Black and white thinking must be abolished

Black and white thinking, for those readers unfamiliar with cognitive distortions, refers to the tendency to reduce complex ideas and situations into simple, dichotomous, and mutually exclusive categories.

Think of good or bad, yes or no, all correct or all wrong, acute pain or chronic pain, neuromatrix or peripheral mechanisms, cure the pain or manage the pain.

It’s a way of simplifying arguments or decisions that can work well when the situation requires very fast decision-making, or where the options are very limited.

It doesn’t work at all in the messy and complicated worlds of clinical reasoning, theory development, or in discussions to broaden understanding.

I’m pondering this because of the way various aspects of pain management and the science of pain are misrepresented as opposed to each other, when maybe it’s not quite so simple.

I hope (crossing fingers and toes) that I’m not doing prone to doing it too often on the pages of this blog, or elsewhere for that matter!

There are multiple strands of research into pain at present. 

There are the reductionists who focus exhaustively on smaller and smaller elements of biology to explain the processes involved in nociception and transmission from noxious input to the perception of pain and back to the responses as a result. 

There are the phenomenologists who focus on the ‘lived experience’ of the individuals who have pain.

There are those who are furiously investigating laterality and cortical processing.

There are others feverishly working on ways to abolish all pain, and those who are equally enthusiastically researching why so many people are unbothered by their pain even though it’s severe.

Can you see all those opportunities for opposing views? for argument and debate?  It’s common for any of us to think mainly in terms of our own orientation, and there are many factors in human cognitive bias and group decision-making that get in the way of us working towards consensus – or even hearing each other.  And that can lead to trouble within teams, especially multi- or inter-disciplinary teams.

I wonder if it’s time to apply some of the cognitive techniques we can use with patients to ourselves as clinicians.  Let’s take a quick look at some of the basics.

Firstly, why do we use black and white thinking?  Well, it simplifies things.  If we’re feeling a little bit sad, we’re more likely to tell a loved one that we’re feeling “terrible”.  We don’t mean to exaggerate, we’re aiming to get empathy from the person we’re talking to, so we unintentionally use dichotomous language – we think in terms of feeling “amazing” vs feeling “terrible”.   Humans like to identify patterns, and to group similar things together so we can generalise.  We like to reduce an argument into “either – or”.  And when we do this, once again because of our tendency to look for information that confirms our own position, we often fail to recognise other alternatives, or information that doesn’t fit with our own views.

What we can do is step back and carry out some metacognition – thinking about our own thinking.

Some questions we can use to challenge our own position are:

  • How did I come to that conclusion?
  • What’s the evidence for the other position?
  • Is it possible to use “and” instead of “either/or”?
  • What are the other options?
  • Are there parts of my argument that can’t explain something the other position can explain?
  • This idea is only an idea – not my personal possession
  • Consider saying things like “at the moment my position is…”, “I’m attracted to this idea currently…”

I’ve personally found it useful to relax a little and recognise that in the end, the data will speak for itself.  So, for example, I was initially not keen on mirrorbox and laterality training for CRPS.  The studies, especially in the early stages, weren’t carried out in people with the degree of chronicity and complex psychosocial background that I saw.   Over time, and as the evidence has been gathering, I’ve changed my position.  I don’t mind acknowledging this change – in the end, it’s not my ego that’s important, nor “my” ideas – it’s what helps this person at this time with this particular problem.

Having said this, developing critical thinking skills, and in particular, being able to unpack and delve into how a study has been conducted and whether the conclusions drawn are supported by the data is vital.  Cherry picking, or selecting studies that support one view or another while ignoring or failing to account for studies with conflicting findings, just doesn’t do – again I try to relax a little, because in the end the balance of evidence does fall one way or another.  Or, in the case of chronic pain management, maybe there is so much to learn that what we know now is not even beginning to find answers.

If you’re keen to learn more about how to develop critical thinking, Foundation for Critical Thinking has a wealth of information.


Catastrophising and pain (i)
One reason I love blogging is the discussion between me and readers. I wrote about the language of pain recently, and out of that discussion I’ve spent a few days digging around the literature to look at what is known about the relationship between language, pain and catastrophising. I’d argued in my post that metaphoric language can reflect distress both in the communicator and the listener, and that this is supported by fMRI studies in which various parts of the brain are activated when emotion-laden communication about pain is being carried out, while one of my readers thought I might be taking this interpretation too far.

Pain behaviour
My reason for being interested in how we communicate about pain is that talking about pain (including describing it) is a pain behaviour. Pain behaviours are a range of behaviours that occur when we are sore and seeking help, and can include voluntary and involuntary actions. There can be an assumption that people are fully aware of the behaviours they do in relation to pain, so when a person demonstrates a lot of pain behaviour some clinicians believe the person “must” know that this is what they’re doing. This is sometimes the case, but there are numerous factors that can influence the behavioural responses we have to an experience of pain.

Pain behaviours occur on a continuum, however, from involuntary such as the withdrawal reflex, through more voluntary actions such as swearing (yes, it does seem to help!) and ultimately to very complex behaviour such as seeking treatment for pain.  And from an evolutionary point of view, pain behaviours are there primarily to communicate to others that we need or want help.

Pain behaviour and catastrophising
There is a relationship between catastrophising, or “an exaggerated negative “mental set” brought to bear during actual or anticipated pain experience” (Sullivan, Thorn, Haythornthwaite, Keefe, Martin, Bradley and Lefebvre, 2001), and pain behaviours – including verbal reports of pain intensity, seeking treatment including hospital stays, use of medications, and has been posited as one reason health professionals may pursue more intensive and invasive approaches to pain assessment and treatment.  Catastrophising is thought to influence the ways in which people interpret their pain – there are several theories identifying how this might occur.  But first, let’s have a look at how catastrophising is identified.

