Pain Article References

by Alan Brandis, Ph.D.

The brief article which I wrote for this website explaining the psychological approach to chronic pain management cannot begin to cover the extensive territory of psychological research into the causes and treatment of chronic pain conditions.

I understand that there are conflicting approaches which are promoted and used by members of the medical and psychological communities to alleviate the suffering of chronic pain patients, as is common in almost any area of medicine. I understand that if an individual feels that he or she has found an approach that works to alleviate his or her suffering, there will be a sense of loyalty to that approach, as there well should be.

I am happy to be provided with information about which I was not previously aware, and I welcome responses which attempt to do that. However, some of the responses to the previous page have been hostile and insulting, as though I just made up something with no personal experience or training to back it up. I believe that this demonstrates that some individuals with chronic pain are, indeed, addicted to their medication or are getting some social or psychological gain out of it, as the level of defensiveness and emotionality with which they responded to my article was quite high.

I have included below some of the references to articles which I used to develop a talk on assessment and treatment of chronic pain, which I have given to the medical staffs of several hospitals. Before you react to my discussion of chronic pain with blind criticism or insult, please seek out and read the following articles. Then we can perhaps have a meaningful discourse.

When a summary or abstract is included in the publication, I have reproduced it here.

Roberts, Alan H. ”The Operant Approach to the Management of Pain and Excess Disability.”. In Holzman, D. and Turk, D., Pain Management: A Handbook of Psychological Treatment Approaches. 1986; Pergamon Press, NY.

Sanders, S., Ph.D. "Contingency Management in the Reduction of Overt Pain Behavior." In Tollison, C. (ed.), Handbook of Chronic Pain Management, pp. 210-221, Williams and Wilkins, 1987.

Roy, Ranjan. A Problem-Centered Family Systems Approach in Treating Chronic Pain. In Holzman, D. and Turk, D., Pain Management: A Handbook of Psychological Treatment Approaches. 1986; Pergamon Press, NY.

Guck, T., Skultety, F., Meilman, P. and Dowd, E. "Multidisciplinary Pain Center Follow-up Study: Evaluation With a No-Treatment Control Group." Pain, vol. 21, 1985, pp. 295-306.

The long-term efficacy of a multidisciplinary pain management center was evaluated by comparing 20 treated patients with 20 no-treatment control patients who met the program's entrance criteria, wanted to participate, but could not because they did not have insurance coverage. At 1-5 years follow-up, 60% of the treated patients met all of the criteria for success established by Roberts and Reinhardt, while none of the untreated patients did so. Treated patients reported less interference with activities, more uptime, lower pain levels, less depression, and fewer hospitalizations than untreated patients. Also, more treated patients reported being employed, while fewer used either narcotics or psychotropic medications at follow-up compared to untreated patients. Pre-treatment-to-follow-up changes are reported for both the treated and untreated groups.

Kames, L., Rapkin, A., Naliboff, B., Afifi, S. , and Ferrer-Breuchner, T. "Effectiveness of an interdisciplinary pain management program for the treatment of chronic pelvic pain." Pain, vol 41, 1990, pp. 41-46.

Chronic pelvic pain has rarely been discussed in the pain management literature, although it is extremely common in general gynecological practice and often refractory to traditional medical and surgical therapy. A chronic pelvic pain program was developed to offer an alternative treatment approach for women for whom standard gynecological procedures were inappropriate or unsuccessful. Sixteen subjects completed the full 6-8 week interdisciplinary program, which included both somatic and behavioral therapies. Compared to a waiting list control the results showed a dramatic decrease in reported levels of pain following treatment. Anxiety and depression also decreased and psychosocial functioning improved, including return to work, increased social activities, and improved sexual activity. The outcome suggests that the interdisciplinary pain management approach is effective for the treatment of chronic pelvic pain.

Keefe, F., Crisson, J., Urban, B. and Williams, D. "Analyzing chronic low back pain: the relative contribution of pain coping strategies." Pain, vol. 40, 1990, pp. 293-301.

Sixty-two chronic low back pain patients were administered the Coping Strategies Questionnaire (CSQ) to assess the frequency of use and perceived effectiveness of cognitive and behavioral pain coping strategies. Analysis of individual variables revealed that CSQ factors, gender, physical examination findings, and chronicity of pain had significant effects on one or more of a series of pain, psychological distress or behavioral measures. To assess the relative contribution of each of these variables, hierarchical stepwise regression analyses were carried out. These analyses revealed that the Helplessness factor of the CSQ explained 50% of the variance in psychological distress (Global Severity index of the SCL-90R) and 46% of the variance in depression (Beck Depression Inventory). Patients scoring high on this CSQ factor had significantly higher levels of psychological distress. None of the demographic or medical status variables explained a significant proportion of variance in the psychological distress measures [emphasis mine - AB]. The Diverting Attention and Praying factor of the CSQ explained a moderate (9%) but significant amount of variance in pain report. Patients scoring high on the [Helplessness] factor had higher scores on the McGill Pain Questionnaire. Coping strategies were not strongly related to pain behavior measures such as guarding or uptime. A consideration of pain coping strategies may allow one to design pain coping skills training interventions so as to fit the needs of the individual low back pain patient.

