Chronic Pain and Anxiety – What’s the Connection?

Chronic Pain and Anxiety - What's the Connection?

We’ve known for a while that chronic pain and anxiety have it in them to fuel each other. It’s not uncommon for people who experience chronic pain to also experience anxiety but up until recently, little was understood about the relationship.

Research published recently in the journal Biological Psychiatry has removed some of the mystery, offering new hope for the treatment of pain, as well as anxiety. The study found that a neurotransmitter in the body called … ready? … here we go … pituitary adenylate cyclase activating polypeptide (‘PACAP’) is released in response to stress and is also elevated in response to chronic pain. Neurotransmitters are chemicals in the brain that help send information between cells.

For neurotransmitters to do their job well, their levels have to be just right – not too high and not too low. When PACAP is elevated, we see symptoms of pain, anxiety or both.  In previous research by members of the same research team, it was found that PACAP was elevated in women who had post-traumatic stress.

Here’s how it works. PACAP is found along one of the nervous system’s pathways to the brain. The pathway travels from the spinal cord to the amygdala, which is the seat of anxiety and emotions.

The researchers noticed that when there is chronic pain it’s not unusual to also see an increase in anxious behaviours – but – when the pathways for PACAP are blocked (effectively reducing the levels of PACAP), both anxious behaviour and pain are significantly decreased.

‘By targeting this [PACAP’s] regulator and pathway we have opportunities to block both chronic pain and anxiety disorders,’ – Victor May, Ph.D., senior author of study and professor neurological sciences at the University of Vermont.

The research team is now turning their attention to developing small molecule compounds that can reduce levels of PACAP.

‘This would be a completely different approach to using benzodiazepine and opiods – it’s another tool in the arsenal to battle chronic pain and stress-related behavioral disorders.’ – Victor May.

Whether chronic pain and anxiety occur together or separately, their intrusion into lives can be relentless. When they appear, they have a wide reach – for those who love someone who has to live with pain or anxiety, the struggle is also very real. Hopefully, this research brings us closer to finding an effective, safe way to manage pain and anxiety.

16 Comments

Dave Topper T

Caffeine is my disaster. One night I ended up in the ER from the anxiety. I had my triggers but the caffeine was the catalyst. But sometimes you’re in a position where an anxiety attack just has to be ridden. This last time ( I work overnight ) I had an attack ( post traumatic stress from current events? ) and had no choice but to ride it. I had the anxiety, the dizziness, the upset stomach, the whole nine. Luckily a friend was also working and we got to talking about other stuff, and had a few laughs. That made me feel remarkably better. Does laughing set off different chemicals in the body? It really tapered off after that. But the fibro took off. But HEY beats the anxiety. So is laughter the best medicine? All honesty here. I refuse medicating any of this short of Ibuprofen ( I prefer my liver and do not use acetaminophen ) for pain. I read about Cymbalta, oh the HORROR. Nope not gonna do it.

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Akanksha

At the time of annexity I feel pain in my head . right behind the eyes. What can I do to get rid of it?

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Karen - Hey Sigmund

If you are sure that your pain is from anxiety, breathe strong deep breaths. I know it might sound simplistic, but let me explain. Anxiety is a physiological response. When your brain senses that there might be threat (this doesn’t mean there is danger – sometimes the brain hits the panic button unnecessarily), it surges the body with a number of different neurochemicals, including adrenaline and cortisol (the stress hormone). These neurochemicals are designed to make you faster, more alert and stronger so that you can deal with any potential threat. When there is no need to fight or no need to flee, there is nothing to burn up these neurochemicals so they build up. You will find a more detailed description of this here https://www.heysigmund.com/dealing-with-anxiety/. This is why anxiety comes with the physical symptoms.

Strong deep breathing activates something called the relaxation response. This is a physiological response that neutralises the fight or flight neurochemicals. When this happens, the physical symptoms will start to ease. The problem is that because the brain is so busy during an anxiety attack, it can be hard to remember to breathe strong deep breaths (in for 3, hold for 1, out for 3). To deal with this, practice strong deep breathing a couple of times a day. You only need to do a few breaths at a time. This will help the response to become more automatic so it will be easier to do when you need it.

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Alysha

Hey! Thanks for this. My gp wants me to attend pain clinics but they’re held 2 1/2 hours away and i don’t enjoy long distance travel. She doesn’t get that attending will cause anxiety which will increase the pain which increases the anxiety…

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Lori

This info sounds promising. As a chronic pain patient, I’m not seeking drugs but I am seeking pain relief. If the answer was simply to stand on my head 5 minutes a day, I would do it (well, maybe not ‘simply’)! My question though is this. What about patients, like myself, that have been taking opiates for 25 years and benzodiazaines for 10 years? I have already been through hell coming off opiates due to DEA & CDC pressure. I’ve heard the coming off the benzos is even more difficult. I just hope there is some built in help for us to make these switches.

