Chronic Back Pain: Psychological Factors
How do psychological issues affect chronic back pain?
The mind-body issue
Traditionally we have thought of pain as a signal transmitted from the periphery to the brain – such as when a finger touches a hot plate. This understanding of pain serves well for very brief acute pain; however, it is only a small part of the story when pain is longer lasting.
Just as there are nerve tracts that carry pain signals upward to the brain, there are also tracts coming down from the brain that regulate the sensitivity of the spinal cord and thus determine how much pain we perceive. These tracts can amplify pain – making a trivial stimulation seem terrible – and can block it, which probably explains why quarterbacks and combat soldiers can carry out remarkable activities, and only after some time realize that they’ve been injured.
Additionally there are genetic differences in the responses to stimulation. For example, a metal disc heated to exactly 120° and placed on the forearm will be experienced by some as barely uncomfortable (pain of 1/10) and by others as excruciating (pain of 9/10). Functional brain imaging at the time of the experiment confirms that those who report severe pain actually have greater activation of several areas in the brain that process pain, while those who feel little pain have little brain activation. Thus we conclude that, unless other factors interfere, pain is whatever the patient tells us it is.
Is it mental?
Psychological factors rarely seem to be an important cause of prolonged pain, but they invariably affect it – for better or for worse.
Attention and vigilance account for much of the psychological modulation of pain. Pain that the brain thinks is important will be amplified, and those that it thinks are of no consequence will be lessened. (Just as a mother in a noisy New York apartment sleeps soundly as ambulances and car horns sound through the night, but awakens instantly when her baby whimpers.)
Mood profoundly affects pain, and even something as simple as reading a short story that it either funny or tragic changes people’s thresholds and tolerance to experimental pain.
Research over the last 35 years has demonstrated that pain, as well as numerous other factors, change the central nervous system in ways that lead to prolonged pain, even when the illness or injury that initiated it has healed. In fact, most chronic pain is more attributable to sensitization of the nervous system than to problems in the body parts that hurt.
These findings help to explain why people with normal-looking feet can have constant burning, why perfectly healthy people have headaches, and why the majority of people with chronic back pain have no findings on exam or imaging to account for it.
In the past, it was often assumed that when people had serious complaints of pain in healthy body parts, that their pain was imagined, psychologically induced, or exaggerated. We now know that this was a misjudgment on the part of medical providers.
What you think governs what you do
Behavior, however, is another matter, and here psychological and environmental reinforcers play a prominent role in determining function. So we see people with very severe health problems and very severe pain who have well preserved work, play, and socialization, while we see others with far less pathology whose lives appear to have stopped.
In addition to such obvious factors as anxiety, stress, and depression, there are others that impact function. One is the person’s intellectual understanding of their health – the person who believes that activity endangers their spinal fusion may become an unnecessary invalid, while a more confident person with the same medical condition may be golfing.
A person’s confidence in his/her own strength and abilities is also important. Those who feel competent tend to function better and have better quality of life than those who lack self confidence.
Catastrophizing, the tendency to assume that the worst that can happen is true, has been shown to promote pain and dysfunction. In the case of back pain, a person whose thoughts tend to run in the direction of, "This is horrible, there’s no way I can stand it, I’m damaged for the rest of my life," will likely suffer more (and have less fun) than one who thinks, "the majority of people have back pain, and I’m getting more than my share of it, but I know there will be days that are better and days that are worse."
Who’s got the power?
People who believe that their future depends on others – surgeons, spouses, Workers’ Compensation insurors, foremen, etc, – tend to be more depressed, more functionally impaired, and in worse pain than those who recognize that they are in charge of their own lives.
Learn to Live with It
These may be the most feared words that a person with chronic pain can hear, with the implication that the rest of your life is going to be about enduring suffering. Fortunately that is not the case. Those who learn to live with pain do have to accept that there is so far no cure for most chronic pains, but most go on to have joyous and productive lives in which they feel a blessing and not a burden to their loved ones.
It’s not easy or automatic, and we don’t come with instruction manuals telling us how to do it. These may be useful hints:
In order to do what we can, we need to stop trying to do what we can’t. At some point, it’s time to stop looking for diagnoses and cures, and to decide to make the best life possible out of an unfortunate situation. Acceptance does not mean giving up; it means taking charge and having the fullest life possible, despite the pain.
There may be nothing more important for reducing pain and increasing function than maintaining physical fitness. It clearly improves not only pain, but the anxiety and depression that often accompany it. Yes, it hurts at first. Yes, it would feel better at first to take a pain pill and go to bed. But over the long term, the fitter you are, the better you’ll feel – and the more you’ll be able to do with those who love you. You do need advice for this, though. The wrong exercises can increase many pains, and most patients require a slow and gradual increase in activities in order to avoid overdoing and crashing.
Fitness means weight management as well. Many studies show that obesity is associated with chronic pain. Weight loss is difficult, but with commercial weight loss programs that provide food guidance along with ongoing support, one can lose weight and keep it off without ever going hungry.
Stress is a funny thing. It can be good or bad. And if you have constant pain, you may want most of all to be comfortable. On the other hand, you’ve probably had more fun in roller coasters than in your favorite recliner, so you don’t want to always take it easy.
Relaxation training, yoga, guided imagery, self hypnosis, and biofeedback training all harness the individual’s ability to learn to regulate the body’s "fight or flight" response, that tends to increase pain.
Cognitive therapy can help, especially if your beliefs about life, yourself, other people, or your health situation have become liabilities, interfering with your quality of life more than helping it.
One of the fathers of pain psychology noted that patients who have something better to do don’t seem to hurt as much. The converse of this is the aphorism that if your life is empty, pain will fill it up.
Indeed, most patients find that when they’re preoccupied with their grandchildren, or involved in some activity that consumes them, they are much less aware of the pain.
Medical advice to "let pain be your guide" is great for acute pain, but it is toxic for chronic pain. Seek clear answers from your physician as to whether you are at risk for harm to your body (as distinguished from hurt), and then let life be your guide.
During acute pain, most have loved ones who are sympathetic and helpful. As the pain becomes chronic it seems that whatever they do is wrong. If they note that there isn’t much physical disease going on and wonder if you’re exaggerating the pain, it tends to lead to depression, anger, and decreased function. If they baby you, wait on you, and/or begin to make decisions for you, it tends to lead to regression, helplessness, and then depression. If friends get tired of hearing about the pain and drift away, it leads to loneliness and resentment.
It seems that the best response for those who love you is to accept that the pain is real, that they can’t take it away, and that you aren’t sick and don’t need to be treated like a child. It helps if they give attention in the form of an invitation to the movies or a picnic rather than in the form of caretaking. It is important that loved ones ensure that your pain does not govern their lives.
There may be nothing lonelier in life than living with chronic pain. It feels as though no one can really understand. Not true.
There are several organizations of people with chronic pain that provide education and support. The American Chronic Pain Association (www.theacpa.org) provides a great deal of education to patients and families about pain, how to deal with it, and various treatments for it. Many cities have ACPA groups in which people provide mutual help and support. And they definitely understand your pain – they have it too.