Distorted thinking in Chronic Pain Patients
– a psychological perspective
Painwise Irish Journal of Pain Medicine Vol. 3, Issue 1, Spring 2004
When we are emotionally upset we regularly engage in patterns of distorted thinking. Such a distortion maintains a low mood and feeds our anger and anxiety. In the last 8 years I have worked as part of a pain management multi-disciplinary team.
Some of the common distortions I have encountered from a psychological perspective are discussed in this paper. This is what I refer to as the psychological emotional trap so many patients with chronic pain experience.
The resultant stress debilitates the patient’s emotional state even further thus regularly warranting referrals to a psychiatrist and necessitating the need for anti-depressants and anxiolytic medication.
Catastrohpizing is perhaps the most common pattern of distorted thinking and it essentially takes the role of assuming the worst. Regularly patients will say ‘I don’t see myself going back to work’, ‘I’ll never exercise again’, ‘I’ll die from the pain’ etc… such behaviour needs to be regularly challenged and pointed out to the patient, in a subtle and non-confrontational way.
Overgeneralization is another common pattern. Patients all too often make sweeping statements based on a single failure. Over generalization needs to be brought under control quite early on in treatment. It necessitates the examination of what evidence you have for your sweeping statements and advancing alternative arguments in the light of it.
Fortune telling is what I refer to when patients try to convince us that they can predict their future in a consistently accurate way. While I have no doubt that many patients do make accurate predictions from time to time, this type of behaviour is usually proceeded by a pessimistic or negative frame of mind e.g. ‘the treatment won’t work as I know I’m in too much pain’, ‘I won’t be able to give up smoking’, ‘I won’t be able to eat regularly or cut down medication’, etc…
Mental filtering is best described as focusing specifically on a single negative aspect of chronic pain and therapy anticipating the entire situation as negative e.g. I had a really bad panic attack in the supermarket and I’ll never be able to go shopping again for a good psychological recovery it is imperative to attempt to stand back and view the consequences of your pain in a more objective fashion.
There is a definite overuse of the words should and must e.g. I should exercise everyday, I must take my medication. During the pain management course one of the first lectures I give is how our use of language influences our thought processes. I encourage patients with chronic pain to eliminate the words should and must and replace them with the concept of choice i.e. I choose to exercise within my limits, I choose to take only the required medication. The introduction of the element of choice gives the patient back a sever of control and eliminates a totalitarian system of thinking.
All too often patients discount the positive e.g. I walked for 20 minutes today but prior to the pain I could walk for 2 hours no problem. Much of the discounting of the positive comes from comparisons being made in how the patient used to live his/her life. These comparisons need to be re-educated as to how to live their lives within the limits of their chronic pain.
Attaching negative labels to oneself is to be avoided at all costs e.g. ‘I am such a failure it makes me feel stupid to have to ask for help and so on’. It is necessary and more effective to focus on behaviour change rather than self-condemnation, which erodes over self-confidence.
Patients with chronic pain regularly report patterns of mind reading e.g. ‘I know what the doctor is thinking, he believes it is all in my mind, my partner thinks I’m using the pain for my own gain’. Ask the patient to find firm evidence to support their beliefs, and point out the mind reading to them.
Patients all use an all or nothing type-thinking framework not allowing to see or attempt to see any middle ground, e.g. ‘if I can’t go back to my old job then there is no point in doing anything else’. The antidote to this type of distorted thinking is to encourage the patient to examine all his/her options.
Magnification is when patients exaggerate the negative thus reducing the positive e.g. ‘I fell once during my exercise programme and it turned out to be a disaster’. Tackling the distortions with a sense of proportion is what is required e.g. ‘falling was only a hiccup but the rest of the exercise session proceeded smoothly’.
Personalisation involves holding yourself to blame for events for which you are not responsible, e.g. my pain has forced my wife to leave and take the children’. Here the patient needs to distinguish between his/her actual and presumed responsibility for a specific event.
Finally emotional reasoning is something that one believes to be true because you feel it strongly e.g. ‘I feel such a failure because of this accident/injury, so I must be one’. Patients need to be thought but feelings are not facts and they never neglect an objective reality. The belief that you feel a failure because of the accident does not define you as a whole person.
In conclusion Psychologists working with chronic pain patients must remember the premise ‘you feel as you think’, it is important to help patients to tap into internal inner speech and teach them to identify, challenge and change the thinking that perpetuates these difficulties. This requires both thinking and acting differently.
Adapting to change means putting into practice your new ideas and behaviours and monitoring yourself for signs of ‘slipping back’. Patients need to play a proactive role in their own recovery for successful management of distorted thinking.
Address all correspondence to:
Dr. G. Moore-Groarke,
5A Block B, Harley Court,