Pain: Psychological Correlates 3

By Dr.Thilini Rajapakse, Dr. Dilani Wijeratne

and Dr. Ranjith Pallegama


Psychosocial Aspects of Chronic Pain


The association of psychosocial issues

     Involvement of psychosocial conditions with chronic pain can be viewed mainly from three aspects as briefly mentioned in the previous section. In patients who are suffering from chronic pain conditions with an organic cause of pain, there can be a considerable amount of psychosocial modulation such as attention seeking, anticipation, mood changes, anxiety and catastrophizing. This explains why certain patients with trigeminal neuralgia (TN) report a cure or an episode of no-pain even after an irrelevant treatment procedure such as extraction of a tooth close to the site of pain. In this case patients presume and expect that the extraction will cure the condition. The modulation through this expectation will alleviate symptoms for a while and known as the “expectation-induced placebo effect”, but, inevitably the symptoms will recur after a short lapse as root cause of the pain condition has not been eliminated. In the current literature, pain related catastrophizing, i.e., extreme negative appraisal of pain, has been identified as a major risk factor for chronic pain and thought to account for 7% to 31% of variation in pain experience. Investigations point to the fact that pain related catastrophizing appears to amplify CNS processing of noxious input. Pain-related fear is one of the most potent predictors of observable performance in chronic pain patients and is highly correlated to self-reported disability levels. It is reported that fear of pain is more disabling than the pain itself.

     There can also be psychological reactions to chronic pain conditions with an underlying organic cause. Frustration, suffering and eventually development of more serious states such as depression are considered as such psychological reactions. But rarely, in some patients, chronic pain conditions with psychological origin (psychogenic pain) can be found. In the ‘classification of chronic pain’ published by International Association for the Study of Pain, different types of pain conditions of purely psychological origin are described. But it is important to remember that prevalence of these conditions is very low and hence, careful examination and exclusion of all above conditions are necessary before confirming that a particular patient has a psychogenic pain condition.


Multidimensional assessment of chronic pain conditions: case formulation

     In multidisciplinary pain management, multidimensional perspective should be the guiding principle in assessment of chronic pain conditions. Initial assessment should identify the main presenting problem and the factors contributing in physiological, demographic, social or environmental, psychological domains. The assessment should include, pain quality, mood (especially anxiety and depression), interference in daily activities due to pain (disability), pain behaviors (limping, etc.), cognition and beliefs (e.g., locus of control, acceptance of pain, catastrophizing, belief about the link between pain and injury), use of pain coping strategies (avoidance, taking drugs, resting etc.) and pain severity assessed on pictorial, numerical or visual analogue scale. Psychometric tools such as Multi-Dimensional Pain Inventory (MPI), Medical Outcome Study (36 items short health survey) (SF-36), McGill Pain Questionnaire as general measures and Pain Catastrophizing Scale (PCS), State Trait and Anxiety Inventory (STAI), and Hospital Anxiety and Depression Scale (HADS) as specific measures can also be used.

     In the ‘case formulation’, which is much more than diagnosis, the other contributing factors to the patients’ condition is identified. These identified factors will be targets for intervention in the management process. For example, a patient with TN will be discriminated from a patient with TN and higher degree of catastrophizing and then approach for management should be planned in a multidisciplinary basis.


Psychosocial approaches to pain management

     In addition to the conventional treatment modalities in chronic pain management, multidisciplinary customized self-management programs should be introduced based on the case formulation. These may include procedures such as cognitive behavioral management programs alongside the medical treatments, reassurance -verbal /feedback, education and graded physical activity combined with physiotherapy. Currently used psychosocial approaches in chronic pain managements include:

Cognitive Behavioral Therapy

Emotional Disclosure Interventions

Hypnosis Acceptance Based Treatments

Partner Based Treatments

     The role of family and the society is highly significant and cannot be ignored in managing patients with chronic pain. Especially the role that should be played by a “significant other” (e.g., a partner or any other close person to the patient whose care, attention and relationship is significant to the patient) is placed at a very high level by modern research for the success in managing chronic pain patients. For example, partner assisted coping skills can be mentioned. Further, the potential role of the entire family and society such as the environment of the working place are considered of paramount importance in managing chronic pain patients. Many familial and social factors, such as conflicts and financial constraints, have been identified to predispose, exacerbate and maintain chronic pain conditions. Readers are referred to more advance text for further details on these techniques.



Aggrawal VR, McBeth J, Zakrzewska JM, Lunt M, Macfarlane GJ. The Epidemiology of chronic syndromes that are frequently unexplained: do they have common associated factors? Int J Epidemiol 2006; 35: 468-76.

Aronson KR, Harett LF, Quigley K. Emotional reactivity and the overeport of somatic symptoms: somatic sensitivity or negative reporting style? J Psychosom Res 2006; 60: 521-30.

Bair JM, Robinson RL, Katon W, Kroenke K. Depression and Pain comorbidity. Archives of Internal Medicine. 2003:163 Nov10:2433-2445.

