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17 Articles in Volume 20, Issue #1
20/20 with Lynn Webster, MD
Correspondence: Opioid-Induced Hyperalgesia; Pain Care in Older Adults
Don’t Discount the Role of Diet for Chronic Pain Relief
Editorial: Why Haven’t There Been More Breakthrough Analgesics?
Gasping for Air: Sleep-Disordered Breathing and Chronic Opioids
How can botulinum toxin be used in chronic pain syndromes?
Inside the Potential of Peripheral Kappa Opioid Receptor Agonists
Neurodestructive Interventions for Cancer Pain
Obesity and Pain Care: Multifaceted Considerations for Treatment
Obesity and Rheumatoid Arthritis: What Clinicians Should Know
Sickle Cell Pain Crisis: Clinical Guidelines for the Use of Oxygen
The Complexity of Sickle Cell Pain: An Overview
The Perseverance Loop: The Psychology of Pain and Factors in Pain Perception
The Rapid Rise of Non-Opioid Pain Policies
Treating Pain by Overcoming Communication Barriers
Visual Artists Tackle What Pain Looks Like
Will 2020 Be the Year of Patient Education?

The Perseverance Loop: The Psychology of Pain and Factors in Pain Perception

Distinct models may help to explain the patient’s pain experience, expression, and ways to cope with the psychological treatment of chronic pain.
Pages 19-22

Pain is a normal feature of the human experience. Commonplace pain has a particular psychology that provides the foundation for all pain management behavior. A normal psychology of pain seeks to explain the shared experience of pain that is uncomplicated and short-lived. It is straightforward in the sense that it is diagnostically minor (such as headaches) or related to slight trauma that does not require clinical intervention (such as bruises).1 There are two core aspects beyond the sensory features of normal pain:

  • its social or communicative function;and
  • its interruption of mental preoccupations or escape/avoidance.3

Pain is hard-wired as a social alarm of a threat, which is then selected over other competing demands and triggers behaviors that interfere with normal life functioning.1 Each individual’s experience of pain and its expression is a product of the sensory experience, the person’s personal background, the interpersonal context, and the meaning it has for the individual.4

Problem-focused coping is most appropriate when situations are appraised as changeable, while emotion-focused coping is most ideal when situations are less changeable. If the wrong approach is used, the stress remains unresolved and creates its own perseverance loop. (Image: iStock)

A Model of Analgesic Problem-Solving

Just over a decade ago, an exploratory model of analgesic problem-solving was proposed (see Figure 1).5 This model helps to capture how normal pain operates to interrupt attention and promote problem-solving behaviors, which range from impassive and persevering to highly dramatic and panic-stricken.The process begins when pain interrupts the person’s attention and forces them into an unwanted and unwelcome focus on their body. The pain is then appraised as a threat, which makes them more vigilant and drives them toward problem- solving behaviors.

Often, patients have no tools, techniques, or methods at their disposal to achieve escape once this process begins. Whichever solution the person does choose to follow will prove to be effective or ineffective. If their method is effective, they return to a pre-interruption state; if it is ineffective, they can become static in the perseverance loop. In other words, they may be actively and repeatedly engaged in effortful attempts to solve the wrong problem.5 For example, a patient may persist with medication consumption despite the lack of any effect because they are from an analgesic culture that avoids pain and distress.6 These attempts will then fail because pain falls outside of the individual’s expectations, lasts too long, does not respond to treatment, and/or impairs their social function.6

Figure 1. A model of analgesic problem-solving. Modified from Reference 5.

The Perception of Pain

The experience of pain is known to have two distinct neural pathways.7 In the first pathway, the pain signal comes from any part of the body and activates the anterior cingulate cortex of the brain, which is associated with the perception of pain. People react differently to this stimulation because the feeling is determined by the activation of the second pathway involving the medial prefrontal cortex and nucleus accumbens, which are associated with motivation and emotion.7 Further, there are non-physiological factors that contribute to the perception of pain, such as personality, cognitions, beliefs, sociocultural variables, learning, and emotional reactivity.8


The perception of pain may be determined by the attachment style of the patient, whether anxious or avoidant. Individuals with an anxious attachment style crave close and intimate relationships but tend to sacrifice their needs to keep their partner happy. Individuals with this attachment style tend to feel more pain in the presence of a person who does not empathize with their condition. Individuals with an avoidant attachment style tend to value independence and self-sufficiency more than intimacy. People with this attachment style also report less pain when alone than when in the presence of another person.7 These two attachment styles are related to a wide variety of close relationship processes and outcomes, specifically, personality constructs.9

Over the past few decades, several theories have been proposed about personality in the chronic pain population.10 With the advent of the biopsychosocial approach in the 1980s, the diathesis- stress model dominates the field. The model accentuates the interplay between an individual’s biological predisposition and the impact of the environment to explain the different responses to chronic pain.10 Overall, patients with chronic pain are characterized by prevailing harm avoidance and lower self-directedness.10,11


The study of cognitive processes underlying all patterns of behavior can be broken down into two categories: its form and/or structure and the contents of thoughts.4 The cognitive structures organize and carry out the direction of the pain experience through attention, memory, decision-making, and other self-regulatory processes. One particular response to pain that may be predictive of its severity is catastrophic thinking. Catastrophic thinking is defined as “an exaggerated negative mental set brought to bear during actual or anticipated pain experiences.”12 Current conceptualizations of catastrophic thinking describe it as an appraisal or a set of maladaptive beliefs.13 Maladaptive thinking falls into four broad categories, or types of cognitive distortions, including: overgeneralization, mental filter, jumping to conclusions, and emotional reasoning.14


