Chronic Pain And Biopsychosocial Research

Abstract

With the change in lifestyle large numbers of people are diagnosed with chronic pain and not only people from old age group but large numbers of people who are in the younger age group are also facing this problem. However, with the advent of medical intervention people are encouraged to learn how to adapt with their illness over the long term. Adaptation or adjusting to illness is a common term used in health psychology. In this regard the present paper is an attempt to review the literature regarding adaptation to chronic pain from biopsychosocial perspective. A study of chronic pain from biopsychosocial perspective will enable us to take into account the various biological, psychological and social perspective into consideration and by focusing on this model the neurological basis of pain could also be studied. A critical component of future research would be to integrate the neural data with behavioral correlate.

Introduction

“Of pain, you could wish only one thing: that it should stop. Nothing in the world is as bad as physical pain. In the face of pain, there are no heroes.” George Orwell

“Pain” is an experience which is almost known to all humankind which is emotionally unpleasant and results in avoidance of the behaviour or activity leading to pain. International Association for the Study of Pain (IASP) defines pain as “a psychological state associated with unpleasant sensory and emotional experience resulting from actual or potential tissue damage”. Unlike acute pain chronic pain is considered difficult to treat and more complex in nature. IASP defines chronic pain as “pain without an apparent biological cause that persists beyond the normal time for tissue healing usually 3 months or 6 months”. The new ICD-11 categorizes chronic pain into seven groups - chronic primary pain, chronic visceral pain, chronic postsurgical or post-traumatic pain, chronic musculoskeletal pain, chronic cancer-related pain, chronic neuropathic pain and chronic secondary headache or orofacial pain. By giving the definition of The IASP taskforce for the classification of chronic pain in ICD-11 has defined chronic primary pain as “ pain in one or more anatomical region that persists or recurs for longer than 3 months, is associated with significant emotional distress (e.g., anxiety, anger, frustration or depressed mood) significant functional disability (interference in activities of daily life and participation in social roles), and the symptoms are not better accounted for by another diagnosis”. The clinical picture consists of both localized and widespread bodily pain. Thus it can be said that for both across disorders and across individuals, there can be variation in the experience of pain. From the patients point of view it is certainly maladaptive and makes a painful picture for people because most often it is seen that the grievance and disability faced by the patients cannot be explained by the ailment and damage which they are facing. In most cases patients don’t get any relief and they are left with no other option other than to go on with their life. An experience like this is quite stressful and makes the individual prone to a number of mental health problems. Last few decades has seen a surge of work on chronic pain with lot of focus in understanding its etiology, symptoms, how it can be assessed and its management. Epidemiological research has shown that 10-20% of adults of the total population get afflicted by chronic pain. Dureja.G.P, Jain P.N etal (2014) did an epidemiological study in eight cities across India and found that on the whole the point prevalence of chronic pain was 13%.The most afflicted city was Chennai (22%) then Kolkata (21%) and the lowest was found in Ahmadabad (6%). About 32%of the patients lost 4 hours of work in the past three months. It requires the person in pain to respond in adaptive ways so as to get away with its source and symptom, it is seen that majority of people are able to adapt to their pain that is they are able to deal with the situations and their feelings. However, the capacity to adapt to and deal with pain is not same among all individual.

Adaptation: The etymology of the word 'adaptation” stems from the Latin roots “ad” which means “towards” and “aptus” which means in the sense of something that is towards a suitable outcome or resolution. Successful adaptation in pain patients is seen when one restores a sense of normalcy to one’s everyday life, where normalcy is defined by their perceived needs and situation. There are various aspects in the process of adaptation of pain patients like physical, psychological, social, spiritual and vocational. According to Stanton & Revenson (2007) both terms adjustment and adaptation are used interchangeably in the literature and for maintaining optimum relationship certain changes in self and adjacent is encouraged. For example, people who are suffering from cancer pain or arthritis pain, adaptation is influenced by a host of personal, social and environmental experiences demanding support and resources and coping strategies from them. According to Stanton & Revenson adaptation includes five attributes:

1. Chronic illness necessitates adaptation in multiple life domains.
2. Adaptation involves both positive and negative outcome dimensions.
3. Adaptation is a dynamic process.
4. Adaptation can be viewed only from within the context of the individual.
5. Heterogeneity is the rule, not the exception”.

In health psychology, preserving functional status and low negative affect when you are ill are the outcomes which generally define the term adaptation. However, when you are facing progressive loss of physical functioning, it is seen that preserving the functional status of your body is not easy. As adaptation is viewed as an ongoing process, the researchers have argued that the process and outcome should be viewed separately. According to Hoyt & Stanton (2012) “adjustment should include multidimensional aspects relevant to psychological, social and physical adjustment of the individual”. According to Moos & Schaefer (1984) “some of the health psychology theories which specifically deal with adjustment to chronic illness state that there are seven categories of adaptive tasks divided into illness-related and general tasks which are core to adjustment where illness related tasks deals with symptoms, disability, treatment, and maintaining relationships with medical staff”. The adaptive tasks have been empirically defined by many approaches into specific illness or common tasks across illness groups.

