Is it all in your mind? EMDR therapy for treating chronic pain
If you’re living with chronic pain, such as chronic lower back pain, have you ever been told that “it’s all in your mind?”, did this sound like “you’re imagining it?” (even if that’s not what was intended). The argument goes that on examination, no physical cause for the pain can be found so therefore, it must be a psychological issue. Treatment can end as there is nothing physical to be fixed, leaving the patient with their pain.
Health professionals sometimes don’t explain clearly enough what they mean by this, which can be confusing as, for you, the pain feels very real – it’s in your lower back, your shoulders, neck, your legs – it impacts on your sleep, your mood, your relationships, career. You can’t move about as before, you’re stiff and sore. That’s why you came to see the doctor in the first place.
There is though, a very real psychological element to chronic pain which, when understood properly, provides opportunities for psychotherapists to help relieve the highly distressing experience of chronic pain for their clients.
So if you are living with chronic pain and have a history of trauma, depression or anxiety, this article may help you understand the connection and how EMDR (Eye Movement Desensitisation and Reprocessing) might be able to help.
The brain, emotions and pain
In one sense, all pain is “in the head” as it is the brain which decides to feel pain or not, but this does not mean the pain is not real, or that you are somehow “imagining” it: the brain contains a body map, with a pain sensor corresponding to each area of the body (your right little finger, lower back, shoulder etc.).
If you put your hand under a hot tap, sensors in your hand send signals via the nervous system to the pain sensors for the right hand to tell it there is a risk of harm to the hand. If the brain thinks the risk is great enough, it sends a signal back to the hand to tell it the water hurts, so that the hand withdraws. You might feel the sensation of pain in the hand but the decision was taken in the brain.
Sometimes, the brain might decide the signals are not significant enough, or that if they are, survival of the body requires the pain to not be registered yet: soldiers sometimes report not feeling a wound until after the end of a battle – the brain’s priority is to keep the soldier alive so it may have decided not to let them feel the pain so that he keeps fighting and is able to get to a place of safety.
With chronic pain (pain lasting longer than 12 weeks), the pain system of the brain and nervous system, receives so many repeated messages that it becomes over sensitised to pain, starting to register a signal as “painful” when there is much less actual damage or potential damage and eventually, when there is no harm at all to the body.
This happens because of neuroplasticity: the brain sends out pain signals via neurons and the more signals it sends, the more neurons get involved and the message spreads, even spreading pain messages to parts of the body which are not harmed, but happen to be next to areas which were, on the body map. This is how referred pain works – pain spreading from the lower back to the gluteal muscles and legs, for instance. (See Norman Doidge’s book The Brain that Changes Itself to learn more about neuroplasticity and chronic pain.)
The pain-signalling neurons get stuck in the “on” position, leaving you feeling pain long after the original tissue damage has healed. This is called neuropathic pain.
Depression and anxiety make pain worse because they lower the level of the neurotransmitter serotonin in your bloodstream. Serotonin is an antidepressant, which lifts our mood and also a painkiller. These conditions also increase “Substance P” levels, which makes us more sensitive to pain. The experiences of depression and anxiety are also processed by the same areas of the brain which process chronic pain. When these areas are inflamed or activated, we feel distress emotionally as sadness and worry and physically as pain.
Trauma creates and exacerbates pain because it is a physical experience: when your fight or flight mechanism is triggered (during or after a traumatic incident), the brain signals the endocrine system to release the stress hormones adrenaline and cortisol: adrenaline gets the body ready for the physical activity of literally fighting the danger or running away from it (lungs breathe more air in, heart rate increases to get more oxygen to working muscles, which contract and tense). This is followed by cortisol to balance this effect, calming the body, especially the immune system, to return it to a state of balance or homeostasis.
If you live in a situation of repeated trauma, danger or threat, you are likely to have been triggered regularly – sometimes this means so much cortisol is released that the cells in the immune system stop taking any notice of it: the immune system stays on high alert in response to the threat, leading to inflammation throughout the body. And where there is inflammation, there is often pain (check out The Meaning of Pain, by Nick Potter, for more about this process).
Trauma involving violence may have caused you physical pain at the time and, just as you feel the same emotions as at the time of the assault when you remember it later (due to the memory still being stuck in the amygdala, your alarm system, which has not sense of time or place, so cannot distinguish between now when you remember the incident and 10 years ago when it happened), your body will also remember the physical pain you felt at the time too.
Treating chronic pain with EMDR
EMDR works with chronic pain at the level of the nervous system and the brain: in neuropathic pain, where the brain continues to signal pain long after the physical damage to the body has ceased, it can be as if one part of the brain thinks the damage continues, while another area knows the body has healed and the pain signals can be switched off.
By focusing on the pain (and the emotions, thoughts and images it invokes in you while you think about it) and then engaging in bilateral stimulation (following the therapist’s fingers as they move from left to right in front of your eyes, or tapping left and right on your collar bones with your fingers, in time with the therapist), both sides of the brain, left and right hemispheres, are engaged. This allows information held in both areas to meet as links are made within the neurons which contain the information. The part of the brain which knows the damage has healed can talk to the part which thinks it's continuing and calm it down, switching off the pain signals in a process known as adaptive information processing.
Processing the underlying traumatic memories themselves using EMDR will also help by reducing the occasions when you are triggered by something reminding you of the incident. Less triggering means less adrenaline and cortisol and hence less inflammation and pain.
Similar effects can be gained through certain forms of visualisation as the Posterior Parietal Lobe (PPL) area of the brain: the PPL is responsible for processing pain and visual information, but not both at the same time. Visualising a shower of pain-relieving light flowing over you and washing the pain away, occupies the PPL and prevents it from signalling pain.
EMDR and other forms of psychotherapy, by addressing and relieving depression or anxiety also contribute to pain relief by boosting levels of serotonin in the blood – the body’s natural pain killer.
Exercise and movement are also incredibly important, especially in chronic lower back pain: exercise boosts serotonin and endorphin levels, raising mood and reducing pain. Movement boosts blood flow to affected areas, helping to heal any tissue damage which may be an issue. In the case of lower back pain, a properly designed programme of core-stability, strength/endurance and flexibility also helps to relieve and prevent pain. Relaxation and improved breathing techniques contribute by enabling the body to relax and relieving tension in the muscles.
Pain is therefore controlled by the brain and our emotional state can have a massive impact on the degree of pain we feel and how we experience it. Because of this, psychotherapy has an important role to play in helping people reduce and recover from chronic pain. It is the combination though of addressing pain in therapy and making use of movement (exercise, physiotherapy, osteopathy), which often has the greatest impact: Move more / talk more!