How many of you have headed off to ‘Therapy Worksheets’ blog? Yes, that’s the one I’ve linked to in my roundup of the best CBT resources on the internet. Will Baum, the editor of that blog is also the author of where the client is, a blog about professional private practice in mental health care. Will contacted me the other day and sent me a link to a really interesting interview with Frances Sommer Anderson, a clinical psychologist who works with people experiencing chronic pain. Her take on chronic pain management is influenced by John Sarno, who has a hypothesis that much chronic pain is influenced by psychological factors (often emotional issues) from childhood. One of the premises of his approach is that people need to heal their ‘repressed’ emotions and in doing so, their chronic pain will vanish.
Now unfortunately there is not a lot of good evidence for Dr Sarno’s hypothesis, particularly the second part (that people need to ‘heal’ their repressed emotions). Having said that, some of the mindfulness and acceptance material I’ve been reading suggests that, instead of repressing, controlling or focusing on negative emotions, we may find it more helpful and less distressing to experience these ‘lightly’ or nonjudgementally, and in doing so, release ourselves from their influence and choose to act according to our values.
In this interview of Dr Sommers Anderson, we are introduced to her approach of helping people identify when they first started to experience their pain, often finding that at that time there were intense and emotionally-laden events. Often memories and emotions from these events have been avoided, and the hypothesis is that by processing this in a supportive environment, the symptoms of pain reduce.
IMHO? I’d prefer to use a neurobiological model for this, because it has fewer assumptions, draws on a large body of empirical evidence, and explains more. I often refer to the work of Muhammed Yunus, who describes the connection between a range of chronic pain disorders such as fibromyalgia, dysmenorrhea, tempero-mandibular disorder, PTSD and others as being of ‘neuroendocrine’ immune dysfunction.
We already know that people in an increased state of physiological arousal appear to trigger a series of events that can lead to central sensitisation. We could call this ‘being under stress’ and there are lots of things that seem to place our nervous system in a state of heightened sensitivity – things like having an accident, having a virus, or being vulnerable due to genetics or events during development. The hypothesis as described by Yunus is that dysfunction in the neuroendocrine immune system initiates ‘hyperexcitement’ of central neurones (in other words, they respond more quickly and to less input than normal), and this leads to general central sensitisation – and the symptoms of ‘central sensitivity syndrome’ are experienced.
These symptoms include increased detection of tactile input (such as pressure), fatigue, poor sleep, and other ‘psychological’ or emotional aspects such as low mood, anxiety and so on. CS is manifested by an abnormal and intense enhancement of pain by central nervous system (CNS) mechanisms. Pain signaling involves activation of a variety of simple nerve endings in skin, muscle and internal organs. The peripheral impulses travel through A-delta and C fibers to both nociceptive and wide dynamic range (WDR) neurons in the dorsal horn of the spinal cord. In a person with a sensitive nervous system, the WDR neurones integrate input from these neurones (both noxious and nonnoxious) so that nearby neurones now transmit information that is normally ‘light touch’ or ‘gentle pressure’ as if it were noxious. As a result, this is felt as painful.
This set of nerve fibres transmit information up the spinal cord to the thalamus, hypothalamus, the limbic system, and finally, the somatosensory cortex; each of which has a job to process the information so that it can be experienced and acted upon.
At the same time as all this information is travelling up the spinal cord, a number of neurochemicals are also released. These chemicals increase the excitability of the neurones in the spinal cord. One of the main chemicals is cutely named ‘substance P’. It spreads the area of excitement by ‘unmasking’ the silent receptors in the synapses and it can diffuse some distance to excite other neurons nearby. There are numerous other substances that also contribute to increased excitability of neurones, so that less and less input is needed to produce a painful experience.
Thankfully, just when you thought all was lost, there are also pathways downward from the brain that work to dampen down this sensitivity. Several descending pathways from the
cortico-reticular system, locus ceruleus, hypothalamus, brain stem, and local spinal cord interneurons use neurotransmitters such as serotonin, and norepinephrine, among others. These work to reduce the reactivity of various neurones and in so doing, reduce the amount of information reaching the areas of the brain that work to detect and interpret information from the body.
The ascending system and the descending system are not directly linked – it’s quite possible to have increased sensitivity in the ascending fibres but a normal descending pathway. I guess one of the problems with our nervous system, or maybe a really valuable aspect, is that there are multiple systems that all interact with each other, with various in-built redundancies, all designed to help us stay alive! BUT all those systems that can also fail to work properly. Just as we can have dysfunctions of every other body system, it’s not surprising we can also have dysfunctions of the system designed to alert us to potential damage. Some people seem to forget this – and keep on looking for the tissue damage that simply ‘must’ be there.
Back to Frances Sommer Anderson and her approach to managing pain. She (and others like her) work to help people get in touch with, or process negative emotional experiences, and help them become more comfortable with experiencing and regulating their emotions. This is also part of CBT and ACT, but may also feed back into some of the information I’ve been blogging about – emotional regulation and self regulatory systems. The line between ‘psychological’ and ‘biological’ is becoming ever more difficult to define. I encourage you to read this interview, and then go back to the posts that I’ve put up, and others like Body in Mind, that start to ponder the way in which our neurobiology underpins what used to be only ‘psychological’.
YUNUS, M. (2007). Fibromyalgia and Overlapping Disorders: The Unifying Concept of Central Sensitivity Syndromes Seminars in Arthritis and Rheumatism, 36 (6), 339-356 DOI: 10.1016/j.semarthrit.2006.12.009