Recent research in cognitive science suggests that emotions can affect the brain’s entropy levels, with positive emotions increasing entropy and negative emotions decreasing it [1,2]. According to this model, emotions serve as a way to process information, where positive emotions correspond to high energy states with high entropy that allows for openness to new information, future oriented behaviors and learning. In contrast, negative emotions are linked to low mental energy, low entropy, leading to dwelling on old memories and rigid thinking patterns.

When considering chronic pain patients, applying this model reveals that anxiety or distress can be interpreted as a low energy state that reinforces old memories and biased beliefs, consequently limiting opportunities for learning. On the other, positive emotions can induce a high entropy state in patients, allowing their mental energy to be directed towards forming new memories and meanings. This can initiate a self-expansion cycle, enhancing their capacity to interact with the world and increasing their degree of freedom (Fig. 1).

Figure 1. The effects of emotion on mental freedom. Positive emotions and meaning expand the freedom (top). Aggravation and anxiety waste time and energy, causing mental rigidity (bottom). (Deli E, Peters JF, Kisv´arday Z: The thermodynamics of cognition: a mathematical treatment. Computational and Structural Biotechnology Journal 2021; 19: 785–93. Copyright 2021 by Elsevier).

Introducing opportunities for new events that are relevant and meaningful for the patient can lead to positive emotional changes and shift them towards a high entropy state. This suggests that developing rational information to help patients make sense of their pain and offering fresh perspectives and learning opportunities can alleviate their distress and enable them to adapt more effectively to their environment.

John Vervaeke, a cognitive scientist, posits that confusion (con-‘fusion’) occurs when our biased interpretation is fused with an event [3]. This can result in self-destructive feedback loop, hindering our ability to better adapt to our environment [4]. In this sense, identifying events and the meaning assigned to them that may hinder a patient’s ability to adapt, and modifying that meaning to promote positive behavioral changes would be crucial for successful rehabilitation. This approach enables patients to develop insight, which is vital for their recovery [5]. To achieve this, a case formulation that can rationalize the chronic pain process for each individual patient would be beneficial, as it can offer a hypothetical framework that assists in comprehending their pain and devising a customized approach to manage it [6].

The cognitive behavioral model of chronic pain proposed by Sharp [7] includes the significance of cognitive appraisal in generation of pain experience. In this model, the pain experience, encompassing mood affect, physiological response, and hypervigilance, is influenced by cognitive appraisal, as well as direct effects stemming from iatrogenic and environmental factors (see Fig. 2A).

Figure 2. Cognitive behavioral model of chronic pain by Sharp [7] and modified version of the model using an event-meaning coupling (Sharp TJ. Chronic pain: (A) The reformulation of the cognitive-behavioural model. Behaviour Research and Therapy 2001; 39: 61–70. Copyright 2001 by Elsevier. (B) The modified chronic pain model that highlights event-meaning coupling and pain experience.

In my proposal, external events that affect appraisal can be classified as ‘event’ (‘Event’ box in Fig. 2B), while appraisals can be represented as a ‘meaning-making’ process (‘Meaning’ box in Fig. 2B). The coupling of events and associated meanings can illustrate how they impact the pain experience (‘Pain experience’ box in Fig. 2B). Additionally, the proposed model highlights how motor behavior can generate positive or negative feedback loops (gray arrow on the right in Fig. 2B), contributing to a self-organizing system that can expand or contract depending on the emotional valence.

Sharp’s model is helpful for case formulation, but its complex diagrams may not be easily understood by patients, and it may give the impression that their pain is too complicated to comprehend. To enhance patient self-efficacy, creating a clear list of events and associated meanings that can establish positive feedback loops by promoting behavioral change can be more effective.

