For example, Fordyce 36 suggested that although resting or taking analgesics may be a good coping strategy in the acute phase, these behaviors might actually facilitate the development of long-term problems. Consequently, treatment programs for people with chronic musculoskeletal pain problems have been built on gradually changing these behaviors, such as by decreasing analgesics and increasing activity levels.
A second basic tenet is that learning involves the whole organism and environment; therefore, pain behaviors may be reinforced by social and environmental consequences. Learning then can be quite important in the development of chronic disability. For example, changes in life routines necessitated by the pain eg, can no longer do the vacuuming might be maintained by other consequences eg, partner gladly does it instead.
Learning paradigms provide a tremendous opportunity for helping patients change ie, to learn skills that allow them to cope better with the pain. If part of the suffering and disability are related to learned changes, it is possible to make further changes toward a more preferable goal by utilizing the principles of learning.
This is why most multidimensional rehabilitation programs use some type of learning paradigm, usually in the form of cognitive-behavioral therapy. Taken together, these processes provide insight into how psychological factors affect the experience of pain.
Nevertheless, it still may be difficult to appreciate how these processes work in reality and how we might utilize them in specific ways in the clinic. To facilitate understanding and application, various models have been put forward. In the next section, we examine pertinent theoretical models of pain that have applied psychological processes to explain how pain problems develop over time and how these models might guide clinical interventions.
A number of theoretical models have been proposed to explain more-specific ways in which psychological factors might have a bearing on pain and disability over time. Most researchers in pain psychology subscribe to a broad, biopsychosocial formulation, but more-specific conceptual models provide a pathway whereby psychological factors affect the transition from acute to persistent pain problems. Although there are many theoretical perspectives of pain and disability, we will present the 5 theories commonly referred to in current studies of pain psychology.
Three of these models fear-avoidance, acceptance and commitment, and misdirected problem solving are specific to the experience of chronic pain, and 2 of these models stress-diathesis and self-efficacy represent broader theories of health behavior that can be applied to pain. Table 2 provides a summary of the models and examples of the basic components, the processes involved, and some implications for treatment.
The 5 models provide ways of understanding how the specific interactions and mechanisms that exist between psychological factors are interrelated. Thus, they help us to understand the development of persistent pain and disability. Moreover, each of these models highlights different mechanisms, which may help us select the most effective ways to address psychological factors in the clinical management of LBP.
One of the most influential models to explain psychological factors in the experience of pain has been the fear-avoidance model, which was advanced to explain how patients with an acute or subacute pain condition might transition over time to a chronic state of depression, disability, and inactivity.
A specific emotion regulation factor in the model is fear. Fear of pain develops as a result of a cognitive interpretation of pain as threatening pain catastrophizing , and this fear affects attention processes hypervigilance and leads to avoidance behaviors, followed by disability, disuse, and depression.
The fear-avoidance model suggests that in the absence of fear-avoidance beliefs about pain, individuals are more likely to confront pain problems head-on and become more engaged in active coping to improve daily function. This model is supported by the evidence that high levels of pain-related fear are associated with distraction from normal cognitive functions, hypervigilance of pain-related sensations, and unwillingness to engage in physical activities.
The fear-avoidance or pain-related fear model. Adapted from Vlaeyen and Linton. Graded exposure to physical activity has been considered a critical aspect of treatment in order to overcome a fear of pain. One relatively new model for understanding psychological factors in chronic pain is that of acceptance and commitment. This model was borrowed from a more general psychotherapeutic approach acceptance and commitment therapy 43 that has been offered as a complement to cognitive-behavioral therapy.
At the heart of this model is a cognitive interpretation process, namely the concept of psychological inflexibility, or the inability to persist in or change behavior patterns that might service long-term goals or values.
As shown in Figure 3 , this model suggests that emotional processes in the form of worries about pain and cognitive evaluations eg, pain catastrophizing are the product of a human predisposition and probably an evolutionary advantage to solve problems a behavioral process by verbally ruminating on possible negative outcomes and plotting methods of avoidance or escape.
