Psychological Approaches to Management of Chronic Pain

INTRODUCTION

This chapter will discuss the various psychological approaches used to manage chronic pain. Chronic pain is a condition that affects a person physically, psychologically, and environmentally. These factors, in turn, interact with each other to impact the pain. It appears logical that all these factors should be addressed in treatment. Medical intervention, that is, treatment that focuses on the physical aspects of the pain, has traditionally been considered to be the primary method of managing and controlling pain. In many cases, the psychosocial issues are usually only addressed after the condition deteriorates with traditional medical interventions. By the time most patients receive psychological intervention, they have had numerous surgeries, may rely on or be addicted to several medications, and are partially or totally disabled. Fortunately, patients and health care providers are beginning to understand the role that psychological influences can play in the pain experience. Just as psychological mechanisms can contribute to the disabling nature of the pain, psychological approaches can assist in helping the person become functional, even with pain.

There are several psychological manifestations associated with pain. A person experiencing chronic pain is likely to be depressed, mainly because of the changes that have occurred in one’s life as a result of the pain. There is likely to be the development of a vicious pain cycle: the extended period of pain usually results in a decrease in activity level. As the person becomes less active and less functional, one is likely to observe an increase in anxiety, tension, stress, and eventually clinical depression. That, over time, will lead to an increase in muscle tension, poor coping ability, decreased sleep, increased use of pain medications and excess reliance on the health care system. That, in turn, can result in an increase in the pain. Some of the psychological symptoms occur as a result of the pain, while others may have been in existence prior to the development of the pain. Regardless of the chronological order, an adverse effect on one’s condition is likely to occur. In order for long term improvement to be observed, the psychological manifestations will need to be addressed and the vicious pain cycle will need to be broken.

Psychological techniques have been associated with improved functioning, which include a decrease in pain perception, decreased psychological distress, use of more appropriate coping strategies, decrease in medications, and a decrease in medical visits. The goal of utilizing the psychological approaches is to learn appropriate techniques so the person can manage the condition without the reliance on the health care system.

A multidisciplinary team can best accomplish the most effective treatment approach. That team includes the physician, psychologist, physical therapist, and in some cases, the case manager. The most positive benefit occurs when the interventions from the various professions are provided simultaneously.

The psychologist’ s role is basically twofold: to identify and treat psychosocial factors which can contribute to the pain; that is, factors that can result in an increase in the pain, and to help identify and implement a reasonable set of treatment goals.

PSYCHOLOGICAL EVALUATION

Prior to participating in treatment, it would be beneficial to obtain an understanding of the psychosocial factors that can be contributing to the pain or making it more severe. That is usually obtained from the psychological evaluation. During the evaluation, the patient participates in a clinical interview and completes psychological testing. During the clinical interview, information regarding the pre-pain level of functioning is obtained. Education, social functioning, stressors, and vocational history can all influence one’s success in a rehabilitation program, and these factors are evaluated. There are various objective psychological test measures that can be used to evaluate the patients, and the psychologist will select an appropriate test battery to address the person’s specific needs.

PSYCHOLOGICAL INTERVENTION

The psychological interventions can be characterized in terms of the component of the pain they are to target; physiological, subjective, or behavioral. Biofeedback and relaxation training address the physiological aspects of the pain. For example, a person would use EMG biofeedback to treat muscle contraction headache or skin temperature biofeedback to treat migraine headache. Hypnosis and 'pain-directed' cognitive methods focus on sensations and feelings of distress and discomfort, while contingency management, or operant approaches, target the behavioral component of the pain experience, such as wincing or taking pills. Patients could be treated with a combination of the various methods simultaneously, depending on the nature of their pain problem. For example, a person would use biofeedback to address the physiological component to assist with decreasing the pain of muscle contraction headache, and at the same time use cognitive coping strategies to change the meaning of the pain on his/her life.

