Monday, September 22, 2014

The Power of Belief: Part III: Strong Self-Efficacy Reduces Pain Severity

Before I explain how self-efficacy can impact pain intensity, I need to explain what pain is and how our mind affects it. If you do not feel like reading this or feel you already have a good grasp on how pain 'works', feel free to scroll down to 'How the Mind Can Change a Pain Experience'.

What is Pain Sensation and Pain Perception?                          
Pain is a process. While it feels instantaneous, our body actually alerts us to pain using steps in a special alert system. These alerts are uncomfortable, sometimes awful, and they are also incredibly important. They are how are body tells us 'you are being harmed'.

Pain can be helpful. Pain is a warning signal! Pain is a message our body uses to warn our brain about danger and harm. It tells us 'something is wrong'. It gives us immediate consequences for injury, to help prevent our bodies from getting hurt or hurt worse, and helps reduce loss of functionality. There is even research that supports that pain can intensify when we try to suppress it/resist it (Turner et al., 2002). Pain wants us to 'get' its signal.

Consider zombies in popular shows and fiction; zombies are often unconcerned with limbs getting injured or even falling off. Without pain, they can simply ignore these losses, and their mobility suffers for it. Without basic warnings, their bodies quickly fall apart. While pain may seem a nuisance, its signals are extremely valuable for our well-being and survival (when properly functioning).

We get these alerts of harm on multiple 'levels', at multiple 'intensities', and multiple tiers of consciousness. We can experience pain consciously, subconsciously, and unconsciously! (Young et al., 2005). Impressively, pain signals for the same event even function at different levels of consciousness. The multiples of pain is all so the warnings can be used to our benefit (Flor et al., 1990). For example, our body often moves from a painful source (like fire), before we even feel it! Afterwards, the sharp pain of a fresh burn can help remind you to 'protect' the injury. Extended pain from exposure helps to encourage keeping injuries clean and bandaged as well. For manageable and short-term injuries, pain signals can help you heal better and faster! Pain reminds you that an area is not 100% and needs extra care. The problems start when the source of pain cannot be helped or healed, and then pain becomes less helpful and more debilitating.

Pain can be changed. Pain signals are an alert for our body and mind, and the multiple steps involved provide opportunities to 'modify' those alerts. Not only through basic biology; pain signals are also heavily influenced by a person's thoughts, beliefs, mental state, and experiences (Hoffman et al., 2011). But how does that work? If pain is a process, what are the steps? How do the body and mind affect the process? Can we make pain signals more useful, or at least less awful? In this third installment of The Power of Belief, I'll touch on these questions, and discuss how belief changes our experience of pain.
Note: I redid this article to add clarification and a simple explanation of how pain 'works', which I will also be adding to an additional article. I hope it helps improve the entry!

Step-by-Step Process of Pain
Research has shown us that there are multiple steps involved in the experience of pain, and that pain is not a simple ‘Injury --> Pain’ experience. The following is an attempt to simplify a complex (and fascinating!) topic. There are entire courses on pain sensation and perception, so please consider this as a sample introduction.

Simplified Summary of the Steps of Pain Signaling: Stubbing Your Toe

  1. Stub toe and 'activate' pain nerves
  2. Pain nerves send a 'pain alert' to the Spine
  3. The Spine receives the pain alert
  4. Spine sends the pain alert to the Brain
  5. Brain takes the alert and 'processes' it, to understand the pain
  6. Brain 'experiences' the Pain (ouch!)

More Details: What happens when you stub your toe? 
When something painful like an injury happens, there are several pathways and junctions that our body uses to ‘inform’ us of that pain. Remember, pain is an alert system, so our bodies want to make sure we notice it. Nerves, the spine, and the brain, all work together to say 'something bad is happening!'. After all, pain's purpose is to call our attention to injury. So it needs to be a clear, strong signal! And because there are many paths and turns for these signals, there are also many opportunities for our bodies to 'adjust' how that pain signal is experienced.

Analogy: Sending a Birthday Gift
For an analogy, consider a day where you need to send a gift to your friend. One morning, you receive a calendar reminder that it is your good friend's birthday. Oh no, you can't believe you forgot! You need to send her a gift right away, so you can then tell her 'happy birthday!' and how the package is in the mail ('What, you haven't gotten it yet? I can't believe it didn't already arrive!...'). For that to happen, you need to (1) get the birthday reminder, (2) go to the store to buy a gift, and (3) go to the post office, where you will wrap the gift, pack it into the box, and pay for your postage/ship it to your friend. Last, (4), your friend will receive the delivery.

