I’m in pain, so why is my doctor suggesting a psychologist?

David Boyce, MD

Contributor

Pain makes us human. It is a bell, fine-tuned by evolution, that often rings in moments necessary for our survival. Because of pain, we can receive warnings that trigger the reflexes to escape potential danger.

But what happens when that bell continues to ring? How do we respond to a signal when it interferes with the other elements that make us human?

Pain that lasts longer than six months is considered chronic, and it may not go away. With chronic pain, the bell’s ongoing signal gets your nervous system wound up and increases its reactivity to incoming messages. This can be quite distressing and anxiety-provoking. Additionally, the feelings of frustration or sadness when pain doesn’t go away can make pain worse.

What’s the link between emotion and my perception of pain?

Pain, depression, and anxiety travel through similar pathways along your nervous system and share many of the same biological mechanisms. One of the areas in the brain that receives pain signals — specifically, the limbic region — shares many of the same messengers as the mood signals. We know from research studies using neuroimaging that the parts of the brain controlling emotion and sensory features of pain are altered in people with chronic pain.

The connection between pain and emotion can also be seen with certain classes of medications. For example, some medications used to treat pain can cause side effects like euphoria, and medications originally developed for psychiatric conditions can be effective treatments for certain types of pain.

The medical community has come to appreciate a direct correlation between improvement in one’s emotional well-being and their experience of pain (and vice versa). Chronic pain increases the risk of depression and anxiety, and depression and anxiety strongly predict the development of chronic pain. This association is seen in conditions like fibromyalgia and irritable bowel syndrome, where behavioral and psychological treatment strategies have shown benefit in reducing symptoms.

What can a psychologist help me address?

  • Pain catastrophizing: This is when you magnify the negative effects of pain and focus on feelings of helplessness while ruminating about the presence of pain in your life. Negative thoughts and beliefs about pain often lead to worsened emotional and social functioning and a decreased response to medical interventions for pain.
  • Fear of pain: Concern or worry about an injury drives avoidant or protective behaviors. The anticipation of an increased sensation of pain may limit you from engaging in physical activity or attending social outings. Pain-avoidant behaviors can lead to physical deconditioning and further decreased quality of life.
  • Pain acceptance: This is a challenging, but highly effective technique focused on developing an accepting attitude towards the pain. It involves doing your best to nonjudgmentally acknowledge the presence of pain and minimize unhelpful thoughts and behaviors that won’t make pain better.
  • Trauma: The link between prior trauma and chronic pain is becoming better understood. Psychological therapies can address ongoing physical and emotional stress responses linked to traumatic experiences.

What type of therapies help with chronic pain?

There are multiple psychotherapeutic treatment options commonly used to help people manage chronic pain. Practicing meditation and becoming as active as possible have been shown to be effective methods that can be done on your own. Mental health professionals who specialize in working with people in pain can guide you with additional evidence-based treatments:

  • Cognitive behavioral therapy (CBT): talk therapy that helps to change your thoughts and behaviors related to pain and improve coping strategies. You can learn CBT techniques with a psychologist or as part of a therapeutic group, which may also provide a support network.
  • Mindfulness-based stress reduction (MBSR): a form of mediation where you learn to nonjudgmentally become aware of your thoughts and feelings and accept pain and other uncomfortable sensations as neither positive nor negative.
  • Hypnosis for pain (hypno-analgesia): a set of techniques intended to modify your thoughts, feelings and behaviors via subconscious suggestions aimed at altering your experience of pain. Hypno-analgesia differs from CBT, which is a conscious recognition of your emotions related to pain and a more self-directed, action-oriented approach.
  • Biofeedback: a technique where your body functions such as heart rate, muscle tension, and skin temperature are monitored to make you aware of your involuntary responses to stress. During biofeedback sessions you learn a variety of ways to control your physical reactions to stress and anxiety.

Where can you find help to manage the emotional aspects of pain?

It is always recommended that you have a primary care physician coordinating your care, and you doctor may be able to provide you with a referral to a pain specialist or psychologist. It is worth finding out what mental health services your health insurance covers as you navigate this process.

Additional resources for finding specialists in your area:

American Chronic Pain Association

www.theacpa.org/

American Pain Society

www.americanpainsociety.org

Will my pain ever go away?

