Psychology in Assessment and Management of Pain

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INTRODUCTION

Psychological considerations are important in both assessment and management of chronic abdominal and pelvic pain (CAPP), ideally by a multi-disciplinary team (MDT) including a psychologist. As in all chronic pain, CAPP has an emotional and cognitive impact in addition to functional limitations [4], and its effects extend to relationships with family, friends, social life, work, and study [57].

BASIC ASPECTS

The biopsychosocial model of pain describes a complex interaction between pain, behaviour, cognition, emotion, and social context [25]. This model underpins problem formulation and integrated care delivered by the MDT. It is, importantly, shared with patients and related to an individual’s particular pain experiences. Psychological components of pain management are included in the evidence-based treatment guidelines of the British Pain Society (BPS) [8] and the European Association of Urology (EAU) [22]. This chapter focuses on how clinicians can incorporate psychological elements into their assessment and treatment.

The term CAPP is used throughout the chapter, applying psychology irrespective of CAPP subtype while recognizing the need to shape it around the patient’s problems and situation.

DESCRIBING THE SUBJECT

Integrating Psychology

Pain experience is modulated through interaction between the brain and afferent and efferent pathways, thus cognitive, emotional, and social networks influence the processing and experience of pain. In the short term, negative emotions and thoughts act to facilitate pain signalling and to reduce its inhibition; these dynamics are subserved by anatomical differences in pathways which may be established over the long term [9], such that the longer the individual has had pain, the more emotional its processing [2]. Social and environmental variables, particularly stressors, are represented in these cognitive and emotional networks [28]. Brain imaging studies show that persistent pain is associated with structural, chemical, and functional changes in the brain [5,56].

There is therefore no simple relationship between physical findings, pain experienced, and resulting distress and change in activity [46, 56]. Secondary to pain and the problems it causes, depression and anxiety are common [23,61], further exacerbating pain, feelings of helplessness and difficulty coping [31,53,57]. In all chronic pain, sexual and relationship difficulties occur [1], but particularly in CAPP.

Despite the widely used notion of ‘somatisation’, the evidence for this in chronic pain is very weak [13]. While longstanding emotional difficulties are likely to predispose to problems managing pain [28], this is far from a straightforward cause and effect relationship, given the complexity of pain as described above. Instruments intended to measure ‘somatisation’ in fact quantify symptoms, attention to them and concern about them, all unsurprising in the context of unresolved and distressing pain [12]. One study found that a third of women with pelvic pain rated anxiety about the cause of pain as the most troubling aspect [61], anxiety represented in some women by distressing mental images of (imagined) causes such as ‘tearing’, ‘ripping’ or ‘falling out’ of internal organs [7].

Aversive sexual experiences, particularly in childhood, are often suggested as major risk factors for CAPP [16, 28], with implications for patients’ and health professionals’ attributions about cause. However, methodological shortcomings mean that effects of sexual abuse cannot be segregated from other possible risks [16, 28], and the incidence of sexual abuse is similar in other chronic pains [44]. Most studies use retrospective accounts by women in clinical settings, and use varied definitions of sexual abuse, sometimes combined with physical and emotional abuse. The only prospective study of young women with previously established sexual abuse showed no relationship with CAPP [44].

The main evidence-based psychological models, which we believe can be integrated with biomedical formulations of pain, are behavioural and cognitive. The behavioural model focuses on avoidance of activities which are feared to exacerbate pain or cause injury, such as sexual activity. In the long-term this avoidance restricts activity and worsens fear, often exacerbated by hypervigilance to pain and pain-related cues [12]. The cognitive model posits that many of the behavioural and emotional phenomena described by pain patients are mediated by changes in processing or content of thoughts, such as catastrophising (interpreting internal or external information as threatening and unmanageable) [27] or holding beliefs about the pain or its meaning which add to distress and disability, such as the images described above, or having little confidence in being able to cope with pain [3]. Although described before the imaging studies cited above, the model has been strengthened by these findings [56].

These phenomena and the psychological models which underpin them are described in some detail because they make sense of how people with CAPP present to health services, and the problems they describe in their lives outside healthcare. Historically, theories of ‘psychogenic’ pain impute moral weakness or motivational deficits as the explanation. For instance, women with pelvic pain commonly report high levels of distress compared to women with no pain, and this was cited as evidence that they were neurotic or exaggerating, often to avoid sexual activity. Once they were compared with women with chronic non-pelvic pain, those differences disappeared: distress is common in any chronic pain [46].

