discussion #11-12 disease

Impact of Psychological Factors
in the Experience of Pain
Steven J. Linton, William S. Shaw

This article reviews the role of psychological factors in the development of persistent
pain and disability, with a focus on how basic psychological processes have been
incorporated into theoretical models that have implications for physical therapy. To
this end, the key psychological factors associated with the experience of pain are
summarized, and an overview of how they have been integrated into the major
models of pain and disability in the scientific literature is presented. Pain has clear
emotional and behavioral consequences that influence the development of persistent
problems and the outcome of treatment. Yet, these psychological factors are not
routinely assessed in physical therapy clinics, nor are they sufficiently utilized to
enhance treatment. Based on a review of the scientific evidence, a set of 10 principles
that have likely implications for clinical practice is offered. Because psychological
processes have an influence on both the experience of pain and the treatment
outcome, the integration of psychological principles into physical therapy treatment
would seem to have potential to enhance outcomes.

S.J. Linton, PhD, is Professor of
Clinical Psychology, Center for
Health and Medical Psychology
(CHAMP), School of Law, Psychol-
ogy and Social Work, Örebro
University, Örebro 701 82, Swe-
den. Address all correspondence
to Professor Linton at:
[email protected]

W.S. Shaw, PhD, is Principal
Research Scientist, Center for Dis-
ability Research, Liberty Mutual
Research Institute for Safety,
Hopkinton, Massachusetts.

[Linton SJ, Shaw WS. Impact of
psychological factors in the expe-
rience of pain. Phys Ther. 2011;
91:700 –711.]

© 2011 American Physical Therapy

Psychologically Informed Practice

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The experience of pain isshaped by a host of psycholog-ical factors. Choosing to attend
to a noxious stimulus and interpret-
ing it as painful are examples of 2
factors involving normal psychologi-
cal processes. To be sure, pain is a
subjective experience, and although
it is certainly related to physiological
processes, how individuals react to a
new episode of pain is shaped and
influenced by previous experience.
Indeed, without learning from expe-
rience, it would be difficult to cope
with pain and maintain good health.
Thus, these psychological processes
have tremendous value for survival.1

Yet, psychological factors are not
completely understood, and the
translation of their use to the clinic
remains a challenge. Therefore, in
this article, we focus on the most
important psychological factors that
have been incorporated into theoret-
ical models of pain that may explain
pain perception and treatment ben-
efits. In our view, awareness of these
factors is crucial for understanding
patients in pain and is a prerequisite
for integrating them into clinical

Applying psychological knowledge
in the clinical practice of physical
therapy, however, has been quite a
challenge. A majority of physical
therapists are aware of the impor-
tance of psychological factors and
attempt to utilize this awareness in
their practice.2,3 The application of
psychological knowledge in physical
therapy might range from providing
reassurance to setting goals or inquir-
ing about the functional conse-
quences of pain. However, there is
an apparent lack of knowledge and
tools to adequately apply this knowl-
edge. For example, although 63% of
physical therapists in a primary care
setting were aware of the impor-
tance of psychological factors, only
47% reported knowledge of utilizing
them clinically.3 Furthermore, when
asked to specify which psychologi-

cal factors are of importance, most
therapists listed some evidence-
based factors but also a host of non–
evidence-based factors.2 Indeed,
many of the factors listed by clini-
cians were difficult for them to
address (eg, economic, drug abuse,
or marital issues) in the clinic and did
not match the evidence-based fac-
tors included in that article.2 Thus, a
key to the problem appears to be a
lack of clear guidelines for applying
the knowledge. We acknowledge
that there is currently a lack of clear
information as to how psychological
factors should be utilized by physical
therapists and other clinicians.

