How can counseling help manage chronic pain when it is not in your head? To answer this question we first must understand pain. Acute pain is a normal physiologic response to tissue damage or potential damage. Acute pain serves a purpose to protect the body from damage. Acute pain goes away, usually within three months. Chronic pain continues after healing has occurred, lasting longer than 3 months. The cause of chronic pain may even be uncertain. In chronic pain, the pain no longer serves a purpose.
Secondly, we must understand how humans feel pain. The human body has nerves (nociceptors) that sense harm or the threat of harm. These nerves are the first step to feeling pain and sensing damage. The nociceptors carry signals to the spinal cord and to the spinothalmic nerves. The spinothalamic nerves carry messages all the way from the spinal cord to the brain (the thalmus). The thalmus is the area of the brain that receives these nerve signals and carry messages to other parts of the brain, such as the somatosensory cortex, the physical pain center. Nerves from the thalamus go to many parts of the brain (amygdala, frontal cortex, limbic system and hippocampus). These areas of the brain help us deal with pain and avoid further pain.
It is vital to understanding pain, to understand that the somatosensory nerves are the most important nerves to feeling pain. Activation of these nerves cause us to feel the physical sensation of pain. If the nociceptor is not activated but the somatosensory nerves are activated by another source, we will experience pain just as if we indeed had tissue damage! In many cases of chronic pain the nociceptors were not activated. Next if the nociceptor is stimulated but there is a disruption in communication before the messages reach the brain, we will NOT feel pain (such as with general anesthesia or a spinal cord injury).
Another critical understanding is that in chronic pain the SS nerves become easily activated by nerves coming from other parts of the brain. By controlling our thoughts and emotions we can decrease pain levels to the SS nerves and experience less pain! This is why behavioral therapy is often helpful in the management of pain.
In understanding chronic pain, we must also understand the causes of chronic pain. There are three main causes of chronic pain, each of these are based on which pain pathway is problematic. First in our discussion is nociceptive pain, pain that is coming from the continued stimulation of the nociceptive receptor. Chronic nociceptive pain is usually caused by chronic inflamation, it may be seen with chronic arthritic conditions. When it becomes debilitating there is almost always central sensitization involved (which we will discuss). Next, is neuropathic pain, this is pain stemming from problems with nerve transmission from the nociceptor to the thalamus. Chronic neuropathic pain is caused by damage between the tissue and the brain. This damage causes irritation to the nerve that causes it to fire excessively, resulting in pain. Chronic neuropathic pain can be severe, but is also associated with central sensitization. Finally, is central sensitization pain, which is the most common and problematic cause of pain. The somatosensory nerves in the brain become extra sensitive and fire when they should not. This causes REAL pain, even though the pain does not originate where the pain is felt. For example if the somatosensory nerves in the region of the brain that feels pain in the cervical spine become activated, real pain is felt in the cervical spine even though it does not originate there. CSP does not occur because the nerves are damaged, but because the nerves have changed. The somatosensory nerves and the nerves that activate them have been altered. The exact cause is not fully understood, it suspected that causes maybe prolonged exposure to pain, to opioids and other medications, and trauma.
Problems with CSP include increased activation of signals to the SS nerves and even light touch activates just a few nociceptors and magnifies and activates the SS nerves. Light touch then feels like pain. There is also inappropriate activation, the SS nerves may be activated without any input from the spinothalamic nerves, but from other areas of the brain that control emotions, thinking and decision making, memory and fear. When this occurs stress, anxiety, depression, worry and other events can cause pain exactly as if there were tissue damage! The pain is real! Finally, pain actually changes the brain! These changes are called neuroplastic changes.
Of all the types of chronic pain, CSP is by far the most significant. It is a factor in chronic back pain, chronic daily headache, fibromyalgia and even whiplash. It has been said to likely be a factor in all types of chronic pain. In CSP the patient is not imaging their pain! There is a common misunderstanding between patients and providers, when it is suggested a patient see a psychologist or counselor. It is not because the pain is “all in the patients head”. The pain is being stimulated or magnified by areas of the brain. The pain lies mainly in the brain! Therefore, that pain can be reduced and better managed by decreasing input from the parts of the brain responsible for emotions, thoughts and fear etc.