fate (external) are engage in maladaptive coping strategies such as wishful thinking or catastrophizing.

(Worsham, 2006)

2. CATASTROPHIZING COGNITIONS:• Pain catastrophizing is characterized by the tendency to magnify

the threat value of pain stimulus and to feel helpless in the context of pain, and by a relative inability to inhibit pain-related thoughts in anticipation of, during or following a painful encounter.

• A “Neurophysiological Model” of catastrophizing proposes that:

• Catastrophizing cognitions are associated with higher levels of brain activity in the areas of anticipation and attention to pain, emotional aspects of pain and motor control and are linked to higher levels of pain intensity, greater disability, poorer psychosocial adjustment.

Cont…• In a research study pain catastrophizing was assessed

pre-surgery.• The results showed significant variance in

postsurgical pain ratings, narcotic usage, depression, pain-related activity interference and disability levels.

• Another study by Edwards, suggested that pain catastrophizing was related to increased suicidal ideation in a large sample of chronic pain patients.

3. SELF-EFFICACY AND

EFFECTIVE COPING:• In a Research study low levels of self-efficacy was found to be

associated with a lower levels of pain tolerance and higher levels of pain intensity in samples of people with chronic pain.

• People who believe that they can alleviate pain are likely to mobilize whatever skills they have learned to preserve themselves.

• The higher the perceived self-efficacy the longer pain can be tolerated and less medications are required.

• Individuals who experience pain may develops two types of coping.

• Adaptive coping: active coping strategies are considered to be adaptive in which patient is an active participant and assumes self management responsibilities.

• Maladaptive coping: these are passive coping strategies in which patient withdraw from activities and shows dependency on others for pain relief. (Placebo)

• Studies have found that active coping strategies decreases the pain intensity and increases pain tolerance.

• However, passive coping is associated with greater pain and related depression.

Cont…

4. PAIN AND EMOTIONS: • The typical emotional reaction to pain includes anxiety, fear, anger,

guilt, frustration, and depression.

• According to FAM (Fear-avoidance model) “Fear of pain” is the most important emotional factor in perception of pain.

• A fear response to pain leaves an individual with two options: Confrontation (Menstrual pain) Avoidance (Fracture pain and hygiene care)

• The “Confronter” is more likely to view pain as temporary , is motivated to return to normal work, social and leisure activities, and is prepare to confront their personal pain barriers.

Cont…• The pain “Avoider” is motivated by fear and avoid both pain experience

(cognitive component) and painful activities (behavioral component).

• Thus, this avoidance leads to more pain and is harmful to the recovery process.

• Certain other negative emotions such as anger, hostility and depressed mood can also influence pain perception.

• Negative emotional states registers in the brain in a manner that strikes brain pathways which are responsible for enhancing pain.

• The expression of anger and hostility are often used as defensiveness and can seriously compromise the therapeutic relationship between nurse-patient, which further deteriorates patient’s condition.

NEUROTICISM EXTRAVERSION (Eysenk’s personality theory): High neuroticism is the result of cortical arousal which increases sensitivity and contributes to emotional instability. Such individuals are more likely to worry about physical symptoms like (pain).

(Eysenk’s personality theory): Extraversions have low cortical arousal, requiring more frequent and stronger stimulation to acquire satisfactory levels of arousal. As a result, extravert exhibit diminished pain sensitivity and higher pain threshold.

These individuals generally do not cope well with stress and perceive painful stimulus as threatening and distressful.

Extraversion is also associated with use of active and strong coping strategies that lead to better adaption to painful stimulus. (For example, being optimistic)

certain dimension of neuroticism negatively correlates with pain (experiment):1.Negative mood decreases pain tolerance time.2.Emotional vulnerability increases pain intensity and unpleasantness.

Extroversion is positively associated with general health perception. Individual both healthy and with self-reported medical problems feel good about themselves and try to mobilize all their resources to maintain this state of health.

Neuroticism is significantly high in patients with lower back pain, joint pain and cancer pain etc.

