Early Care Matters in the Stress-Chronic Pain Connection

Medscape

07-05-2025

Chronic pain affects 150 million people across Europe, according to the European Pain Federation. That is approximately the population of France and Germany combined. This burden drives countless patients to seek help first from general practitioners, incurring substantial costs to patients and healthcare systems, potentially reaching €12 billion annually. That includes direct medical expenses, out-of-pocket costs, and productivity losses due to absenteeism and reduced work capacity. Bigger still is the physical and mental cost patients endure. People with chronic pain experience a lower quality of life, an increased risk for mental health problems like depression and anxiety, and often face social isolation and a reduced ability to participate in daily activities.
While managing the physical symptoms of pain is essential, a critical, often overlooked, factor contributes to its persistence: The intricate and powerful link between stress and the experience of pain. Despite evolving scientific understanding and clinical guidelines advocating for a biopsychosocial approach to pain, this crucial connection may not be consistently addressed during early consultations with nonspecialist healthcare professionals.
Pain specialists see the consequences firsthand.
'In my experience, this is incredibly common,' Ashley Simpson, MBChB, consultant orthopedic surgeon specializing in peripheral nerve injuries at the Royal National Orthopaedic Hospital, London, England, told Medscape Medical News . 'A significant portion of the chronic pain patients I see had clear psychosocial stressors, such as high anxiety and unresolved emotional distress, early on that went unaddressed.'
Ashley Simpson, MBChB
Research supports this observation, with one review finding that psychological factors were associated with pain becoming chronic in 83% of studies. This missed opportunity represents a critical junction where early intervention could potentially prevent acute pain from embedding into a chronic condition.
The Stress-Pain Connection: An Amplified Alarm System
The scientific understanding of pain has moved beyond viewing it solely as a direct signal of tissue damage. Instead, researchers now understand the nervous system, particularly the brain and spinal cord, as a dynamic alarm system whose sensitivity can be modulated by various factors, including stress. In chronic pain, this system often becomes hypersensitive, reacting strongly even to minor stimuli.
Sandrine Géranton, PhD, principal research fellow at University College London, London, England, told Medscape Medical News that chronic stress, whether psychological (anxiety or trauma), physiological (poor sleep or inflammation), or environmental, can significantly amplify this sensitivity.
'There are shared neural substrates between pain and stress,' David Finn, PhD, professor of pharmacology and therapeutics at the University of Galway, Galway, Ireland, said. 'Some of the same brain regions and circuitry within the central nervous system mediate both stress and pain, and so maladaptive alterations in that circuitry due to stress can give rise to sensitization within the somatosensory system, which ultimately can lead to chronic pain,' he told Medscape Medical News .
David Finn, PhD
The opposite is also true. Persistent pain itself acts as a potent stressor, disrupting sleep, mood, work, and relationships, feeding this cycle of sensitization.
What Primary Care Doctors Should Know
Despite the compelling evidence, the integration of this biopsychosocial understanding into initial patient encounters remains often overlooked. Frontline healthcare professionals face significant time constraints, often prioritizing immediate symptom management or investigation of obvious structural issues.
Patients with chronic pain frequently present having received purely biomedical assessments and treatments, such as repeated scans or a focus solely on strengthening exercises, without ever having the stress or psychological component discussed. This is not necessarily a failing of the individual clinician but a reflection of systemic pressures, historical training biases toward biomedical models, and patient expectations often centered on a physical 'fix.'
The consequence, as highlighted by both the clinical and scientific experts, is a missed opportunity. Patients may leave consultations without understanding why their pain persists despite a lack of clear physical findings, potentially feeling dismissed or believing their pain is purely physical when stress is a major contributor. This lack of early psychoeducation and acknowledgement of the stress-pain link can hinder their ability to adopt effective self-management strategies and make the pain much harder to treat later.