Measuring catastrophising
As I’ve mentioned in an earlier post, there are several pen and paper measures of catastrophising.  Questionnaires are simply standardised, or repeatable sets of questions that have been tested and thought to measure some underlying concept – they’re not “x-rays of the mind” and while they’re helpful and allow researchers and clinicians to do statistics on the findings and establish how similar or different one person’s answers are from “the rest”, they are based on language.  The words and phrases that people use reflect the way they interpret a situation, and while the actual wording differs depending on the vocabulary the person commonly uses, the way the person appraises or judges a situation underpins what they say.

There are several problems levelled at questionnaire measurement of catastrophising.  Because catastrophising as a concept is “invisible” – we can’t measure it directly and have to use statements that are believed to be associated with it – some critics have identified that the Coping Strategies Questionnaire, for example, might confuse measurement of catastrophising with measurement of depression.  Others have suggested that catastrophising is so closely related to fear of pain or anxiety or even perceived disability that it might not be worth measuring it as a distinct entity.  The conclusion currently, however, is that catastrophising is a distinct concept, and the most favoured assessment tool is the Pain Catastrophising Scale.

This scale has been found to have three subscales – rumination (or “repetitively (and passively) focusing on the symptoms of distress, and on its possible causes and consequences” – thanks to Wikipedia), magnification, and helplessness.

Three possible theories
Appraisals – Lazarus and Folkman proposed a general model of the ways people respond to situations. Primary appraisal involves determining whether a situation represents a threat, positive or irrelevant. Secondary appraisal involves determining coping options and likelihood of success. The PCS magnification and rumination subscales might form part of primary appraisal, while helplessness might be related to secondary appraisal.
Attention – People who demonstrate elevated levels of catastrophising also seem to focus on pain more than those with lower levels. This suggests that one of the pathways from catastrophising to the experience of pain might be via hypervigilance, or increased tendency to quickly attend to pain – and from there to negatively appraise pain as something difficult to deal with.
Coping – One form of coping is to obtain help from other people. A model that could explain the usefulness of catastrophising might be that by communicating distress, help might be obtained from other people, so that the individual doesn’t have to cope alone. The experimental and clinical evidence supporting this function of catastrophising, as demonstrated through pain behaviour and verbalisations, seems to be reasonably compelling – and my thoughts are that one way in which catastrophising language “works” is through empathy, which itself seems to be related to those darned mirror neurones.

The question nonpsychologists might have is – so do I need to use the PCS to identify people who catastrophise? And if I know someone tends to catastrophise, what does it have to do with me?

And that is for another post, so y’all come back now!

Sullivan MJ, Thorn B, Haythornthwaite JA, Keefe F, Martin M, Bradley LA, & Lefebvre JC (2001). Theoretical perspectives on the relation between catastrophizing and pain. The Clinical journal of pain, 17 (1), 52-64 PMID: 11289089


The language of pain
Have you ever wondered about the ways we communicate our pain? Pain behaviour doesn’t just include nonverbal communication – one of the main ways we communicate our pain is through speech. Words are an incredibly powerful aspect of pain behaviour that strikes me as something we haven’t really studied much. When I was searching for the article to refer to in this post, I looked in PsychInfo under the terms “linguistics” and “pain” – and out of the tens of thousands of articles under each term, and total of 16 included both words. Sixteen!

The stimulus for this post comes from someone who said the term “catastrophising” is a misnomer – a way for health professionals to dismiss or minimise the suffering and distress someone who has pain is experiencing. In this person’s words “Now its no longer just a buzzword but a label that pain docs like to attach to everyone in chronic pain who indicates they are suffering. And of course as most pain docs dont particularly care for hearing about suffering of those in pain they then attempt to get them to go for some cbt or psychotropics.”

Now, I preface this next section with the notice that I’m no linguist (although it’s something I’d love to learn about!).  But in a paper by Elena Semino, it’s absolutely fascinating to read about the ways in which people describe pain – she starts by saying “sensations conveyed by the English word pain tend to be described via expressions that refer to potential causes of bodily damage.”  Note the word “causes”.  She gives the example of someone describing their pain as “sharp“, “like a rake over my eyes and head, digging in and scraping away”, noting that “expressions such as “sharp pain” function metonymically when they describe pain that directly results from physical damage, and metaphorically when no such damage is involved”.  (BTW Metonyms are figures of speech that replace a word with a word that is intimately associated with that thing or concept.  For example, in New Zealand “the Beehive” refers to Parliament, because that is the name of the building in which Parliament is housed.)

The reason we use terms like “sharp” or “stabbing”, argues Semino, is that “that these uses of metaphor may facilitate some form of internal embodied simulation of pain experiences on the part of listeners/readers, which may in turn provide the basis for an empathic response.”

Pain behaviour of all types functions in the same way – evolutionary psychologists suggest that they are remnants of early signalling behaviour designed to elicit a response from those around the individual.  It makes sense that if a group of prehistoric people are hunting, someone who has pain can signal to others through crying or groaning that “something’s wrong”, hopefully eliciting some sort of caring behaviour from the rest of the troup, with the withdrawal response later helping the individual remain still and quiet in the back of the cave so as to minimise the potential for sabretooth snacking!

What Semino and others postulate is that the language we use when describing pain draws upon the neurophysiological aspects of shared experience or empathy – the “mirror neurones”.   fMRI studies of the anterior cingulate cortex, the bilateral anterior insula, rostral anterior cingulate cortex and the sensorimotor areas of the neuromatrix (aka “pain” matrix – but this is probably a misnomer) show these are activated when individuals observe another person experiencing a painful procedure or hear words describing these procedures. 

Semino quotes Avenanti et al., (2005) who suggests that there are “two forms of empathy linked to one another in an evolutionary and developmental perspective.  A comparatively simple form of empathy, based on somatic resonance, may be primarily concerned with mapping external stimuli onto one’s body.  A more complex form of empathy, based on affective resonance, may deal with emotional sharing and with the evaluation of social bonds and interpersonal relations. p.958”.

Semino therefore proposes that metaphorical descriptions of pain that allude to causes of physical damage may trigger embodied simulations of similar experiences – and that both types of empathy are enacted when we use descriptive metaphors when talking about pain.

