UNIT-3

HEALTH PSYCHOLOGY
MEANING OF PAIN
◦Pain is defined as ‘a state of physical, emotional or mental lack
of wellbeing or uneasiness that ranges from mild discomfort or
dull distress to acute often unbearable agony, may be
generalized or localized, and is the consequence of being
injured or hurt physically or mentally and that usually
produces a reaction of wanting to avoid, escape or destroy the
causative factor and its effects.
◦Health psychologists are interested to study pain, its
contributory factors and how to control it since pain is an
extremely important health indicator in life, much beyond the
discomfort and distress it produces.
DIMENSION OF PAIN
◦Sensation of pain can be wide-ranging with different
dimensions. Some pain may be described as sharp and
others as dull, yet others may be involving sensation of
burning, cramping, aching or throbbing. Some pain
may be localized and other may involve a large part
of the body. Most often pain that we experience
depends upon the extent and location of the tissue
damage that has occurred. When damage occurs deep
inside the body individuals may complain of a dull pain
whereas when skin is damaged by a ‘brief noxious event’
DIMENSION OF PAIN
◦ When pain and discomfort occurs due to tissue damage, it is
called organic pain. For other type of pain where medical
examination fails to establish tissue damage, the discomfort arising
out of such pain is referred to as psychogenic pain, since the pain
seems primarily to result from psychological factors. However,
although it was believed earlier that psychogenic pain is
imaginary as perhaps experienced by schizophrenic patients, it was
later found that both organic and psychogenic pain hurt. Just
because medical experts fail to find an organic basis to a pain, does
not mean pain does not exist or it is all in the patient’s mind. Years
of research now reveal that virtually all pain experiences
involve interplay of both physiological and psychological
DIMENSION OF PAIN
◦Another important dimension of pain is the duration
for which it lasts. Some pain can be acute and
others can be chronic.
◦Acute pain is intense and short lived and may be
an indication of an injury, damage or disease in
the body. This type of pain normally goes away once
the injury heals and does not last more than six
months. People seek medical treatment most often
for acute pain due to its severity. Many pain control
techniques are used to deal with acute pain.
DIMENSION OF PAIN
◦ On the other hand, chronic pain may be mild or severe and the
sensation lasts much longer.
◦ It may sometimes begin as acute pain as a result of
damage, disease or injury but may linger on even after six
months. Pain in arthritis, lower back ache, headache, pain
caused by cancer are all chronic in nature.
◦ There are different types of chronic pain. Chronic recurrent
acute pain which is caused by a harmless condition is one
that is not continuous; it surfaces at times as acute pain
and at other times disappears. Migraine headache or
tension headache which is usually a shooting or radiating
kind of pain is an example of chronic recurrent acute pain.
DIMENSION OF PAIN
◦Chronic intractable benign pain is harmless or
benign but persistent; the intensity may vary but
the pain does not really stop. Lower back ache
is a typical case of intractable benign pain.
◦Lastly, the pain that begins due to a malignant
condition and continues to worsen is known as
chronic progressive pain. It is characterized by
continuous discomfort; pain caused by cancer or
arthritis is an example of this type of pain.
DIMENSION OF PAIN
◦Besides, there are mainly two concepts regarding pain,
namely pain threshold and pain tolerance which are
central to the understanding of pain intensity.
◦Pain threshold refers to the point at which a person
begins to perceive the noxious stimulus as painful. Pain
tolerance means the point at which the individual is
unable to bear or is unwilling to accept pain stimulation
of a higher magnitude.
◦Threshold is found to be determined mainly by
physiological variables, while tolerance is found to be
determined by psychological variables like attitude and
PERCEPTION OF PAIN
◦The importance of psychology in the
expression, understanding and treatment of
pain was recognized in early theories of
nociception.
◦Nociception is the process by which the
body's nervous system detects and
responds to potentially damaging stimuli,
such as tissue injury or extreme temperatures.
◦Nociceptors Specialized neurons that detect
PERCEPTION OF PAIN
◦In case of injury, the afferent neurons of the
peripheral nervous system transmits the
signal of tissue damage to the spinal cord
and then to other parts of the brain such
as thalamus, hypothalamus and cerebral
cortex.
◦The afferent nerve endings that respond to
stimulus causing pain are called nociceptors.
Nociceptors Specialized neurons that detect
PERCEPTION OF PAIN
◦However, the confusion surrounding pain
among medical practitioners arises
mainly because nociception and pain
are not always related.
◦It is possible to perceive pain in the
absence of nociception and
nociception can occur without pain
being felt.
PERCEPTION OF PAIN
◦In some cases individuals report of experiencing pain that
has no identifiable lesion, as in many cases of back pain,
headache, angina and an extremely painful condition called
Neuralgia, which is ‘pain radiating along the course of one or
more nerves usually without demonstrable changes in the
nerve structure’.
◦Another such painful condition with no apparent tissue
damage is Causalgia which causes severe burning pain
that sometimes results after a wound has healed and
damaged nerve has regenerated.
◦Both neuralgia and causalgia are believed to be caused by
PERCEPTION OF PAIN
◦ It has also been recognized that it is possible to experience pain in
a location away from the damaged area or to experience
pain in a missing limb. It is termed as referred pain which
