Ella* has been experiencing chronic pain from rheumatoid arthritis for over a year. She becomes easily frustrated with herself because she is no longer able to participation in previously enjoyable experiences like hiking, biking, and practicing yoga. Ella works full-time as a customer service representative and sitting at a computer all day exacerbates her shoulder and arm pain. She becomes easily irritated at her colleagues and customers, but cannot seem to help it despite being a conscientious employee and valued by her supervisor. Ella feels more and more hopeless that her pain will improve because she has seen numerous physicians and tried many different medications and treatments. Her relationship with her husband and daughters has also suffered since when she comes home from a long day at work, she just wants to go to sleep and not be bothered by anyone. Ella sought treatment to address her mood and response to her pain.
Understanding the Chronic Pain Cycle can help to implement strategies to break the cycle and improve overall functioning. Let’s look at the diagram above and focus on how chronic pain can lead to decreased activity and deconditioning. What does that mean? In Ella’s case, her pain and discomfort led to her abstaining from physical activity that she previously enjoyed. She no longer felt able to participate in healthy exercise because she believed that those activities would make her pain worse or cause more problems. It’s important to explore the difference between hurt and harm. When someone with chronic pain exercises and feels pain, that person may believe that he or she is causing more damage instead of understanding that the discomfort is an ongoing stable problem that may improve. Research has shown that when people with chronic pain feel discomfort during exercise, they actually report a higher intensity of pain regardless if damage is occurring. This belief, one of the most important among those with chronic pain, likely will lead to decreased activity and subsequent loss of conditioning/muscle strength. Remember, the goal of understanding the Chronic Pain Cycle is to try and intervene at any of the steps in the negative pattern to break the cycle. Increasing physical activity can be beneficial and can improve overall functioning. What if beginning a slow and easy schedule of exercise can prevent negative thoughts about yourself, others, and the world (“I can’t handle the pain” “I’ll never be normal” “This is hopeless”) and therefore, decrease avoidance and withdrawal that will likely lead to distress that will exacerbate pain and reinforce the cycle?
How does confronting negative thoughts break the cycle? Negative cognitions and beliefs about pain can lead to maladaptive coping, exacerbation of pain, increased suffering, and greater disability. Pain cognitions provide one of the most direct indicators of a patient’s illness perceptions and, as such, it is not surprising that a substantial number of chronic pain studies focus on the role of negative thoughts or cognitive distortions on chronic pain and treatment outcomes. Catastrophizing, or assuming the worst, are among the most problematic of thought patterns associated with pain, contributing to increased pain intensity, distress, and failure to utilize adaptive coping techniques. Ella often stated, “My pain will never stop” or “Nothing can be done to improve my pain.” Positively, her catastrophizing responded to cognitive behavioral therapy (CBT) by helping her to reframe her thoughts, confront the cognitive distortion, and examine the evidence of the veracity of her thoughts. Without these powerful negative thoughts constantly racing through her mind, Ella developed more control over her response to her pain.
Finally, chronic pain can lead to increased avoidance of family and friends, and anything that involves movement since it hurts to move. This combination means more distress and disability, leading to increased pain and suffering. Therefore, making an effort to maintain connections with others is imperative even when you hurt physically and emotionally. Ella continued to have trouble putting forth effort to spend time with her children and husband after work when she was exhausted, wanting only to retreat to her bed. We worked on creating a concrete schedule to follow that included a set amount of time she would spend with her family and also alone time to recharge her emotional and physical resources. Having accountability in treatment, but also the recognition that she needed time for herself (without unhealthy guilt), helped her to reconnect with others and enjoy her family. She experienced a subsequent improvement in mood and increased motivation to continue implementing strategies for change.
Breaking the chronic pain cycle may not alleviate all pain, but it has been found to improve overall functioning. An apt analogy is a radio playing in your car. If you turn the volume way up, it is uncomfortable and impossible to do anything. That’s chronic pain. But what if you can turn down the volume to a low hum. It may still be there, but you can still function and enjoy the scenery. While decreasing pain intensity is ideal, the focus is on how to reduce pain-related suffering.
*name changed to protect confidentiality