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Karen - Hey Sigmund

Coming of benzos is difficult, but with the right support it can definitely be done. It’s really important that it’s done closely with the a doctor. It sounds as though you’ve already done some tough stuff – you have what it takes to do this. I wish you all the best.

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Jasmin Beck

Lori,
I have also been on Benzos for over 30 years, mainly Valium nd Xanax.
I was withdrawn under medical supervision, in hospital and no side affects -over a period of 2 months gradual withdrawal.
I was put on Clonazapan late last year and my new psychiatrist is trying to wean me off that also, but because of sleep issues and and the positive results of combining it with melotonin, he is keeping me on it, until the Pain clinic does their procedures on my back and I see the sleep specialist.
If successful he will gradually withdraw me and HOPE for the best.
I have had no negative side-effects due to gradual withdrawal, Trust your doctor and good luck.

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Karen - Hey Sigmund

Thanks so much Robert. It makes so much sense why you would feel as though you are on a knife edge when you’re in pain from your autoimmune arthritis. I hope research like this is able to move towards finding ways to bring relief for you.

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Robert Hammel

I suffer from autoimmune arthritis. When I flare and the pain level is high, it often feels like being on an emotional knife edge.

Thank you for a great article. Sharing.

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Ang Honeyb

I think like a lot of therapists I’ve felt the connection existed for a long but to have tangible clinical evidence is fantastic. As stated the link is self fuelling, chronic pain begets anxiety, enduring anxiety begets chronic pain.

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Karen - Hey Sigmund

I hear you Ang! There’s a lot we know intuitively, or through personal experience but it’s always great to have the evidence, and to know that science is working on moving things forward.

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Leanne

Any suggestions for what sufferers can do in the meantime?
Currently trying CBT, but it’s been a long gruelling road of severe anxiety and chronic pain.
Thanks

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Jasmin Beck

Once again some brilliant info. Where do you get your research from -used to be able to when I worked for The Black Dog,
This info is great, just wish my doctor here at the Home would read it.
Suffering from severe back pain -new procedures being done shortly and unable to have any more ops, plus complex PTSD, boy did I identify.
Thank you so much for your dedication and help-it should be bottled

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Karen - Hey Sigmund

Thanks Jasmin! Sometimes new research can take a little while to filter through. The good doctors will be onto it though. The references for the research are hyperlinked in the article – just click on the words in dark blue print and that will take you there.

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Behaviour is never from ‘bad’. It’s from ‘big’. Big hungry, big tired, big disconnection, big missing, big ‘too much right now’. The reason our responses might not work can often be because we’ve misread the story, or we’ve missed an important piece of it. Their story might be about now, today, yesterday, or any of the yesterdays before now. 

Our job isn’t to fix them. They aren’t broken. Our job is to understand them. Only then can we steer our response in the right direction. Otherwise we’re throwing darts at the wrong target - behaviour, instead of the need behind the behaviour. 

Watch, listen, breathe and be with. Feel what they feel. This will help them feel you with them. We all feel safer and calmer when we feel our people beside us - not judging or hurrying or questioning. What don’t you know, that they need you to know?♥️
We all have first up needs. The difference between adults and children is that we can delay the meeting of these needs for a bit longer than children - but we still need them met. 

The first most important question the brain needs answered is, ‘Is my body safe?’ - Am I free from threat, hunger, exhaustion, pain? This is usually an easier one to take care of or to recognise when it might need some attention. 

The next most important question is, ‘Is my heart safe?’ - Am I loved, noticed, valued, claimed, wanted, welcome? This can be an easy one to overlook, especially in the chaos of the morning. Of course we love them and want them - and sometimes we’ll get distracted, annoyed, frustrated, irritated. None of this changes how much we love and want them - not even for a second. We can feel two things at once - madly in love with them and annoyed/ distracted/ frustrated. Sometimes though, this can leave their ‘Is my heart safe?’ needs a little hungry. They have less capacity than us to delay the meeting of these needs. When these needs are hungry, we’ll be more likely to see big feelings or big behaviour. 

The more you can fill their love tanks at the start of the day, the more they’ll be able to handle the bumps. This doesn’t have to be big. It just has to be enough. It might look like having a cuddle, reading a story, having a chat, sitting with them while they have breakfast or while they pat the dog, touching their back when they walk past, telling them you love them.

All brains need to feel loved and wanted, and as though they aren’t a nuisance, but sometimes they’ll need to feel it more. The more their felt sense of relational safety is met, the more they’ll be able to then focus on ‘thinking brain’ things, such as planning, making good decisions, co-operating, behaving. 

(And if this today was a bumpy one, that’s okay. Those days are going to happen. If most of the time their love tanks are full, they’ll handle when it drops a little. Just top it up when you can. And don’t forget to top yours up too. Be kind to yourself. You deserve it as much as they do.)♥️
Things will always go wrong - a bad decision, a good decision with a bad outcome, a dilemma, wanting something that comes with risk. 

