💬 Coloquio | Introducción a la clínica del dolor crónico: perspectiva psicológica

Added: 2026-05-20

[00:00:02][music] [music] [music] [music] [music] [music] [music] [ music] [music] [music] [music] [music] [music] [music] He.

[00:04:44][music] [music] [music] [music] [music] [music] [music] [music] [music] [music] [music] [music] [music] [music] [music] [music] [music] [music] [music] [music] [music] [music] [music] [music] [music] [music] [music] [music] [music] [ music] [music] [music] [ music] As director of clinical psychology studies, and in parallel, as a researcher in the psychiatric emergency and care department of Monte P6, she has developed her research and chemistry in various institutions in Chile, Spain, and France. Her main lines of research focus on the psychological impact of hereditary diseases and pain-related disorders. Welcome back, Carolina, we'll give you the floor. Well, thank you all very much for being here, and thank you for the invitation, to Marcela, and to Karina as well for organizing it.

[00:13:59]Well, the idea is to talk a little about chronic pain, about the role of psychology in chronic pain. As Marcela explained, I work at, or rather, I am the director of the Master's in Clinical Health Psychology at PIT. Now, let's differentiate what the master's program is like here compared to there for us. I mean, in France, uh, psychology, the degree is three years plus a license, or there isn't a great selection process there. If you get good grades, you get to the third year; from the third to the fourth year is the big selection where you choose a specialization, and that's what's called a master's degree, which for us would be the last two years of the degree in reality. Already? So there the students are a huge selection, I mean, I tell you that now we are in the selection and we have 13 candidates for 25 places. 13 candidates.

[00:14:48]So this is complicated because many people manage to get their license, but not everyone; only a small percentage manage to become a psychologist because master's degree places are very, very limited. Then, thirdly, psychologists, that is, people who are licensed, choose their specialty, and there we have neuropsychology. psychology, that is, psychopathology, and I am in clinical health psychology.

[00:15:11]So, it actually corresponds to the last two years of the degree, not like here where it's essentially a postgraduate degree. Already.

[00:15:17][suppressed scream] And when I talk about pain, well, precisely in this master's program we have an entire course dedicated to chronic pain. Um, and I always like to start with this phrase, which is a quote from a book by Stephan Nietzsche, which actually says, "All science comes from pain. Pain always seeks the cause of things, while well-being inclines to remain still and not look back." Why do I like this phrase? Because it reminds us that pain is a driving force. Ah, that it has this capacity to help us adapt, like anxiety. It's unpleasant, yes, but it's a driving force for us and it helps us survive. The problem is that there comes a point when this pain no longer has that useful function and it becomes a syndrome, an illness in itself, right?

[00:16:12]The difficulty or paradox we have in clinical health psychology, and what we work on a lot with students there, is that unlike psychologists who go on to work in psychiatry, in psychopathology, where one doesn't ask much of the question of why it has to do with the Psychologist. You know you have a mental problem, psychological suffering, you go to a psychologist. On the other hand, when we work with patients where the somatic complaint is primary, there may be many people who are resistant to consulting psychologists.

[00:16:41]So I gave them this quote, which is good because it's a patient, but this is quite frequent. Finally, when asked about the possibility of seeing a psychologist for his pain, this man is firmly opposed. That's useless. They ask about life, childhood, and sexuality. I'm sick, my body hurts, I'm not crazy. This is the great difficulty we have in clinical health psychology: trying to support patients who might not ask for it because they have a physical problem, and that's sometimes the reason for seeking help. At least in France, this is progressing. Oh, and things are quite good now in the sense that many psychologist positions in somatic health services have opened up.

[00:17:19]When I started, this was quite scarce. We, the students who graduate, find positions very quickly now because It's opened up, and now a clinical health psychologist is going to a somatic health service, which wasn't the case before. Right?

[00:17:37]So, what is psychology? What role does psychology play in chronic pain management? What can we tell these patients who don't understand or don't see the relevance of psychology when their body hurts? Ah, that's a bit of what we're going to try to explore here. So, as I was saying, pain—and this is a basic first classification, we're introducing chronic pain management here—is differentiating between acute and chronic pain. Acute pain is useful pain, right? This pain helps us survive, take care of ourselves, it's a warning sign that something isn't right and motivates us to ask for help, to go to a doctor, and so on.

[00:18:21]Psychologists don't get too involved with this type of pain because it's pain that will usually evolve and has a good prognosis. It occurs when we have an injury, for example, Um, in some tissues. Oh, for example, right, Marcela showing us her skin. Yes. Well, once the tissue regenerates, normally everything will be fine. Okay? The difficulty is that sometimes that pain, which can start as acute pain, can become chronic. And that's where the problem lies, and that's where the clinical health psychologist's field of action becomes very important. So, to distinguish some elements, well, acute, short duration; it's considered chronic after 3 months, when even though the injury, if there is one, regenerates, even though there is treatment, the pain persists. We can see that it becomes chronic, right?

[00:19:17]Acute pain, as I said, is this pain. Ah, although it's extremely unpleasant, it has that alarm and adaptive function. In contrast, chronic pain loses that alarm function, that ability to help, right? And it becomes an illness.

[00:19:33]The origin of acute pain in general is an injury. Okay? We We fracture, we bump into things, we cut ourselves, you know? I mean, an injury to some tissues. On the other hand, chronic pain doesn't always have an identified cause. Well, acute pain will respond well to classic analgesics, like paracetamol. But with chronic pain, that's where we run into a problem.

