What is neuroplastic pain/psychophysiologic disorder/mind-body syndrome?

All of these terms are basically equivalents, and mean that the pain or other symptoms one is experiencing are caused and amplified by psychological processes and are not due to disease or structural damage in the body¹. What occurs is the brain misinterprets safe signals from the body as if they are dangerous and as a result produces pain or other symptoms². The factor that drives the pain to be created, amplified, and maintained is fear. It is important to note that the pain or other symptoms are real and occur in the brain³.

What causes neuroplastic pain/psychophysiologic disorder/mind-body syndrome?

There are three main ways that neuroplastic pain can develop: 1) a perceived injury or belief that something is structurally wrong with the body, 2) a stressful situation or build-up of emotions/stress, and 3) an actual structural injury that has since healed². The common denominator in the different ways neuroplastic pain can develop is fear².

1. A perceived injury or belief something is structurally wrong with the body²

   The primary fear that people with chronic pain have is that something must be structurally wrong with their body that is causing their pain or symptoms to occur. Research has found that fearing or predicting pain, can create, maintain and amplify painful sensations^4,5,6. The mechanism in the brain that activates neuroplastic pain is the danger circuits located in the limbic system (amygdala, insula and anterior cingulate cortex)^4,7. Often people in chronic pain can end up in what is called the pain-fear cycle^2,4. This cycle occurs when pain leads to people having fear about it, and fear leads to the brain feeling in danger causing more pain, and this pain leads then to more fear, and so on. At Pain Psychotherapy Canada we provide treatment that teaches people to begin viewing their painful sensations through a lens of safety, which effectively breaks the pain-fear cycle. Two of the main therapeutic techniques that can put an end to the pain-fear cycle are: education on how and why the pain is not structurally caused, and somatic tracking.

2. A stressful situation or a build-up of emotions

   Stressful situations, life transitions (even positive ones), trauma, adverse childhood experiences, and a buildup of unregulated emotions can cause and amplify neuroplastic pain^2,4. Any situation or emotion that can activate the danger circuits in our brain has the ability to create and maintain pain and other psychophysiologic symptoms⁴. One study that took brain scans (fMRI) of people that had a hot probe put on their arm (physical pain) or were shown a picture of their ex-partner who had broken up with them in the last 6 months (emotional pain), found the areas of the brain activated were very similar⁸.The takeaway of these findings is that during states of emotional distress it is common for the brain to activate physical pain pathways in the brain⁴. However, to state that it is common for emotional distress to cause physical pain is an understatement, and really physiological reactions to emotions is the norm for human beings⁴. Remember neuroplastic pain develops in an environment of fear, so when we feel in emotional danger the brain can produce pain. Pain developing in an environment of fear provides an explanation to why people who have been diagnosed with an anxiety or depressive disorder, have experienced a trauma, or have experienced an adverse childhood event, are much more likely to develop chronic pain^9.10.11.

   People with neuroplastic pain also commonly having the personality traits of perfectionism, conscientiousness, people pleasing, and anxiousness^1,2. Because of these personality traits people are prone to self-criticism, worrying, and placing pressure on themselves, which causes the brain to be on high alert and feel emotionally in danger. When the brain feels emotionally in danger it can trigger and maintain physical pain^2,4,6.

3. An actual structural injury that has since healed

   Neuroplastic pain can also begin with a structural injury. The majority of physical injuries heal within a few weeks to a few months, however after an injury has healed the brain maintains the neuropathways associated with the pain¹². These neuropathways can then be triggered by fear and other emotions causing the pain to continue long after an injury has healed¹².

How is neuroplastic pain/psychophysiologic disorder/mind-body syndrome assessed for in therapy?

At Pain Psychotherapy Canada, when clients initially share their pain history, we look for 12 criteria that can indicate their pain is likely neuroplastic.

1. “Pain Originated During a Stressful Time”²

   For many individuals their pain first appears preceding, during, or after a particularly stressful time. Often the emotional stress is responsible for the physical symptoms^1,2.

   • Stressful situations, such as a wedding, divorce, having a baby, parents or children becoming ill, the death of a family member or friend, beginning university etc.

   It should be noted that it is not about the event itself, as small events can often trigger neuroplastic pain, but an individual’s level of stress or emotional distress resulting from the event.

2. “Pain Originated without an Injury”²

   Pain can often occur with no preceding injury (I just woke up in pain) or just a perceived injury (I bent over weird)^1,2.

   If a person does actually injure themselves pain can be appropriate at first, however after the injury has healed and the pain still persists, it is likely neuroplastic pain. It is important to remember “if we didn’t have the ability to heal from injury we would have died off long ago”² (Dr. Schubiner).

