Pain is a Widespread Problem

Pain is the primary reason for doctor visits. Over one of five doctor visits present with pain.

Over 76 million Americans have chronic pain, according to the American Pain Foundation. This organization has raised the alarm regarding under-treatment of pain.

Pain causes over $60 billion a year in lost productivity. It is costly to have chronic pain.

The majority of people with chronic pain have endured it for more than five years. Such a long duration leads to high levels of depression and frustration in pain sufferers.

Experts have estimated that 50% of the elderly approach the end of their days with inadequately treated pain.

Chronic pain can have many debilitating effects, including affecting workplace performance, family and social functioning, and even memory function. (University of Alberta, 2007)

Pain as a Personal Experience, Social Phenomenon, and Clinical Problem

People experience three types of pain, generally speaking. 1) Pain that doctors can't explain, 2) pain that has a physical medical explanation, and 3) "mental" or psychogenic pain.

All three types of pain can be disabling and very difficult to tolerate. Clinicians today operate under the hypothesis that there is a medical reason for all pain, and that it comes down to a question of what practices or specialties will bring the greatest benefit to the clients.

Many people think of psychogenic or unexplained pain as "all in the mind," as though it existed only as some kind of conscious or unconscious choice. This perception of unexplained pain is an expression of psychological defenses that protect us from feeling responsible, frustrated, or helpless in the face of another person's pain. These defenses convert the feeling of responsibility for someone else into blame, they convert the feeling of frustration into anger, and they convert the feeling of helplessness into denial.

These expressions of psychological defenses cause people with psychogenic or unexplained pain to experience 1) poor diagnosis and treatment, 2) stigma from society, their families, and practitioners, and 3) internalized stigma that can be emotionally disabling and delay the person in seeking help.

Mental health practitioners can offer psychological techniques for managing pain. These techniques range from training and reinforcement in self-help methods to hypnotic methods provided by the practitioner. Resistance to the use of these technique can come from: 1) the forms of stigma and psychological defenses referred to above (e.g., only crazy people need mental approaches), 2) the belief that a psychological approach is contraindicated by the belief or actual fact that structural abnormalities cause the pain, and 3) other misconceptions and lack of knowledge about psychological techniques used for pain.

Issues in the Physiology of Pain

Pain may feel like a single sensation, but it results from a cascade of physiological events involving various areas of the body. Each aspect of pain affords opportunities for intervention with physical and mental techniques. That is, psychological intervention in pain can target specific elements of pain in an approach that could be characterized as a "divide and conquer" mentality.

The brain has various parts that are involved in interpreting pain, called the pain matrix. This matrix tells you where the pain is, how intense the pain is, whether the pain is dull or sharp, and so on. It even tells you how much you do or don't like it!

Despite this knowledge, diagnosis may stop with the discovery of a structural abnormality that is believed to be responsible for the pain. However, many people who are pain free have been shown to have some of these structural abnormalities. In one study, people with pain got better at rates that were totally independent of their MRI findings. This is just one of a general pattern of what researchers are finding. This indicates that, in many cases, we must look deeper into the process of pain. Phantom limb pain provides further evidence of this, because of the diverse and chronic pain that does not respond to intervention on the nerves in the area of the amputation. (MacIver, Lloyd, Kelly, Roberts, & Nurmikko, 2008) If you have ever lost sensation to your lips because of dental anesthesia, you have probably noticed that your lips seem misshapen. This is not because of the anesthesia, or because of your lips changing their shape. It is because, much like phantom limb pain, the brain is attempting to make sense of the loss of perception of a part of the body that is normally there, and normally highly enervated and sensitive.

These physiological changes, and the locations of chronic pain cause much chronic pain to be less susceptible to pain medication than proprioceptive pain. This makes it difficult to treat, and confronts treatment providers with ethical questions regarding appropriate levels of pain medication. Also, the nerves that tend to be involved in chronic pain are not nerves that respond well to pain medication. Resistance to pain medication has been found in people with fibromyalgia.

Inflammation is getting a great deal of attention. Researchers have discovered that it is a complex process that may be implicated in a number of psychiatric disorders, as well as non-psychiatric problems. It is implicated in the intensification and spreading of pain through means that are less obvious than an inflamed injury. For example, it has been found that pain can cause inflammation. In typical injuries, we are aware that injury causes inflammation, and that inflammation causes pain. However, the fact of inflammation causing pain appears to help explain why chronic pain can develop and spread. It has been found that pain signals can initiate inflammation in non-injured areas. This, in turn, may contribute to the development of pain in the new area. Also, nerves connected with the spine can become sensitized by ongoing pain. This may result in the pain being perceived as coming from another area of the body. This, in turn, can develop inflammation.

