Learning Objectives
By the end of this section, you will be able to:
- Describe psychosocial factors affecting pain
- Identify physiological factors affecting pain
- Recognize psychological factors affecting pain
Psychosocial, physiological, and psychological factors can all affect pain. An important part of a pain assessment is recognizing the factors that could be influencing pain (Dydyk & Grandhe, 2023). Factors such as poor social support, past experiences, and age can make an impact on the patient’s perception of pain.
These factors can negatively or positively impact a patient’s perception and expectations of pain. A patient who has had negative past experiences with chronic pain and pain management may believe that their pain can never get better. A patient who has a good support system and believes that improving their lifestyle can heal their chronic pain may find their pain improving over time. It is important that patients are aware of the different factors that can affect pain and how different choices, lifestyle, and mindset can affect their perception and overall outcome of pain.
Psychosocial Factors Affecting Pain
A psychosocial factor is a social factor that relates to a person’s perception of pain. Social factors can include mood, trauma, interpersonal relationships, environment, and education. Research shows that past experience and interpersonal relationships can have a large impact on the perception of pain. Patients who have pain due to past trauma may have a different perception of pain than someone who has never experienced pain. The impact of others can also affect patients’ pain. For example, a patient may be more likely to report pain in the presence of a supportive environment than a patient who is alone.
Mood
Research shows that there is a connection between mood and pain. Mood disorders such as anxiety, depression, and bipolar disorder can impact the perception of pain. Emotions such as fear, frustration, and anger can also impact pain. If negative emotions persist during chronic pain, patients may be at an increased risk of suicide (Antioch et al., 2020). Chronic debilitating pain combined with a history of depression can give patients a feeling that there is no sense of pain relief.
Positive emotions can in turn help patients deal with their pain. Patients who are optimistic and have a positive lifestyle may view pain as a minor inconvenience rather than a life-altering change. Practicing interventions such as cognitive behavioral therapy, mindfulness, and relaxation techniques can help patients keep a positive mood while dealing with pain.
Distress
Negative attitudes in combination with pain can often lead to distress. Distress is experiencing extreme physical or mental suffering such as pain, anxiety, or sadness. Often patients find that their pain is beyond their ability to cope, which can cause distress when dealing with pain (Craig & MacKenzie, 2021). Distress when dealing with pain can lead to decreased quality of life, depression, anxiety, and catastrophizing (Fancourt & Steptoe, 2018). Patients may be so preoccupied with their pain that they begin to catastrophize and neglect other areas of their lives. For example, a patient with severe chronic pain may begin to think that there is no hope for pain relief and withdraw from their daily life. They may stop going into work, reduce physical and social activity, and turn to substance use as a coping mechanism. These poor lifestyle choices can lead to a decreased quality of life and more health complications.
Trauma
Pain and trauma are often interconnected. Many times, a patient’s pain may be directly caused by trauma and therefore be a constant reminder of the traumatic experience (Jackson, 2021). Physical trauma such as car accidents or abuse can cause chronic pain. Patients may have chronic pain due to their injuries sustained in the traumatic experience or experience chronic pain due to post-traumatic stress disorder (PTSD). Post-traumatic stress disorder (PTSD) is a psychiatric disorder where a person experiences lingering effects triggered by a past traumatic event. These lingering effects can include chronic pain and can lead to anxiety and catastrophizing.
Research shows that childhood trauma can be linked to chronic pain later in life (Jackson, 2021). Childhood trauma may include physical, emotional, or sexual abuse, neglect, or parental separation. Children often do not know how to deal with traumatic experiences and may not receive support afterward, so they can have lingering effects of the trauma for many years. Research shows that treating the trauma can provide pain relief. Different types of therapy and mental health resources can help the patient deal with the trauma and any residual effects.
Interpersonal Factors
It is important for nurses to understand how social factors can affect a patient’s perception of pain. Supportive environments may allow patients to be more open in voicing their pain. For example, a patient may be more open in discussing their pain in the presence of a loved one than when alone in a healthcare setting (Gilam et al., 2020). Factors such as culture and socioeconomic status can influence how a patient perceives and articulates their pain (Heshmat, 2023). Certain cultures may be more expressive in their pain than others, and patients may hide their pain in fear of judgement of their socioeconomic status.
The complex interactions between factors affecting pain and individual perception can create a wide range of reactions to pain (Trachsel et al., 2023). Perceived social rejection, lack of social support, and relationship struggles can impact a patient’s perception of pain. A patient without adequate social support may view their pain as more unmanageable than a patient with a strong support system does.
Physiological Factors Affecting Pain
Physical factors that are related to a person’s perception of pain are called physiological factors. Physiological factors can include age, developmental level, sex, ethnicity, and lifestyle choices. Research shows that physiological factors such as hunger, stress, substance use, and sedentary lifestyle can put a person at an increased risk for pain (Dydyk & Grandhe, 2023). Substance use may be used to try to relieve pain. Alcohol is often used by patients to self-medicate, but the pain-relieving properties are short-lived. Healthy lifestyle choices such as exercise, healthy foods, and sunlight can be used to decrease pain and prevent further health complications (Mills et al., 2019).