BIOFEEDBACK

Biofeedback is a widely accepted approach to treat and manage chronic pain. This noninvasive procedure combines a psychological and physiological approach to pain management. Its acceptance is due to the fact that it is a noninvasive procedure that relies on the patient's internal resources. Biofeedback involves the use of electronic equipment or instrumentation to mirror psychophysiological processes. The person is not aware of these processes, but the physiological activity can be brought under voluntary control. Through the use of biofeedback the person learns to alter physiological processes that contribute to pain. Biofeedback has been successfully used to treat a variety of pain syndromes, including muscle contraction and migraine headache, low back pain, myofascial pain syndrome, reflex sympathetic dystrophy, and arthritis.

There are several rationales for the use of biofeedback to treat chronic pain. They include the following:

  1. To facilitate the relaxation response. It is felt that if a person becomes relaxed there will be a corresponding reduction in pain. Stress and tension are factors that contribute to making the pain worse, and relaxation is associated with its relief. By using biofeedback the person can obtain an objective measure of the relaxation response.
  2. To modify the specific physiological process that is thought to underlie the pain disorder. For example, electromyographic (EMG) biofeedback is a treatment used to treat muscle contraction headache. A reduction in muscle tension achieved through biofeedback training should result in a corresponding decrease in muscle contraction headache.
  3. Self-regulation. Through the use of biofeedback, the person can become more aware of his/her own contribution to the pain experience as well as their ability to influence the pain. In order for biofeedback to be effective, patients must take responsibility for coping with the pain. Through the use of the technique, as well as with other cognitive methods, people can learn that it is possible for the pain to be under internal, as opposed to external, control. The patients' view of the pain should change, which could result in greater acceptance of personal responsibility for managing the pain. The internal focus can also facilitate a more positive outlook for the future, and one is likely to see a corresponding decrease in the depression.

The most common form of biofeedback used to treat chronic pain is electromyographic (EMG) biofeedback, followed by skin temperature or thermal biofeedback. EMG biofeedback provides a measure of the electrical discharge in the muscle fibers, which reflects either relaxation or contraction of the muscles. The effective use of EMG biofeedback should result in reduction in muscle tension, which in turn produces a decrease in pain experienced. Pain syndromes that EMG biofeedback has been successfully used to treat includes muscle contraction headache, temporomandibular joint pain, myofascial pain syndrome, and fibromyalgia.

On occasion, the EMG reading may not provide an accurate measure of the muscle tension and pain the person is actually experiencing. In this cases, the pain could be the result of deep muscle tension that is not easily measured by EMG surface electrodes. Another explanation is that the pain may originate at a site different from where it is experienced. Another point to keep in mind is that it is possible for a person to be successfully trained in EMG biofeedback, yet not have an immediate reduction in pain. This occurs because frequently there is a delay between reduction of EMG and the corresponding reduction of pain.

The basis for the use of skin temperature, or thermal, biofeedback in treating chronic pain is the belief that sympathetic nervous system activity results in vasoconstriction of peripheral arterioles and that reduced sympathetic nervous system activity is associated with vasodilation of the arterioles. The goal of skin temperature biofeedback is to increase the skin temperature in the extremity, usually their finger. This results in vasodilation and, subsequently, a reduction in sympathetic nervous system activity. Additionally, studies have shown that an increase in skin temperature is associated with the full relaxation response. Pain syndromes that skin temperature biofeedback has been used to treat include reflex sympathetic dystrophy and migraine headache. However, the exact physiological mechanism by which it works with the syndromes remains unclear.

Studies that have evaluated the effectiveness of skin temperature biofeedback in treating migraine headache have not yielded consistent results, mainly because the researchers complicated the design by using additional techniques, such as autogenic relaxation training. It seems that the use of skin temperature biofeedback is effective in treating selected cases of migraine. Its usefulness may also be related to the nonspecific factors in biofeedback therapy, such as relaxation and self-regulation.

RELAXATION TRAINING

The main purpose of utilizing the various relaxation techniques in pain management is to elicit the relaxation response. Relaxation is thought to reduce pain by reducing one’s emotional arousal. Studies have shown that physiological changes consistent with decreased sympathetic nervous system activity often accompany the relaxation response. Sympathetic changes observed include decrease in oxygen consumption, reduction in heart rate, and a marked decrease in arterial blood lactate concentration. Relaxation also facilitates one's ability to use suggestion and imagination to provide pain relief. Focused concentration helps the person learn ways of disrupting preoccupying thoughts, especially those related to pain.