involves pain that originates in tissue in one part of the body but is
perceived in another. For instance, ache in one tooth may cause pain
in an adjoining one.
◦ Phenomenon of Phantom-limb pain is another medical occurrence
that has been a puzzle for long. It is a pain experienced by either
an amputee in the missing limb or one who has suffered an
irreparable damage in the peripheral nervous system in the
part of the body that has no functioning nerves.
◦ It is believed that innate networks that are initially conditioned by
sensory inputs can continue to create sensation even in the absence
THEORIES OF PAIN
SPECIFICITY THEORY
◦The specificity theory of pain was developed by Max
Von Frey in 1895.
◦The premise of the theory is that the brain has a
completely separate area and system for
perceiving pain, as it does for vision and hearing.
Frey theorized that pain is transmitted from
independent nerve endings in the skin. Pain
signals then travel along dedicated pathways to a
specific part of the brain called the "pain
center.” The brain processes the information in
SPECIFICITY THEORY
◦The specificity theory is no longer widely accepted. It
has been discredited by the study of phantom
limb pain.
◦People who have undergone the amputation of a limb
may still report pain or other sensations that come
from the missing limb (phantom limb pain).
◦The specificity theory of pain is not supported in the
case of phantom limb pain, as there is no longer
any tissue from which the individual should be
receiving pain signals. Therefore, no pain would be
PATTERN THEORY
◦ D.C. Sinclair and G. Weddell’s (1955) ‘peripheral pattern theory’
proposed that all skin fiber endings are identical, and that pain
is produced by intense stimulation of these fibers.
◦ It is proposed that the receptors that are responsible for pain
are the same that transmits sensation of touch, pressure or
vibration and there is no separate system for perceiving pain only.
◦ As such people experience pain when certain patterns of neural
impulse occur, for example, when a particular type of
stimulation is mild it is felt as a caress or touch and when
the same stimulation is intense, it is felt as pain.
◦ This theory also holds that the nerve impulses transmitted to the
spinal cord reach the brain only after reaching certain intensity
and sensation can be summated.
PATTERN THEORY
◦The pattern theory’s proposal that stimulation has to
be intense to perceive pain has been criticized since it
does not take into account cases of neuralgia
and causalgia which occur with no apparent
stimulation.
◦Thus, although the early theories throw some light on
the physiology of pain, they have been unable to
explain pain perception adequately. Most
importantly, these theories do not take into
consideration the psychological factors into the
GATE CONTROL THEORY
◦The Gate Control Theory of Pain, introduced by
Ronald Melzack and Patrick Wall in 1965, offers a
way to understand how pain is perceived and
regulated within the nervous system.
◦This theory suggests that pain is not merely a
result of sensory input from injury or damage, but
rather a dynamic experience that is modulated by a
“gate” in the spinal cord. This “gate” can either
allow pain signals to reach the brain and be
experienced or block them, reducing pain
GATE CONTROL THEORY
◦ The Gate Control Theory proposes that a neural "gate" within the
spinal cord, specifically in the dorsal horn, regulates the flow of pain
signals to the brain. The theory suggests that:
• Pain signals are generated by nociceptors, which are sensory
receptors in the skin, muscles, and internal organs that respond to
harmful stimuli.
• These signals are transmitted via small nerve fibers (C-fibers
and A-delta fibers) to the spinal cord.
• In the spinal cord, a "gate" mechanism can either open (allowing
pain signals to reach the brain) or close (blocking pain signals
from reaching the brain).
• Large nerve fibers, such as A-beta fibers (responsible for
transmitting non-painful sensations like touch and pressure), can
inhibit pain signals from small fibers, closing the gate and
HOW THE GATE CONROL MECHANISM
WORKS
◦The gate mechanism relies on the balance between activity in large and
small nerve fibers:
• Small Nerve Fibers (C-fibers and A-delta fibers): These fibers are
primarily associated with pain transmission. C-fibers carry slow,
dull, aching pain, while A-delta fibers carry fast, sharp pain. When
these fibers are active, they tend to open the gate, allowing pain signals
to pass through to the brain.
• Large Nerve Fibers (A-beta fibers): These fibers carry non-painful
sensory input, such as touch, pressure, and vibration. When stimulated,
these fibers can activate inhibitory neurons in the spinal cord,
which help to close the gate and block pain signals from reaching the
brain.
◦ The idea is that when large fiber activity (such as touch or pressure)
dominates, it “closes” the gate, reducing the perception of pain.
Conversely, when small fiber activity (pain signals) is high, it “opens” the
FACTORS THAT INFLUENCE THE GATE
MECHANISM
◦
The opening and closing of the gate are influenced by multiple factors,
including physical, emotional, and cognitive components.
• Physical Factors: This includes the intensity and type of nerve fiber
activity. For instance, stimulating large fibers through pressure, massage,
or touch can close the gate and reduce pain. Conversely, intense
activation of small fibers through injury or inflammation may open the
gate.
• Emotional Factors: Emotions like stress, anxiety, and fear can amplify
the perception of pain by opening the gate. Positive emotions, relaxation,
and a calm state can help close the gate, reducing pain perception.
• Cognitive Factors: Thoughts, attention, and expectations can also
influence the gate. Focusing on pain or worrying about it may open the
gate, while distraction, mindfulness, or positive thinking can close it. This
means that what we focus on can either enhance or diminish pain
perception.
