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By H. Silas. Franklin College. 2018.

Engel (1959) suggested that those with psychiatric conditions buy cheap cleocin gel 20gm on-line, as described by diagnostic nomenclature of the day (e cheap cleocin gel 20gm online. Amendments to Engel’s model, such as Blumer and Heil- broon’s (1982) position on chronic pain as a variant of major depressive dis- order, or masked depression, added depressed affect, alexithymia, family history of depression and chronic pain, and discrete biological markers (e. The results of a large number of studies suggest that the prevalence of current psychiatric conditions is, indeed, elevated in patients with chronic pain relative to base rates in the general population (e. It is questionable, however, whether the presence of psychiatric morbidity makes one more likely to use pain as an unconscious defense mechanism and, thereby, more prone to persistent pain (see, e. With few exceptions (Adler, Zlot, Hürny, Minder, 1989), the psychody- namic formulations have not fared well against empirical scrutiny (see re- views by Gamsa, 1994; Large, 1986; Roth, 2000; Roy, 1985), and now have di- minished popularity in mainstream psychology. Notwithstanding, they did play a key role in drawing attention to the importance of psychological (and contextual) factors in the experience of pain at a time when treatment for pain was primarily directed by the biomedical model. This attention led to increased and continuing research into a wide array of psychosocial vari- ables (e. Indeed, the interest in psychological factors spawned by psychodynamic theorists served as an essential precursor to the development of contemporary biopsychosocial approaches. However, using Roth’s (2000) analogy of the double-edged sword, it is noteworthy that there are lingering and unwanted scars of this psychodynamic thrust. These include the general tendency to assume (a) that all cases of pain in the absence of identifiable physical pathology are the result of psychological factors, and (b) that these are equally relevant to all people with persistent pain. Although incorrect, these assumptions can (and still often do) have a negative impact on opinions and general treatment of people who suffer from persistent pain conditions. GATE CONTROL THEORY As noted earlier, Melzack and colleagues’ seminal papers on the gate con- trol theory of pain (Melzack & Casey, 1968; Melzack & Wall, 1965) are fre- quently cited as the first to integrate physiological and psychological mech- 40 ASMUNDSON AND WRIGHT anisms of pain within the context of a single model. It is beyond the scope of this chapter to provide a detailed synopsis of the theory; however, given its contribution to current conceptualizations of pain, a brief overview is warranted. Melzack and Wall (1965) proposed that a hypothetical gating mechanism within the dorsal horn of the spinal cord is responsible for allowing or disal- lowing the passage of ascending nociceptive information from the periph- ery to the brain. These essential elements are as follows: · The gating mechanism is influenced by the relative degree of excitatory activity in the spinal cord transmission cells, with excitation along the large-diameter, myelinated fibers closing the gate and along the small- diameter, unmyelinated fibers opening the gate. Since this original proposal we have, of course, moved beyond believing that the key to understanding pain is knowing what happens in the dorsal horn. Melzack and Casey (1968) further proposed that three different neural networks (i. They also recog- nized that processing of input could occur in parallel, at least at the sensory and affective level. This revised model allowed for “perceptual information regarding the location, magnitude, and spatiotemporal properties of the noxious stimulus, motivational tendency toward escape or attack, and cog- nitive information based on analysis of multimodal information, past experi- ence, and probability of outcome of different response strategies” (pp. Think back to the case of Jamie, who had pain associated with muscle strain in the low back. Applying the postulates of the gate control theory, Jamie’s pain experience might be understood as follows: Stimulation of nociceptors in the region of muscle strain facilitated transmission of infor- mation along ascending fibers, through an open gate, and on to Jamie’s brain. At the same time, Jamie’s brain was sending information about her current cognitions and emotional state (i. The summation of the ascending nociceptive input and descending information regarding cognition and 2. BIOPSYCHOSOCIAL APPROACHES TO PAIN 41 emotion, in this case, kept the gate open. Medical and behavioral interventions ultimately served to close the gate, reducing pain, and improving Jamie’s mood state and overall functional ability. Based on this brief overview it should be apparent that the gate control theory challenged the primary assumptions of the traditional biomedical and psychodynamic models. Rather than being exclusively conceptual- ized as sensation arising from physical pathology or somatic manifesta- tion of unresolved emotional conflicts, the experience of pain came to be viewed as a combination of both pathophysiology and psychological fac- tors. On this basis, then, Jamie’s depressed mood would not be viewed as a secondary reaction to pain, nor would the pain be viewed as a result of depressed mood. Rather, each would be seen as having a reciprocal influ- ence on the other.

