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Thoughts, Feelings and Behaviour

First, imagine that you have a headache. Most people have had a headache from time to time and know they normally don’t last too long but aren’t pleasant, and they can make you feel a bit fuzzy or irritable.

Now imagine that you are at work with loads of work to do or you have a grumpy boss wanting to speak to you. If you don’t work, imagine you have just got a large unexpected bill through the post. Your headache is still the same headache, but you might agree that it seems worse if you’re feeling under pressure, stressed or low in mood.

Finally, imagine you are on holiday sat on a warm beach with the sea gently splashing in the background, or you’ve just got some really good or exciting news. You still have the same headache, but somehow it doesn’t seem as bad, doesn’t seem as sore and is easier to deal with.

What does all this mean? 

Well, using our example above, you can hopefully see that the same headache can be felt differently dependent on where you are, what you’re doing and how you are feeling. In other words, things like your thoughts and feelings or the situation you are in can influence your pain in different ways.


Why is this relevant to me?

Most people will understand that pain can influence what we think, feel and do. However, people are not always aware that the opposite is also true: what we think, feel and do influences our pain, and looking at your thoughts and feelings about pain can be a useful step towards managing it better.

Hold on, this all sounds a little ‘out there’. Are you telling me that looking at my thoughts and feelings can help my pain?

In short, yes. As we’ve mentioned in the previous pages about persistent pain, the pain you might be feeling is complicated. A bit like making a cake, you need all the right ingredients to make it work. Pain can have different ‘ingredients’ such as stiffness, difficulty moving, weakness and poor sleep that all influence it, but things like worry, fear, anger or resentment can all act as ingredients too. Sometimes when looking at what is going to help you move forwards with managing your pain, you need to look at all the ‘ingredients’ going into the mix and make sure the treatment is aiming to help all of them.

Rio et al (2016) found that so-called negative health beliefs such as stress, worry and catastrophisation (thinking the worst) can directly affect your immune system, which in turn can contribute to pain sensitivity. In other words, worrying or feeling stressed about your pain can actually make your pain worse.

Have a look at the diagram below as it might show you how what you think, how you feel and what you do are all connected.

Well, isn’t it normal to worry about pain?

It absolutely is. Pain can be unpleasant and can sometimes make you feel quite vulnerable. When pain has been with you for some time, it is quite normal to find your mind wandering towards darker thoughts such as “is there something really wrong with me?” or “is this how I’m going to be forever?”. It is sometimes quite hard to stop these thoughts from growing, as it is actually quite difficult to find positive messages about how you can deal with pain.

Searching the internet, speaking to friends or family or even speaking to different healthcare professionals can sometimes lead to confusing messages, multiple diagnoses and no clear direction to go in. In other words, there is some scary stuff out there in terms of information, especially on the internet, and it can sometimes make your worry worse.

To help with this, we have designed the information on these pages to help you get the best advice there is. It is correct and can be trusted and the main aim is to help you understand that if you have persistent pain, you are not alone, you are not lost and you can feel better.


Ok, well I can’t just switch my worry off, can I?

Of course not, just like you can’t get someone to stop smoking or drinking just by telling them they should. By recognising that your thoughts and feelings can be just as important as your movement, strength or fitness, is a huge step in the right direction.

In some cases, some people can find themselves becoming quite focused on their health and the things that are problems and issues. This is called ‘health anxiety’.

Is there anything I can do?

Yes there is, and sometimes it’s useful to know there are different types of thoughts and feelings that might influence you and your pain more than others.

Some of the more common unhelpful thoughts or patterns of thinking are:

'All or nothing' thinking

By thinking in absolutes, as either black or white, good or bad, with no middle ground, e.g. “I can’t do that”, “there’s no way I could lift that”, “I mustn’t do that”, you may condemn yourself on the basis of a single event, “If I hadn’t lifted that thing then my back wouldn’t be sore.”


Tending to magnify the importance of events and how awful or unpleasant they will be, overestimating the chances of disaster - whatever can go wrong will go wrong. E.g. “If I do that I’ll make my knee worse”, “the pain is so bad it must mean that something is really wrong”, “I’ll end up in a wheelchair if my pain doesn’t get any better.”


Taking responsibility and blame for anything unpleasant, even if it has little or nothing to do with you. E.g. “It is my fault”, “my doctor was irritable because I went to see him for two weeks running”, “I’m not a good mum/dad because I can’t play with my kids anymore.”

Negative focus

Focusing on the negative, ignoring or misinterpreting positive aspects of a situation. You focus on your weaknesses and forget your strengths, looking on the dark side. E.g. “It can’t be getting better because it still hurts”, “look at all the things that I still can’t do.”

Jumping to conclusions / mind-reading

Making negative interpretations even though there are no definite facts. You start predicting the future and take on the mantle of ‘mind reader’ e.g. “They think that just because I don’t look ill, that I am not ill”, “they think I am lazy because I am not at work”, “there’s no point in trying as I failed before”, “what’s the point?”.


Living by fixed rules

Tending to have fixed rules and unrealistic expectations of yourself, regularly using the words ‘should’, ‘ought’, ‘must’ and ‘can’t’. This leads to unnecessary guilt and disappointment. E.g. “If I can’t do the housework I am a useless wife”, “I must do it this way because I always have done it this way”, “I should be able to cope better by now”, “I must not stop until I am finished". 


OK, I do have some of these thoughts, but what can I do about them?

As we’ve said before, being aware that you may have some of these thoughts is half of the battle. Sometimes, challenging yourself into understanding why you think or feel the way you do about your pain can be really useful.


Reasons behind thought

Challenging your thinking can be tough as some of these thoughts simply happen automatically.

Using our Thought Diary below can be really helpful as it may help you explore why you think a certain way about your pain.

Thought Diary

You mentioned ‘health anxiety’, is there anything I can do about that?

Yes. The things that we have mentioned above can be really useful to help anyone look at how they are thinking or feeling towards their pain. If you feel that you might need a little more help with this, then you might find the booklet on the right worth looking at: Health Anxiety.

Northumberland, Tyne and Wear NHS have produced a number of excellent self-help booklets for a range of mental health complaints. You can find their library here: Health Anxiety.

Is there anyone I can actually speak to about these thoughts and feelings?

Yes there is. You can always speak to your physiotherapist as they will help you explore your thoughts and feelings about your pain in more depth, and will work with you to plan a way in which you can move forwards with them and your pain.

Alternatively, you can self-refer to the Wellbeing Service who are able to offer specialist care for problems like this.

So what am I hoping to achieve by thinking ‘differently’ about my pain?

Often, by thinking differently about your pain, you can start to change the relationship you have with your pain. Instead of working against it, often you can start to work with it and move forwards in managing it better.

Thinking differently about your pain is unlikely to be the only thing that you will need to help you move forwards with your pain, but it is a very big step in the right direction.

You may find these videos useful in helping to explore your thinking when considering your pain and how you feel and think about it:

Rio, E., Dawson Kidgell, D., Moseley, G.L., Gaida, J., Docking, S., Purdam, C and Cook, J. (2016). Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. British Journal of Sports Medicine. 50(4): 209–215. doi: 10.1136/bjsports-2015-095215 (accessed 15/04/2021).

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