Dr. Jay Bulloch, DAOM, LAc, C.SMA
Chronic pain is not only related to the amount of injury and tissue damage your body has suffered; your emotions, particularly fear and anxiety (stress), along with other cognitive factors, play an active roll in the development, maintenance, severity, and duration of pain. A vicious cycle can occur where by pain increases anxiety and stress, and/or anxiety and stress causes your chronic pain to get worse. For example, when you are under more stress due to work or financial problems, you may notice that low-grade neck or back pain flairs up. Why are pain and emotions so closely related, and what can you do to start treating this? The answer to breaking the vicious cycle begins by understanding the relationship between body and mind. (Body-mind is one system, not two.)
The body has a tremendous, innate survival and self-healing mechanism. When a person is under threat, or they feel a sense of impending danger, the survival mechanism kicks in. The body releases fight or flight neurotransmitters and hormones (adrenalin and nor-adrenalin), which increase heart rate, blood pressure, and respiration to enable the body to put up a fight or run from danger. At the same time, they fire up the immune system and get it ready to repair any damage done by an external threat, invading organism, or foreign object. These natural chemicals are pro-inflammatory, but despite everything you might here about anti-inflammatories and trying to eliminate inflammation, inflammation is not necessarily a bad thing. It is your body’s natural defense and repair process, so pro-inflammation = pro-defense and repair. It is when inflammation becomes a chronic or systemic that you can run into troubles. So what can cause this to happen? The answer to that question involves looking at the next phase of the stress response.
The second phase of the stress response involves a hormone called cortisol. Cortisol is a type of steroid hormone produced by the adrenals. It is released to mobilize glucose stored in the body and give you the fuel you need to fight or run. It also suppresses functions that are non-essential for your immediate survival such as digestion, so that all your resources can be used for self-protection. When your body is functioning properly, cortisol will also suppress the immune system to a certain extent to keep the inflammatory process from getting out of control. In this regard, it acts as an anti-inflammatory agent, and it will also help to reduce pain. The importance of this aspect of cortisol function is illustrated by the common use in Western medicine of steroid medications like synthetic cortisone and prednisone for treating inflammatory conditions. This self-preservation and survival mechanism is great for short periods. It is, after all, how our ancestors survived and we all made it this far. But, over prolonged periods of stress and anxiety, it can work against you.
The relationship between adrenaline, nor-adrenaline, and cortisol work well for short term, acute stress to ensure survival; however, if you suffer from chronic stress and anxiety (both are fear related), this relationship can become dysfunctional. The body keeps pumping cortisol, and when cortisol is severely elevated, or just elevated for long periods of time (weeks or months), instead of being anti-inflammatory, it becomes pro-inflammatory due to its binding at different receptors in the body. This, I believe, is why medications such as cortisone and prednisone do not work well for some patients.
A further piece of the puzzle is related to how the brain processes information from the body. This is the cognitive piece. As strange as it may sound, pain is as much a brain event as it is a body event. When the body sends signals via the nervous system that there may be something wrong—that a part of the body is injured, or that something may be injuring the body—the brain receives those signals and then must decide what to do about them. When the brain does not think you are safe, when there is greater fear and anxiety, it responds to these signals by creating strong pain sensations to get your attention. The more danger or stress you feel, the stronger these pain messages from the brain are. The longer you have stress, anxiety, and pain, the better the brain gets at creating more pain. You need fewer stimuli from the body for the brain to create more pain. The body and brain becomes more efficient if you like, doing more with less.
All of this leads to the current scientific understanding that your pain is not necessarily related to how much tissue damage there is in the body. It can have more to do with your state of mind. If you feel stressed, afraid, or anxious, you can experience more pain. If you are relaxed, calm, and happy, you can experience less pain. The same amount of tissue damage or injury will create feelings of more or less pain depending on your state of mind. That’s not to say that it’s all in your mind, because it’s not. There is a body component. The body is sending the signals to the brain. But your brain will amplify or reduce your experience of pain depending on how safe it feels.
