Persistent pain is a significant therapeutic challenge and a public health epidemic placing burdens on those experiencing pain as well as society more broadly. Biological, psychological, and social variables play a critical role in the success of chronic pain treatment outcomes. Studies identify several psychosocial characteristics that often accompany the functional consequences of chronic pain. These include perceptions of pain, attitudes and beliefs, psychological trauma or subconscious need, coping abilities, depression and anxiety, catastrophizing, sense of control or helplessness, fear and anxiety, social support, and sleep quality. These factors can play an important role in positive or less than optimal outcomes associated in chronic pain treatment. Psychosocial characteristics can also place individuals at elevated or reduced risk for the transition from an acute to persistent pain state, or for the development of pain-related disability in the context of a persisting pain condition. The complexity and variability of chronic pain highlight the challenge of treating these conditions and the contributory role of these psychosocial factors.
Why Should Organizations Care?
When these psychosocial factors are present and left unaddressed, they can stall the efficacy of treatment and contribute to an organization’s disability claims, productivity losses, and employee absences. Research has found that by addressing pain and related psychosocial issues early, it has a positive effect on the bottom line. See our blog post about how organizations encourage “Total Worker Health” to lower the barriers to multi-layered and more optimal treatments; and “How to Create a Culture of Health” for a discussion of the important aspects addressing optimum solutions.
Below are some of the most common psychosocial factors implicated in the experience of pain and related disability.
Perception of Pain
Our perception of pain varies over time and with circumstance and is regulated by emotion and at times by factors that seem unrelated to the stimulus. Chronic pain may continue without conscious awareness of its actual cause, with only the pain itself perceived consciously. When pain persists unnecessarily, it may be because the individual has been conditioned to perceive it. Subconsciously, if they have learned to expect pain to continue, that learned influence may persist, causing continued pain in contrast to conscious logic.
Attitudes and Beliefs
People are active processors of their experience, which is always reconciled by what they believe and how they interpret the situation. The influence of beliefs on pain is profound. In acute pain situations wherein pain directly arises from tissue damage, protecting the area of pain by refraining from activity may be adaptive. However, beliefs about acute pain are often applied to chronic pain, and such beliefs are accompanied by activity avoidance and deactivation, which in turn significantly contribute to greater pain and disability. Modification of individuals' negative thoughts about their pain seems to predict changes in pain, response to treatment, and disability.
Psychological Trauma/Subconscious Need
Pain can occur in reaction to various psychosocial stimuli, such as guilt or regret. In such cases, pain seemingly becomes the subconscious infliction of self-punishment. These fears may cause muscle contractions, contributing to low back pain or other chronic pain. Consciously unrecognized benefits of pain, may support the reoccurrence of pain, as well as when the pain has become a means of getting attention.
Coping Ability
The literature identifies several coping strategies that include guarding, resting, asking for assistance, relaxation, task persistence, exercising/stretching, coping self-statements, and seeking social support.
Coping refers to efforts to address events that tax perceived available adaptive resources. Coping strategies can be behavioral, like relaxation and pacing one’s activities, as well as cognitive, using distraction or positive thinking. Efforts may be active such as attempting to obtain information, problem solving, guarding, asking for assistance, exercise and stretching, practicing coping self-statements and seeking social supports. Or efforts may be passive such as withdrawing from situations, feeling hopelessness, or becoming dependent on others. Coping may vary depending on the particular problem. Thus, how a person copes with a particular problem at a particular point in time may not predict how they might deal with a different problem at the same point in time or the same problem at a different point in time. How individuals cope with pain can predict pain perception, levels of emotional distress, adaptation, and functional disability.
Depression
Rates of depression are higher in chronic pain populations than in the general population, and it is quite common in specialized pain clinic individuals for >50% of individuals evaluated to experience significant emotional distress. There is a wealth of evidence that symptoms of depression, anxiety, and emotional distress contribute strongly to key long-term outcomes of persistent pain such as physical disability, work disability, healthcare costs, mortality, and suicide.
Catastrophizing
A large volume of evidence suggests that catastrophic thinking about pain plays a significant role in defining the actual pain experience. Catastrophizing is a cognitive process where one assumes the worst possible outcomes, dwells on these, and interprets even minor problems as major calamities. These thoughts can harm perceptions, expectations, memories, and thereby experiences. As a further consequence, such individuals may develop passive coping styles, such as helplessness, that further exacerbate their condition.
