Psychology of Pain 301produce considerably more suffering and behavioral dys-
function than if it is viewed as being the result of a stable
problem that is expected to improve.
People build fairly elaborate views of their physical states
and these views or representations provide the basis for action
plans and coping. Beliefs about the meaning of pain and their
ability to function despite discomfort are important aspects of
expectations about pain. For example, a cognitive representa-
tion that you have a very serious, debilitating condition, that
disability is a necessary aspect of pain, that activity is danger-
ous, and that pain is an acceptable excuse for neglecting re-
sponsibilities will likely result in maladaptive responses.
Chronic pain patients often demonstrate poor behavioral
persistence in exercise tasks. Their performance on these
tasks may not be independent of physical exertion or actual
self-reports of pain, but rather be related to previouspain re-
ports or fear of injury, reinjury, or exacerbation of their pain
(Vlaeyen et al., 1995). These people appear to have a nega-
tive view of their abilities and expect increased pain if they
performed physical exercises. The rationale for their avoid-
ance of exercise was not the presence of pain but their
learned expectationof heightened pain and accompanying
physical arousal that might exacerbate pain and reinforce pa-
tients• beliefs regarding the pervasiveness of their disability.
If people view disability as a necessary reaction to their pain,
that activity is dangerous, and that pain is an acceptable
excuse for neglecting their responsibilities, they are likely to
experience greater disability. Pain sufferers• negative percep-
tions of their capabilities for physical performance form a vi-
cious circle, with the failure to perform activities reinforcing
the perception of helplessness and incapacity. Once again we
can see how behavioral (conditioning) factors interact with
cognitive processes.
To illustrate the important role of cognitive processes in
affective and behavior related to noxious sensations, consider
the case of a person who wakes up one morning with a
headache. Very different responses would be expected de-
pending on whether he attributed the headache to excessive
alcohol intake or a brain tumor. Thus, although the amount of
nociceptive input in the two cases may be equivalent, the
emotional and behavioral responses would vary in nature and
intensity. If the interpretation is that the headache is related to
excessive alcohol, there might be little emotional arousal. He
might take some over-the-counter analgesics, a hot shower,
and take it easy for a few hours. On the other hand, inter-
pretation of the headache as indicating a brain tumor is likely
to create signi“cant worry and might result in a call to a
neurologist.
Certain beliefs may lead to maladaptive coping, increased
suffering, and greater disability. People who believe their
pain will persist may be passive in their coping and fail to
make use of strategies to deal with pain. People who consider
their pain to be an unexplainable mystery may negatively
evaluate their own abilities to control or decrease pain, and
are less likely to rate their coping strategies as effective in
controlling and decreasing pain (Williams & Thorn, 1989).
People•s beliefs, appraisals, and expectancies regarding the
consequences of an event and their ability to cope with it are
hypothesized to effect functioning in two ways. They may
have a direct in”uence on physiological arousal and mood
and an indirect one through their effects on coping efforts
(Flor & Turk, 1988; 1989).
Once beliefs and expectancies are formed, they become
stable and are very dif“cult to modify. As we noted, pain suf-
ferers tend to avoid experiences that could invalidate their
beliefs and guide their behavior in accordance with these be-
liefs, even in situations where these beliefs are no longer
valid. Consequently, they do not obtain corrective feedback.
It is essential for people with chronic pain to develop
adaptive beliefs about the relation among impairment, pain,
suffering, and disability, and to de-emphasize the role of ex-
perienced pain in their regulation of functioning. In fact, re-
sults from numerous treatment outcome studies have shown
that changes in pain level do not parallel changes in activity
level, medication use, return to work, rated ability to cope
with pain, and pursuit of further treatment. If health care
providers hope to achieve better outcomes and to reduce their
frustration from patients• lack of adherence to their advice,
they need to learn about and to address patients• concerns
within this therapeutic context.Self-EfficacySelf-ef“cacy is a personal expectation that is particularly
important in patients with chronic pain. A self-ef“cacy ex-
pectation is de“ned as a personal conviction that you can
successfully execute a course of action (perform required
behaviors) to produce a desired outcome in a given situation.
Self-ef“cacy is a major mediator of therapeutic change.
Given suf“cient motivation to engage in a behavior, it is a
person•s self-ef“cacy beliefs that determine the choice of ac-
tivities that the he or she will initiate, the amount of effort that
will be expended, and how long the individual will persist in
the face of obstacles and aversive experiences. Ef“cacy judg-
ments are based on four sources of information regarding
capabilities, listed in descending order of effects:1.Past performance at the task or similar tasks.
2.The performance accomplishments of others who are per-
ceived to be similar.