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. Ron

    So many of the comments here are missing the point and instead are rushing to criticize psychotherapy for chronic pain. When psychotherapy is recommended to you, its not because your doctor thinks you are crazy or making up your pain or the pain is just ‘in your head’. Its because, as the article tried hard to explain, psychotherapy can give you ways and means to better cope with pain and deal with the emotional and psychological aspects that go with being in chronic pain. Using psychotherapy does not mean you have to stop everything else, your meds and treatments! I wish people would just calm down and be open to at least trying treatments offered instead of jumping to conclusions and attacking info sources, authors and doctors who are just trying to help. And of course, there will always be the folks who will say “do the authors have severe pain? What do they know”. This is the silliest argument ever. Does every doctor who treats diabetes have to be a diabetic? Does every surgeon who fixes a fracture have to suffer from a fracture first? Get real and grow up please. I suffer from chronic pain, have undergone multiple surgeries, but thankfully have the willingness to consider all options.

  2. Mino Pinna

    Very good post.

  3. M W

    The concepts of “Pain catrophizing”, “pain acceptance”, and “fear of pain” are 100% insulting to people in chronic pain, especially women and people of color. This has beem documented by multiple souces. Most chronic pain patients wait 2-9yrs for just a diagnosis!! They are consistently ignored, medically gaslit, and told thier symptoms are just in thier head or they are “malingering”.
    Patients who do not heal according to a specific time line are dubbed at fault for thier own symptoms even when there is a wealth of evidence linking chronic pain with certian procedures/conditions. Millions of chronic pain patients are undertreated for pain, if they can get treatment at all!
    “Pain catastrophizing/acceptance/fear” continues this medically abusive treatment. Patients who are refused acknowledgment of thier symptoms *and* treatment are *NOT* catrasophizing when they are consistently ignored/medically gas lit. They are *NOT* refusing to “accept” anything when they continue to seek proper treatment! They are *NOT* avoiding activities for “fear” of pain when they are seriously under treated for pain!!
    These are significant, life altering issues for patients. There is a wealth of research on the barriers and abuses to pain patients. ***Until these serious issues are abolished, *any* line of thought or treatment places the blame on patients and continues thier medical abuse. While this is not a popular view, it is 100% true. There is ZERO room for a conversation such as this article when patients wait 2-9yrs just for a diagnosis!
    If mental health professionals want to help chronic pain patients, they need to believe patients have legitmate pain that is harmful to them & deserves proper treatment! Mental health profeasionals need to ensure patients get diagnosed in a timely manner with appropriate pain management. If a patient does not have a diagnosis that meets thier needs *and* proper pain management with appropriate medication to reduce thier pain to a level they can function at (individually determined!) then nothing but working for that occur should happen! There should be ZERO talk of “accepting” untreated pain!! We would never tell a heart attack patient to accept the heart attack ans wait 2-9yrs for treatment as a norm! Telling chronic pain patients they should accept lack of care of subpar care is WRONG! Telling patients that activities that truly hurt because they are denied pain management is CRUEL!
    It is beyond conprehension that any “professional” would advocate this cruelty. Yet sadly much of the mental health profession has bought into medical gaslighting and abuse towards chronic pain patients. Somehow pain patients are no longer human enough to deserve individualized, proper care.

  4. L

    This is ridiculous and awful. While pain shares some of the same neuropathways as emotions, it doesn’t mean pain should just be “accepted” as neutral. Living in pain sucks, because it’s painful. Duh! So people in pain should be on appropriate and effective medications, and often that means pain medication. This is another way to pull people off opioid pain meds!! And it is INHUMANE.

    Let’s think of it this way: eating too much sugar often leads to anxiety. Diabetes is a failure to regulate blood sugar. Therefore we should tell all diabetics not to be anxious and practice accepting their blood sugar disregulation, use meditation, self calming techniques, etc. They dont need insulin.

    Does that make ANY sense??!

    No!! So why are we doing it with pain patients?

    Chronic pain causes high blood pressure, depression, anxiety, heart attacks, isolation, high cortisol/stress and weight gain. It is inhumane to allow pain patients to be in pain and tell them to practice “acceptance.” Most of us have accepted that we will be in pain. That doesn’t mean we shouldn’t be treated in accordance with sound SCIENCE and medicine.

  5. Beck Thomas

    I have a wrist injury. I slipped on ice, while getting out of my vehicle, during a freezing rain storm in the beginning of February of this year. I struck the ulnar side of my right wrist on the top edge of my vehicle door on my way down. There was damage to tissue, the ulnar nerve, a few ligaments and more. I have been on restrictions since the injury. My workplace sent me to another specialist, because they didn’t want to believe I still had pain. Their specialist stated that he thinks I have more pain than I am admitting to. I still have a large amount of inflammation – in the form of a hard lump – on the ulnar side of my wrist. Their specialist said it will get better, but it is going to take a long time. He also stated he cannot put a timeline on it. Now work is sending me back to work – against the specialist’s restrictions – which is putting it at risk of being injured again. I do not dwell on the pain, but I do notice it is always there because it is.

  6. Susan Quinn

    I live in severe pain from injuries caused by 2 car accidents and several falls. I have kyposis, scolosis, stenosis, multiple impingements, lateral herniated discs, osteophytes. Smorls, nodes. Faux gout, torn glut, tendons and ligaments, torn rotator cuffs, DDD and DJD, osteoarthritis and many more orth and neurological problems.. I am also a full time care giver for a 45 yrar old son with schizophrenic. My son has illnesses related to black box medications and our criminal mental health system. He also sufferd from back pain due to medications which cause obesity,
    I see a P.A. who works with psychairtrist.
    I am going to a clinic for my back which will require hard surgeries. My son has an ACT team who does as little as possible for my son. I have no one to take care of him if I have surgery. I can barely walk. How a physchairtrist help me?

  7. 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.

  8. 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

  9. 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.

  10. 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.

  11. 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.

    • Cynthia

      There’s information saying it’s a good article but not in agreement with the beginning. Just as you didn’t care for it. The balance of the article was good though. Best to focus on the total.

  12. 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.

    • Ks

      I read it.

      Glad you got your PTSD treated but seeing a psychologist isn’t going to help my cancer or broken neck.

      I have PTSD from lack of pain treatment but it definitely didn’t give me cancer or cause my pain.

      Stay in your lane.

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