Chronic Pain

– by Lee Smith, Ph.D.

In many cases chronic pain is another example of how brains and bodies change through the repeated interplay of several systems. If you do something over and over, you’ll get better at it. Chronic pain can be the neuroplastic outcome of a brain and body that has learned to be in pain and to suffer.

The question might arise of whether chronic pain has a legitimate physical basis or whether it’s a psychological issue, and the answer is, yes. Many ingredients are needed to bake a cake, and a lot is baked in to chronic pain as well. The experience of acute physical pain is a result of injury to or illness in some tissue(s) of the body. Pain sensations also activate stress responses, emotions and thoughts.

Acute pain is a good thing because it tells us when something is doing us harm. It’s a protective signal that says, “Look out! Something is harming me”!! Because harm is also a threat, pain signals bring in our old friend, the stress system. Pain and stress are the dynamic duo of survival. Stress activates the immune and inflammatory systems, and it gets us energized, tense, edgy and on the look out.

A lasting, painful injury can recruit a cast of players. They rehearse their lines together, polishing their act, playing off of one another. And wouldn’t you know it; chronic stress can sensitize our nervous systems to pain signals.

In some cases chronic pain can become a case of ‘brain’s gone wild’. The mind-brain can become unintentionally ‘talented’ at being in pain as the cast of players become interlinked, ‘texting’ each other like teenagers.

When we have a pain-evoking and ongoing injury, we are exposed to ongoing and repeated pain messages about the injury. Our nervous systems can become increasingly on guard, watching for pain, and increased sensitization to pain can develop. Neurochemical changes can lead to nonharmful stimulation producing intense pain. An overprotectiveness develops from these private lessons, and the body-brain learns to react with the same stress and threat, emotion and thought, from a mere nudge or light touch.

As this learning settles in, any one of the players can set the others to howling. A new financial or social surprise can produce stress and pain. The persisting pain and stress can cultivate mood changes. Chronic pain may take centre stage, but there is a strong cast of players also at work.

Stress plays a critical role in the development and maintenance of chronic pain. People who are chronically stressed from childhood maltreatment, trauma, loss or difficult circumstances are understandably more vulnerable to developing chronic pain conditions.

Research shows that when we are more accepting of the presence and existence of pain, we’re much less catastrophic and feel more control of our life.

It’s not a matter of just saying to yourself, “Just stop feeling the pain”. That’s about as helpful as telling a novice to just play piano. And being hard on yourself just adds to the stress.

Chronic pain following an injury is very real. Damage to tissue is real and may not be subject to complete resolution. Learning to live with chronic pain equates to finding ways to accept it’s presence in your life and working with your pain to reduce it’s interference. Living with chronic pain involves learning about your stress reactions and facing all of the facets of the experience of pain. Through this exploration, through unwinding the chronic pain learning with new adaptive learning about what’s going on, through learning how to regulate your stress, the mind-body can be retrained. Yoga, mindfulness training, relaxation skills, and cognitive therapy are all helpful routes to better living through neuroplasticity.

Raiders of Health

Do you remember this scene from Raiders of the Lost Ark:  After Indiana Jones takes an improbable pounding chasing the bad guys, we find him a little worse for wear in the berth of a ship with the enamoured Karen Allen.  Her glow is met by his fatigue, her kiss by his snore, but just before he sleeps she scolds him, “You’re not the man I knew ten years ago”, to which he replied, “It’s not the years, honey, it’s the mileage”.

True that.  What might we learn if we were each fitted with a sort of life odometer that displayed our ‘mileage’, the amount of wear and tear we accrue as the months and years bounce by?

One thing we would see is that chronic stress gets that odometer ticking.  And a remarkable body of research is showing that stress gets under our skin, so to speak, during sensitive periods of our development and changes our long-range vulnerability to depression and anxiety, addiction, social isolation, disease, injury, dementia and death.   Ughh!

The biological processes of a developing child’s body and mind are shaped and changed by the conditions that the child encounters.    Early life adversity, as it’s called, such as physical, sexual, and emotional abuse, harsh discipline, parental unresponsiveness and neglect, poverty and witnessing violence subjects a child to an environment full of threat, shock and danger.  

Danger is biologically important information.  Evolution has it that we naturally adjust in whatever ways those adjustments can be made so that we can most optimally meet future conditions.  Because nature doesn’t have a crystal ball, the adjustments that get made are based in the conditions that are commonplace in the child’s life.  Development tunes the body and mind, reflecting the way it is.  Human and animal research has clearly established that if danger is present with some frequency, then the developing stress and immune systems learn and morph to mirror the requirement to deal with danger, and these changes can persist apparently for the duration of the individual’s life.

Adults who had suffered early life adversity react with more and longer lasting fear and have stronger and longer stress reactions.  The diseases and problems of adulthood that are clearly associated with stress, such as heart disease, are more prevalent in those who suffered childhood adversity.  A Johns Hopkins Medical School study followed medical students/physicians for 40 years and found, in that affluent and educated population, that those who had suffered childhood adversity had 2.4 times the rate of coronary heart disease by age 50.

Childhood maltreatment is borne through a person’s life at the levels of cells and systems; it becomes a part of how we are.   Chronic childhood stressors program changes in certain types of immune cells that result in over-responding to injuries and infections.   These changes get embedded in the way DNA cranks out the battle materials when threats from viruses and wounds occur.  These and other changes produce more inflammation and less responsiveness to the signals that would down-regulate the stress response.

Behavioural changes also get baked in to the cake and further undermine long-term health.  Effected adults more often participate in unhealthy, high mileage lifestyles including poor diet, smoking, alcohol abuse and less exercise.  They tend to be more socially isolated due to the learned tendency for vigilance to threat and mistrust of others.

No child is responsible for the conditions in which they grow up and so it’s most important that health policy catch up with what science is telling us about stress, emotional health and physical health.  I’m sorry to say that the Conference Board of Canada, self-described as,”The foremost independent, not-for-profit, applied research organization in Canada” mentioned “stress” only once, as an afterthought, in their Canadian Heart Health Strategy document from January 2010.  Their slogan, “Insights You Can Count On”, suggests instead that we cannot yet count on seeing policies that embrace the reality that emotional health is a major and very costly public health issue.