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Psychological Considerations
in Perioperative Acute Pain Management
John B. Silva
Abstract Psychology and pain are closely intertwined and have bidirectional effects
on one another. Psychology affects the perception of pain in both positive and negative
ways at the same time that pain can reduce quality of life to a point of creating psycho-
logical disorder. This chapter reviews the interplay of psychology and pain specifi-
cally in the perioperative environment. There is significant evidence to suggest that a
variety of psychological conditions predispose patients to worse acute pain, with the
most research identifying anxiety, depression and the thought process of catastro-
phizing as risk factors. Additionally, the treatment of acute pain in the perioperative
period relies on the appropriate management and treatment of patient psychology
by assessing risk factors for pain as well as employing pharmacologic and non-
pharmacologic forms of treatment. Overall, the treatment of acute perioperative pain
is a multidisciplinary endeavor with proper understanding and management of patient
psychology playing a significant role.
Keywords Psychology
· Pain · Acute pain · Anxiety · Depression ·
Catastrophizing
1 Psychology and Perioperative Pain Management
2 Introduction
Acute pain following surgery has been reported in as high as 86% of patients [1–
4]. Evidence demonstrates that uncontrolled perioperative pain is associated with a
demonstrable worsening of patient outcomes including opioid abuse, chronic pain
J. B. Silva (
B
)
Department of Anesthesiology, University of Wisconsin, Madison, Wisconsin, USA
e-mail: jbsilva@wisc.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
A. Abd-Elsayed and K. Schroeder (eds.), Perioperative Pain Management,
https://doi.org/10.1007/978-3-031-67648-2_15
233
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234 J. B. Silva
development, delirium, increased hospital length of stay, decreased patient satisfac-
tion, increased complications and increased cost [5–8]. Therefore, proper manage-
ment of perioperative pain has become essential to optimal patient care and has
increasingly been used as an indicator to judge the quality of intramural healthcare.
Pain itself can be subdivided into a four-part process of transduction, transmis-
sion, modulation and perception. The process begins with noxious stimuli being
transduced into neural information via nociceptors. These signals are then trans-
mitted from peripheral nerves to the central nervous system where the pain stimulus
continues from one neuron to another and is modulated by input from descending
facilitatory and inhibitory nerves, neurotransmitters and local signaling factors before
terminating in the cerebral cortex. The final step is the act of perception where the
signal is then integrated with cognitive, emotional and sensory characteristics. It is
this last step that converts the process of nociception, a unidimensional biological
process resulting from the stimulation of nerves that convey potential tissue damage,
to pain, the subjective multidimensional experience contextualizing nociception.
The experience of pain is influenced by a variety of factors including genetics,
prior experiences, sociocultural influences and psychological status [9]. Because of
this, the relationship of nociception to pain is non-linear, with similar nociceptive
inputs causing a spectrum of pain responses in different patients [10]. Additionally,
the relationship of pain and psychology is bidirectional with increased pain leading to
psychological dysfunction and psychological dysfunction being strongly associated
with increased pain [9]. Studies assessing predictors of acute postoperative pain after
surgery find psychological factors to be leading predictors of post-surgical pain and
analgesic consumption [11, 12].
Perioperative pain management focuses on the management of acute pain which
is classified as pain that lasts less than three months [13] and is primarily the result
of an insult such as trauma, surgery or significant disease. Acute pain serves a useful
biologic purpose and is limited to the resolution of the disease state. This is in
contrast to chronic pain which lasts longer than three months, and is often related
to altered activities of the neurologic system such as altered activity of peripheral
nerve fibers or central pain related to abnormalities in the responsiveness to neural
activity or psychological states. Chronic pain does not serve a biologic purpose, has
no endpoint and often lasts longer than the time of healing. These differing char-
acteristics lead to differences in treatment approaches with acute pain management
focusing primarily on interrupting nociception. In contrast, chronic pain management
has historically employed a multidisciplinary approach and involved more than one
therapeutic modality [14]. Due to the classical difference in treatment approach,
understanding and treating the psychology related to a patient’s pain has classically
resided in the purview of chronic pain treatment, however more and more research
has shown that psychology plays an important role in acute pain as well.
