The Connection Between Pain and Your Brain
By Linda Rath
You would have every right to be offended if someone said your pain was all in your head. But the truth is, pain is constructed entirely in the brain. This doesn’t mean your pain is any less real – it’s just that your brain literally creates what your body feels, and in cases of chronic pain, your brain helps perpetuate it.
A growing understanding of how this happens – and the need to find better alternatives to pain medications – has led to renewed interest in “biopsychosocial pain management.” This type of treatment addresses situations, beliefs, expectations and emotions that cause a person to perceive pain in a certain way.
Unlike drugs, biopsychosocial methods don’t mask or numb chronic pain. Instead, people learn to manage pain by modifying or changing what their brain tells them. Many say this approach relieves pain without drugs – in some cases, it’s the first time they’ve gotten relief. (Listen to a Live Yes! With Arthritis Podcast on coping with pain
Why You Hurt
Pain is a complicated warning system to protect you from harm. When you stub your toe, your peripheral nervous system sends signals to your brain, which then decides how much danger there is. If it decides the signals are worth paying attention to, the pain volume is cranked up until the problem is resolved; if not, pain is put on mute.
This system works pretty well for acute pain, like an injured toe. But in chronic conditions like osteoarthritis (OA), where there’s no quick fix for, say, cartilage loss in the knee, the parts of the brain that send and receive danger signals become more sensitive over time. Scientists say the more the brain processes pain, the more perceptive it gets until it’s always on high alert. And depending on the person’s emotions, beliefs and expectations, the brain will likely keep registering an aching knee day after day.
This is how people with chronic pain get locked in self-perpetuating pain, but evidence suggests that it’s possible to tone down an overly sensitive brain and moderate chronic pain messages. Here’s what science has found, and how it can work in real life.
For Better or Worse
Lauren Atlas, PhD, heads the section on affective neuroscience and pain at the National Institutes of Health. Much of her work has focused on placebo and nocebo effects. The placebo effect occurs when patients get better with a sham treatment because they believe it will help; placebos appear to work in some cases even when patients know they’re not real. A nocebo effect occurs when patients are told a harmless treatment will make them feel bad, and it does.
Both placebo and nocebo effects are seen as key factors in understanding how the brain works, especially with regard to pain, because they use the same mechanisms: context, beliefs, expectations and emotion.
Filling in the Picture
Context is the setting where something happens – your doctor’s office, for example. Atlas says just stepping through the door activates beliefs and expectations you’ve developed through experience.
“If you have a history of beneficial treatment with a certain doctor, this might enhance your expectations for a positive outcome. Likewise, if you have a history of ineffective treatment, this might lead to negative expectations that worsen symptoms,” she explains.
Similarly, positive expectations can tone down chronic pain, and negative expectations can ramp it up. In other words, if you expect something to hurt like the dickens, it probably will.
How does this happen? Many studies show that positive expectations or beliefs change brain chemistry, Atlas says, causing the body to produce pain-blocking chemicals like opioids and dopamine.
There’s less research on the nocebo effect, but evidence suggests negative expectations and beliefs increase anxiety, which in turn causes the release of cholecystokinin (CCK), a hormone linked to anxiety, creating a self-perpetuating loop. CCK has been shown to reduce or block the action of opioid medications and even acupuncture, which may help explain why people who are anxious or depressed are harder to treat.
Power of Emotions
Pain and emotion circuits overlap in the brain. This shared neural network has been called nature’s “economy route,” because it allows the brain to process a lot of sensations at once.
Negative emotions are like gasoline thrown on the fire of pain, not only making chronic pain much worse, but even causing it in some cases, says Beth Darnall, PhD, a pain psychologist and associate professor at Stanford University. Depressed people are three or four times more likely to develop chronic pain than others.
The opposite is also true. Positive emotions can significantly lower pain when patients stop focusing on how bad they feel. Many with chronic pain agree, noting that when they’re “in a worse place emotionally,” they’re less motivated to exercise and see friends and family. These are essential to changing pain patterns because they help break the pattern of ruminating on pain and they trigger the release of feel-good endorphins and the body’s natural opioids. Darnall says that when patients learn how emotion, expectations, beliefs and context all fit together, “they know there is a pathway for them to gain more control.”
