Postgraduate Medical Journal (December 1984) 60, 835-840

Psychology of pain

KENNETH D. CRAIGM.A., Ph.D.

Department of Psychology, University of British Columbia, Vancouver, B.C. Canada V6T 1 Y7

IntroductionTo the sufferer, pain is a vital reality. While fullyaware of this, the scientist and practitioner must alsorecognize that efforts to understand and manage paincan be only as good as the available theoreticalmodels. Recent decades have seen concepts of painincreasingly embrace psychological models (Merskeyand Spear, 1967; Stembach, 1978; Melzack and Wall,1983). The definition of pain adopted by the Interna-tional Association for the Study of Pain (1979)describes pain as 'An unpleasant sensory and emo-tional experience associated with actual or potentialtissue damage, or described in terms ofsuch damage'.The emphasis on experiential qualities and psycholo-gical processes has major implications. First, theknowledge-base for this complex phenomenon hasexpanded, and we have begun to address questionsabout the personal meaning of pain to the sufferer,relationships between subjective experience andovert expression, and decision strategies for copingwith personal discomfort. Second, the evidence thatpain experience and expression are strongly influ-enced by personal factors and the social contexts ofpatients' lives has resulted in new strategies for painassessment and management. Strategies haveemerged that have proved successful in preventingadverse reactions to acute pain, and for workingwith patients with chronic pain (e.g., Barber andAdrian, 1982; Fordyce, 1976; Sternbach, 1974; Turk,Meichenbaum and Genest, 1983).The impetus for a better understanding of the

psychological component of pain derives from avariety of sources. The substantial range of indivi-dual responses to comparable tissue damage hasdemanded explanation. Reactions can range fromimpassive stoical forbearance to highly dramatic andhysterical behaviour. Considerable evidence nowsupports the view that each individual's experience ofpain, and the manner of expression, can be explainedonly as a product of the sufferer's personal back-ground, the interpersonal context in which pain isexperienced, the meaning the experience has for theindividual, as well as by the sensory input providedby noxious stimuli (Craig, 1980; 1983).

Many chronic pain syndromes, as well as somereactions to acute pain, can only be understood byincorporating psychological variables into explana-tory models. Exclusively sensory and predominantlybiophysical explanatory models, that emphasizetreatment of underlying pathophysiological pro-cesses, have proved inadequate, with large numbersof patients who do not benefit from care based on thismodel. While the majority of painful injuries healthrough spontaneous recovery and medical interven-tion, Bonica (1983) has estimated that one-third ofthe population suffers some form of recurrent orpersistent pain.

Cognitive processes in pain

The study of cognitive processes underlying allpatterns of behaviour has enjoyed considerableenthusiastic development in the past decade (Ander-son, 1980; Neisser, 1976; Weimer, 1982), with manyof the models of immediate relevance to the studyand management of pain. The concepts fall logicallyinto two categories: those concerning the form andstructure of cognitive processes and those descriptiveof the contents of thoughts.Most important in regulating painful experience

are those cognitive structures which organize andimpose order upon experience. They govern thepatterning of attention, memory, decision-making,and other self-regulatory processes. Inherently tacitand superordinate to the contents of experience, thecognitive processes impose limits on the concreteparticulars of experience (Mahoney, 1983; Rosenthaland Zimmerman, 1978). From this perspective, allexperience is an active construction of the nervoussystem with the biological constraints dictating howpeople attend to their environment, the assimilationand organization of experience, and decision-makingstrategies.

Understanding how people serve as active partici-pants in the nature of their experiences has provideda general theoretical framework for a variety ofpowerful pain phenomena; namely, the impact ofbelief systems, placebo and expectancy effects, the

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role of attention and distraction and perceivedcontrol phenomena.

Belief systems attach meaning to experience. Painusually signifies real or potential tissue damage andlife-threat, and provides a powerful incentive tounderstand what is happening to the individual. Boththe person in pain and the health professionalordinarily interpret pain as the cardinal symptom ofdisease or injury. The sufferer can be expected todevote considerable effort towards seeking out andunderstanding the origins and nature of the experi-ence, as well as surrounding circumstances, and toenlist the best possible personal and social resourcesto master the threat.The experience differs with the nature of the pain

(Stermbach, 1974). Acute pain, with its usual courseof rapid onset and reasonably short recovery period,is associated with a search for information aboutwhat is happening and how distress can be con-trolled. Chronic pain in its unremitting, recurrent, orprogresssive patterns is often associated with discon-tinuing the search and acceptance of the invalid role.

