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Pain is an intriguing phenomenon, the source of consternation, irritation, and suffering for millions since the beginning of time. It alerts us that something is wrong—that there is damage or threat of damage to our tissues. Pain is usually produced at the site of an injury and is processed in our complex, computer-like nervous system, causing a vast array of physical and emotional responses. The simplest response is to withdraw from the source of pain and then to protect the area that hurts.

Pain occurs in the body as a result of the interaction of nerve cells, the spinal cord, and the brain (together known as the nervous system). Interactions of a multitude of chemicals, including endorphins, prostaglandins, and neurotransmitters, with electrical impulses coming from the nerve cells create the pain experience, and also pain relief. The brain is exquisitely complex. The part of the brain that processes pain impulses, mainly the thalamus, interacts with other areas of the brain that govern memory, emotions, alertness, movement, blood pressure, hormone levels, and hundreds of other functions. The net effect, in a split second—a composite result of many inputs and outputs—is the experience of pain. Needless to say, this system is efficient beyond that of the most sophisticated computer; however, in the case of chronic pain, the system has gone awry.

Acute and Chronic Pain

There are two types of pain, acute and chronic. In acute pain, the computer functions properly, as it was meant to. With chronic pain, on the other hand, it is as if the computer has been affected by a nasty virus, turning previously healthy and needed mechanisms into overactive and inefficient impulses that disrupt normal function.

Acute pain is time-limited—usually gone within a few hours to days. It may last weeks to a few months, but it eventually goes away. Acute pain can be associated with fractured bones, sore teeth, bruises, cuts, surgeries and their aftermath, infections, and a variety of other injuries and conditions. It exists when there has been damage, and as the damage heals, the pain subsides and eventually resolves, and life returns to the way it was before. Acute pain is part of your body’s “response-to-injury” system, which causes you to try to put an end to the offending, pain-causing experience. You also learn from painful experiences and are less likely to do something that causes pain (although later as we explain addiction, you will that this is not true in all cases).

Chronic pain continues beyond three to six months and has outlived any useful function. It should have gone away, but persists. It is the exaggerated response of the nervous system to damage, but also to other conditions and situations that occur in the brain. It is often pain out of proportion to the prior injury or damage. Sometimes a condition will develop for no apparent reason, and there is not even a clear physical basis for the protracted pain. This is not to say that the pain is in any way unreal or imagined. Some people’s bodies simply respond differently over time to certain conditions, damage, or injury. The result is pain that won’t quit.

Chronic pain is pain that continues beyond three to six months, has outlived any useful function, and may or may not have a clear physical basis.

That’s the worst news about chronic pain—though it may wax and wane, in most cases it doesn’t go away. Twenty-five percent of the US population is affected by chronic pain, according to estimates from the National Center for Health Statistics. It is one of the major reasons people go to doctors. As we age, there is a greater chance we will hurt as a result of damaging events, wear-and-tear, and deteriorating conditions.

{ exercise 1.1 }

Types of Chronic Pain ________________________

Here is just a partial list of the many potential causes of chronic pain. Find the cause(s) of your pain and check it/them off or write them in the space provided if the causes are not listed.

____ Back, neck, and joint pain, which can result from tension, muscle injury, nerve damage, disc disease, or arthritis.

____ Burn pain, which can continue long after a burn wound has healed.

____ Chronic pelvic pain, which refers to any pain in your pelvic region (the area between your belly button and your hips) from tumors, infections, or scar tissue.

____ Cancer pain, which can result from the growth of a tumor with pressure on nerves, from treatment of the disease (chemotherapy or radiation treatments), or from other effects on the body.

____ Infections that didn’t respond to treatment, which can occur almost anywhere in the body.

____ Chronic abdominal pain (with or without physical explanation or findings), ulcers, gallbladder disease, pancreatitis, or gastroesophageal reflux disease (GERD).

____ Inflammatory bowel disease, irritable bowel syndrome, or other intestinal problems.

____ Bursitis, which can affect any joint, most commonly knees, shoulders, hips, elbows, or wrists.

____ Head and facial pain, which can be caused by dental problems, temporomandibular joint (TMJ) disorders, trigeminal neuralgia, or conditions affecting the nerves in the face.

____ Chronic headaches, such as migraines, cluster headaches, and tension headaches.

____ Multiple sclerosis, which can include numbness, aching, or pain.

____ Angina or chest pain from heart disease.

____ Uterine fibroid tumors (growths in the womb that can be associated with bleeding).

____ Chronic obstructive pulmonary disease (COPD) or emphysema.

____ Peripheral vascular disease (inadequate blood circulation to arms and legs).

____ Ankylosing spondylitis (severe arthritis with restriction of spinal movement) .

____ Myofascial pain syndromes (heightened experience of pain coming from the brain, which impacts soft tissue and muscles). This includes fibromyalgia, which is characterized by tenderness in multiple trigger points, widespread muscle pain, fatigue, and stiffness.

