Photo courtesy of Delfina Carmona
Understanding—and Treating—the Emotional and Physical Roots of Chronic Pain
While we have a strange cultural fixation on validating ailments of the body over ailments of the mind, anyone who has experienced chronic pain—be it from arthritis, endometriosis, or a bad back—knows that it is both a sensory and an emotional experience. “Psychology is integral to the pain experience, but curiously, we don’t tend to treat it that way in our society,” says Beth Darnall, PhD, a clinical psychologist and a professor in Stanford’s Department of Anesthesiology, Perioperative, and Pain Medicine. “We instead focus purely on the sensory dimension and the localized site of pain.”
Darnall’s research is focused on the psychology of pain, understanding its mechanisms and how to provide patients with techniques to manage their pain. “When I tell people I’m a pain psychologist, people say, ‘I’ve never heard of that.’ It’s not well known that this treatment pathway exists,” Darnall says. “But the reality of pain is that if we don’t address the psychosocial dimensions, we are doing a disservice to our patients.” And as she explains, it’s not just about lessening pain in the moment—although that is certainly a desired goal. It’s about the greater reward of priming your brain to diminish pain in the future.
A Q&A with Beth Darnall, PhD
I had chronic pain when I was younger and never received treatment for it. In late adolescence, when I was under a great deal of stress after someone very close to me passed away, my pain increased greatly. That left me to seek treatment in the emergency department of a hospital, where I was simply prescribed opioids and given no other treatment options. That was not a good treatment for a young woman who was also grieving; it took me some time to figure out that what I needed was a different approach to managing my pain.
My personal journey led me down a pathway of being very connected to the experience of pain and understanding quite intimately the psychosocial dimensions of pain and how they are a critical aspect of treatment. I don’t live with chronic pain now; I am very blessed. In my postdoctoral training at the Johns Hopkins School of Medicine, I treated patients with complex and painful medical conditions, including catastrophic burn, amputation, and spinal cord injury. I wanted to learn more about how to best help others who were suffering with pain worse than what I had experienced. Thankfully, we have medications to help people with complex painful conditions, and using evidence-based tools can be valuable for gaining some control over one’s experience.
Regardless of where we feel pain in our body, it is processed in the central nervous system—the brain and the spinal cord. While it is important to attend to the local sites of pain in our body, you can think of our central nervous system as our pain computer: It can either amplify or dampen pain. We can go straight to the computer and apply certain skills and tools to downregulate the experience of pain.
Pain is stressful—it is common to be distressed by pain. This is rooted in our neurobiology: Pain, at a basic level, is meant to get our attention. It is meant to motivate us to escape whatever is causing the pain, which we interpret as a threat. Pain registers as a threat both consciously and unconsciously. Escaping short-term pain is a helpful process with a resolution.
When you have ongoing pain, like migraines or back pain or fibromyalgia, you cannot readily escape it. But there are still danger signals firing in your nervous system, and the pain kicks off a whole cascade of biological responses—fight-or-flight—that are meant to prepare you to escape. You’ll have increased heart rate and increased respiratory rate; your blood vessels will constrict; your muscles will tighten. It leads to mental focus on the pain, or the threat, as it is often perceived. The body exists in a state of defense against the pain—against the threat.
Repeated over months or years or decades, these cycles alter our neuromuscular patterns: The continual state of defense leads our nervous system to become primed for greater pain. This process happens because our nervous system, our minds, and our bodies are trying to help us survive the “threat” of pain, but it paradoxically ends up feeding the pain.
Our emotional experience through all of this is integral to what we call pain. Some patterns of thought and emotions amplify distress and pain; it’s helpful to identify those patterns and address them. The good news is that there are good ways to calm the nervous system, and we begin by identifying patterns of thoughts, emotions, and daily choices that may be working against us to unwittingly amplify pain.
