PSYCHOLOGY OF PAIN

1. PSYCHOLOGY OF PAIN

2. Definition: International Association for the Study of Pain: • Sensory and emotional negative experience - induced by or related with real or imagined tissue lesions, or - described in terms that refer to such lesions. Components: • Physiological: receptors, pathways, biochemical processes in the tissues and cells, etc • Behavioral: mimics, gestures, etc that accompany the pain • Subjective: thoughts, feelings, representations connected with pain

3. Classification: • Acute pain: • between 6 weeks and 6 months • associated with anxiety (it may signal life threat) • Superficial: • located in derma, mucosae; sharp, delineated • Profound: • muscles, membranes, internal organs • imprecisely delimited,less intense • more persistent (in time) than the superficial one • described by the patient as burning sensation, pressure, pulling, tearing etc

4. 2. Chronic pain: • lasts more than 6 months; located mostly in internal organs • associated with sensations of compression • distress for the patient and family • benign, recurrent: • Highly intense • recurring episodes, separated by pain-free intervals – for example migraine • persistent:variations in levels of intensity, ex back pain • Progredient: • In rheumatoid arthritis, cancer, etc • intensity – increasing constantly

5. Theories of pain: • Nonspecific model (Weddel, 1962): there are no specific pathways of perception for pain; pain occurs through intense stimulation of nonspecific receptors • Specificity (von Trey, 1985): there are specific stimuli for specific receptors and specific pathways of transmission

6. Theories of pain: • Gate control (Melzack & Wall, 1965) a neural mechanism located in the gelatinous substance of the medulla spinalis – stimuli are either transmitted, or blocked The gate closes (pain is not transmitted) when fibers A beta (non-related with pain) are stimulated (these stimuli have priority) The gate is opened by • Activity of fine fibers A delta and C (these fibers are the specific pathway for pain stimuli) • Very intense stimuli • Information interpreted as painful • Feelings of anxiety, sadness, depression associated with stimuli

7. Psychosocial factors related to perception of pain: • Sex: differences related to sexual hormones higher frequency of non-pathological pain in women (ex childbirth) genetic differences between sexes • Age: differences in perception and control mechanisms of the pain ethnic differences in the behavioral and social expression of pain

8. Psychosocial factors related to perception of pain: • Differences in personality traits: introverted persons are more reactive to pain and have a lower pain threshold subjects with negative beliefs linked with potentially painful events tend to over-represent the pain subjects with a history of abuse in childhood develop • pain-prone personalities • an inability to verbally express negative feelings • the need to be punished when feeling guilty • higher pain threshold

9. Acute pain is influenced by: • Past experience of pain its meaning as alarm signal for the person subject’s expectations (I should have a certain level of coping abilities for pain) • Sources of information Family, peers, medical team When the patient is informed about purpose, duration and methods of a medical intervention before that intervention, the negative impact associated with the perception of pain (awareness about pain) decreases

10. Acute pain is influenced by: • Coping style of the subject • emotion-centered: distracting attention from pain works better • problem- centered: information gathering works better • The therapist • empathy, relational abilities • knowledge, expertise, experience • trust in the prescription • prestige, authority

11. Chronic pain is influenced by: • The significance • the meaning of chronic pain is different from acute pain • nevertheless, the individual feels (senses) acute and chronic pain in the same way • Individual’s affective states: • anxiety, depression, hostility, etc enhance pain perception • negative affect influences information processing • negative affect focuses the person on the painful perception

12. Chronic pain is influenced by: • Cognitive style: • catastrophic thinking (“this means I will die”) • overrepresentation of pain (“this means that I have a serious illness”) • negative expectations concerning consequences of pain (“this means I will lose this leg”) • altered primary and secondary evaluations of pain stimuli

13. PSYCHOLOGY OF CANCER

14. Cancer – regarded as the prototype of human suffering • Specific surgical interventions for different cancer types – since 1900 • Radiation therapy in cancer – since 1915 • Chemotherapy in cancer – developed since 1960 • Immunotherapy in cancer – has developed since 1970 • Clinical trials, new drugs discovered every day – last 2 decades

15. The field of psychooncology was founded in 1970 by Holland (oncologist), with 6 main branches: 1. The role of psychologic, social and behavioral factors involved in mortality and morbidity in cancer 2. Emotional issues in patient and family dealing with the diagnosis of cancer and treatment 3. Quality of life in cancer patients 4. Bioethics in oncology (communication of diagnosis and prognosis, euthanasia etc) 5. Alternative therapies in oncology 6. Stress and burnout syndrome in medical staff involved in treatment of cancer

16. Psychological, social and behavioral issues in cancer Studies since the 1950’s have concluded: • Depression is a major risk factor in development of cancer • Subjects which developed cancer had some common features, such as: - the overwhelming need to live in harmony and to be accepted by others - repressed anger, aggresivity, irritability - apparently well-adjusted socially - repressed positive emotions

17. Specific to subjects with cancer • Repressed emotions and overrepresented rationalization (concrete thinking, lack of imagination) • Learned helplessness, depression, despair, leading to: decreased motivation and activity and negative affect • Coping style: perfectionism, rigidity, self-control, adherence to conventions, stoicism

