Postgraduate Medical Journal (December 1984) 60, 886-892

Psychological approaches to the treatment of chronic pain

H. MERSKEYD.M., F.R.C.P., F.R.C.P.(C), F.R.C.Psych.

University of Western Ontario and London Psychiatric Hospital

Introduction

Much of the earlier writing on the psychology ofpain fails to distinguish between acute pain andchronic pain. Some authors studied chronic pain,explicitly defining their population by the duration ofthe complaint. The differences between acute andchronic pain were particularly emphasized by Stern-bach (1968, 1974). Watson (1983) delineates chronicpain very effectively as follows: '.... persisting pastone month or past the usual time for the particulardisorder to heal. It usually lacks evidence of auto-nomic hyperactivity'.A number of the psychological observations which

apply to acute pain also apply to chronic pain. Butnot all of them matter as much. For example, anxietyand anticipation often make acute pain worse. This isparticularly notable before operation. They are notnearly so prominent in respect of chronic pain.Similarly a sense of control of the situation ofteneases acute anxiety or pain. This can be inferred fromthe animal literature, e.g. Mowrer and Viek (1948)and has sometimes been shown in adults (Bowers,1968; Thompson, 1981), and in children (McGrath,1983).

It has been generally considered since the work ofBeecher (1955) that a placebo effect can be found in35% of patients with postoperative pain and otheracute conditions. This is rarely the experience ofanyone treating chronic pain. In the case of chronicpain, patients are often no longer anxious but aremore often depressed. Many of them have learnt, orhave taught themselves, subjective techniques of paincontrol. Frequently, these involve distractions or analternative method of occupation. Sometimes theyfind a way to occupy themselves with a task in thepresence of distracting stimuli which are deliberatelyprovided; usually this is the radio. It is interestingthat Morgenstern (1964) demonstrated that a combi-nation of tasks and distracting stimuli, like flashing

lights and variable repeated noises helped to reducepain. However, if patients do reach the doctor fortreatment it can be assumed that even though theirefforts in this direction may have had some success,they have not been enough to produce the reliefwhich is needed.

Basic concepts of pain

In the evaluation of patients with pain it isimportant to define basic concepts. Most peopleinterested in the field favour the view that pain has tobe regarded as a subjective phenomenon, whateverits cause. The pain from which psychiatric patientssuffer is usually not distinguishable subjectively frompain which has other causes, although in a few casesthe characteristics of the descriptions of pain or theassociated features may help to achieve distintinc-tions between pain which is due to psychologicalfactors and pain which is due to lesions. Thus, mostpsychiatric patients with pain describe their pain interms similar to the terms of organic disease but in afew instances discriminating techniques will separatesome members of the groups (Leavitt and Garron,1979).For some years I have felt it best not to use the

description 'psychogenic pain'. This is for two rea-sons. First the original notion of a psychogenicsymptom of any sort was one in which a physicaldisorder caused the psychological state (Lewis, 1972).The term has suffered a reversal of usage since itnow, sometimes, but not always, means a symptomwith psychological causes. Second, if 'psychogenicpain' is accepted as an entity this gives credence tothe idea that it is not really the same to the patient astrue or so-called 'genuine' pain-which ofcourse hasto be organic (who ever heard doctors, even psychia-trists or psychologists, talk of 'genuine' learnedbehaviour?). Accordingly, it seems best not to regard'psychogenic' pain as totally distinct from 'organic'pain. This is not to say that we may not recognizesome differences. We must recognize patterns incausation whether organic or psychiatric or both.

Correspondence: H. Merskey, D.M., Director of Education andResearch, London Psychiatric Hospital, 850 Highbury Avenue, P.O.Box 2532, Terminal 'A', London, Ontario, Canada N6A 4H 1.

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Thus it is advisable to see pain as a fundamentallyunitary phenomenon, albeit with various causes.

Those who have a philosophical interest may agreethat this amounts to a monistic attitude to theproperties of the condition and a dualistic, Descar-tian attitude to its causes. The approach rec-ommended requires one to talk of pain of psychologi-cal origin or pain of organic origin or pain which hasboth causes. That is a little cumbersome but retainsthe unitary attitude to pain without giving up theclinical need for discrimination.

Psychiatric considerationsA few cases of acute anxiety or hysteria present

with pain. Cardiac neuroses such as effort syndrome,or precordial pain mimicking angina or resemblingcoronary disease, can be due to sudden stress oremotional conflict. The majority of pain problems inpsychiatric practice represent pain of at least severalmonths duration and this is what is discussed in thissection.