Fig. 3 depicts the dynamics of event-meaning coupling, where Fig. 3A shows a hypothetical scenario with positive feedback loops resulting in the expansion of self-organization, and Fig. 3B illustrates a negative feedback loop leading to maladaptive behaviors. In Fig. 3A, upward arrows indicate the patient’s capacity and resources expanding through positive event-meaning couplings. This, in turn, attracts more mental energy and reduces the significance of pain experiences in their life. Fig. 3B demonstrates a negative feedback loop, where negative event-meaning couplings induce avoidance behavior patterns, leading to decreased opportunities for positive interactions with the environment. This ultimately decreases the patient’s functional capacity and increases the proportion of pain experience in their life.

Figure 3. Effects of positive and negative event-meaning couplings on mental energy state and pain experience. Note. (A) Positive event-meaning couplings (as denoted by ‘Positive Appraisal’-[biopsychosocial] ‘Events’) lead to higher mental energy states, less emphasis on pain experience, and increased empowerment and insight. Positive event-meaning couplings attract more mental energy, decreasing the significance of pain experiences as depicted by two circles in the right corner of the figure. (B) Negative event-meaning couplings (as denoted by ‘Negative Appraisal’-[biopsychosocial] ‘Events’) attract maladaptive behaviors, leading to a lower mental energy state. Pain experiences occupy a higher proportion of total mental capacity, resulting in helplessness and biased judgment. The patient’s functional capacity decreases, and the proportion of pain experience in their life increases, as illustrated by two circles. The feedback loop of motor behavior to the event depicted in Fig. 2B is not included to simplify the representation.

1. Event-meaning couplings for case formation

In what ways can we utilize case formulation to promote the cultivation of insight using positive event-meaning coupling? We can start by inquiring possible events that have impacted the patient’s pain experience, such as interactions with health professionals, workplace, or family and friends. By exploring these events, practitioners can qualitatively assess the patient’s interpretation of their pain and the meanings they have attached to it.

Events can be classified as ‘immediate’ or ‘potential’, based on whether they have already occurred or are likely to occur in the future. In the context of meaning cultivation, potential events can be seen as ‘affordances’ [8] for meaning.

Although it can be challenging to identify significant events, healthcare professionals can identify the most relevant event-meaning couplings that can have a positive or negative impact on pain management by conducting careful interviews from patients. By estimating the degrees of potential for reducing helplessness and promoting empowerment through changing the meaning of events, practitioners can prioritize interventions.

2. Starting with pain education

Let’s examine the examples of the event-meaning coupling in more detail. Perhaps one of the most crucial meaning making aspects of chronic pain rehabilitation is providing pain education to patients. However, a significant obstacle to this process is the potential for patients to attach biased meanings to their pain from their pain education.

Fig. 4 depicts two examples of event-meaning coupling in pain education, where patients may interpret the information differently despite efforts from healthcare professionals to explain it clearly. The case on the left shows a patient who mis- understood the complexity of chronic pain and attributed it to being “all in my head,” leading to confusion, cynicism, and a belief of having no control over the pain, resulting in short-term coping strategies such as substance use.

Figure 4. Examples of the impact of negative and positive event (pain education)-meaning coupling on behavior of patients with chronic pain.

Fig. 4 on the right illustrates a positive event-meaning coupling that resulted from effective pain education. Patients who understand how to manage their pain can feel motivated to optimize different aspects of their behavior and make small changes, leading to further empowerment.

Clear explanations and specific instructions on pain management are essential to avoid biased event-meaning coupling in pain education. Metaphors that illustrate the mechanisms of chronic pain can be especially useful in correcting misconceptions, according to Gallagher et al. [9]. For example, a cup filled with various factors that contribute to pain can serve as a useful metaphor for pain education (Fig. 5). Patients are advised that pain can result when the cup overflows. To prevent this, there are two strategies: reducing other factors that fill the cup, such as stress levels, and expanding the cup’s capacity by increasing physical activity, fitness, or coping strategies. Combining these methods would be the most effective approach.

Figure 5. An example of pain education using a metaphor. Note. An example of pain education using a metaphor of a cup, where pain is depicted as the overflowing of a cup, and strategies to reduce pain experience are shown on the right. The top right strategy involves reducing other factors that contribute to pain, such as mental health, sleep quality, and work-related stress, while the underlying pathological cause remains the same. The middle right strategy involves increasing the capacity of the cup, which can be achieved by improving fitness levels and coping strategies, ultimately leading to a reduction in pain experience. The bottom right strategy involves utilizing both approaches to manage pain experience effectively.

