What are the biopsychosocial influences on pain

The biopsychosocial model of pain was introduced by Dr. George Engel in 1977. This widely accepted theory suggests that pain is a result not only of biological factors but also of psychological and sociological factors. Engel argued that the biomedical model of pain did not allow for the reason why two individuals with the same condition or injury can experience vastly different degrees of pain or disability.

The model considers the interaction of biological, psychological, and sociological factors that contribute to the experience of pain. Examples of biological factors include severity of the health condition, hormones, and genetics. Examples of psychological factors include mood, pain coping, and pain catastrophizing. Examples of social factors include gender roles, ethnic identity, discrimination, and health care provider bias.

According to the biopsychosocial model of pain, the treatment of chronic pain must be multifaceted. The primary treatment goal is to relieve physical pain, increase movement, and improve overall functionality; however, this model also accounts for potential barriers in recovery. Interdisciplinary care may include primary care, psychiatric care, physical therapy, occupational therapy, and case management. Treatment plans should be tailored to the individual based on their physical, psychological, and social needs.

Pain is first and foremost a sign that damage has occurred somewhere in your body, which can lead to a response for your own protection. For example, if you burn your hand on the stove, you will feel pain in your hand and will pull it away as fast as you can in order to protect yourself.

Nevertheless, not everyone will respond to burning their hand in the same way. While one person may cry out in pain, another may not utter a word - just clench their teeth and say they are fine. However, both of them will pull their hand away to protect themselves . This example illustrates how the response to pain differs from person to person, despite the fact that the cause of the pain is the same.

Pain is therefore not only a sign of damage, but also your response to pain is determined by how you are used to dealing with pain. Other additional personal factors, such as whether, for example, you are feeling depressed or anxious, can also make your pain feel worse.

Another important aspect of pain is the effect it has on your daily life, such as your work, housework or hobbies; in other words, on your personal quality of life. The more limited you are by the pain, the worse it will feel.

In addition to physical and personal factors, the amount of pain felt can also be influenced by social factors. For example, how you deal with pain depends on your culture or on the country you live in, which in turn determines how you experience pain.

In short, pain is determined by a number of different factors and is not the same thing as fever during a bout of flu, whereby the infection is the only factor influencing the fever. Pain cannot be measured like fever. With pain, there are several factors involved that can influence the degree of pain felt, and this is also the reason why pain cannot be measured in any simple manner.

The approach to pain we have described above applies to all types of pain, whether or not there is a known cause for the pain. For example, it applies to pain following an operation, pain due to arthritis, or that due to cancer. This approach to pain, which takes into account a number of different factors, is known as the biopsychosocial model of pain. 'Model' means the viewpoint taken by those treating your pain.

Since there are many factors that can influence how much pain you feel (physical, psychological and social), we will test you for all these factors at the outpatient department. We will first look for the physical cause . This involves a general physical examination as well as neurological, orthopaedic and manual/musculoskeletal examinations, in some cases complemented by X-rays, scans and other tests.

We will also deal with any psychological or social factors that may influence your pain. This will be done by means of the pain questionnaires you will have completed before your first visit to a pain specialist at the outpatient department.

The factors that determine the degree of pain you feel come from different areas of medicine, which is why you may require treatment by various medical disciplines (neurology, orthopaedics, psychology, psychiatry and rehabilitation). This is known as the multidisciplinary treatment of pain, and is one of the most important working methods at the outpatient department of the University Pain Centre Maastricht.

Mar 01, 2015

Contexts matter in health too. The onset of a health condition might have two very different trajectories based on the contexts in which its onset occurs. Take, for example, a flu infection. It might be a nuisance for someone who is otherwise healthy, whereas the same infection might be disastrous for an elderly person or for a person whose immune system has been compromised due to undergoing chemotherapy. The overall presentation of flu in these cases is different because of the context. They each share a common precipitating cause – the influenza virus, but their illness is manifested differently due to the contexts that they don’t share.

In this light, we have to acknowledge the importance of context as a cause of health problems. In the common influenza examples described above, the context plays just as an important causal role as the influenza virus itself. Indeed, it’s the context that determines whether the flu will be either a nuisance or life threatening. In other words, the particularities of the person who has the health condition – the host, if you will -- have a causal influence on the overall ways that the condition presents.

Moreover, it’s hard to imagine a health condition that occurs in isolation of the person who has it. As such, we must acknowledge that health conditions almost always have multiple causes – the precipitating event and how it interacts with the particularities of the person who has it and experiences it.

The common reductionistic view of health conditions

In our society, we tend to forget this simple fact about health. We tend to equate a health condition with a single precipitating cause and explain the differences across people who have the same condition by asserting differences in the severity of the precipitating cause. So, in the influenza example above, we tend to explain differences in severity of illness by asserting that one person’s influenza infection (i.e., the precipitating cause) must be due to a more virulent strain than another person’s flu infection.

