IASP Curriculum Outline on Pain for Psychology

Task Force Members: Herta Flor, Patricia A. McGrath (Chair), Judith Turner, Johan Vlaeyen, Amanda C de C Williams

Outline Summary

Introduction
Principles
Objectives
Curriculum Content Outline
 I. Multidimensional Nature of Pain
 II. Pain Assessment and Management
 III. Management of Pain
 IV. Clinical Conditions

Introduction

Psychology aims to increase our understanding of behaviour and related thoughts and emotions. An integrated bio-behavioral approach is required to address the multidimensional nature of pain and choice of management strategies.

Principles

  1. Pain management requires an integrated bio-behavioral approach based on an understanding of the impact of psychological factors, as well as the peripheral and central nervous systems.
  2. Psychological factors can modulate the sensory and affective dimensions of pain.

Objectives

Psychologists at the end of this entry level pain curriculum will be able to:

  1. Provide psychology students with an overview of the multidimensional nature of pain from clinical and basic science perspectives.
  2. Introduce pain assessment and measurement strategies for psychologists to use in clinical practice and in research.
  3. Review how many psychological factors, such as attention and expectation, can modulate pain in different experimental and clinical contexts.
  4. Understand the primary psychological therapies and treatments from an evidence-based perspective.

Curriculum Content Outline

I. Multidimensional Nature of Pain

A. Introduction

  1. Definition of pain
  2. Distinction between pain and pain-related disability
  3. Biopsychosocial perspective for understanding pain and pain behaviors
  4. Classification of pain - acute, breakthrough, chronic, and non-cancer pain; cancer pain
  5. Primary behavioral and psychological factors associated with acute, recurrent, chronic and cancer pain
  6. Nociceptive and neuropathic pain

B. Neurophysiology and mechanisms

  1. Developmental issues (infants, children, adults, older adults)
  2. Nociceptive pathways and pain matrix
  3. Peripheral and central mechanisms of pain
  4. Cognitive and affective influences on pain
  5. Involvement of cortical and descending CNS pathways
  6. Learning, memory and brain plasticity

C. Pain theories and models (implications for treatment)

  1. Diathesis-stress models of chronic pain
  2. Fear and avoidance model
  3. Cognitive-behavioral models
  4. Observational learning and modeling
  5. Biases in information processing, catastrophizing
  6. Attention and hypervigilance
  7. Operant conditioning
  8. Respondent conditioning
  9. Conceptual aspects of gate control model (i.e. ascending and descending modulation and affective, cognitive, sensory aspects)

D. Ethics

  1. Rights of patients for accurate assessment and treatment of pain
  2. Access to care, including interdisciplinary management
  3. Clinical appropriateness: tenets of autonomy, nonmaleficence, beneficence, justice, and human rights
  4. Racial, ethnic and sociodemographic disparities
  5. Legal issues related to the use of controlled substances for the management of pain
  6. Ethical principles of psychologists
  7. Informed consent and assent
  8. Awareness of potential adverse effects of drugs and quality of life issues in severe pain

E. Treatment Outcome and Evaluation Research

  1. Study designs
    1. Study designs: randomized controlled trial, observational studies, comparative effectiveness research
    2. selection criteria
    3. randomization
    4. treatment fidelity
    5. statistical vs. clinical significance
    6. external validity strengths and limitations
  2. Single-case experimental designs
    1. general principles of the single-subject experiment
    2. selecting the outcome variable
    3. selecting the design
    4. applying the statistic
    5. replications
    6. external validity strengths and limitations