Simpson shared some key concepts healthcare professionals should help their patients understand early.
Pain does not equal harm. While pain is real, its intensity is not always proportional to tissue damage. The brain and nervous system interpret signals, and this interpretation is heavily influenced by state of mind, stress, and prior experiences.
While pain is real, its intensity is not always proportional to tissue damage. The brain and nervous system interpret signals, and this interpretation is heavily influenced by state of mind, stress, and prior experiences. The nervous system can learn pain. Persistent pain can lead to lasting changes ('sensitization' or 'priming') in the nervous system, making it more reactive. The longer pain persists, the better the brain becomes at producing it.
Persistent pain can lead to lasting changes ('sensitization' or 'priming') in the nervous system, making it more reactive. The longer pain persists, the better the brain becomes at producing it. Stress is a major amplifier and contributor. Chronic stress, anxiety, depression, poor sleep, and fear significantly affect pain processing and can contribute to chronification.
Chronic stress, anxiety, depression, poor sleep, and fear significantly affect pain processing and can contribute to chronification. Movement is generally safe and therapeutic. Reassure patients that moving within limits, even if it causes temporary discomfort, is vital for recovery and helps calm a sensitized nervous system. Pain flares don't necessarily mean damage.
Practical Strategies for Busy Clinicians (Within ~10 Minutes)
Integrating a stress-informed approach is feasible even in short consultations:
Listen and ask (minutes 1-3): Weave in brief, open-ended questions: 'How has stress been affecting you lately?' 'How has your sleep been?' 'Have there been any major life changes recently?' Listen for cues about mood, anxiety, or fear related to their pain. Simpson noted that 'catastrophizing or fear of movement during an acute injury are much more likely to develop into persistent pain,' suggesting that observing or asking about these responses is important.
Weave in brief, open-ended questions: 'How has stress been affecting you lately?' 'How has your sleep been?' 'Have there been any major life changes recently?' Listen for cues about mood, anxiety, or fear related to their pain. Simpson noted that 'catastrophizing or fear of movement during an acute injury are much more likely to develop into persistent pain,' suggesting that observing or asking about these responses is important. Simple explanation (minutes 4-6): Briefly explain the stress-pain link using the 'alarm system' analogy. Reassure the patient that this is a real biologic process involving the nervous system, not an indication that their pain is 'all in their head.' Explain that understanding this offers them tools to influence their pain.
Briefly explain the stress-pain link using the 'alarm system' analogy. Reassure the patient that this is a real biologic process involving the nervous system, not an indication that their pain is 'all in their head.' Explain that understanding this offers them tools to influence their pain. Actionable first steps (minutes 7-9): Provide one to two concrete, simple, and accessible suggestions: Brief relaxation: Suggest simple, controlled breathing techniques. Sleep hygiene: Offer one key tip, like maintaining a consistent sleep schedule. Gentle movement: Encourage starting small with movement, for example, a short walk and pacing activity, focusing on consistency rather than pushing through severe pain. Reframe movement as 'calming the nervous system' and regaining function. Signpost resources: Mention reliable patient-facing websites or apps for pain education and stress management if known.
Provide one to two concrete, simple, and accessible suggestions: Validate and refer (minute 10): Acknowledge the patient's pain and struggles are real. Explain when a referral might be necessary and mention relevant services like pain psychology or pain-informed physiotherapy.
These steps, though seemingly basic, are 'profoundly important,' Simpson said. 'They help the patient not only physically but psychologically by preventing fear and despair from taking hold.'
'It is important to listen carefully to a patient who is saying that they feel stressed or anxious and to take that seriously,' Finn said. 'Be aware of the possibility that if that's not addressed early, it can exacerbate pain-related conditions or contribute to the development of chronic pain.'
Géranton reinforced the importance of the integrated approach. 'You really need to look at it as one package and never separate the sensory aspect from the emotional aspect of the pain experience.'
Simpson, Géranton, and Finn reported having no relevant financial relationships.