What is chronic pain?

Chronic pain leads to individual suffering and to major costs for all developed countries. Previous studies suggest that both the incidence of disabling chronic pain and the amount of health care consumption due to chronic pain are rapidly increasing. Western medicine is not only often ineffective but may be one of the causes of this epidemic. This article will address the issue of chronic pain of unknown etiology and has the goals of: (1) identifying the factors which have led to our confusion about this topic, and (2) proposing alternative ways of conceptualizing chronic pain and its ensuing behaviors and social consequences. It is concluded that it is essential to discriminate between tissue damage, pain, suffering, pain behaviors, health care consumption, impairment and disability if one is to develop a meaningful conceptualization of the medical, social, economic and political problems of chronic pain. Successful treatment must be defined in behavioral terms such as restoration of normal activities. Disabling chronic pain is often a sign of overwhelming stress engendered by the individual's failure to cope with the demands of industrialized society.     

Social and medical influences on attributions and evaluations of chronic pain

Abstract

Previous research suggests that judgments of pain are subject to social influences, including characteristics of the person in pain, the judge, and the social context in which the judgment occurs. In this experiment, eight vignettes describing a person with chronic low back pain were varied as a function of patient ethnicity (Caucasian vs African-American), litigation status (litigant vs non-litigant), and medical evidence (strong vs weak). Participants (N= 116) read vignettes, made attributions of causality for the person's pain and disability, and evaluated the severity of the pain syndrome. Pain and disability were perceived as more legitimate when the person in pain was a non-litigant and when medical evidence was strong. Evaluations of syndrome severity were more extreme when evidence was strong. A three-way interaction indicated that judgments may have been influenced by ethnic stereotypes. These findings substantiate the influence of social variables in judgments of persons with pain.     

Perceptions of Disability as Related to Medical and Social Factors

This study addressed self-perception of disability and the belief that others perceive one to have a disability. Factors from the medical and social models of disability were tested to determine if social factors still play a role in such perceptions when controlling for medical factors. Cross-sectional data from the 1994–1995 National Health Interview Study on Disability (NHIS-D) provided a stratified random sample of 25,805 noninstitutionalized adults. Logistic regression models were used to demonstrate that even controlling for medical factors (e.g., particular disabling conditions and restrictions in activities of daily living), social and vocational factors were significant predictors of disability perception. Ramifications for the theoretical study of disability, social psychology, and disability policy are discussed.     

Hysterical Again: The Gastrointestinal Woman in Medical Discourse

This article suggests increased attention to how medical discourses of gastrointestinal (GI) disorder and distress are fraught with social assumptions and consequences by examining nineteenth-century and contemporary medical texts focused on chronic constipation and Irritable Bowel Syndrome (IBS). I suggest that these medical discourses present what I call the “gastrointestinal woman,” who is characterized as having unjustified anxiety and is to blame for her condition. My approach to understanding, and ultimately revising, the representation of the gastrointestinal woman is shaped by disability studies scholarship, which encourages intervention in problematic medical discourses and more active shaping of discourses of chronic pain and illness by those who have these conditions.     

Pain coping and social support as predictors of long-term functional disability and pain in early rheumatoid arthritis

Pain-related avoidance factors and social resources, as assessed by pain coping and social support, are supposed to have lasting effects on functional disability and pain in chronic pain disorders. As a follow-up to a prospective study demonstrating short-term effects after one year (Behaviour Research and Therapy, 36, 179-193, 1998), the role of pain coping and social support at the time of diagnosis was investigated in relationship to the long-term course of functional disability and pain after three and five years in 78 patients with rheumatoid arthritis (RA), taking into account personality characteristics of neuroticism and extraversion, clinical status and use of medication. In line with findings at the one-year follow-up, results showed that more passive pain coping predicted functional disability at the three-year, but not the five-year follow-up. In addition, low levels of social support at the time of diagnosis consistently predicted both functional disability and pain at the three and five-year follow-ups. Results indicate that pain coping and social support, assessed very early in the disease process, can affect long-term functional disability and pain in RA, and suggest that early interventions focusing on pain-related avoidance factors and social resources for patients at risk may beneficially influence long-term outcomes in RA.     

