Anxiety Is Not Just an Emotion

By Mara Baer

“Anxiety” made her debut last month on the silver screen in the “Inside Out” sequel and I jumped at the chance to see it with my 12-year-old daughter.

"Inside Out 2" is an imaginative exploration of the human experience, centered around a girl named Riley, set primarily within her mind, where her emotions live in “Headquarters” and guide her through life's experiences. Both the original movie and sequel provide an insightful look at the inner workings of the mind with humor and heart. Although geared towards kids, they provide some great lessons for adults too.

As someone who experiences anxiety, I was interested to see how Disney and Pixar portrayed this character. Anxiety can be an alarming reaction to one’s environment, causing uncertainty, worry and fear.

People like myself who live with chronic pain have elevated anxiety symptoms. Because the region of the brain responsible for generating pain is also partially responsible for anxiety, these connections should not be surprising. I know when I am having anxiety, but it is often hard to understand.

Inside Out’s new character drew me to the story of Riley, a 13-year-old girl in the throes of puberty, who is learning how to manage new feelings. The first movie introduces us to the characters of Joy, Sadness, Fear, Anger and Disgust, with each character’s physicality depicting their primary emotion.

In the sequel, five new emotions show up, just as Riley’s pubescent hormones take hold. In addition to Anxiety, there are Envy, Embarrassment, Ennui, and Nostalgia:

We can all recall our teenage years, when anxiety, envy, embarrassment and ennui became frequent visitors and often defined our interactions. Nostalgia pops up on occasion, to be told by the others that it isn’t her time yet and that she should come back later. Next movie, perhaps?

Anxiety is an eye bulging, shaky, intense character aglow in shades of orange. Her wiry hair and floating eyebrows make clear that Anxiety is intense, alert, and always “on.” While Anxiety’s goal in the movie is to keep Riley safe and protected, she eventually becomes destructive, pushing Riley’s limits in a hockey game in the name of “winning” and at the cost of her true self.

As someone known as a planner (sometimes to a fault), I relate to Anxiety’s need to think ahead and prepare for every problematic scenario, sometimes at the expense of my underlying values. This is the tension with anxiety, always pushing us to the limits for a cause, even at the expense of the individual experiencing it.

Knowing this tension and the shared brain region informing both anxiety and chronic pain got me thinking. What other ways are these two connected? 

As I explained in my article in Chronic Pain Chats, when we experience pain for more than three months, neural pathways can be altered, creating pain signals that are very difficult to turn off. Anxiety can be similar, sending negative feelings and thoughts into a spiral that can feel uncontrollable.

In Inside Out 2 (spoiler alert), Anxiety continues to push Riley at hockey camp to help her achieve success and build new friendships. In doing so, she ignores old friends, begins to fight with her parents, and eventually injures a friend in a game meant to determine if she would make the high school team. She is laser-focused on winning and loses touch with who she fundamentally is.

Chronic pain can do this too, becoming the center of our journey, disrupting our life path, our relationships, and who we are. Both anxiety and pain have robbed me at times of feeling like my true self. Riley experiences the same with Anxiety.

The similarities do not end here. Both anxiety and chronic pain are associated with physical sensations, feeling overwhelmed, excessive worry or fear, negativity, sleep problems, and avoidance. Anxiety can also exacerbate pain levels and lower pain thresholds. 

When Anxiety goes into overdrive during that hockey game, Riley experiences a panic attack. The audience watches as Anxiety goes into a trance-like state, trying to protect Riley and “fix” what has gone wrong, eventually sending Riley to the penalty box in a very powerful scene.

I saw my own anxiety in Riley’s, and feelings of sadness overcame me as I watched how strong and influential my own anxiety can be. That scene in the movie stuck with me, so much that it prompted me to investigate the anxiety/pain relationship and write this article. While I understand a bit better now why anxiety must exist, it can be distracting at best and debilitating at worst. 

How I Manage Anxiety

The key to managing anxiety is how I interpret its function in my life, starting with how I define it.   

While the movie portrays Anxiety as an emotion, there is some debate in the literature about whether it is. Some experts define anxiety as a state of being with feelings at its root -- what’s been called a “visceral form of emotional resistance.”

In essence, when anxiety is happening, it is because our brain is trying to protect us from a fundamental emotion that feels scarier and more threatening than anxiety itself (i.e., fear). Chronic pain is similar, sending a signal to try protect us from physical harm, even if the threat of harm is no longer there.

Other experts see anxiety as a  secondary emotion, meant to replace a more difficult primary emotion. Dr. Lauren Gorog, a Clinical Health Psychologist in Colorado, defines anxiety as a conditioned response (think mental, emotional, behavioral response) to fear. She says anxiety is typically driven by deep beliefs of inadequacy and our human tendency to “awfulize” an unwanted outcome. That can lead to a physiological and psychological state of hyperarousal that produces a distressed emotional state, with a host of mental, physical, and behavioral symptoms that negatively impact virtually all parts of our lives.

While the debate over anxiety’s role will no doubt continue, I choose to NOT define my anxiety as a simple emotion, because it takes away my ability to do something about it. Like pain, not all anxiety is bad, and both have protective factors. But we can still choose how we respond to each. 

Irrespective of whether we call anxiety an emotion or not, it is grounded in one’s mindset and can change. In fact, the best way to counter anxiety is to “feel your feelings.” Many people with chronic pain do not do this, pushing away feelings that harbor themselves in the body, which leads to more pain for longer periods of time.

