James Pabiniak

Honors 222C: Final Paper

June 2015

The Psychology of Chronic Pain: Advocating For the a Biopsychosocial

Approach to Pain Management

Pain is one of the most intriguing issues facing the human race. It is one of the few
universal (except for a few medical rarities) human experiences, and the prevalence of chronic
pain has only risen over time. Pain affects tens of millions of Americans and is growing without
any sign of slowing down (Reliving Pain in America, 2011). Throughout history there has
been an intense focus on the biological aspect of pain. Pharmacological companies have
continued to push drugs to patients by promoting them as the easiest and most effective cure for
pain. This has created a culture that is focused on pills and has created a mentality that views the
treatment of pain as solely a medical issue (Sullivan & Howe, 2013). This is evident from the
fact that from 2000-2010 opioid sales grew by over four times, and, as a result of the increased
availability, deaths have skyrocketed to the point where in 30 states accidental overdoses now
outnumber vehicular deaths (Sullivan & Howe, 2013).
Using opioids for pain management is extremely effective for acute, short-term treatment
but can be disastrous when used to treat chronic ailments. This practice is inefficient for many
reasons, the primary of which is that opioids do not help reduce patients pain or discomfort
long-term because they are inefficient in actually treating the underlying causes or leading to

functional improvement (Sullivan & Howe, 2013). On top of being downright ineffective in
helping chronic pain, using opioids to temporarily relieve pain can frequently lead to long-term
dependence and can create a problem of addiction in a high number of patients (Sullivan &
Howe, 2013). Because of the adverse problems that come from focusing on only the biological
aspect of treating pain, many experts in the field have advocated for taking a biopsychosocial
approach to treating pain. This means that pain management takes into consideration the
cumulative effects of the psychological and social factors affecting individuals as well as
biological issues. This concept has become more and more popular among medical experts;
however, this mentality has not been translated in practice. Some possible explanations for this
are that there is a dearth of trained psychologists in certain geographic areas (such as rural parts
of the country), certain subfields (such as pediatric care), and that taking drugs is simply easier
and more satisfying for patients (Kazak & Noli, 2015). This paper will focus on some of the
many positive ways in which psychology can influence pain management. It begins by analyzing
the need and support for the use of psychological tools in treating pain and examines the
cognitive tools and practices used by psychologist in helping chronic pain patients, and shows
how psychological practices are vital in treating chronic pain.
Psychology and psychological tools are needed to treat chronic pain for several reasons,
and the evidence in support of this claim can be easily broken down into two categories. The first
category of evidence shows that psychological tools are important in treating the resultant issues
that come from chronic pain- specifically depression and suicidality. The second category is
evidence directly showing that psychological tools are effective in treating chronic pain itself.
Perhaps the most important example of the first type of evidence can be seen by the massive

meta-analysis review done by Fishbain et al (1997). They examined the relationship between
chronic pain and several variables including depression, suicide ideation and suicidality to
determine how they are correlated. They found that many of the studies support the claim that
the overall depression rate is independently associated with chronic pain among the general
population (Fishbain, Cutler, Rosomoff & Rosomoff, 1997). Going beyond this, some of the
reviewed studies closely examined specific populations and found similar results within the
specific subgroups, such as among the elderly (Casten, Parmelee, Kleban, Lawton & Katz,
1995). Because this result was found consistently across populations, they conclude that, in any
group, depression is more prevalent in chronic pain patients than in people who do not suffer
chronic pain (Fishbain et al., 1997). Their results also indicate statistical relationships between
depression and frequency of pain and the duration of pain experience (Fishbain et al., 1997),
which combines to indicate that suffering from chronic pain and depression are very closely
linked.
The researchers also examined studies looking at the relationship between chronic pain
and aspects of suicide including ideation (having serious thoughts of suicide, although no actions
are committed), non-successful attempts, and suicide completions. Several studies showed
higher rates of suicide ideation among chronic pain patients (Fishbain et al., 1997). This includes
one report which found that 50% of chronic pain patients surveyed felt depression and
hopelessness stemming from their pain which led to serious thoughts of suicide (Hitchcock,
Ferrell & McCafferey, 1994). Controlled studies also found that chronic pain led to a higher rate
of suicide attempts (Fishbain et al., 1997), and another study found that, among those who
attempt suicide, chronic pain patients were more severely and frequently depressed than those