Relaxation has also been used to teach patients body awareness. Patients experiencing pain, especially myofascial pain, frequently tense their muscles in response to pain or in anticipation of pain. This will result in an increase in the pain. By becoming more aware of the physical sensations in the body, one can learn to reliably decrease the muscle tension and thereby cope with the pain more effectively.

There are various forms of relaxation approaches available. Progressive muscle relaxation is the most common approach utilized. This technique involves tensing and relaxing the major muscle groups, from the forehead to the feet. The purpose is for the person to learn to relax the tense muscles that contribute to pain. When the person has consistently achieved success with progressive muscle relaxation, a shorter version of the technique can be substituted. The eventual goal is to reduce tension by recall, thus eliminating the need to actively tense muscle groups. As the person becomes more advanced with the use of the technique, visual imagery and autogenic phrases to elicit relaxation can be incorporated.

Relaxation training has been used to treat a wide variety of painful disorders, with much success. The syndromes include muscle contraction headache, migraine headache, temporomandibular joint pain, chronic back pain, and myofascial pain syndrome.

COMPARISON BETWEEN BIOFEEDBACK AND RELAXATION TRAINING

Numerous studies have compared the relative effectiveness of biofeedback and relaxation training in managing chronic pain. The majority of studies have indicated that relaxation and biofeedback training are equally effective techniques. However, the two approaches can be useful to the patients in different ways. Biofeedback can provide the person with an overt indicator, i.e. visual or auditory readings, of the relationship between behaviors and cognitions and changes in physiological processes. By being provided with this feedback, the patients can develop control over the specific physiological mechanism that contributes to pain. With the biofeedback, the person can be provided with objective data on the progress made during the treatment sessions. The main advantages of using relaxation training are its practicality and cost effectiveness.

Biofeedback and relaxation are frequently used as conjunctive treatments. The relaxation training provides the technique by which to alter physiological processes and the biofeedback is used to improve the relaxation response. The biofeedback can help pinpoint the source of training problems as well as open up new ways to make changes. In the treatment sessions, the patients should attend to sensations experienced and understand that the goal is to use the techniques learned in daily life. One should not develop excessive reliance on the machine.

BIOFEEDBACK AND RELAXATION TRAINING TREATMENT PROTOCOL

This protocol is part of a multidisciplinary treatment program that incorporates interventions from other disciplines, including physical and occupational therapy. It is a guideline used by many trained professionals. The sessions usually occur once weekly.

Session 1: Collection of Baseline Data/Explanation of Biofeedback.

The purpose of the initial biofeedback session is twofold: 1) to explain the process of biofeedback and discuss how it can be used to help the person cope with the chronic pain; and 2) to collect initial baseline data. Progress made in future sessions will be compared to measures obtained in the initial baseline session. In this session, the person is allowed the opportunity to ask questions regarding the nature of biofeedback. Depending on the nature of the pain compliant, either EMG and/or skin temperature are monitored. The specific site for the placement of the EMG electrodes is dependent on the pain complaint, but they are usually placed on the frontalis or neck and shoulder area. The skin temperature probes are placed on the index finger of both hands.

Sessions 2-6: Relaxation Assisted Biofeedback Training

The person is instructed in the use of relaxation techniques; progressive muscle relaxation initially, followed by autogenic relaxation in the fifth and sixth sessions. The first 15 minutes of each session is an introductory period during which time is spent discussing any concerns and the goals for the session. Following this, the patients participate in 30 minutes of relaxation assisted biofeedback training. The last 15 minutes is spent discussing the training session and any difficulties encountered. Progressive muscle relaxation techniques are implemented to teach general body awareness. With the technique patients are required to tense and then relax the muscle groups. Additionally, they learn controlled breathing techniques. They are taught ways of determining the difference between tension and relaxation of the muscles. After the person has developed mastery over the technique, usually in about three sessions, autogenic relaxation techniques will be incorporated.

During the session the person is provided with visual and/or auditory feedback. At the end of each session, the patient is provided with data on the readings obtained during the session. The mean, as well as the low and high reading, for each minute of the training period is measured.

