Psychological Approaches to Pain Management, Second Edition: A Practitioner's Handbook

Psychological Approaches to Pain Management, Second Edition: A Practitioner's Handbook

by Dennis Turk

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Designed for maximum clinical utility, this volume shows how to tailor psychological treatment programs to patients suffering from a wide range of pain problems. Conceptual and diagnostic issues are discussed, widely used clinical models reviewed, and a framework presented for integrating psychological treatment with medical and surgical interventions.See more details below


Designed for maximum clinical utility, this volume shows how to tailor psychological treatment programs to patients suffering from a wide range of pain problems. Conceptual and diagnostic issues are discussed, widely used clinical models reviewed, and a framework presented for integrating psychological treatment with medical and surgical interventions.

Editorial Reviews

Arguing that psychosocial factors that help cause pain must be evaluated and treated in conjunction with physical and pre- dispositional psychological factors for therapeutic success, Turk (anesthesiology and pain research, U. of Washington) and Gatchel (clinical psychology, U. of Texas Southwestern Medical Center) present 28 contributions that look at methodological and conceptual issues, in addition to providing treatment strategies and documenting their effectiveness. Ten chapters focus on models that transcend specific pain syndromes, examining psychological approaches and specific techniques. An additional 14 chapters cover secondary prevention and treatment of specific syndromes and consider issues of special populations, including children and the elderly. Annotation c. Book News, Inc., Portland, OR
Doody's Review Service
Reviewer: Nicholas Greco IV, MS, BCETS, CATSM (Columbia College of Missouri)
Description: The second edition of this book reflects the ever-changing nature of the field of pain management. The book has been updated with the latest research and current thinking as well as the pertinent information needed for the clinician to use on a daily basis.
Purpose: The purpose is to address the tremendous changes and advances involving the role and nature of different psychosocial and behavioral factors in acute, recurrent acute, and chronic pain syndromes. Additionally, the authors have intended this book to help "bridge the gap between laboratory research and direct application to the clinical environment." Ultimately, this is a clinician's handbook to be implemented in daily practice. The book meets the editors' objectives and will surely meet the needs of clinicians in the field.
Audience: This book is intended for, and will be of most benefit to, those clinicians who work with patients and pain management. The editors and contributing authors are highly knowledgeable and credible authorities in the field.
Features: The book is divided into three parts: part one discusses the conceptual, diagnostic, and methodological issues, part two covers the various treatment approaches and methods, and part three discusses specific syndromes and populations. Part two has an excellent combination of chapters that discuss cognitive-behavioral approaches, hypnosis and imagery, group therapies, and biofeedback. Clinicians especially will find the specific syndromes such as fibromyalgia, cancer, and chronic back pain of interest. The index is helpful and the overall design and content of the book is exceptional.
Assessment: I enjoyed this book and the various approaches discussed in it. Clinicians in the field surely need to add this book to their arsenal of knowledge. Highly recommended.
From the Publisher

"This highly informative book will be welcomed enthusiastically by clinical investigators and health care providers alike. Once again, Drs. Turk and Gatchel have brought together a superb list of respected authors to provide practical information and insights on psychosocial and behavioral factors in acute and chronic pain syndromes. The text is comprehensive and up to date, including an explosion of new material on the most important assessment and treatment issues surrounding persons with intractable pain. I highly recommend this book for both seasoned professionals and students new to the field. It is an absolute ¿must have.'"--Robert N. Jamison, PhD, Pain Management Center, Brigham and Women's Hospital, Harvard Medical School

"This much-needed second edition includes a wealth of new information on emergent approaches to pain management. The authors comprise a veritable who's who of clinicians and scholars who have contributed enormously to current thinking in the field. Unlike many edited volumes, where the chapters do not dovetail well, this one offers a coherent, comprehensive review that skillfully integrates research with clinical practice. Provided are innovative perspectives on assessment and treatment, with application both to the classroom and the clinic. I recommend this highly readable volume both to experienced professionals and to students interested in the expanding field of pain treatment and research."--Raymond C. Tait, PhD, Department of Psychiatry, Saint Louis University School of Medicine

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Psychological Approaches to Pain Management

A Practitioner's Handbook

The Guilford Press

Copyright © 2002 The Guilford Press
All right reserved.

