A Case of Chronic Pain
Marina is a 30-year-old woman who played tennis on her high school team and continued to play recreationally until a lower back injury sidelined her from the courts. One day, she was lifting some boxes in preparation for a move and felt something give out. The pain was excruciating. And even though she did exactly as she knew to do with injuries – rest, ice, etc. – the pain persisted.
After several weeks, Marina went to the doctor, worried about the ongoing pain. Her doctor referred her to physical therapy, which Marina attended diligently. While she saw some minor improvements, she still had multiple days per week when she’d find herself in unbearable pain, unable to work, have fun, or even breathe without discomfort. Her doctor wrote her a prescription for an MRI, which indicated she had a bulging disc. But the degree of this structural concern problem wasn’t commensurate with her pain. While Marina had some good days and the pain seemed to remit entirely on a couple of occasions, the bad pain days persisted, landing her in bed, depressed, and fearing that this was her new lot in life.
Structural Versus Neuroplastic Pain
Like Marina, millions of Americans suffer from back pain and from chronic pain more broadly. According to the CDC, approximately 24% of adults in the U.S. experience chronic pain. Pain like this can wreak havoc on the sufferer’s work, relationships, and mental health.
It’s possible to divide pain into two kinds of cases: structural pain and neuroplastic pain. Structural pain involves physical injury, inflammation, or disease to a bone, muscle, joint, ligament, or tissue. It is localized to a specific part of the body and arises immediately after an injury or other causal event. Finally, it is predictable, with typical triggers leading to the onset of more discomfort.
In contrast, neuroplastic pain is either generated and/or maintained by the nervous system. Here, the brain misinterprets certain safe nervous system signals as dangerous. Structural damage does not exist or isn’t sufficient to explain the level of distress. Compared to structural pain, neuroplastic pain is more difficult to pin down. It often has a delayed onset following an activity, can shift to different parts of the body, and can be inconsistent, with symptoms and intensity not adhering to a clear cause-and-effect pattern. Finally, neuroplastic pain can intensify in the face of stress or other intense emotions.
While Marina did, in fact, injure her back and might have experienced structural pain to start, the duration and inconsistency of her discomfort pointed toward neuroplastic pain. This type of pain often stumps sufferers and healthcare professionals alike. The pain is real, and nothing about this diagnosis means that the person is faking or otherwise manufacturing their distress. But in the case of neuroplastic pain, the pain is generated by the brain rather than by body tissue.
We are usually most familiar with pain caused by bone fractures, ligament tears, tumors, inflammation, infection, or autoimmune dysfunction, but these are the minority of cases. The reality is that most pain that people experience is neuroplastic. If pain originates without an injury or other type of physical explanation, develops during a stressful time and/or intensifies with stress, presents inconsistently, or seems to spread or bounce around to different areas, the likelihood is that it has a neuroplastic component. This type of brain-derived pain might also follow odd rules. For example, if pain arises in a certain setting without any clear explanation, the brain might be to blame.
A False Alarm
While we might feel pain in our backs, limbs, or other body regions, pain is actually processed in multiple parts of the brain. Different regions are associated with the physical sensations we experience with pain and how we think and feel about the discomfort. At its core, pain represents danger, and it’s a signal to us that we need to stop, slow down, or move to avoid further injury. For example, perhaps you twist your ankle while walking. Pain surfaces, which causes you to limp home to avoid further injury instead of continuing on your walk.
But these danger signals can arise even when there’s no structural damage to blame. At times, the brain misinterprets safe signals from the body, believing them to be dangerous, even in the absence of structural injury or dysfunction. Here, pain is like a “false alarm,” similar to your smoke alarm going off when you have something sizzling on the stove. Sure, there’s smoke in your home, just like there’s pain. But your home isn’t in danger of being overtaken by fire, just like nothing is inherently damaged in your body. A similar process is observed in those who experience panic attacks. Here, the brain sends signals of danger that we associate with actual threats to our health. While symptoms such as tachycardia, nausea, and lightheadedness are indeed uncomfortable, they are not predictive of life-threatening concerns.
The Brain on High Alert
Early experiences of feeling unsafe can result in hypervigilance regarding danger signals later on. While others might brush off pain signals, those who endured early trauma are more likely to experience pain due to frequent scanning of the body and are also more likely to feel fear in response to pain. But it’s not just trauma that predicts neuroplastic pain. There are certain personality characteristics commonly associated with this pain, including perfectionism, trait anxiety, conscientiousness, and people pleasing. What these characteristics share in common is that each shifts the brain into a state of high alert, scanning and searching for danger and even assuming its presence.
The Pain-Fear Cycle
Neuroplastic pain is every bit as “real” as structural pain. It hurts. And it often hurts intensely. It’s also often accompanied by fear, or even dread. Those who struggle can get entangled in a pain-fear cycle, which follows this pattern:
- Pain causes us to feel afraid. “Am I going to be okay? What if this never gets better?”
- This fear causes the brain to scan for and hyper-focus on pain, which actually results in more pain.
- With ongoing pain, fear increases.
- People get stuck in a pain-fear loop, causing increasing levels of physical and emotional distress.
As with other problematic cycles, breaking in at any point can change the entire cycle. Exploring and reprocessing the fear associated with pain can break this cycle, reducing the subjective experience of pain.