Interestingly, similar strategies can be used to address chronic pain, including somatic tracking and Pain Reprocessing Therapy, which focus on paying attention to pain without judgement or fear, which has been proven to lead to less pain. 

At the end of the Inside Out 2, Joy tells Anxiety: “You don’t get to choose who Riley is. You need to let her go.”

Anxiety doesn’t choose who I am. Neither does pain. I will make sure of it. 

Mara Baer lives with Thoracic Outlet Syndrome, a nerve entrapment condition that causes severe pain. Mara is the founder of AgoHealth, a health policy consulting firm. She also serves on the Science and Policy Advisory Council for the National Pain Advocacy Center and publishes Chronic Pain Chats, a free newsletter.

Why Pain Is Not ‘All in Your Head’

By Gabriella Kelly-Davies, PNN Columnist

Anyone who lives with chronic pain knows it can affect their emotions. Every morning when I wake with a migraine, I feel a sense of doom. My heart races and I panic about how I will cope with everything that lies ahead of me that day — the meetings, deadlines and responsibilities, not to mention family and social commitments that often end up taking a back seat as I scramble to find ways of simplifying my day.

After decades of living with chronic migraine, I now know these emotions intensify my experience of pain. Having said this, I know it is not “all in my head” as some might claim, but part of a complex interaction between my emotions and the way my central nervous system incorrectly processes pain signals.

Exciting new Australian research using sophisticated brain imaging is shedding new light on what happens at an emotional level for people living with chronic pain.

Chemical “messengers” known as neurotransmitters facilitate communication between brain cells. Some neurotransmitters are inhibitory, helping to dial down our emotions, while others are excitatory and increase the intensity of emotions. A molecule known as γ-aminobutyric acid or GABA is the main inhibitory neurotransmitter.

Neuroscientist and psychologist Sylvia Gustin, PhD, discovered that GABA levels are lower in people with chronic pain and this affects their ability to regulate their emotions. The link between lower levels of GABA and chronic pain had been shown in animal studies, but Gustin’s research, recently published in the European Journal of Pain, is the first time it has been demonstrated in humans.

“A decrease in GABA means our brain cells can no longer communicate with each other properly,” explained Gustin, an associate professor at the University of Sydney’s School of Psychology. “When there’s a decrease in GABA, it makes it harder to keep emotions such as fear, worry, anxiety and depression in check.”

Gustin’s research shows there’s a physical change in the central nervous system that helps explain the roller coaster of emotions people living with pain often experience.

“If you live with chronic pain, it’s important to remember it’s not you -- there’s something physically happening to your brain. We don’t yet know why this happens, but we’re working on finding solutions on how to change it,” Gustin told me.

Her research confirms that chronic pain, which affects one in five people worldwide, is more than just an uncomfortable sensation. “It can affect our feelings, beliefs and the way we are,” she says. “Almost half the people living with chronic pain also experience major anxiety and depression disorders.”

GABA is not the only neurotransmitter that behaves differently in people living with chronic pain. In an earlier study, Gustin and her colleagues found levels of the main excitatory neurotransmitter in the central nervous system – glutamate -- are also lower in people with chronic pain. Lower glutamate levels are linked to increased feelings of fear, worry and negative thinking. They disrupt how brain cells talk to each other, affecting the ability to feel positive emotions such as happiness, motivation and confidence.

“My research results are reassuring for people living with pain because they show that physical changes in the brain are contributing to anxiety and depression and it’s not a person’s fault they struggle with these emotions,” Gustin said.

Her research team recently developed and tested an online recovery program that teaches people skills to help modify negative emotions such as fear, worry, anxiety and depression. The program helps to address the neurotransmitter disruption in chronic pain.

“Online programs offer hope to people living with disabilities or those in rural and remote communities who often struggle to access pain management services,” she said. “Online programs are also ideal during COVID-19 lockdowns.

“We know that chronic pain is always present, and we can’t get rid of it. But we can change the way we experience it by learning new skills. Like all skills, it takes practice to master it, but we hope it will offer another tool for people to change the way they experience pain.”

Gustin says preliminary results of this research, which will be published in a few months, are encouraging. Several organizations, including Australia’s National Health and Medical Research Council and Medical Research Future Fund, the International Association for the Study of Pain (IASP) and the U.S. Department of Defense, are helping to fund her work. To learn more about this research, click here.

Gabriella Kelly-Davies lives with chronic migraine.  She is the author of “Breaking Through the Pain Barrier,” a biography of trailblazing Australian pain specialist Dr. Michael Cousins. Gabriella is President of Life Stories Australia Association and founder of Share your life story.

How Chronic Pain Disrupts Emotions

By Pat Anson, PNN Editor

Does waking up with pain everyday put you in a bad mood? Do you lose your temper easily or worry a lot?

It could be a sign that chronic pain has created a chemical imbalance in your brain that makes it harder for you to keep negative emotions in check, according to a new study by Australian researchers.

“Chronic pain is more than an awful sensation,” says senior author Sylvia Gustin, PhD, a neuroscientist and associate professor at the University of Sydney’s School of Psychology. “It can affect our feelings, beliefs and the way we are. 

