A Biopsychosocial Formulation of Pain

Communication:Concepts and Implications

Presenter: Maryam AbbasiHealth Psychology Course

University of TehranNovember 2011

“The single biggest problem in communication is the illusion that it

has taken place.” George Bernard Shaw

What is chronic pain? Gate control theory The Communication Model of Pain (CMP) Summary Clinical Implications of CMP

Overview of Presentation

Pain is one of the most common complaints made by patients to primary care providers (approximately 50% of patients).

prevalence estimates of persistent pain in population samples range between 7% and 64%, depending on survey methodology and population studied .

For some people pain persists and past the point where it is considered adaptive (more than 3 months) and

contributes to negative mood, disability, deteriorating social functioning, and increased use of healthcare system resources.

The Problem of Pain

The high prevalence of unsatisfactory treated pain demonstrates how pain has been to typical clinical care, despite better understanding of the biology of pain

Pain often remains unrecognized, poorly assessed, underestimated, untreated, or inadequately treated.

Therefore, Understanding the biology of pain is vital but inadequate to challenges of pain control.

This has led to the development of biopsychosocial models of pain

The Problem of Pain

In 19th century advances in our understanding of the biology of pain took place

In the mid-20th century, the Gate Control Theory (GCT, Melzack and Wall, 1965) introduced pain as a complex psychological phenomenon.

Provided a neurophysiological basis for conceptualizing the biological substrates of psychological and environmental determinant of pain .

substantial elaboration of our understanding of the facilitatory and inhibitory mechanisms that modulate nociceptive processes.

Gate control Theory:Biopsychosocial Formulation

The Gate Control Theory

IASP(2005) definition of PAIN: Pain: “An unpleasant sensory and emotional

experience associated with actual or potential tissue damage, or described in terms of such damage”

Nociception: the neuro-physiological translation of events that stimulate

nociceptors and are capable of being experienced as pain

Pain vs. Nociception

In typical adult humans, pain is associated with meaning, learning, and emotional reactions

This definition Leaves room for multiple causes, mediators, and moderators.

Psychological mechanisms has resulted in novel interventions for both acute and chronic pain

Several multi-aspect perspectives emerged: the operant model, cognitive-oriented models, interpersonal formulations of pain

Pain vs. Nociception

The focus on intrapersonal processes, both biological and psychological, leaving the social dimension underexamined

Pain is also has major social features, occurs rarely in silence, and is important to not only the individual but the social environment.

Pain serves as an archetypical sign of threat and commands the attention and responses of others in the social environment.

Others response in turn have an important impact upon the pain experience and wellbeing of patient

Socio-contextual aspect of pain remains understudied

The Communication Model of Pain

(Craig, 2009)

Consistent with biopsychosocial conceptualization

The biological mechanisms are fundamental to Psychological processes engaged during pain

experience and expression

Directs attention to social processes as causes and consequences of pain experience

The Communication Model ofPAIN (Craig,2009)

Process of communication is seen as a three step process (A > B > C).Step A (Action): Internal Experience, pain

expression, and reaction of receiver

Step B (Interaction): Encoding expressive behavior which is embedded in a broader social context

Step C (Transaction): Decoding and Responding with sensitivity to expressive behavior

The Communication Model ofPAIN (Craig,2009)

Where a message is sent or a message is received (e.g., a message left on a telephone or a message is received)

It includes automatic/reflexive reactions of observer (e.g., the gut reaction to another person’s horrifying accident)

Self-reports , and nonverbal expression are the manifestation of pain are considered as communication as action

Communication as Action

Experience of pain :

◦ consists of affective, behavioral, and motivational components

◦ Is affected by (and interpreted through) the cultural, interpersonal, and situational context

◦ Associated with brain mechanisms

Communication Model Step A:The Internal Pain Experience

where a message (verbal & non verbal) is sent, received, and interpreted, whether as intended or incorrectly

Effectively communicating pain , enables observer understand feelings, thoughts, and expressions of the patient.

Communication as interaction

Actions of patient: protective or communicative

The impact of social context on verbal and nonverbal

displays of pain

Brain correlates of pain expression

Communications Model Step B: Encoding of the Pain Experience in

Expressive Behavior

where messages are exchanged, but something other than the exchange of messages results (e.g., “I do” is not just a report of intent but transacts the wedding of one person to another).

