340 Annals ofthe Rheumatic Diseases 1996; 55: 340-345

REVIEW: Series editor: Bruce L Kidd Ann Rheum Dis: first published as 10.1136/ard.55.6.340 on 1 June 1996. Downloaded from Psychological aspects of pain

Robert G Large

'An unpleasant sensory and emotional experi- Another approach that is useful clinically has ence associated with actual or potential tissue been to use body drawings that enable the damage, or described in terms of such patient to show the sites and areas of the body damage'. where pain is experienced.6 This is the definition of pain accepted by the A combination of a measure of intensity, an International Association for the Study of Pain adjectival description, and a pain drawing are (IASP) and it is a modification of Merskey's suggested as a useful set of basic data by which original definition.' 2 The striking character- the subjective experience of pain can be istic of this definition is that it does not tie the measured. experience of pain to a stimulus, thus making In day to day clinical work, it can be quite pain a wholly subjective issue. It is for the useful to obtain estimates of pain at 'present', individual who has the experience to determine at 'worst', and at 'least' severity. These give an whether pain is present or not. It is not for us immediate profile of the range of fluctuation in as neurophysiologists, psychologists, or rheu- pain, the time spent in severe pain, and matologists to decide if another person is in whether the pain is continuous or intermittent. pain, but it is entirely that person's prerogative Perceived severity can be some guide to the to tell us what is being experienced. We may need for action. It is not unknown for clinicians be able to judge by history, examination, or to rush in with interventions, when the severity investigations if the experience is likely to be and duration of pain are actually quite modest. linked to a noxious stimulus, but we cannot Sometimes it may be useful to know how much argue with the individual's subjective experi- pain the patient believes would be bearable. ence. Ifthe patient says there is pain, then there This provides some insight into the expec- is pain-unless he or she is lying about his or tations ofbenefit from treatment. her own experience. So, provided the patient There are no psychological tests that reliably is telling the truth, we must accept that pain is distinguish between 'psychogenic' and 'soma- a matter for the patient and no one else to togenic' pain, and anyone looking for such a judge. test has misunderstood the nature of pain and http://ard.bmj.com/ This ultimate reliance on subjective self the needs of patients with pain. The tests that report makes pain one of the most tantalising are helpful are those which clarify the degree of and challenging of all symptoms requiring distress as indicated by anxiety or , consideration. the tendency to somatise distress, as shown in questionnaires on somatic preoccupation and illness behaviour, and the degree of disability. Measurement These give a multidimensional profile, perhaps on September 25, 2021 by guest. Protected copyright. Unlike so many other symptoms, for which a best modelled by the Westhaven/Harvard in- correlate can be found on physical examin- strument or by Strong's multifactorial ation, pain can frequently be experienced with- assessment.7-9 out obvious physical signs. Acute, severe pain may be accompanied by autonomic changes, but there is no reliable way of gauging the The psychological effects ofpain severity, or even the presence, of pain by Acute pain is nearly always a cause for anxiety physical examination or psychophysiological and avoidance, as befits its function as a measurement. warning mechanism. Children learn to avoid As a consequence, all of the useful measures stimuli they associate with pain, as do adults. of pain are ways of formalising and quantifying Physiotherapists are very aware of this issue the person's subjective description. These start when they engage patients in movement and with simple methods of quantifying severity, as remobilisation after injury, whether accidental in the variety of 'box scales' and visual or surgical. This natural and expected response analogue measures, which are simple to use is a potent cause of continuing pain and dis- and can monitor change over time for the same ability. Many people with chronic musculo- individual.3 skeletal pain avoid activity they believe will Department of A simple measure ofintensity can be