OK, where does this leave us when thinking about “catastrophising”? Catastrophising is the tendency to “think the worst” in a situation.  An example might be saying “my headache is killing me”.  Catastrophising influences an individuals appraisal of their situation.  Although this way of describing their situation does convey an individuals level of distress, catastrophic interpretations actually impede effective problem solving and active coping.  Catastrophising is associated with increased disability, high distress, low mood and high helplessness.

Is it normal to catastrophise?  At times, yes.  Most of us will do a little catastrophising from time to time, if we’re honest with ourselves.  But even if it’s normal, catastrophising isn’t helpful.  Again, most of us will catastrophise for a short while, then change our thinking and begin to speak differently and approach our situation differently – usually with a view to taking steps to exert some level of control over our situation.

I think it’s important to consider our use of language as health professionals, and it’s one reason for thinking about how we write reports, for example.  While we have our own technical language and use it amongst ourselves (and the term catastrophising is one of them) we need to be aware that people who don’t know the meaning of these terms can misconstrue them.  And in the case of some patients, feel misunderstood and sometimes offended.  We need to think about this and avoid using jargon where practicable.

More importantly, we need to be incredibly careful not to use terms in a pejorative or dismissive way.  We’ve moved a long way from describing a woman with pain as being “hysterical” – but terms like “functional pain” or “supratentorial” or “malingering” can still be found in some reports.

I think the best thing we can do when we’ve been talking with someone who does “catastrophise” is make it clear that we are not dismissing their pain as less than what they say it is, but instead to be sensitive to their language and reflect that their pain is very distressing and difficult to deal with.  Because in the end, that’s what the language used when sone tends to catastrophise is intended to elicit from us. 

Descriptions of Pain, Metaphor, and Embodied Simulation Metaphor and Symbol, 25 (4), 205-226 DOI: 10.1080/10926488.2010.510926

Avenanti, A., Bueti, D., Galati, G., & Aglioti, S. (2005). Transcranial magnetic stimulation highlights the sensorimotor side of empathy for pain. Nature Neuroscience, 8, 955-960.


Top down, bottom up or both? Attention to pain
I guess we all pretty much know that our brains don’t seem to capture everything that goes on around us – thankfully we can filter out a lot of unnecessary information (no, I don’t want to know what that funny noise outside is right now!) so that we can focus on what is important. When it comes to pain, the limited capacity of our brains to process information has been used to explain why there are times that, despite a large amount of nociceptive input, we can remain pretty much oblivious to it. Clearly it would be wonderful if we could harness this and use it as a form of analgesia.

The place to start, I guess, is with recognition that one function of our brain is to keep us focused on important goal-directed activity. Because of this function, some information that is available both from inside the body and from outside, needs to be prioritised. ‘Top down’ processing models suggest that our brains have a process of intentionally choosing information that is relevant for whatever goals we are aiming for. In this model, the sensitivity of neural responses is modulated up or down, depending on the goal, and it’s been postulated that prefrontal and parietal areas are likely to influence these mechanisms.

‘Bottom up’ models suggest that there is a process of unintentional ‘capture’ of attention by the stimulus itself – if a fire alarm goes off without warning, we’ll usually be alerted to it without having to stop and think too hard! The term used to describe the characteristic of this ‘alerting’ feature is ‘salience’, or the degree to which that specific stimulus contrasts with surrounding stimuli. For something to be salient, it needs to be novel or new, not often present, or directly relevant to our goals perhaps from previous experience.  It’s thought that ‘pre-attentional’ systems are involved in detecting salient or novel stimuli – two separate systems have been found for the auditory system for example.  These ‘bottom up’ systems can act as a distraction from ‘top down’ goals because the attention can be switched to unimportant features of the environment or body and reduce performance.

It’s thought that ‘bottom up’ attention, while unintentional, is influenced by ‘top down’ processes because the top down processes establish the amount of attention focused on a task (attentional load), so that when load is high, irrelevant information is not processed as much.  Top down processes also establish the ‘attentional set’ or the type of information that is prioritised as being relevant to the goal – if a stimulus that is irrelevant matches one aspect of these features, it’s likely to capture attention.

Pain is known to capture attention ‘bottom up’ when its new or novel, intense, or is threatening.  This means that vague and commonplace pains like epigastric pain, can often be ignored.  Because most of us will have had heartburn, and know that it usually passes without too much of a problem, we don’t usually pay too much attention to it.  The situation would change, however, if we’ve had an MI – because that pain now represents another whole new threat.

The parts of the brain known to be associated with attentional capture by pain are the brain areas underlying the P2 responses of laser-evoked potentials.  The midcingulate cortex (MCC) is one of the main generators of this P2 signal, and it’s known that this part of the brain is associated with novelty detection, directing attention toward a specific stimulus, and where our behaviour needs to be regulated.  The MCC can be seen as a part of the brain that is needed to coordinate a speedy motor response because of its close relationship with premotor areas.

Enough about bottom up attention – what about top down?

Well, there are many studies showing that bottom up attention to nociception can be influenced – the amplitude of P2 potentials is decreased when people are engaged in demanding activities, responses in the MCC, paracentral and operculo-insular areas are decreased when people are doing absorbing tasks, and responses in the primary and secondary somatosensory cortices are influenced by how demanding the task is (attentional load) all supporting the idea that top down attention affects nociceptive processing by biases somatosensory brain activity.  This is why, when we’re engaged in an activity that is interesting and requires a bit of brain effort, our perception of pain is reduced.

Unfortunately, top down attention can also direct us towards painful events – especially when the nociceptive stimulus is being delivered to a part of the body that is also engaged in an activity (similar attentional set), and can be influential in individuals who expect or catastrophise about pain, where it has been shown that there is greater activity in operculo-insular and MCC areas.  It can work both ways.