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Psychological Considerations in Perioperative Acute Pain Management 235
3 Psychological Issues that Predispose Patients to Acute
Pain
Anxiety
Anxiety is defined as an emotion characterized by an unpleasant state of inner turmoil
in anticipation of a future threat [15]. Anxiety ranges from adaptive anxiety that
allows for preparation for future challenges to pathological anxiety such as general-
ized anxiety disorder, panic disorder and phobias. The distinction between the two is
typically diagnosed by symptoms of anxiety that are excessive, persisting for more
than 6 months, causing dysfunction in various domains of life and inhibiting activities
of daily living [15].
Anxiety has repeatedly been shown to be correlated and in some cases a predictor
of acute postoperative pain after elective surgery across multiple studies and metanal-
yses [11, 12, 16, 17]. In fact, a metanalysis performed by Hui Yun et al. of 48 studies
found anxiety to be the most commonly found predictive factor of postoperative
pain. This relationship has been demonstrated across multiple subtypes of surgeries
including gastrointestinal surgery [18–20], obstetrics and gynecologic surgery [21–
23], thoracic surgery [24], breast surgery [25], spine surgery [26] and dental proce-
dures [11]. Moreover, some studies have found direct correlations between anxiety
and post-operative analgesic consumption [25, 27].
One important delineation when assessing anxiety is assessing trait versus state
anxiety. State anxiety is a transient reaction to an adverse situation while trait anxiety
is a more stable personality attribute in experiencing events [28]. Magnetic resonance
imaging of the brain shows that these separate forms of anxiety are mapped differently
in the human brain with trait anxiety related to structural configurations of the brain
while state anxiety correlates with functional patterns of the brain [29]. Some studies
have found state anxiety[18] to be a significant predictor of post-operative pain, while
other have suggested that trait anxiety[30] is similarly associated with pain. It is
unclear if either type of anxiety is a stronger predictor of post-operative acute pain,
however it is important to understand the distinction and further study is required to
assess which anxiety type is more strongly correlated with postoperative pain.
Depression
Depression is a common mood disorder affecting 4.4% of the world’s population [31].
It generally revolves around feelings of sadness that lead to symptoms of fatigue,
weight loss, feelings of worthlessness, anhedonia, insomnia, and difficulty concen-
trating. In severe cases, depression symptomology includes suicide and/or major
effects on a patient’s ability to function in society. The Diagnostic and Statistical
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236 J. B. Silva
Manual of Mental Disorders Fifth Edition has multiple subtypes of depressive disor-
ders that make up a spectrum from dysthymia to major depression with psychotic
features, depending on the severity and duration of symptoms [32].
Pain and depression are frequently comorbid conditions, with an estimated 13%
of the elderly population suffering simultaneously from the two conditions [33].
Pain and depression have bidirectional influences on one another with pain demon-
strating an ability to decrease quality of life and increase the risk of depression[34].
Conversely, individuals who suffer from major depressive disorder are more likely
to suffer from chronic pain[34]. This association is so closely intertwined that it is
remarkably common for patients suffering from depression to present exclusively
with physical symptoms including pain [35]. Evidence linking the perception of
pain and depression symptomology continues to evolve. Some have theorized that
depressed patients experience an altered perception of pain that may be manifested as
a lower pain threshold [36], a higher threshold [37], with some studies demonstrating
no difference [38].
An evaluation of depressed patient’s undergoing laparoscopic cholecystectomy
by De Cosmo et al. with self-rating questionnaire found that not only did depressed
patients have higher pain indicators during the postoperative 24 hours, but regression
analysis revealed that tramadol consumption could be predicted by preoperative
depression[19]. An assessment of acute pain in the postoperative, post-labor, post-
cesarean and dental setting performed by Barman et al. found a statistically significant
and strong correlation between depression and acute pain across multiple clinical
settings [39].
