The Connection Between Thoughts, Feelings, and the Experience of Pain

For many years pain was thought to be caused directly by injury or disease. It wasn’t until it was discovered that pain could in fact exist even after apparent healing, or with no known physical source, that other explanations were sought out to explain the phenomenon of pain.

It is now widely recognized that pain is not a purely physical sensation, but involves how one thinks and feels. According to the International Association for the Study of Pain (IASP), pain is an “unpleasant sensory and emotional experience”. The experience of pain is just that, an experience, which is created by the brain. There are physical factors, emotional factors, and cognitive (thinking) factors which all combine together to define one’s experience and perception of pain. These factors are interconnected, not separate. For that reason, one cannot have an experience with pain without corresponding emotional and cognitive correlates which create the experience.

According to Loggia et al. (2008), the psychological aspects of pain have been proven through neuroimaging studies on the brain. These studies have shown that activity in pain pathways is altered by attention and positive and negative emotions. Therefore, “techniques that modify these variables have the potential to alter pain perception”.

The cognitive aspect of the pain experience has been shown to significantly affect pain transmission. This aspect of pain involves how one views his pain. This includes expectations and beliefs about pain, as well as anticipation of pain. Because of its involvement in the processing of the pain experience, the cognitive aspect of pain, or how one thinks, has the ability to either amplify or inhibit pain messages. Cognitive techniques such as distraction and attention (Apkarian et al. 2005, Villamure & Bushnell, 2002) all tap into this “cognitive modulation [the ability to increase or decrease the intensity] of pain” (Marchand, 2012).

Thought processes are a powerful force and have the capability to “change the balance of chemicals in the same way that [anti-depressant] drugs can.” (Gardner-Nix, 2009). Catastrophizing, for example, a negative thinking style where one overestimates the severity of his condition and expects a negative outcome, has been shown to be particularly influential in increasing pain intensity. Catastrophizing causes increased activity in brain areas related to anticipation of pain and emotional aspects of pain (Gracely et al., 2004). A negative thought is sent by the brain that pain is overwhelming and unmanageable. This preoccupation and attention to one’s pain serves to facilitate the pain message sent to the brain and increase the intensity of pain.

Studies utilizing the “placebo affect” have shown the opposite effect, and have illustrated the ability of positive thoughts to decrease pain. This involves applying a fake treatment (like sugar water), but leading the subject to believe it has effective properties and will be beneficial to them. Because the subject believes that a certain manipulation will be helpful, it does in fact become helpful. The reason? This belief sets off a physiological response within the body which underlies its effectiveness. As noted earlier, this is due to the cognitive modulation effect of pain processing. Otherwise k n o w n as the “descending inhibitory pathway” of pain processing. The brain sends a message to the body that something is going to work. This thought or message triggers the body’s own internal pain inhibitory system, which involves a release of endorphins and endogenous opioids (internal [intrinsic] pain relievers) (Marchand, 2012). Both of which possess analgesic qualities. Through action of the endogenous opioids, the pain message itself is inhibited early on in the transmission process

(“chronic pain: neural plasticity”, n.d.). The volume of the pain message is “turned down” and less pain is experienced. The placebo effect highlights how one’s expectations/attitude towards pain has the potential to increase or decrease pain. A very powerful tool for pain management. Simply believing that one has the power to manage pain effectively will engage the system above and can cause pain to be minimized.

In addition to the cognitive processing aspect of the pain experience, there is an affective/emotional component. This aspect can be thought of as contributing to the unpleasant quality of pain, or the suffering quotient. An experience with pain carries with it this affective emotional component, because pain is in and of itself unpleasant. However, pain can be more or less distressing based on personality characteristics, past experience, mood, and what the pain represents to that person.

