The Pain + Stress Connection

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Pain feeds on stress. Stress feeds on pain. Break the vicious cycle by taming tension once and for all.

Let’s be clear up front: Almost no one denies there’s a link between pain and stress. “Pain activates stress; stress activates the pain, so it’s a vicious cycle,” says Rollin Gallagher, M.D., director for pain policy research and primary care at the Penn Pain Medicine Center at the University of Pennsylvania School of Medicine, in Philadelphia. “The key is that you have to take care of those things together—take care of the pain and take care of the stress—because they feed on each other.”

THE PHYSICAL LINK
So, what exactly is going on inside your body when you’re feeling the strain of a marital disagreement or worrying about being the next one at work to get a pink slip? “It is pretty clear that increases in stress in turn activate the pain signal,” Gallagher explains. “When you have a chronic pain condition and you’re under stress, the sympathetic nervous system sends messages down to the areas that are damaged and activates them, so you’re turning up the signal.”

The link seems to be partly related to chemicals in the body that transmit pain signals—chemicals that are very similar to those that affect our mood, says Gilbert J. Fanciullo, M.D., director of the Pain management Center at Dartmouth¬-Hitchcock Medical Center, in Lebanon, New Hampshire. “Pain and mood are connected intimately. For example, people in pain often develop depression; and an often-prominent feature of depression is pain. There’s no doubt that increased levels of stress will worsen pain and can probably even prolong the duration of pain from injuries.”

Research has begun bearing out the close relationship between pain and stress. Fanciullo cites a study that followed couples where one of the partners was recovering from a wound. For those couples who argued the most, the wound took two days longer to heal. Another trial looked at students who had dental work done just before a major exam and again during summer vacation. During test time the students took significantly more time to heal—an average of three days, or 40 percent, longer.

WORK WORRIES
When the American Psychological Association (APA) released their annual “Stress in America” survey in October 2008, it wasn’t a surprise that anxiety about money and the economy topped the list, or that almost half of all Americans surveyed said they felt increasingly stressed about their ability to provide for themselves and their families. The APA also noted that the uptick in tension is having a physical effect, with more of us reporting stress-related physical and emotional symptoms like headaches, muscular tension, depression, and sadness.

Even those who’ve held on to their job may find there’s now more to do and fewer employees to get work done, creating additional demands for those trying to keep pain under control. “You may not have the flexibility to work around your injuries or condition as much as you normally would,” says Gallagher, who formerly sat on the board of the American Pain Foundation. “You might have to take on more than you normally would because you’ve lost people at work, or you might have to take on an extra job.”

So, in addition to the emotional toll, there’s a purely physical component to this kind of stress: More hours at the computer, fewer breaks to stretch tired and overworked muscles, and longer workdays may aggravate existing pain, and at the same time interfere with your typical ways of winding down, such as trips to the gym, quiet time at a meditation center, or walks in the park. And when tension-relieving activities are neglected, stress and its partner, pain, are bound to become more intense.

Margot Stone*, an artist who owns a small business in New York City, was diagnosed with fibromyalgia six years ago. She says she now sees a clear difference in her pain when she’s under stress, but that it was something she didn’t realize right away. “I put it together after looking in hindsight at how I was affected by what was going on in my life and how my health deteriorated under an intense period of stress.” Yoga and aerobics help counterbalance her symptoms, but Stone confesses that it’s been harder to stay active lately. “I’ve got to get to work, so what goes? The exercise. And then the fatigue takes over. I go back to all my old habits that are not productive.”

THE LAW OF DISTRACTION
It can seem grim, but there is some good news, largely because stress is something we can do a lot to control. Start with simple methods of distracting yourself—from both stress and pain. “When we are distracted we focus less intensely on our pain and can actually diminish the pain,” Fanciullo explains. “Distraction is very important.”

Fibromyalgia patient Penney Cowan, executive director of the American Chronic Pain Association, in Rocklin, California, agrees. To demonstrate the point, she’ll ask people dealing with pain to silently count from one to 25 while saying the alphabet aloud. No one can do it. “That’s because we have a one-track mind,” she says. “So if you’re thinking about how you’re sitting on this warm, sunny beach and hearing the waves splashing against the shore, you’re not thinking about how that pain hurts. For that instant, you’ve reduced that sense of suffering. And you’re releasing tension, so perhaps some healing is occurring.”

