At the end of this session, students will be able to: Define pain. Explain the types of pain. Explain physiological perspective of pain (brief). Discuss psychological perspective of pain (gate-control theory, bio-psychosocial model of pain, etc.). Factors affecting pain perception including psychological, social and biological. Discuss treatment approaches for pain management (recent researches). Discuss the role of nurses in pain management.

1. The Psychology of Pain:
Understanding and
Management in
Nursing Care

2. Group Presentation
SHAHID HUSSAIN

3. OBJECTIVES
At the end of this session, students will be able to:
1.Define pain.
2.Explain the types of pain.
3.Explain physiological perspective of pain (brief).
4.Discuss psychological perspective of pain (gate-control theory,
bio-psychosocial model of pain, etc.).
5.Factors affecting pain perception including psychological,
social and biological.
6.Discuss treatment approaches for pain management (recent
researches).
7.Discuss the role of nurses in pain management.

4. DEFINITION OF PAIN
• Pain is an unpleasant sensory and emotional
experience associated with the actual and
potential tissue damage .
(Fishman, Ballantyne and Rathmell. 2011)

5. TYPES OF THE PAIN
There are several types of the pain. Main types
of the pain are listed below.
1.Acute pain
2.Chronic pain
3.Referred pain
4.Phantom pain

6. ACUTE PAIN:
Acute pain is characterized by injury of body
tissues and activation of nociceptive transducer
at the site of local tissue damage. Acute pain is
severe as compare to the chronic pain .
(Picone, 2012)

7. CHRONIC PAIN:
Chronic pain is characterized by injury or
disease that is caused by remote factors. The
chronic pain extend for long period of time. It’s
represented level of pain is low as compared to
acute pain.
(Stannard, Kalso, Ballantyne (Eds.) 2010)

8. REFERRED PAIN:
Referred pain is defined as the perceived pain at a
site nearby or even at a distance from the pain’s
origin.
(Fishman, Ballantyne and Rathmell. 2011)

9. PHANTOM PAIN:
Phantom pain sensation refers to the perception of a variety
of physical feelings in a part of the body that has been
removed. Although this is generally associated with limb
amputation.
(Flor, Nikolajsen, Jensen, MacIver, Lloyd, Kelly, and Nurmikko, (2010).

10. PHYSIOLOGY OF PAIN
(Yoneda, Hata, Nakanishi, Nagae, Nagayama, Wakabayashi, and Hiraga,
2011).

11. SPECIFICITY THEORY
• Earliest theory of pain proposed by Rene Descartes in 17th century.
• There is a direct relationship between nerve endings and pain spots on our
body.
• Pain travels to the brain in only one pathway, which is the same path used
by other sensations.
• The Specificity Theory stated that pain is "a specific sensation, with its own
sensory apparatus independent of touch and other senses".
• Severity of injury is directly proportional to the level of experienced pain.
CRITICISM:
• All nerve fibers in our body are not pain receptors, but there are some
specialized pain receptors in our body.
– Example: severely wounded soldiers in battle complain of less pain
contrary to extreme pain in minor injuries.
• A single stimulus type (e.g., a blow, electric current) can produce different
sensations depending on the type of nerve stimulated.
(Dean, Gwilym, Carr. 2013)

12. Nerve Fibers For Pain
(http://ucalgary.ca/pip369/mod7/tempain/theories
)

13. Proposed by
Ronald
Melzack &
Patrick David
Wall in 1965.
Proposed by
Ronald
Melzack &
Patrick David
Wall in 1965.
Pain
Pain
stimulus on
stimulus on
skin
skin
Nerve
impulses
transmit
pain to the
spinal cord
Nerve
impulses
transmit
pain to the
spinal cord
Gates in
spinal
cord
Gates in
spinal
cord
Pain is
sensed if
gates are
open
Pain is
sensed if
gates are
open
Pain is
not
sensed if
gates are
closed
Pain is
not
sensed if
gates are
closed
• Opening and closing of gates also
depends upon numerous factors:
– person’s attention to the pain source,
emotion, anxiety, coping ability and
physical damage to the body.
• The brain provides information
about the psychological state of an
individual, including behavioral
and emotional states and previous
experience of similar stimulus.
(Kandel, Schwartz & Jessel. 2000).

