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Pain: Is it All in Your Head?


You twist your ankle, cut your finger, slip and fall, or suddenly experience more severe painin your back, chest or abdomen that sends you to the emergency room. When you feel that pain, your brain is trying to tell you something. Some kind of tissue injury has occurred. Without proper attention, rest or further treatment, things could get worse. In this case, pain, although uncomfortable, is a helpful warning sign.

But chronic pain is different. In the decades I've spent caring for patients who experience chronic pain, especially after the initial injury/condition causing it has apparently healed, I have heard the phenomenon of pain described as a kind of "lonely prison" or "isolating torture chamber." Often, to loved ones and friends, the outward "appearance" of the individual rarely reflects the severity of the inner havoc the pain is wreaking. These comments are common: "But you look fine." "You don't seem like you're in pain." "Maybe it's all in your head…" Over time, individuals often retreat into isolation, interacting less and less with friends and loved ones who "don't understand" or seemingly "don't believe" the degree to which they are suffering. Chronic pain becomes a disease unto itself with complications and consequences that can have wide-ranging physical, emotional and functional effects. The brain is still trying to tell you something, but the message is different. Maybe neuroplasticity has resulted in an abnormality for how electrical signals are being processed. Maybe there's an undiagnosed change in body mechanics, an unresolved emotional issue or poorly managed stress that has heightened sensitivity to pain signals.

As a neurologist specializing in the care and treatment of people who experience chronic pain, I can tell you that pain – no matter where on the body it's felt – is very real for the person experiencing it. And yes, it is all in your head, but I mean that quite literally. Pain is not an electrical signal transmitted to the brain from an area of injury or damage. Pain is the emotional experience associated with the signal. And the signal doesn't become pain until it's processed and experienced in the brain as unpleasant in some emotional context. The emotional context is critical. That's why soldiers can rescue others despite personal injury, and football players can "play through" injuries later to find out the nature and severity is such that it's unbelievable they were able to carry on. Pain is in the brain. And the brain can turn up or turn down the electrical signals to modulate the pain.

Specialized nerves carry electrical pain signals from the site of injury or tissue damage into the spinal cord and eventually to the brain. And the brain sends electrical signals back down to the spinal cord that control or modulate the amount of incoming traffic. We call these pathways ascending and descending pain pathways.

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