Psychological Aspects of Pain

Dennis C. Turk

Kimberly Shawn Swanson

Hilary D. Wilson

Advances in the knowledge of the neurophysiology of pain have resulted in the development of new pharmacologic agents, sophisticated surgical interventions, and the use of innovative technologies (e.g., spinal cord stimulation, implantable drug delivery systems) for the treatment of patients with chronic pain. Despite these advances, the cure of pain remains elusive. Regardless of the treatment, the amount of pain reduction averages only about 35%, and fewer than 50% of persons treated with these interventions obtain this result. The extent of improvement in emotional, physical, and social functioning is often below these dissatisfying levels.¹

Notwithstanding the relatively modest track record for even “newer” chronic pain treatments, patients are often given an expectation, directly or indirectly, that they should expect significant improvements if not elimination of their pain. Although individuals with acute pain can often receive good relief from over-the-counter medications and treatments from their primary health care providers, people with persistent pain become enmeshed in the medical-legal system as they shuttle from doctor to doctor, diagnostic test to diagnostic test, in a frustrating quest to receive successful treatment. This experience of “medical limbo”—the presence of a painful condition that, in the absence of acceptable pathology, is either attributed to psychiatric causation or malingering on the one hand, or an undiagnosed but potentially progressive and untreatable disease on the other—is itself a source of significant and ongoing stress that can initiate high levels of emotional distress or aggravate a premorbid psychiatric condition.²

The person who has a chronic pain condition resides in a complex and costly world that is populated not only by themselves but also by their significant others, including health care providers, employers, and third-party payers. Family members feel increasingly hopeless and distressed as medical costs, disability, and emotional suffering mount while income and available treatment options decline. Health care providers grow increasingly frustrated and feel defeated and ineffective as available treatment options are exhausted while the pain condition remains a mystery and may worsen. They may come to question the veracity of their patients and their complaints. Employers, who are already resentful of growing worker’s compensation benefits, pay higher costs while productivity suffers because the employee frequently calls out sick or is unable to perform at his or her usual level (“presenteeism”), often with coworkers having to pick up the slack. Third-party payers watch as health care expenditures soar with repeated diagnostic testing, often with inconclusive results. In time, the legitimacy of the individual’s report of pain may be questioned because oftentimes, a medical etiology fails to substantiate the cause of the symptoms.

People with chronic pain may begin to feel that their health care providers, employers, and even family members are blaming them when their condition fails to respond to treatment as expected. Some may suggest that the individual is complaining excessively in an attempt to obtain prescriptions for centrally acting and reinforcing medications (e.g., opioids), to receive attention, to avoid undesirable activities, or to be relieved from onerous obligations (e.g., gainful employment, household chores). Others may suggest that the pain reported is not real, they are feigning or exaggerating their symptoms, and is “all in their head”—“psychogenic.” Third-party payers may even suggest that the claimant is intentionally exaggerating his or her pain in order to obtain financial gain, whereas others may attribute reported symptoms to the desire to obtain mood-altering drugs. In this way, people with chronic pain may come to be viewed as “wimps,” “crocks,” or “fakes.” Those experiencing persistent pain may in turn come to view health care providers and claims adjustors as “quacks,” “hacks,” or “thieves.” Often, the ensuring result is an unfortunate, inappropriate, and detrimental adversarial relationship.

As a result of the attitudes, and in the absence of cure or even substantial relief described, individuals experiencing chronic pain may withdraw from contacts; lose their sources of income; alienate family, friends, and coworkers; and become more and more isolated, despondent, depressed, and, in general, demoralized. They become angry, and frustration increases as their bodies, the health care system, legal system, and their significant other have all let them down. They may feel they have even let themselves down as they relinquish their usual activities and responsibilities due to symptoms that are intractable, yet often inscrutable, when not validated by objective pathologic findings. This emotional distress, however, can be exacerbated by a variety of other factors, including fear of disease progression and their vulnerability to escalating sets of symptoms and disability, inadequate or maladaptive support systems, inadequate personal and material coping resources, treatment-induced (iatrogenic) complications, overuse of potent drugs with significant adverse effects, inability to work, financial difficulties, prolonged litigation, disruption of usual activities, and sleep disturbance. In short, living with persistent pain conditions requires considerable emotional resilience and tends to deplete people’s emotional reserves, taxing not only the individual sufferer but also the capacity of family, friends, coworkers, employers, and society to provide support.

