Keywords

Introduction

The concept of “total pain” describes suffering from physical, psychological, social and spiritual causes of pain, the term was first defined by Dame Cicely Saunders, founder of the modern hospice movement. Strong emotional responses, anxiety, depression, post-traumatic stress disorder and fear of the unknown, can cause increased pain and does not respond to analgesics. Therefore, considering and implementing psychological approaches and interventions for pain management is necessary. Effective interventions with proven benefit include education, hypnosis, cognitive behavioral therapy, relaxation with imagery and exercise.

Strong evidence supports the beneficial effects of psychological and behavioral interventions to relieve cancer pain [1]. Education interventions include teaching patients to communicate about their pain as some patients do not discuss pain symptoms believing it will distract from care of the primary condition (i.e. cancer care). Patients may be reluctant to take pain medication due to stigma or fear of addiction. Educating about the pharmacology and correct use, dosing and frequency of analgesia and addressing concerns of addiction can help patients reduce pain. An important part of education is to encourage and develop confidence in the patient in believing they can manage their pain.

Psychological and Behavioral Interventions

During hypnosis the patient is asked to focus their awareness to experience positive changes in symptoms and emotional response. Hypnosis can be provided individually or in a group setting. Montgomery et al. documented the benefit of hypnosis in reducing pain, distress, pace of recovery, and costs associated with diagnostic procedures for breast cancer, lumbar puncture, and bone marrow aspirations in adults and children, and surgical procedures [2]. Hypnosis has been proven beneficial in reducing pain from mucositis in patients undergoing hematopoietic cell transplantation and reducing pain, anxiety, and the need for analgesia during percutaneous treatment of tumors [1, 2].

In cognitive behavioral therapy (CBT) psychotherapy is delivered with the goal of modifying maladaptive thoughts, emotions or behaviors. CBT has been proven beneficial in managing depression, anxiety, and quality of life in patients having difficulty coping with cancer diagnosis or treatment [1, 3, 4].

During relaxation with imagery the patient is asked to focus on releasing muscle tension by focusing awareness and shifting perceptions of pain signals. Multiple cancer diagnoses and treatments including breast cancer treatment respond by reduction in pain to relaxation with imagery [1].

Although additional research is needed to determine effect of pain in patients that exercise while undergoing treatment or post cancer treatment; some studies have shown a beneficial reduction in pain with exercise. A randomized controlled study found that walking while undergoing chemotherapy or radiation therapy reduced pain at the end of cancer treatment [5]. Another randomized clinical trial found exercising during treatment reported improved fatigue and depression, but no improvement in pain or sleep disturbance was reported [6].

High Yield Points

  • Total pain describes suffering from physical, psychological, social and spiritual causes of pain.

  • Psychological factors such as emotional distress, depression, anxiety, uncertainty of the future and fear of suffering affect pain and response to pain treatment.

  • Considering psychological approaches and interventions for pain management is necessary to alleviate pain as this pain does not respond to analgesia.

  • Effective interventions with proven benefit include education, hypnosis, cognitive behavioral therapy, relaxation with imagery and exercise.

Questions

  1. 1.

    All of the following statements are TRUE about pain except:

    1. A.

      Total pain describes suffering from physical, psychological, social and spiritual causes of pain.

    2. B.

      Psychological pain responds well to analgesia.

    3. C.

      Unmanaged total pain can exacerbate pain symptoms.

    4. D.

      Psychological pain can be caused by anxiety, depression, fear of suffering or past experience of illness

    Answer: B

  2. 2.

    All of the following statements are TRUE about barriers to pain management except:

    1. A.

      Reluctance to take pain medication due to stigma.

    2. B.

      Difficulty for patients to communicate they are experiencing pain.

    3. C.

      Easy accessibility of pain medications.

    4. D.

      Belief that discussing pain will distract from the care of the primary illness.

    Answer: C

  3. 3.

    Psychological interventions for pain include:

    1. A.

      Hypnosis

    2. B.

      Cognitive behavioral therapy

    3. C.

      Relaxation with imagery

    4. D.

      All of the above

    Answer: D