The Psychology of Chronic Pain


The perception of pain involves a lot more complex processes than mere feeling. As a matter of fact, the affective and evaluative elements of pain tend to be as significant as the creation and transmission of the pain signal itself. These emotional as well as psychological aspects are most prominent in chronic pain sufferers, but knowledge of the psychology of this type of persistent pain can help greatly enhance the treatment of chronic pain.


Perception of Pain


The limbic system, where emotions and/or feelings are processed, is in charge of regulating the amount of pain experienced for a given noxious stimulus. It has been proven in cancer patients [1] that their affective part of pain can be completely blocked by frontal lobectomy. Lobectomized patients still register intense pain, however, it doesn’t “bother” them. Pain can thus be seen as only a “signal” demonstrating that something has gone wrong somewhere in the body, until it reaches the mental performance element of the brain, where this signal becomes what we believe to be perceived as pain.


The emotional response to pain in the brain requires the function of the anterior cingulate gyrus and the perfect ventral prefrontal cortex. These centers are also activated by social rejection. Serotonin and norepinephrine circuits are also included in the modulation of sensory stimulation, which probably influence how depression and antidepressant drugs and/or medications affect the perception of pain.[2]


Even the perception of acute pain is highly determined by the context in which it occurs [3]. It’s been revealed that the pain involving battle wounds bears very little connection to the degree of the wounds [4]. There are reports of soldiers in conflict who endure a compound fracture, and report just twinges of pain [5]. In research studies of experimental pain in which context, fear, and anxiety are controlled, the placebo effect and opioids are much less effective. This occurs because the decrease of both the fear and anxiety is a large region of the placebo effect and also the purpose of opioids [6].




Focusing one’s attention on pain is often believed to make the symptoms worse [1]. Patients that have somatic preoccupation or hypochondriasis are overaware about physiological senses. It’s been found that by attending these sensations, they amplify them towards the purpose of feeling painful [7].


Conversely, distracting patients is highly effective in reducing their pain. Burn patients undergoing therapies or physical treatment experience excruciating pain, even after they have been given opioids. It has been proven that these patients report only a portion of the pain if they are distracted using a virtual-reality kind of videogame during the process [8].




Anxiety, stress, fear, and a feeling of loss of control leads to individual suffering. Treating anxiety and supplying emotional support was shown to improve pain and decrease analgesic use in patients. Improving patients’ sense of control and allowing them to participate in their care can also be useful [9]. Healthcare professionals should try to make an environment that’s nonthreatening. For procedures, prepare needles and other gear out of sight from the patient. Besides assuring that procedures are performed in the least painful way possible, use nonthreatening words such as “mild discomfort” rather than “pain”. It’s also helpful to divert patients with dialog about subjects that interest them, such as their hobbies or household [10].




Patients with low levels of pain remember it as being worse than they originally reported, which will worsen with time. Almost all patients report relief with treatment, even when true measured changes in pain scale are not significant, and occasionally when quantified pain is much worse, and it’s all often due to the memory of their pain [11].


Learned Pain


Pain can be a learned response, rather than a purely physical health issue. As cancer sufferers may develop nausea as a learned reaction to treatment and report feeling it even before chemotherapy is administered, patients can learn to get pain even in the absence of a physical stimulation [12]. Sometimes, pain can be completely “in the head,” as in the case of a butcher who slipped and caught his arm on a meat hook, and had been reported to be in tremendous distress. When he learned that the hook had simply captured on to his sleeve and his arm was uninjured, his pain solved [13].


Patients may learn how to feel different levels of pain by simply watching different men and women. When research study subjects were shown models demonstrating high pain tolerance, they took 3.48 times higher stimulus before they ranked it as painful, in comparison with those that observed models who showed poor tolerance. Nonaversive shock, usually called “tingling,” was rated as painful by just 3 percent of those who had viewed a tolerant model, in comparison with 77 percent of those subjects who viewed models who revealed lower levels of tolerance [14].




Patients’ expectations of how much pain they ought to have also affected how much pain they feel, their response to treatment [15], and whether or not the illness becomes chronic and disabling. The outcomes of minor whiplash injuries are demonstrated to be very variable in various regions. It was attributed to the local cultures and expectations. Any messages that speak with individuals on whether they have a serious or debilitating injury can lead to deconditioning and maladaptive postures that worsens their pain. Prescribing drugs and/or medications can contribute to the issue. Patients who are not given sick leave and are advised to “act as normal” have much better outcomes [7].