One area that is particularly relevant
is how early physical therapy treat-
ments might prevent the develop-
ment of chronic musculoskeletal
pain. Although many acute low back
pain (LBP) problems resolve, a
minority of people (�10%) directly
develop a persistent problem that
disables them for a long period of
time.4,5 The transition from acute
to chronic pain problems is known
to be catalyzed by psychological
processes (see article by Nicholas
et al6 in this issue). As a review of
psychological interventions designed
to prevent chronicity has shown
positive effects when the psycho-
logical techniques are appropriately
administered,6 competent applica-
tion appears to be vital. In our view,
an understanding of the basic psy-
chological processes is, therefore, an
essential base for competent applica-
tion of psychological principles in
the clinic.

To date, there has been broad recog-
nition of the importance of a biopsy-
chosocial view of pain, but a lack of
clarity in how the psychological fac-
tors actually fit in, not least in clinical
situations. How might psychology
be utilized to improve care? To this
end, we will focus on the central
psychological factors and highlight
the psychological processes that

affect the pain experience over time.
Indeed, we emphasize how psycho-
logical factors may contribute not
only to the experience of acute pain
but also to the development of
chronic pain and disability over time.
What might be quite a normal and
appropriate response in the acute
phase paradoxically may be a poor
method of coping with persistent
pain. Accordingly, we will highlight
how psychological factors affect the
development of persistent disability
and illustrate the processes by
describing pertinent theoretical

Psychological Processes
In this section, we provide an over-
view of fundamental psychological
processes that are involved in most
types of pain problems and high-
light how these processes may con-
tribute to the development of a per-
sistent pain problem. A basic theme
is that the psychological processes
are highly intertwined and function
together as a system. We consider
them individually as a means of pre-
sentation. Note that these processes
also form the basis of the models
presented in the next section.

Available With
This Article at

• Symposium Podcast: Download
an audio or video podcast of the
“Enhancing Clinical Practice
Through Psychosocial Perspectives
in the Management of Low Back
Pain” symposium at CSM 2011
with speakers Julie Fritz, Steven Z.
George, Chris J. Main, and
William Shaw. The symposium
was sponsored by APTA’s
Orthopaedic Section.

• Audio Abstracts Podcast

This article was published ahead of
print on March 30, 2011, at

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There are different ways in which
we might group psychological fac-
tors. In our presentation, we attempt
to portray the influence of psycho-
logical factors, as illustrated in Fig-
ure 1, as a sequence of processes,
starting with initial awareness of the
noxious stimulus, then cognitive
processing, appraisal, and interpreta-
tion that leads people to act on their
pain (ie, their pain behavior).7 These
processes are influenced by their
consequences and are limited by the
environment (eg, cultural and social
values). Although we present this as
a sequence for understanding, we
are aware that this is a model, and
much more work is needed to fully
describe these processes. In addition
to the model, Table 1 provides an
overview of the main factors and

their possible consequences for the
experience of pain.

An obvious prerequisite for pain per-
ception is that our attention is
directed toward the noxious stimu-
lus. In fact, one function of pain is
to demand attention.8 Viewed as a
warning signal, pain is helpful
because this attention should lead to
appropriate responses in dealing
with the injury. This view also under-
scores why it is difficult to simply
ignore pain, particularly if it has
alarming characteristics (eg, being
very intense, sharp, or unusual).

The dilemma is that we sometimes
pay attention to pain when there is
little we can do to alleviate it (eg,

having chronic musculoskeletal
pain), but do not attend to it when it
may be a useful warning signal (eg,
during an accident). Although atten-
tion is under the control of some
basic brain processes, its psycholog-
ical function is to motivate behavior.
If pain is considered a “threat,” then
the threat value of the (noxious)
stimulus helps to steer awareness:
the greater the threat, the more
attention given. Attention to pain
then may be linked to fear and anx-
iety and the need to take action (eg,
escaping or avoiding it). Vigilance
refers to an abnormal focus on pos-
sible signals of pain or injury9 that
might help explain why a seemingly
small injury results in intense pain.
This mechanism also underscores
the close link between emotional
and cognitive processes and atten-
tion.7,10 Attentional factors are quite
pertinent in the clinic because there
are techniques that address them.
Distraction techniques teach
patients to shift their attention to
stimuli other than the pain (eg, by
imagining the sounds of waves hit-
ting the shore), whereas interceptive
exposure shifts attention toward the
pain so that the signal will

