Rethinking coping in chronic pain: a systematic review and dynamic interaction model of coping.

Chronic pain—that is, persistent pain lasting more than 3 months, is a major global health problem. 133 Most chronic pain conditions lack effective cures and treatment options are limited. 58 The individual impact of chronic conditions, such as chronic pain, is variable 98 and is likely influenced by coping. When pain persists over time, its salient nature requires the individual to find ways to effectively adapt. Strategies that are helpful in acute pain may be less effective or even maladaptive in chronic conditions. Importantly, how pain is experienced is influenced by factors that not only amplify 93 or diminish 23 pain but also influence pain coping. 140 These coping processes involve interactions between momentary factors that change with shifting contexts and demands. Yet, current theoretical models of coping with health-related stress are limited in addressing how coping with chronic pain changes with shifting situational demands. To understand how people cope with pain over time, it is essential to outline how factors and their relationships change dynamically, moment-to-moment and long-term. Here, we first aim to systematically map existing relevant theoretical models of coping and summarise their common concepts. Second, we propose a new model of coping specific to chronic pain, drawing on previous models and the wider coping and stress literature, to shed light on how relationships between variables may change over time. Coping is broadly defined as cognitive or behavioural efforts in response to a threat or stressor that taxes the resources of the individual. 73 , 123 Coping is often stratified into categories, as being active or passive, 77 problem- or emotion-focused, 73 approach- or avoidant-oriented, 99 adaptive or maladaptive. 14 , 118 These categories usually distinguish between efforts directed at resolving the stressor (ie, problem-focused) or reducing its impact (ie, emotion-focused). 73 Yet the boundaries between these categories are unclear, and a behaviour may be classified in opposing ways (eg, taking a painkiller as actively resolving a problem or as passively conceding control to a pill). In chronic pain, the distinction between problem- and emotion-focused coping is diffuse, as pain is influenced by emotions and thoughts. 17 , 128 Emotion-focused coping may therefore change pain itself, akin to improvements seen in chronic pain after psychological interventions, such as cognitive-behavioural therapy. 40 , 69 Emotion regulation ability and efficacy is therefore highly relevant to coping. 9 Active and problem-focused coping is often categorised as adaptive, 9 , 14 , 37 implying that coping is more effective when attempting to control the stressor. Yet, adaptiveness arguably depends on specific situational demands. Positive reframing may be adaptive when the problem cannot be changed but could hinder helpful efforts when the stressor is changeable. Coping behaviours are thus not (mal)adaptive by themselves, as is often assumed, 9 but are appraised in relation to the given context. This supports the importance of coping flexibility 9 —adapting strategies to situational demands. 20 Importantly, we define coping as more than discrete behaviours or functional outcomes. It is a process , guided by previous experiences and expectations, that updates with new information. Contextual factors therefore play a large role in coping, both in what strategies the person applies and their perceived effectiveness. 34 , 91 As such, we define coping as “the process of engaging in behaviours, thoughts, or strategies that occur in response to stress, in efforts to mitigate some negative aspect of the situation.” Outlining components of the coping process in chronic pain is crucial to understanding what factors and dynamics contribute to poorer outcomes in some individuals. Drawing from the wider coping and stress literature, we propose a new dynamic model of coping in chronic pain that highlights 5 factors: controllability, predictability, salience, resources, and motivation. We visualise how these interact in dynamic momentary and long-term processes, and how their interrelationships change over time. To inform our model and map the existing state of theoretical models, we initially conducted a systematic review to identify and summarise relevant models of coping in health-related stress or pain. The strengths and limitations of these models informed our own model development.