Prefrontal and parietal areas are known to be involved with top down attention to or from nocicpetive and nonnociceptive stimuli.  Exactly what their job is is unclear, but some experiments suggest that the dorsolateral prefrontal cortex is important for maintaining priorities relevant to goals, by increasing the involvement of executive functions to the job of processing relevant information, thus avoiding the interference from irrelevant stimuli.  Maybe the dorsolateral prefrontal cortex (DLPFC) and the intraparietal sulcus(IPS)  are able to maintain both attentional load and attentional set, to make sure we’re able to focus on the goal we had in mind, rather than being distracted by pain.

So what does this mean for us?

Well, the authors of the paper I’ve been paraphrasing, suggest that the bottom up factors act as a signal to salient events, and this influences the operculo-insular areas, and by the MCC – this triggers attentional bias towards nociceptive input.  Both attentional load and attentional set seem to modulate how much these salient events disrupt our attention away from the task in hand.  Remember that attentional load is the cognitive  ‘grab’ of whatever we are focusing on, so it also allocates resources or effort to maintain that focus.  The DLPFC  keeps this focus by directing executive functions to the most important task.  Attentional set guides that ‘what is important’ or matching qualities that the person is attending to in order to achieve the goal, and all stimuli that meet at least one of those qualities will capture attention.  This is thought to be associated with activity of the IPS which detects similarities of various stimuli and focuses toward or away from responses to features in the environment.  So there is a sort of balance or dynamic between the bottom up and top down influences on attention.

This model is pretty important – most experiments in pain have been with acute pain in controlled settings where there is some degree of expectation that something will happen.  This is not a lot like real life where pain is often unexpected and happens in a busy and demanding context.  For people with chronic pain, it’s already been found that cognitive deficits occur and while there could be some truth in the current explanation of ‘anxiety’ or ‘hypervigilance to pain’, the neurological explanation may well be more along the lines of this top down and bottom up allocation of resource.  It’s especially useful to consider this model when looking at executive functions and how these, and self regulation, can be impaired in people with chronic pain – maybe it’s because it’s more difficult for people with chronic pain to exert down-regulation or to switch attention from one thing to another – or even to inhibit irrelevant signals in order to focus on important aspects.

The authors also suggest that attention management may become a more important part of a cognitive behavioural approach than it has in the past – mindfulness occurs to me as a particularly useful way to develop effective executive control.

Legrain V, Damme SV, Eccleston C, Davis KD, Seminowicz DA, & Crombez G (2009). A neurocognitive model of attention to pain: behavioral and neuroimaging evidence. Pain, 144 (3), 230-2 PMID: 19376654


Intuition and other failings in clinical reasoning
Einstein is accredited with saying “The important thing is not to stop questioning” while Euripedes apparently said “Question everything. Learn something. Answer nothing.” I’m sure of the origins of neither quote – but I think I must have inhaled both of them when I was a toddler because I have never stopped asking ‘why’!

In clinical reasoning, there is a real risk of having our very human cognitive reasoning biases kick in before we can even draw a breath. This isn’t surprising – but it is very, very subtle and we can fail to identify our biases until well after we’ve made decisions based on hunches, intuition or other incomplete information – if we pick them up at all.

And if we think that years of experience make us immune to these errors – think again! Not to mention that if we do have this problem highlighted, we’re also inclined to think that ‘it doesn’t apply to me because I’m so much more thorough, better informed, careful and aware of the problem’. Yeah right, as an infamous advert in NZ says!

Intuition has been a term used and abused in health care.  A strict definition from Princeton Uni, no less, states: intuition n. The act or faculty of knowing or sensing without the use of rational processes; immediate cognition.” In other words, intuition is knowing without thinking.  Some people use it to mean their ‘knack’ of knowing what is ‘really’ wrong with a patient, or their sense of what someone is feeling, or why something has happened.  Other people use it as a way to describe their way of working – coming up with ‘the right thing’ without systematically going through an assessment, hypothesis development and testing process.  And still others use it to defend failing to read the literature or keeping on with learning.

The truth is, because of our human cognitive biases, intuition could be one of a couple of things:

    • It could be simply guessing – putting two and two together and occasionally coming up with four.  While this happens on the odd occasion, we’re likely to think it happens more often than it really does, and this can confirm that we have ‘the knack’.
    • It could be over-learned patterns of observation that we are now no longer aware of. Remember the trip from home to work this morning?  I’ll bet that most of us can’t really recall every kilometer of that journey, and in one sense I guess we could call the trip ‘intuitive’.  Over time, we can very quickly make observations of a patient and arrive at an impression before we’ve carried out any deliberate assessment process.   Some people think that psychics have this ability to very quickly ‘read’ the nonverbal behaviour in people and detect minute changes in facial and body expression that most of us wouldn’t notice.
    • Worse: it could be that we were actually incorrect and the patient hasn’t said anything (demand characteristics), or the intervention by happenstance does ‘something’ – and we are none the wiser!

      I think the problem of biases in clinical reasoning is only exacerbated by ‘self reflection’ as a major approach to looking at our own clinical practice.  This is for many reasons, but one is that we consistently over-estimate our own abilities (the Dunning-Kruger effect).  After all, most of us would estimate our driving ability to be ‘above average’!  So we are likely to look at our therapy and think we’re doing OK especially if we don’t have another referent to use as a bench-mark.  It’s one reason I think a useful strategy is to record a session and review it with a systematic checklist to see how well we’ve followed optimal treatment protocols.  Another strategy is to ask another clinician to sit in on a treatment session.

      A further problem with cognitive biases that particularly plagues clinicians is that we are very good at reasoning back – after the fact! So we may be ‘intuitive’ in-session, then after the session we identify the purpose and processes we used – and a final bias to really knock the reasoning stuffing away is that we’re inclined to convince ourselves of our own ‘rightness’ as part of justifying our treatment.  The more we discuss why we used a particular approach, the more convinced we become that this was the right strategy.