Once the noxious stimulus has been
attended to, cognitive processes are
used to interpret what they mean.
This process is highly intertwined
with emotional processes, and it sets
the stage for behaving.7 How we
think about a noxious stimulus is
shaped by our previous experiences,
which explains why the simple
directive “think about something
else” often is impossible to accom-
plish. Indeed, the paradox is that
attempting to suppress thoughts
about pain actually increases the
pain experience.12 Cognitive pro-
cesses are central in explaining why
we sometimes may experience an
insignificant stimulus, such as light
pressure, as severe pain, or a serious







ily L







l Cog


Situation Consequences

Positive Negative


Coping Strategy



Figure 1.
A modern view of pain perception from a psychological view according to Linton.7

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injury as little or no pain. Several
basic cognitive and emotional
aspects are involved in the interpre-
tation of pain.

Beliefs and attitudes. We all hold
certain assumptions about how pain
works and what it probably means to
feel a given stimulus.13 Beliefs serve
the useful purpose of aiding in rapid
interpretation of stimuli, and they
seem to provide a shortcut that
helps our brain process the enor-
mous amount of incoming stimuli in
a more efficient manner. They pro-
vide a sort of automatic interpreta-
tion of the stimuli; thus, these stimuli
do not need lengthy processing in
the brain. Yet, this very propensity
can lead to responses that may be
detrimental. Beliefs and attitudes
also are influenced by the social
setting we live in so that our views
about what might be causing the
pain (eg, work demands) and what
should be done (eg, get a radio-
graph) reflect a broader social rep-
resentation. Several attitudes and

beliefs have been found to be related
to the development of persistent
pain and disability.14,15 For example,
certain beliefs that set the stage for
activity restrictions are tied to the
development of long-term pain and
disability. These beliefs include the
idea that “hurt is harm” (ie, if it hurts,
something serious must be broken),
that “pain is a signal to stop what you
are doing” (ie, if an activity results in
pain, you should stop before you
injure yourself), and that “rest is the
best medicine” (ie, pain is a signal
you should rest to recuperate your

Expectations. The ideas or per-
ceptions we have about our pain also
are mirrored in our expectations and
may have considerable impact on
our experience of the pain.14 Nor-
mally, we have ideas about the cause
of the pain, its management, and
how long it should take for recov-
ery.16,17 These expectations appear
to drive coping behavior, even in the
seeming absence of actual feedback.

Furthermore, such expectations or
health perceptions are a good pre-
dictor of outcome in a host of med-
ical conditions.16,17 One significant
determinant of our experience of
pain is whether our expectations
are fulfilled. We may expect, for
instance, that we will fully recover
from a bout of neck pain in 3 or 4
days. Epidemiology tells us that this
is a very optimistic expectation, and
when the expectation is not fulfilled,
it may generate further negative cog-
nitions and motivate behaviors that
may not be particularly helpful.18,19

Cognitive sets. In the process of
making sense out of incoming sig-
nals, we use various “ways of think-
ing” to help provide a framework.
This is a normal and helpful process,
but for a variety of reasons, some
patients may use cognitive patterns
that misrepresent actual events or
probable future events. The patient
may fall into a cognitive trap where
the interpretation is tantalizing and
well connected with the emotional

Table 1.
Summary of Psychological Processes

Factor Description
Possible Effect on Pain

and Disability Example of Treatment Strategy

Attention Pain demands our attention. ● Vigilance may increase pain intensity
● Distraction may decrease its pain intensity

● Distraction techniques
● Interceptive exposure

Cognitions How we think about our pain may
influence it.

