The Psychology of Pain: The Connection Between Thoughts, Emotions, and Pain

Perhaps you've been suggested to see a psychologist for your pain, and that upset you, as if it implied your pain was 'all in your head.' Or maybe you've noticed your pain worsens when you're stressed, and you wonder if that's normal. These questions are legitimate, and you deserve clear answers.

• Pain involves sensations and emotions. Biological, psychological, and social factors influence this experience, according to the International Association for the Study of Pain¹.
• Catastrophizing—the tendency to imagine the worst when faced with pain—is associated with more intense pain and greater difficulties. This association does not prove that thoughts alone cause these difficulties².
• Recovery expectations are linked to the course of non-chronic back pain, particularly with regard to returning to work. However, a positive outlook does not guarantee recovery³.
• Cognitive-behavioral therapy helps people work on their thoughts and habits. A Cochrane review reports small to very small overall benefits regarding pain, functional limitations, and distress in adults with chronic pain, excluding cancer and headaches⁴.

This guide explains how your thoughts and emotions interact with your pain. To understand the brain mechanisms involved, please read our article on the neuroscience of pain.

Why Discuss Psychology When You're in Pain?

Psychology helps us understand pain because thoughts, emotions, and life circumstances all play a role in this experience, along with biological factors. Their influence varies depending on the person and the situation¹.

Let's be clear from the start: discussing the psychological aspects of pain does not mean your pain is « all in your head » or that it isn't real. All pain is real, regardless of its cause.

The science of pain describes an experience that includes sensations and emotions. The official definition also acknowledges the influence of biological, psychological, and social factors¹. That’s why understanding psychological factors can help you better manage your chronic pain.

What is the difference between pain and suffering?

Pain is an unpleasant experience that involves sensations and emotions; suffering refers more broadly to the distress a person experiences. This distress may stem from lost activities, roles that have become difficult to fulfill, uncertainty, or a sense of having lost control. The two experiences may overlap.

What Truly Hurts

When someone seeks help for persistent pain, it's generally not just the physical sensation that causes the problem. It's often:

• The distress of not being able to do the activities you love
• The distress of feeling limited in your role as a parent, worker, or athlete
• The distress of not understanding why you are in pain
• The distress of feeling you have no control over your pain
• The distress of not being understood by others

When Pain Takes Over

Two people who report the same level of pain may experience different challenges. The loss of activities, worries, and a lack of support can also take a toll on daily life. One goal of care may be to resume an important activity, even if the pain has not completely gone away.

This does not mean that we should “simply accept” things and do nothing. Acceptance means acknowledging the current reality while actively working toward greater well-being. This approach aims to make room for the activities that matter, without denying the pain or giving up on care.

How do your beliefs influence your pain?

Your beliefs can influence your experience of pain by shaping where you focus your attention and the activities you choose. Prolonged avoidance can limit your activities, but its impact varies depending on your condition.

Where Do Our Beliefs Come From?

Our beliefs about pain are shaped by our past experiences, what we’ve been told (by doctors, family, and the media), and what we’ve observed around us. These beliefs are worth discussing when they cause you concern or limit your activities. Some concerns reflect a real problem that requires evaluation.

Beliefs to Discuss with Your Healthcare Provider

• “Something is missing to truly know what's wrong with me”
• " I need an MRI to figure out what's causing my pain."
• “Only surgery can fix my problem”

• “Pain = injury, so I must avoid anything that hurts”
• “If it hurts, I'm doing myself harm”
• “I need complete rest to heal”

• “I will always be in pain”
• “At my age, you can't expect anything better”
• " There's no cure for osteoarthritis, so I'm doomed."

• “It's up to the healthcare system to cure me”
• “It's my employer's fault that I'm in pain”

How Beliefs Influence Your Behaviors

If you’re worried that a certain movement might make your condition worse, you may be hesitant to do it again. A professional can discuss this concern with you and help determine which activities are appropriate for your situation. Your beliefs matter, but so do your symptoms, your work, the support you receive, and your access to care.

Among workers with subacute or chronic back pain, expectations of recovery and perceptions of changes in health were associated with a return to work. This study does not demonstrate that positive thinking causes healing.⁵

What is fear of movement (kinesiophobia)?