There are other principles that have an impact on how much pain patients feel, including self-efficacy, locus of control, involvement in the sick role, and the placebo/nocebo effect.15 Self-efficacy is a personal judgment of the patient on how well they can execute a course of action required to deal with a prospective situation. Locus of control is the degree to which a patient believes that they have control over the outcome of events in their lives, as opposed to external forces beyond their control. A patient is considered to be involved in the sick role when they adhere to the specifically patterned social role of being sick. The placebo response occurs when a non-specific treatment proves to be effective as an analgesic when administered by an enthusiastic, credible proponent of their efficacy.4 If the patient’s beliefs inadvertently increase their anxiety and expectations of pain, it is assumed they have had a nocebo effect.15

Sociocultural Variables

Early theories of the psychology of pain assessed global factors, such as gender, age, and culture.16  In most studies, women generally report experiencing more recurrent, severe, and longer-lasting pain than men.17  Past research has also shown that pain thresholds increase with age.18  It was once believed that we differed culturally in some way that affected how we experienced pain. For example, there was a notion in the 19th century that racial groups varied in their physiological experiences to pain, which was later found to be unsubstantiated. However, we now understand that there are differences within cultural groups that may affect their pain experience, including generation, acculturation, socioeconomic status, ties to mother country, primary language, degree of isolation, and residence in ethnic neighborhoods. These factors may mediate the relationship between culture and pain.


Pain can be a conditioned response, or learned behavior, rather than only a physical problem.15 The behavior begins purely in response to the presence of an injury, and then it is reinforced and becomes a conditioned response. Pain behaviors, such as guarding, bracing, rubbing, grimacing, and sighing may lead patients to perceive that they have more pain if reinforced. In a similar fashion, inactivity may relieve pain in some patients, but leads to a vicious cycle of deconditioning and further worsening of pain. Pain can result from these conditioned fear reactions, or avoidance behaviors, that persist even after the resolution of pain.15

Emotional Reactivity

Relative to other negative emotions, such as fear, sadness, guilt, self-denigration, and shame,16 anger is the most prominent emotion in patients with chronic pain.19 Anger refers to an emotional experience which can be a current mood state or a general predisposition toward feeling angry. People with significant anger problems may have trouble with empathy; however, it is a skill that can be developed and cultivated over time. Research has shown that human beings tend to be more empathic toward their friends while stress may deter people’s ability to empathize.7


Interventions aimed at enabling patients to break out of the perseverance loop aforementioned and change their perception of pain may be more effective than interventions that appear to endorse the patient’s view of the problem as one that can only be solved by pain relief.5 Psychotherapy, for example, can produce long-term changes in behavior through learning, which generates changes in gene expression that alter the anatomical pattern of interconnections between nerve cells of the brain.8 The regulation of gene expression by psychosocial factors makes all bodily functions, including the brain, susceptible to psychosocial influences.8

Mechanisms of Change

There appears to be a lack of awareness and understanding of the mechanisms of change involved in psychotherapy. There is the physiological process, which includes musculoskeletal activity, heart rate, blood pressure, EEG patterns, sympathetic arousal, production of endogenous opioids, production of neurotransmitters, neurohormonal activity, and cortical functioning.8 Interventions based only on the biomedical approach may appease the patient who is focused on solving their pain by relief.

Another process is creating change through cognitions, which addresses the patient’s covert self-talk, thoughts, and beliefs. The focus of treatment in these interventions is to reduce the rigidity of belief in pain as requiring a biomedical approach and in changing the problem frame from one of needing a cure to one of managing a chronic illness.20

A third process is via a change in overt behavior, which includes the way one acts and talks. A behavioral therapeutic treatment may be focused on addressing the anxiety and hypervigilance for signals of possible pain with heightened fear of possible consequences of pain.21

A final process is change through addressing emotional reactivity. The focus of treatment may be more of a full accommodation of life, which is changed to one in which pain is a feature and not the center.22 A transactional coping model (see Figure 2) can help providers determine which approaches to use in the psychological treatment of chronic pain.


Figure 2. Transactional model of stress and coping. Modified from Reference 23.

Transactional Model of Stress and Coping

Lazarus and Folkman’s Transactional Model, developed in 1984, is one of the most comprehensive theories of stress and coping in the psychological literature, but it has received little empirical attention in chronically ill populations.23  The model assumes that it is a person-situation interaction, or transactional process, when a patient perceives a threat. The threat level is dependent on the initial subjective judgement of the patient, or primary appraisal. A secondary appraisal then occurs, which is a judgement concerning the benefits and consequences of a particular coping style given the person’s goals and constraints.

Problem-focused coping refers to coping strategies aimed at solving or changing the problem, such as obtaining information about the pain or seeking medical attention. Emotion-focused coping is used to manage or regulate the emotional response to the pain, such as exercising, meditating, or engaging in activity to help forget about the pain. Then there is a reappraisal, which determines the effectiveness of the coping strategy and the patient’s psychological adjustment. According to this model’s goodness-of-fit hypothesis, problem-focused coping is most appropriate when situations are appraised as changeable, while emotion-focused coping is most ideal when situations are less changeable. If the wrong approach is used, the stress remains unresolved and creates its own perseverance loop. •

Last updated on: February 4, 2020
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