CBT for Chronic Pain, Part One: Introduction, Pain Scale, Exercise #1

[vom_marlowe]

This is the first in a series of explanations, essays, and exercises for coping with Chronic Pain.  A friend requested I explain how I've used CBT to deal with pain, and I promised to provide both information and practical exercises.  While I'm not sure how many posts this will take, I have at least fourteen exercises to cover.

This post will cover:

• What is pain? 
• What is CBT for Chronic Pain? What do I know about pain? Where did I get this?
• The Pain Scale, with some examples
• Exercise #1 It’s a capital error to theorize before one has data

What is Pain?

Pain is a message from the Body to the Brain, saying, “Houston, We have a problem.”  Sometimes the message is short, like when your hand reaches out and gets close to a hot stove.  The Brain hears the ‘Ow, hot!’ message and yanks the hand back before true damage occurs.  Sometimes the message lasts for a longer time, like when you’ve sprained an ankle and the Body sends out a litany of, “Dearest Brain, the Ankle is not doing well today.  Please do not schedule any hikes, stairs, or strenuous activity.  P.S., if you step on Ankle again like that again, we will have no choice but to throw up.  Sincerely yours, ~The Lower Extremities.”

All of this is fine and straightforward, so far as it goes.

The problem begins when the body has sent eleven thousand three hundred and twenty seven letters about the same damn ankle problem--and it’s only 8 AM.

Pain is intended as information.

Here are examples of appropriate and useful Pain:  Pain tells us that our body has a problem that needs to be fixed, Pain tells us not to injure ourselves, Pain tells us not to overdo, Pain reminds us that we’re healing.

For our purposes, Chronic pain is pain that has become maladaptive.  Pain’s message has become too loud.  Pain has gone beyond its purpose.  Pain is sending so many damn letters we’re seriously considering changing our name and moving to any continent without a post office.

 

What is CBT for Chronic Pain?  Where did you learn it?  What do you know about Pain?

What is CBT for Chronic Pain? 

CBT stands for Cognitive Behavioral Therapy.  CBT is a kind of therapy that deals with cognition (thought) and behavior; traditionally, it is a short-term, problem-focused therapy that helps a person identify unhelpful thinking patterns and replace them with more effective ones, which in turn helps improve behavior.  This page has a straightforward introduction to CBT.  http://psychology.about.com/od/psychotherapy/a/cbt.htm

Australia’s Mood Gym is a very famous and well-respected example of computerized CBT for depression. It’s free.  https://moodgym.anu.edu.au/welcome

CBT for Chronic Pain is a bit different; while we will be examining thought-patterns, we’ll also be doing exercises involving activity, time, relaxation, visualization, images/color, the senses, communication, and relationships.  Plus, there will be some straight-up behaviorism, Skinner-style, some excuses to use art supplies, some assignments involving peer-reviewed journal articles, and some random references to ninja battle weasels.

Where did you learn it? 

I knew that research showed CBT was successful for helping chronic pain, but I wasn’t able to find a therapist who practiced CBT for chronic pain.  Being me, I decided to make up my own CBT course for chronic pain.  Some of these exercises are Frankensteinian creations cobbled together from various sources (a regular CBT therapist, a friend’s suggestion, a self-help book, a magazine article, a Deviant Art tutorial).  Some are traditional CBT exercises that have been turned inside out and upside down.  Some are pain management exercises from now-defunct big Pharma websites.  But a lot of it I just made up.  All of these exercises are ones I used for myself or for loved ones. 

What do you know about Pain?

While most people know I have chronic pain from a work injury a decade ago, most people don’t know that I was in and out of the ICU as a child.  I have a number of serious health problems that have required hospitalizations at various points in my life.  However, I also know pain from the perspective of a caregiver to loved ones over the years.    

The Exercises that I’m going to explain and teach are ones that I have used myself and have taught to others.  That said, please understand that I’m not a psychologist or a medical doctor; please use these exercises responsibly.  If in doubt, ask your health care provider for guidance.  Void where prohibited. Some assembly required.  Must be twenty one or older to enter the dragon.  Additional charges may apply to mustelidae.

Before moving to the nitty gritty, we need to talk about the Pain Scale, because we’ll be using it in Exercise #1. 