“We have discovered, for the first time, that ongoing pain is associated with a decrease in GABA, an inhibitive neurotransmitter in the medial prefrontal cortex. In other words, there's an actual pathological change going on.”

Gustin and her colleagues at Neuroscience Research Australia (NeuRA) used advanced neurological imaging to scan the brains of 48 people. Half of them lived with a chronic pain condition, while the other half had no history of chronic pain and served as a control group.

Their findings, recently published in the European Journal of Pain, showed that participants with chronic pain had significantly lower levels of GABA than the control group – a pattern that was consistent regardless of the type of chronic pain. 

Neurotransmitters help communicate and balance messages between cells in the brain and central nervous system. While some amplify signals (excitatory neurotransmitters), others weaken them (inhibitive neurotransmitters). GABA, or γ-aminobutyric acid, is one of the latter. It acts in the brain as emotional regulator that helps dial down our emotions.

“A decrease in GABA means that the brain cells can no longer communicate to each other properly,” Gustin explained in a news release. “When there’s a decrease in this neurotransmitter, our actions, emotions and thoughts get amplified.”

While the link between chronic pain and decreased levels of GABA has previously been found in animals, this is the first time it’s been demonstrated in humans. Gustin hopes the findings will encourage people with chronic pain who may be experiencing mental health issues. 

“It's important to remember it’s not you – there’s actually something physically happening to your brain,” she says. “We don't know why it happens yet, but we are working on finding solutions on how to change it.”

GABA is not the only neurotransmitter that’s impacted by chronic pain. In a previous study, Gustin and her research team found that levels of glutamate, the main excitatory neurotransmitter, are also lower than average in people with chronic pain. Low glutamate levels are linked to increased feelings of fear, worry and negative thinking.

“Together, our studies show there's really a disruption in how the brain cells are talking to each other,” says Gustin. “As a result of this disruption, a person’s ability to feel positive emotions, such as happiness, motivation and confidence may be taken away – and they can’t easily be restored.” 

Medication can help relieve chronic pain, but there are currently no drugs that directly target GABA and glutamate levels in the brain. Gustin and her team are developing an online emotional recovery program as a non-pharmaceutical option for treating neurotransmitter disruption. 

“The online therapy program teaches people skills to help self-regulate their negative emotions,” says Gustin. “The brain can't dampen down these feelings on its own, but it is plastic – and we can learn to change it.”

Do You Have ANT’s? How Awareness Helps Avoid Negative Thoughts

By Dr. David Hanscom, PNN Columnist  

This is the third in a series of columns on awareness -- a meditative tool that can be used to calm the nervous system to reduce pain and anxiety.  In my previous columns, I looked at environmental awareness (how mindfulness lowers stress hormones) and emotional awareness (how moods affect how we feel physically). 

The third level of awareness I’d like to introduce you to revolves around judgment and storytelling. On this level, you create a “story” or a judgment about yourself, another person or a situation. These judgments tend to be criticisms that are rough and inflexible. The brain has a bad habit of focusing on negative judgments that ramp up our emotions. 

We can categorize these negative thoughts into ten “errors of thinking” outlined by Dr. David Burns in his book “Feeling Good.” Burns calls these thoughts “ANTS,” which stands for automatic negative thoughts.

For example, imagine someone at work walked by you and didn’t acknowledge you. You might think they’re upset with you about a situation that occurred the day before. The error in thinking in this case would be “mind reading.” You can’t read other people’s minds. 

It’s possible that the other person had just received some bad news and wasn’t engaging with anyone. But you don’t really know. If you make assumptions, you’re wasting a lot of emotional energy.

Labeling 

Then there is the error of labeling. For example, a frequently late spouse becomes “inconsiderate.” A forgetful teenager becomes “irresponsible.” In the act of labeling, especially negative labeling, you’re overlooking circumstances and someone’s good qualities, limiting your capacity to enjoy being with them. 

Then there are the labels we have for ourselves: you knock something over and call yourself “clumsy.” If a lover breaks up with you, then you’re “unlovable.”  

Rehashing these critical judgments in our minds turns them into deeply embedded stories. Such stories are much harder to move on from than single judgments. Once a judgment sets into a story, you tend to lose all perspective. Over time, faulty thinking can become your version of reality. 

In my own experience, whenever I have an “ANT,” I become either angry or anxious (or both). I am also sometimes more reactive or impulsive. These emotions fuel negative thought and it becomes repetitive. As the thought keeps whirling around, it becomes stronger, along with my emotions. They quickly destroy my day and negatively affect my relationships. 

I’ve heard this thought pattern described as a vicious cycle or whirlpool. These kinds of thoughts, or stories, can become recurrent and might last for years. They take on a life of their own even though they are often fairly outrageous.  

Regardless of what sets these patterns of thinking off, they are a universal part of the human experience. This is true whether chronic pain is involved or not. With chronic pain you have the added frustration of the physical stimulus to keep these circuits really spinning.  

Self-Perceived Flaws 

To better understand the story concept, consider common situations where the brain focuses on a self-perceived flaw that is not physically painful. It might be your height, weight, the shape of your body, or even an individual body part. Or it might be some particular quality, such as a lack of intelligence, athletic skill, musical talent, etc.  

Thinking about these flaws over and over snares you in a destructive cycle of spinning neural circuits. For example, many years ago I had a patient with neck pain who was absolutely convinced that he was “stupid.” His self-labeling wasn’t rational, as he was clearly a bright guy. I don’t know if his view of himself somehow triggered it, but he eventually developed a significant chronic burning sensation around his mouth. 

