On the putative uniqueness of cancer pain: do psychological principles apply?

A large volume of evidence has supported the important role of psychological principles and variables related to the perception of, and response to, nociceptive stimulation. On the basis of this research, a number of psychological interventions have been developed and used successfully with pain patients. Despite the evidence, there has been a tendency for practitioners to neglect the contributing role of cognitive, affective, and behavioral factors in reports of pain by cancer patients. Cancer seems to hold a unique status in medicine and society at large. In this paper, the cancer pain literature is briefly reviewed and evidence is presented for various psychological determinants of the pain report and response that may be extended to pain associated with cancer. The implications of these data for understanding and treatment of cancer patients are described.     

Unexplained chest pain: a review of psychological conceptualizations and treatment efficacy

This review critically considers psychological theories and models used to understand unexplained chest pain, and efficacy of treatment strategies. It discusses the strengths and limitations of current perspectives, and highlights implications for future research and interventions. A comprehensive range of literature examining unexplained chest pain, and published over the last three decades, was thus reviewed finding that, although unexplained chest pain has been examined as a psychological phenomenon for over 100 years, explanatory models have emerged only in the last two decades. Neither psychophysiological nor psychodynamic models have been significantly advanced. Only cognitive-behavioural models have been explicitly derived to explain and manage the condition, and require further refinement to address conceptual and methodological limitations. Studies assessing treatment efficacy suggest cognitive-behavioural therapy as a first-line therapy, but have failed to establish whether the approach is acceptable and effective in routine care. Comprehensive psychological understanding of unexplained chest pain, and its management, is therefore developing but is far from complete. Cognitive-behavioural interventions show promise but are likely to be enhanced by greater theoretical clarity and understanding of resistance to their implementation.     

Acceptance and values-based action in chronic pain: a three-year follow-up analysis of treatment effectiveness and process

Recent developments in CBT emphasize the promotion of psychological flexibility to improve daily functioning for people with a wide range of health conditions. In particular, one of these approaches, Acceptance and Commitment Therapy (ACT), has been studied for treatment of chronic pain. While trials have provided good support for treatment effectiveness through follow-ups of as long as seven months, the longer-term impact is not known. The present study of 108 participants with chronic pain examined outcomes three years after treatment completion and included analyses of two key treatment processes, acceptance of pain and values-based action. Overall, results indicated significant improvements in emotional and physical functioning relative to the start of treatment, as well as good maintenance of treatment gains relative to an earlier follow-up assessment. Effect size statistics were generally medium or large. At the three-year follow-up, 64.8% of patients had reliably improved in at least one key domain. Improvements in acceptance of pain and values-based action were associated with improvements in outcome measures. A “treatment responder” analysis, using variables collected at pre-treatment and shorter term follow-up, failed to identify any salient predictors of response. This study adds to the growing literature supporting the effectiveness of ACT for chronic pain and yields evidence for both statistical and clinical significance of improvements over a three-year period.     

Pain: Biopsychosocial Mechanisms and Management

Traditionally, pain has been viewed as a sensory event warning of tissue damage or illness. This explanation fails to account for many of the experiences of people suffering from clinically painful conditions. Over the past two decades, a new biopsychosocial perspective on pain has emerged. This perspective emphasizes that pain is a dynamic process that not only is influenced by biological, psychological, and social mechanisms of pain, but also produces biological, psychological, and social changes that can affect future responses to pain. This review presents findings from recent studies of the biological, psychological, and social mechanisms of pain and discusses the implications of these findings for pain research, assessment, prevention, and treatment, as well as for health care policy.     

Measuring Emotional Intelligence Enhances the Psychological Evaluation of Chronic Pain

The assessment of emotional factors, in addition to other psychosocial factors, has been recommended as a means of identifying individuals with chronic pain who may not respond to certain pain treatments. Systematic reviews of the evidence regarding the prediction of responsiveness to a treatment called the spinal cord stimulator (SCS) have yielded inconclusive results. Emotional intelligence is a term which refers to the ability to identify and manage emotions in oneself and others and has been shown to be inversely associated with emotional distress and acute pain. This study aims to investigate the relationship between emotional intelligence, chronic pain, and the more established psychosocial factors usually used for SCS evaluations by clinical psychologists in medical settings. A sample of 112 patients with chronic pain on an acute hospital waiting list for SCS procedures in a pain medicine service were recruited. Psychological measures were completed including: a novel measure of emotional intelligence; usual measures of emotional distress and catastrophizing; and a numerical rating scale designed to assess pain intensity, pain-related distress, and interference. As predicted, findings revealed significant associations between most of the measures analyzed and current pain intensity. When entered into a simultaneous regression analysis, emotional intelligence scores remained the only significant predictor of current pain intensity. There are potential clinical, ethical, and organizational implications of emotional intelligence processes partially predicting pain in patients on a waiting list for a medical procedure. These results may offer new insight, understanding, and evaluation targets for clinical psychologists in the field of pain management.     

