DEALING WITH PAIN:Acute Clinical Pain, Chronic Clinical Pain

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Health Psychology PSY408

Lesson 26

DEALING WITH PAIN

Clinical Pain

Not all of our pain experiences receive professional treatment, and not all of them require it. The term

clinical pain refers to any pain that receives or requires professional treatment. The pain may be either acute

or chronic and may result from known or unknown causes. Clinical pain calls for treatment in and of itself,

and not only because it may be a symptom of a progressive disease, such as arthritis or cancer. Relieving

pain is important for humanitarian reasons, of course--and doing so also produces medical and

psychosocial benefits for the patient. Let's look at medical and psychosocial issues that are associated with

controlling clinical pain, beginning with acute pain.

A. Acute Clinical Pain

By using techniques to prevent or relieve acute pain, practitioners make medical procedures go more

smoothly, reduce patients' stress and anxiety, and help them recover more quickly. Much of the acute pain

people experience in today's world has little survival value. What survival value would there be in feeling the

pain as a dentist drills a tooth or a surgeon removes an appendix? How would people's survival be enhanced

by feeling the intense pain that accompanies normal healing while resting in a hospital during the days after

surgery? But one thing is important; i.e., if acute pain is ignored, it can sometimes develop into more severe

conditions or chronic pain.

B. Chronic Clinical Pain

When pain persists and becomes chronic, patients begin to perceive its nature differently. Although in the

acute phase the pain was very aversive, they expected it to end and did not see it as a permanent part of

their lives. As the pain persists, they tend to become discouraged and angry and are likely to seek the

opinions of many other physicians. This can be constructive. But when this is not successful, and as patients

come to see less and less connection between their discomfort and any known or treatable disorder,

increasing hopelessness and despair may lead them to resort to consulting quacks.

The transition from acute to chronic pain is a critical time when many of these patients develop feelings of

helplessness and psychological disorders, such as depression, especially if he pain is disabling. These

changes typically parallel alterations in the patients' lifestyles, employment status, and family lives.

Chronic pain often creates a broad array of long-term psychosocial problems and impaired

interrelationships, which distinguish its victims from those of acute pain.

Individuals who receive treatment for their pain after it has progressed and become chronic tend to exhibit

certain physical and psychosocial symptoms that characterize a chronic pain syndrome. According to

psychologist Steven Sanders (1985), these symptoms include:

· Persistent pain complaints and other pain behaviors, such as grimacing or guarded movement, when in

discomfort.

· Disrupted daily activity patterns, characterized either by a general reduction or by recurrent large

fluctuations.

· Disrupted social, marital, employment, and recreational activities.

· Excessive use of drugs or repeated use of surgical procedures to relieve pain.

· Disturbed sleep patterns.

· Increased anxiety and depression.

Chronic pain patients usually exhibit the first two symptoms and at least one of the remaining ones.

Generally speaking, the more symptoms the patient presents, the greater the impact the pain has had and

the greater the maladjustment it has produced.

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Because of the differences between acute pain and chronic pain in their duration and the effects they have

on their victims, these conditions usually require different treatment methods. Health care professionals

need to distinguish between acute and chronic pain conditions and provide the most appropriate pain relief

techniques for the patient's needs. Failing to do so can make the condition worse. Keeping this caution in

mind, we will now turn our attention to the many medical, psychological, and physical techniques available

to help control patients' pain.

1. Medical Treatments for Pain

Historically, most of the pain relieving practices adopted by the medical professionals was brutal especially

if they involved some form of surgery. In 19th-century America, alcoholic beverages and medicines laced

with opium were readily available. Today when patients suffer from pain, physicians and doctors try to

reduce the discomfort in two ways-- surgically and chemically.

A. Surgical Methods for Treating Pain

Treating chronic pain with surgical methods is a relatively radical approach, and some surgical procedures

are more useful than others. In some procedures, the surgery removes or disconnects portions of the

peripheral nervous system or the spinal cord, thereby preventing pain signals from reaching the brain. These

are extreme procedures--and if they are successful, they produce numbness and, sometimes, paralysis in the

region of the body served by the affected nerves. But these procedures seldom provide long- term relief

from the pain, which is often replaced after some days or months by pain and other sensations that are

worse than the original condition. Because of the poor prospects of permanent relief and the risks involved

in these surgical procedures, they are rarely used today.

