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The Role of Psychosocial Processes in the Development and Maintenance of Chronic Pain

      Highlights

      • Psychosocial factors play critical roles in the development and maintenance of chronic pain.
      • “Negative” psychosocial factors such as childhood trauma are risk factors for poor pain outcomes.
      • “Positive” variables such as self-efficacy are important resiliency factors.
      • Psychosocial processes influence long-term pain outcomes via multiple biobehavioral pathways.

      Abstract

      The recently proposed Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION)-American Pain Society (APS) Pain Taxonomy (AAPT) provides an evidence-based, multidimensional, chronic pain classification system. Psychosocial factors play a crucial role within several dimensions of the taxonomy. In this article, we discuss the evaluation of psychosocial factors that influence the diagnosis and trajectory of chronic pain disorders. We review studies in individuals with a variety of persistent pain conditions, and describe evidence that psychosocial variables play key roles in conferring risk for the development of pain, in shaping long-term pain-related adjustment, and in modulating pain treatment outcomes. We consider “general” psychosocial variables such as negative affect, childhood trauma, and social support, as well as “pain-specific” psychosocial variables that include pain-related catastrophizing, self-efficacy for managing pain, and pain-related coping. Collectively, the complexity and profound variability in chronic pain highlights the need to better understand the multidimensional array of interacting forces that determine the trajectory of chronic pain conditions.

      Perspective

      The AAPT is an evidence-based chronic pain classification system in which psychosocial concepts and processes are essential in understanding the development of chronic pain and its effects. In this article we review psychosocial processes that influence the onset, exacerbation, and maintenance of chronic pain disorders.

      Key words

      Persistent pain is a significant therapeutic challenge and a public health epidemic placing burdens on those experiencing pain as well as society more broadly. A survey of 10 developed and 7 developing countries suggests that the point prevalence of chronic pain among adults is 41% and 37%, respectively,
      • Tsang A.
      • Von Korff M.
      • Lee S.
      • Alonso J.
      • Karam E.
      • Angermeyer M.C.
      • Borges G.L.
      • Bromet E.J.
      • Demytteneare K.
      • de Girolamo G.
      • de Graaf R.
      • Gureje O.
      • Lepine J.P.
      • Haro J.M.
      • Levinson D.
      • Oakley Browne M.A.
      • Posada-Villa J.
      • Seedat S.
      • Watanabe M.
      Common chronic pain conditions in developed and developing countries: Gender and age differences and comorbidity with depression-anxiety disorders.
      figures which encompass a wide array of diverse conditions. In the United States, chronic pain is estimated to affect over 100 million adults at any given time, is among the leading causes of reduced quality of life, and carries direct and indirect costs of over $600 billion dollars annually in the United States alone.
      • Gaskin D.J.
      • Richard P.
      The economic costs of pain in the United States.
      Moreover, the experience of persistent pain starts early; as many as 38% of children and adolescents in community samples report the presence of chronic pain.
      • King S.
      • Chambers C.T.
      • Huguet A.
      • MacNevin R.C.
      • McGrath P.J.
      • Parker L.
      • MacDonald A.J.
      The epidemiology of chronic pain in children and adolescents revisited: A systematic review.
      Despite the widely recognized effect of chronic pain on global health, however, pain science continues to lack a precise, evidence-based taxonomy of chronic pain conditions, which would facilitate improvements in diagnosis and treatment.
      • Fillingim R.B.
      • Bruehl S.
      • Dworkin R.H.
      • Dworkin S.F.
      • Loeser J.D.
      • Turk D.C.
      • Widerstrom-Noga E.
      • Arnold L.
      • Bennett R.
      • Edwards R.R.
      • Freeman R.
      • Gewandter J.
      • Hertz S.
      • Hochberg M.
      • Krane E.
      • Mantyh P.W.
      • Markman J.
      • Neogi T.
      • Ohrbach R.
      • Paice J.A.
      • Porreca F.
      • Rappaport B.A.
      • Smith S.M.
      • Smith T.J.
      • Sullivan M.D.
      • Verne G.N.
      • Wasan A.D.
      • Wesselmann U.
      The ACTTION-American Pain Society Pain Taxonomy (AAPT): An evidence-based and multidimensional approach to classifying chronic pain conditions.
      The Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks (ACTTION) public-private partnership with the U.S. Food and Drug Administration, and the American Pain Society have joined together to develop an evidence-based chronic pain classification system termed the ACTTION-American Pain Society Pain Taxonomy (AAPT). As noted in the initial description of the taxonomy, pain management stands to benefit substantially from the development of an empirically-based classification system that can serve to illuminate individual differences in the pain experience, inform policy, clarify prognosis, and guide treatment decisions.
      • Fillingim R.B.
      • Bruehl S.
      • Dworkin R.H.
      • Dworkin S.F.
      • Loeser J.D.
      • Turk D.C.
      • Widerstrom-Noga E.
      • Arnold L.
      • Bennett R.
      • Edwards R.R.
      • Freeman R.
      • Gewandter J.
      • Hertz S.
      • Hochberg M.
      • Krane E.
      • Mantyh P.W.
      • Markman J.
      • Neogi T.
      • Ohrbach R.
      • Paice J.A.
      • Porreca F.
      • Rappaport B.A.
      • Smith S.M.
      • Smith T.J.
      • Sullivan M.D.
      • Verne G.N.
      • Wasan A.D.
      • Wesselmann U.
      The ACTTION-American Pain Society Pain Taxonomy (AAPT): An evidence-based and multidimensional approach to classifying chronic pain conditions.
      The structuring of the AAPT was on the basis of a consensus decision that the dimension along which pain disorders would be categorized is organ system/anatomical structure, which includes: peripheral and central neuropathic pain, musculoskeletal pain, pelvic/urogenital, visceral pain, and disease-related pains not classified elsewhere (eg, pain associated with active cancer, sickle cell disease, and Parkinson disease). Some of the most important characteristics of the taxonomy are that 1) it be on the basis of the best available evidence rather than solely on consensus or expert opinion, 2) the diagnostic criteria for specific chronic pain disorders should be determined using existing mechanistic and diagnostic evidence, rather than historical precedent or theoretical biases, 3) it reflects the multidimensional and biopsychosocial nature of chronic pain, and 4) it emphasizes the inclusion of existing information regarding mechanistic features and risk factors for pain conditions, including not only neurobiological but also psychosocial processes.
      • Fillingim R.B.
      • Bruehl S.
      • Dworkin R.H.
      • Dworkin S.F.
      • Loeser J.D.
      • Turk D.C.
      • Widerstrom-Noga E.
      • Arnold L.
      • Bennett R.
      • Edwards R.R.
      • Freeman R.
      • Gewandter J.
      • Hertz S.
      • Hochberg M.
      • Krane E.
      • Mantyh P.W.
      • Markman J.
      • Neogi T.
      • Ohrbach R.
      • Paice J.A.
      • Porreca F.
      • Rappaport B.A.
      • Smith S.M.
      • Smith T.J.
      • Sullivan M.D.
      • Verne G.N.
      • Wasan A.D.
      • Wesselmann U.
      The ACTTION-American Pain Society Pain Taxonomy (AAPT): An evidence-based and multidimensional approach to classifying chronic pain conditions.
      In addition to establishing core diagnostic criteria for numerous chronic pain conditions (dimension 1), the AAPT provides dimensions on which to categorize common features and comorbidities of the conditions (dimensions 2 and 3), as well as detailing the consequences (dimension 4), and contributory mechanisms (dimension 5) of persistent pain disorders. A number of these identified features, consequences, and mechanisms are psychosocial in nature. Indeed, processes such as mood, affect (negative and positive), coping, and social support are included in the taxonomy as specific examples of risk factors, protective factors, or comorbidities that affect the experience of chronic pain and its presentation.
      • Fillingim R.B.
      • Bruehl S.
      • Dworkin R.H.
      • Dworkin S.F.
      • Loeser J.D.
      • Turk D.C.
      • Widerstrom-Noga E.
      • Arnold L.
      • Bennett R.
      • Edwards R.R.
      • Freeman R.
      • Gewandter J.
      • Hertz S.
      • Hochberg M.
      • Krane E.
      • Mantyh P.W.
      • Markman J.
      • Neogi T.
      • Ohrbach R.
      • Paice J.A.
      • Porreca F.
      • Rappaport B.A.
      • Smith S.M.
      • Smith T.J.
      • Sullivan M.D.
      • Verne G.N.
      • Wasan A.D.
      • Wesselmann U.
      The ACTTION-American Pain Society Pain Taxonomy (AAPT): An evidence-based and multidimensional approach to classifying chronic pain conditions.
      The purpose of this article is to highlight the contributory role of psychosocial factors (eg, their function as risk factors, protective factors, or moderators) in the context of the AAPT classification system. The present review is one of a series of foundational supporting articles intended to highlight and describe crucial areas that are common to many or all of the conditions within the AAPT taxonomy. The process of psychosocial assessment (eg, conceptualization of psychosocial domains, evaluation and selection of assessment instruments) is addressed in a complementary supporting article in this Supplement to The Journal of Pain
      • Turk D.C.
      • Fillingim R.B.
      • Ohrbach R.
      • Patel K.V.
      Assessment of psychosocial and functional impact of chronic pain.
      ; to avoid redundancy, in this article we focus specifically on the understanding of the role of psychosocial processes in shaping the development and trajectory of pain conditions. It is also important to note that although the AAPT taxonomy is in many ways a typical category-based diagnostic taxonomy, most of the psychosocial processes described in this article, which have important roles in shaping the development and trajectory of chronic pain conditions, are best considered as continuous, dimensional variables rather than as categorical designations.
      One additional important consideration: although the AAPT describes “psychosocial mechanisms” as part of dimension 5, we have endeavored to limit the use of the term “mechanism” because of some well-known limitations of the existing literature.
      • Bechtel W.
      The challenge of characterizing operations in the mechanisms underlying behavior.
      • Jensen M.P.
      • Turk D.C.
      Contributions of psychology to the understanding and treatment of people with chronic pain: Why it matters to ALL psychologists.
      • Kazdin A.E.
      • Kraemer H.C.
      • Kessler R.C.
      • Kupfer D.J.
      • Offord D.R.
      Contributions of risk-factor research to developmental psychopathology.
      • Kraemer H.C.
      • Kazdin A.E.
      • Offord D.R.
      • Kessler R.C.
      • Jensen P.S.
      • Kupfer D.J.
      Coming to terms with the terms of risk.
      In particular, for a process to function as a causal mechanism, it must be fully distinct from its effect and must clearly precede that effect in time. The literature in this area, although rich in suggestive associations between psychosocial constructs and pain-related outcomes, is impeded by substantial conceptual and theoretical overlap of constructs, as well as overlap in the methods by which they are measured (ie, usually by self-report on numerically scaled questionnaires), and from a relative dearth of clear prospective studies. That is, many of the findings that identify putative psychosocial mechanisms are on the basis of respondent recall of past events or states, or on mediational analysis of cross-sectional data, the limitations of which we elaborate in the Evaluating Psychosocial Contributions to Chronic Pain Outcomes section.