Pain signalling is a bit similar to sending the birthday gift for your friend. Comparing to the toe stubbing example:

  1. Calendar reminder: an injury starts the alert (like stubbing your toe)
  2. Driving to the store: the pain alert travels to the spine
  3. Buying the present: your spine routes the pain alert to your brain
  4. Driving to the Post Office: the pain alert travels to your brain
  5. Wrapping, packing, paying for, and sending the delivery: processing the pain alert in your brain (where your mind compiles the signals into an experience)
  6. Delivery: your brain 'gets' or 'experiences' the pain
Now, if you consider this scenario, all those steps are necessary to send the gift to your friend, but each step also gives an opportunity for those steps to change. Maybe you go to the hardware store to buy her a fancy drill, but you see a stupendous jigsaw that she would love. Or you get the drill, because you remember her saying she needed a pneumatic drill for her collection. Maybe you get lost between the store and the post office, and you take twice as long as normal to get there. Maybe you get distracted at the post office because they sell lots of different wrap for the gift. Maybe there is a long line. Every step is an opportunity for something to go 'differently'.
How this Works in Practice
When you stub your toe, the pain nerves in that toe are activated. How intensely the nerves are activated depends both on (a) the severity of injury (how hard did you hit that toe?) and (b) the sensitivity of my nerves (how easily do those nerves 'fire'?). Those activated nerves send a signal to your spine, which then sends a signal for your brain. Again, the path between the toe and spine gives another opportunity for pain intensity to be affected (this moment in the spine is called the spinal gateway). When the brain finally receives the signal, it must be processed before we are fully aware of what has happened. It processes the intensity, location, and meaning of that pain. These steps are fairly automatic, but they are also affected by how the body and brain is 'set up' to receive pain alerts.

While this is a very simplified version of events, it gives a rough idea of how an injury sends a pain alert signal to the brain, and explains how those steps can change the signal we consciously experience. All that signaling feels instant, but it is actually just very fast. In fact, certain areas of the body have setups called ‘reflex arcs’, where a signal causes an automatic movement, because otherwise it would take too long to 'reach' your brain. Those important signal steps take time to send! Thankfully, with a 'reflex arc' a possibly injured body part will move from danger before the brain gets the message and can react (e.g., bumping your shin kicks out your leg). This allows the body to avoid the step-by-step process of pain perception and protect itself before you can think. 

In full, conscious experiences of pain, the multiple points of pain signal transmission can create opportunities for the body and mind to alter the sensation of pain and the experience of pain (Wager et al., 2004, Hoffman et al., 2011). Meaning, each step of pain is a valuable opportunity for the signal to be modified. After all, pain is an important reminder about danger! The body and mind does its best to package that message meaningfully, so we can then make the most use of it.

Pain signal additions and changes are affected by the set up that they run along. This means that the state of your body and mind affect the pain experience (most importantly, the endurance and intensity of your pain experience). And your beliefs and thoughts can actually allow your brain to 'prepare' that pain experience in less intense ways. 

Pain sense and pain perceived BOTH factor into this number!
(credit: Hyperbole and a Half)

The Mind can Change a Pain Experience

To give an example, take the pain of being pricked with a needle in your finger when you are paying attention versus when you are distracted. The pain of the same prick is vastly different for when you are focused (e.g., at the doctor’s office giving a blood sample) from when you are thinking of other things (sewing and prick your finger by accident). Even though it is technically the same injury, the attention your mind gives it creates a big difference in the processing the injury receives. A point of signal transmission (your mind) changes how that pain was ‘felt’. So while the sensation is the same (needle prick in finger) the processing is different, and thus the experience of severity of pain differs between the two.

While state of mind (current thoughts/moods) can affect pain processing, characteristics (enduring qualities) of a person can modify pain perception as well. Anxiety and depression can make individuals experience more intense pain than individuals without mood disorders. Genders differ in pain experience as well, though research varies in conclusions regarding these differences. Interpretation tendencies regarding pain (e.g., hypochondria) also affect how pain will be experienced.

Pain Experience Severity is affected by Pain Self-Efficacy

As previously stated, pain self-efficacy is a measure of a person's confidence to act, despite the pain they are in. It is also a characteristic that can affect how the mind experiences pain. Confidence in acting, despite the pain, and feeling capable of managing the pain (while acting), are both aspects that affect many mental mechanisms of processing pain. Attention, fear, expectations, etc. (regarding pain and activity), are all influenced by pain self-efficacy. Thus, it makes intuitive sense that a strong sense of pain self-efficacy would impact the minds processing of pain. Research supports this assumption.

Research Findings
Scientific investigation has shown that the experience of pain severity/intensity is affected by pain self-efficacy.

