Thomas S. Bottiglieri, D.O.

A conversation with your doctor about a chronic medical condition might include the suggestion that stress is a contributing factor.  For people experiencing chronic pain this is likely true as well.  Of course our perception of pain and relieving its source is an important tool in survival, but not all perceived pain benefits our survival.  In some circumstances distress caused by the awareness of persistent discomfort can lead to poor outcomes.  Strategies to diminish pain in chronic conditions can improve quality of life.

The basic wiring of pain is called nociception.  These pathways from the periphery of the body to the brain are mapped to the various regions in the brain stem, midbrain, & sensory cortex.  The automated responses to stimuli; such as heat, irritating chemicals, or pressure can lead to increased muscle tension, blood flow, & swelling which mitigate protective mechanisms and potentiate healing of injuries.

Human beings can respond in a very simple stimulus and response manner, but there is also a strong influence from our conscious and unconscious mind on those signals and reactions.  Our minds influence our experience to stings and aches.  There are hints of understanding how this occurs through observation of the placebo effect.  Placebos are inert drugs that have physiologic impact.  The classic example is a sugar pill.  For example, suggesting to a patient that a medication has a specific effect of calming can cause a measurable decrease in stress hormones. The mitigation of this response is strongly regulated by a part of the brain known as the periaqueductal grey through its impact on pain responses.  Endogenous (made in our bodies) opioids, which can impact the experience of agony are increased or decreased by this system.  Administration of placebo changes the activity in this area and has been shown to subjectively correspond with pain relief.  This clue helps to elucidate how our brain receives signals that change the awareness of the pain experience.

Beyond the signaling pathways that contribute information to the brain from the periphery and organ systems of one’s body, our conscious perception of pain is colored by the meaning we assign to pain.  Pain is an experience in the mind. and behaviors associated with pain can covertly influence its severity & persistence.  It is obvious that a noxious stimulus such as fire would warrant retraction of a limb through muscle contraction, and the subsequent increase in alertness to identify and respond to the source.  This stimulus/response system insures our survival by keeping us from dangers in our environment.  That being said, it is important to know that how we perceive pain can have a significant impact on how frequent or severe the pain might be experienced.

In addition to the wiring pathways described, human beings have an autonomic nervous system (ANS) that helps to appropriately tune our systems to respond to stress & relaxation. The sympathetic, or “fight & flight” system can be turned on to up-regulate pain response in stressful situations.  This makes sense in nature where potential catastrophe lurked around every corner and learning to avoid painful stressors could leave an indelible memory that leads to continued existence.  The immediate response of the system to stress in the modern world can often cause unnecessary fear, anxiety, & anticipation of pain which has pathways from our prefrontal cortex to pain centers.  This physiologic stress reaction can propagate pain and diminish pain tolerance, but there are means of decreasing this influence through targeted breathing exercises.

While pain is a signal to adapt to environmental and internal stressors, persistent pain should prompt evaluation for cause.  In many cases the source of pain is not potentially life threatening and diminishing the experience of pain is desirable. Once the source of pain is identified and treatment established, additional training in breathing exercises, guided meditation, and general awareness of the causes & relievers of pain can help to mitigate the subjective experience.  In his book, Wherever You Go, There You Are, Jon Kabat Zinn describes a practice of mindfulness that has been shown to reduce pain in scientific experiments with chronic pain patients.  We have also seen significant improvements in pain through a process of heart rate variability biofeedback breathing exercises in which the stress response can be modulated.

In pain syndromes such as amplified musculoskeletal pain syndrome (AMPS) and tension myositis syndrome (TMS) there is a strong psychological influence on a hyperactive pain response.  In these conditions cognitive behavioral therapy also has significant utility.  Shining a light on underlying anxieties and phobias can provide insight into the true source of these types of pain syndromes.  It is often uncovered in the clinical setting that a person experiencing these conditions has significant stress in the form of a recent divorce, sick family member, financial worry, and many other life strains.  Diving into mental well-being is often difficult for patients to receive when they are presenting for pain that seems to have a pathological cause in the body that is palpable, but in many cases this is an important part of the therapeutic process.  Again it warrants repeating that pain is a signal that something is wrong and certainly warrants investigation with your doctor.  Once a diagnosis is clearly established, possibly including a pain syndrome as described above, strategies should be employed to enhance the normal function of the ANS, mindfulness behaviors, meditative breathing, and psychological support.