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The Significance of Pain
Health Psychology
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Obvious significance
Psychology 46.339 (01)
Summer 2007
Instructor: Dr. Fuschia Sirois
Wednesday August 1:
Lecture 8, Prep. Guides 7,8
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Pain is critical for survival
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The Experience & Perception
of Pain
1)
Warns of potential serious injury
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survival value; produces withdrawal reflex to prevent
further injury
Minor pains provide low-level feedback
Medical consequences
Chapter 10: Pain and its Management
Chapter 11: Chronic illness
Pain serves 3 functions:
Pain hurts and so it disrupts our lives
Pain is the symptom most likely to lead an
individual to seek treatment
The Elusive Nature of Pain:
Overview
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Pain is a psychological experience
Interpretation of the pain influences
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Beecher’s study of WWII injuries
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Pain is influenced by
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2) Pain that prevents further injury promotes
learning to avoid same situations later
3) Certain pains limit physical activity and
promote rest Î facilitates healing processes
The Elusive Nature of Pain:
Measuring Pain - Verbal
Reports
What words do you use to describe pain?
| Large informal vocabulary
The Elusive Nature of Pain:
Measuring Pain
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Pain Behaviors are behaviors that arise as
manifestations of chronic pain
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Pain Behaviors are observable
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Throbbing pain? Shooting pain? Dull ache?
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Help define characteristics of different pain
syndromes
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Gate Control Theory
(Melzac & Wall, 1965)
Physiology of Pain
Pain perception is called Nociception
Nociceptors in peripheral nerves first sense injury
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Afferent sensory neurons (PNS) Æ spinal cord Æ brain
Pain is not just the result of a linear process from sensory
stimulation to brain reception & the experience of pain
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Psychological factors can affect the experience of pain.
Neural gate can open and close thereby modulating pain.
Two major types of peripheral nerve fibers
1.
A-delta fibers – small, myelinated fibers that transmit
sharp pain
Spinal cord modulation
• small A-delta & C-fibre activity opens the gate → pain
• large A-beta fibre activity closes the gate → inhibits pain
C-fibers – unmyelinated fibers transmit dull, aching pain
Descending Brain modulation
• central control trigger activates cognitive processes
• can open or close gate: e.g. attention, past experiences,
anxiety, fear, beliefs, relaxation, mood, all affect gate
small,myelinated fibres →
their activity influence sensory aspects of pain
2.
unmyelinated fibres →
influence motivational & affective elements of pain
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Gate-Control Theory –
(Melzac & Wall, 1965)
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Factors that influence the
experience of Pain
Gate is located in the spinal cord.
3 Factors involved in opening or closing of the
gate:
The amount of activity in the pain fibers.
The amount of activity in other peripheral fibers
z Messages that descend from the brain.
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Conditions That ……
Close the gate…
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Physical conditions
z Medications
z Counter stimulation (e.g.,
heat, message)
Emotional conditions
z Positive emotions
z Relaxation, Rest
Mental conditions
z Intense concentration or
distraction
z Involvement and interest in
life activities
Gate-Control Theory
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Physical conditions
z Extent of injury
z Inappropriate activity
level
Emotional conditions
z Anxiety or worry
z Tension
z Depression
Mental Conditions
z Focusing on pain
z Boredom
Gate is closed
Gate is open
Open the gate…
Brain
Brain
To
brain
From
pain
fibers
Gating
Mechanism
From
other
Peripheral
fibers
Transmission
Cells
Spinal Cord
To
brain
From
pain
fibers
Gating
Mechanism
From
other
Peripheral
fibers
Transmission
Cells
Spinal Cord
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Acute vs. Chronic Pain
Acute Pain: temporary, < 6 months
Chronic Pain: > 6 months; intermittent or
constant
| Chronic Pain
Typically begins with an acute episode
Pain does not decrease with treatment
| Three types of chronic pain
z Pain does not decrease as time passes
z Chronic benign pain
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Recurrent acute pain
Chronic progressive pain
Clinical Issues in Pain
Management: Acute vs. Chronic
Pain
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Acute and chronic pain present different
psychological profiles
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Pain Control Techniques:
Overview
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No longer feels anything in an area that
once hurt
z Feels sensation but not pain
z Feels pain but is no longer concerned
about it
z Is hurting but is able to stand it
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Chronic pain often produces depression
Pain present in 2/3 of patients seeking care from
physicians with primary symptoms of depression
(Bair et al)
Pain control techniques work well with acute pain
but less successfully with chronic pain
Pain Control Techniques
Most common method of controlling pain – through
drugs
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Inhibiting pain in one part of the body by stimulating
or mildly irritating another area
E.g.,
Biofeedback
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Pain Control Techniques
Distraction:
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Morphine has been the most popular painkiller for
decades
Counterirritation
individual is provided with ongoing specific
information about a particular physiological process
Pain control can mean a person
an element of many effective pain management
techniques - redirects attention from pain; e.g. guided
imagery, hypnosis,
Relaxation Techniques
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person shifts his/her body into a low state of arousal
Hypnosis
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involves relaxation, suggestion, distraction, and the
focusing of attention.
