1. Health Psychology - Session 11 Psychological aspects of pain
Dr. Caroline Meyer

2. Outline of session
- definitions of pain
- including psychological conceptualisation
of pain
- measurement issues
- theories of pain perception
- psychological pain management

3. Objectives
- evaluate relationship between sensation
(e.g., tissue damage) and experience
- outline psychological theories of pain perception
- evaluate attempts to measure pain
- describe social & psychological factors involved
in pain perception

4. Definitions
Although pain is a universal experience, due to its
subjectivity, definitions vary.
Example definition:
an unpleasant sensory and emotional experience
associated with actual or potential tissue damage
“ there is no direct relationship between physical
pathology and the intensity of pain” IASP, (1993)

5. Nature of pain - Psychological components
1. Sensory - location, magnitude, sensation
(e.g., burning, aching, stabbing)
2. Emotional response - strong negative emotional
states (e.g., fear, nausea, anxiety, depression,
exhaustion)
3. Evaluative - cognitive responses (unbearable,
miserable, annoying, frustrating)
Individuals cognitive response can have an effect on
pain perception (e.g., Morley, catastrophizing)

6. Duration of pain
Acute - e.g., injections, post-surgical
Chronic - e.g., back pain, cancer
Different meanings - acute is often ‘expected’ to be
short lived and is therefore more bearable than
chronic.

7. Measurement of pain
Why is it important?
- gives health professionals information
(e.g., degree of discomfort, severity of problem
?diagnosis)
- associated with patient satisfaction
(e.g., Bruster, 1994)
- increases medical knowledge - leads to
investigation
Two types of measures:
Objective
Self-report

8. Objective measures
- include physiological measures (heart-rate,
skin conductance, muscle tension -
electromyography (EMG) readings)
Problems with ‘objective’ measures:
- imply relationship between sensation and
experience of pain
- weak correlation between physiological
measures and reported intensity of pain
- other factors may effect physiological
readings (mood, stress, diet, exercise)
- less useful for chronic pain

9. Self-report measures of pain
There is currently no truly objective way of measuring
pain. It is also insufficient to use NVC - Fritz (1988)
Patients self-report is the most reliable indicator
(e.g., Beyer et al, 1990).
One method of assessment is the Visual Analogue
Scale (VAS)
No pain
Worst possible
pain
10cm
Correlates well with verbal reports of pain intensity
issue about perceptual set / relativity

10. As well as pain intensity, it is useful to be able to
measure other components (sensation, emotion)
McGill Pain Questionnaire (MPQ - Melzack, 1975)
- VAS - present pain
- adjectives describing sensory experience
(e.g., Throbbing, Sharp)
- items describing emotional impact
(e.g., tiring-exhausting, fearful)
All rated on a 4-point scale -
none (1), mild (2), moderate (3), severe (4)

11. McGill Pain Questionnaire, continued..
- has been found to be a valid measure of pain
(gives a true reflection of the type, extent and
impact of the individual’s current state)
- However, it requires wide vocabulary & ability to
make very specific distinctions between
different sensations and different levels
Other alternatives have now been developed to
overcome these issues (e.g., Wong/Baker faces rating
scale for children,1986)

12. Measures of pain behaviour
- e.g., facial expressions, verbal complaints,
postural changes, medication consumption
- usually measured by observation (in
structured setting - e.g., physiotherapy)
- poor correlation with self-report measures,
subject to observer bias (e.g., Morley, 1997),
increased pain behaviour under certain
circumstances (e.g., when spouse present)
- pain behaviours may represent attempts to avoid
pain rather than reaction to pain

13. Other psychological considerations
- people can report pain in the absence of
physiological problem (Somatoform Pain
Disorder, DSMIV - American Psychiatric
Association)
- people can report feeling no pain when
physiologically it is clear that they should
(Dissociation - amnesia, depersonalisation;
Alzheimers disease - Scherder et al., 1999, 2000)
- people can deny pain (under report) for many
reasons (e.g., cultural - stiff upper lip; fear of
addiction to pain relief medication)

14. Theories of pain
Early theories
- automatic response; early biomedical models
direct link between biological state and pain
perception
- believed pain to be linearly related to extent of
tissue damage / intensity of stimulus
BUT:
there is not always a clear link (e.g., cause of back
pain is unknown in upto 80% of cases; Deyo, 1986)

15. Gate control theory (Melzack & Wall, 1965)
- gate mechanism modulates pain signals
(encompasses both sensory / perceptual
information and brain function)
- integrates psychology into the stimulus-response
theories of pain

