On June 3, 2018, Dr. Spett presented a workshop to NJ-ACT on CBT for chronic pain. This is the second of two articles adapted from that workshop.

By Milton Spett, Ph.D.

Mr Iqbal had severe pain in his left hand.
Maqbool et al. (2013 Gulf Medical Journal, 2, 2, 26-29) report on Mr. Iqbal (a pseudonym), a 46-year-old carpenter who had an accident in which his left hand was crushed. After the accident, Mr. Iqbal complained of constant pain in his left hand. Mr. Iqbal rated the pain as “severe” – he rated the pain intensity 4 out of a possible 5.

Medications, conventional therapy for pain control, compression therapy, and habituation training did not improve the pain in his left hand.

Now here comes the interesting part: Mr. Iqbal experienced severe pain in his left hand, but his left hand had been amputated immediately after the accident. Mr. Iqbal was experiencing pain in a hand that didn’t exist. This phenomenon is known as “phantom limb pain” and has been well documented. How can this happen?

The brain creates sensations of pain.
When we injure a body part and we experience pain in that body part, we assume that the injured body part is creating the sensation of pain. But this is not correct. In fact, the injured body part is sending a signal to the brain “injury here,” and it is the brain that is creating the sensation of pain in the injured body part.

Phantom limb pain is a very dramatic example of the principle that the sensation of pain is not created by the body part where the pain is experienced. Phantom limb pain also demonstrates that the sensation of pain does not necessarily mean that a body part is injured. Let’s look at some research supporting the concept that the brain can create sensations of pain in the absence of injury.

X-rays and MRIs do not tell us the cause of pain.
Tulder et al. (1997, Spine, 22, 4, 427-434) evaluated all available studies and concluded “There is no firm evidence for the presence or absence of a causal relationship between radiographic findings and nonspecific low back pain. Research has found that orthopedists cannot look at MRIs and determine which patients have pain and which patients do not have pain. This is not a new finding.

As early as 1953 Splithoff (Journal of the American Medical Association, 152, 1610-1613) compared the x-rays of 100 people with backache and 100 people without backache. He concluded “congenital anomalies and degenerative arthritis were present in approximately the same percentage of patients with and without backache.” This research supports four assertions:

1. Many people whose MRIs and x-rays reveal physical abnormalities do not experience pain.
2. Many people without physical abnormalities do experience pain.
3. Many people have both physical abnormalities and pain, but the physical abnormalities are not the cause of their pain.
4. Many people experience pain which is more severe than their injury.
So when is not caused by an injury, what is causing it?

The brain is an information processing system.
1. The human brain receives information from outside the body through the senses.
2. The brain receives information from various body parts inside the body.
3. The brain combines this current internal and external information with beliefs and with information from stored memories of the past and expectations for the future.
4. The brain processes all this information, and creates thoughts, feelings, behavioral urges, and physical sensations.

Pain sensations, like all thoughts, feelings, behavioral urges, and physical sensations, are created by the brain as a result of processing all of this information. So it is reasonable to think of the brain as an information processing system.

Psychological pain is an information processing error.
Nociceptors are sensory neurons that transmit negative sensations to the brain. When an injury occurs, pain nociceptors are activated, and they send injury information to the spinal cord and the brain.

The brain receives this information from nociceptors, along with information from memories of pain, information from thoughts, feelings, social situations, and other inputs. The brain then processes all this information and creates sensations of pain or does not create sensations of pain.

When no nociceptors have been activated, the brain can create sensations of pain based on other inputs. This is called psychological pain, pain in the absence of injury, or pain that is out of proportion to the injury.

People with pain in the absence of injury are often told there is nothing physically wrong with them. They interpret this as saying that they are imagining their pain. They feel insulted, and then reject any advice from the person they believe is accusing them of imagining their pain.

The fact is that they are not imagining their pain. Their pain is real, but it is caused, or partially caused, by psychological factors, not by physical abnormalities.

According to Information Processing Therapy, we should tell patients that their pain, or the psychological part of their pain, is a false alarm erroneously created by the brain. In other words, their brain is making an information processing error, and this is not their fault. They just need to provide their brain with corrective information that they do not have an injury.

I find that patients readily accept this explanation. They do not interpret this explanation as blaming them for their pain or accusing them of imagining their pain.

Information Processing Therapy for the psychological causes of pain
To alleviate psychological pain, we and our patients must send enough “no-injury” information to the brain to cause the brain to reprocess all the information it is receiving, conclude that there is no injury, and stop creating sensations of pain.

But the information that there is no injury is processed by the cortex, the higher part of the brain, while sensations of pain are created by the primitive parts of the brain. So it is necessary for a lot of “no injury” information to be transmitted to the cortex, so that some of it will filter down from the cortex to the primitive parts of the brain and convince the primitive parts of the brain that no injury exists. Only then will the primitive parts of the brain stop creating sensations of pain.

Clinical vignette: Sheldon had chest pains.
Sheldon was seeing me for a different problem when he developed intermittent pain in his chest and in his left arm. Sheldon worked in the health care system, so he knew what these pains might mean. When the pain continued for several days, he called his doctor who immediately referred Sheldon to a cardiologist.

