Psychology of Pain KENNETH D
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Postgrad Med J: first published as 10.1136/pgmj.60.710.835 on 1 December 1984. Downloaded from Postgraduate Medical Journal (December 1984) 60, 835-840 Psychology of pain KENNETH D. CRAIG M.A., Ph.D. Department of Psychology, University of British Columbia, Vancouver, B.C. Canada V6T 1 Y7 Introduction Many chronic pain syndromes, as well as some reactions to acute pain, can only be understood by To the sufferer, pain is a vital reality. While fully incorporating psychological variables into explana- aware of this, the scientist and practitioner must also tory models. Exclusively sensory and predominantly recognize that efforts to understand and manage pain biophysical explanatory models, that emphasize can be only as good as the available theoretical treatment of underlying pathophysiological pro- models. Recent decades have seen concepts of pain cesses, have proved inadequate, with large numbers increasingly embrace psychological models (Merskey of patients who do not benefit from care based on this and Spear, 1967; Stembach, 1978; Melzack and Wall, model. While the majority of painful injuries heal 1983). The definition of pain adopted by the Interna- through spontaneous recovery and medical interven- tional Association for the Study of Pain (1979) tion, Bonica (1983) has estimated that one-third of describes pain as 'An unpleasant sensory and emo- the population suffers some form of recurrent or tional experience associated with actual or potential persistent pain. tissue damage, or described in terms ofsuch damage'. by copyright. The emphasis on experiential qualities and psycholo- gical processes has major implications. First, the knowledge-base for this complex phenomenon has Cognitive processes in pain expanded, and we have begun to address questions The study of cognitive processes underlying all about the personal meaning of pain to the sufferer, patterns of behaviour has enjoyed considerable relationships between subjective experience and enthusiastic development in the past decade (Ander- overt expression, and decision strategies for coping son, 1980; Neisser, 1976; Weimer, 1982), with many with personal discomfort. Second, the evidence that of the models of immediate relevance to the study pain experience and expression are strongly influ- and management of pain. The concepts fall logically enced by personal factors and the social contexts of into two categories: those concerning the form and http://pmj.bmj.com/ patients' lives has resulted in new strategies for pain structure of cognitive processes and those descriptive assessment and management. Strategies have of the contents of thoughts. emerged that have proved successful in preventing Most important in regulating painful experience adverse reactions to acute pain, and for working are those cognitive structures which organize and with patients with chronic pain (e.g., Barber and impose order upon experience. They govern the Adrian, 1982; Fordyce, 1976; Sternbach, 1974; Turk, patterning of attention, memory, decision-making, Meichenbaum and Genest, 1983). and other self-regulatory processes. Inherently tacit The impetus for a better understanding of the and superordinate to the contents of experience, the on September 25, 2021 by guest. Protected psychological component of pain derives from a cognitive processes impose limits on the concrete variety of sources. The substantial range of indivi- particulars of experience (Mahoney, 1983; Rosenthal dual responses to comparable tissue damage has and Zimmerman, 1978). From this perspective, all demanded explanation. Reactions can range from experience is an active construction of the nervous impassive stoical forbearance to highly dramatic and system with the biological constraints dictating how hysterical behaviour. Considerable evidence now people attend to their environment, the assimilation supports the view that each individual's experience of and organization of experience, and decision-making pain, and the manner ofexpression, can be explained strategies. only as a product of the sufferer's personal back- Understanding how people serve as active partici- ground, the interpersonal context in which pain is pants in the nature of their experiences has provided experienced, the meaning the experience has for the a general theoretical framework for a variety of individual, as well as by the sensory input provided powerful pain phenomena; namely, the impact of by noxious stimuli (Craig, 1980; 1983). belief systems, placebo and expectancy effects, the Postgrad Med J: first published as 10.1136/pgmj.60.710.835 on 1 December 1984. Downloaded from 836 K. D. Craig role of attention and distraction and perceived (Kleinknecht, Klepac and Alexander, 1973) or chil- control