Understanding Chest Pain: What Every Psychologist Should Know

Chest pain is one of the most frequent presenting complaints in Emergency Rooms and other medical settings. A considerable number of these patients do not have significant coronary artery disease. This led to plausible alternative explanations for these presenting symptoms and these patients tend to have unremarkable cardiac outcomes. Nevertheless, many studies have also documented that symptoms and related disability persist in the face of reassurances about benign cardiac status. Given the implied threat of chest pain (e.g., myocardial infarction) and the presence of chest pain symptoms in other noncardiac conditions (including anxiety and panic), it is not surprising that many of these patients present with considerable emotional distress. Consequently, chest pain symptoms represent diagnostic and treatment dilemmas for physicians and psychologists alike. The extent to which cardiac and noncardiac factors contribute to all forms of chest pain remains unknown. The function of this review is to provide mental health professionals with a primer on relevant clinical issues in chronic chest pain. We examine several common medical and psychiatric causes of chronic chest pain and selectively review (1) the relevant medical and psychiatric diagnostic and treatment considerations for chest pain and (2) the hypothetical biobehavioral mechanisms relevant to psychological intervention, (3) while expanding on existing conceptual models for understanding chest pain, and (4) offering some suggestions for future research.     

The social nature of hypnosis: An ethogenic analysis of hypnotic pain reduction

This article addresses the central paradox of hypnotic pain reduction: the discrepancy between self-reports and physiological measures of pain, using a constructionist perspective. The analysis is embedded in the ethogenic assumptions about the nature of the social and in realist rather than positivist notions of causality. It reformulates the induction procedure as an entrance ritual, considers the hypnosis experiment proper as a social episode, reveals the causal powers that subjects bring to hypnosis experiments and specifies how the act of hypnotic pain reduction is achieved. The analysis uses, in part, the Olympic athlete and the Olympic competition as analogic models to show that the hypnosis experiment is merely a public occasion for talented hypnotic subjects to display their peculiar powers without risking their standing as rational beings. The paradox is seen to be an artifact of positivist assumptions concerning both the nature of hypnosis and of traditional experimental methods. Two distinct lines of investigation, based on the competence/performance distinction, are recommended as guides for future research.     

Integrating Pain Management in Clinical Practice

There is much evidence to suggest that psychological and social issues are predictive of pain severity, emotional distress, work disability, and response to medical treatments among persons with chronic pain. Psychologists can play an important role in the identification of psychological and social dysfunction and in matching personal characteristics to effective interventions as part of a multidisciplinary approach to pain management, leading to a greater likelihood of treatment success. The assessment of different domains using semi-structured clinical interviews and standardized self-report measures permits identification of somatosensory, emotional, cognitive, behavioral and social issues in order to facilitate treatment planning. In this paper, we briefly describe measures to assess constructs related to pain and intervention strategies for the behavioral treatment of chronic pain and discuss related psychiatric and substance abuse issues. Finally, we offer a future look at the role of integrating pain management in clinical practice in the psychological assessment and treatment for persons with chronic pain.     

The Family Environment in Chronic Pain Patients: Comparison to Controls and Relationship to Patient Functioning

Operant and cognitive-behavioral models of chronic pain have called attention to the importance of examining the marital and family environments of chronic pain patients. In this study, 50 chronic pain patients and their spouses and 33 control participants and their spouses completed measures of the family environment, marital satisfaction, and patient physical and psychological functioning. Patients' overt pain behaviors were coded from videotapes of patient–spouse interactions. Compared to controls, pain patients and their spouses rated their family environments as lower in cohesion and higher in control, and there was a trend for spouses to report more marital dissatisfaction. Chronic pain patient depression was associated negatively with patient-rated family cohesion and expressiveness and spouse-rated family organization and positively with patient-rated family conflict. Overt patient pain behaviors and spouse-rated patient disability were related negatively to spouse-rated family cohesion. Spouse marital satisfaction was associated negatively with patient depression and with spouse ratings of patient disability and pain behaviors.     

A Social Constructionist Model of Therapeutic Factors

Evidentiary support for the efficacy of therapeutic models has been a contentious issue since the professionalization of psychology. Despite advances in evidence-based practices in psychology and common factors research, discontent still exists among postmodern psychotherapists in that evidence is mainly defined in modernist/positivistic terms, thereby excluding therapeutic models based on alternative nonpositivistic epistemologies. I proposes a model, which is based on social constructionist theories, for investigating the therapeutic efficacy of various approaches. This article evaluates and differentiates between two models for viewing the efficacy of psychotherapy, namely outcome versus process efficacy. A social constructionist model of therapeutic factors is proposed as a means to incorporate therapeutic factors into psychotherapy processes that are consistent with a social constructionist theory of change. Three main therapeutic elements, which are identified as central to an effective psychotherapy process, are outlined in the model. The proposed model may be useful as a guide to efficacious psychotherapy and as a means for investigating the efficacy of social constructionist therapies.     

