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The Psychology of Pain

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Lene Forrester

on 23 September 2013

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Transcript of The Psychology of Pain

The Psychology of Pain
Dr Lene Forrester

Understanding persistent pain
Psyche & Soma
Psychogenic pain
Psychological treatment
to be continued...
The importance of meaning
How we make sense of a health condition has large role in determining level disability , degree of pain & ultimate outcome (Petrie & Weinman (2012)
Sense of coherence/meaning attributed to pain more relevant to level of pain, functioning, disability & outcome than severity (Moss-Morris et al., 2007)
Meaning vacuum due to lack of explanations
Persistent pain epidemic
1/6 Europeans (Luo et al., 2012)
1/3 Americans (American Academy of Pain Management, 2012)
70% significant back pain (Barnsley, 2010)
Not reached non-Western countries (Alexander, 2012)
The invisible crisis at the centre of contemporary life (Morris, 2003)
Physical perspectives on pain
Standard biomedical model both physcialistic deductionist & dualistic (Russell, 1996)
Split between psychology & medicine
Advances in medical technology & successful treatment of many conditions; physicalist tendencies worthwhile
No serious advances in medical understanding of the underlying factors of persistent pain
The dogma of persistent pain
Due to physical strain; however
prevalence of disc abnormalities differ little between sedentary & heavy workload (Jensen et al., 1994)
structural abnormalities so common amongst people without pain that their explanatory role should be questioned (Jensen et al., 1994)
impaired median nerve construction in carpal tunnel syndrome also in 40% of people without pain (Lucire, 2003)
Reinforced by clinicians as only see people in pain
The problem with dualism
Western medicine
Hippocrates & Galen: role of psychology in physical ill health (Eysenck, 1985)
Sir William Osler (1906): "It is many times much more important to know what patient has the disease than what kind of disease the patient has (Eysenck, 1991)
Newton, Decartes & Church-approved doctrine, from organic to mechanistic world view
Disease breakdown of the machine & medicine to repair
Mechanistic culture, only physical realities "real"
Dichotomy of psychological/physical issues failing up to one quarter of people seeking medical treatment, not getting better (Sharpe, 2012)
Both physical & emotional trauma makes the brain more vigilant towards potential threat (Alexander, 2012)
Recurrent/multiple trauma give the brain more reason to protect the body & one method is pain (Butler & Moseley, 2003)
Psychological & social factors explain 70% of difference between injury resulting in recovery or persistent pain (Burton et al., 1995)
Pain & psychology
Success or failure of lumbar spine surgery & post-operative pain correlated to (multiple) abusive childhood experiences (Schofferman, 1992)
Personality factors over-represented in persistent pain population: strong work ethic, overly self reliant, strongly identify with caregiver roles, conflict avoidant & deny emotional problems (Barsky, 2009)
Strongest predictor of persistent back pain 4 years from acute; level of work satisfaction (Bigos et al., 1991)
Stress cardiomyopathy (Phan, 2012)
"Pointing the bone"
Around the world health professionals use clinical guidelines 40-60% (Runciman, 2012)
Proust (1921): "For each illness that doctors cure with medicine, they provoke ten in healthy people by inculcating them with the virus that is thousand times more powerful than any microbe: the idea that one is ill"
Australian 'magic-man' predicting death by pointing a bone, rapid death of healthy recipient (Lockwood, 2010
The gift of pain?
Although unwanted, presents with possibility of insight, healing & growth (Alexander, 2012)?
Mrs S
Low grade heart failure
Swelling of ankles
No loss of functioning, working FT etc.
Cardiology Prof. to trainees "TS" (Triuspid Stenosis)
Anxiety & panic: Terminal Situation
Catastropic dysfunction, pulse raced 150/min+, lungs moist crackles due to fluid, pulmonary edema & death (Zabat-Zinn, 2009)
Complex Interaction physical & psychological factors
Peptic ulcers
Thought to be caused by psychological factors, such as stress
Early 1980s: Helicobacter pylori purely physical condition
Current research: Both bacterium & psychological factors like sustained emotional stress
Also stress likely to induce: poor lifestyle choices & over-reliance on medication with side effects
Adrenal fatigue etc.
When injury causes no pain
Meaning of injury: WWI; ticket out, celebrating injury with no pain
New Years Eve event, 'blow to the head', 5 years later, lodged bullet (Alexander, 2012)
Rather than pain necessary result of injury, from brain's assessment of what should result: the brain's 'opinion' (Doidge, 2007)
Brain 'doing' pain
Mirror box for phantom limb pain
Hindu sadhus
Sports, ex. Australian Rules Football
Surgery without anaesthetics under hypnosis (Milne, 2007)
Cultural message
Prevalence
Healing has long since finished by the time the patient is diagnosed with persistent pain behaviour (Cherry, 2009)
Coexistence of common psychosomatic complaints in 88% of patients with persistent back, neck & shoulder pain (Alexander, 2012)
Most persistent pain psychogenic?
Pain & trauma
Abuse grossly over-represented in persistent pain population (Alexander, 2012)
Contrary to most memories, truly terrifying experiences not stored via hippocampus, but by amygdala due to stress hormones (Arden, 2010)
Thinking part of brain overridden by limbic system, causing fragmentary memories/covert recollections
Blind-sight
Unaware of enormity of emotional impact, brain protect through persistent pain (Alexander, 2012)
Persistent pain pattern
Ever increasing pattern of thoughts, feelings, behaviours & resulting social interactions becoming embedded
Debilitating emotions about future & prospects; deeply entrenched
Grief evolves; pre-morbid bias & lost future
Frustration with failed interventions
Anger with body failing
- despair, depression, helplessness
Patterns of bodily movements & muscular tension
Shrinking social & vocational world
Feedback loop of increasing emotional pain
Pain as defence
Physical pain entirely compelling
Not designed to ignore it
Commands our attention
A most effective defense mechanism against unwanted/intolerable emotional pain
Excellent distraction through the search for effective treatment
Brain deciding that physical pain preferable to emotional
From acute to persistent pain
Internalising a structural explanation ('pop, crack, snap')
- no evidence of structural derangement account for this (Alexander, 2012)
- 85% low back pain not pathoanatomological diagnosis (Deyo & Weinstein, 2001)
Psychological overlay: stress & anxiety regarding intensity & ramifications of pain + hopelessness following failed treatment attempts
The power of pain cognitions
Common persistent pain myths:
- the result of damage
- evidence of spinal/bodily weakness
- likely to get worse over time
- ultimately crippling
- precludes independence & productivity
Catastrophising
Hypervigilance
Recovery severly impaired (Moss-Morris et al., 2007)
Brain
Produce pain through various mechanisms & biological pathways, such as diverting small proportion of blood away from nerves & muscles producing pain via oxygen deprivation

WHY?
Pain as protection
Personality type most vulnerable to persistent pain: Copers
Not allow themselves to drown in their misfortune, but 'push on' through unacceptable feelings of embarrassment, hurt, anger/rage, low self esteem, poor attachment, fear of success etc.
Positive emotional style reflected in high communication between pre-frontal cortex & nucleus accumbens; same as in persistent pain (Bakili et al., 2012)
Solution?
Improve our negativity
&...
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