Pain: Perception, Interpretation,

and Management
Defining Pain: More Than a Sensation
What is Pain?

● Pain serves as a critical feedback and warning system, signaling that something is
wrong and motivating protective behaviors. It triggers help-seeking and encourages
adjustments to prevent further harm.
● Pain is not just a physical event; it has significant psychological consequences,
including fear and anxiety. Some pain appears to lack an underlying organic cause and
is primarily psychological.
Acute vs. Chronic Pain

Acute Pain:

● Lasts for six months or less.

● Typically has a clear, definable cause (e.g., a broken leg, surgical wound).
● Usually manageable with pharmacological treatments like painkillers.

Chronic Pain:

● Persists for longer than six months.

● Medical treatments are often ineffective, suggesting a larger psychological role.
● Can be benign (varies in severity, e.g., chronic low back pain) or progressive (worsens over time, e.g., rheumatoid
arthritis).
Early Biomedical Models - Pain as Sensation
Pain as a Direct, Automatic Sensation

Early models described pain within a biomedical framework as an automatic response to an external factor.

Descartes' Mechanistic Model:

● Descartes regarded pain as a simple response to a painful stimulus.

● He described a direct pathway from the source of pain (e.g., a burnt finger) to an area in the brain that detected the painful
sensation.

Core Assumptions

● Tissue damage is the direct cause of the sensation of pain.

● The individual is a passive recipient; pain is an automatic response to an external stimulus with no room for interpretation or
moderation.
● Psychology's role was limited to being a consequence of pain (e.g., anxiety, fear), not a causal influence.
● Pain was strictly categorized as either organic ('real' pain with a visible injury) or psychogenic ('all in the mind' when no
organic basis could be found).
Early Biomedical Models - Pain as Sensation
Later biomedical theories refined the concept of pain transmission but remained within the stimulus-response framework.

Specificity Theory (Von Frey, 1895):

● This theory suggested there were specific sensory receptors which transmit distinct sensations like touch, warmth,
and pain.
● Each receptor was believed to be sensitive only to a specific type of stimulation.
● Like Descartes' model, it maintained that the link between the cause of pain and the brain was direct and automatic.

Pattern Theory (Goldschneider, 1920):

● This model offered an alternative, suggesting that the pattern of nerve impulses determined the degree of pain.
● It moved away from the idea of specific pain receptors, proposing instead that the intensity and frequency of signals
from a damaged area were coded into patterns that the brain interpreted as pain.
● Despite this nuance, the core concept remained the same: messages were sent directly to the brain via these nerve
impulses.
The Paradigm Shift - Evidence for Psychology's Role
Why the Biomedical Models Were Insufficient

Several key observations in the mid-20th century demonstrated the limitations of a purely physiological view of pain.

1. Ineffectiveness for Chronic Pain: Medical treatments like drugs and surgery, which were effective for acute pain, were found
to be "fairly ineffective" for treating chronic pain, suggesting something else was involved.
2. Individual Variability & The Role of Meaning:
● Beecher's WWII Study (1956): A landmark observation where Beecher reported that while soldiers and civilians often
presented with the same degree of injury, 80% of civilians requested medication, whereas only 25% of soldiers did.
● Interpretation: Beecher suggested this reflected the meaning of the injury. For the soldiers, the wound had a positive
meaning—it signified survival and that their war was over. This positive meaning actively mediated their experience of pain.
3. The Paradox of Phantom Limb Pain:
● The majority of amputees feel pain in an absent limb, which can worsen even after complete healing.
● This phenomenon has no peripheral physical basis, directly challenging theories that require a physical stimulus. The
variation in its occurrence, and reports from individuals born with missing limbs, strongly points to a central, psychological
mechanism.
The Gate Control Theory (Melzack & Wall, 1965)
The Gate Control Theory (GCT) was the first major model to formally integrate psychology, reframing pain
as a perception rather than a simple sensation.