Another way pain may spread is through the pain-spasm-pain cycle. Pain can cause tension, which causes additional vulnerability to pain through various means such as increased likelihood of a pulled muscle and increased wear on joints. Somatic psychotherapy techniques and various non-psychological movement training programs may help clients learn to use their bodies in less stressful ways.

Pain Psychology

Many of the psychological interventions for chronic pain target the way the brain represents pain. We can divide any awareness or cognition into sensory modes such as feeling, and subsets of these modes such as intensity or location. By modifying the experience of these subsets, the experience of pain can be dramatically altered for many clients. The results can provide short-term relief, shrt/long&pts can self monitor&apply-when pain is the highest  a self-help practice, or long-term relief.

Pain can be quite vulnerable to such interventions. In fact, hypnotherapists have found that some people's pain improves before the intended intervention is complete. Instead, the pain is resolved or improved during hypnotic preparation for the intervention.

An example of cognitive intervention with a sensory subset of pain targets the perceived size of the affected area. Having the client imagine that the area is shrinking can cause the pain to shrink or recede from awareness. This is referred to as visual analgesia. The literature on the work of Milton Erickson, MD, includes numerous examples of altering the client's perception of pain in conjunction with hypnosis. In the Resource appendix Books section, see The Collected Papers of Milton H. Erickson on Hypnosis for some excellent examples.  

Phantom limb: Surprising evidence of the importance of mental representation of pain comes from work with phantom limb pain. Apparently, the brain's attempt to represent the missing limb may cause it to interpret it as a pain signal. Phantom limb patients may experience a great variety of feelings that may or may not include pain. These can even include the feeling that water is running over the limb or that the fist is painfully, spasmodically clenched. While the patient's effort to unclench the fist may have no effect, the clinician may be able to eliminate the pain by creating a sort of optical illusion with a mirror and the unaffected limb. This was a great breakthrough in helping clinicians recognize the importance of mental representation of pain.

Mental techniques: Pain levels are influenced a great deal by mental phenomena such as expectation. One study used fMRI to find that the expectation of pain can increase the brain's response to actual pain by 40%. (Baliki, Geha, Apkarian, & Chialvo, 2008)

Studies have shown that negative emotions including anger and fear can increase the experience of pain. (Burns, Bruehl, & Caceres, 2004) This supports the value of assisting clients in generating emotional balance. In that regard, mental skills can be an indirect pain treatment. 

Research is showing us that mental imagery (a modality used in pain) reorganizes the brain. (MacIver, Lloyd, Kelly, Roberts, & Nurmikko, 2008)

Psychological and Mental Health Factors

Personality factors? While there is no pain personality, there are certainly personality factors that can interfere with pain recovery or even exacerbate chronic pain. People are in a better position to recover from or manage chronic pain if they are assertive and solution focused. Of course, psychotherapists are adept at helping clients build these abilities. People with these traits have been shown to have less disability from pain.

It is likely that a strong belief in pain-prone personalities results from the biased samples that practitioners experience. John Sarno, MD is probably a good example of this. He is a popular advocate for the idea that perfectionism, being a do-gooder, and having unconscious rage are pain-causing personality factors. He has sold many books and has many adherents. However, his approach is likely to attract certain groups, and his results are likely to be from factors unrelated to his personality theories. His theory of chronic pain is not accepted by medicine or psychology. However, the people who read his book and experience improvement are very impressed. Two more reasons for the pain-prone personality belief to endure are that people with chronic pain desperately want a feeling of control, and those without the pain feel compelled to blame people who have chronic pain for the pain.

Isolation can interfere with receiving help and complying with medical and psychological care. The experience of stigma, rejection, insensitive responses to their pain, and the feelings triggered by the pain itself can all contribute to isolation behavior. The psychological defense mechanisms of others, along with a lack of experience or knowing what to say, can cause people to say things that are surprisingly off-base. The hurt from such statements can have a profound psychological impact. People  who are prone to internalize stigma are especially vulnerable. An important intervention can be education regarding this kind of dynamic and how to overcome it.

Anxiety: We know that anxiety can contribute to some kinds of pain. But anxiety is not a personality profile. There are many psychiatric conditions that involve anxiety and many types of personalities that can have elevated anxiety. However, one trait of people who do not manage their anxiety well is that of catastrophizing. Cognitive therapists are concerned with ways that people can amplify anxiety with thought patterns. Thus, this can prove to be an important area to work on with clients who have chronic pain.