Women are more likely to acquire various chronic pain conditions, and when we do experience pain, it’s more likely to be more intense and last longer than it does for men. We’ve evolved to have a physiology that is more attuned toward protection, which means that pain registers more potently within our minds and bodies for survival value. That’s why it’s more important for women to be equipped with ways to work with our bodies: to be able to calm the nervous system, to communicate a persistent message of safety to the mind and body. Those abilities dampen pain processing in the nervous system and can prime us for pain relief long-term.
I am not saying that pain is all in your head. Nor is women’s pain is more psychological. Neither of those things is true. On average, pain is a greater challenge for women, which makes it that much more important to learn ways to become empowered.
Research tells us that when we can’t focus on anything but the pain and how awful it is, it actually increases emotional distress and the amplification of the pain in the brain. It’s because the regions of the brain that are associated with pain processing are the same regions of the brain that are involved in our emotional experience. When negative emotional experiences—like anxiety about pain—engage the amygdala, for instance, it directly relates to increases in pain intensity in the moment. On the flip side, MRI studies show that when we teach people calming skills they can apply in real time, we can see the shrinking of pain processing occurring in real time on the brain scan.
Doctors have also conducted research on people living with chronic pain, where they scan patients’ brains before they go through cognitive behavioral therapy (CBT) for chronic pain and again after eleven weeks after treatment. What the researchers found was that at baseline, people with chronic pain showed volumetric deficits in the regions of the brain associated with pain control. After eleven weeks of the subjects’ learning and using new pain-management skills, their post-treatment brain scans evidenced volumetric increases in those same regions of the brain associated with pain control. In as little as three months, not only can you change the function of your brain—training it away from pain—but you can actually change the structure of your brain, priming you for future pain relief.
What we know about chronic pain is that it is really a biopsychosocial condition. We historically have focused on pain as being simply a biomedical condition; we’ve ignored aspects of pain treatment that greatly reduce suffering in favor of focusing on the purely medical.
For many people, we find that if we don’t address the whole person, they don’t get better—because we are likely not addressing some of the core drivers of their pain experience. The best treatment for chronic pain is a comprehensive approach, where we’re assessing each person from a multidimensional perspective. What that means is a comprehensive medical workup, a physical therapy evaluation, and a psychological evaluation that takes into account the person’s social and even spiritual life. It’s vitally important for people to hear that pain medication can be a critical component of chronic pain care, and there should be no shame in needing medication. We do endeavor to provide a multimodal approach that also emphasizes what people can do to help themselves.
When we view chronic pain as a reductive symptom and treat it as a reductive symptom, we get suboptimal results, because that is not what pain is. A good analogy is diabetes: Diabetes is affected by a person’s biology, what they eat, their sleep, and activity patterns. Medication may be important, but a whole-person approach that engages the person in the management of all of the factors yields the best results. Chronic pain management is very similar. A pain psychologist is a pain specialist who assesses and addresses the comprehensive needs of individuals living with pain and also works to empower them, to equip them with evidence-based tools, skills, and resources, so that they can live better. That’s not to say that this treatment will obviate the need for all medical treatment now and in the future. In fact, behavioral medicine treatments work well alongside medical treatments and help boost their effectiveness. They give people as much control as possible.
There are decades’ worth of literature supporting this biopsychosocial treatment model for pain, but still, in the United States and around the world, most patients do not have access to this type of care. We have seen great progress in recent years where many primary care clinics now may include a behavioral approach to the management of pain.
At the Stanford Pain Management Center, this is the model and the philosophy that we put forward; the Mayo Clinic and the VA health care system similarly do a great job with interdisciplinary pain care. There are some closed care networks where similar treatment is available: Kaiser Permanente and Intermountain Healthcare offer behavioral medicine for chronic pain. That’s excellent progress.
We’re broadly lacking comprehensive pain care outside of these systems, where perhaps the vast majority of people reside. People on Medicare and Medicaid may have poor access to some of these treatments. Many state-subsidized health care plans simply don’t provide this type of access to pain psychology or behavioral medicine, despite that fact this subset of population tends to have the greatest medical complexity and also tends to access and utilize the most resources. If we shifted our thinking and invested more in this care as early on as possible, that could support resolution of pain and potentially lead to great financial savings at the local, state, and national level.
