Page 31 Guide to Pain Management in Low-Resource Settings

Chapter 4

Psychological Factors in Chronic Pain

Harald C. Traue, Lucia Jerg-Bretzke, Michael Pfi ngsten, and Vladimir Hrabal

Everyone is familiar with the sensation of pain. It usually pain. Concluding the reverse, that the lack of somatic
aff ects the body, but it is also infl uenced by psychologi- causes indicates a psychological etiology, would be just
cal factors, and it always aff ects the human conscious- as wrong.
ness. Th is connection between the mind and body is Th e International Association for the Study of
illustrated by the many widely known metaphors and Pain (IASP) has defi ned pain as “an unpleasant senso-
symbols. Unsolved problems and confl icts have us rack- ry and emotional experience associated with actual or
ing our brains over them, and the folk term for low back potential tissue damage, or described in terms of such
pain in German (Hexenschuss—witch’s shot) entails the damage.” Th is defi nition is fairly lean, but it encom-
medieval psychosomatic belief that a proud man can be passes the complexity of pain processing, contradicts
shot in the back by a witch’s magical powers, producing oversimplifi ed pain defi nitions that pain is a purely no-
the kind of agonizing pain that can cripple him. Many ciceptive event, and also draws attention to the various
cultures believe in magical (often evil) powers that can psychological infl uences.
cause pain. Th is belief in magical powers refl ects the ex- Pain is often accompanied by strong emotions.
perience that the cause of pain cannot always be deter- It is perceived not only as a sensation described with
mined. Sometimes, the somatic structures of the body words such as burning, pressing, stabbing, or cutting,
are completely normal and it is not possible to fi nd a le- but also as an emotional experience (feeling) with words
sion or physiological or neuronal dysfunction that is a such as agonizing, cruel, terrible, and excruciating. Th e
potential source of pain. Th e belief in magical powers association between pain and the negative emotional
is also rooted in the experience that psychological fac- connotation is evolutionary. Th e aversion of organ-
tors are just as important for coping with pain as is ad- isms to pain helps them to quickly and eff ectively learn
dressing the physical cause of the pain. Modern placebo to avoid dangerous situations and to develop behaviors
research has confi rmed such psychological factors in that decrease the probability of pain and thus physical
many diff erent ways. damage. Th e best learning takes place if we pay atten-
It should be mentioned, however, that certain tion and if the learned content is associated with strong
lay theories such as the modern legend of the “worn- feelings. With regard to acute pain—and particularly
out disk” only describe the actual cause of these symp- when danger arises outside the body—this connection
toms in very few cases. In more than 80% of all cases is extremely useful, because the learned avoidance be-
of back pain, there is no clear organic diagnosis. Th e havior with regard to acute pain stimulation dramatical-
diagnosis for these cases is usually “nonspecifi c” back ly reduces health risks. When it comes to chronic pain,
Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel. IASP, Seattle, © 2010. No responsibility is assumed by IASP 19
for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or
ideas contained in the material herein. Because of the rapid advances in the medical sciences, the publisher recommends that there should be independent
verifi cation of diagnoses and drug dosages. Th e mention of specifi c pharmaceutical products and any medical procedure does not imply endorsement or
recommendation by the editors, authors, or IASP in favor of other medical products or procedures that are not covered in the text.