[00:20:01]Today there's no miracle cure for chronic pain. So, let's see later what can be done, modestly, because honestly, neither medicine, nor psychology, nor physical therapy alone will be able to completely improve the quality of life for their patients. We're not in a position today to say, we're going to improve or eliminate the pain. Okay. We're helping patients live better with it.

[00:20:27]Well, that's the first definition.

[00:20:31]I looked at some data in Chile, because epidemiology, epidemiological data, is important to understand the magnitude of the health problem. I'll tell you that in France, the latest data on chronic pain in adults... They went up, so we're worse off, let's say. I mean, in 2018 it was 30%, well, we always know there might be methodological differences, studies that make the figures vary, but well, in 2018 it was 30%, the latest figures give us a 42% prevalence of chronic pain in adults. In Chile, I saw a recent study that says it's 34.7%. In any case, internationally, in general, a third of the population suffers from chronic pain. It's always more frequent in women, in older people, and in people with chronic illnesses. Now, the pediatric population is also quite frequent. Ah, there's a recent meta-analysis that says that roughly 20.8% of the pediatric population of children and adolescents suffer from chronic pain. More importantly, headaches and musculoskeletal pain. Right. Well, you can imagine the social cost, not only the cost for the people who experience it and for their families, but the cost at the societal level. It implies.

[00:21:43]So, we're really talking about a major public health problem.

[00:21:49]Now, um, I think, and this is also very useful for patients, especially thinking about this patient who seems resistant to receiving psychological support when suffering from chronic pain. Remembering a little bit about how the concept of pain has evolved throughout history helps us understand why psychology is so relevant. I say relevant, I mean so relevant in the treatment and assessment of chronic pain.

[00:22:18]If we remember, before we had knowledge of how our bodies functioned, etc., explanations for pain were of a magical or religious nature, right? So, pain was a divine punishment, etc. This well- known illustration was one of the first to evoke a theory based on a linear medical model, right? That is, cause and effect, right?

[00:22:51]And this is what prevailed for a long time, and how this idea worked was that, well, we have an injury, the The cause is identified, known, for example, like the illustration, we burn our foot, and well, there's a stimulus, right?, that travels to the brain, and there we detect this painful perception. And this makes sense for many types of pain, but not for all. Ah, what is the consequence of this model? Because this model fell short. Because, what does this mean? That if the cause is unknown, not identified, then the pain doesn't exist, and if the pain doesn't exist, we're not going to propose anything. Right. And today we know, or rather, for quite some time now, that there are pains in which the cause hasn't been identified. Right. And what happened? That the knowledge or the conception of pain evolved with some findings. For example, the realization of the phantom limb phenomenon, right?

[00:23:48]That after an amputation, there are people who continue to perceive pain. And this study, which is very interesting, very old too, but relevant precisely to understand how things evolved, which is Bitcher's study in the War wounded. What did this doctor do? Ah, he compared two groups of war wounded. One group was military personnel, and the other was civilians. The comparison, obviously, to make sense, was between people with equivalent injuries. Ah, the only difference was that one group was military personnel, and the other was civilians. Right? And what did this doctor observe? He observed that the demand for painkillers was much higher, significantly higher, in the civilians—twice as high.

[00:24:40]What does this suggest? That either the military personnel felt less pain or they were more tolerant of pain. Well, that was the fact. So, I always ask, well, how can we explain this difference? Does anyone have an idea so we can make this a little more interactive? How can we explain this difference?

[00:24:56]Yes. Where did the difference come from? Where could it be prevented? How did that physical change change the civilian? It was like having a doubt about what could happen.

[00:25:14]Right, I mean, in a certain way, the military personnel know what they are exposed to; there is no anticipation of risky situations, and this was part of, let's say, Of course. Civilians. Yes, exactly. Yes. Well, you see, if we keep speculating about this, the explanations that generally come up aren't of an organic nature. Ah, that's exactly what you're saying. Um, what happens is that the two traumas occur in a completely different context. Ah, for the military, well, in the end it's better than dying, let's say. Ah, plus there's social recognition, they're heroes, right? The war ends, we go home, anyway, there's a context that's very, very different from what happens with civilians where everything is loss. They shouldn't have been injured, right? There's loss, there's a situation of injustice, right?

[00:26:04]Financial losses, and so on.

[00:26:06]So, more than the wound itself, because the wound was equivalent, right? It was the context, the interpretation of the context, and then psychological variables are what can make a person tolerate more or perceive more or less pain. Right?

[00:26:24]So, from this knowledge, this famous door theory appears, which... You've probably heard it before; it's fundamental in the study of chronic pain. It's the first theory that integrates psychology into the mechanisms, into the understanding of the mechanisms of pain. Before this theory, it's important to note that psychological factors were considered, but only as a consequence. That is, okay, I have chronic pain, and consequently, I get depressed or anxious. But not here. Here, psychological factors come into play in pain perception at the same level as physical factors, okay? And that's why it's so important, and it's super useful to explain this to patients so they understand why it's necessary to increase our psychological resources and eventually pursue psychological therapy in the case of chronic pain. What does this gate theory, dating back to 1965 by Melsa and War, say? Ah, they say that in the spinal cord there's a metaphorical gate. Okay? This metaphorical gate, in very simple terms, as explained to patients, is a gate that can open and close to painful stimuli. Okay?

[00:27:38]Uh, the point is The question is, what are the factors that allow us to open the door—that is, to let more of these painful stimuli through and therefore have a greater perception of pain—or close it, which would prevent or alleviate this pain in some way?

[00:27:55]Well, these factors are of several types. We have physical factors. Ah, everyone has experienced this.

