Pain Service - Chronic Pain and Stress

Introduction

Chronic pain is a long-term health condition and has long-term effects on a variety of different areas of life. Sometimes you may hear people talk about “persistent pain” – this is the same as chronic pain. Our leaflet “Explaining Pain” gives more information about how chronic pain develops, but in brief we know that:

• Any damage to tissue or bones has usually healed after 3 – 6 months
• In addition to physical changes and changes in activity, a major factor in chronic pain is changes to the nervous system – the nerves sending a pain signal to the brain are constantly “switched on” and we cannot switch them off

Chronic pain can have various effects on people, including on their physical activities, mood and quality of life. One of its effects is stress. This leaflet will explain more about chronic pain and stress and provides the basis for further psychology sessions to build coping skills and strategies. This will help you to improve your functioning and quality of life over time.

How does stress work?

Most people will experience stress at some point in their life. Stress is the feeling of being under too much mental or emotional pressure. We all have an inbuilt response to stress, called our “fight or flight” response (also sometimes known as “fight, flight or freeze”).

Fight or Flight Response

The fight or flight response is an inbuilt system – everyone has this response to stress. It was a vital protective system during our evolution when man started walking upright as it was a system designed to enable us to run away from danger. Blood from your skin, organs, and extremities is directed to the brain and larger muscles in preparation to fight the impending danger or flee from it. In addition, your senses (especially vision and hearing) are heightened, glucose and fatty acids are released into the blood stream for energy, and your immune and digestive systems all but shut down to provide you with the necessary energy to fight the threat (stressor). Once the stressor is over, the body starts to calm down and returns to normal.

What is the physical impact of stress on the body?

Most people can think of a time that they have experienced the immediate physical impact of stress on their body – when the “fight or flight” system has been activated. People often report symptoms such as:

A sudden increase in heart rate – this is due to the heart getting ready to pump blood and oxygen more rapidly around the body, so that you can move fast to get away from the dangerous situation.

Flushed skin – as the stress response starts to take hold, blood flow to the muscles, brain, legs, and arms is increased. You might notice that you become more flushed or red as a result.

Dry mouth – as the body starts to prioritise which activities are important for it to maintain, it slows digestion down (as it is more important to use energy to fight or flee than to digest food). This means that production of saliva slows down, so you may notice your mouth becoming dry.

Breathing becoming shallower and faster – again, this is to allow the body to get more oxygen to fuel the muscles. If the body is not very physically active the reduction in carbon dioxide (CO2) caused by overbreathing may lead to pain in the chest, dizziness or a tingling sensation in your arms or legs.

Muscle tension – the large muscles in the body tense up, ready for action. This can lead to feeling more achy as your muscles can be tense for the duration of the stressful situation.

Sweating excessively or blushing – blood is diverted to the surface of the skin to help with cooling, which can lead to blushing or the skin becoming flushed.

Nausea – the digestive system shuts down temporarily to divert all available energy to the lungs, arms and legs, which can cause feelings of nausea or “butterflies” in the stomach.

How can stress be helpful to us?

The immediate physical response to stress can be a helpful response, for example, when in an acutely stressful situation it can increase your concentration and improve performance.  However, when stress is prolonged, it begins to have the opposite effect. Long term stress is generally unhelpful and can lead to difficulties.

Pain & Stress

Acute pain is the body’s danger signal. Acute pain is often related to injury and indicates to us that there is something threatening or dangerous happening. In this situation, the “fight or flight” response triggered by acute pain is adaptive and helpful to us, as it signals to us that we need to get away from the danger – whatever has caused the acute pain response. The acute response to injury is, therefore, pain plus the stress response described previously.

Chronic Pain

In chronic pain, we know that any damage will usually have healed within six months, but pain is maintained by other mechanisms (such as nerve sensitisation). Therefore, chronic pain activates the stress response even when there is no danger or ongoing harm.  People with chronic pain are therefore more likely to experience the stress response because of their pain, as the “fight or flight” response is an inbuilt biological response.  This means that people with chronic pain also experience the long-term impact of stress on the body.

The Long Term Impact of Stress

Long term stress can impact on us physically, mentally and in how we behave. Some of the symptoms of this are listed below.

Physical consequences

• Increased heart rate
• High blood pressure
• Hyperventilation
• Dizziness, tingling, numbness, sweats
• Muscle contraction – aches, pains, headaches, shakes
• Migraine
• Stomach ulcers, nausea
• Frequent urination
• Diarrhoea
• Low sex drive

Mental consequences

• Concentration problems
• Indecisiveness
• Memory problems
• Increased self-critical thoughts
• Negative thinking patterns (depressive thinking)
• Catastrophic thinking/worrying (anxious thinking patterns)

Behavioural consequences

• Avoidance of anxiety provoking situations
• Social withdrawal
• Excessive drinking/smoking
• Insomnia/waking early
• Increased irritation/aggression
• Accident proneness
• Increase in obsessional tendencies
• Loss of sexual interest
• Change in food intake

This means that in addition to pain, the long-term effects of stress become more disabling over time and become more difficult to manage in and of themselves.

For example:

• Avoidance of anxiety provoking situations in the long-term stops us from doing the activities that we might want to do, because we feel anxious about doing them. This then impacts on our activity levels and can lead to increases in pain due to physical deconditioning
• Increased irritability/argumentativeness can have a significant impact on our interactions with other people. Our friends and family might start to avoid us as we can be irritable, which can make us feel isolated over time. We may also isolate ourselves to avoid our irritability impacting on those around us
•  Insomnia/waking early – changes to our sleep cycle due to chronic stress can make it more difficult for us to function during the day, and we might find ourselves doing things like relying on stimulants such as caffeine, or napping throughout the day to “catch up” on sleep, which can make our sleep cycle more difficult to manage in the long-term

The difficulties listed previously, added to possible stressful life problems such as relationship breakdown, financial worries, and work difficulties serves to increase the overall negative experience of living with pain. This increased pain distress can therefore worsen existing problems, reduce someone’s ability to cope with problems that they might otherwise be able to manage; it can also create new problems in itself. This is a vicious circle, because as pain increases, more problems arise, and as more problems present themselves, pain seems more unmanageable. We therefore need to learn how to manage the effects of stress on the body as well as pain.

The good news is that there are a number of ways that we can modify our experience of chronic pain, and we can also modify our experience of stress:

• Breathing and relaxation techniques can help to manage the stress response, which can help to minimise the short-term experience of pain
• Developing problem-solving skills can help to reduce the life problems linked to pain and stress
• Physiotherapy exercises such as stretching can help to decrease muscle tension and strengthening exercises enable you to engage in activities that you enjoy more easily

If we can modify our response to chronic pain, and how we respond to the long-term and short-term effects of stress, we then often feel more able to tackle the broader impact that pain can have on our lives, such as how to manage relationships and social situations, work, hobbies, and the impact of mood difficulties such as anxiety and depression.

These will be areas we can explore further in psychology sessions to identify where changes can be made.