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Psychology of pain
basis of the conclusions or opinions offered. Given the instrumental empiric orientation of the authors, this is extremely disappointing. As another example, the discussion of the combination of individual psychotherapy and medication in schizophrenia is without source material and extremely general. The outline to review acute treatment, prevention of relapse, providing psychoeducation, and involving community support groups are all worthwhile, but sources and data, particularly applying to the authors’ COMPASS system, would have been invaluable. In summary, this highly readable text provides an interesting background on needs for development of instruments to measure outcomes, with hypothetical examples of the use of the COMPASS system. However, this text, despite the authors’ desires, is not practical because of lack of information on the COMPASS system. It is hoped that in a further text, the authors will provide the detail manual information on the COMPASS that is lacking in the current one that will indeed make it directly applicable to all providers and treatment setting. PAUL
JOEL
GOODNICK, ALINA
PUIG,
MD MD
Miami, FL PI1 SO163-8343(97)00050-9
Psychology of Pain. By Suzanne M. Skevington. New York, John Wiley & Sons, 1995 ($46.95), 359 pp. This is the first substantial single author book since 1968 dealing technically and reasonably comprehensively with the psychology of pain in its medical, psychological, and social aspects. In the intervening period there has been a great growth of work in the field with original research reports, numerous single chapters, and several multiauthor volumes on this topic alone, not to mention some lay attempts to evaluate pain. In addition, the two leading textbooks (Wall and Melzack, and Bonica et al.) gave considerable space to psychological, social, and behavioral issues, and the depth of the knowledge now demanded for a book by an individual author is vast, if not daunting. Dr. Skevington focuses on the many and varied social and psychological influences that affect and are affected by the experience and reporting of
pain. The introduction claims correctly that neither traditional personality psychology nor the behavioral approach has provided an adequate model, and suggests that it may be time for a paradigm shift. Widespread softening of the behavioral approach by the addition of cognitive measures is also insufficient. Instead, Dr. Skevington suggests that the social context of pain will provide an improved and expanded method for understanding chronic pain; sociocognitive techniques that examine the individual’s ideas of pain are part of this. But in addition, we have to appreciate the importance of the patient’s roles and relationships in determining the occurrence of pain, and in understanding the symptoms; at least that is my understanding of how Dr. Skevington sees these matters. She does not reject a physical basis for chronic pain, but rather devotes herself, to the fullest extent possible, to the effects of social influences. Chapter 1 provides a brief and highly compact summary of the basic neurophysiology and biochemistry. The author relies heavily on the gate theory, as later modified, and is fairly up to date on the importance of neuronal plasticity, but this chapter may be too condensed for the average nonphysiologist, although for those with a moderate amount of basic physiological knowledge and in search of quick updating, it should be helpful. The second chapter on measuring painful sensation is meant to prepare the reader for the rest of the book, but is an independent tour de force, with a thoughtful discussion of the implications of different methods of evaluating pain, including threshold studies, signal detection analysis, ratio scaling, psychophysics, and of course, both verbal and analog techniques. The book is worth having for this chapter alone. The next chapter deals nominally with learning about pain but spends more time discussing selection patterns in reporting of symptoms and in consultations, as well as models of the sick role and illness behavior. It concludes that the concepts and methods of behavioral medicine do not adequately represent the diverse range of social phenomena observed in association with chronic pain and its treatment. In her view it is necessary to undertake a social analysis at an intergroup level, and discuss social factors involved in decision making about treatment; there should be an appraisal of the emotions and interpersonal dynamics of the consultation or the process by which it is achieved. These considerations are taken to be integral to a social psychological analysis of chronic pain, and are reviewed in depth in subsequent chapters. Coping with pain and
383
Book Reviews
the social features of treating pain make up the remaining topics, followed by the obligatory opinion chapter entitled “The Way Forward.” Dr. Skevington is clear, balanced, and scholarly. The material is treated in a careful and thorough fashion, and although her effort flags occasionally, overall she provides the best discussion of the psychology of pain from a social perspective that I have seen anywhere. This discussion is set in proper context. She recognizes that medical diagnosis is important and alludes to this occasionally, but it appears more as a background topic than a pressing issue. In my view, this is a pity because there is increasing evidence in the literature that important organic processes are connected with chronic pain. To the unprejudiced observer these processes are evident, but medical rigidity and-dare I say itconflicts of interest which are particularly strong in the USA (much less so in Britain or Canada) appear to press hard upon the American practitioner treating privately insured persons with chronic pain. One of the results is an undue emphasis on the
384
motivational origins of pain and the neglect of its organic basis and affective consequences, sometimes with harmful effects on medical practice, as is evident in the recent controversial Task Force Report on Pain in the Workplace of the International Association for the Study of Pain. This book should not be criticized for those failings of medicine as a whole, but should be read with the thought in mind that there is a large neglected organic component in chronic pain. Its merits can still be recognized for pursuing and illuminating the social context of pain. It is also well organized, clearly printed, and well bound and should be of interest to both clinicians and students among health professionals working with pain.
