Module 3 Psychology and Health Topic Pain

1. Solving the issue of specific
questions in 6b)

2. Be very precise in your answer
• 1. Define the perspective you are using
(validity, demand characteristics, usefulness)
• 2. Give evidence for positive / negative
aspects of the perspective using studies as
examples (Discuss the issue in one or two
paragraphs)
• 3. Give a conclusion regarding the perspective

3. Example 1: Validity (6 sentences)
• Psychological studies can have problems of validity which refers
to whether the studies measure what it is meant to measure,
i.e., if it is meant to measure aggression, it actually does so.
Studies conducted to measure adherence, that is whether
patients are actually taking their medicines and following
instructions about lifestyle changes can sometimes be invalid.
For example, the study by Chung and Naya (2000) used an
electronic Track Cap which is an electronic device on the bottle
top that recorded the date and time of use of the medication.
This method may not be valid as the measures may be more
linked to the times the bottle is opened, but not whether the
patient actually took the medicine. Patients may open the
bottle and throw away the pills. Therefore, psychologists have
to be careful in their research design to make sure that they do
measure what they set out to measure.

4. Example 2: Usefulness (5 sentences)
• Usefulness of psychological studies refers to whether the
results obtained are applicable to real life situations or to
provide remedies for problems identified, such as non-
adherence to medical requests. The study by Sherman
(2000) on asthma medicines checked adherence by
telephoning the patient’s pharmacy to assess the refill rate
is useful. The results showed that the adherence rate was
quite low (61%). The study allows psychologists to guide
doctors and nurses about methods they can use when
they want to know how to verify whether their patients
are taking their medications. Using refill checks is
unreliable and it should be used with caution or together
with another method, such as biochemical tests.

5. Example 3: Ecological validity (5 sentences)
• It is important for studies to be ecologically valid. This
means that the studies (design, methods, procedures)
are true to real life and the results will better reflect
reality. For example, the study done by Riekart and
Droter (1999) used real teenagers with insulin-
dependent diabetes mellitus following treatment in
real clinical settings. The results obtained indicating
that self-reports are unreliable methods to measure
adherence are therefore true to life and ecologically
valid. The results can be taken as generally valid and
applicable to this group of patients.

6. Psychology and Health:
Module 3 - Pain

7. Review: Answer “YES” or “NO”
• 1. Is pain an subjective experience?
• 2. It is easy to measure pain.
• 3. Pain can exist without injury and
injury can exist without pain.
• The 3 theories of pain are not valid.
• Pain cannot be measured by self-
reports.
• Pain can best be measured by having
patients fill in a questionnaire about
their pain experience.

8. • Explain how patients with congenital analgesia
die early.
• Why do medical practitioners have problems to
measure pain in their patients?
• How does the GCT explain patients being able to
control their pain experience?
•

9. Module 3 - Pain
• Types and theories of pain
• Definitions of pain. Acute and chronic organic pain;
psychogenic pain (e.g. phantom limb pain). Theories of pain:
specificity theory, gate control theory (Melzack, 1965).
• Measuring pain
• Self report measures (e.g. clinical interview); psychometric
measures and visual rating scales (e.g. MPQ, visual analogue
scale), behavioural/observational (e.g. UAB). Pain measures
for children (e.g. paediatric pain questionnaire, Varni and
Thompson, 1976).
• Managing and controlling pain
• Medical techniques (e.g. surgical; chemical). Psychological
techniques: cognitive strategies (e.g. attention diversion, non-
pain imagery and cognitive redefinition); alternative
techniques (e.g. acupuncture, stimulation therapy/TENS).

10. What is pain?

11. Types and
theories of
pain

12. Define, in your own words what is meant
by the term ‘pain’ / ‘measuring pain’ /
‘controlling pain’.

13. Pain can be defined as a subjective unpleasant experience (both
sensory or physical and emotional) which can be associated with
actual or threatened tissue damage or irritation. Pain can exist
without injury and nearly every person experiences pain.
Measuring pain refers to a variety of methods and
techniques to assess the type, levels and qualities of pain
experienced by patients. These methods can be self-reports,
physiological tests or even behavioural observations.
Controlling pain is defined as the various techniques used
by medical practitioners to help patients reduce or eliminate the
pain they experience. These techniques include medicines, such as
morphine or physical methods such as massages or even
psychological methods such as hypnosis.

