Pain III: Anxiety, Therapy & Dismissive Doctors

To help manage your pain through recovery, don’t overlook how beneficial psychoeducational treatment can be for you. You may have to wait out the process of it healing, but pain always has two facets: 1) the physical electrical signals to the brain indicating damage/healing at the source (in this case the stomach), and 2) the emotional salience developed in the brain in response to those signals.

Psychoeducational treatment can greatly shift how that emotional salience plays out in your mind and, as a result, your experience of pain can change quite radically. Those who have navigated medical care and always felt as if they were brushed aside (told it’s all in their heads, etc.) feel quite justifiably wary when I encourage therapy as a way to treat pain—the recommendation doesn’t seem any different than the dismissiveness they often receive at the doctor's office.

Here’s an exercise you can apply to get a better sense of how variable emotional salience can be towards nociceptive stimuli. Nociception is our perception of pain. Look out someone in your family or circle of friends who strikes you as pretty laid back and relaxed (someone who doesn’t have an eating and/or anxiety disorder). Now ask them these questions and write down their answers:

  1. Do you ever experience indigestion or an acid, or burning sensation in the chest or throat?
  2. When it happens what do you tend to attribute the problem to?
  3. Do you ever think it could be a sign of something serious?
  4. Does it cross your mind that you should see a doctor about it as soon as possible?
  5. How many times does it cross your mind, while you are dealing with the pain or discomfort, that it could be a sign of something ominous or serious?
  6. Do you Google your symptoms and try to get a sense of whether it should be investigated as a sign of serious illness?
  7. Do you try to brush off the sense that it’s something serious only to find that the thought comes back into your mind?

Almost everyone experiences acid indigestion at one time or another and your interviewees will likely attribute the experience to something spicy or a big meal. Someone who is not on the anxiety spectrum will have low emotional connections to both interoceptive (sense of the internal goings on in your body) and nociceptive stimuli and this lack of connection will show in their responses to questions three through seven in particular.

Those who have symptoms classified as irritable bowel syndrome (IBS) respond to gastrointestinal pain very differently from those who do not have IBS. In a study where balloons were inserted rectally and then inflated while in place in the lower colon, those with IBS experienced much more severe subjective pain and discomfort than those who didn’t have IBS. Additionally, when a foot was stuck in ice water while the balloon was inflated in the lower colon, the distention of the balloon was scored as significantly less painful in healthy controls, but not for those with IBS. Having your foot stuck in cold water in this trial is called a diffuse noxious inhibitory control. Basically the pain of the ice water on the foot inhibits the electrical signal from the colon informing the brain that the inflated balloon is also decidedly no fun. 1 We of course don’t know why the foot in ice cold water doesn’t inhibit the level of pain for someone with IBS when there is also an inflated balloon pressing against her colon, but [t]he main centres affected [as per what was identified on the fMRI] were the amygdala, anterior cingulate cortex, hippocampus, insula, periaqueductal gray, and prefrontal cortex, which form part of the matrix controlling emotional, autonomic, and descending modulatory responses to pain…” 2 This quote is a fancy way of saying that the functional magnetic resonance imaging (fMRI) results indicate proportionately more blood flow occurs in various brain structures implicated in how emotions might change the brain’s ability to dampen responses to pain in the trial's IBS subjects.

Basic cognitive behavioral therapy (CBT) can be a very useful psychoeducational treatment approach to help you recalibrate the emotional importance that is being placed on both your interoceptive and nociceptive responses. 3, 4

Most health care practitioners can easily identify a patient who has a strong connection between emotion and pain and one who doesn’t. And like it or not, most average health care practitioners pass judgment on people’s subjective experience of pain. The end result is that the anxious patient who is experiencing intense pain will be more quickly dispatched and less likely to receive adequate pain management options than the patient who appears calm and somewhat emotionally detached from the pain. It’s a rather unpleasant concoction of patient profiling, cultural bias and sometimes even medical malpractice. However, it also stems from a desire to avoid an inconvenient truth: medicine sucks at treating pain.

Most of the pain we will face in our lives is a) not fatal or suggestive of a serious or fatal disease and b) cannot be successfully eradicated and often cannot even be reduced in intensity or duration. The elephant in your GP’s examining room is not so much an elephant as it is a chimera—it’s a mythical beast formed from the combined anxiety of both patient and doctor and its name is Pain.

No doctor feels she has done her job when she is unable to alleviate a patient’s suffering. No patient feels any sense of relief when her doctor cannot alleviate her suffering either. Both patient and doctor are frustrated and prone to blaming the other for the fact that Pain, the chimera, is still squatting solidly in the middle of the examining room unwilling to budge.

A doctor can scuttle the chimera out the door quickly by validating a patient’s pain. However, I’m not communicating with the doctors in this post, but rather to you as patients. You too can whisk the chimera out the door by validating your pain as well. And here’s how that might be accomplished:

“I realize that the type of pain I face right now is not that easy to treat and that a big part of navigating this is for me to be kind to myself and to be patient because years of damage from an eating disorder will take time to heal. I am doing everything that I can on my side: I am seeing a therapist; I am taking care to rest and re-feed; and I am using as many techniques at my disposal to stay okay through all of this. But I’m here today because I want to discuss what realistic options you think might be available to me from a medical point of view to help with the day-to-day impact this is having on my quality of life.”

You then continue by providing tangible and ideally measurable examples of what the pain is impeding:

“I am losing on average two-three hours’ a night sleep because the pain is really bad at night. It’s a struggle to get to the necessary food intake levels because the acid reflux really flares up as the day progresses.  I’d say at least once a day I am actually in tears on the floor and the level of pain is an 8 or 9 out of 10.”

In taking this approach you have let your doctor off the hook for being the ultimate pain-alleviation provider. More times than not, this means the chimera no longer blocks either of you from hearing and seeing the other. I’m not saying that it shouldn’t be the doctor who leads the process of ridding the both of you of the chimera, but there is no law prohibiting the patient from improving the patient-doctor relationship either.

1. Wilder-Smith, C. H., D. Schindler, K. Lovblad, S. M. Redmond, and A. Nirkko. "Brain functional magnetic resonance imaging of rectal pain and activation of endogenous inhibitory mechanisms in irritable bowel syndrome patient subgroups and healthy controls." Gut 53, no. 11 (2004): 1595-1601.

2. ibid.

3. Nes, Lise Solberg, Abbey R. Roach, and Suzanne C. Segerstrom. "Executive functions, self-regulation, and chronic pain: a review." Annals of Behavioral Medicine 37, no. 2 (2009): 173-183.

4. Lohnberg, Jessica A. "A review of outcome studies on cognitive-behavioral therapy for reducing fear-avoidance beliefs among individuals with chronic pain." Journal of Clinical Psychology in Medical Settings 14, no. 2 (2007): 113-122.