A systematic search was conducted in 3 databases: MEDLINE, Embase, and PsycInfo on June 24, 2025, by an academic librarian (see supplementary materials, available at http://links.lww.com/PR9/A389 , for details on a preliminary search which was conducted on October 4, 2023). Both text search terms and subject headings were used. Search terms included: (pain* OR disable* OR disabilit* OR handicap* OR (stress* ADJ (health OR ill* OR disease* OR condition*)) OR ((chronic* OR physical*) ADJ (ill* OR disease* OR condition*))) AND (cope OR coping OR copes OR “problem-solving”) AND (framework* OR model* OR theory OR theories OR theoretical) restricted to article titles, abstract, and author keywords. Subject headings related to pain, chronic disease, disability, psychological stress, coping, problem solving, conceptual framework, model, and theory were used as specified in the respective databases (see supplementary materials, available at http://links.lww.com/PR9/A389 , for full description). Subject headings related to animal studies were used to exclude nonhuman research, and all searches were restricted to English articles only. A total of 9159 articles were identified, before removal of duplicates (n = 2298). Articles (n = 6861) were screened independently by authors M.B. and S.L. against the inclusion/exclusion criteria based on title and abstract using the Covidence software. 25 Remaining articles (n = 96) underwent independent full-text assessments by authors M.B. and S.L. Conflicting assessments (n = 14) were resolved through discussion with a third assessor D.-M.E. After screening, a total of 21 articles were included for analysis. See Figure 1 for a Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram of the process. Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram of selection process. After the selection process, we read through all selected articles (n = 21) and summarised each theoretical model/framework, including the publication year, topic, central features, and main aims. A thematic synthesis was conducted for each article to identify concepts of interest (see supplementary info, available at http://links.lww.com/PR9/A389 , for further description). Formal quality assessments were not conducted but conceptual limitations of models were summarised in the discussion. Relevant literature on coping, stress, and chronic pain, including coping models that did not meet criteria in the search process, were used to develop a new conceptual model for coping in chronic pain. We included articles (1) written in English, (2) peer-reviewed, (3) focused on human research, and (4) focused on either pain or health-related stress. Exclusion criteria included: The model/framework (1) was missing a novel theoretical model or framework (articles that applied existing models to a new population without adding substantially novel concepts were excluded), (2) was not theoretical (ie, purely empirical or statistical), (3) did not sufficiently focus on the coping process (eg, coping only included as a factor to describe a different process), or (4) was not focused on individual coping (eg, parental coping with child's illness). When evaluating novelty (exclusion criterion 1), the threshold for what is considered “novel” was sometimes difficult to determine, since models often rely on previous frameworks. For example, Sturgeon and Zautra 114 was excluded after full-text review as the model was near identical to another included model by the same authors. 115 However, useful concepts from the revised model were incorporated into our model development. We did not exclude models that focused on acute conditions, despite our model's focus on chronic pain, since many relevant coping factors (eg, symptom features, appraisal) apply in acute settings too.

A total of 21 articles were included after screening (see supplementary info, available at http://links.lww.com/PR9/A389 , for a table overview). Ten models focused on chronic illness, 26 , 44 , 51 , 55 , 72 , 83 , 87 , 104 , 111 , 134 with some applied to conditions such as rheumatoid arthritis 87 , 134 or diabetes. 55 Five models were specific to pain 39 , 53 , 61 , 68 , 115 —3 of which focused on chronic pain states. 39 , 53 , 115 The remaining models focused on general disease, 33 , 112 cancer, 85 , 108 threatening healthcare events, 63 and hospitalisation. 97 Different themes related to coping, such as resilience, 115 spirituality, 51 worry, 39 or problem-solving, 39 , 55 were also presented. Below is a synthesis of general concepts across models, classified into thematic categories (see Table 1 for a visual overview). Overview of concepts in current models. Green fields indicate direct mentions of the concept; yellow fields indicate minimal, indirect, or incomplete mentions; whilst dark grey indicates no mentions. Light grey fields show additional concepts. SES, socio-economic status. Fourteen models directly mentioned individual appraisal as a central component to coping, 26 , 44 , 51 , 53 , 61 , 68 , 85 , 87 , 104 , 108 , 111 , 112 , 115 , 134 6 of which referenced Lazarus and Folkman's 73 terms “primary appraisal” and “secondary appraisal,” used to describe 2 types of assessments in coping. The first describes situational appraisal in which the level of threat is assessed. The second considers what coping options can be applied. Models that did not directly refer to appraisal still maintained that individual interpretations of the stressor were important. 33 , 39 , 55 , 63 , 72 , 83 , 97 Only 6 models explicitly referred to the coping process as dynamic, 61 , 63 , 85 , 108 , 112 , 134 with no consensus on what “dynamic” referred to across models. Some referred to dynamics as model components developing over time and interacting in reciprocal and complex ways. 134 Others described dynamics as factors influencing one another, 61 the presence of feedback pathways, 63 factors changing over time, 112 appraisal, 85 or repetitions of the coping process. 108 It was often unclear whether relationships between factors change or what mechanisms drive dynamic changes. Remaining models mostly viewed coping as a process that develops over time, 26 , 33 , 51 , 72 , 87 with some describing coping in terms of stages. 72 , 111 Several models depicted largely unidirectional pathways ending with coping outcomes. 33 , 39 , 51 , 53 , 55 , 61 , 83 , 104 , 111 , 115 , 134 Fifteen models discussed concepts related to perceptions of control, including self-efficacy, 44 , 55 , 61 , 83 , 87 , 112 , 134 autonomy, 72 , 83 competence, 26 locus of control, 112 control beliefs, 115 , 134 and general sense of control. 