Perspectives on Pain: A Narrative Review of Pain Beliefs, Coping, and Clinical Implications

Chandler Pugh; Kristina Snoddy; Reagan Boyett; Halle Bakir; Daniel Cawley; Mary K Piscura

doi:10.2147/JPR.S603074

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Review

Behavioral Approaches to Pain

Perspectives on Pain: A Narrative Review of Pain Beliefs, Coping, and Clinical Implications

Authors Pugh C, Snoddy K, Boyett R, Bakir H, Cawley D, Piscura MK

Received 12 February 2026

Accepted for publication 14 April 2026

Published 23 April 2026 Volume 2026:19 603074

DOI https://doi.org/10.2147/JPR.S603074

Checked for plagiarism Yes

Review by Single anonymous peer review

Peer reviewer comments 3

Editor who approved publication: Dr Rocío de la Vega

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Pain beliefs, coping, and clinical implications – Video abstract [603074]

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Chandler Pugh,^1,^* Kristina Snoddy,^1,^* Reagan Boyett,¹ Halle Bakir,² Daniel Cawley,¹ Mary K Piscura¹

¹Department of Biomedical Affairs and Research, Edward via College of Osteopathic Medicine, Auburn, AL, USA; ²Department of Graduate Psychology, Pacific University, Forest Grove, OR, USA

*These authors contributed equally to this work

Correspondence: Mary K Piscura, Department of Biomedical Affairs and Research, Edward via College of Osteopathic Medicine, 910 South Donahue Drive, Auburn, AL, 36832, USA, Tel +1334422-4022, Email [email protected]

Abstract: Pain beliefs and coping strategies are often linked to treatment outcomes across various pain conditions, yet their roles are often examined in isolation across specific conditions. This narrative review synthesizes evidence across neuropathic, nociplastic, and nociceptive pain to examine how pain-related beliefs shape coping behaviors, treatment adherence, and clinical outcomes. Guided by the Common Sense Model of Illness, we integrate findings from neurobiological, psychological, and clinical literature to demonstrate how negative pain beliefs, such as fear-avoidance, pain catastrophizing, and lower self-efficacy, have been linked to heightened pain perception, maladaptive coping, reduced adherence, and poorer functional recovery. In contrast, positive pain beliefs emphasizing resilience and self-efficacy are often linked to adaptive coping, improved engagement in care, and more favorable outcomes, in part through modulation of prefrontal, limbic, and descending pain regulatory systems. This review synthesizes findings across diverse patient populations and conditions, with an emphasis on the differences in the various effects of pain beliefs and coping strategies. Across conditions, consistent patterns emerge in which belief-driven processes influence both behavioral and neurophysiological responses to pain. We further highlight gaps in current clinical assessment, particularly the underrepresentation of multidimensional belief constructs in routine care, and discuss implications for multidisciplinary, belief-informed interventions. Targeting pain beliefs through cognitive-behavioral strategies, patient education, and individualized care models represents a critical opportunity to improve adherence, reduce disability, and enhance long-term recovery.

Keywords: pain beliefs, coping strategies, chronic pain, pain catastrophizing, self-efficacy, treatment adherence

Introduction

Pain is commonly described as an unpleasant sensory and emotional experience, often associated with tissue or nervous damage.¹ For many, pain persists even after the causative stimulus is removed. Furthermore, individuals experience pain differently, even when exposed to the same pain-causing stimulus. The experience of pain is influenced by a range of biological and psychosocial factors, rendering it inherently subjective and variable across individuals.² Pain beliefs and pain coping strategies are key determinants of physical and psychological outcomes and contribute to the severity and/or frequency of the pain. Pain beliefs form the cognitive framework through which individuals understand and interpret their pain experiences. These beliefs function as a lens that shapes how pain is encountered, encompassing attitudes, perceptions, and expectations regarding its significance and implications. Conversely, pain coping refers to the cognitive and behavioral responses intended to reduce the impact of pain. These coping strategies represent the ways that an individual compensates for and responds to their pain, such as using relaxation breathing during a pain flare or distracting themselves with an enjoyable activity.³ Both pain beliefs and coping strategies can be classified into categories based on their effect on the individual experiencing pain.

Pain beliefs can be classified as positive or negative. Positive pain beliefs include optimism regarding treatment efficacy, belief that one can control one’s own pain (locus of control) and belief that one can manage pain, even if it is challenging (high self-efficacy). These belief patterns are generally associated with more favorable health outcomes and recovery trajectories. In contrast, negative pain beliefs are chiefly characterized by hopelessness, rumination, and magnification of pain, collectively referred to as pain catastrophizing.⁴ Catastrophizing is associated with higher pain intensity, potentially due to an increased cognitive focus on pain sensations and their anticipated consequences.⁵ While pain catastrophizing is the most widely studied of the negative pain beliefs, others include beliefs of being disabled by pain (low self-efficacy), beliefs that pain is permanent, and expectations that activity will inevitably worsen pain (fear-avoidance).³

While the literature acknowledges inconsistency in how coping is classified, it has been suggested that approaches emphasize their adaptive processes; therefore, in this study, we will define these responses to pain as either maladaptive or adaptive coping.⁶ Maladaptive coping strategies are defined as those that are shown to worsen pain, such as guarding, excessive rest, fear of movement (kinesiophobia), and excessive solicitation of assistance. Adaptive coping strategies, on the other hand, include task persistence, exercise, support seeking, and self-directed coping behaviors, many of which promote movement and social engagement.³ In the postsurgical setting, adaptive coping may be reflected by participation in physical therapy and community engagement, characteristics frequently associated with more favorable surgical outcomes.⁷ Importantly, coping strategies are not limited to pain management alone but may also encompass reliance on external support systems that enhance psychological resilience. For example, individuals who identify as religious or spiritual may demonstrate greater capacity to cope with chronic pain, potentially due to embedded social and psychological support mechanisms within these frameworks.⁸

Pain beliefs are intricately linked to coping behaviors, as individuals’ interpretations of pain shape their emotional and behavioral responses to perceived threat. Pain is frequently appraised as dangerous, eliciting fear and avoidance as protective coping strategies intended to prevent recurrence.⁹ Among patients with inflammatory arthritis, higher pain levels are associated with greater concern about disease progression, treatment-related adverse effects, quality of life, and disruption of daily activities, reflecting increased cognitive and emotional engagement with pain.¹⁰ Persistent worry and rumination promote maladaptive coping patterns such as catastrophizing, which is associated with elevated anxiety and depression and higher reported pain intensity, underscoring the interrelated nature of pain beliefs, emotional distress, and pain outcomes.^11–13