16. Gate control theory, continued
Brain
expectations
experience
mood
behaviour
Gate
Action
system
PAIN
Physiological stimuli (from injury)
Large fibres
Small fibres
Taken from Ogden (2000)
- activity in large nerve fibres (touch) inhibits
sensation of pain
- signals from cortex can alter the sensation
of pain

17. Influences on pain perception - what opens the gate?
Physical factors - injury, activation of small (pain)
fibres
Emotional factors - anxiety, tension, worry, depression
all linked to pain ? Cause & effect
e.g., depression magnifies -ve effects
of pain (e.g., Verma & Gallagher,
2000)
Behavioural factors - attention to pain, boredom,

18. Influences on pain perception - what closes the gate?
Physical factors - medication,stimulation of large
(touch) fibres
Emotional factors - happiness, optimism, relaxation
Behavioural Factors - concentration, distraction
e.g., Shiloh et al (1998, Cognitive Therapy &
Research) high levels of distraction associated
with lower pain reports during childbirth
Pain competes for processing space
(Morley,1997)

19. What other factors might alter the way in which
pain is perceived?
1. Gender
no evidence of gender differences in pain
perception or types of coping
(e.g., Holden et al., 1998)
2. Age
- previously believed that infants were less
sensitive to pain
- no less sensitive than adults & early
experience can have long term effects
(physically & psychologically)

20. - no evidence that elderly patients cope better with
pain, although decreased experience in some
cases (related to dementia)
3. Personality
- ? Is there individual variation in ability to:
detect sensations, pain thresholds, tolerance
- evidence is equivocal - recent study
suggests link between extroversion and
self-reported pain in women receiving
gynaecological treatment (Joseph, 1999)

21. 4. Anxiety and depression
- can be cause or consequence of pain
- treating anxiety and depression (as well as pain)
may help in some cases - ? depends upon type
of pain;
acute pain
treatment
anxiety -
e.g., Fordyce & Steger (1979)
chronic pain
ineffective
treatment
anxiety

22. 5. Self-efficacy
- low self-efficacy associated with increased
avoidance (e.g., not engaging in activity due to
feeling as though it will not be effective)
- high levels of self-efficacy associated with low
levels of reported pain (e.g., in childbirth;
Shiloh et al., 1998)
6. Memory
- some evidence that memories of pain are
unreliable (e.g., recall of labour pain -
underestimated)

23. Psychological management of pain
Two main aims:
- help patients to cope more effectively
- reduce reliance on drugs
Relaxation
- different techniques (e.g., progressive muscle
relaxation) relaxation is incompatible with stress
- helpful because stress and anxiety are important
in onset of pain;

24. - stress has been found to be a significant predictor
of intensity of pain (e.g., in Sickle Cell disease;
Porter et al., 1998, 2000)
- also, differential responses to stress in those with
and without pain
Hassinger et al. (1999). Frequent migraines
associated with different physiological response
to stress (cardiac output, stroke volume)
Stress can also reduce reliance on several coping
techniques (e.g., distraction - rumination)

25. Hypnosis
- only 15-30% can be hypnotised
- little evidence of efficacy ? placebo

26. Behavioural - e.g., Fordyce (1984)
- aims to reduce disability
- focuses on pain behaviours (e.g., excessive
resting)
- works on the assumption that pain behaviours
are reinforced (operant conditioning) e.g.,
care, sympathy (+ve reinforcement) and
avoidance of unpleasant events (-ve reinf.)
- Treatment consists of:
- identifying stimuli, behaviours & reinforcers
- reduction of reinforcement for pain behavs.
- increasing ‘well’ behaviours by social
reinforcement

27. Cognitive Behavioural Treatments
e.g., Turk & Fernandez (1991)
- help patient to re-interpret their pain &
associated problems - tailored to individual:
Includes;
i) initial pain assessment
ii) cognitive therapy or re-structuring -
- focuses on appraisals, expectations &
beliefs about origin & consequences of pain
e.g., catastrophising beliefs may be challenged with
alternatives to provide increased sense of
control over pain

28. - redefinition of pain (seen as less negative)
- improving mood (reconceptualize problems
until viewed as managable)
iii) Education / Information provision
- information about different models of pain
- helps to engage patient in treatment
- requires reflection on individual’s own
understanding of pain
iv) Exercise / activity / sleep management programmes
(?changes beliefs / dysfunctional assumptions about
disabilities)

29. Summary & tips
- pain is a subjective experience comprising
physical, sensory, emotional and cognitive
responses
- pain can be affected by: someone’s emotional
state, expectations & beliefs
- the most effective way of measuring pain involves
self-report, but communication is important here
(believe them even if there is little physiological
evidence)
- psychological treatments involve a range of
techniques - cognitive restructuring, education,
anxiety / depression management