The Changing Nature of Pain Complaints over the Lifespan

“I was annoyed by the poor quality of the coverage throughout, but I read on because occasionally some observations were included which made reading the rest semi-worthwhile. However after 113 pages I’d had enough. This is a terrible book.”

This is what I wrote on goodreads – I of course gave the book one star. I had actually talked myself into not covering the book here at all due to the low quality of the coverage, but I later changed my mind; the main reason probably being that it’d be easier for me to justify having spent time on it if I at least try to retain some of the knowledge included in the book – I generally remember the stuff I blog a lot better than the stuff I don’t.

Below I have added some observations from the book.

…

“Fordyce’s (1983) most significant contribution to the psychology of pain is his operant conditioning model which proposed that pain behaviors are maintained, and even enhanced by verbal reinforcement by the intimates of the patient. This proposition has been tested with RAP patients and their families and to date has some degree of validation […] [One study in this context on a related note found that] parents exhibiting and engaging in pain behaviors were more likely to reinforce illness behaviors in their children. […] [According to learning theory,] there is a distinction between the initial physiological reaction to a painful stimulus and the resulting behaviors. Respondent pain behaviors are conceptualized as actions that result from actual nociception. Operant pain behaviors are actions that develop when the pain experience is linked to forms of reinforcement such as receiving pain medication or attention, or being allowed to avoid unpleasant situations. The association between pain and reinforcement increases the likelihood of the persistence of pain behaviors, which often become separated from the original painful stimulus. If respondent pain behaviors last long enough, learning will occur and behaviors may then be controlled by the operant pain behaviors. In chronic pain both respondent and operant pain behaviors are likely to coexist”

“In summary, among pain prevalence rates in children and adolescents for establishing possible patterns for pain that can be associated with life transition, headache is the most researched pain condition. A number of good epidemiological studies establish prevalence rates during a 1-year interval for nonspecific headaches as somewhere between 70 and 80%. With specific migraine headaches, the prevalence rates across 1 year intervals are less uniformly established in the literature. There is greater variability reported, but most results generally fall between 3 and 20%, with more studies reporting findings in the lower range of figures.” [I have a friend who’s never had a headache (the skeptic would say: ‘claims to never have had…’), so I found these numbers interesting] […] There is also evidence that adolescents who experience frequent headache have more daily stress (Brattberg, 1994), such as a mother having pain, not getting enough sleep, loneliness, and fear of being bullied by other students in school. […] Of all the biological factors associated with patterns of headache, there appears to be only one variable that is consistently reported: A gender variable is present, with females reporting higher prevalence rates. This is true for both nonspecific headaches and migraines. […] The literature that exists, which is very limited, suggests that children from families where chronic pain is present tend to develop pain problems themselves; this is especially the case when the chronic pain is headache”

One observation I wrote down in the margin here is that headaches are generally impossible for a parent to accurately observe/test for in a child, which may not be a coincidence; it’s easier to lie about a headache than about a fever. The authors do not mention this aspect, which is in a way not surprising; they to me seem generally to be very uncritical of the data they have to work with, though they do admittedly observe elsewhere in the coverage that: “Since pain is strictly an individual experience, sometimes with limited medical explanations for its frequency, severity, and duration, it is a phenomenon that is almost exclusively dependent on self-reports”.

“[Longitudinal studies tend] to confirm a generally held belief that the family plays an intricate role in JRA [juvenile rheumatoid arthritis]. The family impacts on the child and vice versa. Families with resilience, those who adapt to the changing demands of living with a young person with JRA, those who show psychological family resources, or families that are “healthy” are best suited to provide a nurturing environment and enable their children to cope successfully with their disease.” [Or, put another way, if you live in a dysfunctional family environment, this may well have negative health consequences and affect physiological responses to pain in a negative manner].

“Thomas (1994) found that the distribution of pain complaints in young adults was not random across individuals but instead was focused frequently within some families and not present or minimally so in other families. […] Payne and Norfleet (1986) reported that 78% of family members of chronic pain patients also reported pain. […] Apley (1975) also found that clinical pain in one sibling was associated with six times the frequency of pain in other siblings compared to controls. Family influences appear to be critical in the distribution of clinical pain behaviors in young adults [also in the nonclinical population]. Yet, it is still not clear what mechanisms are responsible for a skewed distribution of pain complaints within family units rather than having pain complaints randomly distributed on an individual basis in young adults.”

“The pain literature has investigated several possible explanations that could account for biasing factors in distribution of pain complaints in young adults. Possible explanations include such widely divergent transmission mechanisms as reinforcement and modeling to genetic predispositions for the development of pain behaviors […] Attempts to explain systematic patterns of location for pain complaints by age, family, or gender have focused most often on learning theory. This theory asserts that reinforcement patterns of family members for pain behaviors are the primary mechanism to influence individuals’ pain complaints […]. For example, reinforcement of pain behaviors by parents at an early age could influence lifetime pain experiences of individuals […], such that parents who positively respond to their children when they express illness behaviors may predispose their children to chronic pain problems in the future […]. Vicarious learning by observing family models is another possible explanation that might influence distribution of pain complaints, causing them to be focused within families. This process could also be responsible for transmitting physiological responses, which are associated with the experience of pain, from parents to children […] Alternately, the skewed distribution of pain reports within families may indicate the possibility that certain pain experiences are inherited […] Another possible genetic explanation has been that particular physical conditions are inherited” [I’d conclude from the coverage that there’s not nearly enough data and methodologically valid research presented in the book to even attempt to draw a conclusion about which explanation(s) might be the most important one(s).]

“The proposition that somatic pain in young adults can be an expression of childhood neglect and abuse has been proposed […] Berger, Knutson, Mehm, and Perkins (1988) showed that their sample, which consisted primarily of middle-class young adults, had experienced a wide range of physical discipline during childhood. Over 12% of their sample described being injured by the discipline of their parents and identified the specific injuries. It is interesting to note that even though 12.1% of respondents identified themselves as being injured by parents, fewer than 3% of respondents labeled themselves as having been physically abused as a child. This suggests a disparity between what one considers to have been abuse toward oneself and professional or public criteria for abuse. Of those who received broken bones, only 43% classified themselves as being physically abused. Also, only 35-38% of those receiving burns, cuts, dental injuries, or head injuries classified themselves as physically abused.” (Wow…)

“theoretical explanations for pain must include psychological and social context factors, since pain can be experienced in the absence of organic cause, such as with somatoform disorders. Another psychological factor affecting pain reporting is attention […]. Thus, inclusion of psychological factors as contextual variables surrounding pain increase explanatory power for theories attempting to account for variability in pain reporting across age groups as well as individuals. At the same time, psychological context variables also increase the complexity in understanding pain. […] The longer an individual experiences pain and there is some systematic sign of increased autonomic nervous system activity, the greater the likelihood that the pain experience will be influenced by psychological and social factors. For example, in people with chronic pain due to organic etiology, it is estimated that 20 to 40% experience major depression and another 40% have mood disorders […]. Thus, the comorbidity of chronic pain and depression is of continuing research interest. It is currently hypothesized that the relationship is bidirectional. Thus, high levels of depression may result in high levels of reported pain; conversely, high levels of chronicity of pain may lead to development of a major depression”