Cognitive and Behavioral Aspects of Pain

Anna M. Formanek

Vijay Kata

Alan D. Kaye

Introduction

Pain began to be explored through a cognitive and behavioral lens in the latter part of the 1960s. Around this time, scientists came to realize that pain relates to both uncomfortable sensations within the body and unpleasant emotional experiences relating to these physical sensations.¹ The pain that individuals feel modifies the thoughts they experience, and the thoughts in turn influence the pain experience.

In this chapter, cognitive and behavioral aspects relating to pain will be explored. First, common pain perpetuating cognitive distortions and biases will be described. Second, common pain perpetuating behaviors will be described. Third, the tools available to combat these cognitive and behavioral changes will be explored, beginning with cognitive tools, and culminating with behavioral tools.

Common Pain Perpetuating Cognitive Distortions and Biases Seen in Chronic Pain Patients

Cognitive distortions and biases were first described in the 1970s and were originally used to characterize thought patterns seen in patients with depression.² Cognitive distortions are errors in thinking that can be seen in patients with depression and lead to worsening of their depressive state. Similar cognitive distortions are also seen in patients with chronic pain and are equivalently apt to worsen the chronic pain severity. Cognitive biases are like cognitive distortions but apply to a larger frame of relating to the world than each specific distortion. Biases are akin to “lenses” the world is seen through, while distortions are the specific thought abnormalities contributing to the overall world view. These distortions and biases are described below:

Black and White Thinking: The tendency to interpret a situation as ALL bad or ALL good, that is “the pain will never go away, there is no chance of it” or “everything in my life is awful because of my pain” or “I can’t live a full life if I can’t participate in this activity due to my pain.”
Mental Filtering and Discounting the Positive: This occurs when individuals pay attention to features of their reality that are only congruent with their world view. For example, if they have pain when walking up a flight of stairs, they may think “I will never get better, this pain will continue forever.” Yet, when the same individual walks the next day for 10 minutes with no pain, they may say to themselves “even though I didn’t have pain this time that was just 10 minutes, I can’t go up the stairs, I will never get better.”
Catastrophizing: A very common distortion seen in patients with chronic pain, when the stimulus of pain leads to a negative prediction for how the pain will play out, typically thinking thoughts along the lines of “the pain will never go away, this will take away all the things I love to do, I will never be happy again.”
Personalization: A distortion occurring when an individual comes to the conclusion that they are the cause of their fate/pain and that this pain is not something that could happen to anyone else. For example, the individual may think “I have pain because I am a bad person, and this is all my fault, this doesn’t happen to anyone else.”
Over generalization: When an individual predicts that since something bad has happened before in a similar situation, the bad thing will happen again. For example, if a patient with chronic pain has had pain exacerbated by doing a certain activity in the past, he or she predicts that it will happen again and apply it to all similar situation. This exacerbates avoidance behavior, which will be described in the next section.
Emotional Reasoning: Occurring when the emotional response to an event is valued more than the objective event itself. For example, the patient may say “I felt awful when I walked for 10 minutes, I did so badly, this was a bad event overall,” rather than saying “I walked for 10 minutes, and I also had a negative emotional state during that moment.”
Should Statements: The habit of thinking that something “should” go a certain way, or that the result “should” be this or that. It can be seen in patients with chronic pain as “I should be feeling better by now, I shouldn’t be having pain still, there must be something horribly wrong with me.”
Recall Biases: In this bias, patients with chronic pain will interpret health-related and illness-related stimuli more acutely and recall painful situations as more painful or more distressing than paired cohorts who do not experience chronic pain. This narrative harms patients with chronic pain and stilts their future experiences with pain to be more painful.
Attentional Biases: In this bias, patients pay more attention to pain-related stimuli than non-pain-related stimuli. This has been demonstrated comparing patients with chronic pain and patients without chronic pain, and seeing the difference in attention given to pain-related words or pictures vs non-pain-related words or pictures.³ By doing this, patients end up experiencing their pain as more pervasive and more intense, simply due to their increased attention to the pain.
Interpretation Biases: In this bias, patients with chronic pain interpret situations more negatively than patients without chronic pain. For example, they will interpret a period of increased pain as a sign that they will always be in pain. They interpret the pain to align with their cognitive distortion that they will always be in pain and that they are doomed to have pain for life.