The placebo effect can be influenced by patients’ and doctors’ expectations [15]. It can be assumed that the “nocebo” effect, or the understanding of harm caused by an individual’s beliefs, may also bring about messages that inadvertently increase the patient’s stress, anxiety and expectations of pain.


Beliefs and Coping


Other psychosocial problems, such as what patients believe about their pain [16,17], their abilities to manage [18-21], their tendency to “catastrophize” [17,18,20], self-efficacy [17], locus or restrain [22], and their involvement in the “sick role” [13], have an effect on just how much pain patients feel, and the way it ultimately affects them.


In successfully getting low back pain sufferers back to work, the most crucial factor identified is a decrease in subjective feelings of disability [23]. Patients diagnosed with fibromyalgia have to quit catastrophizing to enhance their well-being, and they need to be convinced that they have the capacity to be functional [24]. Consequently, healthcare professionals should focus on improved function and long-term management. Patients should be led to know that they themselves have an essential role in distracting themselves, and they can decrease the disturbance that pain has in their own quality of life.


Chronic Pain


Chronic pain patients frequently have issues with the psychological and emotional facets of pain [25]. Preexisting psychological variables have been demonstrated to be very significant in the evolution of chronic pain after surgical interventions [26,27] and in complex regional pain syndrome, or CRPS [28,29], tension-type headaches [30], and fibromyalgia [24]. The National Institutes of Health Technology Assessment Conference Statement [31] identified six factors that related to treatment failures of low back pain, and they were all psychosocial. Even chronic, episodic, low back pain may have a vital component of socioeconomic and psychological influences [32].


There is a vicious cycle in which pain causes stress and handicap, which in turn worsens the perception of pain [21]. An unhealthy lifestyle, lack of social support, depression, and substance abuse are predisposing factors to chronic pain [33]. Chronic pain has been known to become “complicated” if there are interactions of psychological, legal, drugs and/or medication, and family issues [34].




Immobility may be a factor in adult “reflex sympathetic dystrophy,” that some healthcare professionals feel is overdiagnosed [35]. A research study of reflex neurovascular dystrophy in children revealed that prominent swelling, skin changes, and decreased skin temperature had been due to maintaining the extremity within an immobile, determined position. The prolonged immobility also caused chronic fibrosis of adrenal tissues and contractures of ligaments and tendons. This was effectively relieved with physical treatments, which included active sensory stimulation and usage of the affected extremity [36].


Inactivity is a serious impediment to progress in chronic pain, and also may produce concurrent myofascial pain [37]. Many fibromyalgia patients are found to have a vicious cycle of maladaptive pain behavior, resulting in further deconditioning, social dysfunction, and subsequent worsening pain [24].


Obesity can also be an issue in chronic pain. An overview of patients at a rehab clinic found that among those who could not be returned to gainful employment or function of purpose, 78 percent were morbidly obese [38]. Many lower back pain sufferers have been found to be in the lowest quartile for aerobic capacity [39].


Pain behavior, like guarding, bracing, rubbing, grimacing, and sighing, was shown to be strongly affected by emotional factors [40]. Some chronic pain sufferers demonstrate pain behavior only around staff [41], or decrease this behaviour when they think nobody is watching [42]. Reinforcing this behavior can cause some patients to perceive that they have more pain. Eliminating the behavior leads to improved pain [40]. It’s been noted that when neuropathic pain sufferers are allowed to develop behavioral and guarding disorder, then drugs and/or medications aren’t successful, and the patients need multidisciplinary pain therapy [37].


Pain may be a conditioned response similar to learned nausea related to chemotherapy. The behavior begins purely in response to the existence of harm. It is then reinforced and becomes a conditioned response, an iatrogenic complication of therapy [12], particularly when wages are made contingent on the term of pain behavior [21]. The effect of reinforcement is exemplified by the case of a 10-year-old girl who had chronic daily abdominal pain for which no medical condition could be discovered. During episodes, her mother allowed her to rest in bed together with her toys and view television, and brought her food and drinks. After an hour or so, she would go back to play. After the mother ceased strengthening the patient’s pain behavior, the episodes rapidly diminished, in addition to her use of belladonna and phenobarbital elixir [43].