3. “Symptoms are Inconsistent”²

   Pain with a structural cause does not generally have significant variations in how it presents, such as:

   • The pain is not always present
   • The intensity level of the pain varies, even when the same physical activities are performed
   • The pain is only present certain times of the day or certain days of the week
   • The pain moves around in the body part or throughout the body

4. “Multiple Symptoms”²

   Some of our clients experience pain symptoms in several parts of their bodies. It is important to understand that “having 3 or 4 unrelated physical conditions is improbable, and a single underlying cause is a far more plausible explanation”² (neuroplastic pain). Many individuals enter into therapy only having one current pain symptom, however a review of their history quickly uncovers they have a history multiple symptoms. Having a history of multiple pain symptoms is a sign of neuroplastic pain, of course assuming you do not have a systemic disorder (multiple sclerosis, cystic fibrosis, lupus, etc.).

5. Pain Symptoms Spread and/or Move²

   Individuals with neuroplastic pain frequently have their pain symptoms spread from a small area to a larger area as time passes, or have their pain move around from one area of the body to another. It is important to remember that structurally caused pain does not behave in this way.

6. Pain is “Triggered by Stress”²

   Another clear sign of neuroplastic pain, which many people experience, is when the “pain comes on or worsens during times of stress”². Alternatively, a person’s pain is also likely neuroplastic if it decreases when they are enjoying an activity or life experience. This would indicate the pain is tied to a person’s level of fear or emotional state.

7. Pain “Triggers that have Nothing to do with the Body”²

   Often pain can become linked with a neutral trigger such as, activities, physical positions, the weather, smells, sounds, surrounding environment (e.g. workplace), or the time of day. These triggers are a conditioned response. Conditioned responses are an important evolutionary trait humans developed for the brain to make associations between specific conditions/behaviors and adverse outcomes, as a way to protect ourselves. However, often times people naturally believe and fear that a neutral trigger is causing the pain to come on, when really the brain has simply learned in the past this neutral trigger is dangerous and then produces pain.

8. “Symmetrical Symptoms”²

   People sometimes initially experience pain developing on one side of the body and then it also begins to occur on the opposite side.

   • Example: Both wrists, both legs, both ankles, both arms.

   It is important to understand that it is unlikely for structurally caused pain to behave in this way². Both wrists have developed independent of each other for your entire life, so why would both start to hurt around the same time?

9. “Pain with Delayed Onset”²

   Sometimes clients experience pain symptoms only after they complete an activity, or the next day. Structurally caused pain does not have a delayed onset like this, and if this is occurring it is a sign of neuroplastic pain.

   • Example: I go for a bike ride and only develop pain in my legs the following day.
   • Example: my back pain only starts to hurt after walking for 5 blocks.

   Soreness a day or two after a workout is natural however, due to muscles going through a process of repair.

10. “Childhood Adversity”²

    Experiencing an adverse event during childhood, such as abandonment or neglect, parental divorce or drug abuse, physical, emotional, or sexual abuse, makes you more likely to develop chronic pain later in life^10,11. However, even feeling unsafe growing up can predispose someone to developing chronic pain. Childhood adversity being corelated to chronic pain makes sense, as it causes an individual to view the world through a lens of danger and later their pain symptoms through a lens of danger².

11. “Common Personality Traits”²

    Individuals with neuroplastic pain often share common personality traits including: perfectionism, people pleasing, conscientiousness, and anxiousness. These personality traits make them prone to putting pressure on themselves, self-criticism, and worrying; all which cause the brain to feel emotionally in danger and on high alert. When our brain feels in danger emotionally, especially over a prolonged period of time, it can produce physical pain.

12. “Lack of Physical Diagnosis”²

    Lastly, if individuals have seen several doctors and specialists who have been unable to find a physical cause for the pain symptoms, then it is further evidence they could be experiencing neuroplastic pain.

*Please note it is important to meet with a medical professional to ensure neuroplastic pain is assessed for properly. Please do not use these criteria to diagnose yourself. We request all of our clients first see a physician to ensure medical conditions with a clear structural cause have been ruled out. For a formal diagnosis of neuroplastic pain, we refer our clients to physicians specialized in it.

How long does it take to treat neuroplastic pain/psychophysiologic disorder/mind-body syndrome?

Treatment length for neuroplastic pain differs for each person. It is dependent on when the brain begins to recognize that it does not need to fear the symptoms that are occurring, and soon after this the pain begins to dissipate². Another factor is how long it takes for the brain to not constantly feel in emotional danger, which is dealt with secondly in the Pain Reprocessing Therapy model.