who do not suffer from chronic pain (Stenager, Stenager & Jensen, 1994). Although suicide
completions are very rare (less than 1 in 10,000 successfully commit suicide), multiple reports
demonstrate that the rate of suicide completions in chronic pain patients is much higher than in
the general population (Fishbain et al., 1997). All of the above results indicate that thoughts of
suicide, suicide attempts, and suicides as a whole are much higher among chronic pain patients
than among the general population.
There are three main hypotheses that summarize the above relationships: the antecedent
hypothesis (that depression precedes chronic pain), the consequence hypothesis (depression is a
consequence of chronic pain), or the scar hypothesis, which states that episodes of depression
preceding chronic pain predispose patients to depression after the start of pain (Fishbain et al.,
1997). Of the thirteen studies examining the antecedent hypothesis, it was found that only three
supported it (Fishbain et al, 1997). This indicates that depression likely cannot be said to precede
chronic pain and that this hypothesis likely does not encapsulate the whole story. In contrast to
this, all fifteen studies examining the consequent hypothesis were in supported of it (Fishbain et
al., 1997). This evidence is augmented by studies examining patients with intermittent pain,
specifically looking at how the pain these individuals experience and their mood progressed and
changed over time. All three studies they examined which covered this topic found that, as time
progressed, there was a relationship between pain and depression (Fishbain et al., 1997). This
means that as the pain became more and more serious and the bouts of pain became more
frequent, depression also worsened (or the opposite was true: as pain decreased so did

depression). This evidence, combined with the other findings, makes the consequent hypothesis a
very strong argument.
The studies examining the scar hypothesis have had very mixed results, as some studies
have found that previous depression can be an indicator of chronic pain, while some studies have
shown that individuals can have no relationship with depression before pain develops (Fishbain
et al., 1997). These mixed results indicate that either the hypothesis needs tweaking or that the
samples were misrepresentative. Although nothing has been proven, this means that the most
likely explanation for the relationship between chronic pain and depression is some combination
of the antecedent and consequent hypotheses: meaning that the relationship can be bidirectional.
These results are significant for several reasons, the primary one being that this research makes it
evident that chronic pain and depression are closely linked. This means that treating depression
and suicidality, among other negative mental health effects, has become a vital part of managing
and treating chronic pain.
This finding is corroborated by the National Institute of Mental Health (NIMH), which
states that chronic pain and depression are related and that chronic pain can worsen depression
(Depression and Chronic Pain, 2015). This is especially evident in people with fibromyalgia,
an extremely painful and life altering ailment that can be described as widespread, constant pain.
Studies have shown that fibromyalgia patients are much more likely to have depression
(Depression and Chronic Pain, 2015). One of the main tasks clinical and counseling
psychologists are responsible for is the treatment of mental illnesses such as depression and
suicidality. Herein lies the importance of the psychological aspect of treating pain. The NIMH
lists only three commonly available treatments for depression, two of which are anti-depressant

medications which regulate the neurotransmitters serotonin and/or norepinephrine (Depression

and Chronic Pain, 2015). As I have already briefly discussed in the introduction to this paper,
there has been a shocking rise of the prevalence of pills in American culture. Despite a clear lack
of demonstrated benefits and a clear link with several risk factors, the amount of opioids used to
treat chronic pain in this country has skyrocketed. The market is already over-saturated with
expensive pills and pharmaceutical companies (which are for-profit and primarily are focused on
making money) primary concerns are rarely the needs of the patient. Anti-depressants have been
shown to have many of the same negative effects as opioids, especially the risks of dependence
and addiction, and because of this I firmly believe that simply giving people more pills is
dangerous and should not be our primary solution to this problem. The only other treatment for
chronic pain and depression listed on the NIMH website is Cognitive Behavioral Therapy
(Depression and Chronic Pain, 2015).
Cognitive behavioral therapy, or CBT, is a type of talk therapy that focuses on helping
people use positive thinking mental strategies through a combination of individual and group
counseling. While the treatment was developing, it initially focused heavily on the behavioral
aspects of therapy, including altering pain behaviors through changing environmental
contingencies and the settings in which pain-related behavior occurs (Morley & Williams,
2015). As time progressed, some psychologists shifteds away from strictly a behavioral approach
to a method that focused more on the cognitive aspects of therapy (such as developing new
coping and contingency planning skills), while others shifted their practice to focus more on
mindfulness or acceptance-based therapy (Morley &Williams, 2015). Today CBT can involve
any combination of these tactics depending on the psychologist administering treatment.