[00:28:00]For example, if we bump ourselves, what do we do? We, for example, rub it gently. If I rub too hard, this is a physical factor, right? If I rub too hard, or if I get a burn, it's going to hurt. This would open the door.

[00:28:15]But if I put on, for example, a cold compress, this is a physical factor that will relieve the pain.

[00:28:21]So, this closes the door. Right.

[00:28:24]Physical factors also include, uh, taking paracetamol. This will close the door. Ah. But at the same level are psychological factors, and there we classically find cognitive, behavioral, and emotional ones. For example, everyone Have you ever experienced this? Imagine we have an unbearable toothache, right? But then a friend calls, and what happens? You forget about the pain for a moment because you're distracted. So, these are elements that distract your attention. Plus, you get in a good mood because you laugh, and so on. You're having a good time, your emotions change. And what happens to the pain? At least for that little while, the pain lessens. So, what can we say?

[00:29:04]That these psychological factors, for example, in this case, emotions and distractions, will close the door. Okay? Well, and the same goes for social relationships, and so on.

[00:29:14]So, making patients understand, explaining that it's not just a matter of physical injury, but that our psychological factors or functioning are key and even influence perception, and not just as a consequence, will allow us to work on these aspects because that's the good news. The good news is that all these factors are modifiable, and that's what we... She works in therapy precisely with patients with chronic pain. Hmm. Don't hesitate to interrupt if you have any questions or comments. So, well, this is kind of the same thing, I'm not going to dwell on it, but, uh, a catastrophizing-type commission, I'll never get over it, etc. This is going to open the door. Ah, uh, I avoid moving, something behavioral, right? Uh, it opens the door, and vice versa. I know I can handle it, something more with self-efficacy, right? This is going to close the door. Ah, well, I think the idea is clear. So, if we go back now to the definition, to the current definition of pain, it is an unpleasant sensory and emotional experience. We can see that it's not just a physical issue; psychological factors are included in the definition associated with, or similar to, actual or potential tissue damage. This aspect is super important because, ultimately, what it means is that if a person tells us they are in pain, we believe them, regardless of whether there is an identified injury or not. We already know about fibromyalgia and a lot of other things. In other painful syndromes, we don't do all the medical tests and everything comes back normal. Well, if the person says they're in pain, we believe them because that's the definition, and we know that pain can't always be explained organically.

[00:30:59]So this also leads us to the idea that there are injuries without pain and pain without injury. There isn't necessarily a correlation between the size of my injury and the size of the pain, right? Because a 2 cm wound will hurt less than a 4 or 5 cm one. It's not proportional. It's a whole different world; each person has their own tolerance, and so on. And we have to take all of this into account when we see patients.

[00:31:29]This definition also takes us back to the past, to the old conceptions, where pain, or rather our response to pain, was more passive in the face of an external stimulus. We just waited for the effect of the medication we were given, for the tissue to regenerate. Today, the response is more about self-control and self-management, more or less.

[00:31:53]Effective. But here I always say the same thing, listen, that doesn't mean that if a person is in pain it's their fault, it's not that. I mean, that's like a misinterpretation of this phrase, let's say. No, it doesn't mean that, it means that we all have the capacity to develop psychological resources and modify these things to also be able to modulate our perception of pain. That's where the issue of self-control and self-management comes in.

[00:32:23]Well, classification is also important to consider according to the pathophysiology or according to the origin. Hello.

[00:32:33]Hello. Hello.

[00:32:35]We already talked about how there was an initial classification based on the evolutionary profile. Ah, acute pain versus chronic pain. This, according to the pathophysiology or according to the, sorry, the origin, right?

[00:32:47]Noisceptive pain, neuropathic pain, and what is now called nociplastic pain. Noceptive pain, since you gave me your example, is what Marcela has. She gets an injury.

[00:32:58]Ah, what happens with acute pain.

[00:33:00]We have an identified injury. Well, normally the Receptors carry the inflammation, pain, etc. This has a good prognosis. It will subside as the tissues regenerate. Right.

[00:33:13]And then I gave the example of when we do n't drive in a nail, we fracture something, etc., with that pain, it's the alarm pain, the useful pain, let's say.

[00:33:23]Ah, neuropathic pain is more complicated. Why? Because here there is an injury or dysfunction of the nervous system. So, there are erroneous pain signals sent to the brain, and this can have a greater tendency to become chronic. Yes, it's a question. In neuropathic pain, there is necessarily a structural lesion, not always identified.

[00:33:47]Someone identifies it, it's not always what we're going to talk about.

[00:33:50]Right, I was thinking when I had a little knowledge, like in terms of comparing it to other pain.

[00:33:57]Yes. Well, it's assumed that in neuropathic pain there's something wrong with the nerves, right? With the nervous system, right? And that's going to cause the pain because erroneous signals are sent, right? In plastic surgery, which It's a relatively new term, but it's the same as functional pain, which is what was previously called functional pain. When we add " functional" to a disease, it generally means that we don't know the cause; it hasn't been identified. So it's somewhat synonymous with functional, idiopathic, kineteria (in Latin), or sometimes psychogenic, which is used in other schools of thought. In other words, what's really being said today is that it's an alteration in the processing of pain by the nervous system, and there appears to be a difficulty in inhibiting or an exacerbation of the pain. But generally, when you hear the term " functional" or "plastic," as in the case of fibromyalgia and other syndromes, it means that the cause hasn't been identified. Okay? Now, yes. What would be the main difference between neuropathic and plastic pain?