      What to do, what to do

      1. The first step is to become aware of the probability that any clinical reasoning we do will be subject to these cognitive biases.  No-one is immune, from novice to highly experienced clinicians, we’re all inherently vulnerable to the thinking errors that have given us humans such a headstart in dominating the world.
      2. The next step is to put some strategies in place to counter the most common biases. For me, this means systematically collecting a lot of clinical information across many domains, and delaying making a decision on ‘what is going on’ until after I have done this.  It means investing a good deal of time in assessment before beginning treatment.  It also means generating several competing hypotheses about what ‘might’ be going on.
      3. It means looking at outcomes dispassionately – using outcome measures that are less subject to demand biases than asking ‘How do you feel now?’  Taking at least three outcome measures: one before treatment, one after treatment and one at follow-up (actually, I’d make the one after treatment happen several weeks after treatment, and the follow-up several months – but this takes buy-in from the funder).
      4. It means questioning everything carried out as part of treatment. Questioning and challenging and holding up our processes to someone else’s scrutiny.  Preferably someone who is prepared to challenge and question treatment choices just as strongly.  This can take the form of a file review by the whole team, or maybe a random sample of patient treatments that can be reviewed according to written protocols.  Preferably reviews by someone else other than you!

      While self-reflection is a great approach to use every day it simply is not enough to ensure good therapy.  We all need to be able to hold our work up to others for review because our biases are like blind spots.

      I’ve linked to Croskerry’s 2002 paper on heuristics and clinical reasoning.  While this paper refers to emergency medicine, just because we may work in chronic pain management does not mean we make decisions any differently!  In fact, we often deal with highly complex interacting variables, with outcomes often quite subtle and that develop over a long period, perhaps over months – and this makes our reasoning more challenging.  I liked this paper because it describes the bias, lists several of the common names for it, describes the effect of the bias and provides strategies to counter these.  Read – and weep!  We have to take note of all these biases in some way, or we may be trying to use ‘intuition’ when it doesn’t help one bit.

      Croskerry, P. (2002). Achieving Quality in Clinical Decision Making: Cognitive Strategies and Detection of Bias Academic Emergency Medicine, 9 (11), 1184-1204 DOI: 10.1197/aemj.9.11.1184
      Croskerry, P. (2002). Achieving Quality in Clinical Decision Making: Cognitive Strategies and Detection of Bias. Academic Emergency Medicine; 9: 1184–1204.


      What obstacles get in the way of self managing chronic pain?

      Learning to manage pain using self management strategies ain’t easy – as we know, changing habits and doing things differently is not something any of us do without a bit of effort. It’s especially difficult when life in general is full of challenges, but so much more so when pain is the problem,you have a mood disorder that saps your energy and when other people (even health professionals!) challenge your decision to manage pain independently. There are even some researchers who would say that using self management strategies is not all that important – after all, after about a year, many people don’t use any of the new skills, but still feel differently about pain anyway (Curran, Williams and Potts, 2009).

      The Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) project is a “randomized clinical trial designed to test the effectiveness of a stepped-care approach to deliver a combined medication and behavioral intervention for primary care patients with chronic musculoskeletal pain and depression.” The programme included 12 weeks of antidepressant medication ‘therapy’ followed by six sessions of pain self-management delivered over a further 12 weeks, and was delivered in primary care. The model used was a ‘social cognitive’ one, which essentially aims to enhance self efficacy and social support, and the definition of self management was “the ability to manage the symptoms, treatment, physical and psychosocial consequences and life-style changes inherent in living with a chronic condition.”

      The study itself has been discussed in many publications, so I don’t want to review that aspect, but instead look at this paper which, using a qualitative approach, examines “the challenges patients face, particularly when pain is accompanied by depression, in learning and applying self management skills.” And not only look at obstacles, but also facilitators or factors that enhance using these skills.

      Focus groups consisting of people who had completed the programme and who were willing to be involved in follow-up discussions, met and the following questions used to guide discussion:

      • What difficulties (if any) has your pain caused in your life?
      • Can you share with us some of the challenges you have faced in managing (coping with, dealing with) your pain?
      • What about some of the successes you have had in managing your pain better?
      • Think of some of the ways or strategies the SCAMP Pain Study taught you to better deal with (manage) your pain.
      • Which of these strategies did you find particularly helpful to better manage your pain?
      • Why did you find these helpful (relieve pain, improve activity, or both)?
      • How did they help?
      • Which of these strategies did you not find helpful?
      • Why?
      • What were some of the challenges that you faced in using these strategies to better manage your pain?
      • Do you think stress or mood problems (such as depression) made using these strategies more difficult?
      • What are some things that made these strategies easy to use regularly?
      • Has anyone learned other ways to manage/deal with your pain that we have not discussed today?
      • Let’s say that this discussion was going to be shared with your doctors with the goal to help them better treat your pain, what would you like to tell them?

      (I think these make great questions to ask anyone who has completed a pain management programme, maybe at a six month review!)

      What did they find?

      Barriers to using self management included – pain, over-reliance on medications, the effect of low mood, inadequate tailoring of coping strategies to the individual, fear of activity and that pain reduction didn’t occur with some of the strategies – amongst a few others.

      Facilitators to using self management included – mood improvement, supportive family and friends, support groups, support from nurse care managers (who were responsible for delivering this programme), social comparison (I’m not as badly off as …), being proactive – and others.

      The paper discusses each of these factors in a little more detail, but I’m curious about some of the comments.  While it seems that the material delivered looks like much of what almost every self management for pain programme delivers, I wonder how much attention was paid to the cognitive therapy component – identifying and challenging thoughts and beliefs about pain and activity.

      Things like “the exercise isn’t suitable for everyone (walking)”, or “I’d love to do it (go walking) but the pain gets in the way” suggests to me that it would be helpful to really work with people as they implement exercise (for example) to challenge the belief that pain needs to stop activity.  At least in the programme I work on, by titrating the activity level, working with small goals and helping people learn how to increase activity, and using effective self talk to challenge the reasoning behind the beliefs about pain, people seem to begin to let pain interfere less with what they want to do.  Recently one person returning for the six week followup said ‘My pain isn’t any different, but I feel differently about it’ – this person said he found himself chasing an animal down the road when he would never have thought this possible before the programme!

