understood basis, we have blocked the tissue horm ones with aspirin. N ow th a t we have so m any m ore drugs to control th e release o r effects of tissue horm ones we can achieve considerable pain relief by controlling the tissue response to trau m a — swelling, inflam m ation and the liberation of chem icals fro m the dam aged cell. In o u r age of burgeoning pharm acology we som e­ times overlook th e value of treatm ents th a t restore norm al function to an area of the body. Ischaem ia causes pain; is th ere adequate oxygen supply o r nu trien t supply to the injured p art? D istu rb ed function in one area m ay disturb an o th er area to cause pain. T his is a very large subject and in large m easure it is w hat physiotherapy is about. The Spinal Cord M any of the m ost effective nerve blocks available to us are on the spinal cord a fte r the first reception station of pain inform ation. T hese spinal and ex trad u ral blocks xthat we do offer an o th e r possibility of blocking different itypes of nerves so th a t fast pain m ay be separated from slow pain and m uscle pow er can be unaffected w hile we produce graded sensory block. It is valuable to be able to do this in the investigation of unusual pain syn­ drom es, and to separate autonom ic pain from som atic ^ A u to n o m ic a lly active drugs are frequently overlooked in pain treatm ent. If you can relieve the spasm of an artery in m igraine, o r of the gut in the sum m er fruit season o r of the uterus during m enstruation, you relieve acute pain integrated at spinal cord level. O th er drugs reach th e spinal co rd in th e blood stream ; these the m orphine-like drugs are tcch y the m ost im portant. H ow ever, w ith new u nderstanding of the synaptic transm itters involved in pain pathw ays in the spinal cord, new drugs will w ithout d o u b t be developed. JUNE 1979 The Brain We have drugs th a t influence the objective response b u t do not serve as good analgesics, ra th e r producing sleep, by acting a p p aren tly only on th e cerebral cortex. M any of the drugs used in psychiatry have a place in treating pain which is not unexpected if you think 41 of m uch m ental disease as uncontrolled m ental pain. T h e e u p h o rian t drugs such as cocaine, benzedrine and m ethedrine, w hich we are not allowed to use, have p ro fo u n d effects on pain perception, making it less im portant, m ore bearable. A ntidepressant drugs likewise have an established place in treating chronic pain; un fo rtu n ately m ost are too slow acting to be of use w ith acute pain. If one looks fo r a fast acting antidepressant drug one comes back to m orphine w hich has been used from time im m em orial fo r this purpose. A m nesic drugs, whilst they m ay not ap p ear from the p a tie n t’s response to bring pain relief, are used never­ theless. “T w ilight sleep” with scopolam ine fo r “painless ch ild b irth ” is a n exam ple. W h at should be m ore fully explored is the use of com binations of drugs to suit individuals. W here m o r­ phine is insufficient we frequently com bine it with tranquillizers (diazepam , lorazepam , droperidol) o r a n ti­ depressants such as chlorprom azine and achieve a better effect. Still b etter is to com bine such a com bination w ith one of the peripherally acting drugs, such as in tra ­ venous aspirin. A naesthetics p robably act in a m orphine-like way and also affect fast pain perception by producing sleep. The Response H ow m uch does th e adrenaline secretion, o r the spasm of injured m uscle influence pain p ercep tio n . C ertain ly b o th are pow erful a ro u sal m echanism s of the reticu lar system which is associated with real pain p e r­ ception. W hilst n eith er curare n o r beta adrenergic blocking drugs are regarded as analgesics, they are used in drug com binations w hich m akes it look as it they m ight have analgesic effects. A naesthetists don t o ften think a b o u t this. . . Surely the greatest e rro r we m ake in treating pain is to believe th a t a single ap p ro ach m ust be effective. A nd the second e rro r arises fro m o u r inability to m easure pain in som eone else so th a t we d e c e iv e ourselves th at o u r treatm en t som etim es w orks b etter than it in rac d °If we regard pain as a com plex response w ith p a th ­ ways at all levels fro m the individual cell to the most highly integrated m ental function, then we may better control it. P H Y S I O T H E R A P Y T H E PSYCHOLOGY OF PAINf A. D. M U L L E R * M.A. (U .P.) D .L it. et. al. (A.M.S.T.) IN T R O D U C T I O N A fter all th e in fo rm a tio n you have already received this m orning it w ould seem unnecessary, perhaps even superfluous to add anything else at all, and seeing th at I am painfully aw are o f the fact th a t I will not be forgiven if I just reiterate w hat was said, very elo- quently, by previo