The ICP Supports the Make Your Day Harder Campaign

Recent data in the Lancet show that as societies become increasingly industrialized around the world, rates of low back pain, migraine, depression, obesity and type 2 diabetes increase (among other conditions). It’s an interesting commentary on the social determinants of health.

Why the increase?

modernityIt’s not that as societies industrialize they become awash in contagious viruses or bacteria that make people have these conditions. In fact, as societies industrialize, rates of infectious illness tend to drop and death rates overall drop. And, at any rate, viral and bacterial infections don’t cause the above conditions.

It’s also not that as societies industrialize the people who make up these societies develop genetic mutations that lead to the increasing rates of conditions such as low back pain, migraines, depression, obesity and type 2 diabetes. No, our genetic constitution doesn’t change that fast – at least not over the 50 to 100 years it takes for societies to industrialize.

So, what produces this rise in such conditions? General consensus is that it’s the psychosocial changes that come with industrialization: particularly, the increasingly sedentary lifestyle; the increasing consumption of cheap, processed foods (and the corresponding decrease in consuming traditional, whole food diets); and increases in chronic, non-life threatening, stress.

Sometimes, people get upset when healthcare providers talk like this. But, let’s explain.

The biopsychosocial nature of chronic health conditions

The afore-mentioned conditions are considered biopsychosocial in nature. That is to say, they are caused by a combination of multiple factors, some of which are biological, some of which are psychological, and some of which are social in nature. So, across the population as a whole, and even within any one individual, there are various combinations of these three factors that go into causing conditions, such as low back pain, migraine, depression, obesity, and type 2 diabetes, among others.

Now, with the advent of industrialization, it’s not the biological factors in the mix that seem to be increasing, but rather the psychological and social factors. It’s the increases of certain behavioral lifestyles and stressors, which seem to be accounting for the increases in these conditions. Meanwhile, the biological factors seem to be remaining largely constant.

So, what do we do about it? We educate ourselves. We practice tolerating what we learn and reflecting on it. We then slowly and incrementally begin to incorporate these lessons into our life by taking ownership of our health and begin to make small healthy changes in how we live. Slowly and incrementally, we continue and add to these changes. Over time, we become healthier and come to feel better, physically and emotionally.

The Make Your Day Harder Campaign

To this end, the folks at Dr. Mike Evan’s Health Lab developed an ingenious idea. They call it the Make Your Day Harder campaign. It’s provocative title challenges us to reflect on ways to make small changes in our daily life and get off our seats more. And then do it.

The idea, as Dr. Mike says, isn’t to take on a grand exercise routine. Rather, it is the idea to make small intentional decisions to use technology less. So, for example, walk upstairs to get your daughter from her room rather than texting her from the kitchen that it’s time for dinner; get up and turn the volume down on your stereo rather than using the remote control; walk over to your neighbor’s house to actually talk to him about borrowing some tool you need rather than calling him on your cell phone; use a rake rather than a leaf blower; take the stairs rather than an elevator; intentionally don’t take the closest parking space; and so on.

Now, of course, doing any one of these things once or twice won’t do much for you. However, if you cultivated an attitude of willingness to do them in which you were open to opportunities as they arose through the course of your day, these slow, incremental changes over time would help.

You might slowly become more physically fit. You might come to have a little more energy. You might not gain weight or as much weight over time. You might find that your life slows down a little bit and as a result you feel just a little less hectic and a little less stressed.

As Doc Mike points out in his 4 minute video, the goal, as funny as it might sound at first, is to live just a little bit more like how our parents or grandparents or even great-grandparents lived – for they had less chronic health problems and in some respects were healthier than we are today.

To be sure, these previous generations might have had higher death rates from infectious illness or injuries, but assuming they escaped these fates, they were leaner, more fit, and less chronically ill; which is to say, they were in some ways healthier. Now, as we said, in our current industrialized societies, the death rates from infectious illnesses and injuries have been considerably reduced. However, we suffer now from considerably more chronic health problems. So, maybe, we should get off our seats more and do things the old fashioned way: let’s use our bodies more and our technologies less.

So, Make Your Day Harder. Please pass it on through your social media.

