Understanding Pain Management Practice in Patient ...c.ymcdn.com/.../2018PPT/Understanding_Pain_Managemen.pdf2. History of pain: the many myths 3. ... Behav Sci (Basel) 4(4): 394-409

4/8/18

1

UnderstandingPainManagementPracticeinPatientExperience

Presenter:SusanE.Mazer,PhD

SusanE.Mazer,Ph.D.

UnderstandingPainManagementPracticeinThePatientExperience

BerylInstitutePXConference2018

1. Whatispaintothepatient?2. Historyofpain:themanymyths3. Painrelief:fromopiumtoopioids4. PainTheory:relevancetoday5. Handingthepowerofreliefbacktothepatient

WhatI’llCoverToday

4/8/18

2

WhatEveryoneKnowsAboutPain

ThisisPain

MostCommonResponse

4/8/18

3

ResponsetothePainofOthers

WhatisPaintothePatient?

2018:WhatisPain?

Whatever thepatientsaysitis!

4/8/18

4

2018:WhatisPain?

Noticeable

2018:WhatisPain?

“…canbeoverwhelming,demandsimmediateattention,anddisruptsongoingbehaviorandthought…”

Melzac,R.1968

Painis#1motivator…• “TodoorNottodo,”thatisthedilemma• “TotellornottoTell”• “Totakemoreortakeless(ortakenothing)”• “Totry,tonottry,andtotrystillmore”

Pain:TheBig“P”

4/8/18

5

Painreliefdemotivatesalltheabove.

PainRelief:TheLittle“p”

OpioidEpidemic:HowDidWeGetHere?

Opioids:• Prescribedasneeded• Ondemand• TosecureHCAHPSrating• Easiest/mosteffective*?

Hint:*Thedefinitionofanaddiction.

• Homer:“ArrowshotfromGod”

• Aristotle:“Painisapassionofthesoul”

• Plato:“Painisanemotion,notasensation”

TheMythologyofPain?

4/8/18

6

Thestimulationgoesstraighttothebrain(“PainCenter”).Isfullyofthebody,notthemind.

Breakthrough:ReneDescartes

TheCartesianDivide:“Ithink,thereforeIam.”

• Acutevschronic• Knownvsunknown• Expectedvsunexpected• Mildvsdebilitating• Other?

NotAllPainsAreAlike

Thecausemaybeobjective,buttheexperienceisalwayssubjective.

NotAllPainsAreAlike

4/8/18

7

HistoryofPainRelief

Mandragora:• Hallucinogenic,hypnotic,

poisonous,etc• Analgesicforrheumaticpain• 2ndcenturyBCto7thAD:

Mainlyusedwithopium.

Andinthebeginning…

Dodoens,Rembert,1583.Stirpium historiae pemptades sexsivelibri XXX.Antverpiæ,exofficina Christophori Plantini.(scannedfromReprint1979,Uitgeverij deForel,Nieuwendijk(Netherlands).,PublicDomain,https://commons.wikimedia.org/w/index.php?curid=21709570

• Opium• NitrousOxide• Laudenum• Ether• Cannabis• Morphine• Codeine• Opioids

FromOpiumtoOpioids

4/8/18

8

FirstuseoffullanesthesiainBoston*,1846

PainRelief:Anesthesia

*CrawfordW.Long,Columbus, GA

• Bayer!!• AcetylsalicylicAcid,

1899

PainRelief:Potions

Tylenol,1955• Children’s• Adult

PainRelief:Acetaminophen

4/8/18

9

PainManagementTheories

• Patientcanmodulatepain• Pathwayfromcentralnervoussystemtothebrain• Non-painfulstimulicaninhibitpainfulstimuli• Mayindicatetissuedamage,butmaynot

Melzack/Wall:GateControlTheory(1965)

Melzack/Casey:ExperienceofPain(1968)

• Somatic, orsensationofpain• Perception ofpleasantnessorunpleasantness(whichcanleadtothefightorflightresponse)

• Evaluation or“appraisal,culturalvalues,context,andcognitivestate”

4/8/18

10

Melzack/Casey:MechanismforSelf-Management(1968)• Meaningmaking• DirectedAttention• ActiveDistraction

“Thereignofpainliesmostlyinthebrain.”

Melzack/Casey:MechanismforSelf-Management(1968)

--Cathryn Jakobson Ramin

Whatinfluencestheexperienceofpainandwhetheritisrelieved?