51 , 68 , 85 , 97 , 104 Beliefs about coping efficacy were also believed to influence coping behaviour, for example, by motivating treatment compliance 134 or providing incentive through changing values of (in)action. 61 Perceptions of control were also mentioned in conjunction with general threat orientations, such as seeing it as a challenge to be overcome. 55 Factors related to temporal features of the coping process or stressor were mentioned in most models. This included expectations, 26 , 61 , 63 , 85 , 97 , 115 novelty, 53 , 55 , 97 timing of illness, 26 uncertainty, 39 , 83 , 87 and predictability. 53 , 63 , 72 The role of previous experiences, memories, and schemas was also emphasised in several models 26 , 51 , 55 , 61 , 63 , 85 , 97 , 111 , 112 as well as future predictions and disease progression over time. 26 , 33 , 63 , 68 , 72 , 85 , 87 , 134 Characteristics of the stressor and how it is understood was mentioned in all models. Some referred to concepts such as illness representations or illness beliefs 26 , 63 , 111 , 112 to describe individual illness appraisal. Specific features, including diagnosis 83 , 115 and pain 53 were also seen as important to the coping process. Several models recognised the importance of meaning and significance, including threats to individual roles 26 , 72 , 83 , 87 and identity. 26 , 72 Models also described meaning-making as a form of coping, such as through benefit-finding, 111 and how meaning drives motivation to cope. 51 , 104 Resources were recognised by most models as important determinants of coping options, self-efficacy, and vulnerability to stress. The resources mentioned spanned from cognitive resources, 63 knowledge, 55 and general health 85 to socio-economic resources 33 , 83 and social support. 51 , 68 , 83 , 85 , 87 , 104 , 112 , 115 Few models focused on physiological resources or influences on coping. 33 , 72 , 85 , 97 , 108 , 134 A distinction between dispositional and contextual factors, 44 or personal and environmental factors 26 , 33 , 51 , 83 , 104 was made by some. Personality was mentioned by several models as influencing appraisal or coping. 33 , 44 , 55 , 83 , 85 , 104 , 111 , 112 , 115 , 134 Values, goals, or commitments were discussed as motivating factors in the coping process by most models. 26 , 33 , 39 , 44 , 51 , 53 , 55 , 61 , 63 , 68 , 83 , 85 , 108 , 112 , 115 , 134 When threatened, these were presumed to incentivise coping to uphold valued commitments. 53 , 61 Hope was also discussed by some models as an important contributor to continued coping efforts. 51 , 72 , 104 , 134 Whilst some models focused on possible benefits, such as restoring equilibrium, 111 others emphasised avoidance of negative outcomes, such as pain. 39 , 53 Several articles made the distinction between adaptive and maladaptive forms of coping 53 , 61 , 68 , 112 , 115 or outcomes of good or bad adaptation. 55 , 83 , 85 , 104 , 111 Some categorised specific behaviours as less effective (eg, avoidance, venting, catastrophizing), 53 , 61 , 83 whereas others outlined trajectories of worse outcomes. 39 , 53 Only 1 model emphasised that adaptiveness is context-dependent, and that coping behaviours are not inherently adaptive or maladaptive. 134 Seven articles referred to the categories of problem- and emotion-focused coping. 44 , 51 , 68 , 83 , 108 , 112 , 134 Higher levels of control were considered by one an important prerequisite for applying problem-focused coping. 44 Another model discussed the importance of emotion-focused strategies in maintaining well-being, and that problem-focused coping should not be overemphasised. 134 Some models incorporated problem-solving more generally as the process of coping itself, with patients trying to find ways to resolve their symptoms. 39 , 55 One model described directed coping in terms of adaptive tasks, reflecting needs disrupted by illness that the individual tries to restore by coping. 104

We conducted a systematic search of relevant theoretical models of health- or pain-related coping. After screening 6861 original articles, we included 21 models in our thematic synthesis. Using factors identified from the coping and stress literature, we looked for common themes across models to identify gaps and ensure the relevance of our own model's central factors. We found that most models discussed some form of appraisal, but that a minority of models focused on coping as a dynamic process. Several models also referred to outcomes or strategies as adaptive or maladaptive. Overall, most models were focused on general chronic illness, with only 3 specific to chronic pain. There was also substantial variation in the focus on mechanisms involved in the coping process, and most models only outlined general factors grouped into overarching categories. Additional mentioned concepts included mostly dispositional or contextual factors affecting coping. The reviewed works have several limitations. First, models rarely focused on dynamics of the coping process and specifically lacked descriptions of how interactions between factors change over time. There is a clear need for models that not only describe how factors change over time but that also describe how their interrelationships change through iterations. This is essential to understanding changes of long-term conditions such as chronic pain. Second, most models did not focus on underlying mechanisms of the coping process, such as how individual factors interact or what drives changes over time. Finally, many models focused on coping outcomes as categorical, such as adaptive or maladaptive, or simply as “adaptation.” Such categorisations may help identify general behaviours associated with outcome-measures across individuals. Yet, this can miss the importance of individual outcome appraisal, and whether outcomes align with intentions of coping efforts. The concept of overall “adaptation” also reduces dynamics of adaptative outcomes, which exist on different timescales (ie, momentary or long-term adaptation) and levels of explanation (ie, physiological, psychological). To address these limitations, we propose the “Dynamic Interaction Model of Coping in Chronic Pain” (Fig. 2 ). The model aims to visualise how factors may interact in a dynamic process of coping. Overall, we propose that coping in chronic pain involves parallel primary and secondary appraisal processes which influence the resulting coping effort. After reappraisal of coping efforts, the feedback of these update expectations, shaping future appraisal and coping efforts. Below, we introduce 5 main factors that constitute primary appraisal —the ongoing assessment of the stressor. 