The bidirectional nature of the depression pain relationship was further demon-
strated by Eisenach who found that severe acute postpartum pain led to a 2.5-3
fold increase in postpartum depression[40]. Another facet of this relationship is that
sometimes the presence of pain has the additional negative effect of preventing the
proper recognition and management of depression[41]. Given this tight relationship
between depression and pain, it is clear that the appropriate approach to perioperative
pain includes a simultaneous treatment of both.
Catastrophizing
Research into the relationship between psychology and acute pain is not limited to
mood disorders. Specific cognitive processes have been evaluated with the thought
process of catastrophizing having frequently been shown to be one of the most
important predictors of post-operative acute pain. Catastrophizing is defined as an
exaggerated negative orientation to aversive stimuli that involves rumination about
painful sensations, magnification of threat value of the painful stimulus and perceived
inability to control pain [42]. Catastrophizing is significantly correlated with mood
and personality variables such as depression, fear of pain, coping strategies, and state
and trait anxiety[18].
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Psychological Considerations in Perioperative Acute Pain Management 237
An analysis of 1490 patients found that one of the strongest predictors of moderate
to intense post-operative pain was found in patients who held catastrophizing cogni-
tions about the meaning of pain [12]. This relationship between pain catastrophizing
and pain has been replicated in orthopaedic [43], gynecological [44], thoracic [45],
and dental surgery/procedures [46]. A 2005 study by Granot demonstrated a strik-
ingly and direct linear correlation between the pain catastrophizing scale and pain
score.
A variety of theoretical conceptualizations have been proposed that seek to under-
stand the cognitive process of pain catastrophizing[47]. The first is an attention bias
in information processing that either focuses on sensory and affective pain infor-
mation and amplifies it, or is unable to inhibit pain-related cognitions, to a point
that interrupts ongoing mental processes [48]. There is also an appraisal theory
where a potential stressor undergoes a primary appraisal as to whether or not it is
a severely negative experience, and a secondary appraisal as to whether or not the
person feels they can control it [49]. There is theorized to be a communal coping
component where catastrophizing pain elicits behaviors that engender support from
others [50]. This action and response can create a feedback loop that incentivizes
further catastrophizing and exaggeration of pain responses. The final component is
a neural component where pain catastrophizing repeatedly activates and reinforces
certain brain regions implicated in the processing of pain signals in the spine and
brain [49, 51].
4 Management of Psychology in the Perioperative Setting
Given the close and reciprocal relationship of psychology and acute pain, proper
management and understanding of psychological conditions can theoretically lead
to better pain control and better pain control can improve the psychological health of
patients. Therefore, the remainder of this chapter addresses psychologically focused
interventions that can improve acute pain.
Psychological Protective Factors
Research into the relationship between psychology and acute pain has focused
predominantly on factors associated with worsened acute pain outcomes. Signifi-
cantly less research has focused on identifying and analyzing potentially protective
psychological factors. Bruce J et al. evaluated the concept of psychological robust-
ness, a concept associated with higher values of dispositional optimism, lower values
of trait anxiety, and decreased depression. Evaluation of this variable found that the
presence of higher levels of psychological robustness predicted a lower incidence of
chronic pain at 4 months in women undergoing breast cancer surgery [52].
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238 J. B. Silva
More specifically, trait optimism has been found to improve post-operative pain
outcomes. A systematic review of the effects of trait optimism in the post-operative
recovery from coronary artery graft surgery found that optimism was associated
with reduced pain after surgery and significant improvements in several categories
of recovery, including reduced rehospitalization rate, complications, pain, improved
quality of life, and enhanced rate of return to normal life and psychological status [53].
Notably, this relationship becomes more nuanced when evaluating optimistic pre-
surgical expectations of post-operative outcomes. As a whole, the evidence strongly
supports an association between optimistic expectations and positive psychosocial
outcomes if expectations are based in reality. However, if preoperative optimism is
unrealistic, this optimism can become a liability and lead to worse outcomes [54].