      I was curious about the indication that over-using medication was problematic – it’s something we’ve discussed within our team, along with the prn use of medications and use of other passive modalities like acupuncture, or injection procedures.  Our thoughts have been that it tends to reduce the confidence people have in their own coping skills because it’s so much ‘easier’ to use medication than to use these other skills.  It seems that in this study at least, their medical providers reinforced the use of medications for pain relief rather than endorsing the use of self management.  I have wondered long and hard about this, because it seems that the medical model is so pervasive it’s very difficult for biomedical clinicians to ‘change tack’ to support nonpharmacological strategies.  I don’t know what the answer is!

      In terms of facilitators, it’s great to see that participants in this programme found that improved mood helped them keep on with self management.  While I can understand the hesitation some clinicians have about over-treating depression (“he’s depressed because he’s got pain – reduce the pain and he won’t be depressed any more, simple!”) the debilitating effects of low mood can erode the will to persist with difficult actions.  Not to mention making life more miserable than it needs to be with pain.

      The rest of the facilitators were mainly social support – now I’m not sure whether this is because of the social model used in this programme, but it’s a really important finding.  Why?  Well I observed a couple of days ago that the ‘social’ part of the biopsychosocial model sometimes looks like it’s been lost.  As well, it’s really difficult to get family members and others to attend pain management, and one of my recent patients said ‘but this pain is my problem, not my partners, so why would he get involved?’ But no one is a island, and social support to help maintain newly formed habits is really important.  People can make or break self management!  So an important finding was that practice nurses (nurse managers) were thought to be a vital part of maintaining self management.  Maybe that link between delivering a service and the family health centre is one we need to strengthen.

      A final comment about support groups – while these can be great, they can also be ugly.  It depends so much on the focus of the group – whether it’s on living well or commiserating about hardship.  If it’s the former I think (don’t have any data on this though!) it’s probably a very positive part of living with pain.  If it’s about a pity party or maintaining an identity as a ‘disabled person’ then maybe it’s less helpful.  And if it’s on a self-destruct path (and I’ve seen this happen), it can be very unhelpful indeed.

      Obstacles and facilitators: something to look at more in the future.  Along with defining what self management looks like for each individual – because there is no single recipe for everyone!

      Curran, C., Williams, A. C. d. C., & Potts, H. W. W. (2009). Cognitive-behavioral therapy for persistent pain: Does adherence after treatment affect outcome? European Journal of Pain, 13(2), 178-188.

      Bair, M., Matthias, M., Nyland, K., Huffman, M., Stubbs, D., Kroenke, K., & Damush, T. (2009). Barriers and Facilitators to Chronic Pain Self-Management: A Qualitative Study of Primary Care Patients with Comorbid Musculoskeletal Pain and Depression Pain Medicine, 10 (7), 1280-1290 DOI: 10.1111/j.1526-4637.2009.00707.x

      Travel to interesting places online!

      Today’s post is about some of the interesting links you can find online.  Mostly links to do with brains, psychology and pain – but not all!

      Genes to Cognition Online – featuring the 3-D brain, lovely interactive graphical interface to burrow down into really interesting topics like cognitive processes, disorders, research approaches and neuroimaging research, you can lose yourself for hours.

      Deric Bownds’ MindBlog is full of brain and music information.  It’s in-depth material that can challenge and intrigue – some great podcasts available, and loads of links.

      If you’re ever in need of some stimulating discourse on neuroplasticity and things to do with the nervous system, head to Neurotonics: a PT team blog.  The above two links are courtesy of the contributor’s fascination with brain stuff – and as ever, thought-provoking discussion about the meaning of new discoveries about the brain.

      For a huge collection of brain information, BrainMeta is a place to browse. You can link to BrainMaps which is an interactive brain atlas – they have human brains, cat brains, rat brains and others – great for comparative analysis, with some excellent downloadable desktop tools to use to view the images.

      Challenging our minds is for kids – a cognitive training programme online that adults can also have fun with.  If you don’t mind the rather computerised voice of ‘Al’, the exercises are good for anyone.  Free registration, and it can be used for months so you can see results before any financial investment is needed.

      PsyBlog has been around a while, but never fails to surprise with posts about understanding your mind.  The post on why thought suppression doesn’t work starts like this: It sometimes feels like our minds are not on the same team as us. I want to go to sleep, but it wants to keep me awake rerunning events from my childhood. I want to forget the lyrics from that stupid 80s pop song but it wants to repeat them over and over again ad nauseam.’ – hmm, feel familiar?  A great post on what not to do to forget.

      Finally today, a collection of podcasts on ‘ideas worth spreading’ from TED.  I’m only hoping the place where I work will let me open them up (YouTube is not allowed) – so many excellent clips from great speakers including Dan Gilbert discussing Happiness.

      Have a great day!

      Attention to pain: A neurocognitive model
      Something that really frustrates me is the way psychology can be seen as ‘woolly’ or ‘soft’ simply because the constructs being studied can’t be touched or visualised.  So although I don’t think that neuroimaging represents ‘psychological’ constructs in any sort of a one-to-one sense, it is nice to be able to point to research that provides an underlying biological explanation for some of the abstract concepts that are commonly used to explain psychological aspects of the experience of pain.

      While physics, mathematics and allied sciences have developed a technology to measure and quantify physical substances, it’s psychology we have to thank for the generation of measurement strategies for abstract concepts.  Incidentally, for a nice user-friendly version of the development of measurement in psychology, this page written by Sally Khulenschmidt is well worth a read.

      Anyway, today’s post is about a topical review written by Valery Legrain, Stefaan Van Damme, Chris Eccleston, Karen Davis, David Seminowicz and Geert Crombez examining the behavioural and neuroimaging evidence for a neurocognitive model of attention to pain.