This question is surely at the top of every person’s mind if they are in pain. The difficulty in answering this stems from the variety and types of chronic pain syndromes, as well as individual variability. What has been shown to make a difference in people managing chronic pain is trying a variety of approaches, such as cognitive and behavioral techniques, staying active, practicing meditation, and working with your doctor to find effective medical and procedural interventions. The more of these interventions you try, the more likely you will find something that makes a positive impact.

The challenges of coping with a chronic pain condition cannot be understated. The negative emotions that come from it can be self-perpetuating, as one’s feelings of pain can lead to depression, and that very depression can lead to worsening pain. In coping with this cycle, the goal is to take whatever steps are possible to continue to lead a fulfilling life, including getting emotional and social support.

Our understanding of pain continues to evolve, and with it may come improved personalized treatments and better understanding of chronic pain’s influence on the body and mind.

Comments:

  1. Alicia

    Just out of curiosity, how many of the Doctors and/or authors of this publication personally deal with severe chronic and debilitating pain? How many of you have dealt with this level of pain for over 15 years of your life while working a full time job, being a spouse, raising three kids, and still maintaining a positive attitude?
    I’m not saying I disagree with the article. However, I strongly feel that when writing about and linking two life altering conditions, at least one of you should be writing having dealt with severe chronic pain yourself.
    No matter how brilliant one is, no matter how many degrees one might have, no matter how much research one has done, you will never ever truly understand what it’s like unless you have and continue to experience it yourself.

  2. Pbsaa

    I happen to agree that the body and mind are linked. When it comes to health and healing, the placebo effect shouldn’t be underestimated. Thinking that something will make you better will almost certainly increase its positive impact. For example, seeing a doctor in a white coat with a stethescope can induce the placebo effect and cause any treatments they prescribe to have a greater effect! This was in one of my Psychological and Behavioural Sciences modules at Cambridge

  3. Jane

    Thank you for this article, I’m a full time carer to my 18 year old daughter who has chronic pain following medical negligence during a Laparoscopy 18 months ago. She had tried hypnotherapy, psychotherapy, acupuncture, yoga ( when she is not incapacitated) and she spends at least 2 weeks a month in hospital when the 100+ tablets prescribed by her pain specialist, per week fail her and the pain spikes out of control. I hadn’t heard of biofeedback and I will look into it. Em is a fighter which has helped her to get through the dark times. She did try the Lightening Process in desperation and within the mix of everything it does help.

  4. Margaret Ratterman

    Interesting and helpful. I spontaneously helped myself years ago after I fell, landing hard on my hand, flipping back the wrist in the flexed position. The pain was unbelievable, blinding at that moment. It continued to be unbearable and help was not forthcoming. I stopped, took a breath and went inside: is this all pain or is it also fear of pain? Within seconds of self-assessment the pain diminished by half. This allowed me to wonder what else I could do to help myself better in other situations. Fear makes any experience exponentially worse, scarier, more painful, intense. Learning to distinguish fear in the current acute or chronic experience is immensely helpful.

  5. Barbara M

    As someone who has dealt with chronic pain issues for many years, I liked this blog write up UNTIL I got to the part about “so what can a psychologist do” –
    And the first 2 things mentioned, catastrophic thinking about pain, and fear of pain, make it seem like the patient’s pain is THEIR FAULT. Of course it isn’t, and a psychologist would agree, but don’t lead off with these two issues!
    The subtle feedback loops between depression, anxiety and pain, as you explained, are at the crux of managing it. That should be the first thing emphasized, in my opinion, and based on years of (now successful) treatment for more than 1 pain issue.
    Trying to keep moving is important but is a very tricky thing. It can’t be done when there is a major pain flare.
    Thanks for this article, overall a big step forward in people getting treatment for pain, just be so very careful not to blame folks for their pain. No one but them knows for how long and how much the pain affects virtually every area of their life.

  6. Rachel

    I was very surprised to see this article, and I just wanted to emphasize the importance of it! I repeatedly went to the doctor for physical symptoms that were common in those who have PTSD, and I was never told anything that might make me consider seeing a psychologist to address those issues. It wasn’t until I had more bizarre anxiety symptoms that I finally went to the therapist and was diagnosed with PTSD. More doctors need to know this link between PTSD and common chronic pain issues, like stomach pain/upset, neck/back/head/shoulder pain from tension, etc. and actually MENTION it to their patients. I didn’t want to go to the doctor anymore because I kept being told that I was perfectly fine, despite my pain. That is what led to my body telling me to find help through more uncommon and strange anxiety symptoms. I just want to say that I really appreciate this article and hope more people will read it.

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