If psychiatric considerations are important inpatients with chronic pain, it becomes relevant toknow what diagnoses should be considered. Four canbe mentioned. First, it is very rare to find pain due toschizophrenia as a consequence of significant delu-sions or hallucinations. However a significant minor-ity of schizophrenic patients have headache or othersomatic complaints. The somatic complaints oftenhave a minor organic basis, e.g., from trauma. Theheadache seems to be associated with the illness buthas not been well analysed as to whether it is relatedto thought processes or muscle tension, or susceptibleto any other explanation. In any case, these com-plaints are not often the source or a focus of majorconcern to the patient. Second there is a well-recognized group of patients who are in the minorityin all, or almost all, published studies and who have aclassical endogenous depression. These cases mayhave pain on a delusional basis (e.g., jabbing painsfrom punishment being inflicted on them) or, muchmore often, because associated anxiety producesmuscle tension. The majority of patients with endo-genous depression however do not have notable painsymptoms. Everyone loves to comment on the fewpatients with pain and classical endogenous depres-sion and even more to diagnose them because theyrepresent one relatively small group where treatmentis often very effective and the results are verygratifying. Moreover, they are interesting conceptu-ally.

Third, there is a somewhat larger group of patientswho have reactive depressions and in whom pain,especially headache, is a common symptom. Thesepatients, too, respond quite well to the usual treat-ments for depression. They often show some neurotic

mechanisms such as anxiety to which the pain can beattributed. Fourth, there are patients who haveessentially neurotic conditions such as anxiety, oftenwith hysterical symptoms or personality abnormali-ties. These form the bulk of psychiatric patients whoare seen in pain clinics or who have chronic painwhich is a major problem. There are a number ofways of categorizing them besides the traditionalones which I have used. The term 'learned pain' or'operant pain' is one such set of terms which partlyoverlaps with these notions. The classification systemof the American Psychiatric Association in the thirdDiagnostic and Statistical Manual (DSM-III) coverssome of these patients with the term 'somatizationdisorder' which is a version of what others havecalled 'Briquet's syndrome' (Guze, 1970) and deli-neates a number of these patients but not all ofthem.Conversion disorders and histrionic personality referto others, but not exclusively to patients with pain.There is also an understandable overlap betweenendogenous and reactive depresions and a furtheroverlap between reactive depression and the neuroticdisorders.

Insofar as a distinct psychiatric diagnosis can bemade, the guidelines for treatment are clear. Schizo-phrenic patients normally require phenothiazines aswell as some quite specific social management andattention to the parts played by their families. Thosewith endogenous depression respond well to antide-pressants and those with reactive depression also gainbenefit from medication. In both categories, andespecially in those with reactive depression, psycho-logical support or exploratory psychotherapy isuseful and environmental manipulation is oftenrequired. Anxiety states respond somewhat to antide-pressants and also to both exploratory psychotherapyand behavioural techniques such as relaxation anddeconditioning. Benzodiazepines should be avoidedsince they do not provide satisfactory long-termmedication and this population is at obvious risk ofdrug dependence.Where the predominant phenomena are hysterical

or related to intractable personality syndromes theprognosis is less good. Management in these casesmay be quite effective on a general practitioner leveland may not be much better on the part of those whohave much greater specialization in this field.

However, perceptive handling of these patients canmake a worthwhile difference. The doctor's prefe-rence, and mastery of particular techniques, willusually determine which measures he employs inthose situations. They are a very specialized psychia-tric problem and need not detain us here. Overall, thegeneral methods of psychiatric management of pa-tients who focus on their body are very important inthe care of many chronic pain patients. This appliesalso to patients with cancer pain.

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Secondary emotional changes

There is evidence (Woodforde and Merskey, 1972;Sternbach, 1974) that patients with significant lesionsdevelop secondary emotional changes. This is hardlysurprising. Some of these changes include irritability,frustration, subjective depression, and reduction ofsexual interest (Pelz and Merskey, 1982). There is, ofcourse, impairment of sporting and recreationalactivities as well as work and a corresponding degreeof dissatisfaction in many instances. The depressionin about 10% of patients in pain clinics may reach thelevel of significant illness (Pilowsky, Chapman andBonica., 1977) but is much more often a pattern ofsymptoms as just indicated. Many of these secondarychanges will respond to treatment of the primarycondition or to organic procedures which producepain relief. The latter include physiotherapy, exer-

cise, transcutaneous electrical nerve stimulation(TENS), minor analgesics, and surgery. Psychotropicmedication, especially phenothiazines and amitrip-tyline has some organic basis for its effects even whenpsychiatric illness is not to be found (Monks andMerskey, 1984).

