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 of acupuncture were associated minimizing personal distress. Cross-cultural studies with reductions in pain severity beyond those elicited effectively demonstrate the variability that has by acupuncture in the absence of positive beliefs. emerged in different societies for recognizing and Chen and Chapman (1980) found that cognitive caring for states of disease and injury (Craig, 1980). coping strategies facilitated the analgesic impact of Similarly, styles of pain complaint tend to be aspirin as assessed by evoked brain potentials. common within families (Craig, 1978). For example, Irrational and self-defeating thinking has been children who become particular problems for dentists shown to play an important role in the genesis of Postgrad Med J: first published as 10.1136/pgmj.60.710.835 on 1 December 1984. Downloaded from

Psychology ofpain 837 both unreasonably controlled and excessive re- a dispassionate sense of mastery. In contrast, pain sponses to painful injury and disease. Given that pain syndromes that persist over time are more likely to and illness are fraught with highly salient personal provide opportunities for considered appraisal and meaning, the impact of inaccurate or false beliefs therapeutic intervention designed to provide the may be considerable. The classic illustration was cognitive and behavioural skills that accompany a provided by Beecher (1959) who contrasted the sense of mastery (Gottlieb et al., 1977). reaction patterns of World War II American soldiers wounded during the Italian invasion with civilians New who had sustained comparable wounds during sur- strategies gery. The former required substantially less care and An examination of specific cognitive mechanisms analgesic medication, suggesting that escape alive has improved our understanding of pain and led to from battlefields represented a dramatic source of innovative treatment strategies (Tan, 1982). Atten- relief from stress, or the proverbial 'ticket-home'. In tion, retention and decision-making, have been contrast, the injured civilians had to endure major demonstrated to be important in investigations of crises and disruptions to their lives precipitated pain (Craig, 1983). A focus upon attentional mecha- abruptly by the accidents. nisms has been particularly productive. One can attend to only a limited subset of internal or external events at a given time. Pain tends to be pre-eminent Pain and depression in its capacity to command attention (Chapman, Recent evidence confirms a role for cognitive 1978). It narrows the focus of attention to immediate distortions in chronic pain patients who display events. However, despite the salience of noxious psychological problems. Lefebvre (1981) found that events, substantial evidence supports the position the cognitive distortions characteristic of clinically that distraction can serve to reduce the severity of depressed patients were also descriptive of the pain (Turk et al., 1983). thinking style of chronic low back pain patients who The amount of stress experienced also will be a become depressed. The chronic pain patients were function of appraisals of personal and external by copyright. generally negative in appraising life experiences and resources and support systems (Neufeld and Kuiper, displayed markedly constrictive and negative ideals 1983). Life history and the immediate social context about the impact of their pain problem on their lives. provide the basis for this evaluation. With pain This would be consistent with findings that pain recognized to be a more ambiguous experience than patients who acquire a conviction that they will sensory-specificity models had us believe, prior per- remain chronic invalids are substantially more sonal and social experiences (Craig, 1978, 1983; difficult to treat (Sternbach, 1974; Pilowsky, 1980). Weisenberg, 1983) assume greater importance. In Pessimistic and self-critical thoughts and preoccupa- essence, people must acquire an awareness of their tions appear to produce considerable disruptive bodies, learn to recognize anomalous somatic states, irrational distress and impair performance by and discover when and how to seek help. People http://pmj.bmj.com/ diverting attention from life-tasks to further self- readily recall distressing and painful events with evaluative concerns (Turk, Meichenbaum and miminal cues (Hunter, Philips and Rachman, 1979) Genest, 1983). and benefit substantially from preparation for pain- Perceived mastery over threat has proved to be a ful events that provides information about how they critical determinant of the severity of stress reactions are likely to feel, what the trajectories of discomfort (Neufeld and Kuiper, 1983). Both favourable per- and recovery are likely to be and which cognitive and sonal histories and planned training in cognitive behavioural coping skills minimize distress (Fager- coping strategies may result in a 'sense of mastery' haugh, 1974; Melamed and Siegel, 1980). on September 25, 2021 by guest. Protected that may 'inoculate' against stress (Turk et al., 1983). Turk et al. (1983) review considerable