The Truth About Chronic Pain

By Dr. Rachel Zoffness, PNN Columnist

I’ve never been an athlete, but I’ve always loved exercising because of how it makes me feel. One beautiful spring day, I went for a run. On the way downhill, I was stopped by a sudden pain in my knee. When I woke the next morning, I couldn’t step out of bed without burning pain radiating from my feet, up my leg and into my hip.

I was couch-bound for the better part of a year. I saw countless doctors, was prescribed many medications, and would’ve done anything to stop the pain. That was the beginning of a decade-long journey with chronic pain.

I’ve dedicated my life to understanding pain, and not just because of that injury.

I’m a pain psychologist and assistant clinical professor at UC San Francisco School of Medicine, where I teach pain neuroscience to medical residents. I also founded a private practice dedicated to people living with chronic pain.

One of my earliest patients was a teenager. He’d been bedridden with multiple medical diagnoses for four years, seen 12 physicians and tried 40 medications. But nothing worked.

Not surprisingly, he was depressed and anxious. He had no life, no friends and no hope.

DR. RACHEL ZOFFNESS

As a pain psychologist, I use cognitive behavioral therapy (CBT) as one of my primary treatment tools, so we started a CBT-for-pain program. In addition to other strategies, it involved “pacing” or resuming select activities one small step at a time.

It was hard work, but little by little, he got healthier. As his functioning and mood improved, his pain did, too. Within 6 months he resumed school and rejoined his soccer team. His pain wasn’t gone – but it was significantly reduced and he knew how to manage it. He says pain will never control his life again.

Many of us have noticed this link between how we feel emotionally and how we feel physically. That’s because pain is never purely physical. This is confirmed by neuroscience research indicating that pain is produced by multiple parts of the brain, including the cerebral cortex (responsible for thoughts), prefrontal cortex (which regulates attentional processes), and the limbic system – your brain’s emotion center.

Dialing Back Pain

Imagine that you have a “pain dial” in your central nervous system that controls pain intensity. The function of this dial is to protect you from danger or harm. It can be turned up or turned down by many factors, including:

1. Stress and anxiety

2. Mood

3. Attention (what you’re focusing on)

When you’re feeling stressed and anxious – your thoughts are worried, your muscles are tense and tight, and the pain volume is turned up.  

When your mood is low, you’re miserable and depressed, and your brain similarly amplifies pain volume. 

This is also true when your attention is focused on pain. When you’ve stopped going to work, seeing friends and engaging in hobbies, your prefrontal cortex (which controls attention) sends a message to your pain dial, turning it way up. 

However, the opposite is also true. 

When stress and anxiety are low – your body is relaxed, your thoughts are calm and you’re feeling safe. Your cerebral cortex and limbic system send messages to your pain dial, lowering the volume so that pain feels less bad. 

When your mood is high, your thoughts are positive, you’re feeling happy and you’re engaged in pleasurable activities. Your brain determines that little protection is needed, so pain volume is reduced. 

And finally, when you’re distracted – you’re absorbed in activities, like watching funny movies with friends. The pain dial is turned down, so pain is less bad. 

In summary, when you’re relaxed, happy, distracted, and feeling safe, your pain volume is lower. The pain is still there -- it hasn’t magically disappeared -- but it’s quieter. Softer. Less. 

The truth about chronic pain is this: Your thoughts, beliefs, emotions and attention can all adjust pain volume. 

This does not mean that pain is “all in your head.” It isn’t. Your pain is real, as real as mine, and no one should ever tell us otherwise. It does mean that there are many ways to change pain. One is medication. Multiple medications have been shown to effectively turn down the pain dial.  

There are other methods for lowering pain volume, too. CBT, mindfulness and biofeedback are three biobehavioral approaches to pain management that research suggests can be helpful. They aren’t magic cures and they take time. But if you’ve never tried to manage your pain with these techniques, consider them. They’ve helped me immensely on my chronic pain journey. 

When I was learning about mindfulness, I remember thinking, “What could mindfulness possibly have to do with physical pain?”  

And then something fascinating happened.  

