Cognitive factors can influence pain perception

Research into placebo responses has shed light on several brain neural network modulating pain perception. Pain relief through distraction suggests that pain experience can be modified, and highlights the influence cognitive processes have on pain perception.

The concept of pain as an actively constructed experience that is determined by expectations has implications for chronic pain prevention and treatment, so that patients with chronic pain might be good candidates for placebo intervention.

Follow ClinicalPainAdv. Show More. Login Register. Enjoying our content? Thanks for visiting Clinical Pain Advisor. If you wish to read unlimited content, please log in or register below. Registration is free. Register for free and gain unlimited access to:. Continue Reading. Summary and Clinical Applicability Research into placebo responses has shed light on several brain neural network modulating pain perception. Cognitive and emotional control of pain and its disruption in chronic pain.

Nat Rev Neurosci. Villemure C, Bushnell MC. Mood influences supraspinal pain processing separately from attention. J Neurosci. 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.

Linton SJ. Environmental and learning factors in the development of chronic pain and disability. Google Scholar. Google Preview. Do physical therapists recognise established risk factors: Swedish physical therapists' evaluation in comparison to guidelines.

Do evidence-based guidelines have an impact in primary care: a cross-sectional study of Swedish physicians and physiotherapists. Spine Phila Pa Amsterdam, the Netherlands : Elsevier Science ; Waddell G. The Back Pain Revolution. Edinburgh, Scotland : Churchill Livingstone ; Phys Ther.

Understanding Pain for Better Clinical Practice. Edinburgh, Scotland : Elsevier ; Eccleston C , Crombez G. Pain demands attention: a cognitive-affective model of the interruptive function of pain. Psychol Bull. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med. Villemure C , Bushnell M. Cognitive modulation of pain: how do attention and emotion influence pain processing. Reducing the threat value of chronic pain: a preliminary replicated single-case study of interoceptive exposure versus distraction in six individuals with chronic back pain.

Behav Res Ther. London, United Kingdom : Churchill Livingstone ; Assessment of pain beliefs, coping, and self-efficacy. Handbook of Pain Assessment. New York, NY : Guilford ; : — How important are back pain beliefs and expectations for satisfactory recovery from back pain?

Best Pract Res Clin Rheumatol. Exposure in vivo versus operant graded activity in chronic low back pain patients: results of a randomized controlled trial. The role of illness perceptions in patients with medical conditions.

Curr Opin Psychiatry. Petrie KJ , Weinman J. Why illness perceptions matter. Clin Med. The prognosis of low back pain in general practice. On the course of low back pain in general practice: a one year follow up study.

Ann Rheum Dis. Barlow DH. The pain catastrophizing scale: development and validation. Psychol Assess. Reducing sickness absence from work due to low back pain: how well do intervention strategies match modifiable risk factors? J Occup Rehabil. Craig AD. A new view of pain as a homeostatic emotion. Trends Neurosci. A review of psychological risk factors in back and neck pain. Making sense of hypochondriasis: a cognitive model of health anxiety. Worry and chronic pain patients: a description and analysis of individual differences.

Eur J Pain. Depression and pain comorbidity: a literature review. Arch Intern Med. Clyde Z , Williams AC. Depression and mood. In: Linton SJ , ed. Amsterdam, the Netherlands : Elsevier ; : — Linton SJ , Bergbom S.

Depression and pain: what is the link? Scand J Pain. In press. Currie SR , Wang J. Chronic back pain and major depression in the general Canadian population. Pain Phila Pa Health and disability costs of depressive illness in a major US corporation.

Am J Psychiatry. Nicholas MK. Mental disorders in people with chronic pain: an international perspective. Initial depression severity and the trajectory of recovery following cognitive-behavioral intervention for work disability.

Predicting work status following interdisciplinary treatment for chronic pain. Fordyce WE. Behavioral Methods for Chronic Pain and Illness. St Louis, MO : Mosby ; J Occup Rehab. Descending pathways from cortical areas to the midbrain and spinal levels can facilitate or inhibit spinal nociceptive information and thereby afferent nociceptive input to the brain.

The underlying mechanisms of the various emotional and cognitive modulatory influences may partly overlap, but also have some unique aspects. What becomes clear is that pain is not merely a reflection of the nociceptive input, but should be considered as a complex experience shaped by psychological factors that may be unique for each individual.

This stimulation provokes somatization, in other words, pain responses which are stressors per se, therefore, increasing pain in a vicious cycle. They argued that certain 'psychological' pain could be initiated due to motivation-specific psychophysiological responses.

What they meant was stimuli might be perceived differently according to each individual, and also that the same stimuli could be experienced in many ways by the same person, depending on the given time. To put it simply, according to this view-point, physiological responses are generated as a result of an individual's subjective interpretations of the stimuli.

Investigations with soldiers during the World War II have provided significant evidence consistent with this assumption. Beecher concluded that soldiers who were wounded in the battlefield reported less pain and did not request as many painkillers as civilians who had undergone surgical procedures and experienced similar conditions.

He carried on stating that this would be because of the ways individuals perceived the pain. Research has shown that cultural factors might hugely influence the pre-disposition of certain individual differences, for instance, the ability to best manage pain according to cross-cultural perspectives Taylor, A critical example would be Mexican women experiences of giving birth.

They usually anticipate labour with a great amount of fear which automatically translates into more sensitivity to painful experiences and, consequently more complications in contrast with women from other cultures Straub, ; Taylor, Similarly, those women who see the act of giving birth as something ordinary and, therefore, less frightening, generally describe less pain during pregnancy Straub, ; Taylor, Neuropsychological-based studies involving functional magnetic resonance imaging fMRI techniques have demonstrated how such expectations could potentially induce neural processing prior to noxious stimuli.