Based on what we described earlier about the plight of the person with chronic pain, two conclusions are obvious: (1) Psychosocial and behavioral factors play a significant role in the experience, maintenance, and exacerbation of pain and potentially even the cause³ and (2) because some level of pain persists in the majority of people with chronic pain regardless of treatment, self-management is an important complement to biomedical approaches.⁴ In this chapter, we emphasize a set of important psychological constructs including dispositional, cognitive, affective, and behavioral factors. We discuss them individually for ease of explication. It is important to note, however, that although we describe these separately, there is considerable overlap and integration among them. We conclude with a discussion of integrative models and treatments of chronic pain.

Cognitive Factors: Predispositions, Appraisals, Beliefs, Perceived Control, and Self-efficacy

PREDISPOSITIONS

Temperament is, at least partly, putatively heritable and may show continuity throughout the entire life span. Personality in adulthood reflects the molding of underlying temperament
by life experiences. Temperament and personality may predispose individuals toward misinterpretation of pain sensations and maladaptive pain beliefs, or they can have a protective role contributing to resilience in the face of adversity.

Among the potential vulnerability factors that have been proposed are negative affectivity, anxiety sensitivity (AS), and illness/injury sensitivity. Negative affectivity may be considered as heritable, stable, and promoting a tendency to experience a broad range of negative emotions and to view the world as threatening and distressing.⁵ Negative affectivity has been associated with heightened vigilance to bodily sensations and interpretational biases toward ambiguous internal signals.⁶^,⁷ Studies in nonclinical populations have reported negative affectivity to predict lower pain tolerance.⁸ However, studies in chronic pain populations have, to date, not provided consistent evidence for a role of trait negative affectivity. Thus, although negative affectivity has often been implicated as a vulnerability factor in chronic pain, convincing evidence is lacking.

More convincing has been the research on another potential vulnerability factor: AS. AS is defined as the fear of anxietyrelated sensations and is conceived as a partly heritable personality trait.⁹ Individuals with high AS interpret unpleasant physical sensations (such as rapid heart beating, feeling faint) more often as a sign of danger than individuals with low AS. There is growing evidence that AS may also be a risk factor for the maintenance and exacerbation of chronic pain and disability.¹⁰ AS has been shown to correlate with measures of fear-avoidance (described in the following text) and is associated with distress, analgesic use, and impairment of physical and social functioning in patients across a wide range of different pain-related conditions.¹¹ Moreover, path analyses and mediation models suggest that AS exacerbates fear-avoidance beliefs and the negative interpretation of bodily sensations, which in turn leads to enhanced pain experience and pain avoidance.¹²^,¹³ Studies examining the predictive value of AS in relation to cognitive and behavioral reactions to experimentally induced pain support a causal, negative biasing role of AS in maladaptive cognitive and behavioral pain response.

In contrast to the extensive search after negative predisposing factors described, there has been relatively little research on protective factors for chronic pain and disability. Traditionally, research on resilience has focused on adaptive responses in the wake of significant adversity or challenge (e.g., developmental resilience, posttraumatic growth). In the context of pain, resilience might mean effective recovery from an injury, infection, or other painful experience, both from a physical and psychosocial standpoint (e.g., effective resilience in the wake of an injury might ideally mean total resolution of pain and resumption of normal functioning). However, in patients for whom resolution of pain is unlikely, behavioral, and cognitive responses to pain may have very different implications in terms of their adaptiveness. When a new and unfamiliar painful condition develops, a fearful and avoidant response may be protective; consistent with an evolutionary view of pain, new painful sensations may signal significant danger to the organism, such that mobilization of individual resources to escape pain and threat may prolong survival. However, prolongation of this fearful avoidant response tends to yield fewer benefits in cases of chronic pain and, instead, increase the risk of protracted physical disability, deconditioning, and psychosocial dysfunction.¹⁴ Chronic pain resilience is a construct that has garnered a great deal of attention in recent years (e.g., Friborg et al.,¹⁵ Hassett and Finan,¹⁶ Ruiz-Parraga et al.,¹⁷ Sturgeon and Zautra¹⁸).

Several investigators¹⁸^,¹⁹ have proposed a model of resilience in chronic pain that follows a “temporal” order of adaptation, manifesting in three interrelated factors: sustainability, or prolonged and positive functioning despite the immediate presence of pain; recovery, or expedient and effective recovery from the negative consequences of pain; and growth, or long-term learning or personal development that may result in new strengths, protective attitudes, or skills as a result of chronic pain.