This model explains why persistent pain repeatedly interrupts attention, fuels worries about negative consequences, produces hypervigilance to pain, and produces repeated efforts to alleviate pain, even when there is no belief that a solution exists.
When multiple attempts to get rid of pain fail, worries are further reinforced, and patients are stuck in an endless loop of increasing worries and failed problem-solving attempts to alleviate pain. The practical implication of this model is that repeated efforts to manage LBP through pharmacological, physical, and surgical and even psychological treatments that are focused on pain relief may inadvertently reinforce this misdirected problem-solving strategy.
Instead, a reframing of the problem toward more-functional goals and away from pain relief or biomedical explanations of pain may help to redirect problem-solving efforts that are more likely to be successful. The misdirected problem-solving model.
Adapted from: Eccleston C, Crombez G. Worry and chronic pain: a misdirected problem solving model. The figure may not be reproduced for any other purpose without permission.
Like people with other medical conditions, individuals with chronic or recurring LBP may need to adjust their habits and lifestyles while still trying to maintain basic physical, social, and vocational activities. This model requires that patients make efforts to understand the nature of their pain problem, plan self-care strategies for dealing with pain flare-ups, learn to overcome functional problems effectively, and utilize available supports and resources wisely.
Thus, this model underscores behavioral processes coping as well as cognitive processes interpretation of the problem and degree of control. In terms of clinical management of LBP, this model suggests that provider advice and treatment should be delivered in a way that takes into account individual patient preferences, involves patients in decision making, and provides useful self-management strategies for coping with pain flare-ups and functional difficulties.
This model suggests that when LBP befalls an individual who is already under significant psychological stress or whose coping resources are already stretched thin, pain may result in more significant functional limitations and generate higher levels of emotional distress. Thus, this model highlights the role of emotional processes focusing on stress, depression, and anxiety distress.
Although this model is probably the least formally construed, there is considerable evidence that individuals with a psychiatric history, with depressed mood, with major life adversity, or reporting high levels of stress are at greater risk of transitioning to chronic and disabling LBP.
This model has been at the core of efforts to refocus LBP management on secondary prevention of distress and disability and away from the more-orthodox biomedical approach of uncovering physical abnormalities. Psychological theories and models about pain have provided a better understanding of cognitive, emotional, and behavioral manifestations of pain, but what is their implication for the clinical management of LBP?
To summarize the most significant clinical implications, we provide 10 guiding principles in Table 3 that can be synthesized from our review above of the psychological processes and models of the pain experience. Effective strategies for coping with persistent, recurrent, or chronic pain are very different from those for managing acute pain, and pain that persists beyond a few weeks can lead to emotional and behavioral consequences that are deleterious to pain recovery and functional rehabilitation.
These principles provide insight into providing a patient-centered approach, which underscores the importance of psychological responses to pain from assessment principles 1—3 , to treatment planning principles 4—7 , and to implementation principles 8— One theme that emerges from psychological theories of pain is the need for a patient-centered approach to clinical care that takes into account individual differences in lifestyle, occupational demands, social support, health habits, personal coping skills, and other contextual factors that may dramatically affect goals and expectations for treatment.
Recognizing that a patient is depressed, frustrated by persisting pain, or beginning to severely limit movements and activity are reasons to adopt a more psychological or multidisciplinary approach that might offset some of the negative functional and social consequences of a developing chronic pain problem.
Among patients with persistent pain, even good problem solvers can become frustrated by repeated futile attempts to discover and eliminate the anatomical source of pain. Another theme that emerges from psychological theories of pain is the importance of emotional responses and pain beliefs. Individuals show tremendous differences in their ability to regulate emotions as well as their attributions about pain, their judgments about the seriousness of pain, their expectations of assistance and emotional support from others, and their sense of control and mastery over pain.
Three pain beliefs that have been shown to put patients at greatest risk of a poor prognosis are pain catastrophizing an exaggerated, negative interpretation of pain , fear avoidance a belief that all activity should be avoided to reduce pain , and poor expectations for recovery.