Another trait that has been shown to be beneficial in preventing acute post-
operative pain is an individual’s propensity to engage in adaptive health behaviors. A
multicenter study performed by Andrawis J et al. evaluated patient activation, which
is a measure of an individual’s propensity to engage in adaptive health behaviors,
and found that higher preoperative activation was associated with better pain relief,
decreased pain symptoms, improved mental health and greater satisfaction after total
joint arthroplasty [55]. A similar and related study evaluating self-efficacy, otherwise
known as the conviction that one can successfully execute the behavior required to
produce the outcomes desired, found that self-efficacy was found to be a signif-
icant preoperative predictor of functional ability but was unrelated to reports of
postoperative pain[56].
Overall, there is a dearth of research into the psychological traits and cognitive
thought processes that reduce post-operative acute pain, but what there is suggests
that individuals who have a generally positive outlook and adaptability are the least
likely to experience post-operative pain and most likely to recover better. Further
research is needed to validate risk stratifying patients based on psychological factors
as well as evaluate if there are any preoperative i nterventions that can improve these
positive traits preoperatively.
Pre-operative Psychological Intervention
Analysis of the efficacy of psychological interventions on pain has primarily been
done in the realm of chronic pain. Psychosocial interventions have been shown to be
beneficial in the management of arthritis and cancer pain[57, 58]. Cognitive behav-
ioral therapy has been shown to have beneficial effects on the pain experience [59],
however more recent metanalyses have found the benefit to be small for reducing
pain, disability and distress related to chronic pain (excluding headache) in adults
[60]. Similarly, evaluations of mindfulness and its effect on musculoskeletal pain
have found mixed results across a range of outcomes (pain, sleep quality, depres-
sion, quality of life, physical functioning, mindfulness) [61]. A Cochrane review
of psychological interventions for chronic, non-specific low back pain found that
psychological interventions are most effective and sustainable when delivered as
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Psychological Considerations in Perioperative Acute Pain Management 239
part of a multidisciplinary approach that includes physiotherapy, pain education
and behavioral therapy [62]. One difficulty associated with analyzing psychological
interventions in the treatment or prevention of pain is the breadth of psycholog-
ical interventions available and the variability in intervention implementation. It is
difficult to make a definitive statement on the usefulness of psychological therapy
in chronic pain management, but it seems likely that psychological interventions
do have beneficial effects, however modest, and are best used as a component of a
multidisciplinary approach[62].
A similar conclusion can be found when looking into the realm of periopera-
tive pain management, however, given the significant difference in nature between
chronic and perioperative pain, there are a host of other potential psychological inter-
ventions available. A Cochrane review that evaluated psychological interventions
associated with reductions in needle-related procedural pain and distress in chil-
dren and adolescents found evidence to support the efficacy of distraction, hypnosis,
cognitive-behavioral therapy and breathing interventions [63]. Some hospitals are
even testing out the effects of virtual reality interventions with mixed results [64, 65].
Psychoeducational preparation has also been shown to have positive outcomes [66].
Studies evaluating strategies to reduce patients’ anxiety and pain prior to c-section
found that patient familiarity with the cesarean section operation and operating room
environment caused a decline in anxiety prior to c-section, reductions in pain scores
after the operation, and enhanced hemodynamic stability [67, 68]. Recent metanal-
yses have suggested that psychological preparation may improve postoperative pain,
behavioral recovery, and reduce hospital length of stay. Unfortunately, the evidence
was insufficient to reach firm conclusions at this time [69].
Given the documented effects of pre-operative anxiety and catastrophizing
thought processes, it stands to reason that pre-operative relaxation techniques may
also have a beneficial effect. A randomized controlled trial evaluating the preoperative
administration of quick, basic relaxation exercises in the setting arthroscopic shoulder
repair showed that these patients experienced less postoperative pain and used appre-
ciably lower opioid analgesic doses over the first 2 weeks following surgery [70].
However, this success has not been replicated in other contexts [71].
