The Painful Truth

Highlights

over 90 per cent of cases of back pain have no identifiable tissue damage.

Pain is a horrible feeling that urges us to protect our body: we quickly withdraw the vulnerable body part from the suspected source of danger;

Pain is not a measure of injury. This distinction may seem trivial, but it is utterly transformative. It’s a truth that explains how pain can be made in the brain, yet isn’t ‘all in your head’.

all pain is real, and that the legitimacy of someone’s pain should not depend on the presence of physical damage. Most importantly, it offers an answer to those living with inexplicable pain, and real hope for recovery.

We are living through a pandemic of persistent pain – it is the leading cause of disability globally3 – and we, as a society, are poorly equipped to deal with it.

Injury is neither necessary nor sufficient for pain. This is a point worth labouring,

many of us act (and many health professionals treat their patients) as though pain is produced in the body and detected by the brain.

The tissue sends the pain signal; the brain reacts. This theory has prevailed – whether explicitly or assumed – for the past four centuries. But it’s a theory that is fundamentally wrong.

If pain were a reflex, a simple signalling system from periphery – the edges of the body, which interact with the outside world – to brain, then we should always and only feel pain when our tissue is damaged, and the pain should be directly proportional to the extent of injury.

I am going to call these ‘danger receptors’ and ‘danger signals’, because that is what they are. The information these signals convey is that of damage or danger in the tissue, and while they often play an important part in the creation of pain, they are neither necessary nor sufficient for it. Pain is not created in the tissues and does not ‘travel up’ nerves.

They proposed that non-painful nerve input (such as touch) could activate inhibitory neurons and stop danger signals from travelling up the spinal cord – ‘closing the gate’. This explains why we rub our knee after bashing it on a table. This theory was revolutionary because it offered an explanation for why injury does not necessarily equal pain, and that danger signals can be turned up or turned down.

pain is created entirely by the brain. In other words, pain is not detected by the brain: it is made by it. And for pain to exist, it requires our conscious awareness.

No brain: no pain.

Knowing that pain is a protector and not necessarily an accurate informant of damage, knowing that pain is trying to help us (even when it becomes overprotective and sometimes life-ruining) is the first step towards healing. Our body has other protective mechanisms that work in concert with pain, such as the immune system, but any definition of pain should be rooted in pain’s role as a protector: that is, a feeling that tells us that part of our body is in danger or damaged and that it needs protecting.

Pain is always a personal experience that is influenced to varying degrees by biological, psychological and social factors’.

Pain is a decision made by the brain – the vast majority of which is outside our conscious control – to tell our conscious mind that we are in danger.

Pain is a conscious translation of our unconscious brain’s decision that the body is in danger.

‘Pain is an opinion on the organism’s state of health rather than a mere reflective response to injury.’

Pain is necessary for life, in every sense of the word. But pain can also be life-ruining; it can eat away at the whole person – their mind, body and social world.

In most cases of persistent pain, our brain has – over time – become overprotective, creating pain even when the damage has gone. This might seem utterly illogical, but it makes sense when we look at the painful truth: pain is a protector. If we pull a muscle in our back, it will almost always completely heal.

In most cases of persistent pain, pain stops being the symptom and becomes the disease. Importantly, this makes the pain no less agonizing, and no less real. But our knowledge of this painful truth is vital – and full of hope.

The most effective, evidence-based treatments for chronic pain are ones that provide our brain with evidence of safety and reduce the evidence of threat. Trying to ‘fight’ pain with anger or denial never works, and therapies designed to remove a supposed ‘issue in the tissue’ rarely work, or rarely work in the way they purport to.

Pain is a friend. Pain is a doctor, teacher and bodyguard. Pain is a guardian angel, rather than an informant of injury. Knowing that pain is always trying to protect us, even when it is ruining our lives by being overprotective, is the first step towards living with, reducing and even eliminating persistent pain.

all classes of pain relievers available today are either not wholly effective, have unpleasant side effects or can be destructively addictive,

NHS England’s expenditure on diabetic foot care in 2015 was more than the cost of treatment for breast, prostate and lung cancers combined.

pain is emotional as well as sensory.

the heart of the nature of pain: it is not just a sensation, nor just an emotion, but a remarkable blend of senses, emotions and thoughts.

they demonstrate pain’s key role as a protector. Without pain, we would live lives of unprotected injury and early death. Pain wants to look after us. Even in our search for ways to soothe the life-wrecking effects of persistent pain, this truth is of the greatest importance.