When physician and patient communicate interactively and the physician infers pathophysiological process, provides a diagnosis , and commits to treatment

Communication as transaction

Affected by clarity of patient’s message (verbal is easier than nonverbal)

occurs within the context of contextual, interpersonal, social factors all of which affect interpretation of pain signals

Influenced by observer characteristics (age & gender)

Also sufferer's characteristics influence pain judgments

Patient coping styles

Decoding the Pain Message: Step C

The model serves as a synthesis of preexisting findings and facilitates conceptualization of a vast literature

Recognition of social and psychological parameters affecting pain experience and its communication

Implications for clinical assessment and treatment

Summary

Older adults and seniors with dementia suffering from pain

Pain assessment and interventions in different socio-cultural contexts

Educational interventions for chronic pain patient’s caregivers

Healthcare providers’ education in how communicate with chronic pain patients

Clinical Implications of PCM

On one hand: Seniors have tendency to underreport pain complaints Dementias interfere with effective pain communication,

as cognitive functions decline as a result of dementia. Ability to self-report and describe pain deteriorates, but,

nonverbal forms of pain expression is preserved.On the other hand: Effective communication has been shown to be related to

pain relief.As a result: Pain assessment in seniors should be different from

patients from other ages, and would be better to rely on both verbal (also significant others reports) and nonverbal methods.

Clinical Implications of PCMOlder adults and seniors with dementia

Patients from interdependent cultures are tend to underreport their pain in order to keep the harmony of their social group, so they may underreport their pain.

Hidden assumptions and rules “Big boys don’t cry”, “take it like a man” governs people expressive pain behaviors, which in turn mislead health care providers and caregivers

Clinical Implications of PCMPain assessment and interventions in different socio-cultural contexts

Participant’s receiving painful stimuli while

holding their spouse’s hand communicated

reduced pain unpleasantness (relationship factors

were controlled)

From fMRI standpoint, the activity of neural

system supporting emotional and behavioral

threat responses was attenuated.

Spouse’s cognitions and responses to pain

behavior (e.g., punishing) contribute to patient’s

pain behavior, intensity, and disability.

Clinical Implication of PCMEducational interventions for patient’s caregivers

Psychosocial Mechanisms in developing

Novel Pain Interventions

Tell others what you can and cannot do Inform them that the severity of your

pain varies, even if it is never completely gone

Tell them in a friendly way what kind of help you hope to receive and why

Tell them when they are helping! Praise wins over blame every time

Talk to others regularly, not just when your pain is most intense

Some educational guidelines for improving communication

Frustrations in accurately decoding and interpreting pain messages occur within the context of health care system may lead to patient dissatisfaction and negative mood.

How the practitioner phrases the initial pain question might affect the amount of important information that you respond with (i.e., “How are you today?”)

Oftentimes, we cannot change the external world… So what can we do?

Clinical Implication of PCMHealthcare providers’ education in how communicate with chronic pain patients

We can help patients to: Take the responsibility for reporting pain

and response to the treatment Describe their pain using a pain intensity

scale Describe their pain using pain location Describe their pain using pain sensation Evaluate and describe changes Determine if the health provider understand

the message

Educate your Patients in Communicating their Pain

Body Map

McGill Pain Questionnaire

Reliable in elderly

Gagliese (2001)

Craig, K. D. (2004). "Social Communication of Pain enhances protective functions." Pain 107: 5-6.

Craig, K. D. (2009). "A social communications model of pain." Canadian Psychology 50: 22-32.

Craig, K. D., K. M. Prkachin, et al. (2011). The facial expression of pain. Handbook of Pain Assessment. D. C. Turk and R. Melzack. NewYork, Guilford Press: 117-133.

Craig, K. D., J. Versloot, et al. (2010). "Perceiving pain in others: Automatic and controlled mechanisms." The Journal of Pain 11(2): 101-108.

Hadjistrovropoulos, T. and K. D. Craig (2002). "A theoretical framework for understanding self-report and observational measures of pain: a communications model." Behaviour Research and Therapy 40: 551-570.

Hadjistrovropoulos, T., K. D. Craig, et al. (2011). "A biopsychosocial Formulation of Pain communication." Psychological Bulletin X(X): XXX-XXX.

McDonald, D. D., G. J. Thomas, et al. (2005). "Assisting older adults to communicate their postoperative pain." Clinical Nursing Research 14(2): 109-126.

Sullivan, M. J. L., M. O. Martel, et al. (2006). "The relation between catastrophizing and the communication of pain experience." Pain 122: 282-288.

Vangronsveld, K. and S. J. Linton (2011). "The effect of validating and invalidating communication on satisfaction, pain and affect in nurses suffering from low back pain during semi-structured interview." European Journal of Pain XXX: XXXX.

More resources:

“The way we communicate with others and with ourselves ultimately determines the quality of our lives.” Anthony Robbins

Thanks