      The Biopsychosocial Model of Pain

      Before the 1960s, most people viewed chronic pain conditions as primarily medical issues with clear pathophysiological bases that required physical treatments such as surgery or medication.
      • Jensen M.P.
      • Turk D.C.
      Contributions of psychology to the understanding and treatment of people with chronic pain: Why it matters to ALL psychologists.
      Subsequently, a biopsychosocial understanding has come to dominate the professional scientific community's characterization of chronic pain. Collectively, the biopsychosocial approach describes pain and disability as a multidimensional, dynamic interaction among physiological, psychological, and social factors that reciprocally influence each other, resulting in chronic and complex pain syndromes.
      • Gatchel R.J.
      • McGeary D.D.
      • McGeary C.A.
      • Lippe B.
      Interdisciplinary chronic pain management: Past, present, and future.
      • Jensen M.P.
      • Turk D.C.
      Contributions of psychology to the understanding and treatment of people with chronic pain: Why it matters to ALL psychologists.
      The overlap between affective disturbance and chronic pain has been widely recognized for many decades.
      • Gatchel R.J.
      • Peng Y.B.
      • Peters M.L.
      • Fuchs P.N.
      • Turk D.C.
      The biopsychosocial approach to chronic pain: Scientific advances and future directions.
      • Turk D.C.
      • Okifuji A.
      Psychological factors in chronic pain: Evolution and revolution.
      Pain is defined as a sensory and an affective experience, and reviews of pain assessment invariably emphasize that pain unpleasantness, or affective responses to pain, should be assessed along with pain intensity and other “sensory” features.
      • Fillingim R.B.
      • Bruehl S.
      • Dworkin R.H.
      • Dworkin S.F.
      • Loeser J.D.
      • Turk D.C.
      • Widerstrom-Noga E.
      • Arnold L.
      • Bennett R.
      • Edwards R.R.
      • Freeman R.
      • Gewandter J.
      • Hertz S.
      • Hochberg M.
      • Krane E.
      • Mantyh P.W.
      • Markman J.
      • Neogi T.
      • Ohrbach R.
      • Paice J.A.
      • Porreca F.
      • Rappaport B.A.
      • Smith S.M.
      • Smith T.J.
      • Sullivan M.D.
      • Verne G.N.
      • Wasan A.D.
      • Wesselmann U.
      The ACTTION-American Pain Society Pain Taxonomy (AAPT): An evidence-based and multidimensional approach to classifying chronic pain conditions.
      Reviews of the biopsychosocial model of pain cite its substantial history, including Engel's call for a new “medical model,”
      • Engel G.L.
      The need for a new medical model: A challenge for biomedicine.
      Fordyce's seminal work on the contribution of communication and contextual factors,
      • Fordyce W.
      Pain and suffering: A reappraisal.
      and Loeser's synthesis of biopsychosocial principles,
      • Loeser J.D.
      Pain and suffering.
      and emphasize its nearly universal acceptance in principle if not practice.
      • Lotze M.
      • Moseley G.L.
      Theoretical considerations for chronic pain rehabilitation.
      • Moseley G.L.
      • Butler D.S.
      Fifteen years of explaining pain: The past, present, and future.
      A good deal of empirical evidence underpins the biopsychosocial model, and few would likely argue that psychological constructs and processes are irrelevant to the experience of pain. In practice, however, psychosocial factors are often assigned secondary status and viewed largely as reactions to pain. As we will describe in the Distress section, longitudinal, observational research supports a strong bidirectional link between mood disorders and persistent pain; the development of an enduring pain condition confers a substantially increased risk for the subsequent diagnosis of an affective disorder, and psychosocial variables such as depression, anxiety, and distress are among the most potent and robust predictors of the transition from acute to chronic pain.
      • Asmundson G.J.
      • Katz J.
      Understanding the co-occurrence of anxiety disorders and chronic pain: State-of-the-art.
      • Bair M.J.
      • Robinson R.L.
      • Katon W.
      • Kroenke K.
      Depression and pain comorbidity: A literature review.
      • Edwards R.R.
      • Cahalan C.
      • Mensing G.
      • Smith M.
      • Haythornthwaite J.A.
      Pain, catastrophizing, and depression in the rheumatic diseases.
      • Linton S.J.
      • Nicholas M.K.
      • MacDonald S.
      • Boersma K.
      • Bergbom S.
      • Maher C.
      • Refshauge K.
      The role of depression and catastrophizing in musculoskeletal pain.
      • Nicholas M.K.
      • Linton S.J.
      • Watson P.J.
      • Main C.J.
      Early identification and management of psychological risk factors (“yellow flags”) in patients with low back pain: A reappraisal.
      • Williams D.A.
      The importance of psychological assessment in chronic pain.
      Across numerous studies, individuals with a variety of chronically painful conditions generally have a several-fold increase in the risk of experiencing clinically significant mood or anxiety symptoms,
      • Asmundson G.J.
      • Katz J.
      Understanding the co-occurrence of anxiety disorders and chronic pain: State-of-the-art.
      • Bair M.J.
      • Robinson R.L.
      • Katon W.
      • Kroenke K.
      Depression and pain comorbidity: A literature review.
      • Edwards R.R.
      • Cahalan C.
      • Mensing G.
      • Smith M.
      • Haythornthwaite J.A.
      Pain, catastrophizing, and depression in the rheumatic diseases.
      • McWilliams L.A.
      • Goodwin R.D.
      • Cox B.J.
      Depression and anxiety associated with three pain conditions: Results from a nationally representative sample.
      and instruments used to assess depression, anxiety, and distress have been recommended for use as outcome measures in randomized controlled trials of pain treatments.
      • Dworkin R.H.
      • Turk D.C.
      • Farrar J.T.
      • Haythornthwaite J.A.
      • Jensen M.P.
      • Katz N.P.
      • Kerns R.D.
      • Stucki G.
      • Allen R.R.
      • Bellamy N.
      • Carr D.B.
      • Chandler J.
      • Cowan P.
      • Dionne R.
      • Galer B.S.
      • Hertz S.
      • Jadad A.R.
      • Kramer L.D.
      • Manning D.C.
      • Martin S.
      • McCormick C.G.
      • McDermott M.P.
      • McGrath P.
      • Quessy S.
      • Rappaport B.A.
      • Robbins W.
      • Robinson J.P.
      • Rothman M.
      • Royal M.A.
      • Simon L.
      • Stauffer J.W.
      • Stein W.
      • Tollett J.
      • Wernicke J.
      • Witter J.
      Core outcome measures for chronic pain clinical trials: IMMPACT recommendations.
      • Turk D.C.
      • Dworkin R.H.
      What should be the core outcomes in chronic pain clinical trials?.
      • Turk D.C.
      • Dworkin R.H.
      • Allen R.R.
      • Bellamy N.
      • Brandenburg N.
      • Carr D.B.
      • Cleeland C.
      • Dionne R.
      • Farrar J.T.
      • Galer B.S.
      • Hewitt D.J.
      • Jadad A.R.
      • Katz N.P.
      • Kramer L.D.
      • Manning D.C.
      • McCormick C.G.
      • McDermott M.P.
      • McGrath P.
      • Quessy S.
      • Rappaport B.A.
      • Robinson J.P.
      • Royal M.A.
      • Simon L.
      • Stauffer J.W.
      • Stein W.
      • Tollett J.
      • Witter J.
      Core outcome domains for chronic pain clinical trials: IMMPACT recommendations.
      • Turk D.C.
      • Dworkin R.H.
      • Revicki D.
      • Harding G.
      • Burke L.B.
      • Cella D.
      • Cleeland C.S.
      • Cowan P.
      • Farrar J.T.
      • Hertz S.
      • Max M.B.
      • Rappaport B.A.
      Identifying important outcome domains for chronic pain clinical trials: An IMMPACT survey of people with pain.
      Because of the synergy between pain and negative affect, this makes good logical sense: efficacious analgesic treatments that reduce the frequency and intensity of pain should have a beneficial effect on patients' affective states and appropriate treatment of emotional distress should have a positive influence on the experience of pain.
      • Arola H.M.
      • Nicholls E.
      • Mallen C.
      • Thomas E.
      Self-reported pain interference and symptoms of anxiety and depression in community-dwelling older adults: Can a temporal relationship be determined?.
      • Bair M.J.
      • Robinson R.L.
      • Katon W.
      • Kroenke K.
      Depression and pain comorbidity: A literature review.
      • Kroenke K.
      • Wu J.
      • Bair M.J.
      • Krebs E.E.
      • Damush T.M.
      • Tu W.
      Reciprocal relationship between pain and depression: A 12-month longitudinal analysis in primary care.
      • Lewandowski Holley A.
      • Law E.F.
      • Zhou C.
      • Murphy L.
      • Clarke G.
      • Palermo T.M.
      Reciprocal longitudinal associations between pain and depressive symptoms in adolescents.
      Indeed, several randomized controlled trials in primary care settings have shown that antidepressant treatment in patients with comorbid chronic pain and mood disorders produces fairly rapid analgesic benefits that are anticipated by, and robustly correlated with, improvements in indices of psychosocial distress.
      • Kroenke K.
      • Bair M.J.
      • Damush T.M.
      • Wu J.
      • Hoke S.
      • Sutherland J.
      • Tu W.
      Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain: A randomized controlled trial.
      • Rej S.
      • Dew M.A.
      • Karp J.F.
      Treating concurrent chronic low back pain and depression with low-dose venlafaxine: An initial identification of “easy-to-use” clinical predictors of early response.
      We should note that it is important not to confuse psychological constructs and processes with psychiatric illness. Although psychiatric conditions certainly co-occur with chronic pain, and chronic pain samples do show elevations in rates of psychiatric disorders,
      • Asmundson G.J.
      • Katz J.
      Understanding the co-occurrence of anxiety disorders and chronic pain: State-of-the-art.
      • Bair M.J.
      • Robinson R.L.
      • Katon W.
      • Kroenke K.
      Depression and pain comorbidity: A literature review.
      • Edwards R.R.
      • Cahalan C.
      • Mensing G.
      • Smith M.
      • Haythornthwaite J.A.
      Pain, catastrophizing, and depression in the rheumatic diseases.
      • McWilliams L.A.
      • Goodwin R.D.
      • Cox B.J.
      Depression and anxiety associated with three pain conditions: Results from a nationally representative sample.
      elevated levels of negative affect and diminished cognition at subthreshold levels for a psychiatric disorder also play an influential role in shaping pain responses and pain-related outcomes. For example, evidence suggests that elevations in negative affect and pain-specific distress are associated with reduced benefit from a variety of potentially pain-reducing treatments.
      • Edwards R.R.
      • Cahalan C.
      • Mensing G.
      • Smith M.
      • Haythornthwaite J.A.
      Pain, catastrophizing, and depression in the rheumatic diseases.
      • Wasan A.D.
      • Davar G.
      • Jamison R.
      The association between negative affect and opioid analgesia in patients with discogenic low back pain.
      • Wasan A.D.
      • Jamison R.N.
      • Pham L.
      • Tipirneni N.
      • Nedeljkovic S.S.
      • Katz J.N.
      Psychopathology predicts the outcome of medial branch blocks with corticosteroid for chronic axial low back or cervical pain: A prospective cohort study.
      Wasan and colleagues
      • Wasan A.D.
      • Michna E.
      • Edwards R.R.
      • Katz J.N.
      • Nedeljkovic S.S.
      • Dolman A.J.
      • Janfaza D.
      • Isaac Z.
      • Jamison R.N.
      Psychiatric comorbidity is associated prospectively with diminished opioid analgesia and increased opioid misuse in patients with chronic low back pain.
      reported that back pain patients with high levels of negative affect experienced approximately a 50% reduction in oral opioid analgesia relative to patients with low negative affect. Recently, a number of relevant prospective studies have involved studies of interpatient variability in pain outcomes after surgery. Longitudinal studies evaluating variability in pain-related outcomes after joint replacement surgery highlight the importance of assessing mental health, or psychosocial functioning, preoperatively,
      • Duivenvoorden T.
      • Vissers M.M.
      • Verhaar J.A.
      • Busschbach J.J.
      • Gosens T.
      • Bloem R.M.
      • Bierma-Zeinstra S.M.
      • Reijman M.
      Anxiety and depressive symptoms before and after total hip and knee arthroplasty: A prospective multicentre study.
      • Hanusch B.C.
      • O’Connor D.B.
      • Ions P.
      • Scott A.
      • Gregg P.J.
      Effects of psychological distress and perceptions of illness on recovery from total knee replacement.
      • Vissers M.M.
      • Bussmann J.B.
      • Verhaar J.A.
      • Busschbach J.J.
      • Bierma-Zeinstra S.M.
      • Reijman M.
      Psychological factors affecting the outcome of total hip and knee arthroplasty: A systematic review.
      because patients with higher baseline levels of anxiety and depression report less benefit, more complications, increased pain and analgesic use, and poorer function for years after total knee or total hip replacement.
      • Duivenvoorden T.
      • Vissers M.M.
      • Verhaar J.A.
      • Busschbach J.J.
      • Gosens T.
      • Bloem R.M.
      • Bierma-Zeinstra S.M.
      • Reijman M.
      Anxiety and depressive symptoms before and after total hip and knee arthroplasty: A prospective multicentre study.
      • Hanusch B.C.
      • O’Connor D.B.
      • Ions P.
      • Scott A.
      • Gregg P.J.
      Effects of psychological distress and perceptions of illness on recovery from total knee replacement.
      • Vissers M.M.
      • Bussmann J.B.
      • Verhaar J.A.
      • Busschbach J.J.
      • Bierma-Zeinstra S.M.
      • Reijman M.
      Psychological factors affecting the outcome of total hip and knee arthroplasty: A systematic review.
      Overall, recent reviews and meta-analyses support the importance of a broad array of psychosocial factors in shaping pain-related experiences and outcomes across numerous pain conditions.
      • Nicholas M.K.
      • Linton S.J.
      • Watson P.J.
      • Main C.J.
      Early identification and management of psychological risk factors (“yellow flags”) in patients with low back pain: A reappraisal.
      • Pincus T.
      • Burton A.K.
      • Vogel S.
      • Field A.P.
      A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain.
      • Vissers M.M.
      • Bussmann J.B.
      • Verhaar J.A.
      • Busschbach J.J.
      • Bierma-Zeinstra S.M.
      • Reijman M.
      Psychological factors affecting the outcome of total hip and knee arthroplasty: A systematic review.
      A good deal of this work has involved studies of back pain. For example, Taylor and colleagues
      • Taylor J.B.
      • Goode A.P.
      • George S.Z.
      • Cooke C.E.
      Incidence and risk factors for first-time incident low back pain: A systematic review and meta-analysis.
      noted that variables such as job dissatisfaction, low job control, minimal social support, depression, and interpersonal conflict were strongly associated with incident low back pain (LBP). In another systematic review and meta-analysis, similar processes such as distress, low self-efficacy, and pain-related fear were identified as crucially important in back and in neck pain.
      • Lee H.
      • Hübscher M.
      • Moseley G.L.
      • Kamper S.J.
      • Traeger A.C.
      • Mansell G.
      • McAuley J.H.
      How does pain lead to disability? A systematic review and meta-analysis of mediation studies in people with back and neck pain.
      Reviews of other conditions such as postoperative pain,
      • Schreiber K.L.
      • Kehlet H.
      • Belfer I.
      • Edwards R.R.
      Predicting, preventing and managing persistent pain after breast cancer surgery: The importance of psychosocial factors.
      chronic pelvic pain,
      • Riegel B.
      • Bruenahl C.A.
      • Ahyai S.
      • Bingel U.
      • Fisch M.
      • Löwe B.
      Assessing psychological factors, social aspects and psychiatric co-morbidity associated with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) in men – a systematic review.
      fibromyalgia (FM),
      • Clauw D.J.
      Fibromyalgia and related conditions.
      and neuropathic pain
      • Cohen S.P.
      • Mao J.
      Neuropathic pain: Mechanisms and their clinical implications.
      have reached similar conclusions. Some of these factors are discussed in further detail in the General Psychosocial Factors and Pain-Specific Psychosocial Constructs sections; here we simply note that these variables appear to serve as robust risk factors that confer vulnerability for the development of persistent pain. We should also emphasize that characterizing domains of variables as “psychological” or “psychosocial” refers principally to the method of assessment rather than the presumed underlying pathophysiologic mechanism that drives pain-related outcomes.
      • Diatchenko L.
      • Fillingim R.B.
      • Smith S.B.
      • Maixner W.
      The phenotypic and genetic signatures of common musculoskeletal pain conditions.
      That is, although they may be assessed via patient self-report of cognitive and emotional processes, constructs such as somatic awareness, anxiety, and pain-related catastrophizing likely reflect altered peripheral and central nervous system processing of sensory stimuli. For example, these “psychological” features of patients are often significantly correlated with measures of somatosensory amplification or central sensitization.
      • Diatchenko L.
      • Fillingim R.B.
      • Smith S.B.
      • Maixner W.
      The phenotypic and genetic signatures of common musculoskeletal pain conditions.
      • Edwards R.R.
      • Cahalan C.
      • Mensing G.
      • Smith M.
      • Haythornthwaite J.A.
      Pain, catastrophizing, and depression in the rheumatic diseases.
      • Jensen M.P.
      • Turk D.C.
      Contributions of psychology to the understanding and treatment of people with chronic pain: Why it matters to ALL psychologists.
      Indeed, recent reviews of vulnerability and resilience factors in chronic pain emphasize the association of psychological processes with neurobiological pathways such as epigenetic processes, cellular priming, and alterations in brain networks concerned with reward, motivation, and learning, and descending modulatory control (Fig 1).
      • Denk F.
      • McMahon S.B.
      • Tracey I.
      Pain vulnerability: A neurobiological perspective.
      Thus, neuropathic processes of sensitization at the peripheral, spinal cord, and/or brain levels are likely to be heightened by psychosocial factors, present concurrently, longitudinally, or antecedent in relation to the painful condition.
      Figure thumbnail gr1
      Figure 1Interactive pathways shaping risk for chronic pain.
      From: Denk et al.
      • Denk F.
      • McMahon S.B.
      • Tracey I.
      Pain vulnerability: A neurobiological perspective.
      Despite its widespread support, there has also been some criticism of the limitations of the biopsychosocial model of pain. The model is rather vague about the specific pathways by which its elements interact and there are often no clear boundaries between categories of processes and constructs. Moreover, many of the explanations invoked by the biopsychosocial model to account for interindividual variability in pain-related outcomes are so multifactorial they are unfalsifiable by empirical research.
      • Gatchel R.J.
      • McGeary D.D.
      • McGeary C.A.
      • Lippe B.
      Interdisciplinary chronic pain management: Past, present, and future.
      • Gatchel R.J.
      • Peng Y.B.
      • Peters M.L.
      • Fuchs P.N.
      • Turk D.C.
      The biopsychosocial approach to chronic pain: Scientific advances and future directions.
      • Gatchel R.J.
      • Turk D.C.
      Criticisms of the biopsychosocial model in spine care: Creating and then attacking a straw person.
      • Weiner B.K.
      Spine update: The biopsychosocial model and spine care.
      Additional criticisms include the observation that most “biopsychosocial” studies do not routinely measure variables within each of the 3 domains (biological, psychological, and social)
      • Pincus T.
      • Kent P.
      • Bronfort G.
      • Loisel P.
      • Pransky G.
      • Hartvigsen J.
      Twenty-five years with the biopsychosocial model of low back pain-is it time to celebrate? A report from the twelfth international forum for primary care research on low back pain.
      ; indeed, it has been suggested that the biopsychosocial model may overweight psychosocial factors, especially in the absence of clear anatomic pathology, which risks reverting to a dualistic perspective of mind versus body.
      • Weiner B.K.
      Spine update: The biopsychosocial model and spine care.
      Other researchers have noted that the biopsychosocial model, as commonly described, may be too restrictive because it fails to capture important elements of quality of life, such as spirituality and religion, which has led to the development of a biopsychosocial-spiritual model of chronic pain that was recently applied to patients with sickle cell disease.
      • Taylor L.E.
      • Stotts N.A.
      • Humphreys J.
      • Treadwell M.J.
      • Miaskowski C.
      A biopsychosocial-spiritual model of chronic pain in adults with sickle cell disease.
      Still other approaches have emphasized behavioral aspects of pain, with a biopsychomotor model highlighting the critical roles of communicative pain behaviors, protective pain behaviors, and social response behaviors.
      • Sullivan M.J.
      Toward a biopsychomotor conceptualization of pain: Implications for research and intervention.
      Despite these criticisms, however, the biopsychosocial model of pain has been enormously valuable in shaping our understanding of individual differences in pain, and in guiding the development of efficacious and effective psychosocial and behavioral interventions to reduce the suffering and sequelae associated with persistent pain.
      • Gatchel R.J.
      • McGeary D.D.
      • McGeary C.A.
      • Lippe B.
      Interdisciplinary chronic pain management: Past, present, and future.
      • Jensen M.P.
      • Turk D.C.
      Contributions of psychology to the understanding and treatment of people with chronic pain: Why it matters to ALL psychologists.
      • Williams D.A.
      The importance of psychological assessment in chronic pain.
      The AAPT taxonomy is designed to give balance to the sets of biological, psychological, and social variables and importantly their interactions across chronic pain disorders. Each of these constituent domains should be considered in classifying all chronic pain disorders, hence the multidimensional system outlined.
      • Crombez G.
      • Van Ryckeghem D.M.
      • Eccleston C.
      • Van Damme S.
      Attentional bias to pain-related information: A meta-analysis.

