Think Pain Is Purely Medical? Think Again.

Pain isn’t simply a medical issue—it's psychological and social, too.

Posted Oct 25, 2019

"MRI Scan of a Head" by Ranveig/CC BY-SA 3.0
Pain isn't all in your head, but it IS in your brain.
Source: "MRI Scan of a Head" by Ranveig/CC BY-SA 3.0

Good or bad news first…?

Since good news soothes the bad, let’s go with the bad news first: According to a recent article in the British Journal of Medicine, the U.S. currently faces twin pain-and-opioid crises (Mackey & Kao, 2019). Chronic pain (CP), pain lasting three or more months or beyond expected healing time, is an epidemic currently affecting over 100 million American adults—more than diabetes, heart disease, and cancer combined—at an estimated cost of $635 billion (IOM, 2011). 

CP can interrupt life, impeding the ability to work, exercise, have sex, engage in hobbies, or even go outside. It’s the number-one cause of long-term disability in the U.S. (NIH, 2011). As if this wasn’t bad enough, we now find ourselves in the midst of an opioid crisis—what the U.S. Department of Health calls “the most daunting and complex public health challenge of our time.”

One reason we find ourselves in this pickle is that pain has historically been framed as a “biomedical” problem, due exclusively to biological issues like tissue damage and anatomical dysfunction. It has, therefore, primarily been treated with biomedical solutions, like pills and procedures. However, CP is neither being cured nor solved, addiction rates are skyrocketing, and the prevalence of chronic pain is still on the rise (Nahin et al., 2019). While this does not mean we should rip pills from the hands of long-term pain sufferers—which is unethical at best and cruel at worst—something clearly needs to change.

Now for the good news (and not soon enough!): Thanks to recent advances in science and medicine, we now understand pain better than ever before. Research on pain management and treatment advances daily, and previous wrongs are being made right. There is hope.

To better understand pain, let’s first define it: the International Association for the Study of Pain (IASP) defines pain as an “unpleasant sensory and emotional experience.” Said another way, pain is both physical and emotional 100 percent of the time. It’s never just one or the other. This is confirmed by neuroscience research indicating that pain is processed by multiple parts of the brain, including the limbic system—your brain’s emotion center (Martucci & Mackey, 2018).

Stop. Rewind.

“Physical” pain is also, and always, impacted by your emotions.

So why do we have pain? Answer: pain serves as the body’s danger response system, keeping us safe and alive by warning us of possible harm. Pain teaches us to avoid dangerous situations in the future and motivates us to take action in the present. Step on a nail? Pain galvanizes you to pull it out! Break your ankle on a run? Pain motivates you to stop, get help, and heal. And once you burn your hand on that hot stove, chances are high you’ll learn never to do it again.

You may reasonably believe that pain is located exclusively in your body, in the part that hurts. But while sensory information from the body is critical to pain processing, pain is actually constructed by the brain. Evidence of this is a condition called phantom limb pain, in which an accident victim loses a limb and continues to feel terrible pain in that missing body part. If pain were located exclusively in the body, no limb should mean no pain!  

It’s also reasonable to believe that pain is due exclusively to body-based biological issues, as suggested by the biomedical model (e.g., “the issue is in the tissues”). However, what we now know—and have actually known for decades—is that pain is not biomedical, but rather biopsychosocial (Gatchel, 2004). 

This means there are three overlapping, equally-important domains to target if we want to effectively treat CP: biology, psychology, and social functioning. The biological domain includes genetics, hormones, tissue damage, inflammation, anatomical issues, system dysfunction, even sleep and nutrition. This domain typically receives the most attention. But two-thirds of the model remain, and psychosocial factors, critical to address for effective treatment, are frequently ignored.

The psychological domain of pain includes thoughts and beliefs (e.g., “I’m broken; I’ll never get better”); prior experiences and expectations; emotions (e.g., anxiety, anger, depression), and coping behaviors (e.g., withdrawing, avoiding movement and activity). Social factors include socioeconomic status, access to care, family, friends, culture, community, context, and other socioenvironmental factors. Neuroscience research reveals that negative emotions, catastrophic thoughts, and unhealthy coping behaviors actually amplify pain, exacerbate symptoms, and keep you stuck in a cycle of fear, inactivity, misery, and pain. Said another way: stress, anxiety, depression, catastrophic thinking, negative predictions, focusing on pain, social withdrawal, lack of exercise, and activity avoidance all make pain worse.

On the flip side, however, this revelation offers some optimism: Research confirms that we can exert some control over pain by taking charge of emotions, thoughts, beliefs, attentional processes and coping behaviors using treatments like Cognitive Behavioral Therapy (CBT), biofeedback, and Mindfulness-Based Stress Reduction (MBSR) (Cherkin et al, 2016; Kerns et al, 2011; Nahin et al, 2016; Sturgeon, 2014). These interventions have a robust evidence-base that grows every day. Additionally, providing patients with pain education may reduce pain and disability, increasing understanding of pain while reducing fear of movement and activity-avoidance (Louw et al., 2013; Louw et al., 2016).