In the last few decades, a new approach has especially been influential in the area of chronic pain which replaced the earlier prevalent biomedical model which considered the mind and body as functioning separately and was thus considered inadequate. George Engel is considered to be the first to call for the need of a new approach to the traditional biomedical reductionist philosophy and which subsequently led to the growth of the field of behavioral medicine and health psychology. A major outgrowth was the development and evolution of the biopsychosocial model that focuses on both disease and illness with illness being viewed as the complex interaction of biological, psychological and social factors (Gatchel, 2005). In order to fully understand a person’s perception and response to pain and illness, the interrelationships among biological changes, psychological status and sociocultural context all need to be considered in.

Chronic pain is considered complex and the neural mechanisms that underlie chronic pain have not been understood well, however the field of neuroscience has contributed to a better understanding of basic mechanisms in pain processing by conducting carefully controlled experimental studies. In doing so several experimental pain models have been proposed involving inflammatory pain, neuropathic pain and cancer pain and to investigate these pain models various techniques like genetic, electrophysiological and imaging techniques has been used. Neuroimaging allows us to study neural activity in individuals with chronic pain when they are completely at rest or while they are subjected to various tasks and procedures or activity. Thedese can include applying physical stimuli such as heat, pressure and exposing the patient to event related stimuli, such as emotion evoking images, working memory tasks and auditory stimuli. Neuroimaging experiments use combination of imaging modalities and these various techniques are rapidly advancing our knowledge of how chronic pain affects brain structure and activity. Nowadays researchers have started using a variety of imaging techniques to study pain and the various imaging tools used Computerized Tomography, functional Magnetic Resonance Imaging, Positron Emission Tomography, Single-photon emission computed tomography, magnetoencephalography (CT, fMRI, PET, SPECT, MEG) have greatly enhanced our knowledge because of the advantage of correlating the brain activity with human perception. Large number of studies have been done to study various chronic pain states like headache, migraine, phantom pain, fibromyalgia, trigeminal and low back pain where researchers have observed structural brain alterations. Apkarian et.al (2004) was the first to observe cortical changes in the brain of chronic pain patients. Neuroimaging has also helped us in explaining many of neural correlates that can modulate the experience of pain, like Fairhust M, et.al (2007) investigated brainstem responses during anticipation and processing of thermal noxious stimuli, Zaki J, et.al (2009) studied empathy and his result provide both an experimental and theoretical approach for studying empathy and its dysfunction, Ochsner KN,et.al (2008) also found similar result; Watson eA, et.al (2009) identified the brain structure activated during placebo conditioning; Zeidan F, et.al (2011) studied how mindfulness meditation influences pain in healthy human participants, Ochsner KN et.al, (2006) studied fear and anxiety. Each factor impacts how we perceive pain, and an increasing number of functional neuroimaging studies are investigating how these factors affect pain perception and activity in the brain. Current pain research also uses various neuroimaging techniques to investigate a broad range of translational science that can eventually be tested in clinical trials.

Functional Magnetic Neuroimaging Imaging (fMRI) is now widely used in the medical field to obtain brain changes while doing activity or at rest. It uses deoxygenated hemoglobin to study brain activity and allows for an indirect measurement of brain activity by treating changes in blood oxygenation levels referred to as BOLD signals. fMRI is based on the principle that blood contain magnetic properties and that an increased metabolic demand, due to increased neuronal activity, results in an increase in blood flow beyond metabolic needs, such that the final ratio of deoxygenated hemoglobin actually is reduced and it is this reduction in deoxygenated hemoglobin that alters the magnetic field properties and produces the increased fMRI signal. There are various advantages of fMRI like its noninvasiveness, good spatial and temporal resolution. According to Gatchel et al. (2007) large body of literature has been conducted to investigate brain mechanisms underlying both chronic and acute pain and has been found that brain areas that can be activated include the primary somatosensory cortex (SI), secondary somatosensory cortex (SII), anterior insula, thalamus and cerebellum, while there are other studies on pain, attention, anticipation have that found that slightly different area of brain gets activated when we study their relationship and interaction.to athat On the other hand, the relationship and interaction of pain, attention, and anticipation has been demonstrated to activate slightly different areas of the brain. Recently Nair (2005) has raised concern about the use of fMRI as he says that “BOLD fMRI is dependent on the blood flow response that follows neural activity and does not measure neural activity per se while interpreting data from these studies.”

Literature is flooded with studies about how individual deal with their illness and adapt in the long run and a large body of literature is available which has provided information about the neural state of brain activity in chronic pain. A critical component of future research would be to connect these neural studies with behavioral correlates. To study the adaptation of chronic pain patients and to correlate it with the neural data that is to see whether people who are better able to adapt with their pain are the one who have less activation in the brain during functional imaging and people who have a poor adaptation have more brain areas activated during functional imaging. An integration of field of neuroimaging with psychology would provide a better insight into the field of chronic pain and help us in proposing better interventions for the patients.

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