By Angel Foster, LMSW
Pain can be excruciating. It can push us to the point of begging for mercy and crying out in desperation for relief. Throughout our human experience, pain will be present to varying levels of severity and frequency. We are injured, we have pain, and we heal. But what about pain that seems to stick around long past an injury? Or pain that appears in the absence of any pathological tissue damage? Chronic pain is a challenge for many Americans today. Of those suffering from chronic pain, the overwhelming majority do not have clearly, identifiable structural damage. Studies show that 85% of chronic back pain, 90% of pelvic pain syndromes, 98% of headaches, 99% of fibromyalgia, and 99% of irritable bowel syndrome is brain induced- meaning without evidence of any pathological tissue damage (Deyo et. Al. 1992; Kroenke, 2003). This does not presume that this pain is not real or one has the simple choice to no longer experience it, but rather that the experience of pain is most often a result of learned neural pathways in the brain.
In 2011, The Institute of Medicine put out a Report titled “Relieving Pain in America” giving us some significant insight into pain and how we treat it. The report found that 100 million Americans suffer from chronic pain- more than cancer, diabetes, and heart disease combined. It also shockingly found that none of the pain treatment options currently in use are actually working. Things like pharmacological agents, surgery, steroid injections, and implantable drug delivery systems are not found to be curing pain. Recent studies show that opioids are no better than Tylenol for chronic pain (Krebs EE, Gravely A, Nugent S, et al. 2018). There are no studies showing that surgery is more effective for low back pain than physical therapy, stretching, or doing nothing and waiting it out. Even injection therapies are found to be no more effective than placebo (Chou et. Al. 2009).
Perhaps even more surprising are findings from a study published in 2014 by Waleed Brinjikji from the Mayo Clinic in which MRI’s conducted on completely healthy individuals with no reports of any back pain show that 52% of 30-year-old’s and 80% of 50-year-old’s have disc degeneration. Further, 40% of 30-year-olds and 60% of 50-year-olds have bulging discs. There are no studies that find any significant connection between the experience of pain and MRI results and although bulging disc and disc degeneration are a normal aspect of aging, they are not stand alone in causing pain.
How does pain work in the brain?
Our brains construct our experience of pain. Touching a hot stove inherently does not give us the experience of pain- our brains do that. When an injury occurs, it sends a signal to the subconscious, automatic parts of the brain. The brain decides if there is a need to activate the danger/alarm signal thus resulting in pain. Emotional pain activates this same danger/alarm mechanism which can activate physical pain. All pain is a conscious message from the brain; the message could be that our leg is broken or it could be that something in our life needs attending to.
Once pain occurs it becomes a learned neuropathway in the brain. This becomes a vicious cycle as the pain itself can further activate the danger/alarm mechanism increasing our experience of pain. This is a cycle of chronic or recurrent pain learned by the brain. This works the same as when we learn how to walk or ride a bike- it becomes automatic. Also influencing our pain experience is the way we respond to our pain. That is the more we think about it, monitor it, avoid it, fear it- the stronger these pain pathways in the brain become.
What is missing in our standard treatment of pain?
It is the connection between the mind and body. The understanding that emotional injuries activate and process through the same systems in the brain as a physical injury. One study demonstrating this was done by the University of Michigan using functional MRI scanning to explore the experience of physical vs emotional injury (Kross, et. Al. 2011). Their findings confirmed that physical pain and emotional pain are experienced in exactly the same patterns in our brains. Studies like this show us that emotional pain can lead to physical pain and vice versa.
Further establishing the understanding that emotional injuries activate and process through the same systems in the brain as a physical injury are the multitude of findings related to the impacts of stress on health. Economic uncertainty has been found to greatly increases the psychological sensitivity to physical pain (Chou et. Al 2016). We also know from the widespread ACE Study looking at lifelong impacts of 10 highly stressful adverse childhood experiences (parental separation, witnessing domestic violence, physical sexual or emotional abuse, physical or emotional neglect, a family members incarceration, and a family member struggle with addiction or mental health) that there is a direct connection to early childhood stressors and lifelong physical health and pain. People with 4 or more of these experiences are 3 times as likely to suffer from multiple bodily symptoms, twice as likely to be obese, twice as likely to have emphysema, and on average died 20 years younger (Felitti, et. Al. 1998). Sometimes even decades after some of these stressful childhood experiences, there can be lasting effects on health and physical pain. These above-mentioned childhood experiences are elevated in people with fibromyalgia, migraine headaches, interstitial cystitis (painful bladder), pelvic pain, and irritable bowel syndrome (Goodwin, et. Al. 2003; Sumanen et. Al. 2007; Latthe et. Al. 2006; Meltzer-Brody et. Al. 2007 ; Mayer et. Al. 2001).
The research confirms that the mind and body are living together and a significant proportion of pain is brain induced. It confirms that the brain constructs all pain as a protective mechanism through various neuropathways. Stress and emotions activate the danger alarm mechanism in the same way physical injury does and for many this results in a vicious cycle of chronic pain. Equally important to note is that recovery from pain is possible. Reversal can occur with educational, cognitive, behavioral, and affective interventions.
What happens next?
It is first necessary to identify if symptoms are caused by a structural disorder or by neural pathways in the brain with thorough medical examinations. If no structural damage can be identified, attentions turn to treating neuropathic pain. This new paradigm recognizes that while the pain is both real and powerful, it is a result of neural pathways in the brain. Pain is a prevalent, unavoidable part of the human experience and treatment is available.
Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., … Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 36, 811–6.
Chou R, Atlas SJ, Stanos SP, Rosenquist RW. (2009). Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine. 34(10):1078-1093.
Chou, E. Y., Parmar, B. L., & Galinsky, A. D. (2016). Economic Insecurity Increases Physical Pain. Psychological Science, 27(4), 443–454. https://doi.org/10.1177/0956797615625640
Deyo RA, Rainville J, Kent DL. (1992). What can the history and physical examination tell us about low back pain? JAMA. 268(6):760-765.
Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS.(1998)Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE)Study. Am J Prev Med.(4):245-58. PubMed PMID: 9635069.
Goodwin, Hoven, Murison & Hotopf, 2003; Sumanen, Rantala & Sillanmaki, 2007; Latthe, Mignini, Gray, hills, & Khan, 2006; Meltzer-Brody et al., 2007; Mayer, Naliboff, Chang & Coutinho, 2001. Childhood adversities (divorce, family conflict, sexual abuse, physical abuse etc.) and adulthood experiences of conflict and victimization are elevated in people with migraine headaches, internal cyctitis (painful bladder), pelvic pain, and irritable bowel syndrome.
Krebs EE, Gravely A, Nugent S, et al. (2018) Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 319(9):872–882. doi:10.1001/jama.2018.0899
Kroenke, K. (2003). Patients presenting with somatic complaints: epidemiology, psychiatric co-morbidity and management. Int. J Methods Psychiatr Res. 12: 34–43.
Kross, E., Berman, M.G., Mischel, W., Smith, E.E., & Wager, T.D. (2011). Social rejection shares somatosensory representations with physical pain. Proceedings of the National Academy of Sciences of the United States of America, 108 15, 6270-5 .
IOM (Institute of Medicine). 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press.