Author: Murray J. McAllister, PsyD

Date of last modification: June 12, 2015

Stress, Inflammation and Chronic Pain

People with chronic pain know that they tend to have a pain flare when they are under stress. They are, however, sometimes sensitive to acknowledge it aloud for fear that others might think that their pain is all in the head. Nonetheless, the fact that stress makes pain worse is entirely normal and common. It is a natural product of how we are made.

In fact, stress has a much more significant role in the production of pain than simply making it worse. The development of pain itself, from acute injuries or illness to the long-term maintenance of chronic pain, incorporates what we call the stress response. In other words, were it not for our stress response, we would not have pain as we know it. To review the remarkable and significant role that the stress response has in pain, we would require much greater time and space than this blog post allows. [For a good review within the professional literature, please see Chapman, Tuckett, & Song (2008)].

Instead, in this post, let’s look at one way stress exacerbates pain and leads to what we typically call a ‘pain flare.’ We’ll focus our attention on a particular aspect of the stress response, which leads to increased pain: inflammation. Specifically, let’s review how stress triggers our normal and natural stress response, which subsequently produces inflammation that, in turn, makes pain worse.

The immune system

The immune system is our natural defense system. It works in conjunction with our nervous system and our endocrine (or hormone) system. Traditionally, we have always divided these systems up as if they are three separate systems, but we now know that they do not operate independently of each other. So, whenever we discuss the functioning of one system, as we are today discussing the immune system, we have to keep in mind that structures in the brain, the rest of the nervous system, neurotransmitters, and hormones are almost always also at play when the immune system functions as it does.

So what does the immune system do? Traditionally, we have understood the immune system to have a defensive role in response to injury or infection. When injury or infection occurs, the immune system produces inflammation. Inflammation is a catchall term used to describe a number of different types of chemical messengers and cells that fight off the infection or prepare for healing. For instance, it’s what makes us well when we are sick by fighting off viral or bacterial infections.

Many years of basic science in psychology and biology have allowed us to now know that inflammation also plays a role in changes in mood and behavior, both of which can also allow for fighting off infection or responding to injury with damage control (Sternberg, 2001). In more general terms, these psychological responses are also responses to danger. Indeed, we now think of the immune system, in conjunction with the nervous system and the endocrine system, as part of a three way response to danger, or what we call the stress response.

Stress response

The stress response is our natural cognitive, emotional, motivational, bodily, behavioral and social response to a danger, or what we might more generically call a ‘stressor.’ Take for example, thousands of years ago, we would have been likely living on the savannas of Africa and we would have faced various threats, such as the possibility of being attacked by lions.

In response to the stressor of a lion attack and its resultant injuries, we naturally and automatically react, without conscious awareness or intention, with our built-in stress response. A quick review of the multifaceted – or biopsychosocial – aspects of this stress response are the following:

  • Cognitive responses: Heightened focus on the danger, rapid learning about the danger and subsequent acute memory of the stressor, among others
  • Emotional responses: Heightened alarm, anger and/or fear, increased sense of social belonging, among others
  • Motivational response: Heightened drive to react, increased energy
  • Bodily responses: Among others, increased muscle tension, heart rate, blood pressure; increased glucose in bloodstream; increased immune response
  • Behavioral and social responses: fight-or-flight, and tend-and-befriend (i.e., some combination of taking on the danger or getting away from it and/or joining together, coming to the rescue, and protecting or caring for one another and wanting to be cared for) (Taylor, et al., 2000)

In later posts, we’ll discuss in more detail the various aspects of the stress response, but this quick overview is important for two reasons.

First, and foremost, we see clearly the larger context in which the immune system functions. Its defensive function is part of a greater whole and the whole is the protective, or defensive, function of the stress response. From here, we can also see how the stress response is a whole contingent of automatic responses, from the microscopic to the macroscopic, that occurs when we are threatened by danger. In other words, it is the stress that the human organism undergoes when threatened.

Second, we see that in our society we tend to categorize these microscopic to macroscopic responses under particular headings, such as those that are biological, those that are psychological, and those that are social. We subsequently tend to think that these categories represent actually different things and then begin to wonder how they are connected. However, these categories do not represent distinct kinds of things. They are heuristic categories that reflect different aspects of the same kind of thing, the human organism, or person. In this way, we no longer wonder how “the mind” is connected to “the body,” as if they are two separate kinds of things. No, the cognitive, emotional, motivational and social aspects of the stress response occur within the same kind of thing as the biological and behavioral aspects of the stress response do. That is to say, they occur within a person, not some separate entities called “a mind” or “a body.” As such, in science and healthcare, we typically no longer refer to this mental/physical or mind/body distinction, but rather refer to these aspects of a person with the term ‘biopsychosocial.’