[00:35:08]Well, with neuropathic pain, for example, sometimes if there isn't an anatomical cause— I don't know if it can always be identified—but it can be, for example, you see that there's a... for example, something Post-operative.

[00:35:22]Oh, yes. For example, let's see, one difference that I like is, for example, sometimes when we have a mastectomy, there's scar pain afterward.

[00:35:36]Acute noisceptive scar pain would be right after the operation because there's inflammation, etc. Neuropathic pain would be because there's been damage to the nerves, and that scar pain can have The tendency to become chronic was turning the word in Spanish "cron" into "chronicity". Yes. Is it possible for a disease to fall into two categories?

[00:35:57]Yes. Ah, yes, yes. Thanks for asking, because I just forgot, we have an arrow below that says mixed pain. When you hear mixed pain, it means that there are several types of pain. That can happen in a patient. I, for example, work a lot with a syndrome called hypermobile Darlos, which is a chronic pain syndrome and is considered mixed because we will have, as there is a tendency to injuries due to the fragility of the tissues, a lot of neuropathic pain, but there is also neuropathic pain and there is also non-plastic pain. It is said that he has fibromyalgia-type muscle pains without a known cause, etc. Yes, that can happen.

[00:36:30]Well, but what interests us, and this is the part that interests me most, is that we see what we can do, what our areas of focus are for working with patients. Ah, we already saw that the definition of pain is multidimensional, that is, it includes the physical, somatic aspect, right?, but also the emotional aspect. And we're going to look at some things about this multidimensionality.

[00:36:55]The first dimension would be sensation.

[00:36:58]That corresponds to the discriminative sensory component. In other words, thanks to our nervous system, our functioning, this wonderful body we have, we are able to detect if we have pain or not, give it an intensity, know where it is located, ah, etc. Well, that's the sensory part, but then we have the psychological part. If we start with the emotion, well, we all know that it is very unpleasant, that is what gives the pain its tone, it is because there is an emotion that accompanies it and that in general is unpleasant, even unbearable, that pain helps us to seek help, precisely to consult. Ah.

[00:37:39]And I say this because, of course, the emotion can even be unbearable, and we know that, for example, suicidal behaviors are much more prevalent in people who experience chronic pain, because sometimes the pain is physical, among other factors, but that physical pain can be unbearable. That's what this tone gives us, the color of pain, which is emotion.

[00:38:04]examples. The last thing would be cognition, it would be like ideas.

[00:38:08]We're going to go there, we're going to go there, we're going to go one step at a time. We're feeling the excitement, right? So, well, I'm not going to dwell too much on anxiety and depression here because everyone knows that anxiety and depression, well, anxiety and depression are emotions that more or less everyone has experienced; they are not, we're not necessarily talking about a disorder, but there could also be a mood disorder or an anxiety disorder, okay? and they are associated with the painful experience, that is, how it works as a vicious circle. A very important emotion that must always be explored in patients with chronic pain is the fear of pain and movement, which is kinosophobia. There we are with a key concept in chronic pain. Already?

[00:38:49]What is kinesiophobia? It is defined as an excessive and debilitating fear of movement and physical activity, resulting from a feeling of vulnerability to painful injury. This is something that patients are always evaluated on.

[00:39:04]We have some very well-known questionnaires, such as the Tampa questionnaire for kinesiophobia, among others. And what does that mean? that I anticipate that it will hurt and therefore, ah, for example, yes, in fact, in chronic pain it is often said that worse than chronic pain is the anticipation of the pain. Because? Because if I have a very high fear of this, of having a new injury or of it hurting, I'm going to avoid it. Then comes behavioral avoidance, and in a severe case, this can mean that people stop moving, stop going out, and suffer physical conditioning consequences, etc. Ah, like all phobias, it is a very, very important, irrational fear, but one that carries this behavioral element of avoidance.

[00:39:57]Avoidance, avoidance, I'm going to avoidance. Thank you. Uh, that's in terms of emotion. Now let's talk about cognition, which is what you wanted to ask about. Yes. No, regarding laobia it seems very interesting because I think there is also evidence that physical exercise does indeed improve pain.

[00:40:21]Therefore, it is very important to overcome kinesiophobia. absolutely or well, because it is a factor that paradoxically leads to a reduction in pain. It is a factor, we will come back to this later, but it is a factor of chronicity, that is, it is one of the factors that could explain the transition from acute pain to chronic pain and the maintenance of chronic pain. So, the key, that's why I was saying, the key is that assessment of kinesiophobia. Then we have aspects of cognition. Ah, there we're thinking about attention, distraction, interpretation, and meaning, like what we talked about at the beginning of Bitcher's study, right? From how the context, how the interpretation we give to a context will influence our perception of pain. Another example is, for instance, childbirth without anesthesia, right? Without the epidural. What's it called? Epidural, now? Well, there are many women, aren't there?, who choose this. That means it's natural. But of course, why did we accept?

[00:41:31]Because a woman, one might think, because a woman accepts this knowing that the pain, well, is indeed prepared, there is prior preparation. But why? Because the meaning of that moment is positive.

[00:41:43]In other words, the person wants to live that moment fully conscious, right?, uh, etc., it has a positive connotation that makes us tolerate pain more, which isn't your thing.

[00:41:53]We can think the same about tattoos or piercings. Well, it hurts at first, does n't it? But why do we accept it? Why do we tolerate that pain? because for us it has a positive interpretation, a positive meaning.

[00:42:04]Then we see how these factors modulate our perception of pain.