LIMITATIONS OF GATE CONTROL
THEORY
•Complexity of Pain Processing: Pain perception is a complex process
involving various brain regions, including those responsible for emotion and
memory, which the Gate Control Theory does not fully address.
• Chronic Pain and Central Sensitization: Chronic pain conditions, like
phantom limb pain, often involve changes in the central nervous system
that go beyond the spinal gating mechanism. These conditions involve a
phenomenon called central sensitization, where the nervous system
becomes highly sensitive to pain even in the absence of external stimuli,
which the Gate Control Theory does not fully explain.
• Individual Differences in Pain Experience: Genetic, psychological, and
cultural factors can influence how individuals experience pain. The Gate
Control Theory does not account for these variations, which are now known
to play a significant role in pain perception.
CLINICAL ISSUES IN
PAIN MANAGEMENT
ASSESSMENT CHALLENGES
 Subjective Nature of Pain: Pain is a subjective experience, and its
intensity and nature vary widely among individuals. Standardized pain
assessment tools (such as the Numeric Pain Rating Scale or Visual Analog
Scale) are used, but they may not fully capture a patient’s experience.
 Chronic Pain Misunderstandings: Chronic pain is often “invisible,” and
patients may face scepticism from healthcare providers, which can hinder
effective treatment.
 Impact on Quality of Life: Beyond pain intensity, assessment should
also consider the impact of pain on daily functioning, mental health, and
social relationships. Tools like the Brief Pain Inventory assess both pain
levels and its interference with daily activities.
PSYCHOSOCIAL ASPECTS OF PAIN
 Psychological Factors: Depression, anxiety, and stress can exacerbate
pain perception. Cognitive behavioral therapy (CBT) and other
psychological interventions are often critical components of pain
management.
 Fear-Avoidance Beliefs: Patients with chronic pain often fear movement
and activity, believing it will worsen their pain, which can lead to
decreased mobility and increased disability.
 Social Support and Relationships: Family, friends, and social support
can significantly impact pain management. Patients with strong support
networks generally have better outcomes.
 ________________________________________
PHARMACOLOGICAL MANAGEMENT
 Analgesics: Nonsteroidal anti-inflammatory drugs (NSAIDs),
acetaminophen, and opioids are commonly used for pain
relief. However, each has potential side effects and risks,
especially in long-term use.
 Opioid Therapy Challenges: Opioids are effective for
severe pain but carry risks of dependence, tolerance, and
side effects such as sedation and respiratory depression.
Guidelines now emphasize cautious opioid prescribing and
consideration of alternative treatments.
NON- PHARMACOLOGICAL
MANAGEMENT
 Physical Therapy and Rehabilitation: Physical therapy
can help improve mobility, strength, and flexibility, reducing
pain and improving function. Techniques include stretching,
strengthening exercises, and modalities like heat, ice, and
ultrasound.
 Psychological Therapies: CBT, mindfulness, biofeedback,
and acceptance and commitment therapy (ACT) are
evidence-based approaches for managing chronic pain by
modifying pain perception and coping mechanisms.
 Complementary Therapies: Acupuncture, massage,
chiropractic care, and yoga have shown benefits for some
PATIENT EDUCATION AND SELF-
MANAGEMENT
 Education on Pain and Treatment Options: Educating
patients about the nature of their pain and the benefits and
limitations of various treatments empowers them to make
informed decisions and adhere to treatment plans.
 Self-Management Techniques: Strategies like pacing,
relaxation exercises, and self-monitoring can help patients
take an active role in managing their pain.
 Setting Realistic Goals: For chronic pain, complete pain
relief may not be achievable. Focusing on improving function
and quality of life is often a more realistic and beneficial goal.
ETHICAL AND LEGAL
CONSIDERATIONS
◦Ethical Dilemmas in Opioid Prescribing:
Physicians face ethical challenges in balancing
adequate pain relief with the risk of drug dependence
or misuse. Clear communication about risks, benefits,
and expectations is crucial.
◦Legal Regulations: Laws and guidelines around
opioid prescriptions vary by region and are
continuously updated. Clinicians must stay informed
to ensure compliance and avoid legal repercussions.
MEASURING PAIN
PSYCHO-PHYSIOLOGICAL MEASURES
◦This type of measure is based on the
assumption that pain is manifested in
certain distinct physiological changes
such as muscle tension, skin
temperature, and heart rate.
◦Therefore, in order to assess pain, researchers
have used several physiological measures like
EMG (electromyography) that records
electric activity of muscles measuring the
PSYCHO-PHYSIOLOGICAL MEASURES
◦Another physiological measure relies on the generalized
arousal that may result due to pain. Pain experience may
trigger autonomic activity like heart rate, respiration,
blood pressure and skin conductivity which can be easily
quantified. Measures of autonomic activity are believed to be
useful in assessing the emotional components of pain.
◦Other researchers assuming that more substantial pain is
associated with higher spikes in brain waves have used
EEG (electroencephalogram) to measure electric activity of
the brain. However, most of these measures have failed to
establish a consistent relationship between physiological
responses and the pain experience.
BEHAVIOURAL MEASURES
◦ Pain is manifested outwardly in an individual’s behaviour, therefore
observation of a patient’s physical activities and non-verbal
expressions can be quite a reliable measure of pain. These include
alteration in daily physical activities such as limping, change in
posture or restricted movements, verbal expressions like
moaning, groaning or crying and facial expressions like
grimacing or frowning.

