Pain and Cognition

While acknowledging the importance of appropriate pharmacological intervention, pain is not nociception, it as an alarming sensory, cognitive and social experience. It is the cognitive aspects and how to best manage or indeed in an ACT sense ‘live with’ them that is of particular interest here. The cognitive aspects of procedural pain can exacerbate pain and distress but there is another side to the cognitive coin and that is acceptance, coping and resilience.  Included (not exclusively) in the cognitive aspects of pain are: memory, emotion (any of the ‘big five’ - fear, anger, sadness, disgust and joy), attention, language, learning, thought and consciousness. The practical application of this lies in pain assessment and intervention.

Memory and Learning    These are particularly relevant for children who have repeated procedures. Memories both declarative and emotional associated with what happened last time can impact on the next procedure.  The negative impact is obvious but the memory of a positive experience, something that ‘worked well’ for the child, can be built upon in subsequent procedures.  This is why it is useful to focus on achievement (however small or large) rather than bravery.  How does, ‘Last time you were very brave’ help the child today, now, in this procedure?  Conversely, talking with the child about what he or she did that seemed to help (again, however small or large) involves the child in a manner that shifts him or her from being a ‘recipient’ of treatment to a participant.  The consequences of such a shift are widespread; not the least being a ‘child-centered‘ approach and respect and status for the child (see below).

Emotion    A useful starting point with emotions is that they are all normal and part of the human experience.  They do however have powerful effects, which can be uncomfortable and in the moment, difficult if not impossible to control.  Fortunately, emotions are transient, they come and go.  With this in mind, the notion of a ‘wave’ is a useful metaphor in talking with children about emotions... ‘having a wave’, we all have waves of emotion from time to time.  Waves go up but importantly, they go down again.  The problem is though, pain and emotion are not a good mix because they amplify each other.  Any of ‘the big five’ emotions can impact on the experience of pain; four have a negative valence - fear, anger, sadness and disgust, leaving joy as the positive emotion.  For anyone who is neurologically minded, brain regions (Ploghaus et al. 1999) including the anteriorcingulate cortex (ACC) - neurologically also part of ‘consciousness’ lights up in a person’s anticipation of pain in a laboratory setting in which, by the way, the subject knows he or she can literally pull out of.  For the distressed and resistive child in a procedure one can only imagine the activity in his or her ACC and Amygdala but the Hong Kong night skyline (above) comes to mind.

Note, Anxiety is not considered an emotion. It is a state of hightened physiological arousal typically with enhanced sympathetic output and subsequent characteristic features.

So, why, globally, do health professionals talk about anxiety rather than fear? A significant factor has to be the lack of education on Emotion Theory. Rhetorically, how much time did you, the reader spend in your basic professional education on emotions? If, like me it was zero (until I did my PhD) then it is not surprising we are uncomfortable with patients and families experiencing emotions, especially fear. It is easier to talk about anxiety and walk away. And yet, every day, we are in and around emotions with patients, families, colleagues and ourselves; often floundering in the deep end.

Regarding children and procedural pain the number one emotion is often fear. We experience the full effect of fear when our amygdala is turned on.  Output from the amygdala turns on the hypothalamic-pituitary-adrenal (HPA) axis (LeDoux, 1998) with all the fight or flight effects of sympathetic activation and behavioural response or ‘action tendencies’.  In the case of fear, the action tendency is escape.  Why?  To protect one’s self and survive (Plutchick, 1993).  When viewed through this lens we can understand the fearful child’s attempt to escape the procedure room.  As health professionals or as parents, it is important for us to not get stuck on the child's behaviour. Rather, ask ourselves “Why is this child behaving in this way?”  “What can we do to help this child through the wave she or he is experiencing?”

Sadness is a desperate emotion with the action tendency to cry.  Sadness and 'Hurt' can occur on many levels.  Again, emotions are normal and part of being human.  It is normal to cry when experiencing the emotion sadness or if feeling hurt.  If tears are building then it is best and more-than-okay to let them flow and release the emotion. For any guys out there who find this awkward, Christy Moore put it better than I ever could with his rendition of Cry Like a Man. Any thought of trying to control or hold back tears that need to flow is misguided even if, the wave is uncomfortable.  Drawing on principles from ACT here, acceptance is willingness to experience the feeling/thought/moment.  The opposite to acceptance is avoidance, which comes from an unwillingness to experience the feeling/thought/moment because it is uncomfortable, unwanted and judged to be negative. Avoidance as a coping mechanism in regard to emotion and procedural pain is problematic for the child because the situation and the emotions are literally unavoidable.

