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Health Psychology

Why do we care about pain?. One of the most common health problems that causes people to seek medical attentionPain is actually beneficial to long-term health and survival. What is pain?. ?An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described

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Health Psychology

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    1. Health Psychology Chapter 9 – Pain and Pain Management PY 470 Hudiburg

    2. Why do we care about pain? One of the most common health problems that causes people to seek medical attention Pain is actually beneficial to long-term health and survival

    3. What is pain? “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” ISAP (1979) Pain is what the person says hurts Acute pain – shorter duration up to six months Acute monophasic pain Recurrent acute non-malignant pain Chronic pain – longer duration > six months Chronic malignant pain - progressive Intractable-benign Chronic pain associated with non-malignancy disease – identifiable pathology Chronic non-malignant pain syndrome Recurrent acute - migraine Chronic and acute pain my have different causes – behavioral factors may be involved in acute pain

    4. How do we experience pain? Specificity theory – Descrates posits that there are specific sensory receptors for different types of sensations (i.e., pain, touch, pressure) Pattern theory – Melzack & Wall (1982) posits that pain results from the type of stimulation received by the nerve ending and the key determination of pain is the intensity of the stimulation Both theories have limitations pain can be experienced without tissue damage tissue damage can occur without pain being felt Phantom limb pain experience not accounted for by the theories – Fordyce (1988) study of amputees Continuing to perform despite pain

    5. Gate Control Theory Gate control theory – Melzack & Wall (1965) - Figure 9.2, p. 320 severity of pain sensation determined by balance between excitatory and inhibitory inputs to T cells in spinal cord C & A-delta nociceptor afferents give excitatory input to dorsal root ganglion of spinal cord– A-delta (myelinated) about 40 mph and C fibers (unmyelinated) about 3 mph, other sensory information travels at about 180 -240 mph Substantia gelatinosa, large diameter A-beta non-nociceptor afferents give inhibitory input Increased firing of non-nociceptor afferents causes presynaptic inhibition of T cells and the spinal gate from excitatory cells to the brain is closed. – Figure 9.2, p. 322 Physical agent modalities and physical activities believed to close the gate by activating the non-nociceptor afferents The theory does not explain pain modulation descending from brain

    6. Central Control Mechanisms of Pain Not well understood Periaqueductral gray seems to be involved in pain – electrical stimulation can block the experience of pain – Figure 9.1, p. 320 Spinothalamic tract which carries the impulses up the spinal cord, through the brain stem to the thalamus Cerebral cortex sensory area of parietal lobe: localization and interpretation of pain - somatosensory cortex limbic system: affective and autonomic response temporal lobe: pain memory

    8. Chemical processes involved in pain Substance P – Figure 9.3, p. 323 Chemical mediator thought to be involved with transmission of pain. Associated with inflammatory pain It excites pain transmitting neurons when released Its mechanism is not fully understood Glutamate – release affects amount of pain experienced Prostaglandins, bradykinin – released when tissue damaged

    9. Chemical processes involved in pain Endorphins Pain perception modulated by these opiate like neurotransmitters The endorphins bind to certain sites on the nervous system including peripheral nerves They suppress pain transmission at the spinal cord level by inhibiting the release of the neurotransmitter gamma aminobutyric acid (GABA) in the periaqueductal gray matter (PAGM) and raphe nucleus of the brain High concentration of opiate receptors in limbic area of brain explains the stress relief and euphoria associated with opiates Limbic system involved with emotional component of pain Neuromatrix – pain and amputated limits

    10. How is pain measured? Physiological measures EMG – muscle tension Heart rate Skin temperature EEG and brain imaging Behavioral pain measures Physical symptoms Clusters: guarding, bracing, rubbing, grimacing, and sighing Symptoms can be misrepresented: report and unobtrusive observation differences – Kremer et al. (1981) Self-report measures

