Chapter 1 Biopsychosocial Perspective on Chronic Pain

1. Chapter 1 Biopsychosocial Perspective on Chronic Pain

2. Chronic Pain is a demoralizing situation that confronts the sufferer with not only the stress created by the pain but with many other ongoing issues and difficulties compromising all aspects of their life, leading to increase emotional distress or suffering. • As a result, unrelieved pain is a burden on the societal level by the way of healthcare expenditures disability benefits lost productivity

3. The need for an alternative disease model • The biomedical model of pain relates back to Descartes' 17th-century model. • This assumes that people's reports results from a specific disease state representing a disordered biology • However, it is generally understood that the presence and extent of physical pathology is not sufficient to account for all the reported physical symptoms by patients. • Physical pathology does not always account for or predict the severity of pain and /or level of disability

4. Medical model has a dichotomous view with regard to pain and symptoms being either somatogenic or psychogenic • Hence from this model once the underlying pathology has been addressed other symptoms such as sleep issues, depression psychosocial disability and pain in general should diminish. • However this is not always the case • It may be an issue that these secondary conditions as they call them may already be pre-existing and converge with the pain cause or cause of pain

5. So what can account for the subjective varied expressions and experience of pain • This inherently takes into consideration a Gestalt approach • The biomedical model is been criticized for not being able to account the psychological psychosocial variables and their relationship with disease and illness. • In fact as related to chronic pain so that such conditions like fibromyalgia and TMJ don't fit neatly into the biomedical model • In fact they are accompanied by a manifestation of widespread suffering preoccupation and disability and possibly the adoption of sick role (Parsons, 1958).

6. This has resulted in the gate control theory of pain in 1968 • This theory is the first attempt to combined the physiological and psychological factors in order to develop integrative model • Differentiates three systems related to the processing of nociceptive stimulation • Sensory – discriminative • Motivational – effective • Cognitive – evaluative • NOTE: By emphasizing the CNS mechanisms, this theory provides a physiological basis for the role of psychological factors in chronic pain. • According to this theory, peripheral stimuli interact with cortical variables such as mood and anxiety in the perception of pain.

7. the gate control theory of pain • All of which contribute to the experience of pain • This theory considers somatic and psychogenic factors as potentiating or moderating effects • This model experiences pain as an ongoing sequence, largely reflective in nature of the onset, but modifiable even in the early stages by a variety of excitatory and inhibitory influences as well the integration of ascending and descending CNS activity. • Because this theory considers multiple systems continuously interacting, the potential for the shaping of the pain experience is implied • Physiological details of this model has been challenge since it's beginnings in 1965 but it has demonstrated to be flexible and accommodating of new information.

8. The Neuromatrix theory of pain • Mel Zack suggests that the complex neural matrix relationship between the body and the self • As such, it is believed that this is a genetic predetermined relationship or factor, but it could be modified by sensory experience and learning leading to a dynamic matrix. • On the significantly important point from this theory is that the nerve impulses are hypothesized to be triggered either by sensory inputs or centrally independent of any peripheral stimulation.

9. The Neuromatrix theory of pain • This theory takes into account that when an organism is injured there is an alteration in the homeostatic regulation. • This deviation from the normal status stressful and initiates a complex of hormonal and behavioral mechanisms designed to restore homeostasis. • This reminds me a little bit of diabetes stress-induced diabetes while in the hospital. • Prolonged stress in ongoing efforts to restore homeostasis can suppress immune system and activate the limbic system

10. The neural matrix theory • The neural matrix theory is an extension of the GCT model by essentially integrating it with Hans Selye theory of stress • This limbic system has an important role in emotion, motivation and cognitive processes • Prolonged activation of the stress regulation system can lead to a predispostion for the development of different chronic pain states. • As such, they propose that pain suppression can be produced by sensory- affective processes as well as activation of the endogenous opiates system. • Therefore, the cumulative effects of stress that has preceded are concomitants with the current stress may account for the large variation in individual responses.

11. In this way, this theory incorporates the pain sufferers prior learning history to shape the new matrix by influencing interpretive processes and individual physiological behavioral response patterns • A new stressor may amplify base line stress and related efforts of homeostatic regulation. • Prolonged stress augments tissue breakdown as the body continues to attempt to return to its normal state. • This theory proposes a diathesis stress model in which predispostional factors interact with an acute stressor. • A growing body of research in animals suggests that repetitive or chronic nocicpetive input can result in structural and functional changes that may cause altered perceptual processing and contribute to pain chronicity (wolf & mannion, 1999)

12. Biopsychosocial perspective • In this section, they differentiate disease from illness • Disease being an 'objective biological event' that involved disruption of specific body structures or organ systems caused by pathological, anatomical or physiological changes. • Illness is" subjective experience or self attribution that a disease is present" • As such, illness has multidimensional in that includes the manner in which the pt, family and society perceive and respond to symptoms. • This is similar to the distinction between pain and nociception • What is the difference? • Biopsychosocial perspective includes the disease and illness perspective • It perceives pain as a dynamic process over time.