• PainExpectancy:Isitavoidableornot• PainAcceptance:Ifunavoidable,preparationforit• PainApprehension:Anticipatorysuffering• PainAnxiety: Thegreaterthefear,thegreaterthe

pain

MarkZborowski (1908– 1990)MedicalAnthropology

4/8/18

11

Involvestheimmediacyoftheexperienceanditsexpressionconstrainedbysocialcontextandenvironmentalsetting.

Craig,K.D.:SocialCommunicationModelofPain(2015)

• Distinguishesintrapersonalandinterpersonalsourcesofinfluenceonbothsufferingpersonsandobservers

• Emphasizes(Intrapersonal)whattheindividualbringstothepainfulexperience

SocialCommunicationModelofPain

SocialCommunicationModelofPain

KennethD.Craig,2015

4/8/18

12

Timeline:ChronologyofPain

AntecedentPain

ExperiencePain

Expression

Timeline:ChronologyofPain

Decoding/Response

Action-DeliveryofCare

Antecedent

PainDenial:BeingMetWithDisbelief

• Illness/Pain:deviantbehavior• Judgement:abarriertorelief• Cultural/socialnorms:informself-report/

medicationuse• Under-reporting:under-treatment

4/8/18

13

Autonomousresponsebasedon:• Beliefs

• Anticipation

• Expectancy

ThePlacebo-NoceboResponse

“… themeaningresponse[isthe]physiologicorpsychologicaleffectsofmeaningintheoriginsortreatmentofillness;meaningresponseselicitedaftertheuseofinertorshamtreatmentcanbecalledthe“placeboeffect”whentheyaredesirableandthe“noceboeffect”whentheyareundesirable.”

MeaningResponse

Moerman,D.D.,Jonas,W.B.(2002)

Pain’sImpactonthePatientExperience

4/8/18

14

Thesumofapatient’spriorexperienceswithpain,shapedbyapatient'sbeliefs,expectations,andtheirsocial/culturalcontextthatinformthepatient’sresponsetopainanditsmeaning.

ThePatientExperienceofPain

Painbeliefsfullyinfluencepatients’painthreshold,participationintheircare,andinformtheirsuccessinself-regulation.

• Agitation• Anxiety• Stress• Suffering

HowPainisthePatientExperience

4/8/18

15

• Environmentalstressors

• Expectancy• Placebo/nocebo effects• Social/culturalvalues

HowPainBecomesthePatientExperience

• Minimizeenvironmentalstressors• Provideaccesstobeauty,nature,including

mediatednature• Minimizeclutter• Assessandadjusttheenvironmentwithevery

patientinteraction

CreateaHealingEnvironment

• Asenseofpleasantness• Makestimemovefaster• Musicpacestime,providesanemotionalcontext

Whatdoestalktelevisionprovide?

PositiveValence

4/8/18

16

APositiveDistraction“…anenvironmentalfeaturethatelicitspositivefeelingsandholdsattentionwithouttaxingorstressingtheindividual,therebyblockingworrisomethoughts.”

Isthisscary?Isthistheendorthebeginning?Isithotorcold?Isthisgoodorbad?Whatdoesthismeannow?Arewesafe?AmIsafe?Howlongwillthislast?

4/8/18

17

• Notoneelementworksforeveryone• Notoneelementworks24/7foranyone• Habituation• Variety• Stimulating

PositiveDistraction

• Nature(variousforms)• Music(bothpatientpreferenceandnew)• Conversation(hopeful,personal)• Media

PositiveDistraction

VirtualReality• Cedars-Sinai:24%drop

inpainscores• Universityof

Washington:76-22%dropinamountoftimethinkingaboutpain

VirtualReality/ImmersiveInterventions

4/8/18

18

• 29%reductioninpainmeds

• Fewersideeffects• 1.5dayaverage

reducedlengthofstay

Non-PharmaceuticalInterventions

Theidentificationandmanagementofpainisanimportantcomponentof[patient]-centeredcare.[Patients]canexpectthattheirhealthcareproviderswillinvolvethemintheirassessmentandmanagementofpain.Bothpharmacologicandnonpharmacologic strategieshavearoleinthemanagementofpain.

