Monday, September 22, 2014

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

Pain Sensation and Pain Perception
Research has shown that there are multiple steps involved in the experience of pain and that pain is not a simple ‘Event-Reaction’ experience. While it may initially seem like a single physical event, psychological factors are involved, and a person’s beliefs and perceptions can heavily influence how pain is experienced.

Step-by-Step Process

When a painful event happens, e.g., stubbing a toe, there are several pathways and junctions that the body must use to ‘inform’ a person of the painful event. When I stub my toe, my nerves in that joint are activated. How intensely the nerves are activated depends both on (a) the severity of injury (how hard did I hit that toe?) and (b) the sensitivity of my nerves (how easily they are activated). Those activated nerves then send a signal to my spine, which then sends a signal for my brain. Again, the path between the toe and spine gives another opportunity for intensity to be affected by the body (the spinal gateway). When the brain finally receives the signal, it must be processed before we are fully aware of what has happened. While this is a very simplified version of events, it gives an idea of how and why an injury sends a signal to the brain.

All signaling feels instantaneous in experience, but it is actually just very fast. In fact, certain areas have set ups called ‘reflex arcs’ so that 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. In full pain perception, the multiple points of pain signal transmission create opportunities for the body and mind to differ in the sensation of pain and the experience of pain. Each transmission point is an opportunity for the signal to be modified.

Pain sense and pain perceived BOTH factor into this number!

The Mind can Modify 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

Pain self-efficacy is 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.

Scientific investigation has shown that the experience of pain severity/intensity is affected by pain self-efficacy. 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). The study supported that pain self-efficacy should be considered when treating/managing pain and that it had an impact on the physical experiences of a patient.

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.

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. A meta-analysis takes the results of many different but related studies to statistically analyze the results to measure their consensus or differing meaning. 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 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. Most importantly, it means finding a way to improve your sense of self-efficacy could reduce the severity of pain you experience. 

Sunday, September 21, 2014

The Power of Belief: Part II: Self-Efficacy Protects Against Depression and Disability

Pain Self-Efficacy Affects Patient Outcomes

Now that we understand what self-efficacy and pain self-efficacy is, we can start building up an understanding of how it affects patient outcomes for people with chronic pain. If pain self-efficacy is an important aspect in chronic pain outcomes, what are those outcomes, and why are they affected? 

In this section, we look at two common outcomes found in chronic pain patients: depression and disability. Chronic pain increases a person's susceptibility to both of these conditions, for a variety of reasons. A common factor found to impact both of these outcomes (both in severity and likelihood) is pain self-efficacy. 

Depression is unfortunately common in people with chronic pain, with about 70% of chronic pain patients qualifying for a depression diagnosis (Poole, 2009). As stated in a previous article of mine, research shows that about 75% of depression patients experience chronic/reoccurring pain (Lepine, 2004), and 60% of chronic pain patients report significant depressive symptoms (Bair, 2003). This is a major overlapping issue for pain and, consequently, it gets a lot of attention in research and medicine. There are many factors that likely contribute to the overlap and researchers want to identify those interlinking causes. One identified factor is that of pain self-efficacy.

General self-efficacy already has an impact on any individual’s predisposition to depression (Mukhtar, 2010), but pain self-efficacy is a particularly strong predictor of depression for people with chronic pain. A sense of helplessness in situations (termed 'learned helplessness') is a major part of the thought patterns that lead to depression. Feeling unable to manage pain is a meaningful loss of control. For example, individuals who reported similar levels of pain but differed in their pain self-efficacy, also differed later in their lives in whether they became disabled or depressed. It was not the only factor that led to the difference between groups, but it was a strong mediator between chronic pain and later depression and disability (Arnstein, 1999). Meaning the self-efficacy these people felt in regards to their pain affected their likeliness to develop major depressive disorder.