      It’s well known now that not all tissue damage is immediately perceived by the brain as ‘pain’, and that in fact a whole chain of events need to occur before we become aware of the fact that our body may be in danger.  The relationship between activation of ‘nociceptors’ and the pain experience is influenced by a whole raft of affective and cognitive factors (eg Tracey & Mantyh, 2007, in which different ‘neurosignatures’ are evoked depending on mood and beliefs despite the same nociceptive input).

      Attention, or the process by which a person focuses on one feature of a situation while focusing less on others, plays an important role in how much or how little of a stimulus is perceived. A major model used to describe the role of attention suggests that ‘there is limited capacity for information to be attended to, proposing that sensory signals – including nociceptive ones – exceed processing capacity, and hence require attention to select the signals needed for goal-directed behaviors’ (LeGraine, Van Damme et al., 2009) This is suggested to reduce pain (ie be analgesic) by directing attention away from nociceptive information, so that such information is not processed further and is therefore not perceived as ‘pain’.

      This paper adds to the model I’ve just described by suggesting that there are two mechanisms that help us decide what to attend to and what not – top down, or ‘an intentional and goal-directed process that prioritizes information relevant for current actions’, and bottom up, or ‘unintentional stimulus-driven capture of attention by events themselves … often imposed by the most salient stimuli in our environment, independent of intentional control.‘ (LeGraine, VanDamme et al., 2009).

      Salience is about how ‘unique’ or ‘different’ or ‘distinct’ a stimulus is – perhaps it occurs very seldom, or it’s completely different from anything else, or maybe it’s the amount or degree of difference between this stimulus and ‘the norm’ that is unique.

      The effect of a new or very different stimulus is to interrupt concentration (have you ever tried to read a book when a kid is wandering about blowing on a recorder? or banging on a drum or going ‘peeow, peeow’!!).  But the amount of distraction depends on the goal – if the goal has a lot riding on it, and demands a lot of attention to do it well then it’s going to require a really distracting stimulus to drag your attention from it (ever tried getting a bloke to talk to you during a rugby match? For North American readers, read ‘football’ match?!).  Distraction is much more likely to occur if the stimulus is similar to something the person is concentrating on (for example, if you shout ‘Goal’ during a match!).

      When we’re discussing pain, it seems that ‘attention is unintentionally captured by pain when it is intense, novel and threatening’ (Ecclestone & Crombez, 1999).  This has been studied using neuro-imaging where it has been shown that ‘attentional capture by pain is mediated by the brain areas underlying the P2 responses of laser-evoked potentials’ (Legrain, Damme, Tracey, & Mantyh, 2008).    A specific centre, the midcingulate cortex (MCC) is one of the main generators of nociceptive evoked P2, and is activated by new and interesting information, and especially in areas requiring alteration in behaviour in order to achieve a goal. The authors point out that ‘one may think of the MCC as a structure necessary to prompt urgent motor reaction.’

      Bottom up attention to pain can be changed or modulated by top-down or goal-oriented activities. There are many examples of this – ever noticed how you acquire bruises during the weekend’s activities, and only notice them on Monday morning?

      ‘EEG studies show that the amplitude of the P2 component of nociceptive evoked potentials is decreased when participants are performing a more demanding visual task (attentional load hypothesis)’ The authors suggest that ‘top-down attention affects the processing of nociceptive stimuli at early levels by biasing somatosensory brain activity’ – this can work both ways…it can reduce our attention to pain – as my example above illustrates – but it can also increase the attention that gets paid to parts of the body where pain is expected to be experienced (watch what happens when a kid is given an injection to the arm – they’ll be very aware of any little tickle or touch on the arm for quite a while afterwards!). This is supported by ‘findings that pain catastrophizing is associated with greater activity in operculo-insular and MCC areas’.

      Prefrontal and parietal areas appear to be involved in ‘top down’ processing of attention toward pain – the dorsolateral prefrontal cortex is involved in maintaining goal-relevant priorities, apparently by directing executive functions toward the processing of task-relevant information in order to avoid interference by goal-irrelevant information. The authors of this paper suggest that ‘the DLPFC and the IPS may help to maintain respectively attentional load and attentional set, to prevent attentional capture and interference by painful stimuli.’


      The final conclusions of the authors in this paper suggest that ‘bottom-up’ attention processing may give an attentional bias to salient events that are then held by operculo-insular areas, and by the MCC that triggers an attentional bias to nociceptive signals.’

      Top-down modulators act through both attentional load and attentional set. That is, it influences the amount of effort a person invests into monitoring information relevant to goals, supported by the DLPFC that assigns executive functions to the primary task. Then it determines the stimulus that are task-relevant or irrelevant – attending to anything that is deemed to ‘fit’ with the features that are within this ‘attentional set’ – some of which are not relevant at all to the goal being focused upon. The attentional set depends on specific personal goals, balanced with the general goals of maintaining homeostasis.

      The implications of this model are many.

      Firstly, models like this help develop hypotheses about the differences between experimental pain (acute pain in well-controlled environments) and pain in natural settings (often chronic pain in complex and uncontrolled environments).

      Many of the current explanations about loss of cognitive abilities in people with chronic pain are explained by ‘hypervigilance’ to pain, or anxiety, or even depression and/or lack of sleep. If, however, a model like this is used, it could be that patients cannot exert ‘executive control’ over what input they attend to, so that irrelevant stimuli, such as nociceptive input, are attended to over goal-directed input.

      Or, perhaps a broader-than-necessary attentional set means that certain information is processed and deemed relevant when it is actually irrelevant. The authors suggest that this may be related to the ongoing search for pain relief – which may be directed less by patients and more by doctors.

      The final point these authors make is ‘attention management may be a more important component of cognitive behavioral rehabilitation than traditionally considered’ – and perhaps in different ways too. Not simply being able to direct attention to and from sensations, but also around developing and structuring goals in life.

      Food for thought? I wrote about attention management just a short time ago – it works! Take a look here for that post.

