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January 28, 2015
by Dr. C. Wayne Winkle,Phd

Pain, Stress, Depression: Evidence Proves the Connection

January 28, 2015 05:55 by Dr. C. Wayne Winkle,Phd

Chronic Pain

Pain usually is our body’s way of telling us something is wrong and needs to be handled. Not only a physical experience, pain also has a significant emotional component. And the two, pain and emotions, sometimes work together in a negative way to make each one more noticeable.

Pain is something everyone experiences at some time in their lives. And some people live daily with pain from chronic conditions or some other physical health problem. 

As many as 100 million Americans suffer from chronic pain at any given time (Institute of Medicine, 2011). One survey (Gallup-Healthways, 2012) reported 47% of those living in the United States who responded to the survey suffered at least one kind of chronic pain. This same survey reported another 7% experiencing two or more kinds of chronic pain. 

The total cost of pain experiences to U.S. business and society ranges from $297.4 billion to $335.5 billion per year (Institute of Medicine of the National Academies, 2011). And these numbers don’t count the expense related to medications, physician, and hospital costs. 

These statistics show clearly the epidemic nature of pain in the population of the United States. But they only tell a portion of the human cost of the suffering of the people who deal with pain on a daily basis. Not only do the people with physical conditions causing pain pay this cost, their loved ones also suffer. Loss of ability to work, loss of ability to engage in enjoyable activities, loss of ability to express and/or accept affection and love -- all of these, and more, make up the emotional cost of pain conditions. 

The Realities of Stress

Stress is also part of the human condition. Everyone experiences stress in one form or another on a regular basis. It is a normal response by our bodies to anything that threatens us. When we feel stress, our body goes through a normal physical response designed to protect us. 

This response is automatic; we don’t have to think about any part of it. Once we interpret some event or person in our lives as threatening, the response kicks in. Our hearts beat faster, blood pressure increases, pupils dilate, we breathe faster, and our senses grow sharper. 

Our bodies don’t differentiate between physical and psychological stressors. We respond the same to stress from either kind of stressor. This helps us meet challenges.

It also leads us to feel the hurt from pain more.

Stress and Pain

New research from scientists at Tel Aviv University and McGill University have shown sudden, possibly intense pain causes people to perceive pain to be greater (Geva, Pruessner, & Defrin, 2014). This kind of stress also makes it more difficult for people to deal with their pain. 

In this study, healthy men were subjected to psychosocial stress brought on by thinking they scored more poorly than they actually did on a series of timed arithmetic problems. These subjects felt stress due to not being able to improve their scores, no matter what they did. The experiment was designed to give these false scores. 

Researchers found the higher these subjects perceived their stress levels to be, the less they were able to handle non-harmful pain. The type of stress perceived and how high the subjects thought it was affected their pain perception. 

According to the researchers, they already knew from previous studies that chronic stress affects pain levels more than acute stress. And people today are more likely to be exposed to chronic stress conditions than acute stress.

This fact would seem to suggest those already suffering from continual pain and who are exposed to more chronic stress conditions will subjectively feel their pain more. This may lead them to be more sedentary, which only serves to increase their pain.

Another study on stress and its influence on pain perception also suggested a relationship between stress and pain (Hwang, et al., 2008). This study reported on self-reported stress, coping style, and degree of pain. The higher the stress, the more pain was experienced.

However, another earlier study (Alghamdi & Al-Sheikh, 2009) similar to the new study showed physical stressors increased pressure pain threshold and pressure pain tolerance in young female adults. Mental stressors had no effect on pain tolerance. This finding shows conflicting results compared to the more recent study mentioned above. Possibly the perception of stress by the subjects in the recent study accounts for the different findings. 

Other Effects of Stress on Pain Perception

Significantly high levels of stress often lead to emotional and behavioral symptoms. Among these are depression and anxiety (Smith, Segal, & Segal, 2014). Both of these emotions cause significant stress on a person’s psychological state.

Loggia, et al., (2008) explained that an important aspect of a person’s perception of pain in a dental setting is his or her psychological state, especially anxiety. Frequently, anxiety is labeled as a negative emotional condition, especially by those experiencing it. Negative emotions tend to lead to more feeling of pain than positive emotions (Loggia, et al., 2008). 

Physical therapists have found that lower back pain is increased when it occurs in a person already under a lot of stress and whose ability to handle stress is lessened by overuse (Linton & Shaw, 2011). The perception of pain from lower back problems under these circumstances leads to poorer coping with the pain. 

This appears to be related to the presence of stress, anxiety, and depression. People with depression and high levels of stress appear to be more likely to develop chronic pain conditions related to lower back problems. 

Also a factor to be considered in the case of chronic pain of the type described by Linton and Shaw is a model that incorporates fear, avoidance, and depression. In this model, it seems that people develop a fear of pain because they interpret pain as being threatening. This then leads them to avoid activity that could cause pain. The inactivity leads to disability and depression.

Add into this model the idea that stress results from feelings of being threatened, and another layer of emotional difficulty comes into play. Much of this kind of emotional difficulty is depression and anxiety, both of which lead to increased perception of pain. 

