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REPLAY: The Psychology of Pain with Dr. Adrian Lopresti and Professor Peter Drummond

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REPLAY: The Psychology of Pain with Dr. Adrian Lopresti and Professor Peter Drummond

Professor Peter Drummond, Murdoch University's Director of the Centre for Research on Chronic Pain, and our Ambassador Dr. Adrian Lopresti explore the relationship pain has with thoughts, emotions, mental health and sleep.  

The discussion begins with Prof. Drummond exploring the influence of thoughts and emotions on one’s perception of pain with a detailed discussion on various pathways that pain travels through the brain which results in the experience of feeling pain. Pyschological state seems to play a huge role in colouring pain perception where fear, anxiety, depression leads to an increased pain signalling. Prof. Drummond explains how psycholeducation techniques have been proven to alter one’s experience of pain through reprocessing therapy and relaxation that affects one’s ability to control and manage their pain better. 

Covered in this episode

[00:36] Welcoming Professor Peter Drummond
[01:43] Can emotions affect pain?
[06:24] Fear can switch pain off
[08:33] Perceptions of pain can affect pain sensation chronic pain and recovery
[13:03] The bidirectional relationship between emotions and pain
[16:43] Connections between stress and migraine
[23:40] Affects of sleep on pain
[26:46] The importance of psychoeducation in managing pain
[31:22] Pain reprocessing therapy: changing beliefs about pain
[34:14] Pain-related questionnaires and assessment tools
[36:47] Using relaxation techniques to manage chronic pain
[38:51] Biofeedback
[40:19] Thanking Peter and closing remarks

Key takeaways

  • In addition to physical stimuli - thoughts and emotion affect our sensory experience of pain which may be associated with tissue damage or the potential for damage. Emotion and thoughts are essentially intertwined into the whole experience of pain with the state of mind (positive or negative) and how we think or process the impact of the pain that modifies the resulting sensation. 
  • Fear greatly affects pain perception and has been shown to temporarily switch off pain in “stress induced analgesia” where endogenous opioids can block the travel of pain signals. 
  • Pain signalling activates both the somatosensory parts of the brain along with emotion handling regions. The signal that provides us with the intensity and location of pain travels through the thalamus, somatosensory cortex, and cerebral cortex. Concurrently activity in the anterior singular cortex and prefrontal cortex activate which helps us determine if the pain being experienced is beneficial or threatening. 
  • Pain is generally regarded as a threat. Being in a negative state with thoughts/emotions can colour our experience of pain where one might be more aware of threats leading to an increased painful experience. 
  • Deliberate induction of pain is thought to be beneficial to health. Taking ice baths, a hot sauna or another type of sensory shock experience where people are willingly undertaking a painful experience can lead to a wave of endorphins where the person’s overall emotional experience and thoughts of the painful experience lead to a positive experience of pain rather than a negative one.  
  • The link between pain and depression and/or anxiety are so close that they both involve very similar parts of the brain and neurotransmitters. The emotions we express during depression/anxiety has an influence of the pain and inadvertently causes a spiralling effect,  worsening pain perception and creating the potential for a non-resolving loops of worsening pain, worsening mood etc. 
  • When pain resolves (naturally or assisted) this helps to negate the strong emotional association with a pain experience in-turn overall lowering the pain.  
  • Lifting a patient’s mood can be a tactic in changing their experience with pain. Attenuating mood where the patient can feel a sense of control can disassociate the negative emotions that can exacerbate pain. 
  • Migraine/headache sufferers tend to experience an episode after a stressful experience where once they’ve reached a more relaxed state the pain then ensues.  
  • Lack of sleep (insomnia) greatly increases the likelihood of an increased pain perception and can create a vicious cycle as pain tends to wake those experiencing it. Studies show if people are sleep deprived, they are more sensitive to pain, conversely, if they are well-rested pain tolerance improves. 
  • Pain reprocessing therapy is a form psychoeducation utilised to improve self-efficacy in managing pain and can be helpful in motivating patients in persisting with treatment. The technique targets changing ones beliefs on their pain, changing the concept of the pain from being something “bad” to something that is “supporting” the body to heal. Once that concept was set in the mind, physical challenges can be set to test and challenge activities previously avoided due to that activity strongly linked to a negative pain experience. With a new mindset, working through the positive pain one can have a reduced perception of pain.  
  • Relaxation techniques are another tool that can induce feelings of control and improve self-efficacy in managing pain. 

