The Term "Chronic" Pain and its Effect on: Pain Perception, Pain Acceptance (Pain Experience) and Pain Management Outcomes.  

Moh'd Saleh Faleh Mhaidat*

 

*Correspondence to: Dr. Moh'd Saleh Faleh Mhaidat, Consultant Clinical Psychologist Med and Rehab Fields APA, IASP Affiliate Member, Jordan.               

Copyright

© 2023 Dr. Moh'd Saleh Faleh Mhaidat. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 04 July 2023

Published: 01 August 2023

Introduction

We are all aware of the close relationship between mind and body.

Pain is still a very pervasive medical problem. (1) But actually, it has many psychological consequences.

Healthcare providers in multidisciplinary team know the difficulties in treating chronic pain in spite of all kinds of treatment. Also pain patients recognize this problem. It's important to think about the hidden factors or any other components that might have negative or positive influence in pain management process.

Diagnosing and classifying degrees of pain is very important issue in pain perception, acceptance (Pain Experience), which effects on cognitive and emotional process - that might interfere with management trials.

So, the probable negative impact of the type of diagnoses works as the side effect of any medication, which affects finally on pain experience and all sorts of pain management.

 

According to psychological point of view, I started to think about the "Chronic" term itself, since many years and inquiring:

Is it necessary to use "Chronic" term as diagnoses in medical practice?

Is it suitable to inform the pain patient in this way?

I questioned that "chronic" term might be one of the hidden factors. So, the problem might be related to the classifications of pain diagnoses itself, that worsen the pain management outcomes, which put the pain patients in endless suffering, also it might consider as a stigma and become as any other dangerous disease.

How to deal with pain patient' is an important part in pain management as well, and we need to change the way of diagnosis because pain management starts from the time of pain diagnosis, more the less: Diagnoses is part of treatment.

Before thinking of diagnosis and the ways of treatment of pain patients we should think about:

How to inform them about the nature of pain problem?

How to explain and interpret the complain?

How to select the proper words that affects positively and gently on the cognition and emotion to enable them to accept their pain and to improve pain perception?

How to keep safe communication with pain patients?

How to explain the plan of treatment?

All these things have strong affect in shaping pain perception, pain acceptance and then will affect positively or negatively on pain management strategies.

The probable negative psychological effects of using " chronic " term should be investigates in all medical and psychological practices.

 

Chronic Pain

As a matter of fact: when we describe the pain as "Chronic", we increase, confirming, complicating and amplifying the pain problem.  In this way, pain problem become well established as chronic issue, and it will stand against all endeavors to solve it.

Critical terms in medical diagnosis effect on non - patients as well.

Recent researches interested in patient rights, demands, needs, and committed  with new criteria's of medical and psychological care, for example:  we can find like these  interests through focusing  on patient centered care,  patient experience  issues and suggests to use  "The person served" instead of using term "patient", also they interested in proper strategies in communication and patient-therapist relationship.

Meanwhile, medical studies and medical text books, are full of  critical and fearful medical terms, that need precise revision and modification from psychological and behavioral point of view,  to test the unexpected meanings due to different  reactions and interactions among the patients regarding these terms, and because of  the expected negative psychological impact of these terms, that might occurred to patients and their families, and  effect on  patient health and treatment polices as well.

 

According to that for instance, there are several medical terms that has horrible meanings from its content such as:

Brain death, Brain Damage, Brain bleeding, Stroke, Renal failure, Respiratory depression, cancer, paraplegia and quadriplegia, chronic psychotic disorders, etc.

Any critical or serious medical term might develop fearful meanings to the people who are not familiar with such medical atmosphere, or when translate it to the patient in another languages, these critical terms results additional complications and suffering, in both conditions as well.

Through some articles about chronic pain problem, there is an article mentioned that the patients and healthcare providers should believe in chronicity of "chronic" pain.   In this regard: Murry (2)   mentioned in his article:   "why the healthcare system refuses to accept the chronicity of chronic pain? Most healthcare providers take care to discuss with their patients that there are no cures for these conditions. Patients are commonly told that the interventional or surgical recommendations might rid the patient of pain. Science tells us that chronic pain really is chronic in the sense that there is no pharmacological or procedural cure. Research on the outcomes of interventional and surgical procedures for chronic pain consistently shows that they are largely ineffective or only minimally effective."

According to what Murry reported above: " Most healthcare providers take care to discuss with their patients that there are no cures for these conditions, ".  It is so harmful to tell the patient that he has chronic pain,

and no cures for these conditions, in this way we increase his suffering, increase his medications intake, which might lead to addiction, and increase time duration of treatment, that interfere with pain management and will have ineffective results. So, I can say: pain as a chronic   problem become well established during the communications with the patients, which starts from the healthcare providers side.