Inflammation

So, the stress response involves many natural, automatic responses and one of them is the immune system kicking into high gear to produce inflammation (Kiecolt-Glaser, et al., 2002). This response clearly makes sense. If we go back to the example of a lion attack, we will have a greater chance of surviving if our immune system is functioning in high gear as it fights off any infections from the scratches or bites that we might get.

This peak performance is the product of the immune system working in conjunction with the sympathetic nervous system and the endocrine (or hormone) system. Specifically, different structures in the brain, associated with the fight-or-flight response, send messages via a highway of nerves to the pituitary and adrenal glands, which then produce hormones such as cortisol and adrenaline (also known as epinephrine). These are often called ‘stress hormones’ and they are responsible for getting us ramped up. For instance, cortisol prevents insulin (another hormone that’s produced in the pancreas) from working well and so glucose (i.e., sugar) increases in the bloodstream, giving us increased energy. Initially, these hormones also start the immune response in the form of white blood cells and what are called cytokines. We call this immune system response ‘inflammation.’

Inflammation is what occurs when, upon injury, the injured area becomes red, swollen, and sensitive to the touch. The redness and swelling is our immune system at work, the white blood cells and cytokines engaging in their protective function, engaged in damage control. The sensitivity comes because the immune response irritates the nerves in the area. At this stage, this irritation is good because it serves a protective function. If the injured area is sensitive to the touch, it is going to prevent us from using it or poking it too much or otherwise re-injuring it. Subsequently, we are motivated to protect or guard the area. We’ll come back to this point.

At this time, there are also cytokines in the brain too intermingling with its hormones and neurotransmitters. If the injury or infection is severe enough or widespread enough, this mix of chemicals in our nervous system, including the brain, further lead to a run down feeling, which we call ‘malaise.’ It’s the ‘blah’ feeling we have when sick: run down, achy, fatigued, and unmotivated to do anything but lay around and rest. We are also motivated at this stage to need others, associate with them, and depend on them for help. In other words, we feel upset, perhaps even a bit abandoned, when others ignore us when we are sick or injured. We’ll come back to this point too.

After some time, these processes unfold and the threat passes (for example, microscopically, the infection and injuries from the lion attack have been successfully warded off and subsequently healed, just as we might have banded together, at a macroscopic level, to fight off the actual attack in the first place). Subsequently, cortisol tells the brain to start turning off the stress response.

The whole process is remarkable, even amazing. At all the multifaceted levels, from the microscopic to the macroscopic, we are made to survive. The stress response is an almost beautiful, elegant way to optimize our chances of survival when threatened by danger.

We still respond to threats, or stress, with the stress response

Admittedly, lions don’t attack us much anymore. With some few exceptions (such as the occasional natural disaster or bad car accident, or the activities of soldiers and first responders), our life and limbs don’t get threatened very often in our present day and age. We still, however, face threats.

The threats that we most commonly face nowadays are psychological and social in nature. They are the death of a spouse or child or other family member or friend. They are the loss of a job and subsequent loss of income. They are the bankruptcies and home foreclosures. They are the overly critical bosses or the fights with a sister or brother or when best friends move away. They are a son or daughter joining the armed forces and going off to war. They are the occasions when a family member comes down with a serious illness, say, cancer. They are the times when we have to live with a chronic illness, such as chronic pain. These kinds of stressors are not threats to life or limb, on the order of a lion attack or combat, but nonetheless they are threats. They are threats to our livelihood and well-being.

As such, we are hard-wired to respond to such stressors with the stress response.

Moreover, we also have the ability to anticipate the above-noted psychological and social threats. That is to say, the kinds of threats listed above are not the only kinds of threats that we commonly face. We also face the threat of anticipating the potential for those kinds of stressors.

We call it anxiety. It is the worrying or ruminating or fretting about the possibility that we face any of those threats listed above – the loss of a job, the loss of an income, the home foreclosure, the overly critical boss, the well-being of our loved ones, the loss of our health, the living with pain and all the problems that occur as result.