evidence Bandura (1982) has observed that perceived self- consistent with the position that coping strategies, efficacy, or perception of a personal capacity to attentional distraction, and other cognitive-behav- control a threatening event, lies at the core of all ioural intervention strategies can reduce perceived therapeutic effects. People who enjoy confidence in discomfort and increase pain tolerance. These au- their abilities to cope with pain would be expected to thors also provide the most comprehensive cogni- experience less anxiety and fewer feelings of help- tive/behavioural treatment programme available. lessness. The foregoing review has stressed the position that Perceived self-efficacy would be expected to vary pessimistic and self-critical thoughts and preoccupa- with the nature of the noxious assault. The sudden tions can produce disruptive emotional distress and onset of a traumatic injury or precipitous disease enhance pain. The complexities of interactions would require an extraordinary background of pre- among cognitive, emotional and behavioural aspects paration if the suffering person were to respond with of pain are, however, more complex. Pain, anxiety, Postgrad Med J: first published as 10.1136/pgmj.60.710.835 on 1 December 1984. Downloaded from

838 K D. Craig and depression can lead to the processing of incom- damage, commands attention, disrupts behaviour, ing information in a destructive manner. Strong precipitates action designed to reduce the distress, tendencies have been reported for depressed moods and has strong affective qualities, usually character- to trigger memories of sad and unhappy events ized by fear and anxiety. In general, greater anxiety is (Teasdale and Rezin, 1978) and for anxiety to associated with greater pain, although exceptions enhance the interpretation of innocuous events as have been reported (Craig, in press). dangerous (Rachman, 1980). People suffering from pain can be expected to be biased towards anticipat- Acute versus chronic pain ing the prospect of further unfortunate events and to scanning selectively their external environments and By definition, acute pain is transient and decreases personal experience for threats. From this perspec- as tissue damage heals. Chronic pain, in contrast, tive, those powerful behavioural intervention strat- persists beyond the time healing should have taken egies that focus directly on affective states rather than place. The pathophysiological basis for chronic pain cognitive changes also assume a major role in pain may be highly variable. The pain may either signal a management (Craig and McMahon, 1983). persistent or progressive disease or a condition that has neither real nor impending tissue damage. In contrast, the psychological consequences of chronic Emotional components of pain pain are consistent. Bonica (1974) described chronic The most dominant contemporary model of pain, pain as exclusively malefic because it is powerfully gate-control theory (Melzack and Wall, 1965, 1983), destructive of the physical and psychological well has assigned a major role to those affective and being of the individual and his or her family and motivational processes which were overshadowed by associates, and has no redeeming features. The the emphasis on sensory physiology in earlier models distinction between the two syndromes has become (Craig, in press). Focusing attention upon the dis- so clear that it is now recognized that treatment for tinctly unpleasant, affective qualities of pain, and the acute pain is contraindicated with some types of chronic pain. Certain people suffering from the latter roles of anxiety in acute pain and depression in by copyright. chronic pain (Sternbach, 1974), has had several become at risk for more serious problems if strong benefits. Our concepts of pain processes now coincide analgesics are prescribed, extensive convalescence more closely with patients' experiences as they report and inactivity are recommended, and there is escape them. The feelings of fear, punishment, anguish and or release from ongoing life responsibilities such as despair tend to be major preoccupations, and new work or family routines (Fordyce, 1976; Sternbach, avenues for understanding the nature of pain have 1974). also opened up. There is now an established neurophysiological The language ofpain basis for the different psychological components of pain with the neurophysiological mechanisms for Perhaps the most useful systematic measure of emotional states increasingly well established. Mel- affective qualities of pain yet available has been the http://pmj.bmj.com/ zack and Casey (1968) proposed that (a) sensory- McGill Pain Questionnaire (Melzack, 1975, 1983). discriminative qualities are primarily determined by This instrument permits patients to describe their activity in the rapidly conducting spinal systems; (b) pain on a number ofqualitatively distinct dimensions motivational-affective qualities are subserved by of experience. The development work on the ques- activities in the reticular and limbic structures that tionnaire suggested three main dimensions: sensory, are predominantly