Pain associated with specific injuries and diseasesmay have special significance for individual patientsthat deserves consideration. Burns or facial damagethat is disfiguring may provoke psychologicaltrauma. Angina pain has acquired special meaning inour medically-sophisticated Western culture. Musi-cians and athletes may encounter special problemswith painful limb injuries that threaten their abilityto maintain control over their lives.

Further variations in belief systems and patterns ofthinking about pain and illness have their origins inthe family, peer groups and the community (Craig,1978, 1983). Both information and the strategies usedto collect, process and apply information are primar-ily drawn from countless exposures to the activities ofothers (Rosenthal and Zimmerman, 1978). Here theindividual learns to recognize, interpret, and evaluatewhat become normal and anomalous somatic sensa-tions. Socialization practices provide the basis for thetransmission of beliefs, normative standards, andconceptual skills of the community. The familial andcultural precepts are immediately available, tend tobe consistently applied by others, and are supportedby social sanctions to conform. The individual canreadily learn what is likely to generate pain; whatsensations should be experienced as alarming; howdifferent injuries and diseases are likely to feel; andcognitive, behavioural, and social skills useful inminimizing personal distress. Cross-cultural studieseffectively demonstrate the variability that hasemerged in different societies for recognizing andcaring for states of disease and injury (Craig, 1980).Similarly, styles of pain complaint tend to becommon within families (Craig, 1978). For example,children who become particular problems for dentists

(Kleinknecht, Klepac and Alexander, 1973) or chil-dren with nondiagnosable chronic abdominable pain(Barr, 1983) and pain patients in general (Mohamed,Weisz and Waring, 1978) tend to come from familiesin which other family members present with anomal-ous pain complaint. One can legitimately refer to'pain prone families'.

The placebo response

Recognition of the important role of beliefsystemsin determining pain experience and behaviour wascompelled by the placebo effect (Beecher, 1965;Critelli and Neumann, 1984). Inert chemicals andtreatments that have been determined to be non-specific, or even deleterious to health, frequentlyprove to be strikingly effective as analgesics whenadministered by enthusiastic, credible proponents oftheir efficacy (Shapiro, 1971). Newer therapies alsoenjoy similar social facilitation effects since theycommonly surpass other therapies in comparativeeffectiveness. It has become common practice to testall new drugs and other forms of therapy bycomparing them to pharmacologically inert placebosor non-specific treatment. Client improvement alonehas been judged to be an inadequate criterion fortherapeutic effectiveness of a drug since it may bemediated by psychological factors other than thetreatment or remedy's specific action.

Unfortunately, with the discovery of specific drugand surgical pain-relieving techniques, placebos ac-quired negative connotations. They became charac-terized as a nuisance and clinicians declined to usethem with patients. However, at present their salu-tary effects are being recognized. When properlyused, they do reduce pain without the harmful sideeffects that accompany many analgesic drugs (Mein-hardt and McCaffery, 1983). We are only nowdiscovering the reasons why they work, be it beliefsystems, expectancy, suggestion, or other social influ-ence factors such as context, therapist activities, orpersuasion. The non-specific is becoming specific.While placebo drugs may be inert, the psychologicalprocesses that mediate placebo effects are active,powerful, and amenable to systematic application.Even when demonstrably effective, biologically-

oriented, analgesic interventions are used, psycholo-gical factors may have complementary or synergisticeffects. Norton et al. (1984) found that positive beliefsin the effectiveness of acupuncture were associatedwith reductions in pain severity beyond those elicitedby acupuncture in the absence of positive beliefs.Chen and Chapman (1980) found that cognitivecoping strategies facilitated the analgesic impact ofaspirin as assessed by evoked brain potentials.