Human beings have an amazing capacity to worry about everything that could go wrong. In a sense, it’s a form of the stress response, preparing us for danger. However, anxiety or worry is what happens when our stress response has become stuck in the ‘on’ position. When anxious, in other words, we continue to prepare for danger or threat even when there is no actual threat, just the possibility of one.

Either way – whether we are actually living through a stressor or worrying about the possibility of a stressor, we still automatically, and without much conscious intention, still respond to such threats with the stress response.

Stress and inflammation make pain worse

If you have a chronic pain condition, you know that stress makes it worse. From here, we can see why. When experiencing a stressful event like those listed above or when worrying about the possibility of such a stressful event, you automatically, and without conscious intention, react with the stress response. Your immune system, in conjunction with your nervous system and endocrine system, puts out inflammation in response to the real or perceived threat. This inflammation causes irritation to your nerves, including the nerves in the area of your chronic pain. As a result, the nerves become more sensitive, just as they are supposed to do when the immune system is engaged in the stress response. With the nerves more sensitive due to the increased inflammation, they subsequently require less stimuli to cause pain and you experience increased pain with your normal activities.

For instance, suppose that you have chronic low back pain and usually it doesn’t hurt to get out of a chair. However, when under stress, the stress response leads to higher levels of inflammation, which make the nerves in your low back more sensitive. As a result, the stimuli involved in the act of getting out of a chair makes your low back painful when ordinarily you can get out of a chair without pain at all. What you experience in such instances is the all-too-common exacerbation of pain due to stress.

Notice that your immune system is doing exactly what it is made to do when under threat. While problematic, it is normal and common.

It can become increasingly problematic when the stressor remains unresolved and subsequently goes on for some time. The threat is on-going and so the stress response continues unabated. The level of inflammation becomes higher and higher. The nervous system as a whole becomes more sensitized. As a result, widespread inflammation can lead to both increasing pain and more widespread pain, in the form of body aches.

Moreover, as we saw above, widespread inflammation can lead to malaise, an overall ‘blah’ feeling. You become fatigued and unmotivated to do anything but rest. In addition to higher levels of pain or possibly even more widespread pain, you are now not feeling well. You feel like you have the flu, but without the flu.

At the same time, your needs for others increase. It is the result of the tend-and-befriend aspect of the stress response. These needs are the needs for others to provide comfort and care. You don’t want to be left alone and, if you are, it’s like adding insult to injury.

Now, some people might not want to admit that such emotional and social needs arise when not feeling well. For after all, we have a sense from society that we are supposed to remain strong and independent. If we don’t, we have a good likelihood that we’ll face stigma.

It’s important to recognize, however, that such emotional and social needs are built right into us when the stress response kicks in and, particularly, when it goes on for some time. It’s important to understand that you are not just being weak. The stress response is doing exactly what it is supposed to do in response to a threat against your well-being.

It’s okay to acknowledge it. It is a common and natural consequence to stressors, or threats.

What you can do about chronic pain

With that said, however, it’s also important that you recognize that you are not helpless to it.

Chronic pain rehabilitation programs are a traditional form of chronic pain management that focuses on reducing the stress response in the presence of pain. Through multiple therapeutic modalities, they focus on reducing the reactivity of the nervous system and teaching you how to maintain this reduced reactivity of the nervous system, which, in turn, leads to less inflammation and less pain, greater energy and motivation, and greater abilities to independently do what you want to do. The Institute for Chronic Pain has a number of resources that provide information on chronic pain rehabilitation.

A brief list follows:

References

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.

Kiecolt-Glaser, J. K., McGuire, L., Robles, T. R., & Glaser, R. (2002). Emotions, morbidity, and mortality: New perspectives from psychoneuroimmunology. Annual Review of Psychology, 53, 83-107.

Sternberg, E. M. (2001). The balance within: Science connecting health and emotions. New York: W. W. Freeman.

Taylor, S. E., Klein, L. C., Lewis, B. P., Gruenewald, T. L., Gurung, R. A., & Updegraff, J. A. (2000). Biobehavioral response to females: Tend-and-befriend, not fight-or-flight. Psychological Bulletin, 107(3), 411-429.

Author: Murray J. McAllister, PsyD

Date of last modification: 11-24-2014

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