The Emotional Impact of the Pain Experience

Adapted from a presentation at the SLE Workshop at Hospital for Special Surgery on December 18, 2008


Maris Pasquale, LMSW
Orthopedic Social Worker, Ambulatory Care Center,
Department of Social Work Programs
Hospital for Special Surgery

Introduction

Maris Pasquale, LCSW, has been the social worker for Hospital for Special Surgery's Ambulatory Care Center Pain Management Clinic for the past four years, working with patients who have musculoskeletal pain due to rheumatologic and orthopedic pain conditions.

The Experience of Pain

Many different factors influence the experience of pain, which is different for everyone. These include:

  • Age
  • Gender
  • Culture
  • Ethnicity
  • Spiritual beliefs
  • Socio-economic status
  • Emotional response
  • Support systems
  • Life before pain onset

Other factors can include a learned response that can be related to the response of your family. Parents, for example, may respond to a child’s pain in a certain manner, setting a foundational pain response for an individual that may influence future pain experiences. Also, societal and medical care systems can impact the pain experience. For example, you may not have access to the care of a physician who is an expert in managing pain.

Additionally, changes in functioning, role (societal, social, or family), daily routines, job status, and sleep disturbance may contribute to chronic pain. These factors can cause distress which may also increase pain.

Some common emotional responses to pain can include anxiety, depression, anger, feeling misunderstood, and demoralization.

According to a 2004 study, individuals who are experiencing chronic pain in primary care settings have a higher probability to experience anxiety and depressive disorders than those who are not.(1)

It is important to recognize whether these factors are prevalent in your life. If they are, it's important to seek help from your primary care doctor or social worker, or call 1-800-LIFENET, a multilingual crisis intervention hotline.

Emotions and the Chronic Pain Cycle

Pain is influenced by emotions, and the cycle of pain and emotions are interrelated. Emotions may directly impact physical change as well. For example, when you are anxious or angry, your muscles may tighten, and that physical change may also contribute to increased pain. Another challenge may be that patients might feel stigmatized when they demonstrate intense emotions like these in the context of their treatment.

Believing that you have control over your life and can continue to function despite the pain or subsequent life changes has been shown to decrease depression.

Impact of Pain on Identity

How you identify yourself to others is an important element of your individuality, and having chronic pain and not knowing when it will ever go away, if ever, is a huge issue that can change the course of your identity.

If you are experiencing chronic pain, you might not be able to do certain tasks or fulfill certain roles that were once common, and that can feel disempowering.
 
Where and how people derive value in their identity is culturally informed, including gender, ethnicity, and socioeconomic status. Depending on what roles or characteristics are most valued to an individual, impairment in that area will most affect his or her identity and make the pain feel more pronounced.

For example, someone who feels culturally that physical strength and ability is extremely highly valued may feel the impact of the pain experience more significantly if it impairs this ability and he or she can no longer complete the same physical tasks.

Similarly, the invisibility of pain can be isolating, especially in cases when a person’s outwards appearance remains the same.

Impact of Pain on Family

As you experience pain symptoms, either acute or chronic, this can shift family patterns and roles. For example, a parent might not be able to fulfill certain tasks anymore and communication between family members may change based on not wanting to “bother” the affected member.

Other family factors may include increased stress, financial burden, effect on sexuality and other intimate relationships, and potential resentment in the relationship. For family members of people in chronic pain, a goal is to strike a balance between validating patient’s pain and experience while helping him/her stay involved in life.

Impact of Pain on the Medical System

According to another study in 2005, patients report not feeling heard by their doctors because they may not agree with the medical interpretation of pain.(2) Patients may believe that the pain is related to other ailments or medical history and disagree with the doctor’s opinion.

When patients’ pain does not respond to a certain treatments or interventions, they may feel like symptom magnifiers and complainers. As a result, patients may feel demoralized or feel they are not being heard or taken seriously, all increasing patient distress.

Communicating with Your Doctor

Pain is a disease of reporting. Keeping a home journal may help to be more descriptive, accurate, and increase recall, since pain experience may be different on each day.

To speak the same language as your doctor, become more familiar with common pain scales. Familiarity with these scales and anticipating the way pain is measured medically may help communicate this very personal experience in the most objective way.

Common Pain Assessment Tools

Brief Pain Inventory

The BPI measures both the intensity of pain and the interference of pain in the patient's life. It also asks the patient about pain relief, pain quality, and patient perception of the cause of pain. BPI is based on scales:

“0” represents “no pain” and “10” represents “pain as bad as you can imagine”

“0” represents “does not interfere” and “10” represents “completely interferes”

Wong-Baker Faces Pain Scale

This scale, which goes from Level 0-10, asks the person in pain to choose from a series of faces that best indicate the level of pain he or she is experiencing. 

