Pain and Anxiety

There’s a strong relationship between pain and anxiety. In fact, when they seriously look into it, many people find their anxiety increases their pain, and vice versa.

As a chronic pain specialist, I see many people who have anxiety that goes with the chronic pain. The thing that’s well recognized in the medical literature is that two go together. Something that makes you anxious will make your chronic pain worse. And your chronic pain getting worse will make you more anxious. They feed off each other to create a nasty spiral for both sets of symptoms.

The interesting thing is that the system that causes pain and the system that creates anxiety both have the same basic purpose. Their basic function is protection. Both these systems are there to keep us safe.

This creates some really interesting opportunities and gives the first clue as to why chronic pain and anxiety dance together so much.

The two systems that govern pain and anxiety

Your pain system is there to warn you of physical damage. The systems that govern anxiety are there to search for external threats and to react to them.

To really understand this, you need to go into the part that matters, which is your brain. Essentially, all human beings have two minds. We have what’s called the neocortex. The size of human’s neocortex is what separates us from most other mammals except dolphins and whales. The neocortex which is where we produce complex thoughts, reasoning and language.

Then you have your paleocortex and this is the part of your brain which we share with most mammals in the world. This is commonly called the lizard or reptile brain. In medical terms, it’s your midbrain. It’s the structures deep inside your brain, do amazingly important tasks, more or less on autopilot. It keeps your heart beating, keeps your blood pressure going, keeps your temperature constant, your bowels working, your bladder wall working.

These tasks are vital and necessary, but you don’t have to consciously think of them for them to happen. This is all driven by your lizard brain, or mid brain.

Now, we do have conscious control over some of these functions. For instance, all children learn how to control their bowels and bladders by usually ages two to four. Your bowel sends a message that it’s time to go to the toilet, but your conscious brain overrides the message until the appropriate time. So you have control over the working of your mid brain as long as you realize this fact.

If we come back to these two systems, there’s your pain system that malfunctions to cause chronic pain, and the system that creates anxiety. These are both there for your protection, and both of them are largely located in the mid brain.

They work through the thalamus, which has for pain, and through the limbic system, which is for emotions and anxiety. They are millimeters away from each other in this lizard brain.

How the lizard brain keeps you safe

We share the lizard brain with almost all moving creatures. So let’s take a fly as an example. Our fly is sitting there, doing what flies to best, and I have a fly swatter. I’m intent on dealing to this fly before it lands on my sandwich. As the fly swatter starts to descend, the fly has two choices.

It sees the swatter moving just out of the corner of one compound eye. It can either say to itself ‘danger!’ and get out of there, or it can say, “Isn’t it a nice day…” and splat! It’s dead.

This is how the midbrain works for a fly. It’s a smaller, simpler, system, but it still has this hair trigger reaction occurring in the midbrain when it perceives a threat.

This protective mechanism works as an on/off switch. It’s not a maybe/maybe not switch. Otherwise the fly would be squashed.

The flies that have survived long enough to reproduce were survivors, and always reacted fast to threats. It’s natural selection at work.

Let’s look at how you may get persistent anxiety from a system that should be protecting you. Something that separates human beings from most other creatures is that our brain is a forward looking machine. It’s constantly casting into the future.

A fly just reacts to what’s happening now. However humans trying to stay safe are always trying to look ahead for dangers. But because we live in a much more complex environment, it’s harder for us to recognize danger.

Our lizard brain is constantly looking for danger. Everything from a work email arriving to a traffic jam can signal danger to a primed lizard brain.

The role of traumatic memories

The next question is a key one. How can you make this danger-finding system as efficient as possible? What you do to recognize danger is that this forward-looking is informed by what’s happened in your past.

When your brain asks ‘is this dangerous?’ It immediately checks your memory banks to see whether memory of a similar situation where you ended up getting hurt or distressed.

In the brain, you have two tiny and remarkable structures called the amygdala. The amygdala is the shape and the size of an almond. It sits deep in the temporal lobe, right next to the limbic system. Whenever you have a traumatic event, the memories of this are stored here.

When I say trauma, it could be anything. It could be something, which was terrible at the time, like your older brother stealing your ice cream when you were three. Or it could be a truly terrible situation like child abuse or a serious car accident. It could the death of a loved one, or being caught in a war zone.

All of the memories that have a huge negative emotional impact on your life get laid down in the amygdala. They’re stored extremely close to the part of your brain, which is there to protect you from danger.

How anxiety drives pain

Supposing your in your house and I have to go down to the supermarket. But your lizard brain says checks your memory banks to see if it’s safe.