◦ These observations are usually made by people close to the person

or medical care personnel. Individuals who live with the patient,
especially the spouses are the best persons to make these
observations.

◦ Behavioural measurement of pain may also involve noting the amount

of time the person has been incapacitated and had to be in
bed, the number of times the patient has complained about
BEHAVIOURAL MEASURES
◦Pain behaviour is found out by people in five different
ways (Sanderson, 2004):
◦(a) guarding-as in showing abnormally stiff or rigid
movements,
◦(b) bracing-maintaining a stationary position wherein
one part of the body bears more than other parts,
◦(c) touching, clutching or rubbing a certain part of
the body,
◦(d) grimacing-displaying certain facial expressions
like, crinkling the face, clenching teeth, tightly
closing the eyes and
BEHAVIOURAL MEASURES
◦ Behavioural pain measures are usually accurate in assessment of pain
and also different people are able to assess pain behaviour in a
similar way. Behavioural methods are especially useful in assessing
pain in children who are unable to express pain very accurately
and also in people for whom a certain language becomes a
barrier.

◦ However, despite its utility, behavioural measurements of pain have its

own limitations. First, patients may often either exaggerate or
under-represent their pain deliberately or unmindfully.

◦ Some individuals may use pain as a means of gaining sympathy or

bargaining for something they want, thus expressing more pain than
they really feel. While there may be others who may express less
pain than they feel as a sign of bravery. Thus, relying on
behavioural measures only to assess pain can be misleading.
SELF-REPORT MEASURES
◦Self-report measures ask patients to describe their pain
experience and its intensity through verbal or written means.
◦Although pain has outward manifestations, it is essentially a
subjective experience, only the person can tell the
location of pain and how intense it is. Self-report is
gathered verbally or in written form through interview,
rating scales or questionnaire.
◦Clinicians who often rely on this method interview the
patients and sometimes their family members and co-
workers to gather information in the early phases of
treatment. This is useful to know the duration of the pain,
its impact on their professional and their personal life,
SELF-REPORT MEASURES
◦ Information provided during interview is also supplemented by
asking the patient and significant others to provide information
about their pain experience through rating some aspects of
discomfort on a linear scale.
◦ Rating scales ask the patient to quantify their pain level,
providing a direct measure of pain intensity. It asks a
person to rate the discomfort level on a numerical scale, for
instance, the visual analogue scale asks to choose one end
of scale for no pain and the other end for excruciating
pain.
◦ Other rating scales might ask a person to choose among different
descriptions of pain ranging in increasing intensity from mild,
distressing, intense or excruciating. Repeated rating can be
SELF-REPORT MEASURES
◦ Questionnaires are used to measure the pain experience and assess
the emotional components of pain since the experience of pain
has many dimensions. One of the widely used questionnaires by
medical and psychological professionals is the McGill-Melzack Pain
Questionnaire (MPQ) which has various words to describe
pain.
◦ Ronald Melzack, a professor at McGill University, who
recognized the multidimensional nature of pain, developed this
insight through his interaction with patients. He would write
down the words a woman with phantom-limb pain used to describe
her experience of pain, which very often had an emotional-
motivational component like exhausting, sickening,
punishing, terrifying, which were different from sensory
component like shooting, scalding, cramping etc. He later
SELF-REPORT MEASURES
◦This was the basis on which he developed MPQ inventory
which consists of a list of descriptive words, divided
into three broad dimensions-affective, sensory and
evaluative and 20 subclasses.
◦Individuals are asked to select the words that best
describe the kind of pain he or she feels from the 20
subclasses. Each word in a class is given an assigned