73 These are labelled (1) controllability, (2) predictability, (3) salience, (4) resources, and (5) motivation. A visual overview of these factors and their proposed interrelationships is presented in Figure 3 . The factors interact in complex ways, and arrows between them are not exhaustive. Dynamic interaction model of coping in chronic pain. Expectations interact with incoming information and dispositional and contextual factors to shape perception. During primary appraisal, perception of the pain situation is generated through interactions between the central factors. Secondary appraisal involves a similar evaluation of coping ability and options, which interacts with primary appraisal to shape coping efforts. Following coping outcomes, reappraisal occurs, to feed forward learning and integrate it with expectations through precision weighing. Model pathways are not necessarily unidirectional or mutually exclusive, and changes in multiple pathways may occur simultaneously. Main coping factors. Overview of the proposed 5 factors in the coping model and how they may interact. The amount of perceived or actual control over a stressor (ie, pain) can affect its effect and how it is dealt with. Increased control has been shown to reduce pain 137 and pain-related suffering, 76 although there are likely large individual differences. 103 Definitions of controllability sometimes overlap with coping, by defining control as the ability to successfully cope with a stressor. 131 Here, the distinction between control efforts and control beliefs is helpful. Lazarus and Folkman 73 argued that definitions of controllability involving efforts to handle a stressor were synonymous with coping, unlike beliefs about control, where effort is not a prerequisite. Our concept of controllability encompasses both control beliefs and experienced control over pain during coping. Control beliefs can be both situational or general, transient or relatively stable. General beliefs about the controllability of life events is often termed “locus of control,” 100 where outcomes are attributed as externally or internally driven. Such general beliefs are hypothesised to exert a stronger influence under ambiguous conditions, where controllability cannot easily be detected. 73 External locus of control in pain patients has been associated with higher distress, 28 whereas an internal locus of control has been linked with improved outcomes after physiotherapy treatment in chronic pain patients. 2 Some studies also indicate that coping acts as a mediator between locus of control beliefs and outcomes such as quality of life 110 and mental health outcomes 52 , 138 in illness. However, the relationship between general control beliefs and specific control situations is complex, and control-related beliefs can also change with intervention. 65 Situational control beliefs may be affected both by general beliefs and factors such as momentary resources and demands. General control beliefs may moderate the impact of situational beliefs, as evidenced by differential effects of control depending on locus of control beliefs. 27 , 76 Perceived control also relies on an evaluation that one is able to exert this control, known as self-efficacy. 5 Without the right tools or capacity to enact control, then the stimulus remains uncontrollable, even if such control is possible. Coping effort likely also depends on outcome efficacy beliefs, namely the belief that an outcome is possible given a certain action. 44 High self-efficacy beliefs directed at pain may reduce pain intensity, likely through lower expected pain, 126 and is associated with better functioning in chronic pain. 59 Moreover, situational control beliefs have been proposed in Leventhal's Common Sense Model 75 to interact with other illness-related beliefs in coping, such as the expected cause, consequences, and timeline of pain. 19 The experience of control is built on both control beliefs and efforts to exert this control. We conceptualise controllability in our model as control beliefs, directed either at altering the stressor or its impact, that are supported through outcomes of effortful action to exert this control. For example, a person may believe that they can control (ie, reduce) the duration of their headache by taking a prescribed medication. This belief may be supported by evidence (ie, pain went away), thus fostering a feeling of control, or be reduced (ie, pain persisted), potentially altering the belief. Control beliefs may be altered by different types of evidence, including instruction, observation, or personal experience. 61 In chronic pain, an underlying assumption is that patients do not have full control over pain. 125 Controllability in chronic pain may therefore be better described as perceived success of short-term and long-term coping. In the short-term, each pain episode may have varying degrees of perceived controllability. Yet, even if pain is successfully managed momentarily, the chronic pain condition may still be perceived as uncontrollable long-term. Repeated successful short-term coping could foster a sense of control over time (eg, “although my condition cannot be fully controlled, I manage better on bad days”). Conversely, recurring unsuccessful coping may make future coping more effortful, for example, due to increasing negative emotions or depleting motivation. Over time, control beliefs are likely to influence what coping methods are engaged or abandoned. In experiments, reduced control over pain led to participants using strategies for controlling pain that previously worked. 66 This shows how previous successful coping methods may influence subsequent coping efforts, even if they are ineffective due to changing circumstances. How controllability beliefs influence coping in chronic pain is still largely unknown. However, we hypothesise that updating beliefs using experiences over time plays a substantial role in coping decisions. In our model, we capture this influence through the strengthening of certain pathways in the long-term. The predictability of an aversive event influences how a stressor is experienced and affects the choice and timing of coping methods. A distinction has been made between temporal and sensory predictability—the former referring to knowing when, or under what conditions, something will occur, whereas the latter is knowing what it will feel like. 81 Their effects on pain perception show conflicting results. Sensory predictability of an aversive event may decrease negative responses if presented in a nonthreatening way. 29 Yet, a recent meta-analysis of experimental pain in healthy volunteers showed no direct effect of predictability on pain perception, but suggested moderators such as expectations, stimulus intensity, and state negative affect are central. 