Something similar often happens in the entertainment industry, where performers commonly focus only on their negative reviews. My wife, who is a tap dancer, has seen this in her profession for years. She pointed out to me that a performer might have 99 positive reviews but will fixate on the one that’s negative. It’s a common saying among entertainers that, “You’re only as good as your worst critic.” 

ANT’s and Relationships 

Another common phenomenon is focusing on a spouse or partner’s negative traits. The other person usually has innumerable positive qualities that are forgotten in the face of their “flaw.” Over time the “story” we tell ourselves can become so strong it can break apart an otherwise great relationship. 

One particular event from my own life comes to mind. It shows how creating stories has the power to disrupt your peace of mind and detract from your enjoyment of life. 

One day my wife and I were taking my father for a ride up to beautiful Point Reyes, located on the coast north of San Francisco. About 20 minutes into our trip I noticed that the car’s low-tire-pressure light had come on. It was a brand new car with only a thousand miles on it, so I thought it was probably just a malfunctioning light.  

I wasn’t convinced that we’d made the correct decision to buy this car in the first place -- it was more expensive than I was comfortable with -- so I was more than a little frustrated that the warning light had a glitch. 

I stopped to put a little air in the tire, just in case, and then kept driving for another 45 minutes. As we approached Point Reyes in the early afternoon, we realized that the tire was really low, so I pulled over to change it. But when I opened the trunk, there was no spare.  

The story in my head was starting to ramp up as I wondered in frustration why a new car wouldn’t have a spare. I called the car company’s roadside assist line and they told me these new cars had “run-flat” tires that should be good for 150 miles at a maximum speed of 50 miles per hour.  

I felt a little insecure about that concept. We were a long way from the last large town we’d passed and I thought that we should turn back. My wife thought that since my father rarely made it to California from the East, we should go out to dinner. So, we headed toward a restaurant. About three miles down the road the tire exploded. 

It was now about four o’clock in the afternoon and we were miles and miles from anywhere. Our only option was to get towed courtesy of AAA. It was hard for me to accept the fact that I had to get my new car towed for a flat tire.  

The tow truck driver showed up to take us to the service station and let the three of us ride in the cab, with my wife sitting on my lap. She started to complain about the bumpiness of the ride, which I found a little annoying. “I’m the one on the bottom, why are you complaining?” I thought.  

She wanted to have dinner in San Rafael and take a taxi home. I started to grind my teeth to keep my mouth shut. 

Magnifying the Problem

This is how the afternoon unfolded for me. Starting with the low tire, I’d made a decision to enjoy my time with my family in spite of the problem. I took note of my frustrations and concentrated on listening to the conversation and staying involved in the day. I was successful for a while -- until the tire blew up.  

Then my anger began to bubble. I became aware that in spite of everything I’d learned about dealing with stress, I was greatly magnifying the problem with the ANT thoughts in my head. I was thinking things like, “I can’t believe I got talked into buying this car” and “My wife made me buy it.” 

Although there might’ve been some truth in the things I was telling myself, I recognized that it wasn’t helping us get through the situation. Nonetheless, I wasn’t able to minimize my suffering through the stress relief techniques that had helped in the past, which was frustrating. I tried to talk myself out of it, but it didn’t work. 

Then I began to go really dark with thoughts like, “How can I be married to this woman?” I began to notice how irrational and big these thoughts had become. It felt like a bomb had exploded. I was miserable way out of proportion to the situation. 

I was guilty of multiple errors in thinking. They came in the form of labeling – “My wife is irresponsible”— and catastrophizing -- “Why did we get married?”  

Through it all, I negated her many positive qualities. To cite one, she’s great at keeping things light, no matter what the problem. And unlike me, she was able to keep her cool throughout the day. 

In the past, I would’ve remained in this agitated state of mind for days, with some carryover lasting for weeks. I wouldn’t have been able to separate my wife’s actions from my thoughts and realize that the problem wasn’t her, it was my reaction to the situation.  

It was a major step for me to become aware of how out of proportion the stories in my head had become. This degree of awareness changed the game for me. 

Eventually, we did get towed home. We went out to dinner. I still love my wife. And I learned yet another lesson in humility.

Dr. David Hanscom is a retired spinal surgeon. In his latest book -- “Do You Really Need Spine Surgery?” – Hanscom explains why most spine operations are unnecessary and usually the result of age-related conditions that can be addressed through physical therapy and other non-surgical methods.

6 Emotional Stages of Chronic Pain

By Ann Marie Gaudon, PNN Columnist

Emotions are part of our life experience and influence how we cope with challenging situations such as chronic pain.

Emotional responses to pain are not “bad” or “negative” because they are a natural response to life events. For example, depression is often seen as a sign of poor health, but it can also be a way of conserving bodily energy.

Emotions are never a sign of weakness. Emotions are adaptive responses which have helped us survive as a species.

Did you know there are normal emotional stages of injury and pain? Not everyone goes through every stage and it is not a linear process. Sometimes we bounce from stage to stage in no particular order.

Let’s look at these 6 emotional stages of chronic pain:

Denial

Denial is when we refuse to acknowledge how we feel and try to conceal the problem. When we’re in this stage our thoughts are likely: “It’s probably nothing serious” or “It will pass soon enough.”