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Pain Treatment & Management
Multidisciplinary Pain Management
Quality of Life:
What Is Quality of Life?
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The degree to which a person is able to maximize
his or her
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It also addresses disease or treatment related
symptomatology
It is an important indicator of recovery from, or
adjustment to, chronic illness.
no single method is completely effective &
effectiveness of single treatment modes varies across
individuals
Often the aim is to change pain beliefs and behaviors in
order to increase functionality & quality of life
program may include pain education, sleep hygiene
classes, counseling, exercise, stress management, etc.
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Quality of Life:
Why Study Quality of Life
QoL and Chronic Illness
How would you rate the QoL of someone
with a chronic illness?
| 1 = lowest
5 = highest
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Now if you were diagnosed with a chronic
illness, say arthritis, would you expect your
QoL to decrease, stay the same or
increase?
| WHY?
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Documentation helps improve interventions for
those who are chronically ill
Research helps pinpoint which problems are likely
to emerge for particular patients
Impact of unpleasant treatments can be seen and
reasons for poor adherence identified
Therapies can be compared
Decision-makers have information about long-term
survival and quality of life
Quality of Life and Chronic
Illness
Health-related Quality of Life (HRQOL)
represents the functional effects of an illness and
its consequent therapy upon a patient, as
perceived by the patient
important if treatments aim is to make a patient
feel better and function better in their day-to-day
activities, e.g., well-being, vitality
Coping & Chronic Illness
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Avoidant strategies
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Positive illusions and coping
impact of disease on goals, coping
resources, and identity
| social resources key in adaptation
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Emotional Responses of
Chronic Illness: Anxiety
Emotional Responses of Chronic
Illness: Denial
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A defense mechanism involving the inability to
recognize or deal with external threatening
events
Denial is believed to be an early reaction to the
diagnosis of a chronic or terminal illness
Can serve a protective function
During the rehabilitative phase, denial may have
adverse effects. WHY?
examples
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Anxiety is common after diagnosis:
It increases when people
Are waiting for test results
Are anticipating adverse side effects
z Are awaiting invasive medical procedures
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Anxiety is high when
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Substantial lifestyle changes are expected
People feel dependent on health care
professionals
Emotional Responses of
Chronic Illness: Depression
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When the acute phase of chronic illness has
ended
Then full implications begin to sink in
Depression is common
z Often is debilitating
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Assessing depression in individuals with
chronic illness is problematic
| WHY?
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Positive Effects of Chronic
illness
Chronic Illness, Depression
& Control
Emotional adjustment: depression is more prevalent in
those with chronic illnesses 25-33% vs 10-25% in the
general population
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CI ⇒depression, & depression can exacerbate the CI
loss of control is major cause of depression in CI
Many individuals report positive outcomes from
their chronic illness
| Benefit finding
Life improved overall
Increased joy
z Increased value in family, personal hobbies
z Improved relationships
z Enhanced spirituality
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Control beliefs tend to be lower in individuals with CI
than in healthy populations
Age is an important determinant of depression in
chronic illness
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depression & other psychological problems are more
common in younger vs. older people
WHY?
