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Pain Management: Cognitive Therapy for Chronic Pain and Fibromyalgia

Section 11
Psychological Management of Pain, Part I

Question 11 | Answer Booklet | Table of Contents
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Prevalency estimations of different countries (USA, Germany, Sweden) show that about 5%±7% of the population suffer from chronic pain and as a result cause treatment costs of multiple billions.1, 2 However, there is another fact important in this health political context: long-standing abuse of analgesics causes kidney damage. It is estimated that an abuse of analgesics precedes the illness of about one third of all dialysis patients.

Pain is a subjective experience which can occur in very different qualities and strengths. Pain cannot be measured or objectified. Therefore in assessing the pain of a patient, dependency is on his verbal description, his nonverbal expressions and empathy. Problems with the communication between doctor and patient are a frequent result. Pain is still often only thought of in terms of its primary function, the warning function and it is rarely distinguished as acute or chronic pain. However, the latter frequently follows very different rules. Influenced by an out-dated linear causal thinking, it is often assumed that pain is caused exclusively by a stimulation of a nociceptor. If then such an organ pathological discovery explaining the pain cannot be found, the patients’ experiences are not seldomly questioned. `You only imagine that’ patients sometimes hear; or one searches for further physical causes. This of course increases the conviction of the patients, their pain can only have physical causes (not yet found). All people involved then believe that it needs further diagnostic investigations in order to find the cause. Patients are sent to the nth examination and increasingly are regarded as difficult or annoying. This is already the first step towards chronification. However, since the chances for cures sink drastically with increasing chronification, it is necessary to offer the patient an appropriate, that is interdisciplinary, diagnosis and treatment from the beginning. Therefore, this chapter is generally concerned with the bio-psycho-social control factors of the (acute) pain experience, further with chronic pain and finally with different integrative therapeutic approaches.

Chronic pain
In general, chronic pain is considered after a duration of three months (IASP). One has agreed on this definition for pragmatic reasons, since the actually more obvious criterion (persistence of pain longer than the expected period of time for the healing process) has led to unclear interpretations. Furthermore, the criterion is hardly applicable to the aforementioned painful conditions which do not occur as a result of an injury. Chronification, however, is not only tied to the duration of pain. It is considered as the more pronounced, the more it damages the mental processes and behavior of the affected person. Therefore the following factors are of great importance:

. duration of illness;
. number of treatments and consulted doctors;
. psychological impairments as depression, helplessness, loss of self-esteem;
. social impairments as social isolation, changes in the patient’s social role and position; and
. job-related impairments as having to take days off because of being ill, dismissal.

As frequently neither surgical nor medical treatments lead to a lasting success, the patient alternately experiences hope, disappointment, annoyance, further hope, if a new therapy method is attempted, and so forth. Finally, feelings of helplessness, depression, resignation evolve and the patient gradually withdraws from the outer world. However, the more days he has to take off because of his illness, the more he takes care of his body and the more he withdraws, the more attention is given to the body which is a risk for a renewed negative influence on the way pain is experienced.

This vicious circle also has an iatrogenic component. As known from prospective studies, if a patient, in his own subjective theory about his illness, only considers a physical cause and excludes psychological factors, this increases the probability of chronification. It therefore would be necessary, from the beginning on, not only to consider the (mistakenly) somatic causes of pain, but also to take as many as possible of the involved pathogenetic or modulating factors into account. As a result, the spiral of hope, disappointment and resignation can be prevented and the patient’s personal activity can be supported.

Diagnostic classification of chronic pain
Chronic pain can occur within different psychological disorders. However, the somatoform disorders, section F45 in the ICD-10 are of great importance, especially the numbers F45.0 ± F45.4. Above all, the latter category is to be applied, if the psychosocial factors are of a special importance in a case of chronic pain. It presupposes: (1) a continuous, torturing pain, which; (2) cannot be explained sufficiently by an organic damage; and (3) psychosocial problems or emotional conflicts are recognizable and can be brought into direct connection with the pain the patient experiences.

Concepts explaining chronic pain
Psychosocial pain research is carried out on the basis of two concepts: (a) psychodynamic; and (b) behavioral medicine concepts.

Both pathogenetic concepts have developed particular methods of treatment . The depth psychological concepts shall be discussed first.

Psychodynamic Concepts
Already in the 1960s, in accordance with the psychosomatic viewpoint of the time, Engel8 postulated a `pain prone personality’ which he defined as follows: the personality structure is characterized by compulsive and masochistic tendencies, by inhibiting aggressive needs, by feelings of guilt (mostly closely connected to the aforementioned aggression) for which pain serves as expiation. Concerning localization, an identification with a person to whom the patient was closely related as a child can often be found. In the childhood history of such patients one can find an accumulation of emotional refusal or abuse, chronic quarrels between the parents as well as separation and divorce, chronic illness or death of a parent, early incorporation of responsibility and high orientation towards achievement.

To a considerable extent, these retrospective findings could also be confirmed in prospective studies. It turned out that a proneness for pain can actually be verified.9 The fact that traumas in childhood can be essential contributing factors for a later chronic pain are hardly questioned anymore. Continuous pains after a successfully completed back operation were found in patients with traumatizing experiences in childhood significantly more often than in patients without these traumas. Therefore, it can be assumed that the personality development in early childhood also controls the later occurrence of chronic pains. However, it should be stressed that a dichotomy of `purely psychogenic’ or `purely physical’ pains, and how this was attempted in the 1970s, makes no sense. Chronic pain is always a result of an interaction of numerous factors (physical, psychological , social, cultural and last but not least, iatrogenic factors).
- Frischenschlager, O.; Psychological management of pain; Disability And Rehabilitation; May 2002; Vol. 24; Issue 8.

Personal Reflection Exercise #5
The preceding section contained information about the psychological management of pain part I.  Write three case study examples regarding how you might use the content of this section in your practice.

Under what two concepts is psychosocial pain research carried out? Record the letter of the correct answer the Answer Booklet.

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