The aim of this paper is to provide an overview of psychological interventions used in the management of chronic pain conditions. In this review paper, a biopsychosocial model of chronic illness will be introduced and psychosocial factors mediating pain and disability reviewed. The theoretical basis of various psychological approaches will be outlined and their application to the management of chronic pain presented and discussed with regard to their effectiveness and efficacy. The way psychological approaches may be integrated into nursing management of chronic pain will then be discussed in a later paper.
Biopsychosocial model of pain and illness
Illness, like health, is the result of a complex interaction of biological, psychological and social variables. From this perspective, diversity in illness expression is accounted for by the inter-relationships between biological changes, psychological status and the social and cultural contexts that shape patients’ perception of, and response to, illness (Gatchel & Turk 1996, Adams 2004).
Biological factors alone do not explain reports of pain, pain-related disability or depression associated with chronic pain. For example, not all patients suffering with chronic pain are depressed or disabled to the same degree. The association between pain, depression and disability appears to be mediated by psychosocial variables and a multidimensional biopsychosocial model of pain emphasizes the influence of these variables. Many authors have indicated the role of psychological and social factors in the etiology, severity, exacerbation and maintenance of pain, suffering, disability and response to treatment in chronic illness conditions (Waddell et al. 1993, Fordyce 1995, Romano et al. 1995, Gatchel & Turk 1996, Lackner et al. 1996). These have been found to include factors such as level of emotional distress experienced, perceived life control, attentional focus, prior learning history, cultural background, appraisals, beliefs and expectations, environmental contingencies, social support and financial resources (Skevington 1995, Gatchel & Turk 1999, Adams 2004).
Biopsychosocial approaches have the potential to address a range of physical, psychological and social components of chronic conditions (Nielson & Weir 2001). The following is intended to illustrate the rationale for using psychological interventions in the management of chronic pain. Psychological interventions focus upon emotional, cognitive and behavioral aspects of illness, such as addressing patients’ beliefs by educating them about the condition, reducing anxiety and stress by teaching stress management techniques, and increasing personal control by teaching coping skills. The use of these interventions in chronic pain management have been supported by systematic review and meta-analysis (Morley et al. 1999).
Emotional aspects of pain
Most patients with chronic pain experience emotional distress to a varying degree. The most commonly reported are feelings of anxiety and depression with the latter implicated as a risk factor for developing long-term disability in low back pain (Pincus et al. 2002). Anger, frustration and resentment are also reported, but these have received less attention in the research literature. Various factors such as the nature and prognosis of the condition, coping abilities, social support, attitudes and behaviors of health professionals and patients’ beliefs, can contribute to the extent of emotional distress (Skevington 1995). For example, patients with strong beliefs that their health is controlled by chance or misfortune have been found to be more likely to be depressed, anxious and obsessive–compulsive compared with patients who believed they could exert a measure of control over their own health outcomes (Crisson & Keefe 1988).
Physiologically, anxiety and distress may maintain autonomic arousal with consequent physical symptoms then arising. These in turn may confirm beliefs that an underlying condition exists. Anxiety and depression can also increase the likelihood of patients making cognitive errors or negative appraisals, which could result in avoidance of activity leading to potential disability. Thus negative emotional responses affect biological and behavioral responses which feed back to further negatively affect the emotional response to pain producing a vicious circle with disability as a consequence (Truchon 2001). High levels of anxiety and distress not only affect the experience of pain, but also affect processing and recall of information, hence any treatment plan must address all of these aspects.
A high incidence of depression has been documented among individuals with chronic pain (e.g. Geisser et al. 1994, Banks & Kerns 1996, Fishbain et al. 1997). Depression has been reported to be associated with higher levels of self-reported pain and pain behavior, lower levels of physical and psychosocial functioning and poor response to treatment (Haythornthwaite et al. 1998). Depression alongside chronic pain has been associated with feelings of helplessness and loss of control (McDonald et al. 1999). Therefore, restoring a sense of control to the patient often assists in alleviating symptoms of depression which can otherwise confound chronic pain conditions, resulting in poor motivation and inactivity which further exacerbate the condition.
Those who report high negative affect have been found to be more vigilant to bodily sensations and report more health complaints (Bacon et al. 1994, Crombez et al. 2004). Further, Pincus and Williams (1999) have reported that chronic pain is associated with biases in the processing of information. In a controlled study investigating the interpretation of ambiguous homophones, patients with pain were found to exhibit a recall bias towards pain stimuli but not towards depression-related stimuli. This has been confirmed in a more recent study (McKellar et al. 2003). Pincus and Williams (1999) suggested that depression in chronic pain is qualitatively different from that of other depressed groups in that the focus and self-image of patients with chronic pain appears to be related to suffering, dependency and invalidity (Pincus et al. 1996). This has implications for the management of depressive symptoms in this group of patients. A cognitive–behavioral approach to reduce dependency and increase activity and coping ability may be more appropriate in chronic pain than other approaches as it specifically addresses the pertinent issues, and focuses on reducing dependency and increasing activity and coping ability.
