A Pathway to a Cure for Chronic Pain

Most clinicians were trained in an era in which chronic pain was poorly understood and symptomatically managed; however, the latest psychological approaches to treat chronic pain and many other functional conditions are surprisingly effective.  Recent advances in pain neuroscience have shown that many of these conditions exist without true tissue damage or illness.

Rather they result from a psychophysiological process that creates a hypersensitized central nervous system (CMS). This has led to the creation of innovative evidence-based psychological therapies that move beyond traditional coping-skills-based models. By addressing the root problem these painful symptoms, once believed to be incurable, can now be significantly reduced or eliminated.

How Chronic Pain Works:

Pain and other stress response symptoms function as warning signals created by the brain to alert us to danger. Typically, you burn your hand, the brain creates pain, and you quickly remove your hand. Other danger signals include anxiety, stomach discomfort, and muscle tension. However, when in a hypersensitized fear state, the brain can make prediction errors—overinterpreting normal physical sensations as painful ones and interpreting emotional distress as a threat to physical safety. Thus, when we experience long-term emotional distress, the brain stays in danger mode and physical symptoms become chronic. Further, most chronic pain clients develop an instinctual pattern of hypervigilance and activity avoidance known as the pain-fear cycle. Unfortunately, while self-protective, this cycle further reinforces pain and leads to more learned neural pain pathways. Many chronic pain clients describe their lives as shrinking as they eliminate more and more activities that bring purpose and joy. They also experience a general sense of fragility and come to define themselves as broken or damaged.

Following this emerging science, in 2020 the ICD-10 added two diagnoses: chronic primary pain (CPP) and chronic secondary pain (CSP). The World Health Organization defines CPP as, “pain that persists for longer than three months and is associated with significant emotional distress or functional disability and that cannot be explained by another chronic condition.” Chronic secondary pain occurs when pain begins as a symptom of physical disease or injury but persists beyond successful treatment. Some examples include chronic neck and back pain, ongoing muscle pain and tension, fibromyalgia, irritable bowel syndrome, chronic fatigue; tension headaches, migraines, and many more. It is also important to note that this same process can exacerbate symptoms of chronic medical conditions.

Treatment:

There are now multiple evidence-based therapies that honor the inextricable interconnection between our physical and emotional health. Commonly referred to as mind-body therapy, each has a slightly different approach. For example, Pain Reprocessing Therapy, Emotional Awareness and Expressive Therapy, Intensive Short-Term Psychotherapy, and Internal Family Systems Therapy have all been found effective in treating various painful conditions.

Everyone’s pain story is different, and we work closely with each person to find the interventions most helpful to them. The overarching goal of these mind-body therapies is to break patterns of thinking, feeling, and behaving that reinforce symptoms and keep the brain in chronic danger mode. Essential treatment components include:

Psychoeducation on pain neuroscience and review diagnostic criteria specific to mind-body conditions. Once clients understand why they are experiencing their symptoms, the interventions make sense. As part of this process, it is important to emphasize that addressing the pain psychologically does not imply that the pain is imaginary or exaggerated. Brain imaging studies have established that the pain is quite real.

Brain retraining incorporates concrete easy-to-learn mindfulness techniques that help clients to focus on their symptoms through a lens of safety, thus slowly deactivating the pain signals.

Graded imagery and exposure to feared activities involve supporting clients through slow methodical exposure to feared activities. When incorporated with brain retraining exercising can effectively break conditioned pain responses and help clients get back to living.

Most mind-body pain therapists also integrate well-established interventions such as cognitive-behavioral therapy, mindfulness, and self-compassion work to help calm patterns of hypervigilance, catastrophizing, and self-critical thinking that feeds the pain-fear cycle. Further, helping clients integrate gratitude, joy, and play back into their lives reminds the brain that life can be enjoyable.

Mind-body therapists also work with clients to become increasingly aware of emotional and relational patterns that perpetuate psychological distress. We explore why they developed through a self-compassionate lens; help process deeply held emotions related to the past; improve their ability to sit with strong emotions as they arise; and work toward expressing them to others.

After years of hurting and searching for answers from others, it is incredibly empowering to learn that much healing can come from within. On a personal level, these interventions have been life-changing.  After 20 years of chronic widespread pain, my symptoms have substantially improved and I’m back to living life. This motivated me to shift my practice focus so I could help others achieve relief. Despite the sound research and growing evidence base, there is still much work to do to increase awareness of these paradigm-shifting treatments. If you have further questions or curiosities, I encourage you to investigate the research and resources (below) and consider whether this approach might be a good fit for your clients or perhaps even yourself.

Castro WH, Meyer SJ, Becke ME, Nentwig CG, Hein MF, Ercan BI et al. (2011). No stress – no whiplash? Prevalence of ‘whiplash’ symptoms following exposure to a placebo rear-end collision. International Journal of Legal Medicine, 114, 316-22.

Bigos SJ, Battié MC, Fisher LD et al. (1991) A prospective study of work perceptions and psychosocial factors affecting the report of back injury. Spine, 16(1),1-6.

Baliki MN, Petre B, Torbey S, Herrmann KM et al. (2012) Corticostriatal functional connectivity predicts transition to chronic back pain. Natture Neuroscience 15, 1117-1119.

Derbyshire SW, Whalley MG, Stenger VA, Oakley DA. (2004) Cerebral activation during hypnotically induced and imagined pain. Neuroimage 23(1), 392-401.

Wager, T., Atlas, L., Lindquist, M., Roy, M., Woo, C.W., M.A., Kross, E. (2013) An fMRI-Based Neurologic Signature of Physical Pain. New England Journal of Medicine 368, 1388-1397.

Yoni, Gordon, Schubiner, et. al. (2021). Effect of Pain Reprocessing Therapy vs placebo and usual care for patients with chronic back pain, a randomized clinical control trial,  JAMA  Psychiatry, 2021-2669.

Gordon, A & Ziv, A, (2022) The Way Out: A Revolutionary Scientifically Proven Approach to Healing Chronic Pain, Avery.

Lumley, Schubiner, et al., (2019). Psychological therapy for centralized pain. Integrative assessment and treatment model, Psychosomatic Medicine, Feb-March 81 (2) 114-124.

Lumley, Kruger, et. al., (2021). Emotional Awareness and Other Emotional Process: Implications for the Assessment and Treatment of Chronic Pain, Pain Management, May (11)  325-332.

Lumley, Schubiner, et al., (2017). Emotional awareness and expression therapy, cognitive-behavioral therapy, and education for fibromyalgia: a cluster-randomized controlled trial, Pain, 158 (12) 2354-2363