usefully aggravate their pain.'0 11 The result is de- and with an conditioning, loss of fitness, loss of confidence, Behavioural Science, complemented adjectival description, School ofMedicine, which is formalised in the McGill Pain Ques- and increasing disability."2 In that most enig- University ofAuckland, tionnaire.4 Research on this instrument matic of all pain syndromes-reflex sympath- Private Bag 92019, suggests that there may be a different signifi- etic dystrophy, now called 'complex regional Auckland, New Zealand R G Large cance attached to words that are sensory pain syndrome'-the avoidance of movement stimulation be central to the Accepted for publication descriptors, as opposed to words which have and may patho- 20 December 1995 'evaluative' or 'affective' connotations.5 physiology of the disorder. Much of the Psychological aspects ofpain 341

anxiety, fear and 'neurotic' behaviour of such have an intercurrent psychiatric patients becomes understandable when seen as disorder-commonly a -with

an attempt to avoid pain.'3 Our task in treat- major depression or dysthymic disorder; an Ann Rheum Dis: first published as 10.1136/ard.55.6.340 on 1 June 1996. Downloaded from ment and rehabilitation is to convince patients with generalised anxiety, of the need to move. Hence the development , or phobic anxiety; an adjust- of behavioural programmes based on operant ment disorder related to their pain problem or conditioning theory, as pioneered by Wilbert one of the somatoform disorders, pain dis- Fordyce. 14 orders, or somatisation disorder. The possi- Chronic pain is associated with a range of bility of an underlying must be borne psychosocial problems that have been de- in mind, particularly in the older age group, scribed as part of the 'chronic pain syn- and substance use and abuse are, not in- drome'.'5 Arguments continue about the frequently, complicating factors in the presen- relative importance ofpsychosocial factors that tation.25-27 The important point about these may sensitise patients to the development of a psychiatric presentations is that they seldom chronic pain syndrome, versus the psycho- explain the pain fully and most patients have social sequelae of the pain itself. There can be both medical and psychosocial factors contri- no doubt that pain can and does cause a buting to their pain condition. Table 1 shows concatenation ofadverse psychosocial effects.'6 the distribution of psychiatric diagnoses in a Patients describe changes in relationships with consecutive series of 50 patients, seen at the others and with doctors, a sense of alienation Auckland Hospital Pain Clinic, in whom the within the family, problems with depression diagnoses were validated by independent and anger, and a loss of bodily integrity and of assessors using DSM-III criteria. Only one of a sense of self. Pain is experienced as an added these patients (2%) did not have a clear burden to the normal demands of living, which physical diagnosis.27 saps energy and often cannot be talked about The new DSM-IV classification uses a because others have grown tired of listening. category of '' for patients who are Some patients reach the extremes of helpless- preoccupied with pain, but in whom there is no ness, hopelessness, and suicide.'7 There are clear physical explanation. This is a dualistic now many studies documenting the develop- diagnosis and it is debatable whether this is a ment of such changes after the onset of pain, useful way to characterise pain that lacks and a number of studies showing a reversal of obvious physical pathology. It is interesting such trends when pain is relieved. This does that, in the earlier formulations of DSM-III, not, however, mean that all treatment should the authors had been unable to find a single be directed at pain relief. Repeated, failed representative case of what was then called attempts at definitive treatment or cure consti- 'psychogenic pain disorder', for inclusion in tute one of the more destructive experiences the DSM-III casebook.28 This says something for people with chronic pain.'8 There is also about the rarity of purely 'psychogenic' pain, little evidence to support the idea that simply or at least illustrates our difficulty in identifying http://ard.bmj.com/ providing powerful analgesia is enough. Extant and demonstrating ways in which psycho- studies on the efficacy of chronic opioid use for logical factors can account for pain. Dualistic intractable pain do little to raise any hope of thinking is