On the other hand, it is unfit to tell the patients that the surgical interventions might rid them of pain. So, the doctors put the patients in situation with high positive expectation. Doctors unfortunately push them in indirect way for frustration, which will increase their suffering, due to ineffective surgical results.

Healthcare providers should try to reduce the patients  duration time of  treatment, which  lead to reduce  dosages intake,  and reduces financial costs, via providing  support and reassure to the patients,  and using well organized  communication and gentle talks, that facilitate  reaching  some sort of improvement, which is better  than convincing  them to accept the chronicity of their pain.

Chronic pain as a complex issue may be hidden with the term " chronic "itself, since no body think to study or to investigate the effect of this term on pain patient reactions.

Murry said also: "the chronicity of chronic pain may simply be harder to accept than it is with other chronic health conditions."

Again  Murry seems that he insets to acknowledged that chronic pain is a serious problem, that's harder to be accepted, while patients can easily accept  other chronic disease like : Diabetes, Hypertension, etc., So we should be cautious when we want to tell the patient the type of  his pain, and to select proper words that has no negative reactions on his psych and body.

Murry said also: "The healthcare system has to do a better job at understanding the truly chronic nature of chronic pain."

According to this statement, I can say: the chronicity of pain problem may become from using the term "Chronic" itself, because usually every patient eager to hear good news, hope and safe words about his case.

Healthcare providers acknowledged that chronic pain is the only cause of pain problem, but it is better to let the patients recognize that they have pain only, not "chronic", constant or lasting pain. In the same time the treatment process can deal with pain as chronic one, moreover I prefer to tell the patients that they have just pain, and I suggest to drop the word chronic from the pain classifications, which is the main target of this article.

In fact, if we go deeply interpreting the pain case to the patient as it is, we might increase his worry and anxiety in the same time, which will affect negatively on pain perception, pain acceptance, pain experiences and the treatment plan.

From the other side, if the pain patient read the pamphlet (3) and the description about his pain, and the medication side effects, he might reject the medicine, because some patients feel that he will experience everything written about the symptoms and complications of his pain.

According to the patient, the meaning of the term "Chronic " will interact with his mental function, body and emotional factors, which will affect in all his life elements.

"Chronic" term will develop bad expectations, and will interact with multiple areas of the psycho-social life of the patient, family, study and work, including mood, cognition, and behavior as well.

 Regarding to " Chronic" term, the  power of  mind / body mechanisms shaping pain perception which  revealed positive or negative  responses, that might  reduce  or  increase pain tolerance, then it will effects on pain experience and  effects on the type of  pain management after that, pain experience will again effects on pain management process, and finally effects on the treatment and healing  outcomes, and lessen the  chances of improvement, then it will induce continuous complain, that interfere with quality of life patterns.

If we stop using chronic term, this might lead to positive and normal pain perception, which will develop positive acceptance and improve pain tolerance, then will achieve good pain experience, and finally achieving effective pain management.

When the patient informed that he/she has chronic pain, he/she might be shocked and denied  this diagnosis, then he/she will be occupied to the classification, because the patient  usually trust the doctor, and  can't refuse or challenge his diagnoses  also, because he/she is not qualified to argue the doctor if  he/she has real chronic pain or not. Moreover, most of the patients eager to know good news, and tend to hear what he likes to hear.

Thus, " Chronic Term" might develop anxiety/ depression, and raises new problems to the patient, and leads him/ her to develop bad thinking and bad expectations about his/ her study or work, as well as the personal and familial responsibilities.

 Actually, when the patient realizes that he/ she has real Chronic Pain, we can't know or we can't control his invisible psychological and cognitive reactions, and become difficult to predict his hidden physiological responses, especially the neural system, immune system and endocrine, etc. (4)

Terms/words effects on patient's perception:

Words can inspire, and words can destroy, choose yours well (Robin Sharma)

Always remember: Every word you speak has the power to Hurt or Heal (Posivibe Man)

Be careful with your words, once they are said, they can be only forgiven, not forgotten.

Cases as Example

Case 1- Many years ago, I heard a story about a cancer patient (was treated in one of USA hospitals) he got healed from his disease, it was an incredible event for the doctors, which let them asking the patient: did you got other treatment from another place?

He said: no, and why you asking me?  They replied: because you have dramatic results until now, he said: yes, I heard (he had hearing problem) you were saying during your regular medical rounds that my case is curable. 

