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When the self is in pain



The 2024 Global Year will examine what is known about sex and gender differences in pain perception and modulation and address sex-and gender-related disparities in both the research and treatment of pain.

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Pain frequently interferes with the achievement of goals in daily life of chronic pain patients which often result in severe suffering. Pincus and Morley (2001) have suggested that the enmeshment of patients’ self-schema and pain schema may play an important role in explaining their suffering. The term ‘Schema’ is commonly used by psychologists and could be defined as a pre-existing mental structure that is constructed through previous experiences and is used to actively process incoming stimuli. Schemas are thought to play an important role in organizing and integrating information (e.g., information related to the self) [5]. In particular, Pincus and Morley argued that repeated and simultaneous activation of the content of the self-schema and the pain-schema, which is often the case in chronic pain patients, results in a stronger association between both schemas [4]. This strong association has been suggested to result in poorer pain outcomes (in terms of disability, pain suffering,…) [3,4].

Research on the association between pain- and self- schema in patients with chronic pain is, however, still in its infancy. Until now, this association has mainly been investigated by means of explicit (e.g., interview method) or semi-explicit (e.g., Sentence Completion Test [5]) measures. Yet, both approaches have some limitations. These measures only tap conscious cognitive processes, and explicit measures may be more vulnerable to response bias. The use of implicit measures (e.g., Implicit Association Test) may be helpful as they are less susceptible to bias and can reveal associations between schemata even when people are unwilling or unable to report those associations. The main aims of our study were (1) to compare the strength of association between pain- and self- schema in chronic pain patients and healthy control subjects, and (2) to investigate if stronger associations between both schemas in chronic pain patients are associated with poorer pain-related outcomes (e.g., disability, pain suffering) [6].

Chronic pain patients (N=73) and healthy volunteers (N=53) completed a number of questionnaires to assess pain-related outcomes (pain severity, pain suffering, disability, depression, anxiety, acceptance, and helplessness) and performed an Implicit Association Test (IAT) to assess the strength of association between pain- and self-schema. The basic idea of an IAT is that people are faster at categorizing stimuli related to two associated concepts in the same way (e.g., by pushing the same button) than to categorize these stimuli in a different way (e.g., by pushing a different button) [2]. In this study, participants were required to categorize words related to the self – other dimension (e.g., <participant’s first name> – <unfamiliar first name>), and words related to the pain – free of pain dimension (e.g., ‘‘excruciating’’ – ‘‘relieving’’).

In line with our expectations, we found that  the pain- and self- schema were more strongly associated in patients with chronic pain than in healthy control subjects and that, in patients with chronic pain, this stronger association is related to a heightened level of pain severity, pain suffering, anxiety, and helplessness. Our findings provide support for the use of an IAT to investigate the strength of associations between self- and pain-schema in patients with chronic pain. In the current study, however, we operationalized participants’ ‘‘self’’ at its most fundamental level (i.e., ‘‘me’’ versus ‘‘not me’’). The self is however not a unitary construct. It would be interesting to replicate our research using adaptations of the IAT that tap into other aspects of the self-concept (e.g., by using labels such as ‘‘I want to be’’ versus ‘‘I do not want to be’’ [1]). It would also be interesting to combine the assessment of implicit measures and explicit measures that research the relationship between the self and pain to investigate whether they are related, and which measures, if any, are the best predictor for pain outcomes or changes caused by treatment. Finally, current findings may also have an important clinical implication as they suggest that pain therapies could incorporate techniques that intervene on the level of self-pain enmeshment.

About Dimitri Van Ryckeghem

Dimitri Van RyckeghemDimitri Van Ryckeghem is a doctor-assistant at Ghent University, Belgium. He obtained his Phd (which was supervised by Geert Crombez) in clinical psychology in 2012. His Phd concerned the investigation of the interplay between attention and pain experience (e.g., the role of attentional bias,…). Dimitri’s current research area concerns the investigation of the effectiveness and potential influencing factors of attentional distraction.


[1] Dewitte M, De Houwer J. Proximity and distance motives in adult attachment. Eur J Pers 2008;22:675–94.

[2] Greenwald AG, McGhee DE, & Schwartz JL (1998). Measuring individual differences in implicit cognition: the implicit association test. Journal of personality and social psychology, 74 (6), 1464-80 PMID: 9654756

[3] Morley S, Davies C, & Barton S (2005). Possible selves in chronic pain: self-pain enmeshment, adjustment and acceptance. Pain, 115 (1-2), 84-94 PMID: 15836972

[4] Pincus T, Morley S. Cognitive-processing bias in chronic pain: a review and integration. Psychol Bull 2001;127:599–617.

[5] Rusu AC, Pincus T. Cognitive processing and self-pain enmeshment in chronic back pain. In: Hasenbring MI, Rusu AC, Turk DC, editors. From acute to chronic back pain: risk factors, mechanisms, and clinical implications. Oxford: Oxford University Press; 2012. p. 315–38.

[6] Van Ryckeghem DM, De Houwer J, Van Bockstaele B, Van Damme S, De Schryver M, & Crombez G (2013). Implicit associations between pain and self-schema in patients with chronic pain. Pain PMID: 23932910

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