These belief-driven coping responses have meaningful clinical implications. Higher levels of preoperative anxiety are associated with increased anesthetic requirements, greater postoperative pain, and higher rates of postoperative complications, suggesting that anxiety-mediated coping influences recovery trajectories.¹⁴ Conversely, interventions that target pain beliefs, such as cognitive behavioral therapy (CBT), have been associated with reduced pain and enhanced perceived control in postoperative patients.¹⁵ Greater self-efficacy and stronger control beliefs are linked to a lower daily impact of depression and fewer negative affective symptoms, lower anxiety levels, and increased pain tolerance and endurance, even when perceived pain intensity remains unchanged.^16–19

Collectively, these findings align with the Common Sense Model (CSM) of Illness, which asserts one’s representations about illness guide subsequent behaviors or responses.^20,21 The perceived effectiveness of these behaviors in managing illness symptoms then reinforces or deconstructs initial perceptions, creating a dynamic feedback loop. Holistic extensions of CSM further acknowledge the influence of contextual and sociocultural factors that shape illness representations, such as lived experiences in which pain is normalized or cultural beliefs framing pain as a personal weakness.²² Together, these perspectives highlight the multidimensional and context-dependent nature of pain-related beliefs and behaviors. To illustrate these dynamics, Figure 1 presents a modified version of the CSM that situates the pain experience with acknowledgement of these extensions. This framework offers a critical lens for examining how beliefs direct pain outcomes, which can provide value in improving patient-provider communications, treatment adherence, and effective interventions. Within this framework, contextual factors, including but not limited to race, socioeconomic status, health literacy, and social environment, play a central role in shaping illness representations. These influences affect how pain is interpreted, the degree of perceived control, and the coping strategies employed, ultimately contributing to variability in clinical outcomes. Accordingly, this narrative review explores the ways in which pain beliefs influence patient outcomes and integrates recommendations derived from the synthesized literature.

Figure 1 Modified Common Sense Model (CSM) for Pain. Since its original development by Leventhal et al, CSM has guided the consideration of patient representations and coping strategies for a multitude of illnesses This adapted model is created under the context of pain experiences and includes contemporary considerations from the literature for further influencers of cognitive perceptions.²⁰ Key components of the model include: “stimulus,” which refers to the symptom trigger; “cognitive representations,” which reflect how patients understand and interpret their condition; “emotional representations,” which reflect the emotional responses elicited by the condition; “cognition-driven behaviors” and “emotion-driven behaviors,” which represent coping responses guided by cognitive or emotional processes; and “cognitive appraisal” and “emotional appraisal,” which refer to the evaluation of coping behaviors through cognitive and emotional processes, respectively.

Literature Search and Selection Approach

Relevant studies were identified through targeted searches of PubMed and Google Scholar using keywords such as “pain beliefs”, “pain catastrophizing”, “fear-avoidance”, “self-efficacy”, and “coping strategies.” The search was conducted through December 2025. Articles were selected based on relevance to the conceptual focus of the review, with emphasis on studies examining cognitive and psychosocial influences on pain outcomes. Additional references were identified through citation tracking. Contextual factors, including age, socioeconomic status, health literacy, and cultural influences, are addressed in dedicated sections of the review, as these variables are not consistently reported across all studies. This approach was designed to provide a focused, concept-driven synthesis of key themes related to pain beliefs and coping.

Neurobiological Basis for Pain Beliefs

To better understand the processes shaping the complexity of an individual’s pain experience, it is important to consider the pathways linking pain beliefs to nociceptive processing. Pain signaling involves four key processes: transduction, transmission, modulation, and perception. Nociceptors, or specialized pain receptors, detect harmful stimuli such as extreme temperatures, pressure, or noxious chemicals. Distinct nociceptor subtypes respond to specific stimuli; for example, chemical nociceptors are activated by inflammatory mediators during inflammatory pain states. During transduction, these stimuli are converted into electrical signals that are conveyed to higher centers via afferent neurons (transmission). These neurons, primarily A-delta and C fibers, travel along organized pathways within the spinal and supraspinal systems, with the spinothalamic tract serving as the principal ascending route. Ascending signals are relayed through the thalamus (Th) to the primary (S1) and secondary (S2) somatosensory cortices. Modulation, referring to alterations of these signals, largely occurs at the spinal level through interneurons and the brainstem, such as the periaqueductal gray (PAG) and rostral ventromedial medulla (RVM). These centers generate descending modulatory circuits that can amplify or suppress nociceptive transmission, enabling adaptive regulation of pain. Ultimately, this integrated processing culminates in cortical networks supporting the conscious perception of pain (Figure 2).

Figure 2 Primary Spinal and Supraspinal Pathways for Pain Transmission and Modulation. Pain pathways and modulatory circuits illustrated are synthesized from foundational and contemporary literature on nociceptive transmission, affective–cognitive processing, and descending modulation of pain.^23–29

Abbreviations: ACC, anterior cingulate cortex; AIC, anterior insular cortex; Amy, amygdala; HPC, hippocampus; NAc, nucleus accumbens; OFC, orbitofrontal cortex; PAG, periaqueductal gray; PCC, posterior cingulate cortex; PCu, precuneus; PFC, prefrontal cortex; RVM, rostral ventromedial medulla; S1, primary somatosensory cortex; S2, secondary somatosensory cortex; SG, substantia gelatinosa; Th, thalamus; VTA, ventral tegmental area.

Pain beliefs shape our responses to pain through top-down regulation of supraspinal networks and descending modulatory systems. These processes reflect coordinated activity across distributed neural networks rather than isolated brain regions, with pain emerging from dynamic interactions among cognitive, affective, sensory, and motivational systems. Importantly, these same beliefs and coping strategies also drive the remodeling of those networks over time. Negative pain-related beliefs, particularly pain catastrophizing, are associated with heightened pain perception and increased activity in areas of the prefrontal cortices (PFCs) involved in cognitive and emotional processing and decision-making. These include the ventromedial prefrontal cortex (vmPFC), dorsolateral prefrontal cortex (dlPFC), and orbitofrontal cortex (OFC).^23,24 Functionally, the vmPFC and OFC contribute to appraisal and valuation of stimuli, while the dlPFC has been attributed to regulating decision-making based on assigned emotional value.^30,31 Belief-driven processes also engage reward and motivational circuits, as implicated in involvement with the nucleus accumbens (NAc) and ventrotegmental area (VTA). Corticostriatal connectivity between the NAc and PFC predicts the transition from subacute to chronic pain, linking expectation and valuation processes to pain persistence and affective modulation.^25,32 Similarly, fear-avoidance beliefs reinforce hypervigilance and behavioral disengagement, increasing disability and promoting chronicity within a cognitive-behavioral framework involving the anterior cingulate cortex (ACC).^26,33 Expectancy further shapes conditioned pain modulation, demonstrating that beliefs recalibrate the modulatory system itself through the amygdala, ACC, dlPFC, and PAG.²⁷