Typical denial behaviour would be to ignore the pain, keep going as though you’re not in pain, failure to seek medical attention, and not following medical advice. Basically, you’re acting like nothing is going on in your body.

Denial is also culturally reinforced by beliefs that we should “suck it up, don’t complain and keep working.”

Fear and Anxiety

We feel fear and anxiety when the reality of something wrong hits home. You will likely be thinking quite repetitively during this stage. Typical thoughts would be: “Something is very wrong” or “What’s going to happen to me?” 

In this stage, your behaviour might be to rest and withdraw or avoid activities to protect yourself from further injury or pain. You will find yourself preoccupied with a lot of worry. You will likely begin to scan your environment and your body for threats to either, and it will be hard to commit to work or play.

Depression

Depression is the most common response to chronic pain and tends to come after fear and anxiety. Your thoughts would be normal in this stage if they were: “What’s the use?” or “Why bother with anything anymore?”

Realize none of this is enjoyable or desired; it is a normal response to chronic pain. Your behaviour would be to reduce participation in normal physical activities – even the enjoyable ones.  Social withdrawal would continue as a protective adaptation and you might experience problems with sleep.

Depression can impair your sense of self and you may grieve the loss of your identity. If you’re not an employee and parent anymore, then who are you? It is normal to withdraw in depression when your world shrinks in size.

Anger

Another emotional stage, and one I am quite familiar with, is anger. This defensive behaviour is the “fight” in the fight-flight-freeze response. It energizes you to resist the problems that come with chronic pain, and to ward off danger and restore safety. Normal angry thoughts about your pain would be: “It’s not fair” or “Why me?”

Behaviours in this stage can sometimes be troublesome, as they may become impulsive (acting or speaking quickly without thinking it through) or compulsive (repetitive behaviour not serving a purpose). You may overreact to smaller things and blow up at others. You might also engage in risky behaviour such as abusing alcohol or other substances to try to numb yourself.

The key is to express your anger in a healthy manner and hopefully transform it into affirmative action.  This is where you find the message in your anger and put it to work for you. I put my anger to work for me as I advocate for chronic pain patients on a regular basis.

Shame

Shame is not to be confused with guilt. Guilt says, “I’ve done something bad” while shame says, “I am bad.” Shame comes from how we see ourselves as damaged goods and can lead to feelings of self-loathing and disgust. You might think: “I’m worthless” or “I’m a complete failure.”

As a therapist, I find this to be a particularly powerful and difficult stage for clients, as shame often takes up all the space in the room. Behaviours in this stage would be continued social withdrawal, a decrease in assertiveness and self-confidence, and possibly self-destructive behaviours such as abusing alcohol or drugs.

Acceptance

The final emotional stage of coping with chronic pain is acceptance. Some patients reach this stage fairly quickly and others never reach it.

Let me be crystal clear about acceptance: It does not mean that you want this pain or that you like this pain and gladly accept it. Absolutely not. What it does mean is that you accept yourself without judgment, you live in the present moment, and you accept what is. Your thoughts will be along these lines: “This is not my fault” or “I can and will cope with this.”

Behaviours begin to change in this stage. You will be less focused on the past and have more realistic expectations of yourself. You will maintain appropriate levels of physical activity, use medications appropriately, reduce your emotional stress, and begin to experience feelings of peace rather than constantly beating yourself up.

Acceptance does not mean that you no longer feel any of the other emotions.  You may still experience feelings of denial, fear and anxiety, depression, anger and shame, but they will be less often and with less intensity.

Acceptance -- which includes hefty doses of self-compassion -- does not cure anyone’s physical pain, but it does facilitate better coping and reduced emotional stress. You do not accept pain because you want it or like it, but because it is here, you have it, and you respond to it in a kinder, gentler way.

The purpose of acceptance is to engage in activities that you feel have value. Within this purpose, acceptance becomes relevant and necessary. As a consequence, there is often less time spent struggling against and trying to avoid pain -- time freed up to engage in more valued pursuits.

It may take some time and support to acquire this tool, but once you have, it’s yours for life. Double entendre fully intended.

Ann Marie Gaudon is a registered social worker and psychotherapist in the Waterloo region of Ontario, Canada with a specialty in chronic pain management.  She has been a chronic pain patient for 33 years and works part-time as her health allows. For more information about Ann Marie's counseling services, visit her website.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

One Is the Loneliest Number

By Ann Marie Gaudon, PNN Columnist

Part of what makes pain "painful" is the feeling of being misunderstood and the feeling of aloneness.

"Nothing is quite so isolating, as the knowledge that when one hurts, nobody else feels the pain,” Robert Murphy wrote in his memoir, “The Body Silent: The Different World of the Disabled.”

When you combine a sufferer who sees only pain with someone who can't see it at all, a barrier often springs between the two.  Pain causes this barrier because it inverts our typical perspective. No longer able to reach out to others for work or leisure, pain patients turn inward and life becomes about self-protection. Something is wrong inside of us, so we must tend to it and ensure it doesn't get any worse. This is an evolutionary response for survival; it’s instinctive and quite normal under these circumstances.

Once patients are constrained in their daily activities, a large part of their social world and the emotional health that depends on it can quickly deteriorate. Relationships are arguably the largest part of what makes life worth living.  In contemporary Western society, our self-confidence and identity arise from social interactions.