Self-Efficacy Predicts Pain Intensity

In 2006, Meredith et al. executed a study with a sample of 152 chronic pain patients to examine the effects that pain-self efficacy and anxiety had on pain intensity (as well as disability). The group found that pain self-efficacy was a strong predictor of pain intensity, more so than anxiety, as well as being a good predictor of disability (Meredith, 2006). This means that pain self-efficacy had a correlation with how bad the pain was. This supports that pain self-efficacy should be considered when treating/managing pain and that it had an impact on the physical experiences of a patient.

A large 'mega-study' ( a meta-analysis also investigated how perception of how pain harms self-efficacy can worsen pain self-efficacy and functionality (Xia and Jackson, 2016). A meta-analysis takes the results of many separate, related studies to statistically show consensus or differences. This meta-analysis studied 111 arthritic pain and functionality studies, and found that patients with negative beliefs about pain had more limited functionality, even with similar pain index. This means, the more that you believe pain will prevent you from trying things, the less you are able to do, even between people with similar pain indexes. Having positive beliefs on managing pain impact can improve actual self-efficacy, which in turn can improve pain.

Mental Coping Skills Increase Pain Tolerance

In a practical examination, another study focused on treating pain by improving patient pain self-efficacy beliefs. The researchers taught individuals cognitive methods of pain control and focused on strengthening perceived self-efficacy beliefs (Bandura A. O., 1987).

The groups in this study were divided in both their exposure to cognitive methods to improve pain self-efficacy, as well as whether they were given an opioid placebo or no treatment at all. Those who were taught cognitive coping to strengthen their pain self-efficacy far outperformed the others in both their perceived self-efficacy and in the amount of pain they were able to tolerate. Participants given placebos had a high initial perception of pain self-efficacy, but this seemed to waver in the face of actual pain, meaning that the absence of tools directly affected their ability to cope. Thus, building up pain self-efficacy in a realistic and helpful manner has a direct impact on how pain is experienced.

Another study by Morone et al. (2016) also investigated a mental treatment for chronic lower-back patients, using a mindfulness meditation program. During treatment, those practicing meditation showed significant improvement for their pain index (how 'bad' the pain is). Maintaining that mindfulness meditation practices was also critical for maintaining the benefits of that program. This supports that mental coping skills can help reduce severity of pain.

Higher Pain Self-Efficacy Predicts Less Pain

Numerous studies have investigated the impact of pain self-efficacy in regards to patient outcomes. In comparing outcomes for chronic lower-back pain patients undergoing rehabilitation, those with a higher sense of pain self-efficacy reported lower pain than their counterparts at a 6-month follow up assessment (Altmaier, 1993). Another study showed that in long-term outcomes, pain self-efficacy was a strong mediator of pain intensity changes for chronic lower back pain over 12-months (and stronger than avoidance of painful activities) (Costal, 2011). Other studies have also shown better patient outcomes for those with whiplash injuries.

Perhaps most significant for this argument is the large meta-analytic review of multiple studies done by Jackson et al. this year. In the review, researchers examined 86 studies for the relationship between self-efficacy and patient functioning (particularly pain severity). The results showed that self-efficacy was significantly associated with lower pain severity in chronic pain patients (Jackson, 2014). This means that, in general, 86 studies found that a higher sense of self-efficacy predicted a reduced pain severity

What does it all mean?

What do these papers indicate? What does this relationship between pain self-efficacy and pain severity mean for you? It means that a person’s belief in their ability to do things despite the pain they are in helps to determine how much pain that person is in. This is even if you separate out the painfulness of their condition/reported pain—pain self-efficacy and pain intensity correlate with and interact with one another. What you believe you can do while in pain will affect what you can do. Your pain is affected by your beliefs and thoughts that you have about it. Your beliefs can change the way that your brain 'feels' the pain, and you can make pain more or less intense based on the beliefs you regularly employ. Most importantly, it means finding a way to improve your sense of self-efficacy, could help reduce the severity of pain you experience. 


  1. After reading the article which is very important for me as well and sure that it will be very important for everyone. I hope that we will get some important information about the health and medical.

    1. Thank you so much, I have returned to working on the site and hope to finish this series soon. Thank you for your contributions!


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About The BedRiddenHead

I want to be happy. And this site is about that chance. How to strive to thrive in the body I've got and maybe turn my experiences into something worthwhile.

This site aims to help educate and reach out to people all over that struggle with pain or illness. To try and make something helpful. I work as a medical research writer, my background is in neuropsychology and biology, and I want to share what I learn in a way that is easy to understand. I am not a doctor. I'm definitely not your doctor. I am just some lady who wants to make someone's (anyone's) life a little bit better. Whether you have endometriosis, a chronic injury, a struggling friend, or just want to learn something new, I hope to make a place that has what you are looking for.

Thank you for stopping by, I wish you strength in your health and happiness.