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Chronic widespread pain and increased mortality: biopsychosocial interconnections
  1. Jose A P Da Silva1,
  2. Rinie Geenen2,
  3. Johannes W G Jacobs3
  1. 1 Department of Rheumatology, Faculty of Medicine and University Hospital, Coimbra, Portugal
  2. 2 Department of Psychology, Utrecht University, Utrecht, Netherlands
  3. 3 Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, Netherlands
  1. Correspondence to Professor Jose A P Da Silva, Department of Rheumatology, Faculty of Medicine and University Hospital, 3000-075 Coimbra, Portugal; jdasilva{at}

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Chronic widespread pain (CWP) is associated with excess mortality. Robust evidence is provided in ARD by a study that included over half a million participants and a meta-analysis.1 This adds to the (already overwhelming) recognised burden of CWP and imposes an additional urgency in improving our understanding and management of the condition. Reducing excess mortality in patients with chronic pain requires an accurate knowledge of relevant mechanisms and mediators. Previous research and this new study indicate that this excess mortality is, to a large extent, explained by lifestyle factors such as decreased physical activity, increased body mass index, unhealthy diets and smoking. In this editorial, we will offer arguments and evidence emphasising the need to also take account of psychological factors to explain the link between CWP and early death.

Biopsychosocial model of chronic pain

Decades of research led to the current concept that chronic pain encompasses multiple and mutually interacting biological, psychological and social factors. These include—but are not limited to—nature of pain, peripheral and central pain processing mechanisms, physical disability, sleep disturbance, obesity, smoking, alcoholism and other health risks, psychological resilience and vulnerabilities (emotions, cognitions, behaviour) and social factors (work, support, facilities, financial resources). Relations between all factors of this biopsychosocial model are recognised to be dynamic and reciprocal, with mutually influencing pathways similar to a hanging mobile toy, in which movement of one component may induce change in all others and back. The weight of the distinct factors differs between individuals.

Psychological factors are important players in this context. To start with, they are core determinants of unhealthy lifestyles that turned out to be important in the recent study.1 For instance, reduced physical activity has been shown to be influenced by fear of movement-related pain (kinesiophobia)2 and by catastrophising cognitions (ie, rumination, magnification and helplessness).3 Lifestyle factors including …

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