To facilitate their training in the clinic, patients are usually provided with relaxation tapes and are encouraged to use them at least once daily, and especially when they experience severe levels of pain and tension.

Sessions 7-8: Further Development of Skills

As patients develop an adequate degree of self-control with the relaxation and biofeedback training, there should be focus on further development and improvement of the skills learned. They should also use the skills learned for self-regulation. Instead of practicing the structured progressive muscle or autogenic relaxation, patients can use simple phrases to facilitate the relaxation response and for self-regulation (e.g. I am developing relaxation of my neck and shoulder muscles). During these sessions there should be focus on incorporating these skills into daily routines, such as using the simple phrases when engaged in daily activities. Patients will become more comfortable using these techniques as they recognize the benefit of using them in daily situations.

HYPNOSIS

Hypnosis is one of the earliest forms of interventions used to treat pain. Reports of its use and benefits date back to the 19th century. One of the earliest reports of hypnotic analgesia occurred in India when a surgeon used the technique while performing amputations in India. He reported an 80 percent efficacy in terms of pain relief with the technique. Hypnosis became more widely used as a pain management technique following World War II.

Hypnosis is an altered state of consciousness in which the subject has intense concentration, less awareness of the environment, and is internally focused. Today, hypnosis is widely used to treat a variety of pain syndromes, acute and chronic. One of the main advantages of using the technique over medication management is that hypnosis does not have the potential side effects that may accompany medication usage, such as placing an extra load on respiration, circulation, or potential damage to organs. It is well known that there are psychological factors, such as anxiety, excess attention to pain, and feelings of loss of control, that can contribute to making the pain worse. Hypnosis can address each of these psychological manifestations, thus allowing the patient to have better control over the pain.

This section will discuss the mechanisms involved in hypnotic analgesia and specific hypnotic techniques will be presented.

Theory and Mechanisms

The mechanism by which persons experiencing pain are able to achieve dramatic pain relief reported with hypnosis is not well understood. Studies have been conducted to determine the role of endorphins in producing analgesia, as it has been speculated that hypnosis could be used to stimulate the release of these substances, thus producing analgesia. In an attempt to determine this, researchers administered naloxon; a medication used to reverse the effects of narcotics, to patients experiencing hypnosis and observed that the drug did not consistently reverse the hypnotic analgesia. Additionally, other studies reported no increase in endorphin levels in patients who were experiencing hypnotic analgesia, which provided further support for the belief that hypnotic analgesia is independent from the action of endorphins. Thus, it appears that the hypnotic analgesia experienced is not mediated by the endorphin system. There has been research in support of the theory that cognitions, or thought processes, play an important role in hypnotic analgesia. This seems reasonable, given that hypnosis focuses on the subjective aspect of the pain experience, such as feelings of distress and discomfort.

One author, Hilgard, proposed a theory to explain hypnotic analgesia experienced in persons with pain. In the model, referred to as the “neodissociation model”, he proposed that hypnosis is a specialized form of dissociation. According to Hilgard, hypnosis consists of two different dissociative mechanisms. The first mechanism involves a cognitive component in which the person conforms to the demands of the situation, but it is not a passive experience in that the hypnotist is not in complete control. Hypnotic analgesia involves pain that is covertly experienced in parallel with amnesia for it. Both the pain and the initiative and effort required to reduce it are dissociated from conscious experience by amnesia or by an amnesia type of process. Control of behavior is usually a volitional experience; therefore, the amnesia for pain is a nonovulational experience. This amnesia process is referred to as a dissociative experience. The second dissociative mechanism relates to a hierarchical structure of cognitive control. This dissociative mechanism does not depend on amnesia. Suggestions given to a hypnotized person activate subsystems of control and in doing this basically circumvents executive initiative and control of the behavior. This process is referred to as dissociated control. Another theorist, Wagstaff, proposed a theory that relates to compliance and belief. It has been recognized and accepted that compliance is extremely important in the hypnotic process. Compliance relates to the patient or subject exhibiting behavior requested by the clinician, and not by his or her own personal beliefs. The subject must also believe that the behavior exhibited is consistent with the situation (e.g. noticing dryness in the eyes when told that the eyes are becoming dry).

