“So I have Chronic Pain.  Why would I need to see a psychologist?”

Pain is designed to help you. It is supposed to be your protector. It is supposed to serve as an alarm to alert you that there has been damage done to your body that needs immediate attention.  Some individuals are born with a very rare genetic condition known as congenital analgesia, meaning they are unable to experience pain.  To someone with chronic pain, a person who cannot experience pain may initially seem to be very lucky.  However, the opposite is true.  If you cannot experience pain, your body can be damaged in all sorts of ways which can lead to severe untreated injuries, disfigurement and often times, death.  A person born with this condition can suffer a seemingly benign injury (e.g., a broken bone) that, if immediately treated, can heal.  However, as their brain cannot register the pain signals sent out by the nerves surrounding the broken bone, their injury can go unnoticed and untreated, therefore becoming infected; this can, in some cases, lead to the loss of a limb or even death.  As you can imagine, it would be difficult for someone with congenital analgesia to live a long and/or unassisted life, given that they are in constant danger of unknowingly hurting themselves.

Let me be more specific.  Acute pain is supposed to be your friend.  This is the type of immediate pain that all of us (with the exception of those with congenital analgesia) experience.  Everyone knows what acute pain feels like.  Acute pain accompanies day to day injuries, like a broken bone or a burnt hand. Just because it is acute doesn’t mean it isn’t severe—acute pain accompanies very painful things, like kidney stones and childbirth.  But it has an end point. But what about the chronic pain, fatigue, achiness and exhaustion that someone with chronic pain experiences?  This is chronic pain, which is quite different from acute pain.  I think of acute and chronic pain as very distant cousins.  Though they share the same last name (“pain”) and may have similar origins, they actually have little in common.

Acute pain is that signal of damage.  It’s like a phone that rings, so you pick it up, and someone is on the other end of the line, telling you that you just touched something really hot and you better withdraw your hand quickly.  Of course, this process occurs very quickly in your body.  But when the phone rings, we’re used to someone being on the other end, alerting us of danger.  With chronic pain, the phone rings, you pick it up, but no one is at the other end of the line.  Yet the phone keeps ringing.  So, somewhere along the way, the lines got crossed.  In this case, the pain no longer serves a purpose.  The damage has already been done.  The pain itself is both the symptom and the problem.

Chronic pain is far more complex than acute pain that comes with day to day injuries.  As I mentioned, acute pain has an end.  The end may take weeks or months, like healing from surgery, but eventually, our bodies heal from the damage.  Chronic pain is defined as pain that persists beyond six months.  By then, our bodies are usually supposed to start healing.  This pain that goes on and on will of course impact someone psychologically.  Initially, the person thinks their injury or condition that causes them pain is acute.  And why wouldn’t they?  That is what is supposed to happen.  But then, the person notices their pain is not subsiding.  And by six months, she has probably visited the doctor (and perhaps other healthcare providers) multiple times, seeking relief and an end.  Emotionally, she initially felt concern, yet this concern came with the belief that this pain would go away.  By six months, this initial concern may have grown into something bigger, like chronic anxiety. With chronic pain often comes chronic anxiety. She becomes preoccupied with the pain, becoming more worried by the day as she sees how the pain impacts her.  She may be taking more time off work, becomes less active, and isolates more from her family.  And her family, in turn, is becoming frustrated, confused and stressed in the process.  None of us like to see our loved ones hurt, especially when the hurt doesn’t go away or it comes back at seemingly random times.  All of this makes the mood and stress worse.  She may find she becomes angry more easily, and she may become more “snippy” or short with people. By the time her pain has lasted for a year or more, her chronic stress and irritability may have blossomed into something bigger, like depression.

The emotional experience I just described is just one example of some of the emotional rollercoaster people with chronic pain may experience.  This is quite different than what someone with a kidney stone, for example, experiences.  Yes, the pain initially is excruciating, and they may react with fear or shock.  But they visit with their doctor, who helps them pass the stone, and they get through it.  The pain has an end.  Their emotional experience is radically different.  Acute pain typically doesn’t cause one to develop chronic stress or depression.