Other surgical procedures for relieving pain do not remove or disconnect nerve fibers and are much more

successful. One example is the Synovectomy, a technique whereby a surgeon removes membranes that

become inflamed in arthritic joints. Surgery procedures are commonly used in the United States to treat

back pain, but there is little evidence that they produce better long-term pain reduction than non-surgical

methods, and they are used at a far lower rate in other developed countries, such as Denmark and England.

Surgery for chronic skeletal pain conditions is most appropriate when the person is severely disabled and

non-surgical treatment methods have failed. Physicians and patients usually prefer other medical

approaches, such as chemical methods.

B. Chemical Methods for Treating Pain

The field of medicine has been much more concerned with developing methods for curing disease than

with reducing pain. Let's look at the use of chemical methods for treating acute and chronic pain.

Using Chemicals for Acute Pain

Many pharmaceuticals are very effective for relieving acute pain, such as after surgery. Physicians choose the

specific drug and dosage by considering many factors, such as how intense the pain is and its location and

cause.

Using Chemicals for Chronic Pain

When a patient is dying, practitioners generally view options for pain relief differently from those when a

person has chronic pain from a non-terminal illness. Many health care practitioners have long advocated

using narcotics for the relief of severe pain in cancer patients, and narcotic analgesics are commonly

prescribed when these patients are dying. In some cases of cancer, severe pain becomes chronic as the

disease progresses.

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To summarize, medical treatments of pain focus mainly on using chemical approaches to reduce

discomfort. For chronic pain patients, these approaches can be enhanced when combined with pain control

methods that other health care professions provide. Physicians usually want to minimize the use of

medication by their patients, especially when drugs would be taken on a long-term basis. Reducing the

patient's drug consumption is one of the goals in using other methods of pain control with pain patients.

2. Psychological Methods for Treating Pain

In today's world, plentiful research evidence suggests that pain can be controlled not only by biochemical

methods that alter sensory input directly, but by modifying motivational and cognitive processes, too. This

more complex view of pain provided the rationale for psychologists to develop techniques to help patients

(1) cope more effectively with the pain and other stressors they experience and (2) reduce their reliance on

drugs for pain control. Psychologists have developed approaches involving behavioral and cognitive

methods, and we will examine some of these approaches here.

1. Behavioral Methods

The first approach focuses on changing patients' pain behavior through techniques of operant conditioning.

A. The Operant Approach

Consider the case of a 3-year-old girl whose pain behaviors hampered her rehabilitation after she suffered

severe burns months earlier. The help therapists provided was successful. The approach the therapists used

in changing this girl's behavior involved extinction procedures for her pain behavior and reinforcement for

appropriate, or well, behavior.

Observations of the child's social environment revealed that the hospital staff reinforced her pain

behaviors--crying, complaining of pain, resisting the nurse's efforts to put her splints on, and so forth--by

giving attention to those behaviors and allowing her to avoid uncomfortable or disliked activities, such as

physical therapy. To change this situation, the therapists instructed the hospital staff to:

· Ignore the pain behaviors they paid attention to in the past.

· Provide rewards for obedient behavior--telling her, for instance, "If you don't cry while I put your splints

on, you can have some cookies when I'm finished, or, lf you do this exercise, we can play a game."

Changing the consequences of her behavior in these ways had a dramatic effect: her pain behaviors

decreased sharply, and she began to comply with requests to do exercises, make positive comments about

her accomplishments, and assist in putting on her splints,

The operant approach to treating pain can be adapted for use with individuals of all ages, in hospitals and at

home--and elements of the operant approach can be introduced before pain behavior becomes chronic.

But treatment programs using this approach are usually applied with patients whose chronic pain has

already produced serious difficulties in their lives. These programs typically have two main goals: the first is

to reduce the patient's reliance on medication. The second goal of the operant approach is to reduce the

disability that generally accompanies chronic pain conditions.

