Clinical psychologists are highly skilled at undertaking a patient centred, holistic approach to assessment and developing a bespoke formulation of their presenting difficulties. This is true of all presenting difficulties, including where physical health or injury is involved. Clinical Psychologists use a biopsychosocial framework to understand the array of factors which often contribute to an individual’s experience.
One of the presenting factors which benefits significantly from this approach is persistent or chronic pain.
What do we mean by chronic pain?
The current definition of chronic pain is:
“An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” IASP, 2020
This definition reflects a key clinical point: pain is not a simple, one-to-one indicator of tissue damage. Instead, pain is a complex experience shaped by the nervous system and influenced by context, meaning, and emotion – alongside any physical injury.
So what is pain?
Pain is understood to be a form of communication within the body which indicates something is wrong or requiring attention. However, pain can often present in the absence of actual tissue damage or injury, in which case pain can be understood to serve the function of warning against potential damage, for example feeling burning in your hand if it rests against a radiator before any actual damage has taken place.
Persistent or chronic pain is always produced by the brain, and it is understood to be influenced by several factors including:
- Severity of injury
- Context for the injury
- Current understanding of the injury or nature of the pain
- The impact the injury has on social and lifestyle factors
- The meaning of the injury
- Expectation of recovery
- Underlying nervous system functioning and sensitivity
- Previous trauma or injury experiences
- General health beliefs
All these factors are known to impact on the nature, severity, intensity and prognosis of pain. They are also all influenced by past experience, personality, social norms and expectations, concurrent stressors, mental health and emotional wellbeing.
How a Clinical Psychologist helps in a medicolegal context
In a medicolegal assessment, a Clinical Psychologist considers both the functional impact of an incident (activity levels, emotional wellbeing, and day-to-day functioning) and the factors that may be influencing pain and recovery. This includes exploring the person’s understanding of the injury, expectations of recovery, and any beliefs that may be maintaining distress or avoidance.
Where trauma or emotional distress is present, pain can become linked to threat and act as a reminder of the event. This can trigger a stress response in the body (e.g., increased tension and nervous system arousal), which can amplify pain and contribute to ongoing sensitisation. Psychological input focuses on identifying this cycle and supporting the person to break it -through education and strategies to regulate the nervous system and promote recovery.
Key questions considered as part of a psychological assessment include:
- Why may the pain be persisting beyond the observed physical recovery?
- Why the pain may be disproportionate to the level of injury sustained?
- Why the pain experience may be variable or changeable
And as part of the report generated Clinical Psychologists can offer opinions on
- Suggested interventions
- Anticipated recovery times
- A comprehensive, person centred formulation to better understand the presenting difficulties
Case example
Client X is involved in an RTC which resulted in muscular pain across their shoulders and neck. They developed a fear of driving and report hypervigilance when in a car, either as a passenger or as a driver. They describe feeling tense and on edge when in a car with a sense of what might happen dominating their thinking. After 6 months they continue to experience pain in their neck despite medical examinations explaining that all injury has healed.
From a psychological perspective we can theorise that the client experienced the incident as traumatic and this has resulted in an association of threat every time they get in or even consider getting in a car. Their memory and cognitions tell them that they are not safe, which results in a systemic threat response which includes increased tension across their shoulders which aggravates their underlying muscular injury. Over time, this repeated fear response serves to increase sensitivity of the nervous system which can result in persistent pain.
