5. Aversion
• Motivational Salience
• E.g., Itching, bowel or bladder
urgency, phobia
• Adaptive in Acute Pain
• Maladaptive in Chronic Pain
• Frustrated aversion
• Not useful
• Worsening of Pain
6. Aversion: A
Complex, Derivative
Neuropsychological Function
Cognitive
and Social
Executive Function
AVERSION
Functions
Activity
Emotions and
Behavior
8. Reward/Aversion System
• Related to addiction
• Overlap
• Inverse of “Craving”
• Dopamine, glutamate, opioid systems
• Mu, kappa receptors
• Amygdala, nucleus accumbens
• Analgesia as reward
Seymour B, O'Doherty JP, Koltzenburg M, et al. Opponent appetitive-aversive neural processes
underlie predictive learning of pain relief. Nat Neurosci. 2005;8(9):1234–1240.
9. Pain and Aversion:
Attention
• “Interruption by pain is an inescapable fact of life:
Pain will emerge over other demands for
attention....Chronic pain can usefully be
redefined as chronic interruption by pain. Coping
with chronic pain can be understood as the
ongoing attempt to recover from chronic
interruption by repeatedly switching between
pain and other demands in the environment.”
Eccleston et al. Pain demands attention: a cognitive-affective model of the
interruptive function of pain. Psychological bulletin (1999) vol. 125 (3) pp. 356-66
10. Pain and Aversion:
Cognitive and Executive
Function
• Memory
• Speed
• Mental flexibility
• Verbal Deficits
• Likely others
Kreitler. Cognitive Impairment in Chronic Pain. Pain Clinical Updates (2007) pp. 4
12. Pain, Anxiety, Fear
Text
Neugebauer et al. The amygdala and persistent pain. The Neuroscientist : a review journal bringing neurobiology, neurology and psychiatry (2004) vol.
10 (3) pp. 221-34
13. Chronic Pain and
Aversion:
Anxiety, Fear
• Catastrophizing
• Phobic, avoidant
• Generalizes
• Of illness, injury, complication
• “Illness Conviction
• Of more pain
• Of anything
14. Pain and Aversion:
Fear
Colloca et al. Nocebo hyperalgesia: how anxiety is turned into pain. Current opinion in anaesthesiology (2007) vol. 20
(5) pp. 435-9
16. Chronic Pain And Aversion:
Disgust
• Pain as
foreign
body, parasit
e
Benuzzi F, Lui F, Duzzi D, Nichelli PF, Porro CA. Does it look painful or disgusting? Ask your parietal and
cingulate cortex. J Neurosci. 2008;28(4):923–931.
17. Pain, Aversion:
Impulse, Movement
• Arousal/activation
• Akathisia-like aspect
19. Pain and Aversion:
Behaviors II
• Protective
• Communicative
• Role Commitment
• Environmental Reinforcement
• Deconditioning
• Function and Subjective Experience
20. Pain and Aversion:
Loneliness
Image of My
Pain
Shin: Alone with
Pain
Resendez SLS, Kuhnmuench MM, Krzywosinski TT, Aragona BJB. κ-Opioid receptors within the nucleus
accumbens shell mediate pair bond maintenance. Journal of Neuroscience. 2012;32(20):6771–6784.
21. Psychopathology of
Chronic Pain:
Deconstruction
• Aversion
• Central Sensitization
• Psychiatric Comorbidity
• Personality
• Extrinsic (Interpersonal and System)
• Chronic Illness
• Transference and Countertransference
22. Central Sensitization
• Malignant process of up-
regulation, pain begetting more
pain, becoming autonomous
23. • Hyperalgesia
• Central Sensitization
Hyperpathia
• Paresthesia
• Centrifugal spread
• Referred pain
• Bilateralization
• Persistence, longer after-sensations
• Spontaneous, unpredictable exacerbations
• DNIC reversal
• Reduced gate control
• Cross-modality
• movement effects
• Anhedonia
• Lack of Motivation
25. Central Sensitization:
Psychological Effects
II
• Pain comes to dominate
subjective
experience, activity
• Pain becomes psychic
funnel, organizer, director
• Pain becomes developmental
nidus and trajectory
• Pain as core element of self
26. Central Sensitization:
Psychological Effects
III
• Helplessness, “Frustated aversion”
• Reduced
control, predictability, understanding
• Mortification, self-blame
• Egocentricity
• Regressed relating to others
• Disturbed Self-image
27. Chronic Pain and Self
• Pain as a trait, not a state
• Pain as an essential, not
accidental, attribute
28. Somatosensory Cortex
• Homunculus
• Prominence of painful sites
• Routine persistence
• Body Schema
Elbert T et al. Reorganization of Flor et al. Extensive reorganization
human cerebral cortex: the range of primary somatosensory cortex
of changes following use and injury. in chronic back pain patients.
