Controlling pain

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Controlling pain

• Health Psychology

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There are various techniques for controlling pain

• Pain relieving chemicals
• Behavioural and cognitive methods for treating
  pain
• Hypnosis
• Inside oriented psychotherapy
• Physical and stimulation therapies for pain

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Pain relieving chemicals

• Chemical - Aspirin -Acetylsalicylic acid - found
  in Willow trees, as discovered by a clergyman
  from Chipping Norton in 1763
• it relieved his rheumatism and bouts of fever.

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Chemicals

• Aspirin, Ibuprofen, Paracetamol
  (acetaminophen)Against painAgainst
  inflammationAgainst feverOpium used before
  then, as early as 1550 BC

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Chemicals

• From Opium is produced morphine, heroin and
  codeine - all produce analgesia, drowsiness,
  change of mood, mental clouding.

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Chemicals

• Inhibit pain messages (close the gate).Opiates
  work well because many nerves respond to opiates.

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Chemicals

• Peripherally active analgesics, for example
  aspirin which acts on the peripheral nervous
  system by inhibiting the synthesis of
  neurochemicals
• Centrally acting analgesics, for example
  narcotics derived from the opium poppy, which
  acts on the central nervous system. There is a
  problem of tolerance and addiction though.
• Local anaesthetics. These act directly on the
  site whether pain originates. The problem is that
  the drugs will paralyse muscles in the region as
  well.

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Chemicals

• Indirectly acting drugs. These drugs include
  sedatives, tranquillisers, antidepressants, and
  anticonvulsants. Sedatives, such as barbiturates
  and tranquillisers such as diazepam are
  depressants that depress bodily functions. The
  problem is the patient could become
  psychologically and physically dependent upon the
  drugs. Antidepressants, such as doxepin, helped
  patients by reducing the psychological depression
  that accompanies chronic pain. Anticonvulsants
  inhibit random nerve impulses, which will control
  some types of pain.

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Chemicals

• Patients in hospital tend to demand medication
  too often, which inconveniences the busy staff.
  Allowing the patient to self-administer their
  medication has led to the unexpected result that
  they receive less of the drug than others who
  receive injections on demand. It would seem that
  once the patient feels in control they can manage
  without the drug for longer.

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Chemicals

• Naturally the machine that allows the patients to
  self inject does restrict the amount and rate of
  injections in order to avoid an overdose, but
  this would not explain why self administering
  patients manage on less pain killer than other
  patients, who would be subject to a controlled
  dose as well.

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Chemicals

• In short, Keeri-Szanto (1979) - machine that
  dispenses tablets by the patient's bed, with lock
  to prevent patient from over-dosing - patient
  self-administering in this way reduces their drug
  intake, compared with when issued with tablets
  from the medical staff.

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Behavioural and cognitive methods for treating
pain

• Operant - useful if patient has developed
  inappropriate response to the pain (e.g. too many
  tablets).
• Use social reinforcement to gradually increase
  activity levels
• Gradually decrease the use of medication
• Training carers not to reinforce pain behaviours
  by being sympathetic

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The operant approach

• An example of the operant approach for a child
  with burns.
• The child cries and complains of pain when ever
  she puts on her splints. The hospital staff has
  been giving attention to the crying behaviour.
  The remedy is as follows
• Ignore the pain behaviours
• Provide rewards for compliant behaviour
• Give praise if the child helps in putting on the
  splints etc..

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The operant approach

• A technique for reducing medication is as
  follows
• Use a fixed schedule, such as every four hours,
  rather than when ever the patient requests it.
  The drug therefore does not become a reward for
  the patient. In addition, the medication is mixed
  with flavoured syrup to mask its taste.

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The operant approach

• Over a period of several weeks the dosage is
  gradually reduced, but the patient, because of
  the syrup, does not detect this.

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Problems with these studies

• Studies often do not include control groups, so
  it is difficult to know whether the operant
  methods changed the behaviour or some other
  factor, such as being studied.
• The technique is not suitable for chronic
  progressive pain, such as in cancer patients.

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Problems with these studies

• Patients who are unwilling to participate or who
  receive disability compensation are not likely to
  benefit from this technique.

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Relaxation and biofeedback

• Patients using the technique of progressive
  muscle relaxation focus their attention on
  specific muscle groups while alternately
  tightening and relaxing these muscles. Patients
  who received training in relaxation to control
  pain are urged to use this technique to reduce
  feelings of stress, particularly if they feel
  pain episodes coming on.

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Relaxation and biofeedback

• In biofeedback procedures, patients learned to
  exert voluntary control over a bodily function,
  such as heart rate, by monitoring its status with
  information, usually from electronic devices.
  Muscle contraction headaches can be treated by
  biofeedback procedures.

