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More PsychNotes: Pain Management

April 26, 2017       
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It's Not What You Think But Also How You Think That Affects Chronic Pain
by Monica A. Frank, PhD

We must let go of the life we have planned, so as to accept the one that is waiting for us. Joseph Campbell
Many studies have shown that thinking influences the experience of pain. It's not that the pain is “all in the head” but that certain kinds of thoughts will make the existing pain worse. In fact, two primary styles of thinking tend to increase the level of pain for those with chronic pain:

1) Catastrophizing. Thinking that focuses on how awful the pain is or how much it has ruined your life is shown to make pain worse.

2) Control. Feelings of helplessness and thoughts how not being able to control the pain or to be able to escape it worsens pain.

Research in recent years shows, however, that it is not just what you are thinking but how you process the thoughts that can affect the level of pain you experience. For instance, a common cognitive technique is to attempt to stop the negative thoughts. However, it may be that for some people such an attempt can be seen as punitive and doesn't teach new, less catastrophic, ways of thinking about the pain.

Even thoughts focused more realistically on the pain may still focus attention on the pain which can lead to increased pain. This is not to say these methods are not effective but that for some people such strategies may not be the best choice.

Instead, research by Yoshida and colleagues (2012) shows that how thoughts are processed can also effect the experience of pain. In particular, methods such as mindfulness teaches people to let go of thoughts and not give the thoughts about the pain too much attention.

What Are the Different Cognitive Strategies to Reduce Pain?

1) Thought-stopping. This technique uses mild aversive conditioning to reduce certain thoughts. For instance, a common way of teaching thought-stopping is to pair the thought with a loud noise and say “Stop!” at the same time. Gradually, the person is able to just think “Stop!” or visualize a stop sign to reduce the thought. This method is best when a person knows how to counter the catastrophic thoughts but still has intrusive thoughts.

2) Restructuring. This technique teaches how to challenge the thoughts about catastrophe, helplessness, or lack of control in a more realistic manner. For instance, “I'll NEVER be able to do the things I used to!” can be challenged with “I might not be able to do some things, but by taking care of myself I will do as much as I can” or “Even though I can't do what I used to, there are still plenty of things that I enjoy.”

3) Mindfulness. Training in mindfulness allows a person to gently refocus their attention to other thoughts or experiences. Instead of the more punitive style of thought-stopping, it helps a person to give attention to desired thoughts while letting the undesirable thoughts be there without giving them focus. Mindfulness is often used in combination with restructuring, or changing, the content of the thoughts.

4) Distraction. Engaging in social activity, watching funny movies, listening to music can be forms of cognitive distraction which have been shown to reduce pain. Such distraction not only focuses on more positive experiences but has the effect of reducing the frequency of the negative, catastrophic thoughts.

The research isn't clear on what style of cognitive treatment is best and the conclusion might be that it varies with the patient. Effective treatment may focus on teaching all the methods and letting the person with chronic pain decide which is best.

This strategy of having a choice may have the added benefit of giving the patient a greater sense of control: “Let's try these different strategies. Does this help more or does this? Remember it may only be a slight difference at first but once we find something that seems to help, we will then focus on increasing your skill.”

Yoshida, T., Molton, I.R., Jensen, M.P, Nakamura, T., Arimura, T., Kubo, C., and Hosoi, M. (2012). Cognitions, Metacognitions, and Chronic Pain. Rehabilitation Psychology, 57, 207–213. DOI: 10.1037/a0028903


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