Researchers have found that whenever signals of high expectation of pain are activated in the brain, it results in increased firing of certain brain areas which generate anticipatory responses to upcoming events.

Furthermore, socio-cultural factors may contribute to shape individuals' attitudes towards pain and, in some cases, it results in the formulation of pre-concepts of pain. For instance, it is known that in some particular cultures men adopt a certain role in society, in which, it becomes shameful for them not to be in control of themselves and their own lives. This personal control is described as an individual's locus of control, which might overlap with gender stereotyping Brannon et al.

In fact, a great deal of research has addressed the extent to which pain perception might be influenced by gender. More evidence for the gender-stereotype effect on pain perception comes from dental surgery patients, since it was found that, although gender did not influence the physiological responses to analgesics, women reported much more aggravated pain symptoms than male participants Brannon et al. Nonetheless, this trend of results was not observed, when the gender of the experimenter was manipulated in controlled conditions.

Interestingly, health-related studies have revealed that individuals who scored higher in perceived control tests, usually presented less activation in some brain regions associated with pain responses, such as, the right anterior part of the ventro lateral prefrontal cortex VLPFC Ploner et al. In addition, it has been argued that gender might influence the specific cognitive strategies that men and women use to deal with pain.

For instance, researchers have found that, in general, men tend to focus on the physical sensations of pain. It is also worth noting that individual differences should be considered, while assessing pain as a general topic. Available data have shown that there seems to be a direct relationship between mood resulting from stressful life events, and physiological responses of pain. For this reason, mood changes were observed in an attempt to correlate behavioural with physiological outcomes.

In that experiment, migraine patients rated their moods during specific times per day for a certain period of time. It was found that there was a significant correlation between migraine intensity and mood swings. They argued that emotional content would trigger the repeated activation of systems, thereby promoting the dysfunction in homeostatic regulation, in other words, the breakdown in the equilibrium among systems in the body.

According to this perspective, homeostatic deregulation was the fundamental reason why systems would present affected outcomes pain responses , depending on how much individuals were exposed to stressors. Arguably, pain-specific responses may not only be elicited by hyper muscular activations, but also due to emotional suppression of affective responses, such as anger, research has revealed.

Gross , carried out a series of investigations in which it was found that individuals who were supposed to suppress their behavioural responses to stressful stimuli during tasks, were more likely to present higher levels of arousal and translate those into reporting more pain.

The underlying idea here is that increased anxiety levels, associated with affect suppression, would elicit sympathetic nervous system activation, as well as higher lower paraspinal muscle tension and systolic blood pressure Burns et al.

Not surprisingly, individuals who scored high marks in anxiety tests tend to report more pain and request more treatment than individuals who were classified as having a standard level of anxiety Braams et al. Conversely, fear seems to inhibit pain responses, either in humans and animals, via the activation of endogenous opioids in the brain Brannon et al. According to studies from the University of Bath - Bath Centre of Pain Research Keogh, , women are generally more fearful with regards to anxiety-related sensations and, as a result, tend to interpret those feelings with a greater extent of negativity thus, experiencing more intense pain compared to men.

Equally surprising, a cognitive strategy, namely, acceptance, described as non-judgemental evaluations of one's thoughts, emotions and experiences, was found to decrease the expression of pain and distress in conditions of high stress Braams et al. In fact, the idea of self-regulation towards painful symptoms has been extensively explored for decades. It was argued that in the majority of cases of silent heart attacks that is, when patients have heart attacks without noticing prior signals , individuals tended to be less responsive to any pain-related-stimuli such as electric shocks or muscular pain.

Meaning that, individual sensitivity to stimuli might play a role in general experiences of pain. It was argued that individuals who were classified as the so-called Type A-Personality Pattern would present a higher need for control leading to anxieties and respective consequences as discussed previously.

These sets of characteristics embody fundamental aspects for health-related conditions. Further research, however, must be carried out in order to attribute such health implications as to specifically derived from personality variables Martin et al;, In addition, an important personality factor related to cognitive ascpects directly related to pain experiences, is neuroticism. Even more remarkable is the fact that not only adults tend to exacerbate their reactions to pain, but also adolescents and children who undergo worries and frustrations, usually report more chronic pain symptoms Payne et al.

Studies Muris et al. The findings revealed that perceptual sensitivity was significantly associated with cognitive factors, regardless of individuals' ages and physical conditions. Of similar importance, there are a number of fundamental points that need to be taken into account in terms of personality theory Gray, , in Muris et al.

According to biological approaches, neuroticism-like traits rely on brain systems that help to regulate behaviour. The behaviour inhibition system BIS enhances individuals' alertness to possible danger, and works in a very similar state to the neuroticism pattern. Consequently, it is thought that extreme activation of this system BIS may intensify neuroticism, thus sensitivity to pain leading to catastrophizing responses. At present, however, empirical investigations suggest that there is a direct cognitive - physiological mechanism operating in nociception sensory perception of pain.

Scientists have found that endogenous opiate like substances, or endorphins, are fundamental neurochemicals generated in the brain and body glands, which promote the regulation of pain. For survival reasons, the pain suppression system is not always actively sending inhibitory messages to the brain. Nonetheless, particular factors, such as stressors, might trigger inhibitory activations in the brain.

Researchers have found that stressful conditions might produce a state called "stress-induced analgesia" SIA , when there is an increase in the brain's endogenous opioids Taylor, ; Yilmaz et al. Further possible functions associated with endogenous opioids are still unknown, nevertheless, evidences suggest that they might be released as the body's physical response to stress, acting on the control of pain Taylor, Similarly, cognitive strategies might be used in order to activate endogenous responses, hence reducing pain.