Cancer pain and psychosocial factors: a critical review of the literature

Poor pain assessment is cited as one barrier to the adequate treatment of cancer pain. The identification of relevant psychosocial factors may improve the assessment of chronic cancer pain. This article presents: 1) a critical review of the evidence for an association between chronic cancer pain and psychological distress, social support, and coping; 2) clinical implications of the findings; and 3) recommendations for future research. Fourteen of the 19 reviewed studies on psychological distress found a significant association between increased pain and increased distress. Seven of the eight studies on social support found significant association between higher levels of pain and decreased levels of social activities and social support. Three of the four studies that examined coping strategies found that increased catastrophizing was significantly associated with more intense pain. Based on several criteria, the evidence is considered Strong for psychological distress, Moderate for social support, and Inconclusive for coping. This review suggests that comprehensive chronic pain assessment should include routine screening for psychological distress.     

Does chronic pain predict future psychological distress?

Cross-sectional studies have consistently shown a relationship between chronic widespread pain, the clinical hallmark of fibromyalgia, and psychological distress. These studies cannot distinguish the direction of any causal relationship. Recent population based studies have reported that such pain is predictive of future distress. However, chronic pain is often associated with physical and psychological co-morbid features which may confound this relationship. The aim of this study was to examine the hypothesis that chronic widespread pain increases the risk of future distress after adjusting for the effects of possible confounding factors. A population based survey of 1953 individuals identified subjects' psychological status and whether they satisfied criteria for chronic widespread pain. At baseline co-morbid features of chronic widespread pain, including reporting other somatic symptoms, abnormal illness behaviour, health anxiety, fatigue and low levels of self-care, were measured. All subjects were followed up after 12 months to determine levels of psychological distress. Subjects with chronic widespread pain at baseline were much more likely to be distressed at follow up (OR=4.0, 95% CI (2.5,6.3)). As levels of distress at follow up may simply reflect those at baseline the association was adjusted for baseline levels of distress. Chronic widespread pain was, however, still associated with future distress although the relationship was slightly attenuated (odds ratio, OR=3.0, 95% CI (1.8,5.1)). To examine our main hypothesis a final analysis was undertaken adjusting this association for those co-morbid features assessed at baseline. Following these adjustments chronic widespread pain was no longer significantly associated with future distress (OR=1.5, 95% CI (0.8,2.9)). Chronic widespread pain was associated with increased levels of psychological distress at follow up. However, a more rigorous analysis indicated that the association between baseline pain status with future distress was explained by concomitant features of chronic pain rather than pain per se. These findings indicate that it is those persons with chronic widespread pain in the presence of other physical and psychosocial factors who will become distressed.     

Symptom prevalence and longitudinal follow-up in cancer outpatients receiving chemotherapy

Palliative care for cancer patients receiving chemotherapy in the outpatient setting is important. The aims of this study were 1) to identify symptom prevalence and intensity in cancer patients receiving chemotherapy and 2) to describe longitudinal follow-up data obtained from repeated assessment using the distress thermometer (DT). Questionnaires were distributed to consecutive cancer outpatients newly starting chemotherapy at the first appointment and at every hospital visit. The questionnaire included the severity of 11 symptoms (M. D. Anderson Symptom Inventory [MDASI], Japanese version), the DT, and the need for help in four psychosocial areas (decision-making, economic problems, nutrition, and daily activities). In total, 4000 questionnaires were returned by 462 patients. The frequently identified problems were oral problems (21%), insomnia (19%), psychological distress (defined as a DT score of 6 or more; 15%), help with information and decision-making (14%), severe fatigue (8.2%), and severe appetite loss (6.3%). Cluster analysis identified four symptom clusters: 1) fatigue and somnolence; 2) pain, dyspnea, and numbness; 3) nausea, appetite loss, and constipation; and 4) psychological distress. Of 165 patients with a DT of score 6 or more, 115 patients (70%) demonstrated a DT score below 6 at a median of 17 days follow-up. In the remaining 50 patients who had a DT score of 6 or more at follow-up, 34 patients (68%) had one or more physical symptoms rated at 7 or more on an 11-point numeric rating scale. Compared with patients with a DT score below 6 at follow-up, patients with a DT score of 6 or more at follow-up had higher levels of all physical symptoms. Frequent symptoms experienced by cancer outpatients receiving chemotherapy may be categorized as: 1) psychosocial issues (insomnia, psychological distress, decision-making support); 2) nutrition-gastrointestinal issues (oral problems, appetite loss, nausea); 3) fatigue; and 4) pain, dyspnea, and numbness. Developing a systematic intervention program targeting these four areas is urgently required. The DT score may be highly influenced by coexisting physical symptoms, and future studies to develop an appropriate system to identify patients with psychiatric comorbidity are necessary.     