In another study that examined pain self-efficacy and depression, the same correlation was found between a weak sense of pain self-efficacy and higher proclivity towards depression. This study controlled for pain intensity (meaning the factor was accounted for, its impact quantified, and the effect removed) and still found the same correlation. The study also investigated how the use of pain coping strategies (such as task persistence, coping self-statements, pacing) was associated with pain self-efficacy. Patients who used pain coping strategies were more likely to have a strong sense of pain self-efficacy and a lower incidence of major depression (Turner, 2005). Based on the results of their study, the researchers suggest that not only is pain self-efficacy protective against depression, but that cognitive behavioral and self-management treatments to teach coping strategies could help improve pain self-efficacy.

These observations make sense when we think back to a common cause of depression: a feeling of helplessness. When individuals are able to master this feeling and overcome it, replacing it with a confident belief in their ability to manage their pain, they are less likely to fall victim to this avenue to depression. By developing a strong sense of pain self-efficacy, a person can feel in control over an otherwise distressing challenge.


As mentioned above, a chronic pain patient with a lower sense of pain self-efficacy is more likely to become disabled by their pain. This may appear to be obvious, common knowledge; on the surface, it sounds like a higher pain would result in both lower pain self-efficacy and higher likeliness for disability. But when controlling for pain severity, the finding remains. In a 2001 study by Asghari and Nicholas, higher pain self-efficacy beliefs were found to lower avoidance behaviors for challenging tasks and reduce disability associated with pain, regardless of the severity of pain the subjects were in (Ashari, 2001). This suggests that confronting challenging tasks and believing in the capacity to complete them despite the pain is beneficial in trying to minimize disability associated with a painful condition. And remember, pain self-efficacy is not dependent on the ability to succeed. Rather, it is persistence in the face of failure or success and a centered focus on the task at hand.
short term disabilityAnother study that examined the relationship between pain self-efficacy and disability also included the quality ‘fear avoidance’. Fear avoidance is what it sounds like—the avoidance of activities due to fear. A model called the ‘Fear-Avoidance Model’ was developed to help explain how a type of chronic pain developed despite the absence of a disease/permanent injury. It argues that fear avoidance prevents the use of the body and creates a cycle that leads to debilitating pain and disability. However, in this study, it was shown that self-efficacy had a greater impact on disability than fear avoidance (Denison, 2004). Meaning, based on their findings, they argued that a lack of belief for pain self-efficacy has a larger impact on disability severity than the avoidance of activities associated with pain. What’s particularly interesting about this finding, is that the beliefs that might impact performance of activities seemed to have a greater impact than the actual execution or avoidance of activities.

Disability from pain cannot always be avoided and these studies do not ignore the significant role that pain intensity plays. Neither these researchers nor I are arguing that a weak sense of pain self-efficacy is the sole cause of disability from debilitating pain. What I am trying to say is that it can help protect against eventual disability and offers some amount of buffer against disability, regardless of the severity of pain a person is in. It will benefit both your confidence in and ability to manage the challenges that pain presents. After all, the first step of ability is the belief in a capability to execute it. 

Pain Severity:

Pain self-efficacy has also been found to have an interacting relationship with pain intensity/severity. Numerous studies found that while severity of pain could affect the strength of an individual’s sense of pain self-efficacy, the effect was not limited to one direction. Individuals with a strong sense of pain self-efficacy are better able to manage their pain and report less pain severity. The difference has been observed not only in similarly diagnosed individuals, but also in patients that were taught coping mechanisms to improve their pain self-efficacy. Thus, developing pain self-efficacy can lower the severity of pain experienced. 

***The research explaining and supporting the connection between Pain Self-Efficacy and Pain Severity comprise the next post, Power of Belief: Part III (as there is a lot to cover!)***

Saturday, September 20, 2014

The Power of Belief: Part I: What Self 'Belief' is

The Purpose of this Series:

"The Power of Belief", is my effort to inform/improve the belief readers have in their ability to cope with their pain, and to foster understanding for how that belief impacts their lives. When a chronic pain patient improves their belief in their capability, their outcomes as a patient are better than in patients who do not. They tend to be less disabled by their pain and tend to have less severe pain.

