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Psychology of pain

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 British Journal of Anaesthesia 101 (1): 25–31 (2008)
doi:10.1093/bja/aen123 Advance Access publication May 28, 2008

Psychology of pain
S. Morley*

Institute of Health Sciences, University of Leeds, 101 Clarendon Road, Leeds LS2 9LJ, UK
*E-mail: [email protected]
This article briefly reviews psychological aspects of pain, paying special attention to chronic
pain. The review considers the interruptive and interference effects of pain and its impact on a
person’s identity. The importance of processes related to interruption, interference, and iden-
tity will vary across people and the duration of pain. Although brief phasic pain such as that
presented in the laboratory will have marked interruptive effects, it is unlikely to produce inter-
ference or impact on a person’s identity. Acute clinical pain will have both interruptive and
interference effects, albeit of a temporary nature, but it is unlikely to have any impact on a
person’s identity. Chronic persistent pain or frequent recurrent episodic pain, such as head-
ache, may have profound effects on a person’s life. Each of these themes is illustrated with
examples drawn from the experimental and clinical literature.
Br J Anaesth 2008; 101: 25 – 31
Keywords: pain, acute; pain, chronic; psychological responses

In the clinic, the professional help of a psychologist is unlikely to produce interference or impact on a person’s
more often than not sought when the patient exhibits identity. Acute clinical pain will have both interruptive and
extreme distress or behaves in a way that suggests there is interference effects, albeit of a temporary nature, but it is
a marked discrepancy in their report of pain and the health unlikely to have any impact on a person’s identity. Chronic
professional’s estimate of what they think is an appropriate persistent pain or frequent recurrent episodic pain, such as
level of pain. There is a substantial body of literature sup- headache, may have profound effects on a person’s life.
porting the association of chronic pain with high levels of The repeated interference with tasks that are essential to
emotional distress, particularly depression1 and anxiety.34 achieving various life goals and maintaining a person’s
Historically, attempts have been made to explain persist- status in society will impact on their sense of self, both
ence of pain by recourse to constructs such as the ‘pain their current self and perhaps more importantly their plans
prone personality’ or as a variant of a primary psychologi- and ideas for who they might become. In general, the
cal state such as depression.50 Rather than review this further removed from brief phasic pain the greater the likeli-
extensive literature, this article will outline a contemporary hood that a person’s experience of pain will be determined
approach to the psychology of pain that seeks to under- by factors other than the sensory intensity and primary
stand the experience of pain with reference to normal affective qualities of the pain55 as the opportunities increase
psychological processes. It will focus on some basic for behavioural mechanisms to shape the experience of
psychological processes and illustrate how they may shape pain, especially those relating to learning.
a variety of responses to the presence of both acute and Table 1 also indicates the level at which current treat-
chronic pain. It is necessarily a rather selective review of a ments focus their attention. Treatments that attempt to
large literature, but it can be organized thematically: I will eliminate or modulate the sensory intensity components of
consider the impact of pain in three interrelated themes: pain including pharmacological and surgical do so in the
interruption, interference, and identity (see Table 1 for expectation that once pain intensity is controlled the con-
brief definitions).35 43 sequences of pain for interference and identity will be
mitigated. As most of us who work in the field of chronic
pain know this assumption can be erroneous. Interventions
aimed at reducing the interference function of pain, for
Interruption, interference, and identity example, physiotherapy and behavioural rehabilitation, are
The importance of processes related to interruption, interfer- frequently required in tandem with medically based inter-
ence, and identity will vary across people and the duration ventions. Until recently, little attention has been paid to
of pain. Although brief phasic pain such as that presented therapeutic interventions that target identity. This is likely
in the laboratory will have marked interruptive effects, it is to be most important for patients with chronic pain where

# The Board of Management and Trustees of the British Journal of Anaesthesia 2008. All rights reserved. For Permissions, please e-mail: [email protected]
 Morley

