PSYCHOLOGY OF PAIN

Definition: International Association for the Study of Pain:

• Sensory and emotional negative experience - induced by or related with real or imagined tissue

lesions, or

- described in terms that refer to such lesions.

Components:• Physiological: receptors, pathways, biochemical

processes in the tissues and cells, etc

• Behavioral: mimics, gestures, etc that accompany the pain

• Subjective: thoughts, feelings, representations connected with pain

Classification: 1. Acute pain:- between 6 weeks and 6 months- associated with anxiety (it may signal life threat)

• Superficial:- located in derma, mucosae; sharp, delineated

• Profound:- muscles, membranes, internal organs

- imprecisely delimited, less intense

- more persistent (in time) than the superficial one

- described by the patient as burning sensation, pressure, pulling, tearing etc

2. Chronic pain:- lasts more than 6 months; located mostly in internal organs- associated with sensations of compression- distress for the patient and family

• benign, recurrent:- Highly intense- recurring episodes, separated by pain-free intervals – for

example migraine

• persistent: variations in levels of intensity, ex back pain

• Progredient:- In rheumatoid arthritis, cancer, etc- intensity – increasing constantly

Theories of pain:

• Nonspecific model (Weddel, 1962): there are no specific pathways of perception for pain; pain occurs through intense stimulation of nonspecific

receptors

• Specificity (von Trey, 1985):there are specific stimuli for specific receptors and

specific pathways of transmission

Theories of pain:• Gate control (Melzack & Wall, 1965)a neural mechanism located in the gelatinous substance

of the medulla spinalis – stimuli are either transmitted, or blocked

The gate closes (pain is not transmitted) when fibers A beta (non-related with pain) are stimulated (these stimuli have priority)

The gate is opened byActivity of fine fibers A delta and C (these fibers are

the specific pathway for pain stimuli)Very intense stimuli Information interpreted as painfulFeelings of anxiety, sadness, depression associated

with stimuli

Psychosocial factors related to perception of pain:

• Sex:differences related to sexual hormoneshigher frequency of non-pathological pain in women (ex

childbirth)genetic differences between sexes• Age: differences in perception and control mechanisms of the

painethnic differences in the behavioral and social

expression of pain

Psychosocial factors related to perception of pain:

• Differences in personality traits: introverted persons are more reactive to pain and have a

lower pain thresholdsubjects with negative beliefs linked with potentially

painful events tend to over-represent the painsubjects with a history of abuse in childhood develop pain-prone personalities an inability to verbally express negative feelings the need to be punished when feeling guilty higher pain threshold

Acute pain is influenced by:

• Past experience of pain its meaning as alarm signal for the personsubject’s expectations (I should have a certain level of

coping abilities for pain)• Sources of informationFamily, peers, medical team When the patient is informed about purpose, duration

and methods of a medical intervention before that intervention, the negative impact associated with the perception of pain (awareness about pain) decreases

Acute pain is influenced by:

• Coping style of the subject emotion-centered: distracting attention from pain

works better problem- centered: information gathering works

better• The therapist empathy, relational abilities knowledge, expertise, experience trust in the prescription prestige, authority

Chronic pain is influenced by:• The significance the meaning of chronic pain is different from acute

pain nevertheless, the individual feels (senses) acute and

chronic pain in the same way

• Individual’s affective states: anxiety, depression, hostility, etc enhance pain

perception negative affect influences information processing negative affect focuses the person on the painful

perception

Chronic pain is influenced by:

• Cognitive style: • catastrophic thinking (“this means I will die”)• overrepresentation of pain (“this means that I have a

serious illness”)• negative expectations concerning consequences of

pain (“this means I will lose this leg”)• altered primary and secondary evaluations of pain

stimuli

PSYCHOLOGY OF CANCER

• Cancer – regarded as the prototype of human suffering

• Specific surgical interventionssurgical interventions for different cancer types – since 1900since 1900