Developmental Level
The developmental level of the patient can impact how they perceive and express pain, especially in children. It is important to note that developmental level does not always correspond with the patient’s age. For example, a patient with Down syndrome could be 18 years old but have the developmental level of a school-aged child due the cognitive effects of Down syndrome. Patients with childhood traumatic brain injuries could remain at a lower developmental level as they age.
Infants cannot verbalize pain and express all distress through crying. The nurse must use other behavioral cues and rule out other causes to determine if the crying is related to pain. Toddlers and preschoolers often have difficulty describing, identifying, and locating pain. Instead, pain may be demonstrated behaviorally with crying, anger, physical resistance, or withdrawal. School-aged children and adolescents are more responsive to explanations of pain.
Adults are able to verbally express pain and can understand most pain rating scales. However, adults who are developmentally delayed may express pain similar to how a child does. Pain in older adults can present atypically with confusion and agitation. Patients who are confused may have trouble perceiving and adequately expressing their pain. Pain is often underreported in patients of different developmental levels, so nurses must be aware that people of different developmental levels will express pain in very different ways.
Age
Just as children relate differently to pain based on their developmental levels, older adults can be at greater risk of chronic pain due to age-related health concerns. Older adult patients have a higher risk of illness or injury, which can lead to chronic pain (Mills et al., 2019). Older adult patients have a higher rate of chronic pain due to these age-related changes. Older adults are also less likely to express pain. Many patients have the attitude that pain is “just what happens with old age.” Dementia and confusion can also make expressing pain more difficult (Mills et al., 2019). Patients who experience chronic conditions such as Alzheimer disease may not be able to recognize that they are in pain or adequately communicate how they are feeling. Many older adult patients experience social isolation, which can further discourage them from seeking pain management.
Clinical Judgment Measurement Model
Analyze Cues: Linking Physiological Factors to Pain
The nurse is performing an initial assessment on an older adult patient admitted for a urinary tract infection. The nurse observes that the patient is confused and does not know they are in the hospital. The patient is visibly distressed and states they are scared because they do not know where they are or where their spouse is. The nurse observes that the patient arrived at the hospital in a wheelchair and notes chronic back pain in their health history. The nurse notes that the patient has chronic pain medication listed on their home medication list. When the nurse asks the patient if they are in pain, the patient states “no” and continues to express distress that they are not at home with their spouse. However, the nurse notes that the patient continues to rub their back and struggles to move from the wheelchair to the bed. The nurse understands that confusion due to age in older adult patients can impact the patient’s perception of pain. The nurse notes that the patient’s vocalization of pain does not match the physical signs of pain and may be due to the patient’s confusion. The nurse understands that further evaluation is needed to assess the patient’s pain and factors that may impact their pain management.
Culture/Ethnicity
Culture and ethnicity can play a role in the perception and management of pain. Various cultures can express pain differently. For example, Asian cultures are typically more reserved when discussing pain while other cultures may be more vocal and expressive in their pain (Givler et al., 2023). Research has shown that chronic pain is more prevalent in developing countries (Mills et al., 2019). Cultures with fewer resources and less access to health care have higher risk of pain being underassessed and undertreated.
Research has shown that socioeconomic background may affect pain more than culture and ethnicity. Underrepresented communities often have limited access to health care and can be at higher risk of chronic pain, substance misuse, and opioid addiction (Dydyk & Grandhe, 2023). Patients may not have the education or financial stability to seek out care when dealing with chronic pain. Patients from an underrepresented community may have limited access to health insurance, financial stability, job security, and other factors that complicate their perception of pain and the ability to manage it. Patients experiencing chronic pain may be concerned about the cost of treatment or job security and may avoid seeking care for chronic pain (Mills et al., 2019).
Sex Assigned at Birth
Pain can be perceived differently between males and females. When discussing the impact of biological sex on pain, it is important to differentiate between biological sex and gender. Biological sex refers to the assignment of male, female, or Intersex at birth based on different genitalia and chromosomes. Gender refers to the characteristics of male or female based on social and cultural norms. A person may be assigned a biological sex that does not align with their gender. For example, a person may have sex characteristics of a male, but identify socially and culturally as a female. Both biological sex and gender can play a role in pain.
Research has shown that males are less likely to express pain and seek treatment for pain than females (Mills et al., 2019). People assigned female at birth may also experience pain that males do not, such as menstrual pain and labor pain.
Females experiencing pain are often more likely to be undertreated than males (Casale et al., 2021). The understanding of pain related to specific female health conditions has historically been misunderstood. Many researchers are advocating for development of pain medication specifically designed for females (Casale et al., 2021). Research shows that females are affected by pain more severely and more frequently than males (Casale et al., 2021). Recent research shows that there are significant differences in the physiologic mechanisms of pain related to sex. Females perceive pain differently than males do and hormones can affect pain signals (Osborne & Davis, 2022). Recent research has been more inclusive of females, but there is still more needed. Because of the lack of inclusion of females in studying the effects of pain, many feel misunderstood when seeking pain management from healthcare providers. It is important for nurses to understand how sex and gender can impact patients’ perception of pain and that more research is needed to determine the extent of its effect.