18. Behavioral and social factors involved in cancer • Lifestyle: • Extended, unprotected exposure to sunlight • Sleep deprivation, lack of exercise • Unbalanced diet • Smoking, alcohol etc • Social factors – certain differences between social classes (concerning access to healthcare services, social services, to other facilities etc)

19. Emotional issues in cancer – Elizabeth Kubler-Ross • The book On death and dying – she describes 6 emotional stages in the process of dealing with cancer: • Hope / anxiety: • Symptoms • The diagnosis has not been set yet • The subject feels that something is not right • He considers cancer as a possible diagnosis

20. Emotional issues in cancer – Elizabeth Kubler-Ross 2. Denial (no, not me!): • When the diagnosis is ascertained • Increased risk of suicide. • Denial may be an efficient defense mechanism (protecting the subject from the emotional impact of information) • It may generate decreased compliance, if extended 3. Anger (Why me?) • The patient seeks causes, explanations • Cancer is interpreted as: well-deserved/ undeserved punishment • The interpretation may increase anger and interfere with compliance

21. Emotional issues in cancer – Elizabeth Kubler-Ross 4. Negotiation (please, not me!): • Bargaining with the Divinity • The subject is willing to compromise, to fight for his health • The most effective stage for interventions 5. Depression (Yes, it’s me...) • The signs and symptoms cannot be denied • The cancer may progress • Therapy may prove ineffective

22. Emotional issues in cancer – Elizabeth Kubler-Ross 6. Acceptance: • Final stages – death is seen as a release • It does not occur in all cancer patients • Highly unstable subjects, who have to deal with more than one crisis situations, do not reach this stage

23. Emotional issues in cancer – Elizabeth Kubler-Ross • Actually, we can find in any stage a mixture of • hope (for a miracle) and anxiety (permanent) • guilt (‘I have cancer, I am a burden for the others’) • shame, fear of death and unknown • Cancer (diagnosis, assessments, treatment) entails an existential crisis • The subject’s adjustment to crisis depends on • previous experiences • perceived future threats • available resources: biological, psychological, psychosocial support

24. Early stage of cancer • The early symptoms and signs – it does not coincide with the decision to see a physician • Denial leads to delayed medical assessment, which increases severity of symptoms • In breast cancer – a delay of 3 months, in rectal cancer – 7-10 months • Causes of delay in requesting medical care: • Psychosocial factors (low level of health education in some social layers, old age) may be linked to: • failure to recognize cancer • failure to understand the importance of regular check-up and early treatment • Psychological: avoidance as defense mechanism: fear of - clinical assessment, suffering • bad news • mutilation • Poor therapeutic relationship of patient with physicians – based on previous unpleasant experiences

25. Early stage of cancer • Factors involved in seeking early medical care: • Symptoms: • Complex, obvious symptoms • Physical pain • A certain level of medical information and education • Good therapeutic relationship • Emotional issues • Impulsiveness • High levels of anxiety

26. The stage of diagnosis • Situational crisis, shock – cancer is represented as death sentence – approx. 3 months • Anxiety • Pessimism, despair • Vulnerability • The essence of the individual’s existence, the relationships with the world are being questioned • After 3 months: the patient worries less about the illness, reaches acceptance of • Cancer • Necessity of treatment

27. The stage of diagnosis - family • Family members experience negative feelings elicited by the diagnosis of cancer • Anger, despair • Fear of death and dying • Negative emotions may lead to impaired communication between patient and family • Lack of communication • Distorted communication (listening and understanding are overlooked)

28. The stage of treatment • It requires adjustment: the patient • Is full of hope • Experiences side effects of therapy – financial, psychological, physical • A treatment has the highest chance to be accepted if suggested at the end of the diagnosis stage • Radiation therapy – 2-6 weeks – side effects: • Fatigue, hair loss, skin lesions • Digestive disorders, loss of appetite • Social impact • Affected self-image • The patient fears that it will be ineffective

29. The stage of treatment • Alternative therapies (in the search for a miracle cure for cancer) – instead of/ associated with classical therapies • Metabolic, nutritional • Imunological • Psychological, spiritual healing • Risk of alternative therapies: • Side effects, infections, weight loss • Financial burden, wasted time (when classical therapies are discarded)

30. The stage of remission • Although desired and expected for, it is also a stage of crisis • The evolution from the sick role towards the survivor role • Remission does not always means healing • Emotional distress • The patients feel abandoned, demoralized • The patients feel disoriented, experience loss of control • Constant anxiety, increased by any new symptom • The patient is focused on physical experiences: • Seeking any possible new symptom or sign of disorder • Fatigue • Digestive disorders

31. The stage of remission • Readjustment to professional requirements • Relationships with colleagues may prove difficult • The subject is sensitive to the issue of cancer • Colleagues • Mixed feelings, aggressivity • Overprotection, admiration

32. The stage of relapse • Sometimes – many months, fluctuations in patient’s status • Anxiety, depression • Hope in efficient therapies disappears • The end of a long period of painful uncertainty • Some patients try alternative experiential therapies, as a way of reclaiming control over the illness • Others refuse any other new therapies

33. The terminal stage • Death, dying, bereavment issues • Gradual severing of emotional ties with the peers, family • Gradual severing of emotional and rational ties with reality • The patient is allowed by loved ones to pass on (dying with dignity)