Overcoming Perfectionism

In the last post, we discussed the nature of perfectionism and the problems associated with it. Specifically, we reviewed how perfectionism is problematic and how perfectionism leads to poor coping with chronic pain. In this post, let’s review some basic ways to begin to overcome perfectionism.

Accepting the problematic nature of perfectionism

The most basic step to overcome perfectionism is to recognize and accept that perfectionism is a problem. Despite the kudos that perfectionists might receive for the excellent quality of work that they do, perfectionism comes at a price. The perfectionist, as we saw in the previous post, lives with low-level emotional distress:

  • Nervousness (i.e., can’t sit still)
  • A persistent lack of satisfaction (i.e., things are never quite good enough)
  • Time pressure (i.e., there’s always more to do)
  • A persistent sense of self-criticism (i.e., the perfectionist rarely feels good enough)

Technically, what we are talking about is anxiety and the compulsive need to always do something just a little bit better. The compulsive behavior quiets the anxiety, but only temporarily. It lasts only until you see something else that needs to be done, which usually occurs not long after completing the previous task.

Moreover, none of these characteristics make for effective coping with chronic pain. In fact, they lend themselves to poor coping:

  • Failure to pace one’s activities
  • All-or-nothing approaches to life activities, which lead to persistent exacerbations of pain
  • Anxiety and depression
  • Problems in relationships

So, the first step in the process of overcoming perfectionism is to recognize that it is a problem.

This recognition and acceptance is difficult for some perfectionists. The degree of difficulty depends on the degree to which the perfectionist has skill sets that psychologists refer to as insightfulness and ego strength. These skill sets are important to understand because they have to be developed in order to overcome perfectionism (or most any other unwanted personality trait).

The prerequisite skill sets for learning and self-growth

The capacity for insight involves the ability to reflect on one’s own thoughts, feelings, intentions, or actions. People with insight can step outside of themselves and observe themselves. In so doing, they consider how they have been thinking, feeling, and behaving. This skill set is also sometimes called an ‘observing ego’ or an ‘observational self.’ Whatever we call it, it’s the ability to take yourself as your own object of observation, reflecting on your inner workings and outward behaviors.

The skill set of insightfulness allows you to self-correct and learn from feedback. Suppose someone doesn’t see the error of his ways. Others might point it out, but the person doesn’t see it and so doesn’t take heed. Instead, she continues to think that what she thinks or feels or does is right or accurate or warranted (whatever the case may be). What would allow her to see the error of her ways? It usually doesn’t help to get mad and yell at her, right? What helps in such situations is to help her to be able to step outside of herself and reflect on her thoughts, feeling or actions. We might help her to see that her perspective is but one of many perspectives. Moreover, we would help her to start weighing her perspective against other perspectives, coming to reflect on which ones are more true or accurate or warranted.

In so doing, she comes to the insight that what she thought wasn’t true or what she did wasn’t warranted. In short, she comes to the realization that she was making a mistake, but didn’t know it at the time, but now she does. In other words, she developed insight.

From here, we can see that the skill set of insightfulness goes hand in hand with another skill that we discussed in the previous post: ego strength. If you recall, ego strength is the ability to accept and learn from the feedback of others. To tolerate feedback from others, you have to be able to see that your thoughts and feelings are but one perspective among many and to reflect on how the perspectives of others may have more or less merit than your own. You subsequently come to see that how you had been thinking or feeling may or may not have been right in some way and as a result you learn and grow.

No one learns in a vacuum. Most of the time, in order to learn, we need others to point it out to us, to teach us, to show us. We thus need to be open to the feedback that others can provide.

So, in short, what we have been talking about are the pre-requisite skills for learning and self-growth. They are the following two abilities:

  • To be insightful
  • To accept feedback from others

They allow us to understand that not everything we think or feel is right (i.e., insightfulness) and be open to viewpoints that might differ from our own (i.e., ego strength).

The spectrum of skills

Like any other skills in life, the skill sets of insightfulness and ego strength vary across people. We can see them as occurring along a spectrum from those who aren’t very good at them to those who are really good at them.

The good news is that these skills can be learned, just as any other set of skills can be learned. Sometimes, it takes time and sensitivity, but they can be learned. Typically, people learn such skills in psychotherapy because it allows for learning in a safe and trusting environment in which sensitive issues can be discussed without criticism or judgment.

So, no matter how good you currently are at these skill sets, you can always learn to do them better.

Relationship of insightfulness and ego strength to perfectionism

The skill sets of insightfulness and ego strength lend themselves to personal growth across all facets of life, including learning to overcome perfectionism. They allow the perfectionist to step outside himself and reflect on whether his drive to do better or to do more is really necessary. Without this capacity to self-reflect, the perfectionist simply takes his perfectionistic drive as obviously warranted and persistently engages in excessive activities, attempting to attain some unattainable, perfectionistic standard. With self-reflectiveness and openness to feedback from others, the perfectionist can catch himself in such thoughts and behaviors, consider whether they are warranted, and make an intentional decision to do something different.

Let’s take an example. Suppose a perfectionist with chronic pain wakes up one day with relatively little pain. He’s pleased by the good fortune of a good pain day and thinks, “Oh good, I’m going to get this filthy house clean (or my taxes done or clean the garage).” Prior to this day, he had been beating himself up for having allowed the house to get so messy, even though others in the family might think that the state of the house is pretty clean, or at least clean enough. Nonetheless, as a result of his relatively low level of pain today, our perfectionist comes to clean the entire house and makes it look perfect. In so doing, he relieves himself of the low level of guilt he had been carrying around for the previously perceived lack of cleanliness of his house. For these positive outcomes, he pays the price of exacerbating his pain and being laid up for the next few days.