● Interpretations and beliefs may increase
pain and disability

● Catastrophizing may increase pain
● Negative thoughts and beliefs may

increase pain and disability
● Expectations may influence pain and

● Cognitive sets may reduce flexibility in

dealing with pain and disability

● Cognitive restructuring
● Behavioral experiments designed, for

example, to disconfirm unrealistic
expectations and catastrophizing

Emotions and emotion

Pain often generates negative feelings.
These negative feelings may
influence the pain as well as fuel
cognitions, attention, and overt

● Fear may increase avoidance behavior
and disability

● Anxiety may increase pain disability
● Depression may increase pain disability
● Distress, in general, fuels negative

cognitions and pain disability
● Positive emotions might decrease pain

● Cognitive-behavioral therapy programs
for anxiety and depression

● Activation (to increase positive

● Relaxation
● Positive psychology techniques that

promote well-being and positive

Overt behavior What we do to cope with our pain
influences our perception.

● Avoidance behavior may increase

● Unlimited activity (overactivity) may
provoke pain

● Pain behaviors communicate pain

● Operant, graded activity training
● Exposure in vivo
● Coping strategies training

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state, but where a consistent “error”
in interpreting reality is made.7 This
pattern of interpretation is like a
lens that distorts one’s view of the
world and appears to function as a
part of our response to stress.20 An
example of such a thought process
is pain catastrophizing, which can
be defined as an exaggerated, nega-
tive orientation toward pain where
a relatively neutral event is irratio-
nally made into a catastrophe.21 In
essence, the person imagines the
worst possible result that could hap-
pen, but accepts it as the given
result. Catastrophic thoughts usually
are stated as assumptions (eg, “If the
pain does not get better, I will end
up in a wheelchair” or “The pain will
never stop, it will only get worse
and worse”). Not surprisingly, pain
catastrophizing is associated with a
variety of problems that hinder
recovery, making treatment more
difficult and increasing the risk of
developing persistent pain and dis-
ability.6,9,22 In short, because cata-
strophizing is a marker of the devel-
opment of long-term problems, it
may be an important target for

Emotions and their regulation.
One of the most disruptive features
of pain is the emotional distress. The
typical emotional reaction to pain
includes anxiety, fear, anger, guilt,
frustration, and depression. How
these emotions are regulated by the
patient has implications for their
impact on pain. Indeed, emotions
are powerful drivers of behavior and
shape our experience of the pain via
direct neural connections. Negative
affect is a key reason we associate
pain with suffering. Thus, pain acti-
vates negative emotions that vary
from tolerable to miserable.23 It is
interesting, therefore, that clinicians
often focus more on the sensory
aspects of pain (eg, intensity) than
on the emotional aspects. Indeed,
negative affect is strongly associated
with poor treatment outcome, as

well as the development of disability
from LBP.12,24

Anxiety and worry are prevalent
emotions, as pain represents an
imminent threat to our welfare.25

People with persistent pain typically
have significantly higher rates of
anxiety disorders than do those with-
out persistent pain.25 Fear, which is
characterized by an extreme reac-
tion that prepares us for “fight or
flight,” is one form of anxiety that
has powerful consequences (eg, for
our cognitions, attention, and behav-
ior). Fear, however, is time limited.
More common is worry, which is
distinguished by frequent cognitive
intrusions where the person con-
siders “what if ” possibilities 20 that
are quite negative and aversive.26

Because of this nature, worry drives
behavior, attention, and cognitions.

Depressed mood is a common and
powerful emotional state that affects
the pain experience. Depression is
defined as a psychological problem
characterized by negative mood,
hopelessness, and despair, and an
average of 52% of patients with pain
fulfill the criteria for depression.27

Even more people have a depressed
mood but do not fulfill the diagnostic
criteria for major depression.28 The
presence of depression in a pain con-
dition is associated with higher lev-
els of pain intensity and is a potent
risk factor for disability.27,29 Further-
more, people who have musculo-
skeletal pain and are depressed have
been found to have twice the sick
leave duration as those who have
pain but are not depressed.30,31

Future risk of long-term disability
also is affected negatively, as is treat-
ment outcome.22,27,32 Studies have
shown that high levels of pretreat-
ment depression are associated with
poor rehabilitation outcomes.33–35

