What is Chronic Pain
Chronic pain is defined as pain that lasts for at least 3 to 6 months (depending on the definition). There are lots of different ways that chronic pain can differ person to person. For example, the pain can vary in terms of intensity, ranging from relatively moderate to very severe and debilitating. Chronic pain can also differ by being nearly constant, to flaring up in episodes.
Sometimes chronic pain starts because of an injury or illness and other times there is no obvious reason for the pain. Pain can be due to conditions such as arthritis, cancer, diabetes-related neuropathy (nerve damage), or fibromyalgia.
Chronic pain be present in many different areas of the body including the back, abdomen, knee, joints, hips, shoulders, head, and neck. Pain can even be felt in ‘areas’ of the body that have previously been amputated, which is called phantom limb pain, but that’s probably a topic for a whole different post.
As is apparent, chronic pain is a term that encompasses a wide set of symptoms.
In addition to the physical discomfort, chronic pain can be very isolating. There is a significant amount of stigma related to chronic pain because of the personal nature of pain. We cannot actually see how much pain someone is experiencing and can only guess at the presence and severity of pain based on what people report or by looking at physical signs of pain such as when a person is wincing, groaning, or stooping.
For a bunch of different reasons, friends, romantic partners, physicians, and others may not completely believe that the pain really exists or at least not to the degree that the person is reporting. This experience is incredibly invalidating for the person living with the pain.
In addition to the actual pain felt, chronic pain can have a heavy toll on the body in other ways. Feelings of depression, hopelessness, anxiety, anger, stress, and fatigue are all common. Other effects include changes in sleep and diet and withdrawing from activities.
Just with this brief, noncomprehensive overview, it is easy to see how complex and multifaceted chronic pain is. As such, successful treatment of chronic pain also needs to address many different issues and concerns.
Ways to Treat Chronic Pain
There are a lot of different types of chronic pain that have many different causes and effects. Accordingly, there are a lot of different types of treatments. Like many other problems that will be discussed at the Clinically Relevant Blog, a biopsychosocial model likely best explains chronic pain. As the name suggests, a biopsychosocial model states there are biological factors, psychological factors, and social factors that lead to the development and maintenance of chronic pain.
Given the strong influence of biology on chronic pain, there are many medications used to treat chronic pain, including nonsteroidal anti-inflammatory drugs (NSAIDs), opioids of various strengths, antidepressants, and anticonvulsants. It should go without saying that medical practitioners with training and expertise in chronic pain should carefully monitor any medication use.
My training and experience is with the psychological side of chronic pain. As such, this post is going to focus on some psychological factors that are related to chronic pain.
I do want to be clear that by acknowledging psychological factors influence chronic, this does not mean that chronic pain is “all in your head” or that you can just think the pain away. However, there has been some very interesting research showing that different psychological constructs are related to chronic pain and several psychological treatments do help those living with chronic pain improve their functioning and quality of life.
First, we will start by examining a construct called catastrophizing.
Thinking the Worst Leads to More Suffering
Catastrophizing, or thinking something is much worse than it actually is, is a thinking style that has been linked to chronic pain.
Here is an example of catastrophizing. Say you got a ‘C’ on a test in a class. Next thing you know, you are stressing out because this obviously means you are going fail the class, you won’t be able to graduate on time, and you will be forever unemployed because of your horrible grades.
Clearly when you are able to think with a more logical mind you can see that while a ‘C’ might not be the high grade you were hoping for, it is also not the end of the world. Seeing this grade in a more balanced and realistic way (i.e., not your best work, but also does not necessarily mean you are going to fail the class) will reduce the amount of stress that is caused. We all catastrophize to a certain extent, but when it happens a lot and leads to a large amount of distress, then it has become a problem.
So how does catastrophizing relate to chronic pain? A popular measure of pain catastrophizing, called the Pain Catastrophizing Scale (PCS), includes three main components.