● The GCT proposes that a neurological "gate" exists at the spinal cord level that modulates the flow
of pain signals to the brain.
● According to the GCT, pain is a perception and an experience, not a sensation. This change in
terminology reflects the active role of the individual in interpreting the painful stimuli, much like vision
is an interpretation of light, not a direct mirror image.
● The individual is no longer a passive responder but actively interprets and appraises painful stimuli.
● The theory fundamentally departs from dualism by suggesting an active interaction between
psychological and physiological processes, allowing for psychological causes and interventions.
Ascending Physiological Inputs
Signals Traveling from the Body to the Gate

The GCT details how signals from the periphery travel towards the brain and interact at the spinal gate.

Peripheral Nerve Fibres:

The site of injury (e.g., the hand) sends information about pain, pressure, or heat to the gate.

The Role of Large and Small Fibres:

● This is a key physiological component of the model.

● Small nerve fibres (A-delta and C fibres) are understood to carry pain signals. Activity in these fibres tends
to open the gate, increasing the transmission of pain signals.
● Large nerve fibres (A-beta fibres) carry non-painful information like touch and pressure. Activity in these
fibres tends to close the gate, inhibiting the transmission of pain signals.
Descending Central Influences
Signals Traveling from the Brain to the Gate

This is the most revolutionary aspect of the GCT, where psychology directly influences physiology.

The brain sends information related to the psychological state of the individual down to the gate in the spinal cord. These descending
pathways can powerfully open or close the gate, overriding the peripheral signals.

○ Cognitive State:
■ Expectations & Beliefs: Expecting something to be painful can open the gate before the stimulus even occurs.
■ Previous Experiences: Past experiences with pain can prime the gate to be more open or closed.
■ Self-Efficacy: A belief that one can cope with the pain can send signals to close the gate.
○ Emotional State: Strong emotions like anxiety, fear, and depression are potent gate-openers.
○ Behavioural State:
■ Attention: Focusing intently on the source of pain opens the gate.
■ Distraction: Engaging in another absorbing activity sends signals to close the gate
The gate integrates all of
the information from these
different sources and
produces an output. This
output from the gate sends
information to an action
system, which results in
the perception of pain.
Factors that OPEN Factors that CLOSE
the Gate (Increase the Gate (Decrease
Pain) Pain)

Physical Factors: Injury or activation Physical Factors: Medication,

of the large fibres. stimulation of the small fibres.

Emotional Factors: Anxiety, worry, Emotional Factors: Happiness,

tension, and depression optimism, or relaxation.
Behavioural Factors: Concentration,
Behavioural Factors: Focusing on the distraction, or involvement in other
pain or boredom. activities.
Strengths and Limitations
While revolutionary, the GCT is not without its problems and has been refined over the years.

Key Advancements:

● Introduced a central and causal role for psychology in pain perception.

● Provided a framework for understanding individual variability.
● Shifted the view of the patient from a passive recipient to an active processor of pain.

Limitations:

● While the mechanisms of modulation are well-documented, no one has yet physically located the "gate"
itself; it remains a powerful conceptual model.
● The model still largely assumes that an initial physical injury or organic stimulus is required to start the
process. This doesn't fully account for pain with no discernible cause.
● Although it proposes an interaction, the GCT still largely treats the mind and body as separate entities that
influence one another, rather than a fully integrated system. The processes are described as distinct, even if
they interact.
The Modern Biopsychosocial Framework
Building on the GCT, modern pain research reflects a three-process model, emphasizing the
dynamic interaction between different domains.

1. Physiological Processes:
○ Includes factors like tissue damage, the release of endorphins, and changes in heart
rate.
2. Subjective-Affective-Cognitive Processes:
○ The internal, psychological experience, including learning, emotion (affect), and thought
patterns (cognition).
3. Behavioural Processes:
○ The observable actions and responses to pain, such as pain behaviours and secondary
gains.

Crucially, these processes are not discrete but are interrelated and at times
interchangeable. For example, cognitive factors (catastrophizing) influence emotional states
(anxiety), which in turn influence physiology (muscle tension) and behaviour (avoidance).
The Biological Underpinnings of Pain
These processes encompass the biological and neurological events within the body that contribute
to the initiation and transmission of pain signals.