The reinforcers may be of any kind-- attention, praise and smiles, candy, money, or the opportunity to

watch TV, for example--and may be formalized within a behavioral contract. The therapist periodically

reviews the record of pain behavior to determine whether changes in the program are needed. Studies have

shown that operant techniques can successfully decrease patients' pain reports and medication use and

increase their activity levels.

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B. Relaxation and Biofeedback

Many people experience chronic episodes of pain that result from underlying physiological processes, and

these processes are often triggered by stress. If these patients could control their stress or the physiological

processes that cause pain, they should be able to decrease the frequency or intensity of discomfort they

experience. Thus relaxation and biofeedback methods are effective in treating and reducing pain.

2. Cognitive Methods

To help people cope effectively with pain, medical and psychological practitioners need to assess and

address their patients' beliefs. Cognitive techniques for treating pain involve active coping strategies, and

many of these methods are, in fact, quite effective in helping people cope with pain. These techniques can

be classified into three basic types: distraction, imagery, and redefinition. We will examine these methods

and consider their usefulness for people with acute and chronic pain.

A. Distraction

Distraction is the technique of focusing on a non-painful stimulus in the immediate environment to divert

one's attention from discomfort. We can be distracted from pain in many ways, such as by looking at a

picture, listening to someone's voice, singing a song, counting ceiling tiles, playing a video game, or doing

mathematics problems.

Distraction strategies are useful for reducing acute pain, such as that experienced in some medical or dental

procedures, and they can also provide relief for chronic pain patients in some circumstances. Singing a song

or staring intently at a stimulus can divert the person's attention for a short while--and this may be a great

help, such as for an arthritis sufferer who experiences heightened pain when climbing stairs. People who

want to use distraction for moderate levels of continuous pain may get longer-lasting relief by engaging in

an extended engrossing activity, such as watching a movie or reading a book.

B. Imagery

Sometimes when children are about to receive injections, their parents will say something like, it'll be easier

if you think about something nice, like the fun things we did at the park." Non-pain imagery--sometimes

called guided imagery--is a strategy whereby the person tries to alleviate discomfort by conjuring up a

mental scene that is unrelated to or incompatible with the pain. The most common type of imagery people

use involves scenes that are pleasant to them--they think of "something nice. This scene might involve

being at the beach or in the country, for instance.

Therapists usually encourage, or "guide," the person to include aspects of different senses: vision, hearing,

taste, smell, and touch. As an example, the scene at the beach could include the sight and smell of the ocean

water, the sound of the waves, and the warm, grainy feel of the sand. The person generally tries to keep the

imagined event in mind as long as possible.

The imagery technique is in many ways like distraction. The main difference is that imagery is based on the

person's imagination rather than on real objects or events in the environment. As a result, individuals who

use imagery do not have to depend on the environment to provide a suitably distracting stimulus. They can

develop one or more scenes that work reliably, which they "carry" around in their heads.

Although imagery clearly helps in reducing acute pain, the extent of this technique's usefulness with longer-

lasting pain episodes is unclear. One limitation with using imagery in pain control is that some individuals

are less adept in imagining scenes than others.

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C. Redefinition

The third type of cognitive strategy for reducing discomfort is pain redefinition, in which the person

substitutes constructive or realistic thoughts about the pain experience for ones that arouse feelings of

threat or harm. Therapists can help people redefine their pain experiences in several ways. One approach

involves teaching clients to engage in an internal dialogue, using positive self-statements. There are basically

two kinds of self-statements for controlling pain:

A. Coping statements emphasize the person's ability to tolerate the discomfort, as when people say to

themselves, "It hurts, but you're in control," or, "Be brave-- you can take it".

B. Re-interpretative statements are designed to negate the unpleasant aspects of the discomfort, as when

people think, it's not so bad," "It's not the worst thing that could happen," or, "It hurts, but think of the

benefits of this experience." This last statement can be particularly appropriate when undergoing painful

medical procedures.

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