Stefan Elbers

13 General introduction associative learning does take place in these situations, often reinforcing the relationships between pain, certain activities, fear of injury, and impulses to initiate protective behaviours (Tabor & Burr, 2019). Through generalization within this associative network, for example, by extrapolating the threat value of specific movement actions (such as lifting heavy objects at work) towards general activities (such as lifting anything), chronic pain increasingly interferes with daily life. Over time, the interrupting effect of pain on activities, the associated negative affect, and the impulses towards protective behaviours at the cost of other valued activities increasingly impact a person’s wellbeing and identity. People who valued themselves as parents, partners, friends and colleagues, increasingly regard themselves as patients with pain (Toye et al., 2017). This dominance of pain in the lives of patients is not only corroborated by qualitative studies, where patients report an impoverished and constricted life, but also by experiments where patients with chronic pain have an attentional bias towards pain-related stimuli, compared with healthy controls (Todd et al., 2018; Toye et al., 2017). It is important to realize that these psychological processes do not stand alone, but that they interact with noxious input and peripheral processing (Phelps et al., 2021; Woller et al., 2017). Consequently, the ongoing hypersensitivity and persistent pain that result from sensitization of the pain network will influence how pain is perceived and appraised over time (Brodal, 2017; Phelps et al., 2021). Although the influence of social context has received less attention in both research and treatment programmes, environmental factors, including work, family relationships, and health care provider perceptions, have a considerable influence on chronic pain and its impact on wellbeing (Darlow et al., 2013; Hruschak & Cochran, 2017; Mescouto et al., 2020). Pain-related disability impairs relationships with co-workers, friends, significant others, and children. Furthermore, the culturally dominant view that pain signals injury – often reinforced by health care providers (e.g. Nijs et al., 2013) – can shape beliefs towards a biomedical understanding of their pain. For example, a thematic analysis of readers’ comments to an article in a national newspaper in the United Kingdom that presented a biopsychosocial view of pain revealed themes such as the need for MRI scans to diagnose chronic pain, the danger of exercising with pain, and the idea that people who prescribed exercise were not taking the problem seriously (McCarthy & Yeowell, 2017). This is problematic because a biomedical perspective towards chronic pain is related to ineffective coping strategies, worrying, and increased disability (Eccleston & Crombez, 2007).