Level 0 is a happy face, indicated as “No Hurt”, and the scale goes up to Level 10, which is a sad/pained face with tears, indicated as “Hurts Worst.” More information and a visual example are available at http://www.wongbakerfaces.org/.

Numeric Verbal Faces Pain Scales

This scale also uses facial pictures and a rating scale of 0-10.  Level “0” is “No Pain,” while Level “10” is “Pain as Bad As It Could Be.”

Describing Pain Experience

What is pain? Other commonly used terms:  Aches, soreness, discomfort.

Be descriptive:  Include location, timing, and intensity. Using descriptive words will help medical team be more informed about type of pain, where it roots, etc. Examples:  Burning, aching, stabbing, piercing, throbbing.

Maladaptive Pain Beliefs and Ways to Address Them

As we experience pain, we may have many different beliefs of how we should live our life with the pain we are experiencing; these beliefs may be maladaptive and might hinder our functioning level. In other words, some coping and adaptive mechanisms used by those with chronic pain may not be the most physically or psychologically beneficial.

Examples of maladaptive beliefs as related to pain are:

  1. Catastrophizing:  Exaggerated, negative reaction towards actual or anticipated pain experiences. In this case, patients report higher pain, poorer physical functioning, more depression and stress, and more disability.(3,4,5)
  2. Pain is sign of damage.
  3. Pain means activity should be avoided.
  4. Pain leads to disability.
  5. Pain is uncontrollable.
  6. Pain is permanent.

According to a 2007 study, these maladaptive beliefs can cause higher pain, poorer physical functioning, depression, stress, and more disability.(3)

Maintaining a sense of control over your life and believing you can continue to function, despite the pain, can decrease risk of depression. Gaining control can mean finding more resources to understand the impact of pain, such as patient education about how to live with pain, communicating to your doctor about your different concerns and challenges, discussing if pain is a sign of damage or whether activity can be continued based on tolerance, and accepting your situation.

Coping with Pain through Education and Spirituality

It is important for you to ask for any educational materials that can be helpful to understand the symptoms of pain and how to reduce pain, as well as effective methods to acknowledge your feelings and communicate them to others.

Also, many people find it effective to bring spirituality into their life as a way of coping with pain. Several studies have shown that spiritual belief can help reduce pain. If you so choose, you should be able to feel comfortable to share this component with your health care providers and let them know which methods you feel are helpful to the pain experience.

Mindful Meditation and Other Techniques

Mindful meditation, shown to help decrease stress and pain, involves focusing the mind to increase awareness of the present moment. This method to help cope with pain can be easily done anywhere, even on the bus.

An example of mindful meditation would be to sit up straight, close your eyes, and put aside all thoughts of the future and past. Staying present, the focus of awareness remains on your breathing.

This exercise could be done for just a couple of minutes, letting your thoughts come and go while being aware of your current state. It can be most helpful during stressful times such as holidays or during difficult life events.

Taking a few minutes in the day to do practice mindful meditation can be beneficial. Through performing this kind of exercise, you can create a sense of control, which is crucial in making your pain experience more manageable.

In addition to mindful meditation, yoga and tai chi are recommended.

Resources

Some helpful websites may enhance knowledge and understanding of coping with pain:

• American Pain Foundation (http://www.painfoundation.org/)
• American Pain Society (http://www.ampainsoc.org/)
• PainEDU.org (http://www.painedu.org/)

Most importantly, the impact of pain is an entirely individual experience.

References

1. Gatchel, R. J. Comorbidity of chronic pain and mental health disorders: The biopsychosocial perspective. American Psychologist, 59 (8), 795-805.

2. Harding, G., Parsons, S., Rahman, A., & Underwood, M. (2005). "It struck me that they didn't understand pain:" The specialist pain clinic experience of patients with chronic musculoskeletal pain. Arthritis & Rheumatism, 53 (5), 691-696.

3. Karoly, P. & Ruehlman, L. (2007). Psychosocial aspects of pain-related life task interference: An exploratory analysis in a general population sample. Pain Medicine, 8 (7), 563-572.

4. Gatchel, R., Peng, Y., Peters, M., Fuchs, P. and Turk, D. (2007)  The Biopsychosocial approach to chronic pain: Scientific advances and future directions. Psychological Bulletin, 133:581–624.

5. Peters, M., Vlaeyen J., and Weber, W. (2005) The joint contribution of physical pathology, pain-related fear and catastrophizing to chronic back pain disability. Pain, 113:45-50.

Summary by Lay Tep, SLE Workshop Coordinator and Social Work Intern. Updated summary by Steve Rudolf, SLE Workshop Coordinator and Social Work Intern.

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