Extraversions are more likely to complain about their pain and express their sufferings than individuals high in neuroticism.

http://books.google.com.pk/books?id=vwjIskXBbu8C&pg=PA28&dq=pain+and+extraversion+personality&hl=en&sa=X&ei=zRujUcr7JsezhAeayYAY&ved=0CDAQ6AEwAQ#v=onepage&q=pain%20and%20extraversion%20personality&f=false

CULTURE AND GENDER (SOCIAL FACTOR)

CULTURE: GENDER:

PAIN CONTROL TECHNIQUES

1. PHARMACOLOGICAL CONTROL OF PAIN:

It is the traditional and most common method of controlling pain

Narcotics are well known in controlling pain. Amongst narcotics, morphine (the Greek GOD of sleep) has been the most popular pain killer for decades.

However, pharmacological control of pain is the potential for addiction.

2. SURGICAL CONTROL OF PAIN: Some techniques attempts to disrupt the conduct of

pain from the periphery to the spinal cord, whereas others are designed to interrupt the flow of pain sensations from the spinal cord upward to the brain.

Moreover, there is some indication that surgery can ultimately worsen the problem because it damages the nervous system, and this damage can itself be a chief cause of chronic pain.

3. SENSORY CONTROL OF PAIN:One of the oldest known techniques of pain control is COUNTERIRRITATION, a sensory method. Counterirritation involves inhibiting pain in one part of the body by stimulating or mildly irritating another area. Overall, sensory control techniques have had some success in reducing the experience of pain. However, their effects are often only short-lived, and they may therefore be appropriate primarily for temporary relief from acute pain.

RELAXATION TECHNIQUES Rationale for teaching pain patients relaxation

techniques, is that it enables them to cope more successfully with stress and anxiety, which may also ameliorate pain.

Relaxation may also affect pain directly, for e.g. the reduction of muscle tension or the diversion of blood flow induce by relaxation may reduce pains that are tied to these physiological processes.

In relaxation, an individual shifts his or her body into a state of low arousal by progressively relaxing different parts of the body.

The common relaxation technique nurses use in their practice is encouraging patients in deep breathing exercises mainly to divert their minds from painful procedures for instance IV cannunlation and early labor.

Generally, relaxation is modestly successful with some acute pains and may be value in treating chronic pain when used in conjunction with other methods of pain control.

Cont…

HYPNOSIS In 1829, prior to the discovery of anesthetic drugs, a French surgeon,

Dr. Cloquent, performed a remarkable operation on a 64 year old women who suffered from breast cancer and the tumor was being removed without

anesthesia through hypnosis and the lady felt no pain. First, a state of relaxation is encouraged. Next, patients are explicitly told that the hypnosis will reduce

pain. In the hypnotic trance, the patient is usually instructed to think

about the pain differently It has been used successfully to control acute pain due to surgery,

child birth, dental procedures, burns and headache as well.

In acupuncture treatment, long thin needles are inserted into specially designated areas of the body that theoretically influence the areas in which a person is experiencing pain. (Practiced in china for more than 2,000 years).

How acupuncture controls pain is not fully known. But it is possible that acupuncture triggers the release of endorphins, thus reducing the experience of pain.

When Naloxone (an opiate antagonist) is administered to acupuncture patients, the success of acupuncture in reducing pain is reduced.

DISTRACTION• Individual who are involved in intense

activities like sports or military maneuvers can be oblivious to pain full injuries due to Distraction

Cont… There are two quite different mental

strategies for controlling discomfort.

To distract oneself by focusing on some other activity.

To distract oneself by focusing on some other activity.

Focus directly on the events but to reinterpret the experience.

Focus directly on the events but to reinterpret the experience.

Cont… Distraction appears to be most effective for

coping with low-level pain. Its practical significance for chronic pain is limited by the fact that such patients cannot distract themselves indefinitely.

GUIDED IMAGERY Guided imagery has been used to control some

acute pain and discomfort.In guided imagery a patient is instructed to

conjure up a picture that he or she holds in mind. This process brings on a relaxed state,

concentrates attention, and distracts the patient from the pain or discomfort.