● Tissue Damage: The initial physical event that often, but not always, triggers the pain
process.
● Nociception: The sensory process involving specialized receptors (nociceptors) that detect
actual or potential tissue damage and transmit signals to the spinal cord.
● Neurochemical Activity: The release of chemicals at the site of injury and within the central
nervous system that sensitize nerves and modulate signal transmission.
● Autonomic Changes: Observable physiological responses such as "changes in heart rate,"
sweating, and changes in skin temperature.
● Endogenous Opioid System: The body's natural pain-relief system, involving "the release of
endorphins" that can inhibit pain signals.
The Role of Learning
How Past Experience Shapes Present Pain

Classical Conditioning:

● An individual may associate a particular environment with the experience of pain. For example, if a person
associates the dentist with pain from past experience, their pain perception may be enhanced when
attending the dentist due to this expectation.
● This association can also increase anxiety, which may further increase pain. A study by Jamner and
Tursky (1987) found that presenting migraine sufferers with pain-associated words increased both their
anxiety and pain perception.

Operant Conditioning:

● Individuals may respond to pain by showing pain behaviour (e.g., resting, grimacing, limping, staying off
work).
● Such behaviour may be positively reinforced by sympathy, attention, or time off work, which may itself
increase pain perception and disability.
The Role of Affect: Anxiety
Exploring Worry

● Some research has explored how patients worry about their pain.
● For example, Eccleston et al. (2001) asked 34 male and female chronic pain patients to
describe their experience of pain over a seven-day period.
● The results showed that the patients reported both pain related and non-pain related worry
and that these two forms of worry were qualitatively different.
● In particular, worry about chronic pain was seen as more difficult to dismiss, more distracting,
more attention grabbing, more intrusive, more distressing and less pleasant than non pain
related worry.
Relationship between Anxiety and Pain

● Other research has explored how worry and anxiety relate to pain perception.
● Fordyce and Steger (1979) examined the relationship between anxiety and acute and chronic pain.
● They reported that anxiety has a different relationship to these two types of pain.
The Cycle in Acute Pain 📈
● In terms of acute pain, pain increases anxiety, the successful treatment for the pain then decreases
the pain which subsequently decreases the anxiety.
● This can then cause a further decrease in the pain.
● Therefore, because of the relative ease with which acute pain can be treated, anxiety relates to this
pain perception in terms of a cycle of pain reduction.
The Cycle in Chronic Pain 📉
● However, the pattern is different for chronic pain.
● Because treatment has very little effect on chronic pain, this increases anxiety, which can further
increase pain.
● Therefore, in terms of the relationship between anxiety and chronic pain, there is a cycle of pain
increase.
 The Role of Affect: Fear (Fear Avoidance)
The Experience of Fear

● Many patients with an experience of pain can have extensive fear of increased pain or of the pain
recurring which can result in them avoiding a whole range of activities that they perceive to be
high risk.

● For example, patients can avoid moving in particular ways and exerting themselves to any extent.

How Fear is Described

● However, these patients often don't describe their experiences in terms of fear but rather in
terms of what they can and cannot do.

● Therefore, they don't report being frightened of making the pain worse by lifting a heavy object,
but they state that they can no longer lift heavy objects.
Fear and Pain Onset

● Fear of pain and fear avoidance beliefs have been shown to be linked with the pain
experience in terms triggering pain in the first place.

Research by Linton et al. (2000)

● For example, Linton et al. (2000) measured fear avoidance beliefs in a large community
sample of people who reported no spinal pain in the preceding year.
● The participants were then followed up after one year and the occurrence of a pain episode
and their physical functioning was assessed.
● The results showed that 19 percent of the sample reported an episode of back pain at
follow-up and that those with higher baseline scores of fear avoidance were twice as likely to
report back pain and had a 1.7 times higher risk of lowered physical functioning.
● The authors argue that fear avoidance may relate to the early onset of pain.
Fear and Pain Progression

● Some research also suggests that fear may also be involved in exacerbating existing pain
and turning acute pain into chronic pain.
● For example, Crombez et al. (1999) explored the interrelationship between attention to pain
and fear.