In the case of persistent pain, the most effective treatments we have are often non-pharmacological.

from many conversations I’ve had with soldiers in one of the world’s leading military hospitals, in Birmingham, even the most devastating injuries can feel painless in the heat of battle.

Adrenaline can have the effect of intensely focusing the mind so that it is distracted from pain, but it doesn’t block pain and it can even increase it.

his unconscious brain – his Ministry of Defence – had assessed the visual and nociceptive inputs and made the decision that fighting for his life was more important for his immediate survival than feeling pain, so any danger signals travelling up to the brain from his leg were completely blocked.

In 1954, the British psychologists Hall and Stride found that for anxious subjects the simple inclusion of the word ‘pain’ in a set of instructions made an electric shock agonizing, when it previously had not felt painful at all.

diversion (i.e. distraction) is a potent pain reliever. Any parent can tell you this, but it can be readily used to help with all manner of pain.

when we are distracted from pain, our brain’s drug cabinet opens and doles out a hefty dose of opioids, blocking the stream of nociceptive signals travelling up the spinal cord.

Similarly, engaging in activity that distracts from pain – whether it be music, reading or meeting up with others for a chat and a cup of tea – needs to be encouraged and made more readily available for those living with persistent pain.

IBS is a complex, poorly understood condition, but I was reading that a lot of the evidence indicated that it was caused by a dysfunction of the gut–brain axis. Paper after paper I studied lent more weight to the argument that an irritable mind (in my case, from mental stress from academic studies and hospital shift work) can lead to an irritable bowel.

effective treatment for IBS – one that, despite six years at medical school, I had never come across: hypnotherapy.

Pain is like an ugly, threatening-looking spider, which I slowly learned to view as a harmless friend: instead of fleeing into another room or trying to thwack it with a newspaper, I could now gently pick it up and rehome it in the garden.

Hypnotherapy seemed to work for me, and it clearly works for others too: robust studies show it gives significant pain relief in 50–75 per cent of IBS sufferers.

The researchers found that – particularly in those who were easily susceptible to hypnotic suggestion – pain perception during hypnosis was reduced and pain thresholds were significantly increased.11 This also far exceeded the pain relief participants felt when they were later given a placebo that they had been told was a powerful pain-relieving drug.

for many people, in many types of pain, hypnotherapy works.

These studies tell us that hypnotherapy is not just a placebo, but can change patterns of thinking, training the brain out of pain. The use of hypnotherapy for IBS, even when all conventional medical treatments have failed, has been so successful that the UK’s National Institute for Health and Care Excellence (NICE) has given hypnotherapy its seal of approval

A randomized controlled trial published in October 2020 found that hypnotic cognitive therapy (hypnosis combined with cognitive behavioural therapy) was very effective at reducing persistent pain, and more effective than either hypnosis or cognitive behavioural therapy on their own.24 Hypnotherapy can also relieve pain indirectly by targeting conditions that worsen pain, such as anxiety, insomnia and post-traumatic stress disorder (PTSD).

while hypnotherapy is sadly undervalued, under-investigated and underused in mainstream medicine, I’ve become convinced that this mind–body therapy enables a great many people living with long-term pain to slowly disassemble the mental structures of persistent pain, and begin to live fully again.

Children given a twenty-minute HypnoVR session within seventy-two hours of surgery required half the amount of postoperative morphine compared with those who received standard care, and their hospital-bed time was reduced by twenty-one hours.

attention, distraction and imagination are critical pieces in the puzzle of pain. Their manipulation provides real hope for pain relief.

The placebo effect, like pain, is strange. It is a window into the true nature of pain. It shows that pain is the product of a context-based decision made by our brain – usually without our knowledge.

placebos can change our brain and genuinely alter symptoms and diseases modulated by the brain.

a 2014 review paper found that in fifty-three trials where surgical procedures have been compared to placebo alternatives, in half of the cases the fake surgery was just as effective as the real procedure.

They found that a placebo treatment increased the release of opioids across a range of pain-relevant brain areas. The mere expectation of pain relief – the belief that you will feel less pain – is enough for our brain to unlock its own drug cabinet and dispense a strong dose of wonderful opioids such as endorphins – essentially, non-addictive morphine.

these studies show that the placebo effect reduces pain not by tricking gullible people into imagining that they are feeling better; it genuinely releases a powerful cocktail of painkillers in the brain, and it affects the exact-same pathways exploited by active medications.

