Emotional pain and chronic physical pain are bidirectional: exclusive use of opioid cannot resolve the problem

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A broken heart is often harder to heal than a broken leg. Now researchers say that a broken heart can contribute to lasting chronic pain.

In a reflections column published Dec. 21 in the Annals of Family Medicine, pain experts Mark Sullivan and Jane Ballantyne at the University of Washington School of Medicine, say emotional pain and chronic physical pain are bidirectional. Painkillers, they said, ultimately make things worse.

Their argument is based on new epidemiological and neuroscientific evidence, which suggests emotional pain activates many of the same limbic brain centers as physical pain.

This is especially true, they said, for the most common chronic pain syndromes – back pain, headaches, and fibromyalgia.

Opioids may make patients feel better early on, but over the long term these drugs cause all kinds of havoc on their well-being, the researchers said.

“Their social and emotional functioning is messed up under a wet blanket of opioids,” Sullivan said.

The researchers said new evidence suggests that the body’s reward system may be more important than tissue damage in the transition from acute to chronic pain.

By reward system, they are referring, in part, to the endogenous opioid system, a complicated system connected to several areas of the brain, The system includes the natural release of endorphins from pleasurable activities.

When this reward system is damaged by manufactured opioids, it perpetuates isolation and chronic illness and is a strong risk factor for depression, they said.

“Rather than helping the pain for which the opioid was originally sought, persistent opioid use may be chasing the pain in a circular manner, diminishing natural rewards from normal sources of pleasure, and increasing social isolation,” they wrote.

Both Sullivan and Ballantyne prescribe opioids for their patients and say they have a role in short-term use.

“Long-term opioid therapy that lasts months and perhaps years should be a rare occurrence because it does not treat chronic pain well, it impairs human social and emotional function, and can lead to opioid dependence or addiction,” they wrote.

What Sullivan recommends is if patients are on high-dose long-term opioids and they are not having clear improvement in pain and function, they need to taper down or switch to buprenorphine.

If available, a multidisciplinary pain program using a case manager to monitor their care and well-being, similar to those for diabetes and depression care, may be of benefit.


The present article reports a study that examined the possible relationship between psychological and social factors – anxiety, depression, current stress, quality of life, childhood trauma, as well as pain – and Body Perception Disturbance (BPD) in Complex Regional Pain Syndrome (CRPS). Complex Regional Pain Syndrome is a painful condition affecting the extremities.

It is usually caused by physical trauma and characterized by severe pain. The intensity of the pain stands in no relation to the initiating incident. Pain, as well as the concomitant motor, sensory and autonomic disturbances, typically extends distally beyond the original area of the injury and does not follow the innervation areas of nerves (Schwartzman et al. 2009).

The rate of CRPS is three to four times higher in women than in men (de Mos et al. 2007) and is associated with negative consequences in terms of psychological and social functioning (Lohnberg and Altmaier 2013; Sohn et al. 2016). The connection between chronic pain and adverse psychological (Dersh et al. 2002; Wilson et al. 2002) and social (Gatchel et al. 2007; Turk et al. 2008) effects is well established.

The hypothesis that psychological and social factors influence the development of CRPS has received mixed support. Stressful life events in the year before CRPS onset have been suspected to play an important role; however, results have not been conclusive (Geertzen et al. 1998; Monti et al. 1998).

Beerthuizen et al. (2009) conducted a comprehensive review and found no relationship between chronic CRPS and psychological and social factors. The research group then conducted a large prospective multicenter study (Beerthuizen et al. 2011) and found that depression, anxiety and other psychological factors, as well as stressful life events, did not predict the development of CRPS in patients suffering a physical trauma.

Although such a finding needs to be replicated, it suggests that anxiety, depression, and pre-existing stress are not causative factors for CRPS. Rather, these psychological conditions are likely to be sequelae of CRPS. Studies have shown that chronic pain leads to elevated depression and anxiety (Gore et al. 2012), spatial working memory deficits (Kim et al. 2012), and problems in emotional decision making (Apkarian et al. 2004; Gupta et al. 2009).

These results corroborate the idea that instead of serving as predisposing psychological risk factors, psychological abnormalities in CRPS seem to be a consequence of chronic pain and disability and the resulting changes in the brain.

Indeed, studies employing structural and functional magnetic resonance imaging (Barad et al. 2014; Hotta et al. 2017; Maihöfner et al. 2004; Pleger et al. 2014; Shokouhi et al. 2017) and magnetoencephalographic recordings (Buntjen et al. 2017) have shown cortical reorganization of the primary somatosensory cortex, altered grey matter structure, abnormal brain system morphology, and changed neural activities in brain areas dealing with sensorimotor functions, pain perception, and emotional experiencing.

The prefrontal cortex is thinner in patients suffering from CRPS than in healthy controls (Lee et al. 2015), resulting in impairment of executive functions (Libon et al. 2010) as well as disinhibited pain perception. These results indicate that psychological and cognitive changes in patients with CRPS are due to physiological alterations in the brain (Schwartzman et al. 2009).