3. Immediate event-meaning couplings

Let us examine other significant events that can aid in cultivating better event-meaning coupling for our hypothetical patient, Monica (see Appendix 1A, B). During the interview, it was noted that she believed that the low back is connected to the weak core muscles. Unfortunately, her physiotherapy treatment aggravated her symptoms. She expressed concern that this may be due to more serious underlying conditions such as cancer or lead to long-term disability like her mother’s. She reported experiencing difficulties in performing important work tasks, feeling stressed and irritable, and having trouble sleeping. Furthermore, she revealed that she has gained weight and increased her smoking and alcohol consumption as a way to cope with her pain. Despite the pain, she attempts to remain active by avoiding prolonged sitting and heavy lifting. She acknowledged that her family is concerned about her symptoms because she usually has a high pain threshold.

Firstly, interactions with healthcare professionals can influence Monica’s interpretation of her condition. For example, the use of the term “degenerative” in radiological reports may have a negative impact on the patient’s perception of their condition, leading them to believe that it will worsen over time, thereby increasing anxiety and helplessness [10]. This, in turn, may lead to reluctance to engage in physical activity or even develop kinesiophobia [11]. Moreover, if a patient like Monica has attempted physical therapy in the past but did not experience any improvement, they may develop the misconception that exercise therapy is ineffective, or the pain may be due to serious underlying causes, leading to catastrophic thinking.

The patient’s ability to cope with pain effectively may be hindered by certain beliefs they hold about chronic pain management. One such belief is that pain must be endured, leading them to avoid discussing their symptoms with others and feeling isolated. Dealing with teenage children, who may be rebellious, or an unsupportive spouse can be especially difficult for Monica. The absence of support and feeling isolated can worsen her low mood symptoms and lead to ineffective coping mechanisms that can intensify the pain experience [12].

Experiencing low mood and a sense of helplessness can raise the probability of developing maladaptive coping methods, including smoking, which has been found to have a bidirectional impact on pain and mood in individuals with chronic low back pain [13].

Improving sleep quality can have a positive impact on pain experience [14], and this can be associated with a positive event-meaning coupling for Monica. Cognitive behavioral therapy for insomnia (CBTi) has been shown to be highly effective in treating insomnia [15], which can also be considered in the context of pain management.

The patient’s age can lead them to believe that low back pain is a natural consequence of aging, which can cause a sense of helplessness and anxiety. This belief may be formed based on past experiences of seeing family members (e.g., Monica’s mother) or friends coping with their own musculoskeletal pain [16].

Educating Monica about the mechanisms of chronic pain using the aforementioned event-meaning couplings in a way that would give insights to her current condition would be therapeutic and could help empower her.

4. Potential event-meaning couplings

We can use our imagination to identify potential event- meaning couplings that may be relevant to Monica’s situation. Internal events such as Monica’s health literacy skills, cultural beliefs, and past experiences of managing musculoskeletal injuries may afford new event-meaning couplings with the current injury. External events such as work-related stressors, availability of exercise or relaxation facilities, commuting methods, financial status or burdens, and social support networks can also influence her event-meaning coupling.

For instance, if Monica is working in a short-staffed environment, she may feel compelled to endure pain to meet her boss’s expectations, disregarding the need to pace activities and prevent exacerbation of pain. As a senior employee, she may experience a decline in her performance, leading to feelings of inferiority compared to younger colleagues, further fueling her sense of helplessness. Gender or ethnic discrimination in the workplace is also shown to heighten distress and increase pain experience [17].

The ergonomic features of the work workstation can be a potential meaning making resource for pain management [18]. The quality of the chair, availability of back support, and the provision of break time can all be relevant factors in the work setting, which Monica needs to explore and attach importance to in relation to her pain.