Hypnosis has been used to treat a variety of pain syndromes, including headache, chronic back pain, reflex sympathetic dystrophy, and cancer pain. Hypnosis as a psychological tool in the management of chronic pain has received mixed acceptance, mainly related to the lack of understanding and fear. However, it is becoming more accepted as an alternative method for pain relief and management.

Techniques

Hypnosis can provide an analgesic experience for many patients, but the technique in and of itself is not expected to cure chronic pain. It provides a sensation of peacefulness and comfort, and short-term relief of pain can be experienced. However, in order for lasting benefit to occur, hypnosis should be part of a broader therapy program.

The effectiveness of hypnosis usually depends on two factors: the person’s imagination or individual talent and the ability of the clinician to capitalize on that imagination to make changes in the person's perceptions. It is believed that the ability of a person to experience hypnosis or to go into a trance is on a continuum and the capacity to experience hypnosis varies from individual to individual.

An important first step in using hypnosis is the initial evaluation. The main purpose of the evaluation is to determine the person’s appropriateness for hypnosis and to assess the person's knowledge and conceptions of the procedure. The evaluation should assess psychiatric history, motivation, psychosocial factors that could be exacerbating or maintaining the pain complaint, and psychological resources, such as ego strength. One should exercise caution, for example, in conducting hypnosis with a person if there is concern regarding the existence of psychopathology, such as psychosis or severe depression.

Before hypnosis actually begins, the patient should be prepared for the technique. An introduction to hypnosis should be given and the person should be informed how hypnosis could be useful in managing his/her particular pain. It is useful to ask patients what they know about the technique. During this time the clinician can address the misconceptions and fears about hypnosis. Much of the resistance that occurs in hypnotherapy can be alleviated if the patients' concerns are discussed at the outset.

Various techniques are available to achieve hypnotic pain control. They include the following:

  1. Altering the perception of pain. With this procedure the patient becomes less aware of the pain experienced. Analgesia or pain relief is achieved by suggesting to the person that the pain is diminishing, changing, or that the area is becoming numb. One useful technique is to experience glove anesthesia. One clinician, Bassman, described a technique using this approach that allowed patients to experience glove anesthesia. While in a hypnotic trance, the patient can visualize three objects on a table: a soft velvet glove with a smooth silk lining; a brightly colored pail filled with a sparkling, blue liquid; and a large, open jar of hand cream that is filled with a pleasant and aromatic perfume. The three objects focus on texture, visual stimuli, and olfactory stimuli, respectively. The patient is told that each of the objects contains a potent anesthesia, such that the part of the body coming in contact with the substance will become numb. The patient is to select one of the objects and place a hand in it so that the hand will become numb. The hand that is numb should be rubbed over the part of the body experiencing pain. By doing this, patients can begin to accept some reduced pain perception. Patients in a medium trance are usually able to experience glove anesthesia.
  2. Substitute the painful sensation with a different or less painful sensation. While in a trance, the patient is given the suggestion that the painful sensation is substituted with a different sensation. Some patients are able to use this technique more effectively if the substituted feeling is not totally pleasant. For example, they can substitute stabbing pain with a pinch-like sensation.
  3. Move the pain to another part of the body. Patients are given the suggestion that the pain is moving to a different part of the body. In this technique, patients are able to move the location of their pain to an area that is perceived as being of less psychological vulnerability. An example is to move the pain from the hand to the little finger. The eventual goal of this technique is to have the pain moved outside the body.
  4. Alter the meaning of pain. While in a hypnotic trance, patients are given suggestion that the pain is less debilitating and less meaningful to them.
  5. Distortion of time. Patients are taught ways to distort time so that the actual amount of time experiencing a painful sensation, such as severe spasms, is altered. The patient can be taught to perceive the amount of time when a painful sensation occurs as rapidly passing.
  6. Dissociation. Patients are taught to experience themselves in another state, place, or time, such as in a vivid daydream. This technique is most useful when the patient does not have to be functional, such as when undergoing dental or medical procedures, or in the latter stages of a terminal illness.
  7. Age Regression. Using this technique, patients are able to regress to an earlier period of time of their lives when they did not experience pain.

