by Jackson Rainer, PhD
Pain has a profound impact on human life. Everyone has experienced pain at some point, and we all fear the possibility of suffering with uncontrolled pain. It is the symptom most likely to bring a person to seek medical care and the number one complaint that physicians listen for. And although we may think of pain as a purely physical symptom, it has a significant mental and emotional component. It can arouse very strong feelings in us, and in turn our feelings and thoughts can make pain worse. The key to living well with pain is to understand what contributes to our perception and experience of it — and to use this knowledge to loosen pain’s hold on us.
Different people experience pain in different ways and with differing intensities, and your pain is as unique to you as your thumbprint. While friends might empathetically say, “I feel your pain,” they cannot enter into your subjective world and experience the unpleasant sensations and emotions associated with it. Because pain is particular to each individual and felt only by the person in pain, professionals who study and treat pain use several terms to understand individual pain. Pain threshold refers to the point at which you first perceive stimulation as painful. It appears to be determined primarily by physiological factors. Pain tolerance is the highest level of painful stimulation that you can withstand. This limit is often influenced by psychological factors. A middle-aged man’s description of his experience living with rheumatoid arthritis (RA) illustrates the distinction between pain threshold and tolerance: “As my arthritis has advanced, my pain threshold has gotten lower. As a kid, I could be beaten to a pulp and never worried about it; I just didn’t feel it. Now, there are days when the wind blowing on my back makes me hurt. I’ve always had a good pain tolerance, though. I guess I keep telling myself ‘It’s not that bad.’”
A verbal self-report like this one is one of three ways to measure pain. In addition to asking the person with pain for a written or spoken description of the character and intensity of the pain, a doctor or other health-care professional can also assess pain using physiological measures such as blood pressure and heart rate. When the first two measures are combined with a third — observations of behaviors that indicate pain, such as grimacing, moaning, or complaining — a full sense of a person’s pain can be discerned, organized, and understood by others.
Such detailed analysis is essential for a medical diagnosis of pain, which requires knowledge of the duration and location of the pain, its nature and characteristics, any other symptoms, and activities or other factors that may have led to the pain. For example, the man with RA mentioned above provided important information when he said, “I always hurt worse when I wake up in the morning. Getting out of bed makes me moan and groan, crack and creak. I’ve learned to take my medicine first thing and get in a tub of hot water for about 30 minutes while the drugs take effect. This helps me loosen up and face the day. I know the pain is going to stay with me, but this makes things more manageable.” This description tells us that the man is experiencing chronic pain. Chronic pain lasts more than six months and can be intermittent or constant, mild, or severe. Acute pain is temporary and lasts less than six months. Knowing whether a person is experiencing acute or chronic pain can help a health-care professional identify the cause of pain and recommend the appropriate treatment.
Your experience of pain is partly determined by how you perceive and react to it. Your perception of pain depends on many factors, including your age, sex, social and cultural background, and personality type. Research on pain generally indicates that people’s pain threshold increases with age, but this is not as well understood as once thought. As a group, women have slightly lower pain thresholds than men of the same age and stage of life, but the difference seems to be due to situational factors rather than physiological differences between men and women. Across different cultures, there is remarkable diversity in the way people experience and demonstrate pain. Reactions to pain seem to be related to whether people learn to deny pain, deal with it in a more stoic fashion, or allow themselves to express their distress.
Your tolerance for pain may depend on your personal attitudes and the level of anxiety you feel in response to pain. Some people are pain reducers. They tend to see pain as more of a universal experience, rather than something that happens just to them. They often have a strong body image, are extroverted, and know how to quiet negative thoughts. A reducer might say, “This really hurts, but it isn’t all that bad.” Reducers know how to talk themselves down from anxiety about and hypervigilance of their pain.
Other people are pain augmenters. Typically more introverted, augmenters often have experienced more pain in their lives. They may view anxiety as going hand-in-hand with pain and are more prone to being very sensitive to and concerned about their physical symptoms. Augmenters see pain as the sounding of an alarm that requires attention, in contrast to the emotional distance that reducers employ when attending to pain. One woman, who is more of a pain augmenter, said, “I just fall headfirst into it. Once I start hurting, I know things are going to get worse. I try and soothe myself, but nothing I do gives me any relief.”