Hypnosis and clinical pain

Hypnosis has been demonstrated to reduce analogue pain, and studies on the mechanisms of laboratory pain reduction have provided useful applications to clinical populations. Studies showing central nervous system activity during hypnotic procedures offer preliminary information concerning possible physiological mechanisms of hypnotic analgesia. Randomized controlled studies with clinical populations indicate that hypnosis has a reliable and significant impact on acute procedural pain and chronic pain conditions. Methodological issues of this body of research are discussed, as are methods to better integrate hypnosis into comprehensive pain treatment.     

Task-related and person-related variables influence the effect of low back pain on anticipatory postural adjustments

BackgroundPeople with low back pain exhibit altered postural coordination that has been suggested as a target for treatment, but heterogeneous presentation has rendered it difficult to identify appropriate candidates and protocols for such treatments. This study evaluated the associations of task-related and person-related factors with the effect of low back pain on anticipatory postural adjustments.MethodsThirteen subjects with and 13 without low back pain performed seated, rapid arm flexion in self-initiated and cued conditions. Mixed-model ANOVA were used to evaluate group and condition effects on APA onset latencies of trunk muscles, arm-raise velocity, and pre-movement cortical potentials. These measures were evaluated for correlation with pain ratings, Fear Avoidance Beliefs Questionnaire scores, and Modified Oswestry Questionnaire scores.FindingsDelayed postural adjustments of subjects with low back pain were greater in the cued condition than in the self-initiated condition. The group with low back pain exhibited larger-amplitude cortical potentials than the group without pain, but also significantly slower arm-raise velocities. With arm-raise velocity as a covariate, the effect of low back pain remained significant for the latencies of postural adjustments but not for cortical potentials. Latencies of the postural adjustments significantly correlated with Oswestry and Fear Avoidance Beliefs scores.InterpretationDelayed postural adjustments with low back pain appear to be influenced by cueing of movement, pain-related disability and fear of activity. These results highlight the importance of subject characteristics, task condition, and task performance when comparing across studies or when developing treatment of people with low back pain.     

Chronic pain: a reformulation of the cognitive-behavioural model.

The last few decades has seen psychological theories of chronic pain dominated by behavioural concepts and particularly, by the operant model as described by Fordyce et al. (1968: Fordyce, W., Fowler, R., & DeLateur, B. (1968) An application of behavior modification technique to a problem of chronic pain. Behaviour Research and Therapy, 6, 105-107, 1976: Fordyce, W.E. (1976) Behavioral methods for chronic pain and illness. St Louis, MO: C. V Moseby). More recently, cognitive constructs have been included, giving the impression that the operant theory of chronic pain has been replaced by a cognitive-behavioural theory (CBT). Given the fact that CBTs were introduced essentially to overcome some inherent problems with operant theory, it is notable that they are still very much based on operant theory and continue to be founded upon operant principles. Further, the extent to which CBTs (at this stage) have included contemporary cognitive research has been limited. This paper argues that it is of questionable validity to continue to include problematic concepts (e.g., operant principles) into a revised theory (e.g., CBT). Instead, consistent with research from other areas (particularly the anxiety disorders), chronic pain and the problems associated with it may be better explained by a reformulated cognitive-behavioural theory which although not ignoring the observable behaviours of pain patients and their associations with social reinforcers, interprets these phenomena from a cognitive perspective. Thus, a modified CBT is proffered, focusing more directly on patients' thoughts about, and appraisals of, their pain. Evidence in support of such a theory is provided, as are suggestions for further research and the implications such a theory has for treatment.     

The neurobiology of virtual reality pain attenuation.

During the past decade, virtual reality (VR) has gained recognition as a means of attenuating pain during medical procedures. However, while investigators have examined the effects of virtual environments on level of distraction, subjective pain intensity, and brain activity, there have been only a handful of investigations into the neurobiological mechanisms associated with VR's efficacy. In an effort to explain how VR may alter pain perception and produce analgesia, as well as to guide the development of novel and improved VR pain treatments, this review aims to link the wealth of empirical data examining the neurobiology of pain to the growing field of VR. This review is separated into three main sections: (a) a brief overview of the current literature on the use of VR for the treatment of pain; (b) a review of the basic neurobiology of how pain is detected, processed, and controlled by the brain; and (c) an exploration into how current VR pain treatments may impact the pain system to produce analgesia. In addition, the future of VR for pain treatment is discussed, including how current treatments might be improved and novel ways to use VR to treat pain might be developed. Speculation on future VR interventions is based on our current understanding of how the brain processes pain and how VR appears to alter this process and produce analgesia.     