14. What is Pain?
• Unpleasant sensation related to the perceived or real
affected body part
• Perception of actual or threatened damage
• Perception based on expectations, past experience,
anxiety, suggestions, cognitive factors
– Acute
– Chronic
• The experience of pain is (individual differences) very
subjective
• Simple Spinal Reflex Arc

15. Describe two types / causes of
pain.

16. Types of Pain
Organic – physical
basis for the pain felt
Psychogenic – there
is no physical basis
for the pain felt
Acute Chronic
Chronic
recurrent pain
Chronic intractable
benign pain
Chronic
progressive pain
Phantom-limb pain

17. Two main categories (types) of pain:
Acute & Chronic
• Acute - is a relatively brief sensation, usually
less than six months duration - usually a
response to a specific trauma - forms the basis
for danger warnings and subsequent learning.

18. • Chronic - lasts more than six months - exists beyond
the time for normal organic healing.
• The pain begins to impair other functions Patients
may begin to experience learned helplessness and
hopelessness this leads to the classic signs of
depression (lethargy, sleep disturbance, weight loss)
• May quit work and adopt a self imposed invalid
existence.

19. Chronic Pain
• Characteristics of
– Symptoms last longer than 6 months
– Few objective medical findings
– Medication abuse
– Difficulty sleeping
– Depression
– Manipulative behavior
– Somatic preoccupation

21. Categories of Chronic Pain
• *Chronic recurrent pain -- benign condition consisting
of intense pain alternating with pain-free periods, e.g.,
migraine, tension headaches.
• * Chronic intractable-benign pain -- benign condition
where pain is persistent with no pain free periods,
although the pain may vary in intensity, e.g., lower back
pain.

22. Categories of Chronic Pain
• * Chronic progressive pain --malignant
condition where pain is continuous and
increases in intensity as the organic condition
(disease) worsens e.g., cancer & rheumatoid
arthritis.

23. Phantom Limb Pain
• Melzack (1992) 7 features
1. Phantom limb feels real. Sometimes amputees try to
walk on their phantom limb.
2. Phantom arm hangs down at the side when resting.
Appears to swing in time with other arm, when
walking.
3. Sometimes the phantom limb gets stuck in awkward
position. If it is behind the patients back, then
patient feels obliged to sleep on stomach.
4. Artificial limb appears to fit like a glove. Patients see
artificial limbs as parts of their body.

24. 5 Phantom limbs give impression of pressure
& pain.
6 Even if phantom limb is experienced as
spatially detached from the body, it is still
felt to belong to the patient.
7 Paraplegic people experience phantom
limbs. They can even experience continually
cycling legs.

25. Phantom limb pain
• Not just the cut nerve endings (neuromas)
sending messages to the brain, because cuts
made along the neural pathways only
produce a temporary relief from pain.

26. • Melzack believes that the brain has a map or
a neuromatrix of the body image.
• Connections to this neuromatrix - sensory
systems, emotional & motivational systems.
• It is the emotional and motivational systems
that cause the phantom limb experience.

27. Phantom Limb Pain
• Neuromatrix pre-wired - young amputees
experience phantom limb pain.
• People born without limbs also experience
phantom limb pain.

28. Other types of pain

29. Congenital Analgesia
• When she was examined by a psychologist (Charles
Murray) in 1950 she did not feel any pain when she was
given strong electric shocks or when exposed to very hot
and very cold water.
• When these stimuli were presented to her she showed
no change in heart rate, blood pressure or respiration.
She did not remember ever having coughed or sneezed,
and did not show a blinking reflex.
• She died at the age of 29 as a result of her condition.

30. Congenital Analgesia
• Although during a post-mortem there were no
obvious signs of what had caused the analgesia in
the first place, she had damaged her knees, hips and
spine.
• This damage was due to the fact that she did not
shift her weight when standing or sitting, did not
turn over in bed and did not avoid what would
normally be considered to be uncomfortable
postures. This caused severe inflammation in her
joints.

