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Psychosocial factors and their role in chronic pain: A brief review of
development and current status
Stanley I Innes*

Address: Private Practice 35 Maroondah Highway, Lilydale, 3140, Australia

Email: Stanley I Innes* - [email protected]
* Corresponding author

Published: 27 April 2005 Received: 09 April 2005

Accepted: 27 April 2005
Chiropractic & Osteopathy 2005, 13:6 doi:10.1186/1746-1340-13-6
This article is available from: http://www.chiroandosteo.com/content/13/1/6
© 2005 Innes; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
The belief that pain is a direct result of tissue damage has dominated medical thinking since the mid
20th Century. Several schools of psychological thought proffered linear causal models to explain
non-physical pain observations such as phantom limb pain and the effects of placebo interventions.
Psychological research has focused on identifying those people with acute pain who are at risk of
transitioning into chronic and disabling pain, in the hope of producing better outcomes.
Several multicausal Cognitive Behavioural models dominate the research landscape in this area.
They are gaining wider acceptance and some aspects are being integrated and implemented into a
number of health care systems. The most notable of these is the concept of Yellow Flags. The
research to validate the veracity of such programs has not yet been established.
In this paper I seek to briefly summarize the development of psychological thought, both past and
present, then review current cognitive-behavioural models and the available supporting evidence. I
conclude by discussing these factors and identifying those that have been shown to be reliable
predictors of chronicity and those that may hold promise for the future.

Introduction ever, pain was considered sensorial and organic causes

There is an increasing interest and acceptance in psycho- were offered to explain all pains, even those without an
social factors and their correlations to the onset and out- obvious basis in tissue damage or organic disease. The
comes of acute pain episodes. This review will briefly belief that all pain was a direct result of tissue damage was
review its evolution and summarize the past and present firmly entrenched by the early 20th Century [2].
theoretical models in relation to low back pain (LBP). Psy-
chlit, MEDLINE and medindex searches were conducted to By the late 1950's it became increasingly evident that sen-
identify relevant articles with the search words 'psycholog- sory explanations failed to account for certain puzzling
ical factors, chronic/persistent pain'. pain phenomena (e.g., relief from pain with placebo
interventions, phantom limb pain). Around the mid-20th
Historical development Century several different theories were developed from
The psychological and psychiatric aspects of pain had differing theoretical backgrounds to explain the observa-
been infrequently noted by modern writers as early as tion that sensory input did not always correlate with pain.
1768. For a comprehensive historical review see Merksy & I have summarized these differing schools of thought by
Spear [1]. By the second half of the 19th Century, how- précising a comprehensive review by Gamsa [3,4].

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Psycholanalytic Formulations multidimensional problem of pain [4,19]. The combina-

Here intractable pain, which defies organic explanations, tion of cognitive and behavioural approaches has been
was seen as a defence against unconscious conflict. Emo- employed extensively in pain programmes during the last
tional pain is displaced onto the body where it is more 15–20 years with some reported success [11].
bearable. For example, conscious or unconscious guilt
with pain serving as a form of atonement, or the develop- Psychophysiological Approaches
ment of pain to replace feelings of loss. Critics have raised Examines the influence of mental events (thoughts mem-
serious methodological and conceptual concerns [5,6]. ories and emotions) on physical changes which produce
For example; the ability to quantify and research the con- pain, for a comprehensive review see Flor and Turk [12].
structs of Id, ego and superego. Psychoanalytic thinking For example, general arousal models propose that fre-
no longer forms a significant basis for research or source quent or prolonged arousal of the Autonomic Nervous
of current interventions. System (ANS) including prolonged muscular contrac-
tions, generate and perpetuate pain. Treatment, such as
Behaviourist Models EMG, biofeedback, and relaxation techniques are
Following the work of Skinner [7], behaviourists tried to designed to decrease the levels of muscular tension and
show that all behaviour could be shaped, altered, weak- ANS arousal and thereby decrease the pain. Studies have
ened or strengthened as a direct of environmental manip- shown positive results from these interventions, but not
ulations. Fordyce et al. [8] were the first to apply the necessarily more than other psychological techniques
behaviour model to pain. It was thought that there was a [3,4].
simple causal connection between pain and its reinforc-
ers. Respondent (acute) pain was seen as a reflexive In sum, psychological thought during the past half cen-
response to antecedent stimulus (tissue damage). The tury has shifted from linear to multicausal models of pain.
respondent pain may eventually evolve into operant and Methods of investigation have also improved.
persisting pain if the environment offers pain contingent
reinforcement. Pain behaviour may also be learned by Current theoretical models
observing "pain models" i.e., individuals who exhibit A substantial number of acute painful musculoskeletal
such behaviour. More complex factors such as personal injuries do not resolve quickly and account for the major-
dynamics, emotional state, physical vulnerability, and ity of the associated costs [13]. Early intervention appears
numerous psychosocial variables were not addressed. It to result in improved outcomes [14]. Consequently, it is
proposed that operant pain persists because the behaviour not surprising that the on-going evolution of the under-
of others (family, friends and health care providers) dur- standing of the non-physical aspects of pain has been
ing the acute pain stage reinforced that pain returned sec- applied to the areas of screening for, intervening in and
ondary gains, such as permission to avoid chores, or predicting those at risk of developing into a chronic and
obtain otherwise unobtainable attention and care. Behav- disabling situation [15,16,33]. The recent New Zealand
iour models have however contributed to the study of Government review into LBP, its subsequent published
pain by the introduction of carefully designed control guidelines, and resultant growing acceptance of the "Yel-
procedures and laboratory methods [4]. low Flags" concept is a pertinent example [17-19]. Varia-
bles such as attitudes, beliefs, mood state, social factors
Cognitive Approaches and work appear to interact with pain behaviour, and are
Cognitive approaches were inspired in part by Melzack cumulatively referred to as psychosocial factors. However,
and Wall's [9] gate control theory, which established a to date there has not been developed a comprehensive,
role for the cognitive-evaluative process in the modula- multivariate and empirically supported Integrated Biopsy-
tion of pain. Since the mid 1970's proponents of cognitive chosocial Risk-for-Disability Model. During a plenary ses-
theory studied the influence of the meaning of pain to sion at the Forth International Forum on LBP Research in
patients, and examined the effect of coping styles on pain, 2000 [20] Pincus et al amalgamated the Cognitive and
for further review see Weisenberg [10]. Cognitive theory behavioural thinking and proffered the closest structure
examines intervening variables such as attributions, yet to such a model. It has sought to incorporate many of
expectations, beliefs, self-efficacy, personal control, atten- these factors, and as such offers a structure from which to
tion to pain stimuli, problem solving, coping self-state- review these psychosocial factors.
ments and imagery. Pain studies investigated the effects of
these thought processes on the experience of pain and The cognitive-behavioural researchers in the late 20th cen-
related problems. Cognitive theory has added an impor- tury noted that acute pain was associated with a pattern of
tant dimension to psychological research into pain, but physiologic responses seen in anxiety attacks, whilst
cognitive theorists themselves emphasise that they do not chronic back pain was characterized more effectively by
provide the solution, in isolation from other aspects of the habitation of autonomic responses and by a pattern of