The active ingredient is expectation. This is neatly seen in the hierarchy of fakery; not all placebos are created equal. Saline injections tend to have a greater pain-relieving effect than sugar pills,15 and it wouldn’t be surprising if fake surgery is significantly better than both of these. An expensive placebo is more effective than a cheap one.

seeing someone give you pain relief is analgesia itself. If a pain-relieving drug is given to someone through an intravenous drip, it is 50 per cent more effective when the doctor explains what’s happening, compared with it being administered by a computer and without the participant’s knowledge.

we are highly suggestible at the best of times, but when our body feels threatened or harmed, negative words can have an enormous effect. Verbally induced anxiety releases neurotransmitters that can open the floodgates for pain,25 and imaging shows that they stimulate pain networks in the brain.

We can strongly manipulate the experience of pain – for better or worse – through beliefs and expectations. Our brain is immensely powerful; let’s use it.

Creating daily rituals of healthy living – from exercising to socializing to meditating – also harnesses the placebo effect in a positive way.

Positive information, constructive words, long and meaningful interactions really do work.

‘Placebo pills made of an inert substance, like sugar pills, have been shown in clinical studies to produce significant improvement in IBS symptoms through mind–body self-healing processes.’ Staggeringly, the patients in this ‘open-label placebo’ (also known as ‘honest placebo’) group showed much greater improvement than those in the no-treatment group. Placebos still work even if patients know that they are not real.

if a well-informed physiotherapist, osteopath or doctor explained this to them, and slowly helped them to bend and lift, they’d likely feel pain but not as much as they expected and feared. A large prediction error would have been created that gradually changes their internal model of the world: they start to associate movement with safety and reduced pain, and begin a journey of recovery.

Anyone privileged to be in a position of providing care to someone in pain must strive to secure trust, stop unnecessary anxiety-producing language, strengthen positive associations and create a context of realistic but strong positivity.

Harnessing the expectation effect is not about giving out sugar pills or encouraging treatments that work only via placebo, but about fostering informed confidence and reducing anxiety. Most importantly, it makes medicine human, pointing both the person in pain and the treatment-giver in the direction of hope and healing.

Pain is both sensory and emotional. These elements overlap and intertwine in terms of both the brain’s physical real estate and our own lived experience. They are often so blended as to seem indistinguishable.

The ACC is activated not just when we feel physical pain, but also when we feel the hurt of rejection.5 Remarkably, the painkiller paracetamol reduces the hurt of emotional pain and social rejection, with imaging studies showing that it dampens down activity in this region.

Studies have shown that over-the-counter ‘physical’ pain medications also reduce emotional responses to evocative images and reduce discomfort when people part with possessions.7

all the pain we all experience, whether short- or long-term, is moulded by our moods, emotions and thoughts.

well-designed study shows that anxiety worsens pain, and the fear–pain relationship can become a self-fulfilling prophecy.

Anxiety and fear worsen pain because they increase the sense of damage, danger or threat, which makes the brain want to protect the body even more.

manipulating someone’s emotional state in a negative way turns up an ‘anxiety volume button’ in the brain. This makes sense in light of what the experience of pain boils down to: it is essentially all about protecting yourself from danger or threat. If we are anxious, or fearful, our brain is going to want to amplify this alarm signal.

Negative emotions and feelings of threat do not just worsen short-term pain; they can facilitate the transition from short-term to long-term pain and they can help wire the brain to expect pain and suffering.

In fact, it may not be long before your brain associates any kind of movement with pain. Your avoidance starts to occur in anticipation of pain, instead of in response to it. Feelings of anxiety, threat and low mood worsen the pain, which in turn worsens those moods. These negative moods insidiously rob you of other natural painkillers: good sleep, socializing and a healthy diet. They also distort your body’s hormonal and immune systems, amplifying chronic stress and worsening pain. Down and down the vicious spiral you fall.

As pain becomes long-term, it engages more of the brain associated with emotions and fear (the amygdala, prefrontal cortex and basal ganglia). It appears that this signature can become deeply ingrained in the brain, as they found similar results in those who have lived with persistent back pain for at least ten years. This transition from acute to chronic pain is, perhaps unsurprisingly, more likely if someone has an underlying mood disorder.