Notice in our example that our friend never stops to consider whether his perceptions of the house as ‘filthy’ are accurate. He doesn’t reflect on whether making an already fairly clean house into a perfectly clean house is truly warranted. So too, he fails to consider the predictable consequences of his all-or-nothing approach to house cleaning – i.e., cleaning the entire house in one day.

I once worked with a man who had never considered the fact that most people don’t vacuum their carpets every day. When he finally came to believe me, the conclusion he came to was that most people must be slobs. In the course of the discussion, it didn’t ever occur to him that he was the outlier.

How do you intervene in the face of such perfectionism? Unfortunately, what often happens is that family and friends become frustrated and throw up their hands. Worse yet, some might even get angry and chastise our friend for doing too much and exacerbating his pain. Such reactions only serve to isolate the perfectionist as we saw in the previous post.

What happens, though, if we approached our friend with sensitivity to help him entertain the idea that his house is already clean enough. Remember, it was the perception of others in his family and, because we know our friend well, we know that his perceptions of what is clean or not are usually the outlier and that his family’s perceptions tend to be more accurate. So, in other words, what if we help him to see that his perfectionistic standards color his perceptions. In so doing, he comes to see that there are other legitimate ways to see things. From here, he might progress to the point of doing it on his own: that he can begin to weigh different perspectives against each other and subsequently come to see that he tends to be an outlier in how he sees the world. Still later, he might come to see that the standards of the majority are most often right – that good can truly be good enough. At this point in the process of overcoming perfectionism, he’s ready to practice this insight over and over again.

Practice

Learning any skill requires practice. Typically, you don’t try something once and then have it down pat for the rest of your life. No, to learn something and become proficient at it, you have to practice. So too it is with catching yourself in your perfectionistic tendencies and changing them.

You use the skill sets of insightfulness and ego strength to catch yourself. You literally practice being self-reflective and being open to feedback from others.

It’s actually a very difficult thing to do. Our thoughts, feelings, decisions, and subsequent behaviors fly by almost instantaneously without a moment’s notice. It’s this lack of noticing that makes everything that happens between the ears seem to fly by. We are, of course, the pilots of our own planes, but more often than not we are on autopilot. As such, we simply and automatically react to the events of life as they happen without ever making any intentional decisions to react in the ways we do. That is to say, we typically don’t pay attention to our thoughts and feelings and make an intentional choice as to how to respond to the events of our daily life. However, if we set out to practice remaining aware of our thoughts and feelings and reactions, we can subsequently become more intentional about our actions. It is here where you can begin to break the habits of acting out perfectionistic tendencies. However, this degree of self-awareness and intentionality is difficult for at least two reasons:

  • It’s difficult to remember to pay attention and maintain a degree of self-observation.
  • It’s difficult to gain intentional control over compulsive behaviors, such as acting on perfectionistic needs to do more or do something better.

Oftentimes, when setting out to make personal changes, it’s easy to forget to continue making the change almost as soon as you start. It might be a day or two or even a week before you realize that you haven’t been doing it and in fact had forgotten all about it.

There are a number of ways that you might try to remember to practice your self-awareness. You might, for instance, take some sticky notes and write the phrase ‘self-observation’ on them and then place them strategically around the house. You’ll run into them as you go about your daily life and they can serve as a reminder. You might also place a smooth stone in your front pocket and every time you accidentally touch it, it will serve to remind you to check in with yourself about what it is you are thinking, feeling and doing. If you are religious and have a prayer routine, you could add your intentions to practice self-awareness to your list of prayers. Maybe also you ask some trusted loved ones to help remind you to check in with yourself, especially if they see you engaging in perfectionistic thinking or behavior. When asking others for such help, it’s usually best to agree on some non-critical phrase that they will use when reminding you, such as, “I’m thinking it might be a good time to check in with yourself.” In any of these ways, you get reminders to practice self-observation.

Once you are practicing this kind of self-observation, you might notice that you can sometimes be aware of your perfectionistic tendencies, but be unable to stop yourself from acting on them. Old habits die hard, as the saying goes. This experience is a normal stage in the process of change. Try not to be critical with yourself. Keep trying to catch yourself in the moment and make an intentional decision as to what you are doing. You will get better at it with practice.

Remember that in the course of practicing any new skill there is a stage in which it is uncomfortable. When you first learn to play a musical instrument or a sport, there’s a time in which you aren’t very good at it and it’s sort of an unpleasant experience. Your jobs at that point are to simply tolerate this discomfort and continue to practice. With time and patience, you will get better and it is will become easier and more pleasant.

It helps to foster a sense of curiosity and humor with yourself. It oftentimes seems that those who make personal changes easiest are those who become pleased or excited when making connections between some insight they had and their own behavior. When catching themselves in some behavior that they want to change, they exclaim, “Oh there I go again!” but do so with a light-hearted curiosity or even some humor. In the right spirit, insightfulness can oftentimes be funny. It can also foster a certain sense of appreciation or fascination for how complicated we are as humans.

