A Dual-Focus Approach for Evaluating Contributors to Chronic Pain: The Roles of Psychosocial Risk and Resilience Factors

Abstract

There has been a predominant focus on psychosocial risk factors associated with poor pain outcomes among individuals with chronic pain. However, it is also important to identify resilience factors that may mitigate the negative impact of or confer successful adaptation to pain. We argue for a dual-focus approach that evaluates the contributions of both risk and resilience factors. Person-centered statistical techniques (cluster analysis) may be beneficial to phenotype individuals based on their psychosocial characteristics to help inform treatment selection. Identifying treatment moderators based on individual-level characteristics (race/ethnicity) may provide insight into differences in treatment efficacy. Utilizing a holistic approach can inform the development and implementation of culturally adapted and personalized treatments aimed at reducing risk and bolstering resilience factors.

Introduction

Chronic pain is a leading cause of disability and reduced quality of life, affecting over 100 million U.S. adults[1]. Given the multifactorial nature of chronic pain, it requires a biopsychosocial approach to understand the dynamic interplay of biological, psychological, and social factors that contribute to the development and maintenance of pain[2]. While prior research has predominately focused on risk, or vulnerability, factors associated with poor pain-related outcomes[3], studies have demonstrated significant variability in pain severity and patterns of pain-related disability, suggesting that some individuals may have a greater capacity to adapt to and manage their pain. Thus, there has been a recent shift towards identifying resilience, or protective, factors that may mitigate the negative impact of or confer successful adaptation to chronic pain.

Understanding risk and resilience factors related to pain may inform prevention and treatment interventions. Importantly, resilience is not simply the opposite of risk/vulnerability. Individuals can exhibit varying levels of risk and resilience factors, and a combination of both likely contributes to observed variability in pain and disability. Accordingly, a dual-focus approach may be beneficial to closely investigate how both risk and resilience factors impact chronic pain outcomes[4], better addressing the multifactorial nature of and individual adaption to chronic pain. While an exhaustive review is beyond the scope of this paper, we highlight well-established risk factors, introduce risk factors that have garnered recent attention, and describe commonly assessed resilience factors to emphasize the importance of a dual-focused approach to future investigations.

Risk Factors

Individuals with chronic pain experience heightened levels of emotional distress and pain catastrophizing, both well-established risk factors for poor pain outcomes[3, 5]. Prospective longitudinal studies have shown that depression, anxiety, general negative affect, and pain catastrophizing predict the development of chronic pain and are associated with increased clinical pain severity and disability[6–9]. Relatedly, the incidence of chronic pain doubles in individuals with adverse childhood experiences (ACEs),[10] and there is a greater prevalence of posttraumatic stress disorder (PTSD) in individuals with chronic pain[11]. Experiences of trauma have been associated with greater pain severity, disability, and emotional distress[12, 13], and there is longitudinal evidence that ACEs increase the risk of developing disabling pain later in life[10].

Other risk factors have recently garnered attention. Individuals with chronic pain may experience stigma from others, and over time, they may apply these negative attitudes to the self (internalized chronic pain stigma). Perceived pain-related injustice involves cognitive appraisals about the severity and unchangeable status of pain-related loss and externalizing the blame and unfairness of one’s pain. Studies have shown that both internalized chronic pain stigma and perceived injustice are risk factors associated with greater pain severity, disability, and emotional distress[14, 15]. Throughout life, individuals may also experience discrimination (e.g., based on age, sex, race/ethnicity), and research has shown that both lifetime and everyday experiences of discrimination are associated with higher odds of developing chronic pain, as well as increased pain severity and disability[16, 17]. Racism-based traumatic stress (RBTS) is the emotional impact of experiences of racism or discrimination, which are chronic stressors, which may produce traumatic responses due to potential threats being constantly present, especially within a socio-political context. Although RBTS has shown to lead to similar trauma responses as and shares overlapping symptoms with PTSD, it is an understudied form of chronic stress not only within individuals with chronic pain, but also among Black, Indigenous, and people of color (BIPOC)[18]. Limited work has investigated the relationship between RBTS and pain outcomes, and thus this is an area for future investigations, particularly among racialized groups[18].