Another striking difference between someone with an acute injury versus chronic pain is how other people in their lives react to their condition.  If you break your leg and have a cast, friends and family will empathize and be sympathetic, will send get well cards and flowers, and may be quite accommodating to you while you recover from this acute injury.  This is because everyone knows what that feels like, everyone can relate, and it has an end point.  But what about chronic pain?  First of all, other people cannot see the evidence of the chronic pain, like they can see a cast on someone’s leg or a surgery scar.  Secondly, as the pain is a chronic and more unusual condition, other people often times may not be able to understand it or relate to it.  As a result, their reaction to the person with chronic pain is quite different  from the person with a broken leg.  Friends and family may say, “why aren’t you better yet?” or “can’t you snap out of it?” or “maybe you just need to rest more.”  Sometimes their comments are well intentioned, and sometimes they’re ignorant.  Even more damaging can be the comments from the medical profession.  As chronic pain can be a difficult thing for medical tests to detect, doctors often are baffled and frustrated in trying to find an answer to help the client.  As a doctor once told me, “medical school trained me to treat the symptoms of pain, not the pain itself.”  When pain is the only symptom, this can be quite challenging for doctors who are not pain specialists.  Doctors are in the helping profession, and when they feel they can’t help, this can be very frustrating for them.  Sometimes, they may react to this frustration and tell the patient there is either nothing they can do or that it’s all in the patient’s head.  So how would this impact the person suffering from chronic pain?  You can see a vicious cycle developing.

Chronic pain also requires the individual to be much more mindful of stress, and they self-care must not just be an afterthoughts; it is a requirement.   Again, this is another major difference between chronic pain and acute pain.  What people with chronic pain don’t often realize is how their stress is impacting their body.  Stress is like chronic pain’s evil twin.  The body is already experiencing the pain.  But what many do not realize is it’s also experiencing the toxic effects of stress caused by the pain, which is separate from the pain and fatigue entirely.  Stress produces a chemical known as cortisol.  In small doses, the cortisol is not very harmful, especially if the stress is managed well.  It comes and goes without creating any long term problems.  Long term, however, it takes a toll on a body that is already taking a toll from the psychological effects of stress, as well as the chronic pain.  If the chronic stress goes unmanaged, the body starts to break down.  Our body is like a car; if we don’t get its oil changed, or don’t take it in for regular tune ups, the minor engine problems can change into bigger ones, and a once reliable car is going to be spending more and more time in the shop.

Stress, like pain, is supposed to be your protector.  It has been the alarm system for human beings for thousands of years.  Back when we were nomadic beings who lived in caves and had to hunt for our food, we were faced with a variety of things that could have easily killed us every day; animals, the weather, the threat of starvation and, of course, other human beings who were also fighting to survive.  Stress would alert us to the predator with bone crushing teeth that was charging towards us.  Stress turns on the “fight or flight” response.  So when the predator is charging us, our bodies get “revved up” so we can prepare to kill or disable the predator that was about to attack us, or so we could run for our lives (literally).  Many of us think this process is automatic in our bodies, but it is not; stress is the key ingredient that gets our bodies ready to go.  When the “fight or flight” turns on, a number of things happen.  Think about the last time you experienced a pulse of anxiety—that moment you realized you forgot you were 5 days overdue on your rent payment, or that moment you were preparing to give that dreaded public speech.  Your palms were cold and clammy, your heart was racing, your muscles were tense and shaky.  Your breathing was quick and shallow, and you may have even felt a throbbing in your head from the blood rushing to it.  You may have also felt tightness or cramping in your stomach. All of this was your body reacting to your anxiety.  Even our thinking changes—if you remember the last time you were really stressed, you may remember some of the thoughts going through your mind.  It was probably difficult to think clearly, to focus, and to come up with a solution.  When we get anxious, we tend to ruminate, or focus on the thing that makes us anxious to the point that our thoughts are just a repetitive, unhelpful loop, focused on that one problem. The word “ruminate” actually comes from a term used with cows—if you have ever seen a cow eat, they chew on the grass, it goes from stomach to another, and then comes back up, where they chew it again.  A graphic analogy, yes, but it’s similar to the feedback loop that our thoughts look like when we are anxious. As you can see, stress can get us into a bind if we let it get out of control, and the stress we experience as an emotion immediately has an impact on our bodies, whether we like it or not.