Much like chronic pain, given the modest gains of seemingly all interven-
tions, post-operative acute pain will also require employment of a multidisciplinary
approach across multiple treatment vectors. Employment of a multidisciplinary
management team at TorontoGeneral Hospital Transitional Pain Service that consists
of pain physicians, advanced practice nurses, psychologists and physical therapists
has shown promising results with another randomized control trial underway in
several Ontario hospitals [72].
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240 J. B. Silva
Pre-operative Pharmacological Interventions
There are a host of medications used in the perioperative setting that affect both pain
and psychology in the perioperative setting. Given the significant overlap of the two,
it can be difficult to discern what is being treated at any given time.
Opioids are a mainstay in the treatment of perioperative pain, the effectiveness
of which is so well established that it doesn’t require exploration. More recently,
however, there has been exploration into the role of opioid peptides and their recep-
tors (mu, delta and kappa) as novel targets for antidepressant therapy [73]. In fact,
there is accumulating evidence from animal research models that the opioid system
exerts highly distinct controls over mood-related processes with delta opioid receptor
agonist and kappa mu receptor agonists shown to have promising antidepressant
potential [74, 75]. Unfortunately, study into this area is limited by the high abuse
potential of these drugs. Additionally, these studies have to be weighed against
other studies that have shown that longer durations of opioid use are associated
with new-onset depression[76].
Selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake
inhibitors are a mainstay of depression treatment; however, less is known about
their role as adjuncts for postoperative pain management. A metanalysis evaluating
their use in standard perioperative care found a small reduction in both acute and
chronic postoperative pain and opioid consumption, as well as a small improvement
in patient satisfaction [77].
Again, given the documented effects of pre-operative anxiety and catastrophizing
thought processes, it stands to reason that medications focused on treating pre-
operative anxiety would have a beneficial effect. A study by Kain et al. found
that patients treated with a benzodiazepine (midazolam) 30 minutes before surgery
reported a greater reduction in postoperative pain throughout the first postoperative
week and a greater decrease of anxiety through the first post-operative month [78].
Unfortunately, this finding was not found by the same study group one year later
when evaluating preoperative treatment with lorazepam and midazolam for women
undergoing abdominal hysterectomy [79]. Other anxiolytic medications have been
evaluated including alpha-2 agonists (e.g., clonidine and dexmedetomidine) which
resulted in a reduction in post-operative opioid consumption, pain intensity and
nausea [80]. Gabapentin and pregabalin represent another pharmacologic class of
agents possessing promise in r educing post-operative acute pain. At this time, mixed
results limit the ability to make strong clinical recommendations [81–83].
5 Conclusions
Ultimately, surgical recovery is complicated and multifaceted as patients deal with
pain, disability and multiple setbacks in the setting of an often-uncertain future.
There will never be a single panacea that will solve perioperative acute pain in its
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Psychological Considerations in Perioperative Acute Pain Management 241
entirety. However, what is clear is that psychology and pain are closely intertwined
and psychology affects the perception of pain both positively and negatively. There
is significant evidence to suggest that psychological conditions predispose patients
to worse acute pain and that proper treatment of acute pain in the perioperative
period includes the assessment, management and treatment of patient psychology.
The benefits of this focus are likely to be modest and difficult to understand given
the complex nature of psychology and the wide variety of potential interventions,
however, what is clear is that the proper treatment of psychological derangements
in an integral component of the multimodal and multidisciplinary management of
perioperative pain.
Key Takeaways
•
Psychology plays a significant role in the higher order perception and experience
of pain.
•
Severe pain can have a significant effect on psychology and reduce quality of life
to a point that precipitates psychological dysfunction.
•
Psychologic risk factors for severe acute pain after surgery include anxiety,
depression, and the thought process of catastrophizing.
•
There are a variety of pharmacologic and non-pharmacological psychological
interventions that have shown some promise in the reduction of acute pain.
•
The understanding and treatment of psychology and acute pain represents a signifi-
cant component of the multimodal and multidisciplinary approach required to best
treat acute pain.
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