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

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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.