Table 1 Interruption, interference, and identity. TNS, transcutaneous nerve In the primary task paradigm, participants are required
stimulation; SCS, spinal cord stimulation
to engage in a task, and stimuli associated with pain are
Brief description Treatments concurrently presented.12 In the simplest task, participants
focused at this may be required to respond by pressing a button to audi-
level
tory signals. The experimental set-up allows the manipu-
Interruption The impact of pain on Any treatment lation of two other features. Painful stimuli can be
moment-to-moment that attempts to delivered with precision at any point in the task and the
attention and behaviour modulate the
sensory intensity impact on the performance (response errors or delay in
component of responding) can be observed. Secondly, additional stimuli
pain, for that may or may not be contingently related to the pain
example,
pharmacological, stimulus can be presented. Thus, the influence of environ-
TNS. SCS, mental cues for pain may be explored. The primary task
acupuncture, model has enabled three critical sets of parameters to be
hypnosis
distraction/ explored.
attention control
methods
Interference Failure to complete Treatments aimed Stimulus characteristics
tasks effectively. Tasks at restoring
may be incomplete or functional
Unsurprisingly, the novelty, intensity, and unpredictability
performed in a capacity of pain stimuli influence the interruptive impact of pain
degraded manner (physiotherapy stimuli. Cues that predict the likelihood of intense pain are
which is unacceptable and behavioural
to the person management)
also highly interruptive. It has been argued that the central
Identity The sense of who you Treatments that characteristic of these features is their inherent threat
are and perhaps more aim to change value.6 12
importantly who you the individual’s
might become. relationship to
Limitations on future pain and to Person characteristics
achievement of life restore a person’s
goals capacity to live It is not possible experimentally to manipulate these
according to their features, but using well-defined psychometric instruments,
life values (e.g.
ACT) it has been possible to demonstrate that certain character-
istics such as pain-related fear,8 42 catastrophizing,7 and
health-related anxiety18 enhance the interruptive conse-
quences of painful stimuli.
attempts to modulate the sensory intensity quality of pain
have been unsuccessful and patients are faced with the Task characteristics
problem of living with pain.
The functional account of attention indicates that pain,
because of its threat value will interrupt most ongoing
tasks. Exceptions to this will be tasks with even greater pri-
ority, for example, those relating to avoiding death,
Pain as interruption evidence for the influence of the value of primary task
Painful stimuli have an unrivalled capacity to capture is therefore largely anecdotal, such as Beecher’s2 obser-
attention and to interrupt ongoing cognitive and beha- vations on wounded soldiers. This point is also well made
vioural activity. The brief emotional consequences of this by Wall.56 In non-pain states, there is good evidence that
are seen in increased ratings of negative mood, particularly the salience of unpleasant bodily sensations, such as
frustration.44 Attention is a fundamental psychological fatigue, is greater and that behavioural performance is
process that serves two functions. First, it facilitates the diminished in impoverished environments.41 Even when
control of goal-directed behaviour in an environment the primary task is not highly valued the degree to which it
where there may be many competing stimuli and where an recruits cognitive resources is related to the interruptive
individual may have multiple goals: it ensures the smooth effects of pain. Eccleston11 showed that when a simple per-
flow of behaviour. Secondly, although it must protect the ceptual task was relatively easy, chronic pain patients with
individual from responding to less important demands, the low and high levels of pain were equally able to perform it.
attention system must allow interruption by events that Only when the task was at its most difficult and complex,
signal new more important demands that threaten the that is, exerting the greatest demand on attention did
integrity and well-being of the individual. The interruptive patients with high levels of pain exhibit a demand perform-
capacity of pain has been studied extensively both in the ance. Chronic pain patients often complain of memory defi-
laboratory using the primary task experimental paradigm cits and Grisart and colleagues16 17 have shown that pain
and in clinical populations using correlational methods. interrupts memory tasks that require attentional resources

26
 Psychology of pain

for controlled processing of material. In contrast, memory participate twice on a treadmill test (5 km h21) in which
that requires automaticity is unaffected by pain. they were asked to walk until they felt like stopping due to
pain or fatigue. On one occasion, their partner was
present, whereas on the other occasion they were absent.
The data (from Table 4, p.78 of Lousberg and col-
Pain as interference
leagues)29 show the time in seconds spent walking
Interference is most likely when pain is chronic when it (Fig. 1A) and the pain report on a visual analogue scale
presents problems to individuals who have to adjust to (Fig. 1B). It is clear that the presence or absence of the
living with it. A major point to bear in mind is that pain is partner makes a difference to both the time spent walking
substantially more than a sensory experience with and the patient’s report of pain and that the differences are
(usually) a strong spatial discriminative element and a a function of the reported style of interaction between the
deeply unpleasant affective quality. The aversive nature of patient and their partner. Solicitous partners are character-
pain endows it with powerful reinforcing properties which, ized as being relatively more attentive to their partner’s
when made contingent on a response, act as punisher, the pain state and will act to alleviate their behavioural
effect of which is to suppress the behaviour. Pain also activity by, for example, taking over household chores. It
elicits a range of behavioural responses, for example, is hypothesized that under these conditions patients will
facial displays,58 postural adjustments, and use of aids,23 have learned that the presence of their partner signals the
which are observable by others and elicits a variety of availability of support and that in turn they may ‘under
responses from them. These responses range from perform’ on behavioural tasks. Similarly, it is argued that
expressions of compassion, sympathy, and behavioural expressions of pain are reinforced by the solicitous
attempts to mitigate the pain to ignoring the person and partner, and this is reflected in the increased level of pain.
indifference.15 The essential feature is that the public
expression of pain means that it is subject to environ-
mental, especially social, influences as a result of which Fear avoidance mechanisms and chronic pain
the person’s behaviour in response to pain is shaped and The fear avoidance model examined a different set of cog-
modified by the environment.13 The interference effect of nitive behavioural processes that influence the relationship
pain on behaviour is therefore not simply a function of the between pain experience and behavioural performance or
severity of the pain per se. The following two examples lack of performance. A key component of this is the
illustrate different aspects of this. meaning that a person might place on the experience of
pain.51 If pain is interpreted as a signal of impending
Spouse solicitousness and behavioural performance harm and danger, then activities which give rise to pain
will be feared and the person will tend to avoid engaging
Figure 1 illustrates the influence of the presence of others
in these activities. Persistent avoidance of activities is
on both overt behavioural performance and pain report.
hypothesized to lead to disuse and acquired disability. The
This study involved chronic pain patients and their part-
mechanisms underpinning the fear avoidance model as
ners.29 Pain patients (chronic back pain) were asked to
elaborated in pain are exactly the same as that used to
understand fears and phobias. Although pain may give rise
A B to many fears about the future,35 the fear avoidance model
800 25 has been explicitly applied to pain that signals fear of (re)
Alone
Partner present injury. Typically, this is associated with fears of move-
ment that might give rise to injury: a patient may literally
20
fear that their spinal column will break and they will be
left paralysed if they engage in particular movements. The
Time to tolerance (s)