In contrast, positive pain beliefs are associated with reduced pain perception and are frequently examined within the context of expectancy and placebo-related mechanisms. The vmPFC plays a central role in how one assigns value to stimuli, a function closely tied to perceived control and expectations surrounding pain.^34,35 Control-based reappraisal of pain appears anatomically specific, as activation of the right, but not left, ventrolateral prefrontal cortex (vlPFC) has been observed during such processes.³⁶ Expectancy and cognitive reappraisal recruit prefrontal-cingulo-insular circuits that engage the PAG and brainstem, resulting in inhibition of nociceptive processing and reductions in reported pain.²⁸ Social and contextual influences further shape positive expectancy formation and adaptive coping through engagement of regions such as the posterior cingulate cortex (PCC) and precuneus (PCu), dlPFC, vmPFC, and insula.³⁷

Coping strategies that operationalize positive beliefs are linked with experience-dependent neural plasticity. CBT for chronic pain has been associated with increased gray matter in prefrontal and somatosensory regions, alongside reductions in catastrophizing linked to dlPFC alterations. The same study reports mindfulness and cognitive self-regulation reduce pain via prefrontal and ACC–insula systems while attenuating primary somatosensory responses.²⁹ Control beliefs and self-efficacy engage valuation and control hubs (vmPFC, OFC, ventral striatum), mechanisms that support down-regulation of pain and resilience.³⁸ Although substantial overlap exists among neural circuits involved in pain regardless of belief valence, evidence suggests that amygdala–ACC connectivity preferentially underlies negative pain expectations, whereas OFC–hippocampal connectivity supports positive expectancy and contextual learning.³⁹ Together, these findings support a network-based understanding of pain in which beliefs and coping strategies dynamically shape interactions among prefrontal, limbic, striatal, and brain-stem systems, biasing prediction, valuation, and modulation of nociceptive input. Within this framework, pain is not solely the product of ascending sensory signals, but an emergent experience arising from flexible, experience-dependent neural networks that integrate expectation, emotion, and context.

Types of Pain and Pain Beliefs and Coping Strategies

Pain, though a universal experience, can be classified into three primary categories: neuropathic, nociplastic, and nociceptive. These categories reflect distinct mechanisms of pain generation and modulation, underscoring the importance of examining how pain beliefs and coping strategies interact across pain types to shape patient experiences and outcomes. Although disentangling pain etiology from associated beliefs remains challenging, this review identifies common beliefs and coping patterns across some of the most frequently studied pain conditions.

Neuropathic Pain

Neuropathic pain is defined as pain caused by a disease or lesion affecting the somatosensory nervous system and may be classified as central or peripheral.⁴⁰ The peripheral neuropathic pain conditions discussed here are painful diabetic neuropathy, HIV-related neuropathy, and post-herpetic neuralgia, whereas central neuropathic pain conditions include multiple sclerosis and central poststroke pain. Although not exhaustive, these conditions illustrate the clinical diversity of neuropathic pain, across which patient pain beliefs and coping strategies play a critical role in shaping outcomes.⁴¹

Diabetic Neuropathy

The most common type of neuropathic pain, diabetic neuropathy, is a prominent peripheral disorder that affects both sensory and autonomic fibers. Higher self-efficacy and more positive expectations correlate with better functional outcomes, whereas depression and anxiety are linked to decreased adherence and sustained disability.^42–44 Interventions that target patient beliefs, provide education, and encourage social support have been shown to enhance adherence and reduce diabetic neuropathy-related disability.^44–46

Post-Infectious Neuropathies

Postherpetic neuralgia is characterized by persistent shooting or burning pains following herpes zoster infection, with negative pain beliefs associated with greater pain intensity and disability.^47,48 Psychological factors, particularly maladaptive cognitions, predict symptom severity and poorer outcomes.^49,50 Addressing these pain beliefs through patient education, cognitive-behavioral strategies, and various coping strategies has been associated with meaningful improvements in therapeutic adherence and long-term outcomes.⁵¹

Similarly, human immunodeficiency virus (HIV)-related neuropathy commonly manifests as distal sensory neuropathy resulting from small-fiber demyelination.^52,53 Individuals with HIV-related pain often report lower self-efficacy, reduced health-related quality of life, and greater depressive symptoms compared to those without pain.^54,55 Depression shows one of the strongest associations with neuropathic pain severity in this population, highlighting the reciprocal relationship between mood, pain beliefs, and pain outcomes.⁵⁶ Although psychological management of HIV-related neuropathy remains an active area of investigation, existing research is limited in scope.^57,58

Multiple Sclerosis

Multiple sclerosis (MS) is a common cause of central neuropathic pain, with pain intensity and functional impairment strongly influenced by self-efficacy and coping capacity.^59,60 Studies have reported that high self-efficacy and adaptive coping mechanisms are associated with lower pain severity and better long-term outcomes.^60,61 In contrast, negative pain beliefs are linked to pain exacerbation and disability in MS patients.^62,63 Cognitive behavioral therapy has been beneficial in improving beliefs surrounding MS pain, which improves long-term outcomes.^64,65

Central Poststroke Pain

Central poststroke pain arises from damage to central sensory pathways and significantly interferes with recovery following stroke.⁶⁶ Patients with lower self-efficacy, maladaptive coping strategies, beliefs in pain permanence, and higher levels of psychological distress experience more severe pain, and prolonged disability and recovery.^66–68 Coexisting anxiety, depression, and fatigue have been shown to heighten pain and diminish quality of life.⁶⁹ In contrast, higher self-efficacy and strong social support are associated with better coping, functional recovery, and improved quality of life.^70–73

Nociplastic Pain

Nociplastic pain encompasses a group of conditions characterized by altered central pain processing in the absence of identifiable tissue damage or neural lesions. Common examples include fibromyalgia, chronic tension-type headaches and migraines, temporomandibular disorders, irritable bowel syndrome, and related functional pain conditions.^74,75 These conditions share altered pain modulation, heightened sensory gain, and strong associations with psychological stress, catastrophizing, and impaired self-efficacy, despite the absence of identifiable tissue damage or neural lesions.