To put it simply, mastering your beliefs in your abilities will help you manage your pain. Physically and mentally.

All sorts of psychological states and characteristics have an impact on our physical bodies. Many, many books exist to describe them. Even more research to support the connection. For now, for this series, I'm hoping to teach you about one of these connections: belief in your abilities. What it is, why it's important, how to create a positive change, and to provide some coping mechanisms to help strengthen your belief.

It may appear a bit wordy, a bit lengthy, but it cannot be avoided. The connection between belief and pain involves a lot of information, and this is my attempt to simplify and communicate all that. This series is written for a general audience with research to support claims. However, if you feel frustrated with how it is written, I have good news. The following week, a simpler version of similar information will be posted, written for an audience that does not enjoy scientific reading. Just remember, a shorter/simpler version means that many statements will be unsupported and further explanations withheld. Less information, but easier information to digest. Each article will have its own pros and cons, so choose which ever you feel most comfortable with, or read both and be a super expert in the effects beliefs have on pain!

The Power of Belief: Part I: What Self 'Belief' is

In psychology and personality theory, the concept of self-efficacy is a critical characteristic of an individual’s development, self, and personality. It contributes to not only their perception of self, but also to how an individual interacts with the world and others. Their actions, reactions, and thoughts are all influenced by this important quality.


Describing self-efficacy can be a little tricky. While the definition may sound simple, trying to understand it and map it onto reality can make it a bit more complicated. Regardless, a definition is a good place to start. Self-efficacy is the belief in one’s ability to coordinate actions in order to complete tasks and meet goals (Bandura, 1977). Essentially, it is the belief that you can handle a situation. A measure of, “Can I do this?”

To help clarify the idea, it helps to look at people who possess strong self-efficacy and how they differ from those who do not. For example, for people with a strong sense of self-efficacy, challenges are problems/tasks to be mastered, whereas those with a weak sense of self-efficacy avoid challenges and regard them with fear. In strong sensed individuals, setbacks and failures in/from challenges are quickly recovered from, versus weak sensed individuals experience loss of confidence and are likely to further in the face of failure. A strong sense of self-efficacy makes a person more likely to fully commit to their tasks and activities, whereas a weak sense will lead to fear and withdrawal. A person with a weak sense of self-efficacy will be too focused on their own personal failings to fully immerse themselves in their activities (Bandura, 1982)

Remember, the examples above are at the severe ends of the spectrum of a strong versus weak sense of self-efficacy. Usually people will fall somewhere in the middle. For above, these are just patterns of behavior you would expect to see in people with particularly strong or particularly weak senses of self-efficacy. The contrasts are to help illustrate the idea, but, in real life, you might not see such clear differences (or maybe even a mix of some behaviors). Hopefully you can begin to understand what self-efficacy is though and how the belief in capabilities impacts a person's thoughts and actions.  

Such a pivotal personality trait is bound to spread into many different aspects of a person’s life. You can take the basic idea of self-efficacy in regards to life in general and looking at it from the angle of how people deal with challenges in general. If you were to put a person in any given random situation, how confident in themselves would they feel? What is their belief in their ability to handle life? You can also approach the concept from the perspective of individual, unique applications. For example, a student’s self-efficacy in academics would have significant meaning for their experience in school. You can also take this concept and apply it to dealing with chronic pain (and many researchers have).

Pain Self-Efficacy:

Pain self-efficacy is a measure of a person’s confidence to do tasks despite the pain they are in (Miles, 2011). This characteristic is obviously is going to be influenced by many different factors. How much pain the person is in, the support they have, the tools they have to manage the pain, their self-efficacy in general, their self-efficacy prior to the development of their chronic pain, etc... But that is why the concept is named as is—it is a measure of a person’s confidence in their ability to perform tasks despite the pain. Nothing more or less. This is important to keep in mind when learning about its impact.