One pain specialist gives an interesting comparison between augmenters and reducers. She said, “I had two patients, similar in age and diagnosis. One dealt with her pain in a matter-of-fact way. She would tell me that she just had to ‘put the pain on the shelf’ and separate her body from her mind. The patient would say, ‘It’s just not permissible to cry about it all the time.’ The second patient asked me to eliminate all of her pain, ‘to take it away,’ and she became alarmed at the slightest twinge. She constantly said, ‘I know it is going to get worse, and I can’t stand it.’ She rejected all help that involved suggestions of ways that she might soothe or calm herself, other than by taking high doses of medicine.”
Successful pain control eliminates or reduces pain and increases overall physical, emotional, and social functioning. To achieve the latter goal, you may need to learn to tolerate some pain — to live with it and still have a satisfying and productive life.
In American culture, the medical model relies almost exclusively on surgery and medicines to treat pain. Surgical treatments may involve removing or disconnecting portions of the peripheral nervous system from the spinal cord in an attempt to block the transmission of pain impulses to the brain. Surgical methods address the physiological, and not the psychological, component of pain. Therefore, surgery is considered a fairly drastic measure.
Another way to address the physiological aspect of pain, and the treatment most commonly prescribed by doctors, is the use of pain-relieving medicines, or analgesics. Opioids, which are commonly referred to as narcotics, are one type of analgesic. They help to dull pain by blocking the transmission of pain signals to the brain. Opioids are not often prescribed for chronic pain because of concerns about abuse or addiction. They are typically more appropriate for the treatment of severe acute pain or the pain of terminal illness. For people with arthritis, nonsteroidal anti-inflammatory drugs (NSAIDs) are the most frequent choice of analgesic for chronic pain management. NSAIDs relieve pain by blocking certain enzymes that contribute to pain and inflammation. In general, the use of nonnarcotic medicines can be effective for relatively severe pain if the psychological component of pain is also addressed.
To deal with the mental and emotional side of pain, we need to recognize how our thoughts and feelings contribute to pain and suffering. Faulty logic and other types of unproductive thoughts, and the emotional distress that can result from them, often distort the reality of the pain a person experiences. Often referred to by mental-health professionals as cognitive errors, these thoughts can have serious, negative psychological consequences and interfere with your ability to deal effectively with pain. Fortunately, changing these damaging thoughts can make it easier to cope with pain and can even diminish its intensity and the amount of distress it causes. One woman described her way of thinking about pain: “I can’t change the pain, but I can change how I think about it and live with it. I see arthritis pain as a very unpleasant visitor in my home, one that has moved in without my permission and overstayed his welcome. I do everything I can to keep this obnoxious visitor in the back room, far away from my day-to-day living space.”
Cognitive errors, alone or in combination, may contribute to depression, heightened anxiety, and distress. Common cognitive errors include the following:
Getting caught up in negative thought patterns can heighten the severity and intensity of pain. Learning how to interrupt and change those patterns, as well as how to redefine and reframe thoughts to include hope and self-soothing, can do a great deal to minimize the intrusion of pain on daily living. Psychotherapy (also known as “talk therapy”) with a licensed psychologist or other mental-health practitioner is the most effective setting in which to learn to correct cognitive errors and transform negative thought patterns into more useful pain-management strategies.
Research has shown that how we think about pain can actually change our bodily experience. Treatments that address this mind–body connection can help us learn to redefine pain, distract ourselves from it, and change the mental images we associate with it. Three approaches in particular have shown success in helping people with arthritis live reasonably well with pain.
The first approach is relaxation. One relaxation technique that is especially helpful for chronic pain is progressive muscle relaxation, in which you tense and then relax each muscle group in the body, one at a time. The goal of this practice is to help you reach a state of emotional and physical calm. Other relaxation techniques can be useful as well. Meditation combines a focus on the sensations you are currently experiencing with a detached observation of those sensations. Research has shown that meditation can reduce the impact of pain and decrease negative feelings and symptoms related to pain. One particular form of this type of meditation, called mindfulness meditation, is effective for many different types of pain and seems to be useful not only for reducing negative effects but also for fostering positive effects, such as better functioning in everyday activities and greater self-esteem. In addition, many people with arthritis find that meditative types of exercise such as yoga and tai chi help them reach a more relaxed state while providing gentle physical activity.
