By Les Aria, PhD I October 23, 2024
Read Time: 4-6 minutes
When treating persistent pain, we often focus on two critical components: medical interventions and physical therapy referrals. However, an equally important aspect that is frequently overlooked is pain psychology. This third leg of pain management is essential for creating a comprehensive approach that promotes pain relief and helps patients return to what matters most in their lives.
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Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage
- The International Association Study of Pain (IASP)
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What is Pain Psychology?
Pain Psychology focuses on the synergistic interplay between the experience of physical pain and psychological factors, emphasizing that pain is not solely a physical sensation. Instead, the experience of pain is significantly shaped by cognitive, emotional, and psychosocial stressors. This perspective underscores the importance of treating the psychological factors (e.g., catastrophizing, depression, fear of pain sensations and avoidance of movement) because these psychological elements affect the patient’s pain perception, and thereby the patient’s experience of pain.
Pain psychology applies behavioral brain training skills to retrain the brain’s messages of danger that contribute to the perception of pain.
These behavioral skills helps patients reduce their fear-avoidant behaviors and regain control over their lives.
Adding Pain Psychology Upfront Versus An Afterthought
Case Example
Consider a 58-year-old patient with a long history of low back pain and other musculoskeletal issues, who has not experienced relief from previous medical interventions. Both you and the patient are frustrated, and the patient insists on additional or repeated treatments that you believe will be ineffective. They propose surgery as a last resort, though you question whether it’s the best option. Both of you feel like you're running out of alternatives. If, during the initial evaluation, you had introduced pain psychology services as part of a comprehensive treatment plan, the patient’s openness to such an approach would likely have been much greater.
Research indicates that patients are more receptive to pain psychology services when these are integrated as part of the best practice for treating persistent pain, rather than introduced as an afterthought. Incorporating pain psychology alongside physical therapy as a routine referral creates a 'three-legged stool' of comprehensive treatment for persistent pain.
Studies support this approach, showing that cognitive-behavioral therapy (CBT) and other integrative behavioral medicine interventions can significantly reduce pain intensity and improve coping strategies. For example, a 2017 meta-analysis by Ehde et al. demonstrated the effectiveness of psychological therapies like CBT in reducing chronic pain across various conditions.
Additionally, a 2020 study by Darnall et al. found that incorporating pain psychology early in treatment improved patient outcomes, reducing the reliance on opioids and enhancing overall quality of life. This is further supported by Ashar et al.'s pivotal 2021 study, which demonstrated the significant effectiveness of pain psychology interventions in treating previously untreatable persistent pain. Their findings highlight the value of integrating psychological approaches into pain management, offering new hope for patients with persistent pain that have been resistant to traditional medical treatments.
Tips and Considerations for A Successful Warm Handoff
Emphasize their pain is real
Patients want to explicitly know that their doctor understands their pain, what is causing it, and knows what to do (or else they will be skeptical)
Avoid describing pain as related to the “mind” or as a result of anxiety, depression, or stress (if possible)
Can be helpful to acknowledge how much stress the symptoms are causing the patient
Emphasize that the treatment provides strategies to address the functioning of the brain and nervous system (that keeps the alarm stuck on) over psychology
Conclusion
Discussing pain psychology services with patients requires a delicate balance of empathy, clear communication, and respect. Validating their pain, providing easy-to-understand explanations, and presenting pain psychology as an integral part of their treatment plan—often referred to as the third leg of pain management—can help patients recognize its benefits. This approach minimizes the risk of patients feeling pressured, dismissed, or that their pain is being invalidated. With patience and ongoing dialogue, even the most skeptical patients may become more receptive to exploring pain psychology as a valuable component of their treatment options. Ultimately, pain psychology represents an essential facet of comprehensive healthcare.
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References
Ashar YK, Gordon A, Schubiner H, et al. Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial. JAMA Psychiatry. 2022;79(1):13–23. doi:10.1001/jamapsychiatry.2021.2669
Ashar YK, Chang LJ, Wager TD. Brain mechanisms of the placebo effect: an affective appraisal account. Annu Rev Clin Psychol. 2017;13(1):73-98. doi:10.1146/annurev-clinpsy-021815-093015
Baliki MN, Apkarian AV. Nociception, pain, negative moods, and behavior selection. Neuron. 2015;87(3):474-491.
Barrett LF, Simmons WK. Interoceptive predictions in the brain. Nat Rev Neurosci. 2015;16(7):419-429. doi:10.1038/nrn3950
Cherkin, D. C., Sherman, K. J., Balderson, B. H., Cook, A. J., Anderson, M. L., Hawkes, R. J., Hansen, K. E., & Turner, J. A. (2016). Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: A randomized clinical trial. JAMA, 315(12), 1240-1249.
Ehde, D. M., Dillworth, T. M., & Turner, A. P. (2017). Cognitive-behavioral therapy for individuals with chronic pain: Efficacy, innovations, and directions for research. American Psychologist, 72(2), 109-126. https://doi.org/10.1037/amp0000322
Hashmi JA, Baliki MN, Huang L, et al. Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits. Brain. 2013;136(Pt 9):2751-2768. doi:10.1093/brain/awt211
Lumley MA, Schubiner H, Lockhart NA, et al. Emotional awareness and expression therapy, cognitive behavioral therapy, and education for fibromyalgia: a cluster-randomized controlled trial. Pain. 2017;158(12):2354-2363. doi:10.1097/j.pain.0000000000001036
McCracken LM, Vowles KE. Acceptance and commitment therapy and mindfulness for chronic pain: model, process, and progress. Am Psychol. 2014;69(2):178-187. doi:10.1037/a0035623
Nicholas M, Vlaeyen JWS, Rief W, et al; IASP Taskforce for the Classification of Chronic Pain. The IASP classification of chronic pain for ICD-11: chronic primary pain. Pain. 2019;160(1):28-37. doi:10.1097/j.pain.0000000000001390
Schubiner H, Betzold M. Unlearn Your Pain. Mind Body Publishing; 2010.
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ABOUT THE AUTHOR
Les Aria, PhD is a pain psychologist of 20 years and one of the co-founders of Menda Health. His passion for nervous system interventions promotes a unique style in helping patients shift into pain recovery.
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