    11. McGill Pain Questionnaire – Figure 9.4, p. 327 in textbook has McGill-Melzack scale - sensations - feelings - intensity

    12. Pain Rating Scales Visual Analog Scale(VAS) Graphic Rating Scale(GRS) Simple Descriptor Scale(SDS) Numerical Rating Scale(NRS) Faces Rating Scale(FRS)

    13. Pain Rating Scales

    14. Pain Cycle This slide depicts the possible cycle of pain for those with ineffectively resolved or managed pain. Source: Gill , T. 1997, Patients with Pain and Drug Use Problems, GP Drug and Alcohol Supplement No. 4, Central Coast Area Health Service, p. 3. This slide depicts the possible cycle of pain for those with ineffectively resolved or managed pain. Source: Gill , T. 1997, Patients with Pain and Drug Use Problems, GP Drug and Alcohol Supplement No. 4, Central Coast Area Health Service, p. 3.

    15. How do psychological factors influence the experience of pain? Learning modeling secondary gain / reinforcement – parents and children’s pain financial culturally learned

    16. How do psychological factors influence the experience of pain? Cognition relative to what? causes of pain (i.e., debilitating condition vs. minor (and fixable) problem anticipation of pain is often worse than pain itself expectations of their ability to cope Box 9.1, p. 332, Women’s belief about rates of PMS and PMS symptoms – Figure 9.6, p. 333 Coping strategies – Table 9.2, p. 335

    17. How do psychological factors influence the experience of pain? Personality anxiety and depressive disorders are associated with chronic pain extroversion is associated with higher pain thresholds internal locus of control is associated with believe of better coping – Table 9.3, p. 335 bulk of evidence suggests that chronic pain LEADS to depression, and not the reverse

    18. How do psychological factors influence the experience of pain? Stress pain is influenced by stress such as family/marital problems, work pressures, major life events, etc. stress leads people to engage in behaviors (i.e., grinding teeth, tensing muscles), which in turn lead to pain Figure 9.7, p. 337 – Biological, psychological, and social factors influencing experience of pain

    19. What are some physical methods of controlling pain

    20. What are some physical methods of controlling pain: Medications Opioid analgesics: substance P release into dorsal horn regulated by endogenous endorphins and exogenous opioids. Inhibit substance P release opioid=any antagonist with morphine-like activity opiate=drug from the poppy i.e. morphine and codeine

    21. What are some physical methods of controlling pain: Medications Morphine Acts on mu receptors, produces intense analgesia and indifference to pain alters central processing of pain (thalamus, limbic system and cerebral cortex) receptors present in brain and spinal cord: periaqueductal grey (PAG), caudal and geniculate nucleus, thalamus and spinal cord OxyContin – “hillbilly heroin” – issues of control – Box 9.2, p. 338 Synthetics opiates Local anesthetics

    22. What are some physical methods of controlling pain: Medications NSAID’s - Non-steroidal anti-inflammatory drugs Aspirin, ibuprofen, naproxen, phenylbutazone, ketoprofen, diclofenac may cause kidney damage, bone marrow suppression, rashes, decrease renal blood flow in dehydrated pts Acetaminophen (Tylenol) has analgesic and antipyretic (fever reducing) effect, but no anti-inflammatory effect prolonged use can cause liver damage

    23. What are some physical methods of controlling pain: Surgery Surgery: 115,000 laminectomies and 34,000 lumbar spine operations in U.S. Rotator cuff injury and repair

    24. What are some physical methods of controlling pain? Physical stimulation Physical stimulation Counterirritation – irritating body tissue to ease pain Transcutaneous electrical nerve stimulation (TENS) Acupuncture - Photo 9.4, p. 342 Several techniques but usually associated with Chinese long, thin needles inserted into body – based on body’s energy flow in 14 distinct channels - Cost - $40, usually $80 - Massage therapy There are over 200 massage techniques Acupressure, Aromatherapy, Hot Stone Massage, Reflexology, Swedish Massage (traditional massage) Chiropractic therapy – issue of use and effectiveness Issues: short-term effects In most cases, there was little difference between these and placebo. Interestingly subjective reports state the opposite.