The Future of Psychology in Pain Management

Pain treatment facilities have proliferated in recent years and psychology has enjoyed considerable success in the clinical and research arenas of pain management. However, changes in the health care environment present significant challenges to the future of psychology in pain management. This article discusses concerns in three important areas of pain treatment that psychologists must address if they are to maintain a strong presence in this field: (1) evaluating and treating patients in the pain treatment setting, (2) evaluating and enhancing the efficacy of pain treatment, and (3) applying pain treatment services to other patient populations. With appropriate attention to these issues, psychology can continue to thrive in pain treatment settings.     

Provoked vestibulodynia: Psychological predictors of topical and cognitive-behavioral treatment outcome

Psychological factors have been found to impact the pain experience and associated sexual impairment of women suffering from provoked vestibulodynia (PV). Despite a lack of randomized treatment outcome studies, particularly concerning psychological predictors of outcome, recent studies have shown that topical applications and cognitive-behavioral therapy (CBT) are among the most popular first-line interventions for PV. The present study aimed to determine the extent to which baseline fear-avoidance variables and pain self-efficacy were differentially associated with topical application and CBT outcomes at six-month follow-up. Data were obtained from 97 women who completed a randomized trial comparing these two treatments. Regression analyses revealed that for topical treatment, higher levels of baseline avoidance predicted worse pain and sexual functioning outcomes, whereas higher levels of pain self-efficacy predicted better outcomes. For CBT, higher levels of baseline fear of pain and catastrophizing contributed to higher pain intensity at follow-up, whereas higher levels of pain self-efficacy were associated with less pain. Psychological factors did not predict sexual functioning outcomes for CBT. Consistent with biopsychosocial models of pain and sexual dysfunction, results indicate that psychological factors contribute to pain and sexual impairment following treatment for PV. Specifically, findings suggest that fear-avoidance variables and pain self-efficacy are significant predictors of topical and CBT treatment outcomes in women with PV.     

Parent Anxiety and Infant Pain During Pediatric Immunizations

Infants’ procedural pain and parents’ treatment room anxiety has been largely ignored in the research and clinical domains. To understand and manage infant procedural pain, it is essential to examine the correlates and potential predictors of this pain. Given that parent anxiety is a strong predictor of preschoolers’ procedural anxiety and pain, it is likely that parents play a role in infants’ distress during medical procedures. The purpose of this study was to thoroughly examine parent anxiety and its effects on infant procedural pain for 37 parent-infant dyads. Results demonstrated that only parent self-report measures were intercorrelated and several measures of parent distress correlated with measures of infant distress. Treatment implications and recommendations for future research are discussed.This article is based on the master's thesis of the first author under the direction of the second, at West Virginia University.     

Current trends in neuropathic pain treatments with special reference to fibromyalgia

Neuropathic pain and fibromyalgia are prevalent diseases which have major consequences on healthcare resources and the individual. From the clinical point of view neuropathic pains represent a heterogeneous group of aetiologically different diseases ranging from cancer to diabetes. Patients with fibromyalgia also display clinical features common in neuropathic pain suggesting that there might be some overlap. The mechanisms responsible for symptoms and signs in both diseases are still unknown. Recently, there have been numerous reports of various pharmacological treatments of neuropathic pain and fibromyalgia with often disappointing results. Most of the studies were of short duration, had high attrition rates, and displayed other methodological problems. Some compounds had high rates of adverse effects which makes it often difficult for the patients to tolerate the treatment, especially in the long-term. At present, the best options for medication treatment are tricyclic antidepressants in lower dosage than usual in psychiatric disorders and a wide range of anticonvulsants. Opioids are sometimes recommended but have been found to have minor efficacy. Recently, there have been more controlled trials, which are reported here if they had been published between 2002 and 2004. Various compounds have been tested in different studies. Treatment of fibromyalgia, which has many features in common with depressive symptoms, became the focus of interest. New promising studies with dual serotonin-norepinephrine reuptake inhibitors (duloxetine and milnacipram) and a newer antiepileptic drug (pregabalin) are in progress. Future research will have to apply new approaches (e.g., using a mechanism-based classification of neuropathic pain and carrying out studies in populations with the same symptom but not necessarily the same disease) in order to find effective treatments for these common and often debilitating diseases.     

