Pain and the Brain
What brain science tells us about why we feel pain and how we can change it.
A conversation with Mark P. Jensen, PhD
- What can a psychologist do?
- Psychological treatments for SCI pain
- Cognitive restructuring
- Environmental therapies
- Self-hypnosis training
- Biofeedback-assisted relaxation
- Transcranial direct current stimulation (rTMS)
- Living with chronic SCI pain
What is pain?
“Pain is the brain’s response to physical damage (as from an accident or disease),” says Mark Jensen, UW rehabilitation psychologist and professor in the Department of Rehabilitation Medicine, and an expert in chronic pain in persons with disabilities. “The damage sends signals up to the brain, causing five areas in the brain to become activated. The experience of pain is the interaction between these five areas. Pain is not the end-product of damage but the end-product of activity in the brain.”
In chronic SCI pain, damaged nerves in the spinal cord send abnormal signals to the brain. The brain interprets these signals as pain, and the five areas start “firing up.” This activity in the brain causes pain, and that pain is very real, not imagined or made up. Pain is the biological response to those abnormal inputs.
“Usually people come to psychologists when medications prescribed by their physician don’t work well enough or work well but have intolerable side-effects,” says Jensen. “Traditionally we psychologists are the second line of treatment after pharmacological treatments (drugs), but that makes no sense. If somebody has pain, they deserve to receive all treatments that have demonstrated efficacy and have minimal or beneficial side-effects.” The only treatments that fill that description are cognitive therapy and self-hypnosis. “Research evidence supports the argument that psychological interventions should be one of the first line treatments, not something to do when everything else has failed.”
Right now there is no effective pain medication that works for everyone or has no adverse side effects. A person may take gabapentin or lyrica or an opioid (narcotic) such as oxycontin and be able to tolerate the side effects.But others find the side effects intolerable, and some have tried significant doses and still have severe pain.
Jensen believes people should be referred to psychological treatments sooner. “And there’s no reason not to provide both medications and psychological treatments at the same time.”
Several psychological therapies focus on decreasing pain by changing brain activity. “Patients can learn to get control of brain activity by changing their thoughts, using hypnosis to change brain states, using relaxation to feel more at ease, and getting absorbed in pleasurable activities,” Jensen says. Like pain medications, these methods do not work for everyone, nor do they completely eliminate SCI pain. Unlike medications, however, their side effects can actually be beneficial.
This therapy works on the principal that changing your thinking changes brain activity, which in turn changes your experience of pain, Jensen explains. “We ask people to stop and look at the thoughts they have about their pain and ask themselves if these are comforting and reassuring thoughts (which lead to analgesia or pain reduction) or alarming thoughts (which fire up the brain and lead to more pain).”
Humans are biologically programmed to be alarmed about pain sensations because pain normally means something is wrong. But with chronic pain, alarming thoughts are not useful; rather, they are counter-productive. “So we train patients to identify these automatic alarming thoughts and replace them with automatic calming thoughts,” Jensen says. “And when they do that, they experience less pain.”
“Changing the meaning of pain, from ‘my life is falling apart because of this pain’ to ‘I have tools to manage this’ decreases activity in the part of the brain that tells you how big the pain is so you don’t feel it as strongly,” he says. “It doesn’t mean the pain isn’t real, but the experience is buffered, and suffering is reduced. It’s a biological process. We can take advantage of these processes so a person can learn to hurt less.”
These methods address the patient’s social environment, particularly the family’s response to a patient’s pain. “When a family member, often a spouse, keeps asking about the patient’s pain, they are actually making it worse because they keep the patient focusing on the pain,” Jensen explains. “But if you stop focusing on the pain, the pain diminishes. We encourage the patient and spouse to focus less on the pain and more on valued life activities.” Again, this does not mean the pain isn’t real. Pleasurable activities are actually analgesics because they reduce the brain activity that causes pain.
In hypnosis, a specially trained therapist guides the patient into a state of deep relaxation and then makes suggestions for reduced pain and increased comfort. Once patients are trained in self-hypnosis they can use it whenever they wish.
“We have studied self-hypnosis training and found that it produces substantial decreases in pain that stays away for at least three months in 30% of subjects with SCI,” Jensen reports. He is now in the process of looking at those data to see if the effects last as long as 12 months. In addition, 70% say they continue to use hypnosis even if their pain doesn’t decrease very much because the “side effects” of hypnosis (increased overall calmness and well being) are all positive. Hypnosis reduces activity in the part of the brain that suffers, so the pain may still be there but it doesn’t bother them as much.
This method teaches patients how to relax their muscles by giving them feedback about muscle activity as they go through relaxation training. In EMG biofeedback, electrodes placed on the skin over a muscle send signals to a computer, which turns the information about muscle tension into sounds. These sounds change as the person becomes more relaxed. “In our study comparing EMG-assisted biofeedback relaxation to self-hypnosis, we found that both improved pain, but self hypnosis was more effective,” Jensen says.
Brain signals picked up from electrodes on the scalp appear on a screen as alpha and beta patterns. Patients watch the screen and learn to increase the alpha waves and decrease the beta waves, “changing their brain from one that looks like it’s in pain to one that is relaxed,” says Jensen. He has conducted pilot studies using neurofeedback and hopes to study it further.
In rTMS a mild electrical charge (about the strength of a D battery) is applied to the scalp, and this increases motor cortex activity. “Studies have shown that 20 minutes a day decreases pain in people with SCI.” Jensen believes rTMS holds some promise for chronic SCI pain, and research needs to continue.
While there is currently no widely effective treatment for SCI pain, “there are things you can do now to suffer less. These involve changing the way your brain processes pain information,” Jensen says. “If you are active and absorbed in pleasurable activities, pay attention to your thoughts and tell yourself reassuring thoughts, and get help to learn relaxation skills, you will hurt less and suffer less.”
Meanwhile, Jensen is encouraged about the future of SCI pain therapies because “people around the world are trying to find treatments that are more effective, ranging from medications to specific psychological practices. As we learn more, there will be more options.”
Finally, Jensen feels that pain research is seriously underfunded. He suggests that “if you are involved in political action, you might consider encouraging your elected representatives to support more NIH pain-related research.”