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.     

Temporal dimensions of the self-concept: Entrapped and possible selves in chronic pain

Abstract

The purpose of this qualitative study was to explore temporal aspects of chronic pain patients' conceptions of their selves; what they were in the past, how they were functioning at the present and what they thought about their potential and future. In-depth interviews with 21 chronic pain patients were performed and analysed. The main results of the analysis included four higher-order conceptual patterns: “the body and I”, “maintaining the consistency of past self”, the “entrapped self”, and “projected selves, defined by others”. These results are presented in a systems-oriented model illustrating the temporal dynamic between the perceived functioning self, the body and others, such as health care personnel and significant others. The mechanisms of the process of how selves are developing in the chronisation or healing process of pain are finally discussed. A clinical implication of these findings might be that with an enlarged insight of the temporal dynamic and the importance of interactive and social factors in shaping positive possible selves, health care personnel can contribute more effectively in stew-arding the chronic pain patient toward health-promotive ends and a concomitantly higher quality of life.     

The role of the patient in the management of post surgical pain

Abstract

An experiment was conducted to test the idea that patients do not have the necessary knowledge about pain relief to contribute effectively to their own pain management through such strategies as being more assertive in requesting analgesia. When patients were provided with video-taped information about available pain control techniques, together with a rationale for the minimisation of pain and encouragement to request analgesia as required, they did not achieve significantly less pain than control groups. Since patients were well satisfied with pain levels substantially greater than zero, it is argued that the conventional wisdom that high pain scores indicate that post surgical pain is badly treated should be re-assessed.     

The impact of experiential avoidance on the relations between illness representations,pain catastrophising and pain interference in chronic pain

Objective: The aim of this study was to examine the effects of experiential avoidance (EA) on the indirect relationship of chronic pain patients’ illness representations to pain interference, through pain catastrophising

Design and main outcome measure: The sample consisted of 162 patients diagnosed with an arthritis-related or a musculoskeletal disorder. The effects of EA on the pathway between illness representations, pain catastrophising and pain interference were examined with PROCESS, a computational tool for SPSS

Results: After controlling for patient and illness-related variables and pain severity, the ‘illness representations–pain catastrophising–pain interference’ pathway was interrupted at the higher levels of EA. The reason was that, at the high levels of EA, either the relation of illness representations to pain catastrophising or the relation of pain catastrophising to pain interference was not statistically significant.

Conclusion: The findings indicate that EA is not a generalised negative response to highly aversive conditions, at least as far as the factors examined in this study are concerned. EA may rather reflect a coping reaction, the impact of which depends on its specific interactions with the other aspects of the self-regulation mechanism. At least in chronic pain, EA should become the focus of potential intervention only when its interaction with the illness-related self-regulation mechanism results in negative outcomes.     

Self-conscious emotions in patients suffering from chronic musculoskeletal pain: A brief report

Objective: The role of self-conscious emotions (SCEs) including shame, guilt, humiliation and embarrassment are of increasing interest within health. Yet, little is known about SCEs in the experience of chronic pain. This study explored prevalence and experience of SCEs in chronic pain patients compared to controls and assessed the relationship between SCEs and disability in pain patients.

Design and measures: Questionnaire assessment comparing musculoskeletal pain patients (n = 64) and pain-free control participants (n = 63). Pain was assessed using the McGill Pain Questionnaire; disability, using the Roland–Morris Disability Questionnaire; and six SCEs derived from three measures (i) Test of Self-Conscious Affect-3 yielding subscales of shame, guilt, externalisation and detachment (ii) The Brief Fear of Negative Evaluation Scale and (iii) The Pain Self-Perception Scale assessing mental defeat.

Results: Significantly greater levels of shame, guilt, fear of negative evaluation and mental defeat were observed in chronic pain patients compared to controls. In the pain group, SCE variables significantly predicted affective pain intensity; only mental defeat was significantly related to disability.

Conclusion: Findings highlight the prevalence of negative SCEs and their importance in assessment and management of chronic pain. The role of mood in this relationship is yet to be explored.     

Distinction between mental pain and psychic suffering as separate entities in the patient's experience

Abstract

Mental pain and psychic suffering are herein defined as two separate concepts in psychoanalysis. The concept of mental pain lies at the core of psychoanalysis; it was introduced by Freud and was further elaborated by a number of investigators, mostly by Bion. Mental pain refers to a pain that the patient reports as being impossible to describe in words, and lacking any associations, whereas psychic suffering can be both named and described by the patient. Mental pain is derived from non-tolerance on the part of the psychic apparatus when it is harmed by very painful emotions. In contrast to psychic suffering, mental pain resists elaboration and transformation by dream-work. How to address and transform the patient's mental pain is a major challenge facing the analyst in his clinical work because mental pain may halt or slow the progression of the analytical process. To overcome this hindrance, the work of the analyst is focused on helping patients to modify their mental pain into psychic suffering, that is, to reactivate in the patient the chain of transformations that generates thought. The analyst is also challanged with the mental pain of the patients because he has himself to tolerate the mental patient induced by counter transference. Suggestions for the analyst on how to deal with the mental pain of the patient during psychoanalytic therapy are proposed.     