Resources discussed and further reading

Professor Peter Drummond

Professor Peter Drummond

Clinical Questionnaires and Scales 

Depression, Anxiety and Stress Scale (DASS 21)
Brief Pain Inventory (Short form)
Pain Catastrophising Scale
Oswestry Low Back Pain Disability Questionnaire
Pain Invalidation Scale (located in appendix E)
Pain Self-Efficacy Scale

Research on pain

'Central sensitization and the biopsychosocial approach to understanding pain'. (Journal of Applied Biobehavioral Research, 2018)
'Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial.' (JAMA Psychiatry, 2022)
'Comparison of the effectiveness of cognitive behavioral therapy for insomnia, cognitive behavioral therapy for pain, and hybrid cognitive behavioral therapy for insomnia and pain in individuals with comorbid insomnia and chronic pain: A systematic review and network meta-analysis.' (Sleep Med Rev, 2022)
'Chronic Pain and Mental Health Disorders: Shared Neural Mechanisms, Epidemiology, and Treatment.' (Mayo Clin Proc, 2016)
'The Pain-Invalidation Scale: Measuring Patient Perceptions of Invalidation Toward Chronic Pain.' (J Pain, 2022)


Adrian: Hi, and welcome to FX Medicine, where we bring you the latest in evidence-based integrative, functional, and complementary medicine. 

FX Medicine acknowledges the traditional custodians of country throughout Australia where we live and work and their connections to land, sea, and community. We pay our respects to the elders, past and present, and extend that respect to all Aboriginal and Torres Strait Islander people today.

With us today is Professor Peter Drummond, who is a Professor in Psychology at Murdoch University in Western Australia. Peter is a prolific researcher with a specific interest in the biopsychosocial mechanisms associated with chronic pain, headaches, and migraines, and the psychophysiology of emotions and the impact on health. 

He teaches Health Psychology and Behavioural Medicine in the Clinical Psychology Program at Murdoch University and has supervised many PhD students throughout his career. In fact, Peter was my PhD supervisor when I completed it several years ago. And he continues to be involved in many of the research projects I conduct where he offers valuable advice and support. 

Welcome to FX Medicine, Peter. Thanks for being with us today.

Peter: Thank you for having me.

Adrian: Now, I know that you have a specific expertise in chronic pain and headaches, and migraines. So, these are the areas I wanted to talk with you about today, in particular the area of psychology of pain. From my years of experience working as a clinical psychologist, I know that pain and, in particular, chronic pain, its causes and its treatments are often complex, and there are many factors that can affect pain. Can you just briefly tell us how psychology can possibly affect pain?

Peter: Well, both our thoughts and our emotions affect pain. In fact, in the International Association for Study of Pain's definition, they state that pain is an unpleasant sensory and emotional experience associated with or resembling actual or potential tissue damage. So they are emphasising the role of emotions in our experience of pain and our thoughts, obviously, influence our emotional experience. So, in a sense, the sensory aspects of pain and the emotional aspects of pain combine to give us our experience of what pain actually is. It's very difficult to separate one from the other, the sensation of pain and the emotional response to pain.

Adrian: So, the particular types of thoughts, they can affect how we perceive the pain and the severity of the pain sensation?

Peter: Exactly. Most people have heard about instances of soldiers in battle who suffer quite severe injuries, but nevertheless, don't experience pain on the battlefield. And that pain then starts to develop once they're safe. So, we have inbuilt physiological processes within our nervous system that help us to modify the experience of pain. In this case, extreme fear is enough to switch pain off. But equally, we have a capacity to amplify or facilitate pain. And we do this also, in part, through the emotions that we're experiencing at the time that we're also experiencing pain. 