Satisfaction with abilities appears to mediate the relation- ship between loss of VLAs and depressive symptoms (fig generic cleocin gel 20gm fast delivery. Greater impact of RA on VLAs was found to be associated with greater dissatisfaction with abilities 20gm cleocin gel with visa, which was then associated with higher depression scores. There was no direct relationship between VLA disability and depression when satis- faction with abilities was considered. Individuals who become disabled in val- ued activities and become dissatisfied with their level of functioning are more likely to become depressed; those who become disabled but do not become dissatisfied do not become depressed. The level of satisfaction with function may depend on the specific activities affected or on the value placed on those activities. These results underscore the need to consider individuals’ interpretation of a functional loss or the value placed on the affected or lost activities and shed light on one way in which VLA disability might lead to depression. Disability and Psychological Well-Being 53 Clinical Implications of the Proposed Model Existing evidence suggests that individuals with RA develop consider- able disability in VLAs. Since RA is a chronic condition that often begins early in life and lasts for decades, VLA disability may develop and progress over many years. Performance of VLAs is the type of function most closely linked to satisfaction with functioning. Loss of the ability to perform VLAs, particularly recreational activities and social interactions, has been shown to be a significant risk factor for the onset of depressive symptoms [43, 44, 47, 49]. Because of these established links, VLA disability appears to have the potential for considerable negative impact on individuals’ psychological well-being and quality of life. Economic costs attributable to depression, including direct medical, psychiatric, and pharmacologic care, mortality, and workplace absenteeism and reduced productive capacity, were estimated to be USD 43. A more recent study estimated that depression produced an excess cost of USD 31 billion per year in lost productive work time alone. Depressed persons have also been found to use more of other types of health services than nondepressed persons [30, 35, 59, 60], further increasing the economic costs. Depression has been shown to exert a negative influence on health in diverse ways, including inhibiting recovery following hip fracture surgery, increasing the risk of physical decline [62, 63], and increasing the risk for mortality [64, 65], and may lead to unwarranted changes in medications and overmedication due to the amplification of symptoms that depression may cause [66, 67]. Depression is also associated with poor treatment adherence, which may adversely affect treatment and health status. Enabling individuals with RA to main- tain VLAs or to maintain psychological well-being after VLA disability may avert some of the negative effects that appear to be associated with VLA disability. Medical treatment prescribed for RA, whether analgesic, disease-modifying antirheumatic drug (DMARD), or referral for surgery, is often prescribed in response to functional declines or to maintain function by alleviating pain, limiting damage, or replacing joints. In spite of these best efforts, func- tional impairments may continue to develop or worsen. Thus, it becomes clinically helpful to know that functional declines may create a risk for poor psychological outcomes for a patient. Awareness of worsening functional status can give the physician a cue to ask specific questions about function or activity losses. Answers to those questions may serve as cues for referrals for intervention. Katz 54 Intervention point Intervention point Disability Health status Functional limitations Basic activities Psychological status Difficulty in activities of Pathology Restrictions in basic daily living (e. Extension and modification of the Verbrugge and Jette model of disablement showing points of intervention. The individual may be able to make behavioral changes to lessen the impact of functional limitations in order to maintain activities (i. Such behavioral changes might include making modifications in the way activities are performed, replacing activities, or pacing oneself. Escalante and Rincon suggest that medical therapies can intervene at different stages in the disablement process in RA. Medications may affect pathology or impairment, joint surgery may reduce impairment and functional limitations. Disability and Psychological Well-Being 55 the type of activity affected. Any intervention undertaken to increase behavioral adaptation would need to take such variation into account.

