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DEALING WITH PAIN:Acute Clinical Pain, Chronic Clinical Pain

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Health Psychology­ PSY408
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Lesson 26
DEALING WITH PAIN
Clinical Pain
Not all of our pain experiences receive professional treatment, and not all of them require it. The term
clinical pain refers to any pain that receives or requires professional treatment. The pain may be either acute
or chronic and may result from known or unknown causes. Clinical pain calls for treatment in and of itself,
and not only because it may be a symptom of a progressive disease, such as arthritis or cancer. Relieving
pain is important for humanitarian reasons, of course--and doing so also produces medical and
psychosocial benefits for the patient. Let's look at medical and psychosocial issues that are associated with
controlling clinical pain, beginning with acute pain.
A. Acute Clinical Pain
By using techniques to prevent or relieve acute pain, practitioners make medical procedures go more
smoothly, reduce patients' stress and anxiety, and help them recover more quickly. Much of the acute pain
people experience in today's world has little survival value. What survival value would there be in feeling the
pain as a dentist drills a tooth or a surgeon removes an appendix? How would people's survival be enhanced
by feeling the intense pain that accompanies normal healing while resting in a hospital during the days after
surgery? But one thing is important; i.e., if acute pain is ignored, it can sometimes develop into more severe
conditions or chronic pain.
B. Chronic Clinical Pain
When pain persists and becomes chronic, patients begin to perceive its nature differently. Although in the
acute phase the pain was very aversive, they expected it to end and did not see it as a permanent part of
their lives. As the pain persists, they tend to become discouraged and angry and are likely to seek the
opinions of many other physicians. This can be constructive. But when this is not successful, and as patients
come to see less and less connection between their discomfort and any known or treatable disorder,
increasing hopelessness and despair may lead them to resort to consulting quacks.
The transition from acute to chronic pain is a critical time when many of these patients develop feelings of
helplessness and psychological disorders, such as depression, especially if he pain is disabling. These
changes typically parallel alterations in the patients' lifestyles, employment status, and family lives.
Chronic pain often creates a broad array of long-term psychosocial problems and impaired
interrelationships, which distinguish its victims from those of acute pain.
Individuals who receive treatment for their pain after it has progressed and become chronic tend to exhibit
certain physical and psychosocial symptoms that characterize a chronic pain syndrome. According to
psychologist Steven Sanders (1985), these symptoms include:
· Persistent pain complaints and other pain behaviors, such as grimacing or guarded movement, when in
discomfort.
· Disrupted daily activity patterns, characterized either by a general reduction or by recurrent large
fluctuations.
· Disrupted social, marital, employment, and recreational activities.
· Excessive use of drugs or repeated use of surgical procedures to relieve pain.
· Disturbed sleep patterns.
· Increased anxiety and depression.
Chronic pain patients usually exhibit the first two symptoms and at least one of the remaining ones.
Generally speaking, the more symptoms the patient presents, the greater the impact the pain has had and
the greater the maladjustment it has produced.
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Because of the differences between acute pain and chronic pain in their duration and the effects they have
on their victims, these conditions usually require different treatment methods. Health care professionals
need to distinguish between acute and chronic pain conditions and provide the most appropriate pain relief
techniques for the patient's needs. Failing to do so can make the condition worse. Keeping this caution in
mind, we will now turn our attention to the many medical, psychological, and physical techniques available
to help control patients' pain.
1. Medical Treatments for Pain
Historically, most of the pain relieving practices adopted by the medical professionals was brutal especially
if they involved some form of surgery. In 19th-century America, alcoholic beverages and medicines laced
with opium were readily available. Today when patients suffer from pain, physicians and doctors try to
reduce the discomfort in two ways-- surgically and chemically.
A. Surgical Methods for Treating Pain
Treating chronic pain with surgical methods is a relatively radical approach, and some surgical procedures
are more useful than others. In some procedures, the surgery removes or disconnects portions of the
peripheral nervous system or the spinal cord, thereby preventing pain signals from reaching the brain. These
are extreme procedures--and if they are successful, they produce numbness and, sometimes, paralysis in the
region of the body served by the affected nerves. But these procedures seldom provide long- term relief
from the pain, which is often replaced after some days or months by pain and other sensations that are
worse than the original condition. Because of the poor prospects of permanent relief and the risks involved
in these surgical procedures, they are rarely used today.
Other surgical procedures for relieving pain do not remove or disconnect nerve fibers and are much more
successful. One example is the Synovectomy, a technique whereby a surgeon removes membranes that
become inflamed in arthritic joints. Surgery procedures are commonly used in the United States to treat
back pain, but there is little evidence that they produce better long-term pain reduction than non-surgical
methods, and they are used at a far lower rate in other developed countries, such as Denmark and England.
Surgery for chronic skeletal pain conditions is most appropriate when the person is severely disabled and
non-surgical treatment methods have failed. Physicians and patients usually prefer other medical
approaches, such as chemical methods.
B. Chemical Methods for Treating Pain
The field of medicine has been much more concerned with developing methods for curing disease than
with reducing pain. Let's look at the use of chemical methods for treating acute and chronic pain.