us speakers, I m ust im m ediately d e c la re ’m y interests in this m atter. I am p articip atin g as a hum an scientist an d as such I think th a t I represent a certain perspective which m ay com plem ent w hat was already given to you, * P rofessor of In d u strial Psychology, U niversity o f the W estern Cape. V f P aper read at Pain Sym posium , preceding 13th N a tio n a l C ouncil M eeting 23 - 27 A pril 1979. in th a t way co n trib u tin g tow ards a fuller understanding o f th e vexing problem s surrounding he pain p h en o ­ m enon. As a hum an scientist, a psychologist in my case, I hold certain views w hich m ay differ in certain respects from those already given to you; no t in any way diam etrically opposed, perhaps only certain accents will be placed on different aspects. THE IM PORTANCE OF THE U N IT Y OF A PER SO N ’S EXISTENCE A lthough it is factually so th a t a h u m an being can be described in term s o f body, m ind, o r person lang­ uage as Prof. D egenaar in his excellent paper ex­ pounded, this introduces to m y way o f thinking a th re a t to the full understanding of the unity of a person’s existence n o t as a final product of all the separate approaches but as a starting point. Some protagonist o f th e sam e p oint o f view I hold, once R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 42 facetiously said th a t if w e separate b ody and soul (as psyche an d som a, o r w hatever o th e r term s we m ay use), then, on the one han d w e end u p w ith a soulless body an d o n the o th e r han d w ith a bodyless soul, in o th e r w ords w ith a corpse an d a ghost!! “ A nd all the king’s horses and all th e king's men, w ill n o t be able ____!” etc. I m u st stress the u n ity o f in dividual experience in an im m ediacy th a t precedes th e scientific need fo r g reater specialization and abstraction. I th in k th a t we m ust have it q u ite clear in o u r m inds th a t no individual experiences his p ain as being eith er neurological, physiological or psychological but just as p ain , his pain. P erh ap s it is also im p o rtan t to no te th a t p a in as a generality exists only in the m inds of people talking a b o u t it o r studying it; real p ain , in contrast, is alw ays specific, is alw ays the pain of a specific h u m an being; a person w ith a nam e and a surnam e; w ith a h isto ry and p erh ap s w ith a perceived future. I t is this suffering person, also being aw are of the fact th a t he suffers, th a t we are concerned with. T H R EE M ODES OF BEING -IN -TH E WORLD To u n derstand this sufferer we m u st analyse and try to u n d erstan d th e background against w hich this individual becom es visible to us. F o r this background I w ould lik e to use th e term ‘w o rld ’; a term th a t R ollo M ay (1961): defines as: “T he stru ctu re of m eaningful relationships in w hich a person exists and in the design o f w hich he p a rtic ip a te s” . W e cannot understand the b eh av io u r o f any person fully by describing his environm ent, im p o rtan t as it m ay be, as environm ent constitutes only one m ode of w orld to h im — th e “w orld — a ro u n d ” th at we share w ith all o th er “organism s” . T his is the w orld of biological d eterm in atio n o f b irth , ageing, dying, the w orld o f objects a ro u n d us, th e w orld o f n atu ral laws and n a tu ra l cycles, o f sleep and w akefulness o f desire and relief; th e ‘w o rld ’ into w hich we a re catapulted a t b irth and to w hich each o f us m ust adjust in some w ay o r other. A p a rt fro m th is o r rath er interw oven th ro u g h this, m an creates o th er w orlds fo r him self. Binsw anger (1942) m en tio n ed tw o o f these: The world o f our being with others: T his w o rld is constituted b y o u r in terre latio n sh ip s w ith o th er hum an beings and th e stru ctu re o f m eanings designed by the in terre latio n sh ip s of the persons in it. In ’■the e n v iro n ­ m ent we talk o f adaptation and a d ju stm e n t, but in this w orld-w ith-others the m ore ap p ro p riate term s is ‘re­ la tio n sh ip ’: th e essence of a relatio n sh ip being th a t in th e encounter b o th persons are changed. The own-world or private-world: M y w orld o f con­ sciousness o f m y self-aw areness, o f self relatedness, th e result o f th e m ost intim ate and m ost m eaningful o f all dialogues, m y dialogue w ith m yself. T h is is the realm of my self-image, self-esteem and m y self-confidence. T hese m odes o f world are in th eir m ost creative and p ro ­ ductive form s unique webs of interrelationships, in ti­ m ately b o u n d u p w ith m y ego, as the centre of identity and co n tin u ity th a t guarantees m y conscious being. TEM PORALITY T e m p o ra lity is one o f the m ost im p o rtan t coordinates o f the w orlds we create; coordinates w hich assist us in determ ining