Coping Strategies
When a painful stimulus has been
attended to and interpreted as being

a threat, strategies for dealing with
this threat are activated.7 As illus-
trated in Figure 1, these strategies
first may be activated cognitively and
involve a host of cognitive tech-
niques (eg, ignoring, visualizing) and
overt behavioral techniques (eg,
relaxation, self-statements) believed
to reduce the threat of the pain. Cop-
ing strategies are learned and involve
an integration of emotional, cogni-
tive, and behavioral systems. The
learning experiences help to fine-
tune these strategies by providing
feedback as to whether they work or
not. Although some situations offer
the opportunity to ponder which
strategy might be best, such as a
relapse or flare-up, the choice of cop-
ing strategy may occur quickly with-
out conscious thinking in acute situ-
ations, such as an acute injury (eg,
cut yourself with a knife, smashed
finger with a hammer). Once the
strategy is activated, it is likely that
this process will be reflected in
actual behavioral attempts to cope
with the pain.

Pain Behavior
An important step forward in under-
standing the psychology of pain was
taken in the 1970s when Fordyce
put forth the idea that pain should
be analyzed as behavior.36 Pain is a
private event, but it can be viewed
as a set of behaviors such as taking
analgesics, seeking care, or resting.
Furthermore, internal events such
as thoughts and emotions also are
considered to be forms of behavior.
Although pain is a complex experi-
ence that is difficult to understand, it
basically is no more so than other
psychological problems such as
depression or generalized anxiety
that also are conceptualized in this
way. Viewing pain as a set of behav-
iors renders analyses using learning
paradigms. Most pain behaviors are
learned and are influenced by emo-
tions and cognitions, but in particu-
lar via direct environmental conse-
quences. Thus, one learns to cope

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with pain by taking various actions
or thinking in a certain way. When
these behaviors result in less pain,
this outcome may reinforce the
action and make the behavior more
likely with future pain episodes, as
illustrated in Figure 1.

Learning factors help explain why
persistent problems sometimes
develop. First, a basic tenet is that
behaviors providing short-term ben-
efits (ie, pain relief) sometimes can
be detrimental in the long run. For
example, Fordyce36 suggested that
although resting or taking analgesics
may be a good coping strategy in the
acute phase, these behaviors might
actually facilitate the development of
long-term problems. Consequently,
treatment programs for people with
chronic musculoskeletal pain prob-
lems have been built on gradually
changing these behaviors, such as by
decreasing analgesics and increasing
activity levels. A second basic tenet
is that learning involves the whole
organism and environment; there-
fore, pain behaviors may be rein-
forced by social and environmental
consequences. Learning then can be
quite important in the development
of chronic disability. For example,
changes in life routines necessitated
by the pain (eg, can no longer do
the vacuuming) might be maintained
by other consequences (eg, partner
gladly does it instead).

Learning paradigms provide a tre-
mendous opportunity for helping
patients change (ie, to learn skills
that allow them to cope better with
the pain). If part of the suffering and
disability are related to learned
changes, it is possible to make fur-
ther changes toward a more prefer-
able goal by utilizing the principles
of learning. This is why most multi-
dimensional rehabilitation programs
use some type of learning paradigm,
usually in the form of cognitive-
behavioral therapy.12 It also is why
early interventions designed to pre-

vent the development of persistent
disability tend to focus on changing
cognitions and behavior.4

Taken together, these processes pro-
vide insight into how psychological
factors affect the experience of pain.
Nevertheless, it still may be difficult
to appreciate how these processes
work in reality and how we might
utilize them in specific ways in the
clinic. To facilitate understanding
and application, various models have
been put forward. In the next sec-
tion, we examine pertinent theoret-
ical models of pain that have applied
psychological processes to explain
how pain problems develop over
time and how these models might
guide clinical interventions.

