How you think about physical pain can make it worse

It's not all in your head. But a promising new approach to treatment may offer relief to many sufferers of chronic pain.

Published 11 Apr 2022, 11:32 BST
Vitaly Napadow, a neuroscientist at Harvard Medical School and Massachusetts General Hospital, studies how the brain ...
Vitaly Napadow, a neuroscientist at Harvard Medical School and Massachusetts General Hospital, studies how the brain perceives pain. To do that, he uses electroencephalography to track the brain wave patterns of patients with chronic lower back pain.
Photograph by Robert Clark, Nat Geo Image Collection

Dan Waldrip had been in pain, on and off, for 18 years. He was a healthy 27-year-old when he woke up the morning after mowing his lawn with his back throbbing so intensely he couldn’t get out of bed. Afterward he suffered intermittently, feeling fine for weeks and then experiencing days of stabbing pain or dull aches.

Over the years, Waldrip spent thousands on chiropractic procedures, acupuncture, physical therapy, pain medications, and numerous other treatments. Once, during a business trip to South Africa, desperation drove him to hire an energy healer at an outdoor market. When nothing worked, Waldrip accepted that his “tricky back” would always impact his life.

“If I was walking along and dropped something, I would panic that bending over might make my injury worse,” says Waldrip, who is now a 49-year-old private equity manager in Louisville, Colorado.

Everything changed, though, when he saw a flyer at his daughter’s swim meet recruiting patients with chronic back pain for a clinical trial testing a new treatment called pain reprocessing therapy. The goal was to reprogram Waldrip’s brain by teaching him that his ongoing agony was not caused by lingering tissue injury but by misfiring neural circuits related to his dread of pain, or what experts call “catastrophizing.”

Figures suggest a form of chronic pain afflicts between a third and half of the UK population. In the U.S., the figure is 20 percent, according to the Centres for Disease Control and Prevention. In that country, the devastating consequences of addiction to opioid painkillers—which in 2019 alone killed nearly 50,000 people in the United States—have motivated researchers to look for innovative treatments beyond new drugs. Research on alternative approaches is “absolutely exploding,” says Padma Gulur, director of the pain management strategy program at the Duke University Health System. “All of us are looking for non-opioid, and frankly non-pharmacological, options” to avoid unwanted side effects and addiction, she says.

One promising area of research is looking at the way “catastrophizing” about pain—thinking it will never get better, that it’s the worst ever, or that it will ruin your life—plays a central role in whether these predictions come true. This effect is very different from the dismissive “it’s all in your head” comments chronic-pain patients sometimes hear from doctors when they can’t pinpoint a physical cause, says Yoni Ashar, a psychologist at Weill Cornell Medical College and coauthor of the study in which Waldrip participated. Some contemporary researchers even dislike the term “catastrophizing” since it can imply the thinker is at fault.

“You can have very real, debilitating pain without any biomedical injury in your body because of changes in the pain processing pathways,” Ashar says. It turns out, he says, that “the main organ of pain is actually the brain.” And that’s why for some sufferers, treatments like pain reprocessing therapy seem to help.

During the trial, Waldrip learned that pain from a physical injury would not come and go the way his back pain did. He also realised that both the initial experience and most intense flares all correlated with major stressors in his life. Within a month of starting the treatments, his back pain disappeared permanently. Last month, when Waldrip hit the ski slopes of Utah for five days straight, he didn’t feel a twinge.

During surgery, Brent Bauer eases his pain by playing a virtual reality game called SnowWorld. He participated in a study that suggests VR could decrease the need for general anesthesia, reducing the risks and cost.
Hannah LeBuhn, who suffers from pain in her jaw joints, watches the mesmerizing motion of jellyfish on a virtual reality headset in Luana Colloca's lab at the University of Maryland, College Park.

Demand for non-opioid alternatives

The idea that pain can worsen when someone ruminates on it, exaggerates the level they’re experiencing, or feels helpless in the face of it has been around for decades. A pain catastrophizing scale that rates levels of this thinking was developed in 1995 and is still widely used. Yet most doctors outside of academic circles remain unfamiliar with the impact of this behaviour, experts say.