Perceived Early Childhood Family Influence,Perceived Pain Self‐Efficacy,and Chronic Pain Disability: An Exploratory Study

The authors examined, with adult participants, the relationship between perceived early childhood family influence, pain self‐efficacy beliefs, and pain‐related disability. Perceived pain self‐efficacy explained 37% of the variance in chronic pain disability, but perceived early childhood family influence was not a statistically significant predictor of chronic pain disability.     

The Social Construction of Human Kinds

Social construction theorists face a certain challenge to the effect that they confuse the epistemic and the metaphysical: surely our conceptions of something are influenced by social practices, but that doesn't show that the nature of the thing in question is so influenced. In this paper I take up this challenge and offer a general framework to support the claim that a human kind is socially constructed, when this is understood as a metaphysical claim and as a part of a social constructionist debunking project. I give reasons for thinking that a conferralist framework is better equipped to capture the social constructionist intuition than rival accounts of social properties, such as a constitution account and a response‐dependence account, and that this framework helps to diagnose what is at stake in the debate between the social constructionists and their opponents. The conferralist framework offered here should be welcomed by social constructionists looking for firm foundations for their claims, and for anyone else interested in the debate over the social construction of human kinds.     

Resilience: A Disability Studies and Community Psychology Approach

This paper contests traditional psychological understandings of resilience through reference to a research project exploring resilience in the lives of disabled people. The paper briefly historically locates individualistic accounts of resilience (which have often been unhelpful in the lives of disabled people) and then moves into more recent social constructionist theories of this phenomenon. This latter perspective necessarily locates resilience in a network of resources including material resources, relationships, identity, bodies and minds, power and control, community participation, community cohesion and social justice. We argue that the recognition of resilience as a relational product is important and in tune with attempts to make psychology less an individualistic encounter and more a community intervention. However, disabled people, their politics and the development of critical disability studies, contest and challenge normative ideas of what it means to live with a resilient network of resources. In this sense disability offers new and exciting ways of addressing resilience.     

An evaluation of support groups for patients with long-term chronic pain and complex psychosocial difficulties

There is a significant group of chronic pain patients with complex psychosocial needs who are frequent users of hospital outpatient departments and who do not participate in or benefit from traditional pain management treatments and are convinced there is a medical solution to their problems. They are a particularly challenging group of patients to help, often shunned by medical and psychological professionals. A new type of ten-session psycho-social group for these patients that is less demanding than traditional pain management group programmes is investigated. It is designed to foster the development into community-based self-help groups and reduce the need for professional support and unnecessary medical intervention. Accounts of four groups of patients who participated in support groups and successfully established their own groups is presented. To assess changes in motivation, mood and pain disability standardized questionnaire measures were given before and after group attendance. Findings suggest that patients benefited and took increased responsibility for their pain management but did not demonstrate positive changes on measures of mood or level of pain disability. Patients experienced satisfaction with the groups and established their own self-help community groups. The positive experience of participants and staff suggests further work with support groups would be productive for this group of patients.     

Observer Perceptions of Chronic Low Back Pain1

This study examined the effects of three variables on perceptions of symptoms associated with chronic low back pain: (a) the presence or absence of supporting medical evidence, (b) the valence (positive/negative) of the relationship of an observer to the person in pain, (c) the degree of control (present/absent) of the person in pain over the circumstances of pain onset. The independent variables were manipulated in a (2 × 2 × 2) within-subjects design. Forty-eight undergraduate subjects were asked to estimate levels of pain intensity, emotional distress, and disability for the person in pain described in each of eight vignettes. Significant main effects, a two-way interaction, and a three-way interaction emerged, indicating that these contextual variables exerted substantial and complex effects on observer perceptions. The implications of these findings are discussed for matters such as pain assessment and disability determination.     