So, anticipatory anxiety, by and large, will increase painful sensations. You might have experienced this yourself if you're waiting to be jabbed for a COVID vaccine, for instance. While you're waiting there anticipating a painful sensation, you can feel the emotions actually building, and those emotions will intensify any painful sensations that happen at or around the time that we're expecting to experience pain. 
We as parents use this strategy with kids. If they hurt themselves, if they fall over, we attempt to distract them to get them to think about something other than falling down and hurting themselves in a way to minimise pain. So, I think that there's a very clear understanding out there in the community about the link between emotions and pain. And this comes to the forefront, really, when we're trying to help people whose pain becomes chronic.

Adrian: So, can you actually see, if you have particular thoughts or particular emotions, can you actually through say, MRIs or whatever that you can see differences in how the brain reacts to pain based upon different thoughts and emotions?

Peter: Well, the FMRI researchers talk about a so-called pain matrix. And this consists of parts of the brain that are receiving signals from our so-called nociceptive system. And those signals go through the thalamus to the somatosensory cortex, and also to additional parts of the cerebral cortex, which are telling us about how intense the painful experience is and where it's coming from. 

But at the same time, the emotional parts of the brain are active. And this can be seen on magnetic resonance imaging equipment, in particular, the anterior cingulate cortex, the prefrontal cortex, which are involved in working out what we should do to a threat or a potential threat, very active during pain. So, it's quite clear on neuroimaging that both the emotional parts of the brain and the so-called sensory parts of the brain are simultaneously active.

Adrian: And so is it anxiety? And if we think about from the emotional perspective, is it then anxiety that will exacerbate pain, or it's low mood and depression, or is it anger? The particular emotions that have a greater impact on how we perceive or react to pain?

Peter: Yeah. Well, any emotion I think which taps into our defence system is likely to increase our experience of pain if we're expecting something bad, basically. But this is counterbalanced by the fear system, which can switch pain off. So, before, I was referring to the studies of soldiers on the battlefield. This switch is on a mechanism which is called stress-induced analgesia. It involves the release of endorphins, opiate-like chemicals from the midbrain and from the spinal cord. And these endorphins can actually switch pain messages off temporarily. 

Adrian: Wow.

Peter: So, that strong emotion of fear is enough to switch pain off. And this has an adaptive function. It means that we can focus our attention on what we need to do to deal with the emergency instead of being distracted by pain.

Adrian: Absolutely. Yeah. You think about, obviously, if people were in an accident or something like that, sometimes it takes a while for them to register the pain.

Peter: Well, I've seen this happening in real life, the one and only time I went to a football match. One of the players broke his arm and he continued to play, apparently unconcerned about his broken arm until afterwards. 

Adrian: And so that's the opioids that are being released that's numbing the pain? Wow.

Peter: Within the central nervous system, yes, it's opioids which are blocking pain signals, blocking pain messages from moving up to the thalamus and to the cortex. And so, in a sense, the pain gate has been closed there within the spinal cord.

Adrian: And so we've got then your emotions, that obviously affect pain. And then also how we perceive the pain, how we think about the pain, that will also affect our perception of it and the sensations associated with it?

Peter: Yeah, that's true. These two aspects combined, thoughts and emotions, are likely to influence our perception of pain. If we're experiencing some form of negative affect, which may or may not be related to the pain, well, this is going to colour our experience of pain, so that if we're anxious about something else, we're going to be hyper-vigilant for threats. And by and large, pain is regarded as a threat. And so we're going to then focus our attention upon potential threat and experience a more intense form of pain than we otherwise might.

Having said that, though, the opposite also happens. If we're expecting to experience some discomfort, well, then it's not a threat to us. So, when we exercise, often we're experiencing some discomfort while we exercise and afterwards, we might experience some aches and pains, which we just take as the cost of exercising. And we're unconcerned, generally, because we understand the source of pain, and we understand that it's not a danger, it's not a threat. And so it means that that pain doesn't become important to us. It's something that we can safely ignore. And under those conditions, pain generally is minimal.