The main problem

The commonest problem in pain clinics andperhaps in the practice of most doctors is the patientwho has a lesion and also some evidence of emotionaldisturbance. The emotional disturbance may beindependent and make the pain worse whether thelesion is a major one or a minor one, and it may attimes be the main factor in producing the pain. Thecommonest situation in pain clinics is that personal-ity disorders promote the complaint of pain and theemphasis upon it. Difficulties within the family, thepossibility of compensation, complications from theuse of drugs and dependence on them all compoundthese problems. Frequently, there has been excessivesomatic treatment and sometimes excessive psychia-tric treatment. Many of these issues are dealt with inthe chapter on 'Behavioural Science and ChronicPain' (Fordyce, 1984, this issue).

In general, the first step is to convince the patientthat the doctor truly believes that he has pain.Nothing works better in this context than a compre-

hensive evaluation of the patient's condition. It isessential for every practitioner who becomes involvedwith a patient with chronic pain to establish for thepatient that he has taken the main complaintseriously. This means reviewing and if necessaryrecording in detail the features of the pain, the extentto which it disturbs the patient's life, the things thathave been done for it, and the measures that might ormight not relieve him. If such an approach is adoptedit then becomes very acceptable to the patient to haveenquiries made into his psychological status, whether

the pain has affected him, what emotional conditionsmay make the pain worse, and so forth. Thispragmatic and sympathetic approach frequently en-ables the patient to express and discharge muchfeeling about the troubles which his pain has givenhim. It is essentially supportive but occasionally willserve to explore emotional difficulties.Once the main lines of this approach have been

established the next requirement is to work on anyand every measure which is relatively harmless andwhich may produce some improvement. These mea-sures may be physical but are important psychologi-cally. It is obvious that physical measures of treat-ment like physiotherapy, exercise, nerve blocks,TENS, medication, all serve to encourage the patientin the belief that he may get better. There can betimes when some of them serve in a disadvantageousfashion to help him believe that the responsibility forgetting better is not in his hands. But there is noreason in principle why a variety of physical mea-sures should not be employed, and have someplacebo benefits, without committing either thepatient or the doctor to the view that psychologicalissues must be neglected. In such a context of careand attention and support it may be more possible tolook at different issues in the patient's life which needto be reviewed than in any other context. These issuesinclude the obvious considerations as to whetherfamily relationships are satisfactory, whether thepatient has a difficult boss (if he or she is stillemployed), and whether he or she is engaging inenough activity or other steps to relieve the pain bydistraction or concentration or any other psychologi-cal process. Against this background of generalsupport and care, arrangements can then be made toreview or introduce a number of other more specia-lized approaches.

More specialized methods

Table 1 shows a number of the approaches whichhave been adopted with some sample references ontheir description or evaluation. Those interested inmore detail of particular approaches can refer to thesources cited. Interestingly, I have not found anyextensive discussion of supportive psychotherapy andpain, although it is the form which is perhaps mostoften recommended. The following represents gen-eral comments upon the various approaches.

Analytic psychotherapy was originally fostered byauthors like Hart (1947) and Engel (1951, 1959). Onthe whole, its success in the treatment of psychiatricpatients with pain has been limited and it is little usedin chronic pain patients in pain clinics. Modificationsof analytic psychotherapy offer some promise for asub-group. Brief dynamic psychotherapy which isdeveloped from the foregoing is the most attractive

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TABLE 1. Specialized techniques available for psychological man-agement in chronic pain

Analytic psychotherapy Pilowsky, 1978Psychodynamic treatment Pilowsky and Bassett, 1982Supportive psychotherapyFamily therapy Roy, 1982; Waring, 1982;

Fordyce, 1976Group therapy Pinsky et al., 1979; Baptiste

and Herman, 1982Milieu therapy Herman and Baptiste, 1981Cognitive therapy Tan, 1982; Turner and

Chapman, 1982;Turket aL., 1984

Operant therapy Fordyce, 1976; Turner andChapman, 1982

Hypnosis Barber and Adrian, 1983Combined techniques Roy and Tunks, 1982

form of treatment to be considered. Malan (1976) andhis colleagues have shown that brief dynamic therapy(say up to 9 sessions) can define particular problemsin patients' lives and resolve them with the participa-tion of the patient. There is no reason to think thatpain may not similarly resolve in some instanceswhen it represents a major psychological problem inan individual's life. However, these instances will belimited to a small group.