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QoL reports of those with chronic illness are often
higher than those of non-ill samples
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Cognitive Adaptation & Wellbeing
Coping with Chronic Illness:
Patients’ Beliefs
Cognitive Adaptation Theory (Taylor 1983)
Adjustment to threatening events (including
illness) relies upon 3 themes:
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1) a search for meaning in the experience
2) attempts to regain a sense of mastery or control over
the event
3) efforts to restore self-esteem
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When individuals experience setbacks they respond
with cognitively adaptive efforts to help them return
to or go beyond their initial state of functioning
“Learning to live with what
you can’t rise above”:
Control beliefs and
adjustment to tinnitus
Fuschia M. Sirois
University of Windsor
Christopher G. Davis & Melinda S. Morgan
Carleton University
Sirois, F. M., Davis, C. G., & Morgan, M. (2006). “Learning to live with what you can’t rise
above”: Control beliefs, symptom control, and adjustment to tinnitus. Health Psychology,
25(1), 119-123.
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Stress
Physical injury
Bacteria
God’s will
Self-Blame? Another person? Environment?
Fate?
Research on the consequences of selfblame is inconclusive
Control beliefs and
adjustment
Control beliefs
| An individual’s beliefs about how much control they
have over a situation.
Chronic health condition as a stressor
| Opportunities for control are limited
| Perceptions of control may help offset the feelings of
helplessness
| But perceived control over uncontrollable aspects of
health may diminish well-being
| Meaning of control key for understanding its role in
adjustment
Symptom severity and
control
Different meanings of control
Are different control perceptions equally
adaptive for managing a chronic
health condition?
| General control over health
| Symptom control
| Past or retrospective control
People develop theories about where their
illness came from
Different types of control beliefs influence how
people appraise and cope with a stressor
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General control and main effects on appraisals
Situational control as a coping resource that
moderates threat appraisals
Role of retrospective control in appraisal and coping
process not fully explored
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Tinnitus
The present study
10-15% of the adult population experience
tinnitus
| Characterized by the perception of sound in
the absence of external stimuli
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Examined the moderating role of perceived control
in the relation between symptom severity and
adjustment to tinnitus
Adaptational benefits of perceived control will
depend on symptom severity and type of control
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• Incurable
• Distressing
• Unknown etiology
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Two adaptational outcomes:
Adjustment to tinnitus is not directly related to
the severity of tinnitus
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affective measure (depressive symptoms)
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measure of eudaimonic well-being
Methods
Methods
Perceived control over health
Participants
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319 people with tinnitus, M age 46.5 years (SD = 12.3).
42% females
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Participants recruited via notices posted
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e.g., “If I set my mind to it, I can improve my health”
Symptom control
Procedure
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general control over health, symptom control, and
retrospective control
on-line through tinnitus support message boards
by email sent by the Tinnitus Association of Canada to its
members
e.g., “If I make the effort, I can manage my
symptoms”
Retrospective control
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Participants completed the survey on the Internet
three questions adapted from prior research on
bereavement (Davis et al, 1995, 2000).
Adaptational outcomes
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Results
Results
Table 1. Zero-order Correlations Between Perceived Control,
Symptom Severity, and Adaptational Outcomes.
Variables
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2
3
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1. Tinnitus severity
---
2. Depressive symptoms
.29**
---
3. PWB score
-.24**
-.65**
---
4. General health control
-.20**
-.27**
.38**
---
.07
.34**
-.30**
.03
-.19**
-.27**
.43**
5. Retrospective control
6. Symptom control
Depressed Mood
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General control
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main effect for both depression (β = -.22, t(283) = -3.83, p < .001)
and psychological well-being (β = .35, t(300) = 6.56, p < .001).
Retrospective control
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main effect for both depression (β = .31, t(285) = 5.78, p < .001)
and psychological well-being (β = -.28, t(300) = -5.27, p < .001).
Symptom control
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.57**
moderated the effects of tinnitus severity for both depression (β =
-.15, t(281) = -2.61, p = .01) and psychological well-being (β =
.12, t(297) = 2.33, p < .05).
---.03
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Figure 2. Estimated Psychological Well-being scores as a function
of Symptom Control Beliefs (+/- 1 SD) and Tinnitus Severity (+/- 1
SD).
Figure 1. Estimated CES-Depression scores as a function of
Symptom Control Beliefs (+/- 1 SD) and Tinnitus Severity (+/- 1
SD).
