In a blog post I wrote titled, Doing More to Assist with Pain Management, I spoke about the issue of pain management in long-term care and how we actually need to do more in assisting nursing home residents who experience pain. This article expands on this subject, addressing the issue of the psychology of pain that needs to be considered in taking care of nursing home residents.

Pain definitely influences nursing home residents on the molecular level. However, too often we think that pain is exclusively based on, and ameliorated, through the same molecular level. The nocicepetive pathway is the pain pathway that is responsible for carrying information about pain to the brain. In nursing home residents the most common way to think about pain is envisioning this biological pathway that is stimulated by some type of painful stimuli. Furthermore, viewing the amelioration of pain is also thought of in the same way, by thinking what type of chemical compound can be used to alter, minimize, or eliminate the pain experienced by residents. There is nothing fallacious in this type of thinking. Pain is found in this pathway and is frequently abated through the use of pain medications. 

 Objective and Subjective Reality of Pain

Individuals, whether they are physicians, nurses, physical therapists or other medical professionals, often lose sight of the subjective nature of pain.  Far from being a purely objective feature, it is strongly mediated by the psychology of the individual.¹  The pain experience is not just a purely biochemical process.  There are strong psychological and social psychological aspects of pain that frquently are not taken into consideration.  No two people experience pain in the same manner.² In fact, two people with identical wounds or tissue damage may have dramatically different pain experiences due to the psychological factors that influence each individual.  Furthermore, not only can psychological factors moderate pain experiences, but it can also be responsible for the pain experience in itself.   

Although we often think that there is a nice, neat correlation between the type of tissue damage that is found among many older adults and the pain that they experience, the experience of pain is a very individual and unique individual situation. The level of tissue damage does not correlate perfectly with the pain that a person experiences. Many older adults may experience great levels of pain with smaller amounts of disease or tissue damage than those who have more greater damage or disease.  Why does this exist?  It relates to the individuality of the pain response, which is based on one's underlying biology, as well as their psychological state as well.  Quite frequently we see residents in a nursing home request more pain medication due to their pain experience and wonder why Ms. Jones, who has much more severe issues does not need as much pain intervention? Frequently many people will answer this question my saying that Ms. Smith who requests more pain medication is nothing more than a hypochondriac or a person who is looking for increasing levels of attention. However, in reality, Ms. Smith may actually be experiencing more pain than Ms. Jones just on the basis of their own unique dispositional traits.  

The Influence of Mood

A person's mood is strongly related to their experience of pain.³  A person's mood can amplify or even reduce existing pain. Furthermore, those who experience depression often are more likely to also experience pain issues. It appears that the negative and positive properties of mood work on many of the same areas of the brain. For instance, those that experience a heightened or more cheerful mood often find that it helps decrease levels of pain. Conversely, those that have greater levels of depression have also been found to experience greater levels of pain.  Why is this so? Pleasure and pain share many of the same neurological substrates. 

This seems unfathomable, especially given the paradoxical nature of pleasure and pain. However, just as pain medications rush to mu receptors to reduce the feeling and intensity of pain, a person who experiences a happier or more uplifting mood also releases endorphins, the body's own opiates that decrease pain and help us lead to a feel good experience, similar to the euphoria that those who abuse narcotic agents obtain.  Furthermore, a pleasurable and happy mood leads to a greater release of dopamine, especially in the nucleus accumbens, the brains pleasure and reward center, which also has pain receptors that subsequently leads to the reduction in pain. Conversely, those that experience depression release less endorphins that enhance the pain experience and concomitantly, often release less dopamine, which further amplifies the pain response. 

The question here given this knowledge is how often do we look at the mood of the older adult in the nursing home setting as a contributory indicator for amplifying or reducing pain. Furthermore, even if we do look at mood how many nursing home professionals actually engage in some type of intervention to enhance mood, which may change the brain chemistry and experience of pain?   