dangerous to pain patients, because a breakthrough in treatment.'9 it leads to the dual hazards of the patient being Treatment programmes, therefore, need to dismissed as a 'crazy' obsessive, or having their be comprehensive, with an emphasis on in- psychosocial needs totally ignored whilst creasing activity, education about pain, and the clinicians enthusiastically try to cut, stab, or on September 25, 2021 by guest. Protected copyright. utilisation of cognitive-behavioural techniques poison the pain out of them. We need to for pain management. This approach, com- develop modes of management whereby bined with appropriate management of drugs, proper attention can be paid to physical and is well validated in the literature on psychosocial factors simultaneously. outcome.20 21 Where a clear depression or anxiety state is present, it seems obvious that treatment should be directed specifically towards the psychiatric Psychiatric disorders in chronic pain disorder in addition to attending to the pain. Studies investigating the presenting symptoms Some balance and judgment is required, of patients attending both medical and psy- however. Although psychiatrists often focus on chiatric outpatient clinics have found that pain depression and the good responses to anti- is a frequent presenting complaint in both depressant drugs, many patients continue to these groups of patients.22 Pain, therefore, is as experience pain despite resolution of their likely to be a problem for people with psy- chiatric disorders as it is for those with general Table I Clinicalpsychiatric diagnoses among 50 medical consecutive patients with chronic pain using DSM-III problems.23 criteria There are now a number of published studies that have looked at the psychiatric Diagnosis Frequency (%o) diagnoses in pain clinic patients. These data Dysthymic disorder (ie low grade chronic 28 have to be interpreted cautiously, because of depression) Major depression 8 the selection factors that make it likely that Psychogenic pain disorder 8 patients who reach pain clinics are likely to be Somatisation disorder 8 Anxiety disorders 8 experiencing more psychosocial distress than Psychological factors affecting physical 34 those seen in primary care.24 The general condition No findings are that a majority of patients with psychiatric diagnosis 6 342 Large

depression. Conversely, pain management acute pain to a chronic pain syndrome might programmes have been shown to have an anti- be determined by the adaptiveness of the

depressant effect in their own right.29 individual's defences or coping strategies. Poor Ann Rheum Dis: first published as 10.1136/ard.55.6.340 on 1 June 1996. Downloaded from Depression does not, therefore, mean that anti- prognosis has been linked to a tendency to depressant drugs are necessarily indicated and, 'catastrophise'. This is a common attitude in especially, does not imply that antidepressant patients with chronic pain and depression, in medication should be the sole treatment. whom there is a tendency to see the worst In the case of the somatising disorders, man- possibility in any given situation. This charac- agement becomes more complex. Somatisation teristic, and a tendency toward a low sense of disorder is a well validated psychiatric diag- 'self efficacy', have been shown to predict poor nosis identifying a subgroup of patients who outcome in pain management programme present repeatedly with physical complaints in evaluations.36 various organ systems, for which no clear physical cause can be found. These patients are at great risk of iatrogenic complications, and Coping and chronic pain management is best directed toward limiting Coping is a very topical issue in the current investigations and treatment.30 A controlled psychological literature on pain. Pain can be trial of supportive management versus con- construed as a stressor, and coping as the ventional management has shown clear advan- strategies used by people to manage in the face tages in terms of cost and the reduction of of the stressor. This is a complex process and unnecessary interventions.3' involves some appraisal and evaluation of the threat, in addition to the mental and physical attempts made to deal with the threat as it is Psychosocial precursors to pain perceived. People who appear to be adapted to George Engel published an influential article 'living with' their pain problem seem to on the 'pain prone patient' which suggested emphasise the importance of acceptance, of that many