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Then we administered a second cold pressor task and took outcome measures buy cleocin gel 20 gm overnight delivery. As we predicted generic cleocin gel 20gm amex, the anger flooding intervention significantly reduced anger, distress, pain anxiety, state anxiety, trait anxiety, and worry and significantly improved mood states as well as pain threshold, tolerance, and intensity. The Psychological Behaviorism Theory of Pain Revisited 35 Anger Desensitization To explore the effects of anger desensitization on the experience of acute pain, we obtained baseline measures of cold pressor test pain, worry, anxiety, and anger and randomly assigned 60 participants to one of following interven- tions: anger desensitization (visualizing anger-evoking events while relaxing with pleasant imagery), neutral imagery control, or no-treatment control. When we repeated the measures after the intervention and analyzed our data, we found that the anger desensitization treatment significantly alleviated anger, pain anxiety, state anxiety, trait anxiety, and worry and significantly improved mood states, pain threshold, and pain tolerance. These results confirmed our prediction based on the psychological behav- iorism theory that the emotional management of anger by desensitization would facilitate coping with acute pain. They also confirmed our specific prediction that the anger desensitization group would report significantly less pain than the control groups. Emotional Relaxation for Anger Management To explore the effects on the experience of acute pain of managing anger with relaxation techniques, we randomly assigned 60 participants to three groups: a semantic relaxation intervention (visualizing pleasant events and engaging in coping self-instructions), a neutral imagery control, or a no-treatment control. Prior to and after treatment, we measured cold pressor pain, worry, anxiety, and anger. Analysis of the data revealed that anger management by relaxation sig- nificantly alleviated anger, pain anxiety, state anxiety, trait anxiety, and worry and significantly improved mood states, pain threshold, and pain tolerance. These results confirmed our prediction that anger management by relaxation tactics would have beneficial effects on coping with acute pain. Psychological Behaviorism Therapy Treatment of Osteoarthritic Pain Psychological behaviorism therapy (PBT) is an intervention that integrates strategies derived from the principles of the psychological behaviorism theory of pain. Wells, Hekmat, and Staats explored the efficacy of PBT (stress man- agement training, mood-enhancing imagery, pain-coping self-instructions, and a relaxation exercise designed to alleviate pain) in the management of chronic osteoarthritis pain in the elderly. Both treatment groups showed gains in all outcome measures (pain, self-efficacy, personal resourcefulness, analgesic use, and psychological symp- toms) that were not attained by controls. Compared with the self-efficacy Staats/Hekmat/Staats 36 group, the PBT significantly alleviated arthritic pain, reduced the intake of analgesics, and improved psychological symptoms, such as depression. Both the PBT and the self-management interventions led to significant improve- ments in managing pain and distress compared with controls, and both treat- ment groups maintained these therapeutic improvements and differences at 2-month follow-up (unpubl. The Psychological Behaviorism Theory of the Placebo The psychological behaviorism theory of pain allows us to construct a parallel theory of the placebo in which we may consider the placebo for pain a stimulus (treatment condition) that reduces pain in the absence of a change in the biological condition producing the pain. This placebo/treatment has the ‘power’ to reduce pain because it is a conditioned stimulus for a positive emo- tional response. Thus, little white sugar pills administered as a ‘treatment’ to an unsuspecting subject can elicit a positive emotional response and relieve pain because, in the past, that subject has paired little white pills (e. The pill, however, is not the placebo; the suggestion that the pill offers efficacious treatment is the placebo, and the pill or other device is merely a conditioned stimulus. The placebo is even more potent if, in addition to eliciting a positive emo- tional response, it involves language that enhances the positive emotional responses. What a doctor says to a patient (or a patient says to him/herself), therefore, may improve the patient’s mood and reduce the impact of pain. In fact, the action of a placebo usually involves complex cognitive (language) mechanisms, and an assessment of how language elicits emotional responses is necessary to achieve an understanding of the placebo response. Conditioned stimuli also elicit negative emotional responses that can exac- erbate pain. Such a negative conditioned stimulus is called a negative placebo or ‘nocebo’. According to our theory, language stimuli that elicit a negative emotional state will exacerbate pain. The Results of Research Supporting the Psychological Behaviorism Theory of the Placebo The Placebo and Pain For our first study of the effect of the placebo on pain, we divided sub- jects into three groups and submitted them to a cold pressor test accompanied by (1) a placebo suggestion designed to elicit a positive emotional response, The Psychological Behaviorism Theory of Pain Revisited 37 (2) a nocebo suggestion designed to elicit a negative emotional response, or (3) an emotionally neutral suggestion. As predicted, pain was ameliorated by the placebo, exacerbated by the nocebo, and unchanged by the neutral intervention. Pain Sensitivity and Responsiveness to Placebo Suggestions The personality construct ‘pain sensitivity’ predicts fear of pain and pain avoidance behavior. We conducted a study to test our theoretical predictions that pain-sensitive individuals will experience pain more intensely than those who are not pain sensitive and that subjects receiving a positive placebo instruc- tion regarding anticipated pain will experience less pain than those given a neg- ative placebo, while pain scores of those receiving a neutral placebo instruction will fall in the middle.

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