90 Whether this generalizes to chronic pain is unknown, since predictability in chronic pain may involve fundamentally different expectations and threat values. Being able to predict the timing or intensity of pain can be beneficial by allowing for anticipatory coping to minimize or avoid negative impacts of pain. 107 Moreover, uncertainty can increase dread when anticipating pain for longer periods of time. 21 Anticipating pain can also engage coping that is detrimental to the outcome, such as tensing arm muscles during a vaccination. 29 As such, higher predictability could negatively influence outcomes depending on what coping is applied preemptively. Predictability can also guide planning and decision-making, 43 by estimating the effort and resources required to sustainably cope with a certain intensity or duration of pain. To illustrate how predictability may influence pain, our model applies predictive coding theory of pain perception. This has previously been used to explain how pain and other sensations may be products of the integration between previous expectations and incoming sensory information. 57 , 117 , 139 In this theory, the brain actively infers the likely source of ambiguous incoming sensations using estimates to guide perception and action. 116 Crucially, the relative precision of predictions and incoming information affects the weight they are given. 15 Predictions are then updated when new experiences do not match expectations (ie, prediction errors), to ensure future accuracy. 116 There is substantial evidence that prior expectations can shape perception, 4 , 70 such as in placebo and nocebo influences on pain. 15 , 22 , 42 , 121 Higher confidence in predictions may reduce the reliance on incoming sensory information in favour of prior expectations during perception. 84 Heightened prediction of pain may also explain how harmless sensations can be mistaken for pain in chronic pain patients. 54 In pain, these expectation effects may fail to extinguish over time even in the absence of confirmatory evidence. 62 Expectations (ie, sensory or temporal predictability of pain) are therefore an important part of pain perception and coping. These expectations may be explicit (ie, conscious) or implicit (ie, unconscious), as suggested by earlier theories such as the Common-Sense Self-Regulation Model, 89 and be directed toward the context (eg, social norms) or the individual (eg, previous experiences with pain). In our model, elements of predictive coding show how expectations are updated and strengthened dynamically, for example by increasingly relying on expectations over incoming information as pain persists. Over time, the individual may develop expectations about when pain occurs and what coping methods are likely to succeed. Some behaviours may become associated with increased pain, and thus feared and avoided. 49 This association is summarised in the fear-avoidance model of pain, 74 commonly applied to conditions such as chronic back pain. 130 According to this model, beliefs about the threat value of pain guides pain-related behaviours, such as whether-or-not to resume activity involving the pain area. 31 These beliefs may be based on cues in the environment that signal predictable associations, such as pain when bending over. However, neutral cues may be misattributed as harmful through associative learning. 129 In turn, fear-driven avoidance of certain behaviours may restrict opportunities for belief updating through new nonthreatening experiences. 31 , 41 In these cases, learned associations can lead to increased fear and expectations of pain, which in turn strengthens the fear-pain association. Expectations and beliefs about patterns of pain onset and maintenance are therefore proposed to be central elements in how individuals cope with pain over time. Another important factor is how salient the pain is at a given moment, both as a physical sensation and overall threat. Salience often refers to the distinctness of a stimulus in relation to elements in its environment. 12 Pain is naturally salient and demands attention, 30 but can be assigned added or diminished importance through emotions 8 or thoughts about its cause and significance. 80 This may especially apply to chronic pain, where the individual interacts with the pain differently over time. When pain reoccurs, it is not feasible to always prioritise and attend to pain. Its perceived significance can therefore help decide if pain should be attended to or ignored in favour of other actions. This evaluation is conceptualised as salience in our model, to denote how pain is given attention or meaning based on appraisals. Several factors can enhance or inhibit the relative salience of pain. For instance, acute pain has been shown to be more distracting when the stimuli is novel, has unpredictable timing, or elicits a fear of pain. 32 Pain may further be reduced through distraction 95 or amplified by allocating voluntary attentional resources toward it. 128 In chronic pain, hypervigilance, an excessive attentional monitoring of bodily symptoms, may contribute to the development and maintenance of pain. 124 Patients with chronic pain who report higher attention to pain show higher levels of distress and disability independent of pain intensity. 79 Top-down modulation of pain, such as directed attention, therefore has a significant impact on how pain is perceived and dealt with. Yet, bottom-up features of pain naturally pose limits on this modulation, with high-intensity pain being difficult to ignore. 96 Whether pain is given attention, and the result of this attention on the pain experience, also depends on what it signifies for the person or what is “at stake.” Lazarus and Folkman 73 described cognitive appraisal as central to determining the significance of stress in different contexts. They argue that individuals evaluate situations based on their respective threats to values, needs, or commitments. Pain that interrupts an important goal can be seen as more threatening, such as an athlete experiencing foot pain ahead of an important race. A significant threat may also initiate a strong emotional reaction, which can make coping efforts more challenging, such as by increasing pain catastrophising and limiting the use of cognitive coping strategies. 60 Over time, the acute salience of pain may be reinterpreted, and pain may integrate into a person's life or identity and take on meaning. 