Fibromyalgia

Fibromyalgia is a chronic pain condition marked by widespread pain, tenderness, fatigue, and sleep disturbances, and is now widely recognized as a disorder of central sensitization or pain amplification.^76,77 Although its precise pathophysiology is not completely understood, alterations in neurochemical systems, including substance P, cortisol, serotonin, and growth hormone, have been implicated, with cortisol and serotonin dysregulation contributing to the high prevalence of anxiety and depression observed in this population.⁷⁸ Chronic C-fiber stimulation has also been proposed as a contributing mechanism by producing central nervous system adaptations, such as diminished opioid and GABAergic inhibitory responses, ultimately resulting in heightened pain sensitivity.⁷⁹

Pharmacologic treatments such as pain medication, antidepressants, and gabapentinoids have offered limited relief, prompting increased focus on psychological and behavioral contributors to fibromyalgia.⁵³ Pain beliefs play a critical role in shaping patient experiences and behaviors. Lower self-efficacy, particularly regarding physical activity, is associated with reduced activity levels and increased avoidance behaviors.⁸⁰ Pain catastrophizing not only predicts the severity of fibromyalgia-related pain, but also mediates the relationship between pain self-efficacy and disease severity, suggesting that improving self-efficacy could reduce symptom burden.⁸¹ Chronic pain may further reinforce hopelessness and pain catastrophizing, perpetuating maladaptive coping cycles and worsening outcomes.⁸² CBT may interrupt these cycles by promoting adaptive coping mechanisms, reframing negative thought patterns, and ultimately improving both physical and psychological functioning in fibromyalgia patients.⁸³

Headaches and Migraines

Some of the most prevalent nociplastic syndromes manifest as chronic tension-type headaches and migraines, both of which are increasingly understood through the lens of central sensitization dysregulation and altered pain modulation. Despite differences in symptom presentation and underlying pathophysiology, consistent patterns emerge in how pain beliefs and coping strategies relate to outcomes across these conditions.⁸⁴ Pain catastrophizing, fear of pain recurrence or disability, and reduced self-efficacy are associated with increased headache- and migraine-related disability, greater health care needs, and poorer quality of life.^85–87 Conversely, stronger internal and external locus of control are positively correlated with migraine-related quality of life and psychological states.^88,89 Individuals with higher confidence in their ability to manage headache symptoms are less likely to engage in activity avoidance or rely excessively on pharmacologic treatments and other maladaptive coping strategies, which may further perpetuate symptom chronicity.^90,91 Notably, expectations regarding headache and migraine triggers appear to be largely shaped by individual beliefs rather than consistent diagnostic or environmental factors.⁹² Additionally, interventions that target pain beliefs, such as CBT, stress management, and biofeedback, are shown to substantially reduce headache frequency and severity both alone and in combination with pharmacologic treatments.^93–96

Nociceptive Pain

Nociceptive pain is classically associated with acute tissue injury; however, prolonged or repeated nociceptive input can induce neuroplastic changes that promote central sensitization and persistent pain beyond expected tissue healing. This transition from acute to chronic pain is strongly influenced by psychological factors, including fear-avoidance beliefs, pain catastrophizing, and perceived lack of control, which amplify pain perception and reinforce maladaptive behaviors. Consequently, chronic nociceptive pain often reflects the interplay between ongoing peripheral input and centrally mediated cognitive-affective processes, blurring distinctions between nociceptive and nociplastic mechanisms.

Chronic Musculoskeletal Pain

Chronic musculoskeletal pain (CMSP) is defined as persistent pain or recurrent pain affecting joints, tendons, muscles, and bones for three months or longer, and is best understood within a biopsychosocial framework where psychological and social factors interact with biological processes to drive disability and heightened pain severity.^97,98 Common causes of CMSP include arthritis, connective tissue disorders, gout, myopathies, bone conditions, and regional pain syndromes.^99,100 CMSP also often exhibits features of central sensitization and nociplastic pain, particularly following injury, where altered pain processing contributes to symptom persistence.¹⁰¹ Although maladaptive coping strategies such as catastrophizing exacerbate pain and disability, structured pain education and cognitive-behavioral approaches have been shown to reduce symptom burden.^26,102

Pain beliefs play a central role in the development and persistence of CMSP. Among individuals with low back pain, outcomes are strongly influenced by perceptions of control, illness identity, and pain self-efficacy, while fear-avoidance beliefs and kinesiophobia are consistently associated with greater pain intensity, disability, and reduced occupational functioning.^103–106 Conversely, higher expectations of recovery and self-efficacy predict lower pain and disability over time.¹⁰⁵ Patients who focus primarily on mechanical explanations for pain, such as posture, while neglecting psychosocial contributors, may develop hypervigilance and avoidance behaviors that worsen prognosis and treatment adherence.¹⁰⁷ Similarly, minimizing the emotional dimensions of pain is associated with reduced engagement in self-management strategies.¹⁰⁸ Cultural differences also shape coping strategies in CMSP, with African-American patients more likely to use emotion-focused strategies and report lower self-efficacy compared to Caucasian patients.¹⁰⁹

Effective management of CMSP emphasizes personalized, multimodal care that addresses the whole person.⁹⁹ Maladaptive coping strategies are associated with rumination of symptoms, whereas CBT promoting adaptive coping is linked to reductions in pain severity, catastrophizing, fear, and avoidance.¹¹⁰ Even brief fear-avoidance–focused interventions combining education, graded activity, and feedback have demonstrated improvements in mobility and reductions in fear-related behaviors in chronic low back pain.¹¹¹ As such, current guidelines from the American Psychological Association recommend treating CMSP with nonpharmacological interventions, such as exercise, CBT, physical therapy, and education as first-line treatments.¹¹² Integrating psychological support, supervised physical activity, education, and social support is essential for improving long-term outcomes and quality of life in this population.¹¹³

Perioperative and Postoperative Pain

Surgical care presents a unique model for investigating pain trajectories, as routine follow-up enables repeated assessment of pain beliefs and observation of pain chronification. Postoperative pain is temporally dynamic and shaped by interacting biological and psychosocial factors. While acute postoperative pain largely reflects nociceptive input from the surgical site, chronic post-surgical pain may arise from persistent inflammatory processes, nerve injury, and cognitive–affective influences.¹¹⁴

Negative pain beliefs predict poorer post-surgical outcomes. For instance, those with greater fear of pain and consequent avoidance of physical activity after rotator cuff repair reported worse pain and functionality at follow-up.¹¹⁵ Similarly, kinesiophobia and pain catastrophizing predicted poorer recovery and may reflect more complex injuries, such as an additional muscle tear.^116,117 Long-term effects are also evident, as those with higher pain catastrophizing scores have low-grade inflammation present five years after total knee arthroplasty.¹¹⁸ Across surgical populations, catastrophizing, anxiety, depression, and rumination are associated with worse pain, reduced function, and increased risk of postoperative complications such as infection and revision surgery.^119–121 These findings have been replicated across shoulder, hip, and knee arthroplasty, where preoperative anxiety and pain catastrophizing are significant risk factors for postoperative pain.¹²²

Conversely, positive pain beliefs are associated with improved post-surgical outcomes. Higher self-efficacy and stronger locus of control predict improvements in postoperative quality of life, functional recovery, and return to normal activity.^123–125 Resilience, which reflects a patient’s ability to tolerate their pain and maintain control over it, is also linked to better postoperative knee function.^126,127 Optimism regarding pain resolution similarly predicts better outcomes following rotator cuff repair.¹²⁸

Across pain types, consistent patterns emerge in which maladaptive pain beliefs bias coping strategies toward avoidance and disengagement, whereas adaptive beliefs support engagement, flexibility, and recovery, reinforcing the view that pain outcomes are shaped less by etiology alone than by belief-driven behavioral and neural responses.

