The biopsychosocial approach to chronic pain: Scientific advances and future directions.

The prevalence and cost of chronic pain is a major physical and mental health care problem in the United States today. As a result, there has been a recent explosion of research on chronic pain, with significant advances in better understanding its etiology, assessment, and treatment. The purpose of the present article is to provide a review of the most noteworthy developments in the field. The biopsychosocial model is now widely accepted as the most heuristic approach to chronic pain. With this model in mind, a review of the basic neuroscience processes of pain (the bio part of biopsychosocial), as well as the psychosocial factors, is presented. This spans research on how psychological and social factors can interact with brain processes to influence health and illness as well as on the development of new technologies, such as brain imaging, that provide new insights into brain-pain mechanisms. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Behavioral assessment and treatment of chronic pain: Current status and future directions.

A literature review indicates that behavioral assessment methods assess 3 categories of behavior: overt motor, cognitive-verbal, and physiologic. Evidence for the efficacy of operant conditioning and self-management techniques is presented. Data from both multimodal pain-treatment programs and controlled studies are reviewed. Advances in behavioral assessment research allow for a more precise and objective analysis of the behavior of chronic-pain patients. Controlled treatment–outcome studies suggest that behavioral methods may help modify pain behavior and pain report in chronic-pain patients. (93 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Acceptance and values-based action in chronic pain: A study of treatment effectiveness and process.

Developing approaches within cognitive behavioral therapy are increasingly process-oriented and based on a functional and contextual framework that differs from the focus of earlier work. The present study investigated the effectiveness of acceptance and commitment therapy (S. C. Hayes, K. Strosahl, & K. G. Wilson, 1999) in the treatment of chronic pain and also examined 2 processes from this model, acceptance and values-based action. Participants included 171 completers of an interdisciplinary treatment program, 66.7% of whom completed a 3-month follow-up assessment as well. Results indicated significant improvements for pain, depression, pain-related anxiety, disability, medical visits, work status, and physical performance. Effect size statistics were uniformly medium or larger. According to reliable change analyses, 75.4% of patients demonstrated improvement in at least one key domain. Both acceptance of pain and values-based action improved, and increases in these processes were associated with improvements in the primary outcome domains. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Toward a theory of pain: Relief of chronic pain by prefrontal leucotomy, opiates, placebos, and hypnosis.

Research concerned with the neurological correlates of the pain response and how this response can be mitigated or eliminated by various clinical procedures permit several tentative conclusions: (a) pain producing stimuli activate a variety of nerve fibers rather than activating specific "pain" nerve pathways. (b) Pain producing stimuli set off patterns of neural impulses which are different from those produced by other stimuli. (c) Discomfit due to pain is not necessarily present when the noxious stimulus has been discriminated. Discomfit can be eliminated by various clinical procedures without necessarily altering the sensation of pain. (d) Mitigation of discomfort by clinical procedures appears to be secondary to their more generalized effect, i.e., anxiety reduction. 174-item bibliog. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Chronic pain alters drug self-administration: Implications for addiction and pain mechanisms.

This review article focuses on the impact that the presence of pain has on drug self-administration in rodents, and the potential for using self-administration to study both addiction and pain, as well as their interaction. The literature on the effects of noxious input to the brain on both spinal and supraspinal neuronal activity is reviewed as well as the evidence that human and rodent neurobiology is affected similarly by noxious stimulation. The convergence of peripheral input to somatosensory systems with limbic forebrain structures is briefly discussed in the context of how the activity of one system may influence activity within the other system. Finally, the literature on how pain influences drug-seeking behaviors in rodents is reviewed, with a final discussion of how these techniques might be able to contribute to the development of novel analgesic treatments that minimize addiction and tolerance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Anger management style and emotional reactivity to noxious stimuli among chronic pain patients and healthy controls: The role of endogenous opioids.

Objective: Previous work suggests that elevated trait anger-out exacerbates pain responses in part through endogenous opioid dysfunction. The authors examined whether this opioid dysfunction affects not only perceived pain intensity, but also emotional responses to being hurt. Design: 79 chronic low back pain (LBP) patients and 46 healthy controls received opioid blockade (8 mg naloxone i.v.) and placebo in randomized, counterbalanced order in separate sessions. During each session, participants sequentially experienced finger pressure pain and ischemic forearm pain tasks, with emotional state assessed at baseline and postpain. Main Outcome Measures: Blockade effects indexing opioid modulation of emotional reactivity were derived by subtracting placebo from blockade condition emotional reactivity. Results: Significant Participant Type × Anger-Out interactions on blockade effects indicated that in LBP participants but not in controls, greater anger-out was associated with deficient opioid modulation of anxiety, anger, and fear reactivity to noxious stimulation. Across participant types, greater anger-in was associated with impaired opioid modulation of anxiety and fear reactivity. Anger-in opioid effects were partially due to overlap with general negative affect. Conclusions: Opioid dysfunction associated with trait anger-out may affect not only perceived pain intensity, but also pain-related suffering in individuals with chronic pain conditions. Implications for understanding the health effects of anger management styles are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A different kind of comorbidity: Understanding posttraumatic stress disorder and chronic pain.

Many traumatic events leave lingering physical injuries and chronic pain in their wake, in addition to trauma-related psychopathology. In this review, we provide an overview of developments in the recent literature on comorbid posttraumatic stress disorder (PTSD) and chronic pain. Starting with the conceptual models presented by Sharp and Harvey (2001) and Asmundson, Coons, Taylor, and Klatz (2002), this review summarizes newer studies that examine prevalence of these comorbid conditions. Additionally, we present an updated synthesis of research on factors that may maintain both chronic physical pain and PTSD in trauma survivors. Consideration of the impact of this comorbidity on psychosocial assessment and treatment also is discussed, with particular attention to issues that warrant additional research. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Psychological factors in chronic pain: Evolution and revolution.

