A working pain system is crucial to survival, and people with an inability to feel pain--a rare genetic disorder--frequently injure themselves and tend to have shortened life spans as a result. Many more people, however, have the opposite problem: They feel frequent pain sensations that carry little informational value or signal injuries that physicians simply can't alleviate. In fact, up to 20 percent of Americans report chronic pain, and for many, it can interfere with their ability to lead normal lives.
"With chronic pain, you are hurting, but it is not signaling that anything has gone wrong or that anything is worse today than it was yesterday," says Timothy Tumlin, PhD, a Chicago-based psychologist who specializes in chronic pain management. "It's like a faulty oil light in a car."
But pain is harder to ignore than an oil light. Drugs can dull the sensations, but many are addictive and decrease in effectiveness over time. As a result, some people try to avoid activities associated with the pain, confining themselves to their homes or beds, says Beverly Thorn, PhD, a psychology professor and director of the clinical psychology program at the University of Alabama.
One well-established method for helping people tolerate pain enough to get out of bed and on with their lives is cognitive-behavioral therapy, says Thorn, who researches how thoughts can contribute to the experience of pain.
"We know that…cognitive-behavioral therapy helps reduce pain and perceived disability and medication use," she says. "The question is: What are the exact mechanisms through which it works?"
Targeting those mechanisms is more than just an academic question, Thorn says. Therapy dropout rates among pain patients are high; zeroing in on effective therapy components might encourage clients to stick with the cognitive-behavioral program. So, Thorn and her collaborators have taken to the lab--dunking college students' arms into ice water or squeezing them with blood pressure cuffs after giving them cognitive strategies to manage the resulting pain. Their findings--that using mental techniques for limited amounts of time actually reduces pain--are just now hitting the pain-management mainstream.
"Chronic pain is a highly complex set of issues, so the solution for the patient is also going to be complex," says Tumlin. "Lab work helps us untangle some of these issues and develop an effective toolbox."
Thorn, along with David A. Williams, PhD, a psychologist and professor of internal medicine at the University of Michigan, conducted their first laboratory experiments on time-limited pain tolerance in the 1980s. In one experiment, published in Cognitive Therapy and Research (Vol. 10, No. 5, pages 539-546), they asked 80 undergraduate students to place their arms into 35-degree water. The students then attempted to keep their arms in the water for as long as possible, ranking their discomfort on a scale of 1-100 every 30 seconds.
Prior to the procedure, half of the participants learned relaxation and imagery techniques for tolerating pain; the other half received no training. The experimenters subdivided the groups further by asking half of the trained and half of the untrained participants to endure the pain for three minutes, but telling the others to go "as long as possible."
The participants--both trained and untrained--who had a time limit in mind, reported less pain than those with an open-ended goal, ranking their pain at three minutes about 12 points lower than participants with an open-ended goal. Cognitive techniques also made a difference: Trained participants with an open-ended goal, for instance, rated their pain about six points lower than untrained participants with an open-ended goal.
"What that underscores is that although pain perception is nociceptive in nature--it certainly is the information traveling through the sensory system up to the brain--the belief in how long the pain is going to be enduring influences how you feel it," says Williams.
Denise James, PhD, then a graduate student at the University of Alabama, Thorn and Williams applied that insight to actual pain patients in a study published in a 1993 issue of Behavior Therapy (Vol. 24, No. 2, pages 305-320). They instructed one group of people with chronic migraine headaches to try out coping techniques--such as monitoring pain-related thoughts and muscle relaxation--20 minutes a day for general practice, and for 30 minutes during any time they felt intense pain. A second group was instructed to practice their news skills "as often as possible," and a third group received no treatment.
The participants with specific goals felt fewer headaches during treatment and reported using fewer pain medications than the participants with open-ended goals. Both treatment groups fared better than the wait-list controls. In addition, the participants who tried out new skills for specific amounts of time each day were less likely to drop out of treatment than the other participants.
"We were able to reproduce what we did in the lab with experimental pain with real life patients," Thorn says.
Thorn's lab work may have translated well to chronic pain treatment because of the aptness of the analogy, notes Tumlin, a chronic pain practitioner who uses Thorn's treatment manual. Trying out mental strategies often means that patients must endure more pain--at least for a little while--than they would with other methods of pain control. Relaxation certainly doesn't have the immediate effect that, for instance, morphine would, notes Tumlin. For this reason, applying cognitive techniques during pain flare-ups may be analogous to submerging one's arm in ice water--both can be done for longer if you know the end is in sight.
"If they see it as an open-ended exercise, you will see it as forever, and forever is impossible," says Tumlin. "If you see it as an acute stressor, a time-limited stressor, it is much easier to cope with."
And putting pain within the realm of a chronic pain patient's control is a primary goal of therapy, he notes. Clients who believe they have the skill and ability to manage their pain tend to be less crippled by it, Tumlin has observed.
Some of the lessons from Thorn's studies have been broadened to include other aspects of treatment as well. For example, Williams gives pain patients particular behavioral goals in addition to time goals. Currently, he is training patients with fibromyalgia--a disease characterized by all-over body tenderness--to take frequent breaks while they engage in daily activities. This is an unnatural way to go about one's day, but it reduces pain flare-ups while increasing overall functioning, according to 2002 research by Williams in the Journal of Rheumatology (Vol. 29, No. 6, pages 1,280-1,286).
"These people's lives are incredibly disrupted, and this is a condition where…psychological factors appear to make it worse or better," says Williams. "That's what makes pain such an exciting area to research."
Thorn, B.E. (2004). Cognitive therapy for chronic pain: A step-by-step approach. New York: Guilford Publications.
Turk, D.C., & Winter, F. (2006). The pain survival guide: How to reclaim your life. Washington, DC: American Psychological Association.
Williams, D.A., & Thorn, B.E. (1986). Can research methodology affect treatment outcome? A comparison of two cold pressor test paradigms. Cognitive Therapy and Research, 10, 539-545.
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