The Psychology of Expectancy

The powerful influence that expectancy has on our behavior has been well demonstrated. Probably the most commonly referred to effect of expectancy is found in the placebo effect. For years it has been known that providing a particular inefficacious pill to a person who thinks it is real can produce efficacious effects. Expectancy is a powerful motivational tool. When a person holds expectations for certain future positive or negative consequences, these positive and negative consequences often are realized. The same psychological process is at work with pain.  Those patients who anticipate greater pain will often experience greater pain. Conversely, those that experience less pain often find this expectation come to fruition.⁴  

Expectation for certain things can influence the biochemistry of the brain that in turn can lead to the depression of pain. For instance, anticipating a good dinner or a particular event can actually enhance endorphin release to the mu receptors in the brain, along with dopamine, which also works on the basis of anticipation or expectancy. 

With this information, think about many of the lives of older adults found in nursing care centers. Often the lives of many of these older adults are filled with less than positive psychological expectancy. Many look forward to their next meal and frequently have little else to shape their positive psychological expectancies. Too little activity and too much empty time exists that allows residents to ruminate on their pain and other somatic feelings, which in turn can be psychologically amplified, leading to a chain of continuous obsession about the pain, even when the resident is provided with pain medication.      

What does all of this information on pain mean as it relates to the elderly within the nursing home environment?  Pain is not a constant. Two individuals experiencing the same type of anatomical damage may experience great variance in their evaluation of pain. Far from being an objective and quantifiable feature, pain is based on the subjective and phenomenological nature of the individual. Those who work within the nursing home environment can never make the assumption of pain based on the level of anatomical damage that exists. Since pain is based on the unique subjective state of each person, it must start with the evaluation of the person and not the etiology. 

In addition, we cannot minimize the psychological state of the person, especially in regards to their mood and expectancy. A negative mood often can heighten pain and negative expectancies can also shape, often quite negatively, how we come to experience pain.  In dealing with older adults, issues of mood and expectancy are crucial. There is a considerable level of depression, apathy, and irritability that is found among many residents, along with an environment that commonly fails to foster a level of expectancy needed to abate pain. When one places these issues in the context of a medical environment and medical practitioners that continue to view pain only on the biological level, it becomes evident that we often fail to capture and treat the pain experience in less than a holistic manner. 

Since pain management is such an important issue in long-term care, it behooves the profession to continue and learn more about this important phenomenon. Because of the subjective nature of the pain experience we have to examine each resident and their pain experience as a unique phenomenon. Pain is not a constant, commensurate in proportion to the level of tissue damage that exists. Pain is a highly variable subjective state that is based on listening to, and understanding, the phenomenological state of each individual. Therefore, far from being based just on biology, the unique psychological qualities of each individual has to be closely examined to assure effective treatment and pain management.  

                        References

1. Brannon, L., & Feist. J. (2007).  Health Psychology: An introduction to behavior and health.  Belmont, CA, Thomson Higher Education.

2. Nielsen, C. S., Staud, R., & Price, D. D. (2009).  Individual differences in pain sensitivity: Measurement, causation and consequences.  Journal of Pain, 10(3), 231-237.

3. Fields, H. L. (2009).  The psychology of pain, in Scientific American Mind.  September/October, pp. 42-49.   

4. Keltner, J. R. Furst, A., Fan, C., Redfern, R., Inglis, B., & Fields, H. L. (2006).  Isolating the modulatory effect of expectation on pain transmission: A functional magnetic resonance imaging study.  Journal of Neuroscience, 26(16), 4437-4443.

Dr. Brian Garavaglia is a long-term care administrator, gerontologist, educator and consultant. He has worked in health care for approximately 26 years and has worked in all phases of health care including acute, subacute and long-term care environments. His area of specialization is older adults and the long-term care environment. He has continued to research, publish and be an advocate for the older adult population as well as teach at various colleges within the Detroit-metropolitan area. His research interests are numerous, currently working on how stereotypes influence the diagnostic implications for dementia in the older adult long-term care population. He also has a strong interest in neuroscience and the neuro-social psychological factors related to aging as well as how social-gerontological issues affect the regulatory and political climate in long-term care.

To read Dr. Garavaglia's previous blog posts, go to Inside LTC: Blogs.