 

The Pain Scale

The Pain Scale is used by medical professionals to track a patient’s pain, determine appropriate treatment, tell whether treatment is working, etc.  The scale goes from 0-10, with 0 being no pain and 10 being the worst pain imaginable.  For children, the scale may be a series of pictures instead of abstract numbers.

Pain is subjective, and this sometimes leads patients to believe that the pain scale is purely subjective.  This is not quite the case.  While patients are asked to rate their own pain, the medical establishment does have some broad guidelines for what each number represents. 

One of the goals of chronic pain CBT is to understand the nature of pain, including the potential for pain’s severity.  Some people, too aware of just how bad pain can get, will under-report their number against the standard scale.  Others, including those who’ve rarely had health issues or come from a healthy family, will unknowingly rate their pain too high against the standard scale.

There are several formal pain scales.  I’ll link to a few at the bottom of this article.  The pain scale below is an amalgamation of the pain scale as explained to me by various medical practitioners, the formal pain scales I’ve read and used, my personal pain experiences, and my personal observations of pain in others.

0 No pain

1 Completely Ignorable Pain, very minor; You must consciously think about this pain to answer the question, “Where does it hurt?”  Examples: a minor bug bite that doesn’t itch any longer, a small bruise, a stubbed toe ten minutes later.

2 Minor pain.  Annoying, but ignorable.  Sometimes the pain is more noticeable, in twinges.  Examples: The last stages of healing a sprain, a fading headache.

3 Pain is noticeable and distracting at first.  While this pain is annoying, most people can get used it to and ignore it without sustained conscious effort.  Examples: Mild arthritis, mild sprains.

4 Pain never truly fades from consciousness, it is always there in the background.  Pain begins to invade thoughts of its own accord.  Most people cannot quite get used to this pain, but with conscious effort, people can still do work.  People are able to communicate normally with some concentration.  This is where mood and behavior changes begin, in my experience, with flashes of irritation at others (lashing outward) or withdrawal (lashing inward).  Examples: Toothache, regular headache. 

5 While the pain invades about half of the time, the mind can continue to function and perform.  Normal communication and behavior is possible with concentration, work performance may require occasional breaks.  Additional rest remains helpful. Mood and behavior changes increase, become noticeable to others. Examples: A bad headache.  A sprained ankle.  Sore muscles after a heavy workout or mild injury. 

6 Pain is beginning to take over the senses part of the time, making normal behavior challenging at times.  Thinking can become clouded at times. Concentration and effort allow some work or chores to be done, with breaks; a full eight hour stretch is difficult and work performance may be inadequate.  Mood and behavior changes increase even more, often begin to impact relationships in a significant way. Examples: Bad back pain. Standing on a sprained ankle by accident. Post-op recovery. 

7 Serious pain. Pain dominates the senses, and thinking is unclear about half the time.  Normal communication patterns cease.  While a patient might try to type an email, it will be short, choppy, and badly spelled.  A verbal conversation, while possible, would be tiring and difficult. Patient may cry silently.  Work is not able to be performed; self care and chores are limited.  Relationships typically show significant strain; mood changes are common and serious; may include lashing out at others, anxiety, depression. Examples: Average Migraine, some kinds of post-op physical therapy.

Between 7 and 8, communication abilities begin to fade.  By 9, normal conversations are no longer possible.

8 Severe pain. Patients can communicate, but it takes conscious and significant effort.  Sentences are short, choppy.  Sometimes, patients find comforting touch or similar stimulation painful.  Breathing can be affected.  Patient may cry silently or aloud, may make occasional noises of distress, whimper or whine.  Examples: Childbirth with no epidural, Severe migraine, surgical post-op pain (pre-narcotics) immediately after waking. 

These last two numbers are rarely self-reported, because patients are no longer capable of normal communication.  The last time I had Level 9 pain, six people in scrubs descended on me and had me on a gurney and wheeled off.  I was eventually given a Demerol drip.

9 Excruciating pain.  Patients often curl around the body part affected or into a fetal position.  Shaking, trembling, whimpering, harsh breathing.  The body begins to throw loud side effects such as vomiting, sliding to the floor, inadvertent crying out.  Patients will take medication or surgery regardless of side effect or risk.  Communication ability is very poor.  Patients often chant simple phrases, “It’s OK, it’s OK,” or “Oh God, Oh God, Oh God.”  Examples: Serious forms of Cancer; Single gunshot, crushed hand; Major organ issues like kidney stones or pancreatitis.

