Chronic pain and emotional distress: what is the association?

Chronic Pain

Chronic pain can cause emotional distress which often enhances pain, therefore feeding a a vicious cycle that can be hardly broken.

The International Association for the Study of Pain describes pain as “An unpleasant sensory and emotional experience associated with a present or potential tissue damage, or described as such” (Margari et al., 2014). However, given the interconnection between our body and our state of mind, it is clear that pain cannot only be described in anatomic or functional terms; it is also necessary to consider its multidimensionality (Margari et al., 2014).

Imaging studies conducted on the brain regions controlling pain sensitivity and emotional states have confirmed that the activity of pain pathways can be modulated by negative emotions even when extraneous to a pain stimulus (Crofford, 2015). In particular, the insula, anterior cingulate cortex and prefrontal cortex are the brain regions exhibiting the most clear modifications in chronic pain patients (CPPs) (Crofford, 2015).

In addition to these neurologic phenomena, the correlation between pain (especially its chronic form), emotional states and working/social life has been studied. For example, it has been consistently confirmed that chronic pain has a strong negative impact on patients’ quality of life (QoL). Moreover, CPPs are often affected by psychiatric disorders, e.g. depression, anxiety, personality disorders or, more commonly, by symptoms as frustration, anxious and negative mood in general (Serrano-Ibáñez et al., 2018; Shuchang et al., 2011; Margari et al., 2014). In 45% to 80% of inpatients with chronic pain, this condition contributes to functional impairment, and multiple comorbidities are present (Shuchang et al., 2011)

The scientific literature has also highlighted the bi-directional balance of pain and emotional distress; i.e. depression can be either a causative factor or the result of chronic pain (Margari et al, 2014). Interestingly, this happens because negative emotions may have a reciprocal relationship with chronic pain severity; anger, for example, via a symptom-specific reactivity, increases muscle tension and anxiety alters the perception of the extent of the patient’s disability (Shuchang et al., 2011).
Part of the medical research literature tackling the association between emotional distress and chronic pain has focused on the effects of the perception of continuity and unpredictability of pain itself (Ojala et al., 2014). CPPs recognise pain as dominating their lives, an experience that fuels the perception of chronic pain as uncontrollable (Ojala et al., 2014): as a consequence negative emotions can develop and increase.

Moreover, researchers have analysed the association between chronic pain and emotional distress in depth, trying to understand if patients’ negative emotions are generated more by their physical powerlessness to accomplish normal activities or by the disruption of social relationships that often accompany pain (Sturgeon et al., 2015). These studies have shown that a major role is played by the effects of chronic pain, and consequently of depression and anger, on the patient’s social interactions (Sturgeon et al., 2015).
Effective health policies should be developed to prevent and manage pain and to lower the disability imposed on patients, as well as its effect on their environments (Dueñas et al., 2016). Moreover, it is important that caregivers and health care professionals provide CPPs with multidisciplinary intervention because the negative emotions that develop in these patients can interfere with both treatment and rehabilitation (Margari et al, 2014).


  • Crofford LJ. Psychological aspects of chronic musculoskeletal pain. Best Pract Res Clin Rheumatol 2015;29:147 (freely available from PubMed).
  • Dueñas M, Ojeda B, Salazar A, Mico JA, Failde I. A review of chronic pain impact on patients, their social environment and the health care system. J Pain Res 2016;9:457-467 (freely available from PubMed).
  • Margari F, Lorusso M, Matera E, Pastore A, Zagaria G, Bruno F, et al. Aggression, impulsivity, and suicide risk in benign chronic pain patients – a cross-sectional study. Neuropsychiatr Dis Treat 2014;10:1613-1620 (freely available from PubMed).
  • Ojala T, Häkkinen A, Karppinen J, Sipilä K, Suutama T, Piirainen A. The dominance of chronic pain: a phenomenological study. Musculoskeletal Care 2014;12:141-149.
  • Serrano-Ibáñez ER, Ramírez-Maestre C, López-Martínez AE, Esteve R, Ruiz-Párraga GT, Jensen MP. Behavioral inhibition and activation systems, and emotional regulation in individuals with chronic musculoskeletal pain. Front Psychiatry 2018;9:394 (freely available from PubMed).
  • Shuchang H, Mingwei H, Hongxiao J, Si W, Xing Y, Antonius D, et al. Emotional and neurobehavioural status in chronic pain patients. Pain Res Manag 2011;16:41-43 (freely available from PubMed).
  • Sturgeon JA, Dixon EA, Darnall BD, Mackey SC. Contributions of physical function and satisfaction with social roles to emotional distress in chronic pain: a Collaborative Health Outcomes Information Registry (CHOIR) study. Pain 2015;156:2627-2633 (freely available from PubMed).