Three potential resilience factors are particularly relevant in chronic pain: optimism, hope, and psychological flexibility. Review of the literature suggests that optimism may be one of the most important personality traits in relation to adjustment to chronic pain. Dispositional optimism is defined as “the tendency to believe that one will generally experience good outcomes in life” and is distinguishable from neuroticism and trait anxiety.²⁰ In cross-sectional and prospective studies, optimism was found to be associated with better general health, adaptation to chronic disease, and recovery after various surgical procedures.²¹^,²²^,²³

Only a few studies have explored the role of dispositional optimism or hope in adaptation to chronic pain. Novy²⁴ found that optimism was related to less catastrophizing and more use of active coping strategies in chronic pain patients. Affleck and Tennen²⁵ reported that dispositional optimism predicts pleasant daily mood in fibromyalgia but that it is not related to daily pain. Finally, in studying rheumatoid arthritis patients, Treharne and colleagues²⁶ found that optimism was associated with less depression and pain and higher life satisfaction for patients in the early and intermediate stages of disease.

The primary mechanism of the beneficial effect of optimism may be differences in coping behavior between optimistic and pessimistic people.²⁷ In general, pessimists turn to avoidant coping strategies and denial more often, where optimists employ more problem-focused coping strategies. When problemfocused coping is not possible, they turn to coping strategies such as acceptance, use of humor, and positive reframing of the situation.²⁰ Thus, it may not be the use of specific coping strategies but flexibility of coping that protects against disability and distress.²⁰ Snyder²⁸ has described a similar pathway for hope, with people with low hope showing a tendency to catastrophize, whereas people with high hope seek means to encounter future challenges and show flexibility in finding alternative life goals when their original goals are blocked.

Psychological flexibility manifests as an ability to effectively and flexibly adjust behavioral efforts at goal pursuit in a way that is consistent with one’s own values²⁹ despite the presence of pain and associated problems. Psychological flexibility may act independently of reductions rumination about symptoms and impact on life and other negative patterns of thinking.³⁰

Individuals with chronic pain who better sustain their optimism, hope, and flexibility appear to be more able to persist in painful behavioral tasks³¹ and to be less susceptible to other pain-related difficulties, such as fatigue³² and problematic opioid use.³³ Similarly, positive emotional states have been found to be predictors of better social³⁴ and physical functioning³⁵ in some individuals with chronic pain.

APPRAISAL AND BELIEFS

Specific appraisal and beliefs are largely shaped by an individual’s learning history through direct experience, observational learning, or information acquired from others. These experiences may interact with an individual’s enduring traits, sociocultural background, prior learning and experiences, and the current context in which they reside. That is, personality factors may predispose some people to make certain kinds of appraisals and to be more susceptible to some idiosyncratic beliefs than to others.

Pain appraisal refers specifically to the meaning ascribed to pain by each individual. In accordance with the transactional stress model,³⁶ a distinction can be made between primary appraisal (evaluation of the significance of pain as threatening, benign, or irrelevant) and secondary appraisal (evaluation of the controllability of pain and one’s coping resources).
Beliefs refer to assumptions about reality that shape how one interprets events and can thus be considered as determinants of appraisal. Pain beliefs develop throughout the lifetime as a result of an individual’s learning history and cover all aspects of the pain experience (e.g., the causes of pain, its prognosis, appropriate treatments).

Appraisal and beliefs about pain can have a strong impact on an individual’s response to pain. If a pain signal is interpreted as harmful (threat), it may be perceived as more intense, more unpleasant and evoke more escape or avoidance behavior. For instance, Smith and colleagues³⁷ 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. Perception of danger of an experimental pain stimulus may also lead to avoidance of this stimulus. Arntz and Claassens³⁸ experimentally manipulated the appraisal of a mildly painful stimulus (a very cold metal bar placed against the neck) by suggesting that it was either very hot or very cold. As expected, participants rated the stimulus as more painful in the condition where they were informed that it was hot. The effect appeared to be mediated by the belief that the stimulus would be harmful. These studies demonstrate the important role of people’s interpretations regarding the meaning of the pain.