13. Biopsychosocial perspective • It needs to be perceived or studied or assessed longitudinally • Be sensitive to the multifactorial processes that have a reciprocal interplay • Psychological factors may influence biology by affecting hormone production and processes as well as stimulating the autonomic nervous system • The behavioral aspects can also affect by the way of deconditioning because of refraining from engaging in normal behaviors are tasks • Hallmarks of the biopsychosocial perspective is that it takes into consideration • An integrated action • Reciprocal determinism • Development and evolution

14. Support for the Importance of NonphysiologicalFactors • History demonstrates many cases in which there has been interventions that relieve pain with no clear physiological or medical basis or understandable underlying mechanism. • It was only until the end of the 19th century that curiosity and research began to explore more clearly these mechanisms • Even though there wasn't clear underlying physiological mechanisms, these practices demonstrated to have some effect. • Hence, the idea of placebo effects or psychological cures • Placebo- from nothing is happening to something extraordinary • Fitzpatrick, Hopkins, and Harvard -Wats (1983) did a study with headache patients treated with pharmacological preparations. They concluded that although a large number benefited from the drug treatment most improvements appear to be unrelated.

15. Support for the Importance of Nonphysiological Factos • Biofeedback also demonstrates benefits with pain but the effects may be unrelated to modification a physiological activity ( see text for literature) • Deyo, Walsh, and Mattin (1990) study patients with intractable low pain low back pain for four years. They chose this population because of the duration of symptoms which would suggest minimal improvement in the absence of an effective treatment. However these patients to demonstrate significant statistically significant improvements but the same results were produced with sham interventions suggesting that the treatment effects were not related to physiological mechanisms

16. Support for the Importance of Nonphysiological Factos • Greene and Laskin (1974) and TMD Temporomanidular disorders TMJ- study • Study focused on applying diverse set of treatments which included medications, tranquilizers, physical exercises, intro oral appliances, injections, physical therapy, psychological counseling, including various placebo effects in her drugs, bite plates, mock equilibration of the bite for 6 months to 8 years • All treatments were provided with reassurances, explanation for self-management and sympathetic understanding • 92% of the patients had no or only minor recurrences of Symptoms, this suggest that the nonspecific factors are also important not that these disorders are psychologically-based but that they may be maintained by non-physiological factors

17. Sociocultural factors • Beliefs about illness and health care treatment along with providers is based on previous experience or cultural beliefs • This can lead to expectations that affect participation • Hence, the practitioner patient relationship is significant • Therefore your clear sense of self as a clinician and goals and treatment creates perhaps a reciprocal system • The textbook talks about several authors noting the importance of social cultural factors and sex differences in beliefs about how they respond to pain

18. Sociocultural factors • Social learning mechanisms one aspect of pain behaviors that has been studied is whether expressions of pain distress and suffering can be learned through observational learning. • Richard (1988) found children whose parents had chronic pain chose more pain related responses to scenarios presented to them and were more external in their locus of control versus children with healthy parents. • Operant learning mechanisms Fordyce (1976) contributed significantly to the idea of how environmental factors can shape these pre-existing beliefs into pain behaviors. • Hence behavioral manifestations of pain rather than pain are central in operant formulation • These behavioral manifestations are Hughes or clues to the internal experience or shaping that has taken place

19. Sociocultural factors • People exposed the stimulus that is adversiveimmediately withdraw or attempt to escape the noxious sensation. • These behaviors are observable and therefore enforceable • Positive reinforcement will increase in the lobby would persist • Whereas no attention will decrease and diminish behavior • Lets distinguish the two again

20. Sociocultural factors • Operant conditioning (or instrumental conditioning) is a type of learning in which an individual's behavior is modified by its antecedents and consequences; the behavior may change in form, frequency, or strength. • refers to "an item of behavior that is initially spontaneous, rather than a response to a prior stimulus, but whose consequences may reinforce or inhibit recurrence of that behavior". • Classical conditioning (also Pavlovian conditioning or respondent conditioning) is a mode of learning that occurs when a “Conditioned Stimulus” (CS) is paired with an “Unconditioned Stimulus” (US) that causes an organism to exhibit an automatic "Unconditioned Response" (UR) to the US. • After pairing is repeated (some learning may occur already after only one pairing), the organism exhibits the UR in response to the CS when presented alone. At this point, the UR is then known as the "Conditioned Response" (CR) to the CS. Usually, the CS is a neutral stimulus (e.g., the tone of a tuning fork), the US is biologically potent (e.g., the sight of food) and the UR to the US (which becomes the CR to the CS) is a reflex response (e.g., salivation). The CR is the learned response to the previously neutral stimulus CS. • CLASS EXERCISE Operant conditioning and Pain Behaviors

21. Sociocultural factors • Operant learning • A pain behaviors such as limping can be reinforced positively by the attention of a spouse • there can also be negative reinforcement by the way of avoiding to do any activity so there is an increase of avoidance because there is pain and therefore the pain subsides • additionally there may be increase pain medication in order to decrease the adverse the stimulus • This approach does not concern itself with the initial cause of etiology but simply the behaviors sustained over time

