Interrupting the Cycle of Chronic Pain

pain, chronic pain, depressionIf you have experienced chronic pain, you are not alone. Each year 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, and socializing may be lost to a person with chronic pain. Frequently, no physical cause can be established, or the initial injury has 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 patient is believed. Some doctors do not take the patient’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. However, when pain persists, more often the patient’s 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, the 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 patient seeks medical attention and receives hope, medication, and/or treatment, and then usually improves. But if pain returns, so does fear, anxiety, guilt, and anger. When 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 people who have been abused, tend to react to pain passively. Their feelings of helplessness and victimization paralyze their ability to help themselves and seek effective professional care. Others blame themselves. In fact, interviews with 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. Perfectionists and over-achievers also fall into this group. They think in all or nothing terms, and feel like failures when they are not productive and at their best. In time, there may again be an improvement and more activity.

Usually, with the lessening of pain, the patient 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, the patient enters a stage of constant anxiety. This 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 and 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 patient’s mind, body, and entire life contract, making relaxation and healing nearly impossible. This is why early intervention to reduce the patient’s 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 patient’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.

The patient becomes caught in a downward spiral of depression. A once-active person is now lonely and withdrawn from normal social life, and may have even become chemically dependent as well. The emotional and physical strain of frustration and the loss of confidence, work, and social contacts result in low self-esteem, grief, and hopelessness, all of which magnify the patient’s perception of pain. Patients 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.

To extricate patients from this morass, a comprehensive plan addressing their physical, mental, emotional, and spiritual needs is required. Medication alone can be detrimental, because it builds dependency on the drug and doctor, without encouraging the patient 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. 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. These flare-ups should be normalized as an inevitable part of the healing process, particularly when the patient’s activities begin to increase.

The patient must take an active role in determining what works and what doesn’t, both in terms of treatment and the patient’s own activities. Through journaling and discussion, s/he can be helped to sort this out and to incorporate the positive into his or her life. A corollary principle is that patients learn to focus on what they can do, rather than on what they can’t, and at the same time, not deny their limitations, and do too much. When patients participate in their recovery, they regain a greater sense of control, and feelings of helplessness and depression diminish.

Finding pleasurable activities within the patient’s limits 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 the patient’s 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. Pleasurable and soothing sensations, such as gentle massage, holding, rocking and stroking, activate the patient’s own healing mechanisms and remind and reassure the body that it is safe to relax, in the same way that 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 that patients understand and express their feelings, ideally in individual psychotherapy as well as in a group. Patients who have been isolated need individual support to “en-courage” them to re-enter the world and reach out to others. 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 patients become more hopeful and assertive, they experience less pain and are better able to find and benefit from effective treatment. Increased social activities and a daily exercise regime, in order to build endurance, strength, and flexibility, should be encouraged. As the patient’s mood normalizes and pain lessens, s/he can eliminate unnecessary medications, but even if patients continue to experience pain, they needn’t suffer and can learn to lead fuller, more rewarding lives. Though this challenge may seem daunting, these goals are attainable over time. I know. After fourteen years of chronic pain, and being unable to walk for four years, I regained my ability to walk, even dance, without pain.

Copyright, Darlene Lancer, M.A., MFT, 2001 Published in Many Voices, February, 2003

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