A biopsychosocial approach to Pain management

Biological, psychological, and social factors interact to impact the experience of pain. The interaction among these factors is called a "biopsychosocial model". In the case of chronic pain, individuals often report that pain interferes with their ability to engage to occupational, social, or recreational activities. Their inability to engage in these reinforcing activities may contribute to increased isolation, negative mood (e.g., feelings of worthlessness, catastrophic thinking, and depressive symptoms), and physical deconditioning, all of which can make pain seem even worse.

the cycle of pain

A pain cycle diagram is helpful when describing how chronic pain can impact a person's life. When pain persists over an extended period of time, people may develop catastrophic beliefs about their pain (e.g., “This is never going to get better,” “Something is wrong with me") or negative thoughts about themselves (e.g., “I’m worthless to my family because I can’t work,” , "I could have done so much with my life", “I’m a bad partner/husband/wife”). When this pattern of thinking continues people may begin to become depressed. As pain continues, they may isolate themselves, or avoid doing everyday activities for fear of further injury or increased pain. This may also occur because they are feeling depressed or because they are tired of people asking questions like "Why arent you working? You look fine to me". As they withdraw and become less active, their muscles may become weaker, they may begin to gain or lose weight, and their overall physical conditioning may decline. This "Cycle of Pain" diagram shows how distress and disability feed back into pain and make it seem worse. Those of you who have pain will understand this cycle, and you may see youself in here. The key to breaking the pain cycle is not through increased pain medication.

Effective pain management involves the following strategies:

  1. Set goals and keep moving
  2. Learn how to relax
  3. Change negative thinking
  4. Schedule fun activites
  5. Dont over do it
  6. Sleep

The Gate Control Theory

So how exactly do thoughts and emotions impact the experience of pain? The Gate Control Theory (Melzack & Wall, 1965) was developed in the early 1960s by Ronald Melzack and Patrick Wall to account for the importance of the mind and brain in pain perception. The theory had a significant impact on the study of pain because it recognized that psychological factors can have important roles in the experience of pain.

How does the gate work? When you are injured, a pain signal travels from the site of injury through nerve fibers to the spinal cord and then up to the brain (see figure). The brain interprets the signal about tissue damage, and you perceive pain. The amount or severity of tissue damage is just one thing that influences the amount of pain we perceive. Researchers know that other factors influence the amount of pain we feel as well, especially in the case of chronic pain. In fact, most patients with chronic pain have noticed that their pain seems to increase or decrease on occasions when there is little evidence for change in the amount of tissue damage.

According to the Gate Control Theory, the experience of pain is not just the result of the interpretation of nerve impulses sent directly from sensory neurons to the brain. Rather, messages related to pain or injuries can be modified by other incoming stimuli before reaching the brain. The theory suggests that a type of “gate mechanism” in the dorsal horn of the spinal cord modulates the pain signal. The gate opens and closes depending on feedback from other nerve fibers in the body. This includes descending neural impulses from the brain related to an individual’s thoughts or mood (e.g., anxiety or depression). The opening and closing of the gate modifies how much information is sent to the brain from an injured area. Negative thoughts open the gate, which lets more pain information through, while positive thoughts close the gate and restrict the pain message. The result is that pain signals can be intensified, reduced, or even blocked on their way to the brain.

What causes the gate to open (you feel more pain)?

  • Negative thoughts and emotions and paying attention to pain tend to hold the gate open. Have you ever noticed that pain seems to increase at times when you are bored or unoccupied (e.g., at night while you are in bed), or when you are experiencing anxiety, anger, or feeling down?

What causes the gate to close (you feel less pain)?

  • Positive thoughts and emotions compete with information from the injury and close the gate. Have you noticed that when you are doing something fun like watching a movie, reading a book, or socializing with friends you may not experience as much pain?

Now that you know how important your thoughts and activities are in the experience of pain it is important to realize that the thoughts you have and the things you do are all under your control. By learning ways of addressing negative thoughts and emotions associated with pain, and ways of keeping active, you can take greater control over your pain rather than relying on physicians or medications for pain relief.

Managing Chronic Pain lists some Pain Management Strategies that you can try on your own (or with the help of a professional) who has been trained to help people with chronic pain.

References:

Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965;150(3699): 971–9. doi:10.1126/science.150.3699.971. PMID 5320816.