What is Chronic Pain?
What is Chronic Pain?

Chronic pain is one of the most common and least understood conditions that face our health-care system today.  To begin, I would like to introduce two aspects of human pain: (1) the physical and (2) the emotional.  

Physical Pain
Our brain tells us what part of our body is hurting and with what intensity.  The feeling of pain is dictated by our nervous system and its pain pathways.  Doctors and psychiatrists are in charge of managing that side of pain with varying success.  Physiological solutions are useful and effective. Medicine and surgery should be explored as well as meditation and physical therapy.  Some of the problems with medication are well known, such as addiction, dependency, ineffectiveness, and feelings of powerlessness.  Many of these physical methods listed above are incredibly useful components to pain treatment; however when used alone, can fail to improve the condition.  An organized, multi-dimensional approach to pain treatment is crucial.  Physical therapy, medication, meditation, and counseling are integral parts of this "all-out" attack on pain.

Emotional Pain
You can think of the psychological part of pain as the emotion of "suffering."  This refers to how the mind thinks or feels about the pain and the fact that physical pain is being felt.  These complex emotional responses to pain like helplessness, despair, regret, and anger can magnify pain and sometimes make it worse.  The purpose of therapy or counseling is to counteract the effects of suffering such that you are dealing with the primary concern, the actual physical pain.  Because, anybody that suffers from chronic pain knows that pain can change your body and your life.  It can not only change what you can do but it can change who you are.   

Support Groups
These groups can be incredibly helpful as a place to share ideas and feel supported.  Many times they are not led by trained professionals and can be a place where expensive services are promoted or sold.  Many people are aware that individuals in pain can be desperate and will promise pain reducing strategies to make money.  I am very up front with the fact that I cannot actually change how much pain is felt in your body, but I strongly believe that your individual relationship with your unique pain can be changed such that you feel more satisfied with your life.

My Article
This article reviews the current research on pain, assessment, risk factors, and treatment of chronic pain.  

Chronic pain has become a pervasive medical and psychological problem in the United States.  Pain accounts for eighty percent of doctor visits and currently affects over 50 million Americans, costing more than $70 billion annually in health-care costs and lost work production (Gatchel, 2004). Along with the financial costs of chronic pain to our country, the social aspect of patient's suffering is significant as well.  People who suffer from chronic pain are more likely to be unemployed, abuse alcohol, and present for psychological treatment with complaints of depression or anxiety (Warren, Dillon, Morse, Hall, & Warren, 2000).  Consequently, it is crucial for mental health practitioners to be educated in the psychological effects and physical etiology of pain, as well as to be prepared for an active role in its treatment. 

 

The cause of chronic pain is not well understood and current research into treatment remains focused on reducing symptoms and increasing patient's quality of life.  The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000) uses a description of pain that requires the difficult determination of whether pain is physical or psychological.  The DSM-IV-TR describes a Somatoform Disorder as, "the presence of physical symptoms that suggest a general medical condition and are not fully explained by a general medical condition".  More specifically, it specifies pain disorder as pain being the predominant focus of clinical attention, the pain causing significant impairment, and psychological factors being an important factor in the maintenance of the pain. 

 

A common definition of chronic pain is when pain persists for at least two to four months and is over the threshold of the pain response commonly associated with the injury or condition that caused it (Gatchel, 2004).  Common chronic pain complaints associated with a diagnosis of pain disorder are low back pain, neck pain, and pain in the upper extremities including arms, wrists, and hands.  This pain can be caused by a multitude of factors, from the repetitive motion of typing on a keyboard to poor posture.  Many factory and assembly-line workers suffer from chronic pain as well as people who suffer from diseases such as cancer or diabetes.  Additionally, individuals over the age of 50 are twice as likely to suffer from chronic pain (Gatchel, 2004); and with the rapid increase in elderly Americans, understanding chronic pain is becoming essential.

 

The exploration of the psychological component to persistent pain is in its infancy and radical new treatment programs are swiftly becoming mainstream.  Psychologists are assuming critical roles in pain treatment clinics (Simon & Folen, 2001) and it is important that the mental-health industry take client's somatic complaints seriously.  As in many psychological problems, early intervention and prevention is critical to prevent permanent disability.  The high comorbidity of chronic pain and affective disorders (Turk, 2002), require us as therapists to be prepared to recognize and refer clients who suffer from this potentially debilitating disorder. 

 

Research into the development of pain disorder requires a review of the competing definitions of pain and the theories that explain its etiology and maintenance.  In addition, it is important to review the risk factors, assessment tools, and current treatments for chronic pain in order to fully understand how chronic pain is conceptualized and treated today.