Cognitive and behavioral aspects of pain. Many of the variables that influence pain intensity and physical and psychosocial disability are cognitive in nature. One of the most researched is coping and coping strategies. The general literature on coping has been most influenced by the work of Lazarus and Folkman (1984). Their transactional model of stress defines coping as ‘…constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing, or exceeding the resources of the person’ (p. 141). This definition highlights the notion of coping as a process, subject to change dependent upon the individual’s appraisal of the situation. In terms of chronic pain, coping may be simply thought of as the strategies (or thoughts and actions) that individuals engage into manage their pain on a daily basis (Katz et al. 1996).
Many models of pain and other chronic conditions give coping responses an integral role in understanding and predicting adjustments to the pain and illness (Turner et al. 2001), though recent studies have highlighted the importance of approaches such as acceptance (McCracken & Eccleston 2003). Identification of the pain coping strategies that have greatest influence on adjustment provides the health professional with an empirical rationale for deciding which coping strategies to teach and encourage and which to discourage.
There is debate amongst authors regarding definitions of coping strategies. Estlander (1989) defined coping strategies as the mechanisms utilized for self-regulation when faced with a stressor such as chronic pain. Each individual’s specific ways of dealing with, adjusting to and reducing or minimizing pain and the distress affects the impact of the coping strategies employed. Differences in the coping styles and strategies employed by chronic pain sufferers have been found to explain some of the variation in functioning apparent in this group (Jensen et al. 1991). A wide variety of coping strategies have been identified and have been differentially classified to include: problem/emotion focused (Lazarus & Folkman 1984), avoidant/non-avoidant (Suls & Fletcher 1985), cognitive/behavioral (Rosenstiel & Keefe 1983, Fernandez 1986) and active/passive (Brown & Nicassio 1987).
Fernandez (1986) has suggested that coping strategies can be classified into physical, behavioral and cognitive. Physical strategies include surgery, medication, physical therapy and the use of electrotherapeutic modalities. Cognitive strategies such as problem solving and cognitive re-structuring all involve attempting to modify pain by cognitive processes, and behavioral strategies attempt to modify behaviors through, for example, operant conditioning, pacing and goal setting. In contrast, Keefe et al. (1992) suggested that all coping strategies are cognitive, thus ‘behavioral strategies’ are more suitably viewed as the outcome of a cognitive strategy. In this respect taking medication, which is considered by some to be a behavioral strategy, is seen as the outcome of a cognitive attempt to cope with the pain (Richardson and Poole (2001). Thus in practice it is often difficult to differentiate between a cognitive and behavioral approach and the two are generally combined.
According to Endler et al. (2001), individuals use four main types of strategy to cope with health problems: (i) distraction, (ii) palliative, (iii) instrumental, and (iv) emotional preoccupation. Distraction coping involves thinking or engaging in activities unrelated to the health problem. Palliative coping includes soothing strategies aimed at alleviating the unpleasantness of the health problem. Instrumental coping is analogous to task-orientated or problem-focused coping in the general coping literature and involves strategies such as finding out more information about the illness or seeking medical advice. Emotional preoccupation is similar to emotion-focused coping and involves focusing on the emotional consequences of the illness. In a study conducted on 137 participants with chronic illness and 137 participants with minor acute health illnesses recruited voluntarily from the general public in Canada, Endler et al. (2001) found that that the group with chronic conditions often use more emotional preoccupation coping strategies and instrumental coping strategies than those with acute illnesses, the latter using more palliative coping strategies to soothe their symptoms.
Although the findings may not be as generalizable to a clinic population or those with more severe acute illnesses, it was interesting to note that those with chronic conditions were more likely to use a combination of various and varied coping responses to manage their condition and adjust their lifestyle accordingly.
Brown and Nicassio (1987) classified coping strategies as either active or passive, based upon their relationship to levels of pain severity and psychosocial functioning. On the one hand, active strategies were defined as efforts by the patient to function despite the pain and include positive coping self-statements, pacing, positive social comparisons, regular exercise, distraction, seeking social support and task persistence (Gatchel & Turk 1996).
