This episode is pretty heavy in neuro, psych, and pain terminology, and Dr. Jill was nice enough to help me out with defining those for you. This stuff is interesting, I promise... once you get past all the boring vocabulary stuff, anyway. Also, no one really understands or agrees on how chronic pain happens or should be treated, and there is a surprising lack of good information resources on all this stuff, so take it all with a grain of salt—as Dr. Jill points out in the interview, each person needs to find what works best for them.
You can find Dr. Jill's work at masteringpainmethod.com.
National Suicide Prevention Lifeline: 800-273-8255
Crisis Text Line: Text 741-741 from anywhere in the USA
Trans Lifeline: US 877-565-8860, CA 877-330-6366
Veteran's Crisis Line: 800-273-8255, chat online, or text 838255
Other Common Hotline Numbers
Arthritis Hotline and Resources
Resources from the Mental Illness Happy Hour podcast
Spondyloarthritis: Inflamatory arthritis resulting in pain and stiffness, most often of the spine. It can also cause bone destruction, resulting in deformities of the spine and poor function of the shoulders and hips. Undifferentiated Spondylarthropathy (what Dr. Jill has) is a term used to describe symptoms and signs of spondylitis in someone who does not meet the criteria for a definitive diagnosis of a specific kind of spondyloarthritis like Ankylosing Spondylitis.
More information on Rheumatoid Arthritis from the Arthritis Foundation
More information on Fibromyalgia from the National Fibromyalgia & Chronic Pain Association
More information on Ehlers-Danlos Syndrome from the EDNF
More information on Complex Regional Pain Syndrome (CRPS) from the RSDSA
More information on Adjustment Disorder from the Mayo Clinic
Types of Pain
I had a really hard time finding resources for these, because no one quite agrees on it, but they general get sorted into these three, with subcategories:
Nociceptive Pain: Pain detected in either the body's soft tissues (such as muscles and skin) or organs by specialized sensory nerves called nociceptors, which detect painful stimuli, sending information to the spinal cord and brain for interpretation and response.
Neuropathic Pain: Pain caused by nerves which might be damaged, dysfunctional, or injured. These damaged nerve fibers send "incorrect" signals to other pain centers.
Psychogenic Pain: Pain that is either psychological in origin, or exacerbation of physical pain due to psychological factors. For the record, I think this one is bullshit.
Acute vs. Chronic Pain.
Acute Pain: Specific pains with an identifiable cause that generally resolves within the short term (<6 months), once the underlying cause of pain has been treated or has healed.
Chronic Pain: Might have originated with an initial trauma/injury or infection, or there might be an ongoing cause of pain. Some people suffer chronic pain in the absence of any known past injury or evidence of "body damage." Chronic pain can be present every day, or come and go, but lasts a minimum of 4-6 weeks in duration.
The most basic difference between acute and chronic pain is time frame, but it’s more complicated than that...
Theories + Concepts of Chronic Pain
The Nervous System: The network of nerve cells and fibers that transmits nerve impulses between parts of the body. This network coordinates voluntary and involuntary actions, and transmits signals—like pain—to and from different parts of the body. Like other vertebrates (animals with spines), we have two main parts of our nervous system:
- Central Nervous System: Comprised of the brain and spinal cord
- Peripheral Nervous System: Which consists mostly of the nerves that connect the CNS to the rest of the body. One of the branches of this system is the Autonomic Nervous System, which you may remember from all our episodes on dysautonomia!
Neurobiological Systems: The nervous system’s interaction with the rest of a person's biology, and other bodily systems.
Neuroplasticity: The way that our individual biology changes over time. Our neurobiological systems change to adapt to different situations. Whatever it practices doing the most over time, it will change to become more efficient at doing that thing.
Central Sensitization: The feedback loop. Patients become more sensitized to stimuli, get more pain with less provocation, and can experience “echos” where pain lasts longer than it otherwise would.
Other examples of sensory stimuli that can be amplified includes:
- Hyperosmia: sensitivity to smell
- Hyperacusis: sensitivty to sound
- Photophobia: sensitivity to light
- Sense of touch… which brings us to our next two terms:
Hyperalgesia: Increased pain from normally painful stimuli.
Allodynia: Pain response from otherwise unpainful stimuli.
Examples: With allodynia, even a gentle touch can be painful—a perfectly normal, not-supposed-to-be painful thing that is often very painful for me is just having hair growing out of my head. With hyperalgesia, the things that are supposed to hurt, can hurt a whole lot more—like bumping into a door frame that might cause brief soreness for most people will, for me, often feel like I got hit by a truck.
Yes, it is just as fun as it sounds.
None of this means we’re “too sensitive,” or exaggerating, or that chronic pain is some failure of will; our nervous systems are just doing what they know how to do best—central sensitization is actually a normal thing for someone who is in pain all the time. It’s neuroplasticity at work!
Experience of Chronic Pain
Intensity: How loud the volume of the pain signal is.
Agony: How much that signal bothers you.
Salience: How important a signal is, so the brain devotes attention to it.
Dr. Jill used the example of a paper cut, which is deeply unpleasant for anyone, regardless of whether they experience chronic pain. A superficial cut like that might be low in intensity, but high in agony and salience because it is so bothersome, and is often so easily aggravated.
The Agony Circuit
Amygdala: Grape size bundle of nerves on each side of the brain; serve as our danger detectors ready to put us in a state of fight or flight (part of the Autonomic Nervous System!).
Anterior Cingulate Cortex: The inside of each half of the brain; responsible for understanding complex relationships, seen as part of attention and emotion with pain.
Prefrontal Cortex: Front of our brain; part of our "executive functions," like our ability to judge things, evaluate, think about the future and make decisions. This is where we evaluate the pain signals and think, "I don't like this, I want this to stop, why won't it stop, this isn't fair..."
These three comprise The Agony Circuit, which makes pain more than just a sensation like other sensations—together they make pain a tortuous sensation, making it difficult not to think, "I don't like this, I want this to stop, why won't it stop, this isn't fair…"
And who among us living with chronic pain hasn’t thought that before?
The below pain scale by Allie Brosh of Hyperbole and a Half is better than any of the others I've seen...
0: Hi. I am not experiencing any pain at all. I don't know why I'm even here.
1: I am completely unsure whether I am experiencing pain or itching or maybe I just have a bad taste in my mouth.
2: I probably just need a Band Aid.
3: This is distressing. I don't want this to be happening to me at all.
4: My pain is not fucking around.
5: Why is this happening to me??
6: Ow. Okay, my pain is super legit now.
7: I see Jesus coming for me and I'm scared.
8: I am experiencing a disturbing amount of pain. I might actually be dying. Please help.
9: I am almost definitely dying.
10: I am actively being mauled by a bear.
11: Blood is going to explode out of my face at any moment.
Too Serious For Numbers: You probably have ebola. It appears that you may also be suffering from Stigmata and/or pinkeye.