A second helpful therapy is hypnosis. Long considered a parlor trick, hypnosis is actually an altered state of consciousness achieved through relaxation, a narrowing focus of attention, and suggestion. Used properly, hypnosis can help you learn to attach a new meaning, other than a threatening one, to your pain. Researchers are unsure how hypnosis works, but regardless of its mechanism, hypnosis has been found to help people control both the emotional and physical components of pain, depending on the type of instructions the hypnotized person receives from the hypnotherapist.
The third “mind over matter” approach for chronic pain is behavior modification. Working with a method called applied behavioral analysis, a therapist trained in behavior modification helps you determine how your behavior and other people’s responses to it reinforce your pain. The therapist then teaches you and your loved ones to reward “well behaviors” such as being active and ignore (and thereby discourage) “sick behaviors” such as grimacing. The idea behind behavior modification is that other people often reward pain behaviors with attention, sympathy, and relief from social and work obligations, whereas well behaviors are ignored. As a result, people with chronic pain may learn to express pain as a way of seeking attention or help, and the constant expression of pain behavior can cause them to feel worse. Behavior modification can help to break such a pattern.
If you are interested in trying any of the above techniques, your best bet is to discuss it with a mental-health professional trained in pain management. See Finding Professional Help to learn how to find a pain professional in your area.
For even more information, also on the “mind over matter” approach, see How to Thrive With Mind–Body Techniques.
Other nondrug therapies can also play a useful role in pain management. Counterirritation, or the application of another type of stimulation near the site of pain, can relieve pain by diverting your attention away from it. The signals from the counterirritant reach the brain before the pain signals do, lessening the brain’s response to the pain signals. For example, people who self-inject a biologic drug for RA are taught to vigorously rub ice on the injection site immediately after administration. One woman reported, “I thought the nurse was kidding, but it really does help. I think it just overrides the pain caused by the needle and the medicine. Whatever! I ‘ice down’ my stomach after every shot.”
Topical creams and gels such as ArthriCare, Icy Hot, and Mineral Ice are another type of counterirritant commonly used for arthritis pain. These products relieve pain by creating a sensation of warmth or coolness over the sore area of the joint. Different products have different active ingredients and may contain camphor, eucalyptus oil, menthol, or oil of wintergreen.
Acupuncture is an ancient therapy that helps some people control pain. In the Chinese tradition, it is based on the belief in a vital energy force in the body called qi (pronounced “chee”), and the practice is focused on balancing and restoring energy flow. In Western practice, fine metal needles are inserted under the skin and may be twirled or electrically charged to stimulate nerves believed to be associated with distally located parts of the body. There is relatively little empirical research on acupuncture for chronic pain, but results from the studies that have been done are promising.
More traditional physical therapy, in which a physical therapist guides you through exercises that help you maintain joint flexibility and physical function, can also be a big help, and it continues to be one of the frontline treatments for chronic arthritis pain.
Which approach to pain control works best? All of them: A combination of medical, physical, and cognitive-behavioral therapies seems to be the most beneficial for people with chronic pain. Thinking about pain differently, changing typical pain behaviors, and increasing physical movement may help diminish an individual’s feelings of “pain helplessness” and increase physical endurance.
The woman who defined pain as an unwelcome visitor talked further about her pain. She said, “I sometimes feel like David, and Goliath is my pain. However, I don’t try to go it alone against my Goliath. Because I know that I have to live with pain the rest of my life, I want every method, technique, and intervention that I can find to help me manage — not fight — the pain. This is not a battle that I can win, but it is one that I can work with if I combine the resources of my body, mind, and spirit. If I make room for the pain, then I’m better able to keep it at bay, and I can live reasonably well, most of the time.”
Last Reviewed May 2, 2012
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