Low Symptom Control (-1 SD)
Low Symptom Control (-1 SD)
High Symptom Control (+1 SD)
High Symptom Control (+1 SD)
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Psychological Well-being
S y m p to m s o f D e p re s s io n
4.5
14
12
10
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6
4
4
3.5
3
2.5
2
1.5
1
2
0.5
0
0
Mild Tinnitus (-1 SD)
Severe Tinnitus (+1 SD)
Mild Tinnitus (-1 SD)
Coping with Chronic Illness:
Patients’ Beliefs
Conclusions
Successful coping with tinnitus is associated
with
Severe Tinnitus (+1 SD)
Tinnitus Severity
Tinnitus Severity
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Patients must integrate their illnesses into
their lives
Develop a realistic sense of the illness
Understand restrictions imposed by it
z Follow the regimen required
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Reinterpreting symptoms as manageable
allows people to maintain a meaningful,
purposeful, and enjoyable life.
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Patients need to adopt an appropriate
model for their disorder
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Personal Issues in Chronic
Disease: The Private Self
Self-Identity in Chronic Disease
Self-Concept
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An integrated set of beliefs about one’s personal
qualities and attributes
Acute models won’t be effective
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Major threats to self, because illnesses create
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Adjustment to chronic illness impeded
Self-Esteem
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A global evaluation of one’s qualities and
attributes.
Body Image
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The perception and evaluation of one’s body,
one’s physical functioning, and one’s appearance.
Body image plummets during illness
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Patient’s secret dream seems shattered
Alternate paths to fulfillment need
discussing
The adjustment process takes a year or more
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Psychological Interventions and
Chronic Illness: Social Support
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Social support resources can be threatened by
chronic illness
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Group of individuals who meet regularly
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Support groups are believed to help people cope
because
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Interventions can teach patients to
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“erosion” of social support
Psychological Interventions and
Chronic Illness: Support Groups
Recognize potential sources of support
Draw on these resources effectively
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Family support
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Enhances the patient's physical/emotional functioning
Promotes adherence to treatment
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Internet vs. In person Support
Groups
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Disease-related restrictions may prevent access to
regular support groups for some
Internet based support groups offer convenient source
of support
STUDY: 371 participants sampled from three chronic illness
populations: arthritis (N = 132), inflammatory bowel disease (IBD;
N = 112), and mixed chronic health conditions (N = 117)
Participants completed open-ended questions about their use of
support groups and their reasons for using or not using support
groups in an online survey
Participants were predominately female (78.9 %), Caucasian
(87.3 %), with a mean age of 39.02 (SD = 11.32).
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I have learned more from the people on the online
support groups than anywhere. Any question I have
someone knows it.
It's nice to be anonymous. I don't have to leave my
house. I like to hear other peoples stories, they make me
feel like maybe I am not doing so bad…
Its easier to talk to people that you aren't seeing face to
face when you are describing your latest bathroom
accident.
it takes stress away from having to interact with people.
it helped me realise crohns isn’t going to take over my
life if i don’t let it
I visit online support groups because they are 24/7.
Other support groups can only meet once a month or
once every other month. This way, if I need to talk to
someone, or have a question, I could always post a
message on the message board and get a response
People learn techniques that others have used
successfully to combat problems
They provide opportunities to share concerns and
exchange information with similar others
Support groups may promote better health and
long-term survival
Internet vs. In person Support
Groups
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In person groups may have some disadvantages:
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it did help--but the group as a whole was so medically
disadvantaged, that getting together in person was too difficult
Made me feel worse because everyone there was at least 4
times my age and couldn't relate to my situation/concerns.
it did nothing but make things worse for me. I’m optimistic and
everyone there moaned and groaned Poor me! I’m not into that
feel sorry for me crap!
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Internet vs. In person Support
Groups
Advantages
Share some common problem or concern
Internet vs. In person Support
Groups
Advantages
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The group is much broader. There are others in my age
group or younger.
Quick and easy access, information and friendship from
all over the world, anonymous and FREE!
It is easier to go online than actually get in the car to go
somewhere especially if you are in a flare...
I am homebound and can't get out. Almost anything I do
is via computer. With online groups, I can glean relevant
info and fast forward through the BS. I can get and give
encouragement.
it takes stress away from having to interact with people.
I can control when/if/with whom I communicate.
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Disadvantages???
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