On the other hand, passive strategies reflected a tendency to relinquish control and depend upon others and have been found to include pain-contingent rest (i.e. rest taken in response to the level of pain experienced), guarding, wishful thinking, avoidance of activity, catastrophizing, and the use of sedative hypnotic medication. Brown and Nicassio (1987) noted that whilst active coping strategies were related to reduced pain severity, lower levels of depression and less
functional impairment, the reverse applied to passive coping strategies. Whilst passive strategies may be appropriate in some instances, particularly with regard to acute episodes, in chronic pain without comorbidity, passive strategies are often viewed as ‘maladaptive’. However, as previously discussed, the coping strategies used in any given situation are dependent upon contextual factors and the individual’s appraisal of these. Therefore, a passive strategy in one instance may be in fact be adaptive in another. The skill is to know what is appropriate for each individual’s situation at any given time (Richardson & Poole 2001).
Catastrophizing, defined as ‘an exaggerated negative orientation toward pain stimuli and pain experience’ (Sullivan et al. 1998, p. 253), has consistently been found to be significantly related to heightened pain severity in a wide variety of chronic pain conditions (Sullivan et al. 2001) and has also been found to be related to lower pain thresholds and pain tolerance levels in normal(McCracken & Eccleston 2003). Although there is debate as to whether catastrophizing is best characterized as an appraisal rather than a coping response (e.g. Jensen et al. 1991, Sullivan et al. 2001), it has been found that reducing catastrophic thoughts is useful in terms of increasing adjustment to osteoarthritis pain (Keefe et al. 1990, Severeijns et al. 2001).
Lethem et al. (1983) developed a fear avoidance model of chronic pain where catastrophizing leads to fear of pain, leading in turn to avoidance of activity, hypervigilance, depression and disuse resulting in disability. Fear-avoidance beliefs and fear of movement/(re)injury in particular have been shown to be strong predictors of physical performance and pain disability (Waddell et al. 1993, Crombez et al. 1998, Vlaeyen et al. 2002). Therefore, reducing catastrophizing through education and coping skills training and increasing activity according to this model, will reduce depression and disability. Although Geisser et al. (1999) argued that rather than reduce the use of unhelpful passive strategies the use of helpful active strategies should be encouraged.
Coping is influenced by a number of factors including mood, disability, beliefs, other symptomatology, level of support in the marital relationship and locus of control, i.e. the extent to which individuals believe that they are in control of outcomes and the extent to which they believe in chance or misfortune (Skevington 1995). Patients who are most adaptive are those who have strong internal beliefs, strong beliefs in the powers of others such as health professionals and weak beliefs in chance. Pain beliefs may affect treatment outcomes and patients’ beliefs about their illness affect their attitudes to coping skills, adherence and compliance with treatment, e.g. if patients believe they are not in control of their condition, they are less likely to adhere to a self-management program (Williams & Keefe 1991). In addition, they may believe that a certain course of treatment is effective and another ineffective. Several authors have suggested that coping strategies may be an important mediator between pain and depression and thus disability in low back pain (e.g. Waddell et al. 1993, Gatchel & Turk 1999).
Coping skills can be developed by teaching cognitive techniques such as problem solving, correction of distorted cognitions by education and encouraging physical activity (Harding & Williams 1995). The provision of information is important in that it enhances perceived control about pain and thus anxiety and distress is reduced (Arntz & Schmidt 1989).
A broad range of coping styles should be taught as what may be effective in reducing pain for one individual (adaptive) on one occasion, may not be on another, or for a different individual. Richardson and Poole (2001) suggest that assessment of coping styles could identify the type of coping that leads to a positive outcome for the individual patient in terms of facilitating adaptation to their condition. Coping strategies are reviewed in the second part of this paper.
Perceived self-efficacy (i.e. an individual’s belief that they can succeed at something they want to do) is closely related to coping ability. Perceived control and higher self-efficacy have been shown to be positively related to lower levels of state anxiety and greater use of more adaptive coping strategies (i.e. task-orientated rather than emotion-focused coping), which in turn have been positively related to psychological and functional outcome measures (Scharloo & Kaptein 1997). Any treatment of chronic pain related to the development of coping strategies and anxiety reduction should therefore also include strategies to increase self-efficacy.
- Adams, Nicola, Poole, Helen & Clifford Richardson; Psychological approaches to chronic pain management: part I; Journal of Clinical Nursing; Mar 2006; Vol. 15; Issue 3.
Reflection Exercise #2
The preceding section contained information
about chronic pain management and psychological approaches part I. Write
three case study examples regarding how you might use the content of this section
in your practice.
What is one of the most researched variables of pain that influences pain intensity and physical / psychosocial disability? Record the letter of the correct answer