A psychological profile of fibromyalgia patients: a chiropractic case study.

BACKGROUND: Fibromyalgia is a chronic condition characterized by widespread musculoskeletal pain and tenderness. Reversible modulation of the pain threshold is believed to contribute to the pathogenesis of this condition, and psychosocial stress is known to alter the pain threshold. OBJECTIVE: To describe and compare the psychological profile of fibromyalgia patients attending chiropractic clinics in Australia. SETTING: Chiropractic clinics located in 5 Australian states and the Australian capital territory with practices in inner city, suburban, coastal, and rural areas were included. SUBJECTS: Chiropractic patients with acute and chronic biomechanical conditions, fibromyalgia, and who were undergoing maintenance care were included in the study. METHOD: A case study to explore the psychological profile of fibromyalgia patients was undertaken. The Distress and Risk Assessment Method (DRAM) and Sense of Coherence (SOC) questionnaires were used to ascertain and compare the distress, sense of coherence, and manageability levels of patients with fibromyalgia with patients having maintenance chiropractic care. Purposive sampling of practitioners and convenience sampling of patients fulfilling the study's inclusion criteria were undertaken. Patients were asked to complete two questionnaires and chiropractors to complete one questionnaire and an interview. RESULTS: While more than half of the patients in the fibromyalgia group were distressed, fewer than 1 in 7 maintenance patients were found to be distressed according to the DRAM questionnaire. With several individual exceptions, fibromyalgia patients also tended to have lower SOC and manageability scores than the maintenance group. CONCLUSION: This study supports the view that fibromyalgia may represent a problem of coping with various environmental stresses, including psychosocial stresses. However, owing to individual variation, a diagnosis of fibromyalgia at the clinical level does not accurately predict whether a particular patient is distressed or has a low SOC score. Screening of fibromyalgia patients may help determine whether intensive counseling and stress management by the chiropractor or another health professional should be contemplated.     

Does a Combination of Intensive Cognitive‐Behavioral Pain Management and a Spinal Implantable Device Confer any Advantage? A Preliminary Examination

Abstract:   Research suggests that a combination of a somatic and a psychosocial intervention for chronic noncancer pain should be associated with a better outcome than either alone. This study presents data on a series of 31 patients who underwent sequential treatment with an implantable device targeting pain relief and a cognitive-behavioral pain management program that targeted improved function. A combination of treatments was used as there was a suboptimal response to the initial treatment. There were improvements in a range of outcomes at a long-term follow-up. Significant improvements were found in disability, affective distress, self-efficacy, and catastrophizing, but not in average pain severity. Further analyses failed to demonstrate an order effect. These results support the view that combined somatic and psychosocial interventions can achieve better outcomes than either alone in selected chronic pain patients. This approach requires that psychological assessment is essential before the use of an implantable device. This may not only improve patient selection, but also identify psychosocial factors that may be modified to enhance the effectiveness of invasive interventions. In addition, consideration for an implantable device following a suboptimal response to treatment in a cognitive-behavioral pain management program should include a re-evaluation of the patients' beliefs and use of self-management (coping) strategies before deciding on further treatment options.     

Psychosocial and socio-demographic factors associated with outcomes for patients undergoing rehabilitation for chronic whiplash associated disorders: A pilot study

Purpose. Identify psychosocial and socio-demographic factors (measured prior to treatment) that were associated with post-treatment self-perceived pain and disability and two secondary outcomes: psychological distress, and return to work in patients undergoing multidisciplinary rehabilitation for chronic whiplash associated disorders (WAD).

Method. Interviews were conducted with 28 patients with chronic WAD at entry to and completion of an intensive rehabilitation program, and a telephone interview was carried out three months later. Participants completed pain and disability, and psychological distress questionnaires, at baseline and at both follow-ups. They also completed psychosocial questionnaires and provided socio-demographic information. The effect of each of the independent variables on the outcomes was first evaluated by simple regressions, and then subsequently by multiple regression analysis.