      Mechanism-Based Pain “Models”

      Under the broad umbrella of the biopsychosocial approach to understanding chronic pain, a number of more specific, mechanism-oriented models have been developed to describe the pathways by which particular processes can influence pain-related outcomes. Perhaps the most widely known and influential of these models is the Fear Avoidance Model (FAM), which was advanced nearly 20 years ago to explain the development and persistence of disabling LBP in a subgroup of patients.
      • Vlaeyen J.W.
      • Am Kole-Snijders
      • Boeren R.G.
      • Van Eek H.
      Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance.
      The model proposes that pain-related disability is caused by an interacting, cyclical sequence of fear-related cognitive, affective, and behavioral processes (Fig 2). The basic concept underpinning the model is that fear of pain leads to a cascade of deleterious consequences (Fig 2). ‘Confrontation’ and ‘avoidance’ are postulated as the 2 categories of behavioral responses to fear about pain; the former leads to the eventual reduction of fear over time. Avoidance, in contrast, leads to the maintenance or amplification of fear, which in turn results in disuse and disability.
      • Crombez G.
      • Eccleston C.
      • Van Damme S.
      • Vlaeyen J.W.
      • Karoly P.
      Fear-avoidance model of chronic pain: The next generation.
      • Volders S.
      • Boddez Y.
      • De Peuter S.
      • Meulders A.
      • Vlaeyen J.W.
      Avoidance behavior in chronic pain research: A cold case revisited.
      Since its introduction, the FAM has inspired productive research and has grown to be the leading paradigm for understanding disability associated with a wide range of musculoskeletal pain conditions. Over the past decade, the original FAM has been extended to include learning, motivation, and self-regulation theory.
      • Crombez G.
      • Eccleston C.
      • Van Damme S.
      • Vlaeyen J.W.
      • Karoly P.
      Fear-avoidance model of chronic pain: The next generation.
      In several recent systematic reviews of the elements of the FAM, including thousands of patients in clinical studies, the authors concluded that within cohorts of patients with LBP for less than 6 months, there was high-quality prospective evidence that fear avoidance behaviors were associated with more pain and functional disability, poorer treatment outcomes overall, and reduced probabilities of return to work, and decreased fear avoidance was associated with improved clinical outcomes.
      • Wertli M.M.
      • Rasmussen-Barr E.
      • Held U.
      • Weiser S.
      • Bachmann L.M.
      • Brunner F.
      Fear-avoidance beliefs-a moderator of treatment efficacy in patients with low back pain: A systematic review.
      • Wertli M.M.
      • Rasmussen-Barr E.
      • Weiser S.
      • Bachmann L.M.
      • Brunner F.
      The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: A systematic review.
      Collectively, over three-quarters of published studies reported that baseline levels of fear avoidance significantly influenced treatment outcomes, with participants high in fear avoidance reporting more pain and disability, and showing lower levels of return to work after treatment.
      • Wertli M.M.
      • Rasmussen-Barr E.
      • Held U.
      • Weiser S.
      • Bachmann L.M.
      • Brunner F.
      Fear-avoidance beliefs-a moderator of treatment efficacy in patients with low back pain: A systematic review.
      • Wertli M.M.
      • Rasmussen-Barr E.
      • Weiser S.
      • Bachmann L.M.
      • Brunner F.
      The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: A systematic review.
      In addition, treatment-related reductions in fear avoidance beliefs were important mediators of treatment benefits such as reduced pain and return to work.
      Figure thumbnail gr2
      Figure 2The FAM of pain.
      From: Vlaeyen and Linton.
      • Vlaeyen J.W.
      • Linton S.J.
      Fear-avoidance and its consequences in chronic musculoskeletal pain: A state of the art.
      • Vlaeyen J.W.
      • Linton S.J.
      Fear-avoidance model of chronic musculoskeletal pain: 12 years on.
      A key prediction of the original FAM is the specific, prospective, sequential inter-relationships between catastrophizing, fear, depression, and pain-related disability, and the role of fear as a common barrier to recovery. Many of the initial studies used cross-sectional analyses to test aspects of the FAM; these provided firm evidence of associations between the constructs of interest (eg, pain-related fear was positively associated with measures of disability), but longitudinal designs are needed to confirm the sequence and direction of relationships proposed in Fig 2.
      • Wideman T.H.
      • Asmundson G.G.
      • Smeets R.J.
      • Zautra A.J.
      • Simmonds M.J.
      • Sullivan M.J.
      • Haythornthwaite J.A.
      • Edwards R.R.
      Rethinking the Fear Avoidance Model: Toward a multidimensional framework of pain-related disability.
      Interestingly, several recent studies using a 3-panel, prospective design (in which earlier changes in 1 variable, from time 1 to time 2, are investigated as predictors of later changes in an outcome variable, from time 2 to time 3) have failed to show that changes in pain catastrophizing precede changes in pain-related fear or that changes in fear precede changes in depression.
      • Bergbom S.
      • Boersma K.
      • Linton S.J.
      Both early and late changes in psychological variables relate to treatment outcome for musculoskeletal pain patients at risk for disability.
      • Wideman T.H.
      • Adams H.
      • Sullivan M.J.
      A prospective sequential analysis of the fear-avoidance model of pain.
      These findings highlight a common conceptual problem in research that purports to examine causal psychosocial mechanisms: the hypothesized associations between variables of interest are often strong, but the postulated temporal pathways (variable X affects variable Y, which in turn affects outcome Z) are rarely specific. That is, although these factors inter-relate across time, there is minimal evidence that the sequence of influence unfolds uniquely in the manner specified by the model. Thus, although the extant literature provides valuable information on psychosocial constructs and processes that are related to the experience of pain, and in some cases supports the concept of specific variables as prospective risk factors, or protective factors, there is a general lack of definitive evidence for causal mechanistic influences.
      The FAM emphasizes cyclical relationships between its hypothesized risk factors (catastrophizing, fear, depression), however, recent findings support the central importance of cumulative interactions among overlapping factors, with cumulative risk load being a key contributor to pain outcomes, and potentially serving as the optimal target of treatment.
      • Wideman T.H.
      • Asmundson G.G.
      • Smeets R.J.
      • Zautra A.J.
      • Simmonds M.J.
      • Sullivan M.J.
      • Haythornthwaite J.A.
      • Edwards R.R.
      Rethinking the Fear Avoidance Model: Toward a multidimensional framework of pain-related disability.
      For example, patients with elevated scores on a greater number of risk factors (ie, those with a higher cumulative risk load) are more likely to develop prolonged pain and disability.
      • Wideman T.H.
      • Sullivan M.J.
      Development of a cumulative psychosocial factor index for problematic recovery following work-related musculoskeletal injuries.
      The clinical value of this approach has been highlighted by findings that a single measure of cumulative risk load shows greater predictive strength and scope than combined severity measures of catastrophizing, fear, and depression.
      • Wideman T.H.
      • Hill J.C.
      • Main C.J.
      • Lewis M.
      • Sullivan M.J.
      • Hay E.M.
      Comparing the responsiveness of a brief, multidimensional risk screening tool for back pain to its unidimensional reference standards: The whole is greater than the sum of its parts.
      • Wideman T.H.
      • Sullivan M.J.
      Development of a cumulative psychosocial factor index for problematic recovery following work-related musculoskeletal injuries.
      Additionally, stratifying clinical interventions on the basis of cumulative prognostic risk has been shown to lead to improved outcome and reduced treatment cost.
      • Wideman T.H.
      • Asmundson G.G.
      • Smeets R.J.
      • Zautra A.J.
      • Simmonds M.J.
      • Sullivan M.J.
      • Haythornthwaite J.A.
      • Edwards R.R.
      Rethinking the Fear Avoidance Model: Toward a multidimensional framework of pain-related disability.
      • Wideman T.H.
      • Sullivan M.J.
      Development of a cumulative psychosocial factor index for problematic recovery following work-related musculoskeletal injuries.
      Although the cyclical relationships of the FAM offer appealingly specific clinical implications (eg, treating catastrophizing before fear), model-relevant interventions fail to meet this level of specificity and increasing evidence suggests that cumulative, global risk indices may be a more important target of treatment than particular psychosocial constructs.
      • Wideman T.H.
      • Asmundson G.G.
      • Smeets R.J.
      • Zautra A.J.
      • Simmonds M.J.
      • Sullivan M.J.
      • Haythornthwaite J.A.
      • Edwards R.R.
      Rethinking the Fear Avoidance Model: Toward a multidimensional framework of pain-related disability.
      • Wideman T.H.
      • Sullivan M.J.
      Development of a cumulative psychosocial factor index for problematic recovery following work-related musculoskeletal injuries.
      Because of the complexity of chronic pain,
      • Gatchel R.J.
      • McGeary D.D.
      • McGeary C.A.
      • Lippe B.
      Interdisciplinary chronic pain management: Past, present, and future.
      • Jensen M.P.
      • Turk D.C.
      Contributions of psychology to the understanding and treatment of people with chronic pain: Why it matters to ALL psychologists.
      it should perhaps not be surprising that the FAM fails to identify a universal pathway leading to pain-related disability. Moreover, the unique associations between FAM measures (such as fear of pain and catastrophizing) and outcomes such as longitudinal changes in pain intensity or return to work after a painful injury are generally modest, with these measures often explaining 10 to 15% of the variance in outcomes in the context of multidimensional predictive models.
      • Wideman T.H.
      • Asmundson G.G.
      • Smeets R.J.
      • Zautra A.J.
      • Simmonds M.J.
      • Sullivan M.J.
      • Haythornthwaite J.A.
      • Edwards R.R.
      Rethinking the Fear Avoidance Model: Toward a multidimensional framework of pain-related disability.
      • Wideman T.H.
      • Sullivan M.J.
      Development of a cumulative psychosocial factor index for problematic recovery following work-related musculoskeletal injuries.
      For example, a given patient may indeed experience intense fear during an acute pain episode, which leads to later avoidance behavior and disability, but another may have a preexisting mood disorder that subsequently amplifies negative pain-related cognitions such as fear and catastrophizing. Despite the limitations described, this mechanism-based model has collectively produced enormous heuristic value in facilitating our understanding and testing of some of the pathways by which psychosocial processes can shape long-term pain-related outcomes.
      A number of other explanatory biopsychosocial models have been proposed, and it would require more space than we have available to adequately describe them. We briefly mention one other model—the avoidance-endurance model (AEM)
      • Hasenbring M.I.
      • Chehadi O.
      • Titze C.
      • Kreddig N.
      Fear and anxiety in the transition from acute to chronic pain: There is evidence for endurance besides avoidance.
      • Hasenbring M.I.
      • Hallner D.
      • Klasen B.
      • Streitlein-Böhme I.
      • Willburger R.
      • Rusche H.
      Pain-related avoidance versus endurance in primary care patients with subacute back pain: Psychological characteristics and outcome at a 6-month follow-up.
      —which has some overlap with the FAM, although it emphasizes the importance of particular behaviorally-defined subgroups.
      • Hasenbring M.I.
      • Verbunt J.A.
      Fear-avoidance and endurance-related responses to pain: New models of behavior and their consequences for clinical practice.
      The AEM hypothesizes that while some patients experiencing persistent pain will become fearful and activity-avoidant, others will show an “endurance response,” characterized by maintained activity and task persistence. The type of endurance response is determined by affective and cognitive factors, because patients with high levels of anxiety and thought suppression will show a maladaptive “distress endurance response pattern” and others with high levels of positive affect and a tendency to minimize the threat value of pain will show a more adaptive “eustress endurance response pattern.” Thus, the AEM highlights the interplay of psychosocial processes with behavior, and defines patient subgroups on that basis (ie, the adaptiveness of showing “endurance” in the face of pain depends on the psychosocial correlates of that behavior). Overall, these various models postulate that patterns of affect, cognition, and behavior interact with an array of neurobiological pathways to shape long-term pain outcomes such as disability.
      • Hasenbring M.I.
      • Verbunt J.A.
      Fear-avoidance and endurance-related responses to pain: New models of behavior and their consequences for clinical practice.
      • Rusu A.C.
      • Boersma K.
      • Turk D.C.
      Subgroups of pain patients - the potential of customizing treatments.
      For examples of other disease-related biopsychosocial models, the reader is referred to publications on multiple sclerosis pain,
      • Michalski D.
      • Liebig S.
      • Thomae E.
      • Hinz A.
      • Bergh F.T.
      Pain in patients with multiple sclerosis: A complex assessment including quantitative and qualitative measurements provides for a disease-related biopsychosocial pain model.
      sickle cell pain,
      • Taylor L.E.
      • Stotts N.A.
      • Humphreys J.
      • Treadwell M.J.
      • Miaskowski C.
      A biopsychosocial-spiritual model of chronic pain in adults with sickle cell disease.
      cancer pain,
      • Novy D.M.
      • Aigner C.J.
      The biopsychosocial model in cancer pain.
      and HIV-related neuropathic pain.
      • Marcus K.S.
      • Kerns R.D.
      • Rosenfeld B.
      • Breitbart W.
      HIV/AIDS-related pain as a chronic pain condition: Implications of a biopsychosocial model for comprehensive assessment and effective management.
      A comprehensive assessment of the overlap and the unique features of these models would be well beyond the scope of the present article, but we note that many influential psychosocial factors are common to most of these disease-related models.

