Understanding the Psychological Impact of Chronic Pain
Chronic pain is about biology. Not only does emotional stress affect our pain but emotional stress causes our pain. But who really can claim to live a stress-free life. Seriously? Then why do some people fare better in spite of severe chronic pain while others who appear to suffer less watch their days pass with despair?
Trust me, no one will ever catch me saying “I have no stress in my life!”.
Many doctors, researchers and pain specialists theorize that chronic pain worsens with stress. I can certainly vouch for that. Managing my pain means managing my stress.
Emotions like sadness and anxiety aggravate chronic pain. I think I was the sickest in my life just after my mother died. I suffered my first false diagnosis of Multiple Sclerosis within a few short months. Does that mean that my illness was not real? No. It simply meant that my nervous system was on OVERLOAD and the stress and “pain” had nowhere to go so it buried itself in my nervous system. LITERALLY!
Sometimes, when we talk about pain, we are talking more about our lives, even if our losses are not recent.
People who dwell on their pain tend to be more disabled but it than those who seem to tolerate it well. There have been a lot of studies of people who have been injured on the job and receive compensation for long beyond what the doctors and their bosses imagined they would need it. . Questions often arise about whether they are “faking” it, malingering or whether or not their pain is real. Unless they are indeed “faking it”, all pain is real whether or not it comes from the knee pain of osteoarthritis or by worrying that you won’t be able to feed your family. It can also come from past (or current) unresolved trauma – I’ll get to that later.
SO…when someone tells you that your pain is “all in your head”, they are right. After all, that is where your brain sits.
Whether your chronic pain is affecting you medically or emotionally (or both), it should be treated aggressively. If your doctor refuses to treat it aggressively, find another doctor. Treating pain aggressively does not mean writing out a new prescription for narcotic pain relievers although pain medication may be one of the most important parts of your treatment. If your pain can be moved from an 8-9 or 10 to a 4-5-6 you can become so much more “functional” and able to work on your pain through other means…physical therapy, exercise, stress management, psychotherapy, etc.
BACK TO THE SWITCHBOARD ANALOGY!
So when my pain is a Number 9 on my scale, I am dishrag. (Thank goodness, it is rarely a 9). Little else becomes possible. I can’t read, move around, engage in activities like exercise (even stretching) to help the pain diminish a bit. All of my “outlets” are plugged into my pain…even my creativity is dwarfed which is usually an ally in pain. I consider myself lucky. For some, no amount of pain medication helps, usually malignant pain (like with cancer). Not even LOVE can help these individuals.
Gate Control Theory
Our thoughts and emotions definitely influence our perception of pain.
Some researchers believe that there is some sort of “gating” mechanism in our spinal cords. Studies done in the 1960’s suggest that our spinal cord contains a neurological “gate” that either blocks pain signals or lets them pass on to the brain. The spinal cord is able to differentiate between the types of fibers that carry pain and those that do not.
Pain messages travel along the peripheral nervous system until they reach the spinal cord. (Some pain is carried in the “sympathetic nervous system”. This theory says that there are “gates” in the spinal cord that either allow pain messages to continue on to the brain or they are “blocked”.
The “gates” determine how the gates will manage the pain signals. It depends on a lot of factors, including:
- How intense is the pain
- What other incoming nerve messages are competing (touch, heat, etc.)
- Signals from the brain telling the spinal cord to increase or decrease the priority of the pain signal.
The pain messages are handled in one of the following ways:
- They may be allowed to pass directly to the brain…OUCH.
- They may be modified before being sent to the brain (influenced by your expectations, perhaps?)
- Prevented from reaching the brain.
The Role of Trauma
C.P. is not only caused by physical injury. There has proven to be a connection between chronic pain and mental health, stress and/or trauma.
Trauma occurs “when our ability to respond to a perceived threat is in some way overwhelming” Peter Levine, Trauma Specialist
People with post-traumatic stress disorder(PTSD) often suffer from chronic pain. If fact, 15-30 % of those patients with chronic pain also have PTSD. Chronic pain is also highly correlated with depression. Sometimes, prescribing psychoactive medications helps physical pain, especially fibromyalgia. People with PTSD experience:
- Hyperarousal ( this is like an exaggerated startle response, i.e., someone approaches you from behind and you jump in an exaggerated manner.
- Hypervigilance – when you always need to be aware of your surroundings. A victim of rape may be super-aware of being out by themselves, walking in secluded area, etc.
- Flashbacks – person feels or acts as though traumatic event is re-occurring.
- Helplessness –
- Nightmares– related to traumatic event
- Avoidance -avoids places, activities, persons, physical reminders of trauma – like a victim of sexual assault who avoids all men/women who are heavy-set with black hair. Or the child who refuses to be left with a caregiver who many have been abusive or neglectful.
