Chronic pain is a disorder characterised by complex interactions between physiological, psychological and sociocultural factors. The biopsychosocial approach to pain acknowledges the multiple influences that shape the conscious experience of pain and that determine its clinical presentation. Assessment and management of chronic pain should therefore go beyond purely biomedical approaches to address the various issues with which a patient with chronic pain may be struggling.
Affective dimension of chronic pain
Chronic pain is often associated with negative emotions. As many as 50% of patients with chronic pain have a co-morbid depressive disorder.1 Concurrent depressive symptoms in patients with chronic pain are associated with increased disability and augmented pain experience.2 Anxiety is another negative emotion frequently seen in patients with chronic pain, and which may lead to maladaptive pain behaviours aggravating and maintaining pain and disability.3
Healthcare providers should be aware of and deal with these and other negative emotions because they affect the wellbeing of patients, worsen pain and can impact on treatment success.
Cognitive dimension of chronic pain
Cognitive states also influence pain perception and associated disability and require attention. In particular, pain catastrophising, which is defined as an exaggerated negative appraisal of pain and its possible consequences, has shown robust associations with more intense pain, more interference by pain and more disability in patients with chronic pain.4
Expectancies are another major factor influencing the course of pain as well as treatment efficacy. Negative expectancies regarding the persistence of pain, disability and ability to work may lead to a self-fulfilling prophecy.5 Furthermore, negative expectancies about the effects of treatment may reduce its efficacy in reality.6
The sociocultural context of chronic pain
Finally, how people perceive and deal with pain is also shaped by the sociocultural context. Modelling of pain behaviour by parents or significant others, as well as operant learning processes, affect pain and pain behaviour.7 Verbal and behavioural pain expressions may be reinforced by the attention and sympathy they elicit from others. Cultural factors may affect how pain is expressed, and there are cultural differences in the meaning of pain and treatment-seeking.8 Insensitivity to cultural differences can result in ineffective patient–healthcare provider communication and inadequate pain management.
Biopsychosocial assessment of pain
A biopsychosocial treatment approach to chronic pain takes the dynamic interplay between physiological, psychological, social and cultural factors into account. Consequently, all healthcare providers involved in treating a patient with chronic pain should not only evaluate a patient from a purely biological perspective but also consider the psychological and social dimensions as well. Only after proper multidimensional evaluation can an effective treatment plan be developed that addresses the specific needs of a patient.
Implications of the biopsychosocial approach for treatment
For patients with long-standing and complex pain complaints where multiple issues surrounding their pain problem are identified, multidisciplinary pain treatment may be indicated. Such treatments target a broad range of factors and combine physical, educational and psychological intervention strategies. Multidisciplinary pain treatments are usually delivered in specialised pain clinics or rehabilitation centres.
Although multidisciplinary interventions are the treatment of choice for patients with complex pain issues, they are also time consuming and costly. Therefore a stepped-care approach has been advocated with low intensity interventions offered as a first step, usually in primary care, and more intensive and costly treatments in specialised treatment centres only when a patient does not sufficiently benefit from initial interventions.9
Regardless of the intensity and site of treatment, a biopsychosocial perspective towards chronic pain management is always imperative.
Further reading and resources
Gatchel RJ, Peng YB, et al. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychological Bulletin 2007;133(4):581–624.
Peters ML. Emotional and cognitive influence on pain experience. In: Finn DP, Leonard BE (editors): Pain in Psychiatric Disorders. Modern Trends in Pharmacopsychiatry. Volume 30. Basel, Karger, 2015.
Flor H, Turk DC. Chronic Pain: An Integrated Biobehavioral Approach. Philadelphia, Lippincott Williams & Wilkins, 2011.
Kamper SJ, Apeldoorn AT, et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. Cochrane Database of Systematic Reviews 2014, Issue 9. Art No: CD000963.
Practical Pain Management
IASP Pain: Clinical Updates
Date of preparation: November 2015; MINT/PAEU-15019