Many people who come to the famed interdisciplinary pain program at Spaulding Rehabilitation Network’s Outpatient Center in Medford, Massachusetts, have battled chronic pain for years before arriving. Yet when Spaulding staffers describe how thoughts can play a role in pain, most are surprised, says Eve Kennedy-Spaien, clinical supervisor of the program.

“More research is being done, and more physicians are learning,” but the field has a long way to go before the notion that negative thoughts about pain can make it worse is commonplace, she says.

A growing number of studies document how scoring high on the pain catastrophizing scale correlates with poorer health outcomes. One of the earliest was in 1998, where car accident victims with the highest catastrophizing scores had more intense pain and disabilities (independent of depression or anxiety levels) than other similarly injured patients. Recent findings expand on these results. Last year, European researchers concluded that rheumatoid arthritis and psoriatic arthritis patients who rated their pain level as “very high” had a worse quality of life than others with these diseases, even when objective analyses of their symptoms didn’t support this.

In February scientists studying children with sickle cell disease found that catastrophizing was the greatest single predictor of whether pain interfered with daily activities four months later. How the kids thought about their pain played a bigger role than other possible factors, “more than anxiety, depression, and even how much pain they were in initially,” says Mallory Schneider, a psychologist in private practice in Roswell, Georgia, who coauthored the study. And this month scientists reported that more severe pain was significantly associated with higher pain catastrophizing, as well as more depressive symptoms, in women with breast cancer pain. (Read about the surprisingly human ways that animals feel pain.)

Although experts don’t yet understand the precise mechanisms involved, they do know that catastrophizing does influence the brain. The effects have been documented in functional MRI scans, with brain regions involved in pain perception and modulation lighting up when patients think more catastrophizing thoughts.

Extreme thinking when someone experiences pain is a natural process that makes biological sense, Kennedy-Spaien explains. “Our brains our hardwired to look for danger and to run through worse-case scenarios to protect us,” she says. But in some cases, the alarm keeps ringing long after a physical injury has healed, she says.

Doctors sometimes exacerbate catastrophizing by using scary-sounding medical terms to describe an injury to a patient, such as referring to arthritis as “bone on bone” or pointing out a “herniated disc” even though not all cause pain, which can heighten the sense of danger, Kennedy-Spaien says.

Racism in the medical system may also play a role, Schneider notes, with Black people on average more prone to catastrophizing than White people. “There’s a longstanding history of Blacks not being taken as seriously about pain, and over time this need to explain it in a strong enough way to be heard may become adaptive,” she says.

Catastrophizing can be overcome

Pain doctors who do recognise the importance of quelling catastrophizing generally refer patients for cognitive behavioural therapy, says Mark Lumley, a psychology professor at Wayne State University. This psychological practice is often used to treat depression, eating disorders, and even PTSD. But the literature shows this kind of treatment is not that helpful for pain, Lumley says. One 2019 review of studies on chronic musculoskeletal pain assessed using the therapy along with physical exercise, and it concluded that it adds little to no extra benefit.

A different approach may be for doctors to take more time to speak with patients about the frequency and severity of their pain, Schneider believes. She initiated her own study after routinely hearing children with sickle cell disease describe their pain in extreme ways. “They’d say, This is the worst it’s ever felt, or, It never goes away. But when I would ask a few more questions, I’d get a more balanced perspective,” she says. The kids would realise that their pain had been worse before or that past flares have indeed disappeared, she says.

Rather than just asking patients to rate their pain from one to 10, the classic way pain is measured, Schneider urges doctors to probe further. “This would help patients get a more accurate view of their experience, and it would help the physician, because otherwise they might feel frustration toward the patient and so may not properly treat their pain,” she says.

Including a pain catastrophizing screening with routine paperwork would also be beneficial, she says. “Medical settings are doing a better job of screening for depression and anxiety but not as much for catastrophizing,” she says.

At Spaulding, teams of doctors, psychologists, physical therapists, occupational therapists, and other practitioners all aim to redirect a person’s focus away from the “danger messages” pain patients routinely tell themselves. These messages are often focused on the risk of additional physical injury or extreme pain if they move their body in ways that bring discomfort.