Irrational and self-defeating thinking has beenshown to play an important role in the genesis of

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Psychology ofpain

both unreasonably controlled and excessive re-sponses to painful injury and disease. Given that painand illness are fraught with highly salient personalmeaning, the impact of inaccurate or false beliefsmay be considerable. The classic illustration wasprovided by Beecher (1959) who contrasted thereaction patterns of World War II American soldierswounded during the Italian invasion with civilianswho had sustained comparable wounds during sur-gery. The former required substantially less care andanalgesic medication, suggesting that escape alivefrom battlefields represented a dramatic source ofrelief from stress, or the proverbial 'ticket-home'. Incontrast, the injured civilians had to endure majorcrises and disruptions to their lives precipitatedabruptly by the accidents.

Pain and depressionRecent evidence confirms a role for cognitive

distortions in chronic pain patients who displaypsychological problems. Lefebvre (1981) found thatthe cognitive distortions characteristic of clinicallydepressed patients were also descriptive of thethinking style of chronic low back pain patients whobecome depressed. The chronic pain patients weregenerally negative in appraising life experiences anddisplayed markedly constrictive and negative idealsabout the impact of their pain problem on their lives.This would be consistent with findings that painpatients who acquire a conviction that they willremain chronic invalids are substantially moredifficult to treat (Sternbach, 1974; Pilowsky, 1980).Pessimistic and self-critical thoughts and preoccupa-tions appear to produce considerable disruptiveirrational distress and impair performance bydiverting attention from life-tasks to further self-evaluative concerns (Turk, Meichenbaum andGenest, 1983).

Perceived mastery over threat has proved to be acritical determinant of the severity of stress reactions(Neufeld and Kuiper, 1983). Both favourable per-sonal histories and planned training in cognitivecoping strategies may result in a 'sense of mastery'that may 'inoculate' against stress (Turk et al., 1983).Bandura (1982) has observed that perceived self-efficacy, or perception of a personal capacity tocontrol a threatening event, lies at the core of alltherapeutic effects. People who enjoy confidence intheir abilities to cope with pain would be expected toexperience less anxiety and fewer feelings of help-lessness.

Perceived self-efficacy would be expected to varywith the nature of the noxious assault. The suddenonset of a traumatic injury or precipitous diseasewould require an extraordinary background of pre-paration if the suffering person were to respond with

a dispassionate sense of mastery. In contrast, painsyndromes that persist over time are more likely toprovide opportunities for considered appraisal andtherapeutic intervention designed to provide thecognitive and behavioural skills that accompany asense of mastery (Gottlieb et al., 1977).

New strategiesAn examination of specific cognitive mechanisms

has improved our understanding of pain and led toinnovative treatment strategies (Tan, 1982). Atten-tion, retention and decision-making, have beendemonstrated to be important in investigations ofpain (Craig, 1983). A focus upon attentional mecha-nisms has been particularly productive. One canattend to only a limited subset of internal or externalevents at a given time. Pain tends to be pre-eminentin its capacity to command attention (Chapman,1978). It narrows the focus of attention to immediateevents. However, despite the salience of noxiousevents, substantial evidence supports the positionthat distraction can serve to reduce the severity ofpain (Turk et al., 1983).The amount of stress experienced also will be a

function of appraisals of personal and externalresources and support systems (Neufeld and Kuiper,1983). Life history and the immediate social contextprovide the basis for this evaluation. With painrecognized to be a more ambiguous experience thansensory-specificity models had us believe, prior per-sonal and social experiences (Craig, 1978, 1983;Weisenberg, 1983) assume greater importance. Inessence, people must acquire an awareness of theirbodies, learn to recognize anomalous somatic states,and discover when and how to seek help. Peoplereadily recall distressing and painful events withmiminal cues (Hunter, Philips and Rachman, 1979)and benefit substantially from preparation for pain-ful events that provides information about how theyare likely to feel, what the trajectories of discomfortand recovery are likely to be and which cognitive andbehavioural coping skills minimize distress (Fager-haugh, 1974; Melamed and Siegel, 1980).Turk et al. (1983) review considerable evidence

consistent with the position that coping strategies,attentional distraction, and other cognitive-behav-ioural intervention strategies can reduce perceiveddiscomfort and increase pain tolerance. These au-thors also provide the most comprehensive cogni-tive/behavioural treatment programme available.The foregoing review has stressed the position that

pessimistic and self-critical thoughts and preoccupa-tions can produce disruptive emotional distress andenhance pain. The complexities of interactionsamong cognitive, emotional and behavioural aspectsof pain are, however, more complex. Pain, anxiety,

