People with mental health needs commonly experience unexplained pain symptoms, while those living with pain often find that their mental health suffers as a result of the symptoms and limitations caused by physical pain.
We spoke to Jodie Andrew, an occupational therapist at Sussex Partnership Foundation Trust, about the complex relationship between physical and mental wellbeing and strategies for people living with chronic pain.
What is your role at Sussex Partnership?
I'm an occupational therapist in the NHS, working as a primary care Pathfinder clinician. I receive referrals from GP surgeries and provide short-term support for people with a wide range of mental health conditions. In addition to this, I have a specialist interest in supporting people with unexplained chronic pain (pain which is present, despite no physical disease or injury).
I feel passionately about this area, as I lived with chronic pain for many years and know the suffering it brings. I trained in evidence-based mind-body approaches and these approaches were key in my own recovery.
What causes chronic pain?
People are often surprised to learn that all pain is created in the brain (not the body where it is felt). And, even more surprisingly, there are numerous reasons the brain creates physical pain. These include:
- Tissue damage/ injury/disease. Pain is created as a message to keep ourselves safe, to ensure that we attend to the injury or rest, so that our bodies can recover.
- Neural/ nerve pathway pain. This refers to the pain which persists beyond the normal healing time of the injury/tissue. In this instance, the pain has been conditioned (or learned) and it's like a faulty memory of the brain. Emotional events and stress can also play their part in the pain continuing beyond tissue healing.
- Emotionally induced physical pain. The brain processes emotion, memory and pain in similar regions. There is evidence that our stress levels and repression of emotional experiences (not feeling and processing our emotions) can lead to very real physical pain in the body. It causes our nervous system to be in a constant stress response (fight and flight) which can trigger pain pathways. The stress hormones which are released can affect every system within our bodies.
What types of conditions do you typically see?
Once physical causes have been ruled out by a doctor, chronic pain with a stress-induced or emotional origin can present in many conditions, such as muscular pain, nerve pain, irritable bowel syndrome, migraine, fibromyalgia, pain sensitisation syndrome etc. Sometimes the pain appears to move around the body, but there is no underlying physical disease or injury.
As we are a mind-body system, often the person who is experiencing unexplained persistent pain may also have a stress illness, anxiety and/ or depression. Often (but not always) the person may have experienced trauma in their lifetime (either a single traumatic event or a series of invalidating or challenging experiences over time), which leads to internal stress that can be felt physically in the body as pain or other chronic ailments. Other factors, such as certain personality traits (ie perfectionism and people pleasing), as well as how we talk to and treat ourselves, can also add to internal stress and pressure which can trigger pain pathways.
How does living with pain affect people’s lives generally?
Living with chronic pain can be all-consuming and impact on an individual's ability to function in every area of their daily life, as well as impact their ability to connect in their relationships with others and with themselves. As a result, people can feel very desperate when experiencing persistent pain and may even consider whether their life is worth living.
Their suffering can be exacerbated by misinformation about pain, not being believed in the absence of a physical diagnosis, as well as by the restrictions that pain conditions can bring, for example on employment or going out.
What do you offer people living with pain?
There is definitely a need for more support for people who are living with unexplained chronic pain, as it's extremely common for people with mental health needs to experience pain symptoms and vice-versa.
In my role, I have supported those who are experiencing mental health challenges (many of whom also have persistent pain). When appropriate and the individual is on board, I use a mix of pain science principles and mind-body/ pain reprocessing approaches.
Pain symptoms and physical health needs are also explored as part of an individual's mental health and wellbeing assessment. They are documented in care and support plans to support the notion that mental health and physical health needs are not separate entities and one can affect the other.
Individuals' can speak to their GP about whether they have existing pain clinics in their area and what they offer to see if that could also be a supportive option.
What strategies do you recommend and use?
It goes without saying that if you're in pain, it's extremely important to get underlying physical causes ruled out by your doctor first.
If you are given the all-clear, be open to considering whether other factors are the source of or influencing your symptoms. This involves a shift in perspective and not everyone is open to considering or accepting that although their pain is felt physically, the source is no longer (or in some cases never was) physical. For some people, simply knowing that physical pain can be conditioned and experienced after an injury has healed, or that pain can be triggered by stress or have an emotional origin, can help enormously in their recovery.
Depending on the individual’s needs, strategies for emotional and or nerve pathway chronic pain may include:
- Education on the stress response and basic pain science (and that unexplained chronic pain is reinforced by misinformation, fear and attention).
- Emotional awareness and regulation. This may be through accessing evidence-based therapy or other professional support, especially if you have experienced trauma or have mental health needs. In addition, some people find techniques such as expressive journaling or “emotion check-ins” helpful (making space in the day to pause and feel how their emotions are showing up in their body as sensations, while giving oneself messages of safety).
- Lifestyle changes and prioritising self-care. Self-soothing techniques, such as diaphragm or square breathing, and other relaxation techniques, such as progressive muscular relaxation, may be helpful in getting your system out of the stress response into rest and repair.
- Engaging in meaningful activities, nature and connecting with others. Movement is important and some people will seek physio to build up muscle/ movement safely. Try not to make pain the focus of your day (which can be easier said than done, but I recommend engaging in activities which bring you joy).
- Spend just a few minutes daily checking in with your pain, mindfully attending to physical sensations in the body without fear or judgement, by simply describing the sensations to yourself whilst reinforcing that the sensations are safe. This breaks the fear-pain cycle and creates a new response to the pain which strengthens non-pain pathways. Also, paying attention to positive sensations in your body will be soothing to your system and reinforce non-pain pathways.
- Challenge your thinking patterns. Think about past and present stressors that are keeping your nervous system on high alert (both external stress and self-induced stress). Notice negative self-talk and work to change your inner dialogue by developing greater kindness and compassion to yourself.
- Reframe thought patterns to reduce your inner conflict (this can also be aided by therapy and using cognitive-behaviour therapy principles).
- Set boundaries to further reduce self-induced stress. Remind yourself that, in the absence of tissue damage, disease or injury, mind-body or nerve pathway pain is simply a messenger; it isn’t dangerous and this knowledge can help break the fear-pain cycle.
- Physical-based treatments can be helpful for release of muscular tension and building up movement and muscle/ flexibility etc. But only treating the body and not the mind can limit recovery when there is emotional/stress origin or neural pathway pain. Medication can also be helpful for some people, but it is rarely the whole answer.
What changes would you like to see for people living with pain?
There are so many exciting developments in pain science and recovery which can move people from a place of frustration, fear and hopelessness to empowerment and hope.
In the healthcare field, I would like to see more awareness and delivery of pain science education, as well as the mind-body and pain reprocessing techniques which support chronic pain recovery. This way people suffering with pain can have more knowledge, less fear and more options for support and treatment.
We are exposed to more stress than ever (both external factors and self-induced), which can have very real effects on our bodies and minds. The evidence supporting a mind-body approach for chronic pain is there and it is growing. It would be amazing for this to become more mainstream and easily available in the NHS for those who would like to access it.
Resources to help
http://www.retrainpain.org/ - The Retrain Pain Foundation is an excellent resource with a number of quick, engaging materials around the topic of persistent pain.
http://www.pain-ed.com/ - a website that is run by experienced clinicians working and researching in the pain management world. Their mission is to inform both the public and healthcare practitioners about the latest pain research and to dispel common myths about pain, providing a hope for change.
Pain Recovery Program | TMS Forum (The Mindbody Syndrome) (tmswiki.org)
Ways to manage chronic pain - NHS (www.nhs.uk) - NHS chronic pain website
Pain Concern - charity that works to improve the lives of people living with pain and those who care for them
