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7 Cognitive factors that influence pain

There are many cognitive influences on pain; some of these lessen pain while others increase it. Several cognitive influences are modifiable and have clinical utility in treating pain. Selected cognitive influences on pain are outlined here.

Cognitive influences that increase pain:

 Catastrophizing. Catastrophizing describes maladaptive cognitive patterns in response to challenges, especially: imagining a symptom means something ominous (magnification), focusing on a problem (rumination), and feeling unable to resolve a problem (helplessness). Catastrophizing about pain can amplify pain intensity and suffering and is associated with poorer long‐term outcomes (Quartana et al. 2009). Originally conceptualized by Ellis, catastrophizing has had a great impact on pain research however, large‐scale studies are generally needed to show statistical significance. Clinically, effects of catastrophizing on pain are moderate. Cognitive behavioral therapy can help patients shift negative cognitions and replace defeating “self‐talk” with more positive messages, it is not known whether single interventions are effective, or whether physicians can administer brief interventions (Turk 2003). For patients with chronic pain who catastrophize, clinical psychological evaluation is indicated.

 Anxiety. Anxiety facilitates pain perception. The mechanisms of this are not fully established but one study induced acute pain‐associated anxiety which produced increased experimental pain (Rainville et al. 2005). Chronic anxiety is also associated with increased pain in a clinical setting. It is important for healthcare environments to reduce anxiety where possible and ideally providers will create therapeutic relationships sensitive to patients' anxieties. Measures including: reduced jargon, shared decision‐making, and utilizing web interfaces and videos to explain procedures in advance can help reduce anxieties. When anxiety is excessive, it is treated with medication and psychotherapy.

 Anger. Anger can increase pain. One study of pain‐related emotions used hypnotic suggestion to modulate the mood of normal volunteers while pain was tested. In those patients for whom anger was induced, there was a significant increase in perceived pain intensity as well as pain‐associated unpleasantness. Anger also has important effects in a clinical setting but the relationship between pain and anger is complex. Studies of patients with low back pain have indicated that the suppression of anger expression increased pain and pain behaviors (Burns et al. 2008). Generally, negative emotions heighten pain while positive emotions reduce pain (Yarns et al. 2020).

 Low self‐efficacy. Low self‐efficacy is when a person feels that they can do little to improve their situation. A related concept is called the “external locus of control.” Someone with an external locus of control will feel that their situation is controlled by factors outside themselves. This is contrasted to having an internal locus of control which is when a person feels that they can control their lives and engage in activities that will have a beneficial effect. Patients with internal locus of control have better health‐related outcomes. Physicians can foster self‐efficacy using motivational interviewing techniques: “What are some small steps you could take to start getting control over your pain?.” Many pain self‐management strategies require patients to take active steps, e.g., hotpacks, ice, meditation, and pacing require a commitment from patients.

Factors that decrease pain:

  Empathetic others. The presence of an empathetic other is an important factor in reducing pain levels in specific populations. However, it appears that much depends on the existence of a pre‐established bond and strong attachment. One study indicated that the utterance of empathetic statements by trained personnel, who did not previous know the patients, during a painful procedure was not helpful (Lang et al. 2008). Children benefit from the presence of a supportive other, as do laboring women. There is extensive research exploring the role of spouses although some spousal behaviors can worsen pain. It appears that the nature of the relationship (attachment) may have a predominant effect on the efficacy of empathetic support in reducing pain (Meredith et al. 2005).

  Distraction. Distraction is a well‐established approach for the reduction of transient or mild pain (Primack et al. 2012). It is known that playing video games is an effective technique for reducing pain in some populations, especially children (Gold et al. 2006). It is possible that distraction shows a ceiling effect and may not be sufficient for settings where severe pain is anticipated.

  Hypnosis. Hypnosis has a long and somewhat rocky association with allopathic medicine. Nonetheless, there is some evidence to support the view that hypnosis is among the interventions that may be useful in mitigating pain. A recent Cochrane database review indicated that self‐hypnosis may be beneficial in laboring women (Madden et al. 2016), and a recent study indicated that hypnosis is one of several skills‐based psychosocial interventions that may be beneficial for cancer pain [Sheinfeld Gorin]. Importantly, many adults are not hypnotizable whereas children often are. If a patient is open to the idea of hypnosis, a course of therapy may be worthwhile.

  Diffuse Noxious inhibitory control. Diffuse Noxious Inhibitory Control (DNIC) is a brain mechanism that suppresses a mild pain when a stronger pain stimulus is encountered. For example, if a person has a scrape on the knee and a broken arm, they may not feel the pain of the knee as long as the arm pain is not controlled. If local measures, e.g. immobilization, icing, nerve blocks, are used to control the arm pain, the patient may become aware of the milder injury to the leg. This has important implications for multi‐trauma patients as they may not feel all of their injuries and important problems may be overlooked. Many people do not have effective DNIC and a subset of patients experience heightened pain perception in the presence of other pain problems. It is unclear how to utilize DNIC clinically.

 

References

1 Burns, J.W., Holly, A., Quartana, P. et al. (2008). Trait anger management style moderates effects of actual (“state”) anger regulation on symptom‐specific reactivity and recovery among chronic low back pain patients. Psychosomatic Medicine 70: 898–905.

2 Gold, J.I., Kim, S.H., Kant, A.J. et al. (2006). Effectiveness of virtual reality for pediatric pain distraction during i.v. placement. CyberPsychology and Behaviour 9 (2): 207–212.

3 Lang, E.V., Berbaum, K.S., Pauker, S.G. et al. (2008). Beneficial effects of hypnosis and adverse effects of empathic attention during percutaneous tumor treatment: when being nice does not suffice. Journal of Vascular and Interventional Radiology 19 (6): 897–905.

4 Madden K, Middleton P, Cyna AM, Matthewson M, Jones L. Hypnosis for pain management during labour and childbirth. Cochrane Database Syst Rev. 2016 May 19; 2016(5):CD009356

5 Meredith, P.J., Strong, J., and Feeney, J.A. (2005). Evidence of a relationship between adult attachment variables and appraisals of chronic pain. Pain Research and Management 10: 191–200.

6 Primack, B.A., Carroll, M.V., McNamara, M. et al. (2012). Role of video games in improving health‐related outcomes: a systematic review. American Journal of Preventive Medicine 42 (6): 630–638.

7 Quartana, P.J., Campbell, C.M., and Edwards, R.R. (2009). Pain catastrophizing: a critical review. Expert Review of Neurotherapeutics 9 (5): 745–758.

8 Rainville, P., Bao, Q.V., and Chrétien, P. (2005). Pain‐related emotions modulate experimental pain perception and autonomic responses. Pain 118 (3): 306–318.

9 Turk, D.C. (2003). Cognitive‐behavioral approach to the treatment of chronic pain patients. Regional Anesthesia and Pain Medicine 28 (6): 573–579.

10 Yarns, B.C., Lumley, M.A., Cassidy, J.T. et al. (2020). Emotional awareness and expression therapy achieves greater pain reduction than cognitive behavioral therapy in older adults with chronic musculoskeletal pain: a preliminary randomized comparison trial. Pain Medicine 21 (11): 2811–2822. 2020 May 25:pnaa145. PMID: 32451528.