PAIN AND HUMAN DEVELOPMENT

Chronic Pain through the Lifespan

Pain, Attachment Theory, Human Development and Treatment

PAIN AND HUMAN DEVELOPMENT

Abstract

Pain is defined as "an unpleasant sensory and emotional experience associated with actual or
potential tissue damage, or described in terms of such damage" by the International Association
for the Study of Pain (IASP). Chronic pain is pain that doesnt go away after three months or
after an injury has healed. Chronic pain can be intermittent (occurring on and off). It may vary
with intensity during the day or it can be persistent. Chronic pain can result from a known cause,
such as surgery or inflamed joints, or a consequence of a disease process, such as rheumatoid
arthritis. Varying from individual to individual, chronic pain may affect different individuals at
different levels. However, no matter what these levels are, the overall impact on the life of a
sufferer is largely negative. They are often known to experience, Social Isolation, psychological
shifts or psychosocial traumas, Work/Career Shifts, and an overall pessimistic outlook on life.
Unfortunately chronic pains are incurable as no direct causes are known. Treatment can only
provide comfort to an extent. Thus to live as normally as possible, all forms of attachments, be it
social or personal are essential. This study analyzes the various facets and aspects of chronic pain
while understanding the amount of difficulty sufferers have to go through. It explores the
problems they face analyzing the lifestyles of all age groups and going through the data gathered
by previous researchers to gain an overall perspective. Next it explores how, through the help of
attachment and development, they may live on without agony and what possible treatments are
available. Despite the gruesome observations this study makes, it seems eminent at the end that
all hope is not lost.

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Introduction
Living with chronic pain can be experienced at all the stages in human development and
disability or chronic pain can enter a persons life at any given time. Pain is a complex,
multisided and personally subjective phenomenon. According to the International Association
for the Study of Pain, pain has been defined as "Pain is an unpleasant sensory and emotional
experience associated with actual or potential tissue damage, or described in terms of such
damage." (Bonica JJ. 1979). Most of the pain encountered by normal adults resolves promptly
once the stimulus responsible for pain has been removed and the body has healed from the effect
produced by the stimulus. However, sometimes pain may persist, although the body may have
healed and the associated stimulus removed; and sometimes pain can also be encountered even in
the absence of any detectable stimulus, damage or disease (Raj PP 2007). This aspect of pain is
often classified as chronic pain. Chronic pain is often defined as pain that has lasted longer than
three to six months (Debono, DJ; Hoeksema, LJ; Hobbs, RD 2013). Another popular and
alternative definition for chronic pain proceed thus, Chronic pain is a type of pain that extends
beyond the period of healing with no fixed duration or specified termination. (Turk, Dennis C.;
Okifuji, A. 2001).
People experiencing and living with chronic pain have difficult and challenging lives that
vary greatly. For example, some children are born with medical conditions that involve them in
painful surgeries from birth and they attach to this experience early on. Chronic pain is known to
affect 20% to 35% of children and adolescents around the world (King et al., 2011; Stanford,
Chambers, Biesanz, & Chen, 2008). Chronic pain in children is the result of a dynamic
integration of biological processes, psychological factors, and sociocultural factors considered
within a developmental trajectory. This category of pain includes persistent (ongoing) and

PAIN AND HUMAN DEVELOPMENT

recurrent (episodic) pain in children with chronic health conditions (e.g., arthritis or sickle cell
disease) and pain that is the disorder itself (e.g., migraines, functional abdominal pain, complex
regional pain syndrome) (Walker, L. S., Dengler-Crish, C. M., Rippel, S., & Bruehl, S. 2010).
Some children thus seem to have an on onset of disability or chronic pain in their
childhood and which may be held responsible for stunting their development during a specific
time of emotional and physical maturation. While some individuals will receive a diagnosis of a
painful degenerative condition that will end in full disability as they age, the experience of it
changes their plans for marriage and children. Chronic pain, especially during this period of life
seems to have a psychosocial effect on individuals that hinder their family life (Snelling, J. 1994;
Michelle T. et al. 2006).
For the elderly, chronic pain restricts mobility further thus perpetuating the experience of
limited abilities and it brings about a change in identity in developing a point of view about death
and quality of life. As the patients age, the incidence and prevalence of certain pain syndromes
increase (Kaye AD, Baluch A, Scott JT. 2010). The consequences of this pain include impaired
activities of daily living (ADLs) and ambulation, depression, and strain on the health care
economy. Pain may also be related to complications associated with deconditioning, gait
abnormalities, accidents, polypharmacy, and cognitive decline (Manchikanti L, et al. 2009).
Pain and disability exists for individuals at all stages of life, and this onset and
progression of pain is a roadblock to optimum development in many ways (Leo, Raphael 2007;
Kreitler S, Niv D 2007). . This paper aims to explore the experience of living with chronic pain
throughout the lifespan, by further looking at the relationship between chronic pain, attachment
theory, and the impacts of prolonged pain within the developmental aspects of life.

