Treating the ecosystem

Yellow flags (psychosocial factors)

As we know, pain is multifactorial. It includes biological, as well as psychological and social factors. Yellow flags are an umbrella term referring to the thoughts/beliefs, feelings/emotions, and communal/social factors that contribute to the pain experience. It should also be noted that psychosocial factors aren’t simply negative – they can also have a strong positive effect (e.g., resilience, high self-efficacy etc.). 

Thoughts and beliefs

Your thoughts and beliefs can include beliefs about your body, your pain, your belief in your ability to get better, your coping mechanisms etc. Your beliefs can influence,

• Your pain (doing too much, doing too little, catastrophising, etc.)
• Your care seeking (‘doctor shopping’, over-reliance on passive care, etc.)
• Your disability and pain levels (pain can be worse with expectations of tissue damage and harm etc.)
• Your compliance, acceptance and expectations. 

Some questions to reflect on:

1. What do you understand is causing your problem? 
2. How do you cope with your problem? 
3. What do you think will help you recover?

Here’s the thing, your thoughts and beliefs are impulses too.

If you sprain a ligament in your ankle, messages are sent to your spinal cord that may eventually end up as danger messages in your brain. A danger message may result in pain when thoughts, beliefs, past experiences, expectations, and a heck of a lot of other psychosocial factors interact. Just like the messages from your ankle, your thoughts and beliefs are nerve impulses too; they don’t just float around in a vacuum. A thought makes electricity, brain juice (ie., hormones), and a cascade of neural events that may result in pain just like a sprained ankle. 

If you think you have some thoughts/beliefs that might be contributing to your pain, consider completing the Fear-Avoidance Belief Questionnaire (FABQ) outcome measure. 

Feelings and emotions

Feelings and emotions can include stress, anxiety, depression, fear, frustration/anger etc. Your emotions can, 

• Elevate your pain
• Increase attention on your pain/problem 
• Increase the sensitivity of your injury 
• Increase your muscle tension (e.g., guarding)
• Alter your behaviour (e.g., completely avoiding loading the injury out of fear of further damage etc.)
• Stop you doing the things you love/sport/ hobbies 

Some questions to reflect on:

1. How distressed are you about your pain? 
2. Is stress/depression/anxiety a problem for you? How are you managing it? 

If you think you have some feelings/emotions that might be contributing to your pain, consider completing Depression Anxiety Stress Scales (DASS) outcome measure. 

Communal and social factors 

Communal/social factors are quite broad, and can include your relationships, education, culture, religion, health care etc. Social factors can influence,

• Your care-seeking habits and options 
• Smoking, drug use and alcohol habits 
• Broadly influence your barriers to recovery 

Some questions to reflect on: 

1. How supported do you feel (family, friends, work etc.)? 
2. Do you have significant life stresses going on? 
3. Do you have a good understanding of your pain problem? 
4. Do you have any behaviours that are currently not serving you well?

If you’re concerned about your answers to any of the questions in this article, please get in touch! We’ve helped hundreds of patients in pain and would love to help you with yours.