Pain can result from conditioned fear reactions which persist even after the settlement of pain [42], phobic reactions to pain and also to nonpainful activities [44], and posttraumatic stress disorder, or PTSD [45]. Some individuals have experienced good improvement of the pain or work with desensitization therapy [46].


Psychiatric Disease


Overall, some psychiatric morbidity is present in around 67 percent of chronic pain patients [47]. Personality disorders have been observed in 31 percent to 59 percent of chronic pain sufferers [48]. Among lower back pain patients admitted to a multidisciplinary pain center, 70 percent were found to have a hysterical conversion disorder, and 8 percent had a sociopathic personality disorder [49].


Somatoform Pain Disorders


Somatoform disorders are conditions where the existence of physical symptoms indicates a general medical condition, but cannot be explained by such a condition. One of the somatoform disorders, “pain disorder associated with psychological factors” is specified in the Diagnostic and Statistical Manual of Mental disorders, fourth edition, or DSMIV, [50] as a clinical condition in which pain is the concentration and in which emotional factors have the major role in the onset, severity, maintenance, or exacerbation The epidemiology of the condition isn’t understood, but unexplained chronic pain which causes disability is common in general practice and is often seen in emergency rooms. Pain disorder associated with psychological variables was found in 88 percent of referrals into a pain clinic serving an indigent population [51]. Many somatoform patients had pain which spread to new regions from the site of injury, whereas this did not occur in the patients that had objective signs of injury. Compared with individuals who had severe injuries involving long-term pain, mildly injured somatoform pain patients are over five times as likely to utilize daily opioids [52]. Moreover, one program found a 30 percent prevalence of abuse of opioids among those patients that had somatoform pain disorder, many times greater than that of the other patients [53].


Hypochondriasis, another sort of somatoform disorder that involves anxiety about having a disease if there is none, has also been diagnosed with chronic pain patients [54]. It’s been found to be worsened by the chronic medical use of morphine [55], and by its own abuse [56].


Mood Disorders


In a report on chronic pain patients on opioids, 61 percent have been found to have major depression [57]. It looks like the pain causes depression at least as frequently as depression causes pain [58,59]. However, depression is proven to make the individual’s pain feel worse [48]. In postsurgical pain after cholecystectomy, patients who had subclinical depressive symptoms reported greater pain [60]. Treating depression can improve, and sometimes eliminate, chronic pain [6]. Whether depression is regarded as a cause or an effect of chronic pain, then it needs to be considered at a comorbid condition which needs concurrent therapy [61].


An anxiety disorder was found in 10.6 percent of chronic work-related musculoskeletal pain patients [62]. The lifetime risk of a major anxiety disorder in men who have chronic low back pain is 30.9 percent, compared with 14.3 percent in men who do not have low back pain [59]. It’s likely that some “chronic pain” sufferers are actually using antipsychotic drugs to self-treat anxiety or depression, rather than relying on more effective anxiolytic or antidepressant agents [57]. These patients aren’t merely using the incorrect medication for their condition, but what small subjective advantage they originally feel is rapidly lost with endurance, and substituted with dependence.




Due to the influence of psychological variables on chronic pain, at least brief screening needs to be performed on first evaluation. It’s very beneficial to test for Waddell signs or nonphysiological findings, which may be accomplished quickly during the physical evaluation and test [63]. A particularly good evaluation is that the application of pressure at the top of the head once the patient is standing, to place strain on the backbone or spine. The low back pain patient who has a somatoform pain disorder will frequently complain of increased pain. If the pain were only of spinal root origin, this maneuver wouldn’t increase it.


Whenever psychiatric comorbidity is present or suspected, more comprehensive screening should include tests like the Multidimensional Pain Inventory, or MPI, and the Minnesota Multiphasic Personality Inventory 2, or MMPI-2 [21]. This comprehensive testing is generally impractical in the emergency setting, and ideally should be done by a psychiatric consultant acquainted with chronic pain [48]. Although acute care physicians are not very likely to test themselves, they should insure that it has been finished, or it will be carried out as soon as possible. Failing to address emotional health issues in chronic pain patients might lead to prolonged disability in a substantial number of individuals [25].