This led him to believe (cognition process) that he will get better, which affects positively on his perception, which supported his acceptance and improved his treatment management at the end,  (in fact, his case was not so, it was complicated and hopeless case). 

Then the doctors realized that the patient was happy because he heard the word curable( not incurable) so, this might effects on his perception process  and neural system  and feelings,  which might influenced also, on his  immune system  positively, it seems look like the result of power of mind/ body interaction , and finally he got healed, but nevertheless we shouldn't forget  the effects of  prescribed  medications.

This story should lead us to think and imagine how the case or the fatal situation of this patient if he heard the accurate word " incurable". It will be look like severe or harmful shock and different story.

 

Case 2- A man diagnosed with terminal cancer. Reported by Dr. B.  Klapfer in the Journal of Projective Techniques in 1957, it involved a man with metastatic cancer and tumors that had spread throughout his body. The patient had tried every available form of medicine and his condition had hopelessly deteriorated to the point where he was bedridden and gasping for air. His doctors agreed that he had only a few days to live. Then the man heard (cognition process), about an experimental drug called Kebuzone, which was in the process of being tested.

He insisted on being included in the experimental trials. His doctors, feeling he had nothing to lose and would soon be dead anyway, out of compassion agreed to give him the experimental drug. To them amazement, the man's tumors soon began to shrink dramatically and he was discharged from the hospital.

Two months later, the man read news accounts of the research on Krebiozen that reported serious doubts with the drug. Within a matter of days, the man's tumors had returned and were again threatening his life.

His doctor cleverly convinced (changing his perception) him that new and more potent shipment had been received and proceeded to give him injections of plain water.

His tumors once again began to shrink dramatically. He remained healthy for seven more months until another news report declared "Nationwide AMA Tests Show Krebiozen to Be Worthless as a Cancer Treatment." The man died within two days.

Case 3- A 19 year old male underwent an amputation surgery above right knee due to Cancer,  on the time of daily wound  dressing he refused to do it at the ward, and asking the nurse to send him to the operation room (OR), shouting, fearful and crying,  the nurse did that, then after two days of the  same behavior, she  referred  him  to me for  psychological  consultation.

During the interview, he said  that he feels painful dressing at the ward, while he received  good pain killers in the OR( because somebody told him that, the dressing at OR is better than the ward) that’s why he refused to do it at the ward( it’s a matter of perception), actually  it was the same medication in both places, then after support and rapport, I promised him to bring the same medication from the OR  to make his dressing at the ward, ( to manage his perception issue) Then he agreed, and received the dressing at the ward peacefully without any complains.

 

Patient Rights:

Generally, the idea of this article is not like an invitation to break or to neglect the patient rights, regarding his/ her real medical status, because he/ she has the right to know the correct diagnoses, but logically not in risky or harmful approach.

Sometimes the patient can't tolerate or can't understand the nature of his case, he/ she might have some degrees of negative psychological component in his history, or not ready to hear serious or critical status, concerning his/ her medical situation.

Also, I am not calling to change the nature of treatment plan, systems or polices. The management protocol should be the same, but my concern is about how to inform the patient about his/ her medical status, and how we should interpret his complain, how to classify his diagnosis.

So, we should discriminate between medical teaching and learning situations, on the other hand, the humanitarian atmosphere of medical practice. In this regard, the healthcare providers can use suitable simple and safety words, and avoiding the term "Chronic", because the simple and safety words might have positive component, or neutral response.

Simple and safety words, might works like suggestion effect (look like placebo power). Suggestion has good power effect which can results positive physiological responses and facilitate the steps of treatment. Simple and safety words, help producing secure and comfortable state during all treatment journey.

Surely, the patient will feel cool, relax, satisfied. This leading him to accept his case, which enhancing pain acceptance, and helps in facilitating positive pain perception and smooth treatment process, without worry or noxious thoughts, finally that’s what we are looking to achieve.  As we know pain issue is one of the fifth vital signs, that mean we should be: cautious and careful when dealing with it, especially with cases of hypertension, diabetes.

 

Therapists Behavior:

Some physicians use Critical medical terms frequently and easily Infront of the patient, without paying attention to What does it mean from the patient side? So, how the patient will understand, or receive it?

How he will manipulate, or cope with it?

How it will effect on his mind and body?

Physicians sometimes using critical medical terms, and details in front of family members and their visitors. 

They look to the medical terms as normal subject due to their frequent uses, and because they are familiar with it, while from the patient perspective it is a different story.