April Vallerand, PhD, a pain researcher and professor at Wayne State University in Detroit, says that a sense of powerlessness helps shape her patients’ perceptions of pain.
“If you perceive yourself to be disabled, you’re going to act like it,” she says. “Patients would say to me, ‘I’m fine as long as I don’t move from that recliner.’ Many were afraid to cook, drive, go to the mall. Well, that’s not life, that’s not function. My goal was to maintain or improve their function, despite chronic pain.”
The key is restoring their sense of control, which is known to reduce pain-related emotional distress and improve function. Vallerand designed a program for cancer patients she called Power Over Pain – Coaching (POP-C). It’s delivered by trained nurses through phone calls and home visits. This establishes trust and helps caregivers understand patients’ backgrounds, stories and cultures – all essential for helping them learn to manage pain. POP-C has three main components: medication management, pain advocacy and living with pain.
- Medication management helps patients learn to use pain drugs “in the most effective way,” says Vallerand. Most pain programs wean people off pills, but cancer pain is an exception.
- Pain advocacy focuses on patients’ communication with doctors and caregivers. “There’s a dynamic that goes on when a person just complains, so we work on improving that dynamic,” Vallerand says. She recommends making conversations around pain concrete and actionable, for example, “My pain keeps me up at night,” or “It means I can’t walk the dog.”
- Living with pain is where the real magic happens. Although most people won’t experience a cure for chronic pain, Vallerand says, “Our message is that you have to accept that pain is a normal part of the human experience. But we can get pain to the level where it’s not running your life, where you are in control. And people are thrilled to get to that level.”
POP-C helps people shed many unfounded beliefs, including that movement is bad or pain always equals harm – exactly the type of negative thinking that worsens symptoms.
“We help people learn not to get so distressed, not to listen to their minds,” Vallerand says. “We are not trying to eliminate all pain. We are trying to reduce suffering, relieve distress and help people do more of the things they want and need to do in spite of pain. My question to patients is always, ‘What does this pain keep you from doing?’ If I can find out what that is, we can target that specific thing and work to get them back to functioning and doing the things that are important to them.”
Vallerand recommends nonpharmacological therapies like visualization, distraction and relaxation techniques as well as integrative treatments and spiritual resources.
A couple of years ago, Vallerand and her colleagues put POP-C to the test, enrolling more than 200 cancer patients who are African American – whom research shows experience higher levels of cancer pain and less function than other groups – in a randomized study. During the study, nurses visited and called the patients three times a week, working with them in POP-C’s three key areas. After five weeks, they reported significant improvements in pain, distress, function and perceived control over pain. Patients who received home visits and phone calls but no coaching didn’t improve.
Pain Rehab Programs
The U.S. once had hundreds of pain clinics, where people learned techniques to help manage chronic pain. When opioids hit the market in the 1990s, most of these clinics folded, but now there’s renewed interest in clinical pain programs. Two of the longest running are Mayo Clinic’s Pain Rehabilitation Center in Rochester, Minnesota, and Cleveland Clinic’s Chronic Pain Rehabilitation Program in Ohio. Both have long track records of success, and have helped patients live well without opioids, sleeping pills, anti-anxiety meds or acetaminophen (Tylenol). The goal is to empower patients to manage their pain rather than rely on medical quick fixes.
Hitting Pain From All Angles
Medication management is only one part of pain rehab programs. Jeannie Sperry, PhD, who co-chairs the division of addictions, transplant and pain at Mayo Clinic in Minnesota, stresses that chronic pain’s complexity requires a big tent approach.
“We address all the factors related to pain, so we work on physical conditioning, how people perform daily activities, and we also look at how people think and behave in pain and work on changing those aspects of their life as well,” she explains. “We see that pain starts taking over people’s lives over time. They start thinking about pain and ruminating about pain and worrying about the future. They behave in ways that inadvertently make things worse by avoiding activity and relationships that could be helpful, so we promote a very active rehabilitation approach.”
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