Coping With Stressful Medical Procedures Research Paper

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Many moderately invasive, potentially life saving procedures, e.g., colonoscopy to examine the colon and remove polyps, can be performed on an outpatient or ‘same-day’ basis. Many patients endure these procedures with minimal expressions of discomfort, while others experience and manifest moderate to high levels of pain and distress. Laboratory and clinical studies designed to assess the effects of psychological preparation in reducing distress have increased our understanding of the processes underlying these individual differences in three ways. First, the pain experience is an integration of a sensory experience and an emotional, distress response; pain is not just a sensation that is proportional to the extent of injury. Second, the type and intensity of the emotional response, e.g., fear-distress, is dependent on the patient’s representation of the experience, i.e., how it is perceived and interpreted, and the perceived availability of a means of controlling it. Finally, the patient’s representation of a procedure is based on information from doctors and nurses and by the ideas, beliefs, memories, and perceptions based on their own experience and observations of others.

1. Pain Is Sensation And Emotion

Pain has often been conceptualized as a sensory process. Thus, an injury was thought to activate receptors that sent pain messages to the brain, and pain and distress were expected to be directly proportional to the extent of injury (Leventhal and Everhart 1979). Patients who reported or showed greater discomfort than expected in response to an injury or to a treatment were assumed to have personalities that predisposed them to be excessively sensitive to pain signals or to be malingerers. Observations of wounded servicemen during World War II (Beecher 1946) contradicted the sensory model in two ways. The first was the absence of pain and distress when survival was enhanced by active coping. The second was the failure to alleviate pain and distress with analgesics such as morphine supposed to block conduction of sensory nerves. Administration of barbiturates to reduce emotional reactions of fear and anxiety reduced pain-distress, suggesting that emotional reactions were a component of the pain response that could amplify pain reactions.

Anatomical and physiological studies as well as behavioral data show that the pain-distress experience is a product of parallel and interacting sensory and emotional systems (Melzack and Wall 1970). Situational factors that increase emotional reactions and amplify distress include the unexpectedness of the noxious sensations, the perception that more serious consequences are yet to follow, and the perception that the sensations are not controllable. Inhibition of the emotion system and minimization of pain-distress occurs when the sensations are expected, perceived as benign (imply no serious consequences), and can be controlled. Two mechanisms appear to be involved in this inhibitory process: the body’s opiates, the endorphins, and direct, neural inhibition of pain centers (Strausbaugh and Levine 2000).

2. Distress Reduction In Laboratory Settings

A classic study by Egbert and colleagues (1964) demonstrated that postsurgical distress could be reduced by preparatory information; it triggered both laboratory and clinical studies of preparation. The laboratory studies showed how subtle differences in preparatory information had a substantial impact on the level of pain-distress. For example, subjects about to undergo a cold pressor test kept their hands submerged in the ice water for less time if they were told they were participating in a ‘Vasoconstrictive Pain Study’ (painful label) than if the study was described as a ‘Discomfort Study’ (less painful label; Hirsch and Liebert 1998). The discomfort group also gave lower ratings to their distress. In our earlier studies, subjects told to focus on the benign, sensory experience of the ice water during cold pressor immersion (pins and needles, color of the hand, etc.) experienced less distress and showed an increase in skin temperature in comparison to subjects told the experience would be painful. Distraction often proved ineffective in blocking these noxious experiences unless it was in the same modality as the pain stimulus (auditory; skin sensation).

3. Distress In Response To Invasive Medical Procedures

The study by Egbert and colleagues (1964) and the laboratory studies indicated that a patient’s response to an invasive medical procedure can be shaped by the way their doctors and nurses frame the somatic sensations evoked by the procedure. As Janis and Leventhal pointed out years ago (Janis and Leventhal 1968), the florid symptoms often observed among surgical patients and previously attributed to under-lying psychopathology were often a product of the meaning of the situation and the availability of coping reactions. For example, although the painful sensations experienced during procedures such as endoscopy or bronchoscopy are readily attributed to the procedure, their meaning is ambiguous. They could imply that the instrument has caused damage or contacted a cancer, or suggest to that patient that he will become increasingly frightened and will be unable to retain emotional control if the pain lasts much longer. Ambiguity also can extend to post-treatment symptoms, e.g., the pain experienced after coronary bypass surgery can be identified as wound pain from a healing incision or damage to the heart. The implication of the latter is far more threatening and fear arousing than the first. In the absence of information from medical practitioners, the meaning of somatic experience will reflect the patient’s limited knowledge, memories of similar experiences, anecdotes from others, and their worst fears.