o u r p osition physically and sp iritu ally as we travel th ro u g h life. A lthough w e of th e W est have fo rm ally chopped tim e up into equal blocks o f seconds, hours; o r days, we, as a m a tte r o f fact do n o t experience tim e in this w ay; fo r tw o people in love tim e flies, fo r tw o people aw aiting news a b o u t a son declared lost o n the Border tim e drags. F o r th e euphoric, h ap p y individual the passing 0r tim e is h ard ly noticeable, fo r the depressed individuai tim e stands still, becom es a quagm ire. Patients in a hospital experience tim e differently because all, 0r m ost, o f the usual m ilestones have fallen aw ay and thev create new ones th a t usually becom e extrem ely impor. tant. W e cannot b u t be struck by th e fact th a t th e most p ro fo u n d and central hu m an experiences like anger joy, depression and anxiety always occur in the dimen’ sion o f time. We m ust th erefo re u n derstand w hat the m eaning of tim e is fo r th e suffering patient; how he relates him self to th e tem p o ral stru ctu re of paS( p resent an d fu tu re w here th e past is constituted as that w hich lie behind one, closed, unchangeable, history o pen only to m a n ’s frail and counterfeiting memory- the realm o f th e obsolete, accom panied by guilt re­ m orse. T h e fu tu re on the o ther hand is constituted by that w hich is still to happen, is th erefo re com pletely open to the p o in t of unreality. T h e fu tu re is also the realmd o f hope, expectations an d ethical action — the horizon^ o f our expectations. W hen the fu tu re is perceived in any w ay as closed o r foreshortened, the flow of time is tu rn ed ro u n d and flows back into th e past, invariably followed by feelings o f rem orse o r sham e and guilt and eventually a severe depression. T h e present, that illusive p oint w here fu tu re passes into p ast if we do no t succeed in stopping it. T h is is only possible through consciously acting upon it. To assist and help a p atien t in p ain one must have a n understanding o f these w orlds o f th e patient, one m ust be able to grasp how this p articu lar person gives m eaning to w hatever happens aro u n d him . It is not only im p o rtan t, it is im perative. T h ere are m any problem s su rrounding the pheno­ m enon of p ain th a t w ould, I think, rem ain unanswered, if we do n o t accept the lived w orld as o u r point of d eparture, e.g. is pain th e o p p o site of pleasure? or does the existence o f the m asochist who seems to derive pleasure fro m pain fu l experiences p u t a lie to that? H ow is th e thesis o f a d irect relatio n sh ip between a so-called p ain stim ulus and pain experience altered by phenom ena like “ glove anaesthesia” exhibited by a hysterical p atien t and hypnotically induced anaesthesia, th at in som e cases w orked so well th a t people could be o p erated upon. H ow do we explain B akan’s (1968) experim ent wherei he induced p ain in th e phantom lim b of a patient b \ i referrin g to som e cause of anxiety in the patient’s p riv ate social w orld? Is it not perhaps possible to explain it, in the light o f w hat we have said so far, as follows: This ex­ perience caused the p atien t to restru ctu re his lived- w orld so that he could m eaningfully integrate this new in fo rm atio n , b u t being un ab le to do so successfully constrict his existence to the lim b (w hich is not there in an y case!)? COPING W ITH P A IN P ain as perceived by the sufferer is determined, not only, and p erh ap s n o t even prim arily, by the quality and the q u an tity o f th e p ain stim ulus, b u t by deter­ m inants o f behaviour, like background, education, cu ltu re etc., and, by th e ab ility o r inability of ‘he p atien t to m eaningfully integrate this experience into his w orld. ., In the coping o f th e p atien t w ith his p a in one. f ou'ii see th is as a tw o-pronged ap proach th a t one could c a hygiene app ro ach and a grow th approach. H ygiene approach a s s u g g e s te d b y M e lz a c k (IV JUNIE 1979F I S I O T E R A P I E R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) “gate-control th eo ry . . . suggests th a t p a in control may be achieved by th e enhancem ent o f n o rm al physio­ logical activities ra th e r than th e ir d isru p tio n by destruc­ tive, irreversible lesions. In p a rtic u la r it has led to attempts to control p ain by a ctiv atio n o f in h ib ito ry mechanisms. This not only refers to aspects like ph arm aco ­ logical control o f pain, o r sensory control o f p a in by using anaesthetic blocking agents b u t also to the psycho­ logical control o f p ain by m eans o f m ethods o r tech­ niques like progressive R elaxation (Jacobsen) Autogenic T rain in g (Schultz) or C oncentrative self R e la x a t io n H y p n o t i c suggestion techniques Desensitization techniques