      Evaluating Psychosocial Contributions to Chronic Pain Outcomes

      In this section we discuss 2 broad categories of “mechanistic” studies. In the first, psychosocial processes either exist within an individual as preexisting “vulnerability” factors (eg, childhood trauma
      • Denk F.
      • McMahon S.B.
      • Tracey I.
      Pain vulnerability: A neurobiological perspective.
      ) or potentially “protective” factors (eg, social support
      • Jensen M.P.
      • Moore M.R.
      • Bockow T.B.
      • Ehde D.M.
      • Engel J.M.
      Psychosocial factors and adjustment to chronic pain in persons with physical disabilities: A systematic review.
      • Stewart D.E.
      • Yuen T.
      A systematic review of resilience in the physically ill.
      ), or emerge in response to the experience of pain (eg, fear-avoidance behavior,
      • Crombez G.
      • Eccleston C.
      • Van Damme S.
      • Vlaeyen J.W.
      • Karoly P.
      Fear-avoidance model of chronic pain: The next generation.
      self-efficacy
      • Somers T.J.
      • Wren A.A.
      • Shelby R.A.
      The context of pain in arthritis: Self-efficacy for managing pain and other symptoms.
      • Wright L.J.
      • Zautra A.J.
      • Going S.
      Adaptation to early knee osteoarthritis: The role of risk, resilience, and disease severity on pain and physical functioning.
      ; Fig 3). These psychosocial forces then shape individual variability in pain-related outcomes over time. For example, specific psychosocial characteristics place individuals at elevated or reduced risk for the transition from an acute to a persistent pain state, or for the development of pain-related disability in the context of a persisting pain condition.
      • Linton S.J.
      • Nicholas M.K.
      • MacDonald S.
      • Boersma K.
      • Bergbom S.
      • Maher C.
      • Refshauge K.
      The role of depression and catastrophizing in musculoskeletal pain.
      • Pincus T.
      • Kent P.
      • Bronfort G.
      • Loisel P.
      • Pransky G.
      • Hartvigsen J.
      Twenty-five years with the biopsychosocial model of low back pain-is it time to celebrate? A report from the twelfth international forum for primary care research on low back pain.
      In the second type of mechanistic study, which involves an intervention within a group of patients with chronic pain, the treatment is hypothesized to directly affect a psychological factor, a change that is then associated with a subsequent change in one or more outcome variables of interest. That is, the psychological factor acts as a mediator (though not necessarily a causal mechanism) through which a treatment confers its benefits. This type of study parallels, in its structure, many biological and pharmacological studies in which a medication acts on a specific receptor, a transcutaneous electrical nerve stimulation (TENS) unit reduces the transmission of pain-related information in the distribution of a nerve, or a physical therapy regimen strengthens a particular group of muscles. In general, if a psychosocial process contributes causally to treatment-related changes in outcomes, then several conditions should be met.
      • Burns J.W.
      • Nielson W.R.
      • Jensen M.P.
      • Heapy A.
      • Czlapinski R.
      • Kerns R.D.
      Specific and general therapeutic mechanisms in cognitive behavioral treatment of chronic pain.
      • Kazdin A.E.
      Mediators and mechanisms of change in psychotherapy research.
      First, a change in the psychosocial factor should precede any changes in the outcome. Second, changes in that factor should be statistically related to subsequent changes in the outcome. Third, the temporal relationship should not be reversible; that is, changes in the outcome should not produce subsequent changes in the psychosocial factor (although meeting this criterion is complicated by the dynamic, bidirectional interactions between pain and psychosocial processes). A study meeting these conditions would provide substantive, although not definitive, evidence that the identified psychosocial process is on a causal pathway linking a treatment with an outcome. However, rarely do studies in this area meet such rigorous standards.
      Figure thumbnail gr3
      Figure 3Illustration of the effect of psychosocial constructs and processes on pain-related outcomes. Abbreviation: CNS, central nervous system.
      Often, mediation analysis is used to test the hypothesized effects. Mediation analysis offers a method of testing theories regarding the causal links between a predictor and an outcome.
      • Lee H.
      • Hübscher M.
      • Moseley G.L.
      • Kamper S.J.
      • Traeger A.C.
      • Mansell G.
      • McAuley J.H.
      How does pain lead to disability? A systematic review and meta-analysis of mediation studies in people with back and neck pain.
      • Mansell G.
      • Hill J.C.
      • Kamper S.J.
      • Kent P.
      • Main C.
      • van der Windt D.A.
      How can we design low back pain intervention studies to better explain the effects of treatment?.
      Mediators, also known as intermediate variables, or indirect effects, are variables that are on a causal pathway between predictor and outcome, and “explain” the effect of the former on the latter. Mediation analysis, which is increasingly applied to study psychosocial contributions to the experience of pain, tests whether the influence of a predictor or treatment on an outcome occurs via change in a particular intermediate variable, the mediator. Mediation analysis can be applied to data from various types of study designs, from cross-sectional surveys to randomized controlled trials, although different study designs impose different limitations on the interpretation of mediational effects. Unfortunately, mediation analysis has been most frequently applied to cross-sectional data, often resulting in inappropriate causal conclusions. Cross-sectional mediation analysis, which uses patterns of between-subject variation to substitute for within-subject temporal variation, cannot provide the basis for causal assertions. Longitudinal designs are an essential prerequisite for drawing any type of conclusions about causal associations between variables. In addition, although many mediational studies evaluate a single mediator of the association between predictor and outcome, it is much more likely, in the context of a complex condition such as chronic pain, that a number of mediators contribute to any observed relationships.
      • Lee H.
      • Hübscher M.
      • Moseley G.L.
      • Kamper S.J.
      • Traeger A.C.
      • Mansell G.
      • McAuley J.H.
      How does pain lead to disability? A systematic review and meta-analysis of mediation studies in people with back and neck pain.
      • Mansell G.
      • Hill J.C.
      • Kamper S.J.
      • Kent P.
      • Main C.
      • van der Windt D.A.
      How can we design low back pain intervention studies to better explain the effects of treatment?.
      To assess mediation in pain studies, linear regression, bootstrapping approaches, or structural equation modeling (SEM) techniques are most often applied.
      • Lee H.
      • Hübscher M.
      • Moseley G.L.
      • Kamper S.J.
      • Traeger A.C.
      • Mansell G.
      • McAuley J.H.
      How does pain lead to disability? A systematic review and meta-analysis of mediation studies in people with back and neck pain.
      • Mansell G.
      • Hill J.C.
      • Kamper S.J.
      • Kent P.
      • Main C.
      • van der Windt D.A.
      How can we design low back pain intervention studies to better explain the effects of treatment?.
      Linear regression is relatively simple to use and widely familiar to researchers but makes strong assumptions about the data that are not always met (eg, the assumption of no measurement error). In an influential publication, Baron and Kenny
      • Baron R.
      • Kenny D.
      The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations.
      laid out several requirements that must be met to form a mediation relationship. In short, the independent (predictor) variable must be significantly associated with the dependent (outcome) and the mediator variable in univariate regression analyses, and in a regression in which the mediator and the independent (predictor) variable are entered together, the mediator must remain significantly associated with the dependent (outcome) variable, and the previously significant path between the independent (predictor) and dependent (outcome) variable must be reduced in magnitude, or rendered nonsignificant. Increasingly, mediation studies have used bootstrapping, which is a general approach to statistical inference on the basis of random resampling from the observed data. In general, the traditional Baron and Kenny
      • Baron R.
      • Kenny D.
      The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations.
      regression-based mediation analyses has fairly limited power; bootstrapping has been widely recommended because it improves power, even in relatively small samples, and obviates concerns over violating normality assumptions.
      • Beasley T.M.
      Tests of mediation: Paradoxical decline in statistical power as a function of mediator collinearity.
      • Koopman J.
      • Howe M.
      • Hollenbeck J.R.
      • Sin H.P.
      Small sample mediation testing: Misplaced confidence in bootstrapped confidence intervals.
      SEM can also be used to test mediation effects, and is being increasingly used by psychosocial pain researchers.
      • Akerblom S.
      • Perrin S.
      • Rivano F.M.
      • McCracken L.M.
      The mediating role of acceptance in multidisciplinary cognitive-behavioral therapy for chronic pain.
      • Asmundson G.J.
      • Parkerson H.A.
      • Petter M.
      • Noel M.
      What is the role of fear and escape/avoidance in chronic pain? Models, structural analysis and future directions.
      • Sturgeon J.A.
      • Zautra A.J.
      • Arewasikporn A.
      A multilevel structural equation modeling analysis of vulnerabilities and resilience resources influencing affective adaptation to chronic pain.
      SEM is a combination of regression analysis and factor analysis and, although many of the same assumptions are made about the data, it handles the inclusion of several mediating factors more readily, it can include latent (unobserved) factors, and it can account for measurement error. SEM also provides goodness-of-fit statistics that allow comparisons between tested models. This technique does, however, require substantially larger sample sizes than traditional regression analysis. It is important to emphasize that studies using mediation analysis (including those that use SEM), no matter how sophisticated their statistical approaches, are limited by their design, and that cross-sectional studies cannot provide evidence for causal, mechanistic relationships between variables.

