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Instituting Change https://www.instituteforchronicpain.org Tue, 31 Jan 2023 09:50:05 +0000 Joomla! - Open Source Content Management en-gb Stress and Boredom during COVID-19 https://www.instituteforchronicpain.org/blog/item/220-stress-and-boredom-during-covid-19 https://www.instituteforchronicpain.org/blog/item/220-stress-and-boredom-during-covid-19

Living among the COVID-19 pandemic, with its loss of life and livelihood, and our need to maintain physical distancing to protect ourselves and our communities, we face the dual burdens of stress and boredom. It’s a difficult combination because persistent stress leads to lack of focus and feeling scattered. This distractibility leads to aimlessness and inactivity, which further leads to boredom. In boredom, we have nothing to distract attention away from all the stressors in our lives. Thus, stress can lead to boredom and boredom leads back to stress.

The stress response

The COVID-19 pandemic presents dangers that many of us have never before experienced. Until now, it’s been easy when hearing about Photo by Gift Habeshaw courtesy of Unsplashepidemics or potential epidemics on the news to cast it off and think, ‘Oh, that’ll never happen here.’ However, it is now happening here. It is happening most everywhere, given the worldwide dimensions of the COVID-19 pandemic. Even when communities come to control an outbreak, it comes back when those same communities loosen restrictions and open up. It’s hard to identify any society or country for which it hasn't resurged after a community comes to control the initial surge and loosens up the restrictions. As such, we’ve come to experience a low level dread that it’s only a matter of time before COVID-19 comes for us, if we haven’t had it already. Thus, the potential for serious illness and death to ourselves, our family and friends, and our wider communities heightens our awareness and places us in a persistent state of alarm.

Potential or actual job loss and financial stress that has accompanied the COVID-19 pandemic also raises our guard. Economies across the globe
are experiencing significant recessions, even to the point of some economists wondering about another great depression (Lacurci, 2020) with unemployment levels at about 20%. Job- and financial-related insecurities have thus put life as we know it in danger.

The human response to danger is called the stress response. We evolved this capacity to respond to danger because it helped our ancestors to survive acute threats to life and limb, such as being attacked by predators larger than ourselves.

From the microscopic to the macroscopic, the stress response involves cognitive, emotional, systemic, behavioral and social responses to threat or danger. All of these different aspects of the stress response occur largely simultaneously, interacting with each other. So, in the presence of danger:

  • cognitively, we recognize it as dangerous or threatening, vigilantly focus our attention on it, and begin problem-solving for it; we also tend to learn quickly in these instances and will be able to remember it into the future
  • emotionally, we are in a heightened state of alarm, having fear-based or aggressive feelings and sensations, such as tension, guardedness, gut reactions, rapid heart rate, increased blood pressure, increased perspiration, and flushed
  • systemically, three bodily systems of the nervous system, hormonal system, and immune system work together to produce adrenaline, norepinephrine, and cortisol, leading to the above-described high-energy arousal and an inflammatory response which will have an initial beneficial role in healing from injury or illness
  • behaviorally, we tend to aggressively take on the threat and fight it, or flee and avoid the threat
  • socially, we tend to join together with others along some common lines of us against the threat; we also tend to offer help and tend to the needs of others

All of these aspects of the stress response interact with each other and lead to increased odds of survival when threatened.

We might imagine our distant ancestors in this heightened state of arousal and alarm, fleeing to climb the highest tree if alone in the jungle and caught off guard by a threatening animal, or banding together if in a group to fight a common threat. From the microscopic to the macroscopic, the stress response aids in our survival.

The stress response is like a sprinter, not a marathon runner

The stress response tends to work best when the danger is a distinct event, with a beginning, middle and an end. When zebras get chased by lions, their stress response provides them with a heightened burst of attention, arousal and alarm, leading them to be able to evade the lion by running away at great speeds. Once successfully free from danger, everything about the zebras calm down and they go about eating, resting and socializing in whatever ways zebras do. In this way, the danger and the resultant stress response have beginning and end points.

The same would be true if two territorial stray cats bumped into each other. They’d be apt to fight until one of them gets the upper hand and the other flees. The whole event wouldn’t last for hours, let alone days or months. Rather, it would be a matter of minutes, with largely distinct beginning and end points. Upon getting away and the fight resolving, both cats would calm down and go about their daily cat-like affairs.

At the time when the stress response was evolving, our human ancestors would have faced similar types of threats. It was dangerous back then, to be sure, but the dangers would come and then go. As such, the stress response adapted to be highly effective against distinct threats with a beginning and an end, measured in minutes, not days or months or years.

