Ask a Doctor: Why do some people have chronic pain and others do not?

Medical doctor  with a stethoscope around his neck  holding
Medical doctor with a stethoscope around his neck holding
photo Matt McClanahan, D.O.

Q: Chronic pain seems like an unfortunately common and pretty complicated condition. Some doctors even say it is a "disease" and inevitable with aging. But if that's the case, everyone should develop it! Can you help me understand why some people get chronic pain and some don't?

A: Despite pain being a universal human experience, as both a medical community and society at large, we have a poor understanding of what it is and how it works. Put simply, pain is a danger signal, produced in the brain (not by the body) when our nervous and psychological systems have determined that potential threat outweighs potential safety of the body. It has strong sensory components (information coming from the body), but it importantly has cognitive (thoughts, attention) and emotional (feelings, beliefs) aspects as well. Anesthesiologists and surgeons know this quite well - when someone is asleep, they do not feel pain. Said differently, you cannot have pain and not know about it.

That is a tricky statement, but is at the heart of our misunderstanding. Are pain and tissue damage the same thing? The answer is no. We have all heard of stories when, in a high-stress situation, a soldier or athlete suffers an injury but feels no pain or "plays through it." Conversely, phantom limb pain is commonly experienced following amputation, and fibromyalgia is a relentlessly painful condition that has no identifiable cause and is diagnosed only when we've determined someone is not suffering any tissue damage.

So if pain functions like a warning but isn't 100% indicative of damage, does that mean in chronic pain the brain is feeling chronically unsafe? The answer to that is yes, meaning that when perceived danger outweighs perceived safety, the brain will create some kind of protection response, whether that is hunger, anxiety, fatigue, pain, etc., to motivate corrective action. However, the amount of time we spend focused on what hurts or what's wrong (attention), imagining our body's fragility (thoughts), worrying about what we might never do again (feelings) or fixating on how many times you've been told your core is weak or that your back is out of alignment, unstable or "bad" (beliefs), we are consistently communicating to our brain, "We are not safe; it's not going to be OK," and the danger alarm becomes increasingly sensitized.

Our brains feel safe and the alarms quiet down when we perceive that our needs for empowerment, connection or meaning are being met, in both body and mind. Yet many people have lived lives of stress and even abuse, stuck in bad jobs or relationships, financial, racial or gender insecurity or even internal pressures like perfectionism, pessimism and people pleasing. When these factors arise, we may develop symptoms, and if they persist, the danger alarm becomes overactive, and the brain essentially learns or gets "good" at exacerbating or even producing pain or other symptoms in an attempt to protect us, even in the absence of tissue damage.

Developing this kind of holistic insight, making sense of the story our nervous system is telling us and reducing danger by increasing our sense of power, connection and meaning is critical for our system to recover from any symptom, condition or behavior. It's the start of a journey to a safer, happier, brain and body, and in many it leads to reduction or even resolution of pain.

- Matt McClanahan, D.O., Center for Insight Medicine; member, Chattanooga-Hamilton County Medical Society

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