But as chronic pain sufferers’ lives become more restricted and limited, they frequently experience an erosion of their former self-image without the simultaneous development of a new one.

For example, I have heard: “I was a nurse, a mother, a wife, a friend, a daughter, and a sister, but now all of that is gone and I am alone in a cage with my pain.”

When isolated and in pain, our mind can become our worst enemy. The collapse of one’s social world can result in feelings of anxiety, emptiness, loneliness, anger, sadness, grief, guilt and low self-worth.

All of this psychological stress (aka “dirty pain”) is a response to your physical pain (aka “clean pain”).

Stress is a complex cascade of physical and biochemical responses to strong emotional stimuli. Emotions are electrical, chemical and hormonal discharges of the human nervous system. When not processed in a healthy manner, they can generate or increase pain and illness.

People can and do help themselves. Some join groups. If possible, join a walking group for exercise. If you don’t like walking, join another. The point is not so much what the group is doing, but rather that you are in a social situation.

Online forums are another way that people connect, especially if one is mainly housebound. Online communication can help you feel not so alone with your pain.

Maybe it’s possible for you to open up your home to low-maintenance company. Host a popcorn and movie night, or it could be cards or board games. You do the choosing, including when it begins and ends. Start with a single and simple event to prevent over-exertion and see where it leads.

Remember, what’s important is that you are building and maintaining relationships. To the extent that it’s possible, stick with those who support you. This could mean family, friends or even a support group for your condition, which can be a platform to form meaningful relationships with people who understand you. By listening to each other, you both know that you are heard and that you are not alone.

Some folks make their pain more communicable and thus sharable through pictures, artwork or expressive writing. Oftentimes this helps to bring barriers down to help others understand how you are feeling. There are no rules, you choose your form of expression.

Finally, realize that it is not your fault that you live in a pained body. Adding self-blame to your list of challenges will only make things worse for yourself. Learn to ask for help when you need it. Asking for help is never a weakness but is an act of self-compassion. I work extensively with clients on self-compassion, most of whom are quite naïve about it. If beating yourself up were the way to better health, wouldn’t you be the healthiest person on the planet by now?

I also work with people to get realistic about their life and expectations. What can stay? What can go gracefully to make room for new ways of being?

People aren’t broken, they’re just stuck. It’s not always easy, but with new learning, adaptations and support, people also become unstuck.

Ann Marie Gaudon is a registered social worker and psychotherapist in the Waterloo region of Ontario, Canada with a specialty in chronic pain management.  She has been a chronic pain patient for 33 years and works part-time as her health allows. For more information about Ann Marie's counseling services, visit her website.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Are You ‘Paingry’ About Your Pain?

By Ann Marie Gaudon, Columnist

I’ve learned the hard way how you can stress anyone at all. Put these three factors in their life: Uncertainty, lack of information, and loss of control. Chronic pain patients are slammed with all three.

The stress can manifest itself in a variety of ways -- including anger -- and pain patients have a lot to be angry about. I’ve heard it called “paingry” -- which might even be cute if pain didn’t have the capacity to obliterate lives. People in pain typically experience greater anger than others because they carry the burden of many frustrations related to work, finances, relationships, health care systems, limitations, losses, etc.

We all tend to resort to anger to protect ourselves because someone or something has done us wrong. We protect ourselves from feeling what is “underneath the anger” which is emotional pain and feelings of vulnerability. Pain patients often have these feelings in spades. Anger is a natural, adaptive, emotional response when we feel threatened. It is the “fight” in the fight-flight-freeze response.

It’s no surprise that for chronic pain patients, anger arousal is associated with greater pain intensity, muscle tension, and interference with function and relationships.

So is anger regulation, whether it’s expressed in an outburst of anger (blowing up) or inhibited as anger (stuffing it down).  Blowing up won’t help you, but it will make you untouchable. You don’t want to be touched and nobody wants to touch you either.

Stuffing it down merely buries problems, which won’t go away and can lead to seething anger. These things are bad for everyone’s health and worse if you have chronic pain.

If you’ve got chronic pain, you’re going to be frustrated a lot of the time and acceptance of your condition becomes important. However, even learning acceptance can spark anger. You may think, “Why should I have to accept this? What have I done to deserve it?”

Understand Your Anger

Ironically, getting angry is not the problem. The real problem is a lack of awareness that anger is building into destructive ways of expressing that anger, and poor resolutions when we blow up in anger.

Here’s my message to all chronic pain patients: Don’t waste your anger, put it to work for you.

Understanding your anger is important. It is not caused by anything outside of you but is a response – sometimes not even conscious – that you make based on your interpretation of events. Feeling betrayed by your body? Doctors underestimating your pain? Suspected of malingering at work? Hard up for finances? Relationships breaking down? Denied or restricted medications? Stigmatized and discriminated against because you need opioid pain medication?

I don’t know about you, but I’ve come to loathe the phrase “drug seeking behavior” in reference to a legitimate pain patient because it’s so misguided. “Pain relief seeking behavior”? Now you’re talking.

Anger is an assertion of your most basic rights as an individual. Angry feelings need to be validated or acknowledged by yourself and others in order to move on to problem solving. You’re going to need a commitment to optimal pain management and to process your anger in a healthy way. The question then becomes, “How am I going to live with this in the best way possible?”