The role of pain behaviour and family caregiver responses in the link between pain catastrophising and pain intensity: A moderated mediation model

Objectives: This study investigated the mediating role of pain behaviours in the association between pain catastrophising and pain intensity and explored the moderating role of family caregivers’ responses to pain in the link between pain behaviours and pain intensity.

Methods: The sample consisted of 154 chronic pain patients and their family caregivers. Patients completed questionnaires regarding pain intensity, pain catastrophising, pain behaviours and their caregivers’ responses to their pain. Family caregivers reported their responses to the patients’ pain.

Results: Pain catastrophising was associated with pain intensity (r = 0.37) and pain behaviours partly mediated this association. The positive association between pain behaviours and pain intensity was significant only if patients reported that their family caregivers showed high levels of solicitous (effect = .49) and distracting responses (effect = .58), and if caregivers reported to show high levels of solicitous responses (effect = .51). No support was found for negative responses as a moderator neither based on patients’ perception of negative responses nor based on caregivers’ perception of negative responses.

Conclusions: The findings are in line with the idea that family caregivers’ solicitous and distracting responses convey to patients that their condition is serious, which may reinforce patients’ pain and pain behaviours, especially in those who catastrophise.     

Pain intensity and pain unpleasantness in triathletes: A study examining their associations with pain catastrophizing and pain expectations

ObjectiveTriathletes represent a growing and unique population of individuals willing to endure significant mental and physical stress to practice the sport they love. However, little is known about the pain experienced while training for and competing in a triathlon and how psychological factors influence this experience. This study will assess pain experienced by triathletes in training and competition, and investigate the association between pain catastrophizing and pain expectations with triathlon pain intensity and pain unpleasantness.DesignIn this observational study, a sample of 261 triathletes completed two online surveys before and after participating in a triathlon.ResultsModerate levels of pain intensity and pain unpleasantness were reported during training and competition. Pain catastrophizing was positively associated with expected and actual triathlon pain unpleasantness, but not with pain intensity. Expected pain intensity was also significantly associated with pain intensity experienced while competing, whereas expected pain unpleasantness was significantly related to both triathlon pain intensity and unpleasantness. Finally, regression analysis revealed pain catastrophizing and pain expectations to be unique predictors of triathlon pain intensity and pain unpleasantness.ConclusionThis study highlights the important role of psychological factors in triathletes' experience of pain and could eventually help tailor interventions aimed at improving the practice of triathlon.     

A comparison of pain management outcomes for disability compensation and non-compensation patients

Abstract

In this study, 50 men in an in-patient comprehensive rehabilitation program receiving disability compensation were compared with 25 non-recipients with respect to pre-and post-program measures of personality functioning. physical functioning and reported pain. On the pre-program measures. the only significant difference emerging between the two groups was found on the Mf scale of the MMPI, with the compensation group showing a slightly lower mean score. The two groups responded equally well on virtually all outcome measures. One interesting exception was found on the subjective measure of pain. which showed the compensation group reporting a higher level of subjective pain, and the non-compensation group a lower level than would be predicted on the basis of pre-program scores. Overall. and contrary to popular belief. the results suggest that compensation recipients can derive considerable benefit from pain management interventions despite the ostensible reinforcement provided by disability payments.     

The relationship of depression and somatic focus to experimental and clinical pain in chronic pain patients

Abstract

The present study examined Fields' proposal that depression increases the sensory experience of pain in part through greater somatic focus. Experimental and clinical pain measures were compared to self-report of depression and somatic focus in 60 chronic pain patients. Depression scores were unrelated to pain threshold or tolerance on the cold-pressor test. However, as hypothesized by Fields, path analytic models suggested that depression had a direct influence on the evaluative and affective aspects of pain, but the relationship between depression and sensory pain was mediated by somatic focus. These results provide partial support for Fields' neurobiological model of pain and depression.     

