The relationships between prolonged or chronic musculoskeletal pain and psychological factors are complex and multifactorial. The relationships can be characterized as neurobiopsychological in etiology and manifestation. Mental health influences the experience and perception of pain, treatment adherence, and functional outcomes. Thus, patients with chronic pain should be screened for comorbid mental health conditions. Accurate diagnosis helps determine which integrative modalities are most likely to be effective for treatment of musculoskeletal pain and dysfunction. Pharmacologic treatment can reduce or alleviate mental health symptoms that negatively interact with pain and dysfunction. Integrative modalities include psychological therapies such as cognitive behavior therapy, mindfulness-based stress reduction, acceptance and commitment therapy, and cognitive functional therapy. Physicians should engage their patients in open and nonjudgmental discussion about beliefs regarding pain and dysfunction and the use of integrative therapies. They can educate patients on how to identify accurate information about these modalities, allowing patients to make informed decisions regarding their use. Health insurance will typically pay for short courses of psychotherapies and some somatic therapies, but access to licensed clinicians is limited in many areas. Insurance rarely covers supplements and other integrative, nonmainstream therapies.
Case 4. JJ is a 45-year-old man with chronic low back pain who is experiencing significant stress and anxiety related to the pain, which in turn exacerbate his symptoms. He had cognitive behavior therapy (CBT) for depression as a young adult, and he asks whether CBT will help with his current problem.
Physiology and Psychological Factors in Musculoskeletal Pain
The relationships between prolonged or chronic musculoskeletal pain and psychological factors are complex and multifactorial and can be characterized as neurobiopsychological in etiology and manifestation. Pain signaling in the body begins with sensory reception and interoception, a sense of awareness of the body’s own internal state. These raw sensory data are then processed, producing a perception of pain to alert the conscious mind that something has occurred that is a threat to physical well-being.1 Pain, including the anticipation of pain, activates the autonomic nervous system for a survival response (ie, fight, flight, freeze, or fawn).2
When sufficiently activated, the autonomic nervous system redirects the majority of cognitive, metabolic, and physical resources to the sensory and emotional centers of the brain, making more regulated interpretation and response challenging at best.3 In response to threat detection and activation, stress hormones such as cortisol and adrenaline are released, amplifying inflammation and subsequently the experience of pain.
Increased perception of pain or the experience of unrelenting pain over time leads to negative patterns of thought, feeling, and behavior in response. These patterns then reinforce underlying beliefs about pain and its effects that become cyclical and difficult to disrupt or redirect, a hallmark of the biopsychosocial model of bidirectional impact.4
A key example of this bidirectional relationship is the hypothalamic-pituitary-adrenal axis response to stress. When activated by physical or psychological distress, the hypothalamus releases corticotropin-releasing hormone, signaling the pituitary gland to release adrenocorticotropic hormone, which then activates the adrenal glands to produce cortisol. This intense release of cortisol then activates a series of physiological changes designed to help the mind and body adapt to stress.5
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