The ABCs of Medical Psychology

Recently, an article on the psychology of pain was published in Emergency Medical Clinics of North America (Hansen and Streltzer, 23:339-348, 2005). The paper presents a concise and informative overview of psychological factors associated with the experience and treatment of acute and chronic pain. This publication in a medical clinical journal underscores the increasing recognition that pain—and in the broader context, medical illness—affects the way patients feel, how they behave and what they think. Treating the medical patient thus requires consideration and possible treatment of problematic Affect (anger, anxiety, depression), Behaviors (activity, adherence, hygiene) and Cognitions (attention, catastrophizing, expectations). I refer to these as the ABCs of medical psychology.¹ The following is a brief overview and expansion of the authors’ presentation. I present in alphabetical order the most common idiopathic factors that contribute to maladaptive psychological ABCs. These psychological aspects frequently complicate or impede medical interventions and thus should be addressed either by the treating physician or a medical psychologist during the patient’s routine course of care.

Affect:

1. Anger: Anger is common inpatients with chronic pain (particularly for males), while acute pain elicits irritability. Perceived disability in medical illness may produce similar emotional responses. The use of antidepressants as an adjunct to counseling is effective in managing anger and irritability.

2. Anxiety: Hyper-arousal (i.e. anxiety) and attendant fear and rumination is common in medical illness partially because patients fixate on bodily sensations and self-perceived inadequacies (e.g. diminished income, perceptions by others, physical and sexual limitations, etc.). Distraction and stress reduction techniques are extremely effective in reducing arousal and analgesic consumption. Externalizing activities (e.g. goal setting) and internalizing activities (e.g. guided imagery, hypnosis) are effective treatments. Short term use of anxiolytics may be considered when combined with therapy.

3. Depression: Anhedonic or depressed mood is commonly associated with the course of illness (dx: adjustment disorder with depressed mood), but occasionally may “push” a long-standing major depressive episode particularly if the illness is associated with other stressful experiences (e.g. loss of employment, relational problems, etc.). Again, antidepressants in conjunction with therapy is an appropriate treatment.

Behaviors:

4. Activity: Medical patients frequently become socially isolated and physically inactive. These maladaptive behaviors are associated with affective and cognitive disturbance (i.e. depression, irritability, negative thoughts of self worth, etc.). For patients with chronic pain a recursive cycle of fear of activity-related injury leads to avoidance of activity, which promotes deconditioning, poorer treatment outcome and increased fear. Be aware that with adequate analgesic relief of pain some patients may over-exert, leading to a pain flare-up that may also reinforce the likelihood of future inactivity. Thus, activity attendance is important.

5. Adherence: Patients with poorly controlled pain, particularly those with concomitant psychosocial distress are at risk for poor adherence and follow-through with treatment plans and recommendations. Patients should be encouraged to be involved in their treatment plans and be held accountable to their adherence.

6. Hygiene: Adequate sleep quantity and quality are critical factors affecting patient function. Sleep deprivation increases sensitivity and decreases tolerance, both physically and emotionally. Poor diet is similarly implicated. Monitoring and guidance to ensure healthy sleep and diet maintenance are thus productive and appropriate endeavors. Physical hygiene, such a grooming and dress are important indicators of depression and withdrawal. Recognizing and reinforcing good physical hygiene is a simple but effective psychological intervention.

Cognitions:

7. Attention: Pain and medical illness and medications for their management (e.g. opioids) interfere with the ability to maintain focused attention, either because of distraction (i.e. focused on pain) or because of cognitive clouding (i.e. medication or sleep induced lethargy). Poor attentional function manifests as “poor memory” because presented material is not registered into memory in first place. Patients may have difficulty adhering to prescription or treatment regimens. These patients may also become tangential and circumstantial in their communication style.

8. Catastrophizing: Catastrophizing, an irrational concern regarding a condition or its outcome, is receiving increasing attention in the pain research literature. Catastrophizing is one of the most powerful psychological predictors of treatment outcome. It should be formally assessed, particularly in patients who appear anxious, fearful or depressed. Cognitive-behavioral treatments are particularly well suited for managing catastrophizing.

9. Expectations: Expectations of pain affect how much pain a patient feels. In the broader sense, patient expectations about chronicity and disability has been shown to establish a “self-fulfilling prophecy”, leading to further deconditioning and maladaptive behaviors. Frequently expectations are based upon irrational beliefs or preconceived notions based upon incomplete information. Again, cognitive-behavioral interventions are useful for establishing realistic expectations that facilitate motivated adherence.