Kinesiophobia refers to a significant fear of moving due to the fear of getting injured or making one's condition worse. It can accompany persistent pain and lead to the avoidance of certain activities.

What Is It?

Kinesiophobia is an excessive fear of movement and physical activity due to a fear of getting injured or worsening one's condition.

Why It's Problematic

This fear is understandable. When it leads to avoiding certain activities for a long time, it can be accompanied by difficulties such as:

• Progressive Avoidance of Activities
• A decrease in strength or endurance resulting from reduced physical activity
• Concerns about pain, especially when the nervous system becomes more sensitive
• Reduced confidence in one's abilities
• Difficulty getting back to the activities that matter

The vicious cycle of avoidance

The fear-avoidance model describes how pain, fears, and reduced activity can reinforce one another. This model, which has been studied primarily in relation to back pain, describes a possible course of events rather than an inevitable sequence⁶. Here is an example of this process:

• You feel pain when you move
• Are you worried that this movement might be dangerous?
• You avoid this movement
• Your strength or endurance may decrease if you become less active
• Are you nervous about having to do that movement again?
• New pain can increase your anxiety
• This way, you can further limit the movement

Phrases like “your spine is very worn out” may worry you. However, changes in the intervertebral discs are also visible on imaging in people without pain and become more common with age. The healthcare professional must interpret these images in light of your symptoms and your physical exam⁷.

Under certain conditions, the neural circuits that process signals indicating a potential threat to tissues become more responsive. This sensitization can contribute to more intense pain. It cannot be attributed solely to fear of movement.⁸

How to break the cycle

TheGradual exposure involves gradually resuming the movements you are afraid of. A physical therapist assesses your condition, works with you to select the appropriate movements, and adjusts the progression based on your response.

In a study of workers with neck or back pain, a reduction in work-related fear and avoidance beliefs was associated with a return to work. This analysis does not prove that the reduction in fear alone explains this return.⁹

What is catastrophizing, and how is it related to pain?

Catastrophizing refers to repetitive thoughts that portray pain as highly threatening and difficult to manage; it is associated with more intense pain and greater functional limitations. Studies do not allow us to attribute these difficulties to thoughts alone².

Thinking the worst

Catastrophizing is the tendency to:

• Ruminate on the pain (thinking about it constantly)
• Imagining the worst about the pain (“This is terrible; I can’t stand it”)
• Feel helpless in the face of it ("I can't do anything about it")

These thoughts can arise when pain is distressing or long-lasting. When they become overwhelming, a professional can help you explore them without downplaying what you’re going through.

The impact on the brain

Studies report varying associations between catastrophizing and:

• Differences in brain activity in regions associated with attention and emotions
• Differences in the way the nervous system reduces or increases the pain response
• More pain or limitations after certain surgeries

These associations do not prove that thoughts cause changes in the brain. Catastrophizing is not a sign of weakness and can be one of the topics addressed in therapy.

Strategies to reduce catastrophizing

You can start by noticing the thoughts that portray the pain as unbearable or hopeless. “I’ll never be able to…,” “This is horrible…,” “I can’t stand it…”

You might ask yourself: “What facts support this idea? Are there other possible explanations? What can my professional help me clarify?”

You might also ask yourself, “What can I do right now to improve my situation?”

How do emotions and pain influence each other?

Pain can trigger fear, sadness, or frustration, and these emotions can in turn alter the experience of pain. This influence varies depending on the person and the context.

Mutual influences

Emotions and pain influence each other:

• Pain can cause frustration, sadness, fear, or anger
• Stress and other emotions can affect pain and how we cope with it

Emotions are part of the human experience. If they become difficult to cope with, appropriate support can complement pain management.

After a manual therapy session, talk to your physical therapist about any reactions that concern you. In a survey, people being treated for a lower back problem reported adverse reactions more often than those being treated for a limb injury.¹⁰

First and Second Level Reactions

A sudden surge of pain can trigger a rapid reaction, such as frustration.

It's about how you respond to what you're feeling. You can learn different ways to react, even if you can't control all of your emotions.

• First Level: «Ouch, I have back pain. My heart is racing.»
• Second Level (negative spiral): «Why again? This is terrible. I can't take it anymore. It will never end.»
• Second level (adaptive approach): “This pain is familiar to me. I take a moment to breathe and adjust my activity based on the advice I’ve received.”