____ Whiplash that doesn’t go away after an accident.

____ Broken bones that healed incompletely or in the wrong position.

____ Arthritis (rheumatoid, osteo-, or other forms), which can affect any joint, including hips, knees, neck, back, fingers, wrists, and feet.

____ Neuropathy from a variety of conditions, including HIV/AIDS, injury, and cancer.

____ Other: _____________________ ____________________________ ____________________________ ____________________________

ALL PAIN IS REAL

Since chronic pain frequently cannot be seen or measured, unlike a broken arm (acute pain), doctors, colleagues, friends, or family may question or doubt your pain. In effect, it doesn’t matter if anyone believes you, but it is extremely important for you to acknowledge that all pain is real. Your nervous system is made up of electrical circuits modified by chemical neurotransmitters, and the sum total of how these billions of cells interact is your essence—your joy, fear, sight, smell, and all sensations, and your experience of pain.

Pain Is a Subjective, Personal Experience

For some people chronic pain can be disabling, while for others it is merely annoying. Just as pain is entirely subjective, your responses to pain and the responses of your family may vary widely. Some of you stay in bed when you hurt; some of you go about your business. Your unique experience of pain is based on many personal factors, including:

Age.

Ethnicity.

Religion.

Circumstances (context).

Stereotypes.

Prior experience with pain.

Gender.

Culture.

Environment.

Attitudes.

Social influences.

Hormone levels.

There are countless examples of how these factors can influence your perception of pain. For instance, studies have identified a number of gender differences regarding pain perception. Women are likely to experience pain more often and with greater intensity, while men are less likely to seek help for and express their pain. Attitudes toward and expressions of pain also vary among different cultures. For example, Western cultures tend to have a much lower threshold for pain than some Asian cultures where pain is viewed as having spiritual meaning. If you have had a prior painful experience, you might expect this occurrence to go similarly, and that will affect your actions and, in turn, your pain.

{ exercise 1.2 }

Pain Is Subjective____________________________

Describe how your experience of pain has been affected by the personal factors previously listed or list other factors you believe affected your pain.

________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

Secondary Gain: A Hidden Barrier to Recovery

Secondary gain refers to any perceived benefit you receive from having pain. If not identified, secondary gain gives you unconscious reasons for holding onto your pain. This does not mean you are pretending to hurt for the benefits you get, just that the perceived benefits make the pain rewarding in some ways and thus more complicated to treat.

Some examples of secondary gain that might result from having chronic pain include:

Receiving more attention.

Not having to work.

Being excused from responsibilities.

Being on disability—essentially, being paid to be in pain.

Getting out of activities.

Having an excuse to take medication.

You may view secondary gain as deserved compensation for the pain you experience. These thought processes may be conscious or totally unconscious. Either way, if these beliefs remain unexamined, they may interfere with your ability to improve your condition. Taking inventory of secondary gain you may be experiencing and examining your attitudes about this is an important step in moving toward balance.

In the preface of A Day without Pain, Mel Pohl, MD, recounts the role of secondary gain in his personal story of chronic pain:

Much as I hate to admit it, in some odd way, the pain I was experiencing and the consequences of having that pain served a function in my life. Actually, the pain had some surprising advantages for me. I didn’t realize it at the time, but because of my pain I didn’t have to exercise. I had a great excuse to sit around and watch TV, and, of course I had to eat while I was watching TV, which gave me an acceptable excuse for gaining weight. After all, I was in pain. In most of my conversations with friends and family, the opening line usually was “How’s your back?” A well-timed groan or moan, more often than not, elicited the sought-after sympathetic “poor Melly…”

Now at the time, if you told me that any of this served me, I would have slugged you. After all, I was hurting, frustrated, furious, and miserable a good part of the time. I felt helpless, powerless, and hopeless. How could anyone suggest I was benefiting from my pain? Thankfully, not a soul dared to make such a suggestion. Without question this would have been a good reason to bite some heads off. I needed an excuse to yell and scream. As long as I stayed angry, my muscles stayed tight. The harder I tried to be powerful and overcome the pain, the more powerless and in pain I was. The more I resisted, the worse I hurt.

Today my pain is still there, but it is much less. What changed? My attitude. I experience my pain in an entirely different way. I got tired of the pain, of complaining, and of being miserable. I realized that my identity was my back pain, and I had become locked in the cycle of the futile search for freedom from suffering. By my resisting, paradoxically, the hurt got worse. I learned to stop fighting and judging the pain. And, lo and behold, it disappeared—often for days at a time.

One of the insights I gained was that I was experiencing something known as secondary gain. In other words, I was gaining something (attention, sympathy, support, an excuse for my inactivity) from my negative or maladaptive behaviors. Furthermore, as I gave up my resistance, I found freedom.

{ exercise 1.3 }

Secondary Gain _____________________________

List all the real and perceived benefits you have ever received from having chronic pain. Be sure to include the things you get, as well as things you were or are able to avoid. One example of each is provided for thought.