And in your memory bank, in the amygdala, it finds the memory of a terrible incident when you slipped and fell on the way to the supermarket. It decides that No, it’s not safe. Based on this memory, a trip to the supermarket is dangerous. As your lizard brain connects something in your past with what you plan to do in the future, it changes something.

The limbic system fires with a danger message. It sends this message to your hypothalamus, which sends a message to pituitary, which then pushes out a hormone which goes to your adrenal glands. 

It takes less about a second to do all this. As the blood treaches your adrenal glands, they pump adrenaline into your system. Because if it’s dangerous, this system is there to protect you. You’ve now shifted into fight and flight mode. That’s how we humans protect ourselves from an external danger.

All of this is triggered by the thought that you’re going to go off to the supermarket. That thought becomes real in your brain, and then extremely real in your body. As the adrenaline floods your body, your stomach starts to churn and your mouth dries. Your heart starts pumping faster in your chest. You’re starting to feel shaky. Your hands get cold and sweaty and you feel really awful.

This fight and flight response is great if something or someone is coming to attack you and you have to run away fast. But when it gets tied into a thought of the future, and a memory of past trauma, then it turns on anxiety.

Anxiety is a thought in the future that suddenly becomes unbelievably real for you, and can make your present self very uncomfortable by putting your body into fight or flight mode.

Fight and flight mode

The amount this system gets wound up will depend on how much anxiety you feel. You may feel a small amount, or you may find that just everything fires in an overreactive protective system.

There’s one other thing that happens. Your breathing changes. This is significant. Not only is your body now hyped up, but your breathing changes from relaxed diaphragmatic stress breathing. This is all an unconscious reaction produced by your protective lizard brain.

You simply thought “I’m going to the supermarket,” but your lizard brain did all these connections, and now you are wanting to escape. You start breathing as though you were running, or as though you were fighting. This breathing is known as hyperventilation. Your carbon dioxide levels drop, and this changes the acid base balance in your blood. This acid base balance sets the rates of all the reactions in every cell of your body.

Changing this will really mess with your fundamental metabolism. With this change, you get a feeling of impending doom. It’s a very scary feeling, and will feed back into the fight and flight mode, which causes more stress breathing.

If this carries on, the anxiety may turn into a full panic attack. So that’s the one protection system you have that governs anxiety.

Anxiety is a huge overreaction to a thought which is being fed from something in your past there to protect.

How pain is amplified

If you take pain you’re walking along and as you move, you’ve got little receptors all over your body, under your skin, in your muscles, tendons, ligaments, and joints. All these little receptors send information constantly into your brain from all over your body.

Normally, their messages simply say that everything’s fine. Now, supposing now you walk along and you step off a curb. And as you step off the curb, you twist your ankle. As your ankle twists, the outside of your ankle tears.

This is the important part. As the tissue tears, you don’t know what’s happened until the receptors send a message. The message fires up a specific nerve and comes to your spinal cord. All the messages coming into your spinal cord are from your peripheral nervous system. They reach a point which where the peripheral system joins the central system, which is the spinal cord going up to your brain.

Where they join there is a little connection between one nerve and the other, called a synapse.  The message has to jump across this little synapse.

This is another one of the big keys. When you twist your ankle, you don’t know you’ve hurt yourself until a danger message shoots up the spinal cord, jumps across the synapse and arrives in your brain.

In the brain, it cross from right side over to the left and ends up in the the midbrain, comes into your cortex where there’s what’s known as a homunculus. It’s the representation of your body in your brain.

The message ends up in the ankle portion of this homunculus, and your consciousness suddenly knows you have pain in your ankle. It takes less than a second, but as the message reaches your brain and your attention goes to it, you suddenly become aware of pain in your leg.

Over the next hours and days, you do whatever you need to do to heal. You put ice on your ankle, you go and see a physiotherapist or doctor. Over a few weeks the ankle starts getting better, and the pain messages of start getting less.

This is an example of your pain system protecting you exactly like it should.

How pain becomes chronic

However, there is another thing that can happen. When you look at the figures, what I’m going to describe now happens in perhaps 15% of the population.

What happens in this other scenario is that your ankle is starting to get better, but there’ve been pain messages coming up the synapses for weeks, going up a particular nerve pathway to your brain.  

So you’ve been feeling pain for a week or two. One you’re walking along and you come to a curb or step. Remember that both systems, your pain system and emotion or limbic system, are there to keep you safe. Your midbrain is always seeking ahead for danger and being informed about what’s dangers from your past.

As you come to step down, your lizard brain looks ahead and says, “Oh, there’s a step. Hang on a minute.” And it goes back and it says,
Oh no, the last time you went over the step, you twisted your ankle.”