Other people actually actively induce pain. There seems to be a new trend of people hopping in ice water baths. And if you've actually done this yourself, or even if you've put your hand or your foot into an ice bath, you'll know that after about 20 or 30 seconds or so it becomes very, very uncomfortable. But nevertheless, people do this deliberately to experience heightened arousal and the endorphins rush that that type of stimulation may induce. And so it's something that they're prepared to experience. I suppose you could say the same thing about hot saunas. The first time you hop into a hot sauna, it can be quite uncomfortable, and it can even get to be objectively painful. But people are prepared to experience that sensation because of the rewarding effects of the sauna or the ice water bath afterwards. And under those conditions, pain is not regarded as a threat. In fact, it's expected and it's under our personal control and so is reasonably minimal.

Adrian: Okay. So, obviously, the perception is that there's some type of reward that might be accrued from engaging in that activity and, therefore, the sensation is different.

Peter: Yeah. So, it might be a physiological reward. It might be a sense of self-efficacy. By physiological reward, I'm referring to the arousing effects of saunas or ice water baths or exercising, which can be pleasurable either during or after that type of experience, or it could be an emotional reward in that we've done something that was challenging and we're pleased with how we went. And so that then becomes the reward. 
If you compare that against the types of emotions that we might experience after an injury, or even while anticipating, or after some form of surgical intervention where we're concerned about the outcome, pain then becomes a signal, not of something that we expected, but it's something which is frightening, which is threatening and, therefore, becomes the focus of our attention and a trigger for negative emotions. And under those conditions, we're likely to experience more intense pain.

Adrian: Certainly, I notice through my clinic experience, when there's uncertainty as to the source or when there's going to be recovery, when will I ever get better? Then the association or the pain is certainly exacerbated for people.

Peter: Yes. So if you're uncertain about the future, that's a source of anxiety, and so it is then very difficult to let go of pain.

Adrian: What about people with chronic pain? Are there particular thoughts that people with chronic pain that the research shows can have a negative effect on their pain and their recovery?

Peter: Well, there is a tight link between depression, anxiety, and chronic pain. The majority of people with chronic pain have some negative affect, be it depression, anxiety, anger, or a mixture of those. There are quite close links actually, physiologically, between what's happening in chronic pain and what's happening during negative emotions such as depression, or negative moods such as depression and anxiety. In fact, the link is so close that it involves similar parts of the brain and similar neurotransmitters. So, the thoughts that we have when we're depressed are likely to prompt behaviours and to prompt emotions which may inadvertently make pain worse.

Adrian: And that'd be things like for people who are depressed, the issue of catastrophising, and I've also seen research about pain catastrophising that can also impact on depressed mood and also the pain sensation.

Peter: Yes, exactly. It seems that pain catastrophising is one of the predictors of chronic pain. But it's not all a one-way street, by the way, that we might catastrophise about pain because of our negative experience of pain. We might develop this hyper-vigilance towards pain, simply because of our recent experience. And there is literature to show that if pain resolves through natural means, or through treatments which work, negative emotions also resolve. But before this happens, there is this two-way link between emotions and pain, that experiencing strong emotions can make pain worse, and experiencing strong pain can make negative emotions worse.

Adrian: So, there's that bi-directional relationship, isn't there?

Peter: Mm-hmm. And it's bi-directional in the sense that people who are depressed have a higher risk of developing chronic pain if they injure themselves than people who are not depressed. And conversely, people who develop chronic pain are more likely to become anxious or depressed than people who aren't in chronic pain over a similar timespan.

Adrian: All right. So obviously, that's telling us when we're seeing somebody with chronic pain, we really need to assess for their mood state, whether they're depressed, whether they're anxious because it's certainly going to have an impact on their pain and recovery.

Peter: Yeah. So from treatment provider's perspective, these are targets that can be used to help people not only manage their life more effectively in terms of perhaps brightening their mood but also secondarily might change their experience with chronic pain. It can be a means to manage pain more effectively. It might not mean that pain disappears entirely, but it might mean that the person is able to experience more positive effect, a greater sense of control over their pain than they otherwise would if they're able to manage negative emotions.

Adrian: Yeah, and then generally function better in life obviously.

Peter: Yeah. Their well-being is improved.