influenced by slowly conducting affective, and evaluative. Construct validity studies spinal systems; and (c) neocortical and higher central tend to confirm the validity of distinctions among on September 25, 2021 by guest. Protected nervous system processes exert control over activity these three components but suggest a somewhat more in both the discriminative and motivational systems. complex structure (Reading, 1983). Emotional quali- The recent identification of neurochemical substrata ties appear to represent the major source ofvariation for pain, for example, the action of endogenous in people's descriptions of their painful experiences opioid peptides in analgesia, further complicates our (Crockett, Prkachin and Craig, 1977; Leavitt, Garron understanding of the interaction of the neurochemi- and Bielauskas, 1978). Gracely, McGrath and Dub- cal and neurophysiological substrate ofthe psycholo- ner (1979) have developed useful unidimensional gical components of pain but suggests exciting ratio scales of sensory, affective, and pain intensity therapeutic possibilities. that simplify the task of verbal pain description but Affective qualities of clinical pain vary in accor- do not search for the subtle nuances of differences dance with the important distinction between acute among forms of pain. and chronic pain states (Bonica, 1983; Sternbach, Reports of affective qualities have assumed con- 1978). Acute pain is usually characterized by tissue siderable importance in differential diagnosis. Pa- Postgrad Med J: first published as 10.1136/pgmj.60.710.835 on 1 December 1984. Downloaded from

Psychology ofpain 839 tients with chronic pelvic pain were found to favour The reflexive qualities of pain expression and obser- affective and evaluative words to describe their pain, vers' reactions suggest strong drives to communicate whereas patients in acute pain were prone to use distress to others and innate propensities to be sensory words (Reading, 1983). Leavitt (1983) re- attentive and responsive when others are in distress. ported that chronic back pain patients with psycholo- Of considerable importance has been the discovery gical disturbance endorsed more affective words than that pain behaviours that occur for one set of reasons patients without psychological disturbance. There at the time of onset may persist for a different set of would appear to be prospects of developing psycho- reasons (Fordyce, 1976). In particular, the response metric instruments that would discriminate between of others to the person in distress may perpetuate patients for whom psychological problems repre- illness behaviour (as opposed to the original patho- sented a major component of their pain-related physiological process) beyond the time when healing disability and patients for whom psychological diffi- would take place. This represents an excellent culties do not represent a serious problem (Kremner illustration of an occasion in which pain expression and Atkinson, 1983). does not correspond to a pathophysiological basis for Emotional and behavioural disturbances tend to pain. When others respond by providing sympathetic be common in patients with chronic pain, whether attention, release from work or domestic responsibili- there is an identified, sufficient organic basis for the ties, enforced bedrest or inactivity, and prescription pain or not. Low back pain patients have been of drugs such as strong analgesics, antidepressants reported to have more emotional disturbances as a and anxiolytics contingent upon displays of pain, group than patients with other medical diseases there is an increased risk that the patient may become (Leavitt, 1983), and reported affective distress relates trapped in the role of a sick person or invalid to the severity of psychosocial disturbance (Fordyce, 1983). Behavioural management pro- (McCreary, Turner and Dawson, 1981). Bradley grammes based upon operant learning theory have (1983) reported that a group ofchronic pain patients, been attentive to the importance of these contingent who, through cluster analyses of the Minnesota consequences (Fordyce, 1984) Multiphasic Personality Inventory (MMPI), were Operant pain management programmes appear to by copyright. characterized primarily by elevations on scales Hs, D, mirror the manner in which pain expression and and Hy (the neurotic triad scales), showed greater experience come to reflect the individuals' unique pain-related disturbances in their daily activities familial and ethnocultural background during the (greater endorsement of affective items on the course of socialization. In consequence, there is a McGill Pain Questionnaire, reliance on a greater satisfying integration between the concepts of pain number of analgesic and hypnosedative medications, that have led to effective cognitive/behavioural pain greater use of health professionals, more sleep management strategies and formulations of the disturbance, etc.). Roberts and Reinhardt (1980) impact of socialization experience on pain experience found that their behavioural management treatment and behaviour.

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