Common Pain Perpetuating Behaviors in Patients with Chronic Pain

One in five individuals across Europe and the United States report a history of chronic pain.⁴ Frequent chronic pain episodes lead to a variety of behavioral manifestations that express pain-related feelings or enact protective measures to prevent bodily harm. These behaviors are indicative of the severity of pain that each person experiences and the effects that pain has on a personal and professional level. Chronic pain-related behaviors present differently in each person with varying symptoms and clinical presentations. Behavioral patterns are the results of the cognitive, emotional, psychological, and physical aspects of pain. Chronic pain patients and their providers need to distinguish between behaviors that are habitual vs ones that are associated with pain.⁴ Described below are common behaviors observed in chronic pain patients:

Avoidance: Avoidance behaviors are actions that prevent interaction with an unpleasant stimulus.⁴ Perceptions of pain create fear and a need to escape, inducing protective behaviors. This is a natural evolutionary response to pain and is critical for the survival of the species. Exposure-based treatments, as will be described in subsequent sections, have shown promising results toward remedying these avoidance behaviors for individuals with chronic pain. Avoidance may provide short-term relief from negative emotions but will give rise to unhealthy long-term habits.
Fear of Movement: Fear of movement stems from a reluctance to engage in movement that could bring about additional pain or feelings of anxiety. If this fear continues, it can lead to maladaptive responses that cause increased fear, limited exercise or physical activity, and mental duress.⁵ Furthermore, the increased pain-related fear within patients can elevate ambiguous physical sensations, possibly leading to a new pain occurrence.⁵ Patients who continue to experience pain may stop activities that they previously enjoyed. This begins a vicious cycle of physical deconditioning that will ultimately exacerbate pain.⁵
Withdrawing from Activities: Withdrawal from activities is common in patients with chronic pain. This is often a result of both avoidance and fear of movement, as described above. When individuals remove themselves from meaningful activities, they are prone to episodes of sadness, emptiness, anger, panic, and resentment.⁶
Inactivity: Many studies establish physical activity as a low-cost, helpful, and constructive way to manage chronic pain.⁷ An inactive lifestyle causes health problems such as diabetes, obesity, hypertension, heart disease, and other ailments.⁷ A physician should prepare patients for the dangers of prolonged inactivity with an emphasis on how pain can be managed through active lifestyle changes. Increased activity levels nurture the physiological modulation of pain experienced by a person, decreasing levels of worry, anxiety, and avoidant behaviors.
Immobility: Immobility involves an inability to carry out normal bodily movements without the aid of assistive devices or people. Chronic pain contributes to limited mobility of patients, creating an environment that compromises accessibility to specialists, followup care, and preventative health care services.⁸ Immobility poses threats to exploration of new interests and increases pain-related feelings of discomfort.

Cognitive Tools to Address Chronic Pain

Identifying cognitive distortions and biases seen in chronic pain patients is the first step toward helping alleviate maladaptive cognitive patterns. The next step is to develop tools to address these distortions and biases. Below are described three common cognitive tools directed toward patients with chronic pain. These include pain education, cognitive behavioral therapy (CBT), and acceptance commitment therapy (ACT).

Pain Education

Education regarding the nature of chronic pain and how it compares to acute pain is a commonly employed strategy for treatment of chronic pain. Describing how the body is evolutionarily programmed to respond to pain aids in understanding this difference in response to chronic vs acute pain. In the acute pain setting, humans are designed to always respond to pain with avoidance, fear, and hyperarousal, while in the setting of chronic pain, this response is not helpful. When patients with chronic pain understand how acute pain can be helpful, and how it can then devolve into a nonhelpful process, they can feel more in control of their pain. In other words, as written by Harrison et al. “pain science education teaches people about the underlying biopsychosocial mechanisms of pain, including how the brain produces pain and that
pain is often present without, or disproportionate to, tissue damage” and that “understanding pain decreases its threat value which, in turn, leads to more effective pain coping strategies.”⁹

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