• Engagesmindandbodytoreduceanxiety,increasecopingskills

• Providespositivedistraction• Providesrespitefrommental/emotionalfatigue• Providestooltousebeyondthehospital

GuidedImagery

4/8/18

19

NightsareDifficult

• Elusiverest

• Unfamiliarenvironment(includingnoises)

• Limitedresources• Isolation

• Loneliness• Ruminations

PainIsWorseatNight

• Isolating• Influencedbythemeaningattributedtoit• Ismitigatedbypositivedistractions,evenatnight

NightsDoNotHavetoBeasDifficult

• Planinadvancew/patient-family• Optionsforpatient• Restfulnessshouldbeofferedthroughtheday• Patientandfamilyshouldcoordinate• Whatworksforthispatient?

4/8/18

20

• Acupuncture• Chiropractictherapy• Osteopathicmanipulativetreatment• Massagetherapy• Physicaltherapy• Relaxationtherapy• Immersiveexperiences• Cognitivebehavioraltherapy

Non-pharmacologicInterventions

HandingthePowerofHealingBacktothePatient

• Attheleast,Unpleasant• Notalwaysavoidable,notalwaysbad• Influencedbyphysicalandnon-physicalfactors• Informedbymood,attitude,beliefs,values,

social/familialcontext,andthemeaningattributedtothepainbythepatient.

PainIs…

4/8/18

21

Patientsneedmorethantheblurofactivity.

Painbeliefsinformpatients’painthreshold,participationintheircare,andinformtheirsuccessinself-regulation.

• Aninformedcaregiver/bedsidestaff

• Involvementofthebedsideteamwiththepatient

• Anenvironmentthatminimizesstressors

• Positivedistractions,includingaccesstonature,variety

• Supportofthefamily/closesocialcircle

WhatdoesManagingPainRequire?

4/8/18

22

• Equanimitybetweenpatient/caregiver

• Alignmentbetweensocialvaluesandtreatment

• Acknowledgementandsupportbetweenpatient/caregiver

• Altruisticpracticesembeddedinclinicalexcellence

WhatdoesManagingPainRequire?

Summary

• Communicatesupportandempathy• Createahealingenvironment• Providepositivedistractions• Offerguidedimagery• Offerimmersivetechnologies• Beawareofpositive/negativemedia• Planfornights

• Gate-ControlTheory:Positivedistractionisprimarytoself-managementandincreasingpaintolerance

• SocialCommunicationTheory:Painmanagementusesthesymbiosisbetweenpatient/others

• Painreliefissubjectiveandobjective• Painisephemeral:livesandchangesovertime• Combinationofbiomedicalandpsychosocial

strategiesisrequisiteCaution:Addictionisalwaysariskwhenthegoalisself-medication/management

Summary

4/8/18

23

Howfaryougoinlifedependsonyourbeingtenderwiththeyoung,compassionatewiththeaged,sympatheticwiththestrivingandtolerantoftheweakandstrong.Becausesomedayinlifeyouwillhavebeenallofthese.

GeorgeWashingtonCarver

Theonlydifferencebetweenthepatientandthecaregiverisacuity.

PatLinton

SusanE.Mazer,Ph.D.President&CEO,HealingHealthCareSystems

Email: [email protected]:www.healinghealth.com/susan-mazer-blogLinkedIn:www.linkedin.com/in/susanmazer

QuestionsandThankYOU!

4/8/18

24

BreakoutSession5:00PM

WinachanceforaComplimentary2019ConferenceRegistrationbycompletingtheevaluationforeachsessionyouattend. JustaneasyclickontheFeedbackIconfoundonyourmobileappandafew

momentsofyourtimetocompletetheevaluation.Yourfeedbackisveryimportanttous.

70

Next…

www.theberylinstitute.org

PainManagementandthePatientExperience2018References

SusanE.Mazer,[email protected]

Keywords:Pain,Painmanagement,paintheory,historyofpain,Gate-ControlTheory,SocialCommunicationsModelofPain,Placebo,Meaning-response,psychologyofpain,ReneDescartes

BakerD.W.(2017).“Historyofthejointcommission’spainstandards:Lessonsfortoday’sprescriptionopioidepidemic.”JAMA,publishedonlineFebruary23.doi:10.1001/jama.2017.0935

BermanM.G.,JonidesJ.,KaplanS.(2008).“Thecognitivebenefitsofinteractingwithnature.”PsychologicalScience,19(12),1207-1212.