• Radiation therapyRadiation therapy in cancer – since 1915since 1915

• ChemotherapyChemotherapy in cancer – developed since since 19601960

• ImmunotherapyImmunotherapy in cancer – has developed since 1970since 1970

• Clinical trials, new drugs discovered every day – last 2 decades

The field of psychooncology psychooncology was founded in 1970 by Holland (oncologist), with 6 main branches:

1. The role of psychologic, social and behavioral factors involved in mortality and morbidity in cancer

2. Emotional issues in patient and family dealing with the diagnosis of cancer and treatment

3. Quality of life in cancer patients

4. Bioethics in oncology (communication of diagnosis and prognosis, euthanasia etc)

5. Alternative therapies in oncology

6. Stress and burnout syndrome in medical staff involved in treatment of cancer

Psychological, social and behavioral issues in cancer

Studies since the 1950’s have concluded:• Depression is a major risk factor in

development of cancer• Subjects which developed cancer had some

common features, such as: - the overwhelming need to live in

harmony and to be accepted by others - repressed anger, aggresivity, irritability - apparently well-adjusted socially - repressed positive emotions

• Specific to subjects with cancerRepressed emotions and overrepresented Repressed emotions and overrepresented

rationalizationrationalization (concrete thinking, lack of imagination)

Learned helplessness, depression, despairLearned helplessness, depression, despair, leading to: decreased motivation and activity and negative affect

Coping style:Coping style: perfectionism, rigidity, self-control, adherence to conventions, stoicism

Behavioral and social factors involved in cancer

• Lifestyle:Lifestyle: Extended, unprotected exposure to sunlightSleep deprivation, lack of exerciseUnbalanced dietSmoking, alcohol etc

• Social factorsSocial factors – certain differences between social classes (concerning access to healthcare services, social services, to other facilities etc)

Emotional issues in cancer – Elizabeth Kubler-Ross

• The book On death and dyingOn death and dying – she describes 6 emotional stages6 emotional stages in the process of dealing with cancer:

1. Hope / anxiety: Symptoms The diagnosis has not been set yet The subject feels that something is not right He considers cancer as a possible diagnosis

Emotional issues in cancer – Elizabeth Kubler-Ross

2. Denial (no, not me!): When the diagnosis is ascertained Increased risk of suicide. Denial may be an efficient defense mechanism

(protecting the subject from the emotional impact of information)

It may generate decreased compliance, if extended

3. Anger (Why me?) The patient seeks causes, explanations Cancer is interpreted as: well-deserved/ undeserved

punishment The interpretation may increase anger and interfere

with compliance

Emotional issues in cancer – Elizabeth Kubler-Ross

4. Negotiation (please, not me!): Bargaining with the Divinity The subject is willing to compromise, to fight

for his health The most effective stage for interventions

5. Depression (Yes, it’s me...) The signs and symptoms cannot be denied The cancer may progress Therapy may prove ineffective

Emotional issues in cancer – Elizabeth Kubler-Ross

6. Acceptance: Final stages – death is seen as a release It does not occur in all cancer patients Highly unstable subjects, who have to deal

with more than one crisis situations, do not reach this stage

Emotional issues in cancer – Elizabeth Kubler-Ross

• Actually, we can find in any stage a mixture of hope (for a miracle) and anxiety (permanent) guilt (‘I have cancer, I am a burden for the others’) shame, fear of death and unknown

• Cancer (diagnosis, assessments, treatment) Cancer (diagnosis, assessments, treatment) entails an existential crisisentails an existential crisis

• The subject’s adjustmentThe subject’s adjustment to crisis depends on previous experiences perceived future threats available resources: biological, psychological,

psychosocial support

Early stage of cancer• The early symptoms and signs – it does not coincide

with the decision to see a physician• Denial leads to delayed medical assessment, which

increases severity of symptoms In breast cancer – a delay of 3 months, in rectal cancer – 7-10 months

