Mind Body Approaches to Chronic Pain Management

Dr. Usha Nandini M., MBBS., MD., DNB., (Psychiatry).,

Consultant Psychiatrist, Athma Mind Centre, Kumbakonam, Tamil Nadu.

Chief Doctor and Director, Krish Medical Centre, Thanjavur, Tamil Nadu.

Psychopharmacology textbook says:

“No experience rivals pain for its ability to capture our actions, and cause suffering.”

I ask, ‘Is that why Poets say, ‘’Love is Pain”?’ Because as far as people tell me, nothing captures our actions and cause as much suffering as Love does. Maybe Addictions too? Pardon me, I am a Psychiatrist and the people I meet complain more about the emotional pain and hence I tend to deal more with it. The other half of the patients who present with pain have physical pain but are referred to me to deal with the psychological aspect of it. These are the people for whom Mind-Body Approaches for pain is applicable.

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Why am I quoting the textbook definition again? Because any pain has an emotional component to it. And it is this component that we use in the Mind Body Approaches to Chronic Pain Management. The interventions targeted to change an individual’s emotional or overall mental status which includes but not limited to Cognitive Behavioural Therapy, Yoga, Meditation, listening to music, dancing, painting etc. will ultimately produce changes in the body and hence termed as ‘Mind-Body’ Intervention Approaches.

Patients with chronic pain experience a lot of fear, stress and even depressive symptoms. These also add fuel to the fire and aggravate the already existing pain symptoms. Examples of such chronic pain conditions are Chronic Fatigue Syndrome, Fibromyalgia, Depression, Burnout etc.

In such conditions, sometimes the brain is known to register pain even in the absence of impending or actual tissue damage. This results in Doctors dismissing their pain as a meager stress, attention seeking tendency or sometimes as even con. Even though pain has so many psychological factors associated with it, sadly, it is barely assessed in the routine assessments.

The various Mind-Body Approaches that can be used in Pain Management are:

1. Police your Prescription- In patients with Psychological Components increasing their pain, simply increasing the dosage of analgesics or giving a cocktail of analgesics with different modes of action will push the patient towards Drug Dependence or even Addiction (Iatrogenically Induced). Hence policing the prescription according to the patient is important.
2. Combine and Collaborate- Usually a combined approach works. Include medications, therapy and other psychosocial interventions. Collaborate with your colleagues, physiotherapists and other disciplines to find the best combination that works for that individual. It is never one shoe fits all.
3. Strategize- Stimulate the Opposite- Our body has two Autonomic Nervous Systems, one is for peace and the other is for war. The problem lies with the overenthusiastic war time system – the Sympathetic nervous system (doesn’t sympathize with the body though). It gets the flight or fight activated even when we are not in a battlefield and hence the problem. So, we can strategically deal with it by stimulating the opposite. If it can believe in war, we can stimulate the peacetime nervous system – the parasympathetic nervous system and simulate Peace. How? Using Relaxation techniques like Jacobson’s Progressive Muscle Relaxation, Meditation, even laughing it out works. It enhances the endorphins, reduces inflammation, relaxes muscles (literally), decentralizes pain and reduces emotional reactivity to pain by enhancing the mood.
4. Mindfully practice Mindfulness – Mindfulness based approaches targets the hypervigilance and emotional reactivity in pain production. It includes (i) distraction techniques- shifting their attention to a different stimulus than pain (eg: imagine the beach and focus on the sound of the waves); (ii) Interoceptive Exposure Techniques – shifting attention and focusing on the pain so much so that pain gets habituated; (iii) acceptance of symptoms instead of avoiding it.
5. Hypnotizing the pain Away- Brief hypnotherapeutic interventions have been helpful in dealing with functional abdominal pain especially in children and adolescents, irritable bowel syndrome even labor pain to an extent.
6. Guided Imagery- Using peaceful, soothing or some symbolically related therapeutic mental images, the attention from pain can be unhooked and the mental elaboration of pain reduced. It also enhances relaxation.
7. Yoga-ing the pain Away- Yoga is physical but considered a mind-body intervention because it emphasizes and improves acceptance, attention, meditation and relaxation. It acts as one of the mechanisms to stimulate the opposite ie., the parasympathetic nervous system.
8. Biofeedback – This is a method to strategically control your pain using your mental capacity. It increases the physical awareness and induces a relaxation response through the markers of stress response like controlling the BP by watching your BP and learning to reduce it. This works as an adjunctive in various conditions like headache, facial pain, phantom limb pain and musculoskeletal pain.
9. CBT- Cognitive Behavioural Therapy uses evidence based therapeutic methods to change distorted cognitions and replace automatic thoughts. This has certain evidence in addressing chronic pain conditions like fibromyalgia and back pain.
10. Involve GPs- Since General Practitioners are the people encountering Chronic Pain patients, it is wise to decentralize and teach them how to use and deliver Mind Bod Approaches to pain management. This would address the community level and reduce a huge healthcare burden and expenditure.

Now, for the pain caused by heartbreak, well, that can also be handled by some of these approaches but it is more intense and tends to break you more. Beware of it, avoid it if possible but if push comes to shove, come to me, lets talk it out and numb your pain away.

References:

1. Stahl SM. Stahl’s essential psychopharmacology: neuroscientific basis and practical applications. Cambridge university press; 2021 Sep 16.
2. Hassed C. Mind-body therapies: Use in chronic pain management. Australian family physician. 2013 Mar;42(3):112-7.
3. https://kids.frontiersin.org/articles/10.3389/frym.2021.682687