10 Catastrophic pain, the kind associated with major body trauma and death.  Head on collision car wrecks. Multiple gunshot or stab wounds. Accidents involving farming or industrial machinery. Loss of limbs. Patients are often too injured to communicate in any way.  Their heads often loll.  They will come in and out of consciousness.  More likely to moan softly or pant than sob loudly.  Very few of us will suffer level 10 pain. 

Links to several pain scales and articles about pain scales:

Lane Medical Library, Stanford Medicine. (pdf)
Whitepaper on pain scales, fibromyalgia. (pdf)
How Doctors Interpret the Pain Scale
Visual Pain Scale

Exercise #1: It’s a capital mistake to theorize before one has data

You will need a pocket sized notebook and a pencil, pen, crayon, sharpie, etc.

This exercise is best done over the course of a full week.

The purpose of this first exercise is to begin to understand how/when we are receiving our pain signals and what happens when we do. 

The sort of pain we’re dealing with may start as a simple message but it rarely ends that way.  Most of don’t just have pain, we have thoughts and feelings about our pain. The goal of this exercise is to find out three things: how often we notice the pain; what thoughts we think when that happens; what our body and pain are like at that time.

For the next week, carry the pocket notebook with you wherever you go.   Write down the day and date first thing in the morning, then any time you notice your pain:

1. Write down the time  
2. Write down why you noticed your pain—what brought your pain to your attention? (Was it a sensation from your body? Was it a thought? Was it during movement? Was it a comment from someone else? If you don’t know why you noticed your pain, that’s OK, just write down that you don’t know why it came to your attention)
3. Write down your thought process, as best you can, as it happens.  Don’t try to judge, argue, or dismiss your thoughts at this stage.  Just write down your thoughts as they’re happening.  If it helps, pretend you’re a court reporter, an outside observer, or an alien space weasel reporting on Earthling brain waves.
4. Continue to write down the thoughts for as long as you think you normally would in this circumstance, if you weren’t keeping this notebook.  If that’s for five seconds, OK!  If that’s for the full fifteen minute coffee break, that’s OK, too!
5. When you’re done with the thought process, write down a number for that moment’s pain and a few words to describe the way the pain feels to you right now.
6. Next, check in with your body, then write down in a few words how your body feels. 

A couple of notes:

Does it have to be the ‘right’ kind of pain?  No.  All pain counts.  If you usually have a sore ankle, but you notice headache pain, it counts.  Write it down, noting that it’s a headache.

What if I don’t notice any pain or only notice it once or twice a day?  If you’re doing this because you have chronic pain, try setting an alarm on your computer, phone, or desk so that you’re notified several times a day—for instance at 8 AM, noon, 4 PM, 8 PM, Bedtime.

What if I have pain when I wake up? / What if I wake up in the middle of the night from pain?  Keep the notebook by the bed and fill it out as needed.

I haven't explained what we'll be using the data for yet, but don't worry--all shall be revealed!  In the meantime, keep those pencils movin'.  I'll be writing up more information, more exercises, and more notes for tomorrow.  

Comments

[kore]

That's a really good pain scale -- I like how it focuses on outside stuff like work, and with physical symptoms too. T hates pain scales, but he might be able to use this one!

The notebook reminds me of how I quit drinking -- I kept a record of it in my day planner (yeah) and then wound up graphing it (yeeeah) (on graph paper no less). That was a big incentive to quit. I've also heard the advice to keep a mood diary -- just one or two lines a day noting how you feel, since a lot of depressed people tend to remember "always" being depressed, or being very badly depressed more than they actually are. Which isn't to say they aren't really depressed, just that it's easy to get into that mindset of "Everything sucks and has sucked forever." But if you have the concrete proof to look back on and think "well hmm, last week wasn't so bad, but yesterday I had that bad crash and it's colouring my thinking," that can help someone see their depression in less black-and-white and overwhelming terms.

[loligo]

Thank you for writing this up!

[thistleingrey]

Thank you for this! That's a much clearer pain scale than the ones I've been told to use. I wonder how I'd slot in pain that has gone hoarse and ceased to report--somewhere in 3-5, perhaps. Things like not noticing that water is almost scalding because merely hot water didn't seem anything but wet against quotidian pain in that area.