• Causes of delay in requesting medical care: Psychosocial factorsPsychosocial factors (low level of health education in some

social layers, old age) may be linked to: - failure to recognize cancer- failure to understand the importance of regular check-up and early treatment Psychological: avoidancePsychological: avoidance as defense mechanism: fear of- clinical assessment, suffering- bad news- mutilation Poor therapeutic relationship of patient with physiciansPoor therapeutic relationship of patient with physicians –

based on previous unpleasant experiences

Early stage of cancer

• Factors involved in seeking early medical care:Symptoms: Symptoms: - Complex, obvious symptoms- Physical pain

A certain level of medical information and A certain level of medical information and educationeducation

Good therapeutic relationshipGood therapeutic relationshipEmotional issuesEmotional issues- Impulsiveness- High levels of anxiety

The stage of diagnosis• Situational crisis, shock – cancer is represented

as death sentence – approx. 3 months Anxiety Anxiety Pessimism, despairPessimism, despair VulnerabilityVulnerability The essence of the individual’s existence, the The essence of the individual’s existence, the

relationships with the world relationships with the world are being questioned

• After 3 months: the patient worries less about the illness, reaches acceptance of

CancerCancer Necessity of treatmentNecessity of treatment

The stage of diagnosis - family

• Family members experience negative feelings elicited by the diagnosis of cancer

Anger, despairAnger, despairFear of death and dyingFear of death and dying

• Negative emotions may lead to impaired communication between patient and family

Lack of communicationLack of communicationDistorted communication Distorted communication (listening and

understanding are overlooked)

The stage of treatment• It requires adjustment: the patient Is full of hopeIs full of hope Experiences side effects of therapy – financial, Experiences side effects of therapy – financial,

psychological, physicalpsychological, physical• A treatment has the highest chance to be

accepted if suggested at the end of the diagnosis stage

• Radiation therapy – 2-6 weeks – side effects: Fatigue, hair loss, skin lesionsFatigue, hair loss, skin lesions Digestive disorders, loss of appetiteDigestive disorders, loss of appetite Social impactSocial impact Affected self-imageAffected self-image The patient fears that it will be ineffectiveThe patient fears that it will be ineffective

The stage of treatment• Alternative therapies (in the search for a

miracle cure for cancer) – instead of/ associated with classical therapies

Metabolic, nutritionalMetabolic, nutritionalImunologicalImunologicalPsychological, spiritual healingPsychological, spiritual healing

• Risk of alternative therapies:Side effects, infections, weight lossSide effects, infections, weight lossFinancial burden, wasted time Financial burden, wasted time (when

classical therapies are discarded)

The stage of remission• Although desired and expected for, it is also a

stage of crisis• The evolution from the sick role towards the

survivor role• Remission does not always means healing• Emotional distress The patients feel abandoned, demoralizedThe patients feel abandoned, demoralized The patients feel disoriented, experience loss of controlThe patients feel disoriented, experience loss of control Constant anxiety, increased by any new symptom Constant anxiety, increased by any new symptom

• The patient is focused on physical experiences: Seeking any possible new symptom or sign of disorderSeeking any possible new symptom or sign of disorder FatigueFatigue Digestive disordersDigestive disorders

The stage of remission

• Readjustment to professional requirements

• Relationships with colleagues may prove difficult

The subject is sensitive to the issue of The subject is sensitive to the issue of cancercancer

ColleaguesColleagues- Mixed feelings, aggressivityMixed feelings, aggressivity- Overprotection, admirationOverprotection, admiration

The stage of relapse

• Sometimes – many months, fluctuations in patient’s status

• Anxiety, depression

• Hope in efficient therapies disappears

• The end of a long period of painful uncertainty

• Some patients try alternative experiential therapies, as a way of reclaiming control over the illness

• Others refuse any other new therapies

The terminal stage

• Death, dying, bereavment issuesGradual severing of emotional ties with the Gradual severing of emotional ties with the

peers, familypeers, familyGradual severing of emotional and rational Gradual severing of emotional and rational

ties with realityties with realityThe patient is allowed by loved ones to pass The patient is allowed by loved ones to pass

on on (dying with dignity)