In summary, fearful thoughts, beliefs, and perceptions of danger from the brain trigger the body to release adrenaline, nor-adrenaline, and cortisol. These create an immune and pain response to help protect the body. If the threat is short lived, and the body has an opportunity to come to a calm state of rest, the body can heal, and pain can resolve. If the stress and anxiety is prolonged (for example, in a situation where you cannot fight or run from something perceived as threatening or unpleasant), the immune and pain response can get out of control. Inflammation and pain become chronic conditions, drugs don’t work, and no matter what treatment you try, you can’t seem to get relief. In these cases, it is vital to address stress, fear and anxiety, and other cognitive factors, as not only manifestations of pain but major contributors to it.
When looking for relief from chronic pain, in addition to addressing stress and anxiety, it is also important to consider other factors that may be fueling the immune, inflammatory response. These include such things as certain foods, alcohol, chemicals, or chronic infections. A comprehensive evaluation of your overall physical health is necessary to determine other factors that may be contributing to inflammation and stress on the body. Dietary habits can have a significant impact on pain levels. I will cover that in a separate article.
In the mean time, stress reduction techniques such as exercise, meditation (or mindful breathing practices), massage, and acupuncture can have a significant impact on your pain levels. Sufficient, quality sleep is also an important part of allowing the body to heal and resolve chronic pain. Also, it is important to remain mindful of the brain relationship to pain. Catastrophizing or dramatizing the experience will not help. It can actually increase your experience of pain. Try to find things that help you feel safe, calm, and happy. Stay away from movies or television that make you feel stressed and agitated. Be mindful of those people and relationships who trigger your fear and anxiety, or who agitate you, and find healthier ways to deal with them if you are not able to avoid them.
These new tools and lifestyle changes may seem impossible at first, the thought of which may even make you feel overwhelmed and more anxious. This is obviously not good for your pain. Get support by finding a good holistic healthcare practitioner who can provide you with the necessary guidance and tools. Make lifestyle and cognitive changes bit by bit. Even a few minutes of meditation a day can develop into a habit that is not only easy, but also enjoyable. Eventually you can create meaningful change in your life and reduce your experience of pain.
- Cannon, W.B., Bodily changes in pain, hunger, fear, and rage: an account of recent researches into the function of emotional excitement. 1915: D. Appleton and Company.
- Hannibal, K.E. and M.D. Bishop, Chronic Stress, Cortisol Dysfunction, and Pain: A Psychoneuroendocrine Rationale for Stress Management in Pain Rehabilitation. Physical Therapy, 2014. 94(12): p. 1816-1825.
- Gatchel, R.J., et al., The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull, 2007. 133(4): p. 581-624.
- Asmundson, G.J.G., J.W.S. Vlaeyen, and G. Crombez, Understanding and Treating Fear of Pain. 2004: Oxford University Press.
- Rhudy, J.L. and M.W. Meagher, Fear and anxiety: divergent effects on human pain thresholds. Pain, 2000. 84(1): p. 65-75.
- Vachon-Presseau, E., et al., The stress model of chronic pain: evidence from basal cortisol and hippocampal structure and function in humans. Brain, 2013. 136(Pt 3): p. 815-27.
- Heim, C., U. Ehlert, and D.H. Hellhammer, The potential role of hypocortisolism in the pathophysiology of stress-related bodily disorders. Psychoneuroendocrinology, 2000. 25(1): p. 1-35.
- Barnes, P.J., Mechanisms and resistance in glucocorticoid control of inflammation. The Journal of Steroid Biochemistry and Molecular Biology, 2010. 120(2–3): p. 76-85.
- Tsigos, C. and G.P. Chrousos, Hypothalamic-pituitary-adrenal axis, neuroendocrine factors and stress. J Psychosom Res, 2002. 53(4): p. 865-71.
- Fries, E., et al., A new view on hypocortisolism. Psychoneuroendocrinology, 2005. 30(10): p. 1010-6.
- Norman, M. and S.D. Hearing, Glucocorticoid resistance – what is known? Curr Opin Pharmacol, 2002. 2(6): p. 723-9.
- Müller, M.J., Helplessness and perceived pain intensity: relations to cortisol concentrations after electrocutaneous stimulation in healthy young men. Biopsychosocial Medicine, 2011. 5: p. 8-8.
- Johansson, A.C., et al., Pain, disability and coping reflected in the diurnal cortisol variability in patients scheduled for lumbar disc surgery. Eur J Pain, 2008. 12(5): p. 633-40.