Pain Reprocessing Therapy
Because the brain drives neuroplastic pain, interventions that target how we think and feel are the most effective. Pain Reprocessing Therapy is one such intervention, incorporating cognitive and behavioral components, as well as mindfulness, acceptance, and other aspects of DBT. With Pain Reprocessing Therapy, the goal is to reduce the fear we experience with pain. We move away from experiencing pain as a danger signal, instead reframing it as a safe, false alarm. The less fear we have around our pain, the less pain we have – a more desirable cycle to fuel. The following interventions are part of Pain Reprocessing Therapy.
Education: Since many people with chronic pain have been given a structural diagnosis, helping them understand that neuroplastic pain has taken over requires education. The goal here is to help sufferers understand that much of their struggles are a result of the brain and nervous system, not a structural or physical issue. Clinicians might help people understand that pain originating during a stressful time or presenting inconsistently can point toward neuroplastic origins. In therapy, clients gather evidence for the non-structural elements of their pain. The protocol also offers education about the pain-fear cycle and how breaking this cycle involves reconceptualizing pain as safe, rather than dangerous.
Somatic tracking: In the next phase of Pain Reprocessing Therapy, clients bring their attention to their pain, focusing on their sensations through a lens of safety. Clients might be encouraged to focus on their pain sensations during an episode of pain and/or when faced with a situation that typically triggers their pain, such as sitting, standing, bending over, etc. Clients gain experience with three aspects of somatic tracking: 1) mindfulness, 2) safety reappraisal, and 3) positive affect induction.
For the mindfulness component of somatic tracking, the focus is on observing and describing physical sensations. Clients might be encouraged to describe their pain using neutral adjectives (e.g., tingling, burning, localized). Just like mindfulness of our thoughts or emotions, we’re not trying to change or rid ourselves of these experiences; we’re simply noticing.
But mindfulness alone isn’t sufficient to quell the fear associated with pain. For this, safety reappraisal is required. Here, the therapist helps the client understand that their brains are misinterpreting typical body sensations as unsafe. Clients are reminded that everyone feels sensations in their bodies at times. What causes problems is not these sensations but the assumption that they’re dangerous. Guided self-talk might sound like, “Yes, I’m having a sensation of tightness in my back. That’s okay. My brain is misinterpreting this sensation as dangerous. I’m healthy though. Tightness is okay. This is a safe sensation.” If clients have trouble believing these messages associated with safety reappraisal, it might be time to revisit education, as well as gathering evidence for and against the existence of neuroplastic pain.
The third component of somatic tracking is positive affect induction. Trying to create an atmosphere of ease, lightness, and even humor with somatic tracking can help the client more reliably access an experience of safety. Maybe the client names their body parts with a little levity or narrates their sensations to the tune of a popular song. Anything that serves to improve or lighten the mood works here.
It’s important to note that somatic tracking works most effectively when the pain isn’t uber intense. If it’s too intense, it can be more helpful to distract or avoid. But for less intense levels of pain, somatic tracking can provide a corrective experience, setting folks up to endure even more intense levels of pain.
Expanding the focus to general stressors and emotions: Since Pain Reprocessing Therapy aims to lower the threat that people experience in their lives, we can go beyond pain sensations to help individuals process trauma, emotions, stressful situations, and more. The more progress we make with processing tough emotions and experiences, the more likely we are to interpret bodily sensations as safe, therefore reducing pain. In this part of Pain Reprocessing Therapy, clients might learn more about their emotions, the functions they serve, and how to express them effectively. Problematic patterns such as perfectionism, self-criticism, and people pleasing might also be addressed.
Emphasizing positive feelings and sensations: Pain patients are accustomed to experiencing unpleasant sensations in their bodies, as well as an overall sense of danger. A large part of Pain Reprocessing Therapy involves shifting from danger to safety. In therapy, clinicians might help clients notice and attend to neutral and positive sensations in the body. They might scan their bodies for pleasant or comfortable sensations, really taking these experiences in. Practicing this skill can help them tolerate more painful sensations through a lens of safety too. Pain Reprocessing Therapy can also help clients access positive emotional states, such as joy, pride, satisfaction, gratitude, and self-compassion. These states can help facilitate the shift from danger to safety.
Pain Reprocessing Therapy has shown promising outcomes in clinical research. In a 2021 randomized study, about 2/3 of participants who completed the protocol were pain-free or nearly pain-free following the treatment. Overall, 98% of participants who underwent Pain Reprocessing Therapy improved, and results were maintained at the one-year mark. Treatment effects were confirmed by fMRI, which indicated shifting brain responses to pain, relative to those who did not experience this type of therapy.
Marina’s Recovery
Marina began therapy with a clinician trained in Pain Reprocessing Therapy. It took her a while to accept that much of her experience was neuroplastic. After all, she had injured her back initially, and her scans were positive for a structural issue. But as Marina studied her pain, she found evidence for neuroplastic influences, and because she wasn’t getting better with medical care, she figured Pain Reprocessing Therapy was worth a shot.
As with any intervention, improvement wasn’t immediate, but it did happen. Marina began to experience reduced pain, attributed to a shift in how she viewed and felt about her pain. Over time, she was able to get back to her prior level of functioning. Of course, it wasn’t always smooth sailing. Like other pain patients, Marina experienced setbacks over time, and she wasn’t immune to the fear associated with feeling like she had regressed. But with consistent therapy, somatic tracking, and an emphasis on positive sensations and emotions, her trajectory continued to improve over time.