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performance of daily physical activities may lead more

injury / strain
easily to pain and physical discomfort. As a result, the
avoidance of activity becomes increasing likely, as does
the risk of chronicity. Cognitive-behavioural theorists
have variously described this process that leads to chronic-
ity stemming from pathological levels of fear / anxiety as
disuse "Fear of pain" [25], fear of physical activity and work
depression recovery [26,27], avoiders and confronters [28], kinesiophobia
disability [29] and anxiety sensitivity [30].

When a person experiences pain they experience varying

degrees of psychological distress. A recent study suggests
PAIN that as many as one third of people seeking care at physi-
avoidance cal therapists may have significant levels of distress [31].
hypervigilance
Many dimensions of this process have been identified and
muscle reactivity
their role posited in the development of chronicity.

One such example is catastrophic thinking processes and

fear of pain confrontation is broadly described as an exaggerated orientation towards
movement / reinjury pain stimuli and pain experience [32]. Negative appraisals
about pain and its consequences have been postulated to
be a potential precursor to persistent pain. People who
consider pain as a serious threat to their health are more
likely to become fearful as compared with those who
approach pain as a trivial annoyance [33].
catastrophizing no fear Pain-related fear can also contribute to disability through
interference with cognitive functions. Fearful patients will
Figure
A cognitive-behavioural
1 model of pain related fear [43] tend more to possible signals of threat (hyper-vigilance)
A cognitive-behavioural model of pain related fear [43].
and will be less able to shift attention away from pain
related information at the expense of other tasks, includ-
ing actively coping with problems of daily life [34].

Although these and other factors such as coping strategies

vegetative signs similar to those seen in depressive disor- [35], sense of control [36], personality type [37], faith and
ders. One of the prominent researchers, Waddell, noted religious beliefs [38], have been reported in literature (for
that one of the striking findings was that "fear of pain was a comprehensive review see Keefe et al.[44], the most sig-
more disabling than the pain itself" [21]. As a result the nificant and reproducible factors have been mood /
notion that reduced ability to carry out daily tasks was depression and to a lesser extent somatization / anxiety
merely a consequence of pain severity had to be reconsid- [16,39]. Depression has been associated with decreased
ered. Several studies have indicated that pain-related fear pain thresholds and tolerance levels, reduced ability, gen-
is one of the most potent predictors of observable per- eral withdrawal and mood disturbance such as irritability,
formance and is highly correlated to self-reported disabil- anhedonia (loss of enjoyment of good things in life), frus-
ity levels in subacute and chronic pain [22,23]. tration and reduced cognitive capacity.

In the acute pain situation, "avoidance" behaviours, such Somatization disorder is a chronic condition in which
as resting, are effective in allowing the healing process to there are numerous physical complaints. It is perceived as
occur [24]. In chronic pain patients, the pain and disabil- very similar in nature to, and difficult to differentiate from
ity appear to persist beyond the expected healing time for an anxiety disorder [40]. The most common characteristic
such a complaint. The danger is that a protracted period of of a somatoform disorder is the appearance of physical
inactivity, as a strategy for coping with the persistent pain symptoms or complaints for which there is no organic
may lead to a disuse syndrome (see Figure 1). This is a det- basis. Such dysfunctional symptoms tend to range from
rimental condition. It is associated with physical decondi- sensory or motor disability, and hypersensitivity to pain.
tioning such as loss of mobility, muscle strength and This is a difficult and complex syndrome and is more fully
lowered pain thresholds (allodynia). Consequently, the dealt with elsewhere [41].

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A mention should be made of occupational factors. Job 16. Pincus T, Burton AK, Vogel S, Field AP: A systematic review of
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on fear / avoidance shows much promise; it has yet not 20. Pincus T, Vlaeyen JW, Kendall NA, Von Korff MR, Kalauokalani DA,
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