As a society, we take this stance all the time in chronic pain management. We assume that people with high levels of pain and disability always must have had more severe precipitating injuries than those who have less pain and disability. Of course, sometimes it is true. Someone who breaks her neck in a motor vehicle accident may result in a high level of pain and disability.

Reductionism leads to stigma

Yet, not everyone with pain, perhaps not even a majority, fit neatly into this simple equation that differences in pain and disability are always explainable by differences in the precipitating event or cause.

It’s not uncommon for people to have excruciating pain and severe disability from moderate injuries, such as a fall from a ladder or stairs, or mild injuries such as a muscle strain from lifting something or simply bending over to pick something light off the floor. It’s even common for people to have severe pain and impairment without a precipitating injury or illness at all.

These people don’t fit into our common assumption that severity of pain and disability must always correspond with severity of precipitating injury or illness. Unfortunately, what happens to these people is that they get stigmatized. Others invalidate them by doubting the legitimacy of their pain and disability. “All you did was to bend over and pick up your hammer off the ground,” they might say, “How can you have so much pain that you can’t work?”

But what if there is a rational explanation for their pain and disability?

Chronic pain is multifactorial

We need to recognize that pain is more complicated than we tend to think it is. There is always more than one factor that initially causes pain and always more than one factor that maintains pain on a chronic course. A good place to start to recognize these facts are in the context in which precipitating causes occur.

In healthcare, we tend to categorize the contexts in which health conditions occur in three ways. They are biological, psychological and social contexts.

The 'bio-' in the biopsychosocial

The biological contexts are the health of the person in terms of his or her bodily systems – the nervous system, the endocrine or immune systems, for instance. In the cases above, we described two people with the same precipitating event, an influenza infection, and saw how in one person the flu was a minor illness and in another it became a life-threatening illness because of differences in their immune systems. Whether healthy or compromised, the immune systems of each have an influence on the overall presentation of the illness. Indeed, in the case of the person with the compromised immune system, it is equal in importance to the precipitating cause of the influenza infection itself: it’s what makes the infection life threatening.

Similarly, the health of a person plays a role in the onset and chronic maintenance of pain. We know, for instance, that certain conditions

The overall health of the nervous system also plays a role in the development of chronic pain. We know that people who have been subjected to prolonged stress are more likely to develop a new episode of pain and develop chronic pain once pain occurs. Examples are people who have experienced trauma or who are depressed or anxious or experiencing other life stressors (Croft, et al., 1995; Linton & Bergbom, 2011; McBeth, et al., 2007; Pincus, et al., 2002; Raphael & Widom, 2011). It’s not because they are any more accident-prone or illness-prone. Injury or illness, we might say, is an equal opportunity event. Rather, it’s that nervous systems under prolonged stress tend to have lower thresholds for stimuli to provoke pain and tend to become increasingly sensitive once a new episode of pain occurs.

Obviously, there are countless facets about the overall health of people that can play causal roles in either the development of pain or in the transition from acute to chronic pain. These biological factors provide a context in which a precipitating event, such as a painful injury or illness, occurs and they influence how the pain of the precipitating event is manifested.

The 'psycho'- in the biopsychosocial

The psychological contexts are the psychological conditions and stressors that impact the nervous system, as well as health beliefs and behaviors that might impact the experience of pain and how people react to pain once becoming injured or ill. As suggested above, those who have struggled with trauma, anxiety or depression are at greater risk for developing pain and especially transitioning from acute to chronic pain once having an acute injury or illness. In other words, the state of the nervous system at the time of the acute injury or illness, especially when it’s under prolonged stress, can have a causal role in the development of subsequent chronic pain. In this way, we can rightly say that anxiety and depression can be one of the many multifactorial causes of chronic pain.

Indeed, in people who subsequently develop chronic pain, it’s actually quite common to have experienced trauma, anxiety and/or depression prior to the acute onset of pain (Knaster, et al., 2012; Magni, et al., 1994) and these emotional disorders interact synergistically with biological causes of pain to heighten the overall experience of pain (Domnick, Blyth, & Nicholas, 2012). These factors can tip the scale, as it were, to transition acute pain into chronic pain, following a precipitating painful injury or illness.

Other psychological factors, besides emotions, can exercise a causal role in the development of pain and chronic pain. Beliefs about pain and prior learning about pain can influence how pain is experienced and what we go on to do about it once having it (Arnstein, et al., 1999; Edwards, et al., 2011; Linton, Buer, Vlaeyen, & Hellsing, 2000; Nahit, et al., 2003). Some beliefs about pain and what we are supposed to do about it are helpful. They can reduce the intensity of pain or promote healing or recovery in the case of acute pain. They can also promote coping well with pain and remaining active in the case of chronic pain. Some beliefs, however, are not so helpful and can lead people to inadvertently experience more pain or do things that don’t promote recovery or good coping. Examples are catastrophizing, fear-avoidance beliefs, and engaging in illness behaviors (e.g., persistent resting and activity avoidance).

