Thought processes –and in particular those occurring before sleep-- play a key role in pain-related insomnia.[1,2] Patients with chronic pain (eg, from fibromyalgia, rheumatoid arthritis or lower back pain) have a higher prevalence of insomnia than the general population. In addition, insomnia is thought to increase the levels of pain perceived as well as reduce pain-coping abilities.  Dysfunctional beliefs associated with sleep (eg, worry and anxiety) play a critical role in the maintenance of insomnia, so addressing these belief through modalities such as cognitive behavioral therapy might help tackle insomnia and associated chronic pain. [4,5]
Chronic pain and depression were found to share genetic factors, thus explaining their association.  It was found that a higher number of genetic variants predisposing an individual to depression also led to a higher risk of developing chronic pain.
Patients with chronic pain, including rheumatoid arthritis-related pain, are at higher risk of suicidal ideation and suicidality. [7,8] Populations at higher risk include young adults, the elderly, individuals addicted to drugs, as well as those with anxiety or depressive disorders. A deeper understanding of the mechanisms linking suicidality and chronic pain is required before recommendations for adequate treatments can be formulated.
Still routinely prescribed to manage chronic pain, opioids are oftentimes overused, misused, or abused by patients. These behaviors are associated with a number of adverse effects, the most serious of which, respiratory depression, can result in death. Affectively dysregulated patients may associate negative emotions with recurrent opioid use through operant learning.  It is therefore imperative to prevent, identify, and manage opioid misuse in those patients, and seek to adopt of multi-dimensional approach to the treatment of chronic pain. Numerous initiatives have been initiated, aiming to guide healthcare practitioners in face of the opioid epidemic.
Pain catastrophizing--which encompasses magnification, rumination, and helplessness—was found to predict pain intensity and interference in patients.  In addition, pain catastrophizing also appeared to facilitate the transition from acute to chronic pain following surgery.
Pain is now recognized as an individualized experience, and as such, requires a personalized approach. In addition, many patients with chronic pain have comorbidities--including psychological disorders-- that contribute to the development and maintenance of pain. Adopting a biopsychosocial approach to chronic pain management is increasingly favored by clinicians to tackle both pain and many of its associated comorbidities. This approach is tailored to the patient and addresses the psychological and psychiatric comorbidities, while helping to reduce the levels of opioids prescribed. Cognitive behavioral therapy and mindfulness-based stress reduction have proven effective in reducing pain scores associated with a number of pain modalities, including chronic low back pain. [11,12]
Conditioning is now considered a determining factor for the maintenance of pain. A fear avoidance model has been proposed in an endeavor to both explain and understand the transition from acute to chronic pain.  In this model, a set of behaviors that are thought to either contribute to the perpetuation of (eg, fear, avoidance, negative affect), or breaking from pain (eg, optimism, positive affect) are put forth. By breaking the avoidance-promoted “pain cycle” and emphasizing their positive effects, patients may disrupt the fear-avoidance conditioning and achieve recovery.
Social exclusion and Stigmatisation
Patients with medically unexplained pain often face stigmatization and social exclusion.  In the absence of etiology, pain management presents additional challenges, and it can be essential to adopt a biophychosocial approach. Indeed, as social support represents a critical component of the success of both physical and emotional health, addressing the psychological aspects of the pain experience—particularly in patients with unexplained pain—is essential in any comprehensive pain management program.
Chronic pain is often associated with a range of comorbidities that are either not recognized or treated separately from the pain. Failure to adequately treat pain comorbidities results in a soaring of pain scores, adding to the challenge of managing chronic pain.
The biopsychosocial model of pain management allowing for the comprehensive treatment pain and its comorbidities—many often in the psychological realm—is now recognized as a most effective way of managing chronic pain.
- Tang NK, Goodchild CE, Hester J, Salkovskis PM. Pain-related insomnia versus primary insomnia: a comparison study of sleep pattern, psychological characteristics, and cognitive-behavioral processes. Clin J Pain. 2012 Jun;28(5):428-436.
- Smith MT, Perlis ML, Carmody TP, Smith MS, Giles DE. Presleep cognitions in patients with insomnia secondary to chronic pain. J Behav Med. 2001 Feb;24(1):93-114.
- Jansson M, Linton SJ. Psychological mechanisms in the maintenance of insomnia: arousal, distress, and sleep-related beliefs. Behav Res Ther. 2007;45(3):511-521.
- Edinger JD, Fins AI, Glenn DM, et al. Insomnia and the eye of the beholder: are there clinical markers of objective sleep disturbances among adults with and without insomnia complaints? J Consult Clin Psychol. 2000;68(4):586-593.
- McCurry SM, Shortreed SM, Von Korff M, et al. Who benefits from CBT for insomnia in primary care? Important patient selection and trial design lessons from longitudinal results of the Lifestyles trial. Sleep. 2014;37(2):299-308.
- McIntosh, AM, Hall LS, Zeng Y, et al. Genetic and Environmental Risk for Chronic Pain and the Contribution of Risk Variants for Major Depressive Disorder: A Family-Based Mixed-Model Analysis. PLoS Med .13 (8): 2016 Aug 16. doi:10.1371/journal.pmed.1002090.
- Almeida OP, McCaul K, Hankey GJ, et al. Suicide in older men: the health in men cohort study (HIMS). Prev Med. 2016;93:33-38.
- Fuller-Thomson E, Ramzan N, Baird SL. Arthritis and suicide attempts: findings from a large nationally representative Canadian survey. Rheumatol Int. 2016. doi:10.1007/s00296-016-3498-z.
- Andrzejewski ME, Mckee BL, Baldwin AE, Burns L, Hernandez P. The clinical relevance of neuroplasticity in corticostriatal networks during operant learning. Neurosci Biobehav Rev. 2013;37(9 Pt A):2071-2080.
- Bérubé M, Choinière M, Laflamme YG, Gélinas C. Acute to chronic pain transition in extremity trauma: A narrative review for future preventive interventions (part 2). Int J Orthop Trauma Nurs. 2016;23:47-59. doi: 10.1016/j.ijotn.2016.04.002
- Cherkin DC, Sherman KJ, Balderson BH, et al. Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: a randomized clinical trial. JAMA. 2016;315(12):1240-1249.
- Pincus T, Burton AK, Vogel S, Field AP. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine (Phila Pa 1976). 2002;27(5):E109-E120.
- Vlaeyen JW, Crombez G, Linton SJ. The fear-avoidance model of pain. Pain. 2016;157(8):1588-1589.
- De Ruddere L, Bosmans M, Crombez G, Goubert L. Patients are socially excluded when their pain has no medical explanation. J Pain. 2016; 17(9):1028-1035.