What Is Anger Telling You?

Anger and other raw emotions can be considered warning signs to things that we care about. Feeling enraged about your life with chronic pain can be a signpost that you value health, a productive life, want to be cared about authentically, and that you are not being treated fairly. If we didn’t experience anger, we wouldn’t have the message. It is a very healthy and necessary emotion to help us protect ourselves.

What is your anger telling you? If you misunderstand the message or do not act on it, your body will react and your pain will be escalated. Know that. It’s also crucial that you look for primary emotions. Those will be the underlying the hurt, vulnerability, and feelings of unfair treatment. They can be quite uncomfortable for a lot of folks.

Think of an iceberg. The much smaller top portion that you can see is the anger. What is not so obvious is the much larger mass underneath the water. That is your emotional pain and what you need to process and feel for all its worth. You need to acknowledge the entire iceberg; really get to the bottom of it. Secondary emotions like anger are often not helpful, especially if it leads to rage. Use your anger as a tip off that you need to look deeper to alleviate your distress.

Plenty of chronic pain patients need help with anger because they have so much to be angry about. See a therapist. There are many questions you will need to address. “Is there any unfair treatment in my life? Am I being honest and authentic about how I really feel? Are my needs being met? What is my message and what needs to be changed?”

You can get help becoming aware of your emotions on your way to accepting them. You can learn to take actions guided by these emotions – and put them to work for you.

If you’re a pain patient with no history of mental illness, yet you find yourself damned angry, breathe easier. You couldn’t be more normal. Pathologizing you with a mental health disorder and treating it with medication will not help you with your anger. Get help to listen to your inner dialogue.  See anger as a useful emotion. It’s telling you something that needs tending to.

I have a simple but effective strategy. It doesn’t involve diagnoses, medication, or creating spaces between myself and another person. Rather, I lean in and rely on empathy, respect and compassion for a fellow human being who is clearly overwhelmed with torment. Quietly and gently I ask, “Is it okay if we talk about your suffering?” The floodgates open. Know that is normal too.

Ann Marie Gaudon is a registered social worker and psychotherapist in the Waterloo region of Ontario, Canada with a specialty in chronic pain management.  She has been a chronic pain patient for 33 years and works part-time as her health allows. For more information about Ann Marie's counseling services, visit her website.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Do OTC Pain Relievers Dull Your Emotions?

By Pat Anson, Editor

Ibuprofen, acetaminophen and other over-the-counter pain relievers may do more than just dull your physical pain. They could also dull your emotional and cognitive senses, according to a new study.

Researchers at the University of California, Santa Barbara reviewed a small body of clinical studies that suggest OTC pain medications have an overlapping effect on us, both physically and emotionally.

One study, for example, found that acetaminophen makes people feel less empathy for others.

Research also found that women who took ibuprofen reported less social anxiety and hurt feelings after being excluded from a game or when writing about a time when they felt betrayed.

Yet another study found that acetaminophen lessens the discomfort of parting with a prized possession. When asked to set a selling price on an object they owned, individuals who took acetaminophen set prices that were cheaper than the prices set by individuals who took placebos.

"In many ways, the reviewed findings are alarming," wrote lead author Kyle Ratner, PhD, an assistant professor of psychology at UC Santa Barbara. "Consumers assume that when they take an over-the-counter pain medication, it will relieve their physical symptoms, but they do not anticipate broader psychological effects.

“Are more regulations needed? Should warnings be expanded on drug labels? At this point, drawing strong conclusions from the existing studies would be premature. Nonetheless, policymakers might start thinking about potential public health risks and benefits.”

Ratner and his colleagues say one place to start is to further study the effects of OTC analgesics on pregnant women. Recent research has found higher rates of autism and attention deficit disorder (ADHD) in young children whose mothers used acetaminophen while pregnant.

Acetaminophen -- also known as paracetamol – is the world’s most widely used over-the-counter pain reliever. It is the active ingredient in Tylenol, Excedrin, and hundreds of other pain medications. Ibuprofen is also widely used and can be found in brand name products such as Motrin and Advil.   

“Found in medicine cabinets across the world and used multiple times per week by people of all ages, genders, and ethnic backgrounds, these drugs are woven into modern life. Policymakers should take note of existing findings but not rush to judgment,” said Ratner.

The study is published online in the journal Policy Insights from the Behavioral and Brain Sciences.

Managing Emotions While Living with Chronic Pain

By Barby Ingle, Columnist

Before navigating through the minefield of the healthcare system, we need to get our own lives in order first.

It is important to learn the tools to manage chronic pain in a biological, psychological, social and spiritual approach. This can be quite tricky to do, if you don’t put effort into each area.

The one area most skipped over is the psychological challenge that comes with living in chronic pain. One of the things that negatively affected my healthcare was not having my emotions under control when going into a doctor’s office. I would go in expecting them to fix me and answer in broad sweeping terms that did not help them help me. I would typically cry, because I was in so much pain and trying to get someone else to understand was quite a challenge.

There were five major areas psychologically that I worked on: managing my conditions, avoiding peer pressure, figuring out tools that I was comfortable with, respecting the roles of everyone involved in my care, and setting expectations with my family and friends.

Once I became my own best advocate and learned to present my symptoms in ways that helped them understand, I finally started down the path to a team approach to managing my pain.