      Psychosocial Factors Influencing Pain-Related Outcomes

      In the following sections we evaluate evidence for a number of psychosocial factors that have been studied as contributors to the development, long-term consequences, and sequelae of persistent pain, as well as treatment-related outcomes. In general, these variables do not appear to be condition-specific; most have been studied across multiple AAPT diagnostic categories with similar results. Conceptually, we organize these factors as “general” psychosocial constructs and processes, which are not unique to individuals experiencing pain, and “pain-specific” psychosocial factors, which are defined and measured with reference to individuals' pain experience. This review is not exhaustive; rather we highlight some of the most influential and commonly-studied factors (Fig 3). Specific assessment instruments to measure psychosocial constructs are described in a complementary article in this supplement to The Journal of Pain.
      • Turk D.C.
      • Fillingim R.B.
      • Ohrbach R.
      • Patel K.V.
      Assessment of psychosocial and functional impact of chronic pain.
      It is important to keep in mind that many of the constructs discussed in this article overlap to at least a moderate degree. For example, catastrophizing is often significantly associated with indices of depression, anxiety, and fear of pain, with correlation coefficients that are frequently in the range of .4 to .6, revealing a substantial degree of shared variance among these constructs.
      • Edwards R.R.
      • Cahalan C.
      • Mensing G.
      • Smith M.
      • Haythornthwaite J.A.
      Pain, catastrophizing, and depression in the rheumatic diseases.
      • Hirsh A.T.
      • Kupper A.E.
      • Carter G.T.
      • Jensen M.P.
      Psychosocial factors and adjustment to pain in individuals with postpolio syndrome.
      • Wideman T.H.
      • Adams H.
      • Sullivan M.J.
      A prospective sequential analysis of the fear-avoidance model of pain.
      • Wideman T.H.
      • Sullivan M.J.
      Differential predictors of the long-term levels of pain intensity, work disability, healthcare use, and medication use in a sample of workers’ compensation claimants.

      General Psychosocial Factors

      Distress

      Depression, anxiety, and general indices of emotional distress are probably the most commonly assessed psychological factors in patients with persistent pain, and as a cluster of negative emotions, thoughts, and behaviors are also termed “negative affect.” Recent systematic reviews indicate that chronic pain patients show elevations, relative to pain-free controls, in all of these indices of self-reported negative affect.
      • Burke A.L.
      • Mathias J.L.
      • Denson L.A.
      Psychological functioning of people living with chronic pain: A meta-analytic review.
      • Howe C.Q.
      • Robinson J.P.
      • Sullivan M.D.
      Psychiatric and psychological perspectives on chronic pain.
      Although psychological symptomatology is often interpreted as a consequence of chronic pain, prospective studies suggest that premorbid psychological dysfunction represents a risk factor for the future development of numerous chronic pain conditions.
      • Diatchenko L.
      • Fillingim R.B.
      • Smith S.B.
      • Maixner W.
      The phenotypic and genetic signatures of common musculoskeletal pain conditions.
      • Fillingim R.B.
      • Ohrbach R.
      • Greenspan J.D.
      • Knott C.
      • Diatchenko L.
      • Dubner R.
      • Bair E.
      • Baraian C.
      • Mack N.
      • Slade G.D.
      • Maixner W.
      Psychological factors associated with development of TMD: The OPPERA prospective cohort study.
      • Linton S.J.
      • Nicholas M.K.
      • MacDonald S.
      • Boersma K.
      • Bergbom S.
      • Maher C.
      • Refshauge K.
      The role of depression and catastrophizing in musculoskeletal pain.
      Moreover, similar psychosocial constructs and processes predict the likelihood of transition from acute to chronic musculoskeletal pain (ie, higher distress levels are prospectively related to an increased probability of transitioning to chronic pain).
      • Diatchenko L.
      • Fillingim R.B.
      • Smith S.B.
      • Maixner W.
      The phenotypic and genetic signatures of common musculoskeletal pain conditions.
      • Pincus T.
      • Kent P.
      • Bronfort G.
      • Loisel P.
      • Pransky G.
      • Hartvigsen J.
      Twenty-five years with the biopsychosocial model of low back pain-is it time to celebrate? A report from the twelfth international forum for primary care research on low back pain.
      Overall, there is a wealth of evidence that symptoms of depression, anxiety, and emotional distress contribute strongly (more strongly than pain intensity, in many studies) to key long-term outcomes of persistent pain such as physical disability,
      • Hall A.M.
      • Kamper S.J.
      • Maher C.G.
      • Latimer J.
      • Ferreira M.L.
      • Nicholas M.K.
      Symptoms of depression and stress mediate the effect of pain on disability.
      • Hung C.I.
      • Liu C.Y.
      • Fu T.S.
      Depression: An important factor associated with disability among patients with chronic low back pain.
      • Ross C.
      • Juraskova I.
      • Lee H.
      • Parkitny L.
      • Stanton T.R.
      • Moseley G.L.
      • McAuley J.H.
      Psychological distress mediates the relationship between pain and disability in hand or wrist fractures.
      work disability,
      • Kenardy J.
      • Heron-Delaney M.
      • Warren J.
      • Brown E.A.
      Effect of mental health on long-term disability after a road traffic crash: Results from the UQ SuPPORT study.
      health care costs,
      • Baumeister H.
      • Knecht A.
      • Hutter N.
      Direct and indirect costs in persons with chronic back pain and comorbid mental disorders–a systematic review.
      mortality,
      • Kadam U.T.
      • Thomas E.
      • Croft P.R.
      Is chronic widespread pain a predictor of all-cause morbidity? A 3 year prospective population based study in family practice.
      • Smith D.
      • Wilkie R.
      • Uthman O.
      • Jordan J.L.
      • McBeth J.
      Chronic pain and mortality: A systematic review.
      and suicide.
      • Hassett A.L.
      • Aquino J.K.
      • Ilgen M.A.
      The risk of suicide mortality in chronic pain patients.
      • Ilgen M.A.
      • Kleinberg F.
      • Ignacio R.V.
      • Bohnert A.S.
      • Valenstein M.
      • McCarthy J.F.
      • Blow F.C.
      • Katz I.R.
      Noncancer pain conditions and risk of suicide.
      In general, these studies establish the association of pain with the deleterious outcomes of interest, and then show that some or all of that association can be statistically accounted for by indices of depression, anxiety, or distress. For example, in a recent study of lumbar fusion for degenerative spondylolisthesis, patients were followed after surgery for 2 years to determine the predictors of functional outcomes.
      • Parker S.L.
      • Godil S.S.
      • Zuckerman S.L.
      • Mendenhall S.K.
      • Devin C.J.
      • McGirt M.J.
      Extent of preoperative depression is associated with return to work after lumbar fusion for spondylolisthesis.
      In multivariate analysis, high preoperative symptoms of depression remained the only significant predictor of failure to return to work after surgery, even in multivariate models with pre- and postoperative pain intensity included, fully mediating the prospective association between pain intensity and occupational disability. Patients in the upper half of the distribution of preoperative depression scores were approximately one-third less likely to return to work and, among those who did return, took nearly twice as long postoperatively to begin working again.
      • Parker S.L.
      • Godil S.S.
      • Zuckerman S.L.
      • Mendenhall S.K.
      • Devin C.J.
      • McGirt M.J.
      Extent of preoperative depression is associated with return to work after lumbar fusion for spondylolisthesis.

      Childhood Traumatic Experiences and Post-Traumatic Stress Disorder

      Strong prospective links have been observed between early traumatic experiences and the subsequent development of chronic pain.
      • Afari N.
      • Ahumada S.M.
      • Wright L.J.
      • Mostoufi S.
      • Golnari G.
      • Reis V.
      • Cuneo J.G.
      Psychological trauma and functional somatic syndromes: A systematic review and meta-analysis.
      • Brennstuhl M.J.
      • Tarquinio C.
      • Montel S.
      Chronic pain and PTSD: Evolving views on their comorbidity.
      • Jones G.T.
      • Power C.
      • Macfarlane G.J.
      Adverse events in childhood and chronic widespread pain in adult life: Results from the 1958 British Birth Cohort Study.
      We should note that many of these traumatic experiences are social and interpersonal in nature. Childhood physical, sexual, and psychological abuse are reported to be risk factors for the adult development of pain conditions such as FM, irritable bowel syndrome, chronic pelvic pain, and temporomandibular joint disorders.
      • Afari N.
      • Ahumada S.M.
      • Wright L.J.
      • Mostoufi S.
      • Golnari G.
      • Reis V.
      • Cuneo J.G.
      Psychological trauma and functional somatic syndromes: A systematic review and meta-analysis.
      • Moeller-Bertram T.
      • Keltner J.
      • Strigo I.A.
      Pain and post traumatic stress disorder - review of clinical and experimental evidence.
      Many of these effects are substantial in magnitude; a recent meta-analysis reported that the presence of past trauma was associated with a two- to threefold increase in the subsequent development of chronic widespread pain in multivariate models across dozens of studies; reports of abuse in childhood conferred a 97% increase in risk (ie, odds ratio = 1.97) for having a painful somatic syndrome (eg, FM) in adulthood.
      • Afari N.
      • Ahumada S.M.
      • Wright L.J.
      • Mostoufi S.
      • Golnari G.
      • Reis V.
      • Cuneo J.G.
      Psychological trauma and functional somatic syndromes: A systematic review and meta-analysis.
      To date, it is not clear whether the association between trauma and later chronic pain is a direct result of exposure to the trauma, is driven predominantly by individual affective, cognitive, and behavioral responses to the traumatic event (eg, intense fear, avoidance behavior), or is primarily a retrospective attempt at explaining clusters of diverse symptoms for which there may be no immediately apparent etiology.
      • Brennstuhl M.J.
      • Tarquinio C.
      • Montel S.
      Chronic pain and PTSD: Evolving views on their comorbidity.
      Not all individuals exposed to trauma go on to experience pain-related consequences, of course, but such exposures appear to substantially enhance those risks. A recent meta-analysis reported that individuals who reported exposure to psychological trauma were nearly 3 times more likely (than those with no trauma exposure) to have persistent pain, regardless of the type of trauma.
      • Afari N.
      • Ahumada S.M.
      • Wright L.J.
      • Mostoufi S.
      • Golnari G.
      • Reis V.
      • Cuneo J.G.
      Psychological trauma and functional somatic syndromes: A systematic review and meta-analysis.
      Moreover, it is not only abuse that confers risk for the subsequent development of persistent pain. In a prospective, longitudinal study of over 7,500 children surveyed at age 7 and again at age 45, those with childhood reports of distressing events such as hospitalizations, familial financial crises, and the death of a parent showed an approximately doubled risk for the adult development of chronic widespread pain.
      • Jones G.T.
      • Power C.
      • Macfarlane G.J.
      Adverse events in childhood and chronic widespread pain in adult life: Results from the 1958 British Birth Cohort Study.
      These associations remained even after adjusting for potential confounding variables such as psychological distress and socioeconomic status. Not surprisingly, the links between trauma and pain may summate cumulatively across the lifespan. On the basis of retrospective reporting, several studies have shown that military veterans with combat exposure and post-traumatic stress disorder (PTSD) symptomatology may be more likely to have experienced previous childhood or adulthood traumas as well.
      • Kelsall H.
      • Sim M.
      • McKenzie D.
      • Forbes A.
      • Leder K.
      • Glass D.
      • Ikin J.
      • McFarlane A.
      Medically evaluated psychological and physical health of Australian Gulf War veterans with chronic fatigue.
      • Kelsall H.L.
      • McKenzie D.P.
      • Forbes A.B.
      • Roberts M.H.
      • Urquhart D.M.
      • Sim M.R.
      Pain-related musculoskeletal disorders, psychological comorbidity, and the relationship with physical and mental well-being in Gulf War veterans.
      Thus, it is possible that the large association of adult-experienced trauma (eg, combat exposure) with deleterious pain-related outcomes may reflect the cumulative effect of multiple historical traumas as well.
      Some categories of traumatic stress appear more likely to serve as pain-relevant risk factors than others. For example, one longitudinal study noted that although some childhood stressful medical events such as prolonged hospitalization were associated with chronic pain in adulthood, other events such as childhood surgery conferred no additional risk.
      • Jones G.T.
      • Power C.
      • Macfarlane G.J.
      Adverse events in childhood and chronic widespread pain in adult life: Results from the 1958 British Birth Cohort Study.
      Overall, combat exposure and PTSD in adulthood are reported to have the strongest statistical association with chronic pain.
      • Afari N.
      • Ahumada S.M.
      • Wright L.J.
      • Mostoufi S.
      • Golnari G.
      • Reis V.
      • Cuneo J.G.
      Psychological trauma and functional somatic syndromes: A systematic review and meta-analysis.
      • Brennstuhl M.J.
      • Tarquinio C.
      • Montel S.
      Chronic pain and PTSD: Evolving views on their comorbidity.
      PTSD is a psychiatric condition that results from exposure to a traumatic event, and involves an array of negative cognitive and behavioral response to the trauma, including emotional hyperarousal, avoidance behavior, and re-experiencing of the traumatic event. PTSD has been identified as a risk factor for chronic pain,
      • Jenewein J.
      • Moergeli H.
      • Wittmann L.
      • Buchi S.
      • Kraemer B.
      • Schnyder U.
      Development of chronic pain following severe accidental injury. Results of a 3-year follow-up study.
      • Jenewein J.
      • Wittmann L.
      • Moergeli H.
      • Creutzig J.
      • Schnyder U.
      Mutual influence of posttraumatic stress disorder symptoms and chronic pain among injured accident survivors: A longitudinal study.
      for the transition from acute to chronic pain,
      • Kongsted A.
      • Bendix T.
      • Qerama E.
      • Kasch H.
      • Bach F.W.
      • Korsholm L.
      • Jensen T.S.
      Acute stress response and recovery after whiplash injuries. A one-year prospective study.
      and for elevated severity of pain and disability in abuse victims.
      • Wuest J.
      • Ford-Gilboe M.
      • Merritt-Gray M.
      Pathways of chronic pain in survivors of intimate partner violence.
      • Wuest J.
      • Ford-Gilboe M.
      • Merritt-Gray M.
      • Varcoe C.
      • Lent B.
      • Wilk P.
      • Campbell J.
      Abuse-related injury and symptoms of posttraumatic stress disorder as mechanisms of chronic pain in survivors of intimate partner violence.
      A number of studies have evaluated PTSD symptoms as a statistical mediator of the association between trauma and various pain-related outcomes. In a cross-sectional primary care survey study, patient recall of child abuse was linked with the report of pain and pain-related limitations in adulthood, and current levels of PTSD symptomatology fully mediated those associations.
      • Powers A.
      • Fani N.
      • Pallos A.
      • Stevens J.
      • Ressler K.J.
      • Bradley B.
      Childhood abuse and the experience of pain in adulthood: The mediating effects of PTSD and emotion dysregulation on pain levels and pain-related functional impairment.
      Similarly, in a sample of veterans, PTSD symptoms mediated the association between childhood maltreatment (physical and emotional abuse) and physical health outcomes, including the presence and intensity of persistent pain.
      • Lang A.J.
      • Laffaye C.
      • Satz L.E.
      • McQuaid J.R.
      • Malcarne V.L.
      • Dresselhaus T.R.
      • Stein M.B.
      Relationships among childhood maltreatment, PTSD, and health in female veterans in primary care.
      Finally, although a 30-year prospective study failed to find that PTSD symptoms formally mediated the longitudinal relationship between childhood abuse and chronic pain in adulthood, there was an interactive, synergistic effect of these variables, with the presence of PTSD symptoms amplifying the predictive effect of childhood abuse on later-life pain outcomes.
      • Raphael K.G.
      • Widom C.S.
      Post-traumatic stress disorder moderates the relation between documented childhood victimization and pain 30 years later.
      Collectively, there is strong evidence from a number of studies that abuse and trauma are linked with the subsequent development and effect of pain, with PTSD symptomatology in adulthood making a substantial contribution to those associations.