It is felt that the most appropriate therapeutic strategy for a patient depends on the severity of the pain and the level of hypnotizability. For instance, patients with low hypnotizability and severe pain would benefit most from distraction techniques, whereas patients with high hypnotizability and severe pain would benefit most from techniques that focus on dissociation.

Self-hypnosis

It is important for patients to learn self-hypnosis, as they need to learn to effectively use the techniques to function independently and to cope with pain and other issues that may exacerbate pain. Patients should feel that they can experience hypnotic analgesia by themselves, and that they do not need the assistance of a therapist on a long-term basis. Through self-hypnosis the person should develop a sense of control and mastery over the pain. Effective ways of teaching self-hypnosis include the following:

  1. Record a hypnosis session and use the tape at home to facilitate self-hypnosis. Studies have shown that patients newly trained in self-hypnosis reported a better hypnotic experience if they used a tape than if they attempted to perform the technique unassisted.
  2. Have the clinician provide posthypnotic suggestions while in a trance. These suggestions should be designed to assist in self-hypnosis.
  3. Practice self-hypnosis while in the treatment sessions. In the treatment setting, suggestions can be provided and concerns can be addressed. For self-hypnosis to be most effective, it should be practiced and utilized daily.

COGNITIVE APPROACHES

Over the past decade, pain practitioners have increasingly acknowledged the benefit of cognitive-behavioral approaches in the management of chronic pain, and the approach has been integrated into many practices. The basic premise with the cognitive approaches is that expectations, attitudes, and beliefs affect the manner in which persons cope with pain. Therefore, changes in negative cognitions can result in better pain control. It is believed that behavior and affect result from the way in which a person views the world. The extent to which the person experiencing chronic pain patient becomes disabled is directly related to that person's perception and subsequent evaluation of the pain. Inadequate coping mechanisms seen in chronic pain patients are related to errors in cognitions, or thought processes. Studies have consistently shown that persons who tend to misinterpret their experience of pain are more severely disabled. That is, if the person views the pain as disabling, then that person is more likely to be disabled. The goal of the intervention is to correct faulty thought processes that contribute to prolonged suffering and disability. In using this process maladaptive beliefs are replaced with more adaptive ones. Numerous studies have provided support for the use of cognitive approaches in treating chronic pain. The cognitive approaches have been associated with the following benefits:

  1. Patients have the necessary coping skills to deal with the pain more effectively.
  2. Patients live more satisfying lives despite the presence of physical discomfort.
  3. Patients have decreased reliance on the health care system and a reduction in use of analgesic medications. A message emphasized is that people are not helpless in dealing with their pain and it should not control their lives.

There are a wide variety of therapeutic techniques under the cognitive model, but they have common elements. The interventions are structured; action oriented, and are usually time limited. The approaches can be taught in individual or group sessions. There are three phases of the intervention process:

  1. The person is taught the role that thoughts and feelings have in influencing pain.
  2. Specific methods for coping with pain are presented. The methods taught include relabeling painful sensations, attention diversion, reinterpreting pain sensations, relaxation, and imagery. Four steps are involved in this teaching process:
    1. Preparing for minor painful sensations;
    2. Confronting more severe pain;
    3. Coping with feelings that tend to exacerbate pain, such as anxiety or frustration; and
    4. Learning to provide self-reinforcement for successfully coping with pain.
  3. Generalization of the skills to situations outside the clinical setting are facilitated by initially practicing them in the office setting and then utilizing them in outside situations such as the work or home environment. The therapist should exercise flexibility with the approach and allow patients to proceed at their own pace.

The relative effectiveness of active and passive coping strategies has been evaluated. Active coping strategies requires one to engage in some action, such as exercising, to cope with the pain. Persons using passive coping strategies either withdraw or give up control to an external agent. Examples of passive coping strategies include decreased activity or taking medications. A study conducted revealed that rheumatoid arthritis patients using active coping strategies had better psychological and physical functioning, and passive coping was associated with depression for patients who reported high pain levels. Additionally, longitudinal research has indicated that the use of active and passive strategies during the pain experience predicted long-term (6 months) depression and disability. Use of the active strategies was associated with better long-term adjustments.