Notably, there is substantial evidence that the prevalence of these risk factors is unequal across racial and ethnic groups, which may importantly contribute to why chronic pain disproportionately burdens BIPOC. For example, studies have shown that BIPOC are exposed to a greater number of ACEs[19], higher rates of traumatic and chronic stress, and more frequent experiences of discrimination and racism compared to White individuals[17, 18, 20, 21]. Further, Black individuals report higher levels of perceived pain-related injustice and pain catastrophizing than White individuals[15, 22, 23]. While there is evidence that greater prevalence and severity of these risk factors contribute to observed racial and ethnic disparities in pain outcomes, it remains unclear how risk and resilience factors may differentially impact pain across racial and ethnic groups.

Resilience Factors

Resilience is broadly defined as the ability to adapt, recover, or grow in response to stressors, challenges, or adversity[4]. Resilience is a dynamic, malleable, and multisystemic process that involves the interplay of intraindividual, interpersonal, and sociocultural factors. Several psychosocial resilience factors may protect against poor pain outcomes[24–26]. For example, optimism and positive affect have been shown to be related to decreased clinical pain severity[5, 24, 26–29]. Studies have also shown that both self-efficacy and pain acceptance, an individual’s willingness to engage in valued life activities despite their pain, are associated with less pain severity, disability, and emotional distress[3, 23, 30]. Additionally, higher levels of perceived social support has been shown to be related to improved pain outcomes and physical functioning[3, 31].

Research on the role of resilience factors in BIPOC with chronic pain is still in its infancy. Some researchers have argued that resilience factors may be differentially expressed across racialized groups, and while there is some evidence that White individuals report higher levels of pain acceptance compared to Black and Hispanic individuals[23], racial and ethnic differences in optimism, positive affect, gratitude, and social support have not been observed in other studies[32, 33]. However, initial findings suggest that resilience factors may differentially impact pain outcomes in BIPOC. For example, in a study of low-income women with acute pain who were predominately African American and Hispanic/Latina, a latent resilience variable (optimism, social support, engagement) was unrelated to pain and disability [34]. In another study, higher resilience and gratitude were each protective against pain severity in White but not Black participants, whereas higher gratitude was associated with lower functional performance among Black participants[32]. Similarly, in another study, higher optimism was protective against pain severity in Black participants, whereas higher positive affect was associated with greater pain in White participants[33]. These findings suggest that the relationship between resilience and pain outcomes may differ across racial and ethnic groups, but more research in this area is needed.

Using Psychosocial Factors to Phenotype Individuals

Researchers have argued for the importance of phenotyping, or clustering, individuals based on their psychosocial characteristics[35]. Person-centered statistical techniques (e.g., cluster analysis) allow for the examination of subgroups, or clusters, of individuals who share similar response patterns across multiple variables. While variable-centered approaches assume that variables function similarly across all individuals, person-centered approaches emphasizes that relationships between variables vary among subgroups of individuals, which can inform targeted interventional approaches.

Several studies have clustered individuals based on psychosocial risk factors to identify “risk phenotypes” for poor pain outcomes. These studies have shown that subgroups characterized by high levels of emotional distress (depression, anxiety) reported greater persistent pain severity and disability[36–38]. Other studies have shown a similar pattern whereby subgroups characterized by high emotional distress (e.g., depression, anxiety, pain catastrophizing, stress) reported greater pain severity and interference[39, 40]. Yet, only recently have researchers argued for a multidimensional approach when studying resilience factors to identify “resilient phenotypes” among patients. In two studies of individuals with chronic pain, subgroups characterized by high levels of resilience (pain acceptance, self-acceptance, social support) reported less pain-related interference[41]. Similarly, other studies have shown that subgroups characterized by high resilience (positive affect, hope, optimism, social support) reported less pain-related disability and higher quality of life, and exhibited greater functional performance[25, 42]. Notably, in one study, differences in disability and quality of life were observed despite the high and low resilience groups experiencing similar levels of pain, suggesting that individuals with a more resilient phenotype may be better able to adapt to and manage challenges associated with pain.