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and depression can lead to the processing of incom-ing information in a destructive manner. Strongtendencies have been reported for depressed moodsto trigger memories of sad and unhappy events(Teasdale and Rezin, 1978) and for anxiety toenhance the interpretation of innocuous events as

dangerous (Rachman, 1980). People suffering frompain can be expected to be biased towards anticipat-ing the prospect of further unfortunate events and toscanning selectively their external environments andpersonal experience for threats. From this perspec-

tive, those powerful behavioural intervention strat-egies that focus directly on affective states rather thancognitive changes also assume a major role in painmanagement (Craig and McMahon, 1983).

Emotional components of pain

The most dominant contemporary model of pain,gate-control theory (Melzack and Wall, 1965, 1983),has assigned a major role to those affective andmotivational processes which were overshadowed bythe emphasis on sensory physiology in earlier models(Craig, in press). Focusing attention upon the dis-tinctly unpleasant, affective qualities of pain, and theroles of anxiety in acute pain and depression inchronic pain (Sternbach, 1974), has had severalbenefits. Our concepts of pain processes now coincidemore closely with patients' experiences as they reportthem. The feelings of fear, punishment, anguish anddespair tend to be major preoccupations, and new

avenues for understanding the nature of pain havealso opened up.There is now an established neurophysiological

basis for the different psychological components ofpain with the neurophysiological mechanisms foremotional states increasingly well established. Mel-zack and Casey (1968) proposed that (a) sensory-discriminative qualities are primarily determined byactivity in the rapidly conducting spinal systems; (b)motivational-affective qualities are subserved byactivities in the reticular and limbic structures thatare predominantly influenced by slowly conductingspinal systems; and (c) neocortical and higher centralnervous system processes exert control over activityin both the discriminative and motivational systems.The recent identification of neurochemical substratafor pain, for example, the action of endogenousopioid peptides in analgesia, further complicates our

understanding of the interaction of the neurochemi-cal and neurophysiological substrate of the psycholo-gical components of pain but suggests excitingtherapeutic possibilities.

Affective qualities of clinical pain vary in accor-dance with the important distinction between acuteand chronic pain states (Bonica, 1983; Sternbach,1978). Acute pain is usually characterized by tissue

damage, commands attention, disrupts behaviour,precipitates action designed to reduce the distress,and has strong affective qualities, usually character-ized by fear and anxiety. In general, greater anxiety isassociated with greater pain, although exceptionshave been reported (Craig, in press).

Acute versus chronic pain

By definition, acute pain is transient and decreasesas tissue damage heals. Chronic pain, in contrast,persists beyond the time healing should have takenplace. The pathophysiological basis for chronic painmay be highly variable. The pain may either signal apersistent or progressive disease or a condition thathas neither real nor impending tissue damage. Incontrast, the psychological consequences of chronicpain are consistent. Bonica (1974) described chronicpain as exclusively malefic because it is powerfullydestructive of the physical and psychological wellbeing of the individual and his or her family andassociates, and has no redeeming features. Thedistinction between the two syndromes has becomeso clear that it is now recognized that treatment foracute pain is contraindicated with some types ofchronic pain. Certain people suffering from the latterbecome at risk for more serious problems if stronganalgesics are prescribed, extensive convalescenceand inactivity are recommended, and there is escapeor release from ongoing life responsibilities such aswork or family routines (Fordyce, 1976; Sternbach,1974).