SOME THOUGHTS ON LOVE AND PAIN
As I have said before, I am trying to base my comments on actual research and I found out about a rare heart condition caused by acute emotional stress. It is called Cardio-Stress Myopathy.
I remember a story I heard in my childhood although I am not sure my memory serves me correctly which is not uncommon. Memories fade, connections are lost. Anyway, my paternal grandfather died shortly after the death of my paternal grandmother. They said that he died “of a broken heart”.
Neuroimaging of the brain found that the same brain regions that involve physical pain overlap with those tied to social anguish.
IN OTHER WORDS: LOVE HURTS –
But we all know that love can also be very healing.
In the late 1970’s, researchers were studying social attachment in puppies. When separated from their mother’s, the pups cried much less if they were given small doses of opiates. The same studies were replicated in pigs, monkey, rats and chickens. Humans were tested much later when neuroimaging became available. Induced social pain seems pretty cruel to me but it does make a point.
So why does it hurt physically when we lose someone we love? Physical pain has two components:
- Sensory – provides us with information about the intensity and location of our pain be it a physical trauma (bee sting) or an emotional trauma (rejection).
- Affective (feelings) – although some believe that animals don’t feel emotional pain, I do not believe it. Have you read seen the photographs or videos of grieving dogs sitting my their masters ?
Yup, a kick in the groin may hurt for a minute or two but the pain of a break-up can linger forever.
The remedy for one may double as therapy for the other. Tylenol can actually relieve the pain of emotional stress as well as physical body aches.
SO…now I have established that chronic pain can stem from injuries (that kick to the groin), inflammation (arthritis, infection), neuralgias (fibromyalgia) and neuropathies (nerve pain). But many people suffer from physical pain when none of these is present. And, the physical pain is often accompanied by hopelessness, depression and anxiety (stress). So what gives?
We simply cannot discount the role of negative emotion when it comes to managing pain.
Trauma (when it occurs and decades later if it remains “unresolved”) is such a huge contributor.
When we experience a traumatic event, our sympathetic nervous system goes into “survival mode”. Our blood pressure may rise, we may experience shortness of breath, trembling, a rise in blood sugar, the release of stress hormones and it can even impact how well our immune system works. Some people have a hard time returning to a recovery mode (para-sympathetic nervous system).
This is one of the reasons that children who have experienced trauma fare better if they receive “treatment” as soon after the trauma as possible, as opposed to, days, weeks, months or years later when it is more difficult. At that point, a listening ear, sensitive explanation, the opportunity for a child to tell his or her story, etc.
As an Infant Mental Health worker, many years ago, I visited a young boy (5 years old) who lost his Daddy when he was murdered in a “drug deal gone bad”. The young boy (I will call him Michael) was struggling with confusion and heartbreak. He had witnessed the murder. Even though I had referred Michael for ongoing counseling, I felt the need to offer him immediate help- a chance to process his thoughts with an adult other than his grieving mother. He refused to say much. His stare was vacant. We were sitting in the living room where the incident took place. I gently guided some conversation and commented that Michael had never been given a chance to say “goodbye” to his Dad. I handed him a play telephone and suggested he “call” his Dad. Michael did call his Dad and I listened intently to the one-sided conversation as Michael asked questions, seemingly satisfied but saddened by the answers. He got to say “goodbye”.
Now I am certain that Michael continued to need grief work and support, perhaps throughout his life but I feel that he may have been saved just a little bit of despair having had an almost immediate opportunity to “talk it out”.
If Michael were to experience a different trauma later in his childhood/life, old memories of his Dad’s murder would likely be triggered adding another level of trauma. So, it is important to try to “resolve’ trauma before another one comes along. So many of us (me, included) do not recognize how these cumulative traumas can impact our development, mental state, physical and emotional pain, etc. decades later.
Not everyone experiences trauma the same way. For the most part, people make a good psychosocial adjustment. No two people experience stress the way another does. They may feel or behave like they are being traumatized all over again.
Chronic pain can alert us to the possibility that we have unresolved trauma in our nervous systems. Even if you believe that you have healed from all of your trauma, your nervous system may still be holding you hostage.
It is important to not only take care of yourself physically but also emotionally. There are many types of psychological treatments that can target old stress and trauma and work to diminish it. A traumatic memory can become a simple memory – something that happened that is still present in your nervous system, perhaps but no longer has the POWER it once did.This about sums it up: PAIN/ STRESS equals STRESS/PAIN..one leads to the other in all cases.
WHO REMEMBERS THIS OLD SONG ???
WELL, it’s kind of like that!