Fortunately, we can break this cycle. Our brain remains wonderfully adaptable – or ‘neuroplastic’ – throughout our lives. Through reframing and retraining, the fear–pain cycle can be broken and pain can be significantly diminished, even completely relieved.

One was cognitive behavioural therapy (CBT) for pain. This both educates people about pain and gives them techniques to recognize and change negative thoughts that influence the pain experience. The other was mindfulness-based stress reduction (MBSR). This involved training in mindfulness meditation and yoga, encouraging people to give attention to thoughts, emotions and sensations without trying to change them.

Another psychotherapy garnering a lot of attention is acceptance and commitment therapy (ACT).

ACT enables many to live with their pain, and it can even reduce or sometimes eliminate it.

Persistent pain is often worsened – and sometimes caused – by past traumatic experiences, and addressing these can sometimes powerfully relieve people’s pain.

effective ones have some things in common: they empower the individual by educating them about pain, they reduce the sense of danger and threat, and they facilitate the healthy processing of emotions.

Cultivating a positive outlook and knowing that things will get better, even if it requires hard work and patience, can reduce the suffering and disability caused by pain, and even relieve it altogether. Another key takeaway is that anything that improves mood when mood is low – whether it’s socializing, engaging in purposeful activities, or antidepressants – is also likely to improve the experience of pain.

educating the individual so that they can reframe their outlook from one of fear and hopelessness to one of confidence and hope. Healing from long-term pain is about moving from an outlook of threat and danger to one of protection and safety; the transition from seeing pain as an informant of tissue damage to seeing pain as a guardian angel that wants to protect us but is often overprotective.

It has long been evident that pleasurable experiences such as food, sex or music markedly reduce pain.15,16 While an element of distraction plays a part, it is ultimately down to pleasurable stimuli producing feelings of safety in the brain.

Conversely, the experience of pain reduces pleasure and pleasure-seeking behaviours.

Alongside not seeking or experiencing pleasure, chronic pain interferes with circuits involving goal pursuit and taking action, resulting in impaired decision-making and coping strategies in dealing with chronic pain, leading to a vicious downward spiral.

The reduced dopamine-signalling in persistent pain results in reduced motivation and feelings of depression.

In terms of self-criticism, it appears the lower someone’s self-esteem and the more they believe they are ‘deserving of punishment’, the longer they are willing to endure pain.

A painful stimulus can feel unbearable if coupled with threat, uncertainty or fear, but can be immensely pleasurable if in the context of safety, sexual excitement or the anticipation of a reward.

factors often sneered at or ignored in the medical world – emotions, thoughts, social influences – are central to conditions such as chronic pain, addiction and self-harm, and should be central to their treatment.

Caring and looking after others we see in pain is certainly a reason for the contagious nature of pain, but a large part of it may well be directly due to self-interest.

the evidence shows that this is the same for all of us: it is easier to empathize with those who behave and appear more like us. When the person in pain resembles us,

But – and this is a big but – feeling someone’s pain does not necessarily lead to doing something about someone else’s pain. Empathy does not equal compassion. In fact, it may often have the opposite effect.

carry out experiments showing that people with lower thresholds to physical pain reported greater distress at social rejection,

Physical and social pain are intertwined at deep neurological levels, and while on the surface this seems a bit bizarre, it makes sense when we go back to the essence of pain. Pain is a protector; it’s an unpleasant feeling that drives us to avoid danger and reach a state of safety.

What if I told you that there was a disease that can’t be found in medical textbooks, yet is worse for one’s physical health than smoking, causes depression and suicide, is contagious and affects a large and growing proportion of society? This condition is called loneliness.

Pain causes isolation, and isolation causes pain.

We see this so often in humans: pain discourages mobility, increases fear (of both pain and social stigma), lowers mood and worsens fatigue, all of which keep the sufferer immobile and hidden from the outside world, and they gradually become more and more isolated. As each thread in the individual’s social web is cut, their world continues to collapse in on itself. Social isolation is awful for mental and physical health;

Social isolation in and of itself also worsens persistent pain.7 It’s a terrible, vicious cycle. Humans are social, but we also need agency, individuality and a sense of control over our bodies and our lives. Persistent pain also robs individuals of this control, making sufferers particularly dependent on a support network.

To see how choir-singing impacts people in pain, researchers at the University of Lancaster carried out in-depth interviews with people who had joined a community ‘pain choir’.10 Many of the interviewees described a significant reduction in pain during and after singing: ‘It’s better than all the tablets in the world,’ said one member.