      Social and Interpersonal Processes

      Social forces shape a variety of health-related outcomes, and pain is no exception. As noted in a review of the factors affecting adjustment to chronic pain in individuals with disabilities, most studies have focused on either perceived global social support or solicitous social responses (eg, offering to take over tasks or encouragement to become less active).
      • Jensen M.P.
      • Moore M.R.
      • Bockow T.B.
      • Ehde D.M.
      • Engel J.M.
      Psychosocial factors and adjustment to chronic pain in persons with physical disabilities: A systematic review.
      Of more than a dozen studies of perceived social support as a contributor to pain-related functioning, most reported that more perceived social support was associated with better outcomes in persons with conditions such as spinal cord injury, multiple sclerosis, and acquired amputation,
      • Jensen M.P.
      • Moore M.R.
      • Bockow T.B.
      • Ehde D.M.
      • Engel J.M.
      Psychosocial factors and adjustment to chronic pain in persons with physical disabilities: A systematic review.
      whereas a higher degree of solicitousness in the social environment predicted increased pain-related disability.
      • Jensen M.P.
      • Moore M.R.
      • Bockow T.B.
      • Ehde D.M.
      • Engel J.M.
      Psychosocial factors and adjustment to chronic pain in persons with physical disabilities: A systematic review.
      The social environment may be particularly important for persons with acquired amputation during the first few months after the amputation, because several studies reported that patients with positive general social support were less likely to develop persistent phantom limb pain after amputation.
      • Hanley M.A.
      • Jensen M.P.
      • Ehde D.M.
      • Hoffman A.J.
      • Patterson D.R.
      • Robinson L.R.
      Psychosocial predictors of long-term adjustment to lower-limb amputation and phantom limb pain.
      The immediate social environment in the form of parents (for children experiencing pain) and spouses (for married adult patients with pain) exerts a powerful influence on pain-related outcomes. In the case of children with persistent pain, parents' cognitive and behavioral functioning and responses in reaction to children's pain have also been shown to play an important determining role in children's pain responses.
      • Palermo T.M.
      Impact of recurrent and chronic pain on child and family daily functioning: A critical review of the literature.
      • Palermo T.M.
      • Holley A.L.
      The importance of the family environment in pediatric chronic pain.
      • Palermo T.M.
      • Valrie C.R.
      • Karlson C.W.
      Family and parent influences on pediatric chronic pain: A developmental perspective.
      • Rhee H.
      Physical symptoms in children and adolescents.
      In particular, parental pain catastrophizing is strongly related to the development of children's persistent pain after major surgery,
      • Noel M.
      • Rabbitts J.A.
      • Tai G.G.
      • Palermo T.M.
      Remembering pain after surgery: A longitudinal examination of the role of pain catastrophizing in children’s and parents’ recall.
      and is significantly related to the child's disability.
      • Hechler T.
      • Vervoort T.
      • Hamann M.
      • Tietze A.L.
      • Vocks S.
      • Goubert L.
      • Hermann C.
      • Wager J.
      • Blankenburg M.
      • Schroeder S.
      • Zernikow B.
      Parental catastrophizing about their child’s chronic pain: Are mothers and fathers different?.
      Parental attention to pain and solicitousness behaviors that encourage children to avoid regular activities may provide specific pathways by which parental catastrophizing amplifies a child's pain experience and behavior.
      • Claar R.L.
      • Simons L.E.
      • Logan D.E.
      Parental response to children’s pain: The moderating impact of children’s emotional distress on symptoms and disability.
      • Hechler T.
      • Vervoort T.
      • Hamann M.
      • Tietze A.L.
      • Vocks S.
      • Goubert L.
      • Hermann C.
      • Wager J.
      • Blankenburg M.
      • Schroeder S.
      • Zernikow B.
      Parental catastrophizing about their child’s chronic pain: Are mothers and fathers different?.
      • van Tilburg M.A.
      • Claar R.L.
      • Romano J.M.
      • Langer S.L.
      • Walker L.S.
      • Whitehead W.E.
      • Abdullah B.
      • Christie D.L.
      • Levy R.L.
      The role of coping with symptoms in depression and disability: Comparison between inflammatory bowel disease and abdominal pain.
      It is clear that the interactions between patients with chronic pain and their significant others can either facilitate or impair adjustment to chronic pain.
      • Burns J.W.
      • Gerhart J.I.
      • Bruehl S.
      • Post K.M.
      • Smith D.A.
      • Porter L.S.
      • Schuster E.
      • Buvanendran A.
      • Fras A.M.
      • Keefe F.J.
      Anger arousal and behavioral anger regulation in everyday life among people with chronic low back pain: Relationships with spouse responses and negative affect.
      • Burns J.W.
      • Peterson K.M.
      • Smith D.A.
      • Keefe F.J.
      • Porter L.S.
      • Schuster E.
      • Kinner E.
      Temporal associations between spouse criticism/hostility and pain among patients with chronic pain: A within-couple daily diary study.
      • Leonard M.T.
      • Cano A.
      • Johansen A.B.
      Chronic pain in a couples context: A review and integration of theoretical models and empirical evidence.
      Studies across painful conditions illustrate the important role of significant others. For example, among couples, high levels of spousal depressive symptoms predict worsening patient disability and disease activity in patients with rheumatoid arthritis over a 1-year period.
      • Lam M.
      • Lehman A.J.
      • Puterman E.
      • Delongis A.
      Spouse depression and disease course among persons with rheumatoid arthritis.
      In cancer pain, social support and interpersonal effectiveness seem to play an important role in shaping pain report and general health.
      • Novy D.M.
      • Aigner C.J.
      The biopsychosocial model in cancer pain.
      Patients with partners showing avoidant attachment styles and anxious attachment styles are more likely to report increased pain and decreased well-being.
      • Gauthier L.R.
      • Rodin G.
      • Zimmermann C.
      • Warr D.
      • Librach S.L.
      • Moore M.
      • Shepherd F.A.
      • Gagliese L.
      The communal coping model and cancer pain: The roles of catastrophizing and attachment style.
      • Porter L.S.
      • Davis D.
      • Keefe F.J.
      Attachment and pain: Recent findings and future directions.
      • Porter L.S.
      • Keefe F.J.
      • Davis D.
      • Rumble M.
      • Scipio C.
      • Garst J.
      Attachment styles in patients with lung cancer and their spouses: Associations with patient and spouse adjustment.
      Patients' attachment styles are also important predictors of pain-related outcomes among children and adults; individuals with anxious or insecure attachment styles are at elevated risk for poorer mental and physical health,
      • Laird K.T.
      • Preacher K.J.
      • Walker L.S.
      Attachment and adjustment in adolescents and young adults with a history of pediatric functional abdominal pain.
      for reduced engagement in physical activity,
      • Andrews N.E.
      • Meredith P.J.
      • Strong J.
      • Donohue G.F.
      Adult attachment and approaches to activity engagement in chronic pain.
      and for less treatment-related improvement in affective outcomes among patients participating in a multidisciplinary treatment program.
      • Kowal J.
      • McWilliams L.A.
      • Péloquin K.
      • Wilson K.G.
      • Henderson P.R.
      • Fergusson D.A.
      Attachment insecurity predicts responses to an interdisciplinary chronic pain rehabilitation program.
      It is also important to understand the nature (eg, supportive, solicitous, adversarial) of other important social interactions, such as relationships at work; lack of social support at work and dissatisfaction with coworkers; and interactions with the disability compensation system, which are among the most potent predictors of work disability related to pain.
      • Helmhout P.H.
      • Staal J.B.
      • Heymans M.W.
      • Harts C.C.
      • Hendriks E.J.
      • de Bie R.A.
      Prognostic factors for perceived recovery or functional improvement in non-specific low back pain: Secondary analyses of three randomized clinical trials.
      • Melloh M.
      • Elfering A.
      • Chapple C.M.
      • Käser A.
      • Rolli Salathé C.
      • Barz T.
      • Röder C.
      • Theis J.C.
      Prognostic occupational factors for persistent low back pain in primary care.
      • Melloh M.
      • Elfering A.
      • Stanton T.R.
      • Käser A.
      • Salathé C.R.
      • Barz T.
      • Röder C.
      • Theis J.C.
      Who is likely to develop persistent low back pain? A longitudinal analysis of prognostic occupational factors.
      For example, Li and colleagues
      • Li X.
      • Gignac M.A.
      • Anis A.H.
      Workplace, psychosocial factors, and depressive symptoms among working people with arthritis: A longitudinal study.
      studied workplace support among arthritis patients; those who reported low workplace support were much more likely to develop depressive symptoms and work-related disability 18 months later. Moreover, differing social and occupational structures across countries appear to contribute to cross-national differences in rates of return to work and occupational disability in the context of painful work injury. Anema and colleagues
      • Anema J.R.
      • Schellart A.J.
      • Cassidy J.D.
      • Loisel P.
      • Veerman T.J.
      • van der Beek A.J.
      Can cross country differences in return-to-work after chronic occupational back pain be explained? An exploratory analysis on disability policies in a six country cohort study.
      compared sustainable return-to-work rates between 6 different countries and found that differences in job characteristics and social disability systems were more important than medical interventions, patient, and injury-related factors in explaining the large between-country differences in rates of return to work after painful occupational injuries.
      Of course, the social environment can also be harnessed for adaptive purposes. Keefe and colleagues
      • Keefe F.J.
      • Caldwell D.S.
      • Baucom D.
      • Salley A.
      • Robinson E.
      • Timmons K.
      • Beaupre P.
      • Weisberg J.
      • Helms M.
      Spouse-assisted coping skills training in the management of knee pain in osteoarthritis: Long-term follow-up results.
      • Keefe F.J.
      • Caldwell D.S.
      • Baucom D.
      • Salley A.
      • Robinson E.
      • Timmons K.
      • Beaupre P.
      • Weisberg J.
      • Helms M.
      Spouse-assisted coping skills training in the management of osteoarthritic knee pain.
      have added spouse-assisted coping skills training to standard cognitive-behavioral therapy (CBT) and multidisciplinary pain management programs, hypothesizing that the supportive and reinforcing effects of a spouse will facilitate improved pain-related coping and enhance self-efficacy for managing pain-related symptoms. Such interventions generally involve dyadic sessions that teach couples communication skills and use mutual goal-setting to assist chronic pain patients in acquiring, maintaining, and effectively deploying pain-coping skills. In the most recent randomized controlled trial, in patients with LBP and their spouses,
      • Abbasi M.
      • Dehghani M.
      • Keefe F.J.
      • Jafari H.
      • Behtash H.
      • Shams J.
      Spouse-assisted training in pain coping skills and the outcome of multidisciplinary pain management for chronic low back pain treatment: A 1-year randomized controlled trial.
      the spouse-assisted intervention produced larger decreases in fear of pain and catastrophizing than the standard multidisciplinary intervention.
      Other individual social and interpersonal relationships are also important influences on pain-related outcomes. In particular, the results from many studies of psychotherapy process and outcome confirm that 2 interpersonal factors: 1) stimulating patient expectations that treatment will help; and 2) establishing a sound therapeutic relationship between patient and therapist, are crucial foundations upon which successful interventions are built.
      • Martin D.J.
      • Garske J.P.
      • Davis M.K.
      Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review.
      A handful of studies suggest that an index of the therapeutic relationship (ie, the working alliance) statistically mediates the positive effects of rehabilitative treatments among people with musculoskeletal pain.
      • Burns J.W.
      • Higdon L.J.
      • Mullen J.T.
      • Lansky D.
      • Wei J.M.
      Relationships among patient hostility, anger expression, depression, and the working alliance in a work hardening program.
      • Hall A.M.
      • Ferreira M.L.
      • Clemson L.
      • Ferreira P.
      • Latimer J.
      • Maher C.G.
      Assessment of the therapeutic alliance in physical rehabilitation: A RASCH analysis.
      • Hall A.M.
      • Ferreira P.H.
      • Maher C.G.
      • Latimer J.
      • Ferreira M.L.
      The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: A systematic review.
      Indeed, creating and sustaining an effective therapeutic alliance appears to be a necessary and sufficient condition for promoting the pain-improving effects of diverse interventions.
      • Burns J.W.
      • Nielson W.R.
      • Jensen M.P.
      • Heapy A.
      • Czlapinski R.
      • Kerns R.D.
      Does change occur for the reasons we think it does? A test of specific therapeutic operations during cognitive-behavioral treatment of chronic pain.
      • Burns J.W.
      • Nielson W.R.
      • Jensen M.P.
      • Heapy A.
      • Czlapinski R.
      • Kerns R.D.
      Specific and general therapeutic mechanisms in cognitive behavioral treatment of chronic pain.
      It is also the case that psychosocial processes such as depression can negatively affect patient-provider relationships. For example, a recent study showed that depression was associated with patient–physician discordance in estimates of disease severity
      • Barton J.L.
      • Imboden J.
      • Graf J.
      • Glidden D.
      • Yelin E.H.
      • Schillinger D.
      Patient-physician discordance in assessments of global disease severity in rheumatoid arthritis.
      (ie, depressed patients estimated their disease severity as much worse, on average, than did their physicians). Such discordance is likely to be common, especially in light of the “invisible” nature of pain, and it can have deleterious effects on patient satisfaction and adherence to treatment regimens.
      • Haugli L.
      • Strand E.
      • Finset A.
      How do patients with rheumatic disease experience their relationship with their doctors? A qualitative study of experiences of stress and support in the doctor-patient relationship.