Can Exposure and Acceptance Strategies Improve Functioning and Life Satisfaction in People with Chronic Pain and Whiplash‐Associated Disorders (WAD)? A Randomized Controlled Trial

Although 14% to 42% of people with whiplash injuries end up with chronic debilitating pain, there is still a paucity of empirically supported treatments for this group of patients. In chronic pain management, there is increasing consensus regarding the importance of a behavioural medicine approach to symptoms and disability. Cognitive behaviour therapy has proven to be beneficial in the treatment of chronic pain. An approach that promotes acceptance of, or willingness to experience, pain and other associated negative private events (e.g. fear, anxiety, and fatigue) instead of reducing or controlling symptoms has received increasing attention. Although the empirical support for treatments emphasizing exposure and acceptance (such as acceptance and commitment therapy) is growing, there is clearly a need for more outcome studies, especially randomized controlled trials. In this study, participants (N = 21) with chronic pain and whiplash‐associated disorders were recruited from a patient organization and randomized to either a treatment or a wait‐list control condition. Both groups continued to receive treatment as usual. In the experimental condition, a learning theory framework was applied to the analysis and treatment. The intervention consisted of a 10‐session protocol emphasizing values‐based exposure and acceptance strategies to improve functioning and life satisfaction by increasing the participants' abilities to behave in accordance with values in the presence of interfering pain and distress (psychological flexibility). After treatment, significant differences in favor of the treatment group were seen in pain disability, life satisfaction, fear of movements, depression, and psychological inflexibility. No change for any of the groups was seen in pain intensity. Improvements in the treatment group were maintained at 7‐month follow‐up. The authors discuss implications of these findings and offer suggestions for further research in this area.     

Predictors of COVID-19 precautionary behaviors to protect people with disabilities

Disability is conceptualized using one of two major frameworks: the medical and the social model of disability. The medical model of disability describes disability as an individual issue in which the appropriate intervention is to remove the disability. The social model of disability describes disability as a social construction in which the appropriate intervention is societal change to increase accessibility. This study drew on models of disability to understand predictors of engagement in COVID-precautionary behavior prior to the vaccine to protect people with disabilities (PWD) from contracting COVID-19. Participants (n = 720) with and without disabilities (n = 77 and n = 633, respectively) completed an online questionnaire measuring disability beliefs, attitudes toward PWD, concerns about PWD contracting COVID-19, and engagement in behavior protecting PWD from contracting COVID-19. Medical model beliefs were negatively associated with behavior. In addition, negative attitudes toward PWD and low concern about PWD contracting COVID-19 fully accounted for the relationship. Social model beliefs were positively associated with behavior. In addition, positive attitudes toward PWD and greater concern about PWD contracting COVID-19 partially explained the relationship. These findings suggest that framing disability as a social construction rather than a medical issue could promote greater public health behavior to protect PWD from contracting COVID.     

The self beyond words: comment on ‘Is there a place for individual subjectivity within a social constructionist epistemology’

Roy‐Chowdhury (2010) is on a quest to reclaim the subject in constructionist practice, specifically therapeutic practice. His argument rests on the claim that there is no subject, no self, no individual outside language in social construction. To be sure, the notion of a self‐contained, privately cognizing individual is dismissed within social construction, noting instead that knowledge of self and world is a byproduct of relational interchange. As Lock and Strong (2010 , p.7) put it, ‘meaning and understanding have their beginnings in social interaction, in shared agreements as to what these symbolic forms are to be taken to be’. The relational self – social construction's version of the self – is very much alive and well. The relational self is very much a person.     

Adjustment to chronic low back pain--the relative influence of fear-avoidance beliefs, catastrophizing, and appraisals of control

The present study investigated the relative extent to which patients' adjustment to chronic low back pain (CLBP) was influenced by their fear-avoidance beliefs, their tendency to catastrophize, and their appraisals of control. Eighty-three CLBP patients completed a series of self-report measures before participating in a physical therapist-led intervention. Hierarchical multiple regression analyses revealed that patients' perceptions of their ability to decrease pain explained a small, but statistically significant, proportion of the variance in pain intensity. In addition, patients' levels of catastrophizing, as well as their fear-avoidance beliefs about both work and physical activity, were independently associated with levels of disability. Interestingly, however, when exploring the relative predictive utility of these three psychological factors, it became evident that fear-avoidance beliefs about physical activity (FABs-PA) were the only significant predictor of patients' disability. Specifically, those patients who exhibited higher levels of FABs-PA tended to report greater levels of disability, even after adjusting for age, sex and pain intensity.