Hybrid cognitive-behaviour therapy for individuals with insomnia and chronic pain: A pilot randomised controlled trial

ObjectiveInsomnia is a debilitating comorbidity of chronic pain. This pilot trial tested the utility of a hybrid treatment that simultaneously targets insomnia and pain-related interference.MethodsChronic pain patients with clinical insomnia were randomly allocated to receive 4 weekly 2-h sessions of hybrid treatment (Hybrid Group; n = 10) or to keep a pain and sleep diary for 4 weeks, before receiving the hybrid treatment (Monitoring Group; n = 10). Participants were assessed at the beginning and end of this 4-week period. Primary outcomes were insomnia severity and pain interference. Secondary outcomes were fatigue, anxiety, depression and pain intensity. Ancillary information about the hybrid treatment's effect on psychological processes and sleep (as measured with sleep diary and actigraphy) are also presented, alongside data demonstrating the treatment's clinical significance, acceptability and durability after one and six months. Data from all participants (n = 20) were combined for this purpose.ResultsCompared to symptom monitoring, the hybrid intervention was associated with greater improvement in sleep (as measured with the Insomnia Severity Index and sleep diary) at post-treatment. Although pain intensity did not change, the Hybrid Group reported greater reductions in pain interference, fatigue and depression than the Monitoring Group. Overall, changes associated with the hybrid intervention were clinically significant and durable at 1- and 6-month follow-ups. Participants also rated highly on treatment acceptability.ConclusionThe hybrid intervention appeared to be an effective treatment for chronic pain patients with insomnia. It may be a treatment approach more suited to tackle challenges presented in clinical practice, where problems seldom occur in isolation.     

Big Five personality traits contribute to prosocial responses to others’ pain

ObjectivesTwo studies examined whether observers’ personality traits contribute to prosocial responses to others’ facial expression of pain. Experiment 1 examined the personality traits that could account for observers’ variability in estimating others’ pain intensity. Experiment 2 questioned to what extent the contribution of personality traits on inclination to help people in pain depend on observers’ beliefs about pain’ characteristics.Method59 (experiment 1) and 76 (experiment 2) participants observed to 3-D realistic synthetic face movements mobilizing action units of pain, in order to estimate others’ pain. In experiment 2, painful localizations (e.g., chest, hand) were also manipulated. In each experiment, Big Five personality traits were assessed.ResultsExperiment 1 revealed that agreeableness and conscientiousness contributed to observers’ pain estimates across the increase of facial expression intensity. Experiment 2 showed that conscientiousness contributed to observers’ judgments whatever pain’ characteristics. Neuroticism was only salient for pain referring to life-threatening pain.ConclusionProsocial response to others’ pain depends on agreeableness, conscientiousness and neuroticism. However, these links are modulated by the pain behavior elicited and observers’ belief about the characteristic of pain.     

A prospective analysis of acceptance of pain and values-based action in patients with chronic pain.

OBJECTIVE: Acceptance of pain and values-based action appear important in the emotional, physical, and social functioning of individuals with chronic pain. The purpose of the current study was to prospectively investigate these combined processes. METHOD: 115 patients attending an assessment and treatment course for chronic pain in the U.K. completed a standard set of measures on two occasions separated by an average of 18.5 weeks. RESULTS: Correlation analyses showed that acceptance of pain and values-based action measured at Time 1 were significantly correlated with pain, pain-related distress, pain-related anxiety and avoidance, depression, depression-related interference with functioning, and physical and psychosocial disability measured at Time 2. Multiple regression analyses, in which pain and relevant patient background variables were controlled, showed that the combined acceptance and values measures accounted for between 6.5% and 27.0% of variance in six key measures of patient functioning later in time. CONCLUSION: These results support the importance of acceptance and values-related processes in relation to chronic pain. These results also encourage continued applications of a functional contextual model of psychopathology, the model underlying Acceptance and Commitment Therapy and related approaches such as Contextual Cognitive-Behavioral Therapy.     

Illness representations,pain and physical function in patients with rheumatic disorders: between- and within-person associations

Objectives: Rehabilitation for patients with rheumatic diseases improves both illness representations (IR) and clinical outcomes such as pain and physical functioning (PF). However, it is unclear whether IR may affect and, in turn, are affected by pain and PF. In this study, we examined both between-person associations and within-person associations between IR and pain/PF over time on three measurement occasions. Furthermore, cross-lagged relationships were examined.

Design and main outcome measures: This secondary analysis is based on data from N?=?186 patients with rheumatic diseases. Data on pain, PF and IR were assessed using self-report questionnaires at the beginning, the end and three months after a 3-week inpatient rehabilitation.

Methods: To separate between- and within-person level, data were analysed using random-intercept cross-lagged panel models.

Results: On both the between-person level (r?=?|0.21|???|0.44|) and the within-person level (r?=?|0.15|???|0.46|), pain and PF were related to cognitive and emotional IR. In addition, we found within-person bidirectional cross-lagged effects between emotional IR and PF.