51 , 85 , 111 Evaluations may take the form of illness representations, where knowledge, schema, and contextual factors integrate with experience to create illness-specific beliefs and expectations—as presented in the influential common sense model of illness representation. 35 These representations can be positive or negative and are likely amendable—especially during early phases. 111 A person may reframe their purpose, role, and possibilities in life as their illness poses new restrictions. 111 Depending on appraised threat, habituation or sensitization of pain may also occur. 73 Pain appraised as novel and potentially dangerous may be reappraised as harmless after ruling out serious conditions. Alternatively, reappraisal may increase significance of pain, leading to increased fear and salience if the pain cause remains unknown. Importantly, salience is continuously reappraised as circumstances change and other factors, such as experiencing several concomitant life stressors, may compound negative effects. 50 How individuals cope with pain also depends on what resources they have available. Coping is often described as a process of balance between situational demands and coping resources. 1 , 73 , 108 When demands exceed coping resources, this leads to physical and emotional distress. 73 Matching resources to demands is therefore essential to successful coping. These resources may exist on different levels and timescales, ranging from societal to individual and from momentary to long-term. Distinctions are sometimes made between internal and external resources, 112 although these interact and are hard to separate completely. Our model term “resources” thus includes both internal and external resources, and their application depends on contextual and momentary factors, such beliefs about how effectively they can be applied. 18 , 47 , 73 Therefore, perceived resource availability is greatly influenced by beliefs about self-efficacy, and vice-versa. On a momentary basis, the current state of the person (ie, mood, health state) is central to coping. Experimentally induced negative affect in acute pain situations has been shown to increase pain unpleasantness, 8 which may increase situational demands. Momentary resources are diverse (eg, social support, access to medication) and can affect different parts of the coping process, including outcome appraisal. State-dependent components, such as the physical and emotional states of the individual during the coping process, are included in our model separately from resources to emphasise their wide impact on the coping process. Momentary factors are also influenced by long-term resources and dispositional factors. Positive interpersonal relationships can provide instrumental or emotional support, 109 which are associated with improved quality of life in chronic illness. 24 Factors influencing health, such as genetics, exercise, and diet also shape coping-related resources. Dispositional factors such as optimism, self-esteem, and sense of personal control have also been positively associated with coping outcomes, 119 whereas neuroticism and experiential avoidance may exacerbate negative outcomes. 94 Yet, as pain persists, physical and mental resources may decline because of continuing attentional, emotional, and physiological demands. 36 The disruptiveness of pain can also result in increased emotional impact over time, with chronic pain patients frequently reporting symptoms of low mood and anxiety. 6 , 7 , 10 Dispositional variables such as sex, age, and socio-economic background likely influence several parts of the coping process and are therefore included as a separate component. In chronic pain, financial and socioeconomic status can affect access to expensive and/or time-demanding resources (eg, psychotherapy, exercise). Structural forms of discrimination, such as racism, sexism, and ableism can hinder adequate support from healthcare institutions, and some populations are more likely to have their pain dismissed or disbelieved. 3 , 56 This dismissal may further contribute to low-mood and feelings of helplessness, consequently lowering the overall coping capacity. It is important to recognise barriers to accessing resources such as medical care as limiting factors in the coping process. These limitations are reflected in our model both under availability of “resources” and in secondary appraisal of coping ability. Given its unpleasant nature, pain has a strong motivational effect and relief from pain is inherently rewarding. 86 Pain is also an interruptive signal that shifts resources away from competing goals and tasks. 124 Individual differences in the interruptive impact of pain and motivation to pursue the interrupted goal can influence coping. The motivation-decision model of pain posits that the choice of attending to pain or a conflicting goal substantially influences the degree to which the incoming nociceptive signal is inhibited or facilitated by top-down modulatory processes. 43 For example, in a life-threatening situation, pain from a twisted ankle may be temporarily inhibited to aid escape. Motivation can thus alter the perceived stakes of a stressor and is therefore central to our coping model. When pain threatens a strong personal value, goal, or commitment, the individual may be highly motivated to alter the pain or its impact to avoid disruption. Using a motivational perspective, coping can be seen as a process of either striving to reduce pain or engaging with desired activities and goals despite pain. If the task interrupted by pain is important, then more effort may be spent pursuing the task despite pain, known as task persistence. 123 This may prompt the individual to temporarily ignore pain, especially if pain salience is low. In the short term, this may allow the individual to take part in valued activities despite pain, but may induce fatigue through the recruitment of top-down regulatory processes. 122 Yet, in the long term, repeatedly pushing through pain is linked to long-term disability and negative outcomes. 123 If pain threatens valued commitments over time, this may increase efforts to resolve the pain. 73 We included “competing goals” in the motivational component of our model to highlight the weighing of motivation to prioritize pain or alternative goals. Coping can be costly in effort, energy, and time. Motivation can affect how much effort is exerted, which resources are mobilised, and how long efforts persist. 71 Higher relative benefits of coping compared with costs, may increase the willingness to spend more resources. 