What happens if this “fight or flight” is on all the time?  Another way of looking at this is, what happens if we have chronic stress, and we don’t manage it well?  If our body is always in this “revved up” state, when can we recharge our batteries?  When can our bodies stop being “on alert” so our muscles can get the rest that they so badly need?  If our muscles are constantly in this state, they can’t heal or rest.  We don’t sleep well, we may have chronic headaches, our heart begins to feel the effects (e.g., hypertension), our digestion isn’t so hot so we may develop IBS or ulcers.  If we aren’t aware of the constant tension our muscles are holding, we’ll begin to get sore, achy and be more prone to even more injuries.  Due to this tension, you may also begin to hold tension in other areas of your body to compensate.  For example, if you’re constantly favoring an injured right shoulder that doesn’t improve, you’ll be tensing your left shoulder and overusing it to compensate for the right shoulder that isn’t working.  In turn, your left shoulder will start to wear out, as well.  There is also the increased chance of developing other chronic conditions, like diabetes or cancer.  Stress management should be essential for everyone, but with chronic pain, given the impact of stress on the body, it should be even more of a priority.

The stress caused by chronic pain can sometimes lead us into a vicious cycle—when we’re stressed, it’s easy for us to get into bad habits.  For example, we may not eat well because we’re either looking for a “quick,” fast food meal in the middle of a busy day, or we eat more fatty or sugary foods as a way to soothe ourselves.   This type of eating is fine if it’s on occasion, but if this becomes a regular habit, our bodies and minds suffer.  We may also drink more alcohol, or begin/increase smoking cigarettes.  We also become less active; with stress comes fatigue, and with fatigue comes decreased motivation.  And with decreased motivation, we are less likely to go to the gym, or be active with our family, or go on a walk during our lunch break.  All of these habits can lead to a number of problems (e.g., weight gain, developing other chronic medical problems, increased risk for depression and insomnia, poor self-esteem and libido), which, in turn, make the chronic pain worse.

The list of differences between acute pain and chronic pain is a long one.  I haven’t (and won’t) get into the difference in pain medication usage. Before moving on from this discussion, I would like to mention one more crucial difference that I think is very important from a psychological standpoint.  When I once ask my pain management groups, “what areas of your life have been impacted by pain?” the first response is silence.  Not because they can’t come up with anything to say.  Rather, people cannot initially think of areas of life not impacted by the chronic pain.  One group member once joked, “I think my eye color hasn’t been impacted by this, but that’s about it.”  If you have chronic pain, think of what has changed in your life.  The tentacles of the chronic pain are numerous and far reaching.  It can impact your job, your body, your weight, your brain, your lifestyle, your ability to do household chores, your relationships, your family, your friends, your intimate life, your finances, your mood, your mental well-being, your memory, your sense of self, your self-esteem, your spirituality, your creativity…and on and on.  I say all of this not to be depressing, but to recognize the ripple effect it can have on one’s life.  And to point out that the treatment for chronic pain needs to be so different from something like a broken leg, for example, because of everything it can touch.  This is why one can’t be treated just by a physician.  This is why a chiropractor, physical therapist, a personal trainer, a psychologist, a nutritionist, a nurse practitioner, are often quite essential to chronic pain treatment.  All of these individuals can help you learn how to live a life worth living, even with pain.  And I suppose this would be the goal for all of us, as we navigate through life, whether we have chronic pain or not.  Unfortunately, there is pain in life.  Our goal shouldn’t necessarily be to avoid pain, as we can’t do that, but to live a life that is mindful and satisfying, alongside the pain, loss and disappointment that come with life.