Models of the
Development of
Persistent Pain Problems
A number of theoretical models have
been proposed to explain more-
specific ways in which psychologi-
cal factors might have a bearing on
pain and disability over time. Most
researchers in pain psychology sub-
scribe to a broad, biopsychosocial
formulation, but more-specific con-
ceptual models provide a pathway
whereby psychological factors affect
the transition from acute to per-
sistent pain problems. Although there
are many theoretical perspectives
of pain and disability, we will
present the 5 theories commonly
referred to in current studies of
pain psychology. Three of these
models (fear-avoidance, acceptance
and commitment, and misdirected
problem solving) are specific to the
experience of chronic pain, and 2 of
these models (stress-diathesis and
self-efficacy) represent broader theo-
ries of health behavior that can be
applied to pain.

Table 2 provides a summary of
the models and examples of the
basic components, the processes

involved, and some implications for
treatment. The 5 models provide
ways of understanding how the spe-
cific interactions and mechanisms
that exist between psychological
factors are interrelated. Thus, they
help us to understand the develop-
ment of persistent pain and disabil-
ity. Moreover, each of these models
highlights different mechanisms,
which may help us select the most
effective ways to address psycholog-
ical factors in the clinical manage-
ment of LBP.

Psychological Models
of Chronic Pain
Fear-avoidance model. One of
the most influential models to
explain psychological factors in the
experience of pain has been the
fear-avoidance model, which was
advanced to explain how patients
with an acute or subacute pain con-
dition might transition over time to a
chronic state of depression, disabil-
ity, and inactivity.37–39 The essential
elements of the fear-avoidance
model are shown in Figure 2. A spe-
cific emotion regulation factor in the
model is fear. Fear of pain develops
as a result of a cognitive interpreta-
tion of pain as threatening (pain cata-
strophizing), and this fear affects
attention processes (hypervigilance)
and leads to avoidance behaviors,
followed by disability, disuse, and
depression. Both negative affectivity
(a tendency to see the cup as “half
empty” rather than “half full”) and
threatening types of illness informa-
tion can help to fuel catastrophic
thoughts about pain. The fear-
avoidance model suggests that in
the absence of fear-avoidance beliefs
about pain, individuals are more
likely to confront pain problems
head-on and become more engaged
in active coping to improve daily
function. This model is supported by
the evidence that high levels of pain-
related fear are associated with dis-
traction from normal cognitive func-
tions, hypervigilance of pain-related

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sensations, and unwillingness to
engage in physical activities.40 Essen-
tially, the fear-avoidance model pur-
ports that fear of pain and of injury
or reinjury sometimes is more dis-
abling than the pain itself.41 Over

time, fear of pain results in musculo-
skeletal deconditioning, reduced
pain tolerance, and fewer attempts
to overcome functional limitations.

One practical implication of this
model is that patients expressing
catastrophic thoughts about pain
(eg, “I can’t stand it anymore”) are at
greater risk of delayed recovery.21

These individuals may require a

Table 2.
Summary of Psychological Models of Pain and Disability Highlighting the Psychological Processes Involved and Examples of
Treatment Interventions

Theory Description
Psychological Processes

Featured Mechanism
Examples of Treatment
Intervention Strategies

Fear-avoidance model A painful injury may result in
catastrophizing and fear,
which lead to avoidance
of certain movements.
This behavior, in turn,
leads to more avoidance,
dysfunction, depression,
and ultimately more pain.

● Cognitive interpretation featuring

● Emotions: fear, worry, and

● Attention: fear keys attention on
internal stimuli (hypervigilance)

● Behavior: avoidance of

Activity avoidance leads to
physical degeneration
and social isolation;
vicious circle

Promote physical and social
activation (eg, with
graded activity)

Acceptance and
commitment model

Rigid beliefs (eg, that the
pain must be cured) may
block the pursuit of
long-term life goals.
Reducing futile attempts
to achieve unrealistic
goals (acceptance)
produces flexibility and
engagement in pursuing
important life goals

● Cognitive: flexibility in beliefs,
life goals, and commitment

● Emotions: anger and frustration
● …

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