Results. Higher baseline pain and disability predicted higher pain and disability at both follow-ups (p < 0.001), and higher psychological distress at program completion (p = 0.003). Younger age (p = 0.028) and higher baseline psychological distress (p = 0.002) were associated with higher psychological distress three months post-rehabilitation. Greater social support at work was prognostic of return to work at program completion (p = 0.04).

Conclusions. Baseline pain and disability was the only factor that affected pain and disability post-rehabilitation. Psychosocial factors played a role in the prognosis of psychological distress and return to work.     

Psychological Characteristics of Chronic Pain: a Review of Current Evidence and Assessment Tools to Enhance Treatment

Purpose of Review

The complicated nature of chronic pain involves an interplay between psychological and physical factors, often resulting in increased emotional distress and reduced quality of life. This review is designed to help the medical practitioner who is working with chronic pain patients to be aware of psychological assessment techniques that can add to comprehensive patient understanding and more effectively guide treatment. Enhanced ability to assess and understand the emotional life of the chronic pain patient provides a basis for intervening and treating more successfully.

Recent Findings

There are a broad range of assessment techniques, some of which require a background in psychology and some that do not, that can identify psychological differences in chronic pain patients and serve to guide intervention strategies. Chronic pain is often comorbid with depression, anxiety, catastrophizing, and various ineffective coping strategies. Some patients, however, have demonstrated more adaptive and effective strategies for cognitively and behaviorally coping with pain and normalizing their lives. Proper assessment enables the individualization of treatment to overcome and/or build upon each patient’s psychological frame of mind to maximize the potential for effective functioning.

Summary

The use of standardized and documented psychological assessment techniques can lead to a better understanding of chronic pain patients and contribute in ways that can enhance response to medical treatment and improve quality of life. It is recommended that certain psychological tools be included to supplement the medical assessment of patients who have chronic pain. A basic assessment can include a short psychological-based clinical interview along with brief measures of depression, anxiety, and coping strategies. It is also recommended that the pain physician have access to professional psychological practitioners as a resource for more complicated assessments and psychological intervention services.

     

Pain Intensity as a Lagging Indicator of Patient Improvement: Longitudinal Relationships With Sleep,Psychiatric Distress,and Function in Multidisciplinary Care

Despite a common assumption that reductions in chronic pain intensity must precede improvements in other pain-relevant domains, there has been limited empirical inquiry into the temporal ordering of improvements in chronic pain treatment. Cross-lagged models using retrospective clinical data examined relationships between average pain intensity and symptoms of psychological distress, difficulties with sleep initiation and maintenance, and disability in 666 treatment-seeking patients with chronic pain who demonstrated improvement in pain intensity (≥1-point reduction on 0-10 numeric rating scale) over a 1-year span. Results indicated that decreased difficulties with sleep initiation, depressive and anxious symptoms, and disability predicted later improvement in pain intensity, whereas greater pain intensity predicted only later difficulties in sleep initiation and maintenance. A combined lagged model highlighted fewer baseline symptoms of post-traumatic stress disorder and lower levels of baseline disability as significant predictors of later improvements in pain. Overall, our results indicate that reductions in pain intensity may not be the first factors to change in effective chronic pain management. The current findings should be replicated using prospective studies utilizing structured approaches to maximize data capture, as well as uniform interventional approaches to permit greater inferences regarding causal and temporal aspects of the model.PerspectiveThis study demonstrates that pain intensity scores are not robust predictors of psychosocial outcomes longitudinally. Instead, other factors such as sleep initiation, psychological distress and disability appear to be important targets for intervention that may promote effective pain reduction.     

Orofacial Pain and Headache: A Review and Look at the Commonalities

Research has shown that psychosocial factors can predict poor outcome for spinal cord stimulation (SCS) for patients with chronic pain, substantiating the need for standardized assessment techniques to incorporate psychosocial factors in patient selection. Presurgical psychological assessment is often required for SCS. Best practices include clinical interviews by psychologists and use of standardized measures of psychosocial risk factors. Psychologists should assess mental health and social risk factors, as well as an individual’s understanding of SCS and expectations for pain relief, while consulting with physicians to support a multidisciplinary based patient selection. In addition, psychologists take part in preparing patients who were initially deemed unsuitable for SCS by providing recommendations and potential access to clinical care addressing psychological issues in chronic pain. Barriers to presurgical psychological assessments include limited access to skilled psychologists and issues with feasibility and appropriateness of standardized measures, and further work is needed to improve standardized methodology.     