BertoR.(2014).“Theroleofnatureincopingwithpsycho-physiologicalstress:aliteraturereviewonrestorativeness.”BehavSci(Basel)4(4):394-409

BrownD.K.,etal.(2013).“Viewingnaturescenespositivelyaffectsrecoveryofautonomicfunctionfollowingacute-mentalstress.”EnvironmentalScience&Technology47(11):5562-5569.

CaseyK.L.,BushnellM.C.(Eds.)(2000).“Painimaging.”Seattle,WA:IASPPress.

CepedaM.S.,FarrarJ.T.,BaumgartenM.,BostonR.,CarrD.B.,StromB.L.(2003).“Sideeffectsofopioidsduringshort-termadministration:effectofage,gender,andrace.”ClinPharmacolTher;74:102-12.

Craig,K.D.(2009).TheSocialCommunicationModelofPain.CanadianPsychology,50(1),22-32.doi:10.1037/a0014772

Craig,K.D.,Versloot,J.,Goubert,L.,Vervoort,T.,&Crombez,G.(2010).PerceivingPaininOthers:AutomaticandControlledMechanisms.TheJournalofPain,11(2),101-108.doi:https://doi.org/10.1016/j.jpain.2009.08.008

CzerniakE.,etal.(2016).“Manipulatingtheplaceboresponseinexperimentalpainbyalteringdoctor’sperformancestyle.”FrontPsychol7:874.

deKortY.A.W.,MeijndersA.L.,SponseleeA.A.G.,IjsselsteijnW.A.(2006).“What’swrongwithvirtualtrees?”Restoringfromstressinamediatedenvironment.JournalofEnvironmentalPsychology,26(4),309-320.

DevineE.C.(1996).“Effectsofpsychoeducationalcareforadultsurgicalpatients:ameta-analysisof191studies.”PatientEducCouns,19:129-142.

DietteG.B.,LechtzinE.,HaponikE.,DevrotesA.,RubinH.R.(2003).“Distractiontherapywithnaturesightsandsoundsreducespainduringflexiblebronchoscopy.”Chest,123,941–948.

EggertJ.,etal.(2015).“Effectsofviewingapreferrednatureimageandhearingpreferred

musiconengagement,agitation,andmentalstatusinpersonswithdementia.”SAGEOpenMed3:2050312115602579.

FinlayK.A.,AnilK.(2016).“Passingthetimewheninpain:Investigatingtheroleofmusicalvalence.”Psychomusicology:Music,Mind,andBrain26(1):5666.

FontaineD.(2005).“Impactofcriticalcareenvironmentonthepatient.”In:GonceMortonI.P.,FontaineD.,HudakC.,GalloB.(Eds.)“Criticalcarenursing:aholisticapproach.”LippincottWilliams&Wilkins,Philadelphia;36–45.

GimenoM.(2010).“Theeffectofmusicandimagerytoinducerelaxationandreducenauseaandemesisinpatientswithcancerundergoingchemotherapytreatment.”MusicandMedicine2(3):174-181.

GoldscheiderA.(1894).“Ueberdenschmerzinphysiologischerundklinischerhinsicht:nacheinemvortrageinderBerlinerMilitärärztlichenGesellschaft.”AnnArbor,MI:UniversityofMichiganLibrary(quotedinMassiehMoayediK.D.D.,2013).

GreenspanJ.D.,CraftR.M.,LeRescheL.,ArendtNielsenL.,BerkleyK.J.,GoldM.S.,HoldcroftA.,LautenbacherS.,MogilJ.S.,MurphyA.Z.,TraubR.J.(2007).“Studyingsexandgenderdifferencesinpainandanalgesia:aconsensusreport.”TheConsensusWorkingGroupoftheSex,Gender,andPainSIGoftheIASP.

GreenspanJ.D.,CraftR.M.,LeRescheL.,ArendtNielsenL.,BerkleyK.J.,GoldM.S.,HoldcroftA.,LautenbacherS.,MogilJ.S.,MurphyA.Z.,TraubR.J.(2007).“Studyingsexandgenderdifferencesinpainandanalgesia:aconsensusreport.”TheConsensusWorkingGroupoftheSex,Gender,andPainSIGoftheIASP.

