Pain is a universal and yet intensely personal experience. It is the invisible scourge that cannot be adequately explained to those around us; it is the constant companion that accompanies us in a thronging crowd or in the quietness of a cloistered bedroom. As pain becomes prolonged and persistent, our ability to cope with it seems to break down. We come to feel helpless, lonely, anxious, depressed and even angry. We get frustrated when others cannot understand our pain and we become annoyed when they tell us that they empathize with us. How can I deal with this pain? How do I make it stop? The poignant words of patient Job of old come to mind, "Yet if I speak, my pain is not relieved; and if I refrain, it does not go away." (Book of Job 16:6)
The first difficult lesson to grasp is that pain is natural. It is the response of the body to both external (exogenous) and internal (endogenous) events, signalling us to danger or caution, providing us with a survival mechanism and allowing us to respond to injury. One way to understand the mechanism of pain is to view pain as messages descending from the higher brain or ascending to the extremities of the body through a massive highway of nerve fibres. These nerves converge at a "gate" (actually, a series of gates) where the spinal cord joins the brain. Like a "bottleneck" at peak traffic, pain messages crowd in with other messages gathered by the body waiting for a chance to get through. As a result, some messages are received and others don't get through at all.
This system vastly affects our perception of pain. People suffering from chronic pain feel their pain more acutely during the night hours when they are trying to sleep than in the day. This is because the number of competing messages arriving at the "gate" at night is usually far less than in the day. As a result, many more pain messages get sent through. Acupuncture works partially on the principle of sending competing messages to the brain by exciting nerve centres directly.
Is It All In My Head?
...we are not ourselves When nature, being oppressed, commands the mind To suffer with the body.
Shakespeare, King Lear
We've all heard it before: "It's in your head." The truth is that all chronic pain has both the physiological and psychological components. The diagnostic problem is to assess the relative contribution of these components on your experience of pain. Nevertheless, there is a persistent tendency to ignore or deny the psychological component of pain because of either fear or misinformation.
The term psychogenic pain has been used to describe the experience of pain where the psychological component is predominant, and where the source is not readily observable, or where the experience of pain may exceed the physical injury. Experiencing psychogenic pain, however, does not mean that pain does not exist. In fact, chronic pain very often induces psychological factors.
What Chronic Pain Does
Consider some of the more devastating psychological effects of chronic pain:
1. Loss of mobility. Chronic pain and suicide ideation have been shown to be strongly related. However, recent research shows that chronic pain is usually a secondary cause of suicide ideation. One of the chief intermediary factors is the severe effect that chronic pain has on limiting mobility. Being unable to move around comfortably, constantly being constrained by pain, being unable to enjoy normal sexual relations with one's spouse or carrying one's children without fear of injury leaves a damaging mark on the sufferer's emotions.
2. Depression. Patients with depression are also heightened in their perception of pain, and will very often be reluctant to carry out treatment modules provided to them for fear of encountering more pain. The combination of immobility and depression leads to irritability, nervousness (or anxiety) and an unhealthy desire for isolation. Marital conflicts develop and escalate. As depression sets in, chronic pain patients tend to become more angry, easily frustrated, often moody, and plagued with feelings of hopelessness.
3. Misperceptions. Sufferers of chronic pain often misperceive the degree of recovery they achieve with therapy. Some underestimate their recovery and become progressively inactive, often avoiding pain altogether. They fail to distinguish hurt from harm, and shrink away from treatment that may bring about some degree of pain. Others tend to overestimate their recovery, often injuring themselves repeatedly by carrying out tasks too difficult for them.
4. Sleep Disturbances . Chronic pain also influences the amount of sleep the patient is able to get. Difficulty falling asleep and early night awakenings both contribute to progressive depression, lethargy, and poor memory (especially vigilance tasks). The last effect, that is, the decline in vigilance due to sleep loss often presents other problems, such as proneness to accidents.
5. Medications. Medications that limit the effect of pain may also produce nagging side-effects such as gastro-intestinal problems or excessive sleepiness that create further irritation. In addition, some patients become dependent on pain killers to sleep or function through the day. Although there is evidence that narcotic drugs prescribed to chronic pain patients do not produce physical dependencies, these dependencies are often not biochemical but psychological. In addition, the patient may develop a tolerance to pain medications that are consistently prescribed.
6. Anxiety. Pain may feature in anxiety disorders because of increased muscle tension or spasms. Tension headaches, post-infarct precordial pain and other pain syndromes affecting the musculoskeletal system may occur. Patients injured in motor-vehicle accidents often suffer from flashbacks of the accident, frequent nightmares, fear of driving or crossing the street, and extreme anxiety when returning to the site of the accident.
Without psychotherapy and professional counselling, the psychological impact of chronic pain deepens. Often, attempts at physical therapy are hindered by a combination of depression, anxiety, anger, insomnia, fears of further injury or else continuous reinjury, irritability, isolation, hopelessness, and seeking more and more medication for pain. The simple joys of life become a hardship. The poet, Alexander Pope put it this way:
You purchase pain with all that joy can give,
And die of nothing but a rage to live.
Yet, there is help. Research on limiting chronic pain goes on. Surgeons, physicians, and chiropractors continually make gains in treating chronic pain. Methods for symptomatic relief of pain such as acupuncture and hypnosis have been under much investigation. It should be noted that hypnosis has not been well established as a means of relieving chronic pain. Typically, it acts as a means of relaxation therapy which is not hypnosis but a type of behavioral therapy.
Psychotherapy aimed at ameliorating the effects of chronic pain are largely of a type known as "cognitive behavioral therapy". Such therapy is effective in dealing with depression and anxiety that results from chronic pain, and correcting associated problems such as sleep disturbances, inability to relax, social isolation, dependency on medications, and poor eating habits. Where sexual, familial or marital problems are present, psychotherapy would need to address issues of communication and conflict. Virgina Woolf once wrote, "The merest schoolgirl when she falls in love has [great writers and poets] to speak her mind for her, but let a sufferer try to describe his pain to a doctor and the language at once runs dry."
Make contact. Find help. The suffering that comes from chronic pain does not need to shut the door to emotional health.
God shall wipe away every tear from their eyes; and there shall no longer be any death; there shall no longer be any mourning, or crying, or pain; the first things have passed away.
Author: T. Quek
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Copyright © 2002 Timothy Quek, Ph.D.