Explaining symptom severity, distress and disability in chronic pain: The role of mental defeat
Lead Research Organisation:
University of Warwick
Department Name: Psychology
Abstract
Chronic pain is a global health problem that affects around 8 million people in the UK. Although it cannot be seen, its impact on people's day-to-day activities, physical health and psychological wellbeing is highly visible and far-reaching. Research has shown that chronic pain is the reason for >4 million GP appointments each year and that the presence of chronic pain raises the risk of depression and suicide by two to three times.
Most cases of chronic pain do not have a specific known cause, and hence are impossible to cure. Helping people to live well despite chronic pain is therefore the ultimate goal of pain management programmes, although the effect of these psychological interventions has been frustratingly modest. Identifying the psychological factor that explains the progression of symptom severity and predicts the development of distress or breakdown of self-management will offer important clues to advancing these treatments.
Existing psychological interventions for chronic pain typically focus on symptom management, overlooking the impact of chronic pain on the person's deeper sense of self and identity. Work by our group has discovered that people who are most distressed and disabled by chronic pain tend to have a strong sense of mental defeat, such that they feel that they have lost an important battle with chronic pain. Such defeated state of mind is characterised by a perceived loss of autonomy, social rank and human integrity. The concept of mental defeat is relevant to the explanation of depression, post-traumatic stress disorder and suicide. It can be measured and we have initial evidence to suggest that mental defeat can better explain pain interference and the seeking of specialist pain treatment, compared to psychological processes (e.g., pain catastrophising) targeted by current treatments.
The proposed research will provide an in-depth investigation of the role of mental defeat in the development of symptoms, distress and disability associated with chronic pain. The research has three methodologically complementary components. Specifically, we will carry out a tightly-controlled experiment in the laboratory, a questionnaire study and an experience sampling study in the participant's natural living environment over the course of a year. Together, these will generate the first experimental and longitudinal evidence necessary to:
Aim 1 - evaluate how pain responses are altered when the sense of mental defeat is activated,
Aim 2 - determine the extent to which mental defeat is associated with physical, psychological and social outcomes in 6 and 12 months, and
Aim 3 - delineate the potential day-to-day processes, such as attention, mood, stress, physical and social activity, sleep and use of medication, through which mental defeat aggravates symptoms and translates into a source of distress and disability.
The proposed research aims to inform treatment development and will be carried out with people living with chronic pain to maximise its clinical relevance. Earlier research on mental defeat in chronic pain was limited by their qualitative and correlational nature due to understandable ethical concerns and a lack of viable experimental protocol. The proposed research will apply a thought manipulation technique successfully developed by our group to temporarily activate a pain-related sense of mental defeat without causing undue distress to the participants. It will also capitalise on data monitoring and analytic techniques the group is known for, to evaluate the temporal relationship between mental defeat and outcomes of interest in the real world from the patient's perspective. Findings of the research will have a bearing on future psychological theories of chronic pain and open up exciting avenues for a broader understanding of chronic pain and its closely aligned ailments, including depression, post-traumatic stress and suicide.
Most cases of chronic pain do not have a specific known cause, and hence are impossible to cure. Helping people to live well despite chronic pain is therefore the ultimate goal of pain management programmes, although the effect of these psychological interventions has been frustratingly modest. Identifying the psychological factor that explains the progression of symptom severity and predicts the development of distress or breakdown of self-management will offer important clues to advancing these treatments.
Existing psychological interventions for chronic pain typically focus on symptom management, overlooking the impact of chronic pain on the person's deeper sense of self and identity. Work by our group has discovered that people who are most distressed and disabled by chronic pain tend to have a strong sense of mental defeat, such that they feel that they have lost an important battle with chronic pain. Such defeated state of mind is characterised by a perceived loss of autonomy, social rank and human integrity. The concept of mental defeat is relevant to the explanation of depression, post-traumatic stress disorder and suicide. It can be measured and we have initial evidence to suggest that mental defeat can better explain pain interference and the seeking of specialist pain treatment, compared to psychological processes (e.g., pain catastrophising) targeted by current treatments.