patients with chronic pain had a using a wide range of mental and physical pattern of defeat, punishment, and emotional strategies, of having flexible strategies, and of deprivation in early life, that continued on into being able to hope for a better future. Despite unsatisfactory relationships in adult life, often the high value placed by professionals on with continuing abuse and defeat.32 Engel was coping, those people with pain who define struck by how often his patients seemed to themselves as copers tend to regard this as present with pain just when they had found a something of a 'necessary evil' and would far more sympathetic partner, and when one might rather be free of their pain. Health care expect matters to improve. He implicated guilt professionals need to bear in mind, therefore, as a central issue. There has been continuing that even individuals who appear to be exploration of these ideas, with some authors managing their pain well may be longing for coming out very strongly in favour of pain the day when their pain will stop.37 http://ard.bmj.com/ proneness as a full explanation of chronic pain. The literature on coping is beginning to offer Systematic research is difficult here, because of some insights into those coping strategies that the problems inherent in unravelling subtle are adaptive in the face of pain and those that psychodynamic variables from complex life are not. There is some way to go before we can histories. There are, however, some studies become sanguine about our knowledge of how that lend credence to the idea that life's dis- to teach people to cope better. Perhaps the advantages can predispose some people to a most promising avenue lies in attempts to teach on September 25, 2021 by guest. Protected copyright. chronic pain problem. In recent years, people to reduce catastrophising and to attention has focused on the frequency of past increase their sense of self efficacy.36 sexual abuse in patients with chronic pain and for some groups, particularly women with chronic pelvic pain, the incidence is very high Psychological processes as a cause ofpain indeed.33 The linking of past sexual abuse to Speculation about the ways in which pain any medical or psychiatric disorder is fraught might be caused by psychological processes has with difficulty as one tries to distinguish the been rife for decades, often leading to heated factor of sexual abuse from other social disad- debate, but progress has been slow in de- vantage, but in the case ofpain there does seem veloping the research and the research methods to be some face validity to the idea that past that can sensibly explore this interesting painful experiences could sensitise the question. individual to later pain problems.34 Muscle tension is a possible candidate as a One way ofunderstanding these connections causative factor, and much of the current is to postulate some process of sensitisation emphasis on relaxation training and biofeed- that may follow traumatic and painful experi- back has been founded on the notion that ences. This sensitisation could be psycho- excess muscle tension causes pain. The usual logical or neurophysiological, or both, and theoretical explanation has been to invoke the there are parallels here in current thinking notion of muscle contraction leading to about possible 'kindling' processes in post- ischaemia and ensuing pain." To date there has traumatic disorder and in bipolar mood been little scientific validation of this idea, disorders.35 though some studies concerned with this Another possibility might be that such ex- question have made some positive findings. periences determine the coping strategies The literature on outcome in electromyography people develop and that the transition from (EMG) feedback has pointed to the likelihood Psychological aspects ofpain 343

that the favourable response of musculoskeletal hypochondriacal, and may have to defend that pain to biofeedback is probably mediated by position actively by providing evidence of their