31. Congenital Analgesia
• Although there is some evidence that this condition
may be inherited, there are other causes such as
neurological damage.
• However, some cases cannot be explained in this
way. Most people with this condition learn to avoid
causing themselves too much harm but, as in the
case of 'Miss C, may die as a result of the problems
caused by the analgesia.

32. Episodic Analgesia
• Serious injury (e.g., loss of limb) - little pain felt.
• 6 characteristics (Melzack and Wall 1988).
1. The condition has no relationship to the severity or
the location of the injury.
2. No simple relationship to circumstances - occurs in
battle or at home.
3. Victim fully aware of injury but feels no pain

33. Episodic Analgesia
4. Analgesia is instantaneous
5. Analgesia lasts for a limited time
6. Analgesia is localised, pain can be felt in other
parts of the body (Arm blown off is not felt,
but injection is!)

34. Episodic Analgesia
• Carlen et al (1978) - Israeli soldiers - Yom
Kippur War. Loss of arm - 'bang', 'thump' or
'blow'.
• Melzack, Wall and Ty (1982) - 37% of
accident victims reported the experience of
episodic analgesia.

35. Fibromyalgia: Pain Without Injury
• The occurrence of body-wide pain in the absence of
tissue damage, as in fibromyalgia, interferes with all
aspects of a person's life and undermines their
credibility. The problem is that normal activities can
be exhausting, sleep is disturbed, the ability to
concentrate is impaired, gastrointestinal function is
often abnormal, persistent headaches are common,
and the unrelenting pain that no one can see is often
detrimental to their personal and professional lives--
as it creates a "credibility gap."

36. Pain - Injury
• Neuralgia - sharp pain along a nerve pathway.
• Causalgia - burning pain
• Both develop after wound or disease has ended.
Triggered by a simple stimulus e.g., breeze or
vibration.
• Physiological cause of headaches not known.
• Melzack and Wall (1988) report that migraine causes
dilation of blood vessels, not the other way around!
Pain out of proportion to the injury.
• Some cancers produce little pain until they are
advanced. (Serious illness, little pain). Kidney stones
are not serious, but produce excruciating pain.

37. Purpose of pain
• Prevents serious damage. If you touch something
hot, you are forced to withdraw your hand before it
gets seriously burnt.
• Teaches one what to avoid
• If pain is in joints, pain limits the activity, so no
permanent damage can occur.
• but pain can become the problem, and cause people
to want to die.

38. Pain Theory: Historical Perspectives
• Theories regarding the cause, nature, and purpose of
pain have been debated since the dawn of
humankind.
• Most early theories were based on the assumptions
that pain was related to a form of punishment.
• The word “pain” is derived from the Latin word
“poena” meaning fine, penalty, or punishment.

39. Old and new theories of pain
• Specificity theory
– 4 types of sensory receptors – heat, cold, touch, pain
– A nerve responded to only one type
– Nerve was continuous from the periphery to the brain
• Pattern theory
– A single nerve responded to each type of sensation by creating
a code (i.e., like different ring tones)
• Gate control theory
– Melzack & Wall, 1965 – the basis for theories today
– Non-painful stimulus can block the transmission of a painful
stimulus

40. Pain – Melzack & Wall (1965)
Gate Control Theory

42. Melzack & Wall’s Theory of Pain (1965)
What opens the gate?
• Physical Factors
Bodily injury
• Emotional Factors
Anxiety & Depression
• Behavioural Factors
Attending to the injury &
concentrating on the
pain

43. What Closes the Gate?
• Physical Pain
Analgesic Remedies
• Emotional Pain
Being in a ‘good’ mood
• Behavioural Factors
Concentrating on things
other than the injury

44. What else closes the gate?
Friction – when you rub a part of your body it
causes friction, friction signals compete with
pain signals to pass through the gate, if both
signals are trying to get through, the friction
signal will make it first.

