Welcome to the second part of the Pain is Complex Series.
If you missed Part 1, please stop at this point and head over there by clicking here.
(There is a flow to this blog series that will make what is written in this part make sense - so please start there).
Pain & the Psychological side of life.
We now turn our attention to the psychological side of life and how this relates to pain. This is an overview/intro type post and whilst some examples will be provided - the nitty gritty will appear in future blogs.
In Part 1, we described how the brain receives messages from the nociceptive system about my injured ankle and it begins to figure out what this message means. The process of “figuring this out” involves a lot of cross-communication between different brain areas. On some level, conscious or unconscious, my brain will make a judgement or appraisal about how bad the potential injury to my ankle is. That appraisal is influenced by many psychological factors such as:
My previous experiences/injuries,
The beliefs I have about my body,
How much attention I give to the symptoms in my ankle
How much fear I have about this injury
How this injury relates to my future (am I going to be able to work or contribute to my football team etc)
How I coped with an ankle sprain before
All of this information (and more) is referenced or sampled by my brain during this cross-communication we mentioned earlier. It all shapes the appraisal or perception my brain makes about my ankle immediately after I have rolled it. To help you understand a little more we will briefly touch on a few of these.
My previous experiences & previous ankle injuries
These memories or reference points will have a significant influence on my brains perception of what has just happened my ankle.
If I've been lucky enough to never have suffered an ankle sprain before, I don't really have any specific references here to factor in. It’s unlikely that this will significantly influence my symptoms.
Even if I haven’t had an ankle injury before, other injured body parts and what those injuries have meant for me, are likely to be referenced too. A really bad back injury that lingered for a long time and that created powerful meaning and reference points for me, may shape how my brain perceives any subsequent injuries that I might have.
If I have had a few really bad ankle sprains in the past that maybe kept me out of work or away from exercise / sport - it's much more likely that my brain is going to perceive this ankle sprain as a big threat for me. Last time something like this happened - it really didn’t go so well. I wasn’t able to play football, I let my team mates down, it took me ages to get back to training again and I was a miserable old sod while all of this was happening.
It’s pretty likely that this influences my perception in a negative way because based on my previous experience of having an ankle sprain - this current injury represents a pretty big threat to my ambitions as king of the astroturf leagues in my local town! These memories will serve to amplify the perception of threat - which is the biggest driver of symptoms.
The attention given to pain
Pain is designed to draw your attention. It is designed to change your behaviour and it is pretty good at both of these things! In an acute injury setting such as my ankle sprain, heightened attention to pain is completely normal. I’ve just had a tissue injury and I want to make sure that I protect my ankle and avoid further injury.
What happens though when symptoms linger for weeks or months? Or when they appear out of the blue with no known mechanism of injury? Again, it’s normal for us to pay attention when the symptoms show up - but if they do not subside what role does continued attention to pain play then?
Inside the brain there is likely a gazillion and one things competing for the brains computational powers. The hormonal inputs that tell you that its time to eat, the stress that your overdue college assignment is weighing onto your shoulders and of course the ultimate question: “How do they get figs into the fig rolls?” (jokes - if you don’t get that, I must be getting old!)
When we shift our attention to something - it’s pretty likely that our amazing processing power shifts to sample that stream of data in more depth. When we are in pain and we shift our focus and attention to the pain the same thing likely happens. Our amazing brain will shift more of its resources to sampling and processing these streams of data.
This is like dousing petrol on a fire, expecting the fire to go out and to avoid getting burned!
That ain’t happening!
A quick glance at the scientific research around this will tell you that when attention is focused onto pain, the pain is felt more intensely.
That is obviously not what we want to happen!
Try this for a simple little demonstration of your brain shifting its sampling and processing of the data streams it is receiving:
Sit upright with your hands on your thighs.
Close your eyes.
Relax your breath.
Place your focus as fully as you can on the contact of your feet on the floor.
Notice how you can describe more about the contact of your feet on the floor while focusing vs when you weren’t focusing on the feet.
Now switch your focus to your hands. The same thing will happen - you can describe with more precise detail about your hands.
Somehow, somewhere deep inside your nervous system, more input from the area you are focusing on is allowed to reach the conscious areas of the brain - enabling you to describe them in more detail. We perceive with greater clarity when we shift our focus toward something.
No sh*t Sherlock I hear you say! Now imagine focusing your attention on that troublesome back pain that’s been happening. Based on what we have just described - isn’t it reasonable to think that placing your focus on the pain will enable your nervous system to perceive this with more detail?
What might that do to threat perception?
If you are thinking “increase it” - you’re correct! And that is really not useful! As I mentioned before - it’s like dousing petrol onto a fire and thinking you aren’t going to get burned!
FYI - if you regularly experience pain, when possible (I know it is not always easy or possible) - do your best to shift your focus away from pain. This will often give you the best change to minimise it. Locking on with laser focus onto your pain will likely not help things!
Pain and Beliefs
This one is a personal favourite. The beliefs we hold about our bodies and ourselves are a tremendously important influence on our experience. Beliefs are like the lenses in your glasses. They shape the world you see. For the context of a pain experience - the beliefs you hold about:
Your symptoms,
Your body
The treatment you receive
Your ability to recover and make progress
Exercise
Genetics
Your support structures
These, and many more, will all influence how your brain perceives threat and safety.
It should be pretty obvious to understand that a person who holds a belief that their lower back is fragile and crumbling (regardless of what is actually happening to the joint structures of their back) will experience a more heightened perception of threat about lifting something heavy than a person of equal strength and ability who believes their back is robust, capable and adaptable.
I will go as far as saying that experience has shown me that for a person with ongoing symptoms - the beliefs they hold are among the most important of influences on those symptoms.
And yet, as straightforward as that all sounds, beliefs are tricky. We all have them, we might not be fully aware of what they are or where they came from. And it may take time and effort to change them.
How and what we believe, is how we process and perceive.
Our beliefs all colour our version of reality aka our conscious and unconscious perception and as a result, must be considered as a potentially helpful or unhelpful influence on our symptoms.
Probably one of the most important beliefs that is prognostic (will determine what happens for you in the future) is your belief in your recovery.
Do you fully believe that you will overcome the symptoms and problems that you are facing?
If you don’t, this is the very first thing you should work on.
I will write a blog for you about this and link it here when it is done. In the meantime, it will be useful to get a pen and paper out and have a little writing session about what it will take to make a full recovery from the symptoms you are facing. When you are clearer on what it will take (think about HOW it can happen and WHAT will be needed) you then have more chance of believing it can happen.
As this is a general overview post - I will not elaborate more on beliefs here. Look out for a future series on the most common unhelpful beliefs I come across in clinic where I will elaborate on this topic in much more detail.
In Part 3 we will dive headfirst into how the emotional side of life and our behaviour influence pain and recovery from symptoms.
Please share this with a person who is suffering with ongoing pain and is struggling.
Thanks for reading.
David