[00:42:08]Well, all of that has to do with cognition. The same applies to the issue of attention when we give the example of getting distracted by a friend who calls us when we have a toothache, etc. Already.

[00:42:17]Uh, the decision, the decision-making.

[00:42:19]That's where we're dealing with the more uh aspects of executive function, right? In other words, there are people who are in pain but don't seek help. Ah, so, also the decision to look for information online or go and consult.

[00:42:34]Yes, the issue of accepting pain would also fall under the category of a cognitive process.

[00:42:41]Yes, definitely. I believe it's cognitive- emotional. Yes, we classify it as such here, but there are many processes that are indeed intertwined, without a doubt. Yes, yes, yes.

[00:42:53]Well, in terms of cognition, another key element, catastrophizing, which we had already mentioned in people with chronic pain, is another key element that can help us understand situations of chronicity, since it is, well, the name kind of indicates it, right? It's about imagining the worst possible scenario, the worst possible outcome in this case regarding pain. It is already said to have three components: rumination, magnification, and helplessness. with some example sentences. My neck cracks every time I move, my bones are slowly breaking, I'm going to end up paralyzed, I can't do anything. It's horrible. Already? In other words, this feeling of helplessness and that everything is going to go terribly wrong. Ah, well, this uh catastrophism, there are theories like the community adaptation theory that understands catastrophism as a coping strategy, right? It's about coping, since it has a positive aspect in the sense that it shows that there are patients who catastrophize about the pain, and what happens then? that receive more attention from the environment. Clear. Ah, so in that sense, if it receives more support, it can have a function. The problem is that this is short-term, because afterwards, with constant complaining and catastrophizing, what is also observed is that the same environment, the family, etc., end up here. Ah, so they can start issuing punitive responses, or the opposite of what is expected, right? And in any case, catastrophizing is a well-studied issue in chronic pain, which is seen, as I was saying, as a key factor that explains chronicity. It's slipping away. Okay, we'll look at it later with a model, okay? Then, self-efficacy, belief, and meaning. I'm not going to dwell on this for long because belief and meaning are the same as what we saw with Bitcher, right? Self-efficacy is the belief we have that we are capable of organizing and executing actions and obtaining good results.

[00:44:52]These are issues that can be addressed with patients, and in the case of chronic pain from any chronic illness, where self-management is very important, we are interested in increasing people's self-efficacy.

[00:45:05]Yes.

[00:45:06]Uh, and they mentioned it sooner rather than later, but it catches my attention in terms of catastrophizing and the method of self-interest with exaggeration, magnification, and defense, the possibility of developing cognitive distortions in reality and that leading to mental disorders due to comorbidity with other disorders, even cases like psychosis, like interpreting the world as a curse, not having that pain, which can lead to strong cognitive distractions and comorbidity with mental disorders.

[00:45:49]Yes of course. Total. Yes, yes, yes, yes, yes. Here we are talking about catastrophizing in relation to pain, but in patients with anxiety disorders it will be the same thing. So, what does a person with generalized anxiety disorder do? He only anticipates catastrophic scenarios and that's why he ca n't go out anymore, in other words, everything is a threat. Ah, here we are seeing it in pain, but indeed this catastrophic way of thinking is going to be seen in a lot of mental disorders and we also know that chronic pain has comorbidity with many disorders. Yes, mental. I imagine there is a greater prevention of cognitive distortions.

[00:46:30]Clearly, it would be a cognitive distortion. Yes. And it's a therapeutic focus because there are elements there, that is, there are cognitive restructuring techniques that allow you to relativize and make your thinking more flexible so you're not always in the "everything is nothing" phase, in catastrophe or zero danger. Well, yes.

[00:46:49]And the last element, the psychological one, on the topic of behavior, is super important in pain, because what is it that behavior helps us with? which are our verbal or non- verbal manifestations, ah, which in the end will help us to survive. Because?

[00:47:11]Because if we complain about how we see them in children, we take care of that person, we go to the doctor, right? And that's where we have all these critical behaviors, right? If I cover my arm, it hurts. When my stomach hurts, no, I get like this. Ah, uh, uh, how do you say it? limping, right? Well, those are all pain-related behaviors, but vegetative responses are also considered, right? Sometimes I get sweaty, or well, anyway, all that too, these automatic responses, right? They are also considered in behavior and have the function of communicating with the environment. Already.

[00:47:48]These are responses, for example, when you... all the automatic responses of the nervous system. So, you, for example, are going to sweat, sometimes there are people who are in a lot of pain and faint, right? All these issues, or palpitations, or you turn red, or all that kind of stuff.

[00:48:07]If we go back to these elements we've discussed, and especially these key ones I mentioned, such as the emotion of exacerbated fear with kinesiophobia, the cognitive aspect of catastrophizing, right?

[00:48:22]Uh, and a behavioral aspect such as avoidance of the activity. Yes. Yes. Um, there's this model that's very useful and well- known in chronic pain, which is by Ban Crombes, which is the activity pattern. In patients with pain codes, a subgroup of patients can be seen where we will see that these are patients who will avoid activity. Already? How do they explain it? authors.

[00:48:52]Let's look at the diagram. We've got to focus on injury and exertion, okay?

[00:48:58]We have an injury, we hurt ourselves, or we make an effort that is painful. So, let's go here to the middle.

