Going for a walk with friends
It is probably not helpful, depending on pain source. Yes, the pain is acute and is not expected to last.
Yes, activity is helpful in chronic pain. No, it is generally considered better to take long-acting pain medications.
More pain.
Positive punishment of a well behavior.
LESS
Less pleasure, more social withdrawal, less physical activity. Poorer overall pain control.
MORE
Taking narcotic pain medications only in immediate response to pain, rather than around the clock
Relief of pain Reinforcement of using “as needed” or short-acting pain medication for chronic pain.
In the treatment section of this course, ways to change the kind of behavioral learning that exacerbates pain in the operant model are discussed in greater detail. In the treatment section of this course, ways to change the kind of behavioral learning that exacerbates pain in the operant model are discussed in greater detail. Cognitive factors One criticism of behavioral models in general is that they do not do enough to account for an individual’s cognition, or thoughts. Human beings are self-aware thinkers who consider actions and their consequences. This criticism also holds in chronic pain, an area in which a number of attitudes, beliefs, and expectations about the pain experience have been shown to predict different outcomes (Durgante, 2017). There is good evidence from the scientific literature that certain thinking patterns (particularly those that are excessively negative or catastrophic) may put individuals at risk for developing chronic pain problems and might partially explain why for some people pain is so disabling. Higher levels of catastrophizing are associated with increased levels of pain intensity and severity and with more emotional distress (Petrini and Arendt-Nielsen, 2020). Some of the most widely studied cognitions in chronic pain are labeled catastrophizing, perceived control, perceived harm, solicitude, and medical cure: ● Catastrophizing : Refers to “making a mountain out of a molehill” when it comes to pain (although, in fairness, there are no molehills with chronic pain; it’s more like making a small mountain into a bigger mountain). People who catastrophize tend to take an event that is transient and manageable and make it into something that is global, unmanageable, and overwhelmingly negative. Examples of catastrophic thoughts regarding pain might be “I can’t handle this; it’s never going to get any better” or “This is the worst pain I’ve ever experienced in my life, and I think I’m going to black out.” A person who engages in mental catastrophizing is also likely to engage in hypervigilance, or scanning the body for more pain signals (Petrini and Arendt-Nielsen, 2020). Catastrophizing is probably the most widely studied cognitive variable in pain and has been shown to relate to a large number of negative outcomes, including further disability and worse pain (Petrini, et al. 2020; Bonafe, et al., 2019). Catastrophizing is also associated with depression and might help to partially explain the link between pain and negative mood (Craner, et al, 2016). ● Perceived control : Refers to self-efficacy, or an individual’s sense that he or she can manage the pain. Individuals with high levels of perceived control would say that they have some influence over the amount of pain they feel, and that they have skills to “take the edge off” their pain. Individuals with low perceived control might say that they feel there is little that they can do to ease the pain they feel. Perceived control is associated with lower levels of pain and disability (Durgante, 2017; Vanhaudenhuyse, et al., 2018). ● Perceived harm : Refers to the belief that pain equals damage. Individuals who tend to think this way often limit what they do because they interpret pain flare-ups as signals that they are damaging their bodies. Although this might be the case after an acute injury, in chronic pain the ongoing pain rarely signals ongoing tissue damage. Nevertheless, this
belief is associated with increasing avoidance of activities that might generate or exacerbate pain (like exercise) and greater levels of disability (Gatchel, et al., 2016). Eventually, fear of pain can become a fear of movement or activity in general, in a condition described as kinesiophobia (Luque- Suarez, et al., 2019). ● Solicitude : Refers to the belief that other people should be responsive to requests for help with pain and should offer assistance to people with pain. This belief is the opposite of stoicism or radical self-reliance. Of course, in many cases it is appropriate to ask for help when in pain, but high levels of solicitude have been associated with worse pain and more pain-related disability with the pain-related behavior a means to obtain solicitude from other people. The belief that people must be solicitous to a patient with chronic pain can encourage the patient to avoid or reduce activities which would benficial to their health (Barbosa, et al., 2018; Vanhaudenhuyse, et al., 2018). ● Medical cure : As the label implies, refers to a belief that there is a medical cure for chronic pain or a chronic pain condition. This belief is associated with poorer mood and greater pain in persons with chronic pain. This might seem counterintuitive, as it might be assumed that a person with hope for a cure would be more optimistic and engaged. But in reality, data suggest that believing there is a medical cure predicts greater pain-related disability with patients having a decreased optimism for the potential of a medical cure (Barbosa, et al., 2018). It is possible that a person looking for a medical cure may not be learning the pain management strategies needed in order to function in the present day, or it may be that believing in the existence of a medical cure puts the locus of control outside of oneself. Engagement of the patient in a process which places them in an active/ control position rather than one which places the in a passive/victim position can enhance their ability to meet the multiple challenges of a chronic disease (Vanhaudenhuyse, et al., 2018). As is true for behavioral factors, approaches are available for minimizing unhelpful beliefs or cognitions in chronic pain. These approaches are discussed in greater detail in the treatment section. Social factors When trying to understand why some people develop chronic pain or high levels of pain-related disability, while others do not, the question might be asked: Are these people just exaggerating? Is someone “faking it” for medical or legal reasons? People can have many reasons for wanting their symptoms to appear worse than they are. For those who are exaggerating their pain, a distinction may be made between those who are looking for primary gain versus those who are hoping for secondary gain: ● Primary gain : Refers to direct, clear, external, and tangible benefit, such as a large insurance settlement or payout from a lawsuit. Pain medications taken recreationally would also be an example of primary gain. Individuals who deliberately feign or exaggerate symptoms for primary gain are said to be malingering. ● Secondary gain : Factors include attention, time off from work, sympathy, and other less tangible factors. Secondary gain factors may contribute to greater disability. People who
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