135 Pain acceptance, the acknowledgement that pain is unavoidable and not expending energy to reduce it, can be adaptive for conserving resources over time. 48 Yet, giving up prematurely could be akin to the concept of learned helplessness, and foster depressive behaviours. 78 Fatigue, which is frequent in chronic pain, 38 has been proposed to signal a motivational urge to shift behaviour when costs outweigh benefits. 122 In chronic pain, increased perceived costs from effort over time or changes in expectations and reward processing may explain why fatigue is prevalent. 122 Contextual weighing of relative cost, reward, and utility of coping behaviours is therefore vital in driving motivation to pursue coping efforts. Judgments of control, coping efficacy, expectations, and value are all needed to avoid continued effort without results or lacking effort when action could be effective. When pain threatens goals over time, one can attempt to change the situation to align with personal goals, or alter goals to match the situational constraints, known as assimilation and accommodation, respectively. 13 In chronic pain, this may involve coping efforts to reduce the impact of pain on valued activities or to adjust activities to accommodate for pain levels. If pain is uncontrollable, or previous coping efforts have failed, then altering personal or work-related goals may be most adaptive. 106 With time, the individual may also change their conceptualization or measurement of constructs, such as “success” or “health”—a process known as response shift. 127 Yet, giving up on valued activities and goals may also have negative effects over time, as evidenced by negative associations between pain interference and quality of life. 64 , 92 Whether persisting in coping efforts or altering goals is more effective relies on a momentary evaluation of several factors, including the controllability, predictability, and salience of pain, along with available resources. Integrating these different factors in a coherent model is therefore crucial to understanding dynamic coping processes and their outcomes. The 2 light-grey boxes in the model capture how dispositional and contextual factors influence the coping process. Some common dispositional factors are mentioned, although the list is not exhaustive. Context and state-dependent factors affect expectations and perceptions throughout and may be influenced by each element of the process. For example, strong uncontrollable pain, may result in frustration or helplessness which could in turn increase physiological stress, making pain worse. Chronic pain is highly emotional, and interventions aimed at improving tolerance for emotional distress may be particularly helpful. 88 , 102 Emotion regulation processes are therefore important in the coping process, 9 , 67 especially as negative emotions may exacerbate pain and hinder coping efforts 45 and poor emotional regulation can result in overemphasis on negative stimuli. 88 The model uses concepts from predictive coding theory— expectations , feedback , and precision-weighing —to explain how perception is generated and updated with new experiences. 15 , 46 These expectations interact with incoming sensory information to shape primary appraisal. Expectations and their interactions with sensory signalling are believed to influence every step of the coping process, in line with previous work emphasising the role of appraisal. 73 Secondary appraisal describes ongoing assessments of coping options and ability—and is not necessarily second to primary appraisal , but the 2 are co-occurring. 73 Here, interactions between the 5 central factors form perceptions of momentary ability to cope and the relative load of pain . If pain load is high, then it may require more resources and/or effort to cope. Similarly, if ability to cope is low, then coping may be difficult even for smaller pain loads. Momentary ability to cope consists both of contextual and relatively stable factors. For example, physical stamina may be good overall but temporarily reduced in illness. What coping methods are viable also depends on efficacy beliefs , or thoughts about how effective coping efforts will be. Once possible options and the situation have been assessed, then coping efforts are engaged. These coping efforts are not restricted to behaviours but may include thoughts or emotional strategies. This selection process is likely mostly unconscious, with automated processes detecting and resolving health-related threats. 89 We hypothesise that during strong pain, this process may be even more automatised, especially if pain disrupts cognitive functioning. 82 As the situation changes, reappraisal takes place throughout the model. For example, pelvic pain first believed to indicate an endometriosis flare-up is later reappraised as transient and mild, requiring less coping effort. The model visualises 2 main pathways for reintegrating coping outcomes with future expectations , but feedback arrows are present throughout. We hypothesize that coping outcomes will be appraised positively or negatively relative to the goal(s) of coping (ie, reducing pain or its impact). Although there are 2 separate pathways, coping most often results in both positive and negative outcomes, to varying degrees. For example, resting may reduce pain but could trigger feelings of isolation from missing out on valued activities. The relative success of coping efforts informs expectations about which methods are effective and when , through feedback . In line with predictive coding, incoming information is given relative precision weighing depending on signal uncertainty. 15 Additional factors likely influence what information is integrated, such as a negativity bias, where there is prioritisation of negatively valanced information. 101 In this case, negative effects of coping may be overemphasised, which could lead to the avoidance of otherwise helpful strategies. In chronic pain, the coping process changes over time as efforts are reinforced or abandoned. The efficacy of coping is evaluated through outcome appraisals, thus strengthening future expectations and behaviour. If strategies are ineffective, negative expectations may drive future behaviour, for example, by reducing willingness to try new strategies or facilitating helplessness. 105 The relationship between factors in the model is therefore expected to change with time, which is a unique feature of our model (see Fig. 4 for an illustrated example). If pain is increasingly experienced as uncontrollable and salient, a negativity bias may develop, fostering a maladaptive pattern resistant to change, with new information being less likely to be integrated into the predictive model. 