Pain appraisal and pain beliefs are also prominent determinants of adjustment to chronic pain.³⁹ Pain that is viewed as a signal of damage, leads to disability, is uncontrollable, and is a permanent condition has been shown to affect individuals’ responses,⁴⁰^,⁴¹ and these beliefs are widespread.⁴²^,⁴³

CATASTROPHIZING AND FEAR-AVOIDANCE BELIEFS

Pain catastrophizing can be defined as an exaggerated, negative cognitive and emotional orientation toward actual or anticipated pain experiences. Current conceptualizations most often describe it in terms of appraisal or as a set of maladaptive beliefs.⁴⁴ Pain-related catastrophizing thought patterns are fairly common in both acute and chronic pain and show significant relationship to pain intensity and functional disability.⁴⁵^,⁴⁶ For example, prospective studies indicated that catastrophizing might be predictive of the inception of chronic musculoskeletal pain in the general population.⁴⁷^,⁴⁸^,⁴⁹ For patients undergoing surgery, catastrophizing has been shown to predict postoperative pain severity, length of hospital stay, poor quality of life, greater postsurgical opioid use, opioid misuse,⁵⁰ as well as later development of chronic pain and disability (e.g., Khan et al.,⁵¹ Theunissen et al.⁵²). Catastrophizing has been associated with increased perceptions of pain severity in both acute⁵³ and chronic pain severity⁵⁴ and disability among groups with diverse pain diagnoses.⁵⁵^,⁵⁶ Catastrophizing also alters perception of noxious stimulation. In addition, catastrophizing is related to greater sensitivity to experimentally induced pain in pain-free volunteers and pain patients.⁴⁶^,⁵⁷^,⁵⁸ The relationship has been observed in healthy adults⁵⁴ as well as children.⁵⁹ In a systematic review, Wertli et al.⁶⁰ reported that catastrophizing was a prognostic factor predicting outcomes of patients with low back pain. Conversely, following treatment, reductions in catastrophizing were related to reduction in pain intensity and physical impairment and maintenance of treatment benefits.⁶¹

Imaging studies have shown how catastrophizing is associated with specific brain regions.⁶²^,⁶³^,⁶⁴ Several studies⁶⁵^,⁶⁶ used the diffuse noxious inhibitory control/conditioned pain modulation (DNIC/CPM) paradigm demonstrated that catastrophizing may influence the pain modulatory process in pain-free individuals and predict pain following surgery.⁶⁷ Catastrophizing has also been associated with immune function (i.e., interleukin-6) responses to acute pain⁶⁸ and stress hormones in response to laboratory-induced pain in individuals with chronic pain and pain-free individuals.⁶⁹

People with chronic pain often anticipate that certain activities will increase their pain or induce further injury. These fears may contribute to avoidance of activity and subsequently greater physical deconditioning, emotional distress, and, ultimately, greater disability.¹⁴ Their failure to engage in activities prevents them from obtaining any corrective feedback about the associations among activity, pain, and injury.

In addition to fear of movement, people with persistent pain may be anxious about the meaning of their symptoms for the future—will their pain increase, will their physical capacity diminish, will they have progressive disability where they ultimately end up in a wheelchair or bedridden? In addition to these sources of fear, people experiencing persistent pain may fear that on the one hand, people will not believe that they are suffering, and on the other, they may be told that they are beyond help and will “just have to learn to live with it.” Such fears can contribute to additional emotional distress and to increased muscle tension and physiologic arousal that may directly exacerbate and maintain pain.

The role of catastrophizing and the belief that pain means harm and activity should be avoided has been most articulated in fear-avoidance models (FAMs) of chronic pain.¹⁴^,⁷⁰ Although FAMs are multifaceted and include affective (fear) and behavioral (avoidance) components, cognitions are identified as the core determinants of entering into a negative pain cycle. The tenets of contemporary FAMs can be summarized as follows: When pain is perceived following injury, an individual’s idiosyncratic beliefs will determine the extent to which pain is catastrophically interpreted. A catastrophic interpretation of pain gives rise to physiologic (arousal), behavioral (avoidance), and cognitive fear responses. The cognitive shift that takes place during fear enhances threat perception (e.g., by narrowing of attention) and further feeds the catastrophic appraisal of pain.⁴⁹^,⁷⁰

There is substantial evidence that fear-avoidance beliefs are associated with disability and impaired physical performance in chronic pain.¹⁴^,³⁷ A systematic review of the literature on psychological risk factors in back and neck pain indicated that the evidence for the association between fear-avoidance beliefs and increased pain and disability was of the highest level.¹⁴^,³⁷ In addition, prospective studies have shown that fear-avoidance beliefs in patients seeking care for acute pain may be predictive of pain persistence, disability, and long-term sick leave.⁷¹^,⁷²^,⁷³ A number of treatment approaches have been developed and implemented to address pain-related fear and anxiety in chronic pain patients (e.g., Bailey et al.⁷⁴).