The Neuroscientist (2004) vol. 10 Neurosci Lett (1997) vol. 224 (1)
(2) pp. 129-41 pp. 5-8
Schmidt-Wilcke et al. Affective Yang et al. Noninvasive detection of
components and intensity of pain cerebral plasticity in adult human
correlate with structural differences somatosensory cortex. Neuroreport
in gray matter in chronic back pain (1994) vol. 5 (6) pp. 701-4
patients. Pain (2006) vol. 125 (1-2)
pp. 89-97
Dykes. Mechanisms controlling neuronal plasticity in somatosensory cortex. Can J Physiol Pharmacol (1997)
29. Self, Identity
Values
Conscience Ego-Ideal
Wished-for
Self
Self- Identifications Self-
Confide Esteem
nce
Gender
Body Image
Identity
Self-Image
Identity
The ego is first and foremost a bodily ego....If we wish to find an anatomical analogy for it we can
best identify it with the “cortical homunculus” of the anatomists, which stands on its head in the
cortex, sticks up its heels, faces backwards and, as we know, has its speech-area on the left-hand
side.
-- Freud
30. Central Sensitization: Changes in “Self”
• Damaging to “Self”
• Loss of “Self”
• Damaged “Self”
• Broken “Self”
• Fragmented Self
• Unintegrated Self
• Unstable Self
31. The Chronic Pain
Conundrum
Pain is a part
Pain cannot be
of self, and
accepted as a
must be
part of self.
accepted.
32. Psychopathology of
Chronic Pain:
Deconstruction
• Aversion
• Central Sensitization
• Psychiatric Comorbidity
• Personality
• Extrinsic (Interpersonal and System)
• Chronic Illness
• Transference and Countertransference
35. Depression Makes Pain Worse
• Augmented pain perception
• Subjective amplification of negative
• Poor self-care
• Physical inactivity
• Further sleep impairment
• Constriction of compensating, positive thoughts and
activities
Strigo et al. Association of Major Depressive Disorder With Altered Functional Brain Response
During Anticipation …. Arch Gen Psychiatry (2008)
Klauenberg et al. Depression and changed pain perception: Hints for a central disinhibition
mechanism. Pain (2008) vol. 140 (2) pp. 332-343
36. Chronic
Pain, Mania, Hypomania, Mixed
• Not euphoric
• Irritable or dysphoric
• Not hyperactive
• Compensated
• Pain as partial stabilizer
• Opiates as partial behavioral control
39. Chronic Pain:
Psychiatric
Antecedents
• Very common
• Multiple bases for vulnerability to
chronic pain
• Multiple pathways of pathogenesis
40. Chronic
Pain, Addiction I
• Addiction:
• Craving
• Compulsive use
• Characteristic modifications in the
brain reward/aversion system
41. Chronic Pain, Addiction II
• Højsted J, Sjøgren P. Addiction to opioids in chronic pain
patients: A literature review. European Journal of Pain.
2012;11(5):490–518.
• Overall review of 24 studies
• 0-50% risk
• Criteria needed, rarely used
• ICD-10
• Portnoy
42. Chronic Pain, Addiction
III
• Fishbain et al. What percentage of chronic nonmalignant
pain patients exposed to chronic opioid analgesic
therapy develop abuse/addiction and/or aberrant drug-
related behaviors? A structured evidence-based review.