[00:49:05]The optimal path, let's say, the green path, right? Um, it would be that, okay, I have this injury, I feel pain, but I don't have an exaggerated fear of what, of exposing myself to the activity, of having new pain. Ah, that's moderate. What I do? I confront myself, that is, I expose myself to the activity. Imagine I fell off my bike. Ah, I hurt myself. Well, I'm not too afraid to get back on the bike. I'll wait for it to pass, I don't know what. I'm putting myself out there, I'm cycling again, and this has a good prognosis because it leads to recovery. That would be ideal, wouldn't it? However, on the other hand, we see what happens with many patients with chronic pain, who, faced with this experience of pain, resort to catastrophizing. Ah, I mean, there's a catastrophic way of thinking where I tell myself, well, if I get back on the bike, I'm sure I'll fall again, it's going to hurt more, it's going to be worse, etc., etc. If I have these thoughts, the emotional correlate will be that I am afraid, so I start to develop this kinesophobia, right? And what does that lead us to? To be avoided. I never ride my bike again, I don't go out and I start to isolate myself, sometimes to a practically total isolation, because what does it lead to? Depressive mood, etc. And there we are in a vicious circle.

[00:50:20]So this model is always a model, a simplification of reality, but it allows us to understand how it works, what the pattern of activity is for people who are in this mode of avoiding activity.

[00:50:33]Yes.

[00:50:34]Well, because of chronic pain, especially not acute pain, but more chronic pain, I think that sometimes it can happen, I do n't know if generally, but a temporary process where the person starts with catastrophizing, starts with depression, and from there it begins and leads the therapist towards confrontation and recovery, acceptance. I don't know if my question is whether that pattern is common or if the answers are more like no. I think the variability between people is enormous.

[00:51:22]This may last a moment, a while. The point is, okay, we are with a person where we see high catastrophizing, high kinesiophobia, activity avoidance and this persists over time.

[00:51:36]Well, be careful with this. Ah, there are scales to evaluate performance at the pates level. Sorry. That's what I wanted to ask, if there's some kind of questionnaire.

[00:51:45]There are questions, although I don't know if they are validated in Spanish, we would have to see, but there are questionnaires to evaluate this. But at the behavioral level, there are people who operate with a pattern, with an almost opposite pattern, but which leads us to the same place. And when these patterns exist, whether it's the avoidant pattern as we discussed earlier or the persistent pattern, they are risk factors for chronic pain. So, identify it. What did these same researchers realize? That, well, not everyone functioned with this avoidance and with the avoidant father? Didn't they realize that there was a group of patients who, on the contrary, despite the pain, persisted in the activity, but thoroughly, right? In other words, we're not talking about someone who can always maintain an activity level; we're talking about an excess of activity, okay? I mean, we workaholics, we can say that, right?

[00:52:40]Hyperactivity is also mentioned, and so on. Well, all this is an exaggerated activity, and that despite the pain. Already? So, if we place ourselves in this model, let's start here with a person with chronic pain, here in the little blue square that says positive mood, pain is not very intense. So, a person who has chronic pain, who functions in this way, on the day they feel a little better, since it hurts a little less, right? She's in a more pleasant mood, less depressed, etc., she throws herself into doing things, she does the cleaning and goes shopping and I don't know what else, it's all about making the most intense effort, they don't know how to regulate their activity. That's the question. Where does this lead us? to exhaustion, ah, and then to incapacity, to pain, to negative mood, avoidance and abandonment. In other words, it takes us to the same place as before, but we start from an excess of activity.

[00:53:43]So, these two behavioral patterns can be seen in patients with chronic pain, and, well, they would need to be identified in order to intervene at that level. Already. Well, so at the behavioral level, all these issues we 've been mentioning are, as I was saying, therapeutic focuses. Oh, and as I insist, the good news is that these are issues that can be addressed with patients, which will help to modulate the painful experience. Already.

[00:54:10]Now, in terms of treatment, what can we do? When treatment begins with the evaluation, right? Um, there are all these aspects that I have mentioned, psychological uh uh, evaluation scales, questionnaires. It's true that I don't know if they are... Well, there are many that are very well known, catastrophism that I'm not so sure are available in validated Spanish, the one about activity I don't know because in France we only have one validated one out of all that exist. So, I don't know if it's available in Spanish, but it's a matter of searching for it or running the validation process because they are useful. And well, let's see what is evaluated in terms of pain. How are we doing on time? Karim, well, you tell me, I'll stop. Ah, I see.

[00:54:50]Okay. By 1:30.

[00:54:52]So we're past that point, then, aren't we? Ah, okay. Well.

[00:54:57]Ah, I see. Perfect. Okay, thanks. Well, pain, there are many things to evaluate, aren't there? We have the pain intensity, the typical 1 to 10 rule, how much does it hurt today, right? In research we often use habitual pain, for example, from the last 15 days or the current dollar or the most intense pain I have had, right? In other words, the most intense pain suffered. We also have location, qualitative pain scales, where people are asked what kind of pain they experience, characterizing it in terms like a nail, like a burn, it 's unbearable, etc. What do you call it when an electronic device has, uh, it's like before, it has higher levels, then at some point it decreases, I mean, it's constant, but I don't remember the word for it. I don't know, a fluctuating pain. I don't know what you mean, but it's true that I saw it as episodic pain.

[00:55:59]Ah, another word is true that it depends on the syndrome, there are no pains like, uh, how do you say it? like P for pain and there is pain.

[00:56:10]Of course, it varies from patient to patient depending on the conditions, depending on the stress they are under at that moment.

[00:56:18]Yes. And there are syndromes characterized by painful episodes where we also have periods where there may be no pain, just mild pain, but there are also peaks of pain like that. Yes. Well, these are the factors, or rather, sorry, the assessments regarding pain. Well, knowing that everyone expresses and experiences it differently. Let us always remember that there is no correlation between the pain I feel and the magnitude of my injury. Two people can have the same injury and complain about it differently, experience it differently. Already.