We can thus think of the stress response as a sprinter, coming out of the gait with a burst of attention, arousal and alarm, and effectively managing an event that’ll be over in a matter of minutes.

However, sprinters don’t tend to be good marathon runners.

Our current dangers associated with COVID-19 have no immediate end in sight.

The COVID-19 pandemic presents us with dangers to life and livelihood for each of us individually and for those with whom we join in these common threats. Just as it is supposed to be, our stress responses are kicking in to keep us safe. These dangers lead us to engage in the following:

  • cognitively, they capture our attention and we engage in persistent problem-solving; as a result we might find ourselves watching our news feeds often, looking up do-it-yourself face masks or other COVID-related tasks
  • emotionally, they lead us to be in a heightened state of alarm, with varying levels of anxiety and irritability, muscle tension and agitation
  • systemically, our nervous, hormonal, and immune systems are working together to produce adrenaline, norepinephrine, and cortisol, leading to arousal and a widespread inflammatory response
  • behaviorally, the dangers lead us to physically distance from each other, wear masks, shelter-in-place or engage in ways to respond to the pandemic through the institutions of healthcare, government, business and non-profits
  • socially, lead us to engage in acts of compassion towards one another in our united fight against the virus; we may also tend to splinter into competing groups that differ on how best to respond to the pandemic and thus come to fight against each other

Based on what we know about how the stress response functions, these aspects are predictable and in fact describe the actual aspects of our individual and communal lives.

Notice too that some of these aspects of the stress response are leading to unhelpful responses when they continue indefinitely.

The stress response initially heightens our focus and attention on the danger, but over time they become impaired. The heightened attention of the stress response is like a sprinter being asked to run a marathon after the runner has already left the starting line in a full-blown sprint. The sprinter just can’t keep it going. Similarly, our initial heightened focus on danger becomes exhausted when asked to maintain it over time and as a result we become attentionally sloppy. Our attention spills out over anything and everything, and we become distractible.

Distractibility leads to aimlessness. Tasks and goals for the day are thwarted by other demands and they all become in partial states of completion. Photo by Christopher Ott Courtesy of UnsplashBy the end of the day, it can seem like nothing got done and yet you’re exhausted.

Aimlessness is fatiguing. A persistent state of arousal associated with the stress response takes a lot of energy to maintain. It’s like an engine idling at too high of a rate. It uses up all the gas without ever really going anywhere. Similarly, when the stress response remains engaged for too long, the resultant distractibility and aimlessness is exhausting.

Sleep can become an avoidance strategy. While it may initially prove helpful, sleep as an avoidance strategy can outlive its usefulness, just as the attentional aspects of the stress response are outliving their usefulness. Avoidance sleep is rarely refreshing when done on a repetitive basis.

This odd combination of distractible over-activity coupled with pockets of inactivity and rest leads to a persistent boredom. It can feel like you have too much to do and not enough to do at the same time. In addition to sleep, other avoidance strategies such as binge watching TV or stress eating can provide temporary relief but they lose their luster in time. As a result, we come to have a vague sense of futility through our days called boredom.

In this boredom, we have little to hold our attention but for the threats associated with COVID-19 and a tanking economy.

The stress response thus leads to boredom and boredom leads back to stress in this age of COVID-19.

References

Lacurci, G. (2020, July 21). A second great depression? Unemployment crisis hits big cities hard. CNBC. 

https://www.cnbc.com/2020/07/21/some-big-cities-are-hitting-great-depression-unemployment-levels.html

Date of publication: July 27, 2020

Date of last modification: July 27, 2020

About the author: Dr. Murray J. McAllister is the publisher and editor at the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Our mission is to lead the field in making pain management more empirically supported and to make that empirically-supported pain management more publicly acessible. To achieve these ends, the ICP provides scientifically accurate information on pain that is approachable to patients and their families.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Stress Mon, 27 Jul 2020 14:24:02 +0000
Stress and Chronic Pain https://www.instituteforchronicpain.org/blog/item/123-26stress-and-chronic-pain https://www.instituteforchronicpain.org/blog/item/123-26stress-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 publication: 11-4-2013

Date of last modification: 2-18-2018

About the author: Dr. McAllister is a pain psychologist, and founder and publisher of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Our mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides scientifically accurate information on chronic pain that is approachable to patients and their families. Dr. McAllister consults to pain clinics and health systems on redesigning pain care deliver in order to make it more empirically supported and cost effective. He is also a frequenter presenter on pain, addiction, and redesigning healthcare.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Stress Mon, 04 Nov 2013 20:06:49 +0000