Apart from calm and pleasant guided imagery, some patients take more personally aggressive stance towards pain, these patients use it to rouse themselves into a confrontive stance by imagining a combat and action filled scene.

Cont… These two virtually opposite forms of

imagery may actually achieve some beneficial effects in controlling pain through the same means i.e. inducing positive mood state and both focus attention and provide a distraction from the pain.

COGNITIVE BEHAVIORAL THERAPY FOR PAIN

ACCEPTANCE AND COMMITMENT THERAPY

ACCEPTANCE AND COMMITMENT THERAPY

AWARNESS AND PERSPECTIVE

AWARNESS AND PERSPECTIVE

MINDFULNESSMINDFULNESS

COGNITIVE DE-FUSIONCOGNITIVE DE-FUSION

WILLINGNESSWILLINGNESS

COGNITIVE BEHAVIORAL

THERAPY

COGNITIVE BEHAVIORAL

THERAPY

McCracken, (2005).

COGNITIVE BEHAVIORAL THERAPY FOR PAIN

1. ACCEPTANCE AND COMMITMENT THERAPY:• Aim for ACT is to reduce the feelings of failure (drug dependency)

of strategies to control pain.

• The therapist creates a collaborative environment in which Patients with pain can review their actual problem and find out their previous way of struggling to solve this problem. This gives a clear understanding of the time duration of persisting problem and range of strategies tried by patient to improve situation.

• It helps identifying the actual problem which is not the pain itself, rather the behavior of disregarding oneself for the repeated failures to achieve an effective pain control.

2. AWARNESS AND PERSPECTIVE:

AnnoyingAnnoying Cramping

Throbbing

Weakening Stressful Radiating

Pulling Tiring Aching Tingling

DepressedAngry Frustrated

3. MINDFULNESS:

4. COGNITIVE DE-FUSION:• Marry had a………….• London bridge is……..

• Humpty dumpty sat on a………

• Ring-a-ring o' roses, A pocket full of posies, A-tishoo! A-tishoo! We all………

• But, what if, I can’t…..

5. WILLINGNESS:

REFERENCES • Ballanytyne, J. C., & Rathmell , J. P. (2010). Pain and its

taxonomy. In S. M. Fishman (Ed.), Bonica's management of Pain (14th ed., pp.13-20). Bostan, Massachuesetts: Lippincott William And Wilkin.

• Dean, B. F. F., Gwilyn, S. E., & Carr, A. J. (2013).Why does my shoulder hurt? A review of the neuroanatomical and biochemical basis of shoulder pain. British Journal of Sports Medicine,1-12. doi:10.1136/bjsports-2012-091492.

• Field, H.L. (2007). Pain perception — The Dana guide. Retrieved from

http://www.dana.org/news/brainhealth/detail.aspx ?id=10072

• Ge, H. Y., Nie, H., Madeleine, P., Danneskiold- Samsøe, B., Graven-Nielsen, T., & Arendt-Nielsen, L. (2009).

Contribution of the local and referred pain from active myofascial trigger points in fibromyalgia syndrome. Pain, 147(1), 233-240.

• Kandel, E. R., Schwartz, J. H., & Jessell, T. M. (2000). Principles of Neural Science (4th ed.). New York: McGraw-

Hill.• Macintyre, P. E., Scott, D. A., Schug, S. A., Visser, E. J., &

Walker, S. M. (2010). Acute pain management: scientific evidence. NHMRC.

• McCracken, L. M. (2005). Contextual cognitive-behavioral therapy for chronic pain, Progress in Pain Research and

Management, 33. pp. 74-89.

• Stannard, C. F., Kalso, E., & Ballantyne, J. (Eds.). (2010). Evidence-based chronic pain management. Wiley- Blackwell/BMJ.

• Theories of pain perception. (2013). Retrieved from http://ucalgary.ca/pip369/mod7/tempain/theories

• Yoneda, T., Hata, K., Nakanishi, M., Nagae, M., Nagayama, T., Wakabayashi, H., & Hiraga, T. (2011). Molecular events of

acid- induced bone pain. IBMS BoneKEy, 8(4), 195-204.