These psychological factors play a key role in the development of chronic musculoskeletal pain. In particular, dysfunctional beliefs about pain and fear of pain increase pain through increase pain processing, but also fear of pain creates pain behaviours which are problematic: “Fear of pain leads to avoidance of activities that patients have associated with the occurrence or exacerbation of pain, even after they may have physically recovered. Whereas this response is adaptive in the acute phase- rest promotes recovery – it leads to disability and distress when avoidance behaviour is continued after the injury has healed.” (International Association for the Study of Pain,2009)

Activity avoidance and disability can cause distress, keeping people house bound and isolated from social support. For that reason, people with chronic physical health conditions often experience coinciding poor mental health.

While pain can cause negative emotions and avoidant behaviour, the reverse is said to be true. It has been suggested that emotions, specifically repressed emotions such as anger and anxiety, actually cause pain conditions and could be responsible for a large percentage of unexplained back, neck, and shoulder pain (Sarno, 1978). The suggestion is that rather than experience painful emotions, the body instead utilizes a defense mechanism of creating physical pain to distract a person from internal distress. This condition has been termed (TMS) or tension myositis syndrome, a tension-induced disorder. The result is persisting pain with no structural explanation.

“Research has shown that anger affects how much pain one feels, and can increase the dosage of narcotics needed to reduce pain…In addition, emotions can affect inflammation and nerve irritation at the site of tissue damage” (Gardner-Nix, 2009). Emotions create pain. Painful emotions send pain messages to the brain in the same way a physical stimulus can. For that reason, despite tissue healing, pain messages can still be sent as a function of negative emotions “(Gardner-Nix, 2009).

These concepts are difficult for many people to accept. It is easier to attribute a physical source to a physical manifestation. However, we are now beginning to recognize that emotions have physiological underpinnings in terms of brain structures and autonomic nervous system connections which cause other physical manifestations such as pain.

As illustrated, painful emotions can create pain conditions and pain conditions can cause feelings such as anger, hopelessness, sadness and anxiety. “Pain is depressing, and depression causes and intensifies pain” (“Depression and Pain”, 2009). Regardless of which occurred first, the cart or the horse, co-existing mental and physical conditions diminish ones quality of life and lead to longer illness duration and worse health outcomes (Patten, S., 1999).

Considering the effect that psychological factors have on pain transmission and pain experience, it is important for both the clinician and the patient to access this often under-utilized avenue for pain management/control. By recognizing negative thoughts and beliefs about pain, managing emotions, reducing anxiety, and utilizing cognitive strategies to modulate pain, patients can be active participants in their own pain control.
Article written by Lisa Carlson, Registered Psychologist

*Lisa practices at the OWC Airdrie Active and OWC Marlborough Locations

Apkarian A., Bushnell M., Treede R., Zubieta J., (2005). Human brain mechanisms ofpain perception and regulation in health and disease. Eur J Pain, 9(4):463–84.

Chronic Pain: Neural Plasticity and Therapeutic Perspective (n.d.). Retrieved from

Depression and Pain. Harvard Health Publications. Harvard Medical School (2009, June09). Retrieved from depression_and_pain.

Gardner-Nix, J. with Costin-Hall, L. (2009). The Mindfulness solution to pain: Step-by-step techniques for chronic pain management. Oakland, CA: New Harbinger Publications, In

Gracely, R.H., Geisser, M.E., Giesecke, T., Grant, M.A.B., Petzke, F., Williams, D.A., Clauw,
(2004). Pain catastrophizing and neural responses to pain among persons withfibromyalgia, Brain, 127, 835±843

International Association for the Study of Pain (2009). Global year against Musculoskeletal pain: Fear Avoidance and Musculoskeletal P a i n .
Loggia, M.L., Schweinhardt, P.,Villemure, C., Bushnell, M.C. (2008). Effects of Psychological State on Pain Perception in the Dental Environment, JCDA • • September, Vol. 74, No. 7

Marchand, S. (2012). The Phenomenon of Pain. Seattle, WA: IASP Press

Patten, S.B, (1999) “Long-Term Medical Conditions and Major Depression in theCanadian Population,” Canadian Journal of Psychiatry 44 no. 2: 151-157.

Villemure C, Bushnell MC. (2002). Cognitive modulation of pain: how do attention andemotion influence pain processing? Pain; 95(3):195–9