Supportive psychotherapy is advocated strongly byPilowsky and Bassett (1982) who write '(it) ... aims tosupport and strengthen the patient's own copingmechanisms ... with no attempts ... to challenge de-fences. The therapist is usually more active andpositive with maximal reality testing and encourage-ment ... in the management of pain patients suppor-tive psychotherapy is often the patient's majortherapy'. I concur fully with this although publishedformal evidence for it is lacking. In one unpublishedstudy (Hall, 1980) it was shown that supportivepsychotherapy was valuable. Group psychotherapy isof use, probably, in patients who have alreadyentered into programmes within specialized clinics.There are few, if any, reports ofgroup psychotherapyor patients who have that modality of treatmentalone. The results described by Pinsky et al. (1979)and Catchlove and Cohen (1982) show however thatgroup approaches based on a dynamic model andcombined with other types of treatment can produceexcellent results comparable with those from othertypes of programme.

Cognitive therapy is logical and has been shown byKhatami and Rush (1982) to work for specificindividuals in pain at specific points in their care. Itsoverall value remains subject to assessment. Exten-sive reviews of this have been provided by Tan (1982)and also by Turner and Chapman (1982). Detailedmethods of treatment can be found in the book byTurk, Meichenbaum and Genest (1983). Miller andBerman (1983) review cognitive therapy in general.

Perhaps the essential feature of cognitive therapy isto make systematic what we all think of doingempirically, such as distancing oneself from pain andsaying 'It isn't really me that is suffering', orfavouring distraction techniques which emphasizesomething different like pleasant experiences (think-ing about some nice experience which may help toreduce the impact of current pain) and so forth.The methods which are classed as cognitive

therapy are very varied. Tan (1982) mentions theprovision of preparatory information, preparedchildbirth techniques and 'coping skills'. The lattercomprise strategies like imaginative inattention('think of a pleasant day at the beach'), imaginativetransformation of the pain ('those sensations arereally contractions, not pain'), imaginative transfor-mation of the context ('that hurts but it's like beingthe hero in a James Bond film'), diversion ofattention (counting ceiling tiles, doing mental arith-metic) and somatization (focusing on the part in painbut analysing the experience as if for a biologyreport). Relaxation, deep breathing exercises, theprovision of external distractions (e.g., tasks whichpre-occupy the individual or variable noises) all formpart of the complex of strategies which may be calledcognitive therapy. Some workers, especially Turk etal. (1984), have developed 'stress innoculation proce-dures' in which the individual is exposed to painful ornoxious stimuli, usually in the laboratory, as part of aprocess of becoming accustomed to the painfulsituation and adapting to it with the various cognitivetechniques recommended.On the whole, it seems that cognitive therapy may

have some benefit but this is still speculative. There isreason to think that it may work best in pain of mildor moderate severity (cf. Melzack, Weisz and Spra-gue, 1963)). It tends not to prove popular withpatients when the pain is severe. It then produces,apparently, only very limited gains. However, sinceall the gains with cognitive therapy are got at theexpense of little or no risk to the patient, they deservealways to be considered and sometimes at least to besought out.

Hypnosis is sometimes linked with cognitive ther-apy. In the writer's view hypnosis is just one form ofsuggestion and has nothing to commend it over othermodes of suggestion except that it too is usuallyharmless. Occasionally, patients and their therapistsget into a mess with it but that is not common. Thereader who wants a sceptical view of hypnosis canrefer to Merskey (1971). A discussion of its place intreatment today by those who use it is available in thevolume by Barber and Adrian (1983).

Like hypnosis, behavioural methods are oftenlinked in discussion with cognitive ones. They havepreceded cognitive techniques in development. Theirformal development is principally due to Fordyce

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(Fordyce et al., 1968; Fordyce, 1976) and since hisfirst description they have become increasingly popu-lar, particularly in North America. The kernel of thisapproach is provided by the notion that conditioningwill reduce or abolish 'pain behaviour'. In operantconditioning, as distant from classical conditioning,behaviour is increased if it is rewarded ('reinforced')and decreased if not rewarded ('negative reinforce-ment') or otherwise discouraged. Chronic pain pa-tients are held to show much pain behaviour whichdistorts their lives and which they may use as a formof interpersonal manipulation. Following from this itis argued that pain is 'learnt' or 'unlearnt' and that asuccessful operant programme would enable patientsto unlearn the pain which has been manifest in theirpain behaviour. There are conceptual problems inthis viewpoint to be discussed shortly.

