Biopsychosocial perspective

This volume endorses the biopsychosocial model of health and illness that posits biological, psychological and social factors must be considered in understanding human health or illness, whether one is interested in being well‐informed about the nature of pain or caring for an individual [6]. Figure 4.1 illustrates dimensions of the model, signifying the importance of each component to the wellbeing of the person. It has been embraced by those arguing the necessity of multidisciplinary care for people suffering from chronic pain and calls for the integration of contributions from various healthcare practitioners, including medicine, nursing, physical therapy, psychology, social work and rehabilitation. Multidisciplinary care is demonstrably more effective and cost‐efficient than single practice care [7, 8]. Nevertheless, attention to biological phenomena overwhelms the field; psychologically based approaches are often ignored by those with strong biomedical orientations, and social determinants of pain have received relatively minimal attention. Healthcare professionals who do not have competencies in all domains must engage in consultation to insure comprehensive care. Integrative care models ensure interdisciplinary collaboration in the use of multimodal therapies for persistent pain [9, 10, 11].

Social Communication Model of Pain

This systemic model begins to provide a detailed framework for describing the complex interactions among psychological and social factors of pain (see Figure 4.2) [12, 13]. The model is structured around the typical temporal sequence of events during a painful episode: (a) there is exposure to events in a person variably disposed to experience pain; (b) pain is perceived; (c) the distress becomes manifest in pain expression; (d) pain may be inferred by an observer; and (e) observer decisions are made concerning delivery of care. Note inclusion of persons other than the suffering person in the model as their role is typically important to the continuing process. Benevolent care is not the only possibility – indifference and malevolent exploitation are not unusual in human relationships, but less common in clinical settings. The model directs attention to both intrapersonal (biological and psychological) and interpersonal (social) determinants of the experience and its overt expression, as well as to the caregiver’s perception of the person’s distress and the process whereby decisions are made concerning delivery of care. Both intrapersonal and interpersonal determinants of each stage are important to an understanding of this dynamic temporal sequence.

Intrapersonal determinants concern the personal dispositions to experience or express pain, in the case of the patient. Similar dispositions govern the reactions of caregivers. For the person in pain, the dispositions are embodied in the biological substrates that support pain. These are plastic and dynamic. While inherited dispositions to respond to noxious events with pain are important [14], the biological substrates of pain also reflect personal life experiences, including the individual’s medical and social history. Personal life histories include a myriad of personal, familial and ethnocultural events that are formative of the individual’s experiences and modes of painful expression. A parallel analysis is needed for caregiver dispositions during assessment and treatment. Their reactions, both in terms of what they perceive and how they respond, are similarly constrained by biological systems and reflect informal and formal education and life experience.

The interpersonal context interacts with the intrapersonal dispositions to determine the individual’s unique response at the time pain is experienced and expressed. Patients often confront difficult work, family and other interpersonal challenges which influence pain, personal coping, pain‐related disability and demands for healthcare. These, and the immediate context, are related to the substantial variability in how people experience pain and express their distress as well as how observing people interpret and respond to those reactions. The social context and the manner in which those present treat the person in pain have a potent impact on the individual’s current and future status. Access to a clinician able to deliver effective interventions is a key feature of the patient’s interpersonal context.

Clinicians serve as pivotal social agents who control services provided to individuals, with public health and institutional policies dictating availability of resources, including determining whether and which caregivers will be available. Their training and competence in delivering effective interventions are crucial determinants of whether the person in pain will receive relief from acute or chronic pain. Observations that pain has been ignored, poorly assessed, underestimated, not treated, inadequately treated or poorly treated draw attention to the necessity to include psychosocial factors in the care of people suffering from pain.

Psychological and social features of pain can be as important as their biological counterparts, despite biocentric orientations that often prevail among clinicians, administrators, policy makers and patients. Early psychosocial assessment and intervention can address major problems, thereby enhancing the effectiveness of all therapies and preventing long‐term difficulties [15]. This was evident in a study [16] identifying psychosocial difficulties among consecutive new patients (a total of 1242 patients were enrolled) referred to a tertiary care, hospital‐based pain clinic. Both psychosocial and biomedical issues were important in 51% of the patients. For an additional 20.9% of the patients, no medical factors could be established and painful experience and disability were attributed to psychological factors. Importantly, the pain of only 25.5% of the patients could be attributed directly to general medical conditions. About 75% of the patients had detectable biomedical pathology and close to 72% had diagnosable psychological issues. Similarly, mental health problems, including depression (61%) and anxiety (45%) were common in patients with chronic pain presenting as unable to cope with chronic pain to an emergency department [17]. Life challenges were also evident among 935 patients presenting to a community‐based multidisciplinary chronic pain clinic, as 50% lived below the poverty line, 30% were not working due to disability and 63% reported severe functional disability [18]. Evidence of high levels of psychosocial difficulties indicate the importance of treating the whole person rather than focusing exclusively on physical pathology.

Pain experience

Clinical care begins with careful attention to the subjective experience of the patient. Pain is typically initially assessed as a unidimensional construct, using self‐report of numerical and verbal descriptor scales focusing upon pain severity; however, these reports obscure the complexity of the experience [19] and should be conceptualized as integrating sensory/discriminative, emotional/motivational, cognitive/appraisal and social dimensions, thereby offering focused targets for different forms of intervention [20].

Intrapersonal determinants

Patients bring to any painful episode, acute or chronic, dispositions to respond that often vary substantially, both in sensitivity to pain and qualitatively [21]. These variable dispositions are determined by genetic inheritance [22] and personal life histories of environmental interactions with both physical and social worlds. Each person represents a relatively unique embodiment of the interaction between these “nature” and “nurture” determinants of pain reactivity. Tissue damage, or the perception of tissue damage, would account for modest to moderate proportions of variations in pain experience, expression, functional capacity and risk of persistence of pain‐related disability, in addition to these dispositions [21, 22].

Assessment of personal, medical, family and social history often discloses the formative role of life history events. Several chapters in this book discuss excessive stress reactivity and emotional reactions (e.g. debilitating fear of pain or depression), destructive thinking (e.g. catastrophizing, passive coping), behavioral maladjustment (excessive avoidant behavior and inactivity) and deteriorating social relationships as risk factors for excessive pain and disability, including failure to respond to treatment.

Intrapersonal factors also have been identified that protect against the debilitating impact of painful injury or disease and the development of disability. Key protective factors include:

1. A strong sense of self‐efficacy, or confidence in one’s ability to follow a course of action that will accomplish desired outcomes (e.g. control of pain) [24, 25].
   
2. Effective use of cognitive, affective and behavioral coping skills, such as muscle relaxation, distraction, commitment to activity and an ability to redefine situations in less catastrophic ways [26].
   
3. A readiness or willingness to engage in active roles that are contradictory to lapsing into maladaptive patterns of thinking, feeling and behaving [24, 27].
   
4. A capacity for accepting certain limitations or handicaps, thereby avoiding one’s life being consumed by unsuccessful efforts to eliminate pain [28, 29].

These processes not only describe resilience to pain and pain‐related disability, but they represent reasonable objectives for therapeutic intervention.

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