The role of cognition

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correlation between high anxiety levels and increased pain perception in children with
migraines and sufferers of back pain and pelvic pain (Feuerstein et al. 1987; McGowan
et al. 1998). In a recent experimental study participants took part in the cold pressor test
which involves placing the hand and arm in icy water as a means to induce pain. Their
trait anxiety was assessed and some were actively distracted from thinking about their
pain (James and Hardardottir 2002). The results showed that both distraction and low
anxiety reduced the pain experience.
Fear
Many patients with an experience of pain can have extensive fear of increased pain or
of the pain reoccurring which can result in them avoiding a whole range of activities
that they perceive to be high risk. For example, patients can avoid moving in particular
ways and exerting themselves to any extent. However, these patients often don’t describe
their experiences in terms of fear but rather in terms of what they can and cannot
do. Therefore, they don’t report being frightened of making the pain worse by lifting a
heavy object, but they state that they can no longer lift heavy objects. Fear of pain and
fear avoidance beliefs have been shown to be linked with the pain experience in
terms triggering pain in the first place. For example, Linton et al. (2000) measured fear
avoidance beliefs in a large community sample of people who reported no spinal pain
in the preceding year. The participants were then followed up after one year and the
occurrence of a pain episode and their physical functioning was assessed. The results
showed that 19 per cent of the sample reported an episode of back pain at follow-up and
that those with higher baseline scores of fear avoidance were twice as likely to report
back pain and had a 1.7 times higher risk of lowered physical functioning. The authors
argue that fear avoidance may relate to the early onset of pain. Some research also
suggests that fear may also be involved in exacerbating existing pain and turning acute
pain into chronic pain. For example, Crombez et al. (1999) explored the interrelationship
between attention to pain and fear. They argued that pain functions by demanding
attention which results in a lowered ability to focus on other activities. Their results
indicated that pain related fear increased this attentional interference suggesting that
fear about pain increased the amount of attention demanded by the pain. They concluded that pain related fear can create a hyper-vigilance towards pain which could
contribute to the progression from acute to chronic pain. These conclusions were further
supported by a comprehensive review of the recent research. This indicates that treatment which exposes patients to the very situations that they are afraid of, such as
going out and being in crowds, can reduce fear avoidance beliefs and modify their pain
experience (Vlaeyen and Linton 2000).
The role of cognition
Catastrophizing
Patients with pain, particularly chronic pain, in line with many other patients often
show catastrophizing. Keefe et al. (2000) described catastrophizing as involving three
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components: (i) rumination: a focus on threatening information both internal and
external (‘I can feel my neck click whenever I move’); (ii) Magnification: overestimating
the extent of the threat (‘The bones are crumbling and I will become paralysed’); and
(iii) Helplessness: underestimating personal and broader resources which might mitigate
the danger and disastrous consequences (‘Nobody understands how to fix the problem
and I just can’t bear any more pain’). Catastrophizing has been linked to both the
onset of pain and the development of longer-term pain problems (Sullivan et al. 2001).
For example, in the prospective study described above by Linton et al. (2000), the authors
measured baseline levels of pain catastrophizing. The results showed some small associations between this and the onset of back pain by follow-up. Crombez et al. (2003)
developed a new measure of catastrophizing to assess this aspect of pain in children.
Their new measure consisted of three subscales reflecting the dimensions of catastrophizing, namely rumination, magnification and helplessness. They then used this measure to explore the relationship between catastrophizing and pain intensity in a clinical
sample of 43 boys and girls aged between 8 and 16. The results indicated that catastrophizing independently predicted both pain intensity and disability regardless of age and
gender. The authors argued that catastrophizing functions by facilitating the escape from
pain and by communicating distress to others.
Meaning
Although at first glance any pain would seem to be only negative in its meaning,
research indicates that pain can have a range of meanings to different people. For
example, the pain experienced during childbirth although painful, has a very clear cause
and consequence. If the same kind of pain were to happen outside of childbirth then
it would have a totally different meaning and would probably be experienced in a
very different way. Beecher (1956), in his study of soldiers’ and civilians’ requests for
medication, was one of the first people to examine this and asked the question: ‘What
does pain mean to the individual?’ Beecher argued that differences in pain perception
were related to the meaning of pain for the individual. In Beecher’s study, the soldiers
benefited from their pain. This has also been described in terms of secondary gains
whereby the pain may have a positive reward for the individual.
Self-efficacy
Some research has emphasized the role of self-efficacy in pain perception and reduction.
Turk et al. (1983) suggest that increased pain self-efficacy may be an important factor
in determining the degree of pain perception. In addition, the concept of pain locus
of control has been developed to emphasize the role of individual cognitions in pain
perception (Manning and Wright 1983; Dolce 1987; Litt 1988).
Attention
There has also been research exploring the impact of attention on pain. Much work
shows that attention to the pain can exacerbate pain whereas distraction can reduce the
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