“We help people understand the difference between hurt and harm,” Kennedy-Spaien says. Certain movements may trigger unpleasant sensations or even agony, but that doesn’t mean damage is being done, she says. Slowly beginning to engage in these movements is especially crucial, she says, because “when someone avoids activities completely it doesn’t allow the brain to recalibrate” and realise the movement is safe.

Spaulding patient Michael Cross says that learning to reduce his own negative messaging has been a godsend. The 68-year-old retired entrepreneur was severely injured in 2019 when he fell onto steel flooring near an outdoor dumpster. Cross has had 10 major surgeries (and counting) to fix bone and nerve injuries in his face and arm. Until last month, pain consumed all his waking moments and he feared he would never be free of it. (Read about the medical marvels that helped piece a shattered body back together.)

Nerve damage still makes him feel like he’s “being stung by bees 24/7,” but changing his brain’s messaging is giving him hope for the first time since the accident.

“I’m learning how my mind can control the high pain levels and bring it down,” he says. What especially helps is to replace fears with more positive “safety” messages and images; previously an avid boater, Cross often conjures visions of himself fishing on a beautiful boat at sunrise, something he hopes he will one day do again.

Driving the pain to zero

The new method of pain reprocessing therapy takes more direct aim at catastrophizing. The study that Waldrip participated in compared pain reprocessing therapy with either a placebo saline injection or no additional care in 150 people with long-standing chronic back pain. During eight one-hour sessions spanning four weeks, PRT participants learned how easily brain pathways influence pain.

Like at Spaulding, they were also taught to reevaluate their experiences of moving in ways they had considered harmful. Waldrip, for example, was asked to sit in an uncomfortable chair and describe the resulting ache in detail. Because he now understood it was coming from a false alarm, the pain dissipated before he even finished describing it.

Some 66 percent of the pain reprocessing therapy patients in Ashar’s study became totally or nearly pain free when treatment ended, compared with 20 percent in the placebo group and 10 percent of those who received no extra care. After following up a year later, the results still held. “PRT aims not just to reduce but to eliminate pain with a psychological treatment,” something no one thought possible, Ashar says.

As part of the study, participants’ brains were imaged with fMRI when they thought about their back pain. At the end of the study, three frontal brain regions involved in assessing threats showed reduced activity, indicating that the alarm bells behind their increased pain had been dampened, Ashar says. Additional trials testing PRT for other types of body pain and in minority populations are in the works, he says.

Another treatment type, emotional awareness and expression therapy, aims to uncover the unresolved emotions believed to be responsible for chronic pain in some people, says Wayne State’s Lumley, who is pioneering this work. Whether from traumas like childhood abuse or the pressure to be a perfect child, the emotions of anger, shame, and others can be “a driver of the brain’s alarm mechanism” that triggers physical pain, Lumley says.

Emotional awareness and expression therapy enables people with chronic pain to realise and express these feelings, either in group or individual sessions. Although research is in the early stages, one study comparing this therapy to cognitive behavioural therapy in 50 male veterans with chronic pain found a third of people in the former group reduced their pain by more than half, while no patients in the other group had similar results.

Lumley thinks the new therapy approach could be especially valuable for people with conditions like fibromyalgia or irritable bowel syndrome for whom pain is their primary symptom, not a result of another condition. “In that category, I would say the majority of people have some psychological emotional driver that contributes to their pain in a substantial way,” he says.

But whatever technique is used, Lumley mainly wants the goal for treating chronic pain to be set much higher than it currently is. “Too many pain clinics say, We can help you learn to live with your chronic pain,” while doctors dealing with other seemingly intractable conditions like post-traumatic stress disorder strive to eliminate the condition altogether, he says. Tackling catastrophizing is a key strategy to do that, he says.

Experts would also like the pain catastrophizing scale to be used not just to evaluate long suffering pain patients, but also to proactively identify people whose early pain risks becoming chronic.

“At Duke we’re now identifying patients before surgery … It’s been phenomenal,” Gulur says. “I can look at the score and have a great sense that when we invest the resources for preventive, proactive measures for this person, their outcome will be far different than it would have been.”

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