      Pain-Specific Psychosocial Constructs

      Catastrophizing

      Catastrophizing is a pain-specific psychosocial construct comprised of negative cognitive and emotional processes such as helplessness, pessimism, rumination about pain-related symptoms, and magnification of pain reports.
      • Edwards R.R.
      • Cahalan C.
      • Mensing G.
      • Smith M.
      • Haythornthwaite J.A.
      Pain, catastrophizing, and depression in the rheumatic diseases.
      Although catastrophizing positively correlates with general measures of negative affect such as depressive symptoms and anxiety, it also shows a unique and specific influence on pain-related outcomes.
      • Edwards R.R.
      • Cahalan C.
      • Mensing G.
      • Smith M.
      • Haythornthwaite J.A.
      Pain, catastrophizing, and depression in the rheumatic diseases.
      • Khan R.S.
      • Ahmed K.
      • Blakeway E.
      • Skapinakis P.
      • Nihoyannopoulos L.
      • Macleod K.
      • Sevdalis N.
      • Ashrafian H.
      • Platt M.
      • Darzi A.
      • Athanasiou T.
      Catastrophizing: A predictive factor for postoperative pain.
      • Pinto P.R.
      • McIntyre T.
      • Almeida A.
      • Araújo-Soares V.
      The mediating role of pain catastrophizing in the relationship between presurgical anxiety and acute postsurgical pain after hysterectomy.
      Overall, a higher level of catastrophizing has been shown to be a risk factor for the development of long-term pain, and for negative sequelae of pain such as worsening physical disability, higher health care costs, and the amplification of pain sensitivity among patients with LBP and joint pain.
      • Campbell C.M.
      • Kronfli T.
      • Buenaver L.F.
      • Smith M.T.
      • Berna C.
      • Haythornthwaite J.A.
      • Edwards R.R.
      Situational versus dispositional measurement of catastrophizing: Associations with pain responses in multiple samples.
      • Edwards R.R.
      • Mensing G.
      • Cahalan C.
      Alteration in pain modulation in women with persistent pain after lumpectomy: Influence of catastrophizing.
      • Edwards R.R.
      • Wasan A.D.
      • Michna E.
      • Greenbaum S.
      • Ross E.
      • Jamison R.N.
      Elevated pain sensitivity in chronic pain patients at risk for opioid misuse.
      Retrospective survey studies in patients with musculoskeletal pain have indicated that catastrophizing often emerges as one of the most important pretreatment variables predicting surgical outcomes,
      • Lewis G.N.
      • Rice D.A.
      • McNair P.J.
      • Kluger M.
      Predictors of persistent pain after total knee arthroplasty: A systematic review and meta-analysis.
      • Schreiber K.L.
      • Kehlet H.
      • Belfer I.
      • Edwards R.R.
      Predicting, preventing and managing persistent pain after breast cancer surgery: The importance of psychosocial factors.
      and a risk factor that impairs the effectiveness of pain-relieving interventions.
      • Hill J.C.
      • Lewis M.
      • Sim J.
      • Hay E.M.
      • Dziedzic K.
      Predictors of poor outcome in patients with neck pain treated by physical therapy.
      • Karels C.H.
      • Bierma-Zeinstra S.M.
      • Burdorf A.
      • Verhagen A.P.
      • Nauta A.P.
      • Koes B.W.
      Social and psychological factors influenced the course of arm, neck and shoulder complaints.
      Longitudinal studies show associations of catastrophizing with worsening pain and reduced treatment benefit among, for example, arthritis patients recovering from knee surgery.
      • Edwards R.R.
      • Haythornthwaite J.A.
      • Smith M.T.
      • Klick B.
      • Katz J.N.
      Catastrophizing and depressive symptoms as prospective predictors of outcomes following total knee replacement.
      • Forsythe M.E.
      • Dunbar M.J.
      • Hennigar A.W.
      • Sullivan M.J.
      • Gross M.
      Prospective relation between catastrophizing and residual pain following knee arthroplasty: Two-year follow-up.
      • Riddle D.L.
      • Wade J.B.
      • Jiranek W.A.
      • Kong X.
      Preoperative pain catastrophizing predicts pain outcome after knee arthroplasty.
      • Vissers M.M.
      • Bussmann J.B.
      • Verhaar J.A.
      • Busschbach J.J.
      • Bierma-Zeinstra S.M.
      • Reijman M.
      Psychological factors affecting the outcome of total hip and knee arthroplasty: A systematic review.
      Multiple randomized controlled trials have shown that pain patients with high pretreatment catastrophizing scores report less benefit from topical analgesics,
      • Mankovsky T.
      • Lynch M.
      • Clark A.
      • Sawynok J.
      • Sullivan M.J.
      Pain catastrophizing predicts poor response to topical analgesics in patients with neuropathic pain.
      cortisone,
      • Makarawung D.J.
      • Becker S.J.
      • Bekkers S.
      • Ring D.
      Disability and pain after cortisone versus placebo injection for trapeziometacarpal arthrosis and de Quervain syndrome.
      oral analgesics,
      • Schiphorst Preuper H.R.
      • Geertzen J.H.
      • van Wijhe M.
      • Boonstra A.M.
      • Molmans B.H.
      • Dijkstra P.U.
      • Reneman M.F.
      Do analgesics improve functioning in patients with chronic low back pain? An explorative triple-blinded RCT.
      pain-relieving surgeries,
      • Vissers M.M.
      • Bussmann J.B.
      • Verhaar J.A.
      • Busschbach J.J.
      • Bierma-Zeinstra S.M.
      • Reijman M.
      Psychological factors affecting the outcome of total hip and knee arthroplasty: A systematic review.
      and psychosocial treatments such as CBT.
      • Desrochers G.
      • Bergeron S.
      • Khalife S.
      • Dupuis M.J.
      • Jodoin M.
      Provoked vestibulodynia: Psychological predictors of topical and cognitive-behavioral treatment outcome.
      • Turner J.A.
      • Holtzman S.
      • Mancl L.
      Mediators, moderators, and predictors of therapeutic change in cognitive-behavioral therapy for chronic pain.
      A recent study of patients with persistent orofacial pain, randomized to 6 weeks of either standard care or CBT and followed for 12 months, confirmed the treatment-mediating effects of catastrophizing.
      • Litt M.D.
      • Porto F.B.
      Determinants of pain treatment response and nonresponse: Identification of TMD patient subgroups.
      Patients with high levels of pretreatment catastrophizing, and those whose catastrophizing scores did not change after treatment, were significantly more likely to be nonresponders at 1 year follow-up. Indeed, baseline levels of catastrophizing in the nonresponder group were >1 SD higher than baseline catastrophizing scores for the responder groups.
      • Litt M.D.
      • Porto F.B.
      Determinants of pain treatment response and nonresponse: Identification of TMD patient subgroups.
      It is interesting to note that catastrophizing may have its most influential mechanistic effects in the context of active, rather than placebo treatments. In a recent trial of TENS for postoperative pain,
      • Rakel B.A.
      • Zimmerman M.B.
      • Geasland K.
      • Embree J.
      • Clark C.R.
      • Noiseux N.O.
      • Callaghan J.J.
      • Herr K.
      • Walsh D.
      • Sluka K.A.
      Transcutaneous electrical nerve stimulation for the control of pain during rehabilitation after total knee arthroplasty: A randomized, blinded, placebo-controlled trial.
      patients who underwent joint replacement surgery were randomized to receive TENS, placebo TENS, or standard care (no TENS) for 6 weeks. Those in the TENS group with high baseline catastrophizing scores showed less pain reduction and reduced functional outcomes (eg, lower range of motion) at 6 weeks. In contrast, there was no association of catastrophizing with pain-related outcomes in the other groups (ie, those receiving placebo or standard care treatment).
      Furthermore, the benefits of many diverse analgesic therapies appear to be explained partly by their effects on cognitive–emotional processes such as catastrophizing. This is certainly true for CBT and similar psychosocial treatments. Longitudinal process analyses indicate that changes in catastrophizing and negative affect precede changes in clinical pain,
      • Burns J.W.
      • Kubilus A.
      • Bruehl S.
      • Harden R.N.
      • Lofland K.
      Do changes in cognitive factors influence outcome following multidisciplinary treatment for chronic pain? A cross-lagged panel analysis.
      • Litt M.D.
      • Shafer D.M.
      • Ibanez C.R.
      • Kreutzer D.L.
      • Tawfik-Yonkers Z.
      Momentary pain and coping in temporomandibular disorder pain: Exploring mechanisms of cognitive behavioral treatment for chronic pain.
      • Thorn B.E.
      • Burns J.W.
      Common and specific treatment mechanisms in psychosocial pain interventions: The need for a new research agenda.
      • Thorn B.E.
      • Pence L.B.
      • Ward L.C.
      • Kilgo G.
      • Clements K.L.
      • Cross T.H.
      • Davis A.M.
      • Tsui P.W.
      A randomized clinical trial of targeted cognitive behavioral treatment to reduce catastrophizing in chronic headache sufferers.
      that CBT can produce substantial reductions in catastrophizing even among patients whose chronic pain has persisted for decades,
      • Morley S.
      • Williams A.
      • Hussain S.
      Estimating the clinical effectiveness of cognitive behavioural therapy in the clinic: Evaluation of a CBT informed pain management programme.
      • Naylor M.R.
      • Krauthamer G.M.
      • Naud S.
      • Keefe F.L.
      • Helzer J.E.
      Predictive relationships between chronic pain and negative emotions: A 4-month daily process study using therapeutic interactive voice response (TIVR).
      and CBT's catastrophizing-reducing effects may last for months or years.
      • Turner J.A.
      • Mancl L.
      • Aaron L.A.
      Short- and long-term efficacy of brief cognitive-behavioral therapy for patients with chronic temporomandibular disorder pain: A randomized, controlled trial.
      Multiple studies that use cross-lagged panel analyses, or similar statistical approaches, have shown that substantial portions of the variability in end-of-treatment outcomes for CBT and multidisciplinary treatment can be accounted for by early-treatment changes in catastrophizing.
      • Burns J.W.
      • Day M.A.
      • Thorn B.E.
      Is reduction in pain catastrophizing a therapeutic mechanism specific to cognitive-behavioral therapy for chronic pain?.
      • Burns J.W.
      • Glenn B.
      • Bruehl S.
      • Harden R.N.
      • Lofland K.
      Cognitive factors influence outcome following multidisciplinary chronic pain treatment: A replication and extension of a cross-lagged panel analysis.
      • Burns J.W.
      • Kubilus A.
      • Bruehl S.
      • Harden R.N.
      • Lofland K.
      Do changes in cognitive factors influence outcome following multidisciplinary treatment for chronic pain? A cross-lagged panel analysis.
      Interestingly, as recent reviews point out,
      • Jensen M.P.
      Psychosocial approaches to pain management: An organizational framework.
      • Thorn B.E.
      • Burns J.W.
      Common and specific treatment mechanisms in psychosocial pain interventions: The need for a new research agenda.
      we know relatively little about the mechanisms underlying CBT and other nonpharmacologic pain treatment approaches, and it may be that disparate treatments operate in part via common mechanisms. For example, changes in catastrophizing statistically mediate the benefits of CBT,
      • Burns J.W.
      • Glenn B.
      • Bruehl S.
      • Harden R.N.
      • Lofland K.
      Cognitive factors influence outcome following multidisciplinary chronic pain treatment: A replication and extension of a cross-lagged panel analysis.
      • Burns J.W.
      • Kubilus A.
      • Bruehl S.
      • Harden R.N.
      • Lofland K.
      Do changes in cognitive factors influence outcome following multidisciplinary treatment for chronic pain? A cross-lagged panel analysis.
      • Jensen M.P.
      • Turner J.A.
      • Romano J.M.
      Changes in beliefs, catastrophizing, and coping are associated with improvement in multidisciplinary pain treatment.
      • Turner J.A.
      • Mancl L.
      • Aaron L.A.
      Short- and long-term efficacy of brief cognitive-behavioral therapy for patients with chronic temporomandibular disorder pain: A randomized, controlled trial.
      and multidisciplinary treatment programs,
      • de Rooij A.
      • de Boer M.R.
      • van der L.M.
      • Roorda L.D.
      • Steultjens M.P.
      • Dekker J.
      Cognitive mechanisms of change in multidisciplinary treatment of patients with chronic widespread pain: A prospective cohort study.
      as well as exercise- and activity-based physical therapy interventions that do not explicitly target catastrophizing.
      • Leeuw M.
      • Goossens M.E.
      • van Breukelen G.J.
      • de Jong J.R.
      • Heuts P.H.
      • Smeets R.J.
      • Köke A.J.
      • Vlaeyen J.W.
      Exposure in vivo versus operant graded activity in chronic low back pain patients: Results of a randomized controlled trial.
      • Smeets R.J.
      • Vlaeyen J.W.
      • Kester A.D.
      • Knottnerus J.A.
      Reduction of pain catastrophizing mediates the outcome of both physical and cognitive-behavioral treatment in chronic low back pain.
      Smeets and colleagues
      • Smeets R.J.
      • Vlaeyen J.W.
      • Kester A.D.
      • Knottnerus J.A.
      Reduction of pain catastrophizing mediates the outcome of both physical and cognitive-behavioral treatment in chronic low back pain.
      compared CBT, active physical treatment (ie, aerobic and strength training), and their combination, and found that the 3 active treatments did not differ significantly on pre- to post-treatment change in pain catastrophizing, but that pre- to post-treatment changes in pain catastrophizing predicted pre- to post- changes in most outcomes across the intervention groups (ie, catastrophizing diminished just as much in the active physical treatment group as in the CBT group, and reductions in catastrophizing were equivalently influential predictors of improvements in pain across groups). Across the active treatments, catastrophizing reduction accounted for 35 to 40% of the benefit of treatment in terms of reduced pain and disability. Collectively, these results suggest that reduction in catastrophizing among chronic pain patients may account for some of the beneficial effects of many behavioral pain treatments.
      Catastrophizing clearly overlaps with numerous other psychosocial processes, showing positive associations with indices of depression, anxiety, distress, and fear of pain, and inverse associations with self-efficacy, optimism, and other positive factors.
      • Edwards R.R.
      • Cahalan C.
      • Mensing G.
      • Smith M.
      • Haythornthwaite J.A.
      Pain, catastrophizing, and depression in the rheumatic diseases.
      • Hirsh A.T.
      • Kupper A.E.
      • Carter G.T.
      • Jensen M.P.
      Psychosocial factors and adjustment to pain in individuals with postpolio syndrome.
      • Mounce C.
      • Keogh E.
      • Eccleston C.
      A principal components analysis of negative affect-related constructs relevant to pain: Evidence for a three component structure.
      However, even when controlling for some of these related factors, catastrophizing often retains a significant unique, predictive influence (although it is true that no published studies, to our knowledge, control for every other variable listed here). For example, after statistically adjusting for indices of depression and anxiety, catastrophizing remained significantly associated with such diverse outcomes as return to work,
      • Gauthier N.
      • Sullivan M.J.
      • Adams H.
      • Standish W.D.
      • Thibault P.
      Investigating risk factors for chronicity: The importance of distinguishing between return-to-work status and self-report measures of disability.
      • Sullivan M.J.
      • Ward L.C.
      • Tripp D.
      • French D.J.
      • Adams H.
      • Stanish W.D.
      Secondary prevention of work disability: Community-based psychosocial intervention for musculoskeletal disorders.
      pain-related physical disability,
      • Hirsh A.T.
      • Bockow T.B.
      • Jensen M.P.
      Catastrophizing, pain, and pain interference in individuals with disabilities.
      risk for prescription opioid misuse,
      • Martel M.O.
      • Jamison R.N.
      • Wasan A.D.
      • Edwards R.R.
      The association between catastrophizing and craving in patients with chronic pain prescribed opioid therapy: A preliminary analysis.
      • Martel M.O.
      • Wasan A.D.
      • Jamison R.N.
      • Edwards R.R.
      Catastrophic thinking and increased risk for prescription opioid misuse in patients with chronic pain.
      brain responses to a noxious stimulus,
      • Gracely R.H.
      • Geisser M.E.
      • Giesecke T.
      • Grant M.A.
      • Petzke F.
      • Williams D.A.
      • Clauw D.J.
      Pain catastrophizing and neural responses to pain among persons with fibromyalgia.
      • Loggia M.L.
      • Berna C.
      • Kim J.
      • Cahalan C.M.
      • Martel M.O.
      • Gollub R.L.
      • Wasan A.D.
      • Napadow V.
      • Edwards R.R.
      The lateral prefrontal cortex mediates the hyperalgesic effects of negative cognitions in chronic pain patients.
      pain intensity,
      • Archer K.R.
      • Abraham C.M.
      • Song Y.
      • Obremskey W.T.
      Cognitive-behavioral determinants of pain and disability two years after traumatic injury: A cross-sectional survey study.
      pain tolerance,
      • Trost Z.
      • Strachan E.
      • Sullivan M.
      • Vervoort T.
      • Avery A.R.
      • Afari N.
      Heritability of pain catastrophizing and associations with experimental pain outcomes: A twin study.
      and suicidal ideation.
      • Edwards R.R.
      • Smith M.T.
      • Kudel I.
      Pain-related catastrophizing as a risk factor for suicidal ideation in chronic pain.
      Moreover, catastrophizing likely interacts with other processes such as social support.
      • Buenaver L.F.
      • Edwards R.R.
      • Haythornthwaite J.A.
      Pain-related catastrophizing and perceived social responses: Inter-relationships in the context of chronic pain.
      It is not just the patient's degree of catastrophizing that has been shown to influence important pain-related outcomes; spousal levels of catastrophizing and patient catastrophizing are modestly correlated with each other and often both emerge as unique influential predictors.
      • Lemieux A.J.
      • Bergeron S.
      • Steben M.
      • Lambert B.
      Do romantic partners’ responses to entry dyspareunia affect women’s experience of pain? The roles of catastrophizing and self-efficacy.
      • Pence L.
      • Cano A.
      • Thorn B.
      • Ward L.C.
      Perceived spouse responses to pain: The level of agreement in couple dyads and the role of catastrophizing, marital satisfaction, and depression.
      Similar findings were obtained when evaluating the influence of parental catastrophizing on children's reports of pain, particularly postoperative pain.
      • Noel M.
      • Rabbitts J.A.
      • Tai G.G.
      • Palermo T.M.
      Remembering pain after surgery: A longitudinal examination of the role of pain catastrophizing in children’s and parents’ recall.
      • Page M.G.
      • Campbell F.
      • Isaac L.
      • Stinson J.
      • Katz J.
      Parental risk factors for the development of pediatric acute and chronic postsurgical pain: A longitudinal study.
      • Rabbitts J.A.
      • Groenewald C.B.
      • Tai G.G.
      • Palermo T.M.
      Presurgical psychosocial predictors of acute postsurgical pain and quality of life in children undergoing major surgery.

