I work with a lot of patients who have chronic pain that impacts their lives in many ways. Unfortunately, for many of them chronic pain produces chronic stress. This results in ongoing physiological stress which often produces neurotoxic influences in key brain regions, including the prefrontal cortex, amygdala and hippocampus, and drives maladaptive neuroplastic changes that may further fuel a chronic pain condition.
For example, chronic stress generates extensive dendritic spine loss in the prefrontal cortex, hyperactivity in the amygdala, and neurogenesis suppression in the hippocampus. Patients with chronic pain have been shown to exhibit reduced gray matter in the prefrontal cortex, increased neuronal excitability in the amygdala, and reduced hippocampal neurogenesis.
These brain areas have been identified to play a key role in fear learning as well as memory. When impacted by stress hormones and stress-induced neuroplastic changes, stress may:
(a) enhance the memory of the initial pain experience at pain onset;
(b) promote the later persistence of the pain memory;
(c) impair the memory extinction process and the ability to establish a new memory trace.
As time goes on, the repetitive stress reactions that are a result of the emotional response and processing of chronic pain (as well as stresses that occur in daily life) produce a strengthened memory of pain. This means that the feeling of pain may be generated by the memory of pain and not just by the pain-producing actions. This learning process and continued pain memory can be a big influence on driving chronic pain.
Understanding the complex factors that contribute to chronic pain can help guide treatment choices. Utilizing strategies that reduce fear and anxiety, promote relaxation, and control one’s stress reaction can be useful over time to reverse the maladapted changes that continue the cycle of pain and stress.
Cognitive-behavioral therapy (CBT)
One method that has gained a lot of popularity is cognitive-behavioral therapy. The goal of this is to challenge the mind’s distorted thoughts of pain. It focuses on altering the automatic negative thoughts that can contribute to and increase depression, anxiety, and emotional difficulties.
This is not a new approach in psychology. Psych Central explains that cognitive behavioral therapy was invented by a psychiatrist, Aaron Beck, in the 1960s. He was doing psychoanalysis at the time and observed that during his analytical sessions, his patients tended to have an internal dialogue going on in their minds, almost as if they were talking to themselves. But they would only report a fraction of this kind of thinking to him. For example, in a therapy session the client might be thinking to herself: “He (the therapist) hasn’t said much today. I wonder if he’s annoyed with me?” These thoughts might make the client feel slightly anxious or perhaps annoyed. He or she could then respond to this thought with a further thought: “He’s probably tired, or perhaps I haven’t been talking about the most important things.” The second thought might change how the client was feeling.
Beck realized that the link between thoughts and feelings was very important. He invented the term automatic thoughts to describe emotion-filled thoughts that might pop up in the mind. He found that people were not always fully aware of such thoughts but could learn to identify and report them. If a person was feeling upset in some way, the thoughts were usually negative and neither realistic nor helpful. He found that identifying these thoughts was the key to the client understanding and overcoming his or her difficulties.
Beck called it cognitive therapy because of the importance it places on thinking. It is now known as cognitive-behavioral therapy (CBT) because the therapy employs behavioral techniques as well. The balance between the cognitive and the behavioral elements varies among the different therapies of this type, but all come under the umbrella term cognitive behavior therapy. CBT has since undergone successful scientific trials in many places by different teams and has been applied to a wide variety of problems.
Patients can opt to see a psychologist trained in this technique to help address their pain. While not all patients will be willing to commit to this, some things that we can do in the therapy clinic can use this technique. CBT clinic recommends trying these techniques with patients with chronic pain:
- Tell your patients to identify and notice their thoughts and emotions as they come to them. Instruct them to notice when their thoughts shift to things like, “I can’t cope with this pain.” Have them try to change their thought patterns to thoughts like, “I CAN cope with the pain.” They can actually “trick” their brain to believe their new thoughts and possibly turn off the “fight or flight” response.
- Have your patients track their thoughts on a daily basis and turn them into positive thoughts. They can write them down in a notebook or utilize these helpful worksheets to replace them with positive thoughts. Explain to them that they can tell themselves that they CAN cope and that they CAN relax. The power of positive thinking combined with the action of writing down thoughts can be powerful.
- Your patients can also work to change their “brain maps.” Have them think about the way they used to move before their illness or injury. If they have back pain, you can have them think about the way they used to get up from a chair or complete an activity they really enjoy. By doing so, they can “reactivate” the brain map for the way they used to use it, instead of using the pain map that has grown over time. Visualize it, relax, take a big breath. If your patients keep doing this exercise over time, they may actually shrink the pain map and regrow that old map back.
Mindfulness-based stress reduction (MBSR)
There are other approaches that have been shown to be effective in reducing stress that contributes to chronic pain. Mindfulness-based stress reduction (MBSR) has been used since 1979 and has shown to be of benefit for pain reduction.
Kabat-Zinn, founder of this technique, states, “In MBSR, we emphasize that awareness and thinking are very different capacities. Both, of course, are extremely potent and valuable, but from the perspective of mindfulness, it is awareness that is healing, rather than mere thinking. Also, it is only awareness itself that can balance out all of our various inflammations of thought and the emotional agitations and distortions that accompany the frequent storms that blow through the mind, especially in the face of a chronic pain condition.”
According to this technique, mindfulness provides a more accurate perception of pain. For instance, you might think that you are in pain all day. However, when you bring awareness to your pain you might reveal that it peaks, valleys and completely subsides. For example, a client believed that his pain was constant throughout the day. When he examined his pain, he realized it hits him about six times a day. This awareness helped to lift his frustration and anxiety.
Three easy techniques that can be used with patients are:
- Body scan: A body scan involves bringing awareness to each body part. The patient mentally scans each part of their body. But bringing attention to what the brain usually wants to move away from teaches your mind to not immediately react. Instead it shows the brain that experience that it can actually be with what is there.
- Breathing: When pain begins our brains react immediately with negative thoughts. While it may be difficult to stop these initial reactions, a patient can be trained to calm their mind and “ground your breath”. By simply breathing in slowing, then out slowly while thinking “in” and “out,” we train our minds to calm and not overreact.
- Distractions: A distraction can be a helpful tool when pain intensity is high. Patients should be encouraged to pick a healthy distraction. This could be anything from playing a game, talking to a friend, or listening to music.
While different techniques may work for different patients, clinicians should be aware of the impact stress has on chronic pain and seek ways to reduce the pain for effective management.
To learn more about chronic pain management, we recommend the following CE courses:
- Chronic Pain: A National Problem (for nurses)
- Chronic Illness and Depression (for occupational therapists)
- Cognitive Therapy: Theory, Techniques, and Applications, 2nd Edition (for psychologists)
- Video: Fascial Manipulation as a Pain Management Tool (for massage therapists)
Editor’s note: This post was originally published on November 18, 2020 and updated on September 22, 2021.