cognitive changes, notably a belief that the pain illness to family members and doctors. A Ann Rheum Dis: first published as 10.1136/ard.55.6.340 on 1 June 1996. Downloaded from can be controlled, rather than by direct re- redefinition of social role and self constructs is ductions in levels of muscle tension.38 Never- likely to be a potent factor in locking the theless, it seems unlikely that this question has individual into the pain experience, especially as yet been thoroughly explored, and some if the alternative is to be defined as a investigators are now using EMG mapping hypochondriac or malingerer.35 4 techniques in conjunction with stress interviews Another concept in common usage is the in a revisiting of the research on psychosomatic notion of 'secondary gain'. This idea is close to connections in back pain.39 40 A more sophisti- the behavioural notion of re-enforcement and cated version of the muscle tension hypothesis is a way of looking at the environmental factors was put forward by Whatmore and Kohli, with that might be maintaining the symptom ofpain considerable detailed polygraphic data in once it has developed. It is a problematical support of the notion that many individuals notion, in that there is considerable confusion with pain might engage in excessive bracing as about the accepted definition and usage of the part of their management of daily living.41 They term. It is often used as a jargon phrase in place used the term 'dysponesis' to describe the of accusing the patient of malingering, and excessive 'work' done by these individuals in carries connotations of deliberate deception. In dealing with day to day adversities. Clinically, fact, the term was originally used to describe it is common to hear from patients how they the unplanned, fortuitous advantages of being find themselves clenching fists, bracing in the 'sick' role and which may maintain the shoulders, and clenching jaws almost unwit- status quo. Just as frequently, there are tingly. Jaw clenching and parabuccal habits secondary 'losses' also, for which the secondary may be an important contribution to facial pain gains are scant compensation!46 syndromes.42 Another mechanism ofcausation ofpain that is suggested, but presents an even greater Psychological treatment strategies challenge to scientific validation, is that of Table 2 summarises the overall approach to 'conversion'. This process was best articulated treatment. by Freud and Breuer a century ago.35 Demon- There is now strong research support for the strations of 'hallucinated' pain in laboratory use of comprehensive multidisciplinary pain experiments with hypnosis suggest that there management programmes in the treatment of are mental mechanisms by which an idea or a chronic pain of non-malignant origin. Within suggestion can be translated into physical pain. the context of such programmes, however, are Some authors have explicated such mechan- packaged a variety of psychological treatments isms in the pain presentations of individual with varying validity. Relaxation strategies in patients. These reports are exclusively case general are well validated in the treatment of http://ard.bmj.com/ reports that present retrospective explanations tension-type headaches, but are also useful of pain in the course of intensive psycho- generally. In group studies, EMG feedback therapy. Recent discussion about descending seems to add little to the general efficacy of pathways that might amplify pain signals adds relaxation. Hypnosis is at last being system- some credence to the possibility of conversion, atically evaluated, and there are some en- as do studies looking at the effect of a mental couraging controlled trials demonstrating effi- phenomenon such as hypnosis on pain cacy in temporomandibular pain, headache, on September 25, 2021 by guest. Protected copyright. tolerance and, in a recent report, on the fibromyalgia, and irritable bowel syndrome.47 regulation of spinal nociceptive mechanisms.43 A wealth of experience is being built up Conversion, dissociation, and hypnosis create around the world about the ways in which to a difficult landscape for science, representing engage and encourage patients in working on very much the subjectivity of individual human psychological strategies for pain management. experience. Behind the controlled trials, the themes of One of the oldest and most prevalent of encouraging acceptance, enhancing self effi- psychosomatic notions has been the idea that cacy, and developing adequate coping strat- repressed affect could lead to illness and egies emerge. This emphasis and the success of disease. Migraine, for example, has been thought of as a syndrome related to the Table 2 Summary of the main features of the treatment suppression or repression of anger.24 This idea process is making something of a comeback in recent Diagnostic assessment Pain assessment research on the effects of 'confession'. Much of Intensity-present/worst/least Adjectives (McGill) this work is focused on psychoimmunological Pain drawing effects, but it is likely to have some relevance Distress-anxiety/depression/somatic Disability to pain also.44 Some writers have speculated Psychiatric disorders that people who are unable to translate feelings Depression, anxiety, somatoform 'Getting alongside' Acknowledgement of pain of distress into words may focus on the body Consequences of pain and bodily symptoms instead. This brings the Education Neurophysiology discussion into the field of human interactions, Mind-body connections Treatment Treat psychiatric disorder if indicated where pain has been seen as a communication Education/activation/relaxation and as a way of defining relationships. Patients Cognitive-behavioural treatment with chronic pain begin to construe themselves Follow up Periodic review and encouragement and as being physically ill as opposed to Relapse-anticipation prevention 344 Large

this approach raises some particular dilemmas pain, I can cope, I know what to do'. The for the practice of medicine in relation to essentials of cognitive therapy often seem

chronic pain. The model of management for banal, but there is considerable skill required Ann Rheum Dis: first published as 10.1136/ard.55.6.340 on 1 June 1996. Downloaded from chronic pain is very different from that of acute in engaging people in this process without pain, for which history, examination, investi- sounding like a 'positive thinking' Pollyanna! gation, diagnosis, and specific treatment inter- Cognitive approaches usually consider issues ventions win the day. In management of such as stress, anger, anxiety, depression, self chronic pain, the acute illness model may often assertion and communication as part of the clash with the principles of enhancing self package. Relaxation training should be suited efficacy, of encouraging patients to accept and to individual preferences and needs. Some take responsibility for their pain and to reduce people do far better with simple physical tech- pain behaviours, and the endless search for the niques such as progressive relaxation, whilst holy grail of the cure. Clinicians who base their the more imaginative, highly hypnotisable practice on curing chronic pain frequently individuals will gain far more from imagery and maintain their patients' disability by not self hypnotic techniques. allowing them to move on to a way of living Part of the treatment programme should with their pain that gives them back the include discussions about relapse-that is, the opportunity to live their own lives and not the likelihood that bad times will occur-and the life of illness. patient needs to be involved in planning how Managing chronic pain begins by 'getting he or she will manage when this happens. alongside' the patient. Pain patients are often Follow up should be set up as a time to review angry, suspicious, and defensive, expecting to progress and encourage continued self man- be disbelieved and readily dismissed. One can agement, not as an occasion to feel helpless and begin by accepting the pain at face value, cast about desperately for ever more powerful showing an interest in the patient's experience treatments! of the pain and exploring the impact the pain The success of multidisciplinary approaches has had on their lives. A very effective strategy to pain management makes clear the advan- is to use the pain as a vehicle to discuss tages of integrating physical and psychological emotional issues. People respond very much modalities in pain management. This does not better to a question like 'how has this pain necessarily mean that every patient with pain made you feel, does it get you down?' as must be referred to a pain clinic, but it does opposed to 'are you depressed?'. When pain emphasise the need for all clinicians to develop has been acknowledged and accepted by the a collaborative network of colleagues from doctor, it is much easier to move on to the other disciplines. Having said that, many ofour educational discussions that must follow. more motivated, intelligent (and perhaps more Patients need to be informed about modem fortunate) patients-those with good social neurophysiological understandings of pain, as and personal resources-will make remarkable this information often allows them to see the changes if encouraged to read actively about http://ard.bmj.com/ 'bridge' between mind and body and the ways pain and to implement a self designed pain in which psychological approaches can have an management programme. The field is ripe for effect. Concepts such as muscle tension, stress a systematic evaluation of such 'self manage- and depression are readily understood by many ment' in selected patients. patients and accepted as relevant, provided they feel safe in the knowledge that we are not