Using Chemicals for Acute Pain
Many pharmaceuticals are very effective for relieving acute pain, such as after surgery. Physicians choose the
specific drug and dosage by considering many factors, such as how intense the pain is and its location and
cause.
Using Chemicals for Chronic Pain
When a patient is dying, practitioners generally view options for pain relief differently from those when a
person has chronic pain from a non-terminal illness. Many health care practitioners have long advocated
using narcotics for the relief of severe pain in cancer patients, and narcotic analgesics are commonly
prescribed when these patients are dying. In some cases of cancer, severe pain becomes chronic as the
disease progresses.
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To summarize, medical treatments of pain focus mainly on using chemical approaches to reduce
discomfort. For chronic pain patients, these approaches can be enhanced when combined with pain control
methods that other health care professions provide. Physicians usually want to minimize the use of
medication by their patients, especially when drugs would be taken on a long-term basis. Reducing the
patient's drug consumption is one of the goals in using other methods of pain control with pain patients.
2. Psychological Methods for Treating Pain
In today's world, plentiful research evidence suggests that pain can be controlled not only by biochemical
methods that alter sensory input directly, but by modifying motivational and cognitive processes, too. This
more complex view of pain provided the rationale for psychologists to develop techniques to help patients
(1) cope more effectively with the pain and other stressors they experience and (2) reduce their reliance on
drugs for pain control. Psychologists have developed approaches involving behavioral and cognitive
methods, and we will examine some of these approaches here.
1. Behavioral Methods
The first approach focuses on changing patients' pain behavior through techniques of operant conditioning.
A. The Operant Approach
Consider the case of a 3-year-old girl whose pain behaviors hampered her rehabilitation after she suffered
severe burns months earlier. The help therapists provided was successful. The approach the therapists used
in changing this girl's behavior involved extinction procedures for her pain behavior and reinforcement for
appropriate, or well, behavior.
Observations of the child's social environment revealed that the hospital staff reinforced her pain
behaviors--crying, complaining of pain, resisting the nurse's efforts to put her splints on, and so forth--by
giving attention to those behaviors and allowing her to avoid uncomfortable or disliked activities, such as
physical therapy. To change this situation, the therapists instructed the hospital staff to:
· Ignore the pain behaviors they paid attention to in the past.
· Provide rewards for obedient behavior--telling her, for instance, "If you don't cry while I put your splints
on, you can have some cookies when I'm finished, or, lf you do this exercise, we can play a game."
Changing the consequences of her behavior in these ways had a dramatic effect: her pain behaviors
decreased sharply, and she began to comply with requests to do exercises, make positive comments about
her accomplishments, and assist in putting on her splints,
The operant approach to treating pain can be adapted for use with individuals of all ages, in hospitals and at
home--and elements of the operant approach can be introduced before pain behavior becomes chronic.
But treatment programs using this approach are usually applied with patients whose chronic pain has
already produced serious difficulties in their lives. These programs typically have two main goals: the first is
to reduce the patient's reliance on medication. The second goal of the operant approach is to reduce the
disability that generally accompanies chronic pain conditions.
The reinforcers may be of any kind-- attention, praise and smiles, candy, money, or the opportunity to
watch TV, for example--and may be formalized within a behavioral contract. The therapist periodically
reviews the record of pain behavior to determine whether changes in the program are needed. Studies have
shown that operant techniques can successfully decrease patients' pain reports and medication use and
increase their activity levels.
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B. Relaxation and Biofeedback
Many people experience chronic episodes of pain that result from underlying physiological processes, and
these processes are often triggered by stress. If these patients could control their stress or the physiological
processes that cause pain, they should be able to decrease the frequency or intensity of discomfort they
experience. Thus relaxation and biofeedback methods are effective in treating and reducing pain.
2. Cognitive Methods
To help people cope effectively with pain, medical and psychological practitioners need to assess and
address their patients' beliefs. Cognitive techniques for treating pain involve active coping strategies, and
many of these methods are, in fact, quite effective in helping people cope with pain. These techniques can
be classified into three basic types: distraction, imagery, and redefinition. We will examine these methods
and consider their usefulness for people with acute and chronic pain.
A. Distraction
Distraction is the technique of focusing on a non-painful stimulus in the immediate environment to divert
one's attention from discomfort. We can be distracted from pain in many ways, such as by looking at a
picture, listening to someone's voice, singing a song, counting ceiling tiles, playing a video game, or doing
mathematics problems.
Distraction strategies are useful for reducing acute pain, such as that experienced in some medical or dental
procedures, and they can also provide relief for chronic pain patients in some circumstances. Singing a song
or staring intently at a stimulus can divert the person's attention for a short while--and this may be a great
help, such as for an arthritis sufferer who experiences heightened pain when climbing stairs. People who
want to use distraction for moderate levels of continuous pain may get longer-lasting relief by engaging in
an extended engrossing activity, such as watching a movie or reading a book.