Activity-related pain in patients with chronic musculoskeletal disorders

Purpose.?Activity-related pain may be a barrier to rehabilitation in patients with chronic musculoskeletal disorders. This study investigated patients' reports of increased pain during activity, and the association between such pain and psychological factors and pain variables.

Method.?Questionnaires from 232 adults with chronic musculoskeletal pain measured pain intensity, spread of pain and pain duration. Pain during activity was assessed both on a 11-point Numeric Rating Scale (NRS), and operationalised as a dichotomous measure, where responders defined if they experienced pain during general activity and exercise. Psychological factors were measured by the Hopkins symptom check list 25, the Tampa Scale for Kinesiophobia and a subscale of the Arthritis Self-efficacy Scale. Multiple and logistic regression were used to analyse associations between increased pain during activity and associated variables.

Results.?Increased pain during activity was reported by 69% of participants. Fear of movement was a significant factor for reporting increased pain during activity, both general activity and exercise also in a subsample with low psychological distress. Other significant factors were spread of pain and a low sense of self-efficacy.

Conclusion.?Patients with high fear of movement, large spread of pain and low self-efficacy were more likely to report increased pain during activity even in the absence of psychological distress.     

Risk factors for chronic pain following breast cancer surgery: a prospective study.

Chronic pain following breast cancer surgery is associated with decreased health-related quality of life and is a source of additional psychosocial distress in women who are already confronting the multiple stresses of cancer. Few prospective studies have identified risk factors for chronic pain following breast cancer surgery. Putative demographic, clinical, and psychosocial risk factors for chronic pain were evaluated prospectively in 95 women scheduled for breast cancer surgery. In a multivariate analysis of the presence of chronic pain, only younger age was associated with a significantly increased risk of developing chronic pain 3 months after surgery. In an analysis of the intensity of chronic pain, however, more invasive surgery, radiation therapy after surgery, and clinically meaningful acute postoperative pain each independently predicted more intense chronic pain 3 months after surgery. Preoperative emotional functioning variables did not independently contribute to the prediction of either the presence or the intensity of chronic pain after breast cancer surgery. These findings not only increase understanding of risk factors for chronic pain following breast cancer surgery and the processes that may contribute to its development but also provide a basis for the development of preventive interventions. PERSPECTIVE: Clinical variables and severe acute pain were risk factors for chronic pain following breast cancer surgery, but psychosocial distress was not, which provides a basis for hypothesizing that aggressive management of acute postoperative pain may reduce chronic pain.     

The relationship between disease features and quality of life in patients with cancer--I.

The high incidence and the severe symptoms of cancer have a considerable effect on quality of life in patients. The relationship between quality of life in patients with cancer and treatment, early diagnosis, disease acceptance, pain, psychological distress, loss of organ, duration of disease, and caregivers was investigated. This study included 508 patients with cancer treated in either inpatient or outpatient clinics of 5 oncology centers in Ankara, Turkey, between August 1 998 and January 2000. Patients were selected by interviews. Data were collected by a questionnaire to determine disease features and to evaluate patients' quality of life. We found that several disease features, including treatment, early diagnosis, disease acceptance, pain, psychological distress, and caregivers, had an effect on patients' quality of life (P < 0.05), whereas loss of organ and duration of disease did not. The results of this study underline the significant effect of psychosocial care programs on quality of life. In the future, assessments of quality of life can help healthcare personnel to prepare psychosocial care programs.     

Psychosocial factors in chronic spinal cord injury pain.