      Self-Efficacy

      Self-efficacy is a broad concept that refers to an individual's belief in his or her own ability to perform a certain behavior to achieve a desired outcome.
      • Keefe F.J.
      • Somers T.J.
      Psychological approaches to understanding and treating arthritis pain.
      • Stewart D.E.
      • Yuen T.
      A systematic review of resilience in the physically ill.
      According to Bandura's social cognitive theory, self-efficacy is a major determinant of individuals' thoughts, feelings, and behaviors in stressful situations, and affects individuals' ability to cope successfully when confronted with difficult challenges. Pain-related self-efficacy is often measured using self-report scales such as the general chronic pain self-efficacy questionnaire,
      • Anderson K.O.
      • Dowds B.N.
      • Pelletz R.E.
      • Edwards W.T.
      • Peeters-Asdourian C.
      Development and initial validation of a scale to measure self-efficacy beliefs in patients with chronic pain.
      or disease-specific measures such as the arthritis self-efficacy scale (for patients with arthritis pain),
      • Lorig K.
      • Chastain R.L.
      • Ung E.
      • Shoor S.
      • Holman H.R.
      Development and evaluation of a scale to measure perceived self-efficacy in people with arthritis.
      which assess patients' perceived ability to control pain symptoms and to function despite pain (see Turk et al
      • Turk D.C.
      • Fillingim R.B.
      • Ohrbach R.
      • Patel K.V.
      Assessment of psychosocial and functional impact of chronic pain.
      in this supplement to The Journal of Pain). Self-efficacy has been characterized as a protective psychological resource in patients with persistent pain, and a resiliency factor associated with improved functional outcomes among children, adolescents, and adults with chronic pain.
      • Stewart D.E.
      • Yuen T.
      A systematic review of resilience in the physically ill.
      A number of prospective studies have assessed self-efficacy as an influential contributor to functional outcomes in a variety of painful conditions. For example, a longitudinal study in patients with chronic LBP showed that self-efficacy partially mediated the association between pain and disability at multiple study time points.
      • Costa L.C.
      • Maher C.G.
      • McAuley J.H.
      • Hancock M.J.
      • Smeets R.J.
      Self-efficacy is more important than fear of movement in mediating the relationship between pain and disability in chronic low back pain.
      Moreover, changes in self-efficacy (but not changes in pain-related fear) over the 1-year course of the study partially mediated the association between changes in pain and changes in disability.
      • Costa L.C.
      • Maher C.G.
      • McAuley J.H.
      • Hancock M.J.
      • Smeets R.J.
      Self-efficacy is more important than fear of movement in mediating the relationship between pain and disability in chronic low back pain.
      Very similar findings (eg, high self-efficacy is associated with better functional outcomes, and variability in self-efficacy mediates the association between pain intensity and disability) have been observed in other pain conditions such as arthritis, headache,
      • Kalapurakkel S.
      • Carpino E.A.
      • Lebel A.
      • Simons L.E.
      “Pain Can’t Stop Me”: Examining pain self-efficacy and acceptance as resilience processes among youth with chronic headache.
      FM,
      • Miró E.
      • Martínez M.P.
      • Sánchez A.I.
      • Prados G.
      • Medina A.
      When is pain related to emotional distress and daily functioning in fibromyalgia syndrome? The mediating roles of self-efficacy and sleep quality.
      and pediatric pain conditions.
      • Hermann C.
      Psychological interventions for chronic pediatric pain: State of the art, current developments and open questions.
      To illustrate, in a prospective treatment study, self-efficacy was among the most potent mediators of CBT-related improvements in pain and disability among patients with persistent orofacial pain.
      • Turner J.A.
      • Holtzman S.
      • Mancl L.
      Mediators, moderators, and predictors of therapeutic change in cognitive-behavioral therapy for chronic pain.
      Overall, high levels of self-efficacy are associated with lower reported intensity and unpleasantness of pain, and with less physical disability. As noted in recent reviews,
      • Keefe F.J.
      • Somers T.J.
      Psychological approaches to understanding and treating arthritis pain.
      • Somers T.J.
      • Wren A.A.
      • Shelby R.A.
      The context of pain in arthritis: Self-efficacy for managing pain and other symptoms.
      the persistent and pervasive nature of chronic pain requires patients to make constant adjustments to learn to live with their disease. Thus, many nonpharmacologic treatments target self-efficacy as an important process variable.

      “Positive” Factors

      Most of the frequently studied psychological facets of the biopsychosocial model could be broadly classified as having a negative valence (eg, negative affect, distress, trauma, catastrophizing). Indeed, some past reviewers of this literature have called for more attention to positive factors that may confer protection from and resilience against chronic pain and related suffering.
      • Bonanno G.A.
      Loss, trauma, and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events?.
      • Bonanno G.A.
      • Mancini A.D.
      The human capacity to thrive in the face of potential trauma.
      • Kerns R.D.
      • Sellinger J.
      • Goodin B.R.
      Psychological treatment of chronic pain.
      • Thorn B.E.
      • Ward L.C.
      • Sullivan M.J.
      • Boothby J.L.
      Communal coping model of catastrophizing: Conceptual model building.
      Such resiliency research focuses on how individuals successfully adapt to adverse stimuli or situations, such as prolonged and persistent pain, and its effect on multiple areas of physical, emotional, and social functioning.
      • Chen E.
      • Miller G.E.
      • Lachman M.E.
      • Gruenewald T.L.
      • Seeman T.E.
      Protective factors for adults from low-childhood socioeconomic circumstances: The benefits of shift-and-persist for allostatic load.
      • Kalapurakkel S.
      • Carpino E.A.
      • Lebel A.
      • Simons L.E.
      “Pain Can’t Stop Me”: Examining pain self-efficacy and acceptance as resilience processes among youth with chronic headache.
      Although resiliency factors have been linked to outcomes in the FAM, previous research suggests that risk and resilience factors do not represent opposite ends of a spectrum because individuals can be concurrently high or low in both types of factors.
      • Wideman T.H.
      • Asmundson G.G.
      • Smeets R.J.
      • Zautra A.J.
      • Simmonds M.J.
      • Sullivan M.J.
      • Haythornthwaite J.A.
      • Edwards R.R.
      Rethinking the Fear Avoidance Model: Toward a multidimensional framework of pain-related disability.
      This research suggests that consideration of risk as well as resiliency factors may help explain how individuals can live with chronic pain without concurrently experiencing disability.
      • Wideman T.H.
      • Asmundson G.G.
      • Smeets R.J.
      • Zautra A.J.
      • Simmonds M.J.
      • Sullivan M.J.
      • Haythornthwaite J.A.
      • Edwards R.R.
      Rethinking the Fear Avoidance Model: Toward a multidimensional framework of pain-related disability.
      A number of studies have indicated that improving active pain-coping is an important component of many nonpharmacological treatments.
      • Burns J.W.
      • Nielson W.R.
      • Jensen M.P.
      • Heapy A.
      • Czlapinski R.
      • Ke