value depending on the degree of pain experienced.
◦Several dimensions of pain can be assessed at a time
by this inventory. The pain rating index is calculated by the
sum of values of the words selected by the individual
across the 20 subclasses.
SELF-REPORT MEASURES
◦There are other self-report measures of pain such
as West Haven Yale Multiphasic Pain
Inventory (WHYMPI) which assesses the
impact of pain on the patient’s life, others’
response to the patient’s pain and the
degree to which pain has incapacitated the
patient.
◦Multidimensional Pain Inventory (MPI) and
Pain Behaviour Check List (PBCL) are other
examples of self-report measures of pain which
SELF-REPORT MEASURES
◦Although self-rating scales are an easy tool to assess
pain both for researchers and clinicians, providing
information that other methods are unable to get, it
has certain limitations.
◦First, a patient requires fairly strong language skill
to answer it. For instance, the MPQ scale makes
very small distinctions among words describing
pain in English. This can make people with
limited vocabulary, people from other cultures
and also children find it difficult to understand,
affecting the pain rating index.
SELF-REPORT MEASURES
◦Second, the limitations of behavioural method of
measuring pain are also applicable here, since people are
sometimes either unable to gauge their pain correctly or
they tend to misrepresent their pain.
◦Thus they may either downplay or underestimate their
pain on the one hand and exaggerate or overestimate
on the other.
◦In order to make a proper assessment of pain in patients a
combination of methods are usually resorted to. This is
helpful in countering the limitations of each method. Moreover,
there is no single measure of pain that records an
individual’s pain experience completely.
DIFFERENCES IN
PAIN RESPONSES
PERSONALITY
◦Is there really a pain-prone personality? Several research studies
have attempted to answer this question. It was earlier thought that
those who were less hardy or less exposed to the hardships of
life would show less tolerance to pain and would complain
more.
◦It was also believed that the pain expressed by patients was a
manifestation of guilt or of loss, or that pain revealed a self-
destructive style of sexual development. In addition, common
perception holds that people who suffer from migraine are tense,
hostile and are perfectionists.
PERSONALITY
◦ Is there really a pain-prone personality? Several research studies have
attempted to answer this question. It was earlier thought that those who
were less hardy or less exposed to the hardships of life would show
less tolerance to pain and would complain more.
◦ It was also believed that the pain expressed by patients was a
manifestation of guilt or of loss, or that pain revealed a self-
destructive style of sexual development. In addition, common
perception holds that people who suffer from migraine are tense,
hostile and are perfectionists.
◦However, no evidence emerged to support these ideas. There
may be differences in individual personalities in pain
tolerance and pain expression, but the search for a unified
pain personality type was unsuccessful.
PERSONALITY
◦Some evidence however suggests that people who experience
chronic pain are more likely to have anxiety or
depressive disorder.
◦Some other evidence also suggests that extroverts are more
tolerant to pain with higher aim threshold than introverts.
◦Locus of control is another personality variable that has been
found to affect pain experience (Seville & Robinson, 2000).
People with internal locus of control cope with pain more
effectively when compared to people with external locus of
control since they believe that they have a control over their
pain experience.
GENDER
◦Researchers have found the relation between gender and
pain to be a complex issue. However, studies do suggest
that pain experiences, the type of pain and also the pain
responses tend to differ between men and women.
◦In a well received review of this field, Anita Unruh reported
that ‘In most studies, women report more severe levels of
pain, more frequent pain and pain of longer duration
than do men (Unruh, 1996). Women are more likely to
experience recurrent pain, have moderate and severe
pain from menstruation and childbirth and may be at
increased risk of disability arising from pain.
GENDER

