Maladaptive Cognitions and Chronic Pain: Epidemiology,Neurobiology, and Treatment

Maladaptive cognitions are widespread and play a significant role in the development of chronic pain. (1) Catastrophizing seems to increase the risk of chronicity. In the laboratory it amplifies temporal summation of pain with repeated stimulation and delays the disengagement of attention from pain. In neuroimaging it is associated with increased activation in regions of the cortex involved in attention, the aversiveness of pain, and possibly pain intensity. (2) Fearful anticipation of pain seems to pre-activate brain regions involved in both the sensory and emotional intensity of pain and primes a stronger initial pain response. It may lead to abnormal patterns of muscle recruitment that, speculatively, may predispose to injury. (3) Belief that normal activity should be avoided seems to promote unnecessary long-term disability in nonspecific low back pain. Extreme guarding may intensify pain through loss of inhibition from motor cortex. (4) Educational programs targeting maladaptive beliefs have shown benefit in the primary prevention of chronic back pain in both pain-free and acute pain populations. In established chronic pain, cognitive-behavioral therapy has shown efficacy in improving pain intensity, coping and pain behaviors when compared with usual treatment. (5) Possible future research directions and clinical implications are discussed.