Regardless of the specific type of CBT, its effectiveness in treating depression has been
demonstrated time and time again.
An example of this finding came when researchers performed a meta-analysis of the
effects cognitive behavioral therapy had on patients suffering from fibromyalgia. In their review,
Bernardy, Fber, Kllner, and Huser (2010) found that CBT was consistently effective in
reducing depressed mood in post-treatment and also led to fewer post-treatment visits to the their
physicians. Overall they claimed that CBT should be considered to reduce depressed mood,
amount of healthcare behavior, and negative coping strategies (Bernardy et al., 2010). Another
study found that CBT demonstrated efficacy in treating a variety of psychiatric disorders and
physical illnesses (Sturgeon, 2014). One of the reasons CBT is effective is because it addresses
maladaptive behaviors such as pain catastrophizing (freaking out over simple pain-the I am
going to die mentality from a clearly non-lethal injury). The same review found that, of all
psychological treatments examined, cognitive behavioral therapy produced positive results the
most consistently, especially when compared directly to operant behavioral therapy tactics
(Sturgeon, 2014). One final thing to note about CBT is that the risks of adverse effects to the
patients undergoing it are relatively low (Sturgeon, 2014). Although risks exist if treatment is
carried out incorrectly or unethically, as long as proper training and approved practices are
followed, patients can likely expect to come away from treatment without any harm-something
that can definitely not be said of opioid.
I have personally seen the positive effects that can come from treating chronic pain and
mental illness using cognitive therapy and positive reinforcement. I have spent the last quarter
working as a research assistant for the University of Washingtons Behavioral Research and

Therapy Clinics, a clinical lab administering and researching dialectical behavioral therapy or
DBT. This is a form of CBT used to treat patients with severe depression, borderline personality
disorder, or a combination of mental health issues. They accomplish this by combining
traditional, and previously separate, approaches to therapy. DBT is a combination of behavioral
therapy tactics (such as solving problems and practicing contingency management) and more
Rogerian, cognitive therapy tactics (meaning high acceptance and validation-being nothing but
positive) (Linehan et al., 1999). The methods used include having patients participate in
individual therapy, group skills training (where new coping tactics, mindfulness training, and
emotional regulation, among other skills are taught) and phone coaching (Linehan et al., 1999).
It also combines elements of mindfulness training taken from Buddhist ideology; making it a
strong combination of many of the most common psychotherapies.
DBT has been repeatedly shown to be effective in treating highly suicidal patients, and is
one of the only treatments for high-risk individuals with replicable results (Linehan et al., 1999).
I have mainly spent my time at the UW BRTC (the central hub of DBT research and practice
throughout the world) entering and analyzing data that looks at the effectiveness of this therapy.
However I have heard many personal stories from people who have experienced firsthand the
positive effects that DBT can have on individuals suffering from severe mental illness. Many of
the patients they work with have either attempted suicide multiple times or frequently self-injure
themselves. They have been bounced around from treatment center to treatment center and have
had very little hope until their exposure to DBT. One such person had attempted suicide over
twelve times and was completely lost until they enrolled in DBT therapy; something that they

said saved their life. This intervention and the intense relationship and community it builds are
vital to helping sufferers control their lives again.
Two of the most important aspects of cognitive and dialectical behavioral therapy are
emphasis on the validation of patients claims and supportive community. The importance of
chronic pain subcultures has been well documented, as some claim that this enables patients to
feel validated and understood, despite the unpleasantness they experience (Hilbert, 1984). For
those who cannot form these vital subgroups, a sense of isolation occurs: the patients pain
becomes a wholly internal issue that cant be verified, categorized, or treated, and is indicative of
a life in chaos (Hilbert 1984). According to Hilbert, when medical experts cannot find an
underlying cause of the pain (as is so often the case for chronic pain patients), they believe that
the pain is imaginary or simply a manifestation of some mental anguish. This causes the
invalidated to question their experience of reality (Hilbert 1984). The pain may act as an everpresent reminder of their estrangement and, when medical professionals and experts tell them
that there is nothing wrong with them, a severe sense of hopelessness may set in. The opposite is
true for those who are able to form communities: their pain management is ongoing and they can
begin to cope (Hilbert, 1984). The fact that validation and a strong sense of community can help
ease depression and enable patients to manage and control their chronic pain indicates the need
for supportive cognitive behavioral therapy when creating a plan for treatment. This is also
significant because it indicates that the pain we experience is not simply the sum of the firing of
our pain fibers: it is distinctly influenced by things ranging from our cognition to our roles in
society.