Treatment Adherence

As discussed thus far, pain-related beliefs are closely tied to subsequent behaviors and clinical outcomes. Similarly, these same beliefs play a central role as to whether one persists with recommended therapies, behavioral changes, and treatments. Adherence is shaped by psychological factors that overlap with pain beliefs, such as self-efficacy, catastrophizing, perceived control, and treatment effectiveness. The following section examines how these factors interact to support or undermine adherence across various pharmacological and nonpharmacological pain management approaches.

Pharmacological Adherence

Patients’ beliefs about their pain and its treatment can influence psychological, physical, and pharmacological outcomes. In postoperative settings, greater distress tolerance has been associated with lower morphine consumption following laparoscopy, whereas higher pain catastrophizing is linked to increased opioid use.¹²⁹ Importantly, patterns of opioid use and adherence are not inherently beneficial or harmful, but are highly dependent on individual pain severity, treatment goals, risk profiles, and clinical context. Higher self-efficacy has been associated with greater consistency in following prescribed opioid regimens; however, individuals reporting more severe pain may demonstrate increased medication use as an attempt to maintain function and symptom control rather than as an indicator of optimal pain management. Conversely, negative beliefs about opioids, such as fears of addiction, are associated with poorer adherence to prescribed dosing schedules, underscoring the need for clear patient-provider communication that addresses concerns, aligns expectations, and supports informed, individualized decision-making regarding opioid use.¹³⁰

Pain-related beliefs also shape medication adherence in chronic disease populations. Among individuals with HIV/Acquired Immunodeficiency Syndrome (AIDS) experiencing neuropathic pain, pain catastrophizing is strongly associated with pain severity and disability; however, neither catastrophizing nor depressive symptoms independently predict medication nonadherence.¹³¹ In contrast, HIV/AIDS patients reporting pain are less likely to adhere to antiretroviral therapy than those without pain, a relationship that may be bidirectional, as poor adherence can worsen pain through increased viral load. Importantly, adherence self-efficacy partially mediates the relationship between pain and antiretroviral adherence, whereas depression severity does not, highlighting the central role of perceived control in adherence behaviors.⁵⁴

In other chronic pain conditions, adherence is influenced more by beliefs about treatment effectiveness and disease mechanisms than by pain severity alone. Patients with psoriatic arthritis or axial spondyloarthritis who discontinued medication therapy demonstrate greater catastrophizing and higher pain levels, suggesting that perceived treatment inefficacy may contribute to nonadherence.¹³² Conversely, in fibromyalgia, medication adherence is higher among individuals reporting greater affective pain, potentially reflecting differences in treatment targets and patient expectations.¹³³ In inflammatory arthropathies, persistent pain despite disease-modifying therapy may lead patients to disengage from treatment when perceived benefits are limited. In contrast, fibromyalgia treatments often target centralized pain processing and psychological distress, and adherence is highest among patients prescribed antidepressants rather than anticonvulsants, suggesting that addressing mood symptoms may play a particularly important role in supporting adherence in this population.¹³⁴

Non-Pharmacological Adherence

Adherence to non-pharmacological pain interventions is also subject to influence by patient beliefs. Exercise therapy, a first-line intervention for CMSP, demonstrates moderate evidence for reducing pain and improving function compared to no intervention or usual medical care. Programs that are individualized and supervised demonstrate higher adherence and better patient outcomes than generalized approaches.^135,136 In fibromyalgia, self-efficacy and perceived effectiveness of exercise strongly predict adherence over extended periods, whereas pain catastrophizing and depression are associated with poorer adherence and diminished maintenance of treatment gains.^137–139 Despite awareness of exercise benefits, adults with chronic pain report greater barriers to participation, such as pain, fatigue, fear of injury, and comorbidities, compared to those without pain.^{137,140–142}

Mind-body therapies similarly demonstrate belief-dependent adherence patterns. Adherence to yoga is influenced by depressive symptoms, whereas adherence to acupuncture is more closely tied to belief in its efficacy.^143,144 Yoga has demonstrated modest improvements in pain and function with relatively low adverse event rates compared to other exercise modalities.^145–147 Patient preference further shapes adherence, as mind-body practices such as yoga, tai chi, and Pilates may differentially influence psychosocial factors and quality of life.¹⁴⁸

Manual therapies and physical rehabilitation also rely on belief-driven adherence mechanisms. Engagement with physical therapy is higher among individuals reporting greater self-efficacy and perceived benefit, particularly when combined with supportive therapeutic relationships.^149–151 Across home-based and supervised rehabilitation programs, self-efficacy, motivation, intention to engage, prior adherence, and social support consistently predict treatment compliance.^152,153 These findings highlight the importance of reinforcing adaptive beliefs and addressing fear-avoidance during rehabilitation. Although direct measures of pain beliefs in osteopathic manipulative treatment (OMT) studies are limited, clinical research demonstrates that OMT is associated with reductions in pain, anxiety, and sleep disturbance in chronic low back pain, and pain relief in geriatric oncology and other populations.^154,155 These contextual effects mirror findings from the broader manual therapy literature, where patient expectations, mood, and adjunct psychosocial elements enhance treatment outcomes, implicating belief-related mechanisms in engagement and coping with hands-on interventions.¹⁵⁶ In some OMT research, treatment credibility and expectancy have been considered explicitly, reflecting the importance of belief constructs in interpreting clinical responses.¹⁵⁷

