It Is Not All In Your Head

But Where is It?

Chronic back pain is a debilitating condition that affects up to 20% of people. It causes real suffering and prompts billions of dollars in annual healthcare expenditures. Although serious underlying pathology can cause chronic back pain, in many cases even extensive diagnostic workups do not yield a reason for even very severe symptoms. But back pain really hurts and people who have it do not want to be told the pain is “all in your head” just because doctors cannot find a medical reason for it.

         How then to explain a recent study in which a psychological treatment for chronic back pain produced substantial, lasting relief? A collaboration of scientists led by investigators at Weill Cornell Medical College and Dartmouth College randomized people suffering with moderately severe chronic back pain to receive a psychological intervention called pain reprocessing therapy (PRT), saline injections in the back (placebo), or usual treatment. At one year follow-up, two-thirds of the patients randomized to PRT reported being completely or nearly-completely pain free, compared to 20% in the placebo group and 10% in the usual care group. The investigators also performed functional magnetic resonance imaging (fMRI) scans on the participants and showed small but significant changes in brain activity in the PRT group in areas of the brain known to be involved in pain perception and interpretation, like the anterior insula and anterior cingulate cortex.

Chronic back pain is a common and debilitating condition that prompts extensive healthcare utilization but often has no apparent cause and is difficult to treat. A psychological treatment, however, was recently reported to be very effective in relieving pain (image: Shutterstock).

         The psychological treatment in this study—pain reprocessing therapy (PRT)—is described by the study authors as seeking to “promote patients’ reconceptualization of primary… chronic pain as a brain-generated false alarm. PRT shares some concepts and techniques with existing treatments for pain and with the cognitive behavioral treatment of panic disorder.” Patients randomized to PRT had one telehealth evaluation and educational session with a physician and then eight one-hour sessions with a PRT therapist. The results of the study, which were published in JAMA Psychiatry, are clearly impressive. Chronic back pain usually does not remit on its own and indeed in this study patients who received placebo or usual care for chronic back pain were for the most part still in pain at the one-year follow-up point.

Why Should a Psychological Treatment Work?

         So, if a psychological treatment is effective in relieving pain that clearly emanates from someone’s back, what does that tell us about the origin of the pain? There are many other instances in which pain and other symptoms that are experienced in various parts of the body but for which no underlying medical pathology is found respond to psychological treatment. Cognitive behavioral psychotherapy (CBT), for example, is an effective treatment for irritable bowel syndrome, a condition characterized by abdominal pain and other gastrointestinal symptoms.

         The reason why psychological treatments work for painful conditions is not a  surprise to neuroscientists, but seems hard for some people to accept. While back pain is not “all in your head,” the brain is. Think for a moment about what happened the last time you accidentally touched a hot object, like a hot stove. Without thinking your hand immediately withdrew and then fractions of a second later you felt the pain. The reason for the delay in pain perception in this situation is that it takes longer for neural impulses to travel from sensory receptors in the skin of the hand to the brain than it does to travel to neurons in the spinal cord, where the reflex arc that causes your hand to pull back is initiated. It is only when the neural impulses reach specific regions in the brain that you can feel pain. In that sense, all pain is “in your brain” and therefore interventions that operate at the level of the brain, like psychotherapy, have the capacity to alter our perception of pain.

Neural impulses from sensory receptors in the skin travel first to the spinal cord and then to the brain. This explains why we withdraw our hand from a hot object before we actually feel the painful sensation (image: Shutterstock). 

         What we have described with the reflex arc that occurs when we touch hot objects does not mean that someone who touches a hot stove is “making the pain up” or that the pain we feel when we touch hot stoves is “psychosomatic.”  It means that pain is a symptom dependent on a particular organ of the body, the brain, which is susceptible to psychological intervention. Other symptoms of common diseases are similarly dependent on the brain, like fatigue, memory problems, and, of course, “brain fog.” Incidentally, the specific regions of the brain that perceive pain in the hot stove example, like the anterior insula and anterior cingulate cortex, are also the ones where changes in brain activity were seen on the fMRI scans in the patients with chronic back pain who received the psychological intervention PRT.

         It is probably the case that almost all “physical” illnesses have at least some components that are brain related. Sometimes this is the sadness, anger, and other emotions that often occur to us when we are seriously sick. In other instances, however, the brain is intimately involved in the basic physiology of the illness, as appears to be the case with chronic back pain, irritable bowel syndrome, long COVID, and a host of other syndromes for which obvious medical causes are elusive but suffering and disability are real.

         The chronic back pain study tells us that considerations of providing psychological interventions should be a prominent part of the approach to many illnesses. This starts with how healthcare professionals talk to patients about the steps they take to evaluate and treat an ailment. If a doctor first performs a lengthy work-up of some pain complaint that is bedeviling her patient, for example, finds no abnormalities on a myriad of tests, and then says “I can’t find anything wrong, it must be psychological,” it is likely that the patient will feel dismissed and angry. But if that doctor begins the evaluation by saying “it is often the case that even the most sophisticated tests don’t show anything, so we won’t be surprised if all the tests come back with normal results. We have good treatment options if that is what we get and we’ll work together to help you with your symptoms,” it is more likely that the doctor establishes a collaborative and trusting relationship with her patient in pain, one that has a better chance of seeing the patient get better. Some of the effective interventions in such situations will, unsurprisingly, be psychological. We need to better prepare and educate both healthcare professionals and patients that this is so. 

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