Mechanism: Attentional Interference

● They argued that pain functions by demanding attention which results in a lowered ability to
focus on other activities.
● Their results indicated that pain related fear increased this attentional interference suggesting
that fear about pain increased the amount of attention demanded by the pain.
● They concluded that pain related fear can create a hyper-vigilance towards pain which could
contribute to the progression from acute to chronic pain
The Role of Affect
Anxiety and Fear as Pain Amplifiers

Anxiety:

● Fordyce and Steger (1979) described how anxiety has a different relationship with acute versus chronic [Link]
acute pain, successful treatment reduces pain, which in turn reduces anxiety, creating a positive cycle of pain
[Link] chronic pain, because treatment often has little effect, this increases anxiety, which can further increase
pain, creating a vicious cycle of pain increase.
● Worry about chronic pain is qualitatively different from other worries; it is more difficult to dismiss, more distracting,
more intrusive, and more distressing.

Fear & Fear-Avoidance Beliefs:

● Many patients develop an extensive fear of increased pain or re-injury, leading them to avoid a range of activities
they perceive to be high-risk.
● Linton et al. (2000) found that healthy individuals with higher baseline fear-avoidance beliefs were twice as likely to
report an episode of back pain one year later and had a 1.7 times higher risk of lowered physical functioning. This
suggests fear can precede the onset of pain.
● Pain-related fear can create a hyper-vigilance towards pain, which could contribute to the progression from acute to
chronic pain.
The Role of Cognition

● Catastrophizing: A negative cognitive-affective response to pain, defined by Keefe et al. (2000)

as involving three components:
1. Rumination: An obsessive focus on threatening information (e.g., "I can feel my neck click whenever
I move").
2. Magnification: Overestimating the extent of the threat (e.g., "The bones are crumbling and I will
become paralysed").
3. Helplessness: Underestimating one's ability to cope (e.g., "Nobody understands how to fix the
problem and I just can't bear any more pain").
● Meaning: The interpretation of pain significantly alters its perception. The pain of childbirth, for example, is
experienced differently than a similar level of unexplained pain.
● Self-Efficacy: An individual's belief in their own ability to manage or control their pain is a key factor in
determining the degree of pain perception.
● Attention: Focusing attention on pain can exacerbate it, whereas distraction can reduce the experience.
Eccleston and Crombez (1999) argue that pain's function is to interrupt and demand attention to
encourage escape and action.
Link to Pain Problems

● Catastrophizing has been linked to both the onset of pain and the development of longer-term pain problems (
Sullivan et al. 2001).
● For example, in the prospective study described above by Linton et al. (2000), the authors measured baseline levels of pain
catastrophizing. The results showed some small associations between this and the onset of back pain by follow-up.

Research in Children

● Crombez et al. (2003)

developed a new measure of catastrophizing to assess this aspect of pain in children.
● Their new measure consisted of three subscales reflecting the dimensions of catastrophizing, namely rumination, magnification
and helplessness.
● They then used this measure to explore the relationship between catastrophizing and pain intensity in a clinical sample of 43
boys and girls aged between 8 and 16. The results indicated that catastrophizing independently predicted both pain intensity
and disability regardless of age and gender.
Behavioural Processes
How We Act Influences How We Feel

Pain Behaviours: Observable responses to pain, defined by Turk et al. (1985)as:

● Facial/Audible Expressions: Clenched teeth, moaning.

● Distorted Posture/Movement: Limping, protecting the painful area.
● Negative Affect: Irritability, depression.
● Avoidance of Activity: Not going to work, lying down.

Reinforcement & Secondary Gains:

● It has been suggested that pain behaviours are reinforced through attention and through secondary gains, such as
not having to go to work.
● Positively reinforcing pain behaviour may increase pain perception and lead to a sick role, lack of activity, muscle
wastage, and no social contact, which can all increase pain perception.

Communication:

Williams (2002) provides an evolutionary analysis, arguing that facial expressions are a means to communicate pain and
elicit help. However, stronger expressions may be interpreted by others as amplified or as indications of malingering,
affecting the social response.
The Three-Process Model - Dynamic Interactions
Pain as an Integrated Experience

The power of this model lies in understanding that these three processes are not isolated but are constantly interacting.
They are "interrelated rather than discrete categories of discrete factors".