HAROLD
MERSKEY,
D.M.
London, Canada PI1 SO163-8343(97)00050-9
JOEL
GOODNICK, ALINA
PUIG,
MD MD
Miami, FL PI1 SO163-8343(97)00050-9
Psychology of Pain. By Suzanne M. Skevington. New York, John Wiley & Sons, 1995 ($46.95), 359 pp. This is the first substantial single author book since 1968 dealing technically and reasonably comprehensively with the psychology of pain in its medical, psychological, and social aspects. In the intervening period there has been a great growth of work in the field with original research reports, numerous single chapters, and several multiauthor volumes on this topic alone, not to mention some lay attempts to evaluate pain. In addition, the two leading textbooks (Wall and Melzack, and Bonica et al.) gave considerable space to psychological, social, and behavioral issues, and the depth of the knowledge now demanded for a book by an individual author is vast, if not daunting. Dr. Skevington focuses on the many and varied social and psychological influences that affect and are affected by the experience and reporting of
pain. The introduction claims correctly that neither traditional personality psychology nor the behavioral approach has provided an adequate model, and suggests that it may be time for a paradigm shift. Widespread softening of the behavioral approach by the addition of cognitive measures is also insufficient. Instead, Dr. Skevington suggests that the social context of pain will provide an improved and expanded method for understanding chronic pain; sociocognitive techniques that examine the individual’s ideas of pain are part of this. But in addition, we have to appreciate the importance of the patient’s roles and relationships in determining the occurrence of pain, and in understanding the symptoms; at least that is my understanding of how Dr. Skevington sees these matters. She does not reject a physical basis for chronic pain, but rather devotes herself, to the fullest extent possible, to the effects of social influences. Chapter 1 provides a brief and highly compact summary of the basic neurophysiology and biochemistry. The author relies heavily on the gate theory, as later modified, and is fairly up to date on the importance of neuronal plasticity, but this chapter may be too condensed for the average nonphysiologist, although for those with a moderate amount of basic physiological knowledge and in search of quick updating, it should be helpful. The second chapter on measuring painful sensation is meant to prepare the reader for the rest of the book, but is an independent tour de force, with a thoughtful discussion of the implications of different methods of evaluating pain, including threshold studies, signal detection analysis, ratio scaling, psychophysics, and of course, both verbal and analog techniques. The book is worth having for this chapter alone. The next chapter deals nominally with learning about pain but spends more time discussing selection patterns in reporting of symptoms and in consultations, as well as models of the sick role and illness behavior. It concludes that the concepts and methods of behavioral medicine do not adequately represent the diverse range of social phenomena observed in association with chronic pain and its treatment. In her view it is necessary to undertake a social analysis at an intergroup level, and discuss social factors involved in decision making about treatment; there should be an appraisal of the emotions and interpersonal dynamics of the consultation or the process by which it is achieved. These considerations are taken to be integral to a social psychological analysis of chronic pain, and are reviewed in depth in subsequent chapters. Coping with pain and
383
Book Reviews
the social features of treating pain make up the remaining topics, followed by the obligatory opinion chapter entitled “The Way Forward.” Dr. Skevington is clear, balanced, and scholarly. The material is treated in a careful and thorough fashion, and although her effort flags occasionally, overall she provides the best discussion of the psychology of pain from a social perspective that I have seen anywhere. This discussion is set in proper context. She recognizes that medical diagnosis is important and alludes to this occasionally, but it appears more as a background topic than a pressing issue. In my view, this is a pity because there is increasing evidence in the literature that important organic processes are connected with chronic pain. To the unprejudiced observer these processes are evident, but medical rigidity and-dare I say itconflicts of interest which are particularly strong in the USA (much less so in Britain or Canada) appear to press hard upon the American practitioner treating privately insured persons with chronic pain. One of the results is an undue emphasis on the
384
motivational origins of pain and the neglect of its organic basis and affective consequences, sometimes with harmful effects on medical practice, as is evident in the recent controversial Task Force Report on Pain in the Workplace of the International Association for the Study of Pain. This book should not be criticized for those failings of medicine as a whole, but should be read with the thought in mind that there is a large neglected organic component in chronic pain. Its merits can still be recognized for pursuing and illuminating the social context of pain. It is also well organized, clearly printed, and well bound and should be of interest to both clinicians and students among health professionals working with pain.
HAROLD
MERSKEY,
D.M.
London, Canada PI1 SO163-8343(97)00050-9