Dealing with chronic pain: a psychological perspective

Who hasn't had a little headache before. A hangover. A tummy ache. We all have, of course we have. But between one third and one half of the British population is experiencing pain on a regular basis. Chronic pain.

I have been experiencing chronic headaches and migraines for more than 20 years of my life, starting in primary school. The doctors did some EEGs and an MRI, asked some questions, and I had a misdiagnosis of epilepsy for a while. 20 years later, I still don't really have more answers than I did as a child. And the funny thing is, I don't really have many more coping strategies than I used to have back then either.

Don't get me wrong, I don't want to blame the medical system, or anyone else for that matter. I'm not a doctor. This won't be an account on how headaches and migraines manifest in the brain, or on what doctors should do to treat them.

But I do have a background in psychology. And pain aside, there is a lot that happens psychologically when one is experiencing a chronic condition like that.

A qualitative study published in the Journal of Head and Face Pain mentions the following psychological factors (amongst others): isolation, frustration, guilt, hopelessness, fear, avoidance behaviour, and stigma. I'd like to comment on some of these from a personal perspective.

Guilt. Oh, guilt is a big one. Why, you might ask? Why would someone experience guilt when it comes to medical symptoms showing up in their body. Why blame yourself?

Well, chronic pain is often defined as the prolonged experience of pain for longer than 12 weeks. That sounds so serious, right? Then hear this: Chronic migraines can be defined as having at least 15 headache days a month, with at least 8 days with migraine features, for more than 3 months.

I never felt like my pain was serious enough. I always felt like I should be able to manage it on my own. People tend to feel like a failure when they end up needing pain medication. Sometimes it's possible to take the right steps early enough (e.g. lie down immediately, put a heat pad on the forehead, close the eyes, shut the world out), managing to keep the headache from ruining the whole rest of the day. Other times (many times), it seems impossible to prevent the pain with whatever strategy. I then end up taking the 768th ibuprofen tablet or triptan medication of my life when it's already pretty bad, and I feel sorry for my poor liver having to metabolise it.

Thoughts like 'I should be able to manage this' are common, and feelings like 'No one would take this seriously' sound familiar.

Stigma. I've been lucky. Very rarely, if ever, have I been questioned about whether my headaches 'are real'. We call that externalised stigma, the feeling of judgement by others. But what about internalised stigma, feeling different than others because of a certain condition? Participants in the aforementioned study reported thoughts like: 'I have a rotten brain. Why do I have a defective brain? I just blame myself. It's my brain so it's my fault.'

Hopelessness. We all like being in control. We like to make things work. You try to see patterns and you're happy when you seem to have found something: 'It must be the change in the weather!', 'If I just drink enough water, it won't happen again.' Or 'I'm on a holiday, so I probably won't be having any headaches this week.' And then you end up getting it wrong. Getting disappointed. Feeling like it's unpredictable.

You hear people say they can count on one hand how many times they've taken pain meds in their life. And you quietly wonder: Am I maybe just overly sensitive to pain? Would other people not find this as bad, would they push through it?

As a woman, I also frequently wonder how it will be going through pregnancy without pain medication, having been confronted with pain and pain management so often in my life. Ibuprofen is not usually recommended in pregnancy. I'm pretty sure there has not been a 9-month period in my adult life where I wasn't reliant on that particular drug, which is the one that often works best for me.

Participants reported thinking thoughts like: 'I wondered if I can continue living with them.'

A guest editorial published in the journal mentioned above states that it is exactly these types of thoughts that are so crucial to take into account when it comes to understanding the full burden of someone's pain, especially for practitioners. For doctors, this may help to better select more suitable treatment options. For mental health practitioners, it might highlight cognitive and behavioural patterns that may be useful to consider, like anticipatory anxiety and avoidance behaviours.

The authors finish by calling for more research with more diverse groups, for example children and young people with migraines, and the impact on the family life. This resonates with me, having been 'that weird 7-year-old' that no one knew what to do with. It's one thing managing the pain. Ibuprofen and triptans work wonders for me and when I take them, things go back to normal for me quite quickly. But the beauty of our ever-thinking brain is that just because the pain is gone, doesn't mean our thoughts stop there. The psychology of chronic pain is a fascinating field and I'm looking forward to more diverse research and hearing more patient voices in the future.

Natascha Niekamp is a graduate member of the BPS, a research assistant at the University of Oxford, and an incoming trainee clinical psychologist at the Oxford Institute of Clinical Psychology Training and Research.