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Attachment Theory Applied to Chronic Pain

According to the diathesis stress models of chronic pain, some individuals seem to be
more vulnerable towards developing a disability following an experience of acute pain because
they possess particular psychosocial vulnerabilities, which network with physical pathology to
impact negatively upon outcome (Meredith, 2008; Peng, Y. B., Fuchs, P. N. and Gatchel, R. J.
2006; Banks, Sara M.; Kerns, Robert D. 1965).
A range of cognitive, affective, and behavioral factors are related to the perception of
pain, maintenance of pain and disability, exacerbation of pain, and response to treatment. There
is some evidence that individual differences and prior learning history also have a significant
influence on the experience of pain and related disability (Turk, Dennis C 2002).
It is now well established that pain is a multidimensional phenomenon, affected by a
gamut of psychosocial and biological variables. Attachment theory, a theory of social and
personality development, has been proposed as a comprehensive developmental model of pain,
implicating individual adult attachment pattern in the ontogenesis and maintenance of chronic
pain (Elliot, A. J., & Reis, H. T. 2003). It has been proposed since, as a comprehensive
developmental model of pain for explaining and treating prolonged pain experiences.
Developmental psychology concerns the importance of attachment" in regards to personal
development. Specifically, it makes the claim that the ability for an individual to form an
emotional and physical "attachment" to another person gives a sense of stability and security
necessary to take risks, branch out, and grow and develop as a personality (Bowlby, John 1969).

PAIN AND HUMAN DEVELOPMENT

Consistent with the belongingness hypothesis, people form social attachments readily
under most conditions and resist the dissolution of existing bonds. This perspective of Social
psychology on attachment theory suggests the importance of the existence of social bonds and its
role in an individuals life. Lack of social attachments is linked to a variety of ill effects on
health, adjustment, and well-being (Baumeister, Roy F.; Leary, Mark R 1995).
The researches cited above, whether approached from a social or developmental
perspective, is implicating individual adult attachment patterns from early childhood in the
evolution and maintenance of chronic pain, thus further offering support for the role of insecure
attachment as a diathesis and predictor for a problematic adjustment to pain (Turk 2002,
Meredith 2008). The Attachment-Diathesis Model of Chronic Pain combines adult attachment
theory with the diathesis-stress approach to understanding the pathology of chronic pain,
advancing understanding of the developmental origins of chronic pain conditions which can
hopefully guide in applying interventions to pain therapies and give new potential to tailoring
interventions to suit specific patient needs (Meredith P. , Ownsworth T., Strong J. 2007).
Attachment theory provides a full developmental outline for understanding illness
behaviors as a whole, which looks into various phenomena occurring at times in the influence of
chronic pain, such as: maladaptive behaviors, emotions and cognitions associated with
attachment insecuritypotentially explaining why some people may be more vulnerable to
developing chronic pain conditions than others (Laura S. Porter, Deborah Davis, Francis J. Keefe
2007).
The integration of chronic pain and attachment theory may have several advantages in
terms of early intervention and treatment so far, including:

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a) Identifying individuals at risk of developing chronic pain following episodes of acute pain,
b) Identifying individuals at risk of adjustment difficulties to chronic pain prior to treatment,
c) Tailoring treatment protocols for these individuals based on an attachment-informed
understanding of their needs, and
d) Guiding ongoing intervention for these individuals at the completion of a standard
rehabilitation program (Meredith, 2008).
Individuals with insecure adult attachment styles have been shown to experience more pain
than people with secure attachment, though results of previous studies have been inconsistent
(Davies KA, Macfarlane GJ, McBeth J, Morriss R, Dickens C. 2009). Recently, there has been
increasing recognition of the importance of adult attachment style in the experience of pain.
Insecure attachment in healthy populations is associated with hypochondriacal beliefs (Wearden
A, Perryman K, and Ward V J 2006), hypervigillance to pain (McWilliams LA, Asmundson GJ,
2007), increased pain-related fears (McWilliams LA, Asmundson GJ, 2007), reduced pain
threshold (Meredith P, Strong J, Feeney JA 2006), and poor pain coping.
Among subjects with chronic pain, insecure attachment has been linked to more negative
appraisals of pain (Meredith P.J., Strong J., Feeney J.A. 2005), increased pain perception and
disability (McWilliams LA, Cox BJ, Enns MW, Clin J 2000), increased psychological distress
(Ciechanowski P, Sullivan M, Jensen M, Romano J, Summers H, 2003), impaired coping with
pain (Meredith P, Strong J, Feeney JA 2003) and greater healthcare utilization (Ciechanowski P,
Sullivan M, Jensen M, Romano J, Summers H, 2003). These findings suggest that individuals
with insecure attachment are more likely to develop pain, and once pain has developed they are
more likely to perceive it as more intense, disabling and distressing.

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Impact of Prolonged Pain within Developmental Aspects

It is now well established that pain is a multidimensional phenomenon, affected by a
range of psychological, social, and biological variables unique unto the person living through it
(Elliot, A. J., & Reis, H. T. 2003). Individuals usually report experiencing several losses caused
by chronic pain, such as impaired health and loss of work or social relations (Harvey, 1998).
While understanding pain as a multifaceted experience, the concept of loss must be included and
acknowledged as an aspect of which, the experience of grief is a natural element (Furnes &
Dysvik, 2010). Moreover, loss and grief experiences are expressed through the movement
between relearning the world and adaptation (Furnes & Dysvik, 2010, p. 137).
Developmentally this demand upon an individual by the stressors of chronic pain, usually take a
toll, negatively impacting ones life, until new ways of living are integrated in to the self as part
of adjusting to a new lifestyle.
Suffering from chronic pain may reduce capability and impair concentration (Davis,
2000) within the stage of developmental growth the person is at in their life. Chronic pain has
such a strong influence on the whole person that it can invade all aspects of ones life (Davis,
2000). This, notably, may affect the desire and capacity to participate actively in everything from
self-care to social interaction to therapeutic treatment for a person with chronic pain. Isolation
and low levels of social interaction and physical movement are prominent in individuals with
chronic pain. Much research has been done on the cycle of self-concealment and pain. Selfconcealment is defined as the tendency to hide negative or distressing personal information from

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others (Larson & Chastain, 1990). The concealed information has three characteristics; it is
private and personal, consciously accessible, and actively kept hidden (Larson & Chastain,
1990). In other words, self-concealment entails an active, conscious process to hide distressing
personal information. Past studies suggest that self-concealment is associated with negative
health outcomes. For instance, self-concealment is linked to physical symptoms and
psychological distress (Larson & Chastain, 1990), depression and anxiety (Kahn & Hessling,
2001; Kelly & Achter, 1995), rumination (King, Emmons, & Woodley, 1992), and overall wellbeing (Uysal, Lin, & Knee, 2010).
Moreover, self-concealment accounted for a significant amount of variance in these
outcomes, even after controlling for self-disclosure. Studies have also shown the long-term
health consequences of self-concealment. For example, in a longitudinal study involving women
who had an abortion, it was found that keeping the abortion secret predicted increase in distress
two years after the abortion (Major & Gramzow, 1999). In other words, concealment of chronic
pain could result in lower need satisfaction and higher pain intensity, which then could lead to
more concealment. Social life often changes relationship status quo, as physical conditions that
exist over time are likely to alter traditional family roles often creating financial difficulties and
distress for all family members, in addition to the problems created for the identified patient
(Turk, 1992). Notably, individuals living with chronic pain have an elevated risk of suicide. .
Suicide rates are often elevated among medical patients and, compared with the general
population; they are at least doubled among people with chronic pain (Tang & Crane, 2006).
Because of these aspects of chronic pain, attachment and social engagement seem
especially important for research. Interpersonal concepts that include schemas about feelings of
belonging and self-perceived burden to others, (Kowal, Wilson, Mc- Williams, Ploquin, &

