Adopting the Biopsychosocial Model to Prevent, Assess and Treat Chronic Pain

SAN ANTONIO — In the biopsychosocial model, relying on the “complex and dynamic interaction among physiologic, psychologic and social factors, which perpetuates and may worsen the clinical presentation,” central and peripheral processes interact.

Biological, affective, somatic and cognitive factors that are processed in the central nervous system send efferent feedback to the peripheral nervous system, where they interplay with the endocrine, immune and autonomic systems. Conversely, the periphery sends afferent feedback to the central regions.

Robert J. Gatchel, PhD, ABPP, a professor in the Department of Psychology at the University of Texas at Arlington and director of biopsychosocial research at the Osteopathic Research Center, University of North Texas Health Science Center, presented a lecture at the American Academy of Pain Management’s Annual Meeting on how the biopsychosocial model may be leveraged to assess, treat, and prevent chronic pain.¹

Because of those feedback mechanisms between the central and peripheral nervous systems, treating pain is not “from the neck up,” Dr Gatche said, so one has to take this afferent feedback into account. The concept of central sensitization posits that once an injury occurs, pathways become sensitized and hyperexcitable.

In order to measure this phenomenon, Dr Gatchel and colleagues developed a “central sensitization inventory.”² This inventory, created to identify patients presenting with central sensitization syndrome, has triggered tremendous interest around the world, Dr Gatchel noted, and has since been translated into 20 different languages.

“To get rid of pain, it is not enough to severe a nerve […as this] will leave a lot of scar tissue that will be sensitized and will perseverate and linger, [turning it into] a nociceptor,” Dr Gatchel pointed out. “So that you might cut out the original nociceptor, but you replace it with a central sensitization phenomenon.”

He advocated against operating, if at all possible, noting the high rates of spinal fusions performed in the United States, which are effective in relieving back pain in only about 40% of cases. In addition, psychological and social factors, as well as interactions between the autonomic, endocrine, and immune systems with the hypothalamic-pituitary-adrenal axis, all play a role in the process.

These complex interactions constitute the foundation of the biopsychosocial model and require an integrative approach. “[Everyone in] this Academy [has] been accepting the biopsychosocial approach,” he added.

Dr Gatchel concluded that the “inter-relationships among biological changes, psychosocial status, and the socio-cultural context all need to be considered,” when managing pain in patients. “This [model] helps to explain the diversity of pain or illness expression, including its severity, duration and psychosocial consequences.”

It is essential to evaluate which part of the puzzle (eg, the biological underpinnings, social factors or emotional distress) is important in order to perform a very careful biopsychosocial assessment and adopt the adequate treatment. Cultural differences should also be taken into account, Dr Gatchel noted.

This biopsychosocial approach emphasizes a management approach to a disorder, as opposed to a “curative” one. Telling patients that their pain will be cured is setting them up to disappointment, according to Dr Gatchel.

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References

1. Gatchel R.The whole story: biopsychosocial approach to the assessment, treatment, and prevention of chronic pain. Presented at: AAPM 2016. San Antonio, TX; September 21-25, 2016.
2. Mayer TG, Neblett R, Cohen H, et al. The development and psychometric validation of the central sensitization inventory. Pain Pract. 2012;12(4):276-285. doi: 10.1111/j.1533-2500.2011.00493.x.