II. Pain Assessment and Measurement

A. Experimental Pain

  1. General issues
    1. recognition of specificity of context in which measures are appropriate
    2. importance of accuracy of pain stimulus delivery
    3. appreciation of lack of correlation among responses to different stimuli
    4. relevance/advantages of specific experimental pain measures
    5. limitations of specific experimental pain stimuli in eliciting cognitive, emotional and behavioral responses characteristic of clinical pain
  2. Goals of experimental pain research
    1. investigation of mechanisms of pain and pain control
    2. evaluation of pain models or theories
    3. investigation of psychological processing biases
    4. assessment of analgesic efficacy
  3. Pain stimulation methods
    1. properties of different pain stimuli
    2. additional requirements re onset, termination, nature and specificity of activation
  4. Properties of an ideal pain measure
  5. Neuro/physiological/motor correlates of pain
    1. motor reflex, autonomic effects
    2. effects on attention and processing
    3. brain activity imaging methods
    4. measurement of physiological stress/arousal
    5. peripheral measures (surface electromyography)
  6. Subjective measures of pain intensity
    1. single-point measures: pain threshold, pain tolerance
    2. scaling (magnitude estimation):
      1. numerical and verbal category scales
      2. visual analog scales
      3. verbal category scales
      4. pictorial scales (e.g., for use with children)
      5. ratio scaling methods
      6. combination methods
      7. multidimensional scaling
      8. psychophysical matching
  7. Measurement of diffuse noxious inhibitory controls
  8. Measurement of temporal summation
  9. Pressure algometry

B. Clinical pain

  1. Specific goals of clinical pain assessment
    1. diagnosis
    2. identification of pain in non-verbal individuals
    3. selection for treatment
    4. design of treatment
    5. assessment of change
    6. evaluation of treatment
  2. Assessment of clinical pain
    1. properties of an ideal clinical pain measure: valid, reliable, sensitive to change
    2. sensory, affective, cognitive/evaluation dimensions
    3. qualitative versus quantitative characteristics
    4. measures of pain sites, diffuseness of pain
    5. pain dimensions: least, worst and usual pain, temporal and activity fluctuations
    6. pain diaries
    7. assessment of neuropathic pain
    8. facial expressions and motor behaviors

C. Assessment of pain-related problems

  1. Pain-related interference with daily activities/functional disability
  2. Sleep
  3. Quality of life
  4. Energy/fatigue
  5. Mood/anxiety

D. Epidemiological assessment

  1. Methodological issues
    1. differing methodologies and pain definitions in estimates of incidence/prevalence
    2. differences in population samples
    3. differences across countries
    4. influence of differing health-care, disability, and legal systems
    5. Cross-sectional versus longitudinal studies

E. Psychological and Behavioral Assessment of the Individual with Chronic Cancer and Non-Cancer Pain

  1. Purposes of patient-centered assessment
    1. identification of psychosocial influences on pain
    2. identification of pain impact on quality of life
    3. identification of associations of pain, sleep, fatigue, mood
    4. identification of psychological disorders
    5. identification of deficits and strengths in coping skills
    6. decision making and treatment planning
    7. medico-legal assessment
  2. Basic principles of psychological measurement (psychometrics)
    1. item generation and selection
    2. standardization; sampling
    3. reliability: internal consistency, stability (test-retest), intra- and inter-
    4. validity: content, face, predictive, construct, convergent, discriminant
    5. assessment of clinical relevance: utility, sensitivity and efficiency
    6. qualitative methods
  3. Behavioral assessment
    1. Background: operant vs respondent pain, learning theory, operant behavioral principles, positive and negative reinforcers
    2. Observational methods
      1. observational pain behavior ratings
      2. direct observation in naturalistic or clinical settings
      3. videotape ratings
      4. observations in clinical interviews (e.g., of guarding, limping, bracing, changing position)
    3. Diaries of activity and function
    4. Patient self-report measures of pain behaviors
    5. Pain impact on activities
    6. Functional analysis of pain behaviors; analysis of the influence of social and environmental factors on pain problems; family responses to pain behaviors
  4. Assessment of pain beliefs, appraisals, and coping strategies
    1. rationale and background for assessment of beliefs, appraisals, and coping
    2. content domains and available instruments: measures of self-efficacy, perceived control over pain, fear, avoidance, catastrophizing, coping strategy use, pain beliefs, outcome expectancies
    3. ability to control pain and associated symptoms using self-management strategies
  5. Assessment of anxiety and mood disorders
    1. rationale
    2. content domains and available instruments
      1. anxiety disorders and measures
      2. mood disorders and measures
      3. anger and hostility
    3. DSM-IV and ICD classification of anxiety and mood disorders
    4. problems of assigning somatic symptoms of measures to pain and/or mood
  6. Assessment of other psychological/psychiatric disorders
    1. Post-traumatic stress disorder
    2. Substance abuse
  7. Psychosocial stress
    1. Background, relationship of stress and pain
    2. Physiology of stress and pain
    3. Available self-report measures
  8. Assessment of functional disability
    1. Background/rationale; relationship of pain to functional disability
    2. Self-report measures
    3. Observational measures
  9. Work issues
    1. General issues-pain impact on work, work impact on pain-related disability
    2. Measures to assess work issues
  10. Personal and family history
    1. Childhood; history of illness and of physical, psychological, or sexual abuse
    2. Education
    3. Marital history
    4. Children
    5. Work history
    6. Family history of psychiatric and pain problems
  11. Cultural issues in pain experience, pain behaviors, health care seeking, and disability