Adrian: Now, I know you've done a lot of work in headaches and migraine. So, obviously, what you're mentioning here is that our emotions and our thoughts are going to affect the pain associated with the migraine or with the headache. Does our thoughts and emotions also increase the likelihood of actually having a migraine or developing a migraine in the first place?

Peter: And getting a headache. Yeah. Psychological stress is regarded by migraine sufferers as the most common trigger for their headaches. The headache doesn't necessarily start during the stressful period. That seems to be associated either with the experience of stress or develop shortly after the stress resolves.

I remember back when I was a university student and collecting data for my PhD. This involved interviewing lots and lots of people with different forms of headache. And it was quite a common theme that seemed to emerge that people who experienced frequent migraine would say that the headache didn't necessarily come during the period of stress, but as soon as they relaxed, that's when they were most vulnerable. They might rush around preparing a dinner party, for instance, the headache wouldn't necessarily develop during that period of psychological stress while they're preparing for the party, it would develop very soon before the guests actually arrived when they actually had prepared everything and were just taking a breath and waiting for their guests to come, just when they were preparing to relax and to enjoy themselves. So, there must be something about psychological stress that increases vulnerability to headaches. 

We explored this actually in some of the research studies here that have been done mostly by my students. And in one of the studies, we tried to induce headaches by means of a stressful experience. And about 50% to 60% of the participants actually did develop a headache during the stressful test. Interestingly, though, people in our control group who had been selected because they didn't experience headaches, migraine headaches very often, if at all, developed headaches during this full psychological stress as frequently as people who had migraine headache. 

Adrian: Wow.

Peter: What seemed to predict whether they developed a headache or not was the sense of self-efficacy that they had about solving the stressful task. So, those people who tried hardest actually experienced the strongest emotions while they were trying to manage the task, and also experienced the greatest decrease in self-efficacy during the task when they realised that the task was simply insoluble.

And we were able to actually track the development of the headache against the development of negative affect during this task, because every five minutes we stopped and asked people to provide ratings of their mood. And it was very informative in that negative effect developed 5 or 10 minutes before the onset of the headache in most people. So, we could see this clear link between a stressful experience of thoughts that people had about managing that stressful experience, trying but failing, experiencing negative affect, and then developing a headache. So, that's one model that we have of this link between psychological stress and headache.

In some of my earlier work, I was interested in what might be happening to the vascular system when headaches began, or during the headache itself. And, according to this theory, swelling up or swelling of scalp blood vessels, in particular, or intracranial vessels, vessels which supply the brain itself was potentially a source of pain in migraine headache. And so we were interested in the effects of psychological stress on the response of these blood vessels, whether these blood vessels dilated during psychological stress. And indeed, we found that they did. 

This didn't necessarily translate immediately into a headache though. So, there must be additional steps there that link this vascular response to the development in the experience of the headache. We think that something goes wrong within the brainstem pain control processing centres to take the brakes off, basically, the flow of pain signals into the brain. So, it's a type of inhibition process that we normally screen out intense sensations or sensations which potentially are unpleasant from our conscious awareness. But during migraine headache, this process fails. And so that as well as experiencing pain from dilated blood vessels, we also experience discomfort from bright light, and we also experience discomfort, or distorted noise, discomfort from loud noise. So, people with migraine headache often prefer to wait it out in a quiet dark room until the headache is gone.

Adrian: Wow. So really then, obviously, if anybody's seeing someone who's coming with chronic pain, with headaches, migraines, they really need to be asking about their mood, they really need to be asking about their thoughts. And you mentioned self-efficacy, the confidence in being able to manage a situation. That seems it plays a big part in pain too, doesn't it?

Peter: Yeah. And the coping strategies that people use to try to manage psychological stress seem to be important. We need to match an appropriate coping strategy to the form of stress that we're facing. So if stress can be regarded as a challenge, and we're able to actually meet that challenge, then we're not likely to experience strong negative affect. It’s only when we try hard and fail where this negative affect builds where the sense of self-efficacy decreases, and which seems to make us vulnerable to headache because somehow that impacts upon the way that we process sensory information.

