Pain – It’s All in Your Head!

We have excellent news to share for all you chronic pain and acute pain sufferers out there. According to recent news articles and narratives pushed by various pain organizations and media sources, your pain that might be so debilitating, so mentally and physically disabling, well… It’s all in your head!

No need to worry about treatments anymore! Just do some deep breathing exercises, meditate a while, and stop focusing on your pain that causes so much distress in your life. Finally, a cure for you and your loved ones to end all your suffering!

 

Is pain really just in my head?

Ok, let’s jump back to reality and slow down on our hyperbole. There has been a disturbing trend and movement that has seemed to misinterpret the role mental health plays in pain. One that seems to be pushing a narrative that pain (especially chronic pain) is in the “heads” of patients, and that control of it ultimately comes down to them. A narrative somehow highlighting the biopsychosocial model of pain while minimizing actual biomedical concerns…

REALLY? Are you kidding me?

In a literal sense, yes, technically any and all types of pains are processed in the brain (it’s how we feel that pain is in our right knee when we bang it against a door). And, yes, our own emotions, mental health, situational behavioral health, and life stressors/circumstances all can impact our experience of acute and chronic pain, just as pain can certainly impact our emotions and mood… If our pain is high, most of us here aren’t in the best of moods.

However, dismissing the pathological features underlying acute and chronic pain, as well as the role our own body plays in trying to regulate pain, by framing the context of pain as something we can control absolutely with our emotions? That is a little more disingenuous. That narrative dismisses the reality that the psychosocial aspects of pain are extensions of the reality around the biomedical inputs of a patient’s pain in the first place.

Let’s break this down between acute pain and chronic pain models.

 

Acute pain: It’s all in your head

Acute pain, per the International Association for the Study of Pain (IASP), is a sudden pain that is caused by an injury, surgery, illness, or trauma that can last from minutes to months (has to be less than 6 months). Evolutionarily, acute pain serves as a warning sign of disease, threat, or injury to parts of our body to trigger a response, and usually resolves once the threat or disease resolves.

Now, over the past years, we have learned more about the underlying pathology of acute pains, and, of course, a lot of this depends on what the underlying cause is. Take surgery for example. Anytime parts of our body are being cut into, inevitably (not always), because various tissue and bones surrounded by neurons are cut through, specific responses will be invoked. Surgical procedures can instantly amplify a cascade of various inflammatory and pain-inducing neurotransmitters, up-regulate pro-inflammatory proteins and cytokines, and increase neuronal hyper-excitability. All of this leads to… You guessed it! PAIN!

 

Chronic pain is surely in your head!

Chronic pain, on the other hand, is a different animal altogether. While we have learned more about the underlying pathologies involved in the development and maintenance of chronic pain, again, this largely depends on what the specific root of the chronic pain is. Plus, there is still a ton we don’t know… The more we discover, the more questions we end up having (especially on the concepts of central sensitization and transition from acute pain to chronic pain).

However, for most types of chronic pain, there is usually a generator associated with actual or potential tissue damage (think of avascular necrosis of the hip, diabetic peripheral neuropathy, a tumor blocking the colon, etc). It is a pain that persists for more than 3 months and may continue despite successful management of the condition that initially caused it. Sometimes, there is no procedure that will successfully resolve the underlying generator causing damage. Thus, that generator is able to cause continual tissue damage in perpetuity. It can be associated with disability (thus financial loss), reduced productivity, declines in motivation, emotional and social problems, and poor well-being.

In many cases, neither our behaviors nor emotions can substantially change the underlying physical cause or pathology of the chronic pain itself.

 

So why all the buzz about therapy as a treatment of pain?

Understanding that the pathology of an acute or chronic pain generator may not be able to be physically corrected in a substantial way is one of the most crucial aspects when considering mental health as it relates to pain. And, in many cases, the goal of behavioral health directed at chronic or acute pain is *not* to change the pathology of the pain itself. Really, the goal of working with behavioral health as it relates to pain is trying to help control the emotional part of the pain process. We can target the psychosocial aspect of pain!

This is where the disinformation has thrown itself into the ring from all sides!

On the one side, no amount of specific behavioral health training, mindfulness techniques, CBT, or breathing exercises are going to substantially change certain underlying pathologies. And, realistically, no, the goal of those methods is not to get rid of pain all together! So, to the zealots who think chronic pain is just in our patient’s heads and can be fixed completely by mindfulness techniques. Or, to those who dismiss the biomedical inputs and influence on psychosocial aspects of pain because it isn’t consistent with the “biopsychosocial model”… You are WRONG!

On the other side, there is some fantastic evidence out there showing that specific forms of behavioral therapy in the appropriate patient can actually reduce both acute and chronic pain, improve function (to a degree), and improve certain aspects of quality of life. It may also help the emotional and social difficulties that can arise from pain conditions. For the vast majority of patients, these types of treatments should be offered and encouraged as a part of the multimodal treatment approach to pain. Certainly, no one would argue that garnering better control over our emotional response to pain would hurt?

Or, at the very least, exploring how our mental health is impacted by the pain we suffer from.

Of course, there are several barriers that often prevent successful integration of behavioral health into our treatment approach. Some of these include a limited number of psychologists/therapists trained in CBT for pain, a lack of understanding by clinicians in how to discuss this subject with patients, and, frankly, some patients having a difficult time understanding how these modalities could help. Costs and coverage of these services will always be an issue in our healthcare system (why work on behavioral health when there’s a pill for it).

Finally, too often is this used as a one and only crutch by providers, or interpreted by patients as ‘I’m crazy for having pain’. These are stereotypes that have to be addressed at the individual and system level!

 

So, tell me doc, is pain really in my head?

NO! Pain is not just in your head!

Pain may be processed in our brains and impact our behaviors, emotions, and mood, as well as be impacted by our own behavioral health. However, none of this substantially changes the underlying pathology of most pain types. Maybe we should start believing our patient’s pain again!

That being said, engaging with behavioral health directed at helping treat pain (and it’s associated symptoms) can produce beneficial results for patients and improve their quality of life. Just understand that it is not the only modality that should be considered when treating pain comprehensively.

 

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