The Psychology of Emotion: Morbid and Normal (International Library of Psychology)
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A normal psychology of pain is better suited to the exploration of all of the functional characteristics of pain complaint. In summary, pain is not only inevitable, but is fundamentally threatening. It promotes avoidance and urges escape by interrupting other behavioural priorities, focuses attention to self, signals danger to others and increases vigilance for cues to pain. These functions, we have argued, are far from abnormal and can parsimoniously be understood as features of a normal attention and motivational system operating in the context of chronic alarm.
Attention and pain Viewing pain as an interruptive signal, functioning to alarm an organism of possible danger, requires that we account for how pain achieves interruption and what the consequences of that interruption are. Important for how quickly one can attend back to other important aspects of life once interrupted by pain is the speed and effectiveness of our evaluation of pain as unthreatening Legrain et al.
Pain is an important warning system, but like all warning systems it can deliver false alarms, or the source of the alarm emerges as less important than other demands. A good example of our control over pain is when a superordinate goal is at play: we are willing to endure needle pain because we judge inoculation to be important, some can run Consider chronic pain from this normal psychological understanding of attention.
Experiencing chronic pain is to experience chronic interruption and chronic alarm. Imagine what life would be like if every 90 seconds one was interrupted by an unpleasant and threatening signal of danger that has priority into your awareness pushing aside any other thoughts, goals, plans or emotions. People who are chronically alarmed report this not only to be distressing, but also depressing as one struggles ineffectually to control the interruption and return to other valued life activities Linton et al.
In such a context of persistent interruption one would expect neuropsychological problems to emerge, and indeed patients report memory loss and attentional dysfunction Dick et al. Faced with inescapable pain, depression, anxiety and the relatively punishing responses from those fatigued by their own failure to help Cano et al. Typically, however, people do not surrender, and instead persist in a variety of analgesic behaviours, including treatment seeking.
This paradox is one that frequently challenges health professionals, who, when faced with seemingly healthy i. A normal psychology of pain can help explain this seemingly paradoxical behaviour. We have not evolved to ignore warning signals. To do nothing in the face of pain interruption is not only counter-cultural but it is also counter-biological. In my experience, the average chronic pain patient is far from passive; people are actively engaged in ruminating about possible causes and consequences of pain, and possible actions. This model of misdirected problem solving presents people as active in their pursuit of pain management.
Figure 1 represents the psychological processes involved in making sense of pain. People typically construct pain as diagnostic and attribute the cause of pain to potential damage. Such attributions promote problem-solving behaviours such as seeking treatment. Some people develop a heightened awareness of cues for pain and become hypervigilant for signals of possible pain Van Damme et al.
This is a specific feature in which cues for possible pain become generalised. Others persist in seeking a solution to the problem of pain, in which the pain must be removed. Some persevere in seeking solutions for pain regardless of the negative outcomes.
A problem-solving model of chronic pain helps guide different approaches to psychological treatment. However, where the focus of treatment is on a more thoroughgoing accommodation of a life changed to one in which pain is a feature, but not a central one, then acceptance and commitment therapy is emerging as the treatment of choice McCracken, Evidence-based psychological treatments Psychological treatments for chronic pain have a strong tradition of empirical investigation. For the Cochrane Library www.
We are now updating both reviews. There are now 60 randomised controlled trials of cognitive behavioural and behavioural interventions for adult chronic pain and 20 for child chronic pain. For adult chronic pain there are some empirical studies of exposure interventions for those with high fear of pain and damage e.
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Leeuw et al. However, the evidence base is dominated by studies of cognitive behavioural or behavioural treatments for chronic pain.
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These vary from multifactorial, multidisciplinary residential treatment programmes running for four weeks e. Williams et al. Turner et al. In general, the goals of treatment are to reframe the problem of pain toward one of self-management, improve engagement in valued activities, reduce affective distress, and reduce the complaint of pain. Many treatments have additional specific targets depending on the particular population or treatment.
In general, the news is good and treatments are promising, although there is some cause for concern. In the last 10 years the quality of design of randomised controlled trials has improved. There is now a better understanding of how to undertake well-controlled studies free from bias. Unfortunately, however, as more studies are conducted and added, the overall effectiveness of psychological interventions is reducing.
It is not exactly clear how to understand this, but there are at least three related explanations. First, in recent years there has been social pressure to develop shorter treatments that can be delivered by a range of healthcare professionals. The database is now overrepresented by studies of relatively weak treatments delivered by staff with minimal training, producing weak effects. Second, many of the studies that dominated early systematic reviews were those of pure behavioural interventions, such as biofeedback and relaxation training, delivered intensively following theoretically informed manuals.
These are now rarely reported. Third, the recent studies are better designed, with larger populations, and have increased power. The next generation of studies will benefit from a clear rationale as to the aims of treatment, and from being delivered effectively and at an appropriate dose. In addition, sorely needed in this field is some control over what is labelled a psychological intervention and better discrimination over what enters meta-analyses Eccleston et al.
For children in chronic pain most empirical treatments have been developed for headache, which is the most common childhood pain complaint. These treatments are remarkably effective in reducing the frequency and severity of headache, and represent one of the great good news stories of psychotherapy. Brief behavioural interventions, principally relaxation training, habit management and targeting cues for intermittent pain episodes, are very effective and inexpensive interventions.
Such therapies have been delivered in school settings with excellent results.
Despite this effectiveness these treatments are rarely offered or practised, due in part to a general ignorance of their effectiveness and availability. Great advances can be made in the treatment of childhood pain by improved effort at knowledge transfer. Evidence is lacking, however, for the effectiveness of psychological interventions for the non-pain child outcomes, including distress and disability. Also rare are randomised controlled trials of interventions for chronic conditions other than headache.
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There have been developments in programmatic, multifaceted and multidisciplinary psychological interventions eg. Eccleston et al. But this is a young field that is growing quickly.
Exciting developments are being generated in computer-assisted therapies. For example, Tonya Palermo has created an effective online coping skills training programme for young people with headache, which promises greater access for a large number of currently untreated sufferers Palermo et al. Overall, the evidence base for psychological interventions is promising. The next generation of studies will need to respond to three main developments in the field.
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First, we will see tailored treatments for specific conditions. For example, there is a growing population of new chronic pain sufferers with pain from iatrogenic causes such as treatment for cancer, and new populations of people presenting with complex comorbid conditions such as pain and obesity, pain and chronic heart failure, and pain and dementia. Second, there are advances in psychotherapy such as exposure therapy, attentional retraining, and acceptance and commitment therapy that have yet to be tested in controlled trials.
Third, there are developments in electronics, computing and robotics that offer the promise of increasing access to effective treatments by remote delivery. Telemedicine for pain is at a very early but exciting stage Keogh et al. Conclusion Chronic pain can devastate the lives of both adults and children. People with pain often persevere in misdirected attempts to solve the problem of pain, unwittingly working deeper into distress and disability.
Applying a normal psychology of pain can help us understand the origins of disability and guide the development of better treatments. If patients are offered or sold it, we are interested in whether it works. Attention and motivation: Dr Ed Keogh, a senior lecturer in psychology and Deputy Director of the Centre for Pain Research, runs the pain laboratory and our studies on the effects of pain on cognition.
We are particularly interested in how pain interrupts, and how to mitigate its effects. He has developed novel treatments for chronic pain focusing on a contextual approach and is currently running randomised controlled trials to examine their effectiveness.