    25. What are some physical methods of controlling pain? Physical therapy – increase flexibility and muscles conditioning Exercise Regular exercise has lasting effects – Frost et al. (1998) – to reduce back pain, two years after participation reduced disability Combined with other treatments to increase effectiveness – Turner et al. (1990) use of behavioral therapy and exercise

    26. Is this pain? Will this be painful?

    27. What are some of the psychological methods of controlling pain? Hypnosis Biofeedback Relaxation and distraction Cognitive - Behavior therapy Behavioral Medicine – Society of Behavioral Medicine - pain

    28. What are some of the psychological methods of controlling pain? Hypnosis Trancelike state Mesmer made famous Multiple Definitions altered state of consciousness trait of hypnotizability Hypnotized people: will perform minor feats, won’t hurt self, others

    29. Hypnosis Process Relaxation Told it will ? pain (suggestion) Induction = being placed under hypnosis (distraction) Instructed to think of pain differently (reinterpretation)

    30. Hypnosis Outcomes Surgery, childbirth, dental procedures, burns, headaches Unclear: block pain OR alter reports NOT better for low suggestible points Better for high suggestible points Figure 9.8, p.345 – burn patients – Patterson et al. (1992) Figure 9.9, p.346 – susceptible levels and pain reduction – Hilgard (1975)

    31. What are some of the psychological methods of controlling pain? Biofeedback Definition = providing information on typically involuntary bodily process to learn to control it e.g., bp, hr, skin temp Electromyograph (EMG) = electrical discharge in muscle fibers Thermister = skin temperature Audio/visual signal Trial/error- pt changes thoughts, behaviors

    32. Biofeedback Outcomes Joint pain, migraine headache, hypertension Expensive technology & trained personnel Relaxation & hypnosis cheaper & easier NOT better for stress Better for migraines Figure 9.10, p. 347 – Gauthier et al. (1994) for headaches

    33. Behavioral/Cognitive Approaches Distraction Other activity (e.g., pledge of allegiance) – Box 9.3, p. 351 – movie before vaccinations – Cohen et al. (1999) Reinterpretation (e.g., secret agent) Better for short-term, low-level pain Music and pain reduction – Figure 9.11, p. 349 – Anderson et al. (1991) Relaxation Progressive technique Autogenic technique – use of self instructions of warmth and heaviness Treatment of recurrent headache – Holroyd & Penzien (1994)

    34. Behavioral/Cognitive Approaches Guided Imagery – Table 9.5, p. 348 TRIP Systematic desensitization Reframing Meditation Stress management techniques – not as effective as other techniques Thinking about the pain and expectations – Box 9.5, p. 354-355 – Bandura et al. (1987) – Figure 9.12, p. 355 – an increase in endorphines with cognitive technique

    35. Can placebos decrease pain?- Figure 9.13, p. 359 – Gracely et al. (1985)

    36. How do placebos influence pain? Patient’s expectation about the effects of the treatment Ariely (2008) study of differential effectives of placebo based on perceived cost ($.10 v. $2.50) http://www.npr.org/templates/story/story.php?storyId=87938032 Classical conditioning Patient’s may change behaviors Physiological changes which inhibit the experience of pain

    37. How do placebos influence pain? Research Expectation effects Interactions with health care providers – Talbot (2000) – 70 -25 % effective based on attitude of the practitioner toward the placebo Nocebo effect – negative effects of the placebo condition

    38. Lingering issues Does the duration of pain matter? Time limiting aspects of pain may affect pain experiences Can placebo surgeries be effective? Suggested research – Beecher (1959), Moseley et al. (2002) – no difference in pain levels but actual surgery patient more functional – patients’ belief is important

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