This neuroplasticity is particularly crucial to understanding the change in body perception in CRPS. It is estimated that between 50% to 80% of patients with CRPS develop so-called “neglect-like symptoms” (Förderreuther et al. 2004; Galer and Jensen 1999; Lewis et al. 2007), similar to those seen in patients who have had a right-sided stroke (Förderreuther et al. 2004; Frettlöh et al. 2006; Kolb et al. 2012).

However, studies have shown that neglect-like symptoms in CRPS are not quite the same as in patients who have had a stroke (Förderreuther et al. 2004; Frettlöh et al. 2006; Kolb et al. 2012). Therefore, the term body perception disturbance (BPD) was introduced (Lewis et al. 2007; Lewis and McCabe 2010).

Body perception disturbance encompasses elements of body schema (for example, reduced proprioceptive acuity and mislocalization of tactile stimuli) and body image disturbance (for example, the affected limb is perceived to be larger and not belonging to the body (Moseley et al. 2012; Trojan et al. 2019). Body schema is defined as a “non-conscious system of processes that constantly regulate posture and movement” (Gallagher 1986), and is maintained through tactile, visual and proprioceptive stimuli.

The primary (S1) and secondary (S2) somatosensory cortices (Maihöfner et al. 2004; Pleger et al. 2014) as well as the motor cortex (M1) and occipitotemporal cortex (OTC) (Orlov et al. 2010) play an important role in forming and maintaining body schemata.

In turn, body schema influences a person’s body image, defined as “a system of sometimes conscious perceptions, attitudes, and beliefs pertaining to one’s own body” (Gallagher 1986). Body image is easily manipulated, not only in persons with chronic pain conditions but also in people with no pain or other medical conditions (Giummarra et al. 2008; Lackner 1988; Ramachandran 1998).

Because personal beliefs, memories, physical changes, as well as psychosocial factors can have modulating effects, a person’s body image is considered unstable. For example, it has been shown that depression and anxiety as well as physical and emotional trauma affect a person’s body image (Fang et al. 2015; Levine et al. 2005; Sabik 2017; Sack et al. 2010; Taylor and Pooley 2017).

Bean and colleagues (Bean et al. 2015) found that patients with CRPS who had low levels of anxiety and disability at the time of diagnosis also reported the least pain – and conversely, those with the highest levels of anxiety had the highest amount of pain. This held true for the twelve months following the diagnosis.

Poorer outcome after one year was associated with anxiety and pain-related fear. Depression, anxiety and pain intensity are also predictors of disability in CRPS (Bean et al. 2014). Symptoms of a changed body image are prevalent in other chronic pain conditions although not as severe as in CRPS (Frettlöh et al. 2006; Michal et al. 2017).

Studies have shown that pain severity and the degree of felt body image distortion are linked (Senkowski and Heinz 2016; Wittkopf et al. 2018). Punt and colleagues (Punt et al. 2013) argue that due to pain and immobility in CRPS, fear-avoidance behavior develops, resulting in suppression of movement. This so-called “learned nonuse” leads to modifications in the cortical regions representing the diseased body part.

Traumatic childhood experiences are another possible factor influencing the development of CRPS and therefore, BPD. An increasing number of studies support the hypothesis that traumatic experiences in childhood, i.e. sexual, physical and emotional abuse, significantly increase the risk of developing psychological and physical diseases in later life, in particular diseases with inflammatory processes (Burke et al. 2017; Davis et al. 2019; Dube et al. 2009; Felitti 2009; Kraynak et al. 2019; Van Niel et al. 2014). Similar to CRPS, the affected population is predominantly female.

Patients with a history of abuse often suffer from body image disturbance, which is also associated with other comorbidities, such as depression, anxiety, borderline personality disorder, and eating disorders (Dyer et al. 2013; Malecki et al. 2018). Therefore, it seems possible that individuals with traumatic experiences may be more likely to develop CRPS.

There is no consistent evidence to determine whether BPD symptoms arise as a direct result of CRPS-induced changes in specific brain areas; or if these symptoms occur in response to maladaptive learning (e.g. fear-avoidance behavior); or if BPD is influenced by psychological and social factors (Michal et al. 2017). Based on the literature, the present study sought to examine the possible role of psychological and social factors in BPD.

Based on the research described above, we tested the following three hypotheses:

1. In chronic CRPS Type I of the upper extremity, the severity of body schema disturbance correlates positively with psychological and social factors, including depression, anxiety, current stress, quality of life, traumatic experiences during childhood, stressful life events in the 12 months before onset of the disease;

2. In chronic CRPS Type I of the upper extremity, severity of body schema disturbance correlates positively with pain intensity;

3. In chronic CRPS Type I of the upper extremity, severity of body schema disturbance correlates positively with duration of the disease.

reference link : https://link.springer.com/article/10.1007/s12144-020-00635-1


Source: University of Washington

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