14. INHIBITORY
INTERNEURON
Aβ fiber
PROJECTION
NEURON
C fiber
Pain sensed

15. INHIBITORY
INTERNEURON
Aβ fiber
PROJECTION
NEURON
C fiber
Pain not sensed

16. Biopsychosocial Model
BIOLOGICAL
BIOLOGICAL
Nociception
Tissue Damage
Disease Process
Nociception
Tissue Damage
Disease Process
PSYCHOLOGICAL
PSYCHOLOGICAL
Pain beliefs
Locus of control
Lack of self-efficacy
Limited coping
Pain beliefs
Locus of control
Lack of self-efficacy
Limited coping
Emotions
Emotions
SOCIAL
Cultural influences
Learning mechanisms
SOCIAL
Cultural influences
Learning mechanisms
social learning
reward/punishment
classical conditioning
social learning
reward/punishment
classical conditioning

17. PSYCHOLOGICAL FACTORS
1. LOCUS OF CONTROL:
• Rotter (1996) stated that there were “internal” and “external” Locus
of control.
• The “internals” (believe that their own actions significantly influence
their health)
• The “externals”(believe that they don't have much control over their
health)
• People with a strong internal LOC believed to have good control over
their pain and are able to adapt by effective coping strategies and
manage pain better than those with an external LOC.
• Persons who believe that the prognosis for their pain is influenced
mainly by luck or fate (external) are engage in maladaptive coping
strategies such as wishful thinking or catastrophizing.
(Worsham, 2006)

18. 2. CATASTROPHIZING COGNITIONS:
• Pain catastrophizing is characterized by the tendency to magnify
the threat value of pain stimulus and to feel helpless in the
context of pain, and by a relative inability to inhibit pain-related
thoughts in anticipation of, during or following a painful
encounter.
• A “Neurophysiological Model” of catastrophizing proposes
that:
• Catastrophizing cognitions are associated with higher levels of
brain activity in the areas of anticipation and attention to pain,
emotional aspects of pain and motor control and are linked to
higher levels of pain intensity, greater disability, poorer
psychosocial adjustment.

19. Cont…
• In a research study pain catastrophizing was assessed
pre-surgery.
• The results showed significant variance in
postsurgical pain ratings, narcotic usage, depression,
pain-related activity interference and disability levels.
• Another study by Edwards, suggested that pain
catastrophizing was related to increased suicidal
ideation in a large sample of chronic pain patients.

20. 3. SELF-EFFICACY AND
EFFECTIVE COPING:
• In a Research study low levels of self-efficacy was found to be
associated with a lower levels of pain tolerance and higher levels
of pain intensity in samples of people with chronic pain.
• People who believe that they can alleviate pain are likely to
mobilize whatever skills they have learned to preserve
themselves.
• The higher the perceived self-efficacy the longer pain can be
tolerated and less medications are required.

21. Cont…
• Individuals who experience pain may develops two types of
coping.
• Adaptive coping: active coping strategies are considered to be
adaptive in which patient is an active participant and assumes
self management responsibilities.
• Maladaptive coping: these are passive coping strategies in
which patient withdraw from activities and shows dependency
on others for pain relief. (Placebo)
• Studies have found that active coping strategies decreases the
pain intensity and increases pain tolerance.
• However, passive coping is associated with greater pain and
related depression.

22. 4. PAIN AND EMOTIONS:
• The typical emotional reaction to pain includes anxiety, fear, anger,
guilt, frustration, and depression.
• According to FAM (Fear-avoidance model) “Fear of pain” is the
most important emotional factor in perception of pain.
• A fear response to pain leaves an individual with two options:
 Confrontation (Menstrual pain)
 Avoidance (Fracture pain and hygiene care)
• The “Confronter” is more likely to view pain as temporary , is
motivated to return to normal work, social and leisure activities,
and is prepare to confront their personal pain barriers.

23. Cont…
• The pain “Avoider” is motivated by fear and avoid both pain
experience (cognitive component) and painful activities (behavioral
component).
• Thus, this avoidance leads to more pain and is harmful to the
recovery process.
• Certain other negative emotions such as anger, hostility and
depressed mood can also influence pain perception.
• Negative emotional states registers in the brain in a manner that
strikes brain pathways which are responsible for enhancing pain.
• The expression of anger and hostility are often used as
defensiveness and can seriously compromise the therapeutic
relationship between nurse-patient, which further deteriorates
patient’s condition.