The action tendency with anger is to strike, to hit out.  Again, it is important to not get caught up in the child’s behaviour.  If a child is hitting out there is a reason and it is better to give the child an opportunity to express, to ventilate his or her anger in a manner that is not harmful to the child or others.  It is also useful to give the child his or her voice, to be fair and listen and importantly to let the child know you are listening.

If you have ever had a child vomit during or after a distressing procedure he or she may have been experiencing the emotion disgust.  The action tendency for disgust is to vomit, to reject, quite literally.  The emotion disgust is a powerful feeling and as with all emotions, it is normal and difficult, if not impossible to control.

We round off the ‘big five’ emotions with joy.  Thankfully one of them is positive!  Is it possible for a child to experience joy during a procedure?  The answer to that is anything is possible and yes. Sometimes we see the joy of achievement in a child who despite fusing with, ‘there is no way I can get through this’ actually sail through the procedure and feel very positive, even with a hint of joy.  Another way we can see joy in a child during a procedure is in guided imagery when the child is experiencing the emotion linked to whatever is unfolding in his or her imagery.  

If you navigate to ‘Guided Imagery Audio’ above you can listen to an 11 year-old boy playing cricket in his imagery while having a venepuncture. He hits the ball again and again over the fence for ‘a big six’; you will hear the joy in his voice at the end of the procedure.

Attention and Consciousness     These are not easily defined and rather than get bogged down in complex neurological discussion, I am more interested in the practicalities of experience in managing procedural fear and pain.  Having said that, the efficacy of both distraction and imagery as interventions draws upon shifts in attention and consciousness.  Obviously with effective distraction the child’s attention shifts from the ‘procedure’ to whatever the distraction is, and when that happens the distraction, if absorbing and engaging, becomes the focus of conscious awareness.  Pain is also experienced in consciousness and awareness but there is only so much the brain can process in the moment.  In the case of imagery the child’s consciousness and awareness becomes that of the ‘imagery reality’ and it competes for primacy with the ‘procedural reality’.  In the case of hypnosis there is an additional neurological string to the bow and that is responsiveness to suggestion, which amplifies the efficacy of top-down processing on consciousness and awareness.

Language and Thought    Language and thought are inextricably intertwined because we ‘think in language’ - the process of ‘having a thought’ has already brought it to language (personal communication from Dr Blake Peck, 2009).  In regard to pain, the language we as health professionals or as parents use with children can impact positively and negatively on the child and his or her experience of pain.  For an excellent overview of language and how to soften information about pain and procedures (as well as a host of useful and practical ways of helping children in pain) see Dr Leora Kuttner’s excellent text: 'A child in pain: what health professionals can do to help'. Also on the impact of language, I am mindful of Dr Sam LeBaron’s comments years ago at a presentation on pain at Royal Children’s Hospital, Melbourne, the gist of which was: To what extent do we as health professionals and as parents, with our constant reassurance, ‘You are going to be okay’, You can get though this’  ‘It won’t or might not be as bad as you are thinking’ and so on... Are we (with best intentions) actually winding the child up?  It is a bit like approaching the issue of fear with a child who is not particularly fearful... ‘I was okay until you started talking about fear’.

Language can have a positive and powerful effect without being direct.  This notion is well established in hypnosis with regard to the efficacy of both direct and indirect suggestion.  Children hear conversation between health professionals in the procedure room.  Upon removing a dressing for example, for obvious reasons we would never exclaim, “Oh no, this is a mess, this is going to take ages, you go to lunch without me”.  However, what about making a positive comment to a colleague (even if the task is complex) but with the intention of letting it slip within the child’s earshot?  For example, how would you feel in the dentist’s chair if the dentist turned to the dental nurse and said, ‘No, we won’t need the .... (some technical name for a piece of equipment) the ... will be fine, this is very straightforward... reassured perhaps?