Interrupting the Cycle of Chronic Pain
If you suffer from chronic pain, you are not alone. Millions of Americans seek treatment for chronic pain, pain that continues for more than six months. Chronic pain is no longer viewed as a symptom, but as an illness in itself. Things we take for granted, such as eating, sleeping, dressing, walking, laughing, working, socializing, and independence may be lost to a person with chronic pain. Frequently, no physical cause can be established, or the initial injury has long since healed, but the pain persists, and generally worsens over time. Nonetheless, each person's pain is both real and unique.
It is important that the person is believed, but some doctors do not take the person's physical complaints seriously, and blame their treatment failures on the patient. An occasional headache, stomach ache, or muscle spasm may occur in reaction to a stressful situation, but the symptom usually resolves quickly, sometimes just from the doctor's reassurance that there is nothing seriously wrong. But when pain persists, more often the emotions are a reaction to the physical pain, rather than the reverse.
The cycle of pain involves the physical body and the mental/emotional body - symptoms of each reinforce the other. The body and mind experience injury and pain as a threat, sending the sympathetic nervous system into a fight or flight response involving electrical and chemical changes that alter heart rate, blood pressure, respiration, body temperature, and muscle tension. Pain signals to immobilize the affected area. The body tightens, breath shortens, and a "whole" mental/physical reaction sets in. Accompanying emotions, ranging from mild concern to extreme fear - fear of pain, disability, loss of function, or even death - exacerbate the pain.
So the person seeks medical attention, receives hope, medication and/or treatment, and usually improves. If pain recurs, the patient rests, but fear returns, along with anxiety, guilt, and anger. If the pain is not relieved, or only temporarily abated, there is greater alarm, setting up a negative feedback loop, perpetuating emotional reactivity.
Certain personality types experience chronic pain as especially difficult. For those who see themselves as strong and invulnerable, their entire self-image is threatened. Pleasers and those who have been abused, tend to externalize power and react to pain passively. Their feelings of helplessness and victimization paralyze their ability to help themselves and seek effective professional care. They may give up easily if their doctor has no solution or blames them for their pain.
At the other extreme are those who typically blame themselves. Guilt is a very common reaction. Interviews with many amputee Israel soldiers revealed that nearly all blamed themselves for their injury, thinking "if only I had . . . (behaved differently)," despite the fact that the enemy was clearly responsible. (Wall, 2000) Perfectionists and over-achievers fall into this category. They think in all or nothing terms, and feel like failures when they are not productive or at their best. (Swanson, 1999)
In time, there may again be improvement and more activity. Usually, the person is overactive to make up for lost time, followed by another flare up. Now, s/he becomes increasingly focused on the pain and fearful of physical activity, instinctively guarding the affected part of the body, and alert to anything that might trigger another episode of pain. When the pain doesn't relent, a stage of constant anxiety sets in. This state of hyper-vigilance contracts not only the mind, but also the body, which increases the pain. In some cases, just thinking about and describing the pain increase muscle tension. Restorative sleep, the body's PH, blood flow, hormones and brain chemicals are negatively affected, compromising the body's ability to regulate homeostasis and pain. Eventually, the person's mind, body and entire life contract, making relaxation and healing nearly impossible. This is why early intervention to reduce pain and anxiety is vital in order to interrupt the cycle and to avoid long term chronicity and debilitation.
Without relief, muscles lose tone and posture is altered in the person's attempt to avoid pain, contributing to muscle spasm, weakness, imbalance and shortening. The pain begins to spread, as the myofascial sheath tightens around regions of the body, restricting movement and sending pain from head to toe. Over time, muscles atrophy, bone deteriorates, and the immune system weakens, making the body vulnerable to disease.
A once active person becomes caught in a downward spiral of depression, is now lonely and withdrawn from a normal social life, and may have even become chemically dependent as well. The emotional and physical strain, and the loss of confidence, work, and social contacts result in low self-esteem, grief and hopelessness, which magnify the perception of pain.
People often search unsuccessfully for doctors who can alleviate their misery, while simultaneously are distrustful and phobic of pain and change. Unconsciously, they may be seeking confirmation that no one can help. By this time, the person presents as someone needing psychological help. When no physical cause can be established, the doctor may assume that the cause is emotional, reinforcing hopelessness and distrust.
So how can one be extricated from this morass? A comprehensive plan addressing physical, mental, emotional and spiritual needs is required. Medication alone can be detrimental, because it builds dependency on the drug and doctor, without support and encouragement for the person to become actively engaged in learning skills to understand and reduce their pain and live a fuller life. The first essential ingredient is a support system. The caregivers' personality and ability to generate a safe environment are just as important as their professional experience. Today there are numerous allopathic and alternative treatment modalities available, but many may provide only temporary relief or none at all. Only the patient can assess whether a treatment is both suitable and effective. Commitment to treatment may be difficult, particularly when there are pain flare-ups, which undermine confidence in the caregiver. The person may want to withdraw from treatment or even blame the doctor or therapist for the recurrence. These flare-ups should be normalized as an inevitable part of the healing process, particularly when the person's activities begin to increase. It may not mean that progress is being compromised. The person must take an active role in determining what works and what doesn't, both in terms of treatment and his or her own activities. Through journaling and discussion s/he can be helped to sort this out. A corollary principal is learning to focus on what is possible, rather than on what is not, without denying ones limitations, and doing too much. As the person participates in his or her recovery, s/he regains a greater sense of control, and feelings of helplessness and depression diminish.
Finding pleasurable activities is very important. Small steps, such as listening to music, arranging flowers, helping someone else, or enjoying a special food, movie, or book serve as a distraction from pain, and gradually lift self-esteem and mood, which further reduces pain. Creative activities that stimulate the intuitive "feminine" or "yin" side of the psyche are particularly relaxing and healing. Carl Jung strongly believed in the healing power of creativity.
Pleasurable and soothing sensations, such as gentle massage, holding, rocking, and stroking, activate the body's own healing mechanisms, and remind and reassure the body that it is safe to relax, the way a horse whisperer tames a wild horse. This begins to break the cycle of anxiety and create a safe internal healing environment. Relaxation techniques, including breathing, sounding, biofeedback, hypnosis, and visualization are all useful in calming the body/mind. Of course, good nutrition and adequate sleep are essential.
It's vitally important to understand and express feelings, ideally in individual psychotherapy as well as in a group. People who have been isolated need individual support to "en-courage" them to re-enter the world and reach out to others. Then they can benefit from group interaction. Cognitive-behavioral changes, along with improved communication skills, build self-esteem and reduce emotional reactivity in interpersonal relationships. As the person becomes more hopeful and assertive, s/he experiences less pain and is better able to find and benefit from effective treatment.
Increased social activities and a daily exercise regime build endurance, strength and flexibility. Some individuals may need assistance in organizing their day to increase functioning. For example, they may require an afternoon nap or help driving or shopping. As the person's mood normalizes and pain lessens, s/he can eliminate unnecessary medications. Even if some pain continues, the person needn't suffer, and can learn to lead a fuller, more rewarding life.
This challenge may seem daunting, but these goals are attainable over time.
Bresler, David E., Free Yourself from Pain; Simon & Schuster, 1979
Swanson, MD, David W., ed., Mayo Clinic on Chronic Pain, 1999
Wall, Patrick D, Pain, The Science of Suffering; Columbia University Press, 2000; p. 6