Lihi Lisser
What is pain? Why does it happen? And why do certain types of pain get “stuck” and become chronic?
To deactivate pain, we must first understand how it works. As you will see, pain is a neurological response to actual or potential danger. For this reason, healing from pain requires us to move the spotlight away from the body and towards the central nervous system and the brain.
In this section, you’ll be able to read about the psychosocial model for understanding pain and the changes that take place within the brain and central nervous system when the pain response is activated for an extended period.
This knowledge is critical, because it's the primary tool you can use to start changing how you perceive your symptoms. As you’ll see later, this change in perception is central to all therapeutic interventions that have been found to be effective for treating pain.
The International Association for the Study of Pain (IASP) defines pain as follows:
Two points stand out from this definition of pain: first, that pain is always, 100% of the time, an experience that involves both body and mind. Second, pain is connected to “actual or potential” damage to the body itself.
As we’ll see further on, pain reflects the level of danger perceived by the brain and the central nervous system, and not the health of the tissue itself.
To understand this in greater depth, we’ll start with the basic question:
Why do we even feel pain?
Research shows that sensory information coming from tissue is only part of what the brain considers when it evaluates the level of danger present. This information comes from the “control room” in the brain that’s responsible for evaluating the danger, and a “staff meeting” takes place there with 3 primary speakers:
who provides information about the condition of the tissues, genetic factors, physical factors connected to the immune system, the hormonal system, nutrition, sleep, and so on.
who provides information about the immediate surroundings, the level of social or family support, negative events in the past, traumas, external stressors, “where am I and who is with me” and so on.
who speaks about emotions (mostly anger, grief, helplessness, frustration, fear), thoughts (for example: “all is lost”), beliefs, meaning assigned to the pain, expectations about the future, ways to cope with it, and even increased stress the person causes within himself sometimes without his knowledge (for example, a tendency towards perfectionism, a desire to please others, sharp self-criticism, etc.).
The conclusion reached at this staff meeting will lead the brain to assess the level of danger it perceives. This assessment will determine whether the brain will activate the neural pathways of pain or not, and at what intensity. Research shows that on a neurological level, there is no difference between a sensory threat or a psychological threat; the brain even processes this information in the same centers. For the brain, it doesn’t matter whether you sustained a blow to your back or found yourself in a difficult situation at work with a boss making your life miserable; in both situations, the same defense mechanism may be activated in the form of a backache. You might start feeling stomach pain as a result of a fight with a good friend or social ostracism or food poisoning. A threat is a threat, whether its source is social (current stress or early trauma), or physical, and the only way your brain has to let you know that you’re in danger is transmitting pain.
What Happens in the Body When the Brain Perceives Danger Signals?
As mentioned, all pain is created in the brain (through activation of signals/neural circuits responsible for creating pain). Pain is not imagined or “in your head,” and it’s always real and felt within the body! It doesn’t matter whether its source is a sensory, psychological, or social threat. When the brain interprets a stimulus as a threat or danger, our systems respond by activating the neural pathways of pain.
Pain is there to bring our attention to the source of the danger. The problem is that sometimes when the danger passes (for example, the stress dissipates) or the injury heals (usually within 3–6 months), the pain continues, and might even get stronger or spread to other areas. We can look at chronic pain in these cases as a false alarm, or a misunderstanding in the conversation between the body and the brain. For some reason, the brain and central nervous system continue activating the neural pathways of pain even though no real danger is present.
Chronic pain, in and of itself, is one of the greatest sources of stress one can imagine. It’s impossible to remain indifferent to it. It changes a person’s life and evokes a series of characteristic responses:
Life with ongoing pain can bring up fear, worry, anger, guilt, and shame. A person who suffers from long-term pain is very familiar with the fear that maybe they are suffering from something very rare and dangerous and maybe that’s why it hasn’t been discovered yet? There’s also worry: what if I will stay this way my whole life? There’s fear of future pain, fear that the body will never get back to how it was, and anger about the situation and about the pain “ruining my life.”
This refers to thoughts that arise as a result of the pain, often of a “catastrophic” nature about the present situation and the expected future, for example: “I am disabled,” “Something is wrong with me,” “All is lost,” “It will never go away.”
Pain draws a great deal of focus. Lots of time, attention, and resources are invested in “pain management.” The mood crashes and thoughts that accompany them empty one’s batteries and drain away one’s energy and motivation. Very active people find themselves closing themselves in at home as a result of the pain, avoiding physical activity or social interactions, and their lives become narrower and narrower. The pain “runs their lives” and drags them down.
Research shows that when chronic pain develops, the way we react to it has a critical effect on its strength and duration. Think about how your brain “listens” to the thoughts and feelings and to the way you behave and respond to the unpleasant physical sensations. When you worry, experience fear, and avoid activities, this information is fed back into your danger response system and what does it conclude? Not only that the danger hasn’t passed, but that it has increased. When the symptoms evoke a response that fuels continued activation of the pain pathways, a chronic pain cycle is formed.
In this way, the pain develops a life of its own, and the neurological system continues to produce it in a closed circuit.
