++
With so much at stake for the patient with chronic pain, it is
not surprising that psychological evaluation is a required or highly
recommended feature of comprehensive evaluation in many pain management
centers.6 For many patients, some form of psychological
intervention is also recommended as part of the comprehensive treatment
plan. Such interventions are usually prescribed to run concurrently
with medical treatment and other therapies and may include one or more
of many available modes of individual or group psychotherapy. When
offered as part of a multidisciplinary package, psychotherapeutic
approaches to managing chronic pain have demonstrated their efficacy
repeatedly, and there is considerable evidence to suggest that the
more effectively such interventions are integrated into a comprehensive
or team approach, the greater are the chances of improvement for
health and quality of life.7
++
With the IASP reporting an incidence of chronic pain in the United
States of 70 million, and with more than 50 million being partially
or totally disabled for periods ranging from a few days to a few
months, a concerted multidisciplinary effort becomes even more critical
to the effective marshaling of available medical resources.8 Especially
for patients whose chronic pain has remained initially intractable
to medical and surgical interventions, a careful plan of treatment
coordinated by a team of providers can ultimately result in greatly
reducing the costs of health care, as well as raising the quality
of that care—improving patients’ response to treatment,
level of functioning, and satisfaction—and enhancing the
morale of all the providers concerned.9 Psychotherapeutic
management, in this context, necessarily involves not only a multidisciplinary approach,
but an interdisciplinary effort in which the interventions of each
member of the team—physicians, nurses, physical therapists,
medical and complementary specialists, and mental health providers—can
be seen as having a psychotherapeutic impact on the patient and
must be directed toward having a complementary effect on the interventions
of all other members of the team.
+++
Psychological
Factors in Chronic Pain
++
It is, by now, a generally accepted, if not always carefully
considered tenet, that stress is influential in the development,
expression, and tractability of chronic pain.10 Because
stress is also influential in the development and expression of
somatization and other psychological symptoms, associations among
chronic pain, stress, and psychiatric disorder are frequently observed
and well-documented in the literature of both pain and psychiatry.11 Attempting
to parse or separate these influences prematurely for the sake of
treatment is frequently tantamount to disregarding the often-volatile
interactions among these factors and the cyclically reinforcing
relationship between chronic pain and stress.
++
When such a unilateral approach is taken, it often represents
the attempt of physicians adhering to too strict a medical model
to establish the extent to which a patient’s problem may
be mental, as opposed to physical. As a result, both physician and
patient may be left wondering why a clearly prescribed nerve block
or medication has not achieved the expected relief. It may also
lead to the premature and potentially harmful conclusion by the
physician and the patient’s health insurance carrier that
nothing further can be done medically or surgically to assuage the
patient’s pain and that the problem is no longer a medical
one but strictly a psychological one, now unrelated to a precipitating
injury or historical tissue damage. What is being overlooked is
the individual patient’s stress-reactivity and the enduring
influence of the pain-stress cycle on the development and maintenance
of chronic pain.
+++
Stress-Reactivity
and the Pain-Stress Cycle
++
The term stress-reactive is suggestive of a continuum of the
degree to which any individual reacts to external or internal stressors,
including the stressors of pain and its psychosocial sequelae. We are
all on this continuum, but highly stress-reactive individuals are
likely to develop a broader spectrum of more severe psychological
and social concomitants or consequences, as well as to experience
their pain with greater affective involvement and suffering. Less
stress-reactive individuals may still experience the need to accommodate
to their pain, psychologically, socially, and occupationally, but
their adjustment to living with chronic pain is typically more successful
and their adaptation to their limitations, more enduring.
++
The term pain-stress cycle is indicative of the unfolding neuropsychosocial
matrix in which (1) pain tends to amplify the impact of stress while
(2) stress magnifies the subjective experience of suffering associated
with pain. The former occurs when a patient’s experience
of pain facilitates the development of new and secondary psychosocial
stressors, as in Case 1, earlier; but it may also be evident in
the patient’s tendency to rely on or resort to maladaptive
coping strategies, such as self-medication, social withdrawal, and
the development of generalized, reactive pain behaviors. The latter
refers more specifically to the contributions of heightened autonomic
arousal and musculoskeletal tension in the maintenance and intensity
of the experience of pain.