Often, the ‘right thing’ lives somewhere in the very blurry bounds of the grey. Sometimes it will be about what’s right for them. Sometimes what’s right for others. Sometimes it will be about taking a risk, and sometimes the ‘right’ thing just feels wrong right now, or wrong for them. Even as adults, we will often get things wrong. This isn’t because we’re bad, or because we don’t know the right thing from the wrong thing, but because few things are black and white. 

The problem with punishment and harsh consequences is that we remove ourselves as an option for them to turn to next time things end messy, or as a guide before the mess happens. 

Feeling safe in our important relationships is a primary need for all of us humans. That means making sure our relationships are free from judgement, humiliation, shame, separation. If our response to their ‘wrong things’ is to bring all of these things to the table we share with them with them, of course they’ll do anything to avoid it. This isn’t about lying or secrecy. It’s about maintaining relational ‘safety’, or closeness.

Kids want to do the right thing. They want us to love and accept them. But they’re going to get things wrong sometimes. When they do, our response will teach them either that we are safe for them to come to no matter what, or that we aren’t. 

So what do we do when things go wrong? Embrace them, reject the behaviour:

‘I love that you’ve been honest with me. That means everything to me. I know you didn’t expect things to end up like this, but here we are. Let’s talk about what’s happened and what can be different next time.’

Or, ‘Something must have made this (wrong thing) feel like the right thing to do, otherwise you wouldn’t have done it. We all do that sometimes. What do you think it was that was for you?’

Or, ‘I know you know lying isn’t okay. What made you feel like you couldn’t tell me the truth? How can we build the trust again. Let’s talk about how to do that.’

You will always be their greatest guide, but you can only be that if they let you.♥️
Whenever there is a call to courage, there will be anxiety - every time. That’s what makes it brave. This is why challenging things, brave things, important things will often drive anxiety. 

At these times - when they are safe, but doing something hard - the feelings that come with anxiety will be enough to drive avoidance. When it is avoidance of a threat, that’s important. That’s anxiety doing it’s job. But when the avoidance is in response to things that are important, brave, meaningful, that avoidance only serves to confirm the deficiency story. This is when we want to support them to take tiny steps towards that brave thing. It doesn’t have to happen all at once.l and it doesn’t matter how long it takes. Brave is about being able to handle the discomfort of anxiety enough to do the important, challenging thing. It’s built in tiny steps, one after the other. 

We don’t have to get rid of their anxiety and neither do they. They can feel anxious, and do brave. At these times (safe, but scary) they need us to take a posture of validation and confidence. ‘I believe you, and I believe in you.’ ‘I know this feels big, and I know you can handle it.’ 

What we’re saying is we know they can handle the discomfort of anxiety. They don’t have to handle it well, and they don’t have to handle it for too long. Handling it is handling it, and that’s the substance of ‘brave’. 

Being brave isn’t about doing the brave thing, but about being able to handle the discomfort of the anxiety that comes with that. And if they’ve done that today, at all, or for a moment longer than yesterday, then they’ve been brave today. It doesn’t matter how messy it was or how small it was. Let them see their brave through your eyes.‘That was big for you wasn’t it. And you did it. You felt anxious, and you stayed with it. That’s what being brave is all about.’♥️
A relationally unsafe (emotionally unsafe) environment can cause as much breakage as as a physically unsafe one. 

The brain’s priority will always be safety, so if a person or environment doesn’t feel emotionally safe, we might see big behaviour, avoidance, or reduced learning. In this case, it isn’t the child that’s broken. It’s the environment.

But here’s the thing, just because a child doesn’t feel safe, doesn’t mean the person or environment isn’t safe. What it means is that there aren’t enough signals of safety - yet, and there’s a little more work to do to build this. ‘Safety’ isn’t about what is actually safe or not, it’s about what the brain perceives. Children might have the safest, warmest, most loving adult in front of them, but that doesn’t mean they’ll feel safe. This is when we have to look at how we might extend bigger cues of warmth, welcome, inclusiveness, and what we can do (or what roles or responsibilities can we give them) to help them feel valued and needed. This might take time, and that’s okay. Children aren’t meant to feel safe with every adult in front of them, so sometimes what they need most is our patience and understanding as we continue to build this. 

This is the way it works for all of us, everywhere. None of us will be able to give our best or do our best if we don’t feel welcome, liked, valued, and free from hostility, humiliation or judgement. 

This is especially important for our schools. A brain that doesn’t feel safe can’t learn. For schools to be places of learning, they first have to be places of relationship. Before we focus too sharply on learning support and behaviour management, we first have to focus on felt sense of safety support. The most powerful way to do this is through relationship. Teachers who do this are magic-makers. They show a phenomenal capacity to expand a child’s capacity to learn, calm big behaviour, and open up a child’s world. But relationships take time, and felt safety takes time. The time it takes for this to happen is all part of the process. It’s not a waste of time, it’s the most important use of it.♥️

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