Maybe it is all in your head

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When I can’t find an explanation for a patient’s pain, he or she will sometimes ask me, “Doc, is it all in my head?” Some types of chronic pain may indeed be all in the patient’s head, although not in the way we have thought about it in the past.

Origin of pain: Brain vs body. Recent research provides strong evidence that in some cases of intractable chronic pain, the origin of the pain signal is in the brain—rather than the body. In this issue of JFP, Davis and Vanderah discuss this type of pain as “a third kind” that needs to be treated in a manner that completely differs from that for peripherally generated pain. They refer to the traditional kinds of pain as either nociceptive (resulting from tissue damage or insult), or neuropathic (due to dysfunctional stimulation of peripheral nerves). The neurophysiology of the third kind of pain, which I will call “centrally generated pain,” is not fully understood, but neuroimaging and other sophisticated methods are identifying areas of the brain that become activated by psychological trauma, leading to significant painful suffering in the absence of tissue damage, or that is far out of proportion to physical insult.

The bad news for primary care physicians is that this third kind of pain is difficult, if not impossible, to treat with our traditional armamentarium of pain medications and physical modalities. In fact, these patients are often at risk for addiction, as doses of ineffective narcotics are escalated.

Recent research provides strong evidence that in some cases of intractable chronic pain, the origin of the pain signal is in the brain—rather than the body.

The good news is that clinical researchers have begun to identify ways to effectively treat centrally generated pain. For example, Schubiner et al used a novel psychological approach that involved helping patients "learn that their pain is influenced primarily by central nervous system psychological processes, and to enhance awareness and expression of emotions related to psychological trauma or conflict." 1 Thirty percent of the 72 participants in the preliminary, uncontrolled trial experienced a 70% reduction in pain. Dr. Schubiner’s research is ongoing and supported by funding from the National Institutes of Health.

Proper diagnosis is paramount. Of course, proper diagnosis is paramount because an individual may suffer from more than one of the 3 kinds of pain and require different approaches for each. Thorough evaluation at a multidisciplinary pain clinic is a good place to start. Once the diagnoses are sorted out, it will then be possible to treat each component of pain appropriately.

Dr. Schubiner’s methods and other new and developing treatment approaches to chronic pain will help us better relieve patients’ suffering, reduce narcotic overuse, and relieve our own anxiety about caring for these challenging patients.

1. Burger AJ, Lumley MA, Carty JN, et al. The effects of a novel psychological attribution and emotional awareness and expression therapy for chronic musculoskeletal pain: a preliminary, uncontrolled trial. J Psychosom Res. 2016;81:1-8.

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