G. Treatment Outcome Evaluation

  1. Nature and purpose of outcome assessment
    1. evidence-based practice and issues related to emerging evidence base for some interventions
    2. principal outcome measures and extended set
    3. IMMPACT consensus for adults and children
    4. measures of pain intensity
    5. self-report measures of emotional distress
    6. self-report measures of functional disability and work disability
    7. pain-related beliefs and coping strategies
      1. as mediators of patients' outcomes
      2. as clinical end-points
      3. as "risk-factors" for outcomes
    8. psychophysiologic/psychophysical measures
      1. relative independence of different measures
      2. relatively low associations between psychological, behavioral and psychophysiological/psychophysical measures
    9. health care use after treatment and costs of health care to individual and third party funder
  2. Methodological issues
    1. efficacy versus effectiveness
    2. statistical versus clinical significance of change
    3. quality issues: therapists, treatment content, treatment process, integration of treatment components, adherence
    4. systematic review, meta-analysis, and guidelines

III. Management of Pain

A. Enhancing motivation to change and relevance to pain behaviors

  1. Specific motivational strategies
  2. Strategies strengthening commitment to change
  3. Maintenance of change
  4. Strengths and limitations of the motivational enhancement methods

B. Early Intervention

  1. Conceptual background
    1. economic and human costs of un-treated pain
    2. primary, secondary and tertiary intervention
    3. identification of barriers to intervention
  2. Identification of increased risk for chronicity based on group-level statistical associations
    1. medical risk factors
    2. psychosocial and psychosocial risk factors
    3. workplace risk factors
    4. socio-economic risk factors
  3. Integration of early intervention into clinical practice
    1. stepped-care algorithm
    2. prevention of acute pain from becoming chronic
      1. provision of adequate care plan
      2. role of patient education
      3. appropriate management
      4. early interdisciplinary rehabilitation program
      5. follow-up and adherence
  4. Promotion of health
    1. individual health behaviors (exercise, physical fitness, stress management)
    2. management of health behavior in workplace programs and community health programs
  5. Specific issues in prevention
    1. Consideration of appropriate time-points for intervention
    2. promotion of active participation and adherence
    3. communication between stakeholders (professionals, insurers, workplace, family)
    4. integrating role of economic factors into plan for prevention
  6. Strengths and limitations of prevention and early interventions

C. Operant treatment

  1. Operant conditioning model of pain behavior
    1. Reinforcement, punishment and extinction
    2. Discriminative stimulus control
    3. Functional behavioral analysis
    4. Response generalization
  2. Establishing baseline tolerance levels
  3. Defining functional treatment goals
  4. Reinforcement of "well" behaviors
  5. Social reinforcement
  6. Training of spouses and family members
  7. Methods for maintaining and generalizing treatment gains
  8. Strengths and limitations of the operant treatment approach, including extinction and extinction memory