Adrian: All right. Now, the other question I wanted to ask you about was the relationship between sleep and pain. What's the relationship there?

Peter: Well, again, it's a reciprocal relationship. If we suffer from insomnia, we're likely then to be more vulnerable to developing chronic pain. And obviously, the opposite is important too. If we're experiencing pain, it's harder to sleep. Pain can wake us up. If we move during sleep, the discomfort that we experience often is enough to wake us up. Very frequently, people who have chronic pain also have some sleeping problem. Again, we're looking at a complex, multifaceted problem that the person in pain has to manage somehow.

In fact, I think from a brief look at the literature, that about 50% of people with chronic pain also have a sleeping problem. And then in people that come to pain management programs, the prevalence of sleeping problems is even higher. Within a study that one of my students carried out, the prevalence of sleep problems was up around 70% to 80% in the participants within these pain management programs through a multidisciplinary pain clinic. This has been studied experimentally, this link between pain and sleep. If you deprive people of sleep, they'll become more sensitive to painful stimulation. If they sleep well, the opposite happens. There seems to be this direct association between adequate sleep and our experience in processing of pain.

Adrian: I actually read a review paper recently, and they were talking about, obviously, the relationship between pain and sleep, and one of the conclusions was that, certainly, pain can affect sleep. But it seems as though from what I was inferring from it was that sleep can affect pain more than pain can affect sleep. Does that make sense?

Peter: Yes, it might well be so. We found actually in the study that we carried out through the pain clinic that people with the sleeping problem, who, by definition, had chronic pain, because they're attending a pain clinic were also likely to be depressed and also likely to catastrophise about pain and about negative affect in general. They have the full package of negative affect, sleep problems, and chronic pain. So, it's hard to tease out what is the primary problem, whether it is the pain, whether it is the sleeping disturbance, or whether it is the negative affect, but I think they all feed upon each other.

Adrian: Then you've got obviously if somebody is coming in with chronic pain, you could treat the chronic pain, and then potentially the mood and sleep will improve, or alternatively, you could treat the sleep or treat the mood problem and the pain could improve too. You could start from a few different areas, couldn't you? You could do the pain management, but you could also do the counselling around the mood and the depression and the anxiety, or you could do some sleep hygiene work and you could improve the pain in that way too.

Peter: Exactly. One important thing I think to include in pain treatment program, pain management program is some education around how these different components of pain interact with each other so that it's very clear to the person seeking help that they're likely to benefit not only in terms of better sleep if that becomes the first form of treatment, but also this is likely also to have positive benefits in terms of their pain experience, and if they're sleeping better, it is also likely to help to lift their mood.

And we can actually through the process of psychoeducation help the person to feel motivated enough to actually persist with treatment if they understand why the treatment is being recommended and why we think it might work and why we think it might work, in particular, for them, then they're likely to engage more closely in the treatment and likely to benefit more from it. So, I think that that psychoeducation component is quite critical.

Adrian: Absolutely. And that's the thing, because if you start treating the mood or you start treating the sleep and not necessarily the pain, and they don't understand why you're doing that, it can be quite invalidating, potentially, for them, and they think, well, I’m not depressed, potentially, and they drop out or not receive the benefits from treatment.

Peter: Exactly. Often that is the problem for people being referred from a pain clinic or from a pain specialist, or even a GP to a psychologist. They feel like they're being fobbed off in some way, and they have this sense of not being listened to, that the doctor or the health practitioner has concluded that it's not a physical problem that needs to be treated, it's a psychological problem. And the inference there is that, therefore, they are to blame for their chronic pain. 

Adrian: Yeah.

Peter: This is something also that needs to be addressed early on in treatment, trying to get the point across and to explain to the pain sufferer that pain really can't be teased out from negative affect. Pain really can't be teased out from sleep problems if there are sleep problems that are happening in parallel with the experience of pain. And because they can't be teased out, if we work on one part of the problem, it's likely to have benefits on the other part of the problem. And if they understand and accept that, I think you increase the likelihood of the person benefiting from treatment substantially.