phenomena. dren with nondiagnosable chronic abdominable pain Belief systems attach meaning to experience. Pain (Barr, 1983) and pain patients in general (Mohamed, usually signifies real or potential tissue damage and Weisz and Waring, 1978) tend to come from families life-threat, and provides a powerful incentive to in which other family members present with anomal- understand what is happening to the individual. Both ous pain complaint. One can legitimately refer to the person in pain and the health professional 'pain prone families'. ordinarily interpret pain as the cardinal symptom of disease or injury. The sufferer can be expected to The placebo response devote considerable effort towards seeking out and understanding the origins and nature of the experi- Recognition of the important role ofbeliefsystems ence, as well as surrounding circumstances, and to in determining pain experience and behaviour was enlist the best possible personal and social resources compelled by the placebo effect (Beecher, 1965; to master the threat. Critelli and Neumann, 1984). Inert chemicals and The experience differs with the nature of the pain treatments that have been determined to be non- (Stermbach, 1974). Acute pain, with its usual course specific, or even deleterious to health, frequently of rapid onset and reasonably short recovery period, prove to be strikingly effective as analgesics when is associated with a search for information about administered by enthusiastic, credible proponents of what is happening and how distress can be con- their efficacy (Shapiro, 1971). Newer therapies also trolled. Chronic pain in its unremitting, recurrent, or enjoy similar social facilitation effects since they progresssive patterns is often associated with discon- commonly surpass other therapies in comparative tinuing the search and acceptance of the invalid role. effectiveness. It has become common practice to test Pain associated with specific injuries and diseases all new drugs and other forms of therapy by may have special significance for individual patients comparing them to pharmacologically inert placebos that deserves consideration. Burns or facial damage or non-specific treatment. Client improvement alone that is disfiguring may provoke psychological has been judged to be an inadequate criterion for trauma. Angina pain has acquired special meaning in therapeutic effectiveness of a drug since it may beby copyright. our medically-sophisticated Western culture. Musi- mediated by psychological factors other than the cians and athletes may encounter special problems treatment or remedy's specific action. with painful limb injuries that threaten their ability Unfortunately, with the discovery of specific drug to maintain control over their lives. and surgical pain-relieving techniques, placebos ac- Further variations in belief systems and patterns of quired negative connotations. They became charac- thinking about pain and illness have their origins in terized as a nuisance and clinicians declined to use the family, peer groups and the community (Craig, them with patients. However, at present their salu- 1978, 1983). Both information and the strategies used tary effects are being recognized. When properly to collect, process and apply information are primar- used, they do reduce pain without the harmful side ily drawn from countless exposures to the activities of effects that accompany many analgesic drugs (Mein- http://pmj.bmj.com/ others (Rosenthal and Zimmerman, 1978). Here the hardt and McCaffery, 1983). We are only now individual learns to recognize, interpret, and evaluate discovering the reasons why they work, be it belief what become normal and anomalous somatic sensa- systems, expectancy, suggestion, or other social influ- tions. Socialization practices provide the basis for the ence factors such as context, therapist activities, or transmission of beliefs, normative standards, and persuasion. The non-specific is becoming specific. conceptual skills of the community. The familial and While placebo drugs may be inert, the psychological cultural precepts are immediately available, tend to processes that mediate placebo effects are active, be consistently applied by others, and are supported powerful, and amenable to systematic application. on September 25, 2021 by guest. Protected by social sanctions to conform. The individual can Even when demonstrably effective, biologically- readily learn what is likely to generate pain; what oriented, analgesic interventions are used, psycholo- sensations should be experienced as alarming; how gical factors may have complementary or synergistic different injuries and diseases are likely to feel; and effects. Norton et al. (1984) found that positive beliefs cognitive, behavioural, and social skills useful in in the effectiveness