2…..And the beat goes on
So where did I leave off?
I talked about how doctor’s try to measure our pain with a 1 to 10 scale. Pain is subjective. There are so many words to describe pain, probably 100’s but I will try to provide a few adjectives that I have heard.
Pain is a very personal experience.People with the exact same illness or injury experience their pain differently.
We experience pain differently because we all have different “perceptions” of our pain. So many things can influence our pain. Here are just a few.
* CONTEXT: where and when the pain occurs. Say that you are in a plane crash. You are not alone. There are people laying on the ground with many types of injuries. You have a complex fracture of your left leg. Still, you crawl about trying to tend to victims with even more serious injuries. You barely feel your own pain until you are rescued and the crisis passes.
* HOW YOU THINK ABOUT YOUR OWN PAIN: Sometimes my pain is so bad that I can barely think about anything else. I am up there around an 8 or 9 on the pain scale. I am a dishrag because I am totally immersed in the pain experience so I do not allow for “distraction”.
One of my worst fears is getting burned in a fire. I know through my research that burn victims suffer unimaginable pain as they undergo treatments or therapy. However, research also has found that burn victims experience less pain if they allow themselves to be distracted by playing interactive video games as they get treated. So, I guess the lesson here is that when I am in severe pain, I need to “distract” myself with music, TV, movies (not too intense), etc. Most recently I started playing solitaire on my tablet (so long as my pain does not rest in my wrists) and I believe it is helpful. Not completely, but it may bring the pain down to a 6 or 7 which is more manageable.
• ANXIETY AND FEAR – sometimes I fear that I have absolutely no control over my illness/pain. Negative emotions contribute to pain. However possible, added stress needs to be avoided. To avoid those awful feelings I have no power in my illness, I try to “participate” more in my treatment by discussing medications, procedures, surgeries and diagnostic procedures with my doctors. It really helps you feel like you are more of a “partner” in your care, as opposed to being somebody’s “patient” with no will of my own.
• MEMORY – Ask yourself if you have ever felt “this kind of pain” before. We all have expectations of pain. I had a very painful inflammation of my rib cage awhile ago. Practically any movement (lifting, raising my arms, breathing, etc.) caused pain in the range of 9. Just a few days ago, I thought I was feeling the onset of another bout of “chondroitis” and almost felt like I had to cancel my mini-vacation as I was certain the pain was going to be debilitating. I had the “expectation” that the pain would be incapacitating. Instead, whatever the “pain” was it disappeared within 24 hours. I went on that vacation!
Doctors have found that when they as their patients how the pain was after a “procedure”, patients often rate their pain as a 3 or 4. But ask them again 10 days later and they report that their pain was much higher.
There is sometimes what is referred to as “anticipatory” pain. I had an embarrassing experience with my rheumatologist. My wrist was very inflamed. I could barely move it. ,It was time for another “injection”. Getting injections in your wrist is no laughing matter. It really hurts. The doctor went to touch my wrist to assess my pain and before his fingers even reached my wrist, I cried out in pain. What I was feeling was “anticipatory” pain. I remembered how awful I believed it was going to hurt like and responded to that expectation.
* FAMILY MATTERS- Your “expectations” for pain can really determine how much you “feel” your pain. Say that as a child you suffered from a chronic illness or just had frequent colds or allergies. If your parents doted on you (pots of chicken soup, cartoons and, of course, no school) you may grow up subconsciously enjoying being ill. As an adult, you may expect from your caregivers the same degree of attention and nurturing you received as a child. If, however, your parents provided just routine care and said something like “it’s just sniffle now get yourself out of bed and on the school bus”, you may view illness and pains simply as a nuisance. The risk: if you ignore or minimize your pain you may miss something important as pain is a warning.
* Personal and Cultural Beliefs- As a man do you believe it is not acceptable for a man to express his level of pain/distress? Do you believe that women are more susceptible to pain than men or that women are allowed to express pain more than men?
• FINALLY, there are coping abilities: Do you have good stress management skills? Stress management is essential as stress adds to the perception of pain. I know that when I am stressed, I experience far more pain than typically from my fibromyalgia.
So I guess that sums it up. There are a lot of influences that determine how much pain we feel and how we allow it to limit our lives.
It is Monday morning and heavy rain pummels my window. The rain is much needed. Rolling over to silence the alarm clock, I note that my wrist is stiff and painful. This is usually an indication that my level of inflammation is high and that it is going to be an uncomfortable day. Maybe not.
Sometimes it feels like pain is the only thing that is predictable in my life. Certainly not the weather.
I need to understand what my pain is about and perhaps, then, I will have more control over it. And so, I begin my research into Chronic Pain (C.P.)