The proposed research will provide an in-depth investigation of the role of mental defeat in the development of symptoms, distress and disability associated with chronic pain. The research has three methodologically complementary components. Specifically, we will carry out a tightly-controlled experiment in the laboratory, a questionnaire study and an experience sampling study in the participant's natural living environment over the course of a year. Together, these will generate the first experimental and longitudinal evidence necessary to:
Aim 1 - evaluate how pain responses are altered when the sense of mental defeat is activated,
Aim 2 - determine the extent to which mental defeat is associated with physical, psychological and social outcomes in 6 and 12 months, and
Aim 3 - delineate the potential day-to-day processes, such as attention, mood, stress, physical and social activity, sleep and use of medication, through which mental defeat aggravates symptoms and translates into a source of distress and disability.
The proposed research aims to inform treatment development and will be carried out with people living with chronic pain to maximise its clinical relevance. Earlier research on mental defeat in chronic pain was limited by their qualitative and correlational nature due to understandable ethical concerns and a lack of viable experimental protocol. The proposed research will apply a thought manipulation technique successfully developed by our group to temporarily activate a pain-related sense of mental defeat without causing undue distress to the participants. It will also capitalise on data monitoring and analytic techniques the group is known for, to evaluate the temporal relationship between mental defeat and outcomes of interest in the real world from the patient's perspective. Findings of the research will have a bearing on future psychological theories of chronic pain and open up exciting avenues for a broader understanding of chronic pain and its closely aligned ailments, including depression, post-traumatic stress and suicide.
Technical Summary
Chronic pain is a disabling condition that often does not have a clear underlying pathology. Around 8 million people in the UK are living with severe chronic pain for which long-term management is required. Current psychological interventions tend to focus on symptom management and has so far only demonstrated modest therapeutic impact.
Based on previous research in depression and post-traumatic stress disorder, we propose that helping people to live well despite chronic pain requires a better understanding of the deeper impact of chronic pain on people's sense of self and identity. We hypothesise that mental defeat is an important cognitive factor that alters pain responses and predicts symptom severity and the development of distress and disability. We further hypothesise that these effects of mental defeat may be mediated by its impact on people's day-to-day cognitions (attention to pain, perceived stress), emotions (positive and negative mood) and behaviour (physical and social activity, sleep, use of medication).
The proposed research will test these hypotheses in samples of chronic pain patients. It has three complementary components, comprising an experiment, a questionnaire and a 1-week experience sampling exercise (ESE). The questionnaire and the ESE each has 3 waves of data collection at baseline, 6-month, and 12-month. This enables the effect of mental defeat in the short and long term to be both evaluated and the performance of a cross-lagged mediation analysis. The ESE will involve in vivo data collection using actigraphy and an online survey to be administered at 3 random times a day, over 7 days. Data collected will be fitted with multilevel models to decipher the day-to-day relationship between mental defeat and the hypothesised mediators. Together, findings of the proposed research will inform treatment development and illuminate the plausible pathways through which mental defeat translates into symptoms, distress and disability.
Based on previous research in depression and post-traumatic stress disorder, we propose that helping people to live well despite chronic pain requires a better understanding of the deeper impact of chronic pain on people's sense of self and identity. We hypothesise that mental defeat is an important cognitive factor that alters pain responses and predicts symptom severity and the development of distress and disability. We further hypothesise that these effects of mental defeat may be mediated by its impact on people's day-to-day cognitions (attention to pain, perceived stress), emotions (positive and negative mood) and behaviour (physical and social activity, sleep, use of medication).
The proposed research will test these hypotheses in samples of chronic pain patients. It has three complementary components, comprising an experiment, a questionnaire and a 1-week experience sampling exercise (ESE). The questionnaire and the ESE each has 3 waves of data collection at baseline, 6-month, and 12-month. This enables the effect of mental defeat in the short and long term to be both evaluated and the performance of a cross-lagged mediation analysis. The ESE will involve in vivo data collection using actigraphy and an online survey to be administered at 3 random times a day, over 7 days. Data collected will be fitted with multilevel models to decipher the day-to-day relationship between mental defeat and the hypothesised mediators. Together, findings of the proposed research will inform treatment development and illuminate the plausible pathways through which mental defeat translates into symptoms, distress and disability.
Planned Impact
In terms of the wider impact of the proposed research, we believe a better empirical understanding of the role and predictive function of mental defeat will have a tangible social, clinical, and economic impact on our society.