      LeGraine, V., Van Damme, S., Eccleston, C., Davis, K., Seminowicz, D., & Crombez, G. (2009). A neurocognitive model of attention to pain: Behavioral and neuroimaging evidence Pain DOI: 10.1016/j.pain.2009.03.020

      Eccleston C, Crombez G. Pain demands attention: a cognitive-affective model
      of the interruptive function of pain. Psychol Bull 1999;125:356–66.

      Legrain, V., Damme, S., Tracey I, Mantyh PW. The cerebral signature for pain perception and its
      modulation. Neuron 2007;55:377–91Legrain V. La modulation de la douleur par l’attention. Les apports de la
      neurophysiologie. The modulation of pain by attention. Insights arising from
      neurophysiological studies. Doul Analg 2008;21:99–107.

      Fine tuning activity levels

      A couple of days ago I wrote about activity patterns, and a study from Maastricht University that looked at the variable levels of activity that people with chronic pain can engage in. The study was designed to look at the pattern of activity from day to day, and found ‘… that for most of the participants, their activity levels varied from day to day, with high activity levels interspersed with low activity level days.’

      Huijnen, Verbunt, and colleagues suggested that ‘for patients with chronic pain this could represent an activity pattern characterised by interfering involuntary rest stops due to pain. The high level of fluctuations could be a representation of the sawtooth pattern in their activities. Patients go on with their activities till the activity is finished and afterwards they have to take rest to recover.’(2009) While the overall (mean) activity level may be fairly ‘normal’ and not directly associated with their reported disability level, the higher their disability level the higher the peaks and troughs of activity. The conclusion was that ‘patients who have a disabling fluctuating pattern in their activities, [may] benefit more from learning strategies to fine tune their activities during the day instead of increasing their activity level.’

      Many self-help books and resources developed for professionals to use contain the concept of activity ‘pacing’ – this is typically about setting a baseline level of activity, and gradually building up activity tolerance until the desired level is achieved. The problem with this concept is that when you ask a person what pacing is, they invariably say something like ‘break the activity up into smaller chunks’ or ‘take breaks in the middle of an activity’ – which can actually lead to pain being the guide and overall lower levels of activity. I wrote about this some time ago when I discussed the lack of evidence for pacing, and a paper by McCracken and Samuels found that it loaded on to a set of ‘passive coping strategies’ used by patients, rather than being an ‘active’ coping strategy (2007).

      Perhaps the problem is, as Huijnen & Verbunt et al suggest, one of ‘fine tuning’ activity levels. And maybe the term ‘pacing’ needs to be banished! I suggest calling it either a ‘quota’ system, where a pre-determined amount (either time or portion of an activity) is used, or calling it ‘activity regulation’ – where the amount of activity is regulated just as we regulate emotions, physiological arousal and exercise.

      I’m keen to get some sort of definition around this term because while the name itself isn’t important, the pervasive view from both therapists and patients is that pacing involves slowing down how much should be done at one time – and it almost always leads to pain being used as the guide.

      In practical terms I think what can happen is this: a person starts on a certain amount of activity, say 10 minutes vacuuming, then 5 minutes dusting, back to vacuuming for 10 minutes, and so on. On a good day, this is manageable – or maybe a little too easy, so the person decides to do a little more – 15 minutes vacuuming. By the end of that day, pain intensity has risen, the person sleeps badly (I’ve written about the relationship between pain intensity and poor sleep – poor sleep leads to increased pain intensity which leads to poor sleep and so on). So the next day, instead of doing 10 minutes of vacuuming, the person does 5 minutes, and sits down to rest in between.

      Or perhaps all goes well for a day or two, then a ‘high risk’ situation arises – someone is coming to visit! The person decides to go all out and vacuum furiously and do the whole house, collapsing by the time the visitor arrives. Next day, the person is too sore to do anything.

      Or maybe even the person carries on with the paced level of activity, and after a week increases the amount of vacuuming as instructed, but this immediately increases pain intensity (which is expected), but the person forgets this – and adjusts the vacuuming level back to the original amount on the day following.

      The key things that may help are these:

      1. Never ever let pain be your guide in setting activity levels!
      2. Do no more on a good day,  no less on a bad
      3. Work through cognitions that may trip you up ‘I must’, ‘I should’
      4. Especially work through ‘I can’t do this because my pain is too bad’
      5. Develop coping strategies for when the pain levels do increase (and they will!)
      6. Remind the person that an increase in pain is to be expected when increasing activity level – but that it will pass and the body will habituate to it
      7. When planning increases in activity level in a graded way, work through at least one increase successfully with the person before you stop your support – this way the person might just see that it’s possible to successfully increase activity without the world falling apart, even though pain levels do increase

      Developing activity regulation is as much about thoughts and emotions as it is about planning, fitness, and physical ability.  It’s my belief that any therapist who is helping someone change their activity level either through exercise or daily activities (ie physiotherapists, occupational therapists, nurses, social workers, psychologists) need to actively help the person develop awareness of, and ability to challenge, their thoughts about fluctuations in pain.

      HUIJNEN, I., VERBUNT, J., ROELOFS, J., GOOSSENS, M., & PETERS, M. (2009). The disabling role of fluctuations in physical activity in patients with chronic low back pain European Journal of Pain DOI: 10.1016/j.ejpain.2008.12.008

      McCracken LM, Samuel VM. The role of avoidance, pacing, and other activity
      patterns in chronic pain. Pain 2007;130(1–2):119–25.

      Reflections on ACT case formulation in chronic pain

      I’ve been reviewing ACT and contextual cognitive behavioural therapy in chronic pain management over the past year or so, and it’s really interesting reflecting on the different way in which I see people after being exposed to the ACT approach.

      Just to recap, some of the main precepts of ACT and CCBT are:

      • people’s attempts to control their negative emotions lead them to avoid encountering these emotions
      • but in doing so they often increase the intensity and frequency with which they experience them
      • and their attempts to avoid the experiences also lead them away from pursuing activities that enable them to achieve things that are important to them (eg values)
      • this becomes evident through ‘cognitive inflexibility’ or the difficulty to do things in different ways in order to maintain value-aligned behaviour (more…)