Conclusion: IR show complex relationships with pain and PF. Improving PF might improve subsequent illness-related emotional distress and vice versa.     

Exploring the associations shared by mood,pain-related attention and pain outcomes related to sleep disturbance in a chronic pain sample

Objective: Sleep disturbance in chronic pain is common, occurring in two-thirds of patients. There is a complex relationship between chronic pain and sleep; pain can disrupt sleep and poor sleep can exaggerate pain intensity. This may have an impact on both depressive symptoms and attention to pain. This study aims to evaluate the relationship between chronic pain and sleep, and the role of mood and attention.

Methods: Chronic pain patients, recruited from a secondary care outpatient clinic, completed self-report measures of pain, sleep, depressive symptoms and attention to pain. Hierarchical regression and structural equation modelling were used to explore the relationships between these measures. Participants (n = 221) were aged between 20 and 84 (mean = 52) years.

Results: The majority of participants were found to be ‘poor sleepers’ (86%) with increased pain severity, depressive symptoms and attention to pain. Both analytical approaches indicated that sleep disturbance is indirectly associated with increased pain severity Instead the relationship shared by sleep disturbance and pain severity was further associated with depressive symptoms and attention to pain.

Conclusions: Our results indicate that sleep disturbance may contribute to clinical pain severity indirectly though changes in mood and attention. Prospective studies exploring lagged associations between these constructs could have critical information relevant to the treatment of chronic pain.     

Chapter 4 Interpretation in Short-Term Therapy

Abstract

There is much theoretical and clinical literature on the role of interpretation in psychoanalysis, psychoanalytic psychotherapy, and brief dynamic psychotherapy, but little supporting research data. Using 112 audiotaped sessions from 38 patients in supportive-expressive time-limited treatment, the present study hypothesized that therapists would modify the object and temporal content and frequency of their interpretations in relation to the level of patient functioning. The results did not support this hypothesis. Therapists were not less active with more interpretations for higher functioning patients, nor were they more active with fewer interpretations for lower functioning patients. Therapists were more active and made more genetic interpretations with married patients, regardless of level of patient functioning. The findings are discussed in terms of their implications for supportive-expressive psychodynamic therapy.     

Changes in health status after one year for persons at-risk for and with HIV infection

Abstract

Health status is an important component of the evaluation of patient outcome in HIV infection where disease is chronic, progressive, and debilitating. This paper compares patient self-report for 9 dimensions of health status for patients followed in ATHOS (AIDS Time-Oriented Health Outcome Study). We compared changes in functioning after 12 months for 1, 524 patients with varying HIV disease severity: 238 asymptomatic, 447 symptomatic, 441 AIDS, and 398 HIV-negative individuals who are at-risk for infection.

Declines in health status were observed for all HIV-infected persons, including also asymptomatic patients. Individuals with symptomatic disease or AIDS had significant declines (p < 0.001) in physical functioning, energy, global health, pain, and increased disease symptoms, but no significant declines in health distress, cognition, or mental health. Persons with AIDS had greater declines than those with symptomatic disease. All HIV-infected individuals reported significantly fewer hours at work and more disability days than HIV-negative patients from similar risk pools. The adverse impact that HIV infection has on the health status of HIV-positive asymptomatic individuals is striking; HIV-negative individuals are more similar to HIV-positive individuals than to the general population.     

Medical help-seeking by different types of chronic pain patients

Abstract

This paper reports on a study of the use of health services by different types of patients with chronic benign pain. The purpose of the study was to identify differences in medical consumption between different types of pain patients. In the course of one year 586 patients were selected by 45 general practitioners: they included patients who had had almost daily chronic pain symptoms for at least six months, without a medical diagnosis (such as cancer or arthritis) to explain the pain. Patients were categorized according to the Multidimensional Pain Inventory which distinguishes four categories: the dysfunctional, who perceive severe pain and gain social support; the interpersonally distressed, who combine pain with affective and relational distress; adaptive copers, who cope with their pain in a number of ways; the average type, with characteristics of all three other types. It was hypothesised that adaptive copers would make less use of health services and would be more involved in self-help activities than dysfunctional or interpersonally distressed patients. Frequent use of psychological services by the interpersonally distressed group was expected. It was predicted that difference in health services use would continue during the subsequent year.

No differences were found between the four groups in location, temporal characteristics, or possible medical causes of the pain symptoms. Dysfunctional patients used more services than the others. Adaptive copers used the least. The four groups did not differ in self-care activities. Group-membership as well as pain severity are related to the use of health services. None of the groups showed a significant decline in the use of health services during the year. It is concluded that chronic pain is invalidating, but that not all patients are equally excessive in their use of medical services.