Providers can provide patients with information so that they will experience procedures in a nonthreatening way and minimize pain-distress. Two types of information were given to patients prior to an endoscopic examination and each had beneficial effects: sensory information regarding what they would feel during the examination (e.g., having air pumped into your stomach will make it feel that you have just eaten a large meal) and behavioral plans (e.g., techniques for mouth breathing and swallowing to reduce gagging while swallowing the endoscopic tube). Patients given both types of information were least likely to gag when swallowing the endoscope (36.4 percent) and had lower heart rates in contrast to 90 percent of those gagging who received neither type of information. Patients given only one type of information fell in between (Johnson and Leventhal 1974). Thus, providing patients with information that minimizes the threat value of an experience reduces their anxiety and helps patients to coordinate behavioral procedures with their somatic sensations. The efficacy of this combination is well illustrated in studies of preparation for childbirth. The simple act of monitoring the sensory features of labor contractions lowered postdelivery pain reports in women who had participated in LaMaze classes and were trained in the behavioral responses needed to facilitate child birth (E. Leventhal et al. 1989). Women who were offered various ways of distracting themselves did not benefit with reduced pain from their childbirth classes. Thus, monitoring increased familiarity with body sensations, ‘… reduced emotional behaviors and lowered the levels of pain, by facilitating the coordination of breathing and pushing with contractions’ (p. 369).

Practitioners seeking to help patients cope with stressful procedures need to be aware of the influence of current levels of pain-distress on retrospective pain reports. For example, chronic pain patients underestimated the pain they had reported on electronic diaries during the prior week if their retrospective reports were given after physical therapy when their current pain was low (Smith and Safer 1993); patients who reported their prior pain before physical therapy overestimated their diary reports. Redelmeier and Kahneman (1996) found that retrospective ratings of the overall painfulness of colonoscopy and lithotripsy was related to the peak level of pain during the procedure and the level of pain experienced at the end of the procedure. The duration of the procedure was unrelated to overall judgments of pain. Thus, memories of pain-distress during medical procedure are biased upward if patients are experiencing much pain when making their judgments, and can be biased downward if the procedure is designed to end at a low level of pain and distress. This bias may be of clinical importance as the recall of pain may affect willingness to undergo future, protective examinations.

There is evidence that interventions to reduce paindistress are particularly helpful for patients who are most vulnerable to upset. Baron and Logan (1993) proposed that patients who have a high desire for control during a dental, i.e., root canal, procedure (perhaps because they interpret the procedure as threatening), yet perceive themselves as having little control (because they feel incapable of coping with the threat), are highly vulnerable to upset and experience the greatest anticipatory anxiety before treatment and the greatest discomfort during it. When given sensory and procedural information that reframed the procedure in a less toxic way, these patients with high desire for control but low perceived control were no more distressed by their root-canal procedure than other, nonvulnerable patients. Vulnerable patients given only ‘placebo,’ filler information were highly distressed.

An important caveat is whether the factors effective for the reduction of pain-distress in response to brief procedures such as colonoscopy will be effective in reducing pain and distress for prolonged stressors such as the pain and distress experienced following surgery. Informing people about somatic sensations may be ineffective in reducing pain postsurgery (Johnston and Vogele 1993) unless the information provides clear and believable nonthreatening interpretations of these somatic events. Recent work on recovery from myocardial infarction suggests that this is critical. Behavioral techniques for distress control seem to be effective in long-term stress settings if the control is effective. For example, hospitalized patients allowed to self-administer analgesics use less analgesic and report less pain.

4. Summary

The pain and distress experienced during invasive procedures can be modified by effective preparation. The key constituents of such preparation appear to be nonthreatening interpretations of the sensory cues evoked during the procedure and strategies for effective situational control linked to these cues. This combination appears to be effective for regulating the emotional component of the pain-distress response. Individual differences, however, can modify the effectiveness of behavioral preparation; patients lacking a sense of efficacy in controlling either the situation or their own affective reactions may benefit more when they see trusted others in control of the procedure. Preparation may also have different effects on different outcomes, some reducing pain experience, others physiological reactions, and others the time for completing the procedure. Though studies are needed to identify the mechanisms underlying the control of pain-distress during noxious medical procedures (Strausbaugh and Levine 2000), it is clear that patients can benefit from information. A humane system will provide information with regard to what patients will experience and help them to interpret these experiences as an expected part of a healing process. It will also provide behavioral procedures to facilitate the control of these noxious sensations and their associated affects.

Bibliography:

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