D. Cognitive-behavioral treatment

  1. Cognitive-behavioral model of pain
    1. the role of feelings, thoughts and actions
  2. Providing patients with a treatment rationale
  3. Cognitive restructuring
  4. Skills training
    1. pleasurable and meaningful activity scheduling
    2. breathing and relaxation techniques
    3. imagery techniques
    4. coping self-statements
    5. behavioral activation
    6. focal point and visual distraction
    7. problem solving
    8. attention diversion
    9. goal setting
    10. relapse prevention methods
    11. homework assignments
  5. Exposure in vivo for pain-related fear
    1. the fear and avoidance model of chronic pain
    2. the paradoxical effects of reassurance
    3. fear hierarchy
    4. behavioral experiments
    5. stimulus generalization
  6. Mindfulness
  7. Acceptance and commitment therapy
  8. Partner-assisted CBT
  9. CBT for disease-related pain
  10. Evidence base for CBT, strength and limitations of CBT

E. Relaxation and Biofeedback

  1. Models of psychophysiological reactivity
  2. Relaxation
    1. rationale for relaxation
    2. protocols for relaxation
      1. progressive muscle relaxation
      2. brief relaxation methods
  3. Negative side-effects of relaxation (panic attacks and relaxation-induced anxiety)
  4. Biofeedback
    1. rationale for biofeedback
    2. protocols for biofeedback training
      1. EMG for various types of musculoskeletal pain
      2. EEG neurofeedback
      3. temperature biofeedback for migraine
      4. vasoconstriction biofeedback of the temporal artery for migraine
  5. Interventions based on brain changes in pain such as sensory discrimination training mirror treatment brain computer interfaces virtual reality use

F. Hypnosis

  1. Models of hypnosis
  2. Basic procedures used in hypnosis
    1. hypnotizability assessment
    2. general induction techniques
    3. analgesic suggestions
    4. post-hypnotic suggestion
    5. self-hypnosis
  3. Hypnosis in disease-related pain
  4. Strengths and limitations of hypnosis

G. Psychological treatment of children's pain

  1. Psychological aspects of children's pain
  2. Situational factors
    1. misbeliefs about etiology and pain control
    2. beliefs about the role of stress
    3. child and parent behaviors during pain episodes
    4. parent behaviors in response to pain behaviors
    5. emotional factors
  3. Strengths and limitations of psychological treatment of children's pain

H. Family therapy for chronic pain

  1. Family systems model of chronic pain
    1. Operant behavioral perspective
    2. Cognitive-behavioral transactional model
  2. Strengths and limitations of family therapy for chronic pain

I. Interdisciplinary treatment approaches

  1. Nature of multi- and interdisciplinary pain treatment
    1. purpose of multi/interdisciplinary treatments
    2. distinction between multidisciplinary and interdisciplinary
    3. organization and description of pain clinics and pain centers
  2. Specific role of the psychologist
    1. specific assessment skills including interview methods
    2. assessment of the social context of consultation, including the specific role of the spouse and family
    3. identification of specific psychological treatment goals and obstacles to progress
    4. psychological preparation of the patient for pain management
    5. application of cognitive-behavioral strategies, relaxation techniques, contingency management, to both patient and significant other/family
    6. role as a mediator/interventionist within the team
  3. Strengths and limitations of the interdisciplinary treatment approach

IV. Clinical Conditions

A. Classification

  1. DSM classification
  2. ICD classification
  3. IASP classification

B. Co-morbidity

  1. Relationship of somatic and psychological factors in chronic pain
  2. Comorbidity of chronic pain and mental disorders
  3. Pain in various mental disorders
  4. Multiaxial approach to chronic pain

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