The role of emotion in determining pain.

One of the perplexing features of pain is the wide variety in patients' responses to ostensibly the same extent of physical pathology. One reason for this is that emotional states (feelings) and thoughts (cognitions) mediate our pain perception. Furthermore, it has been shown that maintenance of pain and disability as well as response to treatment is related to a number of factors such as self-efficacy beliefs and fear avoidance. Indeed, it has been shown that these pain-related beliefs are more important determinants of disability and functioning in some disorders than pain intensity or duration. This chapter attempts to outline the role of predisposing, precipitating and maintaining factors in patients with chronic pain. The importance of a multi-dimensional assessment of patients with pain that takes into account factors such as specific feelings (emotions), thoughts (cognitions), pain behaviours and pain-coping strategies is emphasised. The key role in certain patients of 'catastrophising', as well as causal beliefs and attributions on pain outcomes and disability, will be outlined. It is useful to adopt a 'stepped care' approach to treatment. Most patients with irritable bowel syndrome will respond to reassurance, whereas those with more enduring and/or difficult to manage symptoms may require treatments of a different type and level of complexity. This may include antidepressant drug treatment or, in certain situations, cognitive behavioural treatment. It is quite acceptable to adopt more than one treatment approach concurrently. Antidepressant treatment has also been shown to be effective in concert with psychological treatments and to lead to improved quality of life.