◦It has been found that despite the fact that

women suffer and also report of more pain than
men, they are at greater risk of being labelled
as having a psychogenic pain disorder. They
are more vulnerable to their pain experience being
explained as a purely psychological phenomenon
and hence they find it difficult to convince
clinicians about their pain experience
(Unruh, 1996).
GENDER
◦One of the explanations provided for a gender difference in pain
perception, attitude towards pain and response to pain treatment
hints at hormonal difference. Although estrogen, progesterone
and testosterone are present in both men and women, the
levels of the hormones differ between them.
◦In addition, hormone levels in men remain relatively stable
but in women monthly fluctuations occur.
◦Evidences have also been found by researchers that structural
and neuronal organization differences in the male and
female brains exist which may also play an important role.
Besides, the social and cultural factors too cannot be
overruled.
AGE
◦Early research on age difference and pain concluded that the
threshold of pain steadily increases with. This was attributed to
decreasing sensitivity in older persons to pain or an increasing
reluctance by them to see noxious stimuli as painful.
◦However, later research revealed that very little is known about the
specific effects of age and ageing and about the psychology of
pain for specific age groups. For instance, effective pain
management in children has been hampered by the erroneous
beliefs that neonates and infants could not feel pain and that
children would respond addictively to opioid use. For instance, it
was a common practice earlier to conduct minor surgeries like
circumcision on infant boys with little or no anesthesia. The later
research has proved that it is not true.
AGE

◦Pediatric treatment can be improved by understanding

pain threshold and pain tolerance in children. Many
psychological factors such as the parents’
reaction to pain and reinforcements that parents
provide for their children’s pain behaviour certainly
affect children’s response to pain stimuli (Bush, 1987).
For instance, it is commonly noticed that if parents or
adults overreact to the child’s falling, the child too
reacts similarly. On the other hand, if the fall is
downplayed, the child’s reaction to pain is also subdued.
SOCIO-CULTURAL DIFFERENCE
◦Differences in pain tolerance might be due to social learning and
social comparisons since people tend to learn to react to pain
and show physical and facial expressions of their own social
group.
◦Social environment also influence the meaning we give to the
pain giving stimuli. In some social/cultural group pain expression
like grimacing or wincing may get sufficient attention while in
another culture it may be completely ignored. Pain reactions
thus get accordingly reinforced.
◦How we utilize the medical services may also be influenced by
culture. This is because the importance that is given to pain
sensation to a large extent is perhaps culturally dependent.
FEAR
◦Fear and anxiety processes have been studied from a number of
perspectives, which is relevant to clinicians. Some people have
increased or heightened attention to pain sensation.
◦When the threat of pain for a person is constant or recurrent,
a pattern of pain behaviour develops where vigilance is kept
or attention is paid to pain.
◦McCracken developed a measure of vigilance to pain with a
sample of chronic low back pain patients and found that patients who
report high levels of attention to pain also report higher pain
intensity, increased use of health-care resources and more
emotional distress. Vigilance to pain was a significant predictor
of disability, distress and use of healthcare resources.
FEAR
◦ Repeated attention to threat may give rise to the development of a fixed
pattern of responding to threatening stimuli and pain.
◦ One particular response to threatening pain which is proving to be predictive
of the severity of pain complaint has been termed ‘catastrophic
thinking’ or ‘catastrophizing’. People with such behaviour pattern
habitually almost immediately see a threatening stimuli or pain
causing situation as extremely and globally catastrophic.
◦ It was found that people who tend to catastrophize pain reported significantly
more negative pain-related thoughts more distress and higher pain
intensity compared with people who did not catastrophize.
◦ Patients with pain try to avoid pain-inducing activity. A number of
studies now show that the pain alone may not explain disability and avoidance
fear of pain was found to be more disabling than pain itself.
DEPRESSION
◦On the one hand, the experience of pain and the threat of
pain can lead to negative emotions. On the other hand,
emotional distress may also act as a pain magnifier.
◦Persistent feelings of frustration and anger and negative
or destructive self-appraisal are common effects of
chronic pain. In fact, majority of adult chronic pain
patients who visit clinics for treatment are also depressed
to some degree.
◦However, this depression is not brought about directly
by the pain severity but by the disabling
consequences of how one reacts to the chronic pain.
DEPRESSION
◦Depression greatly affects the ability of a patient to cope with
several aspects of life when experiencing pain. Depressed
patients tend to rate their pain higher and are more
emotionally affected than non-depressed patients.
◦There are several facets of depression that are important in
understanding the pain of the patient. One of the main factors
that contribute to depression is the extent to which
individuals perceive themselves negatively. Research
suggested that negative self-appraisal may promote a
self-fulfilling prophecy in which patients learn to be
helpless and hopeless.
ANGER
◦Anger is relatively a common experience for pain patients as
well as the pain professionals. Where there is no clear
immediate object of anger (e.g., an aggressive person or an
immediate agent of injustice), it is often associated with global
frustration and hostility, feelings of aggression and a
feeling of being blamed.
◦Patients with chronic pain often express anger as a means by
which they attempt to claim self-control and self-esteem
which often go unrecognized by others. Anger and
hostility can have significant deleterious effects upon both
health and treatment effectiveness.
ANXIETY
◦Anxiety of a person tends to magnify pain perception since
it hinders with the much needed relaxation that is needed
to cope with pain.
◦Anxiety has been found to increase the fear of pain and the
likelihood of avoidance. It worsens anticipation pain
which is known as anticipatory anxiety. In treating patients
in a medical set this becomes particularly important since
anticipatory anxiety can make a person avoid certain
medical procedures like surgery or even injections and
the patient may also be aggressive towards health care
professionals.
STRESS
◦Highly stressful situations are associated with the development of
ulcers, recurrent abdominal pain with no detectable
physical cause.
◦Stress influences the experience of pain since it makes people
tense their muscles which in turn cause pain.
◦For instance, excessive contraction of forehead during a
stressful situation may cause headache after a period of
time. In addition, people undergoing high levels of stress may
indulge in health compromising behaviours like neglecting
proper diet or exercise, social relationships which in turn
may rob them of essential social support and thereby
increase distress and cause migraine, ulcers, backache etc.
PAIN CONTROL AND
PAIN MANAGEMENT
1. PHARMACOLOGICAL APPROACHES
◦Pharmacological management involves the use of medications
to alleviate pain. These medications can be categorized into
several classes:
◦a. Non-Opioid Analgesics
• Acetaminophen (Tylenol): A common over-the-counter pain
reliever. It is often used for mild to moderate pain, such as
headaches, arthritis, or muscle aches.
• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): These
include ibuprofen (Advil, Motrin), naproxen (Aleve), and aspirin.
They reduce pain by inhibiting inflammation and are used for
conditions like arthritis, back pain, and soft tissue injuries.
1. PHARMACOLOGICAL APPROACHES

