Psychosocial contributions to the development of pain

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Investigations into predisposing, precipitating, and maintaining causes of chronic pain show that in several respects the origins are similar to those of somatization and the somatoform disorders. The family histories of patients with chronic pain include an excess of mood disorders, pain and disability, substance abuse, and personality disorders. Engel(7) described the dynamics of 'the pain prone patient' involving abusive childhood experiences, and noted how pain can become a pathway for the expression of guilt and expiation. Recent research(8) has focused on childhood physical and sexual abuse, but it is not clear whether the relationship with pain is, at least to some extent, determined by selective reporting, or whether it is mediated by the presence of mental disorders. Pain is particularly likely to become chronic in those who have limited coping strategies, as indicated by premorbid personality traits, although this may not be evident until they are faced with negative life events (particularly physical illnesses), to which they may have difficulty in adapting.

The concept of gain helps to illustrate some of the processes that are involved. Primary gain may be evident where pain serves to remove the patient from a situation that evokes conflict and helps to maintain self-esteem, for instance where there is little hope of finding a new job following redundancy owing to inadequate skills (the term 'primary gain' is used here in a sense different to that in psychoanalytical writings). Secondary gain includes the concern of others and enhanced financial benefits, particularly where there is the opportunity for compensation. Tertiary gain is the benefit to others, such as the impotent husband who gains from his wife's headaches.

Using a learning theory model, Fordyce(9) classified all pain into 'operant' and 'non-operant' pain. The former includes all pain that is modified by positive or negative reinforcement, whether or not organic pathology is present. This has led to the assessment of pain behaviours and their environmental reinforcers, and the development of pain-treatment programmes that originally focused on behavioural change by modifying reinforcement. Inappropriate beliefs of patients tend to contribute to pain behaviours, and these may be facilitated by the beliefs of carers and health professionals. Thus cognitive approaches to treatment have been integrated with behavioural management. Recently, there have been striking changes in policies concerning the management of acute pain, with increasing awareness of the importance of early mobilization, for example in the management of back pain, and this may help to prevent the development of chronic pain.

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