Adrian: I certainly agree. That psychoeducation is imperative. I did read that 85% of the time there's no definitive peripheral cause… People with chronic back pain, 85% of the time, they can't find a physical cause. And then if that psychoeducation is not happening, then that can be quite invalidating. They're going, "Oh, it's all in my head." And it is in your head. The brain triggers, obviously, the brain's response to the pain sensation.

Peter: Yes, exactly. And there's the inference, again, that if pain is in my head, it's my fault for experiencing pain. But that's not necessarily true. We know that pain can be operantly conditioned and that this process can happen outside of our conscious awareness. The experimental literature is quite clear on this that signals which aren't painful can be experienced as inducing pain if pain has been conditioned in the sense that pain is presented at the same time as that signal, as that warning. This can actually evoke not only an alarm response but a physical sensation of pain in some people.

Adrian: It's interesting you sent a paper to us looking at the pain reprocessing therapy. And just some of the outcomes that they had was, looking at the paper right now I've got in front of me, that 66% of the people who were randomised to a four-week pain reprocessing therapy were pain-free or nearly pain-free post-treatment compared to only 10% who were receiving randomised usual care.

Peter: Yes and that's a fantastic outcome.

Adrian: Absolutely.

Peter: The focus of this treatment was on changing beliefs about pain, away from back pain as a source of threat to reconceptualising that sensation that they experience as non-threatening. And once people actually took that on board, and believed, or changed their beliefs around pain, that seemed to be the green light in terms of actually coming to terms with their pain and actually doing things which previously they had avoided because they were frightened that that would make their pain worse.

Part of the problem in people with chronic pain is this very natural desire to avoid things which might hurt. The difficulty for the person is actually working out whether their beliefs are true or not. And part of psychological treatment is encouraging people to actually go ahead and test their beliefs about what hurts and what doesn't hurt, and about the meaning that they attach to feelings of pain if it does hurt.

We talk about good pain and bad pain. The examples that I gave previously about exercising, that's a good form of pain, about the painful sensations that we might experience during physiotherapy or during ice water baths or saunas as being a good form of pain, non-threatening pain. We can actually reconceptualise the pain that we might be experiencing in our back or in our neck as potentially a good form of pain rather than as a threatening pain. It might be that the muscles around our back when we think certain thoughts start to tighten up, and the source of pain that we're experiencing is from muscles protecting what we assume is a weakened part of our body. If we go ahead and test out whether that part of our body is, in fact, sound or not, we might find out that our body is actually working better than we thought. We might then have the confidence to go ahead and try new activities that previously we had avoided. And that seems to be the key to then getting back into a more pain-free state.

Adrian: Yeah. Obviously, if a practitioner is seeing somebody with chronic pain, obviously, assessing mood, they could use something like I suppose the Depression, Anxiety, and Stress Scale to assess the severity of their mood, obviously, asking about their mood and so forth. They need to assess for sleep, and there's various sleep-related questionnaires that they could do. Are there any specific pain-related questionnaires or assessments that you would recommend practitioners use?

Peter: Well, there's the Brief Pain Inventory. This is a fairly short form to assess the person's pain experience over the past week or so I think. So, that's worth looking into. The Pain Catastrophising Scales, it's very widely used. So, it's been well-validated. I'd recommend disability questionnaires, such as the Oswestry or the Roland-Morris scales to work out how pain might be impacting on the person's day-to-day activities. And another one that I would add to the list would be a scale that one of my PhD students developed recently, the Pain Invalidation Scale, because this actually taps into this sense of feeling not listened to or not being believed, not only by healthcare practitioners but also by immediate others that might inadvertently impact upon the person's self-confidence or colour their mood.

We included in this Pain Invalidation Scale also a subscale dealing with self-invalidation because often people are very critical about themselves for being too weak to do things that they believe that they should be able to do. And these negative beliefs can then have flow-on effects in terms of negative mood. So, I think that recognising that many people in chronic pain will have negative views about themselves and will have experienced negative interactions with others because they're in pain needs to be recognised by healthcare practitioners and needs to be built into any form of intervention.