Dr. Alex Jimenez’s Insight

Whether it’s headaches, back pain, arthritis or fibromyalgia, chronic pain is a common and persistent health issue which often lasts for an extended period of time, greatly affecting an individual’s quality of life. Approximately 30 million people in the United States alone suffer from some for of chronic pain, which is influenced by a variety of factors, including a person’s emotions and memory. Many chronic pain patients report a dull ache or even a throbbing pain and it can last months or years for some people. Other common symptoms associated with chronic pain include mood swings, sleep problems and fatigue. As mentioned in the following article, chronic pain can also lead to stress, anxiety, depression and low self-esteem, among other health issues.


The Psychology of Opioid Dependence


The topic of opioid dependence in patients complaining of chronic pain is controversial. It should be mentioned that persistent opioid usage, especially in large doses, can make a condition of enhanced pain sensitivity [64]. Patients dependent on daily doses feel worse as soon as the drug and/or medication wears off, and closer to baseline amounts of pain temporarily when they take that, even though the general pain condition fails to improve [65]. These patients may observe opioids as necessary for survival. It may become hard to control using opioids, and they see the emergency room when they run out. They complain of increased pain from ailments that wouldn’t typically call for opioids. The individual who escalates demands for opioids when these are not coming is typically opioid-dependent, and may have issues of problematic use.


The psychology of this doctor also influences the use of opioids for chronic pain, and the interpretation of the efficacy. Some patients are insistent that specific medicines must be prescribed. They’ll exaggerate the advantages and deny adverse effects. Some physicians have difficulty setting limits. It is quicker and easier to give into the patient’s requirements than to institute another course. The doctor may understand that the prescription is in excess of regular practice, but rationalizes that for this specific patient, nothing else works. The emergency physician can anticipate these problems, and strategy, with consultation if desired, the way to deal with them.


CBD for Chronic Pain Relief


Cannabidiol (CBD) oil is used by some individuals with chronic pain. CBD oil may decrease pain, inflammation, and overall discomfort related to many different health conditions. CBD oil is a product. It’s a kind of cannabinoid, a compound found naturally in marijuana and hemp plants. It doesn’t cause the “high” feeling often related to cannabis, which is brought on by another type of cannabinoid called THC. Studies on CBD oil and chronic pain management have shown a fantastic deal of promise. CBD can supply an alternative for those who have chronic pain and also rely on more dangerous, habit-forming drugs and/or medications like opioids. However there should be more research in order to verify the pain-relieving benefits of CBD oil.


CBD products are not approved by the U.S. Food and Drug Administration (FDA) for any medical condition. They are not controlled like other drugs and/or medications for dose and purity. Researchers believe that the CBD interacts with pain receptors on the brain and immune system. Receptors are miniature proteins attached to your cells which receive chemical signals from different stimulation and assist your cells to react accordingly to a specific stimulus. This produces anti-inflammatory and painkilling effects which help with pain control. This means that CBD oil may benefit people with chronic pain, including chronic low back pain.


One 2008 research study evaluated how good CBD works to relieve chronic pain. The review looked at studies conducted between the late 1980s and 2007. Based on these reviews, researchers concluded that CBD was successful in total pain management without adverse side effects. They also noted that CBD was valuable in treating insomnia linked to chronic pain. The authors of this study also noted that CBD was helpful in people with multiple sclerosis, or MS.


Overall, researchers agree that while there is no conclusive data to support CBD oil as the preferred method of pain control, these kinds of goods have a lot of potential. CBD products may be able to offer relief for many individuals that have chronic pain, all without causing intoxication and dependence. Oil versions of CBD might not be as powerful as other forms, and more human studies are required. CBD oil is available in some clinics in areas where its use is lawful.




Emotional and evaluative problems are fundamental in the evaluation and treatment of pain. Treating the physical pain can leave these issues unresolved, and potentially exacerbate them during reinforcement. Understanding the effect of anxiety, fear, expectations, and attention can help doctors deal more efficiently with acute pain. Psychological issues are especially notable in chronic pain. Though acute care doctors may not be treating those emotional conditions, they could help by referring patients into the proper psychological or multidisciplinary setting. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .


Curated by Dr. Alex Jimenez



Additional Topics: Back Pain


Back pain is one of the most prevalent causes for disability and missed days at work worldwide. As a matter of fact, back pain has been attributed as the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience some type of back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.




EXTRA IMPORTANT TOPIC: Lower Back Pain Management


MORE TOPICS: EXTRA EXTRA: Chronic Pain Care Center



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