Understanding Pain: Is it all in your head?

You’ve been having pain for years and it just doesn’t seem to go away, no matter what you do. You finally go see your doctor and imaging results show everything is normal… WHAT?!? Your doctor’s diagnosis is simply, “It must be in your head!” The last thing you want to hear is that your pain is in your head; it makes you wonder if you are making up the symptoms and negates what you are truly feeling. However, scientifically speaking, all pain is actually felt in your brain and not in the injured body part. It is commonly believed that the amount of tissue damage should dictate the amount of pain experienced. Furthermore, once the tissue is healed, the pain should disappear. Unfortunately, it is not that simple, and it is possible that once the body has healed, that some people will continue to have pain.

How do you feel pain?

Pain begins with an injury that activates pain receptors called nociceptors. These receptors send a message up your spinal cord to an area in your brain called the thalamus. From the thalamus different areas of the brain are activated to help understand the pain. How you eventually perceive the pain will be based on your emotions at the time, the memory of having a similar pain and your attitude and behaviour following the painful experience. Because so many different aspects of the brain are involved, no two people will experience pain in the same way following the exact same injury. Furthermore, people will vary on time of recovery above and beyond the normal physiological healing time of the tissue.

How does chronic pain develop?

Chronic pain lasts longer than 3 months, and well after the injury should have healed. It is still not fully understood as to why some people continue to have long-standing pain. However, research has demonstrated that individuals with chronic pain have differences in brain activity that could be causing their long-term symptoms. More specifically, it has been shown that individuals who attach strong emotional reactions to the initial injury and over-monitor their symptoms afterwards can amplify the experience of pain. This may cause the brain to become more sensitive, so that even non-painful stimulus can be perceived as painful. For example, if you get into a minor fender bender on the way home from winning the lottery, you will likely attribute less negative emotions to the accident versus coming home from losing your job and getting into the same accident. If you are already in a negative state of mind at the time of accident, you will attribute more negative feelings around the accident, which may create a stronger emotional connection, and likely cause you more anxiety and distress. Studies have shown that anger, anxiety, depression and fear are all related to increased pain and symptoms following an injury.

Can chronic pain be prevented?

Chronic pain costs the health industry millions of dollars a year, so finding ways to prevent and treat chronic pain has been a hot research topic. One theory that is receiving a lot of attention is a behavioural strategy called fear avoidance. It has been demonstrated that people who develop chronic pain are more likely to over-monitor their painful sensations, avoid activities that they think may cause pain and have a higher fear of pain or re-injury. This heightened anxiety and fear towards pain creates a vicious cycle, whereby the individual avoids activity, leading to a more sedentary lifestyle, which could create more disability.

One of the main treatment strategies for health care professionals to help prevent chronic pain is to identify patients early on, that have the attitudes and behaviours that will put them at risk for chronic pain.

In addition, because chronic pain is closely associated with anxiety and fear, providing re-assurance and education at the onset of injury can provide positive reinforcement that the injury will heal. If the patient can change their negative thoughts surrounding pain and their injury, then they are less likely to catastrophize about it.

Furthermore, patients need to get mobile as soon as possible (within pain-free range) in order to prevent fear towards activity and exercise. The sooner the patient can see that movement will not be painful, the higher chance that they will resume normal activities in a timely fashion.

Take home message:

  • Yes, all pain is in your head, but it is still very real and can be treated. You do NOT need to live with chronic pain.
  • Don’t underestimate the power of positive thinking. Lots of research has been developed to show that people who are positive and optimistic about recovery will get better faster than those who are negative.