By Shoba Sreenivasan, Ph.D. and Linda E. Weinberger, Ph.D.
A patient in chronic pain wants their pain gone. Perhaps this is easier said than done. Pain management is complex and has no certain or easy solutions. Surgery may not improve, or may even exacerbate, the pain (e.g., as in low back pain). Non-opioid pharmacological treatments may also prove less than satisfactory. Chronic pain causes emotional pain; which, ironically, can result in heightening the patient’s sensitivity to their physical pain. The debilitating effects of chronic pain span across physical, emotional, social, and occupational functioning. In its 2014 report, The National Institutes of Health (NIH) Office of Disease Prevention estimated that chronic pain impacted one-third, or 100 million Americans. It has a high cost: via lost work and medical expenses. The dollar cost was estimated by NIH at $560 to $630 billion a year.
The use of opioids may lessen pain in the short-term, but long-term use remains problematic. For example, it may produce a chronic pain state, may potentiate abuse, and may deepen depression. Moreover, the side-effects of opioids alone, or in combination with other drugs (prescribed or illicit), or if misused by persons with co-morbid conditions (e.g., sleep apnea), can range anywhere from sedation to respiratory suppression to liver damage to death.
Thus, alternate strategies to opioids for pain management have been developed. These include approaches focusing on psychosocial factors, including psychotherapy (such as cognitive-behavioral treatments to address distorted thinking, mindfulness treatment to reframe pain, acceptance commitment therapy to augment psychological flexibility) meditation, yoga, aromatherapy, and acupuncture. These modalities have gained prominence as complementary to traditional medical interventions. These methods have support in the form of small to moderate effect sizes in meta-analytic studies.
Despite the negative effect of chronic opioid use, they remain widely used in the management of pain. In part, this may be because discussing non-pharmacological interventions may not be met with receptivity by a patient in pain. Recommending non-opioid treatment may: 1) signal to the patient that their condition is hopeless; 2) worsen their emotional distress; 3) suggest that their physician believes they are abusing opioids; and/or 4) suggest that the severity of their pain is doubted by the physician.
Is there a way that a medical provider can begin the discussion of alternate treatments that avoid a defensive reaction by the patient? Reframing pain management as the management of emotional, or psychological nutrition may be one such method.
Psychological Nutrition: This is a concept developed by the authors, is readily accessible and intuitive as it adopts terminology and concepts that patients are well familiar: nutritional labels on foods, but applies them to emotions. Psychological reactions are conceptualized from the unique perspective that emotions are ingredients one consumes.
Today, many people are concerned about eating a healthy diet. They may examine the ingredients of the food they eat to find out whether it’s high or low in fat, sodium, calories, fiber, etc., before they buy or eat it. Yet, people are not as attuned to assessing whether their interactions with certain people or their experiences with certain situations may be emotionally nutritious for them. Consequently, many unthinkingly consume a diet of unhealthy emotions.
A diet that is high in fat (full of negative emotions) is not healthy. It can be energy draining and lead to feelings of anger, bitterness, fear, depression, and hopelessness. Whereas a low fat emotional diet is energy augmenting and reinforces a positive sense of self. Just as there is junk food, there are junk emotions.
Why would understanding one’s emotional nutritional intake help manage pain?
Chronic pain is associated with the activation of brain centers related to the interpretation of pain (pre-frontal cortex) and emotion (limbic system); thereby, providing the “why” of how emotional reactivity and cognitive mindsets can change one’s perception of pain. Indeed, “pain literacy;” that is, having knowledge about how and why the pain is caused and what to expect regarding duration and intensity can also reduce pain.
Self-management strategies where the individual reframes their thoughts and feelings about pain, may actually bring about changes in neural activity (such as reducing activity in the amygdala linked to anxiety/stress responses) that in turn help decrease the perception of pain. Understanding how negative emotional states heighten pain is another aspect of pain literacy and a self-management strategy. These three concepts provide the basis of psychological nutrition:
- High fat (or negative) emotions are draining; they can heighten the perception of pain.