[00:56:50]Uh, and culturally it's very, very different. Ah, I always tell my students in France, "Well, I'm Latina, and we Latinos are much more expressive with our emotions. Ah, the Japanese are completely different, well, there are cultural issues that also show, that differ, that make our expression of pain different, right?

[00:57:13]What else are we going to evaluate? The functional aspects, a description of a normal day, activities, what is done, what was left undone, family life, social life, I mean, it's multidimensional, so we have to look at all spheres of life, right?

[00:57:31]Relational implications of rejection, compassion, financial implications, compensation. This is super important because there can be secondary gain, right? Which is also a factor in chronicity or maintenance of the pain. Ah, this is difficult to work with, but well, we have to recognize it, right? Because it sabotages therapy, right? It sabotages, well, the emotional state, obviously, the Anxiety, depression, and mental disorders. Well, you know that post-traumatic stress disorder is very common in these patients. Um, well, mood disorders, addictions, ah, uh, sleep disorders, suicidal ideation. I'm not going to talk about research here, but well, I 'll give you a link later. We have research on these things.

[00:58:15]Kinesiophobia, well, ah, like a phobia of movement, and evaluating all the cognitive aspects we've already mentioned, and especially beliefs regarding pain, religious beliefs.

[00:58:29]Sometimes they give us a very objective explanation for something that happens to us, right? It's an injury, but we always tell ourselves a very personal, very subjective story about what's happening. Maybe it's a punishment, ah, because I behaved badly toward my brother, I don't know when, etc. I was telling you about cognitive inactions and psychotic states that can occur. Well, psychosis is like a curse that happened, but without reaching psychosis, we can have this type of belief, or people who have certain religions, right? or that adheres to certain beliefs. In short, one always tells oneself a personal story that isn't always compatible with, or doesn't always integrate, the objective explanation that might exist, right? So, this is something to always explore, is n't it?

[00:59:14]The person's narrative.

[00:59:15]Exactly. Yes, yes, yes. Exactly. Yes. And the other thing is the expectations of the treatment. And here we have to be very clear, I mean, if there are unrealistic expectations, for example, "I want my pain to be cured." The truth is that no one today, unfortunately, is in a position to propose any pharmacological, psychological, or physical treatment that can completely eliminate pain.

[00:59:40]So, we hit a wall. And the person begins psychological treatment, a psychological intervention, or another with unrealistic expectations regarding what can or cannot be achieved. Our expectations are to improve the quality of life despite the pain. Right, and this is an issue that needs to be seen or explored, isn't it?

[00:59:58]Initially, uh, just... and I'm going to skip some of... well, no, but I can leave you the slides in case you're interested. Just Just a moment, a special mention.

[01:00:12]Pain in vulnerable populations, and especially in people without functional language. And this is something we 've worked on: pain, for example, in people with autism spectrum disorder and without functional language. For a long time, there was a misconception that these people, and not only them, but also babies, young children, people with intellectual disabilities or developmental delays, didn't feel pain or had a higher pain tolerance. I mean, it wasn't until the 80s and 90s, if I'm not mistaken, that the first pediatric pain manual came out. So, this idea was widespread for a long time, and perhaps there are still these kinds of beliefs that people with autism don't have, or have, a different pain tolerance. What we know, and why was this thought? It's not just because people don't understand. Why was this thought?

[01:01:01]Because of, for example, paradoxical reactions to painful stimuli. So, Studies show that people with autism react differently, some with typical reactions, others with paradoxical reactions, for example, laughing in response to a painful stimulus, others with hyporeaction or hyperreaction. The whole spectrum of reactions is observed. What we know today is that these are atypical reactions, but they feel the pain just the same. So, the difficulty lies there, and also because of the thought that there was a lot of self-harm. One might think, well, if there is self- harm, it means that the perception or tolerance of pain is higher. No, no. The point is that the pain is still there; we simply have to learn to interpret it. And therein lies the methodological and clinical challenge of learning to interpret pain in these individuals, right?

[01:01:52]And here, well, as I already mentioned, the difficulty isn't just learning to interpret these atypical manifestations, but also that studies show that pain in people with autism is much more frequent than in the general population. Typical. Already?

[01:02:07]Why? Well, because there are comorbidities that are, well, among the reasons there are comorbidities that are going to be a source of pain, for example, gastrointestinal problems, dental problems, epilepsy with muscle pain, then genetic syndromes, which I study as those that derive from joint hypermobility. All of this generates pain in these people with the medical procedures that can also generate pain. I mean, if I have a dental problem, well, going to the dentist isn't pleasant for anyone.

[01:02:35]So this adds sources susceptible to generating pain. So there's attention to behavior. Ah, I'm obviously a person with functional autism who can express their pain, not a problem, but here we're not at the point, the underdiagnosis is in people who don't have functional impairment, and there any modification of behavior will evoke a pain problem. I think we're, right? Just to finish, just to finish the objectives of a psychological treatment. Well, we 've already seen it. To mitigate The perception of pain, not eliminating it.

[01:03:15]Developing psychological resources to cope better, reducing unpleasant emotions, and so on. Modifying all these factors that will help us close the door on pain, right? To modulate our painful experience. I do n't think I need to explain this to you; it's clear that psychology has a fundamental role. CBT, second- and third-generation cognitive behavioral therapies, have a lot of evidence of how useful they can be. The problem is that not everyone has access. I looked at some studies, and we see—well, the one on the left is from the United States, the one on the right, in my opinion, is German—and we see, just to illustrate, that very few people have access to chronic pain patients. In both cases, look, 14%, a small sample of 90, but only 14% had access to CBT, and in the other, less than 0.8%, that is, less than 1%, who were elderly people, did not have access.