84 With reoccurring pain, experienced control may decrease when pain is not easily managed. In addition, resources likely diminish as pain limits participation in social activities or work. 36 Pain interference over time may make competing goals more effortful, as the pain requires consistent management and energy. With higher disruption, motivation to reduce pain may increase as salience strengthens and pain becomes more significant. Example of a long-term change in model dynamics. Wider arrows represent stronger influence of one factor on another, whilst narrower arrows indicate reduced influence. Elements coloured orange indicate a moderate or large increase in this factor, and light yellow represents a decrease. The state-dependent context is coloured pink to indicate a slight negative transition, as negative information is prioritised. In the short term, adjustments can be made, even if momentarily disruptive, but over time frequent accommodations become problematic. It may become difficult to uphold commitments or perform self-care activities. As a result, chronic pain may become associated with the person's identity 132 and their illness representation may update with new experience and knowledge (visualised in Fig. 5 ). As the process repeats, long-term factors update with repeated evidence. For example, recurring pain after coping attempts may reinforce general beliefs that the pain is uncontrollable and will never go away. Example of how momentary coping integrates over time. Feedback from each momentary process is integrated into the next through updating expectations, represented by curved arrows. Over time, each iteration affects long-term factors such as life goals or identity. The impact on these variables is proposed to increase over time, but their influence may differ. One benefit of our model is that it applies predictive coding theory to explain how changes in the coping process may occur. Unlike previous models, we illustrate how relationships between factors may change over time through updated expectations, providing a new dimension of model dynamics. This helps visualise how coping may change to become more rigid or negatively focused over time. The model also emphasises that coping actions are not necessarily inherently (mal)adaptive but are appraised as relatively (un)successful by the individual. By acknowledging the relative value of coping actions, patients may feel less guilt or judgment when applying different strategies to relieve distress. Furthermore, the model visualises proposed relationships between mechanistic factors, providing several potential targets for facilitation of positive coping experiences. For example, it may be beneficial to increase perceptions of control through strengthening control beliefs and to decrease pain salience through reframing pain as nonthreatening. This may in turn lower the perceived pain intensity, making coping more manageable. Owing to feasibility limitations, our model was informed by the wider stress and coping literature and a selection of theoretical models. However, a wider review of empirical research would strengthen the proposed theoretical foundations of our work. Because our model targets chronic pain, the focus of coping was pain itself. However, the influence of other co-occurring symptoms, such as brain fog or fatigue would help improve the explanatory power of the model. Although dispositional and contextual factors are included as factors in our model, we were unable to discuss their influences on coping outcomes in detail. Although the model does not distinguish between conscious and unconscious pathways, it is not assumed that appraisals are always conscious or deliberate, but likely exist on multiple levels of automation. Finally, the factors in the model likely interact in highly complex and dynamic ways that cannot easily be visualised with feedback pathways. For simplicity, factors grouped subconcepts together although they each likely have unique influences and contribute to several factors simultaneously (ie, values can influence perceived threat of pain and motivation to pursue goals). Future studies should test the model and see how relationships between factors change over time. This could be performed using Ecological Momentary Assessment (EMA) methods, 16 , 120 which allow investigations into how momentary factors influence experienced pain and subsequent coping efforts. One way of applying EMA measures is using single-case experimental designs, where each participant acts as their own control. 113 This method could investigate changes in coping processes during psychological interventions that target coping-related factors, relative to a within-subject baseline period. Monitoring how perceptions of control, predictability, or resources change within a single day or over the course of weeks, may visualise their relative contributions in chronic pain progression. In addition, it may be possible to test whether primary and secondary appraisal are connected bidirectionally, for example, by investigating changes in perceived coping ability in relation to changes in pain perception. The directional strength of causality between primary and secondary appraisal, and whether these may be state-dependent, could also be investigated using a single-case design. This could be probed using nonzero lag associations between self-reported and/or behavioural outcomes representing primary and secondary appraisal components. Moreover, experimental work could test the proposed relationships between factors through manipulating parameters of experimental pain, to see the relative influence of controllability, predictability, and salience on pain perception. A novel ecologically valid approach could be to experimentally administer painful stimuli (eg, mild electric shocks) using a wearable device, and manipulate parameters such as stimulus duration and intensity, predictability, and controllability. This could be combined with EMA outcomes reflecting factors proposed by our model. Individual differences in factors contributing to coping decisions should also be investigated, for example using network analysis. 11 Similar studies have been applied in the testing of symptom networks in mood disorders, 136 to identify key influential symptoms. Such networks may be valuable in creating personalised treatment plans and interventions targeting the most central nodes.

Supplemental digital content associated with this article can be found online at http://links.lww.com/PR9/A389 .

The authors have no conflicts of interest to declare.