++
We have only an inchoate appreciation of how these mechanisms
work and interact, but advances in our understanding of the neurophysiology
and molecular biology of our perception and experience of pain strongly
suggest that the influence of psychosocial factors and emotions
is translated neurophysiologically into the realm of perception
and behavior.12 Stress, regardless of its origin,
can result in physiologic deterioration and the exacerbated experience
of pain through a variety of mechanisms. Neurosignature patterns
can be modulated or altered destructively by stress of psychological
origin, no less than by sensory input. Because any stressor, whether
external or internal, physical or psychological, can affect stress-regulation
systems adversely, the resulting lesions or tissue damage can influence
the neurosignature patterns that originate chronic pain.13
++
Seen from this perspective, the distinction between stresses
of psychological versus physical origin tends to assume less importance,
and a multidisciplinary or comprehensive approach to treatment becomes
paramount. All models of chronic pain acknowledge the neuropsychosocial relationship
and interaction between stress and pain; however, it is yet a further
step to begin to understand and appreciate how this works in the
life of a particular patient or how to incorporate this approach
into a successful plan of treatment. In a multidisciplinary approach
to treating chronic pain, therefore, making an assessment of the
degree to which any patient is stress-reactive and addressing the
nature of his or her unique expression of the pain-stress cycle
become primary objectives of intervention in pain management.
++
There is a tendency to regard this as the special province or
purview of the psychologist, psychiatrist, or clinical social worker,
but, in a team approach, all interventions may be seen as having
a psychotherapeutic action. The reassurances of the physician or
nurse that a patient’s pain is being taken seriously, the
verbal reinforcement to the patient by all providers that progress
in pain relief and management can be achieved, and even the comforting
touch of physicians, nurses, and physical therapists during examinations,
procedures, or exercises—all may possess a powerful psychotherapeutic
dimension. What is shared in team meetings and clinical rounds can
also prove critical to all providers in assessing a patient’s
progress and determining the extent to which he or she remains stress-reactive,
as well as how the pain-stress cycle continues to unfold in the
context of his or her family, social relationships, work, and livelihood.
+++
Influence of
Psychopathology
++
As the ongoing evaluation and treatment of chronic pain proceeds,
one area in which psychologists, psychiatrists, and clinical social
workers can be especially valuable lies in determining the extent
to which psychopathology is present and influential. As psychological
intervention begins, the first important consideration—one
that will likely have implications for both prognosis and treatment—concerns
the juxtaposition of psychological factors affecting the patient’s
pain experience, especially with regard to the order, magnitude,
and relative duration of influence. In some cases, psychopathology
occurs as a complicating feature in the diagnosis and treatment
of chronic pain and existed prior to the development of the pain
syndrome. In these instances, some delineation of the premorbid
or existing psychopathology becomes critical to understanding the
role and meaning of pain from the patient’s perspective.
In other cases, psychopathology is reactive to and arises within
the context of the patient’s experience of pain, and special
care may be needed to introduce the idea of and address the disorder
without the patient’s feeling that the focus has been removed
from his or her pain.
++
Chronic pain is far more prevalent among the psychiatrically
disordered than in the general population, and there is considerable
evidence that alterations in pain experience occur in conjunction with
some psychiatric disorders, including mood disorders, anxiety disorders,
and psychotic disorders.14 Prevalence rates for
depression among chronic pain sufferers in clinic-based samples vary
in the literature from 30% to 54%,15 with
significant depressive symptoms ranging from 60% to as
high as 100% in some samples.16 The question
of which came first—the depression or the pain—remains
controversial,17 and clinical evaluation can certainly
reveal depressive symptomatology to be a premorbid or disposing
influence in the development of chronic pain, as well as a comorbid
one. That depression might be a consequence of chronic pain is acknowledged
by many patients; but that pain might constitute the somatized expression
of premorbid but unacknowledged depression or intrapsychic conflict
typically meets with resistance from some patients and their families,
who may find a psychiatric diagnosis both less accessible and less
acceptable than a medical one.
