As mentioned above under Assessment methods for disability and daily functioning, there are many psychological responses to pain that are considered important for patient functioning. In recent clinical studies these include catastrophizing,57, 58 coping,59 self-efficacy,60, 61
and stages of change,62 among others.63 Discussing all of these is well beyond the scope of the present chapter. However, there are a small number of other processes that have been the focus of work for our group, first in Chicago, and now in Bath. These are both effects of chronic pain, in the sense that they are changes in quality of behavior patterns resulting from the experience of chronic pain, and processes of suffering and disability, as they appear to lead to higher levels of emotional distress and greater restrictions in patient functioning. These processes include experiential avoidance, values-failures, and disturbances of awareness.64
When pain occurs, the pain sufferer naturally will try to avoid it. When chronic pain leads to painful emotions, memories, and other unwanted experiences (e.g. feelings and thoughts that come with facing unwelcome changes in life or from challenging social situations), the pain sufferer will naturally attempt to avoid these as well. This is normal human behavior. This process, called "experiential avoidance,'' is proposed as the source of much of human behavior disturbance and suffering.65 The problem with experiential avoidance is that attempting to avoid private experiences, including psychological experiences that come from one's personal history, is often not possible, often brings the person, paradoxically, in contact with the material they are attempting to avoid, and can be extremely restricting of a person's functioning. If one is unwilling to feel painful or unwanted feelings, one will be unable to do any activity that brings one in contact with those feelings. Numerous studies demonstrate the disutility of avoidance in relation to chronic pain.66,67,68 Our work has focused on a process that is intended to undermine experiential avoidance, namely, acceptance of chronic pain, and we have shown that acceptance is consistently correlated with higher patient emotional, physical, social, and work-related function-ing.47,69,70
A second type of change in the quality of the pain sufferer's behavior that occurs with chronic pain is that it is increasingly influenced by pain and not by other concerns. Rest, medication consumption, seeking help, refusing invitations, seeking treatment, complaining, withdrawing socially, and using assistive devices can be behavior patterns that serve only as attempts to limit contact with pain, and do not serve purposes the pain sufferer would otherwise rate as most important and meaningful in their life. In essence, dealing with pain can move an individual, unwittingly, away from what they care about most. Part of this process can be referred to as a values failure or a failure of values-based action.71 We have found that patients with chronic pain rate their success at living according to their values in areas of family, intimate relations, friends, work, health, and growth or learning, as significantly lower than the level of importance with which they hold their values in these domains.72 We have also found that the losses that come with the failures of values to guide action contribute to significant anxiety, depression, and disability in patients with chronic pain. Additional analyses in this same study demonstrated that both acceptance of pain and values-based action contribute uniquely to patient functioning.72 A third behavioral dimension within the chronic pain experience that can demonstrate significant changes is the quality of contact the pain suffer has with the environment, or their level of awareness. For the purposes of discussing this process, the environment needs to be considered broadly as made up of experience available to the senses inside and outside the body and experience in the content of thought. When a person has chronic pain, their awareness of their social and physical situation can be disrupted by a number of experiences, including their sensations of pain73 and experience of emotions, changes in the way they observe or try to block out these experiences, and by preoccupation or entanglement with the content of their own thinking in ways that limit their awareness of the actual situation around them.74 When people suffer, they seem particularly prone to dwell on the past or to become distressingly preoccupied with the future - this seems to be particularly true for those with chronic pain. Processes of getting caught up with psychological influences of pain and related thoughts, experiencing the distress of reliving experiences from the past or from events in the future that likely will never come to pass, and having behavior disorganized from a loss of contact with what is occurring at that particular moment, each appear to contribute to the suffering and behavior-restricting effects of chronic pain. In a sense, data from studies of catastrophizing and pain document the impact of these cognitive processes.57 Counteractive processes for some of these are included in what is referred to as "mindfulness.'' Mindfulness is full, accurate, moment-to-moment, present-focused, and nonreactive awareness.75 Mindfulness methods of treatment have long been advocated as a way to undermine the otherwise natural effects of distressing experiences on emotions and behavior.76 Uncontrolled treatment outcome studies of mindfulness support the role of awareness and disturbances of awareness in chronic pain.76 An additional preliminary investigation of mindfulness demonstrated that it significantly predicts pain-related anxiety, depression, and physical and psychosocial disability, independent of patient age, gender, education, duration of pain, pain severity, and acceptance of pain.77
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