I’ve been both researching and focusing on opioid reduction for a good chunk of my career. It’s not about taking opioids or not taking opioids: What’s most important is first providing patients with conservative methods that require less medication. Then, if medication is needed, you know the patient is equipped to best manage their pain and need less of it. But certainly, some patients require opioid medication, and their access to the medication should be preserved.
In this country, there’s a huge focus on opioid restrictions, and it’s problematic for people who have been taking those opioids long-term and now are now being told they have to scale back. That leaves patients asking, “Well, now what are you going to do for my pain? What am I supposed to do?” Physicians and health care clinicians may recognize that they need to reduce opioid prescribing, but how are they going to help people? We can’t not treat their pain. If we simply focus on reducing opioid doses, we’re missing the point, which is to help people live better with pain. Reducing opioids alone is poor pain treatment for most people, and if it’s not done the right way and with the right patient, it can inflict suffering and harm.
The best pain care begins with comprehensively assessing each person and attending to their individual needs. This is why creating rigid policies that place limits on pain treatments is short-sighted. The solution is patient-centered pain care: understanding and treating each person as an individual, because while we could say that certainly opioids have been overprescribed, opioids can be absolutely essential medicine for a certain fraction of the population with highly complex medical conditions. We need to allow the flexibility in our policies to provide them with the pain care that they need.
There’s a lot of evidence to support the efficacy of physical therapy, behavioral medicine (or what I call pain psychology, which includes skilled-based cognitive behavioral therapy for pain), and mindfulness-based practices.
All of these behavioral modalities have a very strong emphasis on educating patients about what pain is, and the wide array of things—such as your sleep hygiene, activity level, stress levels, and even your relationships—that can impact it, through both influencing your ability to administer self-care and altering the long-term trajectory of your pain. People armed with this information tend to slowly make changes in their daily lives that support rehabilitation versus debilitation.
It’s important to work with professionals who can provide this assessment and the right information. Physical therapy with a skilled therapist trained in the management of chronic pain can help people engage in appropriate movement; both psychologists and physical therapists can help patients create goals that are appropriate, achievable, and relevant to a rehabilitative mind-set.
Over time, patients become more active and can engage in activities that are meaningful to them. Pain level may not change for some, but if they’re able to go to their children’s school events or go out with their spouse, it’s a vastly meaningful improvement in their life. Those changes may actually be more important than reducing some of the pain: When you talk to people with chronic pain, often what they say is, “The worst part of the pain is how it has robbed me of my life.”
So we try to help people reclaim their lives. Often through that process, people observe decreases in pain itself. That’s not always the case—and we discourage a focus on the pain, because what we know is that the more we focus on pain, the more it is maintained. We focus instead on function. What can I do right now to help myself? If I’m having pain, what can I do that will calm my nervous system? What are the goals that are meaningful to me and what steps can I take today to help me get one step closer to that goal?
Effective tools are ones that lead to a relaxation response in the nervous system. Pain automatically triggers a defensive response, so what we try to do is dampen that response. We try to help the body get down to a state of comfort and relaxation because it counteracts those hardwired defensive responses to pain.
One of the ways this can be accomplished is through diaphragmatic breathing. It’s essentially deep breathing that slows the heart rate, dilates the blood vessels, relaxes the muscles, and calms the mind. This counteracts those pain responses and dampens pain processing in the nervous system.
That is one example of a vitally important skill, but there are many ways you can access a relaxation response. Some people prefer meditation as a pathway to get there. It’s also one of the reasons why exercise, like gentle yoga, is beneficial. Hypnosis is another route.