Adrian: We'll definitely put links to all those questionnaires in the show notes. They sound like some great ideas. I suppose the other one I've seen is the Pain Self-Efficacy scale too which sometimes I've seen...

Peter: Oh, yes, of course.

Adrian: Okay. Now, obviously, you've talked about thoughts, we talked about emotions. Just a question about relaxation, the potential of relaxation treatments and relaxation therapies to manage chronic pain. You got any comments on relaxation?

Peter: Well, relaxation, obviously, is a useful tool for managing emotions. It's a useful tool for inducing physical relaxation, a calmer physiological state in terms of slowed breathing and decreased heart rate and blood pressure, etc., which can also then flow on to feeling a greater sense of control over our body. I think it's this sense of control, which is quite useful in terms of managing our sensations and interpreting those sensations as threatening or not. If we have a sense of control, we're less likely to be frightened about pain or less likely to be anxious about pain. This then translates into actually experiencing less pain. It becomes self-fulfilling.

So, I think that relaxation strategies such as controlled breathing, progressive muscle relaxation can be useful. One caveat with muscle relaxation is to be careful around the site of injury or site of previous injury because the tissues there might be quite sensitive to muscle movement. So, part of the progressive muscle relaxation process is to tense and to relax muscles so that we can distinguish between the sensations of a tense versus relaxed muscle group. This needs to be done quite carefully around the area of injury to make sure that we don't inadvertently increase painful sensations when we're intending to produce a more comfortable state.

Adrian: Have you tried any experience with biofeedback? What's your thoughts about biofeedback as a potential option?

Peter: Well, it depends what form that feedback takes. If we're wanting to decrease physiological arousal, we might target, for instance, some aspect of the cardiovascular system. We might give feedback around heart rate or heart rate variability. Or it might be that we're wanting the person to target their breathing, in which case we might measure their breathing and give feedback about when they're breathing regularly versus when they're not. And these biofeedback messages can be helpful for people to see whether they're on track or not, whether what they're doing in terms of their behaviours, their thoughts, their emotions, is actually translating into what they're aiming to achieve in terms of reduced physiological or psychological arousal.

We can target particular muscle groups if those muscle groups are found to be a source of tension or a source of pain and help the person to relax those particular muscle groups through providing feedback about how tense or how relaxed those groups are at any instant in time. And so feedback can be used effectively there as well.

Adrian: Wow, all right. So, we've really then... I think you've provided us with lots of great information about, obviously, the link between thoughts and emotions and pain, whether it be acute or chronic. The reality is that if we're seeing anybody with chronic pain, we really need to assess their mood and treat it accordingly, you need to assess their sleep and treat it accordingly. Certain thoughts that they may have, and we can change some of the thoughts that they have around pain and change, I suppose, the relationship they have with pain that's going to have dramatic effects. And obviously, a lot of natural practitioners, they're including different herbs, anti-inflammatory herbal ingredients, and diets and all those components too that we as psychologists don't necessarily do so much. But I think collectively, if you put it all together, we can really get some really nice outcomes with people experiencing chronic pain.

Peter: Yes. I think so too. I think there's a real role for a range of healthcare practitioners to help people with chronic pain because pain is such a multi-faceted problem. People with different expertise can help in their area of expertise, but it's also really important to be aware of the areas in which the patient might benefit, and working within a multidisciplinary team is ideal.

Adrian: All right, well, thank you very much, Peter, for taking the time out to provide us with your years of experience. I know you've been around for a while. You taught me when I was doing my master's. So, what are you? About 35 now, aren't you?

Peter: Well, a little older than 35. I'm not quite double 35, but nearly.

Adrian: All right. But yeah, and certainly throughout the years in terms of the knowledge that you've given me, and obviously, the expertise and the papers that you've published, and the research that you've done, particularly in the area of pain has been amazing. So, certainly, thank you very much for joining us today.

Peter: Thanks, Adrian.

Adrian: All right. So, thank you, everyone, for listening today. Don't forget that you can find all the show notes, transcripts, and other resources from today's episode on the fx Medicine website. I'm Dr. Adrian Lopresti, and thanks for joining us. We'll see you next time.


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