It then sends a danger message.

This is the third key. The message goes flying down to the little synapse where one nerve talks to another in your spinal cord. When it gets there, it does something quite profound. It turns UP an amplifier in that synapse.

The messages coming from your ankle, which is starting to get better, become amplified. As the message jumps across the synapse, it shifts to a different receptor. The message changes from normal sensation to you feeling lot of pain.

As you take a step off the curb and put your weight on your ankle, you feel this amplified pain. Consciously, you’re thinking “Ouch! My ankle. Why is it so sore? I seemed to be getting better.”

You look down at it, and it looks okay, but your lizard brain has decided that, based on past experience, stepping down and putting weight on your ankle is a dangerous thing.

To keep you safe, whenever this situation arises, it amplifies messages from your ankle, so you feel pain.

In this scenario, even if you keep getting the right treatments, and your body heals, your pain does not get better. Your pain system combined with your lizard brain is keeping that message amplified and you continue to feel exactly the same pain. 

In some unfortunate cases, the pain may continue to amplify. It can spreads up into your lower leg. You go and see a specialist who gets an MRI and tells you there’s a tear in your ligament.

However the real problem is sensitization of your pain system. Now you have this horrible pain which is as real as if your damaged ankle was still damaged.

This scenario can happen anywhere in your body. Many people experience it after leg, back, neck and shoulder injuries.

How pain drives anxiety

This amplified pain problem is driven by your lizard brain, specifically the area called the thalamus. The thalamus lives right next to the limbic area, which runs your anxiety center.

When amplification becomes chronic, everything in this area is now on red alert. You’re hyper aware of danger.

The next time you’re walking along see a step ahead of you, not only does your pain system turn up its amplifiers, but also your protection center reacts to this perceived threat. It sends messages to push up adrenaline. So you become anxious even as you’re walking towards the step. You know your ankle is going to hurt, and these two systems malfunctioning ensure that you’re right.

This is the fundamental reason why anxiety and chronic pain are connected. They both have the same basic function: protecting you from harm.

When they work well, they keep you safe. If they malfunction like I’ve described, your life becomes full of pain and anxiety. Unfortunately, many health professionals do not understand this process.

Could this be happening to you?

It’s difficult to diagnose this situation because there are no objective tests for it. The only way you can really arrive at a diagnosis is to eliminate all other possibilities Unfortunately, MRIs will show all past damage, including injuries that have healed, which makes it easy to miss this as a cause of persistent pain.

If you have pain that’s not getting better, and you’ve ruled out other causes, the question is what to do to get better?

How to break the chain of pain and anxiety

The first thing is to understand this underlying process. These systems that keep you safe are supposed to be serving you. However, you are the boss. The second step is to use something which is a powerful tool. Inside our neocortex, somewhere mysterious is our consciousness.

Your consciousness has a fantastic tool: your attention. Wherever your attention goes, that will determine your reality. Until now, if you have anxiety and chronic pain, your attention has been going to both of these things, and as been feeding the whole process.

Now that you understand what’s happening, you can change this. The next time you’re at home, and decided you’re going to the supermarket, you may get this awful feeling combined with horrible anxiety. 

Step one is to recognize: this is your protection system overreacting. It’s creating all these symptoms. Take your attention away from your thought of the future, put it back on your immediate surroundings.

Use your five senses to analyse: is there anything dangerous here right now?

This process will take just a few seconds. What you’re doing is you’re taking your attention away from the horrible feelings of danger.

Once you can reassure yourself that everything’s safe and normal, you send a very firm message down to that little gremlin in your midbrain and to say it’s all safe.

The vital role of breathing

The next thing you do is become aware of your breathing. Close your mouth and breathe through your nose. This is important because when fight and flight mode switches on, you start breathing through your mouth to suck in more air, which begins hyperventilation. When you instead move air slowly in through your nose, you’re putting the brakes on this process.

You lean back and you take a very slow in breath. Count slowly to five for each in breath. Count of seven on each out breath. As you gently breathe out, you’re shifting your fight and flight system back to chill mode.

As you do these slow breaths, your heart rate slows down and you’ll find the awful feeling of impending doom just dissipates.

The earlier you get onto this the better, so you can halt the process before it ramps up. Understand you have immense power to change processes that used to be automatic.

Later on, you can start to work on any traumatic memories you have which turn on anxiety and pain. You can look at going deeper into the amygdala, and depending on what you find, you may need professional help.

To begin, though, this will help you get started, and if you practice it diligently, it may make a tremendous difference to the quality of your life.