Chronic pain is a problem among patients with spinal cord injuries, but the psychosocial factors associated with spinal cord injury (SCI) pain are not well understood. To understand SCI pain further, 54 patients (19 with quadriplegia and 35 with paraplegia) completed the Beck Depression Inventory, State-Trait Anxiety Inventory, Profile of Mood States, Acceptance of Disability Scale and SCI Interference Scale. Forty-two patients stated they had SCI pain and completed the Multidimensional Pain Inventory and the Pain Experience Scale. Results revealed that anger and negative cognitions were associated with greater pain severity. Patients who reported pain in response to a general prompt experienced more severe pain than patients who reported pain only when directly questioned about the presence of pain, but these different reporting groups did not differ on emotional variables. Those who were less accepting of their disability reported greater pain severity. Additionally, patients who perceived a significant other expressing punishing responses (e.g., expressing anger at the patients or ignoring the patients) to their pain behaviors reported more severe pain. Level of lesion, completeness of injury, surgical fusion and/or instrumentation and veteran status were not associated with pain severity. Finally, pain was associated with emotional distress over and above the distress associated with the SCI itself. Overall, psychosocial factors, not physiological factors, were most closely associated with the experience of pain. Multidimensional aspects of pain are used to explain these findings and suggest that treatment should be directed at the emotional and cognitive sequelae of chronic SCI pain.     

Patient-Reported Outcomes and Opioid Use by Outpatient Cancer Patients

The Memorial Sloan Kettering Pain Registry contains patient characteristics, treatments, and outcomes for a prospective cohort of 1,534 chronic pain cancer patients who were seen at outpatient pain service clinics. Average pain intensity (Brief Pain Inventory) was reported as mild by 24.6% of patients, moderate by 41.5%, and severe by 33.9%. The patient's report of average percent pain relief and health state (EuroQOL 5 dimensions) was inversely related to average pain intensity category, whereas measures of pain interference, number of worst pain locations, and physical and psychological distress were directly related to pain intensity category. Eighty-six percent of patients received an opioid at 1 or more clinic encounters. Regression analysis revealed that male sex or being younger (65 years of age or younger) was associated with a greater likelihood of an opioid ordered. Male sex nearly doubled the likelihood of a higher dose being ordered than female sex. Bivariate analysis found that patients receiving opioids reported significantly more pain relief than no-opioid patients. However, patients receiving opioids had higher pain interference scores, lower index of health state, and more physical distress than no-opioid patients Our results identify the need to consider opioid use and dosage when attempting to understand patient-reported outcomes (PROs) and factors affecting pain management.

Factors related to the quality of life in adolescents with chronic pain

OBJECTIVE: This study examined the relationships between pain characteristics, psychosocial factors, and quality of life among adolescents with chronic pain that existed for at least 3 months, either recurrently (ie, pain with pain-free intervals) or continuously. METHODS: The authors conducted a cross-sectional study in 194 adolescents aged 12 to 18 years who completed questionnaires on pain, psychosocial factors (ie, vulnerability, reinforcement, modeling, and coping), and quality of life, and also kept a diary about their pain complaints for 3 weeks. RESULTS: Multiple hierarchical regression analysis revealed that psychosocial variables accounted for a significant variance in the adolescents' quality of life, even when controlling for pain characteristics. Analysis of the independent variables showed that pain intensity and vulnerability contributed significantly and uniquely to the variance of most quality-of-life domains. In addition, the authors found that emotion-focused avoidance coping strategies (ie, catastrophizing) strengthened the negative relation between pain intensity and psychological functioning. CONCLUSIONS: In addition to pain, psychosocial factors (vulnerability, reinforcement, modeling, and coping) are strongly associated with quality of life in adolescents with chronic pain. These results may contribute to psychological interventions focused on psychological adaptation in young pain patients to improve their quality of life.     

Altered body image: appearance-related concerns of people with visible disfigurement

AIM: The aim of this paper is to report a study to establish the extent and type of psychosocial needs of outpatients attending for treatment of a wide range of disfiguring conditions. BACKGROUND: Visible disfigurements can be associated with extensive psychosocial difficulties. The majority of research to date has been carried out with people identified by themselves or others as experiencing difficulties. Little is known about levels of distress in the broader population of patients receiving treatment for a range of disfiguring conditions. METHODS: A cross-sectional survey was conducted, with a convenience sample. Participants (n = 458) drawn from 15 outpatient clinics completed standardized measures of anxiety and depression (Hospital Anxiety and Depression Scale), social anxiety and avoidance (Derriford Appearance Scale short-form) and quality of life (World Health Organization Quality of Life Brief Scale). A semi-structured interview was used to generate further quantitative and qualitative data about individual concerns, and satisfaction with the provision of care. Staff views about levels of psychosocial distress were elicited through group discussions. RESULTS: The results revealed high levels of psychological distress in the sample, compared with normative values. The majority of difficulties related to problems experienced in social situations. Patient satisfaction with care was generally high; however, and 71% of participants expressed a moderate to strong desire for a health care professional with training to deal with their appearance-related concerns. Nursing staff felt unable to address patients' appearance-related difficulties because of time constraints, lack of an environment conducive to the discussion of patients' concerns, and lack of appropriate knowledge and training. CONCLUSION: A significant proportion of participants experienced psychosocial distress in relation to their visible difference. Psychosocial needs were poorly met in current outpatient care provision, and a range of options could be considered to address these more effectively.     