Conclusion

In summary, what you are practicing is the following:

  • Remaining observant of your thoughts, feelings, intentions (or lack thereof) and behaviors
  • Come to recognize that your perfectionism clouds your perceptions and that your perceptions can tend to be outliers when compared with those of others (i.e., you might tend to see something as not good enough when in fact most others would see that it is good enough)
  • Make an intentional decision to do something different than your usual attempts to make something better when it’s already good enough (i.e., you practice being satisfied)

The ultimate goal is to become satisfied when things are good enough. When you can do that, you’ll have a handle on your perfectionism.

Author: Murray J. McAllister, PsyD

Date of last modification: June 8, 2015

Catastrophizing and Chronic Pain

It’s not uncommon to exclaim, at the beginning of a pain flare, “I’m not going to be able to stand it!” Another might express, “Now, I’m not going to be able to do anything today!” Yet, another takes it as a given that the increased pain is an indicator that the underlying health problem is getting worse. From this assumption, it’s easy to start thinking about how the future holds nothing but increasing disability, wheelchairs, and suffering.

These sentiments are examples of catastrophizing.

What is catastrophizing?

Catastrophizing is what we do when we see something through the lens of it being the worst-case scenario. We believe and feel that something is worse than it actually is.

We all do it. Everyone catastrophizes at least occasionally. Some of us do it a lot. Most of us are somewhere in between. The point, though, is that we all do it.

The most common example of catastrophizing is simple worrying. When we worry, we don’t ponder good things happening to us. We don’t even tend to think about minimally bad things happening to us, such as inconveniences or hassles. We don’t tend to waste a lot of time worrying about those things. Rather, it’s the really bad stuff that we tend to worry about. It’s the worst-case scenarios that hold our attention and get us worked up.

Now, the thing about catastrophizing is that we tend to overestimate the likelihood that the worst-case scenarios will occur. Of course, worst-case scenarios are possible. Sometimes, they do in fact occur. If, however, we step back and take a real objective look at them, we might compare how often they occur with the countless number of times when they don’t occur. The comparison is stark. Worst-case scenarios are possible, but they are not likely. They tend to be once or twice in a lifetime events. When catastrophizing, though, we see the worst-case scenario as all-but-inevitable or, worse yet, already happening. There’s an assumption of certainty about it. That is to say, this sense of certainty comes about by overestimating the likelihood of the worst-case scenario.

Like anyone else, people with chronic pain can catastrophize. Take the common sentiments expressed in the above examples. When experiencing a pain flare, common automatic reactions are that you aren’t going to be able to stand it or that now you’ll never get anything done or that you think the increased pain is indicative of an inevitable worsening of the underlying health condition that initially started the pain. There is a sense of certainty that goes along with these automatic reactions. You just “know” that you won’t ever be able to stand it, or that you’ll never be able to get anything done, or that increasing disability is inevitable. However, if you can step out of the moment, and hold on your judgment of such certainty, you might begin to reflect on how true, really, these sentiments are.

What makes you so sure that you’ll ‘never be able to stand it’? How do you ‘know’ that this pain flare is going to be the whopper of all whoppers? Maybe it would be best to hold judgment, and see if it will be as bad as you anticipate. It might just turn out to be a run-of-the-mill flare. In fact, it is much more likely that it will be an average pain flare than the one that you’ll ‘never be able to stand.’

How warranted is your certainty that you’ll ‘never be able get anything done’? How likely is that scenario to occur? With a little creativity, there is almost always going to be something that you can do, even while experiencing a pain flare. Maybe you could sit and pay bills. Maybe you could call someone who you have been meaning to call but haven’t gotten around to it. Maybe you are at work and you decide to use the afternoon to catch up on reports and emails. You sit for a while at the computer and then you stand for a while at the computer, putting a few books under the keyboard, so you can still work at the computer. You also might take breaks to walk the hallway or stretch or both. Now, it won’t be the most productive day you’ll ever have, but, with pacing and a little adaptability, it’s much more likely that you’ll be able to do something productive.

What about the certainty that your pain flare is a sign of your inevitable decline? How true is that worst-case scenario? Of course, it is possible, but it’s not very likely. The nature of chronic pain is that pain waxes and wanes – pain flares come and pain flares go. What’s the likelihood that this pain flare is the one that won’t ever go away and from which you’ll start the decline into becoming wheelchair-bound? Isn’t it much more likely that this pain flare, like the others that come before it, will come and go?

While always possible, worst-case scenarios are low probability events. When we catastrophize, though, we overestimate the likelihood that the worst-case scenario will occur and become certain that it will happen or is already happening. We lose perspective on the problem and become certain that it is worse than it actually is.

Catastrophizing influences our perceptions

The sense of certainty that goes along with catastrophizing colors our perceptions, making what we experience worse than it actually is. This fact is what leads psychologists to categorize catastrophizing as a form of cognitive distortion. Catastrophizing distorts what it is we perceive.

It’s not very mysterious. Rather, it’s super common. We can think of any number of examples. Suppose your boss makes a critical remark about you and later looks at you strange after you say something in a meeting. You associate these events with some problems you have been having at work and before you know it you are taking the boss’ remark and the look as confirmation that any day now you are going to be let go. If you don’t step out of the moment, and gain some perspective on how you are perceiving these events, your experience is that you simply and unquestionably are in the process of getting fired and it can’t get much worse. To take another example, suppose you are arguing with your spouse and he or she walks out of the room hurt and angry. Your first thought is that your last hurtful remark put your spouse over the edge and that he or she is now leaving you. Your immediate reaction is one of ‘Don’t leave me!’ For the moment, your thoughts are going a million miles an hour and you have all the accompanying feelings of fear, anger, and abandonment. If you don’t step out of the moment, get grounded, and reflect on what’s going on, your experience is that your marriage is unquestionably ending and it can’t get much worse. In both these cases, we see that catastrophizing distorts our experience of what is really happening.