The experience of chronic pain can have a multitude of effects on a client's life.  Pain generally leads to a decrease in physical activity, weight gain, a decrease in pain threshold, and disturbances in the sleep cycle (Simon & Folen, 2001, p. 125).  Many of these phenomena can be seen as symptoms or causal factors for depression and anxiety.  The comorbidity of affective disorder further compromises the patient's ability to cope with their chronic pain.  More specifically, depression lowers the pain threshold and leads to a vicious cycle of fear and catastrophizing of the pain response (Leo & Barkin, 2003).  Thus, the act of defining chronic pain with single factors would be remiss.  Gatchel (2004) proposes that each patient has a distinct experience of pain.  This individuality results from a unique blending of physical tissue damage, emotional reaction, and behavior such as avoidance of painful activities. 

 

Historically, using mind-body theory, pain was described as either a result of physical tissue damage or, conversely, created by the psyche.  This duality limited treatment to either invasive medical procedures to repair tissue or psychotropic medication to block psychogenic pain (Novy, Nelson, Francis, & Turk, 1995).  Research has proven that such rigid and restrictive models of pain are empirically unsound and that a more comprehensive model including behavioral, affective, sensory, and cognitive components is more accurate (Turk & Rudy, 1986).  The International Association for the Study of Pain proposes a more comprehensive definition for pain as, "an unpleasant sensory and emotional experience associated with actual or potential tissue damage” (Merskey, 1979, p. 250).  This perspective on the complete experience of pain encourages the removal of unfair labels such as "real" or "imagined" pain.

 

The shift away from the medical model in describing chronic pain has created alternative theoretical perspectives; however, most chronic pain is in fact triggered by a period of acute trauma or overuse.  Current research and spending by major governments such as Great Britain, Canada, and the United States have erased the skepticism that existed concerning the link between RSI and pain disorder (Barr & Barbe, 2002).  Barr and Barbe recognize that, "these injuries continue to pose a substantial source of worker pain and discomfort as well as potential long-term disability" (p. 175). 

 

The reason for this newfound acceptance of chronic pain is partly caused by Barr and Barbe's findings of human tissue biopsy studies and animal models of repetitive movement.  Tissue biopsy has consistently found structural changes in human muscle tissue in patients with painful chronic overuse symptoms due to high force, long duration, or awkward postures.  Studies on rats and rabbits confirmed that chronic low-impact use can create irreversible deterioration of muscles, tendons, and nerves.  Barr and Barbe repetitively invoked rabbit's scratch reflex movement for periods of two hours per day for six to eight weeks.  This study was meant to approximate the effects of easy, low impact, and natural movements when done inappropriately repetitively.  The findings suggested increases in localized inflammation consistent with what human RSI patients describe as dull, burning aches. 

 

Current literature tracks the progress in pain theory from its inception in the medical model to the comprehensive biopsychosocial (BPS) approach.  The "gate control theory of pain" was introduced in 1965 by Melzack and Wall and was the first theory to involve psychological factors when considering pain (Gatchel, 2004).  Furthermore, Kirmayer, Robbins, and Paris (1994) considered the impact of personality traits on the predisposition for the development of pain disorders.  Kirmayer et al. (1994) studied the personality traits of neuroticism, agreeableness and conscientiousness to search for a "pain prone personality" (p. 130).  Although Kirmayer et al. found little conclusive evidence connecting personality and pain, the expansion toward focus on alternative factors in pain research has proved stimulating.

 

Turk and Rudy (1986) proposed a cognitive approach to pain theory.  They investigated how patients' thoughts and appraisals contributed to their experience of pain.  Maladaptive cognitive processes such as distortions and self statements served to increase the patient's perception of pain.  Conversely, pain could be reduced through the use of cognitive coping strategies.  Many of these cognitive strategies have been incorporated into the integrative approaches to treatment.

 

Loeser (1982) started describing pain more comprehensively using four dimensions: the sensation of pain, the physical process of the nervous system transmitting the pain, the emotional response to pain described as suffering, and pain behavior such as avoidance or immobilization.  Loeser's model takes into account such actions as avoiding activities for fear of re-injury, feeling depressed as a result of chronic pain, and the physical act of the brain interpreting nerve responses.  This level of comprehensiveness is critical in exploring how pain is filtered through a person's genetic composition, mental health status, prior learning history, and social interactions (Gatchel, 2004). 

 

Theories of pain have been gradually moving from the medical model that focuses on the physical etiology of pain to a more comprehensive approach that encompasses cognitive, behavioral, and affective components.  In fact, the BPS approach to pain is becoming so widely accepted that some organizations now require that doctors consider pain a "fifth vital sign" along with pulse, blood pressure, temperature, and respiration (Gatchel, 2004).

 

 

References

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