Social - individuals living with chronic pain, their carers, health care professionals interacting in the same system
Often times, people living with chronic pain find it difficult to understand the persistence of symptoms despite their every effort to eliminate pain. They also find it difficult to explain to their carers and health care professionals their struggle to manage pain, in a way that is readily accepted and understood by those who cannot see or feel it. The identification of mental defeat as a clinical phenomenon and the accompanying effort to study it as a cognitive factor affecting physical functioning and psychological wellbeing is, in itself, validating. It gives people living with chronic pain a theoretically sound and evidence-based concept to make sense of what is going on in their body and mind. It gives them a framework to see how their sense of self could be affected by chronic pain, and how a defeated state of mind could in turn affect their pain experience and long term prognosis. It gives people with chronic pain a terminology to communicate their pain experience. An improved awareness of mental defeat as a clinical phenomenon, with theoretical and empirical basis, will help shift social attitude towards people struggling to cope with chronic pain and the clinical culture where medications and surgical interventions are considered as the primary solutions.
Clinical - treatment development; more accurate screening and effective prevention
Current pain management programmes are typically multi-component by design to address multiple issues associated with chronic pain. These programmes vary in their contents, ranging from basic psycho-education about pain to exercise and physical activity management; from cognitive-restructuring to drug-tapering; from assertiveness training to mindfulness meditation. The selection of these treatment targets is often opaque and dictated by resources and expertise available. Recent systematic reviews of randomised controlled trials of psychological treatments for chronic pain have revealed that the treatment effects on pain, mood, and disability are modest to negligible. The need for change is clear. However, as these programmes are often developed and evaluated as packages, it is difficult to pinpoint which individual component is effective (and hence should be kept) and which one is not (and hence should be removed, refined or replaced). The proposed research will inform treatment development from the bottom-up, by first gathering the necessary empirical evidence to evaluate whether mental defeat is a worthy treatment target, before moving on to design and evaluate the effectiveness of treatment strategies for reversing the defeated state of mind. If mental defeat is shown to be a key cognitive factor predicting outcomes and breakdown of self-management, it will drive a shift in treatment focus from symptom management to whole-person recovery and make a strong case for early psychological support for individuals displaying a strong sense of defeat. If the research findings support a temporal association between mental defeat and subsequent suicidal thoughts and behaviour, there will be implications for the screening procedure for identifying and caring for those individuals at risk.
Economic - reduced use of health care resources
If mental defeat is indeed associated with the breakdown of self-management, we can expect those with elevated levels of mental defeat are more likely to seek external help for pain management. Any evidence suggesting a link between mental defeat and poorer future functioning would pave the way for early intervention and possible economic savings from reduced use of health care resources.
Social - individuals living with chronic pain, their carers, health care professionals interacting in the same system
Often times, people living with chronic pain find it difficult to understand the persistence of symptoms despite their every effort to eliminate pain. They also find it difficult to explain to their carers and health care professionals their struggle to manage pain, in a way that is readily accepted and understood by those who cannot see or feel it. The identification of mental defeat as a clinical phenomenon and the accompanying effort to study it as a cognitive factor affecting physical functioning and psychological wellbeing is, in itself, validating. It gives people living with chronic pain a theoretically sound and evidence-based concept to make sense of what is going on in their body and mind. It gives them a framework to see how their sense of self could be affected by chronic pain, and how a defeated state of mind could in turn affect their pain experience and long term prognosis. It gives people with chronic pain a terminology to communicate their pain experience. An improved awareness of mental defeat as a clinical phenomenon, with theoretical and empirical basis, will help shift social attitude towards people struggling to cope with chronic pain and the clinical culture where medications and surgical interventions are considered as the primary solutions.
Clinical - treatment development; more accurate screening and effective prevention
Current pain management programmes are typically multi-component by design to address multiple issues associated with chronic pain. These programmes vary in their contents, ranging from basic psycho-education about pain to exercise and physical activity management; from cognitive-restructuring to drug-tapering; from assertiveness training to mindfulness meditation. The selection of these treatment targets is often opaque and dictated by resources and expertise available. Recent systematic reviews of randomised controlled trials of psychological treatments for chronic pain have revealed that the treatment effects on pain, mood, and disability are modest to negligible. The need for change is clear. However, as these programmes are often developed and evaluated as packages, it is difficult to pinpoint which individual component is effective (and hence should be kept) and which one is not (and hence should be removed, refined or replaced). The proposed research will inform treatment development from the bottom-up, by first gathering the necessary empirical evidence to evaluate whether mental defeat is a worthy treatment target, before moving on to design and evaluate the effectiveness of treatment strategies for reversing the defeated state of mind. If mental defeat is shown to be a key cognitive factor predicting outcomes and breakdown of self-management, it will drive a shift in treatment focus from symptom management to whole-person recovery and make a strong case for early psychological support for individuals displaying a strong sense of defeat. If the research findings support a temporal association between mental defeat and subsequent suicidal thoughts and behaviour, there will be implications for the screening procedure for identifying and caring for those individuals at risk.