Catastrophizing tends to happen when we are ungrounded, vulnerable, anxious, or upset already and then something bad happens. In such cases, it’s hard to see the problem clearly. We are too ungrounded or anxious or upset. As such, the overall experience of the problem is that it is worse than it actually is. Conversely, when a problem occurs during a time that we are grounded, focused, supported, and confident, we deal much better with it because, in part, we see the problem more accurately.

The two parts that make up experience

This last notion leads to an exceptionally important, yet often overlooked, fact about human experience. We tend to think that whatever it is that we experience is solely due to what is happening to us. That is to say, we often simply assume that the quality and intensity of our experiences are only due to the qualities and severity of the external things that occur to us. It’s as if we forget that there’s a perceiving subject, who has these experiences.

Now, of course, what we experience is determined in part by external events – what they are, whether they are bad or good, and how bad or good they are. But, our experience is also determined in part by where we are at when these events occur.

When we are grounded and present, we might notice the beautiful sunset and fully appreciate it. The sunset subsequently might have a big impact on us. If, however, we are lost in our thoughts, or fretting because we are stuck in rush hour traffic, we might hardly even notice the beautiful sunset, let alone appreciate it, and subsequently it has little to no impact on us. It’s the same external event, but two very different experiences and the experience is determined by how we are at the time of the external event.

Human experience is made up from two parts: 1) the things that happen to us and 2) how we are when things happen to us. When we are grounded, supported, confident and well-rested, we tend to experience the same event differently than when we are anxious, upset, vulnerable, lonely, abandoned, or overly tired and fatigued.

Catastrophizing is one of the ways that we color our perceptions of events when we come to the event feeling anxious, upset, vulnerable, left alone, or fatigued.

Catastrophizing is all-too-human

Sometimes, people are reluctant to acknowledge that they catastrophize. You can sometimes feel judged when people tell you that you’re making a mountain out of a molehill. You might automatically want to respond with assertions that the problem really is that bad — it really is catastrophic — and then feel invalidated when they don’t believe you.

It’s important to remember, though, that we all do it. It’s part of our all-too-human condition. Human beings are not perfect. We are not omnipotently objective observers of the things that happen to us. We have all sorts of beliefs, attitudes, and feelings that bias and distort our perceptions. And, yes, we also catastrophize. All of us sometimes perceive things as worse than they really are. Some people do it rarely while other people do it a lot. Most of us are somewhere in between, catastrophizing more than rarely and less than all the time.

A good healthcare provider tends to remind us of things that we already know, but tend to forget in our day-to-day routines. One of these reminders is that it is a mark of health to be able to admit our imperfections. The first step towards getting better with regard to a problem is always to admit that you have the problem. In the case of catastrophizing, it’s a mark of health when we can acknowledge that we catastrophize, especially at the time when we are actually doing it. Indeed, an important health skill is the ability to step out of any given moment, reflect on what’s going on, and come to see the problem more clearly. By gaining perspective on the problem, we reduce the distress that’s associated with the problem and the problem comes to no longer have such a big impact on our lives. The problem comes to be less problematic as we initially experienced it to be.

This process is one of the many ways that people come to cope better with problems in life, including chronic pain. That is to say, we come to cope better with a problem when we get better at catching ourselves catastrophizing it, acknowledge that we are doing it, and reality-checking it. We thereby come to see the problem more clearly and subsequently we cope with it better– the problem becomes less distressing and less impairing.

Author: Murray J. McAllister, PsyD

Date of last modification: 11-24-2013

Stress and Chronic Pain

“Why do you guys always want to know how much stress I have?” While the patient who asked this question the other day had fibromyalgia, she could have had chronic low back or neck pain, chronic daily headaches, complex regional pain syndrome, or any other chronic pain condition. She was expressing a sentiment that I often hear in one form or another. It goes something like the following: ‘I’m hear to talk about my pain and what we can do about it, but you ask me about all these things that are unrelated to pain, like whether I worry, whether the worry keeps me up at night, what’s going on at home, whether my spouse believes me that I hurt as much as I do. In effect, I’m here to talk about my pain but you want to know how stressed I am. Why?’

It’s true. Providers who specialize in chronic pain rehabilitation always evaluate the patient’s pain, of course, but they also always assess the stressful problems that the patient experiences. To the list above, we might add such stressors as depression, anxiety, past trauma, sleep problems, persistent problems with concentration and short-term memory, financial problems, loss of the role in your occupation or family, the loss of sexual and emotional intimacy in your relationship, and the list could go on. All these problems cause stress, which is why we call them stressors. Why is it important to deal with stressors when having chronic pain?

There are a number of reasons why it is important, but let’s review two today:

  • If you can’t fix the pain, you might as well work on reducing the problems that occur because of the pain.
  • To successfully self-manage chronic pain, you have to manage your stress.

Let’s look at these reasons one at a time.