psychotherapeutic relief of anxiety or depression All these I refer to as hygiene m ethods. Grow th methods: T h ere is enough evidence th a t in term s of personality grow th b etter results can som etim es be obtained by freeing the p atien t to face up to the pain /^experience. As M aslow (1962: 97) puts it peak expe- Triences like pain are usually acute identity experiences, jUNE 1979 43 i.e. experiences th a t could assist a person to face up, not only to pain, b u t u ltim ately to him self, to see him for w h at he really is, to try an d live a really authentic existence. In such an existence pain w ould not neces­ sarily be seen as an enem y, b u t as an oppo rtu n ity for self developm ent and self-enhancem ent. F o r after all, w hat w ould life be like if th ere was no pain left? N o headaches when I have drunk too m uch, no tum m y aches w hen I have eate n too m uch. If p a in as signal, sym bol and significance disappeared, w ould n o t death be n e a r a t hand? Bibliography: 1. D egenaar, J. Some Philosophical C onsiderations on Pain. 2. M ay, R ollo (1961) Existence. Basic Books. N ew Y ork. 3. B insw anger, L. (1942) G rundform en un d E rkenntnis M enschlichen D aseins. V erlag. M ox N eihaus. 4. B akon, D . (1968) D isease, P a in and Sacrifice. 5. M elzack, R . T h e Puzzle o f P ain. Penguin Books. 6. M aslow , A. H . T ow ard a Psychology o f Being. P H Y S I O T H E R A P Y THE H O L E OF T H E RADIOTHERAPIST IN TH E CONTROL OF P A IN f H . S. K IN G * M.B. Ch.B. (W itw atersrand), M .M ed. (R a d io th e ra p y ) (U.C.T.) It is a popular m isconception that all patients with malignant disease die in great pain, in fact, fe w patients do have this problem . It can be dealt with by radiation — particularly fo r bone pain, cytotoxics, and analgesic drugs. Regular use o f drugs is better than waiting fo r pain to become severe. I shall be ado p tin g a p u rely practical ap p ro ach to this subject, as you will have heard, o r be going to hear, the philosophical, psychological and spiritual approaches. I like to th in k th a t we are aw are o f these other aspects and are able to help th e p a tie n t in these other spheres, but we are m edical personnel faced w ith the practical m anagem ent of patients w ith m alignant disease, and term inal p ain and discom fort, i Firstly, I w ould like to disperse the com m on belief Jthat all patients w ith m alignant disease necessarily die in great pain. In only a fa irly sm all p ro p o rtio n o f patients is severe p ain a problem , p articu larly in the terminal stages. O th er form s o f discom fort and distress may often be present, fo r we do n o t shuffle off this mortal coil all th a t easily, b u t even these sym ptom s can be dealt w ith if handled skilfully. For patients w ho do have pain, how ever, we have three specific m odalities — rad iatio n , cytotoxics, and analgesic drugs. R A D IA T IO N This is used very often in early disease w ith curative intent, bu t in late disease it can also be a very useful modality. Bone metastases . Breast carcinom a, bronchial carcinom a and gastro­ intestinal carcinom as can all m etastasize to bone, and R adiotherapy D ep artm en t, G ro o te Schuur H o sp ital and U niversity o f Cape Town. Paper read at P ain Sym posium , preceding 13th National C ouncil M eeting 23 - 27 A pril 1979. these are the m ost com m on cancers in the W estern w orld. In ad dition, m yelom a, m elanom a, th y ro id tum ours and a v ariety of o th e r tum ours m ay m etasta­ size to bone, and I believe ra d ia tio n to be th e m ost effective m eans o f dealing w ith this type o f pain. Pressure F o r p atien ts in w hom pressure on nerves o r o th er organs m ay cause p ain , ra d ia tio n m ay be a rapid m eans o f alleviating th e latter. T h e nerves involved m ay be th e b rachial plexus, sciatic nerve, o r those in the retro p erito n eal region. These, being local problem s, are best treated w ith a local form o f therapy, even in late disease. Enlarged organs G ross enlargem ent o r distension of organs due to tu m o u r m ay cause severe pain. T his m ay be relieved by irra d ia tio n by reducing th e bulk. CYTOTOXICS 'C y to to x ics can be used in com bination w ith irra d ia ­ tion in all these instances, b u t they are seldom effective on th e ir own except in very sensitive tum ours o r w here irra d ia tio n has already been used. H ow ever, even sensitive tum ours such as lym phom as and sem inim as, m ay need to be treated w ith irra d ia tio n if they have m etastasised to bone. ANALGESIC D R U G S P atien ts who present a problem w ith pain m ay have developed a p ro b lem because th e ir doctors are fearful o f addiction. I do n o t believe th a t this is a facto r in p atien ts w ith severe p a in due to m alignant disease. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )