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A model for interdisciplinary learning
Reviews
Journal
01 Pain and Symptom Managment
50
Book Review
A Model for Interdisciplinary J.H. Atkinson
and M.A.
Slater
of Pain (2nd edition) Edited by R.A. Sternbach Published by Raven Press New York, 1986, 255 pages, $29.50 The Psychology
This monograph is a collection of papers aimed at a systematic review of the literature on what is broadly defined as the psychology of pain. The contributors, leading authorities in the field, address the diversity of pain and the pain experience; neurochemistry, neurophysiology, neuromodulation, learning theory, social modeling, pain measurement, perception, and Freudian metapsychology are all discussed in excellent summary fashion. The length of the monograph (245 pages) allows more complete presentations than are possible in the usual journal review article. Yet the chapters are short enough that the non-expert can bring himself or herself up to date relatively quickly. As such, the book fills a gap in the literature. The editor’s stated purpose was to revise and update the first edition to address changes in the literature since 1978. The editor and the reader must, in view of this purpose, be highly pleased with many chapters. For example, Liebeskind and associates provide a marvelous update on neural mechanisms of pain inhibition. Fordyce elaborates his most recent thinking on operant models of pain and broadens its perspective and areas of interface in an instructive and delightful fashion. Some of the other chapters reiterate-sometimes verbatim-material from the first edition. This is not necessarily a flaw.
These
reviews
still
Learning
provide
much
infor-
mation for the first-time reader. This is particularly true of Melzack’s chapter on neurophyJ.H. Atkinson, MD, is Associate Clinical Professor of Psychiatry, and M.A. Slater, PhD, is Adjunct Assistant Professor of Psychiatry, both at the School of Medicine, University of California San Diego, La Jolla, California.
siological foundations of pain. Like a good poem it refreshes and intrigues its audience at each reading with its richness. In this first chapter of the volume, Melzack discusses brain structure and the neuroanatomy and neurochemistry of pain and then relates these structures to brain functions of processing and inhibiting stimuli. He connects structure to sensory, affective, and motivational outcomes in acute and chronic pain. Next, Liebeskind and associates describe the multiple systems that modify pain. Nonopioid and opioid mechanisms, for example, are differentially activated by the nature of impinging stimuli. Furthermore, various types of environmental stressors (forced swimming, footshock) elicit endogenous nonopioid-and at least two types of opioid-analgesia, according to characteristics of the stressor. How fear, helplessness, and other emotional states may inhibit pain by these mechanisms is discussed. In his chapter on learning processes in pain, Fordyce summarizes and updates his seminal observations. The chapter is both provocative and enlightening, and it is not at all rigid and restrictive
in its conceptualization
played by conditioning iors.
Fordyce
reminds
of the
role
in chronic pain behavus that reinforcement
is
only one of three major factors that should be considered in a comprehensive assessment of the patient (nociception and cognitive are the other two). In this regard, we learn that recognizing the patient’s suffering-his anticipation of future negative events-as well as identifying limps, grimaces, and moans is critical to the behavioral understanding of pain. His
summary
of how
an individual
can
per-
ceive, and be disabled by, pain in the absence of nociception should be required reading for all clinicians
treating
pain
patients.
Fordyce’s
approach to psychogenic pain is an interesting
-Vol; 3 No. 1 Winter 1988
counterpoint for later papers by Merskey and Pilowsky on psychiatric and psychoanalytic perspectives of the same problem. Craig follows Fordyce and provides a wealth of information on social modeling effects on subsequent development of a chronic pain disability as well as on therapeutic uses of modeling to promote pain control. Merskey, in presenting a psychiatrist’s perspective, emphasizes that the person with chronic pain is not a “psychiatric case.” By taking an epidemiological perspective, he points out that many people cope well with their disability and that patients attending pain clinics are a highly selected group. What we see as a pain clinic personality may simply be a “clinic” personality, ie, a person with illness who is seeking help and who is anxious or depressed. Acknowledging that psychiatric illness and pain often coexist, Merskey helpfully defines often misapplied psychiatric terms, eg, hysteria, masochism, compensation neurosis. The author, as usual, presents all this with his particularly learned overview of the literature, Pilowsky presents the classical psychoanalytic formulations pertinent to chronic pain in wholly understandable English. This material would have been even more intriguing if explicated by case examples from his obviously extensive clinical practice. Wolffs chapter on measurement of pain is a first-person account of the development of this discipline. It serves as a useful introduction for those new to experimentally induced pain
Reviews
51
and psychophysical measurement. It is, as well, a nice overview for clinician-researchers. Including more recent information on sensory decision theory and verbal response methods would be helpful in future editions. In an excellent introduction to the often neglected role of perceptual psychology in conceptualizing pain, Chapman offers a perspective probably new to most clinicians and researchers. His discussion of the two functions of nociception, to warn and to remind, is particularly valuable as is the material on information processing. The clinical relevance of this chapter will intrigue a broad audience. And it makes interesting reading when combined with Hilgard’s chapter on pain control by hypnosis. Finally, Sternbach nicely surveys clinical aspects of acute and chronic pain. Who then would profit from this monograph and why? Clinicians and researchers increasingly must be trained in interdisciplinary settings and with multidisciplinary perspectives. This monograph provides an initial framework for such training. Thus, a graduate-level psychology course on pain or on behavioral medicine could use this book as its “core” reading. The work also offers much to psychiatrists and psychologists further along in their careers. Each chapter may be too short to inform one who closely follows his or her own field, but it is an ideal antidote to the subspecialization that inevitably narrows us. We look forward to subsequent editions.
