340 Annals ofthe Rheumatic Diseases 1996; 55: 340-345 REVIEW: PAIN 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 depression, 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- Psychiatry 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 chronic pain have an intercurrent psychiatric patients becomes understandable when seen as disorder-commonly a mood disorder-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 anxiety disorder with generalised anxiety, of the need to move. Hence the development panic disorder, 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 dementia 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 'pain disorder' 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.