A personalized, multidisciplinary approach that targets unhelpful pain beliefs and behaviors is increasingly being suggested to improve treatment adherence and more effectively manage chronic pain.^148,158,159 Multidisciplinary rehabilitation, such as coordinated programs integrating physical and psychological components delivered by professionals across specialties, has demonstrated small but significant benefits in pain and disability compared with usual medical care. The American Psychological Association and the American Academy of Pain Medicine recommend multidisciplinary care, given its ability to address biological, psychological, and social aspects of pain, with improvements most notable in the long term.^{112,160–162} Older adults’ willingness to engage in such programs is also shaped by beliefs, with negative or fatalistic views reducing adherence.¹⁶³

Importantly, psychological constructs can be leveraged to improve adherence. Reducing catastrophizing and fear-avoidance and enhancing self-efficacy through multidisciplinary approaches may reduce disability more effectively than pain relief alone.^164,165 Thus, a low baseline self-efficacy with high pain catastrophizing predicts greater disability and pain six months after treatment, further emphasizing the importance of early intervention.¹³³ Setting realistic, patient-driven goals increases adherence.¹⁶⁶ Structured strategies such as CBT, reminders, and booster sessions also improve long-term compliance.¹⁶⁷ Nevertheless, adherence rates remain suboptimal, suggesting that targeting belief systems and coping strategies may ultimately prove effective.^168–170

Social and Demographic Determinants

Consistent with the CSM, pain beliefs and coping behaviors are shaped not only by symptom experiences but also by broader social context. While not exhaustive, this section summarizes how factors such as race and ethnicity, age, sex/gender-related factors, socioeconomic status, education/health literacy, and faith traditions influence pain beliefs, coping strategies, and downstream outcomes.

Race and Ethnicity

Race and ethnicity are associated with differences in reported pain intensity, pain-related interference, and coping patterns, reflecting an interaction between lived experience, healthcare access, structural factors, and cultural context. Hispanic Americans (HAs) and non-Hispanic Blacks (NHBs) report higher pain intensity and interference than non-Hispanic Whites (NHWs), with NHBs showing the greatest interference even after adjustment for sociodemographic and clinical factors.^171–173 Despite elevated pain severity, HAs often report fewer mobility and functional limitations and fewer missed work hours than NHBs, suggesting meaningful differences in coping styles, resources, and behavioral adaptation.^171,174,175

Coping tendencies also vary across groups. NHBs report lower perceived control over pain, greater reliance on coping strategies, stronger catastrophizing, and higher expectations of interpersonal interaction with others.^109,176,177 In addition, they more frequently use praying/hoping, distraction, and catastrophizing, whereas NHWs more often report ignoring pain and task persistence.^{176,178–180} HAs commonly report religious coping and at-home remedies such as teas, herbal products, and topical treatments.¹⁸¹ NHBs also show higher baseline catastrophizing and lower pain self-efficacy that may contribute to heightened pain sensitivity, whereas NHWs typically exhibit higher self-efficacy, a factor generally protective for pain outcomes.¹⁸² However, this protective effect appears diminished in NHBs.¹⁸³

Importantly, pain and physical functioning reflect the intersection of race/ethnicity with structural and clinical factors.¹⁷⁷ Provider misconceptions that lead to undertreatment, as well as limited insurance coverage restricting access to effective pain care, can heighten both pain severity and functional impairment.^{174,184–186} In addition, HAs may also experience a lack of Spanish-speaking physicians and difficulties with interpretation, which limit critical communication and increase distrust of the healthcare community.^187,188 These disparities contribute to the higher prevalence of anxiety among this population and subsequent avoidance of healthcare experiences and worse clinical outcomes.^189,190 Cultural beliefs and contextual factors, including norms surrounding health, activity, and body ideals, as well as structural barriers to access, shape pain-related beliefs and influence adherence to recommended pain treatments.^191–193 Given heterogeneity within and across groups, culturally responsive assessment and communication remain essential for optimal care.^194,195

Age

The literature identified in this review primarily reflects adult populations; however, available evidence suggests meaningful differences in pain beliefs and coping across adulthood. Chronic pain is highly prevalent in older adults and contributes to considerable suffering and disability.^196,197 For instance, older patients are more likely to have severe and disabling low back pain than younger individuals with back pain.¹⁹⁸ However, older adults tend to report less pain-related suffering and greater perceived control over their pain than middle-aged or younger adults.¹⁹⁹ They also demonstrate lower levels of pain catastrophizing and depression, with higher levels of pain self-efficacy and pain acceptance compared to these younger age groups.²⁰⁰ These patterns may stem from the association between aging and psychological resiliency and accumulated coping experience.²⁰¹ Similarly, pain-related beliefs play an important role in functioning in youth with physical disabilities, with stronger emotion-related pain beliefs linked to poorer physical and psychosocial outcomes. Interventions in younger individuals that target maladaptive beliefs, enhance perceived pain control, and build skills for managing the emotional impact on pain can improve quality of life.²⁰²

Older adults may also possess a stronger belief in their ability to cope with pain and pain-related disability because they face fewer work and family responsibilities than middle-aged and younger adults.²⁰³ In older adulthood, beliefs that chronic pain is a “normal” part of aging may promote acceptance and reduce emotional distress.^200,204,205 However, the development of a belief regarding the normality of pain with aging can lead to entrenched pain beliefs that result in ineffective pain management and greater cognitive decline.^196,204 Clinicians can respond to this and leverage positive control beliefs to increase compliance with therapeutics and physical therapy in elderly patients.^200,206,207

Sexes and Genders

Differences in pain perception and coping have been reported across sex- and gender-based categories in the literature. Biological sex (eg male, female) and gender (eg men, women) represent distinct but related constructs, with sex referring to biological classification and gender reflecting social and cultural roles and expectations. Sex-based differences have been observed, with female patients often reporting more intense pain, longer and more frequent episodes of pain, and lower pain tolerance than their male counterparts, patterns that may contribute to greater use of catastrophizing in some samples.^172,208,209 At the group level, female-classified participants more frequently report emotion-focused coping strategies, including seeking social support and internalizing or catastrophizing pain, whereas male-classified participants more often report behavioral distraction or problem-focused coping.²¹⁰ Perhaps because of this, men were found to have higher self-efficacy, while women had more robust emotional and social support.²¹¹ These differences are commonly interpreted in relation to gendered social expectations, including pressures for men to minimize pain expression.^210,212 Women seek medical care for pain more frequently; however, they continue to experience inequitable assessment and management.²¹³ Sex and gender-based stereotypes may lead providers to attribute pain to psychosomatic causes,^214,215 resulting in underestimation of pain severity, reduced likelihood of receiving analgesics despite comparable pain scores, and greater prescription of psychotropic medications.^216–220 Sociodemographic factors such as lower educational attainment, shift work, low baseline fitness, and physical activity-related limitations have been associated with lower adherence among female healthcare workers.²²¹ However, overall adherence rates appear similar across gender categories, with time constraints and health-related barriers commonly reported across groups.²²² Collectively, these patterns highlight how pain beliefs, coping strategies, and healthcare interactions jointly contribute to observed differences in pain outcomes across sex- and gender- based groups.