45. Past Experience of Pain
Beecher (1946 & 1956) looked at requests for
pain relief amongst soldiers and compared
these to the request made by civilians with the
same injuries. Most of the soldiers claimed not
to perceive any pain and only a quarter of
them requested pain relief.
80% of civilians asked for analgesic support.
Beecher argued that the context in which the
pain was experienced had an impact on the
way in which it was perceived.

46. Evaluation of the Gate-Control Theory
• For
• Experiments with
animals (rats) show that
stimulating certain
areas of the brain
produce numbing effect
on animals & humans
• Most influential model
of pain so far
• Against
• GCT still assumes
simple stimulus-
response model of pain
• No evidence of a ‘gate’
• Still considers physical
& psychological
processes as separate

47. Describe what psychologists have found out
about pain / measuring of pain...

48. Measuring Pain

49. How would you do it?
• Your patient is 15 years old who has been in a car
accident. He is hospitalised and is taking pain
medications for a broken arm.
• Your patient is an elderly woman who has broken
her hip when she slipped on the tiles in her kitchen.
She is unable to speak.
• Your patient is the schizophrenic, with hypomanic
states. He is the 37 year old man, who lives alone
and also has severe migraines from time to time.

50. Difficulty to measure pain
• Doctors often have problems assessing levels of
pain
• Why?
• It is not their own experience
• Experience of pain is subjective
• Expression of pain is subjective
• For example:
• Soldiers and civilians have different levels of pain
experiences & requests for pain medications

51. Which is the better way to measure pain?
• Self reports – simply ask patients about their pain
• Psychometric measures – tests to determine pain levels
• Visual Analogue Scale – have pictorial or visual depictions
of pain
• Behavioural scales / Observation of patients – study
patients to see if they are in pain or not or their levels of
pain being felt
• Pain measures for children – find ways to know if children
are experiencing pain

52. Use self-reports ???

53. Subjective methods:
Clinical Interviews
• How severe is your pain?
• Describe your pain...
• Rated from ‘not at all’ (0) to ‘extremely’ (100)
• Verbal scales: describe your pain
– No pain
– Mild pain
– Moderate pain
– Severe pain
– Worst pain

54. Evaluation
• Validity  Self reports are subjective and it may
be difficult to prescribe exact doses of medicines
to control pain. However, pain experience is
itself also subjective.
• Usefulness– Give an indication of what patients
are feeling, but unfortunately self reports may
not be useful to prescribe doses of medicines.
Behavioural measures to control pain would be
more useful when self reports are used.

55. Use objective methods ???
• Psychometric measures?
• Visual rating scales?

56. The McGill Pain Questionnaire
(MPQ)
– Part I: is used to localize the pain and identify whether the
perceived source of the pain is superficial (external), internal, or
both.
– Part II: incorporates the visual analogue scale.
– Part III: is the pain rating index, a collection of 76 words grouped
into 20 categories. Patients are to underline or circle the words in
each group that describes the sensation of pain being
experienced.
• Groups 1-10= somatic in nature
• Groups 11-15= affective
• Group 16= evaluative
• Group 17-20= miscellaneous words that are used in the
scoring process.

58. Evaluation
• Ecologically valid & useful - used in clinical
settings with real patients
• However, patients need high level of literacy
and awareness to respond to the MPQ;
therefore, it lacks validity and reliability
– Can anyone explain how the MPQ lacks validity or
reliability?

59. Pain Scales
• Visual Analog Scale
• VAS typically consist of a 100 mm horizontal line with
anchors indicating "no pain" at the left endpoint and
"worst pain possible" (or a comparable term) at the
right endpoint.
None Severe
0 10

60. Visual analogue scales can be
improved by having verbal or pictorial
scales.

61. Examples of Visual analogue scales

62. ExamplesofVisualanaloguescales

63. Examples of Visual analogue scales

64. Evaluation
• Patients can mark a continuum of severity
from "No Pain" to "Very Severe Pain“
• Simple and quick to use and can be filled out
repeatedly
• Can track the pain experience as it changes -
this could reveal patterns such as situations or
times of the day when the pain is better or
worse

65. Evaluation
• This method has adequate reliability, however limits
pain to a single dimension (intensity, relief)
• Downie et al., evaluating degree of agreement
between various scales in patients with rheumatic
diseases, found high correlation among different
types of scales.
• Simple to understand & do not demand high degree
of literacy or sophistication on the part of patients,
unlike other pain measurement tools, such as the
semantic differential scales (MPQ).

