‘The sorrow that has no vent in tears makes other organs weep’ (Henry Maudsley, 19th-century anatomist).
The impact of chronic pain and how psychotherapy can help
The British Pain Society (2008) defines chronic pain as continuous, long-term pain lasting more than 12 weeks or continuing after the expected time of healing from trauma or surgery.
Chronic pain is a major concern in modern medicine, affecting around 30% of people in economically developed countries (Berman et al., 1997). In the UK it accounts for 208 million days off work equating to an annual loss of £18 billion to the economy (Elliot et al., 1999). Data shows that between 15-40% of Europeans experience chronic pain, 20% of which will suffer for more than 20 years (Pain in Europe, 2003). These numbers are surprising when we consider the advances in health care and the increased availability of complementary treatments like acupuncture (In 2005, $27 billion was spent on complementary medicine with chronic pain being one of the most common presenting issues). Patients who have chronic pain see their doctor around five times as often than those who do not. This accounts for almost 5 million GP appointments a year and is the third most common reason for GP visits in the UK. Often GPs cannot identify the cause (Elliot et al., 1999). Medically unexplained symptoms in general make up around 15% to 30% of all primary care consultations (Kirmayer et al., 2004 and Kroenke, 1992). Pain can start in childhood and adolescence, with a tendency to persist in later life (Stahl et al., 2008).
The negative impact of musculoskeletal conditions on quality of life is higher than cardiovascular conditions, cancer, endocrine conditions, visual impairments, and chronic respiratory diseases (Sprangers et al, 2000). Chronic pain is hard to treat because a precise medical explanation for it is often lacking (Fast et al, 1988 and Kirmayer et al, 2004), and diagnoses are unclear (Deyo et al, 2001). Even high-resolution medical imaging technologies, which can detect structural aberrations, and electrodiagnostic techniques (Date et al, 1996) often fail to provide an accurate diagnosis for pain as they poorly correlate.
Results for chronic pain are often disappointing. One study showed that 90% of patients in primary care stopped treatment within three months and still had symptoms 1-year later (Croft et al., 1998). The 2003 report ‘Pain in Europe’ states that two-thirds of those surveyed in the UK reported inadequate pain control. A 2-year cohort study in six countries showed that few of the often practised medical interventions in chronic low back pain had any positive results (Hansson et al, 2000). The same applies to surgical interventions; Fritzell et al (2001) showed that only one-sixth of patients had an excellent result from lumbar fusion to treat chronic low back pain.
Why is chronic pain so difficult to treat?
One difficulty is that chronic pain is not easily characterised as either physical or psychological. This is because it often lacks a precise anatomical location (Goode, 1992). Pain is felt in the body and not in the mind. Its bodily impact is unquestionable and yet it remains invisible even to modern medical imaging and tactile physical examination. Despite its excruciating and debilitating nature, without an objective anatomical location, diagnosis becomes challenging to establish (Honskasalo, 1998). Research indicates the medical approach is not enough and chronic pain does not fall into a purely medical domain. Despite an ever-increasing understanding of physiology pain remains one of the most poorly understood phenomena in medicine (Branco et al, 2004). Chronic pain conditions like fibromyalgia remain in the “undefined or unexplained disorders” category and are thus still challenging for modern medicine (Steihaug, 2005).
Does psychology have a role in pain?
Many biomedical researchers believe that psychology can interact with the body and cause painful physical symptoms. A study of 5700 people in their twenties found that experiencing psychological stress made them 2.5 times more likely to have back pain in their thirties compared with unstressed individuals (Power et al., 2001). Another study showed that lack of stressful work predicted absence of back disorders and that back disorders strongly correlate with lower job satisfaction (Reigo et al., 2001), monotonous tasks, unsatisfactory work relations, high work demands, and stress (Linton, 2001). In 380BC, Plato declared meaningful occupation and purpose as essential to good health and their absence as causes of illness. He referred to excessive focus on the physical body as the greatest hindrance; ‘He is always on the lookout for some headache or dizziness and this puts a complete block on excellence being practiced in this way’.
Can psychotherapy help with chronic pain?
Pain is a subjective experience (IASP, 2001) and bringing biomedicine and psychology together might better understand the complex processes involved (Chapman & Nakamura, 1999). In chronic pain, symptoms usually do not fit a biomedical model of any disease resulting in patients being viewed as malingering, histrionic, hysterical (Kirmayer 2014). The stigma of psychological influences on physical symptoms makes many patients resistant to considering factors beyond the physiological (Bullington, 2013). Patients can view psychological involvement in their symptoms as derogatory because of the stigma involved (Bullington, 2013). Lack of understanding on psychogenic causation (Kirmayer, 2004) can lead to psychological factors being communicated ineffectively to patients and not addressing their concerns (Bullington, 2013). Psychotherapy can help by validating the symptoms and the meaning of the patient’s suffering. This helps patients to acknowledge stress, social conditions, and emotions have an effect on their physical condition, which can open the door to psychological strategies to address the psychosocial factors that contribute to chronicity and disability (Bullington, 2013).
An article discussing manual and physical therapies in back pain