What is Chronic Pain Management?

By Dina Perez Neira, Ph.D., Clinical Psychologist

The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” This is a broadly used and accepted definition of both short-term acute pain and Chronic Pain. Every person experiences pain differently and nobody is able to know what the sensation of pain feels like for somebody else.

Acute pain is of short duration or recent onset, may act as a warning or have a protective purpose. It follows injury and generally disappears when the injury heals. It can occur when we get sunburn, sprain an ankle, get a headache, develop kidney stones, suffer a heart attack, break a bone and other short term events.

Chronic Pain, however, refers to persistent pain that typically occurs without signs of autonomic nervous system hyperactivity, serving no purpose, and often associated with hopelessness, helplessness, inability to experience joy, with changes in appetite, sleep disturbances, irritability and decreased social interactions, among other difficulties. The IASP defines Chronic Pain as “pain which has persisted beyond normal tissue healing time.” Although there is no officially accepted time, any pain lasting for more than three months is generally considered to be Chronic Pain. Some individuals may suffer Chronic Pain for decades.

Possibly the most common complaint of people with Chronic Pain is that their sleep is negatively impacted, either because they are awakened by pain every hour or so, or because they cannot find a comfortable position. During the night as there are less distractions, pain seems to become more prominent. People with Chronic Pain find themselves thinking about what the pain means in their lives, whether the doctors have failed to detect something ominous, whether this is their end, whether the pain will kill them, and whether it is worth it to continue living as they imagine this pain will only get worse and render them incapacitated. Upon awakening, the patient feels non-rested and his energy is depleted to engage in any activity during the day. They feel worn out. Because of their biological and psychological reaction to lack of rest and to stress, they are less able to tolerate any pain and often become hypersensitive to any kind of physical or emotional stimulus. And this is only the beginning of the Chronic Pain Syndrome.

Chronic Pain patients report that they have gradually grown more irritable and impatient, becoming angry at the most insignificant reason, saying cruel things sometimes, which then brings feelings of guilt and increasing isolation from friends and family. Some patients either lose their appetite or overeat, which combined with their lack of physical activity, contributes to obesity, negatively impacting their self-esteem. There is a significant incidence of major depressive disorder as result as well. Many Chronic Pain patients are unable to continue working and support themselves with disability or workers’ compensation funds, which contributes to changes in their family power dynamic and their self-worth.

Frustration begins to be felt by medical providers and patients alike, over inability to control the pain that the patient describes. Mutual blaming can develop as the doctor is unable to heal the patient and the patient believes there must be something that can stop his pain.

Chronic Pain Treatment

The purpose of the treatment of Chronic Pain is two-fold, to increase functioning and improve quality of life. First and foremost, it is important to realize that Chronic Pain is not a symptom, is not a warning sign, and is not a need-state for rest. Rather, Chronic Pain is a syndrome. This means that it is composed of physical, emotional, and behavioral changes. Chronic Pain is a warning sign that serves no purpose, similar to a broken alarm. The purpose of the treatment of Chronic Pain is to lower the volume of this alarm to levels that allow the patient to recover function and quality of life comfortably. In other words, to keep Chronic Pain under management, like any other chronic disorder (e.g., asthma, diabetes).

Because Chronic Pain impacts all aspects of the individual — body, mind, and spirit — it is important to keep in mind that all aspects will need to be addressed in order to learn how to manage it. Biologically, medications, surgery, nutrition, and exercise need to be considered. Socially, consideration will be required to healthcare, family, work, and friends. Psychologically, the approach will include cognitions, emotions, behaviors, sleep, and attention.

The management of Chronic Pain includes believing the patient’s pain complaint, taking a thorough and careful history of the pain complaint, evaluating the psychological history and the impact pain has had on the life of the patient. The pain psychologist keeps in mind that the diagnosis of the patient, whatever the etiology, is Chronic Pain, and thus considers coordinating complementary methods with other pain professionals during the initial evaluation and continually reassesses the pain complaint during the prescribed therapy.

With the goal of increasing functioning and improving life quality, a Chronic Pain psychologist provides among other benefits, skills for the management of Chronic Pain. Psychological methods used to manage pain include:

Patient Education: teaching the patient about what may aggravate and relieve pain, with the purpose of reducing Pain, analgesic use and potential length of hospital stay.
Contingency Management: includes manipulation of environmental consequences of pain behavior, to help the patient to change behavior.
Neuroscience: at the patient’s level, neuroscience is introduced to ensure that the pain sufferer realizes that rewiring his brain means that the more he practices a new skill, the more his brain changes to make the skill come easily but also to balance his autonomic nervous system.
Cognitive Behavioral Therapy: combining cognitive and behavioral techniques to alter pain perception or labeling by decreasing negative thoughts, emotions and beliefs, increasing sense of control and decreasing maladaptive behavior. Considering the brain neuroplasticity, Cognitive Restructuring may be used to teach the patient to monitor and evaluate negative thoughts, and to generate more accurate and adaptive ones.
Coping Skills Training: helping the patient develop coping skills to manage pain and stress. Relaxation techniques with imagery, hypnosis, biofeedback, and autogenics are often used.
Finally, Psychotherapy to establish a relationship with the patient to achieve goals identified by the patient that include modifying symptoms, changing maladaptive behaviors, and promoting growth and development. Psychotherapy may include different approaches, including psychodynamic therapy.

Conclusively, keep in mind that making changes in negative lifestyles, behaviors and attitudes has been found to result in a number of specific health benefits and can greatly improve the ability of the patient to cope with Chronic Pain.

SOME SUGGESTED READINGS RELATED TO CHRONIC PAIN TREATMENT:

Arden, J. B. (2015). Brain2Brain.
Buchholz, M.D. (2002). Heal Your Headache.
Caudill, M.A. (1995). Managing Pain Before it Manages You.
Martin, P.R. (2003). Psychological Management of Chronic Headaches.
Sternback, R.A. (1988). Mastering Pain.
Turk, D.C., Melzack, R. (1992). Handbook of Pain Assessment.

About this Contributor: Dina Perez-Neira, Ph.D., is a clinical psychologist in private practice in San Francisco, specializing in the treatment of Chronic Pain, Post Traumatic Stress Disorder (PTSD) and Mood Disorders. Dina received her B.A in Psychology from San Francisco State University and Ph.D. in Clinical Psychology from PGSP (now Palo Alto University). She has been a Clinical Professor for the University of California, San Francisco, Department of Family and Community Medicine, Pain Management Program and a Psychologist at San Francisco General Hospital Chronic Pain Clinic. She provides individual, couple, and group therapy using evidence-based psychological treatments and is bilingual (English/Spanish). Dina writes: “I have always had an interest in helping people. Through my work as a psychologist, counselor, and educator, I’ve had the opportunity to see significant improvements in a person’s life and well being.” For more information about Dina’s work, please visit her website: DrDinaPerezNeira.com or call her office: 415-271-4546.