++
A 52-year-old married woman with a previous lumbar laminectomy
and a well-documented history of mild, episodic, but well-managed
low back pain developed an exacerbation shortly after the last of
her three children left home to enter college. Her pain did not
resolve as easily as it had in the past, and 2 months later, she
presented to a pain management center, tearful, agitated, and in obvious
distress, having exhausted her primary care physician’s
ordinarily effective armamentarium of conservative treatments. Her
husband reported that she had become increasingly withdrawn from
her friends and previously busy schedule and now stayed mostly in
bed, watching television or sleeping. With a diagnostic workup and
clinical examination devoid of any findings except a few mild trigger
points, the patient’s pain physicians prescribed an antidepressant,
which they were careful to explain is also considered a “pain
medication,” and referred her to a structured group psychotherapy
program, emphasizing the importance of learning techniques for greater
musculoskeletal relaxation. One month later, the patient presented
for follow up, excitedly discussing her cognitive-behavioral assignments
for stress management from her group and chatting with the nurses
about the success of her children, with whom she had developed a
frequent e-mail correspondence. She complained of occasional, mild
residual pain but was not allowing this to impede the gradual resumption
of her daily schedule.
++
In this case, the patient had little insight into the development
of her reactive depression or its relationship to her worsening
pain. Considering her history of surgery and episodic low back pain, it
is difficult to ascribe her distress solely to somatization; but
instances of pure somatization are usually difficult to document
convincingly. As in most cases, this woman’s exacerbation
of pain appears to stem from both physiologic and psychological
factors; and, especially when discussing her experience with the
patient herself, it is important not to become distracted by questions
of primacy. When there is a clear, established history of a premorbid
psychiatric disorder, it becomes critical to understand how such
psychological factors may have contributed to the development of chronic
pain and how they shape the patient’s experience of chronic
pain. When there is little to suggest premorbid psychiatric influences,
however, it is far more important to maintain a clinical focus on
the relationship between psychological and physical factors, as
a whole, as well as their ongoing interaction.
++
For this reason, a model reflecting the influence of stress-reactivity
and the pain-stress cycle is probably more versatile and more efficacious
in such cases, because it promotes a view of health that takes into
account the interaction of psychological and physical factors, without
the need or presumptive burden of trying to establish causal direction—an
enterprise that, despite our best efforts and intentions, might
easily result in harm to the patient. With such a model, psychological factors
can be viewed as both amplifying pain and inhibiting successful
adjustment to it, whereas chronic pain itself can be viewed as a
potent psychological stressor in its own right and one that can
easily give rise to other psychosocial stressors.18
++
The disposing premorbidity, for example, of personality disorders,
depression, and posttraumatic stress in the development of chronic
pain is often accepted uncritically in the clinical arena. That they
are found in significantly greater proportion comorbidly is indisputable.19,20 Yet,
when viewed according to a diathesis-stress model, even personality
disordered and posttraumatic stress disordered behaviors may emerge
for the first time and coalesce around chronic pain.21 So
the question becomes less a chicken-or-egg issue of, “Which
came first, the chronic pain or the psychiatric disorder?” but
rather, “What approach is more helpful to the patient in
understanding and assisting in the resolution, both psychologically
and physically, of his or her pain?”
++
Somatization, according to this model, can be seen as an immature
psychological defense capable either of giving rise to pain in the
apparent absence of organic pathology or of complicating and magnifying
pain in the established presence of organic pathology. As a defense,
it simply represents the symbolic displacement of intrapsychic conflict
onto the somatic sphere in an unconscious attempt to avoid distressing
affects associated with psychosocial stress. All stress-reactive individuals
tend to somatize, when under sustained or escalating stress; and,
because we are all on a stress-reactive continuum, we all tend to
express affects through our bodies to some degree. Highly stress-reactive
patients may have well-documented histories of somatization and
physical complaints at many sites, but any tendency toward somatization
can magnify a patient’s suffering well beyond what is expectable,
given the nature and extent of actual tissue damage.
