A pain in the neck, mind, brain and society

Technology Review has an article that looks at recent work on the neuroscience of chronic pain. While understanding the problem in terms of neurobiology is essential, understanding the psychology and social influences on pain is equally important.

Chronic pain is an interesting condition because it can continue even when the original tissue damage has healed.

The article talks about chronic pain purely in terms of its neurobiology, but there is now a great deal of evidence that we can explain how pain is maintained through social and psychological explanations.

This is remarkably hard for some people to take on board, as there is still the attitude that explaining something in psychological terms somehow implies the pain isn’t “real” or is somehow a figment of their imagination.

As he recounted in a recent article for the British Medical Journal, Ben Goldacre came across exactly this when he recently discussed the psychosocial aspects of pain on the radio and got a number of outraged listeners contact the programme to say they were offended by the implication that their suffering was imaginary.

This is exactly the opposite of what the standard scientific approach aims to do though. It accepts that pain is experienced, but attempts to work out the biological, psychological and social factors that can increase or decrease pain.

One of the most important findings in the last few decades is that psychological and social factors have a huge influence.

A recent review article, published in Psychological Bulletin [pdf], examined all of the factors and recounted some fascinating studies that have found that people’s beliefs about pain have a huge impact both on how unpleasant they rate the pain to be, and on how disabled they are in everyday life.

This is just a sample from the huge amount of research done on the psychology of pain:

Appraisal and beliefs about pain can have a strong impact on an individual’s affective and behavioral response to pain. If a pain signal is interpreted as harmful (threat appraisal) and is believed to be associated with actual or potential tissue damage, it may be perceived as more intense and unpleasant and may evoke more escape or avoidance behavior. For instance, pain associated with cancer is rated as more unpleasant than labor pain, even when the intensity is rated as equivalent (Price, Harkins, & Baker, 1987). Similarly, Smith, Gracely, and Safer (1998) demonstrated that cancer patients, who attributed pain sensations after physiotherapy directly to cancer, reported more intense pain than patients who attributed this pain to other causes… These studies demonstrate the important role of people’s interpretations regarding the meaning of pain.

Pain appraisal and pain beliefs are also prominent determinants of adjustment to chronic pain (Jensen, Romano, Turner, Good, & Wald, 1999; Turner, Jensen, & Romano, 2000). The following pain beliefs have been identified as particularly maladaptive in dealing with pain: Pain is a signal of damage, activity should be avoided when one has pain, pain leads to disability, pain is uncontrollable, and pain is a permanent condition (Jensen, Turner, Romano, & Lawler, 1994; Turner et al., 2000). The belief that pain is a signal of damage and the belief that activity should be avoided in order to recover from pain appear to be widespread (Balderson, Lin, & Von Korff, 2004; Ihlebaek & Eriksen, 2003).

Because of the importance of our beliefs about pain on the experience of pain itself, we know that psychological therapy can lead to significant improvement.

A key 1999 study [pdf] gathered evidence from all the relevant clinical trials to date and found that cognitive behaviour therapy was a useful and powerful treatment.

Although we typically associate pain with physical damage to the body, thinking only in terms of physical damage is counter-productive. We also need to tackle the psychology and neuroscience of pain both to fully understand it and to help people affected by it.

Link to TechReview article on the neuroscience of chronic pain.
Link to Ben Goldacre on the challenges of communicating psychosocial factors.
pdf of scientific article on psychology and neuroscience of pain.
pdf of scientific article on effectiveness of CBT for pain.

2 Comments

  1. Lexi
    Posted November 16, 2007 at 9:33 pm | Permalink

    For me, I love the fact that my chronic pain (pinched nerve) might be reduced because part of its influence is that of my mind!

  2. Posted November 20, 2007 at 2:37 am | Permalink

    Hi
    Thanks for a thoughtful summary on chronic pain and neurobiology, and the need to understand it as a biopsychosocial phenomenon. It’s a shame that almost as soon as people hear ‘it’s in the brain’, the assumption is that it’s ‘imaginary’ or ‘psychiatric’. I see that response in the previous commentator! While the pain of chronic pain may not reduce through CBT, the disability and interference from chronic pain certainly does reduce, as well as distress.


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