The psychological aspects of pain include the emotional and social factors that contribute to chronic pain and the experience of pain conditions ranging from osteoarthritis to fibromyalgia.
Several factors have been identified that place a person at a higher risk of developing chronic pain, including a history of substance abuse, job dissatisfaction and a history of psychological abuse. Depression, anxiety or sleep disorders can contribute to, be a symptom of or result from a number of pain conditions, such as chronic fatigue syndrome and migraines. People with conditions such as rheumatoid arthritis or lupus may experience issues with body image.
The psychological aspects of pain may be evaluated during a pain assessment or clinical interview where a physician may inquire about the nature of the pain experienced and the patient’s psychiatric history and mental status. Some patients are asked to fill out a questionnaire, which is designed to obtain similar types of information.
The psychological aspects of pain can be treated in several ways, such as medication and therapy. Medications may include antidepressants, tranquilizers or anticonvulsants.
Some patients are treated with cognitive behavioral therapy, which is based on the idea that thoughts and behavior patterns influence symptoms. Patients learn relaxation techniques, stress management and other ways to cope with pain. Biofeedback is another technique sometimes used to treat physical and emotional pain.
About the psychological aspects of pain
The psychological aspects of pain include the emotional and social factors that contribute to the perception of pain. They can also involve the emotional impact experienced by people who live with chronic pain, such as arthritis, fibromyalgia, lupus or chronic fatigue syndrome.
In recent years, the medical community has recognized that pain is not simply a physical response to an unpleasant external stimulus (noxious stimulus). Rather, there are a number of biological, psychological and social factors that interact in complex ways to influence the experience and perception of pain. Although this is an area that is recognized by the medical community, it is not fully understood and is still being investigated.
Factors that can influence a patient’s experience with pain include:
Past experiences with pain
Genetic factors
Depression and other mood disorders
Pain coping methods
Beliefs or fears surrounding the pain
Understanding the psychological aspects of pain may be particularly important among people who experience chronic (long-term) pain. Some patients with chronic pain do not respond to traditional analgesics and may be treated with other drugs, such as antidepressants. Lithium, a treatment for bipolar disorder, is sometimes prescribed as a headache medication to prevent cluster headaches.
Chronic pain patients may experience several physiological and psychological consequences as a result of the pain. They include:
Insomnia or other sleep disturbances
Anxiety and depression
Loss of enjoyment of life
Inability to maintain close relationships
Feelings of hopelessness and helplessness
Suicidal thoughts
Chronic pain patients are also at a higher risk of developing mood disorders, such as depression, and attempting suicide.
Scientists have identified several factors that are associated with patients who have difficulty recovering from injury and are at a greater risk of developing chronic pain and disability as a result. They include:
History of major psychopathology. Patients with a mood, anxiety, thought or personality disorder have a greater chance of developing chronic pain due to poor coping mechanisms.
History of substance abuse or dependence. Patients with past substance abuse problems are more apt to experience chronic pain. Patients can also develop substance abuse problems through the use of medications to treat pain, such as opioids.
Job dissatisfaction. People who are unhappy with their jobs are more likely to have chronic pain.
History of psychological abuse. This may result in a higher risk for chronic pain.
Negative or anxiety-producing beliefs about pain. People with little confidence in their ability to overcome pain are at a greater risk for developing chronic pain.
Overall attitude towards pain. Patients with optimistic attitudes about their abilities to recover from pain are better able to avoid chronic pain than patients with negative attitudes.
Fear of social stigma prevents some people from addressing the psychological aspects of their pain. However, awareness of the widespread toll of pain on emotional health can ease such concerns. For example, depression, anxiety and sleep disorders are common in the 15 percent of the population suffering recent migraines and other severe headaches, the U.S. Centers for Disease Control and Prevention (CDC) reported in 2006.
Psychological consequences of pain
People who experience chronic pain may experience a range of psychological consequences, including:
Changes in mood:
Fear and anxiety. Some people experience fear and anxiety as a result of chronic pain. They may be fearful of performing activities that may cause pain. In some cases, the fear may be more disabling than the pain itself.
Depression. Chronic pain and chronic depression are risk factors for suicide. When people experience both chronic pain and chronic depression, it is particularly dangerous.
Changes in ability to cope. Some patients develop patterns of negative thinking that impede their ability to cope with pain. These include:
Catastrophizing. Anticipating the worst.
Filtering. Exaggerating the negative aspects of an experience and minimizing the positive ones.
Personalizing. Automatically accepting blame when something bad happens.
Generalizing. Viewing a troublesome event as the beginning of a never-ending cycle.