implying that they are 'imagining' their pain. Conclusion on September 25, 2021 by guest. Protected copyright. The therapeutic discussion often has to be Our understanding of pain is both limited and finely balanced between validating psycho- enriched by the fact of its subjectivity. Limited logical interventions as effective and admitting because neuroscience does not perform well in the uncertainties of aetiology. It is important the subjective domain. Enriched because too, not to oversell the possible treatment psychological, psychiatric, and phenomeno- benefits. Many pain patients have been logical approaches can appropriately explore, if promised cures in the past, only to be disap- not explain, the subjective. Hence we have pointed. It is better to focus the discussion on come to accept the validity of subjective the notions of coping with pain, managing it, measures of pain, the profound psychological and taking charge of one's life. 'The pain has consequences of being in pain, and the been your boss, now we want to help you frequency of psychiatric disorders in conjunc- become the boss ofyour pain!'. tion with the physical condition. We have some Effective treatment is usually embedded in a appreciation of the psychological precursors of comprehensive approach emphasising edu- pain and can speculate about possible ways in cation, activation, and psychological strategies. which psychological processes might cause Cognitive-behavioural therapy involves a pain. Comprehensive treatment strategies combination of looking at the ways in which emphasising cognitive-behavioural approaches patients think about their pain, and the words, have much to offer, and doctors who under- images, and feelings associated with the pain, stand these psychological issues are likely to be and then discussing and rehearsing alterna- more effective in meeting the needs of those tives." Many patients, for example, catas- with chronic pain. trophise their pain with thoughts like 'this is terrible, I can't cope, what will become of me', 1 IASP Subcommittee on Taxonomy. Pain terms: A list with definitions and notes on usage. Pain 1979; 6: 247-52. which can be disputed gently in therapy and 2 Merskey H, Spear F G. Pain: psychological and psychiatric replaced with 'this is my old, familiar, useless aspects. London; Bailliere, Tindall & Cassell, 1967. Psychological aspects ofpain 345

3 Strong J, Ashton R, Chant D. Pain intensity measurement 26 Large R G. The psychiatrist and the chronic pain patient: in chronic low back pain. Clin J' Pain 1991; 7: 209-18. 172 anecdotes. Pain 1980; 9: 253-63. 4 Melzack R. The McGill Pain Questionnaire: major 27 Large R G. DSM-III diagnoses in chronic pain: confusion

properties and scoring methods. Pain 1975; 1: 277-99. or clarity?J NervMent Dis 1986; 174: 295-303. Ann Rheum Dis: first published as 10.1136/ard.55.6.340 on 1 June 1996. Downloaded from 5 Reading A E. The McGill Pain Questionnaire: an appraisal. 28 Williams J B W, Spitzer R L. Idiopathic pain disorder: A In: Melzack R, ed. Pain measurement and assessment. New critique of pain-prone disorder and a proposal for a York: Raven Press, 1983; 55-61. revision of the DSMIII category psychogenic pain 6 Margoles M S. The pain chart: spatial properties of pain. disorder. J Nerv Ment Dis 1982; 170: 415-9. In: Melzack R, ed. Pain measurement and assessment. New 29 Maruta T, Vatterott M K, McHardy M J. Pain management York: Raven Press, 1983; 215-25. as an antidepressant: long-term resolution of pain- 7 Kems R D, Turk D C, Rudy T E. The West Haven-Yale associated depression. Pain 1989; 36: 335-7. Multidimensional Pain Inventory (WHYMPI). Pain 30 Ford C V. The somatizing disorders. New York: Elsevier 1985; 23: 345-56. Biomedical, 1983; 69-71. 8 Turk D C, Rudy T E. The robustness of an empirically 31 Smith G R, Monson R A, Ray D C. Psychiatric consultation derived taxonomy ofchronic pain patients. Pain 1990; 43: in : a randomized controlled study. 27-35. NEnglJMed 1986; 314: 1407-13. 9 Strong J, Ashton R, Stewart A. Chronic low back pain: 32 Engel G L. Psychogenic pain and the pain-prone patient. Toward an integrated psychosocial assessment model. J AmJ Med 1959; 26: 899-918. Consult Clin Psychol 1994; 62: 1058-63. 