66. Evaluation
• The Visual Analogue Scale is simple and quick to
administer, and may be used before, during, and
following treatment to evaluate changes in the
patient's perception of pain relative to treatment.
• The scales may also be completed throughout the
course of a day to assess change in pain intensity
relative to activity or time of day.

67. Evaluation
• Verbal, numerical, and visual analogue scales cannot
be used with all patients.
• Ineffective with patients who have cognitive or motor
problems, in patients who are unresponsive (e.g., due
to injury), & in young children and elderly patients.
• Pain often cannot be accurately described & measured
on the basis of severity alone. Qualities of the pain are
absent.
– It is like describing sight only in terms of light or dark,
without regard for colors, patterns, or textures.

68. What about using behavioural and
observational scales?

69. UAB Pain Behaviour Scale
• A commonly used example of an observation tool
for, assessing pain behaviour is the UAB Pain
Behaviour Scale designed by Richards et al
(1982).
• 10 target behaviours and observers have to rate
how frequently each occurs.
• The UAB is easy to use and quick to score; it has
scored well on inter-rater and test-retest
reliability.

71. Evaluation
• Correlation between scores on UAB & on MPQ
is low indicating that the relationship between
observable pain behaviour & self-reports of
the subjective experience of pain is not a close
one.

72. What about measuring
physiological signs to identify
levels of pain???

73. Physiological measures of pain
• Muscle tension is associated with painful conditions
such as headaches and lower backache, and it can be
measured using an electromyograph (EMG). This
apparatus measures electrical activity in the muscles,
which is a sign of how tense they are.
• Evaluation
• Some link has been established between headaches
& EMG patterns, but EMG recordings do not
generally correlate with pain perception (Chapman
et al 1985) and EMG measurements have not been
shown to be a useful way of measuring pain.

74. electromyograph (EMG).

75. Physiological measures of pain
• Another approach has been to relate pain to
autonomic arousal. By taking measures of pulse rate,
skin conductance and skin temperature, it may be
possible to measure the physiological arousal caused
by experiencing pain.
• Finally, since pain is perceived within the brain, it
may be possible to measure brain activity, using an
electroencephalograph (EEG), in order to determine
the extent to which an individual is experiencing
pain.

77. Physiological measures of pain
• It has been shown that subjective reports of
pain do correlate with electrical changes that
show up as peaks in EEG recordings.
• Moreover, when analgesics are given, both
pain report and waveform amplitude on the
EEG are decreased (Chapman et al, 1985).

78. Evaluation
• The advantage of the physiological measures of pain
described above is that they are objective (that is, not
subject to bias by the person whose pain is being
measured, or by the person measuring the pain).
• On the other hand, they involve the use of expensive
machinery and trained personnel.
• Their main disadvantage, however, is that they are not
valid (that is, they do not measure what they say they are
measuring). For example, autonomic arousal can occur in
the absence of pain — being wired up to a machine may
be stressful & can cause a person’s heart rate to increase.

79. Evaluation
• If someone is very anxious about the process of
having his or her pain assessed, or else is worried
about the meaning of the pain, this will cause
physiological changes not necessarily related to the
intensity of the pain being experienced.
• Autonomic responses can be affected by many other
factors such as diet, alcohol consumption & infection,
e.g., infection present can get increased pulse rate.
• Better to be used as a signal for the presence of pain
rather than as a direct indices of pain.

80. Measuring pain in children
• How can this be done in a reliable &
valid way?
• We already know that measuring pain
in adults is very difficult due to validity
& reliability issues

82. Various pain assessment tools
are available for children who
are old enough to
communicate. Pain scales
have been developed using
numbers, colors, and facial
expressions.
In preverbal children, several
pain scales have been
validated. The CHEOPS
(Children’s Hospital of Eastern
Ontario Pain Scale) is a well-
validated tool for the
assessment of pain in
children.
It was initially developed for
postsurgical patients, but has
been used broadly since.

