Mr. B* was a 71-year-old veteran who had lived with chronic arm pain ever since a car accident 25 years earlier had left his right arm paralyzed. Medication after medication, including potent opioids, failed to bring relief. When he met Brandon Yarns, M.D., a health sciences assistant clinical professor in the UCLA Department of Psychiatry and Biobehavioral Sciences, he’d recently been hospitalized for a pain flare-up and felt hopeless.

Mr. B joined a study led by Dr. Yarns exploring the mind-body connection in chronic pain. He and 125 other older veterans, most suffering from chronic back or neck pain, were randomly assigned to one of two types of psychotherapy. The first was cognitive Behavioral therapy (CBT), the current psychotherapeutic gold standard for pain, which teaches patients skills to manage their pain (guided imagery, progressive muscle relaxation) while reframing how they think about their pain “I’ll never feel better” becomes “Although my pain level was high yesterday, I read a book with my granddaughter.”

The second group tried emotional awareness and expression therapy (EAET), which explores unresolved emotions and past or present life stressors that may be perpetuating the chronic pain cycle—anything from adversity endured in childhood or adulthood to interpersonal conflict to a coexisting mental health condition like anxiety or depression. The theory: Addressing and processing traumas that one has spent years or decades consciously or subconsciously blocking out calms the brain regions responsible for transmitting pain signals to the body.

The results, recently published in JAMA Network Open, made a splash in the chronic pain world. Close to 70 percent of veterans in the EAET group reported clinically significant pain reduction (meaning at least a 30 percent reduction) after nine sessions; only 17 percent of CBT subjects experienced the same degree of relief. Twelve percent of EAET patients had complete resolution of their pain versus 2 percent of CBTpatients. We spoke with Dr. Yarns about his research.

Bottom Line Health: Why explore the link between unresolved trauma and chronic pain?

Dr. Yarns: Pain doctors frequently encounter patients who have endured chronic pain for years, yet nothing on an X-ray, MRI, or other imaging scan points to an obvious source. (Unlike, say, arthritis or carpal tunnel syndrome, both of which can be visualized on scans.) They may have a bulging disk or other common age-related condition, but not something you would expect to cause significant, unrelenting pain. These patients have a type of chronic pain called centralized pain that occurs when the nervous system essentially gets stuck in a high-activity state, causing hypersensitivity to pain. It can happen after an acute injury, like tweaking one’s back, or with no apparent injury at all.

The thought is that in centralized pain patients, psychological factors like post-traumatic stress disorder (PTSD), anxiety, or distressing childhood events like physical or emotional abuse prime specific circuits in the brain to be more sensitive to pain.

BLH: Many chronic pain patients report feeling dismissed and defeated when a doctor tells them their pain is “all in their heads.” But that’s not what you’re saying, correct?

Dr. Yarns: Their pain is not imaginary—they genuinely hurt. But the fact is that all pain is processed through the brain. When you burn your finger on a hot stove, your brain sends an “ouch” message down the nerves to your hand, and you feel a burn in your finger.

In chronic pain, the brain plays an even larger role. When you put chronic low-back pain patients in an MRI scanner and ask them to rate their pain, you’ll often see the brain regions more involved in emotional processing light up, even more so than the brain regions involved in pain perception. Northwestern Medicine researchers did this with 40 individuals who had recently injured their backs and followed them for a year. The biggest predictor as to who fully recovered and who transitioned into a chronic pain patient had to do with activity in these emotional brain regions—the more emotionally a person’s brain reacted to the initial injury, the researchers discovered, the higher the odds that their pain would continue even after they’d healed physically.

Besides musculoskeletal pain, centralized pain is often seen in chronic tension headaches, irritable bowel syndrome, fibromyalgia, and chronic pelvic pain.

BLH: So, some people are psychologically predisposed to develop chronic pain?

Dr. Yarns: Correct. For instance, 50 percent of veterans with chronic pain have post-traumatic stress disorder (PTSD), and even those without PTSD frequently report histories of psychological trauma or interpersonal conflict. Racism and discrimination can also take a toll in a way that predisposes one to centralized pain. Even characteristics like perfectionism or keeping secrets may be implicated. Still, because of conventional medicine’s emphasis on medication as a cure-all, most chronic pain patients never consider psychotherapy.

BLH: What happened with Mr. B?

Dr. Yarns: We looked at his life around the time his pain first started. Not only did he have that motor vehicle accident, but soon after, he lost his job, which required physical labor he could no longer perform. Then, his wife divorced him. So much anger and grief surrounded the accident that he hadn’t fully processed. Additionally, he had PTSD as a result of his time in combat.

We also learned that his pain often flared when he urinated. Anatomically, there’s no connection to be made. But during therapy, he revealed that as a child, his parents had sternly punished him when he wet the bed. So we connected the shame he’d held onto for so long with his current pain.

The EAET group learned how ignoring emotions like grief, rage, guilt, and fear can alter brain pathways involved in the processing of both pain and emotion, triggering or amplifying pain. They engaged in practices like purposefully experiencing trauma- or stress-­related emotions in their body or writing them down and casting them out to sea. The resulting newfound emotional awareness and self-compassion often translated into improvements in not only pain but mood and relationships. CBT doesn’t focus on the brain’s role in pain generation; it assumes there must be something wrong with your body if you have chronic pain, which isn’t always the case. It can help, but the effects are small.

For Mr. B, working through the anger he harbored towards his parents and his grief over his divorce, and learning to show compassion for his younger self was enormously impactful. His whole appearance changed; you could see the tension in his neck release and his breathing slow down. His pain dropped by more than 50 percent. A former amateur artist, he started drawing again and planned a fishing trip with friends, neither of which he’d done in decades. He started getting back out there and living life again.

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