Economic - reduced use of health care resources
If mental defeat is indeed associated with the breakdown of self-management, we can expect those with elevated levels of mental defeat are more likely to seek external help for pain management. Any evidence suggesting a link between mental defeat and poorer future functioning would pave the way for early intervention and possible economic savings from reduced use of health care resources.
People |
ORCID iD |
Nicole Tang (Principal Investigator) | |
Swaran Singh (Co-Investigator) |
Publications
Themelis K
(2023)
Mental Defeat and Suicidality in Chronic Pain: A Prospective Analysis.
in The journal of pain
Themelis K
(2023)
The Management of Chronic Pain: Re-Centring Person-Centred Care
in Journal of Clinical Medicine
Tang NKY
(2023)
Cognitive factors and processes in models of insomnia: A systematic review.
in Journal of sleep research
Gillett JL
(2023)
Investigating mental defeat in individuals with chronic pain: Protocol for a longitudinal experience sampling study.
in BMJ open
Collard V
(2021)
An exploratory investigation into the effects of mental defeat on pain threshold, pain rating, pain anticipation, and mood
in Current Psychology
Collard TJE
An exploratory investigation into the effects of mental defeat on pain threshold, pain rating, pain anticipation, and mood
in Current Psychology
Cheatle, Martin D., Foster, Simmie, Tang, Nicole KY
(2020)
Cover Overlapping Pain and Psychiatric Syndromes: Global Perspectives
Cheatle MD
(2023)
Suicidal thoughts and behaviors in patients with chronic pain, with and without co-occurring opioid use disorder.
in Pain medicine (Malden, Mass.)
Description | MRC IAA Award |
Amount | £5,000 (GBP) |
Organisation | Medical Research Council (MRC) |
Sector | Public |
Country | United Kingdom |
Start | 02/2023 |
End | 03/2023 |
Description | Dr Martin Cheatle - Mental Defeat and Suicidality in Chronic Pain and Substance Misuse |
Organisation | University of Pennsylvania |
Department | Perelman School of Medicine |
Country | United States |
Sector | Academic/University |
PI Contribution | data analysis and co-authoring papers (empirical and systematic review commissioned by Pain Medicine) |
Collaborator Contribution | same as above + organising symposium at major conferences (e.g., World Congress on Pain) to increase visibility of work. |
Impact | Two manuscripts currently under review: 1. Themelis, K., Gillett, JL., Karadag,PK., Cheatle, M.D., Giordano, N.A., Balasubramanian,S., Singh, SP.,Tang, KY.,Mental defeat and suicidality in chronic pain: A prospectivelongitudinal analysis. (Under Review) 2. Cheatle, M.D., Giordano, N.A., Themelis, K., Tang, N.K.Y. Suicide Risk in Patients with Chronic Pain with and without co-occurring Opioid Use. (Under review) One grant application submitted for consideration by the American Foundation for Suicide Prevention ($350,000) - selected for second round - awaiting outcome. |
Start Year | 2021 |
Description | Prof Dr Sakari Lemola - University of Bielefeld, Germany |
Organisation | Bielefeld University |
Country | Germany |
Sector | Academic/University |
PI Contribution | Co-investigating the MRC dataset using network analysis and experience sampling models |
Collaborator Contribution | Co-investigating the MRC dataset using network analysis and experience sampling models |
Impact | Gillett, JL., Karadag,PK, Themelis, K., Li, Y.M., Lemola, S., Balasubramanian,S., Singh,SP.,Tang, KY. (In Press) Investigating Mental Defeat in Patients with Chronic Pain: Protocol for a longitudinal Experience Sampling Study. (In press in BMJ open) |
Start Year | 2022 |
Description | Prof Mark Ilgen - University of Michigan |
Organisation | University of Michigan |
Country | United States |
Sector | Academic/University |
PI Contribution | Professor Mark Ilgen is Professor of Psychiatry at the University of Michigan. He's research career scientist at the VA Centre for Clinical Management Research, directing the University of Michigan Addiction Treatment Services. We are currently co-authoring a paper, continuing the discovery on the role of mental defeat in predicting suicide risk. |
Collaborator Contribution | Content expertise and data curation |
Impact | The paper is in preparation. |
Start Year | 2023 |
Description | Airing Pain Podcast |
Form Of Engagement Activity | A broadcast e.g. TV/radio/film/podcast (other than news/press) |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Patients, carers and/or patient groups |