Psychodynamic interpersonal therapy and improvement in interpersonal difficulties in people with severe irritable bowel syndrome

The aim of the present study was to assess the relationship between change in interpersonal difficulties with change in chronic pain, health status and psychological state in 257 irritable bowel syndrome (IBS) patients in a randomized control trial comparing psychotherapy, antidepressant and usual care. We assessed at three time points interpersonal problems (IIP-32), abdominal pain and bowel symptoms, psychological distress (SCL-90), and health status (SF-36). Analysis included repeated measures (ANOVA) to assess change over time and multiple regressions to identify whether change in IIP was associated with outcome after controlling for psychological status. The main findings were: (1) difficulties with social inhibition and dependency were associated with longer disease duration; (2) change in mean IIP-32 over 15 months was significantly correlated with changes in pain, but these relationships were mediated by change in psychological distress; (3) change in IIP-32 was an independent predictor of improved health status at 15 months only in the psychotherapy group. These results indicate that improvement in interpersonal problems in IBS patients appear to be primarily associated with reduced psychological distress but, in addition, the association with improved health status following psychotherapy suggests that specific help with interpersonal problems may play a role in improving health status of patients with chronic painful IBS.     

Chronic idiopathic pain syndrome

Chronic idiopathic pain syndrome is a common, disabling and costly condition. It is believed to be of psychological origin but may involve both cerebral and peripheral physiological mechanisms. It is often associated with depression. Its assessment and management need to be multifactorial, i.e., medical, psychosocial and psychiatric. A thorough initial medical assessment is crucially important in order to identify any organic contributory factors and to gain the patient's trust. It is also essential to carry out a psychosocial and psychiatric assessment so as to evaluate the role of psychological and socioeconomic factors and establish whether a diagnosable psychiatric disorder is present. The latter is most likely to be a depressive, anxiety, or somatoform disorder. If the medical assessment fails to come up with a plausible organic explanation for the patient's pain, he or she should be told so clearly. The patient should be told that the goal of the treatment is not to cure the pain but to help him/her improve his/her functioning and sense of control over pain and life generally. The type of management most likely to succeed in this goal is one that is multifactorial and comprehensive rather than focused on one treatment modality only.     

General psychological acceptance and chronic pain: There is more to accept than the pain itself

An increasing body of research demonstrates that acceptance of pain is significantly associated with the quality of daily functioning in people with chronic pain. The aim of the present study was to examine acceptance more broadly in relation to a wider range of undesirable experiences these people may encounter, such as other physical symptoms, experiences of emotional distress, or distressing thoughts. One hundred forty‐four, consecutive, adult patients attending interdisciplinary treatment for chronic pain participated in this study. They completed the Acceptance and Action Questionnaire‐II (AAQ‐II [Bond F, Hayes SC, Baer RA, Carpenter KM, Orcutt HK, Waltz T, Zettle RD. Preliminary psychometric properties of the Acceptance Action Questionnaire‐II: a revised measure of psychological flexibility and acceptance, submitted for publication]), measuring their general psychological acceptance. They also completed measures of emotional, physical, and psychosocial functioning, pain acceptance, and mindfulness. The AAQ‐II achieved satisfactory internal consistency, α = .89, and factor analysis revealed a unitary factor structure. Primary results showed that general psychological acceptance significantly correlated with depression, r = −.69, pain‐related anxiety, r = −.59, physical disability, r = −.42, and psychosocial disability, r = −.65, all p < .001. Hierarchical regression analyses showed that general psychological acceptance added a significant increment of explained variance to the prediction of patient functioning, independent of patient background characteristics, pain, acceptance of pain, and mindfulness. These results suggest that, when people with chronic pain are willing to have undesirable psychological experiences without attempting to control them, they may function better and suffer less. General acceptance may have a unique role to play in the disability and suffering of chronic pain beyond similar processes such as acceptance of pain or mindfulness.