Psychological Factors Affecting Pain
A patient’s expectations of pain can often increase or decrease the severity. If a patient believes they will have a lot of pain, their perception can increase. In contrast, if a patient believes an intervention will be effective, their pain may decrease (Heshmat, 2023). The interpretation of pain can also have an impact on pain perception. How pain affects a patient’s quality of life can change their perception of pain. For example, a patient who is having pain from an elective surgery may perceive their pain differently than a patient who is having chronic pain from cancer treatment does.
Patient Conversations
What If Your Patient Believes Nothing Will Work to Treat Their Pain?
Scenario: The nurse is caring for a patient who is experiencing chronic pain from cancer treatment. The patient is exhibiting signs of withdrawal and depression and looks worried when the nurse walks into the room.
Nurse: Hi, my name is Emily, and I am going to be your nurse today. Do you mind verifying your name and birthday for me?
Patient: Sure, Alice Wilde 12/13/1960.
Nurse: Nice to meet you, Alice. Are you experiencing any pain right now?
Patient: Yes, I am always in pain. I don’t think it’s ever going to go away.
Nurse: What would you rate your pain on a scale of zero to ten, with zero being no pain and ten being the worst pain?
Patient: A seven. It’s always a seven. You all ask me the same questions every day. My pain is in my abdomen, and it feels dull and achy. I never get any relief from it even though they have me on all these medications that make me so sleepy.
Nurse: I am sorry to hear that. Have you tried anything besides the medications for your pain?
Patient: Why bother? I know it won’t get any better. I have pain because I have cancer. Everyone I know who has had cancer was in so much pain all the time, so I know it will be that way for me.
Nurse: Sometimes having a positive mindset can make a big difference in your pain. I know that can be hard to do, but maybe we could try a few techniques to see if it will help?
Patient: I guess, although I really do not think anything will help my pain. The doctors tell me I’m on the maximum dose of medications and nothing is helping.
Nurse: I understand it can be frustrating that the interventions are not helping your pain. Why don’t we try looking at your pain a different way?
Patient: What do you mean?
Nurse: Sometimes, you experience pain when you expect it. So, if you think your pain will always be a seven, then that is what it will feel like. If you can change your mindset to a more positive outlook for your pain, you may find your pain decreasing.
Patient: I have never thought about it that way. I am willing to give that a try.
Experience
Past experience of pain can impact how a patient perceives pain in the present or future. Pain can be a learned behavior (Cosio, 2020). Children who see their parents in chronic pain may assume that all adults experience pain. Children learn to express pain by watching others. For example, a child who stubs their toe may yell a profanity and grab their toe because they saw their father do the same thing. Patients also learn what pain interventions are effective, even if they can have negative consequences. For example, a patient may realize that lying on the couch relieves their back pain. However, prolonged inactivity can lead to chronic pain and more adverse effects (Cosio, 2020).
Expectation
The perception of pain can be shaped by expectations. If a patient believes they will have a lot of pain, their perception can increase. Patients may catastrophize and assume the worst possible outcome for their pain. This can cause the patient to feel worse pain and add negative emotions, such as fear and anxiety, to their pain (Heshmat, 2023).
Patients can also improve their pain with appropriate expectations. If the patient expects an intervention to work, they may experience decreased pain (Heshmat, 2023). This is called a placebo effect. A placebo effect is when a certain treatment proves to be an effective pain reliever due to the patient believing it will be effective (Cosio, 2020). Nurses can educate patients on the importance of appropriate expectations when managing their pain to improve patient outcomes.
Interpretation
Patients all have different interpretations of pain. Because pain is a subjective experience, it is important for nurses to accept the pain for whatever the patient says it is. Some patients may interpret pain as debilitating whereas another patient may interpret the same pain as mild (Heshmat, 2023). A patient may interpret ankle pain as “dull and achy” whereas another patient may interpret ankle pain as “sharp and stabbing.” Situational awareness can also impact a patient’s interpretation of pain. For example, a patient who is having their first child may interpret pain as a joyful sign of new life and welcome the pain. Another patient who is in hospice care for chronic pain may interpret pain as a sign that death is imminent. It is important for nurses to remember that all patient interpretations of pain are correct and to be mindful of how a patient interprets their pain when providing pain interventions.
Avoidance
Some patients may choose to deal with pain by avoiding it. Patients may refuse to discuss their pain or may not disclose pain at all. Patients who are unable to cope with their pain may be more likely to ignore it (Cosio, 2020). It is natural for a person to run away from pain so patients should be aware that this is an understandable reaction to pain (Fournier, 2020). However, patients need to understand that avoiding pain does not make it better or go away. Sometimes avoiding pain can make it worse. Pain can also be a sign of further health complications and ignoring it can lead to negative outcomes. For example, a patient experiencing chronic migraines may ignore the pain because they do not want to seem like a burden on their family. However, the pain could be a sign of a more serious issue such as a brain tumor. Ignoring the pain could lead to the patient delaying diagnosis and treatment of a more serious issue.