Socioeconomic Status

Individuals with disadvantageous early life conditions, such as low socioeconomic status (SES), are at risk for increased pain catastrophizing, higher perceived sensitivity to pain, and higher levels of pain-related fear.^223,224 These findings suggest that without consistent access to basic needs, individuals become predisposed to increased pain sensitivity and intensify affective and fear-related processing of pain. Individuals with a higher income also can be more self-efficacious in seeking and receiving care as they do not suffer from difficulties accessing or affording care that those with a lower socioeconomic status might. Indeed, high-income individuals with chronic back pain were more likely to score higher on surveys assessing both their self-efficacy and ability to cope, suggesting that monetary stability correlates with the perception of being able to manage pain.²²⁵ Similarly, higher SES was also associated with lower pain scores, higher function, and less pain catastrophizing after post-total knee arthroplasty.²²⁶ Socioeconomic disadvantage has emerged as a consistent contributor to heightened pain burden and functional impairment, in part through its influence on pain-related beliefs, perceived control, and access to effective coping resources.^174,175,178

Education and Health Literacy

Health literacy is associated with lower pain intensity and greater perceived pain control.²²⁷ Individuals with higher health literacy may better interpret pain-related information, communicate effectively with healthcare providers, and engage in self-management behaviors that promote functional improvement. Several studies emphasize the importance of health literacy for designing effective patient education interventions and supporting sustainable self-management strategies for individuals with chronic pain.^228,229 Enhanced health literacy can lead to more positive pain beliefs, reduced fear-avoidance behaviors, and improved adherence to multidisciplinary treatment plans.²³⁰ Accordingly, health literacy is an important target within integrated care models and supports patient empowerment, shared decision-making, and quality of life.²³¹

Faith Traditions and Spiritual Practices

Spiritual and religious coping may influence pain beliefs and perceived pain control for some individuals, including the use of prayer and other meaning-based coping strategies.^8,232 In burn care, spiritual care interventions have been associated with reduced pain intensity during dressing changes, suggesting that addressing spiritual needs may affect pain experiences in severe acute pain contexts.²³³ In perioperative settings, intrinsic coping (eg, self-distraction) and extrinsic support (including religious-based coping and emotional support) have been associated with lower pain and reduced morphine consumption in women undergoing major gynecologic surgery.²³⁴ Evidence from chronic musculoskeletal pain populations suggests that religiosity and spiritual beliefs may be associated with aspects of pain-related emotion, beliefs, and coping, but the existing literature is limited and inconsistent, indicating the need for further research to clarify these relationships.²³⁵

These findings collectively highlight how contextual factors systematically shape pain interpretation and the coping strategies individuals employ. Across populations, these influences contribute to consistent patterns in belief formation and behavioral response, which, in turn, help explain variability in treatment engagement and clinical outcomes. Importantly, these factors often interact rather than act independently, reinforcing the need to consider patients within their broader social and environmental contexts when evaluating pain beliefs and designing interventions.

Clinical Tools and Gaps in Quality of Care

Throughout this review, pain beliefs have been framed as central determinants of pain-related behavior, coping, and outcomes, consistent with the CSM. Within this framework, individuals’ representations of pain, including beliefs about its cause, controllability, consequences, and duration, guide coping behaviors and influence recovery trajectories. Despite this, clinical assessment tools and care pathways continue to emphasize pain intensity and functional outcomes while underrepresenting the belief systems that drive these processes.

One effort to standardize pain assessment is the American Pain Society Outcome Questionnaire–Revised (APS-POQ-R), which evaluates activity, emotional distress, pain severity, satisfaction, and safety.²³⁶ While such tools provide useful information regarding pain impact, they do not assess the cognitive representations or coping appraisals that the CSM identifies as central drivers of behavior. Moreover, quantitative pain ratings have inherent limitations. For example, it has been demonstrated that patients often incorporate non-pain sensations into ratings and approach pain scoring as a comparative rather than linear task, raising concerns about the validity of numeric pain scales as stand-alone measures of pain experience.²³⁷

Several instruments have attempted to address components of pain beliefs (Table 1). The Pain Self-Efficacy Questionnaire, for instance, demonstrates excellent validity, reliability, and responsiveness, though it has primarily been evaluated in individuals with chronic back pain. To expand its utility, it should be validated across broader populations.²³⁸ Even when belief-focused instruments are used, they tend to isolate single constructs, such as self-efficacy, rather than capturing the multidimensional illness representations described by the CSM. As a result, commonly used assessment batteries provide an incomplete picture of how patients understand and respond to their pain.

Table 1 Validated Instruments for Quantifying Pain Beliefs and Coping Strategies

This gap extends to pain treatment research and clinical practice. Many studies employ psychological and non-pharmacological interventions, such as CBT, eye movement desensitization and reprocessing, exercise-based self-management, and mindfulness-based approaches, without routinely measuring changes in pain beliefs or coping strategies that are presumed to mediate treatment effects.^74,274 Consequently, improvements in pain or function are often reported without clarity regarding which belief-driven mechanisms contributed to these outcomes, limiting both mechanistic understanding and treatment personalization.

Clinical frameworks for integrated pain management emphasize the importance of assessing pain-related beliefs, coping strategies, expectations, and emotional responses alongside symptom severity; however, these domains remain inconsistently measured in routine practice.²⁷⁵ Recent shifts toward multidisciplinary pain management align more closely with the CSM by addressing biological, psychological, and social contributors to pain simultaneously. Such models may promote adaptive illness representations, greater perceived control, and engagement in active coping, and have demonstrated benefits compared with opioid-centered approaches,¹³⁰ underscoring the limitations of treatment models that do not adequately address belief-driven contributors to pain and recovery. Although harm-reduction strategies such as naloxone distribution have reduced mortality,²⁷⁶ persistent pain-related disability highlights the need for assessment and treatment frameworks that systematically integrate pain beliefs and coping processes into routine care.²⁷⁷

Discussion

This narrative review highlights the central role of pain beliefs and coping strategies in shaping how individuals experience, interpret, and manage pain across conditions. Negative pain beliefs, including catastrophizing, fear-related expectations, and low self-efficacy, are consistently associated with poorer outcomes, such as greater pain severity, increased analgesic use, reduced functional recovery, and lower adherence to treatment. In contrast, positive pain beliefs, such as stronger self-efficacy, perceived control, and optimism regarding recovery, are associated with greater resilience, engagement in care, and more favorable recovery trajectories. These findings reinforce that pain is not solely a sensory or physiological phenomenon, but one shaped by cognitive and emotional processes that meaningfully influence recovery.