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10

Duong, 2012) should also be of importance when considering the psychology involved with
chronic pain. It is possible, therefore, that these dimensions explain aspects of suicidal behavior
in chronic pain patients (Kanzler, Bryan, McGeary, & Morrow, 2012) patients.
Depression is a hallmark symptom of living with chronic pain. Turk (1992) noted that
spouses of patients suffering from chronic pain had high frequencies of psychophysiological
disorders and depressed moods themselves. Furthermore, there is a higher than average number
of patients with chronic diseases who are depressed. Patients who are depressed may be more
challenging to support. It is important that these factors be considered in trying to understand the
role of spouse attention in chronic pain and disability. Chronic pain has been shown to have a
deleterious effect on marital and sexual functioning, and to be associated with increased
symptoms of depression and psychophysiological disorders among spouses of chronic pain
patients (Flor, Turk, & Scholz, 1987; Kerns & Turk, 1984) influencing their growth and
development.
The most prominent perspectives on the role of families in chronic illness, and chronic
pain, specifically, can be labeled as family systems and social support. Therapeutically it is
important to understand what influence chronic pain and disability have on attachment,
individuation, emotional development, social and family relationships, and sex at various times
in the lifecycle. In a study conducted by Jamison RN and Virts KL (1990), Two hundred and
thirty-three patients who described their family as always being supportive and never having any
conflicts were compared with 275 chronic pain patients who endorsed having family disharmony
and limited support. One year after completing an out-patient pain program a random sample of
181 of these patients were followed to determine the extent to which family support influenced
treatment outcome. The patients who reported having non-supportive families tended to have

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11

liability and work-related injuries, relied on medication, reported having more pain sites and
used more pain descriptors in describing their pain. These patients also tended to show more pain
behaviors and more emotional distress compared with pain patients coming from supportive
families. On follow-up, patients who described their families as being supportive reported
significantly less pain intensity, less reliance on medication and greater activity levels. They
tended to be working and not to have gone elsewhere for treatment of their pain compared with
patients who described their family as non-supportive. The main aim of this study was to
determine the role family support played in insulating chronic pain patients from maladaptive
behaviors associated with their pain. Based on the results (stated above) Jamison RN and Virts
KL (1990) concluded that perceived support was an important factor in the rehabilitation of
chronic pain patients.
Similliar results have been obtained from various other studies conducted in the same
regard. (Palermo MT, Valrie RC, Karlson WC 2014; Lewandowski W, Morris R, Draucker BC
and Risko J. 2007).

Treatment
Pain is now understood as a multifaceted experience that incorporates the individuals
thoughts and feelings. Pain management programs based on cognitive behavioral therapy (CBT)
are often recommended in chronic pain rehabilitation (Turk 2002).

Cognitive Behavioral

Therapy (CBT) is a psychotherapeutic approach that addresses dysfunctional emotions,

maladaptive behaviors and cognitive processes through a number of objective based explicit

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12

systematic procedures. Most therapists working with patients dealing with anxiety and
depression use a blend of cognitive and behavioral therapy. This technique acknowledges that
there may be behaviors that cannot be controlled through rational thought. CBT is "problem
focused" (undertaken for specific problems) and "action oriented" (therapist tries to assist the
client in selecting specific strategies to help address those problems) (Schacter, D. L., Gilbert, D.
T., & Wegner, D. M. 2010).