With cognitive behavioral therapy, we help individuals identify patterns of thoughts and behaviors that amplify the stress of pain. Of course pain is distressing, but if we find our mind is focused on it, and we fear that it’s only going to get worse, this cognitive rumination increases our pain. We can learn to identify those thoughts as early as possible, which over time allows those neural patterns to extinguish instead of taking on a life of their own. While doing so will not cure a person’s pain condition, they can begin to steer themselves toward greater relief.
- “Why It Hurts to Lose Sleep” by Benedict Carey (The New York Times, 2019)
- “The Neuroscience of Pain” by Nicola Twilley (The New Yorker, 2018)
- “Treating Pain without Pills” by Stephani Sutherland (Scientific American, 2017)
- “Opioids Won’t Solve the World’s Chronic Pain. This Idea Might” by Christina Nunez (National Geographic, 2018)
- “Unlocking the Healing Power of You” by Erik Vance (National Geographic, 2016)
More from Beth Darnall:
- Darnall, B. (2018). To treat pain, study people in all their complexity. Nature, 557, 7-7./
- “Change Your Mind-Set, Reduce Chronic Pain” by Beth Darnall (Scientific American, 2018)
- Less Pain, Fewer Pills: Avoid the Dangers of Prescription Opioids and Gain Control over Chronic Pain by Beth Darnall (2014)
- The Opioid-Free Pain Relief Kit: 10 Simple Steps to Ease Your Pain by Beth Darnall (2016)
Studies on behavioral medicine and pain psychology:
- Chapin, H. L., Darnall, B. D., Seppala, E. M., Doty, J. R., Hah, J. M., & Mackey, S. C. (2014). Pilot study of a compassion meditation intervention in chronic pain1 . Journal of Compassionate Health Care, 1(1), 4.
- Jensen, M. P. (2009). Hypnosis for chronic pain management: a new hope2 . Pain, 146(3), 235-237.
- Quartana, P. J., Campbell, C. M., & Edwards, R. R. (2009). Pain catastrophizing: a critical review3 . Expert Review of Neurotherapeutics, 9(5), 745-758.
- Rosenzweig, S., Greeson, J. M., Reibel, D. K., Green, J. S., Jasser, S. A., & Beasley, D. (2010). Mindfulness-based stress reduction for chronic pain conditions: variation in treatment outcomes and role of home meditation practice4 . Journal of Psychosomatic Research, 68(1), 29-36.
- Veehof, M. M., Oskam, M. J., Schreurs, K. M., & Bohlmeijer, E. T. (2011). Acceptance-based interventions for the treatment of chronic pain: a systematic review and meta-analysis5 . Pain, 152(3), 533-542.
- Vowles, K. E., McCracken, L. M., & Eccleston, C. (2008). Patient functioning and catastrophizing in chronic pain: The mediating effects of acceptance6 . Health Psychology, 27(2S), S136.
Beth Darnall, PhD, is a pain psychologist and scientist. She is a clinical professor at Stanford University in the Department of Anesthesiology, Perioperative and Pain Medicine, and she is affiliated faculty in the Stanford Wu Tsai Neurosciences Institute. Her research involves applying behavioral medicine strategies to facilitate pain control and opioid reduction, as well as developing and investigating digital behavioral pain medicine solutions for chronic pain and post-surgical acute pain. She is a principal investigator for $14 million in federal and independent research awards and is the author of three books: Less Pain, Fewer Pills: Avoid the Dangers of Prescription Opioids and Gain Control Over Chronic Pain, The Opioid-Free Pain Relief Kit, and Psychological Treatment for Patients with Chronic Pain. In 2018, she was an invited speaker at a Congressional Briefing on pain and opioids in America. Her work has been featured in Scientific American, The Washington Post, BBC Radio, JAMA Internal Medicine, and Nature. She spoke at the 2018 World Economic Forum in Davos, Switzerland, on the psychology of pain relief. Follow her on Twitter @bethdarnall.
This article is for informational purposes only, even if and to the extent that it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice. The views expressed in this article are the views of the expert and do not necessarily represent the views of goop.