During the first year of my practice, my pain changed. It didn’t go away entirely and I wasn’t cured. But the pain changed. It became less intense, less frequent, less distracting, and got less in the way of the rest of my life. 

Rachel Zoffness, PhD, is a pain psychologist and assistant clinical professor at the UCSF School of Medicine. Rachel serves on the Steering Committee of the American Association of Pain Psychology, where she founded the Pediatric Division. She is the author of The Chronic Pain and Illness Workbook for Teens. You can find Rachel on Twitter @DrZoffness.  

A New Psychological Treatment for Chronic Pain

By Ann Marie Gaudon, PNN Columnist

Cognitive behavioural therapy (CBT) has dominated the field of psychological treatment for chronic pain for the last three decades. Studies have shown that it is effective, yet some researchers say CBT also has its limits and could be improved upon.

As CBT treatment approaches continue to evolve, what is noteworthy is a departure from the logic of everyday thinking. “Suffering” is not seen as pathology, but rather as inherent in the human condition. We don’t want it and we don’t like it, but suffering is inescapable.

Following this principle, the utility of “normal thinking, analyzing, and problem-solving” is called into question. Our brains have evolved into powerful problem-solvers that serve very well with things are external to us. For example:

Problem: your car malfunctions and no longer starts. If you have the knowledge and skills, you find the problem and repair the car. Problem solved. If you do not have the skills, you find someone who does and repairs it for you. Problem solved.

But chronic pain is an internal problem that cannot be easily solved. No matter the effort from our powerful problem-solving brains, doctors and patients often cannot work it out. For a sufferer to spend a lifetime attempting to analyze and logically think their way to being pain-free can be a lifetime spent in futility.

Acceptance and Commitment Therapy

Newer psychological approaches such as Acceptance and Commitment Therapy (ACT) are guided by the premise that we cannot change the pain we’re left with, so let’s change our response to that pain. ACT was outlined in a 2014 article in the journal American Psychologist.

ACT differs notably from traditional CBT in method. Rather than challenging and changing thoughts, ACT seeks to reduce their influence over our behaviour. This core treatment process is called “psychological flexibility,” which is the ability to contact the present moment fully and consciously, based on what the situation affords.

In other words, we act on our long-term values rather than short term impulses, thoughts and feelings. I have a personal example of this:

“Knowing that I love to dine out and see live theatre, my partner reserved an evening of these as a surprise birthday present for me. After the reservations were made, I endured a serious back injury, which makes sitting for long periods particularly painful. He offered to cancel immediately, but I stopped him.

My thoughts told me, ‘Don’t go! You’ll be in more pain. Stay home and protect yourself!’

I applied a few of the many skills I have learned through ACT and was able to hold these thoughts lightly, and essentially not buy into them. I committed to continue with the dinner and theatre plans, and accept the pain in the service of my value of nurturing a social life. Result: my pain was not in charge -- I was.”

Why would one choose these strategies? It’s because thoughts and emotions tend to be unreliable indicators of long-term value. They ebb and flow constantly and we have little control over them. If we act based solely on them, we can lose out on experiences that bring true meaning and vitality to our lives.

In my case, I could have held onto my thoughts tightly and isolated myself at home with my pain, but instead I chose not to buy into those thoughts, to be willing to have the pain (acceptance), and commit to an experience which brought richness to my life. I knew my evening out would not reduce or eliminate my pain. I chose to do something of value to me -- the pain came along for the ride.

The catch is that unhelpful thoughts and emotions can dominate without a person even being aware of them. This results in “psychological inflexibility,” which leads to rigid, ineffective behaviour. If I let my thoughts run the show, the result would have been that I isolated myself at home with my pain and likely more suffering. Other positive behaviours and experiences would have been essentially blocked from me. No thank you.

Evidence to support ACT for chronic pain continues to grow, and its efficacy is about the same as CBT at this point. This is no small feat, considering CBT has been the gold standard for decades.

There are at least six randomized controlled trials which support the use of ACT for chronic pain. Most show ACT increases the acceptance of pain, along with improvements in anxiety, depression, and reductions in disability. This psychological flexibility significantly improves life satisfaction, disability, emotional distress and fear of movement.