Polarizing. Viewing situations as all good or all bad, black or white. Not recognizing the middle ground.
Emotionalizing. Letting emotions control judgment. For example, a person who feels stupid is stupid.
Difficulty with daily life. Some chronic pain patients experience problems with activities of daily living, such as sleep disturbances and disruption in work activities. Many pain conditions interfere with sleep, such as fibromyalgia, chronic fatigue syndrome, myofascial pain syndrome, polymyalgia rheumatica, headaches, back pain, heartburn, restless legs syndrome, benign prostatic hyperplasia and neuropathy. Loss of sleep causes fatigue and increases sensitivity to pain. Sleep disorders may promote accidents and falls that can cause fractures or other trauma.
In addition, disability caused by conditions such as rheumatoid arthritis or advanced Lyme disease can lower self-esteem.
Problems with interpersonal relationships. Some patients experience problems with family members, friends and co-workers.
Altered body image. Diseases that can deform a patient’s joints, skin or other physical features, such as rheumatoid arthritis and lupus, often cause emotional distress, researchers have found.
In some cases, treatments for psychological conditions can contribute to pain conditions and pain treatments can contribute to psychological conditions. For example, antidepressants can disrupt sleep and sometimes trigger restless legs syndrome. Corticosteroids and some other medications can also hinder sleep. However, the benefits may outweigh the side effects, and patients should not discontinue medications without consulting their physician.
Diagnosis of psychological consequences of pain
The first step in diagnosing psychological consequences of pain is for a physician to review the patient’s medical history, including a list of medications, and to perform a physical examination. Patients may be asked to fully describe the pain, including location, severity and duration. Physiological causes of pain are sometimes identified during a physical examination.
In some cases, patients undergo a clinical interview to better understand the psychological components that may be contributing to their experience of pain. A psychologist, psychiatrist or clinical social worker may conduct this type of pain assessment.
The goal of the interview is to determine the impact the pain has had on the patient’s life, such as how it has affected work and family, financial status and personal goals. Patients may be interviewed using the Psychosocial Pain Inventory (PSPI), a questionnaire aimed at identifying psychosocial factors that may be contributing to a patient’s pain. The PSPI has 25 questions. Factors evaluated in the PSPI include life changes, use of medication and environmental stress.
Other information that may be obtained during a clinical interview includes:
Mental status. Questions are aimed at patient’s attitude, mood, speech, perception, quality of thinking, judgment and cognitive and intellectual functioning. Patients may also be asked if they have ever had suicidal thoughts or wanted to commit acts of violence.
Level of functioning. Patients will be asked to describe how the pain has impacted their lives, such as whether they have missed work because of pain or have difficulty completing daily activities, such as dressing or bathing.
Identifiable stressors. Related or unrelated problems to the pain experienced, such as conflicts at home or work or litigation that is being considered as a result of injury.
Psychiatric history. Past consultations with psychiatrists or psychologists. Patients may be asked about prior psychiatric treatment, including medications and hospitalizations.
History of substance abuse. Any prior treatment for substance abuse, including participation in detox or 12-step programs. Patients may also be asked to describe current use of substances such as alcohol, nicotine and caffeine.
Developmental and social history. The patient’s childhood, relationships with parents and siblings and current social network.
Sometimes patients are asked to fill out questionnaires about their experiences with pain rather than being interviewed. There have been several questionnaires developed for this purpose. Among the most frequently used is the McGill Pain Questionnaire (MPQ), which incorporates a series of adjectives to describe the characteristics and intensity of pain. For example, patients may be asked to describe pain using words, such as burning, throbbing, or tingling.
Symptoms of depression may include:
Feelings of guilt, hopelessness or worthlessness
Lack of interest in favorite activities
Sleeplessness or excessive sleepiness
Suicidal thoughts or recurrent thoughts of death
Trouble concentrating
Marked decrease or increase in appetite
Significant weight loss or weight gain
For depression to be classified as major, five of these symptoms must persist for at least two weeks.
Treatment options
Patients experiencing pain, particularly those with chronic pain, often experience negative emotions such as panic, fear, grief and anger. One coping strategy is to acknowledge those feelings. Techniques for addressing feelings include:
Recognizing the seriousness of feelings
Talking about feelings to friends, family members and others
Seeking the assistance of a therapist or counselor, if necessary
Some patients record symptoms in a pain diary. This can assist patients in monitoring pain and determine factors that may alleviate or worsen pain.
Lifestyle changes that are commonly used to treat chronic pain include:
Staying active. Exercise and increasing the level of activity have been shown to improve chronic pain and enhance mood.
