Stephanie Livingston–Psychologist

Pain–Is It All in Your Head?

by on Jan.02, 2009, under Articles



Stephanie L. Livingston, PhD




Pain is the most common presenting complaint by patients to their physicians and pain medications are the second most prescribed drug.  The direct and indirect costs for the treatment of pain is staggering.  These costs include surgeries, loss of job, absenteeism, pain treatment (medical and psychological), legal implications, and the impact on families.  Despite the costs and the fact that the concept of pain is better understood than a decade ago, the assessment and treatment of chronic pain is complex. One of the reasons for this complexity is the fact that pain is a subjective experience.  One can only make inferences about another’s experience of pain, by looking at “pain behaviors”.  Talking about the pain, walking with a limp, taking pain medication, being irritable, or grimacing are all examples of how one might demonstrate their experience of pain.  Consequently, a multidisciplinary approach to the treatment of chronic pain is needed and  includes the expertise of physicians, psychologists, physical therapists, and occupational therapists. Each healthcare professional offers a unique perspective in understanding chronic pain.


Many people do not realize that acute pain and chronic pain (six months or greater) are very different experiences.  Acute pain is typically thought of as a signal that something is wrong in the body and once the injury goes through a healing process, the pain disappears.  This is not the case with chronic pain.  Some people have had pain for many years, long after the original injury has resolved physically.  At this point, there are many factors which influence one’s experience of pain. From a Biopsychosocial perspective these factors include biological, psychological, and social/environmental  aspects.  Pain tolerance, genetic predisposition, and medication effects are examples of biological factors.  Depression, anxiety, stress, and anger are psychological factors.  Weather, exposure to toxins, work or family situations address social and environmental factors that influence chronic pain. 


Melzack and Wall, early pioneers in the area of the pain, introduced the idea of acute (ie, sensation) versus chronic (ie, perception) pain in their Gate Control Theory of Pain in 1965.  This theory attempts to explain the interaction of multiple factors in the production of the sensory and emotional experience of pain.  Some stimuli “open the gate” or increase one’s perception of pain and some stimuli “close the gate” or decrease one’s perception of pain.    The latter suggests subjectivity, meaning that how the person experiences the pain will depend upon whether or not the “gate” is open or closed. Examples of things that open the gate are sedentary lifestyle, negative mood states, low pain tolerance, and stress.  Examples of things that close the gate are medication, exercise, positive emotional states, relaxation, hypnosis, distraction and biofeedback, to name a few.  Therefore, many pain programs incorporate ways of closing the gate into their pain management strategies.  These treatment approaches might include, but are not limited to surgery, injections, medication, psychotherapy/psychoeducaction, physical therapy and occupational therapy.  In the case of surgeries for the management of pain, psychological assessment is a critical element in evaluating the prognosis for outcome after surgery (eg, compliance with treatment recommendations, making lifestyle changes).  Although psychological approaches are helpful in understanding pain, none can actually identify whether the pain is organic or psychogenic.


So, is the pain all in your head?  In many respects the answer is yes.  Not because the pain is not real, but because psychological factors, that originate in the mind can  play a role in one’s pain perception.  By learning to control psychological aspects of pain, the pain may be managed better.  If you have chronic pain and are having difficulty managing it, consider seeing a psychologist who specializes in pain management, in conjunction with your treating physician.


Stephanie Livingston, PhD is a licensed psychologist practicing at the Woodland Pain Clinic. Call 312 907-3644 for an appointment.


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