The so-called “stress hormone”, cortisol, has been studied as a factor in pain perception, also (Vachon-Presseau, et al., 2013). Under conditions of stress, cortisol is released from the adrenal glands. This is an automatic physiological response to stress. In this study, anatomical magnetic resonance imaging (MRI), along with functional MRI (fMRI) images showed subjects with chronic pain conditions to have a smaller hippocampus and higher cortisol levels than healthy subjects. This condition appears to make these individuals to have a stronger response to stress and thus become more sensitive to pain sensations. 

The above study appears to show the biological reason for the observed reciprocal relationship between stress and pain perception. Experiencing pain may lead to continual stress response from the automatic processes that come from pain. This condition of the body constantly being activated by stress leads to an increased perception of pain, which in itself is stress producing (Vachon-Presseau, 2013). 

Persistent stress often leads to depression (McAllister, 2012). And depression increases the perception of pain, especially chronic pain. It makes the pain harder to tolerate. Thus, the same kind of cycle of pain and depression each leading to more of the other is set in motion, much as the cycle of stress and pain as mentioned above. 

This cycle is explained by a process called central sensitization. Constant stress leads to the nervous system becoming continually activated. This lowers a person’s pain threshold and sets the nervous system in a state of reactivity in which only a small stimulus is needed to stimulate the stress response again.

A part of the reason for this kind of cycle is the idea that the mind and body are so interrelated that they can’t truly be separated (Ma, 2013). What affects one, affects the other either directly or indirectly. 

According to the Harvard Health Publications (2009), individuals who suffer from chronic pain are three times more at risk of developing depression or anxiety. And individuals who suffer from depression are three times more at risk of developing chronic pain.

Dealing With the Pain-Stress Connection

Just as there are a number of ways stress can come into a person’s life, there also are a number of ways of increasing tolerance for stress and potentially overcoming the effects it may have. By increasing the ability to deal adequately with stress, a person may also decrease his or her perception of pain. Keep in mind there is no single way of dealing with stress and stressful situations that works for everybody. Individuals are unique. What works for one, may only lead to more stress for another. Find what works for you and stay with it for long-term results.

Smith, Segal, and Segal (2014) suggest keeping mind the four As: avoid, alter, adapt, and accept.

• Avoid as much stress as possible. Of course, not all stress can be avoided, but much can be removed by learning to say no and by staying away from people and situations that usually lead to stress.

• Alter stressful situations. This involves dealing with things right away and telling others how you feel about those things.

• Adapt yourself to stressors. When you can’t change situations, change yourself. Look for positives in your life and realize not everything is worth getting upset over.

• Accept what you can’t change. This doesn’t mean you have to like stressors. But you do need to understand you can’t do anything about some of the things that happen to you.

Improving overall physical health is a great way to increase tolerance of stress, also. Relaxation, regular exercise, a good diet, and enough sleep go a long way toward lessening the impact of stress and thus lowering the perception of pain.

Smith and Segal (2014) propose several ways of successfully dealing with stress. The first of these is to identify where your stress comes from. The source of stress isn’t always obvious, so some thought is required to pinpoint it. 

A stress journal can help. Answering these questions can help you specify the source of your stress:

• What was going on when you felt stressed?

• How did you feel both physically and psychologically?

• What did you do when you felt this stress?

• What made you feel better?

Once you identify what stresses you, use the four As mentioned above to deal with the stress. If you can, take control of what goes on around you. Stay away from those triggers that are guaranteed to stress you. This may include staying away from some people.

Compromise is a good thing, especially in close relationships. Assertion also can be good; be sure to be assertive and not aggressive.

Keep your stress in perspective. Is this worth getting stressed over? How important is it in the long term?

There will always be things in your life that are out of your control. Accept this. Don’t try to control everything. Learn to forgive.


Alghamdi, K. S. & Al-Sheikh, M. H. (2009). Effect of stress on pain perception in young women. Saudi Medical Journal, 30(4):478-84.

Gallup-Healthways. (2012). Results of survey reported in

Geva, N., Pruessner, J., & Defrin, R. (2014). Acute psychosocial stress reduces pain modulation capabilities in healthy men. Pain; 155(11):2418.

Harvard Health Publications. (2009). Depression and pain. Retrieved from

Hwang, G. et al. (2008). Influence of psychological stress on physical pain. Stress and Health; 24(2):159-164.

Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education. (2011). Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education and Research. The National Academies Press. Retrieved from

Institute of Medicine of the National Academies Report. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. (2011). The National Academies Press, Washington DC. (page 260). Retrieved from

Linton, S. J. & Shaw, W. S. (2011). Impact of psychological factors in the experience of pain. Retrieved from

Loggia, M. L., et al. (2008). Effects of psychological state on pain perception in the dental environment. JCDA; 74(7):651-656.

Ma, C. B. (2013). Pain and your emotions. Retrieved from

McAllister, M. J. (2012). Understanding chronic pain. Retrieved from

Smith, M., Segal, R., & Segal, J. (2014). Stress symptoms, signs, and causes. Retrieved from

Smith, M. & Segal, R. (2014). Stress management. Retrieved from

Vachon-Presseau, E., et al. (2013). Preventing chronic pain with stress management. Retrieved from

Vacon-Presseau, E. (2013). A stress model of chronic pain. Retrieved from

About the Author

C. Wayne Winkle C. Wayne Winkle

I have over 30 years experience as a psychologist. My current 'day job' involves writing job descriptions, policy and procedure manual entries, and other writing activities for a mental health center.

C. Wayne Winkle can be found at
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