Blumer, D., M.D. and Heilbron, M., Ph.D. "Dysthymic Pain Disorder: The Treatment of Chronic Pain as a Variant of Depression." In Tollison, C. (ed.), Handbook of Chronic Pain Management, pp. 197-209, Williams and Wilkins, 1987.

Craig, K. "Emotional Aspects of Pain." In Wall, P., and Melzack, R. (eds.), Textbook of Pain, pp. 153-161, Churchill and Livingstone, NY, 1984.

De Bennedittis, G., Lorenzetti, A. and Pieri, A. "The role of stressful life events in the onset of chronic primary headache." Pain, vol. 40, 1990, pp. 65-75.

This study investigated the relationship between stressful life events and the onset of chronic primary headache (CPH) using both normative group ratings and self-report ratings of the desirability and the perceived impact of stressful events. We hypothesized that CPH patients (n=63) would report significantly more stressful life events with negative impact on their life style in the year prior to headache onset compared with headache-free controls (n=44). The prediction was fully confirmed. CPH patients were exposed to a significant increase (P<0.001) in their final year life change unit (LCU) totals prior to headache onset as compared to the previous corresponding time interval and to headache-free controls. Furthermore, a highly significant peaking (P<0.001) of negative change scores, based on personal ratings of the distress concerning life events in the same time interval, was observed in the CPH group. In terms of event content, exits or losses were prominent in being perceived as stressful. Significant differences between headache subgroups (chronic tension-type headache, migraine, mixed headache and psychogenic headache) were not found, although mixed headache sufferers reported a higher incidence of interpersonal arguments and difficulties than migrainous patients.

We conclude that a sudden increase in the frequency and magnitude of stressful life events, associated with a cognitive-emotional appraisal of their negative impact on life patterns, appears to herald the onset of headache, independently of the developing clinical headache syndrome.

Fordyce, W., Ph.D. and Steger, J., Ph.D. "Chronic Pain." In Behavioral Medicine, Theory and Practice, pp. 125-163, 1979.

Subheadings include:

Etiology of Pain: Pain As Behavior; Acute and Chronic Pain; Psychogenic Pain; The "Disease" Model of Pain; Operant vs. Respondent Pain; "Well" Behavior; Time Limitations; Direct Reinforcement; Indirect Reinforcement; Modeling.

Review of Treatment Strategies For Chronic Pain: Methodological Issues; Inpatient Strategies; Outpatient Strategies.

Evaluation Phase: Time Pattern; Identification of Pain Behaviors; Environmental Responses to Pain Behaviors; Pain Activators; Pain Diminishers.

Treatment Phase: Patient and Spouse Orientation; Management of Medication [includes a detailed discussion and sample Pain Cocktail Regimen for detoxifying iatrogenically addicted patients and reducing their dependence on medication for pain relief]; Increasing Exercise and Activity Levels.

Jamison, R. and Virts, K. "The influence of family support on chronic pain." Behavioral Research and Therapy, vol. 28 no.4, 1990, pp. 283-287.

This study examined the role family support plays in insulating chronic pain patients from maladaptive behaviors associated with their pain. Two hundred thirty-three patients who described their family as always being supportive and never having any conflicts were compared with 275 chronic pain patients who endorsed having family disharmony and limited support. One year after completing an out-patient pain program a random sample of 181 of these patients was followed to determine the extent to which family support influenced treatment outcome. The patients who reported having non-supportive families tended to have reported more pain sites and used more pain descriptors in describing their pain. These patients also tended to show more pain behaviors and more emotional distress compared with pain patients coming from supportive families. On follow-up, patients who described their families as being supportive reported significantly less pain intensity, less reliance on medication and greater activity levels. They tended to be working and not to have gone elsewhere for treatment of their pain compared with patients who described their family as non-supportive. The results of this study demonstrate that perceived support is an important factor in the rehabilitation of chronic pain patients.

Wade, J., Price, D., Hamer, R., Schwartz, S. and Hart, P. An emotional component analysis of chronic pain. Pain, vol. 40, 1990, pp. 303-310.

The present study sought to determine the relative contribution of frustration, fear, anger and anxiety to the unpleasantness and depression pain patients experience. Sixty-nine women and 74 men, with an average age of 47 years, were included. Patients underwent psychological evaluation which included use of the Minnesota Multiphasic Personality Inventory (MMPI), Beck Depression Inventory (BDI), and 7 visual analog scales (VAS) measuring degree of emotional unpleasantness, pain intensity, anxiety, frustration, fear, anger, and depression. Test-retest reliability coefficients were significant for the negative feeling VAS yielding an average reliability coefficient of 0.82. Analyses relating the negative feeling state VAS to pain unpleasantness and depression indices from the MMPI (scale 2) and BDI (sum score) yielded significant canonical correlations. Multiple regression was used to clarify the relationships between negative feeling VAS, pain-related unpleasantness, and indices of depression. After statistically controlling for intensity of pain, anxiety and frustration predicted pain unpleasantness. Regression analyses indicate that anger is an important concomitant of the depression that pain patients experience. The results suggest that anger and frustration are critical concomitants of the pain experience. Treatment techniques specifically targeting anger and frustration in these patients may prove efficacious.