750
15 fear avoidance model clearly articulates that the relation-
Pain report

ship between the experience of pain and behavioural

activity is mediated by expectation of harm and the antici-
10 pation of catastrophic consequences if certain actions are
700
carried out. The behavioural pattern is sustained by sus-
tained avoidance of activity, which is a function of the
5
fear rather than the pain per se. Many components of the
fear avoidance model have been validated—see Leeuw
0 and colleagues26 for a recent review—and the model has
Non-solicitious Solicitious Non-solicitious Solicitious led to a precise and well-validated treatment in which
Fig 1 The effect of the presence and absence of a partner on walking patients are asked to perform the feared activities in a
performance on a treadmill (A) and ratings of pain (B). See text for graded manner. Preliminary evidence supports the efficacy
commentary and Lousberg and colleagues.29 of this approach.27 53 59

27
 Morley

Pain as a threat to identity self. Contemporary psychological theory has explored the
The impact of chronic pain on a person’s humanity and self in a number of ways, all of which recognize multiple
sense of self has long been represented in art and litera- facets of the self. For example, self-discrepancy theory
ture.47 This is a difficult and complex area and it is only (SDT) considers three aspects of the self: the actual-self
recently that social scientists have begun to explore the (what I am now), ideal-self (what I would like to be), and
topic using systematic and replicable methodologies. ought-self (what I think I ought to be). Discrepancies
Qualitative methods have been used to explore patients’ between the actual and other selves have two properties.
experiences of living with chronic pain.14 19 – 21 25 28 30 31 45 First, they generate characteristic feeling states pro-
These studies capture patients’ conversations about their portional to the magnitude of the discrepancy. An
experiences using semi-structured interviews to ensure that actual-ideal discrepancy generates emotions of dejection/
an appropriate range of experiences is obtained. The result- depression whereas actual-ought discrepancies generate
ing material is systematically scrutinized using one of feelings of agitation/anxiety. Secondly, the discrepancies
several possible methods such as Grounded Theory4 or act as guides, directing behaviour to reduce the discre-
Interpretive Phenomenological Analysis.40 These methods pancy.22 One would expect chronic pain patients to be
vary somewhat in their aims and objectives, but the resul- subject to the same phenomenon, and indeed there is evi-
tant data are usually summarized as a set of themes with dence for this.57 The self-pain enmeshment model
supporting quotations from participants. At present, there is suggests that in addition to discrepancy, the extent to
no meta-synthesis of these studies, but consistent themes do which aspects of the self are trapped by pain will also be
emerge and their salient features will be recognized by related to emotional experience. In two studies, we asked
clinicians who have listened to their patients. chronic pain patients to provide descriptions of their
actual-self and what they hope to become (the hoped-for
self: this is very similar to the ideal self ).39 48 As predicted
Personal themes by SDT, the magnitude of discrepancy between the actual
Unsurprisingly, a theme representing the impact of pain on and hoped-for selves is associated with depression, even
the patient’s sense of their body frequently emerges. The after statistical adjustment for differences in patients
content of this varies somewhat but frequently refers to a characteristics, pain, and disability measures. Both of our
sense of alienation from the body, that is, the experience studies also showed that the degree to which a person
that their body is not what they had expected and antici- regarded themselves as trapped by pain was also statisti-
pated for this stage of their development. This is some- cally predictive of depression. In our second study,48 we
times captured with a phrase such as I am ‘old before my also showed that if a highly valued aspect of the self is
time’, reflecting slowness, difficulty of movement, and the trapped by pain, this was associated with greater emotional
use of prosthetics. The theme of the self in relation to distress. Thus, in patients who valued their personal auton-
developmental time emerges in several analyses with a omy enmeshment of characteristics representing autonomy
strong sense of disruption to natural lifespan development. led to greater distress at lower level of enmeshment. A
Patients may feel as if they have been ‘thrown forward’ in similar finding was observed for patients who valued
time—so 45-yr-old patients may report that they feel and social interaction: if characteristics representing the social
act as if they are 70 (but without the privileges of age or aspects of their self were enmeshed, they were more dis-
the experience of the intervening 25 yr, but with a sense tressed at a lower level of enmeshment. These findings
of loss of the intervening 25 yr). This temporal shift is rep- were quite specific for each valued motivational state
resented as references to experiences of dislocation, dis- (autonomy and sociotropy).
ruption, and decline. Paradoxically, patients may also
experience a sense of ‘suspended identity’45 in which they
consider that the ‘real’ them is suspended at an earlier
Persistent attempts to solve the problem of pain
time point, usually before the onset of chronicity. One The problem faced by a patient whose future is blocked by
implication of this is that they use this point of time as a persistent pain is considerable. In our studies, we explicitly
reference for setting goals of recovery. These may be asked participants whether they thought they could
entirely inappropriate with reference to their actual age. achieve their hoped-for futures with the continued pre-
sence of pain. One would expect that those answering ‘no’
would be expected to invest time in trying to solve the
Future possible selves in chronic pain problem of pain. For many, this will be an unsolvable
Another recurrent theme is the feeling of entrapment by problem, and relentless pursuit of this goal may have pro-
the pain (the trapped self ). This has been investigated found emotional and personal consequences. Faced with
using quantitative methods. For example, we have recently failure in their attempt, they will persist with the same
used theories and methods developed by social psycholo- strategy; this can be observed when patients engage in
gists to investigate the relationship between pain and ‘doctor shopping’ resulting in multiple medical interven-
entrapment (also called enmeshment)43 of aspects of the tions with the attendant increasing risks of iatrogenic