Fear-avoidance beliefs of health care providers have also been found to be related to their treatment behavior and their recommendation for engaging in physical activities.⁷⁵^,⁷⁶^,⁷⁷ The beliefs of patients and health care providers may further interact with each other in a mutually reinforcing way because a patient’s beliefs may guide the choice of which health care provider is visited.⁷⁸

PERCEIVED CONTROL AND SELF-EFFICACY

Perceived control over pain refers to the belief that one can exert influence on the duration, frequency, intensity, or unpleasantness of pain. Perceived controllability of a pain stimulus may modify the meaning of this stimulus and directly affect threat appraisal.⁷⁹ As a consequence, pain may be rated as less intense or less unpleasant, and pain tolerance may increase.

The belief that one has control over pain has a strong influence on disability in patients with chronic pain⁴⁰^,⁸⁰ and an increase in this belief after multidisciplinary pain treatment may predict pain reduction and decreases in disability⁸¹^,⁸²^,⁸³ demonstrated that perceived control over the effects of pain was more strongly related to better adjustment and less disability than perceived control over pain itself.

Related to perceived control is the construct of self-efficacy. Self-efficacy is the conviction that one can successfully perform a certain task or produce a desirable outcome.⁸⁴ A major determinant of self-efficacy is prior mastery experience. In laboratory experiments, self-efficacy beliefs predict pain tolerance.⁸⁵^,⁸⁶ In chronic pain patients, self-efficacy positively affects physical and psychological functioning,⁸⁷^,⁸⁸ and improvements in self-efficacy after self-management and cognitive-behavioral interventions are associated with improvements in pain, functional status, and psychological adjustment. Recent reviews of psychological factors in chronic pain have concluded that the evidence for the role of self-efficacy across a broad range of pain populations is impressive (e.g., Jackson et al.,³⁹ Riddle et al.⁸⁹). Moreover, self-efficacy also influences the prognosis after acute physical interventions like surgery.⁸⁹^,⁹⁰ Prospective studies in patients who underwent surgery demonstrated that high self-efficacy before the start of rehabilitation and larger increases over the course of rehabilitation speed recovery and predict better long-term outcome.⁹¹^,⁹² A preoperative intervention (an instruction video demonstrating movement and breathing skills) in hysterectomy patients was able to enhance preoperative self-efficacy and decrease pain associated with postoperative activities and promote earlier mobilization.⁹³ Perceived self-efficacy has been shown to have a direct effect on the body’s opioid and immune systems⁹⁴ confirming the important association between psychological constructs and physiology.

COPING

Self-regulation of pain and its impact depend on people’s specific ways of dealing with pain, adjusting to pain, and reducing or minimizing distress caused by pain; in other words, their coping strategies. Coping is assumed to involve spontaneously employed purposeful and intentional acts, and it can be assessed in terms of overt and covert behaviors. Overt behavioral coping strategies include rest, use of relaxation techniques, or medication. Covert coping strategies include various means of distracting oneself from pain, reassuring oneself that the pain will diminish, seeking information, and problem solving. Coping strategies are thought to act to alter both the perception of pain intensity and the ability to manage or tolerate pain, and to continue everyday activities (e.g., Skinner et al.,⁴ Flor and Turk⁹⁵). Some studies have found active coping strategies (efforts to function in spite of pain or to distract oneself from pain, such as engaging in activity or ignoring pain) to be associated with adaptive functioning, and passive coping strategies (such as depending on others for help in pain control and restricting one’s activities) to be related to greater pain and depression (e.g., Benyon et al.,⁸⁷ Ip et al.,⁹⁶ Samwel et al.⁹⁷). However, beyond this, there is no evidence supporting the greater effectiveness of any one active coping strategy compared to any other. It seems more likely that different strategies will be more effective than others for some people at some times but not necessarily for all people all the time.⁹⁸

Stress and Autonomic Responses: Hypothalamic-Pituitary-Adrenal Axis Dysregulation

It is becoming clear that the pain experience is determined by a multitude of factors. Although the focus has historically been directed at sensory mechanisms, more attention is being placed on factors related to cognitive and homeostatic factors. The primary basis for including discussions of homeostatic factors is that chronic pain threatens the organism and produces a cascade of events that eventually contributes to the maintenance of such conditions. If one views pain as a primary threat to the organism, then mechanisms should be present to engage and motivate the organism to restore basic homeostatic function.⁹⁹ The major consequence of homeostatic imbalance is stress. Regardless of the source, stressors activate numerous systems such as the autonomic nervous system and the hypothalamic-pituitary-adrenal (HPA) axis. Prolonged activation of the stress system has disastrous effects on the body¹⁰⁰ and sets up a condition of a feedback loop between pain and stress reactivity.

