Understanding Pain Disorders

Posted on Friday, December the 28th at 6:29pm

Dr. Stephen F. Grinstead, LMFT, ACRPS, CADC-II

To understand pain management it is important to understand the concept of pain. Pain is a signal from the body to the brain that communicates that something is wrong. There are three components of pain—biological, psychological, and social/cultural.

In 1979, the International Association for the Study of Pain (IASP) published its first working definition of pain: “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

Pain is a total biopsychosocial experience. A person hurts physically. They psychologically respond to the pain by thinking, feeling, and acting. They think about the pain and try to figure out what is causing it and why they are hurting. They experience emotional reactions to the pain and may get angry, frightened, or frustrated. They will talk about their pain with family, friends, and coworkers who help them to develop a social and cultural context for assigning meaning to their personal pain experience, which leads to taking appropriate action.

The Gate-Control Theory of Pain

A theory of pain that was developed in the early 1960’s was called the gate control theory of pain that was developed originally by Melzack and Wall. The gate control theory changed the way in which pain perception was viewed. The basis of this theory is that physical pain is not a direct result of the activation of pain receptor neurons, but rather its perception is modulated by the interaction between different neurons. This theory also proposes that cognitive and emotional factors influence the perception of pain—that there is much more than just physiological factors involved.

The brain commonly blocks out sensations that it knows are not dangerous, such as when the feel of tight-fitting shoes that are put on in the morning has all but vanished a short time later. A similar process is at work when processing some moderately painful experiences.

In the gate control theory, the experience of pain depends on a complex interplay of two systems as they each process pain signals in their own way. Upon injury, pain messages originate in nerves associated with the damaged tissue and flow along the peripheral nerves to the spinal cord then on up to the brain.

In the gate control theory, before the pain messages can reach the brain they encounter nerve gates in the spinal cord that open or close depending upon a number of factors (including instructions coming down from the brain). When the gates are open, pain messages get through more or less easily and pain can be intense. When the gates close, pain messages are prevented from reaching the brain and pain may not even be experienced. The gate control theory attempts to explain the experience of pain (including psychological factors) on a physiological level.

When working with chronic pain patients it is important to carefully explain the gate control theory of pain along with simple to understand examples. This provides an excellent foundation to discuss what factors can open and close the spinal nerve gates. An in-depth explanation of the gate control theory is beyond the scope of this article but this is a good starting point.

Three Essential Levels Of Pain Management

Successful pain management systematically approaches the treatment of pain at all three levels (bio-psycho-social) simultaneously. This means using physical treatments to reduce the intensity of the physical pain. It also means using psychological treatments to identify and change the thoughts, feelings, and behaviors that are making the pain more intense or distressing and replacing them with positive thinking, as well as feeling and behavior management skills that can reduce the intensity of the pain.

Therefore, effective pain management must involve not only the patient, but also the significant people in their life who can help them to develop a social and cultural context in which to experience their pain in a way that reduces suffering.

Biological pain is a signal that something is going wrong with the body. The biological, or physical, pain sensations are critical to human survival. Without pain people would have no way of knowing that something was wrong with their body. So without pain they would be unable to take action to correct the problem or deal with the situation that is causing the pain.

Psychological Pain results from the meaning that the individual assigns to the pain signal. The psychological symptoms include both cognitive (thinking changes) and emotional (uncomfortable feelings) that often lead to suffering. Most people are not able to differentiate between the physical and psychological. All they know is “I hurt.” For effective pain management patients need to learn all they can about their pain.

Social and Cultural Pain results from the social and cultural meaning assigned by other people to the pain the patient is experiencing, and whether or not the pain is recognized as being severe enough to warrant a socially approved sick/injured role. These three components determine whether the signal from the body to the brain is interpreted as pain or suffering.

Imagine the following vignette: Bob is his college’s star football player. In the previous week’s homecoming game Bob scored the winning touchdown but broke his arm in the process. This week Bob is sitting on the bench with a cast on his arm that everyone has signed. This cast and how he earned it are seen as an honorable reason for him to be sitting on the bench instead of out on the field helping his team. But, in that same game Karl, a big hulking lineman, “tweaked” his back and was also sitting on the bench this week. Unlike Bob, Karl doesn’t have an observable injury and people keep asking him why he isn’t out on the field helping his team. Karl is much more apt than Bob to experience shame/guilt, which will probably amplify his pain symptoms.