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Relaxation and biofeedback

• Patients learned to control the tension of
  specific muscle groups -such as those in the
  scalp and neck- by receiving biofeedback from an
  electromyograph (EMG.) device.

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Relaxation and biofeedback

• Another method used for migraine headaches,
  focuses on the constriction and dilation of
  arteries -such as those in the head- which can be
  measured indirectly on the basis of the
  temperature of the skin in the region of the
  target blood vessels. Biofeedback techniques,
  such as these, can be used at home whenever a
  patient feels a pain episode is about to begin.

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Relaxation and biofeedback

• Biofeedback techniques have been shown to be
  successful in controlling headaches, but there
  has been little evidence of biofeedback
  procedures being effective in relieving other
  types of pain. Treatment with relaxation and
  biofeedback is about twice as effective in
  relieving pain as placebo conditions.

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Relaxation and biofeedback

• A combination of relaxation and biofeedback has
  been shown to be more successful than biofeedback
  on its own. Biofeedback has been shown to be more
  successful than relaxation techniques. (Holroyd
  Penzien, 1985). There is much variability in the
  success of these techniques.

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Relaxation and biofeedback

• Middle-aged and elderly patients seem to gain
  relatively little relief with these treatments
  (Blanchard Andrasik, 1985). Biofeedback
  treatment is relatively expensive to conduct, and
  the likelihood of improvement beyond just using
  relaxation for many pain conditions may not
  justify its expense (Turk, Meichenbaum Berman,
  1979).

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Relaxation and biofeedback

• There is some evidence that most children and
  people who show certain psychophysiological
  patterns, such as a high correlation between
  their pain and EMG. Levels, may be better
  candidates for biofeedback treatment than other
  people (Attanasio et al., 1985).

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Cognitive techniques

• Researchers asked children and adolescents what
  they think about when getting an injection at
  their dentists (Brown, O'Keeffe, Sanders,
  Baker, 1986). Over 80 of these subjects reported
  thoughts that focused on negative emotions and
  pain, such as, "this hurts, I hate injections,"
  "I'm scared," and "my heart is pounding and I
  feel shaky."

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Cognitive techniques

• One fourth of the subjects had thoughts of
  escaping or avoiding the situation, as in, "I
  want to run away." These types of thoughts focus
  the persons attention on the unpleasant aspects
  of the experience and make the pain worse (Turk,
  Meichenbaum, Genest, 1983).

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Cognitive techniques

• Many people use cognitive strategies to modify
  their experience of pain. For instance, by 10
  years of age, many children reports that they
  tried to cope with pain in a dental situation by
  thinking about something else or by saying to
  themselves such things as, "it's not so bad," or,
  "be brave" (Brown, O'Keeffe, Sanders, Baker,
  1986).

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Cognitive techniques

• People cope with chronic pain by using one of two
  strategies
• Active coping, in which they try to keep
  functioning by ignoring the pain or keeping busy
  with an interesting activity.
• Passive coping, such as taking to bed or
  curtailing social activities.

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Cognitive techniques

• The problem with passive coping is that this
  leads to feelings of helplessness and depression,
  which leads to more passive coping, and so on
  (Smith Wallston, 1992).

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Cognitive techniques

• Patients who feel that their pain will last a
  very long time and their doctors don't know what
  causes their pain tend to cope poorly. On the
  other hand, patients who believe that they
  understand the nature of their pain and that
  their conditions will improve tend to use active
  coping strategies.

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Cognitive techniques

• Coping techniques can be classified into three
  basic types
• Distraction,
• Imagery,
• Redefinition (Fernandez, 1986).

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Distraction

• Distraction is the technique of focusing on a
  non-painful stimulus in the immediate environment
  in order to divert our attention from discomfort.
  Research has shown that distraction is more
  effective if the pain is mild or moderate than if
  it is strong (McCaul Malott, 1984).

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Distraction

• A laboratory experiment involving college
  students rated the subjects pain distress for
  holding their hand in cold water. Subjects given
  a distraction task involving numbers did not give
  lower pain ratings than controls, who just
  watched numbers being displayed (McCaul, Monson,
  Maki, 1992).

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Distraction

• This result might be because subjects needed to
  believe that these distraction techniques would
  relieve pain.
• Subjects believing that loud sound would relieve
  pain, listened to the sound and did not feel as
  much pain (using the cold-presser procedure, hand
  in cold water) as did controls who were listening
  for a non-existent hum (Melzack, Weisz,
  Sprague, 1963).

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Distraction

• Distraction works best for acute pain, such as
  the pain experienced in a dental surgery.
• Chronic sufferers might find it useful to engage
  in an extended activity, such as watching a film
  or reading a book.

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Imagery

• Non-pain imagery-sometimes called guided
  imagery-is a strategy whereby the person tries to
  alleviate discomfort by conjuring up a mental
  scene that is unrelated to or incompatible with
  the pain (Fernandez, 1986). Therapists encourage
  the patient to include aspects of a variety of
  senses vision, hearing, taste, smell, and touch.

