Moving Beyond Anticipatory Pain for Effective Chronic Pain Management

Posted on Tuesday, July the 21st at 5:27pm

By: Dr. Stephen F. Grinstead, LMFT, ACRPS, CADC-II

If you’re living with a chronic pain condition you may have noticed that sometimes you are so fearful about conducting basic tasks of daily living that you become immobilized. It can also manifest with overwhelming anxiety, so much so, that you trigger a phenomenon that actually amplifies your perception of pain. We call this Anticipatory Pain.

Because you believe that you are going to hurt, you can activate the physical pain system just by thinking about doing something that you believe will cause you to hurt. You start hurting even before you begin doing whatever it is that you believe will cause you to hurt. All you have to do is to start thinking about doing that thing.

Once the physical pain system is activated, the anticipatory pain reaction actually makes your perception of your chronic pain management symptoms worse. Whenever you feel the pain, you interpret it in a way that makes it feel worse. You begin thinking about the pain in a way that makes it worse. You tell yourself that “this pain is awful and terrible,” and “I can’t handle it.” You convince yourself that “it’s hopeless, I’ll always hurt, and there’s nothing I can do about it.”

This way of thinking contributes to the development of emotional reactions that further intensify or amplify the pain response. The increased perception of pain causes you to keep changing your behavior in ways that create even more unnecessary limitations and mounting emotional discomfort. These reactions can make you believe you are trapped in a progressive cycle of disability.

Moving Beyond Anticipatory Pain
In December of 2007 I wrote an article titled “Coping with Anticipatory Pain.” This has been one of the most requested articles on our website over the past few years. I believe it’s time to take another step in supporting people to not just cope with anticipatory pain, but to move beyond it.

I learned a long time ago that what we expect is usually what we get which can be both beneficial and harmful. When it comes to feeling pain and development an effective chronic pain management plan, it is crucial to understand the role of anticipatory pain. It has both biological and psychological components.

On the biological side, the cascade of effects from a pain sensation occurs on many levels and involves a variety of different areas within the nervous system. As a result, a wide variety of nervous system chemicals are produced and dumped into the blood while other brain chemicals are rapidly absorbed or depleted. Pain doesn’t just hurt — it changes the most basic neurophysiologic processes in the human body.

On the psychological side, anticipation of an expected pain level can influence the degree to which you experience your pain. In some cases, when your anticipatory level of pain expectation is lowered, your brain responds by influencing special neurons. This renders your brain less responsive to an incoming pain signal and your sensation of pain decreases. In any event, both ascending (pain signals coming from the point of injury to the brain) and descending nerve pathways (signals from the brain to the point of injury) will influence or modify the effects on your body.

Fortunately, you can learn how to change your anticipatory pain response. You can lower the amount—or perception—of pain that you anticipate by changing what you believe will happen when you start to hurt. You can also change your thinking, or your self-talk, and learn how to better manage your emotions. You can learn new ways of responding to old situations that used to cause or intensify your pain. As you come to believe that you really can do things that will make your pain sensations bearable and manageable, your brain responds by influencing special neurons that reduce the intensity of your pain. Your brain becomes less responsive to an incoming pain signal.

There are things you can do that will make you habitually less responsive to incoming pain signals. Herein lays the rationale for including biofeedback, positive self-talk, meditation, and relaxation response training as part of your pain management treatment plan. In any event, both ascending (pain signals coming from the point of injury to the brain) and descending nerve pathways (signals from the brain to the point of injury) influence or modify the effects of pain on your body.

Whenever you are experiencing pain, it’s helpful to ask: What is my pain trying to tell me? Pain is the signal that says something is wrong; that you need to find out what is it, and then learn how to manage it. Sometimes it can be difficult if not impossible to pinpoint the pain generator, and as human beings we want to know why something is happening and we want to know “right now.” But when we’re in pain the more important question is: What can I do, right now, to manage my pain in a healthy way that supports me physically, emotionally and spiritually? The answer will be different for each person.

Pain versus Suffering
But what if you can’t answer that question because your chronic pain has become unmanageable, no matter what you try? This brings us to a discussion of pain versus suffering. The psychological meaning that you assign to a physical pain signal will determine whether you simply feel pain (Ouch, this hurts!) or experience suffering (This pain is awful and will just keep getting worse; this is terrible and why is it happening to me!). Although pain and suffering are often used interchangeably, there is an important distinction that needs to be made. Pain is a physical sensation, a warning signal telling you that something is going on in your body. Suffering results from the meaning or interpretation your brain assigns to the pain signal.