Results and Impact | In this edition of Airing Pain, Paul Evans interviews the team at the Warwick Study of Mental Defeat in Chronic Pain (WITHIN Project) and research participants, as well as taking part in the study as a participant himself. The study, which runs until May 2023, is investigating how mental defeat can influence pain sensation, sleep patterns, social activity, physical activity and the general health of individuals who have chronic pain. Mental defeat is defined as the perceived loss of autonomy in the face of uncontrollable, traumatic events. In the context of chronic pain this can be explained as a loss of identity and self in relation to repeated episodes of pain. Paul talks to the team about their experimental, lab-based study and the sleep-tracking survey, then undergoes the lab experiment himself. He discusses how he found it, the possible outcomes of the research and also interviews other participants. The WITHIN Project will generate information to help further understand the influence that mental defeat has on distress and disability in chronic pain patients. This is essential listening for anyone wanting to know more about the research process, or wanting to participate. Issues covered in this programme include: Mental defeat, pain research, insomnia, psychological effects of pain, chronic pain, patient perspective, acceptance and commitment therapy, research participation, pain thresholds. |
Year(s) Of Engagement Activity | 2022,2023 |
URL | https://audioboom.com/posts/8201560-warwick-study-of-mental-defeat |
Description | Footstep Festival 2021 |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Patients, carers and/or patient groups |
Results and Impact | In this session, our lab demonstrated and shared our experiences using different at-home sleep-tracking gadgets (such as Fitbit and Apple Watch). We covered other areas like using sleep diaries to record and analyse sleep patterns. The team talked about different ways to understand the information collected by these sleep tracking devices and how to use of this information to have a better quality sleep. Participation from the audience was great - We received many questions and the discussion went on much longer than the 1 hour slot allocated for. |
Year(s) Of Engagement Activity | 2021 |
URL | https://my.livewellwithpain.co.uk/festival/the-wellbeing-tent/the-wizardry-of-sleep-gadgetry-help-hi... |
Description | Pain Matters - The Magazine of Pain Concern issue 82 |
Form Of Engagement Activity | A magazine, newsletter or online publication |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Patients, carers and/or patient groups |
Results and Impact | An article about our project is featured in this magazine, with a user-led review on the podcast we did for Airing Pain. |
Year(s) Of Engagement Activity | 2023 |
Description | Resonate Festival |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | Regional |
Primary Audience | Public/other audiences |
Results and Impact | A community science outreach event, in which our team did demonstrations pain sensitivity and motion capture. |
Year(s) Of Engagement Activity | 2022 |
URL | https://www.resonatefestival.co.uk/ |
Description | WITHIN Study Blog |
Form Of Engagement Activity | Engagement focused website, blog or social media channel |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Study participants or study members |
Results and Impact | The purpose of this blog is for sharing interesting research articles we have read regarding our work, as well as any useful commentaries and resources related to our project and research. Five blog posts were up since March 2020. |
Year(s) Of Engagement Activity | 2020 |
URL | https://warwick.ac.uk/fac/sci/psych/research/lifespan/sleeplab/projects/within/blog/ |
Description | WITHIN project webpage |
Form Of Engagement Activity | Engagement focused website, blog or social media channel |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Public/other audiences |
Results and Impact | A dedicated webpage that provides information about the MRC-funded project, with links to our Twitter feed and facebook page. There's also information about the project and people and research partners on the study team. We also use this page for participant recruitment and dissemination purposes. |
Year(s) Of Engagement Activity | 2019,2020 |
URL | https://warwick.ac.uk/fac/sci/psych/research/lifespan/sleeplab/projects/within/blog/ |
Description | Warwick Sleep and Pain Lab |
Form Of Engagement Activity | A magazine, newsletter or online publication |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Study participants or study members |
Results and Impact | To provide an update of our latest research and related activities to all who have signed up to our participant database (~700). This is a quarterly publication. Three newsletters were published since March 2020. |
Year(s) Of Engagement Activity | 2020 |