One study of individuals with chronic pain used both risk and resilience factors to cluster individuals and found that a subgroup characterized by high levels of optimism and low levels of negative affect and depression reported the least pain and disability[43]. Although individuals can exhibit varying levels of both risk and resilience factors, and a combination of both likely contributes to observed variability in pain and disability, the use of a dual-focus approach to investigate the contributions of both risk and resilience risk factors has been underexplored and should be a focus of future research.

Clinical Implications and Future Directions

Although there is considerable evidence that supports the efficacy of cognitive behavioral therapy (CBT) for pain, as well as growing evidence for the efficacy of acceptance and commitment therapy (ACT), these benefits are often modest and not consistently maintained over time[44, 45]. Notably, traditional treatment approaches tend to overlook an individual’s strengths and abilities, which can be harnessed to improve outcomes. Strength-based approaches are embedded in positive psychology and leverage an individual’s strengths and personal resources. Positive psychology interventions (PPIs) focus on boosting positive affect and improving cognitions (e.g., “happy despite pain” exercise)[46] and engagement in positive behaviors (e.g., exercises in compassionate mind training)[47]. Studies have shown that PPIs reduce pain severity, disability, and psychosocial risk factors (depression, negative affect, catastrophizing), while increasing resilience factors (positive affect, hope, pain self-efficacy)[47–51]. However, the effects in these studies were variable, with stronger effects observed in studies with a waitlist or treatment-as-usual control group, and long-term efficacy remains limited. The integration of PPIs with existing treatments could broaden the therapeutic options available, providing a more comprehensive approach by addressing both resilience factors and traditional risk factors and symptoms.

There is substantial heterogeneity in how individuals respond to treatments for chronic pain, emphasizing the importance of a personalized medicine approach. Furthermore, the majority of studies evaluating the efficacy of these treatments have been conducted in samples that are primarily White with higher education, and thus, these treatments may not be appropriate for BIPOC. For example, in a study of pain coping skills, researchers found that the most educated individuals showed the strongest treatment effects[52]. Because BIPOC are more likely to have lower educational attainment[53], it stands to reason that they may be less likely to benefit from this type of intervention. However, adapting traditional approaches and PPIs is promising. For example, a literacy-adapted CBT for pain intervention improved pain and physical function among a sample of primarily Black adults with chronic pain who had low levels of educational attainment[54]. Likewise, due to culturally relevant factors that contribute to pain resilience[32, 33], there is a need for culturally adapted interventions that promote the uptake of such resilience factors[55].

Furthermore, the majority of studies assess whether an interventional treatment, compared to a control condition, is beneficial among all individuals within the treatment group, overlooking the heterogeneity that exists within the group (responders and non-responders to treatment). Understanding treatment moderators based on individual-level characteristics (e.g., race/ethnicity, educational attainment) may provide insight into differences in symptom improvement and treatment efficacy, and better predict individuals who may derive greater benefits from a treatment[56]. Research should also investigate the differential efficacy of treatments among individuals who possess different risk and resilience factors to identify for whom a treatment may be most beneficial. Homogeneous subgrouping using person-centered statistical techniques to identify individuals that share similar characteristics may also help inform treatment selection. Together, this information can be used to inform a personalized medicine approach whereby treatments are tailored to individual characteristics and preferences, and individuals are matched with the most appropriate treatments.

Conclusion

Despite a predominant focus on risk factors for poor chronic pain outcomes, we argue for a dual-focus approach that also considers resilience factors (Table 1). In fact, rather than examining these constructs separately, modern clustering and phenotyping techniques are imperative in understanding the heterogeneity in the pain experience and treatment outcomes. As pain researchers continue to apply this more holistic approach, we will be better equipped to develop and implement culturally adapted and personalized interventions aimed not only at reducing risk factors but also in bolstering resilience factors, especially among BIPOC individuals who are at higher risk of poor pain outcomes.

Table 1.

Key Risk and Resilience Factors

Risk Factors	Resilience factors
Emotional distress (anxiety, depression)	Optimism
Pain catastrophizing	Positive affect
Adverse childhood experiences/trauma	Self-efficacy
Internalized chronic pain stigma	Pain acceptance
Perceived pain-related injustice	Social support
Discrimination
Racism-based traumatic stress

Data availability:

No data were used for the research described in the article.