Providing psychologically oriented treatment techniques or simply utilizing psychological principles involves the application of the basic processes and models presented in this article. There is a growing need to translate these ideas into useful clinical tools and interventions for widespread dissemination. Psychological interventions range from simple techniques involving communication skills to advanced methods requiring considerable training and practice under supervision.
Thus, although we encourage application, we also believe that professional competency is warranted. Assessing psychological factors in patients with LBP is a critical first step, and successfully utilizing them in treatment may be a key to improving outcomes and preventing the development of chronic disability.
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Psychol Methods 17 , — Kuha, J. Download references. We would like to thank M. Parker, S. Chobert and N. Begum for their valuable contributions to this paper. Hird, W. El-Deredy, A. You can also search for this author in PubMed Google Scholar. Correspondence to E. Reprints and Permissions. Boundary effects of expectation in human pain perception.
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Advanced search. Skip to main content Thank you for visiting nature. Download PDF. Subjects Human behaviour Perception. This article has been updated. Abstract Perception of sensory stimulation is influenced by numerous psychological variables. Introduction The experience of pain results from both sensory input and psychological variables such as personality traits and anxiety level 1 , 2 , 3 , 4 , 5.
Figure 1. Full size image. Results Manipulation check: effect of cued intensity on pain rating We first assessed the extent to which cued intensity and stimulus intensity influenced pain intensity ratings.
Figure 2. Table 1 Results of the fixed effects model on Dataset 1, assessing the extent to which stimulus intensity, cued intensity and trial influenced pain intensity rating. Full size table. Table 2 Results of the basic models fitted in Dataset 1 and 2. Figure 3. Table 4 Results of the complex models fitted in Dataset 1 and 2.
Figure 4. Methods Participants For both Dataset 1 and 2, participants aged 18—35 were recruited via university advertisements. Apparatus Visual stimuli were presented on a desktop computer screen one metre away from the participant.
Procedure Upon arrival to the lab, participants were briefed by the experimenter, who introduced the study as a test of pain perception. Figure 5. Table 6 A summary of all Trials Full size table.
Change history 04 November An amendment to this paper has been published and can be accessed via a link at the top of the paper. References 1. Google Scholar 2. Google Scholar 3. CAS Google Scholar 4. Google Scholar 5. Google Scholar 8. CAS Google Scholar PubMed Google Scholar Google Scholar Acknowledgements We would like to thank M. Talmi Authors E. Hird View author publications. View author publications. Ethics declarations Competing Interests The authors declare no competing interests.
Supplementary information. Supplementary Materials. If there are choices your child can make, such as which arm they receive an injection, these should be offered. Even if the choices are small, the act of making a choice is a step forward. As a result, your child should feel they are regaining control, and may experience less pain along with more positive emotions and behaviour. It is important to assess all the factors that can affect pain and, since fear and anxiety are so closely related to pain, evaluating whether your child is afraid and anxious is part of evaluating whether they have any pain.
Children can sometimes deny that they are hurting for fear of a needle or some more frightening treatment. For these reasons, an accurate assessment of how much pain your child feels is important to make sure that everything is being done to relieve both their pain and any anxiety they may have. Being honest with your child about their pain is a step in the direction of reducing beliefs that might negatively affect pain assessment. Much of how we express our pain is learned behaviour.
There are also gender differences associated with pain; that is boys and girls will often react differently to pain. Conversely, young girls may cry more because this behaviour is deemed acceptable. Older children behave very differently than younger children and all ages may behave differently depending on whether they are with their parents or peers.
Cultural differences can account for a wide variety of reactions to situations. People of some cultures may express themselves freely. Others may repress their emotions or react in a way contrary to what is considered normal in the western world. For example, parents may be very reluctant to show concern or may believe it is disrespectful to ask hospital staff questions. Parents may even constantly smile through their child's painful procedure though they are not feeling happy.
As well, parents and children may behave the way they believe health-care professionals want them to behave.
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