There are countless more psychological factors that can influence how pain and disability are manifested. Nonetheless, the point here is to recognize that the context in which pain occurs has an influence. It has a causal role – even if it’s not the initial or precipitating cause – in how we experience pain and what we go on to do about it once becoming injured or ill.

The ‘social’ in the biopsychosocial

The social contexts are those social conditions and stressors that can impact the nervous system or otherwise affect the trajectory of people’s health. These aspects widen the context further, beyond the biological and psychological make-up of the individual. They involve the make-up of the individual’s surroundings in terms of their relationships and social resources. We know that these factors too have a causal influence on health, pain included.

To illustrate the point, let’s take an all-too-common example that occurs within our field of chronic pain management. Suppose you see a woman who has chronic daily headache. Outside your clinic, she’s been treated for many years with medications and interventional pain procedures. She tells you that she’s been told she has cervicogenic headache, which means that her headache is thought to be due to structural problems in the cervical spine (i.e., neck). On MRI, she does in fact have modest degenerative changes, but these findings are common in people of her age. As such, we might consider this way of understanding her pain as a biomedical conceptualization. You, however, are a provider who understands chronic pain from a biopsychosocial conceptualization and so you ask, in your initial evaluation, about her psychological health as well as about her relationships, home life, financial stressors, and about where she lives in the community. At first, she’s a little taken aback. No one, she tells you, has asked about such things, at least not in the depth that you go into. She also doesn’t understand, she says, what all of this has to do with her pain. With budding trust, however, she begins to tell you that she has been involved in a domestically violent relationship for many years.

Might it not be reasonable to suppose that the persistent stress of physical, emotional and sexual violence plays a causal role in her headache pain? How could it not? Such prolonged stress would have to adversely affect her nervous system and thereby exacerbate her chronic pain. Even if, as has happened to her, we adequately treated any ‘cervicogenic’ aspects of her pain, wouldn’t it be insufficient to adequately manage her pain? We have to address the social causes of her pain condition as well.

Domestically abusive relationships are not the only type of persistently stressful relationship that can affect the trajectory of chronic pain. Care-taking relationships are also chronically stressful: care-taking an elderly parent with dementia, care-taking a spouse with cancer or a spouse disabled by a stroke, care-taking a child with special needs. Chronic marital conflict, short of domestic abuse, might be another. The absence of relationships can also be a chronic stressor in the form of loneliness that can influence the development of pain (Jaremka, et al., 2013).

These chronic social stressors affect the nervous system, likely making it more sensitive to stimuli, and thereby exacerbating pain, as well as sapping the ability of such people to cope with the pain that they experience. As such, social stressors have a causal influence on pain, even if they are not the initial precipitating cause.

We also know that poverty and living in dangerous neighborhoods can affect overall health as well the onset of pain and its chronicity (Gooseby, 2013; Ulirsch, et al., 2014). These social-based stressors adversely affect the nervous system and thereby adversely affect pain levels as well.

We know too that lack of access to adequate healthcare affects the trajectory of pain once having an acute injury or illness. Lack of insurance or being underinsured can often lead to emergency room based care or other stop-gap measures that are poorly suited for chronic conditions. Lack of availability of effective chronic pain management, even for those with adequate insurance coverage, can also play a role (Prunuske, et al., 2014). For example, the most effective form of chronic pain management, interdisciplinary chronic pain rehabilitation programs, is not widely available in the United States (Schatman, 2012). As such, many people with chronic pain simply do not have ready access to them and so must rely on less effective means to manage their pain. These social factors thus influence the pain levels of an individual’s condition.

Conclusion

Like all health conditions, pain is multifactorial. Meaning, multiple factors go into causing pain and maintaining it on a chronic basis. In our society and healthcare system, we tend towards understanding pain in reductionistic terms – understanding pain as solely the result of the event that precipitated it – an injury or illness. This reductionistic understanding leads to the belief that severity of pain and disability is solely the result of the precipitating event. So, if pain and disability are severe, there must have been a severe injury or illness. Most people’s pain or chronic pain, though, simply don’t fit neatly into this reductionistic model. They can have high levels of pain and disability in the absence of severe injuries or illnesses. As a result, they often get stigmatized: others doubt the legitimacy of their pain and disability. However, there is a rational explanation for these people’s pain and disability. Their pain, as with all people’s pain, is not solely caused by the precipitating event that started it all. Pain is multifactorial: there are multiple causal influences to pain in terms of the overall contexts in which injuries and illnesses occur. The biological, psychological, and social health of these contexts play a part in the onset and chronic maintenance of pain. These causes provide a rational, accurate and legitimate explanation for how pain and chronic pain become manifested in individuals.

(For more advanced study of the biopsychosocial nature of chronic pain, please see Gatchel, et al., (2007). The biopsychosocial approach to chronic pain: Scientific advances and future directions. Psychological Bulletin, 133(4), 581-624. doi: 10/1037/0033-2909.133.4.581)

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Date of publication: 3-1-2015

Date of last modification: 3-21-2021

Author: Murray J. McAllister, PsyD, LP