PHYSICAL {example: I don’t have to help around the house.}

SOCIAL {example: If I don’t show up or cancel at the last minute, everyone understands.}

EMOTIONAL {example: If I get frustrated or angry, I can blame it on my pain.}

FAMILIAL (include emotional, as well as specific household or practical responsibilities) {example: My family pays more attention to me when my pain is bad.}

WORK LIFE {example: If I call in sick, I can always say it’s because of my pain.}

FINANCIAL {example: I receive workers’ compensation payments. It’s less money than I made when I worked, but enough to live on. I can’t do the same job, so why should I take a job that pays less?}

SEXUAL {example: My partner no longer expects me to work as hard at providing him or her with sexual pleasure.}

It’s important to look closely at secondary gain, as the perceived benefits might not be as attractive as you believe. Most of the time secondary gain is not gain at all, but loss. Chronic pain sufferers often inadvertently buy into secondary gain without looking at primary loss.

Most people find they are just stuck and afraid to move forward. Once you walk through this fear, you will find you gain much more by a return to normalcy in your life.

{ exercise 1.4 }

Examining Secondary Gain _________________________

Go over the list of examples of secondary gain you identified and take a minute to look at what is actually going on. Write about your observations.

Manifestations of Chronic Pain

Chronic pain can be a troublesome annoyance or a devastating curse that interrupts life functions, relationships, employment, and most things that bring us satisfaction. It takes over our lives, consumes us, and threatens our well-being and the well-being of those who care about us—family, friends, coworkers.

For many with chronic pain, and probably most of you who are reading this, traditional pain management (medication and physical interventions) has not helped sufficiently. You have developed a constellation of troubling symptoms.

{ exercise 1.5 }

Pain Manifestations__________________________

Here is a list of some of the manifestations of chronic pain. Please check off those you have experienced.

____ Feelings of depression, anger, worry, discouragement, and irritability.

____ Sleep difficulties.

____ Financial problems.

____ Problems relating to others, causing significant disturbance in relationships.

____ Inability to tolerate physical activities.

____ Withdrawal from social activities.

____ Inability to concentrate.

____ Poor memory.

____ Isolation from support systems, including family, friends, and coworkers.

____ A decrease in sexual activity or performance.

____ A decrease in self-esteem.

____ Secondary physical problems.

____ Problematic use of pain medications and/or alcohol or addiction.

____ Avoiding work and leisure activities.

____ Negative attitudes concerning everyday life.

____ Other: _____________________ ____________________________

Write about the feelings that come up as you review this list.

Many Have Difficulty Telling the Difference between Physical and Emotional Pain

If you identify with some of the features listed, your life is probably damaged significantly by chronic pain. Chances are your family has been gravely affected as well. Pain has invaded your life, and life has become drudgery. Depression can result and even lead to hopeless or suicidal feelings. The suffering that accompanies chronic pain (your emotional responses) is often much greater than the pain itself.

Furthermore, often your responses to the pain exacerbate the pain itself. You judge it (negatively of course), resist it, get angry at it, and try to get away from it, and the pain gets worse. In fact, much worse. Resisting the pain causes the pain to get worse.

Pain is not right or wrong, good or bad. Pain simply exists in your life. You can change your experience of pain and your attitude toward it.

{ exercise 1.6 }

Developing a New Awareness _______________

Let’s try an experiment. Identify a source of pain in your body right at this moment. Get mad at it—tighten the muscles in the area—worry about how much worse it is getting—throw hatred and loathing right into the pain—feel the despair because this is the way it is and will always be. Hold these negative feelings for a few moments…

Now relax for a minute. Just take a deep, slow breath. If you are having any angry or despairing thoughts, try to set them aside for a moment. Just breathe. And breathe again. Try to loosen the muscles that you just tightened. Think about something positive—a memory, a favorite place, a song, a loved one. And relax. Keep breathing.

Write below about any emotions, thoughts, and spiritual or physical experiences that came up for you. Did you feel the pain get worse as you tightened your body and mind? Were you able to relax, and as you did, did the pain lessen? If not, what got in the way?

If you are caught in the negative spiral of chronic pain, it may seem like there is no way out, but that’s not the truth. You now have some clues to your experience of pain and some potential ways out. As the simple exercise above demonstrates, when you tighten your muscles and send negative energy toward the pain, the pain gets worse.

It’s as straightforward as that. If you successfully reduced your muscle tension, stopped judging the experience as negative, and paid attention to your responses, the pain diminished, even if only a little. Always take notice of small improvements, for those add up. If you noticed your pain increase and then decrease with this exercise, you have just seen that you have the beginning of the answer to chronic pain. Please don’t underestimate the significance of this!

A lot of the work you will be doing in this book will be to help you notice your pain, but notice it in a very different way. It will require that you be open to changing the experience, and you will be amazed at the differences in how your pain “feels.”

These techniques cannot help but help—a little for some, a remarkable amount for others—and a lot depends on your openness, willingness, and tenacity in applying yourself to these ways of changing your thinking about your pain.