These observations align closely with the CSM, which posits that individuals’ representations of illness, including beliefs about cause, duration, controllability, and consequences, guide subsequent coping behaviors and health outcomes. Contemporary extensions of the CSM further emphasize the influence of contextual and sociocultural factors, including social support, cultural norms, and belief systems such as spirituality, in shaping illness representations. This expanded framework offers a more integrative understanding of pain, moving beyond a narrow biomedical or traditional biopsychosocial approach to account for how meaning-making and context influence coping responses and outcomes. Importantly, the findings synthesized in this review suggest that these contextual influences are not secondary modifiers, but central drivers in the formation and reinforcement of pain beliefs. Across populations, factors such as socioeconomic conditions, cultural expectations, and access to care shape perceptions of control, anticipated outcomes, and engagement with treatment, thereby contributing to variability in coping behaviors and recovery trajectories. Recognizing these influences within a unified conceptual framework may help to explain why similar pain conditions may result in markedly different experiences and outcomes across individuals. As such, integrating contextual factors into both assessment and intervention is essential for advancing more personalized, equitable, and effective approaches to pain management.

From a clinical perspective, interventions that target negative pain beliefs and promote positive pain beliefs, particularly cognitive-behavioral therapies and structured pain education, have demonstrated effectiveness in reducing suffering, enhancing self-efficacy, and supporting adaptive coping strategies. Multidisciplinary pain management programs that integrate psychological, physical, and educational components are especially well-suited to address belief-driven mechanisms underlying pain-related behavior. However, despite these advances, substantial gaps remain in clinical implementation, particularly in addressing disparities related to race, socioeconomic status, and cultural background. In addition, individuals with rare or under-recognized conditions may experience unique and underexplored challenges related to pain beliefs and coping. Diagnostic uncertainty, limited access to disease-specific information, and fragmented care may contribute to more negative illness perceptions and reduced perceived control.²⁷⁸ These factors may increase psychological distress and reinforce maladaptive beliefs, including feelings of helplessness commonly associated with pain catastrophizing.²⁷⁹ Evidence from such complex conditions suggests that belief patterns are associated with poorer coping and reduced quality of life, highlighting the potential importance of belief-informed approaches in these populations. Addressing these gaps will require larger, longitudinal studies that explicitly examine how belief-focused interventions influence coping and outcomes across diverse populations.

The literature demonstrates contradictions in the relationship between pain beliefs and outcomes, highlighting important limitations related to measurement context and timing. One study reports no association between pain beliefs and postoperative outcomes following total knee or hip arthroplasty,²²⁴ while others using similar belief measures identify predictive relationships in spinal surgery populations.²⁸⁰ Likewise, pain catastrophizing has not consistently predicted outcomes after foot and ankle surgery, while other negative pain beliefs, such as magnification and helplessness, have shown associations with postoperative outcomes at three months.²⁸¹ Evidence suggests that timing of assessment may partially account for these discrepancies, as preoperative catastrophizing does not reliably predict outcomes following anterior cruciate ligament reconstruction, whereas catastrophizing assessed during recovery more closely reflects concurrent pain and function.²⁸² Despite these inconsistencies, the findings discussed extensively throughout this review strongly support the value of psychological, educational, and social interventions in modifying negative pain beliefs, strengthening positive pain beliefs, and promoting adaptive coping strategies that improve adherence and functional outcomes. The biopsychosocial model, when operationalized through belief-informed assessment and intervention, remains an effective framework for reducing disability and improving quality of life in individuals with pain.

While the discussed psychosocial and belief-informed interventions demonstrate promise, the degree of their impact has been variable across studies, with some evidence suggesting modest effect sizes depending on the clinical context and timing of intervention. Additionally, implementation at scale presents practical challenges, including limited access to trained providers, variability in healthcare infrastructure, and associated costs. Reliance on self-reported measures also introduces limitations, including response bias and variability in interpretation, while repeated assessment may contribute to survey fatigue and reduced engagement over time. These factors may limit the feasibility of widespread adoption in certain settings. As such, although psychosocial factors are clearly associated with pain experience and outcomes, further work is needed to determine how best to integrate these approaches in a manner that is both effective and sustainable across diverse clinical environments.

Given these considerations, future research should prioritize the integration of belief-informed approaches into standard clinical pathways. First, early screening for negative pain beliefs during initial assessments may help identify individuals at risk for poor outcomes and facilitate timely intervention. Second, there is a need to develop and validate multidimensional assessment tools that capture illness representations consistent with the CSM, rather than relying on isolated constructs. Third, expanding multidisciplinary care models that integrate psychological, educational, and social components alongside biomedical treatment may more effectively address belief-driven mechanisms underlying pain-related behavior. Fourth, training clinicians to recognize and address belief-driven contributors to pain through communication and targeted intervention remains essential for improving patient engagement and treatment adherence. Finally, future work should more systematically incorporate contextual and sociocultural factors, such as socioeconomic status, health literacy, and cultural influences, into both research and clinical practice to better understand variability in outcomes and support more equitable care. By systematically incorporating pain beliefs and coping strategies into assessment and treatment, pain management can move toward more effective, individualized, and sustainable models of care that reduce reliance on opioids and promote long-term recovery.

Conclusion

Pain beliefs and coping strategies are central to how individuals experience, interpret, and respond to pain. Within the framework of the CSM, these pain beliefs are shaped by cognitive, emotional, and contextual inputs, guiding coping behaviors that ultimately influence health outcomes and subsequent belief updating. Across neuropathic, nociplastic, and nociceptive conditions, positive and negative pain beliefs shape recovery trajectories, psychological well-being, and healthcare decision-making, in part through their influence on adaptive and maladaptive coping behaviors. Future work should prioritize integrated pain assessments, early identification of negative pain beliefs, and clinician training focused on belief-informed communication and intervention. Embedding pain belief assessment within routine care may support more adaptive coping, improve adherence, and reduce suffering across diverse patient populations.

Generative Artificial Intelligence

ChatGPT v5.2 was used to review the manuscript after initial writing and literature search was completed by the authors. This was done to condense the paper and review interpretations made by the authors.

Acknowledgments

We would like to thank Mr. Hiram Rogers for contributing to the initial literature search for this project, as well as Drs. William G. Pearson Jr. and Jody Brewer for their helpful comments in the final stages of editing this review.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Funding

No external funding was provided for this project.

Disclosure

The authors report no conflicts of interest in this work.

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