In 1989, researcher M.K. Nicholas developed the Pain Self Efficacy Questionnaire (PSEQ) (Nicholas, 1989). A questionnaire is a tool that has been researched, tested, and validated to be a reasonable measure of a psychological characteristic. While we cannot directly observe thoughts/feelings of people, we can create measures to get an idea of them and somewhat reliably testing for them. For example, IQ tests are considered a well-tested measure of intelligence, but no IQ test can say exactly what someone’s intelligence is—but it gives a useful idea. And this Pain Self Efficacy Questionnaire is just that—a useful idea of what someone’s pain self-efficacy is.

Other, more recent pain self-efficacy measures exist, with varying reliability and accuracy. What is important to know is that in research focused on pain self-efficacy, some useful tool is used to gain a reliable idea of participants pain self-efficacy. Using such tools help to improve the quality of the study and results and give us, the readers, more to trust when making conclusions. 

The Point: 

Why are pain researchers so interested in self-efficacy and pain self-efficacy? Past and current research has supported that self-efficacy, particularly pain self-efficacy, is a useful predictor and contributing factor towards outcomes for people with chronic pain. Self-efficacy affects the outcomes for a patient, and knowing as much is useful in: (a) predicting how the patient will be affected by their self-efficacy and (b) providing a treatment point for improving a patient's pain management. Knowing the relationship between the two helps researchers and patients to better understand how to improve the livelihood for that patient.

Researchers used measures of pain intensity, pain self-efficacy, and other qualities related to chronic illness/pain, and found that pain self-efficacy had an impact on other problems that patients would face. Tomorrow, in Part II, we will go over some of that research and the meaning it has.

***To be continued in Power of Belief: Part II (to be posted 9/21/14)***

Thursday, September 11, 2014

Personal Announcement

Much time has passed since my last update. The exercise project has undergone changes, events have happened, and I have decided that it would be best to make a personal announcement to give any readers and passerbys a little bit of information. I am currently in the process of working on the general exercise plan for individuals with chronic pain. But I know there has not been much communication lately, and I wanted to amend this.

Some of you know me personally, some know me as the individual who runs this site, and some might not really think 'who is this' at all when they pass through. That is okay--all I want is to make a useful site that helps people get through difficulties and strife. I am not really meant to be anything other than a face for the message. Regardless of myself, I really hope that eventually this site becomes a handy source for those suffering and those helping.

But today's post is about me.

My father, a wonderful, kind, and generous man, recently had a terrible accident and passed . His death was unexpected and has been incredibly difficult for his family and loved ones. My Papi guided our family in how to love, how to help others, and how to be the best we could be. The loss has been heavy.

While I am trying to reassess how to move forward in my life from this and how to properly honor his memory, it is difficult for me to properly maintain my work in the chronic pain and endometriosis communities. Messages have gone untended and questions unanswered. I am sorry. I do not plan to abandon what I have started and I have every intention of resuming the exercise project as soon as I possibly can. I love that so many are interested and feel they would benefit from this idea. It makes me so happy.

So please, forgive this inactivity and unresponsiveness. I am very sorry for those who have gone ignored or are worried about the status of the project. I will do my best to answer questions while I am healing, but please (for general items) just keep a weather eye for updates. When I am ready to resume work on it, I will make a post and will keep people updated. I will need all the help that has been offered.

Thank you so much for your interest in both me and the work I am trying to do. For those who do not know, before I became so ill, I wanted to go to medical school and become a diagnostic specialist. I love science, medicine, and people. I wanted to help them heal. While my doctorate is physically impossible currently, I still get to use my knowledge and talents to help people deal with pain, and it feels incredibly rewarding. Thank you for caring about what I have to say and giving my ideas a try.

--Ash the Bedhead

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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, struggles, and happiness.