It will be interesting to see future studies as ACT continues to advance and helps us find new and different ways “to act successfully in the world.”

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 over 30 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.

4 P’s That Can Help Lower Pain Levels

By Barby Ingle, Columnist

Having lived with chronic pain for 21 years -- with diagnoses such as arthritis, TMJ disorder, endometriosis, hypothyroid, ischemia, seizures, reflex sympathetic dystrophy (RSD) and thoracic outlet syndrome -- I know what life with a chronic condition is like.

I have tried many different treatment options, yet still have not found “the cure.” That doesn’t mean I have stopped looking. As part of my continuing alphabet series on alternative pain treatments, this month I am covering 4 P’s of pain management: physical therapy, pain medications, prolotherapy and psychology. 

Physical Therapy

Also known as PT and physiotherapy, physical therapy uses movement through manual therapy, exercise, and electro-therapy to improve range of motion, mobility, function and daily living.

Used incorrectly, physical therapy can be harmful. It is very important to get a physical therapist that understands your health condition, knows when to push you and when to hold you back, and can teach you exercises you can learn to do independently.

A good physical therapist will do research on your condition and help educate you about your body’s limits and potential for improvement. They will also be in regular contact with your doctor and other healthcare providers.

Due to insurance practices in the United States, the number of physical therapy sessions is often limited and rarely lasts throughout a chronic illness. But many of the techniques can be continued at home on the patient’s time, once they learn how to do them properly.

When I first started physical therapy, I did all of the wrong exercises because my therapist didn’t know or understand the conditions I have. My mentality at the time was no pain no gain, so we both over-worked me. It made things far worse than if had I done nothing in the first place.

Once I was with the right physical therapist, I began to see improvements in my daily function. We learned together it wasn’t about pushing my limits, but more about working as a team to find ways around the physical limitations I had.

Pain Medication

When the average person hears the words “pain medication” they often think about opioids. But there are a many different types of pain medication available, including medical cannabis, NSAIDs, benzodiazepines, tricyclic antidepressants, alcohol, kratom, cox-2 inhibitors, and muscle relaxers.

Based on my speaking with medical professionals and researchers, I believe that all options -- including opioids -- should be on the table when a provider is deciding what is best for the patient.

I have heard from thousands of patients (of the millions who use opioids daily) who swear by two things. First, they have no other treatment option due to access or cost.  Second, there is no other treatment option that works as well as opioid medication.

I know that the evidence is weak on the long-term use of opioids. Every test, assessment and research study can be torn apart by opioid critics. But for me, it all comes down to this: If I have something that helps me function better and live a better quality of life, I want to have access to it. I have lost many friends to suicide due to uncontrolled pain and a few to addiction.

Opioids are not typically the first line of treatment. More and more, due to insurance company policies, guidelines and legislation, pain patients will get acetaminophen or NSAIDs, or be given nerve blocks, spinal injections or some other invasive procedure. Opioid medications are far less prescribed than they used to be. And many patients can’t get them at all.

Doctors are now being taught in medical school that what they prescribe should be determined by the type of pain someone has. For neuropathic pain, they are taught that traditional analgesics are less effective. Therefore, many providers will prescribe tricyclic antidepressants and anticonvulsants for nerve pain. And they will use topical NSAIDs creams and ointments for muscle sprains and overuse injuries.

Prolotherapy

Prolotherapy is an injection-based treatment used for pain conditions that involve musculoskeletal disorders, such as low back pain, tendonitis and knee osteoarthritis.

The injection is typically administered where joints and tendons connect to bone.  In theory, the injection creates an irritation to the injured area that helps stimulate healing. This technique that has been practiced since Roman times, when they used hot needles on gladiator injuries to promote healing.

Patients may report mild pain and irritation at the injection site, which usually goes away within 72 hours. They also may report numbness or minor bleeding right after the injection. There have been cases of disc and spinal injuries reported.

I used to hear a lot about prolotherapy 10-15 years ago, but I hear less and less about it now, as it is not typically used to treat nerve diseases. It is also not well reimbursed by insurance companies and Medicare has decided not to cover prolotherapy injections for low back pain at all.

