How to Deal with Chronic Pain: Psychological Causes and Treatments

Chronic Pain in line

We like instant gratification. Who doesn’t? You desire a thing, you want it as soon as possible. This is entirely rational. The food looks good, you’re (relatively) hungry, so let’s eat. That gadget would be fun to play with, you’ve got the money (or credit) for it, so let’s buy it. This is why we sign up for and can never relinquish our Amazon Prime same-day shipping, why we demand antibiotics for viral infections, and why we can purchase and collect entire buckets of fried chicken without ever leaving our cars. We don’t like to wait if we don’t have to. And we rarely have to wait. This extends to how we deal with physical pain: my arm hurts, I want this pain to go away right now, so I’ll take a painkiller.

The problem with this approach to pain is that the quick solutions rarely work like they do for other physiological messages. Hunger is simple. You put something in your mouth, chew, and swallow. Hunger gone. But pain is complex. Pain is communication. When something hurts, your nervous system is telling you that something is wrong with your body (that stove is hot, your ankle is sprained, you pulled your hamstring) and you should fix it (pull your hand away, elevate and stay off your ankle, warm-up before you sprint next time). People born without the ability to feel pain are extremely vulnerable to death and dismemberment. It might sound cool to live without pain, but we desperately need it to survive.

Acute pain can usually be trusted. Chronic pain is trickier. There may have been initial tissue damage, but instead of decreasing the pain as the damage healed, it increased: chronic pain usually gets worse, not better.

How does the conventional medical system deal with most chronic pain?

Strong drugs: Opioid painkillers don’t work. Well, they “work,” but a little too well. You have to keep taking them to keep the pain at bay in increasingly larger doses, which increases the risk of addiction. They don’t actually help you heal or resolve the pain, and if anything, they increase your sensitivity to chronic pain. Dulling the pain or killing it with strong drugs usually doesn’t fix the underlying problem. Especially for chronic pain—the kind of pain that lingers and follows you through life—magic bullets don’t really exist. It’s no wonder that millions of Americans are addicted to prescription opioids like oxycodone.

Surgery: Though it’s great for acute tissue damage, surgical interventions for chronic pain have mixed results. Back fusion surgery outcomes are generally inferior to non-surgical interventions, and failed back surgeries have the potential to increase chronic pain and dysfunction. That a condition called “failed back surgery syndrome” even exists is telling. And research pitting knee surgery against placebo knee surgery suggest that arthoscopic knee surgery may not be required to “fix” chronic degenerative meniscus tears.

Pain is an output from the brain, not an input from the body.

When tissue is threatened/damaged/burned/lacerated/sprained, peripheral nerves called nociceptors send alarm signals to the brain, but the brain must interpret those signals and decide if you should “feel pain” or not. Utility determines pain: you’ll feel it if it’s helpful. The basketball player who sprains his ankle in the 2nd quarter of a pre-season game will immediately feel it, because his brain wants him to rest instead of finishing out the game. If that same injury occurred in game six of the NBA finals, his brain might “allow” him to continue playing because the stakes are so high. The soldier whose leg was mangled by a grenade probably won’t feel pain commensurate with the damage done, because his brain wants him to drag himself to safety.

Physical damage doesn’t always cause pain, and you don’t even need to possess the supposedly painful tissue to feel pain in the tissue. Consider phantom limb pain, where amputees still feel pain in the missing limb. There’s no limb to hurt, no nerves to send or receive signals, yet it still hurts. Thank the brain.

First off, I’m no doctor. Like anything involving the brain, chronic pain can be incredibly complicated. What I can offer are a few low-impact, non-interventional Primal ideas for improving your pain situation. I won’t be telling you how to adjust your own spine or anything like that. In fact, I’ll save the physical interventions for another post. Today is all about the psychological causes and fixes for physical chronic pain.

What are some things to consider?

Try the Sarno Method

A doctor of rehabilitation, for years Dr. John Sarno had seen back pain patients treated the conventional way. Throw ’em in the imaging machine, identify bulging discs or other trauma, and go from there. Sometimes it was surgery, sometimes physical therapy. It rarely worked. Then he realized something wild: while almost everyone had some sort of physical trauma to their back, the pain they felt didn’t always correlate to the site of the trauma. Someone might have a bulging disc at the L1/L2 but feel pain higher up, or vice versa. Furthermore, back surgery to fix the trauma rarely reduces pain. And acute back injuries, like a crushed disc hurt like hell but usually stop hurting after a few weeks, just like a broken leg. What Sarno discovered is that a lot of chronic back pain stems from bottled up stress, anger, or repressed emotions. The psychological pain becomes physical. Sarno dubbed this tension myositis syndrome, or TMS.

The Sarno method has two phases:

  • The patient must address the psychological causes of the pain.  They didn’t necessarily have to fix the problems causing the stress and emotional turmoil, but they do have to acknowledge their existence and confront them head on.
  • Since the root cause is psychological, not physical, the patient must resume physical activity. This is crucial. You have to “prove” to your brain that your body isn’t suffering from physical trauma that would restrict movement.
  • A 2007 study confirmed it: the Sarno method works for back pain patients without specific structural pathologies, especially those with chronic pain. Many patients find that merely reading Sarno’s book, even just the introduction, reduces their chronic back pain. They aren’t medical references, but check out the gushing reviews on Amazon for Sarno’s book. Just becoming aware of the psychological origin of the pain is often enough to fix it.