Journal
01 Pain and Symptom Managment
50
Book Review
A Model for Interdisciplinary J.H. Atkinson
and M.A.
Slater
of Pain (2nd edition) Edited by R.A. Sternbach Published by Raven Press New York, 1986, 255 pages, $29.50 The Psychology
This monograph is a collection of papers aimed at a systematic review of the literature on what is broadly defined as the psychology of pain. The contributors, leading authorities in the field, address the diversity of pain and the pain experience; neurochemistry, neurophysiology, neuromodulation, learning theory, social modeling, pain measurement, perception, and Freudian metapsychology are all discussed in excellent summary fashion. The length of the monograph (245 pages) allows more complete presentations than are possible in the usual journal review article. Yet the chapters are short enough that the non-expert can bring himself or herself up to date relatively quickly. As such, the book fills a gap in the literature. The editor’s stated purpose was to revise and update the first edition to address changes in the literature since 1978. The editor and the reader must, in view of this purpose, be highly pleased with many chapters. For example, Liebeskind and associates provide a marvelous update on neural mechanisms of pain inhibition. Fordyce elaborates his most recent thinking on operant models of pain and broadens its perspective and areas of interface in an instructive and delightful fashion. Some of the other chapters reiterate-sometimes verbatim-material from the first edition. This is not necessarily a flaw.
These
reviews
still
Learning
provide
much
infor-
mation for the first-time reader. This is particularly true of Melzack’s chapter on neurophyJ.H. Atkinson, MD, is Associate Clinical Professor of Psychiatry, and M.A. Slater, PhD, is Adjunct Assistant Professor of Psychiatry, both at the School of Medicine, University of California San Diego, La Jolla, California.
siological foundations of pain. Like a good poem it refreshes and intrigues its audience at each reading with its richness. In this first chapter of the volume, Melzack discusses brain structure and the neuroanatomy and neurochemistry of pain and then relates these structures to brain functions of processing and inhibiting stimuli. He connects structure to sensory, affective, and motivational outcomes in acute and chronic pain. Next, Liebeskind and associates describe the multiple systems that modify pain. Nonopioid and opioid mechanisms, for example, are differentially activated by the nature of impinging stimuli. Furthermore, various types of environmental stressors (forced swimming, footshock) elicit endogenous nonopioid-and at least two types of opioid-analgesia, according to characteristics of the stressor. How fear, helplessness, and other emotional states may inhibit pain by these mechanisms is discussed. In his chapter on learning processes in pain, Fordyce summarizes and updates his seminal observations. The chapter is both provocative and enlightening, and it is not at all rigid and restrictive
in its conceptualization
played by conditioning iors.
Fordyce
reminds
of the
role
in chronic pain behavus that reinforcement
is
only one of three major factors that should be considered in a comprehensive assessment of the patient (nociception and cognitive are the other two). In this regard, we learn that recognizing the patient’s suffering-his anticipation of future negative events-as well as identifying limps, grimaces, and moans is critical to the behavioral understanding of pain. His
summary
of how
an individual
can
per-
ceive, and be disabled by, pain in the absence of nociception should be required reading for all clinicians
treating
pain
patients.
Fordyce’s
approach to psychogenic pain is an interesting
-Vol; 3 No. 1 Winter 1988
counterpoint for later papers by Merskey and Pilowsky on psychiatric and psychoanalytic perspectives of the same problem. Craig follows Fordyce and provides a wealth of information on social modeling effects on subsequent development of a chronic pain disability as well as on therapeutic uses of modeling to promote pain control. Merskey, in presenting a psychiatrist’s perspective, emphasizes that the person with chronic pain is not a “psychiatric case.” By taking an epidemiological perspective, he points out that many people cope well with their disability and that patients attending pain clinics are a highly selected group. What we see as a pain clinic personality may simply be a “clinic” personality, ie, a person with illness who is seeking help and who is anxious or depressed. Acknowledging that psychiatric illness and pain often coexist, Merskey helpfully defines often misapplied psychiatric terms, eg, hysteria, masochism, compensation neurosis. The author, as usual, presents all this with his particularly learned overview of the literature, Pilowsky presents the classical psychoanalytic formulations pertinent to chronic pain in wholly understandable English. This material would have been even more intriguing if explicated by case examples from his obviously extensive clinical practice. Wolffs chapter on measurement of pain is a first-person account of the development of this discipline. It serves as a useful introduction for those new to experimentally induced pain
Reviews
51
and psychophysical measurement. It is, as well, a nice overview for clinician-researchers. Including more recent information on sensory decision theory and verbal response methods would be helpful in future editions. In an excellent introduction to the often neglected role of perceptual psychology in conceptualizing pain, Chapman offers a perspective probably new to most clinicians and researchers. His discussion of the two functions of nociception, to warn and to remind, is particularly valuable as is the material on information processing. The clinical relevance of this chapter will intrigue a broad audience. And it makes interesting reading when combined with Hilgard’s chapter on pain control by hypnosis. Finally, Sternbach nicely surveys clinical aspects of acute and chronic pain. Who then would profit from this monograph and why? Clinicians and researchers increasingly must be trained in interdisciplinary settings and with multidisciplinary perspectives. This monograph provides an initial framework for such training. Thus, a graduate-level psychology course on pain or on behavioral medicine could use this book as its “core” reading. The work also offers much to psychiatrists and psychologists further along in their careers. Each chapter may be too short to inform one who closely follows his or her own field, but it is an ideal antidote to the subspecialization that inevitably narrows us. We look forward to subsequent editions.