The language ofpain

Perhaps the most useful systematic measure ofaffective qualities of pain yet available has been theMcGill Pain Questionnaire (Melzack, 1975, 1983).This instrument permits patients to describe theirpain on a number of qualitatively distinct dimensionsof experience. The development work on the ques-tionnaire suggested three main dimensions: sensory,affective, and evaluative. Construct validity studiestend to confirm the validity of distinctions amongthese three components but suggest a somewhat morecomplex structure (Reading, 1983). Emotional quali-ties appear to represent the major source of variationin people's descriptions of their painful experiences(Crockett, Prkachin and Craig, 1977; Leavitt, Garronand Bielauskas, 1978). Gracely, McGrath and Dub-ner (1979) have developed useful unidimensionalratio scales of sensory, affective, and pain intensitythat simplify the task of verbal pain description butdo not search for the subtle nuances of differencesamong forms of pain.

Reports of affective qualities have assumed con-siderable importance in differential diagnosis. Pa-

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tients with chronic pelvic pain were found to favouraffective and evaluative words to describe their pain,whereas patients in acute pain were prone to usesensory words (Reading, 1983). Leavitt (1983) re-ported that chronic back pain patients with psycholo-gical disturbance endorsed more affective words thanpatients without psychological disturbance. Therewould appear to be prospects of developing psycho-metric instruments that would discriminate betweenpatients for whom psychological problems repre-sented a major component of their pain-relateddisability and patients for whom psychological diffi-culties do not represent a serious problem (Kremnerand Atkinson, 1983).

Emotional and behavioural disturbances tend tobe common in patients with chronic pain, whetherthere is an identified, sufficient organic basis for thepain or not. Low back pain patients have beenreported to have more emotional disturbances as agroup than patients with other medical diseases(Leavitt, 1983), and reported affective distress relatesto the severity of psychosocial disturbance(McCreary, Turner and Dawson, 1981). Bradley(1983) reported that a group ofchronic pain patients,who, through cluster analyses of the MinnesotaMultiphasic Personality Inventory (MMPI), werecharacterized primarily by elevations on scales Hs, D,and Hy (the neurotic triad scales), showed greaterpain-related disturbances in their daily activities(greater endorsement of affective items on theMcGill Pain Questionnaire, reliance on a greaternumber of analgesic and hypnosedative medications,greater use of health professionals, more sleepdisturbance, etc.). Roberts and Reinhardt (1980)found that their behavioural management treatmentapproach was more successful with patients withsubstantial organic basis for their pain complaintsthan for patients without an adequate organic basis.

Behavioural expression

Pain is a private experience and does not becomerecognized by others, or become the target of others'caring efforts, until it has some behavioural expres-sion, either through self-report or non-verbal display.Most attention has been devoted to verbal report, butvocal qualities, facial expression, posture, and grossbodily movement convey considerable informationof importance to observers in natural and clinicalsettings (Craig and Prkachin, 1983; Craig and Pa-trick, in press). This social component of pain is ofconsiderable importance. Pain is frequently a highlypublic and visible event; qualities which may affectboth the sufferer and observer. It is the meanswhereby sufferers solicit help from others, and allowsobservers to discover that they may be in personaldanger themselves or that the sufferer needs help.

The reflexive qualities of pain expression and obser-vers' reactions suggest strong drives to communicatedistress to others and innate propensities to beattentive and responsive when others are in distress.Of considerable importance has been the discovery

that pain behaviours that occur for one set of reasonsat the time of onset may persist for a different set ofreasons (Fordyce, 1976). In particular, the responseof others to the person in distress may perpetuateillness behaviour (as opposed to the original patho-physiological process) beyond the time when healingwould take place. This represents an excellentillustration of an occasion in which pain expressiondoes not correspond to a pathophysiological basis forpain. When others respond by providing sympatheticattention, release from work or domestic responsibili-ties, enforced bedrest or inactivity, and prescriptionof drugs such as strong analgesics, antidepressantsand anxiolytics contingent upon displays of pain,there is an increased risk that the patient may becometrapped in the role of a sick person or invalid(Fordyce, 1983). Behavioural management pro-grammes based upon operant learning theory havebeen attentive to the importance of these contingentconsequences (Fordyce, 1984)

Operant pain management programmes appear tomirror the manner in which pain expression andexperience come to reflect the individuals' uniquefamilial and ethnocultural background during thecourse of socialization. In consequence, there is asatisfying integration between the concepts of painthat have led to effective cognitive/behavioural painmanagement strategies and formulations of theimpact of socialization experience on pain experienceand behaviour.

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