The definition of pain is always worth remembering, especially when one spends their days trying to treat this vexing problem. For the record, by the International Association for the Study of Pain, pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. The take home message is that pain is always subjective. Pain is always considered unpleasant and therefore is also an emotional experience. The definition purposely avoids tying pain to a noxious stimuli and activity of sensory receptors for nocioception. Pain is always a psychological state.
As a specialist in medicine, learning is never done. Several weeks ago, I was again at a major national meeting. This time it was for the annual meeting for Physical Medicine and Rehabilitation, which brings together practitioners in this specialty from around the world. This is my specialty, and practitioners in this discipline have an extremely broad range of practice. One of the few common threads is we tend to treat people who have had some sort of “injury” to their body, and our goal is to restore function. Pain and the comprehensive management of the problems associated with it are always a major topic.
The Brain and The Emotional Pain Link
Pain is so complex because it is an event that occurs in the brain. If a patient is complaining of pain, one always is trying to determine what are the associated emotional components. When the symptoms have not resolved quickly with management, then the emotional components often become more important than the actual stimuli that are occurring. By the time a patient is seen by a pain specialist, the emotional components of pain are often some of the most important to treat to solve the overall problems. The hardest thing for most patients to understand is that pain is an emotional experience, and if pain is ongoing, many patients become anxious about the pain and depressed. Furthermore, if depression, anxiety, or personality issues are pre-existing conditions to pain, then treating the psychological problems often become a necessity to successfully treat pain.
In the brain, the regions that are responsible for interpretation of pain are actually in the same area as those for anxiety, stress, and sensations associated with depression. If there are a lot of signals for pain, they can secondarily stimulate stress, anxiety and depression regions. If there is significant anxiety and depression, pain often becomes intolerable. Pain and the associated emotional problems often appear inseparable. Further, many feel that if someone wants to treat the emotional aspects of pain, then it must not be real and its all in their own heads.
If the patient has ongoing issues with anxiety, stress and depression, the body interprets emotional pain as physical symptoms. Treating the peripheral issues often provides no relief of pain because there is still an emotional experience occurring. Both the patient and the physician become frustrated since the experience of pain is so complex with multiple levels of meaning. Further, addressing psychological issues that may have existed for years is often more daunting then treating a simple structural issue that caused noxious stimuli, but once the two start interacting, often they become inseparable.
Pain is an emotional experience. Treating both the emotional aspects of pain, the stress, anxiety and depression often is the only way to improve the function of a person. Having a patient recognize the importance of the emotional aspects of pain and start addressing these issues can be miraculous in successful pain management. Often the toughest discussions with a patient are how pain affects a person emotionally and the quality of their life. Recognizing stress, anxiety and depression is often equally important in effectively treating other body symptoms.
Thomas Cohn, MD
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