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Imagery

• Imagery is like distraction except that imagery
  is based on the person's imagination rather than
  on real objects. The advantage here is that the
  patients can develop one or more scenes that work
  reliably and carry them around in their heads.
  Imagery works best for people with mild or
  moderate pain than with strong pain. A
  disadvantage is that some patients are less adept
  in imagining scenes than others.

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Redefinition

• Pain redefinition is when the person substitutes
  constructive or realistic thoughts about the pain
  experience for ones that arouse feelings of
  threat or harm. Therapists can help by providing
  information about the sensations to expect in
  medical procedures.

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Redefinition

• There are basically two kinds of self-statements
  for controlling pain
• Coping statements emphasise the person's ability
  to tolerate the pain by saying to themselves, "it
  hurts, but you're in control," or, "be brave-you
  can take it."

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Redefinition

• Reinterpretative statements are designed to
  negate unpleasant aspects of the pain, as when
  people think, "it is not so bad," "it's not the
  worst thing that could happen," or, "it hurts,
  but think of the benefits of this experience."

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Evaluation of cognitive strategies in controlling
pain

• Cognitive strategies are effective in reducing
  acute pain. Distraction and imagery seem to be
  particularly useful with mild or moderate pain,
  and redefinition appears to be more effective
  with strong pain.

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Evaluation of cognitive strategies in controlling
pain

• A combination of behavioural and cognitive
  methods is at least as effective as chemical
  methods in reducing chronic muscle-contraction
  headaches (Holroyd et al., 1991). Patients with a
  variety of medical problems including arthritis,
  amputation, and spinal cord injury reported that
  redefinition helped in reducing the experience of
  pain more than distraction did (Rybstein-Blinchik,
  1979).

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Evaluation of cognitive strategies in controlling
pain

• Arthritis sufferers received a five-week pain
  control programme that included training in
  distraction, imagery, and redefinition. The
  programme gave special emphasis to having the
  patients use these techniques in specific painful
  activities, such as carrying groceries, climbing
  stairs, and mopping floors.

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Evaluation of cognitive strategies in controlling
pain

• A control group simply received a self-help book
  for arthritis sufferers. The control group showed
  little improvement but the treated group reported
  having less pain, greater self-efficacy, less
  depression, and improved Sleep patterns.

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Hypnosis

• Hypnosis produces a high degree of analgesia in
  only a minority of individuals. Those people who
  can be hypnotised very easily and deeply seem to
  gain more pain relief from hypnosis than those
  who are less hypnotically susceptible. Hypnosis
  could be seen as a form of relaxation. Hypnosis
  often produces states of heightened attention to
  internal images and inattention to environmental
  stimuli.

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Cold Pressor Task (CPT)
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Muscle Ischemia Task
(is-KE'me-ah)
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Hypnosis

• Laboratory research on acute pain, induced by
  cold-presser or muscle-ischemia procedures, has
  found that
• Hypnosis can reduce pain.
• The people who gained the most pain relief are
  highly responsive to other suggestions, such as
  that their arm is becoming light.
• Whether under hypnosis or not, people tend to use
  distraction and redefinition techniques.

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Hypnosis

• People usually show as much pain reduction using
  cognitive strategies as they do under hypnosis
  (Barber, 1986).
• Hypnosis is mainly effective for relieving acute
  pain. There is little evidence to suggest that
  hypnosis would be effective for relieving chronic
  pain.

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Insight-oriented psychotherapies for pain

• This technique involves chronic pain patients
  gaining insights into the way that the pain is
  affecting their behaviour and the way their
  interpersonal relationships are being affected.
  Pain behaviour is seen as part of "pain games"
  they play with other people (Szasz, cited in
  Bakal, 1979).

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Insight-oriented psychotherapies for pain

• In these games, the patient takes on a role in
  which they continually seek to confirm their
  identity as suffering persons, maintain their
  dependent lifestyles, and receive various
  rewards, such as attention and sympathy. The
  patients are most likely unaware of the game they
  are playing it is the purpose of this
  psychotherapeutic approach to make them aware.

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Surgical attempts

• Cutting nerve pathways - gives temporary relief.
  Only recommended for people who are terminally
  ill.

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Physical therapies

• Manual therapies e.g. massage
• Mechanical therapies e.g. traction
• Heat treatments e.g. microwave diathermy,
  ultrasound.
• Cold treatments e.g. ice packs

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Physical therapies

• Transcutaneous electrical nerve stimulation.
• Not known how heat works, but fits in with the
  gate theory (closes the gate)Mild pulses of
  electricity in painful areas probably works in
  the same way.

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Transcutaneous electrical nerve stimulation.
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The end