Think for a moment: how did you learn to ride a bicycle? At first, you fell off a lot, but as you practiced, your ability to hold the handlebars in the correct position, maintain your balance, and turn the pedals improved. Gradually, riding a bike became smooth, and you didn’t need to invest thought or planning into it; it became automatic.
In neurological terms, practicing created a pathway of connections between your brain cells. From that point on, every time you get on a bike, that pathway is activated quickly and automatically, and is translated into action (riding). Why does our riding improve the more we do it? The reason is biological:
The more the neurons fire or are activated together, the connection between them strengthens, and the code they create becomes stronger.
The same principle applies to pain. Pain is also a kind of “neurological code,” a connection between neurons that translates into a certain physical experience.
What happens when we experience pain again and again, for months or years?
The neurological pathway strengthens, and the brain activates it more quickly and smoothly.
The pain turns into a sort of automatic habit that requires no thought from us.
What makes the neural pathway expressed as pain more “stubborn” is connected to another mechanism for learning new things: conditioning. Our brain “takes shortcuts” and creates connections between stimuli and responses. Oftentimes, pain will appear alongside another stimulus (a certain noise, a certain action etc.).
For example, lower back pain will appear alongside an action that we’re used to: bending over, tying our shoes, lifting something, driving, sitting, etc. The brain begins to interpret the neutral stimulus as problematic or dangerous, and creates a connection between it and the activation of the pain pathways.
The connection created between the stimulus and the pain through conditioning sparks the pain over and over again, which begins to develop a life of its own. In neurological terms, this is increasing efficiency: the brain sends warning signals quickly and immediately when encountering the stimulus it suspects is damaging. Now, bending over/sitting/walking or any other stimulus activates the pain pathways even if it’s not actually dangerous. The problem is that the longer this connection is activated, the more we will be afraid of those stimuli (triggers), and will try to avoid them (avoiding carrying, lifting, bending over, sitting etc.).
The fear and the avoidance, as mentioned, fuel the danger response system with more threat signals, and maintain the pain cycle.
Pain Changes and Increases Sensitivity in the Danger Response System Itself. The brain and central nervous system are always changing and adapting to changes. This is the reason we can always learn new things. Neural connections in the brain are formed, strengthened, or weakened according to how often we use them.
This ability of the brain to adapt is called neuroplasticity (neuro=brain, plastic=flexible and changing).
The amazing fact is that pain changes the brain. Yes, you read that right!
The more we experience pain, our central nervous system (our brain and spinal cord) and peripheral nervous system (the nerves running throughout our bodies) can become more sensitive or “better” at producing pain. For example, the brain can give a command to create more sensors in the tissues, causing them to be more sensitive.
Now, more environmental stimuli will be perceived by these sensors and will be signaled to the spinal cord, and the brain will receive exaggerated signaling from this area. Another change occurs in the spinal nerves that pass danger signals to the brain.
The brain can increase their sensitivity to chemicals that increase their activation, and even cause additional cells in the region to signal and cause pain. This causes the painful area to grow larger, and it no longer reflects the health of the tissue where the pain occurs. Basically, in this new situation, the brain begins to rely on information that points to exaggerated danger. Based on this information, it continues to create pain pathways. It’s like an overly sensitive smoke detector. Instead of sounding the alarm only when there is smoke in the apartment, it beeps constantly even if someone lights a candle in the stairwell.
This process of increasing sensitivity in the central nervous system and brain to sensory stimuli is called “central sensitization.” It’s very important to understand this process because it stands behind many of the phenomena experienced by people living with chronic pain. It’s a mechanism that’s responsible, for example, for a painful area becoming more sensitive over time (when even superficial and gentle touch increases the pain) or for pain expanding and spreading to the surrounding areas.
The brain holds the “remote control”: it can create pain, stop it, and control its intensity. Pain does not reflect the level of physical damage, but rather the brain’s opinion of the level of danger present in a given moment.
This opinion is formed by calculating data brought to the brain from various channels: from the tissue and the body, from emotions, thoughts, beliefs, behaviors, assumptions, expectations, memories, and present context.
When the brain and nervous system identify danger, a series of neural connections between various brain cells is formed that becomes a kind of neural pathway transmitted back to the body as pain.
Physical and emotional threats are one and the same to the nervous system. The neurological defense system responds via the autonomic nervous system (the sympathetic branch) and activates chemical and physiological changes that can cause symptoms throughout the body.
Chronic pain that is not structural (neuroplastic pain) is a “miscommunication” in the conversation between the brain and the body. The brain continues to activate neural pathways of pain despite the fact that there is no actual danger present.
When pain continues for an extended period, the natural response to it (fear, worry, and focus on the symptoms) “fuels” the neurological danger response system to continue producing the pain response.
The neural pathways of pain turn into a kind of learned habit and are produced with greater efficiency by the brain and nervous system.
Over time, the neurological danger response system itself changes and becomes more sensitive to receiving stimuli and signals (sensory, emotional, or cognitive) and interpreting them as dangerous. In this new situation, the brain begins to rely on information that points to exaggerated danger to the tissues, which doesn’t reflect their actual health.
