Effect of cognition on pain experience and pain behavior: Diathesis-stress and the causal conundrum

Abstract

Should we assess cognitions? The evidence for a causal link between cognitive factors and outcome in patients with painful physical conditions is not as strong as it is at times presented in the literature. However, the evidence is promising enough to suggest that research continue. It is reasonable to assume that the role of beliefs and attributions impacts on patients' wellbeing and behavior no less than physiological measures or even pain itself. When we have a much better understanding of which cognitions have what effect, under what circumstances, and at what point in time, we should be able to significantly reduce suffering, decrease health costs, and improve the quality of our lives. Which cognitions should be assessed? Although the jury is out on the causal role of cognitive factors, some appear to derive from more coherent conceptual model than others. This, in turn, means that interventions attempting to change cognitions can become more focused and that the assessment of success in such interventions is more transparent. Among these are fear avoidance/fear of pain and negative affect/distress. Other factors where research is needed include coping strategies and especially catastrophizing. How should cognitions be assessed? The issue of valid, reliable, and sensitive measurement of psychological factors is a vast Pandora's box. It is easy, however, to indicate how they should not be assessed: We should cease pulling questionnaires off the shelf indiscriminately, regardless of the population in which they were developed. Single items should not be considered adequate measurement, especially if removed from in-depth instruments without further validation. We should attempt triangulation whenever possible, by testing the relationship between different measurements and behavior and by including more objective measures, such as experimental tests when there is a good theoretical rationale for their inclusion. Another conundrum (which will not be discussed here) is who should carry out this assessment and what skills/training are needed to carry it out efficiently. Although it would be nice to have an optimal time to assess cognition in patients with pain, so that interventions can be carried out at early stages and risk resulting from cognitive maladaptive factors is reduced, this reductionist approach will only yield limited success. Cognitions must be regarded as part of human experience at all rehabilitation and developmental stages, through pain and healing and through health and illness. Cognitions change, are impacted by external events, and impact behavior in a parallel fashion. More research is needed on health outcome, cognitions, and their interactions with the person and her or his context throughout the lifespan (e.g., on the relationship between the meta-cognitions of different cultural groups and how they affect their well-being and health).