[01:04:25]So, the problem is access. To finish, uh, well, you know, pain, a major public health problem and a key area of ​​work in clinical health psychology, but, I mean, very, very important, there's a lot to be done, it's not just a problem for doctors.

[01:04:43]We have a lot to do there, much better results with multimodal approaches, that is, approaches that will bring together physical therapies, psychological therapies, and so on. Um, CBT in particular has very good empirical support, but limited access. Well, that's something that needs to be promoted. And I'd like to take this opportunity to tell you that we 're quite happy because these two books on chronic pain, which were initially published in French, are now available in Spanish.

[01:05:13]There's one for clinicians, which is the one on the left. Um, it's a program, a kind of script for facilitating group sessions with patients with chronic pain, where we work on all these aspects I mentioned: cognitive restructuring, mindfulness, hypnosis, and so on. I mean, it's really a practical manual. There are already some chapters available as well. about how to energize the group, etc., but in France I've had feedback from people who also apply it in individual therapy; it's really very widely used. And the second one is the same, but for patients. This is what the publisher asked us to do.

[01:05:48]Why don't we do the same thing so that the patient can work on the same things independently with exercises and such?

[01:05:53]So, well, I know they're already available in Spanish, [clears throat] so, and the last invitation is to— I didn't talk about research here, but if you want to know a little about what we do—I specialize in a group of diseases that present with chronic pain, which are connective tissue diseases, joint hypermobility, etc. And, well, we're in Paris. This year I had the pleasure of hosting two students from Chile for a stay: Karina, who was in Paris for three weeks and is helping us; she went to put together the systematic review, so we're going to continue working until the article is published. And also a student from the University Oigina, from Rancagua, was also in Paris doing an internship within this program. Ah, so I'm open to anyone who wants to come there and see what we do and spend some time in Paris, which is never unpleasant, right? Well, thank you very much for your attention and time, okay? 5 minutes to ask a couple of questions. Um, we're going to ask Carolina if she can give us the PowerPoint presentation. We want to tell you that this was already broadcast on YouTube, so you can repeat it in its entirety. It will be available for you to use for other people. Um, so in the same email I contacted you, the communications team (and I'm not very experienced with this) will probably send you both the link and the PowerPoint itself. Okay? So there you have it for Carolina. Um, a basic question, going back to a previous slide, you've already seen this. If it's available, is it possible to buy it in Chile?

[01:07:37]Yes, yes, I think it's available online, and I know it's also physically available at the Mediterráneo bookstore, which is a... Medical bookstore, right? Uh, but I think the internet is already available because the SE handles the distribution. You would send the PPT to Karina.

[01:07:56]Yes, of course.

[01:07:57]So she can send it.

[01:07:59]Yes, yes, no problem.

[01:08:00]That we can gather two questions from Carolina's time because we have other activities to attend to later.

[01:08:11]Any questions?

[01:08:14]Regarding the books, the book that is only for patients, uh, is intended for the patient to come and buy it, for the therapist to recommend it, for the therapist to work in a mixed way. What experiences do you have with this? Good books.

[01:08:31]Yes, thank you for the question, because it's true that sometimes people think they are like, no, you can completely separate them. Ah, I mean, the book for patients is made to work on the same topics independently.

[01:08:44]Right? Uh, and the other book for clinicians already has, let's say, exercises that the clinician can give to the patient. Ah, uh, yes, no, you can completely separate them.

[01:09:03]Yes, ask.

[01:09:07]What other Which authors could you recommend for us to research a little on chronic pain?

[01:09:13]Well, let's see, in chronic pain, in psychology, there's Brian, who, by the way, we were very happy agreed to write the preface for our book. Oh, they're Belgian. They're really into clinical and psychological studies. I think he doesn't do clinical work directly, but he's involved in research and psychology. And one of the great advances that we owe to him, precisely because he's incorporated psychology into the treatment of chronic pain, is Ben Crombes; they're both Belgian. Oh, there are several more, but I'd say those are the ones who are still alive. [laughs] Oh, don't hesitate to look at their articles. Oh, because they're people who have generated a lot of knowledge regarding the role of psychology in chronic pain.

[01:09:58]Yes, yes. I saw a study from the Catholic University; I was very happy to see that there was a recent study published by Zamora or Zamorano, the first author, in 2025. I don't think it's a woman, in the BMC Medicine, I do n't know what. Well, anyway, from 2025, where the effectiveness of a multimodal chronic pain program that included cognitive behavioral therapy was evaluated. It was done in Chile with a large group of patients, around 500 or 600, who are professionals from the Catholic University. So there are things being done there too, because, well, I've seen that health psychology is only offered here at the Catholic University and in Concepción. So, I think there's a whole area to develop there in the Health Clinic, in clinical pain. I don't know much about how it works here, but I've seen that there's a really nice study recently published on this, so I recommend you also look at it. Shall we give Carolina a round of applause? Oh, thank you very much.

[01:11:00]Thank you very much, Carolina. First, let's take a picture of just Carolina with your book and Carolina with all of us. Sound good?

[01:11:07]I'm going to ask someone to take a picture of us. Okay, thank you. So, if you want, a double, sure, but I'm going to ask you to please not pose, I don't know.