ISBN: 1-57230-642-4

Chapter One

Biopsychosocial Perspective on Chronic Pain

* * *

Dennis C. Turk Elena S. Monarch

Chronic pain is a demoralizing situation that confronts the sufferer not only with the stress created by pain but with many other ongoing difficulties that compromise all aspects of his or her life. Living with chronic pain requires considerable emotional resilience as it depletes people's emotional reserves. In the presence of chronic pain, the continuing quest for relief often remains elusive, which can lead to feelings of demoralization, helplessness, hopelessness, and outright depression. Moreover, chronic pain taxes not only the sufferer but also the capacity of significant others who provide instrumental and emotional support. Health care providers share patients' and significant others' feelings of frustration as the reports of pain continue, despite the provider's best efforts and, at times, in the absence of pathological signs that can account for the reported pain.

On a societal level, unrelieved pain creates a burden in, health care expenditures, disability benefits, lost productivity, and tax revenue. Third-party payers are confronted with escalating medical costs, compensation payments, and frustration when patientsremain disabled despite extensive and expensive treatments.

Despite advances in knowledge of the physical mechanisms, development of sophisticated diagnostic procedures, and development of innovative treatments, currently no treatment is available that consistently and permanently alleviates pain for all those afflicted. This chapter examines how psychological and social factors can be integrated with physical factors to create a biopsychosocial framework that can help us to understand chronic pain patients and their disability. We review research focusing specifically on psychological, behavioral, and social factors, and we discuss the implications of these contributors for treatment and rehabilitation. The factors discussed here underlie many of the treatment approaches described in other chapters of this volume.

The Need for an Alternative to the Disease Model

The biomedical model of pain-which dates back to the ancient Greeks that was inculcated into medical thinking by Descartes in the 17th century-assumes that people's reports result from a specific disease state represented by disordered biology. The diagnosis is confirmed by data from objective tests of physical damage and impairment and medical interventions are specifically directed toward correcting the organic dysfunction or source of pathology. There is general agreement, however, that the presence and extent of physical pathology are not sufficient to account for all reported physical symptoms. Decidedly diverse responses to objectively similar physical perturbations and identical treatments have been noted clinically and have been documented in many empirical investigations. Although they are related, the associations between physical impairments on the one hand and pain report and disability on the other are modest at best (see, e.g., Flor & Turk, 1988; Waddell & Main, 1984). Identified physical pathology does not predict severity of pain or level of disability. Moreover, pain severity does not adequately explain psychological distress or extent of disability observed. The question that remains to be answered is this: What factors can account for the highly varied expression of subjective experience and behavioral responses?

From the perspective of the biomedical model, accompanying features of chronic conditions, such as sleep disturbance, depression, psychosocial disability, and pain, are not viewed as pathognomonic of a particular disease or syndrome. Rather, they are viewed as reactions to the malady and are thus considered of secondary importance. It is assumed that once the disease is "cured," these secondary reactions will evaporate. If they do not, speculations are raised as to possible psychological causation. Thus, traditional medicine has adopted a dichotomous view in which symptoms are either somatogenic or psychogenic. Although evidence to support this dichotomy is lacking, the view remains pervasive.

The biomedical model has been criticized because of its failure to address the roles of psychological and psychosocial variables in health and disease, particularly the dynamic interaction of these variables with pathophysiological factors (Engel, 1977). Specifically, problems arise when patients' symptoms and illnesses are not commensurate with the degree of observable pathology. In these circumstances, common in such chronic pain conditions as back pain, headache, fibromyalgia syndrome (FMS), and temporomandibular disorders (TMDs), the patient's presentation does not fit neatly within the biomedical model.