Research has demonstrated the importance of psychological factors in coping, quality of life, and disability in chronic pain. Furthermore, the contributions of psychology in the effectiveness of treatment of chronic pain patients have received empirical support. The authors describe a biopsychosocial model of chronic pain and provide an update on research implicating the importance of people's appraisals of their symptoms, their ability to self-manage pain and related problems, and their fears about pain and injury that motivate efforts to avoid exacerbation of symptoms and further injury or reinjury. They provide a selected review to illustrate treatment outcome research, methodological issues, practical, and clinical issues to identify promising directions. Although there remain obstacles, there are also opportunities for psychologists to contribute to improved understanding of pain and treatment of people who suffer from chronic pain. The authors conclude by noting that pain has received a tremendous amount of attention culminating in the passage of a law by the U.S. Congress designating the period 2001-2011 as the "The Decade of Pain Control and Research." (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Research on telehealth and chronic medical conditions: Critical review, key issues, and future directions.

Objective: To provide a critical review of studies on the impact of telecommunication-based interventions for persons with chronic disabilities. Design: Only those studies that focused on specific health care or clinical interview outcomes and included at least 1 comparison condition were selected for review. Ten studies met these criteria. Results: Overall, the results of initial studies suggest that telecommunication-based interventions may be an efficient and effective way of providing services for chronically disabled populations, even for those who have no previous experience with the technologies. Conclusions: The number of controlled trials examining telecommunication-based interventions for those with chronic disabilities remains small. Future research should endeavor to increase sample size, use conceptually meaningful control groups, focus on cost utility, and investigate which types of telecommunication-based interventions provide the best match with specific populations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Twenty years of cognitive assessment: current status and future directions

This commentary examines a number of methodological and conceptual issues that were raised in this special section on cognitive assessment. Although progress has been made in a number of areas since cognitive-clinical researchers first addressed the assessment of cognition almost 20 years ago, important conceptual and methodological questions still remain unresolved. These include questions about the validity of retrospective self-report questionnaires of cognition, the low convergent validity between different assessment methods, and the failure to specify the range of generalizability of specific cognition measures. Further advances in cognitive assessment will depend on a more concerted research focus on the methodological and conceptual issues raised in this special section.     

Effects of anger suppression on pain severity and pain behaviors among chronic pain patients: Evaluation of an ironic process model.

Objective: Evidence for links between anger inhibition or suppression and chronic pain severity is based mostly on studies with correlation designs. Following from ironic process theory, we proposed that attempts to suppress angry thoughts during provocation would increase subsequent pain intensity among chronic low back pain (CLBP) patients, and do so through paradoxically enhanced accessibility of anger. Design: CLBP patients (N = 58) were assigned to suppression and nonsuppression conditions while performing a computer maze task with a harassing confederate. A structured pain behavior task (SPBT) followed. Main outcome measures: Self-reported anger, anxiety, and sadness following maze task. Self-reported pain severity and number of observed pain behaviors during SPBT. Results: Patients told to suppress during provocation: (a) reported greater anger following the maze task, reported greater pain intensity during the SPBT, and exhibited more pain behaviors than patients not suppressing; (b) postmaze anger levels significantly mediated group differences on pain behaviors. Conclusion: Attempts by CLBP patients to suppress anger may aggravate pain related to their clinical condition through ironically increased feelings of anger. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pain, nicotine, and smoking: Research findings and mechanistic considerations.

Tobacco addiction and chronic pain represent 2 highly prevalent and comorbid conditions that engender substantial burdens upon individuals and systems. Interrelations between pain and smoking have been of clinical and empirical interest for decades, and research in this area has increased dramatically over the past 5 years. We conceptualize the interaction of pain and smoking as a prototypical example of the biopsychosocial model. Accordingly, we extrapolated from behavioral, cognitive, affective, biomedical, and social perspectives to propose causal mechanisms that may contribute to the observed comorbidity between these 2 conditions. The extant literature was 1st dichotomized into investigations of either effects of smoking on pain or effects of pain on smoking. We then integrated these findings to present a reciprocal model of pain and smoking that is hypothesized to interact in the manner of a positive feedback loop, resulting in greater pain and increased smoking. Finally, we proposed directions for future research and discussed clinical implications for smokers with comorbid pain disorders. We observed modest evidence that smoking may be a risk factor in the multifactorial etiology of some chronically painful conditions and that pain may come to serve as a potent motivator of smoking. We also found that whereas animal studies yielded consistent support for direct pain-inhibitory effects of nicotine and tobacco, results from human studies were much less consistent. Future research in the emerging area of pain and smoking has the potential to inform theoretical and clinical applications with respect to tobacco smoking, chronic pain, and their comorbid presentation. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Everyday competence in later life: current status and future directions

This article reviews the literature on the antecedents and outcomes of everyday competence in later life and discusses future directions. It is argued that there is a fairly solid knowledge base with regard to the antecedents and outcomes but not in terms of the components and mechanisms of older adults' everyday competence. Five key issues are identified and discussed in terms of a future research agenda. For each key issue, directions for future research are outlined and a transactional approach is advocated. It is emphasized that older adults should be viewed as proactive individuals who are motivated to minimize the losses and maximize the gains associated with the aging process.