◦b. Opioids
• Examples: Morphine, oxycodone (OxyContin),
hydrocodone (Vicodin), fentanyl.
• Opioids are potent analgesics that work by binding to
opioid receptors in the brain and spinal cord, reducing
the perception of pain. They are generally used for
severe pain, such as post-surgical pain, cancer pain,
or trauma-related pain, but they carry risks of
dependence and addiction.
1. PHARMACOLOGICAL APPROACHES
◦c. Adjuvant Medications
◦Antidepressants (e.g., amitriptyline, duloxetine): These
are used for neuropathic pain(Neuropathic pain, also known as
nerve pain, is a type of pain that occurs when the nervous
system is damaged or malfunctions) (e.g., diabetic
neuropathy, post-herpetic neuralgia) because they can alter
the way the brain processes pain signals.
◦Anticonvulsants (e.g., gabapentin, pregabalin): These are
effective in managing nerve pain, such as that caused by
diabetic neuropathy.
1. PHARMACOLOGICAL APPROACHES

◦d. Topical Analgesics

• Examples: Lidocaine patches, capsaicin cream,
diclofenac gel.
• These are applied directly to the skin to reduce
localized pain, such as in conditions like
osteoarthritis, muscle strains, or shingles (Shingles
is a painful rash caused by the varicella-zoster virus
(VZV), the same virus that causes chickenpox.)
2. PHYSICAL THERAPIES
◦a. Physical Therapy (PT)
• Purpose: A trained physical therapist uses
exercises, stretches, and manual therapy to
improve strength, flexibility, and function while
reducing pain. This is effective for
musculoskeletal pain, including back pain, joint
pain, and sports injuries.
• Example: Strengthening exercises for the core
2. PHYSICAL THERAPIES
◦b. Heat and Cold Therapy
• Cold Therapy: Applying ice packs or cold
compresses can reduce inflammation and
numb sharp pain. It's typically used for acute
injuries (sprains, strains, and bruises).
• Heat Therapy: Using heating pads or warm
baths can help relax muscles and increase
blood flow to an area, which is useful for
chronic pain conditions like arthritis or muscle
2. PHYSICAL THERAPIES
◦c. Transcutaneous Electrical Nerve Stimulation
(TENS)
• How it works: A TENS unit uses low-voltage
electrical currents to stimulate nerves, which can help
interrupt pain signals sent to the brain. This is
commonly used for conditions like
fibromyalgia(Fibromyalgia is a chronic (long-lasting)
disorder that causes pain and tenderness throughout
the body, as well as fatigue and trouble sleeping.),
osteoarthritis, and lower back pain.
2. PHYSICAL THERAPIES
◦d. Massage Therapy
•Purpose: Therapeutic massage
involves manipulating muscles and
soft tissues to relieve pain, improve
circulation, and reduce tension. It can
be particularly effective for muscle
pain, tension headaches, and
3. PSYCHOLOGICAL TECHNIQUES
◦a. Cognitive Behavioral Therapy (CBT)
• Purpose: CBT is a type of talk therapy that helps
individuals change negative thought patterns that
contribute to the perception of pain. It is commonly
used for chronic pain conditions such as back pain,
fibromyalgia, and migraines.
• Example: Helping a patient reframe catastrophic
thoughts (e.g., “I’ll never get better”) to more
adaptive thoughts (e.g., “I can manage this pain
with the right strategies”).
3. PSYCHOLOGICAL TECHNIQUES
◦b. Mindfulness and Meditation
• Purpose: Mindfulness-based stress reduction (MBSR)
and meditation techniques help individuals focus on
the present moment and reduce the emotional
distress associated with pain. These techniques are
effective in managing chronic pain, anxiety, and
depression.
• Example: Deep breathing exercises and body