During periods of short-term stress and homeostatic imbalance, the hypothalamus activates the pituitary gland to secrete adrenocorticotropic hormone, which acts on the adrenal cortex to secrete cortisol. Secretion of cortisol elevates blood sugar levels and enhances metabolism, an adaptive response that allows the organism to mobilize energy resources to deal with the threat and restore homeostatic balance (i.e., fight or flight response). The situation is much more serious during prolonged periods of stress and homeostatic imbalance that is associated with longterm psychological stress, chronic pain, and other pathologic conditions. Prolonged, elevated levels of cortisol are related to the exhaustion phase of Selye’s¹⁰⁰ general adaptation syndrome. The negative effects of this stage of the adaptation syndrome include atrophy of muscle tissue, impairment of growth and tissue repair, and immune system suppression, which together might set up conditions for the development and maintenance of a variety of chronic pain conditions.¹⁰¹^,¹⁰² According to Melzack,¹⁰³ psychological stress, as well as sensory and cognitive events, modulates the neurosignature of the body-self neuromatrix which, as a consequence of altered neuromatrix output, is associated with chronic pain conditions. The concept of the neuromatrix has potentially important explanatory implications for brain function in general and also provides a theoretical framework for the biopsychosocial perspective of chronic pain. As will be discussed later, there is a growing literature demonstrating the importance of psychosocial factors (emotion and cognition) in this neuromatrix conceptualization.

Emotion

Pain is ultimately a subjective, private experience, but it is invariably described in terms of sensory and affective properties. As defined by the International Association for the Study of Pain, “[Pain] is unquestionably a sensation in a part or parts of the body but it is also always unpleasant and therefore also an emotional experience [emphasis added].”¹⁰⁴ The central and interactive roles of sensory information and affective state are supported by an overwhelming amount of evidence.¹⁰⁵ The affective component of pain incorporates many different emotions. Depression and anxiety have received the greatest amount of attention in chronic pain patients; however, anger and hostility have received considerable interest as a significant emotion in chronic pain patients (e.g., Burns et al.,¹⁰⁶ Burns et al.,¹⁰⁷ Burns et al.¹⁰⁸). Additionally, the ability to maintain positive affect during times of stress has been investigated in relationship to pain.¹⁰⁹

In addition to affect being one of the three interconnected components of pain, emotions and pain interact in a number of ways. Emotional distress may predispose people to experience pain, be a precipitant of symptoms, be a modulating factor amplifying or inhibiting the severity of pain, be a consequence of persistent pain, or a perpetuating factor. Moreover, these potential roles are not mutually exclusive, and any number of them may be involved in a particular circumstance interacting with cognitive appraisals. For example, the literature is replete with studies demonstrating that current mood state modulates reports of pain as well as tolerance for acute pain.¹¹⁰ Levels of anxiety have been shown to influence not only pain severity but also complications following surgery and number of days of hospitalization.¹¹¹^,¹¹² Individual difference variables, such as AS, have also been shown to play an important predisposing
and augmenting role in the experience of pain.¹¹³ Level of depression has been observed to play a significant role in premature termination from pain rehabilitation programs.¹¹⁴

Emotional distress is commonly observed in people with chronic pain. As described previously, people with chronic pain often feel rejected by the medical system, believing that they are blamed or labeled as symptom magnifiers and complainers by their physicians, family members, friends, and employers when their pain condition does not respond to treatment. Although most of the literature has focused on the relationship between negative affect and pain, research has indicated the ability to maintain positive affect during stress is an important factor contributing to ongoing adaptation to chronic illness. Positive affect serves to decrease distress in chronic pain patients by broadening the individual’s range of affective and cognitive responses permitting a wider range of experiences.¹¹⁵ Positive affect can serve as psychological immunity in that chronic pain patients may experience more optimal functioning and improved quality of life while living with ongoing pain. Although we provide an overview of research on the predominant emotions—anxiety, depression, and anger—associated with pain individually, it is important to acknowledge that these emotions are not as distinct when it comes to the experience of pain. They interact and augment each other over time.

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