The first step was getting my emotions under control and taking responsibility for what happens between appointments. That meant making sure that I was organized, learned about my diseases and treatment options, and understood how my insurance worked. Getting organized really helped me get my emotions under control, let go of anxieties, and focus on maximizing my care and energy.

I also learned each provider has their own way of treating pain, and if that provider was not on board with me, I’d find a new one who was willing and able to help me accomplish my goals.

Avoid Peer Pressure

You may face some peer pressure from others in the pain community to try whatever they are doing. Remember to research and only do what you are ready to do for yourself. If it’s not right for you, then it’s not right for you. The stress of allowing others to pressure you into trying a treatment that you are not comfortable with can create a bad situation for you.

Don’t be misguided by the pressure to fit in with others who have the same disease as you. Be sure to stand up for yourself and the care you deserve.

Take Responsibility

We are taught from childhood that doctors fix sick people. Providers and parents make decisions for us about our medications and treatments. But as we age, it is important to learn that we are responsible for our own care, and to think through and develop our own solutions. This is an essential life skill for everyone, but when you are chronically ill it is even more important to develop.

Respect that pain takes a toll on us physically and emotionally, and that we must devote time, effort and energy to improve our living situation and be as mentally healthy as possible. So many times, I wanted to scream or have a tantrum. Can’t they hear me? Can’t they help me? Can’t they do something for me?

Finding more positive ways to say what I was going through and productive ways to communicate helped me get the best care possible in the worst of situations. No one helped me when I let my negative emotions lead me. I have learned to respect myself and others to get the care I need, know when to walk away, and when to find a better way.

Set Expectations Early

Most of my family understood that I was living with chronic pain and that it was not by choice. But not all of my husband’s family understood, and took the word of a nurse who said that I was acting up, looking for attention and nothing was wrong with me. Over the years most of them have come around, after I learned to be patient and stay consistent in my drive and determination.

I have only had to cut a few people out of my life and most of that happened because I was unable to set expectations. Now it is something I have learned to do at the start of any relationship. There is so much less frustration when I have to say sorry I can’t make it because of a pain flare or seizure. They know I want to be there, there just are times that my body doesn’t allow it.

Having chronic pain will challenge you in ways that you never imagined. Preparing for daily activities and pain flares becomes a must. So does searching for small ways to boost your own self-confidence.

Managing the emotional side of chronic pain can be done -- it just takes understanding, effort, and learning to choose your battles.

Barby Ingle lives with reflex sympathetic dystrophy (RSD), migralepsy and endometriosis. Barby is a chronic pain educator, patient advocate, and president of the International Pain Foundation. She is also a motivational speaker and best-selling author on pain topics.

More information about Barby can be found at her website. 

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Researchers Say Acetaminophen Dulls Emotions

By Pat Anson, Editor

Health experts have been warning for years about the risk of liver damage caused by taking too much acetaminophen.  Now a new study is out that found a previously unknown side effect of the drug: It also dulls emotions.

Acetaminophen -- also known as paracetamol – is the world’s most widely used over-the-counter pain reliever. It is the active ingredient in Tylenol, Excedrin, and hundreds of other pain medications.

Researchers at Ohio State University conducted two studies involving over 80 college students, half of whom took a large dose of 1000 milligrams of acetaminophen and half who took a placebo. They waited 60 minutes for the drug to take effect.

The students then viewed 40 photographs from a database used by researchers to elicit emotional responses. The photographs ranged from the extremely unpleasant (crying, malnourished children) to the neutral (a cow in a field) to the very pleasant (young children playing with cats).

After viewing each photo, participants were asked to rate how positive or negative the photo was on a scale of -5 (extremely negative) to +5 (extremely positive). Then they viewed the same photos again and were asked to rate how emotional they felt, ranging from 0 (little or no emotion) to 10 (extreme amount of emotion).

Results in both studies showed that participants who took acetaminophen rated all photos less extremely than did those who took the placebo. Positive photos were not seen as positively under the influence of acetaminophen and negative photos were not seen as negatively. The same was true of their emotional reactions.

“People who took acetaminophen didn’t feel the same highs or lows as did the people who took placebos,” said Baldwin Way, an assistant professor of psychology at the Ohio State Wexner Medical Center’s Institute for Behavioral Medicine Research.

For example, people who took the placebo rated their emotional response relatively high (average score of 6.76) when they saw jarring photos of the malnourished child or the children with kittens. But people taking acetaminophen didn’t feel as much in either direction, reporting an average emotion level of 5.85 when they saw the same photos.

Neutral photos were rated similarly by all participants, regardless of whether they took the drug or not.

“This means that using Tylenol or similar products might have broader consequences than previously thought,” said Geoffrey Durso, lead author of the study and a doctoral student in social psychology at The Ohio State University.

“Rather than just being a pain reliever, acetaminophen can be seen as an all-purpose emotion reliever.”

Previous research has shown that acetaminophen reduces not only on physical pain, but also psychological pain.

“Most people probably aren’t aware of how their emotions may be impacted when they take acetaminophen,” said Way.

The study is published online in the journal Psychological Science.

Over 50 million people in the U.S. use acetaminophen each week to treat pain and fever. The pain reliever has long been associated with liver injury and allergic reactions such as skin rash. In the U.S. over 50,000 emergency room visits each year are caused by acetaminophen, including 25,000 hospitalizations and 450 deaths.