Many people believe that: I shouldn’t have pain! Or Because I have pain and I’m having trouble managing my pain, there must be something wrong with me. A big step toward effective chronic pain management occurs when you can reduce your level of suffering by identifying and changing your thinking and beliefs about your pain, which in turn can decrease your stress and overall suffering. Because of the two parts—pain and suffering—chronic pain management must also have two components: physical and psychological. The way you sense or experience pain—its intensity and duration—will affect how well you are able to manage it.

The Role of Neuroplasticity
Before discussing the role of Neuroplasticity in chronic pain management and how it applies to moving beyond anticipatory pain, it is important to have a working definition of the term.  Neuroplasticity (variously referred to as brain plasticity or cortical plasticity or cortical re-mapping) refers to the changes that occur in the organization of the brain as a result of experience.

A surprising consequence of neuroplasticity is that the brain activity associated with a given function can move to a different location as a consequence of normal experience or brain damage/recovery. It is now been found that this capacity for rewiring of the neuronal synapses to allow for re-development of entire regions of the brain is present in adults as well as children. Newly discovered principles of adult neuroplasticity are at the heart of some of the most revolutionary and groundbreaking brain research.

Constantly living in anticipatory pain actually changes your neuro network. Although learning and practicing ways to change your beliefs, thoughts, and conclusions about pain can also change your neuro network, so you will eventually move beyond your previous anticipatory pain responses.

Pain research presented by the American Society of Anesthesiologists has emphasized the molecular transduction of painful stimuli, the sensitization processes that occur after injury and long-term phenomena such as pain memory. Neuroplasticity after surgery occurs at the transduction process, in the periphery at the sub-cellular level, or in the central nervous system, where central sensitization occurs.

According to Kenneth Sufka in his article published in Brain and Mind Journal in 2004:

Pain that persist long after damaged tissue has recovered remain a perplexing phenomenon. This so-called chronic pain serves no useful function for an organism and, given its disabling effects, might even be considered maladaptive. However, a remarkable similarity exists between the neural bases that underlie the hallmark symptoms of chronic pain and those that serve learning and memory. Both phenomena, wind-up in the pain literature and long-term potentiation (LTP) in the learning and memory literature, are forms of neuroplasticity in which increased neural activity leads to a long lasting increase in the excitability of neurons through structural modifications at pre- and post-synaptic sites.

Cognitive Behavioral Restructuring for Reprogramming the Neuro Network
As my friend and mentor Terry Gorski says, language is the key to reprogramming the neuro network. I’ve adapted Mr. Gorski’s TFUAR (Thoughts, Feelings, Urges, Actions, and Reactions) cognitive behavioral restructuring model for chronic pain management; especially for moving beyond anticipatory pain. Below are some basic principles that can help you to better understand how the TFUAR process works.

The main premise is: Thoughts cause Feelings. Whenever we think about something we automatically react by having a feeling or an emotion.

Thoughts and Feelings work together to cause Urges. Your way of thinking causes you to feel certain feelings. These feelings, in turn, reinforce the way that you are thinking. These thoughts and feelings work together to create an urge, or impulse, to do something. An urge is a desire that may be rational or irrational. Sometimes the irrational urge is to isolate and give into your depression. At other times you might be tempted to use inappropriate chronic pain management medication, including alcohol or other drugs, even though you know that it will hurt you, which is also called craving. Other times you want to use self-defeating behaviors that at some level you know will not be good for you and could worsen your depression.

Urges plus Decisions cause Actions. A decision is a choice. A choice is specific way of thinking that causes you to commit to one way of doing things while refusing to do anything else. The space between the urge and the action is always filled with a decision. This decision may be an automatic and unconscious choice that you have learned to make without having to think about it, or this decision can be based upon a conscious choice that results from carefully reflecting upon the situation and the options available for dealing with it.

Actions cause Reactions from other people. Your actions affect other people and cause them to react to you. It is helpful to think about your behavior like invitations that you give to other people to treat you in certain ways. Some behaviors invite people to be nice to you and to treat you with respect. Other behaviors invite people to argue and fight with you or to put you down. In every social situation you share a part of the responsibility for what happens because you are constantly inviting people to respond to you by the actions you take and how you react to what other people do. Sometimes these reactions help you manage your pain more effectively, but at other times it leads to increased stress levels that cause you to making poor decisions.

This TUFAR process is a suggested starting point to support you in moving beyond anticipatory pain so you can develop an a more effective chronic pain management plan. However, this is only a first step, although a critical one, that needs to be enhanced as you move forward in your chronic pain management journey. Please remember that the anticipatory response can also work for you. If you expect to have success with your chronic pain management that is what you will tend to manifest. You can learn to make this a positive self-fulfilling prophecy and continue to move beyond anticipatory pain.