24. NEUROTICISM EXTRAVERSION
(Eysenk’s personality theory): High neuroticism is the
result of cortical arousal which increases sensitivity
and contributes to emotional instability. Such
individuals are more likely to worry about physical
symptoms like (pain).
(Eysenk’s personality theory): Extraversions have low
cortical arousal, requiring more frequent and stronger
stimulation to acquire satisfactory levels of arousal.
As a result, extravert exhibit diminished pain
sensitivity and higher pain threshold.
These individuals generally do not cope well with
stress and perceive painful stimulus as threatening
and distressful.
Extraversion is also associated with use of active and
strong coping strategies that lead to better adaption to
painful stimulus. (For example, being optimistic)
certain dimension of neuroticism negatively correlates
with pain (experiment):
1.Negative mood decreases pain tolerance time.
2.Emotional vulnerability increases pain intensity and
unpleasantness.
Extroversion is positively associated with general
health perception. Individual both healthy and with
self-reported medical problems feel good about
themselves and try to mobilize all their resources to
maintain this state of health.
Neuroticism is significantly high in patients with lower
back pain, joint pain and cancer pain etc.
Extraversions are more likely to complain about their
pain and express their sufferings than individuals high
in neuroticism.
http://books.google.com.pk/books?id=vwjIskXBbu8C&pg=PA28&dq=pain+and+extraversion+personality&hl=en&sa=X&ei=zRujUcr7JsezhAeayYAY&

25. CULTURE AND GENDER (SOCIAL
FACTOR)
CULTURE: GENDER:

26. PAIN CONTROL TECHNIQUES
1. PHARMACOLOGICAL CONTROL OF
PAIN:
 It is the traditional and most common method of
controlling pain
 Narcotics are well known in controlling pain. Amongst
narcotics, morphine (the Greek GOD of sleep) has been
the most popular pain killer for decades.
 However, pharmacological control of pain is the
potential for addiction.

27. 2. SURGICAL CONTROL OF PAIN:
 Some techniques attempts to disrupt the conduct of
pain from the periphery to the spinal cord, whereas
others are designed to interrupt the flow of pain
sensations from the spinal cord upward to the brain.
 Moreover, there is some indication that surgery can
ultimately worsen the problem because it damages
the nervous system, and this damage can itself be a
chief cause of chronic pain.

28. 3. SENSORY CONTROL OF PAIN:
One of the oldest known techniques of pain control is
COUNTERIRRITATION, a sensory method.
Counterirritation involves inhibiting pain in one part of
the body by stimulating or mildly irritating another area.
Overall, sensory control techniques have had some
success in reducing the experience of pain. However, their
effects are often only short-lived, and they may therefore be
appropriate primarily for temporary relief from acute pain.

29. RELAXATION TECHNIQUES
 Rationale for teaching pain patients relaxation
techniques, is that it enables them to cope more
successfully with stress and anxiety, which may
also ameliorate pain.
 Relaxation may also affect pain directly, for e.g.
the reduction of muscle tension or the diversion of
blood flow induce by relaxation may reduce pains
that are tied to these physiological processes.
 In relaxation, an individual shifts his or her body
into a state of low arousal by progressively relaxing
different parts of the body.

30. Cont…
 The common relaxation technique nurses use in
their practice is encouraging patients in deep
breathing exercises mainly to divert their minds
from painful procedures for instance IV
cannunlation and early labor.
 Generally, relaxation is modestly successful
with some acute pains and may be value in
treating chronic pain when used in conjunction
with other methods of pain control.

32. HYPNOSIS
 In 1829, prior to the discovery of anesthetic drugs, a French surgeon,
Dr. Cloquent, performed a remarkable operation on a 64 year old women who
suffered from breast cancer and the tumor was being removed without
anesthesia through hypnosis and the lady felt no pain.
 First, a state of relaxation is encouraged.
 Next, patients are explicitly told that the hypnosis will reduce
pain.
 In the hypnotic trance, the patient is usually instructed to think
about the pain differently
 It has been used successfully to control acute pain due to surgery,
child birth, dental procedures, burns and headache as well.

33.  In acupuncture treatment, long thin needles are inserted into
specially designated areas of the body that theoretically
influence the areas in which a person is experiencing pain.
(Practiced in china for more than 2,000 years).
How acupuncture controls pain is not fully known. But it is
possible that acupuncture triggers the release of endorphins,
thus reducing the experience of pain.
When Naloxone (an opiate antagonist) is administered to
acupuncture patients, the success of acupuncture in reducing
pain is reduced.

34. DISTRACTION
• Individual who are involved in intense
activities like sports or military maneuvers can
be oblivious to pain full injuries due to
Distraction

35. Cont…
 There are two quite different mental
strategies for controlling discomfort.
To distract oneself by
focusing on some other
activity.
To distract oneself by
focusing on some other
activity.
Focus directly on the
events but to reinterpret
the experience.
Focus directly on the
events but to reinterpret
the experience.

36. Cont…
 Distraction appears to be most effective for
coping with low-level pain. Its practical
significance for chronic pain is limited by the
fact that such patients cannot distract
themselves indefinitely.