Communication skills, specifically assertiveness skills, can be another potential area for event-meaning coupling. Patients with low assertiveness skills may feel overwhelmed as they may have to take on more responsibilities without being able to refuse them. Furthermore, it has shown that female patients who have difficulty expressing their distress to healthcare professionals may receive less support [19]. By developing assertiveness skills, Monica can cultivate a positive meaning for pain management.

Katz et al. [20] reported that people experiencing low back pain have a greater likelihood of experiencing sexual dysfunction than the general population. This can negatively impact their relationships with their partners and decrease the support they receive. By asking Monica about this aspect, additional insights may be gained into her experience of pain. Furthermore, menopause has been found to intensify pain, moderated by affect [21]. Raising awareness of this correlation can help Monica understand the link and provide hope that managing post- menopausal symptoms can alleviate her pain.

5. Evaluation

Once all immediate and potential event-meaning couplings have been identified and listed from the history taking, the next step is to quantify the degree to which relevant factors affect the pain experience. This can be done by using a questionnaire that allows for comparison to normative values for quantification of the pain experience and affording factors.

Monica has been experiencing pain for 3-6 months with an intensity averaging 6/10. She scored moderately (29/60) on the Pain Self-Efficacy Questionnaire, which measure patients’ confidence in managing pain [22] but showed a high score (33/52, severe) on the Pain Catastrophizing Scale. Her mood, as measured by the Depression, Anxiety and Stress Scale - 21 Items, showed moderate levels of depression (16/42) and stress (24/42). Pain has significantly affected her sleep (9/10), daily activities (8/10), and work-related functions (7/10).

In Fig. 6, a preliminary case formulation is presented, which employs event- meaning couplings to assist Monica in comprehending her pain and minimizing any tendency towards catastrophizing. Furthermore, the formulation provides an opportunity for a metaphorical interpretation of Monica’s pain and serves as a guide for the overall direction of her management plan.

Figure 6. Case formulation using event-meaning couplings and overall direction of pain management plan using a metaphor.

To determine the validity of the case formulation using event- meaning couplings, we can use the list and the results of the questionnaires to address each hypothesis of the event-meaning coupling and observe trends in changing values across interventions. We can also gain feedback from Monica related to relevant events that were previously discussed during the initial consultation. We should continually evaluate the effectiveness of the interventions over time, create new hypotheses through ongoing identification of meaning-event couplings, and adjust the intervention strategies accordingly to ensure positive outcomes for her.

6. Limitations of the model

The proposed model is a hypothesis and may lack scientific validation. However, it shares similarities with Victor Frankl's logotherapy, wherein individuals seek meaning in life to confront the challenges posed by adversity and crises [23]. Specifically, research in the literature has confirmed the effectiveness of logotherapy in alleviating the suffering of individuals with chronic conditions such as terminal cancer in adolescents [24] and patients with cervical cancer [25], or undergoing dialysis [26]. The efficacy of logotherapy partly supports the possible benefits of this model in chronic pain conditions.

A primary distinction between logotherapy and the event- meaning hypothesis outlined in this paper lies in the granularity of meaning resolution. While logotherapy encourages patients to link life’s meaning to significant events, the proposed hypothesis delves into fine-grained resolution, encompassing everyday perceptions and belief systems.

Initiating efforts to reinforce the evidence to support this model, starting with pilot studies, would be the next critical phase in its advancement, enabling broader acceptance and implementation.

To manage chronic pain effectively, it is important to provide patients with a holistic understanding of their pain experience, identify affording resources, redirect any biased event-meaning couplings, and promote positive event-meaning couplings. Addressing event-meaning couplings from the biopsychosocial realm, whether immediate or potential, can provide patients with insights, enhance their empowerment, and encourage positive behavioral changes that lead to greater functional freedom. Standardized pain questionnaires can be used to objectively assess the hypotheses of case formulation using the event-meaning couplings, which can allow for modification of interventions to better suit individual patients.

The author has no conflict of interest to declare and received no financial support for the report and/or authorship of this manuscript.

No potential conflict of interest relevant to this article was reported.