33 Walker E, Katon W, Harrop-Griffiths J, Holm L, Russo J, 10 Fordyce W E, Roberts A H, Sternbach R A. The behavioral Hickok L R. Relationship of chronic pelvic pain to management of chronic pain: a response to critics. Pain psychiatric diagnoses and childhood sexual abuse. Am J 1985; 22: 113-25. Psychiatry 1988; 145: 75-80. 11 Fordyce W E. Pain and . Am Psychol 1988; 43: 34 Hudson J I, Pope H G. Does childhood sexual abuse cause 276-83. fibromyalgia? Arthritis Rheum 1995; 38: 161-3. 12 Bortz W. The disuse syndrome. West Jf Med 1984; 141: 35 Large R, Butler M, James F, Peters J. A systems model of 691-4. chronic musculo-skeletal pain. Aust N Z J Psychiatry 13 Van Houdenhove B, Vasquez G, Onghena P, et al. 1990; 24: 529-36. Etiopathogenesis of reflex sympathetic dystrophy: a 36 Turner J A. Coping and chronic pain. In: Bond M R, review and biopsychosocial hypothesis. Clin J Pain 1992; Charlton C E, Woolf C J, eds. Proceedings ofthe VIth World 8: 300-6. Congress on Pain. Amsterdam: Elsevier Science Publishers 14 Fordyce W E. Behavioral methods for chronic pain and illness. BV, 1991; 219-27. St Louis: C V Mosby, 1976. 37 Strong J, Large R G. Coping with chronic pain: an ideo- 15 Black R G. The chronic pain syndrome. Surg Clin N Am graphic exploration through focus groups. Int J Psychiatr 1975; 55: 999-1011. Med 1995. In press. 16 Pinsky J J. Chronic intractible benign pain: a syndrome and 38 Nouwen A, Solinger J W. The effectiveness of EMG its treatment with intensive short term group psycho- biofeedback training in low back pain. Biofeedback Self therapy. J Hum Stress 1978; 4: 17-21. Regul 1979; 4: 103-11. 17 James F R. The meaning of pain. In: Psychological investi- 39 Cram J R, Steger J C. EMG scanning in the diagnosis of gations ofthe experience ofchronicpain [Thesis], chapter IV. chronic pain. Biofeedback SeylRegul 1983; 8: 229-41. Auckland: University ofAuckland, 1991; 60-72. 40 Turk D C, Flor H. Etiological theories and treatments for 18 Sternbach R A. Clinical aspects of pain. In: Stembach R A, chronic back pain. II Psychological models and inter- ed. The psychology ofpain. New York: Raven Press, 1978; ventions. Pain 1984; 19: 209-34. 241-64. 41 Whatmore G B, Kohli D R. Dysponesis: a neuro- 19 Large R G, Schug S A. Opioids for chronic pain of non- physiological factor in functional diseases. Behav Sci malignant origin-caring or crippling. Health Care 1968; 13: 102-24. Analysis 1995; 3: 5-11. 42 Kotani H, Kawazoe Y, Hamada T, Yamada S. Quantitative 20 Large R, Peters J. A critical appraisal of outcome of electromyographic diagnosis of myofascial pain- multidisciplinary pain clinic treatments. In: Bond M R, dysfunction syndrome. J Prosthet Dent 1980; 43: 450-6. Charlton J E, Woolf C J, eds. Proceedings ofthe VIth World 43 Kiernan B D, Dane J R, Phillips L H, Price D D. Hypnotic Congress on Pain. Amsterdam: Elsevier Science Publishers analgesia reduces R-III nociceptive reflex: further BV, 1991; 417-27. evidence concerning the multifactorial nature of hypnotic 21 Flor H, Fydrich T, Turk D C. Efficacy of multidisciplinary analgesia. Pain 1995; 60: 39-47. pain treatment centers: a meta-analytic review. Pain 1992; 44 Pennebaker J W, Kiecolt-Glaser J K, Glaser R. Disclosure 49: 221-30. of traumas and immune function: health implications for 22 Devine R, Merskey H. The description ofpain in psychiatric psychotherapy. J Consult Clin Psychol 1988; 56: 239-45. and general medical patients. J Psychosom Res 1965; 9: 45 Large R G, James F R. Personalised evaluation of self- 311-6. hypnosis as a treatment of chronic pain: a repertory grid http://ard.bmj.com/ 23 Delaplaine R, Ifabumuyi 0 I, Merskey H, Zarfas J. analysis. Pain 1988; 35: 155-69. Significance of pain in psychiatric hospital patients. Pain 46 Large R G. Advantages of illness. APSJ 1994; 3: 282-4. 1978; 4: 361-6. 47 Large R G. Psychological and psychiatric approaches in the 24 Merskey H. Psychiatry and chronic pain. Can J Psychiatry treatment of musculoskeletal pain. In: Vaeroy H, 1989; 34: 329-36. Merskey H, eds. Progress in Fibromyalgia and myofascial 25 Fishbain D A, Goldberg M, Meagher B R, Steele R, pain. Amsterdam: Elsevier Science Publishers BV, 1993; Rosomoff H. Male and female chronic pain patients 369-74. categorized by DSM-III psychiatric diagnostic criteria. 48 Turk D C, Meichenbaum D, Genest M. Pain and behavioral Pain 1986; 26: 181-97. medicine. New York: The Guilford Press, 1983; 247-57. on September 25, 2021 by guest. Protected copyright.