Hirsh,A.T.,George,S.Z.,Bialosky,J.E.,&Robinson,M.E.(2008).FearofPain,PainCatastrophizing,andAcutePainPerception:RelativePredictionandTimingofAssessment.Thejournalofpain:officialjournaloftheAmericanPainSociety,9(9),806-812.doi:10.1016/j.jpain.2008.03.012

Hodges,P.W.,&Tucker,K.(2011).Movingdifferentlyinpain:anewtheorytoexplaintheadaptationtopain.Pain,152(3Suppl),S90-98.doi:10.1016/j.pain.2010.10.020

Hooper,V.D.(2015).WhyIsPainStillAPain?JournalofPeriAnesthesiaNursing,30(3),260-261.doi:10.1016/j.jopan.2015.04.001

KahnP.H.,GillB.,HagmanJ.,SeversonR.L.,FreierN.G.,Carre`reS.,StolyarA.(2008).“Natureandmediatednature.”JournalofEnvironmentalPsychology,28,192199.

KaplanR.,KaplanS.(1989).“Theexperienceofnature:Apsychologicalperspective.”NewYork:CambridgeUniversityPress.

KamdarB.B.,NeedhamD.M.,CollopN.A.(2012).“Sleepdeprivationincriticalillness:itsroleinphysicalandpsychologicalrecovery.JournalofIntensiveCareMedicine,27(2),97-111.doi:10.1177/0885066610394322

KamdarB.B.,KnauertM.P.,JonesS.F.,ParsonsE.C.,ParthasarathyS.,PisaniM.A.(2016).“Perceptionsandpracticesregardingsleepintheintensivecareunit.Asurveyof1,223criticalcareproviders.”AnnAmThoracSoc,13(8),1370-1377.doi:10.1513/AnnalsATS.201601087OC

KaplanS.(1995).“Therestorativebenefitsofnature:towardanintegrativeframework.”JournalofEnvironmentalPsychology,15,169–182.

KaiserStateHealthFacts(2012)Retrievedfromhttp://www.beckershospitalreview.com/finance/average-cost-per-inpatient-day-across-50-states.html

KlineG.A.(2009).“Doesaviewofnaturepromoterelieffromacutepain?”JHolistNurs27(3):159-166.

KeefeF.J.,SomersT.J.,MartireL.M.(2008).“Psychologicinterventionsandlifestylemodificationsforarthritispainmanagement.”RheumaticDiseaseClinicsofNorthAmerica,34(2):351–368

KellertS.,WilsonE.O.,Ed.(1993).“TheBiophiliaHypothesis.”Washington,DC,IslandPress.

Lovering,S.(2006).CulturalAttitudesandBeliefsAboutPain.JournalofTransculturalNursing,17(4),389-395.doi:10.1177/1043659606291546

LumleyM.,BorszczG.,et.al.(2011).“Painandemotion:abiopsychosocialreviewofrecentResearch.”JClinPsychol.67(9):942–968.

MalenbaumS.,etal.(2008).“Paininitsenvironmentalcontext:implicationsfordesigningenvironmentstoenhancepaincontrol.”Pain134(3):241-244.

MassiehMoayediK.D.D.(2013).“Theoriesofpain:fromspecificitytogatecontrol.”JournalofNeurophysiology109(1):5-12.

Mazer,S.E.(2017)“PainManagementandC.A.R.E.,”http://www.healinghealth.com/resources/pain-management-whitepaper/

Mazer,S.E.(2016)“WholePersonCareandC.A.R.E”http://www.healinghealth.com/resources/whole-person-care-and-c-a-r-e/

MazerS.E.(2014).“Musicasenvironmentaldesign.”HealingHealthCareSystems.Retrievedfromhttp://www.healinghealth.com/wp/wp-content/uploads/2014/06/mazer_music_as_environmental_design.pdf

MazerS.E.(2014).“Natureasenvironmentaldesign.”HealingHealthCareSystems.Retrievedfromhttp://www.healinghealth.com/wp/wp-content/uploads/2014/06/mazer_nature_as_environmental_design.pdf

McKinney,C.H.,Antoni,M.H.,Kumar,M.,Tims,F.C.,McCabe,P.M.(1997).“Effectsofguidedimageryandmusic(GIM)therapyonmoodandcortisolinhealthyadults.”HealthPsychol,16(4),390-400.

