During the many years that I directed the UCLA Pain Control Unit, one of the most valuable things I learned was that it is possible for someone to have pain and yet not suffer. When two patients were admitted with similar diagnoses, histories, demographics, and objective findings, we would often find tremendous variability in how well they were coping with pain and its consequences.
The poorly coping patients were anxious, depressed, unable to sleep, work, or engage in personal relationships, and they grieved their inability to function as well as they did previously. Many were stuck in anger about their pain or denial about its impact on their work and family relationships. Most regretted various choices they made that led to the pain experience, and many tearfully mourned their loss of health, function, purpose, meaning, income and relationships. Clearly, they were suffering and had little, if any, tolerance to their pain.
The highly coping patients reported much greater tolerance to pain in general, as well as a consistently positive attitude and focus on the future. “You don’t go forward looking backward,” one said. Although they had to make major lifestyle adjustments to cope with pain, most continued working as best they could. Many benefited from strong family or church relationships and support. All were eager to learn about any treatment alternative that might be of help, and most remained hopeful and optimistic about the future.
Pain tolerance can have a huge impact on how patients respond to any type of medical treatment. With this understanding, we established five primary goals for the UCLA Pain Control Unit:
- To correct the underlying condition causing pain, if possible.
- To reduce or block the pain signal from reaching consciousness.
- To increase tolerance to pain so that it interferes less with work, sleep, relationships, and lifestyle activities.
- To increase the ability to self-manage pain, and decrease dependence upon medications and medical care.
- To treat people in pain, rather than pain in people.
In the clinical situation, there are limitations in our ability to reverse severe physical pathology such as in treating degenerative neurological diseases, so our first goal often remained unmet. The Unit was based in the UCLA Department of Anesthesiology and despite our use of many interventional pain management techniques, we were also not always successful in blocking pain.
However, we found that guided imagery could be used to raise pain tolerance, facilitate restful sleep, elevate mood, increase motivation, reduce dependence, and promote self-management. Guided imagery techniques enabled us to best meet our remaining three goals, and they became one of the most effective ways to help our patients reduce suffering even when “nothing more (medically) can be done.”
Increasing pain tolerance is the basis of effectiveness of some of our most potent analgesics. I’ve long believed that opiates have little to do with pain, and everything to do with suffering and the inability to tolerate pain. When people in pain are given an injection of morphine, they often state that “it still hurts, but it doesn’t bother me.” This represents enhanced central tolerance to pain rather than decreased pain intensity, yet it enables patients to become significantly more comfortable and functional in their lives. Other techniques that mimic or stimulate endorphin release, such as acupuncture, may also be effective because of their ability to raise pain tolerance.
Factors Affecting Pain Tolerance
Pain tolerance is defined as the amount of pain that a person can withstand before breaking down emotionally and/or physically. Pain tolerance is distinct from pain threshold or sensitivity, which is the minimum stimulus necessary to produce the experience of pain.
The ability to tolerate pain has been studied by numerous researchers in their laboratories, and many interesting findings have been published. For example, experimental studies have demonstrated that pain tolerance decreases with age, that men have higher pain thresholds and tolerances and lower pain ratings than women, and that whites tolerate more pain than Asians [1, 2].
Other studies have shown that the presence of an individual who provides passive or active support reduces experimental pain. Whether the person who is with them during the painful event is a friend or a stranger, just the presence of another human helps subjects to tolerate a much higher level of pain than when alone .
How relevant the results of such experimental pain studies are for clinical practice remains a controversial issue. Subjects in experimental studies know how and why the pain is being caused and that it will not continue for long or permanently harm them. This is not the case for people in chronic pain who often feel that their suffering will never end.
Some believe that regular exposure to painful stimuli will increase pain tolerance by helping the body to build “immunity” to the pain. However, the opposite appears to be true, for repeated painful experiences can teach a person how severe pain can become and how difficult it can be to get relief. In addition, greater exposure to pain results in more painful future exposures due to synaptic sensitization [4, 5].
Assessing Clinical Pain ToleranceMost busy clinicians do not have the time, expertise, or temperament to measure pain tolerance utilizing complex experimental protocols with dolorimeters or cold pressor tests, even though it might be helpful to do so. Fortunately, there are two simple guided imagery techniques that can be used to assess a patient’s clinical tolerance to pain. The first involves having them create a mental picture of their pain at its worst by offering the suggestions in Table 1 .
Once a clear image of their pain has formed, a variety of helpful Interactive Guided Imagerysm techniques can be employed, which I have described in detail elsewhere . For example, an experienced imagery guide can invite the patient to enter a dialogue with their pain, to ask why it’s there, what it wants, what it needs, what it has to offer, and under what circumstances it would be willing to leave. This can reveal important information about the source of the pain experience and how well patients relate to their pain .
A Picture of Pain At Its Worst
I strongly encourage all clinicians to provide colored marking pens and paper so their patients can draw the image that represents their pain at its worst. Let your patients know that they do not have to be an artist and that their drawing can be as simple, abstract, or comprehensive as they want.
As they say, “A picture is worth 1000 words” and a close examination of such patient drawings can reveal critical information about their pain experience that you will not find revealed in any medical history or standardized psychometric tests.
For example, Figure 1 (the featured image of this article at the very most top position) shows a drawing by a patient with post-laminectomy pain who has been totally victimized by chronic pain. He ultimately revealed that the pressure on the clamp that was making his pain unbearable was being applied by a close family member who he could not control. By resolving this family conflict and learning to use imagery techniques for pain control, this patient was able to raise his pain tolerance sufficiently to permit his return to gainful employment. While this patient obviously has artistic talent, such pictures can be as simple as stick figures while still providing clues to the patient’s pain.
Another picture drawn by a patient with migraines – depicting hands clamping the legs, tearing out guts, punching the jaw, choking the neck, pulling out an eyeball still attached to its optic nerve, pulling hair, and stabbing and shooting pointblank into the head – clearly is not tolerating the pain well.
The SUTS Scale
The second assessment technique is equally simple. Many clinicians use a SUDS (Subjective Units of Discomfort) scale to measure pain intensity by asking, “On a scale of 0 to 10, where 0 represents no discomfort, and 10 represents the greatest discomfort you can imagine, how uncomfortable is your pain right now?”
We can also utilize a SUTS scale (Subjective Units of Tolerance Scale) by asking, “On a scale of 0 to 10, where 0 represents no ability whatsoever to deal with or tolerate pain, and 10 represents the greatest tolerance, endurance, and strength you can imagine yourself achieving, how well are you tolerating your pain right now?” As I record their tolerance ratings, I respond by saying, “How would you like to learn a way to make it 20, 30, maybe even 100?” and rarely get turned down.
In Part 2 of this series, I explore guided imagery and healing, positive and negative imagery, and the importance of relaxation, as well as discuss guided imagery techniques, such as “Mind Controlled Analgesia.”
David E. Bresler, PhD, LAc, DiplAc (NCCAOM)
Practical Pain Management is a monthly journal that contains tutorial articles designed to help diagnose and treat various aspects of pain. This publication is sent free of charge to medical practitioners in the United States.
Citation / Material adapted (with permission) from:
Bresler, D. (2010). Raising pain tolerance using guided imagery. Practical Pain Management, July/August, 10(6), 25-31.
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6. Excerpted from Bresler DE. Mind Controlled Analgesia. LA: Imagery Resources. 2008. Available from www.acadgi.com/imagery store.
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