● Cognitive-Affective-Behavioural Links:
○ Fear (affect) influences attention (cognition).
○ Fear (affect) interacts with catastrophizing (cognition).
○ Catastrophizing (cognition) influences attentional interference.
● The Vicious Cycle in Practice:
○ Example: A patient with back pain (Physiological) catastrophizes about re-injury (Cognitive). This leads to
fear and anxiety (Affective). As a result, they avoid physical activity (Behavioural). This leads to muscle
deconditioning, which increases their baseline pain (Physiological), thus confirming their catastrophic beliefs
(Cognitive), and the cycle intensifies.
● Framework for Understanding:
○ The three-process model offers a framework for mapping out the different factors that influence pain. This
categorization helps organize our thinking, but in practice, the components are deeply intertwined
Psychological Interventions for Pain Management
Chronic pain has proven resistant to purely pharmacological approaches, leading to the establishment of multidisciplinary pain clinics.

Goals of Pain Clinics:

● Improve physical and lifestyle functioning.

● Decrease reliance on drugs and medical services.
● Increase social support and family life.

Key Therapeutic Methods:

● Respondent Methods: Modify physiological systems directly.

○ Examples: Relaxation, biofeedback, and hypnosis to reduce muscular tension and anxiety.
● Cognitive Methods: Target and modify maladaptive thoughts about pain.
○ Examples: Attention diversion, positive imagery, and Socratic questions to challenge automatic negative thoughts.
● Behavioural Methods: Use principles of operant conditioning to change behaviour.
○ Examples: Graded exercises and reinforcement to help patients become more active.
 Psychological Interventions for Pain

Acute pain is mostly treated with pharmacological [Link], chronic

pain has proved to be more resistant to such approaches.

Recently, multidisciplinary pain clinics have been set up that adopt a

multidisciplinary approach to pain treatment.

Current treatment philosophy also emphasizes early intervention to prevent the

transition of acute pain to chronic pain.
The Goals of Multidisciplinary Pain Treatment
Multidisciplinary pain clinics adopt a broad, functional approach to treatment, especially
for chronic pain. The goals include:

● Improving Physical and Lifestyle Functioning: To improve muscle tone,

self-esteem, self-efficacy, and distraction, while decreasing pain behaviour and
boredom.
● Decreasing Reliance on Medical Services: To improve personal control,
decrease the "sick role," and increase self-efficacy.
● Increasing Social Support and Family Life: To increase optimism and
distraction while decreasing boredom, anxiety, and sick role behavior.
Psychological Treatment Methods
Biofeedback: Aims to decrease anxiety and tension by giving patients real-time feedback on
physiological processes. However, some research indicates it may not add significant
benefits beyond standard relaxation methods.

Hypnosis: Used as a tool to induce deep relaxation and alter pain perception. It appears to
be most useful for acute pain and for managing repeated painful procedures like burn
dressing changes.

Behavioural Methods: Based on operant conditioning, these methods use reinforcement

and graded exercises to incrementally encourage patients to become more active and
overcome fear [Link] example, if a chronic pain patient has stopped activities that
they belief may exacerbate their pain, the therapist will incrementally encourage them to
become increasing more active. Each change in behaviour will be rewarded by the therapist
and new exercises will be developed and agreed to encourage the patient to move towards
their preset goal
Cognitive Behavioural Therapy (CBT): The Gold Standard
The Integrated Approach

● The three components of psychological therapy are often integrated into a cognitive behavioural treatment package
(CBT).
● CBT focuses on these aspects of pain perception and uses a range of psychological strategies to enable people to
unlearn unhelpful practices and learn new ways of thinking and behaviours.

Components of CBT

● CBT draws upon the three treatment approaches described above namely respondent methods such as relaxation
and biofeedback, cognitive methods such as attention diversion and Socratic questioning and behavioural
methods involving graded exercises and reinforcement.
● Techniques used include attention diversion (i.e. encouraging the individual not to focus on the pain), imagery (i.e.
encouraging the individual to have positive, pleasant thoughts) and the modification of maladaptive thoughts by the
use of Socratic questions. Socratic questions challenge the individual to try and understand their automatic thoughts
and involve questions such as ‘What evidence do you have to support your thoughts?’ and ‘How would someone
else view this situation?’. The therapist can use role play and role reversal.