Psychology

Psychology is used to help prevent the reliving of psychological distress or dysfunction, and to promote positive thoughts, well-being and personal skills. Psychology should not to be confused with psychiatry, which is the medical specialty devoted to the diagnosis, prevention and treatment of mental disorders.

I have undergone psychological counseling in both group and individual settings over the years. The time when I found it most helpful was before I finally got a proper diagnosis of RSD and started infusion therapy. At the time, I was beginning to feel like a guinea pig. Some providers didn’t know what to do with me and having a psychologist providing support and making sure my mental attributes were strong was very helpful. 

I still use some of the mindfulness techniques he taught me to this day. When I was getting ready for infusion therapy, I felt like I had tried every treatment available on earth. Having a professional psychologist to speak with and go over what happens if the infusion didn’t work prepared me for a worst-case outcome.

Luckily, I didn’t need it, but it did teach me that even though I felt like I had tried everything, there are always new options being created and that I had not actually tried everything.

This is one of the reasons I am so sure that the alternative treatments I have been presenting over the last 8 months are helpful to others. I never realized until I did the research that there are so many different things to try. Using a multi-modal approach to pain and understanding that the mind, body and spirit connection are real is important not to neglect.

There were times when my providers suggested that I go to a psychologist, and other times when I had to get psychological clearance for different procedures. I found that when I went to a session, I felt better about myself. It was "me time" -- a time to focus on getting through the depression and anxiety of living with a chronic illness.

I learned that chronic pain affects our brains and causes depression and anxiety, and that it was not the other way around. That there are tools and medications to address them, and that knowing myself and what is going on with my health was one of the best ways to get past the depression and anxiety.

Psychologists gave me aptitude tests to check my general knowledge, verbal skills, memory, attention, reasoning, and perception. A few also gave me personality and neuropsychological tests. The more I learned about myself, the better I was able to navigate through chronic illness, the people around me, and the better relationships I was able to achieve.

I once again look forward to reading your comments. What treatments have you tried, what has worked, and what didn’t work? What tips do you have to pass on to other readers? Have you found the treatment protocol that works for you?

I personally don’t believe that there is a magic pill or procedure that can cure chronic pain - yet. I also strongly believe that the patient and their providers should be making the decisions for what is best for the patient.

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.

Why You Should See a Psychologist

By Crystal Lindell, Columnist

The weirdest part about getting psychiatric help is that people notice it.

They notice it in the same way they notice when you lose weight, or dye your hair blue. Like the IT guy at work, who says you just seem more confident lately. Or the friend’s husband who says you seem happier these days. Or the old Tinder guy who finds you on Facebook to comment that you seem so different, so much happier — and even your eyes seem brighter somehow.

I didn’t expect that. When I was in the thick of it, in the blackest night, I didn’t think anyone really noticed how bad it was. I don’t think I even noticed how bad it was. But if they’re noticing that things are better, then it’s probably safe to assume that they noticed how bad it was.

The fact is, getting psychiatric help in this country is depressingly difficult. The first time I sought help three years ago, I had just gotten sick and the pain was so horrific that I had been planning on slitting my wrists in the bathtub.

I finally worked up the courage to tell my primary care doctor that I was suicidal. He referred me to a psychologist who he said worked with people in pain.

But the psychologist refused to see me because she only worked with cancer patients in pain. I apparently wasn’t sick enough for her. So she referred me to someone else, and then weeks later I finally got in for an appointment.

To recap: I literally had a plan to kill myself, and it took weeks for me to find any help.

I’m a well-educated white woman with health insurance. If it’s this hard for me, what are other people going through?

Luckily, the doctor I got paired up with was great and helpful and sometimes a little mean, but always very good at helping me figure out how to deal with all the pain I was suddenly enduring.

The sessions weren’t so much about her telling me what to do, but how to do it. For example, we both agreed that I couldn’t work when the pain was 10/10, but instead of letting it get that bad and then ending up hysterically crying in my boss’ office begging to leave, we came up with a different plan. At the beginning of the week, talk to my boss and agree on days I could work from home. This way there was a plan everyone could feel secure with, and my pain wouldn’t reach 10/10 in the first place.

