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Chronic Pain Patients:
Perspectives and Approaches
Chronic pain
may have an organic basis, but it is driven by psychological factors.
The psychological issues that drive chronic pain, when ignored,
continue to grow in strength and impact.
It is estimated that pain plays a major role in over 50% of all
suicides.
Current research indicates that over 100 million North Americans
suffer from chronic pain. Of those, half are considered partially or
totally disabled. Chronic pain costs business and industry
approximately 70 million workdays per year, and over 60 billion
dollars yearly. Pain is the number one reason for doctor visits.
The Agency for Healthcare Policy and Research (AHCPR) issued a
position paper on back pain. This paper emphasized the impact of
psychosocial issues in the experience of back pain, leading to the
search for data to document if, how and why stress relates to the
experience of pain.
Psychological Disorder and Pain
There have been many psychological studies assessing the prevalence of
psychological pathology in chronic pain patients. The patients have
been consistently found to be angry, anxious, demonstrate poor coping
skills, addictive trends, have over solicitous family, negative
feelings about their employer, or have histories of sexual and/or
domestic abuse. These individuals have been found to report a much
higher than expected experience of back pain when compared to patients
whose psychological testing data were within normal limits.
These patients also exhibit higher levels of somatization, nonorganic
patterns of pain drawings, poor coping skills and increased
anticipation of pain.
As a result, it has increasingly become a standard of care to utilize
well-validated psychological testing to identify these individuals at
high risk for amplified experience of pain and poor capacity to deal
with pain complaints.
Early recognition of psychosocial factors and pathological personality
characteristics are often essential in identifying and addressing
chronic pain complaints. Among these factors are pathological means of
dealing with anger, resentment, depression, anxiety, sleep disorders,
and trends toward social isolation, as well as secondary gain,
malingering and other forms of manipulation.
Recent studies indicate that pain sufferers perceive themselves as
enduring the highest levels of ongoing stress. In turn, many
researchers believe that chronic stress can be one of the leading
causes of breakdown of the immune and nervous systems. Stress becomes
a major contributor to compromise of mental and emotional functioning.
The stress-pain connection, however, may go unrecognized in
traditional medical settings.
The Nature of Stress
Stress is caused by an individual’s perception and/or interpretation
of situations and life events. This perception evolves from reliance
upon past experience and often false or outdated belief systems to
interpret new situations or events.
It has long been recognized that the
Fight or Flight
response
in association with stress-producing stimuli triggers
(sympathetically mediated) nervous system responses. These include
elevated blood pressure, tachycardia (rapid heartbeat) and tachypnea
(rapid breathing), increased muscle blood flow and decreased skin
blood flow. Relaxation techniques to deal with stress help minimize
exaggerated behaviors.
Studies report a resulting improvement in immune system function,
decreased blood pressure, pulse rate, respiratory rate, muscle tension
and improved coping skills among other benefits. Not unexpectedly,
these stress-reducing techniques are well documented as working with
chronic pain populations, reducing their pain complaints and
perceptions of their level of disability.
In addition to relaxation or biofeedback therapy, most pain patients
may also benefit from the addition of antidepressant medication to
their drug regimen. Antidepressants have proved beneficial in the
management of neuropathic pain by changing the patient’s experience of
pain through 1. mood regulation, 2. potentiating or enhancing opioid
analgesia and 3. direct analgesic effects. Additionally, appropriate
anti-depressant therapy may also improve the quality of sleep.
Patients with chaotic psychosocial histories are predictably at risk
for increased pain experiences. However, prolonged and severe pain
can also affect individuals who, prior to the onset of pain, had no
reported psychological disorder. For the chronic pain patient, anger,
isolation, helplessness, hopelessness and the development of
maladaptive coping behaviors presents a real challenge to the
healthcare system.
Early identification of the psychological factors driving chronic pain
enables more targeted health care delivery. Management of those
stress-related issues will expedite coping and maximum recovery.
D.B.A. |