T
Cognitive Behavioural Therapy (CBT) for Pain
An Integrated Gold-Standard Approach

CBT is an evidence-based therapy that integrates the previously mentioned methods and is increasingly used for
chronic pain patients.

● Core Premise: CBT is based upon the idea that pain is influenced by an interplay of four sources of
information:
1. Cognitive: The meaning attributed to the pain ("This will stop me from working").
2. Emotional: The feelings associated with the pain ("I am anxious it will never end").
3. Physiological: The sensory signals from the site of physical damage.
4. Behavioural: Actions that may either increase or decrease the pain (e.g., avoidance vs. exercise).
● Mechanism: CBT focuses on these aspects of pain perception and uses a range of psychological
strategies to enable people to unlearn unhelpful practices (like catastrophizing) and learn new ways of
thinking and behaving. It systematically combines respondent methods (relaxation), cognitive methods
(attention diversion), and behavioural methods (graded exercises) into a structured package.
The State of the Evidence

Several individual studies have been carried out to explore the relative effectiveness of CBT compared to other forms of
intervention and/or waiting list controls.

● van Tulder et al. (2000)

○ carried out a systematic review of randomized controlled trials which had used behavioural therapy
for chronic non-specific low back pain in adults.
○ The analysis showed that behavioural treatments effectively reduced pain intensity, increased
functional status (e.g. return to work) and improved behavioural outcomes (e.g. activity level).
● Morley et al. (1999)
○ carried out a systematic review and meta analysis of trials of CBT and behaviour therapy for chronic
pain in adults excluding headache.
○ The analysis showed that CBT was more effective than alternative active treatment approaches such
as relaxation, exercise and education in terms of pain experience, positive coping, and the
behavioural expression of pain.
○ In addition, the results showed that CBT was more effective than waiting list controls on all these
outcome measures and also for mood, negative coping such as catastrophizing and social
functioning.
● Overall, therefore psychological therapies which include CBT seem to be an effective way to reduce aspects
of chronic pain.
Eccleston et al. (2002, 2003)

● searched a range of data bases and located 18 trials which included some form of psychological
therapy... for chronic or recurrent headache, abdominal pain and sickle cell pain and involved over
800 patients.
● The control groups received standard medical care, placebo or were waiting list controls.
● The results of their analysis showed that psychological therapies were very effective at reducing
headache in children and adolescents.
● However, the authors concluded that there was no evidence to date for their effectiveness for
other pain related problems or for outcomes other than pain severity and frequency
 Placebo Research: Sham Operations

Diamond et al. (1960) carried out several sham operations to examine the effect of placebos on pain relief.

The Procedure

A sham heart bypass operation involved the individual believing that they were going to have a proper operation, being
prepared for surgery, being given a general anaesthetic, cut open and then sewed up again without any actual bypass being
carried out.

Results and Implications

● This procedure obviously has serious ethical problems.

● However, the results suggested that angina pain can actually be reduced by a sham operation by comparable levels to an
actual operation for angina.
● This suggests that the expectations of the individual changes their perception of pain, again providing evidence for the role of
psychology in pain perception.
A ROLE FOR PAIN ACCEPTANCE?
Traditional Outcomes

○ The psychological treatment of pain are mostly used in conjunction with pharmacological
treatments involving analgesics or anaesthetics.
○ The outcome of such interventions has traditionally been assessed in terms of a reduction in
pain intensity and pain perception.

The New Focus

○ Recently, however, some researchers have been calling for a shift in focus towards
pain acceptance.
Beyond Control - Placebos & Pain Acceptance
Shifting the Focus of Treatment

● The Placebo Effect:

○ Placebos, defined as inert substances that cause symptom relief, provide powerful evidence for the role of psychology in
pain perception.
○ Beecher (1955) suggested that 30 percent of chronic pain sufferers experience pain relief after taking placebos.
○ In the 1960s, Diamond et al. conducted sham heart bypass operations. The results suggested that angina pain was
reduced by the sham operation at levels comparable to an actual operation, highlighting the profound impact of patient
expectation.
● Pain Acceptance:
○ A newer concept in pain management that shifts the treatment goal from pain
elimination to improving functioning and living a valuable life despite the pain.
○ Acceptance involves three underlying beliefs: (1) acknowledging a cure is unlikely; (2) shifting focus away from pain to
other aspects of life; and (3) resisting the idea that pain is a sign of personal weakness.
○ A study by McCracken & Eccleston (2003) showed that pain acceptance was a better predictor than coping
strategies for positive outcomes, including lower disability, depression, anxiety, and better work status.
Research by Risdon et al. (2003)

● Risdon et al. (2003) asked 30 participants to describe their pain using a Q factor analysis.
● This methodology encourages the participant to describe their experiences in a way that enables the researcher to derive a
factor structure .