Getting support can help you cope with these reactions with less distress. Having trouble managing them doesn't mean you're responsible for your pain.

In a study of people with neck pain, better sleep quality at the start of the study was associated with an improvement in pain after three months. Improvements in sleep and symptoms were also linked, though this does not prove that one caused the other.¹¹

What is self-efficacy in the face of pain?

Self-efficacy refers to your confidence in your ability to cope with pain and continue your activities despite it. In particular, it can relate to your confidence in managing an episode of pain at home.

What is Self-Efficacy?

Self-efficacy refers to what you feel capable of doing in a difficult situation. For example, you may be confident in your ability to walk for a few minutes or to adapt a task.

Why it's important

A meta-analysis links higher self-efficacy to less pain, fewer limitations, and less emotional distress. These results vary across studies and do not guarantee a person’s recovery¹². The following points help explain this concept:

• Confidence can stem from the ability to stay active despite pain
• It may relate to the ability to use management strategies
• It is associated with a more favorable trend in certain challenges
• It does not mean that the pain will necessarily go away

How to Develop Self-Efficacy

Choose a realistic challenge, then adjust it based on your response. Successes can help you recognize your abilities.

Talking with people who are going through similar challenges can provide insights and support. However, their experiences do not determine your own.

A professional can help you set goals, track your progress, and adjust your plan.

A professional can explain which sensations are to be expected and which ones require further evaluation. Pain is not a direct measure of the severity of an injury, but it should be taken seriously.

Why might your pain seem unfair to you?

Your pain may feel unfair when it disrupts your life, seems undeserved, or follows an event for which you are not responsible. That feeling deserves to be heard.

When Pain Feels Unfair

Some people develop a strong sense of injustice regarding their pain:

• “It’s not fair that this is happening to me”
• “It’s the fault of the accident/my employer/the doctor”
• “Nobody understands what I’m going through”

A professional can help you explore this feeling and:

• Express your anger and what you feel is unfair
• Choose possible steps you can take for your health and to move forward

Towards Acceptance

Accepting does not mean approving of what happened or giving up your rights. You can acknowledge your current difficulties, ask for support, and continue taking the actions that matter to you.

Does talking about psychology mean that your pain is imaginary?

Pain psychology does not question the reality of your pain. It helps you understand certain factors that influence your experience and can complement treatments such as physical therapy for chronic pain.

A Crucial Distinction

Talking about the psychology of pain does not mean that:

• Your pain is imagined
• You are weak or “too sensitive”
• You should “just calm down”
• You don't need physical treatment

It means that:

• The brain is involved in all pain
• Your thoughts, beliefs, and emotions influence your experience
• You can try different strategies with your healthcare team
• For chronic back pain, a Cochrane review reports modest average benefits from a multidisciplinary, multi-professional rehabilitation program compared with usual care or certain physical treatments. The certainty ranges from low to moderate; these results do not apply to all types of pain¹³.

What are the key points to remember about the psychology of pain?

The psychology of pain shows that thoughts, emotions, and behaviors can influence the experience of actual pain. These factors can be incorporated into pain management strategies tailored to your needs.

• Pain involves sensations and emotions; suffering can also relate to losses and the difficulties experienced in daily life
• Your beliefs can influence your behavior; you can discuss them without questioning the reality of your pain
• Fear of movement can lead to avoidance; a gradual, tailored return to activity can help you resume your activities
• Catastrophizing is associated with greater difficulties; support can help you examine these thoughts
• Self-efficacy refers to your confidence in coping with pain; progressive goals can help build that confidence
• You are not to blame for your pain; your care can take into account your body, your emotions, and your life circumstances

If you feel that these factors play a significant role in your back pain, neck pain, or pain elsewhere, don’t hesitate to discuss them with your healthcare provider. Your provider can take these factors into account to tailor your care to your specific situation.

What other resources can help you?

The following articles can help you understand chronic pain, the role of the brain, and strategies for managing it on a daily basis.

• Understanding Chronic Pain
• The Neuroscience of Pain
• Acute and Chronic Pain
• Pain Management Strategies

References

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