83. Varni & Thompson Paediatric Pain
Questionnaire (PPQ)
• A multidimensional questionnaire for assessing childhood
pain, with separate forms for:
– Paediatric patient (child)
– Parent
– Clinician.
• Modeled after McGill Pain Questionnaire (Melzack, 1975).
• PPQ assesses physician, patient, & parent perceptions of
the patient's pain experience in a developmentally
appropriate format.
• More specifically, this instrument measures pain intensity,
location, and the sensory, evaluative, and affective qualities
of the pain.

84. • The different forms use different formats, such
as using colours for younger children &
descriptive terms for adolescents.
• PPQ has been translated into numerous
languages, inc. Danish, French for France & for
Canada, Norwegian, Portuguese for Brazil,
Spanish for the United States, & Swedish.

85. Evaluation
• In terms of psychometrics, good test–retest estimates
for 1-week, 3-week, and 6-month intervals and
correlations between child, parent, nurse, and
physician ratings of present pain and worst pain have
been found for the PPQ.
• Furthermore, significant cross-informant ratings have
been obtained but correlations have been higher
between parent–child versus those with physicians.
• Considered as "well-established.“= valid + reliable

86. Managing & controlling pain

87. Medical techniques
• 2 main possibilities:
– Medication
– Surgery
• Other physical methods:
– Massage
– Applying heat
– Transcutaneous Electrical Nerve Stimulation (TENS)

88. What type of surgery can be done to
alleviate pain?
• Severing nerves, either at the periphery or in
the central nervous system (spine & brain)
• Implanted pain control systems
– Implanted pain control systems involve inserting
devices under your skin or elsewhere in your
body. The devices use medicine, electric current,
heat, or chemicals to numb or block pain.

89. Implanted pain control systems
• Intrathecal drug delivery sends medicine to the
area of your pain.
• Electrical nerve stimulation uses electric current
to interrupt pain signals.
• Nerve ablation destroys or removes the nerves
that are sending pain signals.
• Chemical sympathectomy uses chemicals to
destroy nerves. This treatment may be used for a
type of chronic pain called complex regional pain
syndrome, which affects the nervous system.

90. Medicines…? But, what types??
• Over-the-counter (OTC) pills, e.g.,
aspirin (acetylsalicylic acid),
acetaminophen (Paracetamol,
Panadol / Tylenol / Advil)
– Non Steroid Anti-Inflammatory Drugs
(NSAIDS)
• Opioids – codeine, morphine
• Implantable drug pumps

91. Chemicals
• Aspirin, Ibuprofen, Paracetamol
(acetaminophen)
– Against pain
– Against inflammation
– Against fever
Opium used before then, as early as 1550 BC

92. Evaluation - surgery
• Immediate relief by going to the source of the
problem
• Done under doctor’s supervision
• BUT
• Invasive
• Expensive
• Time-consuming
• Does not always work

93. Evaluation - Medications
• Immediate relief
• Self-management
• OTC available & easily accessible
• BUT
• Lots of side-effects (Aspirin – stomach lining burn,
ulcers, thins the blood  excessive bleeding)
• Opioids are very addictive; needs medical supervision.
Can be diverted to illicit markets.
– Solution? Disguise taste, reduce doses, give in regular
intervals & not when requested by patients, use
psychological techniques
• Tolerance develops quickly = needing higher doses.

95. Evaluation
• Not known how heat works, but fits in with
the gate theory (closes the gate)
• Mild pulses of electricity in painful areas
probably works in the same way.
• Suitable for some patients, not all
(Remember: customising treatment)

96. Psychological techniques
• Relaxation
• Biofeedback
• Hypnosis
• Cognitive coping skills
• Operant techniques
• Mental imaging
• Self-efficacy
• Counselling

98. Evaluation
• Hypnosis produces a high degree of analgesia in only a
minority of individuals.
• Those people who can be hypnotised very easily and
deeply seem to gain more pain relief from hypnosis
than those who are less hypnotically susceptible.
• Hypnosis could be seen as a form of relaxation.
• Hypnosis often produces states of heightened
attention to internal images and inattention to
environmental stimuli.