Pain medicine (Malden, Mass) (2008) vol. 9 (4) pp. 444-
59
• Those with no prior history of addiction:
• ADR 0.6%
• Addiction 0.2%
43. Chronic Pain, Addiction Risks
• Highest with
• Hx of substance abuse or addiction
• Concurrent psychiatric disorder
• Noncompliant patient
• Otherwise, risk is present, but low
• Still requires management
Carroll I, Barelka P, Wang CKM, et al. A Pilot Cohort Study of the Determinants of Longitudinal Opioid Use
After Surgery. Anesth Analg. 2012;115(3):694–702. Available at: http://www.anesthesia-
analgesia.org/content/115/3/694.
44. Chronic
Pain, Addiction
• Prevalence of chronic pain syndromes among
patients with addiction disorders
• Sheu R, Lussier D, Rosenblum A, et al. Prevalence and characteristics of
chronic pain in patients admitted to an outpatient drug and alcohol
treatment program. Pain Medicine. 2008;9(7):911–917.
• 29%
• Rosenblum A, Joseph H, Fong C, Kipnis S, Cleland C, Portenoy RK.
Prevalence and characteristics of chronic pain among chemically
dependent patients in methadone maintenance and residential
treatment facilities. JAMA. 2003;289(18):2370–2378.
• 37%
45. Chronic Pain, Addiction:
History of Addiction
• Prone to relapse by “cues”
• “No treatment” is not ethically
acceptable
• Special precautions
Savage SR, Kirsh KL, Passik SD. Challenges in using opioids to treat pain in persons with
substance use disorders. Addict Sci Clin Pract. 2008;4(2):4–25.
Compton P, Athanasos P. Chronic pain, substance abuse and addiction. Nursing Clinics of
North America. 2003.
46. Psychopathology of
Chronic Pain:
Deconstruction
• Aversion
• Central Sensitization
• Psychiatric Comorbidity
• Personality
• Extrinsic (Interpersonal and System)
• Chronic Illness
• Transference and Countertransference
47. Personality Factors
• Coping deficiencies
• Problems with impulse or affect control
• Volatile, overreactive
• Alexithymic
• Somatizing tendencies
• Unmet psychological needs
• Dependence
• Guilt, punishment
• Loss
• Identification
• Sexual, aggressive impulses
50. Developmental Factors
• Early psychological
trauma, especially violent or
sexual
Ringel et al. Effect of Abuse History on Pain Reports and Brain Responses to Aversive Visceral
Stimulation: An …. Gastroenterology (2008)
51. Chronic Pain, Early
Abuse I
• Pain Clinic
• 104 women
• 40% childhood abuse
• 59% sexual
• 33 % continuing abuse
• 79% both sexual and physical
Green et al. The role of childhood and adulthood abuse among women presenting for chronic pain
management. The Clinical journal of pain (2001) vol. 17 (4) pp. 359-64
52. Chronic Pain, Early
Abuse II
• OB/GYN Clinic
• 36 women with chronic pelvic pain
• 36% sexual abuse before age 15
Lampe et al. Chronic pelvic pain and previous sexual abuse. Obstetrics and gynecology (2000) vol. 96 (6) pp.
929-33
57. Psychopathology of
Chronic Pain:
Deconstruction
• Aversion
• Central Sensitization
• Psychiatric Comorbidity
• Personality
• Extrinsic (Interpersonal and System)
• Chronic Illness
• Transference and Countertransference
58. Chronic Pain:
Pain as Central Psychological and
• Attachment to pain itself
Developmental Organizer
• “Pain is part of what and who I am.
• Pain and patient role as identity
• Self-image with pain
• Narcissistic defenses
• Attachment to, investment in
• Sick role, disability role
• IP role (family)
• Secondary attachments
• People, money, activities
• Treatment as threat
59. Abused Child Transference
Stalemate
• Repetition from a provider (parental figure)
• Idealization and mistrust of physician as nurturer
and abuser
• Pain, punishment as love (investment in pain)
• Pain, illness as dependence, nurturance
(Investment in illness)
• Suffering as disempowering the rescuer-abuser
by guilt-tripping, defiance
60. Chronic Pain Treatment Team
• Complexity: limited effectiveness of simple unimodal
approaches
• Team Approach
• Physical management and monitoring
• Rehab
• Psychiatry and Psychology
• Social Work
• Group support
• Prognosis