++
Alexithymia can be a predisposing, complicating, and exacerbating
feature of somatization,22 because patients who
are unable to articulate their emotions and affective states in
words may have few outlets, other than bodily expression, for their
intrapsychic pain and discomfort. For those who have come to regard
the experience of psychological distress or displays of affect as signs
of weakness or occasions for shame, displacing intrapsychic conflict
onto the body may also allow them to feel that they have more legitimate
claims to others’ attention and the fulfillment of their
needs—a phenomenon or symptom also known as secondary gain.
Such constructs as alexithymia and secondary gain, in turn, raise
the question of whether the phenomenologic focus of the interaction
between pain and stress is more appropriately placed on psychiatric
disorder or on temperament, personality traits, coping attributes,
and even environmental factors, such as availability of support.23 Shifting
the clinical focus too quickly to that of psychiatric disorder can
discourage the patient further or even lead to the termination of
treatment.
++
The dangers of prematurely settling on a psychiatric diagnosis
are especially apparent in the case of the somatoform disorders,
the common feature of which is the presence of physical symptoms suggesting
a general medical condition but which cannot be completely attributed
to such a condition or the effects of a substance or another mental
disorder.24 The category of somatoform disorders—conversion
disorder, somatization disorder, pain disorder, and hypochondriasis—may
be both descriptive of a patient’s symptoms and representative
of clinical observation, but too often such diagnoses represent
the closing of the door to continued medical attention and intervention.
So, too, the coincidence of mood, anxiety, and personality disorders
should not be considered a medical end point, but rather should
highlight the need for multidisciplinary approaches to the treatment
of chronic pain. Psychiatric diagnosis in chronic pain is valuable
only insofar as it develops a deeper and richer understanding of
the patient and promotes multidisciplinary options for treatment,
including that of psychotherapeutic intervention.
+++
Preparing for
Psychotherapeutic Intervention
++
Not all patients with chronic pain exhibit significant psychopathology,
of course, or experience the complicating influences of the range
of psychological factors that can affect the course of physical
symptoms. Many individuals adjust well to the limitations imposed
by their pain and continue to work productively and to enjoy satisfying
relationships and rewarding personal interests. Most of them have
no histories of premorbid psychopathology; and, by virtue of resilient temperaments,
adaptive personality traits, and successful coping skills, they
manage to avoid the comorbid development of psychological distress
and psychiatric symptoms that can become associated with chronic
pain.
++
Those who are less fortunate, however, include among them the
most memorable and challenging patients in any primary care practice
or pain management center. Their suffering is often dramatic and,
even when their numbers are few, their drain on resources is considerable,
when calculated in terms of time, money, and the morale of staff.
Their families, other physicians, employers, and even health insurance
carriers frequently become demanding agents in their behalf, even
as their pain remains puzzling and intractable to an ever-lengthening
list of interventions; while their escalating sense of urgency continually
reminds us of our limitations as health care providers. When all
else appears to have failed and all available resources have been
tapped, it is a small step toward collusion with the patient’s
own escalating sense of urgency to make one more referral to yet
another specialist or to raise the level of pain medication, one
more time; to consider one more improbable intervention or, as is
often the case, to simply close the door, abandoning the patient to
begin the process all over again.
++
It is under such circumstances that psychologists and psychiatrists
frequently find the chronic pain patient at their doors. Having
been told that there is nothing further that can be done, that there
is no hope of further surgical or medical palliation, patients can
be left to begin the process of psychologically adjusting to their
pain and its sequelae in the most angry, anxious, and despairing
of states. For these individuals, pain may already have become an
organizing principle, and the enterprise of psychotherapeutic management
is no longer only that of addressing transiently reactive mood or
anxiety or difficulties with adjustment, but that of attempting
to alter a way of life or effecting change at the level of personality.
Chronic pain of this nature continues to call for a multidisciplinary
approach, often just at a time when patients are most discouraged
by or disillusioned with their medical care; and it is often a long
road back to successful pain management, made far more arduous for
having been consigned to being undertaken in pieces.
