What are the risk factors?
Psychological and social covariates play a substantial role in the chronic pain experience (Table 2). How patients experience chronic pain also is influenced by personality and premorbid, semi-dormant characteristics that become activated by the stress of unremitting pain.7
- mood
- thought patterns
- perceptions
- coping abilities
- personality.
Table 2
Patient factors that contribute to or perpetuate chronic pain
| Poor modulation of emotions (anger, depression, anxiety) |
| Somatization (using pain to avoid confl icts, express anger, or punish others) |
| Problematic cognitive styles (catastrophizing, perceived loss of control) |
| Poor coping skills |
| Psychiatric comorbidities |
Social/interpersonal variables:
|
Reinforcement for remaining sick and/or disabled:
|
| Source: Adapted from reference 3 |
CASE CONTINUED: Underlying causes
Psychological and psychosocial factors appear to play an important role in Mrs. A’s pain. After her husband’s job was restructured, the couple moved away from Mrs. A’s mother, which she found distressing. Additionally, Mrs. A reports that her son has incurred substantial gambling debt.
Mrs. A admits she has “a hard time” accepting these events, but she cannot acknowledge anger or frustration. She avoids questions about such feelings and focuses on her pain. She reports, “The pain is always there and ruins my entire life. Absolutely nothing gives me relief.”
She does not endorse depressive or psychotic symptoms. She sometimes has passive thoughts of death when she feels hopeless about her persistent pain, but she vehemently denies suicidal ideas, intent, or plans. She has smoked 1 pack of cigarettes per day for 12 years but denies alcohol abuse or use of illicit substances.
Biopsychosocial assessment
Assessing a chronic pain patient includes evaluating somatic, psychological, and social factors (Table 3).3 A biopsychosocial approach recognizes that the patient’s experience of pain, presentation, and response to treatment are determined by the interaction of:
- biological factors
- the patient’s psychological makeup
- psychological comorbidities
- the extent of social support
- extenuating environmental circumstances.3,10
A thorough psychiatric assessment may reveal psychiatric comorbidity and psychological conditions that mediate pain.8 Recognizing and treating coexisting psychiatric disorders often will enhance effective pain management.
Subsyndromal psychological factors—such as troubling affective states, problematic cognitive styles,14 and ineffective coping strategies and interpersonal skills—can accompany pain. If unattended, such factors can heighten the patient’s pain awareness and compromise rehabilitation.
For example, patients such as Mrs. A can aggravate pain by catastrophizing.15 Having a tendency to exaggerate pain and the significance of related life events interferes with their ability to attend to matters within their control and pursue productive activities.16 Catastrophizing is associated with increased pain and perceived disability, poor adjustment to pain, and marked emotional distress.17,18
How pain shapes beliefs. Pain can shape the manner with which patients make sense of events in their lives by altering the way they perceive themselves and the world. Problematic beliefs of the self (inadequacy and helplessness), of the world (dangerousness), and of the future (hopelessness) can produce significant distress. A patient with such beliefs may experience a loss of self-esteem, self-efficacy, and connections with others and may experience marked disappointment and disillusionment.