- Low fat (or positive) emotions are energizing; they can decrease the perception of pain.
- High stress-low reward experiences lead to a diet heavy in high fat (negative emotions) and lead to psychological malnourishment; low stress-high reward diets are rich with positive emotions and lead to a psychologically nourished state.
- Developing a “snapshot” of one’s day: ratio of high fat to low fat emotions will provide the patient with an understanding whether one is in an emotionally nourished or malnourished state.
Pain causes emotional distress and in turn emotional distress heighten the perception of pain which then heightens the suffering. Therefore, understanding the cyclical nature of how one’s emotional responses impact their perceptions of pain is important. For example, the more we focus on the pain, the greater the sensation. This is turn leads to psychologically non-nutritious (high fat) emotions, such as stress, fear, frustration, helplessness, and depression. Consequently, the patient is less motivated to follow the prescribed treatment, and so the pain and medical condition can worsen. But, if the patient consumes a diet of low fat emotions (such as optimism, calmness, confidence, joy), their sensations of pain could be relieved and less apparent to them, and thus making them more inclined to follow their medical regimen.
Psychological Nutritional Prescription for Pain Reduction
The initial step consists of a quality of life assessment. This helps the patient and doctor better understand what events and people contribute to the patient’s psychological nutrition or malnutrition. Once they understand this, the patient will be better prepared for the following:
- In an easily understood manner, provide the patient with education and information about their medical condition and the nature of the pain to be experienced. Lack of information can be highly anxiety-arousing.
- Encourage the patient to develop self-efficacy that they can exert control over their pain. Just as people can control their nutritional intake of food, patients can control their psychological nutritional intake of emotions.
- Help the patient recognize their negative emotional reactions (high fat) to pain (such as fear and depression) and how they can be regulated if they focus less on them and increase their intake of positive emotions (low fat, such as spending more time on and being more preoccupied with thoughts and activities that do not center on pain, engaging in fun or spiritual activities).
- Emphasize stress management, coping skills, and relaxation. If the pain cannot be reduced entirely, its sensation can be diminished if the patient learns better adaptation strategies.
- Just as there are support groups to help people modify their diet and lose weight, the patient should be encouraged to attend pain support groups. Sharing with people who have similar problems may feel more authentic for the patient and can help modify their emotional amplification of the pain.
Periodically, the patient should reassess their quality of life and level of psychological nutrition. As their emotional diet improves, so should their experience and reaction to pain. Psychological nourishment means living a meaningful life, one that places pain in the background rather than the foreground.
Dr. Shoba Sreenivasan and Dr. Linda E. Weinberger are authors of the new book Psychological Nutrition, which encourages women to live happier and healthier lives by monitoring emotions that are consumed on a daily basis.
Dr. Shoba Sreenivasan earned a Ph.D. in Clinical Psychology from UCLA in 1986 and completed a post-doctoral forensic fellowship at USC. She is a Clinical Professor at Keck School of Medicine of USC, works as a VA psychologist, and has a private forensic psychology practice. She’s co-authored Totally American, a motivational book, and authored the Mattie Spyglass series. She has also written numerous scholarly publications and book chapters in the fields of forensic psychology, violence risk assessment, and Veterans’ issues.
Dr. Linda E. Weinberger earned a Ph.D. in Clinical Psychology from the University of Houston in 1979 and subsequently completed a postdoctoral forensic fellowship at USC. She has been the Chief Psychologist at the USC Institute of Psychiatry, Law, and Behavioral Sciences, and Professor of Clinical Psychiatry at Keck School of Medicine of USC for over three and a half decades. She is the author of numerous book chapters and scholarly publications in the fields of forensic psychology, suicide risk, and violence risk assessment.
Learn more about authors on www.psychologicalnutrition.com