++
When psychological factors are influential in the development
or maintenance of chronic pain, the greatest progress is likely
to be achieved most expediently when there is not only interdisciplinary cooperation
but an integrated, comprehensive plan of treatment in which all
providers are working together, with the same goals in sight. Undertaking
medical and psychotherapeutic approaches to chronic pain separately—or
worse, sequentially—greatly reduces the chances of making
global progress in patients’ adjustment to their pain,
while increasing the chances that interventions from different disciplines
may compete or contradict one another, leaving patients feeling
confused and helpless. It can also leave physicians and psychotherapists
feeling alone and unassisted in their attempts to help their patients
and more likely, as a result, to communicate their own anxiety and
sense of helplessness about the slowness or lack of progress back
to the patient.
++
The patient’s developing stability and success with
managing chronic pain may well depend on an abiding trust that his
or her physicians are doing everything possible to offer appropriate
relief and comfort through medical means, while his or her psychotherapist
is doing everything possible to assist with the adjustment to what
the patient sees as the emotional impact and consequences of pain.
This does not mean that there is a strict division of labor, however;
and patients often will turn to their physicians and nurses for
emotional support and ask their psychotherapists for reassurance
about medical decisions. Patients with chronic pain often ask their
providers, without respect to discipline, for validation—the
reassurance that their physicians, nurses, physical therapists,
and psychotherapists have heard their concerns and understand their
experience. Many have gone from provider to provider, encountering
repeated disappointments in their search for answers, and their
often challenging and sometimes provocative presentations may reflect
the defensiveness, hypersensitivity, and hypervigilance of the scars,
both physical and psychological, they have sustained in their search
for relief and solace.
++
Establishing a good working alliance is, therefore, critical
for all members of a multidisciplinary team. Patients’ compliance
with directives and interventions and their cooperation with a plan
of treatment often depend on their perception that all members of
the team are working together in their behalf. When patients lose
trust in their providers or sense that providers are not fully engaged
in the process of helping them in their search for answers and relief,
the alliance deteriorates, sometimes irredeemably. Patients’ complaints
of feeling rushed, dismissed, or devalued may result, not surprisingly,
in an increase in pain behaviors and dependency, as well as tendencies
toward the expression of retaliatory impulses. In a multidisciplinary
approach to treatment, the responsibility for maintaining the integrity
of the alliance is shared among all providers, with the result that
the patient’s urgency is experienced by all as less demanding
or overwhelming.
++
When the psychologist, psychiatrist, or clinical social worker
enters the scene, patients frequently need the reassurance of the
rest of the team that their pain has not suddenly been relegated
to the uncertain status of being purely psychological in origin,
or “all in the head.” Especially in the initial
psychological interview, it is reassuring to patients to be able
to focus on what they know best—namely, the emotional impact
of pain on their lives—and not to feel as if their beliefs
and psychological defenses are being challenged or threatened. When
the patient feels secure that his or her story has been heard and
fully appreciated, the direction of the psychotherapist’s
inquiry can turn toward a consideration of the psychological and
behavioral antecedents, correlates, and sequelae of pain—all
of the factors influencing the pain-stress cycle. Once the patient
is willing to acknowledge and discuss the possibility that stress
may contribute to his or her subjective experience of pain, the
way is prepared for psychotherapeutic intervention.
++
It is, nevertheless, critical not to presume too much or too
quickly here. A final, essential question to consider in preparing
for psychotherapeutic intervention concerns the range of variables
in individual temperament and personality that make psychological
adjustment possible: Is the patient disposed toward making the changes
necessary to facilitate more adaptive coping? Because patients vary
widely in their receptiveness to making the behavioral changes that
lead to more successful adjustment, their readiness for change20,25 may
require continual monitoring and nurturing in psychotherapy (see
Chap. 13). Suggesting to someone who is waiting for his or her physician
to “fix the problem” that relaxation exercises might
assist in the management of pain is unlikely to result in anything
but frustration. Accurately assessing and nurturing the patient’s
readiness for change, therefore, becomes one of the principal prerequisites
for the successful psychotherapeutic management of chronic pain.