On top of the demonstrated uses of cognitive behavioral therapy to treat depression, it has
been shown to be effective in actually treating pain directly. Some researchers claim that there is
an imperative need to use methods such as CBT to target treating pain instead of just using them
to improve patients coping ability and mood (Morley & Williams, 2015). A major review of the
effectiveness of CBT that covered several meta-analyses on the subject found that, overall, CBT
as an intervention for chronic pain is helpful for the average patient (Morley & Williams, 2015).
This result has been shown to be true regardless of the population-whether it is adults with
chronic low back pain or adolescent fibromyalgia patients, and researchers suggest it could be
extremely effective in treating chronic pain and post-traumatic stress disorder in patients (Morley
& Williams, 2015). One of the meta-analyses covered in the aforementioned survey looked at
how effective psychological interventions were for adults with chronic low back pain. The
results were overall very encouraging across the 22 studies included, indicating that
psychological interventions had positive results regarding pain intensity, health-related quality of
life, and depression (Hoffman, Papas, Chatkoff & Kerns, 2007). Specifically they found
cognitive-behavioral treatments to be among the most efficacious and with these findings they
concluded that overall psychological interventions had positive results for patients suffering from
chronic low back pain (Hoffman et al, 2007). Yet another study found a unique relationship
between decreases in catastrophizing and helplessness resulting from CBT and decreases in pain
intensity and pain-related interference later in life (Sturgeon, 2014). This is indeed indicative of
the fact that using CBT to treat chronic pain can be instrumental in lowering the overall level of
pain experienced.

A more specific example of the role of CBT is illustrated by Kazak and Nolis article The
Integration of psychology in pediatric oncology research and practice. They claim that using a
multimodal treatment approach to helping children with cancer has led to dramatic
improvement in survival (Kazak & Noli, 2015). Psychological tools have been instrumental in
reducing the pain of these pediatric oncology patients and increasing their quality of life (Kazak
& Noli, 2015). These methods are especially crucial for pediatric cancer patients because of the
urgent need for intense treatment and because almost 70% of survivors develop chronic late
effects which can be detrimental for the rest of their lives (Kazak & Noli, 2015). Primary care
physicians and oncologists rely on CBT and other tools to reduce the suffering from the chronic
pain that these young individuals go through (Kazak & Noli, 2015). Researchers rely on these
methods and treatments to improve mood and other measures of satisfaction among the patients,
and to improve coping and social skills (Kazak & Noli, 2015).
Another strong argument supporting the use of psychological tools in treating chronic
pain lies in how our mind can control our perception of pain. Nociception is the term that
describes the physical act of pain fibers sending signals to the brain. This is a separate
phenomenon from pain itself, which is something experienced by the person and the mind- our
fibers do not feel pain, only we do. As I have learned more and more about the mind and
cognition, it has become clear that our mind misinterprets information, lies to and tricks us, and
inaccurately represents stimuli a shockingly high percentage of the time. One of the most
important applications of this is that we can use the faults in our perceptual ability to lower pain
through psychological tools and cognitive tricks.

One of the ways we can influence our perception of pain is through the cognitive ability
of attention. The role of attention is vital to our ability to function: without it we would be
frequently overwhelmed with irrelevant stimuli and it would be nearly impossible to select
relevant information. The effect of attention on pain has been well documented. One study
looking at this topic was carried out by McCracken, who created a measure of pain entitled the
Pain Vigilance and Awareness Questionnaire (PVAQ). The PVAQ recorded participants
awareness and observation of pain. The results from the measure found that scores were
positively correlated with consciousness of pain and were negatively correlated with ignoring
pain (McCracken, 1997). These results were interpreted to show that chronic pain patients who
pay more attention to their pain also report higher intensity of discomfort and emotional distress.
Further analysis showed that attention to pain was a strong predictor of amount of pain and painrelated disability (McCracken, 1997). This result can be discouraging on the surface: when
patients are faced with intense persisting pain, it is extremely not to pay attention to it as it can
consume your life and be impossible not to notice. However, this is also encouraging because it
brings forth new techniques that can take advantage of this knowledge. One such technique is the
use of distraction.
A slightly older meta-analysis of the effects of distractions (or the removal of attention)
from pain found promising, although mixed, results. McCaul and Mallot (1984) examined the
findings of many studies looking at the outcomes and possible roles of distraction in pain
management. They then saw if these findings were consistent with a distraction based theory of
pain reduction. Specifically, they were examining four principles associated with distraction.

