[Cancer pain: Coping and communication.].
Anxieties and emotional disturbances associated with cancer often cause pain therapy to be unsuccessful. When psychological support is required it is mostly aimed at supporting cancer patients in attempts to cope with their disease so as to improve the efficiency of pain therapy. In our study we focused on the barriers to cancer pain management that lie in patient's beliefs about pain and their coping behavior. A pilot study was designed to examine the subjective experience of pain and coping strategies. In a sample of 146 cancer outpatients with pain we found moderate pain intensity levels and good physical conditions (Karnofsky), but an extensive impact on mood and vegetative symptoms associated with "constant or daily pain" and/or attribution of pain to cancer. Coping was characterized by stoicism, "being brave", comparison with others and self-encouragement, but seldom by communication, requests for help or such strategies as distraction, enjoyment and relaxation. Only one third of the pain patients communicated their pain. Women and the patients who had higher pain intensity levels were more likely to suffer in silence, but those who communicated had better acceptance levels of pain intensity than those who did not. In a second study we focused on two questions. What do patients think about pain therapy? Can patients' attitudes on pain and pain management be changed by an information brochure? Selected results obtained in a sample of 72 cancer pain patients are reported. From a 30-item list of statements about pain and pain management, which were extracted from the previous interviews, three distinct types of attitudes in pain patients were derived by cluster analysis. One group of 29 patients was characterized by "non-acceptance of analgesic pain management'. With respect to medication intake, they were afraid of subjecting themselves to physical stress, of addiction and side effects and of loss of control over the disease. They hoped their pain would disappear when the tumour therapy took effect (as with acute pain) and thought they could tolerate it stoically. These patients wanted to take medication only if tumour therapy had no effect and when death was imminent. They had a pain intensity level of 5.5 VAS (without therapy). Adequate pain therapy was given to 14.3% of the "nonacceptors", significantly less (P=0.002) than to the "acceptors" (n=31) who had pain intensity levels of 7.7 VAS (without pain therapy) and had attitudes quite opposed to those of the first group. Adequate pain therapy was given to 58.6% of this group. The third group of patients (n=12) was characterized by "ambivalence toward analgesic pain management". They were similar to the acceptors insofar as they did not fear addiction and side effects of medication, but they were similar to the non-acceptors insofar as they were afraid of losing control over the disease and of putting their body under stress. They also tended to bear pain stoically. Their pain intensity level without therapy was 6.3 VAS. With respect to coping strategies, communication was found significantly less often (P=0.001) than cognitive and behavioural coping. Those patients who used cognitive coping strategies and did not communicate often received inadequate pain therapy. Those who talked about pain but did not use any other coping strategies were mostly well treated. We have designed a brochure, "What tumour patients should know about pain" directly oriented on the above pain beliefs; this is now being evaluated with reference to its educational effect.
Seemann
H
H
Abteilung Psychotherapie und Medizinische Psychologie der Psychosomatischen Klinik, Universität Heidelberg, Bergheimer Strasse 20, D-69115, Heidelberg.