Stress caused by pain

Understandably, patients with chronic pain want to focus on how to reduce pain. To some extent, this focus is helpful. There are indeed a number of lifestyle changes, such as mild aerobic exercise and regular relaxation exercises, which, when done over time, can reduce pain. There are some medications, such as tricyclic antidepressants and antiepileptics, which have been shown to reduce pain too. However, these treatments are only so effective. We really don’t have any treatments that are super effective for chronic pain. (Procedures, such as injection therapies and spine surgeries, are known to be largely ineffective, despite how often they are pursued.) At the end of the day, chronic pain is chronic. It’s not ultimately fixable. While some of things that can be done to reduce chronic pain are helpful, they are only mildly so.

Given this fact, if you can’t fix the pain, then you might as well work on the problems that occur as a result of the pain. It’s possible to have chronic pain and not have it disrupt your life. It’s possible to have chronic pain and not be depressed about it. It’s possible to have chronic pain and sleep well at night. It’s possible to have chronic pain and work full-time. It’s possible to have chronic pain and have a fulfilling and intimate relationship.

Now, many people have to learn how. But, if they are open to learning, they can learn to self-manage pain well enough to be able to overcome these secondary problems. Such learning can take time and practice. It also takes a certain amount of devotion to maintain lifestyle changes, once you learn how to do them. Nonetheless, it is possible.

What patients learn could be called stress management and it involves cognitive behavioral therapies.

Good self-management of chronic pain involves stress management. When you overcome depression, even if chronic pain remains, it’s still a win for you. When you come to sleep well at night, after a period of chronic insomnia, life gets better, even if you continue to have chronic pain. When the strain in your relationships subside, your marriage and family life deepen, making life more meaningful and fulfilling, despite having chronic pain.

Overcoming the stressors in life, even when they occur as a result of chronic pain, is a way to get better when there is no cure for the pain itself. Patients with chronic pain might initially wonder why chronic pain rehabilitation providers want to focus on the stressors in their life, but from here we can see why. It’s a way to get better when there is no cure. If you can’t fix the pain, focus on overcoming the stressful consequences of living with pain. By doing so, you make life easier and better.

You also make the chronic pain more tolerable by coping better with it. By overcoming your depression or anxiety, everything in life gets easier to deal with – pain included. It becomes more tolerable. When you sleep reasonably well, on most nights, you deal with everything better – pain included. It becomes more tolerable. The same is true with any of the stressful problems that go along with living with chronic pain. When you overcome them, you cope better with the pain itself. By focusing on reducing stress, you come to cope better and pain can go from what was once intolerable to what is now tolerable.

Chronic pain rehabilitation is the form of chronic pain management that most focuses on helping patients to overcome the stress of living with chronic pain and thereby cope better with pain. The other forms of chronic pain management – spine surgery clinics, interventional pain management clinics, medication management clinics—focus mostly on reducing pain, and not on the stressors that occur as a result of pain. Chronic pain rehabilitation programs focus on both. They provide empirically proven methods to reduce pain, while also providing therapies to overcome depression, anxiety, insomnia, cognitive deficits, relationship problems, and disability.

Stress management and chronic pain management

We just saw how overcoming stressors related to pain makes life easier and better, even though you continue to have chronic pain. We also saw how overcoming stressors can lead to better coping, which, in turn, makes chronic pain more tolerable. Doing so, however, is important for another reason: managing stress well also reduces pain itself.

We all know that stress makes chronic pain worse (Alexander, et al., 2009; Flor, Turk, & Birbaumer, 1985). No matter what the original cause of your pain, stress exacerbates the pain. You have probably noticed this fact.

Whether it’s from depression, insomnia, relationship or financial problems, stress affects us by its effect on the nervous system. Stress makes us tense and nervous – literally. Our muscles becomes tight, particularly in certain areas of the body – the low back, mid and upper back, shoulders, neck, head, forehead, and jaw are the most common areas (we also feel it in our gut, by the way, with upset stomachs, reflux, diarrhea, among other things). Over time, the chronically tense muscles can ache and spasm. In other words, the persistent stress that results from chronic pain can cause chronic muscle tension, which, is painful.

Chronic pain causes more pain! It does so through the stress that it causes, which subsequently activates the nervous system and the persistently stressed nervous system leads to chronic muscle tension, which becomes painful in and of itself.

When understanding the role of stress from this perspective, most every chronic pain patient readily understands it because they live it. They see how stress affects their pain levels from their own experience.

Stress and its effect on the nervous system can exacerbate pain through more direct routes too. It’s not just the effect that stress has on muscle tension. It’s harder to see from your own personal experience, however, and so you’ll have to rely on a more textbook-like explanation. Stress, particularly the persistent stress of problems that occur as a result of chronic pain, causes changes to the nervous system itself. These changes occur in the spinal cord and brain and they result in changes in how sensory information is processed. An example of sensory information is pain signals that travel from nerves in the body, through the spinal cord, and up to the brain; the brain subsequently processes this information and the experience of pain results. As a result of persistent stress to this system, the brain comes to process such information with greater and greater sensitivity and as a result less and less stimuli (i.e., sensory information) is required to experience pain (Baliki, et al., 2006; Chapman, Tuckett, & Song, 2008; Curatolo, Arendt-Nielsen, & Petersen-Felix, 2006; Imbe, Iwai-Liao, & Senba, 2006; Kuehl, et al., 2010; Rivat, et al., 2010).

It’s generally accepted that by overcoming the persistently stressful problems that occur as a result of living with chronic pain – such as insomnia, depression, anxiety, you can make some headway in reversing these changes. You might not be able to change them entirely, but enough to reduce the pain itself. Indeed, most providers would concur that to adequately manage chronic pain these kinds of stressors must be addressed (Asmundson & Katz, 2009; Kroenke, et al., 2011; Vitiello, Rybarczyk, Von Korff, & Stepanski, 2009).

Concluding remarks

In all, good stress management is essential when it comes to successfully self-managing chronic pain. There is only so much that can be done to reduce pain when you have chronic pain. The most effective therapies we have for chronic pain are at best only mildly or modestly helpful at reducing pain. There is, however, no end to how well you can get at managing the stressors that result from chronic pain. It’s possible to overcome depression or anxiety or insomnia or relationship problems or any other stressor, even if you continue to have chronic pain. Now, these problems are not easily overcome. They take work and motivation and perseverance. Nonetheless, it is possible. By doing so, you get better. Pain becomes more tolerable too. In fact, by reducing the amount of stress in your life, you also reduce pain itself.

It’s for all these reasons that your healthcare providers keep wanting to focus on the stress in your life, in addition to the chronic pain in your life.

References

Alexander, J. K., DeVries, A. C., Kigerl, K. A., Dahlman, J. M., & Popovich, P. G. (2009). Stress exacerbates neuropathic pain via glucorticoid and NMDA receptor activation. Brain, Behavior, and Immunity, 23(6), 851-860. doi: 10.1016/j.bbi.2009.04.001.

Asmundson G. J., & Katz, J. (2009). Understanding the co-occurrence of anxiety disorders and chronic pain: State-of-the-art. Depression and Anxiety, 26(10), 888-901.

Baliki, M. N., Chialvo, D. R., Geha, P. Y., Levy, R. M., Harden, R. N., Parrish, T. B., & Apkarian, A. V. (2006). Chronic pain and the emotional brain: Specific brain activity associated with spontaneous fluctuations of intensity of chronic back pain. Journal of Neuroscience, 26, 12165-12173.

Castillo, R. C., Wegener, S. T. , Heins, S. E., Haythornwaite, J. C., MacKenzie, E. J., & Bosse, M. J. (2013). Longitudinal relationships between anxiety, depression, and pain: Results from a two-year cohort of lower extremity trauma patients. Pain, 30. doi: 10.1016/j.pain.2013.08.025.

Chapman, C. R., Tuckett, R. P., & Song, C. W. (2008). Pain and stress in a systems perspective: Reciprocal neural, endocrine and immune interactions. Journal of Pain, 9, 122-145.

Curatolo, M., Arendt-Nielsen, L., & Petersen-Felix, S.  (2006).  Central hypersensitivity in chronic pain:  Mechanisms and clinical implications.  Physical Medicine and Rehabilitation Clinics of North America, 17, 287-302.

Flor, H., Turk, D. C., & Birbaumer, N. (1985). Assessment of stress-related psychophysiological reactions in chronic back pain patients. Journal of Clinical and Consulting Psychology, 53(3), 354-364. doi: 10.1037.0022-006X.53.3.354.

Imbe, H., Iwai-Liao, Y., & Senba, E.  (2006).  Stress-induced hyperalgesia:  Animal models and putative mechanisms.  Frontiers in Bioscience, 11, 2179-2192.

Kroenke, K., Wu, J., Bair, M. J., Krebs, E. E., Damush, T. M., & Tu, W. (2011). Reciprocal relationship between pain and depression: A 12-month longitudinal analysis in primary care. Journal of Pain, 12(9), 964-973. doi: 10.1016/j.jpain.2011.03.003.

Kuehl, L.  K., Michaux, G.  P., Richter, S., Schachinger, H., & Anton F.  (2010).  Increased basal mechanical sensitivity but decreased perceptual wind-up in a human model of relative hypocortisolism.  Pain, 194, 539-546.

Rivat, C., Becker, C., Blugeot, A., Zeau, B., Mauborgne, A., Pohl, M., & Benoliel, J.  (2010).  Chronic stress induces transient spinal neuroinflammation, triggering sensory hypersensitivity and long-lasting anxiety-induced hyperalgesia.  Pain, 150, 358-368.

Vachon-Presseau, E., Roy, M., Martel, M., Caron, E., Marin, M., Chen, J., Albouy, G., Plante, I., Sullivan, M. J., Lupien, S. J., & Rainville, P. (2013). The stress model of chronic pain: Evidence from basal cortisol and hippocampal structure and function in humans. Brain, 136, 815-837. doi: 10.1093/brain/aws371.

Vitiello, M. V., Rybarczyk, B., Von Korff, M., & Stepanski, E. J. (2009). Cognitive behavioral therapy for insomnia improves sleep and decreases pain in older adults with co-morbid insomnia and osteoarthritis. Journal of Clinical Sleep Medicine: JCSM: Official Publication of the American Academy of Sleep Medicine, 5(4), 355.

Author: Murray J. McAllister, PsyD

Date of last modification: 11-4-2013

Chronic Pain and Insomnia

Insomnia is common among people with chronic pain. It’s also problematic. It typically makes your pain worse and saps your abilities to cope. Understanding and overcoming insomnia is therefore important to successfully self-manage chronic pain.