37. GUIDED IMAGERY
 Guided imagery has been used to control some
acute pain and discomfort.
In guided imagery a patient is instructed to
conjure up a picture that he or she holds in mind.
This process brings on a relaxed state,
concentrates attention, and distracts the patient
from the pain or discomfort.
Apart from calm and pleasant guided imagery,
some patients take more personally aggressive
stance towards pain, these patients use it to rouse
themselves into a confrontive stance by imagining
a combat and action filled scene.

38. Cont…
 These two virtually opposite forms of
imagery may actually achieve some
beneficial effects in controlling pain
through the same means i.e. inducing
positive mood state and both focus
attention and provide a distraction from
the pain.

39. COGNITIVE BEHAVIORAL
THERAPY FOR PAIN
ACCEPTANCE AND
ACCEPTANCE AND
COMMITMENT THERAPY
COMMITMENT THERAPY
AWARNESS AND
PERSPECTIVE
AWARNESS AND
PERSPECTIVE
MMIINNDDFFUULLNNEESSSS
WWIILLLLIINNGGNNEESSSS
CCOOGGNNIITTIIVVEE D DEE--FFUUSSIIOONN
COGNITIVE
BEHAVIORAL
THERAPY
COGNITIVE
BEHAVIORAL
THERAPY
McCracken, (2005).

40. COGNITIVE BEHAVIORAL
THERAPY FOR PAIN
1. ACCEPTANCE AND COMMITMENT THERAPY:
• Aim for ACT is to reduce the feelings of failure (drug dependency)
of strategies to control pain.
• The therapist creates a collaborative environment in which Patients
with pain can review their actual problem and find out their
previous way of struggling to solve this problem. This gives a clear
understanding of the time duration of persisting problem and range
of strategies tried by patient to improve situation.
• It helps identifying the actual problem which is not the pain itself,
rather the behavior of disregarding oneself for the repeated failures
to achieve an effective pain control.

41. 2. AWARNESS AND PERSPECTIVE:
AAnnnnooyyiinngg Cramping
Throbbing
Weakening
Stressful Radiating
Pulling Tiring Aching
Tingling
DepresseD
Angry
Frustrated

42. 3. MINDFULNESS:

43. 4. COGNITIVE DE-FUSION:
• Marry had a………….
• London bridge is……..
• Humpty dumpty sat on a………
• Ring-a-ring o' roses, A pocket full of posies, A-tishoo! A-tishoo!
We all………
• But, what if, I can’t…..

44. 5. WILLINGNESS:

45. REFERENCES
• Ballanytyne, J. C., & Rathmell , J. P. (2010). Pain and its
taxonomy. In S. M. Fishman (Ed.), Bonica's management of
Pain (14th ed., pp.13-20). Bostan, Massachuesetts:
Lippincott William And Wilkin.
• Dean, B. F. F., Gwilyn, S. E., & Carr, A. J. (2013).Why does
my shoulder hurt? A review of the neuroanatomical and
biochemical basis of shoulder pain. British Journal of
Sports Medicine,1-12. doi:10.1136/bjsports-2012-091492.
• Field, H.L. (2007). Pain perception — The Dana
guide. Retrieved from
http://www.dana.org/news/brainhealth/detail.aspx ?id=10072

46. • Ge, H. Y., Nie, H., Madeleine, P., Danneskiold- Samsøe, B.,
Graven-Nielsen, T., & Arendt-Nielsen, L. (2009).
Contribution of the local and referred pain from active
myofascial trigger points in fibromyalgia syndrome. Pain,
147(1), 233-240.
• Kandel, E. R., Schwartz, J. H., & Jessell, T. M. (2000).
Principles of Neural Science (4th ed.). New York: McGraw-
Hill.
• Macintyre, P. E., Scott, D. A., Schug, S. A., Visser, E. J., &
Walker, S. M. (2010). Acute pain management: scientific
evidence. NHMRC.
• McCracken, L. M. (2005). Contextual cognitive-behavioral
therapy for chronic pain, Progress in Pain Research and
Management, 33. pp. 74-89.

47. • Stannard, C. F., Kalso, E., & Ballantyne, J. (Eds.). (2010).
Evidence-based chronic pain management. Wiley-
Blackwell/BMJ.
• Theories of pain perception. (2013). Retrieved from
http://ucalgary.ca/pip369/mod7/tempain/theories
• Yoneda, T., Hata, K., Nakanishi, M., Nagae, M., Nagayama, T.,
Wakabayashi, H., & Hiraga, T. (2011). Molecular events of acid-induced
bone pain. IBMS BoneKEy, 8(4), 195-204.