Abuse and traumahistories: It has been shown that people with child abuse histories have greater risk for pain after back surgery. One study showed 85% risk for persons with childhood abuse histories, but only 5% for those who did not. This may relate to a genetic vulnerability to a variety of problems that results from childhood abuse, including higher incidences of anxiety and depression. Vulnerability to inflammation is an area of research for this population.

Changes to the brain observed in abuse survivors involve cortical thinning in areas that process pain. This has also been observed in persons who later develop fibromyalgia. Psychological abuse history is a risk factor for fibromyalgia.

Incidence of PTSD is elevated in migraine patients. The reason for the association has not been established.

Stress: Research has revealed that stress is a major predictor of pain and recovery from pain. One very large study was conducted by physicians who were not biased in favor of psychological explanations. They found emotional distress, stress, and depression to be the most significant risk factors for chronic pain. Psychological problems were associated with worse pain.

Approaching clients: When approaching the use of mental techniques and mental or emotional factors in pain, it is very important to present the ideas and information in a way that will not elicit a stigmatized reaction from the client. Normalizing the condition and the factors involved, and generating a positive, supportive atmosphere are very important, given what we have covered about pain as a biopsychosocial phenomenon.

Suffering as a Perception of Pain

Imagine experiencing a pain such as during a dental procedure. Now imagine that the pain is only information. You don't cringe, knit your eyebrows, or feel an emotional desire to stop the pain. You are fully capable of responding to pain that is injurious, but only because you know it is bad, not because of the need to avoid the immediate suffering associated with pain.

This description matches that of persons who have had a cingulotomy, an operation that disconnects the anterior cingulate gyrus in such a way that it cannot perform its function of producing suffering. The same is true for people who have experienced significant injury to this part of the brain.

This is another example of how pain is a series of physiological handoffs, interpretations, and integrations. In this example, pain only equates to immediate suffering with the involvement of a specific part of the brain. Without it, the pain experience is dramatically altered.

Because a cingulotomy involves deep brain surgery, it is a last resort in the treatment of intractable pain. There are drawbacks to the cingulotomy. They may result in problems with focus and attention, and other symptoms that resemble attention deficit disorder. Memory loss or problems may occur. Rarely, there may be seizures or urinary problems. Also, the surgery may lose its effectiveness, typically after about three years. The surgery is also being used for obsessive compulsive disorder, mood disorders, and addictions, producing very good results including the elimination of addictive cravings.

Research is being conducted on less invasive ways of modifying brain responses to pain. These include deep brain stimulation (DBS), using magnetic stimulation to decrease the intensity of functioning in specific areas of the brain for pain. This involves a brain implant, so it is also a surgical method. (Spooner, Yu, Kao, Sillay, & Konrad, 2007)

Given the survival value of reacting vigorously to pain, and communicating pain or danger to others, it's no wonder that there would be a part of the brain that specializes in mobilizing us with intense emotion in response to pain. There is a similar reaction to falling. Many of us have involuntarily screamed when falling from a height, even in a carnival ride. It is likely that this is a drive to alert others, and that it was selected for because it functioned to increase the odds of the person being retrieved after a fall. There is clinical value in perceiving suffering from an evolutionary perspective and as a specialized brain function; it can improve our objectivity and our understanding of effective interventions.

Since suffering is an expression of pain perception, psychological techniques for chronic pain can target this interpretation. Since drives have "off switches," imagery or other symbols of help and responsiveness improve pain in some clients.

Pain and Policies

There is a growing appreciation of the importance of intervention in pain. For example, there are two areas which, until recently, have not been recognized widely as requiring additional attention. One is the experience of pain in the elderly (to some degree, this has also been true for young children and babies), and the other is people with chronic pain who are not getting adequate results from pain medication. Treatment of pain in the elderly has been challenged by cultural conditioning that tells us pain is a normal part of aging and should be tolerated. This has led to under-treatment of pain. In the case of medication, the provision of high levels of pain medication has been affected by stigma and the possibility of opiate addicts malingering in order to get opiates. Activism and growing recognition of these issues by professional organizations is producing improvements in the treatment of pain by overcoming preconceptions and stigma. While it may be true that pain can build character, we also know that long-standing and overly intense pain can create additional pain. For this and other reasons, professionals in pain treatment advocate for perceiving pain itself as a medical issue requiring treatment.

Causes of Chronic Pain

Not all chronic pain results from long-standing, painful illnesses or orthopedic problems. A high level of pain can cause physical changes that make the body more vulnerable to producing chronic pain, even when the initial problem is relieved.