The Eight Factors of Acceptance

● From their analysis the authors argued that the acceptance of pain involves eight factors. These were:
1. Taking control
2. Living day-by-day
3. Acknowledging limitations
4. Empowerment
5. Accepting loss of self
6. A belief that there's more to life than pain
7. A philosophy of not fighting battles that can't be won
8. Spiritual strength
Implications of Pain Acceptance
Pain and Identity

● The authors of these studies suggest that the extent of pain acceptance may relate to
changes in an individual's sense of self and how their pain has been incorporated into
their self identity.

A Way Forward for Research

● In addition, they argue that the concept of pain acceptance may be an important way
forward for pain research, particularly, given the nature of chronic pain.
 MEASURING PAIN: The Core Problem
The Need for Measurement

Whether it is to examine the causes or consequences of pain or to evaluate the effectiveness of a treatment for pain,pain
needs to be measured.

Key Questions and Problems

This has raised several questions and problems. For example:

● 'Are we interested in the individual's own experience of the pain?' (i.e. what someone says is all important).
● 'What about denial or self-image?' (i.e. someone might be in agony but deny it to themselves and to others).
● 'Are we interested in a more objective assessment?' (i.e. can we get over the problem of denial by asking someone
else to rate their pain?).
● 'Do we need to assess a physiological basis to pain?'
These questions have resulted in three different perspectives on pain measurement:

1. Self-reports
2. Observational assessments
3. Physiological assessments

Analogy to Health Status

These are very similar to the different ways of measuring health status.
Self-Reports
Self-report scales of pain rely on the individuals' own subjective view of their pain level.

Examples of Self-Report Scales

● Visual analogue scales (e.g. How severe is your pain? Rated from 'not at all' (0) to 'extremely'
(100)).
● Verbal scales (e.g. Describe your pain: no pain, mild pain, moderate pain, severe pain, worst pain).
● Descriptive questionnaires (e.g. the McGill Pain Questionnaire (MPQ); Melzack 1975).
The McGill Pain Questionnaire (MPQ)
The MPQ attempts to access the more complex nature of pain.

It asks individuals to rate their pain in terms of three dimensions:

■ Sensory (e.g. flickering, pulsing, beating)

■ Affective (e.g. punishing, cruel, killing)
■ Evaluative (e.g. annoying, miserable, intense).
Self-Reports: Assessing Functional Impact

Some self-report measures also attempt to access the impact that the pain is having upon
the individuals' level of functioning.

They ask whether the pain influences the individuals' ability to do daily tasks such as
walking, sitting and climbing stairs.
Observational Assessment
Purpose

● Observational assessments attempt to make a more objective assessment of pain.

● They are used when the patients' own self-reports are considered unreliable or when they are unable to provide
them.
● In addition, they can provide an objective validation of self-report measures.

Target Populations

● For example, observational measures would be used for children, some stroke sufferers and some terminally ill
patients.

What is Measured

● Observational measures include an assessment of the pain relief requested and used, pain behaviours (such as
limping, grimacing and muscle tension) and time spent sleeping and/or resting.
Physiological Measures
Both self-report measures and observational measures are sometimes regarded as unreliable if a supposedly
'objective' measure of pain is required.

In particular, self report measures are open to the bias of the individual in pain and observational measures are
open to errors made by the observer.

Therefore, physiological measures are sometimes used as an index of pain intensity.

Such measures include an assessment of inflammation and measures of sweating, heart rate and skin
temperature.

However, the relationship between physiological measures and both observational and
self-report measures is often contradictory, raising the question ‘Are the individual and the
rater mistaken or are the physiological measurements not measuring pain?’