The cardiologist ordered an angiogram. Dye was injected into Sheldon’s blood stream, so the functioning of his cardiovascular system could be evaluated. When the procedure was over, Sheldon’s cardiologist told him that his arteries and his entire cardiovascular system were in perfect condition. Sheldon’s pain in his chest and left arm immediately ceased.

Sheldon’s brain had made an information processing error. It had created sensations of chest and arm pain when there was no arterial constriction. Sheldon was definitely not having a heart attack. His cardiologist transmitted authoritative, corrective, “no injury” information to Sheldon’s brain, and Sheldon’s brain immediately corrected its information processing error and stopped creating sensations of pain.

The case of Sheldon is unusual. Most pain patients’ brains need to receive “no injury” information over and over and over before they stop creating sensations of pain. But the case of Sheldon is useful because it was so simple. There was one and only one intervention, so when Sheldon’s chest pains ceased, we know exactly what caused them to cease.

Cognitive therapy for psychological pain
The case of Sheldon is an example of a purely cognitive cure for psychological pain. Cognitive therapy for psychological pain means patients should use logic and evidence to convince their brains that they do not have an injury or that the injury they do have is much less serious than their pain would indicate.

Ask patients to use every opportunity to remind themselves that they do not have a serious injury. They either have no injury or they have a minor injury which has probably been caused by unusual postures or movements they have made to compensate for their “non-injury.” Here are two cognitive techniques you can use in therapy sessions:

1. The legal brief. Patients can write a legal brief, as if they were trying to convince a judge that they do not have a serious injury. They should include all the evidence they can marshal that they do not have a serious injury. They should then read this essay every day and work on improving it, making it more and more convincing. Of course, the person they are trying to convince is themselves.
2. The debate technique. First patients argue that they have a serious injury and must curtail their activities. The therapist then argues that patients do not have a serious injury and they should do whatever they would do if they did not have an injury. Then the patient and the therapist switch roles. The therapist argues that patients have a serious injury and the patients argue that they do not.

Six behavioral techniques for transmitting no-injury information to the brain
1. Move and walk normally, as if you have no injury. This sends corrective, “no injury” information to the brain. Moving abnormally sends injury information to the brain.
2. Do not take any medication for the non-existent “injury” and the information processing error that is psychological pain. Almost all pain patients discover that they can reduce or eliminate their medication with little of no increase in their pain.
3. Focus on living your life as fully as possible. Do not focus on the “injury,” do not focus on the pain, do not focus on reducing the pain. Attention is a powerful reinforcer, so pay as much attention as possible to living your life fully, and pay as little attention as possible to your pain and your “injury.” Living life fully sends “no injury” information to your brain. Paying attention to pain sends injury information to the brain and worsens pain.
4. Exercise as you would if you had no injury, but do not overdo exercise, especially when you begin exercising again after an injury or operation. Begin with mild exercise and gradually increase the intensity of your exercise.
5. Do not consult doctors or friends about your “non-injury.” Do not do internet research into diagnosis or treatment of the “non-injury” or the pain.
6. The most powerful behavioral treatment for the psychological causes of pain is to do whatever you would do if you had no injury. This will send powerful “No-injury” information to your brain. The brain will process this no-injury information and gradually, or occasionally rapidly, decrease sensations of pain.

When patients begin to implement these guidelines, they discover that their pain sensations diminish or at least are no worse. Then they become willing to gradually increase the implementation of these guidelines.

Conclusion — Pain Problem #6: My neck hurt when I turned it to the right.
Several years ago I developed a pain in my neck when I turned my head to the right. What made this particular pain a problem for me is that I swim once or twice a week, and when doing the crawl, I turn my head to the right and out of the water to breathe. Each time I did this, I felt pain in my neck.

So I tried the Mindful Exercise System. First I tried turning my whole body to the right, so I wouldn’t have to turn my head so much. This didn’t help. Then I tried range of motion exercise, first turning my head to the right, and then to the left, thinking this might loosen up my neck muscles. This didn’t help. Then I tried stretching. This didn’t help. Then I tried  resting my neck, not swimming for about six weeks. This didn’t help.

I spoke to my primary care physician. He suggested swimming with a snorkel so I wouldn’t have to turn my neck at all. But there was no way I was going to do that and give up on curing my neck pain.

And then, while I was swimming, it suddenly came to me: What would I say to a patient who came to see me for this problem? Of course I would tell the patient to swim normally, swim as he would if he had no pain and there was nothing wrong with his neck.

So right there in the middle of a lap, I started swimming normally, turning my head to the right when I took a breath, as I used to before I developed neck pain. My neck pain instantly diminished by about 80%. Subsequently I started doing some gentle neck stretches, and after a number of weeks of mindful, graduated neck stretching, my neck was 100% pain-free.

To me, this instant cure of my neck pain was very convincing evidence for the therapeutic value of Information Processing Therapy for the psychological causes of pain.