The answer lies in aspects of pain production that are not as familiar as the kind of pain we experience from a stubbed toe. Chronic pain that comes from the physical changes (independent of the initial illness process) we are discussing, occurs farther along in the pain process. These physical changes can be caused by long-standing pain, especially when the pain is relatively intense.

1. A perfusion of pain nerves can develop, and this causes heightened pain sensitivity and production. This appears to be caused by gene activation. In other words, excessive pain can activate genes that cause pain nerves to grow in great numbers in the area (perfusion). This susceptibility to pain can become so extreme that even blowing on the area can produce intolerable pain.
2. Actual biochemical changes in the pain transmission pathway can increase sensitivity and pain production.
3. Changes in the brain can cause pain perception to continue unabated. These changes often result from the strengthening of nerve conduction that occurs when a nerve pathway is highly utilized.  In addition, some people are more vulnerable to pain because of the way their brain perceives or generates pain. It appears that this condition is congenital or developmental. 

Types of Pain

The sensation of pain comes from several types of nerves and phenomena.

1. The pain nerves that tell us about injuries such as a stubbed to are the proprioceptive nerves, and they produce proprioceptive pain, also called somatic pain.
2. Pain produced by stretching of internal organs is called visceral pain. These pain sensors are not as varied and dense as on the surface of the body. Also, many of these nerves use the peripheral nerves to get pain signals to the brain. For these reasons, visceral pain generally does not give as clear a location, or may even give the wrong location for the source of the pain.
3. Ischemic pain is produced when the body senses an area in which there is not enough blood flow, and the tissues in that area are deprived of oxygen. This is sensed by sympathetic nerves. These nerves sense damage occuring inside the body. They, too, are not very good at telling the brain exactly where the pain is. This is why people sense the pain of a heart attack (ischemia) as coming from other areas such as their left arm. Pain felt in the wrong location is called referred pain. An ice cream headache (brain freeze) is actually caused by a nerve in the throat. This is an example of referred pain. Another example is pain felt in the lower back during childbirth. This is actually pelvic pain.

The somatorsensory cortex of the brain determines where pain is located, as best as it can, by developing a map based on interacting with the world, as well as innate development.

Diverse Means of Disrupting Pain Interpretation

The discovery that pain perception can be altered has led to the exploration of countless ways of altering or disrupting pain perception. Often, the result has been a durable change in pain perception that has reduced suffering. Just as preparing for hypnosis may improve pain, anticipating a miracle may alter pain. This appears to explain why sacred places and rituals, and various forms of psychic healing have helped many people. It also explains why many people claim to have experienced great improvement in pain from  pills, bracelets, and other interventions that have been proven to have no ability to affect pain other than through the placebo effect. Research has not supported any form of psychic or so-called energy healing or intercessory prayer in affecting pain or other medical conditions when compared to the placebo effect. While this may be disappointing, the placebo effect itself has become a target of research and is proving to be a source of knowledge about not only the psychology of pain, put also the physiology of pain.

It has been shown that psychological pain techniques alter the way the brain processes or creates pain. Some examples include, 1) targeting areas of the brain that contribute to a sort of feedback loop that can make pain chronic, 2) reducing pain generated directly in the brain, 3) interfering with factors that contribute to pain generated in higher spinal areas, 4) targeting peripheral pain be reducing muscle tension through relaxation and movement training, 5) disrupting and altering the encoding and interpretation of pain so that less agony or intensity is produced. This may cause the brain to experience a kind of "reset" effect.

The placebo effect is not in this list, because it is likely that this effect is produced by a number of factors singly or in combination. An evolutionary psychology theory regarding the placebo effect has to do with the need to fulfil drives in order to turn them off. Since suffering can be perceived as a drive, as we have discussed, responding to this drive with something symbolic of help may turn off the expression of that drive. It has been noted that the power of a placebo in reducing pain can be enhanced by the doctor using the word "help" as in, "I believe that this will help you." This would explain the use of faith healers, since they powerfully represent help in many cultures.

Researchers are working to better understand the physiology that produces the placebo effect. Two types of placebo effect have emerged. One involves the production of opiates, while the other involves the disruption of the interpretation of pain. Psychological techniques may attempt to trigger this effect, but through other means than fooling the client with a pill. 

Lifestyle and Pain

Most clients are aware that lifestyle factors such as diet can affect well being. There are numerous factors specifically relevant to developing or maintaining resistance to developing chronic pain. Knowledge and skills in these areas should be encouraged. Meditators have been shown to enhance cortical thickness in areas that correspond with pain management.