It seems like little things, but when you find yourself sick, it’s like you’re in a new country and having any sort of map can be extremely helpful.

Even if someone can get an appointment with a psychologist though, AND their insurance will cover it, there’s still another hurdle. A lot of psychologists suck. Just like a lot of doctors suck. And a lot of mechanics suck. And a lot of restaurants suck.

I hear all the time from people who say things like, “I don’t even bother seeing a psychologist, because they aren’t any good anyway. They don’t get me. They don’t help. They just want to get me in and out.”

But people don’t just stop going to restaurants because the Mexican place in town gave them food poisoning. And they shouldn’t just give up on therapy because they had some bad experiences.

Of course, even if you get past all that, there’s still the stigma. There is this idea that if you’re getting mental health help that you’re somehow weak. But getting your brain healthy doesn’t make you weak. It makes you strong. Life doesn’t come with an instruction manual, but getting a neutral opinion from an outside party is almost as good.

These days I see a team, a psychiatrist and a psychologist. The psychiatrist works with me on medical options, while the psychologist offers cognitive therapy to help me navigate my life.

And, honestly, my biggest regret is that I didn’t get help for my anxiety sooner. After going through opioid withdrawal over the last year, I’ve realized that I had been struggling with anxiety since at least my teen years.

It was as if all the pain meds I was on masked it just long enough to show me that there was, in fact, a better way to live. That there existed a possibility for a life that didn’t include waking up literally everyday feeling sick to my stomach, with anxiety attacks on the bathroom floor at work, and obsessing over every little thing.

I confess I was extremely resistant to the idea of going on a long-term anxiety medication, but I’m so glad that I worked with my doctor to find one that works on my brain. And aside from easily bruising, the side effects have been very minimal.

People don’t talk enough about the mind-body connection, but it’s there. And when you’re in pain or dealing with something like opioid withdrawal, getting mental health care may not be the first thing people seek. But it turns out, getting your brain healthy is just as important as getting your body healthy.

In the end, the question that psychology asks is simple: Can people actually change? I have to believe the answer is just as simple: Yes.

And if people can change, maybe the world can too.

Crystal Lindell is a journalist who lives in Illinois. She loves Taco Bell, watching "Burn Notice" episodes on Netflix and Snicker's Bites. She has had intercostal neuralgia since February 2013.

Crystal writes about it on her blog, “The Only Certainty is Bad Grammar.”

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

The 7 Psychological Stages of Chronic Pain

By Jennifer Martin, PsyD, Columnist

Have you ever wondered if other people with chronic health conditions feel the same way you do?

Throughout my years with chronic pain and illness, along with the hundreds of patients I have counseled, I have found that, while everyone copes in their own way and experiences their condition uniquely, there are common feelings that most of us share.

When I first began counseling chronic pain patients, I often used Elizabeth Kübler-Ross’s “Five Stages of Grief” to help them understand what they were going through. 

But as time went on, I reflected on what I experienced with my own chronic conditions and also on my patients’. It seemed that these stages, while very helpful, didn’t fully explain the broad range of emotions that people with chronic illness experience. 

After all, Kubler-Ross developed them to explain the responses to grief and loss. Having a chronic illness can be viewed as a type of loss, but they were not developed specifically to explain the emotions of people experiencing chronic conditions.

I used Kübler-Ross’s stages as a model to develop the Seven Psychological Stages of Chronic Pain and Illness: 

1. Denial

In this stage, we are in a state of shock and refusal. We wonder how our life is going to change and how we are going to live with those changes. Denial and shock help us to cope and make survival possible.

This stage can be dangerous for people with chronic pain and illness because if they are in denial about their condition, they may not take the necessary steps to get themselves the treatment they need.

Example: “It’s not a big deal, it will go away” or “The doctor is wrong, I don’t have diabetes.”

2. Pleading, Bargaining & Desperation

This is the stage where we want more than anything for life to be what it once was. We become fixed on anything that could make our illness and pain go away -- or anything that could give us some semblance of the life we once had. 