    Learn about pain science

    A funny trick about pain is that merely learning about how it works can often reduce it. This may have happened just a few paragraphs back when you read about the brain interpreting signals from the nerves and deciding whether or not to send pain back.

    First of all, everyone can learn and understand it. Doctors may think it’s too confusing for most patients, but in 2003 they actually tested this. Chronic pain patients with inaccurate conceptions of pain science were able to understand the neurophysiology of pain when it was properly and accurately explained (even the doctors improved their knowledge of pain science).

    Second, learning about pain neuroscience can reduce chronic pain. An older systematic review of the literature concluded that educating chronic pain sufferers about pain neurophysiology and neurobiology has a “positive effect on pain, disability, catastrophization, and physical performance”; a 2016 review came to the same conclusion.

    To learn more abut pain science (and hopefully improve your own chronic pain), look no further than Todd Hargrove, whose book and blog offer great insight into the physiological origins of—and potential solutions for—all types of pain.

    Deal with, or at least acknowledge, the major stressors in your life

    This isn’t an easy or even simple solution. Stress is hard and the things that cause stress are numerous and unending!

    But if there are any obvious ones, any real whoppers, take them on.

    Bad relationship? Address it. Try counseling. Try a “we need to talk.” Don’t ignore the issues and tell yourself it’s okay. Your brain knows it’s not okay, even if you’re trying desperately to convince it otherwise.

    Hate your job? No one should spend 40+ hours a week doing something they loathe. It’s not healthy. And research out of the US shows that people who hate their job are more likely to progress from acute to chronic pain. Chronic pain is more common among dissatisfied workers in Japan, too.

    Plagued by a perpetually messy house? Don’t just walk by those dirty dishes for the tenth time this week. Clean them, go minimalist, or hire a de-clutterer. Or all three.

    It’s different for everyone—I can’t anticipate every stressor in everyone’s life—but this all boils down to “don’t run away from your problems.” You must at least acknowledge them (remember the Sarno method?).

    Understand that fear may be holding you back and making the pain worse

    Pain needs fear to work. When you touch that hot stove or prod that wasp nest, the pain you receive scares you away from repeating the mistake in the future. As a response to acute pain, fear-avoidance works—it prevents future instances of pain. As a response to chronic pain, fear-avoidance worsens outcomes and hastens the progression to disability. Research has found that among people with chronic pain, those exhibiting more fear-avoidance are more likely to become disabled, to miss work, and to avoid normal daily activities.

    But pain-avoidance doesn’t just predict bad outcomes; it also has real effects. The more they avoid the activities they assume will cause pain, the worse they get. Their muscles atrophy. They actually get more sensitive to pain. In one controlled trial of patients with chronic low back pain, inducing “pain anticipation” before a behavioral test reduced performance and increased pain. As some pain researchers put it, the fear of the pain is more disabling than the pain itself.

    Consider how being scared of your pain goes down: you live in a constant state of anxiety, worried that one wrong turn or miscalculated twist of the body will send you reeling to the floor.

    In the end, it’s no different than being wracked with physical agony. You’re scared to move. You think about pain all day. You curtail your normal existence. Your fear of pain has disabled you.

    Increase the stakes of painful movements

    Recall how the NBA player turning his ankle in a pre-season game is more likely to feel it and take a couple weeks off than if he were to turn it in a playoff game. Pain is a negotiation, it’s the culmination of the brain deciding whether the stakes are high enough for you to keep doing the activity that triggered the nerves to send the “pain request” signal. You can control the stakes and thus affect the negotiations.

    Get some competition in your life or join a team sport; if people are counting on you or you’re up against your arch nemesis, your brain is more likely to turn down the chronic pain to let you participate. If you’re walking ten miles to raise funds for cancer research, maybe your foot or back or knee won’t hurt so much.

    Live the good life

    A big part of the pain response comes from the brain’s assessment of your overall situation: if things in general are bad, it’s more likely to err on the side of causing pain. Research into the psychosocial causes of non-specific chronic low back pain in Japanese adults finds that anxiety, life dissatisfaction, and feeling underappreciated at work have the most predictive power. Sound familiar?

    Do things that make you happy. Take warm baths at night with a good book. Hang out with friends; don’t be a hermit. Get some midday sun, work on that promotion, build that business you’ve been milling over for years. Improve the quality of your life. Avoid regret. There are innumerable ways to improve your life and increase happiness.

    Know that it’s not “all in your head”

    Pain comes from the brain, true. It’s the result of the brain’s deliberation over the situation, true. The brain decides if you feel pain or not, true. But the pain is real. You’re not crazy, you’re not “imagining” the pain. The brain isn’t conjuring pain without reason. You may not agree with the reason, and the physical damage to the tissue may not warrant the amount of pain you currently feel, but there’s still a there there.

    That’s it for now, folks. Next time I’ll discuss some “physical” causes of and treatments for chronic pain, but for now be sure to direct any comments and questions down below.

    Do you experience chronic pain? Does any of this ring true for you?

    Thanks for reading!

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