28
 Psychology of pain

complications.9 10 Repeated failure heightens the sense of motivation for concealment. It is, however, clear that the
frustration and distress and anger towards health pro- social contexts in which sufferers find themselves is
fessionals. This approach to problem solving has been important, insofar that there are some settings where dis-
called assimilative coping.3 The alternative problem plays of pain behaviour and reports of pain are not inhib-
solving strategy ‘accommodative coping’ involves a subtle ited, for example, hospital and clinical settings.15 37
but significant shift in a person’s orientation towards the
problem of continuing pain. Here, the person relinquishes
the pain relief as their primary goal and begins to consider Conclusions
alternative ways of achieving their hoped-for futures, by
Pain is a complex psychological phenomenon and this
either developing new aspects of their hoped-for selves
review has only touched briefly on some of its facets. I
that match their values or finding new ways in which they
have tried to show that psychological influences are perva-
can express their hoped-for self.
sive and shape a person’s response to pain whether it is a
brief phasic experimental pain or more persistent chronic
Acceptance of pain and acceptance and commitment pain. Psychological interventions reflect this complexity.
therapy Treatments for chronic pain are generally multimodal and
include elements that specifically address the interruption
The challenge chronic pain presents to the person’s sense
and interference components. Techniques for helping
of identity—their sense of self—is considerable and can
patients manage there attentional system are widely used
have profound consequences, especially when a techno-
in cognitive behavioural programmes38 49 and programmes
logical fix is either not available or simply not successful.
nearly always incorporate components of behavioural acti-
A contemporary development in psychological therapy
vation and operant reinforcement principles to help
explicitly recognizes this. Acceptance and commitment
patients change the relationship between pain and activity
therapy (ACT) aims to help patients learn new ways to
(addressing the interference component).24 46 More
live with pain.33 The term acceptance can be misleading:
recently, the focus has been to develop better specified
it does not mean ‘putting up with it’. ACT ‘focuses on
treatments to focus on specific subgroups of patients with,
acceptance of thoughts and feelings that have been
for example, marked problems of fear avoidance.52 54 The
occasions for unhelpful responses in the past. Acceptance
evidence for the efficacy of psychological treatments is
methods are combined with work on personal values,
supported by many randomized controlled trials.36
behavioural commitments, and traditional behaviour
change strategies to help patients live a fuller life’.32
Acceptance therefore aims to help the sufferer disengage
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