Overcoming insomnia is possible for most people with chronic pain. Like most good things in life, though, it takes some work. There are no quick fixes when it comes to overcoming insomnia. There are actually a number of steps in the process. First, it’s helpful to understand the cyclical nature of chronic pain and insomnia. Second, it’s helpful to understand something about the three basic treatment options that are available for insomnia. Third, pursue one or some combination of these options.

Understanding the cyclical nature of chronic pain and insomnia

It’s common to think of chronic pain as the sole cause of insomnia – as if it’s a one-way street from chronic pain to insomnia. In some ways, of course, it makes sense as pain does in fact make it hard to sleep at night. Pain is a function of our nervous systems and when in pain our nervous systems are reactive. Our normal physical, emotional, and cognitive responses to pain are indicative of this reactive nervous system as well: we remain tense, alarmed, and focused on the pain. None of these automatic reactions to pain are conducive to falling or remaining asleep!

From these observations about pain and its effect on sleep, it seems logical that the best thing to do is to get rid of the pain. This approach, however, is insufficient in most cases of chronic pain.

First, this approach assumes that we can get rid of chronic pain. The reality, though, is that we can’t get rid of it. This fact is one of the things we mean when we use the adjective “chronic.” The most powerful procedures and medications can only reduce chronic pain, and don’t tend to get rid of it. So, there is no way around the fact that most people with chronic pain go to bed with pain. Even if it’s reduced, pain can continue to disrupt sleep.

Second, even if there was a way to fully cure chronic pain, it still might not be sufficient to overcome insomnia once you have it. Certainly, pain can start a bout of insomnia. However, insomnia is almost invariably maintained by more factors than just pain. One common factor is anticipatory anxiety about experiencing another night of insomnia. As you experience an insufficient amount of sleep night after night, it’s almost inevitable that you’ll start to worry about not sleeping as it comes time to go to bed. The arousal associated with this worry –as a form of anxiety or nervousness – can itself prevent you from falling asleep. In other words, insomnia can come to maintain itself!

Third, anxiety of all types can cause or maintain insomnia. People with chronic pain can become anxious for any number of reasons: loss of work; how to pay the bills; people not understanding what you are going through; loss of social or recreational activities; loss of your role in the family; and so on. People with chronic pain can also have anxiety disorders unrelated to their chronic pain. All of these issues can initiate and/or maintain insomnia.

Indeed, in most people with chronic pain, insomnia has multiple contributing causes. Certainly, pain can be one of those causes, but typically it is not the only cause. Moreover, these multiple contributing causes can come to exacerbate each other, making a vicious cycle of chronic pain and insomnia.

For example, say that chronic pain initially causes insomnia in someone. Over time, the insomnia becomes further complicated by nightly bed-time anticipatory anxiety about not getting enough sleep. At some point, worry sets in about loss of work, medical bills, strained marriage, and so forth. All of these factors come to maintain the insomnia over and above the role that pain has in maintaining insomnia. This chronic lack of sleep further stresses the person’s nervous system, making the reactive nervous system even more reactive. As such, the stress of it all makes the original chronic pain worse via its effects on the nervous system. As a result, we have a vicious cycle of chronic pain causing insomnia, which, in turn, makes the chronic pain worse.

This state of affairs reduces the individual’s ability to cope with pain and any of the other life’s stressors. Chronic pain and chronic insomnia can take its toll on anyone. This decreasing ability to cope fosters a greater sense of stress, which, in turn, elicits further pain and insomnia.

Chronic pain and insomnia are therefore complex phenomena that occur in a cyclical nature.

Therapies to address these problems must reflect this complexity. It just isn’t realistic to think that there can be simple, easy or quick fix to insomnia related to chronic pain.

Therapies for insomnia related to chronic pain

Many people rely on so-called “sleeping pills” to cope with insomnia. These pills are from two classes of medications that are technically called hypnotics (e.g., zolpidem) and benzodiazepines (e.g., diazepam). While common, their use is controversial in the healthcare field.

A number of problems are associated with their use. While providing short-term relief, they do not actually cure insomnia. Upon stopping their use, insomnia typically returns and, in the case of using benzodiazepines, the insomnia typically returns worse than when you initially started the use of the medication (Longo & Johnson, 2000). Moreover, the use of hypnotics has been associated with sleep-walking and other behaviors performed while sleeping (Morganthaler & Silber, 2002). In addition, it’s generally known that both classes of medications aren’t very effective. When compared to placebo, people taking hypnotics fall asleep on average 12.8 minutes sooner and people taking benzodiazepine medications fall asleep 10 minutes sooner (Buscemi, et al., 2007). Lastly, their use reinforces subtle, yet important, beliefs about yourself and your abilities to overcome insomnia. Namely, they foster associations that insomnia is a medical problem and that you need to rely on medicines to resolve this medical problem. In other words, they serve as a nightly reminder that you can’t overcome it yourself. You remain, in a word, helpless and must rely on something external to you (i.e., the pill) to do it for you. Now, of course, no one has these thoughts on an overt basis when going to bed at night after taking these medications. But, these subtle beliefs inevitably come to mind when the prospect of reducing the use of these medications is raised. After their long-term use, people can become quite concerned about reducing their use. The prospect is almost inevitably distressing and leaves people feeling helpless to the return of insomnia. What we are really talking about, here, is a subtle form of psychological dependence – the belief that you need the “sleeping pill” in order to sleep at night.

For all these reasons, the use of hypnotics and benzodiazepines for insomnia is controversial.