 

Cautious in Diagnosis

Pain patient needs support, encouragement, reassurance, comprehensive and unique care psychologically and socially, to be able to encounter the pain and its treatment journey, in addition to other different medical services.

In pain management we should be cautious in telling the patient his diagnoses, because:

1- Most of the people has some kind of knowledge about chronic pain and the difficulties in treatment process, from media, relative or friend, etc.

2- Logically, do we obliged to tell the pain patient that he has chronic pain?

Because, more serious and critical information and classifications might increase patient's tension and anxiety which will effect on management plan.

3- Some pain patients have other or multiple medical issues.

4-   Some persons dislike to be labeled as Patient, and have bad expectations about illness and medication.

5-   Some people dislike to visit hospitals or medical clinics,

because they are so sensitive to medical issues, and other sorts of management which might develop tension, anxiety and frustration.

6- Some people become tensed, worry and fall in fear if they see (blood, injured person, etc..) hear (ambulance alarm) or smell any stimuli related to medical atmosphere.

7- Some patients exposed to bad experience from sort of medical management, and fears from critical diagnoses.

8 - The patient might have kind of psychological problems or disorders, precipitating factors, trigger points, which might interfere with actual critical diagnoses.

9- There is a depressive, obsessed and anxious personalities- traits or states- in different degrees among most of people, which might increase the pain problem, and it's difficult to discover them without specific and comprehensive evaluation, during pain treatment process.

10- Every patient has different degrees in pain threshold and different pain tolerance level, regarding to individual differences.

11- Every patient understands and interact with " chronic Term" in different way, due to individual differences in pain Perception, regarding: culture, religion, believes and values, and other previous experiences, which will affect on the patient's way of coping according to pain management plan.

12- The patient might consider " Chronic Term" as dangerous issue, which puts him in harm position,  and tension  that effects on his way of thinking and behavior, puts him in a critical situation, and adding other symptoms of pain, it means pain will last or will stay for long time, then the endocrine, neural system and immune system will be effected as well.

13- Chronic word enhance indirectly   pain suffering and develops frustration unconsciously, which might complicate or worsen the Pain problem.

14-The psychological response of patients to chronic term is look like hopeless case, or may be similar to the same response when other patient informed that he has cancer disease or any other critical diagnosis?

 

Goals /Objectives from this article:

If we avoid using the term " Chronic" we might reach the following:

1- To control and reduce the expected negative psychological complications: tension, anxiety, depression, which interfere with pain healing chances.

2- To reduce medications intake: pain killers and narcotics in order to avoid the side effects of these medications, addiction, peptic ulcer and renal failure…etc.,

 3- To avoid some unsuitable or useless surgical interventions- because some pain patients ask for surgery as alternative trial-.

4- To enhance the efforts that lead to reduce the financial costs of treating pain problem, by lessen the periods of hospitalization, recurrent admission and regular follow up visits.

5- To enhance the positive results during treatment process.

6- To build good relationship with team therapists and the patient as well.

7- To support and reassure the patient to achieve good improving results.

8- Offering the patient normal and peaceful life without stigma.

9- To know the necessity of changing the term " Chronic "   in general manuals or cancelling it from medical references and to stop using it in medical fields, practice and medical education.

10- To encourage researchers to review the effects of using any other similar critical medical terms and classifications in specializations of hypertension, diabetes, neurological diseases, cancer and cardiology etc.., that affects or interfere with treatment programs.

11- Involving the psychiatrist and clinical psychologist, when the pain management team want to inform the patient about his medical condition and diagnoses.

 

Conclusion

According to the close relationship between mind and body, there are some critical diagnostic terms, that have negative psychological effect on patients in medical practice, which might effect on the treatment plans, especially in pain management.

The term chronic is one of these critical terms, that need to be tested empirically to rule out its effect on pain management outcomes.

Reference

(1)R.J.Gatchel&D.C.Turk(Eds).1999, Psychosocial factors in Pain: Critical Perspective(pp3-17).New York: Gilford Press. In Robert J.Gatchel:(2005) Clinical Essentials of Pain Management. American Psychological Association. Washington DC.

(2)J. McAllister, PsyD,( whats is chronic pain) 2015, editor and founder of the Institute for Chronic Pain (ICP).

(3)J. Schmitz et al :    Impact of patient information leaflets on pain medication intake behavior: a pilot study, Pain, 1-6 (2017)

(4)F, Benedetti: How the doctors words affect the patient's brain, Evaluation and the health professions, Vol. 25 No.4,2002 369-386.

(5)Klopfer, B. 1957. Psychological variables in human cancer. Journal of Projective Techniques 21:331-40.)