Explaining symptom severity, distress and disability in chronic pain: The role of mental defeat

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.

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.

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.