One of these components is magnification, which is when a person believes the pain and its negative consequences will increase in the future. Another component is rumination, or continuing to think about pain before, during, and after a painful event. The final component is helplessness, which is when a person feels that they cannot deal with a painful event and feels that there is no control over the pain. Together, these three components help us understand ways in which catastrophizing is related to pain.
So what is the evidence that catastrophizing is related to chronic pain?
There have been several studies done in this area. For example, a study of patients living with chronic pain from a spinal cord injury looked at how different pain coping strategies (including catastrophizing, distracting oneself from the pain, and attempting to ignore the pain) were related to pain intensity, psychological distress, and pain-related disability (i.e., pain interfering with activities; Turner et al., 2002). What this study found was that catastrophizing was the pain coping strategy that was most strongly and consistently related to pain intensity, psychological distress, and pain-related disability.
This area of research indicates that targeting a person’s tendency to catastrophize pain-related thoughts is an important goal of treatment for chronic pain patients. However, catastrophizing is not the only thinking style related to chronic pain.
The Cycle of Fear, Avoidance, and Disability
To understand why some people with pain develop chronic pain syndromes after physically recovering from an injury, a model was created that looks at fear of pain and the subsequent avoidance of activities due to this fear (Vlaeyen & Linton, 2000).
This fear-avoidance model works as follows. When a person engages in certain actions or activities (e.g., bending over, lifting an object), this causes the person pain. Eventually, the connection between activities and pain becomes strong over time, leading the person to fear the pain, as well as a potential injury, before even starting the activity.
After some time, this person will start avoiding activities expected to cause pain as a way to decrease their suffering, which will lead to a restriction of these activities. In the short term, this can reduce the amount of pain a person experiences. Unfortunately, long-term consequences of this connection leads to negative outcomes such as depression and reduced physical strength. Losing physical strength will in turn result in greater disability and can cause more physical pain that what might be otherwise experienced.
In addition, because of the pain-related fear, this avoidance of activities will happen regardless of whether the movement will actually cause pain. As there are no opportunities to correct this faulty thinking (due to the avoidance), activities will be avoided even when they may not actually lead to pain.
Fortunately, there are ways to interrupt this cycle. Specifically, confronting pain-related fear will help lead to recovery. There are many reasons why this pain-related fear may exist.
Catastrophizing, which was discussed in the previous section, has been identified as one of the thinking styles related to pain-related fear. However, catastrophizing is not the only construct related to fear and avoidance.
Other targets for improving pain-related fear include correcting misinterpretations of physical sensations, reducing the amount of attention a person places on physical sensations, and perhaps most importantly, slowly exposing the person to their feared activities.
Fear of pain can often be more debilitating than the actual pain itself. Confronting this fear directly is the best way to set oneself on a path to a healthier and happier life. The final psychological construct that we are going to examine is acceptance of pain.
Accepting Pain As A Strategy To Decrease It
One, perhaps counterintuitive, strategy to decrease chronic pain is to increase your acceptance of the pain. This has been demonstrated with a type of cognitive-behavioral therapy (CBT), called acceptance and commitment therapy (ACT, which is pronounced like the word ‘act’).
ACT is similar to traditional CBT, although it differs in a few key ways. For example, ACT (as the name would suggest) places a big emphasis on acceptance of one’s experiences, including anxiety and pain. Acceptance of pain involves experiencing the pain without attempting to avoid or control the pain. ACT believes that much of human suffering is because we try to avoid or change our experiences and that by accepting our experiences, we can reduce our suffering.
In addition to acceptance, ACT also emphasizes behaving in ways that are consistent with one’s values, also called values-based action. It is thought that doing more actions that are consistent with your values will increase your happiness and quality of life.
For example, if someone values fitness, a values-based action would be going to the gym and working out. On the flip side, if someone values fitness and stays on the couch all weekend binging on Netflix, that person will probably not feel so great about themselves (speaking from personal experience).
Research has shown that ACT leads to positive changes for the chronic pain patients in multiple areas, including experiencing less pain, depression, and pain-related anxiety, having fewer medical visits, and improving physical performance (Vowles & McCracken, 2008).