OPERANT APPROACHES

The operant approach in the management of chronic pain is based on the assumption that a person’s behavior is governed by its consequences in that the consequences of a behavior determine whether or not it will reoccur. If the reinforcers are positive, there is an increased likelihood that the behavior will reoccur, while negative reinforcement decreases the likelihood. The goal of the operant approach, or contingency management, is to replace learned maladaptive behaviors with behaviors that are incompatible with the sick role. Environmental contingencies, or rewards, are changed so that appropriate, "healthy" behaviors are reinforced and pain behaviors are not rewarded. In order for this to occur, the targeted behaviors and possible reinforcers need to be identified. Family members and health care providers are instructed in this approach so as to reinforce appropriate behaviors, while ignoring pain behaviors, such as complaining of pain, using narcotics, and remaining inactive. Other forms of intervention, such as marital counseling, family therapy, and vocational planning, can be incorporated in the treatment.

GROUP THERAPY

An important component of a pain management program is group therapy. There are two main purposes for group intervention: to provide psychological support and for the dissemination of information. The group format allows multiple ideas to be presented, shared, and discussed. The members of the group provide support, encouragement, and can serve as a reality check for other participants in the group process.

In the group setting, patients can obtain information regarding the psychosocial influences on their pain experience. Topics for discussion in the group setting include the vicious pain cycles (e.g. pain-depression cycle, pain-narcotics cycle, and pain-stress cycle), effective coping strategies, acceptance of the pain, and compliance issues. It is believed that education is power, and the more education the person has the more he/she will be able to self-regulate the condition. Knowledge and information can also increase compliance.

The role of antidepressant therapy in pain management

It is frequently necessary to incorporate antidepressant therapy in the pain management treatment plan. Depression is commonly seen in a person experiencing chronic pain; that is, pain of extensive duration. Chronic pain usually results in reduced activity level, as it can be quite uncomfortable to become active. That, over time, will result in lowered physical stamina. This can be followed by feelings of helplessness, hopelessness, and depression. The depression, as it continues, results in increased pain perception and decreased ability to tolerate the pain. That can eventually result in an exacerbation of the pain, thus perpetuating the cycle. In some cases the depression occurred prior to the onset of the pain. Regardless of the chronological occurrence of the depression, it needs to be effectively managed as it can result in an exacerbation of the pain or contribute to the disability. Depression symptomatology frequently observed in persons experiencing chronic pain include the following: loss of interest in activities previously enjoyed, social isolation, concentration and memory difficulties, sleep disturbance, appetite disturbance, loss of interest in sex, feelings of worthlessness, pessimism, and in severe cases, suicidal ideation. The psychological techniques previously presented can assist in decreasing the symptoms of depression. However, in many cases the symptoms may be so severe that they affect the ability to engage in the therapeutic process that would allow change to occur. Therefore, it may be beneficial to treat the depression symptoms with antidepressant medication. Studies have been conducted which show that antidepressants can also be useful as a mild analgesic, especially the tricyclics. It is common to have low doses of the antidepressant prescribed for both purposes; to decrease the depression and to provide mild analgesia.

The antidepressants are generally divided into four classes; tricyclic antidepressants (amitriptyline, doxepin), selective serotonin reuptake inhibitors (fluoxetine, sertraline), monoamine oxidase inhibitors (phenelzine, tranylcypromine), and atypical antidepressants (trazodone, bupropion). Factors that should affect drug selection include the past history of response, concurrent medical history, potential drug interactions, side effects, and costs. Most antidepressants have equivalent results when comparable doses are administered; however, failure to respond to one class does not predict failure with another agent. The physician who specializes in chronic pain will assist in determining the most appropriate medication to meet the needs of the patient. Regardless of the antidepressant used, it should be stressed that the person must maintain some form of personal responsibility in the rehabilitation process. No pill, by itself, will cure chronic pain. It is a condition that needs to be effectively managed.

SUMMARY

In summary, there is much support for the above mentioned approaches in managing chronic pain. In order for the approaches to be successful, the patients must accept responsibility for successful management of the pain. The interventions are most beneficial when they are incorporated into a comprehensive pain management program.

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