Why were you referred to a psychologist in a chronic pain clinic?


By Desiree Azizoddin, PsyD

Maybe a physician treated you 10 years ago and suddenly you’re being ordered to discontinue all the medications that help you. Perhaps you had surgery a year ago and your pain has persisted, yet you’re also being advised to continue with your Tylenol regimen? You think to yourself, “I’m not abusing any opioids” or “The opioids were the only thing that worked.” You think to yourself, “It’s such a low dose… why can’t I get a refill?” I’m not abusing the opioids, it’s the other people abusing them on the streets.

There has been a shift in today’s media, medical care, and legislation on reducing and significantly avoiding the use of opioids, but I’m not surprising you by bringing up this topic, right?

Let’s back up 30 years or so: Opioids were the standard treatment and our understanding of substance abuse was limited. The study of Psychology and pain was growing, yet new.

So, maybe you envision Freud on a couch or talking about how your mom and dad reprimanded you as a child, and you think … “Why do I need a psychologist? I had a fine childhood. I’m just in pain and the doctors can’t seem to fix it.”

Now let’s take a step back to today’s view. Yes, scientists have identified that a trauma history increases your risk of developing chronic pain and even abusing opioids, but maybe that’s also not you… back to the topic, why were you referred to a psychologist in a chronic pain clinic? It’s not that just “talking out loud” about stress in your life will relieve your pain, or even that distraction can change your pain.

The history of cognitive psychology began in the depths of sensory and perception. What happens when your environment gives you a message … like the bright light of the sun? — You squint. Or when you’re walking barefoot to get the mail and you step on a rock? You immediately flinch, grab your leg and check if it’s bleeding. All normal, seemingly understandable processes. Your brain does some interesting things. It begins by interpreting the external stimuli (through your peripheral nerves) and translating it to messages that are understandable to you consciously (your central nervous system). The same thing happens with your internal stimuli. For example, your brain perceives discomfort in your belly and you assign a feeling. That feeling might be hunger, that you ate something bad, that you need a Tums or to use the restroom, etc. Those messages seem clear-cut and direct, yet what scientists have found over the years is that actually, the messages evaluating our internal stimuli (e.g., soreness in your lower back) are actually not so clear.

I’m sure many of you have heard “I’m sorry we’re all confused here… there doesn’t seem to be damage in your vertebra or discs that would explain the type or severity of pain you’re having…” This is unfortunately sorely miscommunicated. Data shows that “bulging discs” frequently appear on MRI’s in people without pain, at a surprisingly high rate of 25% of the population, and vice versa, that people reporting significant chronic pain frequently have a generally clear MRI too. All of which leads to this statement noted above, “the pain you’re feeling and the picture we are seeing of your spine just don’t match.” This is not to say that your pain isn’t real or that “It’s in your head.” What this is really saying, is that the messages between your central and peripheral nervous systems are confused and now disorganized.

Going back to what you read a minute ago, you’ll remember that your spinal cord and all the nerves throughout your body are one complicated system sending messages back and forth to your brain, bringing consciousness to your experience. Repeated activation of those messages, like during repetitive movement in sports, or even damage from trauma (like a car accident) can lead to changes in the nervous system and the brain. What scientists also know is that continuous changes in your perception, including things like the words you use to label your pain, can lead to structural changes in your brain too! Let’s go through an example. You notice pain in your spine, and you tell yourself “O man, this hurts so bad, there must be something seriously wrong with my spine.” This thought, yes this thought in itself, activates those nerves even further, and actually sparks your amygdala, what’s noted as the “fear” center in your brain. Over time, continuous, fearful thoughts about your pain lead to over-activation of the fear center in your brain and therefore intensify pain messages. Scientists believe that this is how chronic pain develops. Yet the good news is, get this, it can also work in the reverse.

So once again why were you referred to a psychologist in a chronic pain clinic? It’s mainly about the treatment. Though scientists know psychological factors play a large part in chronic pain development and its persistence, the main focus is on interventions that can help improve and better manage your pain above and beyond medications and injections. Cognitive Behavioral Therapy (CBT) for chronic pain is an evidence-based treatment, which basically means this treatment was tested and proven as effective and is usually provided by psychologists. Brain imaging of patients before and after CBT for chronic pain treatment shows increased activation and actual growth in brain matter in the areas that help regulate pain processing, and reduce the “fear center” we talked about earlier. Psychological treatments can change your brain.

The “how” is the most important part though. CBT for chronic pain teaches you how to calm that “fear” part of your brain. We start by helping you alter your beliefs (cognitive) about your pain and helping you find ways to calm your nervous system. Yes, we will review behavioral techniques geared towards finding ways to “pace activities,” like the concept of training for a marathon; no, you won’t be training to run. Sure, this means we will review ways to manage your daily life and hopefully increase functioning, that’s the “behavioral” part in cognitive behavioral therapy. But the most important part is that we help you figure out how to look at your own thoughts, specifically how to find those thoughts that turn on the “fear alarm.” The same thoughts that make your pain feel more intense, and we adjust them so that the “fear” center is not so readily activated. You’re basically learning how to change how your brain processes the pain messages. If you keep practicing, you can reduce the strength of those pain messages being sent throughout your nerves. Your chronic pain didn’t develop overnight, but with practice and consistency over time, your function and quality of life should improve too. And there you are, voilà, this is why you were sent to a psychologist in a chronic pain clinic!

Dr. Desiree Azizoddin completed her pain psychology fellowship at Stanford University School of Medicine in 2017. She is currently pursuing a research fellowship focused on cancer pain in the department of psychosocial oncology and palliative care (POPC) at the Dana Farber Cancer Institute and Harvard Medical School.

Connect with Desiree on Twitter.

Stanford Pain Medicine

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