Complicating Factors Associated with Mild Traumatic Brain Injury: Impact on Pain and Posttraumatic Stress Disorder Treatment

The nature of combat in Iraq and Afghanistan has resulted in high rates of comorbidity among chronic pain, posttraumatic stress disorder (PTSD), and mild traumatic brain injury (mTBI) in Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF). Although separate evidence-based psychological treatments have been developed for chronic pain and PTSD, far less is known about how to approach treatment when these conditions co-occur, and especially when they co-occur with mTBI. To provide the best care possible for OEF/OIF Veterans, clinicians need to have a clearer understanding of how to identify these conditions, ways in which these conditions may interact with one another, and ways in which existing evidence-based treatments can be modified to meet the needs of individuals with mTBI. The purpose of the present paper is to review the comorbidity of pain, PTSD, and mTBI in OEF/OIF Veterans, and provide recommendations to clinicians who provide care to Veterans with these conditions. First, we will begin with an overview of the presentation, symptomatology, and treatment of chronic pain and PTSD. The challenges associated with mTBI in OEF/OIF Veterans will be reported and data will be presented on the comorbidity among all three of these conditions in OEF/OIF Veterans. Second, we will present recommendations for providing psychological treatment for chronic pain and PTSD when comorbid with mTBI. Finally, the paper concludes with a discussion of the need for a multidisciplinary treatment approach, as well as a call for continued research to further refine existing treatments for these conditions.     

前列腺增生电切术后膀胱痉挛的对策

比较三种方法缓解经尿道前列腺电切术(transurethral prostatic resection,TURP)后膀胱痉挛性疼痛的效果。54例TURP术后患者发生膀胱痉挛性疼痛,分别给予以下处理:单纯清通管道处理组23例;清通管道加口服药物(双氯芬酸钾片)处理组20例;术后给予镇痛泵处理组11例。采用国际通用视觉模拟评分法,(VAS:0=无痛,10=剧痛)评估镇痛效果。观察术后三日内以及三日后膀胱挛缩性疼痛发生情况。结果单纯清通管道处理组,术后三日后仍有膀胱挛缩疼痛13例;清通管道加口服双氯芬酸钾片处理组,连服三天轻度膀胱痉挛疼痛,停药再发6例;给予镇痛泵处理组轻度膀胱痉挛疼痛,三日后再发3例。术后清通管道加双氯芬酸钾片组和术后给予镇痛泵处理组缓解膀胱痉挛性疼痛无明显差异,但均较单纯清通管道组效果明显。因此,清通管道加双氯芬酸钾片治疗TURP术后膀胱痉挛性疼痛的方法值得推广。     

Fear of routine dental treatment in adults: Its nature and management

Abstract

The fear of dental treatment in adults can be characterised in several ways, loosely related, such as anticipating being afraid, avoiding dental check-ups and seeking treatment only under general anaesthesia. Defined thus, at least a quarter of adults are highly afraid of dentistry. The feared experiences are many, including most frequently, pain. Several studies have shown that anxious patients experience less pain during treatment than they expect. It remains to be confirmed that these are typical experiences because other studies show that local anaesthesia can fail to protect patients from sudden pain in 13% of treatments on average. Expectations of pain are highly resistant to change, the result probably of several influences including distortion in recall of pain-free treatment, intermittent experience of sudden severe pain, expecting pain in order to reduce its impact, and uncertainty about treatment. It has yet to be shown that experience free of discomfort can reduce these expectations. However, relaxation instructions and information about pain management and stop signals can reduce pre-treatment fear. To prevent the onset and the maintenance of anxiety: the prevention of pain is essential; controlled behavioural studies of the treatment of pain and other experiences such as panics are needed. Finally, the need for new instruments to assess all aspects of fear of dentistry is described.     

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.     

Invited Special Review: Psychological Approaches for Managing Chronic Pain

Psychologists have had an important impact on the conceptualization, assessment, and treatment of chronic pain. Their contributions have been in the areas of emotional distress, behavioral limitations, cognitive mediating events, and psychosocial disruption of chronic pain. These foci have enabled them to clarify the multidimensional nature of chronic pain and to support the biopsychosocial framework as a conceptual guide for research and clinical purposes. Clinically, along with members of an interdisciplinary team, psychologists have a key role in the assessment and treatment of patients with chronic pain. Interdisciplinary collaboration allows the team to recognize important interactions between biomedical and psychosocial dimensions and to appreciate a broader conceptualization of patients' problems. The literature documents strong empirical support for operant-behavioral and cognitive-behavioral therapies for the treatment of chronic pain. On the other hand, although widely accepted from a clinical perspective, the use of motivational interviewing and motivational enhancement therapies is more recent and less well documented for use with patients with chronic pain.     

基于神经生理学的疼痛测量

疼痛是一种受多重因素影响的复杂主观感受。临床上,疼痛测量主要依赖于患者的主观评价。然而,这种传统的疼痛测量方法具有多方面的局限。近年来,研究者借助生理记录、脑电和功能磁共振等技术,揭示疼痛的神经生理、心理机制,挖掘与疼痛相关的神经生理指标,进而构建有效、客观和精确的疼痛评价体系。在基础研究和临床实践中,这些技术有望弥补传统疼痛测量方法的不足,从而极大推动疼痛测量及其治疗等相关领域研究的发展。