Focusing on others. Staying active in the community and keeping close contact with friends and family members often makes patients feel less isolated and better able to cope with pain.
Staying healthy. Maintaining a healthy weight and sleeping on a regular schedule can improve chronic pain.
Some chronic pain patients develop emotional disorders, such as depression, as a result of pain. Patients diagnosed with a mood or anxiety disorder resulting from pain may be treated with medication or with therapy. Medications used to treat emotional disorders include:
Antidepressants. Most antidepressants exert their effect on brain chemicals known as neurotransmitters. Two such neurotransmitters are serotonin and norepinephrine, which play roles in the regulation emotions, behavior, appetite and sleep.
Tranquilizers (group of drugs that are used to treat medical conditions such as severe anxiety, stress disorders and muscle tension). These are usually classified as major or minor. Major tranquilizers are often prescribed as antipsychotic medications, and minor tranquilizers induce a feeling of calm and relaxation.
Psychostimulants (drug having antidepressant or mood-elevating properties). The most common stimulant used in treating pain is caffeine.
Anticonvulsants (drugs used to prevent or treat seizures). Their effectiveness in treating some types of pain has not been proven.
Cannabinoids. Some studies have shown that marijuana has pain-relieving qualities. Some U.S. states have laws supporting medical marijuana, but the federal government has outlawed it.
Some patients are treated using cognitive behavioral therapy (CBT), which is based on the idea that thoughts and behavior patterns affect symptoms. With this type of therapy, patients learn relaxation techniques, stress management and other methods to cope with pain.
The goal of CBT is to change the way the patient thinks about pain so the mind and body respond better to episodes of pain. CBT usually consists of attending several one-hour sessions with a therapist. Sometimes sessions are one-on-one, and sometimes they are in a group setting. Therapy sometimes consists of learning exercises that help the patient cope with feelings. Other forms of psychotherapy, or support groups, may also be options.
Patients may benefit from biofeedback, in which the mind gains control over the body. They can also ask their physician about other treatments that may help relieve chronic pain, such as acupuncture, acupressure, manipulation therapy, electrical therapy, thermotherapy, hydrotherapy and cryotherapy.
Pain relief issues
According to the American Pain Foundation, more than 50 million people in the United States experience chronic pain that interferes with daily life. But most pain is either untreated, undertreated or treated improperly.
Some patients, particularly elders, underreport pain for a variety of reasons. Some fear complaints will not be taken seriously or caregivers will lose respect for them. Others underreport pain because they believe adequate remedies are not available or they will become addicted to pain medications.
Tolerance, dependence and addiction can develop with opioids. Tolerance occurs when the body becomes accustomed to medication and a higher dose is required to treat a similar amount of pain. Dependence is when a person is prescribed a medication and experiences withdrawal symptoms if the drug is suddenly removed. Addiction is the overwhelming urge to use a drug even when pain relief is no longer needed.
Physicians sometimes do not treat pain sufficiently because they fear patients will become addicted. Opioids rarely cause addiction when used correctly under a physician’s close supervision for acute pain or cancer pain. There is a risk when opioids are used to treat chronic pain, even in patients with no history of drug abuse.
There are a number of ways that patients can address undertreatment or mistreatment of pain, including:
Accurate diagnosis. Determining the correct underlying condition or disease causing pain can lead to a more effective treatment plan.
Advocacy. Patients should understand that pain cannot be ignored. It needs to be assessed and treated.
Commitment. Patients are encouraged to find a specialist in pain management, a new growing specialty, and to stick with their pain management plans.
Information. It is recommended for patients to research their conditions and pain management options to ensure the best treatment with their physician.
Clear descriptions of pain. Patients are encouraged to accurately describe the location, severity and type of pain to physicians. This may ensure that pain is correctly assessed and treated. Maintaining a pain diary may help to describe pain.
Appropriate healthcare provider. Patients should make sure healthcare providers are trained and committed to the assessment and treatment of pain.
Questions for your doctor
Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about psychological aspects of pain:
How do psychological factors affect my pain?
My pain does not seem to be disappearing. Do I have a chronic pain condition?
If a relative had a chronic pain condition, am I likely get it at some point?
What tests might be used to assess the psychological aspects of my pain?
What do my test results show?
How will you address the psychological aspects of my pain?
Standard medications have not been effective in treating my pain. Can other medications help?
Which nonpharmaceutical methods can help me? Do you recommend exercise, cognitive behavioral therapy, biofeedback, massage therapy, acupuncture or other treatments?