Chronic pain rehabilitation providers typically prefer to use a combination of two other types of therapies. These therapies are the use of tricyclic antidepressants and cognitive behavioral therapy.

Tricyclic antidepressants are old style antidepressants that are typically no longer used for depression. They are, however, used for chronic pain and insomnia. One of them, amitriptyline, is one of the most effective pain medications available (Hauser, Wolfe, Tolle, Uceyler, & Sommer, 2012; Wong, Chung, & Wong, 2007). They are also somewhat sedating and so are used at night to aid in falling and staying asleep. They do not produce a sense of dependency as often seen in hypnotics and benzodiazepines.

Cognitive behavioral therapy for insomnia is a short-term psychotherapy, usually provided by the psychologist on the chronic pain rehabilitation team. Cognitive behavioral therapy by itself can resolve insomnia once and for all. It breaks the vicious cycles of insomnia and creates new patterns of sleeping. However, it takes a whole lot more work than taking a pill.

Cognitive behavioral therapy requires a multi-pronged effort over time on the part of the patient. It involves the following:

  • Sleep hygiene changes
  • Regular use of relaxation exercises
  • Regular mild, low impact aerobic exercise
  • Cognitive interventions in which you learn how to overcome worry, or anxious thinking
  • Cognitive interventions in which you change your conceptualization of sleep to a more accurate and healthy understanding
  • Stimulus control (i.e., breaking patterns or associations that have developed over time between being in the bedroom and being awake)
  • Sleep restriction (i.e., intentionally limiting when you lay down to sleep or remain asleep in order to develop a normal sleep-wake cycle within the 24-hour day)
  • Tapering hypnotic or benzodiazepine medication use

Cognitive behavioral therapy is generally considered the most effective treatment for insomnia (Mitchell, Gehrman, Perlis, & Umscheid, 2012; Riemann & Perlis, 2009; Smith, et al., 2002; Taylor, Schmidt-Nowara, Jessop, & Ahearn, 2010).

While cognitive behavioral therapy is hard work, it neatly fits into the established protocols of a chronic pain rehabilitation program. As we have discussed in previous posts, chronic pain rehabilitation programs are cognitive behavioral based programs that already involve engaging in regular mild aerobic exercise, regular relaxation exercises, lifestyle changes some of which overlap with fostering sleep hygiene, and cognitive interventions for managing pain which have some overlap with those for managing insomnia.

The right approach for you

Whenever you decide upon a therapy that’s best for you, it is important that you discus it with your healthcare providers and allow them to be part of the decision making process. They are working for you and should have your best interests in mind. They also have an expertise in the field as well as knowledge of you as an individual, which puts them in the best position to advise you on what’s best.

It’s also important to get advice from healthcare providers who practice in the manner that’s right for you. As discussed in a previous blog post, all pain clinics are not alike. There are chronic pain rehabilitation clinics. There are long-term opioid management clinics. There are interventional pain clinics. There are spine surgery clinics. They can all go by the name of a “pain clinic.” Some of these clinics may be more prone to recommend hypnotic or benzodiazepine medications for your insomnia. Some of these clinics, specifically clinics with chronic pain rehabilitation programs, are apt to be more prone to recommend tricyclic antidepressants and cognitive behavioral therapy for your insomnia.

 

References

Buscemi, N., Vandermeer, B., Friesen, C., Bialy, L., Tubman, M., Ospina, M., Klassen, T. P., & Witmans, M. (2007). The efficacy and safety of drug treatments for chronic insomnia in adults: A meta-analysis of RCTs. Journal of General Internal Medicine, 22, 1335-1350.

Hauser, W., Wolfe, F., Tolle, T., Uceyler, N. & Sommer, C. (2012). The role of antidepressants in the management of fibromyalgia: A systematic review and meta-analysis. CNS Drugs, 26, 297-307.

Longo, L. P. & Johnson, B. (2000). Addiction: Part 1. Benzodiazepines – side effects, abuse risk and alternatives. American Family Physicians, 61, 2121-2128.

Mitchell, M. D., Gehrman, P., Perlis, M., & Umscheid, C. A. (2012). Comparative effectiveness of cognitive behavioral therapy for insomnia: A systematic review. BMC Family Practice, 13, 40.

Morganthaler, T. I. & Silber, M. H. (2002). Amnestic sleep-related eating disorder associated with zolpidem. Sleep Medicine, 3, 323-327.

Riemann, D. & Perlis, M. L. (2009). The treatments of chronic insomnia: A review of benzodiazepine receptor agonists and psychological and behavior therapies. Sleep Medicine Reviews, 13, 205-214.

Smith, M. T., Perlis, M. L., Park, A., Smith, M. S., Pennington, J., Giles, D. E., & Buyesse, D. J. (2002). Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. American Journal of Psychiatry, 159, 5-11.

Taylor, D. J., Schmidt-Nowara, W., Jessop, C. A., & Ahearn, J. (2010). Sleep restriction therapy and hypnotic withdrawal versus sleep hygiene education in hypnotic using patients. Journal of Clinical Sleep Medicine, 6(2), 169-175.

Wong, M., Chung, J. W., & Wong, T. K. (2007). Effects of treatments for symptoms of painful diabetic neuropathy: A systematic review. British Medical Journal, 335, 87.

Author: Murray J. McAllister, PsyD

Date of last modification: 10-16-2013