The name for the practice of picturing yourself on that beautiful seashore is imagery. Belleruth Naparstek, a psychotherapist and author of Invisible Heroes: Survivors of Trauma and How They Heal (Health Journeys, 2004), is an authority on guided imagery and uses it with those suffering from, among other ailments, post-traumatic stress disorder (PTSD). “[People with PTSD] have tons of physical pain either from injuries or related to stress,” says Naparstek. “These folks will say, ‘My headache is gone. I had it for five years and it’s gone,’ or ‘My back feels better.’ It becomes very clear. Even if they aren’t interested in doing guided imagery in the beginning, they’ll do it for the reduction in pain—and then they start to love it. So they keep doing it and they end up healing.”

TAKING CARE
Another way to break the stress-pain cycle: Figure out the best ways to truly take care of yourself. Ask yourself: What really helps you feel calmer, stronger, healthier, and pain-free more often? Lenore Fishman,* a 45-year old writer in Santa Barbara, California, learned to do that after she broke her neck in a car accident in 1984 and then underwent surgery to fuse the top two vertebrae in her spine. With limited range of motion, Fishman had to learn to move in ways that put less strain on her neck and eventually found a way to control her pain through a drug-free combination of exercise and massage therapy. “Opening up my neck and shoulders keeps everything moving and flowing,” she says. “It affects and preserves what range of motion I have.”

Like Margot Stone, Fishman has a tendency to stop taking care of herself when she’s feeling weighted down by anxiety. “I don’t sleep as well, and I think my body just doesn’t have a chance to do what it needs to do to regenerate.” Lately, money worries have made her question whether she really needs her once- or twice-a-week massages. “This week I was thinking, oh, maybe I shouldn’t go to my massage appointment. But I can only do that for so long before I start feeling the effects of it,” she says. “If I take care of myself when I’m stressed my body feels strong and capable. If I don’t, the pain I feel leaves me feeling suffocated and disabled.”

If pain lasts long enough and isn’t well-controlled, it can change the spinal cord and brain, says Rollin Gallagher. “Without appropriate treatment these changes may progress. Once your brain has been remodeled in such a way, stress and other strong emotions and normal sensations such as touch, pressure, and temperature change may cause pain by activating those areas without any stimulation to the physical areas where the pain initially began.”

THE ANTI-STRESS ARSENAL
To begin getting a handle on stress, both pain- and stress-management experts say it’s crucial to avoid what’s known as “catastrophizing”—or making dire predictions that pain and other problems will only worsen. “Yes, the pain is worse, but that doesn’t mean something horrible is going on,” says Fanciullo, who adds that the increased anxiety caused by catastrophizing can lead to a “spiral of negative effects,” including more pain, depression, and disability.

Even if you’ve never considered yourself the meditation type, now may be the time to look into it. Sharon Salzberg, co-founder of the Insight Meditation Society, in Barre, Massachusets, and author of The Kindness Handbook: A practical Companion (Sounds True, 2008), asks her students to focus on what they’re adding to their experience of pain—worry, fear, anticipation, tense muscles-and to learn how to release it through mindfulness. “As soon as even a minor level of discomfort beings, we might think, “What’s it going to feel like in 20 minutes, in 40 minutes, tomorrow?” she explains. “We’ve added to it all of that anticipated pain, and we’re trying to bear it all at once, so of course we feel defeated and overcome.” Even worse, we often blame ourselves, Salzberg notes. “We may be adding on a quality of self-judgment or humiliation: “I should have been able to control this,” something that adds a great deal of mental anguish to an already painful experience.” Carefully observing our own experience of pain as we’re having it allows us to see that even a very steady pain has variations in intensity and character, whether it be stabbing or twisting, dull or sharp. “If we look at the pain and see it that way instead of as inert, it still hurts but…we can experience the changes within it,” Salzberg says.

By taking a close look at your pain and also your stress you can begin to get some answers that will help ease both. And no one can do either for you: Stress, like pain, is ultimately very personal-an activity that one person finds relaxing might be anxiety-provoking for someone else. And while you can’t cut out stress entirely, you can, says Gallagher, “become a watchful observer of your own behavior. Identify things that cause you stress and avoid them or recognize them and find ways of managing them more effectively. How? Insight. Look at your relationships and make sure you cope better, the relationships that are supportive and not destructive in any way.”

*Names have been changed.

Written by: Lisa Schoenfein, writer in New York City
Originally published in Pain Solutions Magazine, Fall 2009

Stock Photo Credit: by Pemotret courtesy of Stock Free Images

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