MelzackR.,WallP.D.(1965).“Painmechanisms:anewtheory.”Science.150(3699):971–9.doi:10.1126/science.150.3699.971

MelzackR.,CaseyK.(1968).“Sensory,motivational,andcentralcontroldeterminantsofpain:anewconceptualmodel.”In:TheSkinSenses,editedbyKenshalo,D.Springfield,IL:C.C.Thomas,p.423–439.

MelzacR.,andKatzJ.(2004).“TheGateControlTheory:ReachingfortheBrain”.In:Pain:PsychologicalPerspectiveseditedbyT.Hadjistavropoulos&K.Craig,Mahwah,NewJersey:LawrenceErlbaum.(pp.13-34).P.23.

MillerL.E.,EldredgeS.A.,DaltonsE.D.(2016).“Painiswhatthepatientsaysitis.”AmericanJournalofHospiceandPalliativeMedicine.August4,10.1177/1049909116661815

MillerA.C.,HickmanL.C.,LemastersG.K.(1992).“Adistractiontechniqueforcontrolofburnpain.”J.BurnCareRehabil.13,576–580.

MoermanD.E.(2002).“Meaning,medicine,andtheplaceboeffect.”NewYork:CambridgeUniversityPress.

MoermanD.E.,andJonasW.B.(2002).“Deconstructingtheplaceboeffectandfindingthemeaningresponse.”AnnalsofInternalMedicine,136(8),471-476.

MosseyJ.M.(2011).“Definingracialandethnicdisparitiesinpainmanagement.”ClinicalOrthopaedicsandRelatedResearch469(7):18591870.

NahinR.L.,StussmanB.J.,HermanP.M.(2015).“Out-of-pocketexpendituresoncomplementaryhealthapproachesassociatedwithpainfulhealthconditionsinanationallyrepresentativeadultsample.”TheJournalofPain:OfficialJournaloftheAmericanPainSociety,16(11),1147–1162.doi.org/10.1016/j.jpain.2015.07.013

CREATINGENVIRONMENTSTHATHEAL|WWW.HEALINGHEALTH.COM

Page11NationalInstituteofHealth.(2010).“NationalInstituteofHealthfactsheetonpain.”Retrievedfromhttps://report.nih.gov/nihfactsheets/Pdfs/PainManagement(NINR).pdf

NightingaleF.(1860).“Notesonnursing:whatitisandwhatitisnot.”(FirstAmericanEditioned.)NewYork:D.Appleton&Co.

NationalInstituteofMedicine(U.S.)CommitteeonAdvancingPainResearch,Care,andEducation(2011).“RelievingpaininAmerica:ablueprintfortransformingprevention,care,education,andresearch.”Washington(DC):NationalAcademiesPress(US);3,CareofPeoplewithPain.

RoyM.,PeretzI.,andRainvilleP.(2008).“Emotionalvalencecontributestomusic-inducedanalgesia.”Pain134(1-2):140-147.

RudinD.,KissA.,WetzR.V.,andSottileV.M.(2007).“Musicintheendoscopysuite:ameta-analysisofrandomizedcontrolledstudies.”Endoscopy,Jun:39(6):507-10.

Rutledg,D.N.,etal.(2013).“ChronicpainmanagementstrategiesusedbylowincomeoverweightLatinos.”Chronicillness9(2):133-144.

ScarryE.(1985).“Thebodyinpain:themakingandunmakingoftheworld.”NewYork:OxfordUniversityPress.

TeaterD.(2013).“Thepsychologicalandphysicalaideeffectsofpainmedications,”NationalSafetyCouncil,Colorado.

TuttleA.H.,TohyamaS.,RamsayT.,KimmelmanJ.,SchweinhardtP.,BennettG.J.,andMogilJ.S.(2015).“IncreasingplaceboresponsesovertimeinU.S.clinicaltrialsofneuropathicpain.”Pain,156(12),26162626.doi:10.1097/j.pain.0000000000000333

UlrichR.S.(1984).“Viewthroughawindowmayinfluencerecoveryfromsurgery.”Science224:420421.

VanHeckeA.etal.(2016).“Painintensityinhospitalizedadults:amultilevelanalysisofbarriersandfacilitatorsofpainmanagement.”NursingResearch65(4):290-300.

ZborowskiM.(1952).“Culturalcomponentsinresponsestopain.”JournalofSocialIssues,8(4),1630.doi:10.1111/j.1540-4560.1952.tb01860.x