Benedetti F, Lanotte M, Lopiano L, Colloca L: When words are

Biver F, Wikler D, Lotstra F, Damhaut P, Goldman P, Mendlewicz J: Serotonin 5-HT2 receptor imaging in major depression: focal changes in orbito-insular cortex. Br J Psychiatry 1997; 171, 444-8.

Blier P, Abott FV. Putative mechanisms of action of antidepressant drugs in affective and anxiety disorders and pain. J Psychiatry Neurosci. 2001; 26: 37-43.

Burns J, Johnson B, Mahoney N, et al. Cognitive and physical capacity process variables predict long-term outcome after treatment of chronic pain. J Consult Clin Psychol 1998; 66:434-439.

Dinan TG: Inflammatory markers in depression. Curr Opin Psychiatry. 2008; 22: 32-36.

Drevets W, Videen T, Price J, Preskorn S, Carmichael T, Raichle M: A functional anatomical study of unipolar depression. J Neurosci 1992; 12, 3628-41.

Edwards RR, Smith MT, Kudel I, Haythorthwaite J. Pain-related catastrophizing as a risk factor for suicidal ideation in chronic pain. Pain 2006; 126: 272-9.

Fayad F, Lefevre-Colau MM, Poiraudeau S, Fermanian J, Rannou F, Wlodyka Demaille S, Benyahya R, Revel M.  Chronicity, recurrence, and return to work in low back pain: common prognostic factors. Ann Readapt Med Phys 2004, 47:179-189.

Fix JD. Neuroanatomy. 4th Ed.  James DF. Philadelphia; Lippincott Williams & Wilkins: 2008.

Gallagher RM, Verma S,. Managing pain and cormorbid depression: A public challenge. Semin Clin Neuropsychiatry. 1999; 4; 203-220.

Ganong WF. Review of Medical Physiology. 15th Ed. Norwalk; Appleton & Lange: 1991.

Gureje O. Psychiatric aspects of pain. Current Opinion in Psychiatry.2007, 20:42-46.

Kaila-Kangas L, Kivirnaki M, Riihimaki H, Luukkonen R, Kironen J, Leino Arjas P. Psychosocial factors at work as predictors of hospitalization for back disorders. Spine 2004, 30:1823-1830.

Keefe FJ, Rumble ME, Scipio CD, Giordano LA, Caitlin L, Perri M. Psychological Aspects of persistent Pain: Current state of the science. Journal of Pain 2004, 4:195-211.

Kenneth C, Tri T: Cortical mechanisms mediating acute and chronic pain in humans. In: Handbook of Clin Neurology. Eds: Cervero F., Jensen T. S., Elsevier, Boston, Massachusetts. 2006.

Klauenberg S, Maier C, Assion H-J, Hoffmann A, Krumova EK, Magerl W, et al. Depression and changed pain perception: hints for a central disinhibition mechanism. Pain. 2008; 140:332-343.

Mogil J. Pain 2010. An Updated Review (Refresher Course Syllabus: 13th World Congress on Pain). International Association for the Study of Pain, IASP Press, Seatle: 2010

Ohayon MM, Schatzberg AF. Using chronic pain to predict depressive morbidity in the general population. Arch Gen Psychiatry. 2003; 60: 39–47.

Psychological Comorbidity: prevalence, risk, course, and prognosis. Can J Psychiatry. 2008; 53(4):224–234.

RobinsonJM, Edwards SE, Iyengar S, Bymaster F, Clark M, Katon W. Depression and Pain. Frontiers in Bioscience 2009;14, 5031-5051.

Schatzberg AF. Functional Pain Syndromes: Presentation and Pathophysiology. Seattle: IASP Press, 2009.

Simon G.E., VonKorff M, Piccinelli M, Fullerton C, Ormel J. An international study of the relation between somatic symptoms and depression.  N Engl J Med. 1999; 341(18):1329-35.

Slattery DA, Hudson AL, Nutt DJ.  Invited review: the evolution of antidepressant mechanisms. Fundam Clin Pharmacol. 2004; 18(1):1-21.

Tunks ER, Weir R, Crook J. Epidemiology of Chronic Pain with

Vlaeyen JW, Kole-Snijders AM, Boeren RG. Fear of Movement/ [re] injury in chronic low back pain and its relation to behavioral performance. Pain 1995; 62: 363-372.

Woby SR, Watson PJ, Roach NK, Urmston M.  Adjustment to chronic low back pain – the relative influence of fear-avoidance beliefs, catastrophizing, and appraisals of control. Behavioral Research and Therapy 2004, 42:761-74.



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Ž Pain: An Overview

Ž Physiology of Pain

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Ž Neuropathic Pain

Ž Abdominal Pain

Ž Orofacial Pain: An Overview

Ž Pain: Psychological Correlates

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Ž Management of Musculoskeletal Pain and Chronic Pain Syndromes

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