The primary task of CBT within the broad framework of learning theory is to improve
quality of life, coping skills and physical functioning. Cognitive behavioral therapy for chronic
pain involves a variety of interventions that share three basic components:
1. Emphasizing the patients ability to help themselves rather than depending on
therapists
2. Interest in the nature and modification of the patients thoughts, feelings and
behaviors, which may worsen the pain experience, and
3. The use of CBT procedures in promoting change (such as homework, relaxation,
social skill training and physical activity) (Turk, 2002).
Increasing awareness, gaining understanding, and new insights are essential in therapy, and are
certainly essential aspects of dealing with chronic pain. Feelings of anger in particular are
considered a key factor in the maintenance of chronic pain.
In a study conducted by Kems DR, Rosenberg R and Jacob CM (1994), Intensity of
angry feelings and styles of expressing anger were examined for their relationship to measures of
the chronic pain experience. Subjects were 142 chronic pain patients. Multiple regression
analyses revealed that a style of inhibiting the expression of angry feelings was the strongest

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13

predictor of reports of pain intensity and pain behavior among a group of variables including
demographics, pain history, depression, anger intensity, and other styles of anger expression. In a
similar manner anger intensity contributed significantly to predictions of perceived pain
interference and activity level. More conservative hierarchical regression analyses supported
these findings. Results were consistent with explanatory models of pain and disability that
hypothesize an etiologic role of a pervasive inability to express intense negative emotions,
particularly anger. Research over the past two decades reveals a robust relation between anger
and adverse pain outcomes. Higher anger expression has been linked with decreased
experimental pain tolerance and greater reported pain intensity, as well as with increased postsurgical pain report and analgesic intake (Bruehl S, Chung OY, Donahue BS, Burns JW 2006).
Anger is thus an essential aspect when considering therapeutic treatment for chronic pain.
When the source of anger, in such cases, has been identified, problem-solving methods can be
used to cope better with such feelings (Keefe et al., 2002).
Treatment approaches and primary goals are to typically aimed at increasing attachment
security within the individual experiencing chronic pain. Strategies include the provision of a
secure base of support and use of secure base priming techniques (Mikulincer & Shaver, 2001),
which are worked out with the therapist. Relationship based or emotion focused
psychotherapeutic approaches (Dallos, 2004) have also proven to meet attachment needs. Brief
psychotherapeutic attachment informed interventions have been described, and have also been
adapted for use with medically unexplained symptoms (Maunder & Hunter, 2004) and proven
successful. These authors have managed to developed a brief, integrated attachment and
existential psychology approach titled Meaning and Attachment Based Intervention (Maunder &
Hunter, 2004), which might prove to be usefully incorporated into pain treatment programs. The

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14

application and evaluation of these clinical interventions constitutes one of the most promising
areas of research in this field.
In the last two decades there has been an emergence of a number of cognitive behavioral
therapies that place less of an emphasis on thought content, and a greater emphasis on the
patients relationship to his or her thoughts (Hayes, 2004). These third wave therapies (Hayes,
2004), including Dialectical Behavior Therapy (Linehan, 1993), Acceptance and Commitment
Therapy (Hayes, Strosahl & Wilson, 1999), and Mindfulness-Based Cognitive Therapy (Segal,
Williams & Teasdale, 2002), teach skills and use exercises that encourage patients to relate
differently to their thoughts in ways that will help patients achieve their goals. One of these
therapeutic approaches, ACT, has been developed specifically for chronic pain treatment as
Contextual Cognitive-Behavioral Therapy (CCBT) for chronic pain (McCracken, 2005). Where
acceptance of the condition and diagnosis are processed and integrating pain experiences into life
with mindfulness techniques is promoted.
The influence of mindfulness on pain perception could potentially encompass anxiety,
catastrophizing and cognitive affective pain perception to the point of sensory pain experience
(Quartana JP, Campbell MC, Edwards RR 2009). Pain acceptance and willingness to experience
pain in order to have a positive social experience is key. Alleviation of pain and the possibility of
a better or more enjoyable life may be achieved when the sufferer plays an active role in the
relearning and adaptation process. Emotional processing is revealed as a crucial element in the
adaptation process.
The chronic pain experience and impacts are unique to the specific human being,
manifesting for individuals differently at all stages of life throughout the lifespan, often creating
a stagnation or rupture in that part of an individuals life affecting their optimum development

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PAIN AND HUMAN DEVELOPMENT

potentials. Because chronic pain is a biologically, psychologically, and socially informed

condition it needs to be treated holistically within the psyche on those specific levels including
the unconscious processes in order to fully understand the impacts of prolonged pain within the
developmental aspects of life.

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