B. Imagery
Sometimes when children are about to receive injections, their parents will say something like, it'll be easier
if you think about something nice, like the fun things we did at the park." Non-pain imagery--sometimes
called guided imagery--is a strategy whereby the person tries to alleviate discomfort by conjuring up a
mental scene that is unrelated to or incompatible with the pain. The most common type of imagery people
use involves scenes that are pleasant to them--they think of "something nice. This scene might involve
being at the beach or in the country, for instance.
Therapists usually encourage, or "guide," the person to include aspects of different senses: vision, hearing,
taste, smell, and touch. As an example, the scene at the beach could include the sight and smell of the ocean
water, the sound of the waves, and the warm, grainy feel of the sand. The person generally tries to keep the
imagined event in mind as long as possible.
The imagery technique is in many ways like distraction. The main difference is that imagery is based on the
person's imagination rather than on real objects or events in the environment. As a result, individuals who
use imagery do not have to depend on the environment to provide a suitably distracting stimulus. They can
develop one or more scenes that work reliably, which they "carry" around in their heads.
Although imagery clearly helps in reducing acute pain, the extent of this technique's usefulness with longer-
lasting pain episodes is unclear. One limitation with using imagery in pain control is that some individuals
are less adept in imagining scenes than others.
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C. Redefinition
The third type of cognitive strategy for reducing discomfort is pain redefinition, in which the person
substitutes constructive or realistic thoughts about the pain experience for ones that arouse feelings of
threat or harm. Therapists can help people redefine their pain experiences in several ways. One approach
involves teaching clients to engage in an internal dialogue, using positive self-statements. There are basically
two kinds of self-statements for controlling pain:
A. Coping statements emphasize the person's ability to tolerate the discomfort, as when people say to
themselves, "It hurts, but you're in control," or, "Be brave-- you can take it".
B. Re-interpretative statements are designed to negate the unpleasant aspects of the discomfort, as when
people think, it's not so bad," "It's not the worst thing that could happen," or, "It hurts, but think of the
benefits of this experience." This last statement can be particularly appropriate when undergoing painful
medical procedures.
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Table of Contents:
  1. INTRODUCTION TO HEALTH PSYCHOLOGY:Health and Wellness Defined
  2. INTRODUCTION TO HEALTH PSYCHOLOGY:Early Cultures, The Middle Ages
  3. INTRODUCTION TO HEALTH PSYCHOLOGY:Psychosomatic Medicine
  4. INTRODUCTION TO HEALTH PSYCHOLOGY:The Background to Biomedical Model
  5. INTRODUCTION TO HEALTH PSYCHOLOGY:THE LIFE-SPAN PERSPECTIVE
  6. HEALTH RELATED CAREERS:Nurses and Physician Assistants, Physical Therapists
  7. THE FUNCTION OF NERVOUS SYSTEM:Prologue, The Central Nervous System
  8. THE FUNCTION OF NERVOUS SYSTEM AND ENDOCRINE GLANDS:Other Glands
  9. DIGESTIVE AND RENAL SYSTEMS:THE DIGESTIVE SYSTEM, Digesting Food
  10. THE RESPIRATORY SYSTEM:The Heart and Blood Vessels, Blood Pressure
  11. BLOOD COMPOSITION:Formed Elements, Plasma, THE IMMUNE SYSTEM
  12. SOLDIERS OF THE IMMUNE SYSTEM:Less-Than-Optimal Defenses
  13. THE PHENOMENON OF STRESS:Experiencing Stress in our Lives, Primary Appraisal
  14. FACTORS THAT LEAD TO STRESSFUL APPRAISALS:Dimensions of Stress
  15. PSYCHOSOCIAL ASPECTS OF STRESS:Cognition and Stress, Emotions and Stress
  16. SOURCES OF STRESS:Sources in the Family, An Addition to the Family
  17. MEASURING STRESS:Environmental Stress, Physiological Arousal
  18. PSYCHOSOCIAL FACTORS THAT CAN MODIFY THE IMPACT OF STRESS ON HEALTH
  19. HOW STRESS AFFECTS HEALTH:Stress, Behavior and Illness, Psychoneuroimmunology
  20. COPING WITH STRESS:Prologue, Functions of Coping, Distancing
  21. REDUCING THE POTENTIAL FOR STRESS:Enhancing Social Support
  22. STRESS MANAGEMENT:Medication, Behavioral and Cognitive Methods
  23. THE PHENOMENON OF PAIN ITS NATURE AND TYPES:Perceiving Pain
  24. THE PHYSIOLOGY OF PAIN PERCEPTION:Phantom Limb Pain, Learning and Pain
  25. ASSESSING PAIN:Self-Report Methods, Behavioral Assessment Approaches
  26. DEALING WITH PAIN:Acute Clinical Pain, Chronic Clinical Pain
  27. ADJUSTING TO CHRONIC ILLNESSES:Shock, Encounter, Retreat
  28. THE COPING PROCESS IN PATIENTS OF CHRONIC ILLNESS:Asthma
  29. IMPACT OF DIFFERENT CHRONIC CONDITIONS:Psychosocial Factors in Epilepsy