It takes time, training, and practice to use bodywork, exercise, and rehabilitative practices to their greatest advantage for pain resistance or recovery. Egoscue and Prudden's work provide good overviews (see the Resources appendix). The clinician can refer clients to resources with the understanding that it is an important investment in time with real payoffs in feelings of well being.

Our understanding of the impact of diet on pain resistance is progressing. For example, numerous studies suggest that adequate levels of vitamin D are valuable in preventing pain. Clients can learn about dietary factors such as pro- vs. anti-inflammatory foods. Appropriate sleep is important in preventing pain.

Sleep disorders are very common, but many people do not realize that they are not sleeping well. Sleep disorders should be diagnosed and treated.

Research has shown us that a great deal of bed rest is not rehabilitative for pain problems, generally. There are various challenges, however, to resuming activity when there is or has been a pain problem that has limited mobility or activity. Challenges include regaining normal responses to activity (i.e. reflexes and emotional tolerance), overcoming the modifications of behavior that pain induces (e.g. a behavior modification effect resulting from associating pain with activity), and rebuilding strength and structural integrity. This may require assistance from a properly trained professional. Occupational or physical therapists may be useful or have referrals to appropriate professionals. 

Group support has been shown to aid pain sufferers. These take place in-person and online in various forms. The Resources appendix provides examples of online group forums.

Resources

Organizations

The American Chronic Pain Association

www.TheACPA.org

"Since 1980, the ACPA has touched the lives of millions of people who have chronic pain. Through a national network of peer support and education, the ACPA continues to help those with pain improve their quality of life."

The American Pain Foundation

www.PainFoundation.org

"Founded in 1997, the American Pain Foundation is an independent nonprofit 501(c)3 organization serving people with pain through information, advocacy, and support. Our mission is to improve the quality of life of people with pain by raising public awareness, providing practical information, promoting research, and advocating to remove barriers and increase access to effective pain management."

The Mayday Pain Project

www.PainAndHealth.org

"The Mayday Pain Project was created in 1994 by an educator with a background in rural health issues and a pharmacist with critical care nursing experience. Initial funding was provided through a grant from the Mayday Fund of New York. The Pain Project's initial goal was to improve pain assessment and care of patients in Michigan's rural, isolated Upper Peninsula. That goal still drives us today, but has now expanded to a national and international scope."

Partners Against Pain

www.PartnersAgainstPain.com

"Partners Against Pain is a resource that serves patients, caregivers, and healthcare professionals to help alleviate unnecessary suffering by advancing standards of pain care through education and advocacy."

In the Face of Pain

www.InTheFaceOfPain.com

"In the Face of Pain Advocacy Toolkit provides you with a series of tools to advocate for people in pain. You can learn the basics of how to share messages about the rights of people in pain through your community, your local media outlets, your elected officials and your professional organizations. You also have access to current data and statistics about condition or population-specific pain that can be used to support your advocacy efforts. Lastly, you have the capability to build a personalized advocacy plan, tailored to your specific interests."

The National Headache Foundation

www.Headaches.org

Help For Headaches

www.Headache-Help.org

Educational services for those suffering from and treating headaches and migraines.

National Arthritis Foundation

www.Arthritis.org

The Complete Guide to the Alexander Technique

www.AlexanderTechnique.com

Online Discussion Forums and Resources

HealthCentral.com

HealthCentral.com has pain forums for general and specialized issues

"Make a connection, ask a question, share a concern, give advice or just chat. Our message boards connect you with a community of people who understand where you're coming from and what you're going through."

Google and Yahoo Groups

Chronic Pain Anonymous is a Google group.

MSN.com hosts a forum on chronic pain

Recordings

Brainwaves for Sleep Reinforcement

Personal Journey, Robert A. Yourell

Delta Sleep System, Jeffrey Thompson, Ph.D.

Visualization and Mental Techniques

Health Journeys: For People Managing Pain, Belleruth Naparstek

Shimmering, Robert A. Yourell

Books

Pain Free: A Revolutionary Method for Stopping Chronic Pain. Egoscue, P. New York: Bantam, 2000. This is a broad overview of myofascial health.

The Permanent Pain Cure: The Breakthrough Way to Heal Your Muscle and Joint Pain for Good. Ming, C. New York: McGraw Hill, 2008. This, too, is a broad overview of myofascial health.

Pain Erasure. Prudden, B. New York: M. Evans and Company, Inc., 2002. This explains how to use trigger point self-therapy for myofascial pain.

The Collected Papers of Milton H. Erickson on Hypnosis. Erickson, M., Rossi, E. Irvington Publishers, Inc., 1980. The sections on pain are very helpful for developing clinical intervention.

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