scanning techniques can reduce tension and improve
pain tolerance in conditions like chronic back pain.
3. PSYCHOLOGICAL TECHNIQUES
◦c. Biofeedback
• Purpose: Biofeedback involves using electronic
devices to monitor physiological functions (e.g., heart
rate, muscle tension, skin temperature) and teach
individuals how to control these responses. It can be
helpful for managing tension headaches, migraines,
and muscle pain.
• Example: A person with chronic headaches learns
how to reduce muscle tension and lower blood
pressure to prevent migraines.
4. INTERVENTIONAL PAIN
MANAGEMENT TECHNIQUES
◦a. Nerve Blocks and Injections
• Examples: Epidural steroid injections, facet
joint injections, and nerve blocks.
• These procedures involve injecting a local
anesthetic, steroid, or other medications
directly near or into a nerve to interrupt pain
signals. They are commonly used for back
pain, sciatica, and neck pain.
4. INTERVENTIONAL PAIN
MANAGEMENT TECHNIQUES
◦b. Intrathecal Drug Delivery Systems
• Purpose: A pump is implanted to deliver
medications like morphine directly into
the spinal fluid, providing targeted pain
relief with lower doses. This is used for
severe chronic pain that is not responsive
to oral medications.
5. COMPLIMENTARY AND ALTERNATIVE
THERAPIES
◦a. Acupuncture
• Purpose: Acupuncture involves inserting
thin needles into specific points on the body
to stimulate nerve fibers, increase blood
flow, and release endorphins (natural pain-
relieving chemicals). It is effective for pain
related to conditions like osteoarthritis,
migraines, and fibromyalgia.
5. COMPLIMENTARY AND ALTERNATIVE
THERAPIES
◦b. Chiropractic Care
•Purpose: Chiropractors use manual
manipulation of the spine to correct
misalignments that may be causing
pain. It is most commonly used for
musculoskeletal pain, including back
pain and neck pain.
5. COMPLIMENTARY AND ALTERNATIVE
THERAPIES
◦c. Herbal and Nutritional Supplements
• Examples: Turmeric (curcumin), ginger, glucosamine,
and omega-3 fatty acids.
• Some people use herbal remedies and supplements
to help reduce inflammation and manage pain,
particularly in conditions like arthritis. However, it's
essential to consult a healthcare provider before
using these supplements, as they can interact with
medications.
5. COMPLIMENTARY AND ALTERNATIVE
THERAPIES
◦d. Yoga and Tai Chi
• Purpose: These mind-body exercises combine
slow, controlled movements with deep
breathing and mindfulness, which can help
improve flexibility, strength, and pain
tolerance. They are especially beneficial for
individuals with chronic pain, including arthritis
and fibromyalgia.
6. SURGICAL INTERVENTIONS

◦For severe, intractable pain that does not respond to

other treatments, surgical intervention may be
considered:
• Examples:
• Joint Replacement Surgery (e.g., hip or knee
replacement for osteoarthritis)
• Spinal Surgery (e.g., for degenerative disc
disease)
• Neuroablation: A procedure where nerve fibers
CONCLUSION
◦Pain management involves a variety of techniques tailored to
the individual’s needs, the type of pain, and its underlying
cause. Effective management often requires a combination of
approaches. For instance, pharmacological treatments may be
combined with physical therapy, psychological support, and
complementary therapies to provide the best outcomes.
Chronic pain, in particular, may require ongoing management
and adjustments to treatment strategies as the patient’s
condition evolves.
◦When implementing any pain management technique, it’s
crucial for patients to work closely with their healthcare
providers to ensure safe and effective pain control.