Biobehavioral interventions like these have been shown to change both brain and body, neuroscience and biology, showing potential to calm the pain system and increase functioning (Davidson et al., 2003; Flor, 2014; Petersen et al., 2014; Martucci & Mackey 2018). Indeed, psychosocial approaches to pain management are so promising that some pain programs, such as those at UCSF and Stanford, now incorporate them into their integrative pain management clinics. As a pain psychologist, I see the effectiveness of these therapies every day in my practice, as patients get out of bed and resume their important lives.  

So if you’re coping with chronic pain, remember this: Changing your brain can change your pain. Addressing your emotional health directly impacts your physical health because brain and body are always connected. Consider hiring a therapist to be your “pain coach”—it doesn’t mean you’re crazy, and it’s not all in your head. Try biobehavioral interventions like CBT, biofeedback, and mindfulness, and request that your insurance company reimburse these approaches to pain management in addition to pills and procedures.

If you’re a therapist or health provider, your help is desperately needed. Learn more about pain and spread the word about biopsychosocial pain management. Check the reference section for books and articles that can help pave the way. Hire pain psychologists and other integrative providers in your hospital or clinic. Teach patients how pain works, connect the mind with the body, and offer hope.

Knowledge is power. Let’s empower our patients—and each other—to find integrative solutions that work.

Facebook image: Dmytro Zinkevych/Shutterstock

LinkedIn image: By Marcos Mesa Sam Wordley/Shutterstock

Read next: What Changes Pain?

References

Zoffness, R. (2019). The Chronic Pain & Illness Workbook for Teens: CBT & Mindfulness-Based Practices to Turn the Volume Down on Pain. New Harbinger Press.

Mackey S, Kao MC. (2019). Managing twin crises in chronic pain and prescription opioids BMJ (Clinical research ed.); 364:l917.

Institutes of Medicine: Relieving Pain in America: A Blue-print for Transforming Prevention, Care, Education, and Research. Washington, DC, The National Academies Press, 2011.

King S, Chambers CT, Huguet A et al. (2011). The epidemiology of chronic pain in children and adolescents revisited: a systematic review. Pain 152(12), 2729–2738.

National Institutes of Health (2011) Pain Management. [Online] Available from:  https://report.nih.gov/nihfactsheets/ViewFactSheet.aspx?csid=57 [Accessed 23 Oct 2019].

Nahin, R. L., Sayer, B., Stussman, B. J., & Feinberg, T. M. (2019). Eighteen-year trends in the prevalence of, and health care use for, noncancer pain in the United States: Data from the Medical Expenditure Panel Survey. The Journal of Pain. 20(7):796-809.

Martucci KT & Mackey SC. (2018). Neuroimaging of Pain: Human Evidence and Clinical Relevance of Central Nervous System Processes and Modulation. Anesthesiology: The Journal of the American Society of Anesthesiologists, 128(6): 1241-1254.

Gatchel RJ and Maddrey AM. The Biopsychosocial Perspective of Pain. In: Raczynski J and Leviton L, eds. Healthcare Psychology Handbook. Vol II. American Psychological Association Press. Washington, DC. 2004.

Cherkin DC, Sherman KJ, Balderson BH, et al. (2016) Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain: A Randomized Clinical Trial. JAMA. 315(12):1240–1249.

Kerns RD, Sellinger J, Goodin BR (2011) Psychological treatment of chronic pain. Annual review of clinical psychology 7: 411–434.

Nahin RL, Boineau R, Khalsa PS, Stussman BJ, Weber WJ. (2016). Evidence-based evaluation of complementary health approaches for pain management in the United States. In: Mayo Clinic Proceedings. 91(9):1292-1306.

Sturgeon JA. (2014). Psychological therapies for the management of chronic pain.  Psychol Res Behav Manag. 7:115-124.

Louw A, Butler DS, Diener I, Puentedura EJ. (2013). Development of a preoperative neuroscience educational program for patients with lumbar radiculopathy. Am J Phys Med Rehabil, 92:00Y00.

Louw A, Zimney K, Puentedura EJ, Diener I. (2016) The efficacy of pain neuroscience education on musculoskeletal pain: a systematic review of the literature. Physiotherapy Theory and Practice, 32(5):332-55.

Davidson RJ et al. (2003). Alterations in brain and immune function produced by mindfulness meditation. Psychosomatic Medicine, 65(4):564–570.

Flor, H. (2014). Psychological pain interventions and neurophysiology: Implications for a mechanism-based approach. American Psychologist, 69(2):188.

Petersen, GL, Finnerup, NB, Grosen, K, Pilegaard, HK, Tracey, I, Benedetti, F, Price, DD, Jensen, TS, Vase, L (2014). Expectations and positive emotional feelings accompany reductions in ongoing and evoked neuropathic pain following placebo interventions. Pain, 155:2687–98.