Psychological Factors in Pain

Cognitive theories of depression, anxiety and pain hold that thoughts and beliefs are major determinants of affect; i.e., how we feel is less determined by events than by our interpretation of them. For example, one person may conclude from an unsuccessful job interview that the company has no openings; whereas another may infer that he is undesirable and unlikely to find work. The terminal cancer patient who believes that “the surgeon got it all” will be more content than the healthy person who believes his intractable pain is due to severe but undetected pathology. Maladaptive cognitions tend to be automatic and habitual, so they rarely are examined for validity. They simply are accepted.

Cognitive factors have an impact on pain in several ways. First, the adverse quality of pain is modified by its interpretation. Such “catastrophic” interpretation of pain as in,“My nerves are being crushed,” or “I may become paralyzed,” impede coping. The situation is not helped by physicians who attribute pain to such pathology when this may not be true. Take, for instance, the very common experience of back pain, which is the leading cause of disability and absenteeism from the workplace. Specific causes of back pain, such as infections, tumors, osteoporosis, spondyloarthopathies and trauma, represent a minority of pain syndromes. Conversion of acute back pain to chronic may be in part iatrogenic, meaning it is at least in part made worse by the doctor who is trying to treat the pain.

Back pain also is often strongly driven by psychological and psychosocial factors, including fear of pain and reinjury, “catastrophizing,” depression and anxiety. Failure to address these issues in treatment of chronic back pain often leads to continued disability. Pain tolerance is reduced by thoughts emphasizing the averseness of the situation, the inadequacy of the person to bear it or the physical harm that could occur. Such beliefs as “I will have a life again only after I am cured,” “I can’t go out to dinner if I am in pain,” and “I shouldn’t exercise if it hurts,” have obvious impacts upon adaptation.

Self-appraisal may be as important as appraisal of the pain itself. Those who feel unable to influence events eventually give up. Belief in personal helplessness fosters pain and disability; on the other hand, a sense of self-efficacy promotes efforts to cope. Thus, perceptions of helplessness lead to depression, resignation and passivity, which, in turn, increase disability and pain. Self-efficacy, the opposite of helplessness, is correlated with successful rehabilitation in fibromyalgia, for instance.

The term “locus of control” refers to one’s sense of the origins of events. The perception that events are a consequence of the individual own behavior (internal locus of control) is associated with better mood and function. Those with an external locus of control tend to see events as contingent on other people or “fate.” People with chronic pain who have an external locus of control report depression and anxiety, feel helpless to deal with their pain and often rely on maladaptive coping strategies, such as excessive rest and eating. Decreased perception of self-control may explain much of the relationship between depression and pain.

Anxiety seems to intensify such symptoms as myalgias and neuropathic pain. Anxiety can be the major reason for failure of rehabilitation. Phobic processes have been implicated on a cycle of unnecessary self-protection, leading to deconditioning. When people became afraid to move, disability and dysfunction can result as much from unwarranted fear as from the pain itself.

Education may be one of the most critical of the “therapies” provided, because a patient’s behavior and their family’s reaction to the disease may be based on faulty information or misconceptions. Education can clarify the problem and indicate the best response. As already noted, chronic nonmalignant pain is “real” but should be interpreted as a “false alarm” that needn’t dictate activity.

Biofeedback, relaxation training, self-hypnosis and progressive muscle relation all have been shown to be effective in the treatment of pain. They not only can have a direct effect on tense and painful muscles but also reduce levels of stress hormones. These techniques also can help patients to regain a sense of mastery over their bodies and to learn the effects of emotions on pain. Once learned, these techniques can be used without professional assistance whenever and wherever needed.

Within a behavioral program, rehabilitation is facilitated by behavior modification or contingency management in which pain behaviors are no longer reinforced but healthy behaviors are. Family members also learn the roles they play in maintaining the patient’s “sick role” and are encouraged to treat the patient as a healthy person who may have pain. It is often a challenge for spouses who have spent years adjusting to the role of caregiver to recover their roles as playmate, partner and lover.

Cognitive behavioral therapy has been shown to be effective in the treatment of chronic pain. This therapy focuses on beliefs about pain. The extent to which one has the necessary coping skills to deal with pain markedly affects the degree of emotional distress and the extent to which someone becomes physically disabled by pain. A number of techniques are used in cognitive behavioral therapy, including self-talk, relaxation and distraction, and positive coping strategies.

As previously noted, stress can increase pain perception. Learning to identify and manage stress can play an important role in the treatment of chronic pain. Often patients come to the experience of pain with few coping mechanisms and major life stresses. Group, individual and family therapy can help address stresses and teach new ways of managing pain and stress as an individual and as a larger family unit.We know that chronic pain not only affects the patient but the family as well, which is why it is vital to work with family members and close friends who interact with the patient.