22. Sociocultural factors • there has been literature since the 70's to support this approach • significant literature supports that pain behaviors and well behaviors could be increase with verbal reinforcement and by setting exercise quotas • Gaylor (1980) demonstrated that patient reported different levels of pain when they knew that they were being observed • is this manipulation • or is this once we are observed were attempting to communicate our internal experience for someone else to clearly understand it

23. Sociocultural factors • consider the cough at a doctor's office once you have major appointment not being the same as the night before yet we may try to enhance it to demonstrate that it's there • solicitous others versus non-solicitous others increases pain reports, why • respondent learning • so despite there being an operant conditioning experience but it may have been initiated via classical conditioning • Linton (1985) discussed how avoidance of activities was related more to the anxiety about having pain than the actual pain so there is a conditioned stimulus-

24. Sociocultural factors • WHICH IS THE CONDITIONED STIMULUS? • Therefore classical conditioning can be followed by operant conditioning ( see text page 11 first column bottom) • Initially in acute pain it may be useful to reduce movement but eventually you do need to begin to do successive approximations or desensitization • teaching how to manage the sympathetic activation with relaxation and pain management is helpful to buffer and moderate the operant learning that can take place • prediction of pain promotes pain avoidance and over prediction • promotes excessive avoidance but people who repeatedly engage in behaviors that produce less pain than predicted will likely make adjustments and subsequent expectations which will eventually become more accurate accurate predictions tend to lead to decrease avoidance behaviors

25. Cognitive factors • idiosyncratic beliefs and appraisals and coping methods become critical beliefs about pain • certain beliefs may lead to maladaptive coping, exacerbation of pain increased suffering • It can do otherwise as well consider someone with religious schemas. • The suffering may be perceived as the cross that I bear • Individuals that see their pain is in unexplainable mystery tend to suffer more • personal example with physical therapy and low back pain • beliefs can directly affect mood which in turn can affect muscle tension and production of endogenous opioids • These belief systems as they are constantly stimulated by a chronic noxious stimulant may be altered; therefore affecting how we label a threshold for a noxious stimulus allowing us to become hypersensitive

26. Cognitive factors • Hence, people with chronic pain will tend to refrain from engaging in certain activities because they have relabeled their threshold so as to be distressful in engaging in activity because it may stimulate discomfort. • Once cognitive structures based on memories and meaning form, they tend to become stable and difficult to modify • Many additional pain treatment outcome studies support the idea that reducing negative appraisals is one way to reduce the pain and associated suffering • Simultaneous accomplishment of muscle tension reduction and lowering reported pain convinces patients that muscle tension and subsequent pain could be controlled

27. beliefs about controllability • many studies support the control of an aversive stimulus leads to decreased impact page 15 • Conversely, expectation of uncontrollable pain may cause nociceptive input to be perceived as greater • Flor & Turk (1988) discovered in this study of pain related thoughts and sections of personal control pain severity disability levels of people low back pain and arthritis the general and situation specific convictions of uncontrollable pain and helplessness were more highly related to pain and disability and were disease-related factors

28. Self Efficacy • Closely related to the sense of control is self-efficacy which is the belief of conviction that one can successfully take a course of action to produce a desired outcome • Efficacy judgments are based on four sources of information regarding one's capabilities, in descending order: • One's own past performance at a similar task • The performance accomplishments of others we proceeded to be similar • Verbal persuasion by others that one is capable • Perception of one's own state of physiological arousal

29. Self Efficacy • Hence, encouraging patients to undertake subtasks it increasingly difficult for close to desire behavioral repertoire can create performance mastery (this can also be seen as successive approximations) • Cioffi (1991) has suggested at least four psychological processes that may be responsible for the association between self efficacy and behavioral outcomes • As self-efficacy is perceived to be decrease anxiety is illogical arousal, the person may approach a task with less distressing physical information • A person with high self-efficacy is able to willfully distract attention from potentially threaten physiological sensations • the efficacious person perceives and was distressed by physical sensations but simply persist phase (stoicism) • Physical sensations are neither ignored nor necessarily distressing, but rather a relatively free to take on broad distributions

30. Cognitive errors • catastrophe rising • over generalizations • personalization • selective abstraction

31. Coping • Studies of so that I could cook strategies such as efforts to function in spite of pain to disturbance of from pain like in the case of self-efficacy is associated with more adaptive unction. While passive coping strategies such as dependent on others to student activities pain and depression. • Affect the factors • According to Romano and Turner (1985) 40 to 50% of chronic pain patients suffer from depression • The majority of cases this is in reaction to their pain not before • Those individuals that can retain some sense of control despite pain not become depressed • Anxiety Is commonplace for chronic pain • Anger has been widely observed patients with chronic pain • In a study Summers et al (1992) they found that spinal cord injuries patients’ anger and hostility explained 33% of the variance in pain • However, pain is exacerbated by anger • One reasonable possibilities that it exacerbates pain by increasing autonomic arousal