For the individual with CAPP, the experience of unremitting pain whose cause cannot be identified is often frightening and confusing, with fears based on models of acute, not chronic, pain. The hope of finding a treatable cause of pain and eliminating the pain persists in patients and in those who treat them [11, 51], with serial investigations for possible causes. A study of women with chronic pelvic pain receiving negative laparoscopy results found that “women and the professionals with whom they have contact appear to be operating within a medical system designed for acute illnesses” [47]. How test results are delivered to the patient is important: being told that “nothing is wrong” can be seen as a denial of pain, and usually destroys the therapeutic relationship [34]. Test results need to be contextualised within the question, the risk profile, and the entire pathway.

When the symptoms are not eliminated by interventions (often more appropriate for acute pain), patients are understandably distressed and frustrated. Both patient and clinicians may experience a sense of failure, and clinicians may use quasi-psychological explanations [35], such as ‘medically unexplained symptoms’, interpreted by patients as scepticism or disbelief about the pain [47]. These experiences tend to strengthen the patient’s search for validation by diagnosis, still within an acute and predominantly medical framework.

A more helpful framework for conceptualising the emotional, behavioural and cognitive changes associated with chronic pain is a “normal psychology of pain” [19]. Worry about health problems is normal, but particularly distressing when about pain [18]. The recourse to medical help is also normal, given its frequent success for acute pain. Serial consultation is not ‘doctor-shopping’ or ‘dependence’ so much as persistence in seeking a solution to something which has seriously disrupted normal life [14]. Reluctance to accept that the problem is chronic and unresolvable is also understandable.

A key task for the clinician is to help the patient to understand chronic pain within a fuller biopsychosocial model, recognising that thoughts, emotions, and behaviour influence the pain and its impact, and that the wider socio-cultural context may also be unsupportive. This reassures patients that they are believed rather than ‘making it up’, that they are not ‘going mad’, and inclines them towards accepting advice and treatment from that clinician.

Assessment

A detailed assessment is essential to working successfully with patients with persistent pain, and to understanding their preferences and decisions about treatment. Psychologists tend to conceptualise assessment and intervention as overlapping rather than distinct processes, with ongoing assessment taking place during intervention sessions as a therapeutic alliance develops and the patient becomes more able to divulge their deeper fears or more intimate difficulties. This leads to a formulation of the patient’s pain experience and its impact on life, shared between patient and clinician, set in the broader context of the patient’s ways of thinking about the world, emotional changes, social circumstances, life events and relationships. On this foundation, treatment goals are identified, and risk and abuse history can be assessed. We describe below how other clinicians can use these assessment principles when opportunities arise.

Beyond symptom assessment, asking how the patient’s life has changed because of pain, such as in activities, mood, sleep, work, and close relationships, enables the clinician to appreciate the impact of pain. Specific worries about ability to cope with exacerbations of pain are common, and are often combined with negative cognitive bias. For instance, “I won’t be able to work if my pain is this bad, and if I keep missing work I’ll lose my job”, describes a genuine concern but with catastrophic thinking that pain precludes work, and that job loss (and the consequences of that) is inevitable. Such thinking is typically associated with emotional distress such as sadness, shame, or frustration. Helping to explore the other possibilities and resources which will avoid the catastrophe alleviates distress; recognizing the pattern of thinking enables the individual better to identify it and counter it.

Asking about worries and ideas about what is causing pain, including images, provides the opportunity to give accurate, realistic and personalized information. A question such as “After talking to so many different specialists over the years, what is your understanding of why you have pain?” can start this process. Clinicians may be concerned that eliciting these worries will add weight to them, but on the contrary this conversation generally unburdens the patient and legitimises his or her feelings [47]. Patients who are particularly anxious and find it hard to dismiss their worries, despite negative investigations, will benefit from a biopsychosocial explanation of pain and provision of self-management strategies from the outset (see next section), as these help to contain anxiety. This explanation also lays the ground for a more active role for the patient in self-management, even if only reading more about what chronic pain is and is not. It is useful to provide or direct the patient to good quality information, as there is much of poor quality [49].

Questionnaires can be used to elicit more detail, or to gather information from patients who struggle to talk about particular subjects. The Pain Catastrophising Scale [54] effectively identifies catastrophic thinking; the Pain Self-Efficacy Questionnaire [59] measures confidence in engaging in being active despite pain. Assessing mood is complex and often poorly captured by questionnaires, as symptoms such as disrupted sleep and reduced activity are associated with mood and with chronic pain, and some with medication. Publications by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) group give further guidance on measuring mood as an outcome in chronic pain [57

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