Sense of Control/Helplessness
A sense of control represents the perceived ability to manage pain or pain-related matters. How individuals conceptualize their ability to control pain and associated stress seems to be an influential determinant for how they cope with pain. An increased sense of control has been shown to be linearly related to greater functionality in individuals with chronic pain. Furthermore, improvement in control beliefs after treatment typically results in a reduction of pain and disability. At the other end of the control spectrum is a sense of lack of control—that is, helplessness, which is associated with greater pain and poorer physical and psychological adjustment in chronic pain.
Fear and Anxiety
Individuals may experience fear about how physical activity and work may affect their pain. Fear-related problems and anxiety are more prevalent in individuals with chronic pain than in the general public. The prevalence of any anxiety disorder among people with chronic pain may be twice as high as in the general population (35% vs. 18%); panic disorder and post-traumatic stress disorder are three times more common in individuals with chronic pain. Although fear and anxiety are often viewed as a single mood condition, they are likely to separate entities with distinctive physiological and emotional experiences. Anxiety is a future-oriented emotion; it is experienced as worry and nervousness related to some often vague future issues, whereas fear is a present-oriented mood state about something specific that one wants to escape from or avoid.
Fear and anxiety reflect key components of the dysfunctional circle of pain maintenance. It has been shown that pain-related fear-avoidance is significantly associated with functional limitations and perceived disability in individuals with acute and chronic pain.
Additionally, workers’ experiencing chronic pain can worry about being able to do their jobs, fear being let go, worry about keeping up or pulling their weight. Often these fears are not productive to the healing process.
Social Support
Significant attention has been devoted to the important role of social context at each step along the trajectory of chronic pain. Social support is simply the resources perceived as or actually being available from others in social networks and includes family, friends, and coworkers, the employer, among others. The literature suggests that those with chronic pain who perceive high degrees of social support report less distress and pain as well as better adjustment promoting adaptive coping responses. Conversely, support in the form of anxious behavior in response to communications of pain behaviors has been shown to be associated with increased pain and pain behaviors and maintenance of disability.
Sleep and Fatigue
Sleep disturbances are common among individuals with chronic pain, and pain and sleep problems appear to have a corresponding effect. Acute and chronic pain can disrupt sleep, resulting in difficulty falling asleep, staying asleep, and reducing the quality and duration of sleep. Studies indicate that sleep deprivation lowers the cognitive ability to cope with pain, and increases ratings of pain intensity, which in turn exacerbates poor sleep. Sleep disturbance can aggravate pain, inflammatory processes, increase emotional distress, and reduce well-being. It can be a vicious cycle.
Conclusions
Psychosocial factors have been found to have a substantial impact on injured workers’ chronic pain and can significantly contribute variations in disability and responses to treatment over time. The presence of symptom does not begin in isolation; pain does not represent just discomfort in a specific body part but occurs within a person with a unique constitution, learning history, and adaptive resources. Moreover most people do not live in isolation but rather in a social context, and this context contributes to the experience of pain and adaptation. Whether psychological factors precede the onset of pain or evolve in response to the presence of longstanding symptoms, it is recommended that an integrative approach that considers both the physical and psychosocial contributors are addressed for optimized treatment outcomes.
Sources:
- “Assessment of Psychosocial and Functional Impact of Chronic Pain,” The Journal of Pain. http://dx.doi.org/10.1016/j.jpain.2016.02.006
- “The Role of Psychosocial Processes in the Development and Maintenance of Chronic Pain,” The Journal of Pain. http://www.jpain.org/article/S1526-5900(16)00018-3/fulltext
- “Can we look deeper to the root of pain? What’s Missing from this Puzzle?” The Pain Practitioner: http://pain-practitioner.aapainmanage.org/doc/american-academy-of-pain-management/the-pain-practitioner---november-2016/2016102601/#0
- “The Psychology of Pain”: https://www.ncbi.nlm.nih.gov/pubmed/15829386
- "Why You Need Wellness Programs Fostering Emotional, Spiritual, and Social Wellbeing: /need-wellness-programs-fostering-emotional-spiritual-social-wellbeing/