We may find fault in ourselves and what we think we could have done differently. We may even bargain with the pain or illness because we would do anything not to feel them anymore. Guilt is common when bargaining. 

Example: “Please just don’t let this ruin my life” or “If you make the pain go away, I promise I’ll be a better person.”

3. Anger

After we conclude that our pleading and bargaining is not going to change the diagnosis, anger sets in. 

Anger is a necessary stage of the healing process. Feelings of anger may seem endless, but it is important to feel them. The more you truly feel anger, the more it will begin to subside and the more you will heal.  Your anger has no limits and it may extend to your doctors, family, friends and loved ones.

Anger is often felt later on when the illness and pain progresses, or holds us back from doing the things we would like. 

Example: “This isn’t fair! I didn’t do anything to deserve this!” or “Just give me something that will make me feel better!”

4. Anxiety and Depression

Feelings of emptiness and grief appear at a very deep level.  This depressive stage feels as though it will last forever.  It is important to understand that this depression is not a sign of mental illness.  It is the appropriate response to a loss or a life-altering situation. 

We may withdraw from life and wonder if there is any point in going on.  Depression after a loss is too often seen as unnatural or something that needs to be snapped out of.  Being diagnosed with a chronic illness or experiencing chronic pain is a loss – a loss of the life you once had.

Having a chronic pain or illness may also bring up feelings of anxiety; anxiety about what the future holds, anxiety about not being able to live up to expectations, anxiety about social situations, anxiety about medical bills, etc.

Example: “I’m going to be in pain forever so why even bother?” or “I’m going to be in debt forever.  How am I ever going to pay off these medical bills?”

5. Loss of Self and Confusion

Having chronic pain or illness may mean giving up some key aspect of what made us who we were.  It may mean an inability to be physically active like we once were.  It may mean not being able to be as sociable as we would like or it may even mean giving up a career. 

You may wake up one day and not recognize the person you are now.  You may question what your purpose in life is now.  This stage may occur at the same time as anxiety and depression, or it may be separate.

Example: “I don’t even recognize myself anymore.” or “My career was my identity.  Who am I without that?”

6. Re-evaluation of Life, Roles and Goals

Having a chronic condition often means giving up a lot.  We are forced to re-evaluate our goals and futures.  We are forced to re-evaluate who we are as a husband, wife, mother, father, sibling or friend.  While we once had a successful career that gave us purpose, we may find ourselves beginning to question what we can do for work in the future and how we can contribute to our families. 

While we were once able to do it all, we are now re-evaluating what absolutely has to get done during our days and how we can accomplish these goals while still remaining in a positive mood.  Re-evaluating your life, roles and goals is a crucial first step in accepting your condition.

Example: “I may not be able to be a nurse anymore but maybe I could teach classes a couple times per week.” or “I can’t be as physically active with my husband anymore so what else can I do to show him I love him?

7. Acceptance

Acceptance is often confused with the idea of being “OK” with what has happened. This is not true.  Many people don’t ever feel OK about having to live with pain or an illness for the rest of their lives.

This stage is about accepting the reality of your situation and recognizing that this new reality is permanent. We will never like this reality and it may never be OK, but eventually we accept it and learn to live life with it. It is the new norm with which we must learn to live.

We must make adaptations and alterations to our lives. We must find new things that bring us joy.

Example: “I’m not going to let this define me. I will learn to deal with this the best I can.”

It's important to remember that these stages are not linear.  While some people begin in the denial stage, move through each stage and end with acceptance, many people jump back and forth throughout the stages.  I hope that these stages give some comfort to those who are experiencing chronic conditions.

Jennifer Martin, PsyD, is a licensed psychologist in Newport Beach, California who suffers from rheumatoid arthritis and ulcerative colitis. In her blog “Your Color Looks Good” Jennifer writes about the psychological aspects of dealing with chronic pain and illness. 

Jennifer is a professional member of the Crohn’s and Colitis Foundation of America and has a Facebook page dedicated to providing support and information to people with Crohn’s, Colitis and Digestive Diseases, as well as other types of chronic pain.