These were: 1) Distractions reduce discomfort more than the control condition (no techniques
used); 2) The strategies will be more effective the more of our attention they take up; 3)
Distractions will work very well for low intensity and 4) They will work marginally well for
medium-intensity pain but will be ineffective for intense pain (McCaul & Mallot, 1984). The
results they found regarding their first proposed principle indicate that distraction was a better
tool to manage pain than either a placebo or a control group that used no tool (McCaul & Mallot,
1984). When examining the second principle they ran into some difficulty due to the lack of a
clear way to determine which processes took up more of our attention. Despite this, they found
that more complicated processes were in general more effective than simpler distraction
techniques (McCaul & Mallot, 1984). And, as the researchers predicted, they found that the third
and fourth predictions were both true: distractions work best to block lower intensity stimuli,
however as the pain gets more intense it becomes less and less effective (McCaul & Mallot,
1984). They proposed that this is because we cannot block out the negative stimuli from out pain
fibers at high concentrations (McCaul and Mallot, 1984).
Another reason why a renewed emphasis on the social and psychological aspects of pain
management is needed can be found when we think about what will happen if we continue to
increase drug use. The term cultural iatrogenesis can be defined as the progressing
medicalization of healthcare, and this has become a major fear of some professionals (Sullivan &
Howe, 2013). Our medical culture has become more and more influenced by financial
institutions and pharmaceutical companies who primarily care about making a profit. They do so
by promoting the use of expensive medicines that do not actually aid bodily function or
contribute to long-term loss of pain. Researchers suggest that if there is no demonstrable

improvement in the overall level of pain or function after prolonged opioid use; patients should
stop or lower their consumption of the drugs (Morley & Williams, 2015). Unfortunately this
practice rarely occurs, and patients are often in danger of addiction or other longer-term health
problems such as hyperalgesia (which is an increased sensitivity to pain frequently by damage to
nociceptive nerves) and issues affecting the endocrine system(Morley & Williams, 2015). As
Sullivan and Howe (2013) warn, another serious consequence of this widespread long-term
opioid therapy is that we will become unable to treat pain in other ways. This creates
unreasonable expectations for pain relief, and will only increase the rates of opioid addiction and
overdose. A revamped effort in non-medicinal treatments of pain is necessary because the loss of
alternative treatments puts society at risk of major health issues.
The studies outlined here are just a few examples of the mounting evidence that indicates
the promising role psychology can play in improving chronic pain management. However it is
important to make clear that psychological interventions alone will not cure chronic pain. They
do have their limitations and their resolution of pain as a whole is far from perfect. They cannot
reduce pain alone and are most effective in reducing suffering and other aspects of chronic pain
(Kazak & Noli, 2015). They are ineffective for those experiencing high levels of discomfort and
are best for aiding low intensity chronic pain (McCaul & Mallot, 1984). However, the
demonstrated effects these methods have had in treating and improving emotional, physical and
social functioning indicate their importance in creating a holistic treatment plan for managing
chronic pain.

Psychological interventions must be an equally important complement to social

understanding and biological and medicinal treatment together they create the most
comprehensive and thorough approach to the management of chronic pain. Although this paper
does not discuss the importance of considering the social aspect of pain, it is a vital concept to
understand when creating a treatment for chronic pain. The concept of social roles (the
identities we take up in life including gender we identify with, parent, spouse, and
employed worker) can greatly influence our pain experience (Thorn, 2004). For example,
women are much more likely to report high levels of pain, and this is hypothesized to stem from
the fact that as children girls receive more attention and help than boys when experiencing pain
(Thorn, 2004). Because of examples like this, it is evident that social roles can influence pain
and must be considered. Like psychology, understanding of social roles and influences on pain
needs to complement biological treatment.
Despite the widespread acknowledgment and approval of the biopsychosocial approach
from experts, the use of opioids for treating chronic pain continues to rise. Nevertheless, there is
hope for the future, as technology such as skype and online therapy formats can bridge the gap
between psychologists and isolated rural patients. Similarly, the internet is increasing the
availability of training techniques for psychologists who want to learn how to treat patients using
CBT and DBT. For example, one of the graduate students in the lab I work in is currently
developing an online training program that will certify psychologists in proper DBT techniques.
Changing the way our society views and treats chronic pain will require a conscious effort from
physicians, psychologists, researchers and patients alike to not just take the simple, quick
treatment of pills to ease chronic pain, and instead take a holistic approach. This is crucial not

only because of the demonstrated effectiveness of these treatments, but because continuing to
focus on solely the biological aspect of pain is a costly mistake we cannot afford.

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