Chronic pain is more than a physical symptom. Its continuous presence creates widespread manifestations of suffering, including preoccupation with pain; limitation of personal, social, and work activities; demoralization and affective disturbance; increased use of medications and of health care services; and a generalized adoption of the "sick role" (Parsons, 1958). Although the importance of such factors has been acknowledged for some time, only within the past half century have systematic attempts been made to incorporate these factors within comprehensive models of pain (for a review, see Turk, 2001). Dissatisfaction with the conventional model of pain led to a seminal event: the formulation of the gate control theory of pain by Melzack and his colleagues (Melzack & Casey, 1968; Melzack & Wall, 1965).

The Gate Control Theory of Pain

The first attempt to amalgamate physiological and psychological factors and to develop an integrative model of chronic pain that circumvents shortcomings of unidimensional models was the gate control theory (GCT) (Melzack & Casey, 1968; Melzack & Wall, 1965). Melzack and Casey (1968) differentiated three systems related to the processing of nociceptive stimulation-sensory -discriminative, motivational-affective, and cognitive-evaluative-all of which contribute to the subjective experience of pain. In this way, the GCT specifically includes psychological factors as integral aspects of the pain experience. In addition, by emphasizing central nervous system (CNS) mechanisms, this theory provides a physiological basis for the role of psychological factors in chronic pain.

According to the GCT, peripheral stimuli interact with cortical variables, such as mood and anxiety, in the perception of pain. Pain is not considered either somatic or psychogenic; instead, both factors have either potentiating or moderating effects. From the GCT perspective, the experience of pain is an ongoing sequence of activities, largely reflexive in nature at the outset, but modifiable even in the earliest stages by a variety of excitatory and inhibitory influences, as well as the integration of ascending and descending CNS activity. The process results in overt expressions communicating pain and strategies by the person to terminate the pain. Because the GCT invokes the continuous interaction of multiple systems (sensory-physiological, affect, cognition, and behavior) considerable potential for shaping of the pain experience is implied.

Whereas prior to the GCT formulation psychological processes were largely dismissed as reactions to pain, this new model suggested that cutting or blocking neurological pathways is inadequate because psychological factors are capable of influencing the peripheral input. The emphasis on the modulation of inputs in the dorsal horns and the dynamic role of the brain in pain processes and perception resulted in the integration of psychological variables (e.g., past experience, attention, and other cognitive activities) into current research and therapy on pain. Perhaps the major contribution of the GCT has been its highlighting of the CNS as an essential component in pain processes and perception.

The physiological details of the GCT have been challenged, and it has been suggested that the model is incomplete (see, e.g., Nathan, 1976; Price, 1987). As additional knowledge has been gathered since the original formulation in 1965, specific mechanisms have been disputed and have required revision and reformulation (Nathan, 1976; Wall, 1989). Overall, however, the GCT has proved remarkably resilient and flexible in the face of accumulating scientific data and challenges to these data. It still provides a "powerful summary of the phenomena observed in the spinal cord and brain, and has the capacity to explain many of the most mysterious and puzzling problems encountered in the clinic" (Melzack & Wall, 1982, p. 261). This theory has had enormous heuristic value in stimulating further research in the basic science of pain mechanisms. It has also given rise to new clinical treatments, including neurophysiologically based procedures (e.g., neural stimulation techniques), from peripheral nerves and collateral processes in the dorsal columns of the spinal cord (North, 1989), pharmacological advances (Abram, 1993), behavioral treatments (Fordyce, Roberts, & Sternbach, 1985), and interventions targeting modification of attentional and perceptual processes involved in the pain experience (Turk, Meichenbaum, & Genest, 1983). After the GCT was proposed, no one could continue trying to explain pain exclusively in terms of peripheral factors.