It has long been recognized that active rehabilita-tive measures and concentration upon positive en-deavours is beneficial to patients with both psycholo-gical and physical disorders. Exercise has also beenseen to be valuable-despite initial pain from it-inmany musculoskeletal disorders. Travell et al. (1942)observed that disuse gave rise to muscle pain. It istherefore appropriate to expect that any approachwhich includes these features will have advantages forat least some chronic pain patients. The specificoperant procedure requires that patients be reinforcedpositively by the responses of staff if they are activeand uncomplaining, and that they receive the reversetreatment if they do little or talk about their pain.Some good results have undoubtedly followed

from operant programmes (Greenhoot and Stern-bach, 1974; Newman et al., 1978; Roberts andReinhardt, 1980). In a fairly representative report,Cairns et al. (1976) describe the results when behav-ioural approaches were employed in the secondphase of treatment of a severely disabled group oflow back pain patients, the first phase coveringregional blocks and other somatic techniques. Apostal survey of 100 patients, averaging ten monthsfrom discharge, elicited replies from 90 ofwhom 70%were improved and 75% were working. Typically, inthis report as in others, it is hard to disentangle thepure effects of the operant approach from otherthings which are going on at the same time. Increasedactivity and a reduction in medications used for pain,however, are common results of behavioural pro-grammes. The latter effect is often obtained byoffering the patient a 'pain cocktail' through whichthe medication taken is reduced without the patientbeing able to see the size of a decrease or when it ismade. These particular types of change seem to bereported more often from behaviourally orientatedcentres.

Fordyce (1982) has no difficulty in making a soundcase that the behaviour of patients in pain is

influenced by environmental factors. Sternbach(1983) has noted, however, that there is no proof thatoperant programmes work any more than otherinterventions because operant programmes havenever been studied in an adequate controlled fashion.In practice it is extremely difficult to isolate operantmeasures and present them as part of a totalprogramme controlled by another programme inwhich the sole difference is the absence of specificallyoperant activity by the therapists. Linton (1982) hasassessed the situation in the treatment ofchronic painother than headache not only in regard to studies ofoperant conditioning but also with respect to relaxa-tion in cognitive and multimodal behavioural ap-proaches. He says 'in general the quality of thestudies was poor .., few data were found whichconclusively demonstrate that any of the approachesare effective or they are the treatment of choice'. Headds, however, that the data do imply that behav-ioural approaches may help patients lead morenormal and productive lives and agrees that theliterature suggests that '(1) the operant methods leadto increased activity levels and decreased pain anddrug intake; (2) the relaxation approach results indecreased electromyogram levels and some painreduction; (3) the cognitive techniques are specula-tive at this time; and (4) the multimodal methodregularly produces a variety ofimprovements but thediversity of the treatments makes general statementsabout utility impossible'.The neglect of the experience of the patient is one

aspect of the behavioural approach which remainsunacceptable to the present writer. There need be noobjection to recognizing that it is unhelpful forpatients and their relatives to persist in ruminatingabout and talking about pain and avoiding anyconstructive activities. But it is also difficult tosuppose that when pain is promoted by movement itwill be abolished as a result of operant relearning,rather than because, after substantial exercise, themuscular status and respondent input of the indivi-dual will be changed. Likewise, even if unwantedbehaviour is diminished, it seems very unlikely thatthe experience of pain will go away unless some otherchange has been effected, either in the individual'sphysical status or in his thought processes. Thepatient is likely to comment that he still has his painbut he is not permitted to mention it. Special effortsare needed to get around this particular conflict ofattitude between patient and practitioner. In anycase, such methods would not resolve the conceptualdilemma. Any approach which insists on speakingonly of 'pain behaviours' whilst skirting around thenature of the subjective experience, is likely to leave asignificant group of doctors and patients dissatisfiedwith its comprehensive quality. The usual answer tothis is that the patient's descriptions of his experience

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Psychological approaches to chronic pain 891

are part of his behaviour and that is how we knowabout it and it will be taken into consideration.Nevertheless, in practice the behaviourist approachseems to make a virtue of discounting the subjectiveexperience and is accordingly deficient.

ConclusionsThe theme of this article has been to emphasize

that there is an important field for psychiatric andpsychological contributions in the management ofchronic pain. Some of the limitations of theseapproaches have also been expressed. I believe thatthe best approach is founded upon a clear concept ofpain. I have criticized attempts to discount thesubjective experience. At the same time behaviouralmethods have a role to play in comprehensivemanagement. As is so often the banal case, an eclecticand comprehensive position should appeal to allthose who agree that no single current theory isadequate on its own. This can also be expected to bemore practical and to offer the best chance ofeffective treatments.

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