OK, pretty awesome, but how does ACT lead to these positive changes? Well it seems that ACT leads to changes in acceptance and values-based action, and these changes then predict better functioning later on. It is pretty incredible that increased acceptance of pain and values-based action can lead to so many positive benefits.
Let us look at another treatment that uses acceptance as a strategy to decrease suffering called mindfulness-based stress reduction (MBSR). There will be a separate post in the future talking about mindfulness in detail. However, in brief mindfulness is often described as paying attention, on purpose, to the present moment, in a non-judgmental way.
Dr. Jon Kabat-Zinn, the creator of MBSR, is widely credited for bringing mindfulness to Western culture, but he by no means created mindfulness. Mindfulness has been practiced for thousands of years and is strongly tied to Buddhism. Similar to ACT, MBSR focuses on acceptance of thoughts, feelings, and emotions in the present moment. MBSR was developed in part to treat people with chronic pain.
A meta-analysis (collection of a bunch of studies, in this case 22 studies) looked at the overall effectiveness of ACT and MBSR for treating chronic pain (Veehof et al., 2011). The findings of this meta-analysis show that these two acceptance-based therapies led to improvements in pain intensity, depression, anxiety, physical well-being, and quality of life. However, the findings also showed that the acceptance-based strategies were not any better than CBT for treating pain or depression.
Does this mean that acceptance-based strategies are a bust? Not really. It is possible that some people will naturally respond better to acceptance-based therapy compared to traditional CBT and vice versa. In addition, it is also possible that by combining both therapies together could lead to improved outcomes. More work is clearly needed but there is a lot of exciting research being done in this area.
So that was a lot of information, what are some of the takeaways? Well, first it is important to note that chronic pain is incredibly complex and manifests itself in multiple ways. Therefore, it’s not likely that any one cause is responsible for chronic pain. Instead, it is most likely that several different causes, consistent with the biopsychosocial model, that are related to chronic pain.
This post focused on psychological factors related to chronic pain, but as stated previously, biological and social factors also play an important role. In terms of psychological factors, constructs such as catastrophizing, fear of pain, and acceptance all appear to be related to chronic pain.
Psychological treatments such as CBT, ACT, and MBSR all appear to help those living with chronic pain, in part by addressing the psychological factors related to pain. Unfortunately, psychological research is not yet sophisticated enough to tell us who exactly will benefit from what treatment. Therefore, some people may respond better to traditional CBT whereas others respond better to ACT.
This was not a comprehensive overview of all the psychological factors related to chronic pain and instead highlighted just some of the research done in this area. It is highly recommended that if you have interest in this area you do some additional readings and research to learn more.
Chronic pain is terrible to deal with, but there are a lot of great treatments out there that can help reduce suffering and improve one's quality of life. Changing one's thoughts can be effective in treating chronic pain, but the important thing is to find what works for you. Get out there and show your pain who's boss!
The Clinically Relevant Insights Blog, part of ShawnWilsonPhD.com, shares news and research related to psychology and wellness.
Turner, J. A., Jensen, M. P., Warms, C. A., & Cardenas, D. D. (2002). Catastrophizing is associated with pain intensity, psychological distress, and pain-related disability among individuals with chronic pain after spinal cord injury. Pain, 98(1), 127-134. doi:10.1016/s0304-3959(02)00045-3
Veehof, M. M., Oskam, M., Schreurs, K. M., & Bohlmeijer, E. T. (2011). Acceptance-based interventions for the treatment of chronic pain: A systematic review and meta-analysis. Pain, 152(3), 533-542. doi:10.1016/j.pain.2010.11.002
Vlaeyen, J. W., & Linton, S. J. (2000). Fear-avoidance and its consequences in chronic musculoskeletal pain: A state of the art. Pain, 85(3), 317-332. doi:10.1016/s0304-3959(99)00242-0
Vowles, K. E., & McCracken, L. M. (2008). Acceptance and values-based action in chronic pain: A study of treatment effectiveness and process. Journal of Consulting and Clinical Psychology, 76(3), 397-407. doi:10.1037/0022-006x.76.3.397