Neuromatrix Theory

Recently, Melzack (1999) extended the GCT and integrated it with Selye's (1950) theory of stress. The neuromatric theory makes a number of assumptions about pain. For example, Melzack proposes that the multidimensional experience of pain produced by characteristic patterns of nerve impulses generated by a widely distributed neural network that comprises a "body-self neuromatrix." The neuromatrix is to some extent genetically determined, but it is modified by sensory experience and learning. Another important feature of the neuromatrix theory is that the patterns of nerve impulses are hypothesized to be triggered either by sensory inputs or centrally, independent of any peripheral stimulation.

When an organism receives an injury there is an alteration and disruption of the homeostatic regulation. This deviation from the body's normal state is stressful and initiates a complex of neural, hormonal, and behavioral mechanisms designed to restore homeostasis (Selye, 1950). Melzack (1999) hypothesizes that prolonged stress and ongoing efforts to restore homeostasis can suppress the immune system and activate the limbic system. The limbic system has an important role in emotion, motivation, and cognitive processes. As originally proposed by Selye (1950), prolonged activation of the stress regulation system can lead to a predisposition for the development of different chronic pain states (e.g., FMS, cumulative trauma disorders, whiplash-associated disorders).

According to Melzack (1999), a person's unique body-self neuromatrix is the primary determinant of whether the organism experiences pain and is the basis for the individual differences observed. Building on the GCT, pain suppression can be produced by sensory and evaluative processes, as well as activation of the endogenous opioid system.

The cumulative effects of stresses that preceded or are concomitant with the current stress may account for the large variation in individual responses to what might appear to be objectively the same degree of physical pathology. In this way, the theory incorporates the pain sufferer's prior learning history to shape the neuromatrix by influencing interpretive processes and individual physiological and behavioral response patterns. A new stressor may amplify baseline stress and related efforts of homeostatic regulation. Prolonged stress augments tissue breakdown as the body continues to attempt to return to its "normal" state. In a sense, the neuromatix theory proposes a diathesis-stress model in which predispositional factors interact with an acute stressor (Okifuji & Turk, in press; Turk, 2002). Once pain is established, however, it becomes a stressor in and of itself, as the body continues to attempt return to homeostasis and the presence of pain is a continual threat that creates demands on the body. Fear, worry about the future, and the meaning of the nociceptive stimulation contribute to the ongoing stress producing additional deviations from homeostasis.

Nociception involves activation of energy impinging on specialized nerve endings. The nerve(s) involved conveys information about tissue damage to the CNS. A growing body of animal research suggests that repetitive or ongoing nociceptive input can lead to structural and functional changes that may cause altered perceptual processing and contribute to pain chronicity (Woolf & Mannion, 1999). These structural and functional changes, demonstrate plasticity in the nervous system and may explain why a person experiences a gradual increase in the perceived magnitude of pain referred to as neural (peripheral and central) sensitization. Moreover, once these changes have occurred, they may contribute to nociception even after the initial cause has resolved. These changes in the CNS offer an explanation for the reports of pain in many chronic pain syndromes (e.g., FMS, whiplash-associated disorders and back pain) even when no physical pathology is identified. According to Melzack, these CNS changes can be accounted for by modification of the body-self neuromatrix.

The neuromatrix theory poses intriguing hypotheses and integrates a great deal of physiological and psychological knowledge. However, components of the theory and the theory itself await systematic investigation. As was the case with the GCT, the neuromatrix theory offers a heuristic way of thinking that should stimulate research.

The Biopsychosocial Perspective: A Basic Description

People differ markedly in how frequently they report physical symptoms, in their propensity to visit physicians when experiencing identical symptoms, and, as noted, in their response to the same treatments (Desroches, Kaimen, & Ballard, 1967; Zborowski, 1969). Often the nature of patients' responses to treatment has little to do with their objective physical condition (Mechanic, 1962). For example, White, Williams, and Greenberg (1961) noted that less than one-third of people with clinically significant symptoms consult a physician. Conversely, from 30 to 50% of patients who seek treatment in primary care do not have specific diagnosable disorders (Dworkin & Massoth, 1994), and for up to 80% of people with back pain (Deyo, 1986) and the majority of chronic headache suffers, no physical basis for the pain can be identified.


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