Can being mindful of pain cause pain?

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“I cannot be mindful when I’m in pain – it hurts too much!”

As someone who has suffered with cluster headaches (also referred to as “suicide headaches” because of the pain severity) I totally understand this sentiment. When I first experienced a cluster headache, it came out of the blue and the agonising pain could not be described in any way that would accurately capture it. I woke up to it and panicked. I felt sick with the degree of pain, which I imagine would be akin to being shot in the head over and over (unsubstantiated estimation I’ll admit). At one point I started banging my head against the wall (much to my partner at the time’s dismay). It sounds odd, but it was the only thing I could think to do in the blinding pain I was in. It did not help and would not recommend.


So, I get it. I understand being in pain and how it impacts on your capacity to approach experiences in any way other than reactive. However, typically what people mean when they say they can’t be mindful when in pain, is that they are frightened being mindful will increase the pain experience. Let’s address this first by defining and describing mindfulness.


Mindfulness is the cultivation of present moment awareness with non-judgment and compassion. Important here is the attitude and quality of the present moment awareness: non-judgemental and compassionate. You may be fully aware of the present while intentionally berating yourself and upon observing that berating, endorsing it entirely. “Yes I should be telling myself off right now!” One could not describe that as mindfulness. That would be awareness with a heavy slice of endorsed self-criticism. To be truly mindful, there must be compassion. A will to be kind and gentle with yourself (and others). Mindfulness is not reactive but responsive. What mindfulness is often confused with is awareness, specifically fearful awareness that may be more akin to bodily/symptom hypervigilance. Hypervigilance to pain or uncomfortable sensations can be defined as the automatic prioritisation of pain-related stimuli compared with other stimuli[1]. Awareness of sensations here is with a quality of fear, threat detection and resistance, much the opposite of mindfulness. To illustrate the difference further, a questionnaire measure pain hypervigilance has been developed, with items such as “I notice immediately when pain starts or increases” and “I notice pain even if I am busy with another activity[2].

While mindful awareness of pain may decrease negative pain experiences and perhaps even pain severity itself[3], hypervigilance is likely to increase pain severity[4] and negative emotional experiences around pain[5]. To further understand the subtle differences between mindful awareness versus pain hypervigilance, it can be helpful to unpick the mechanisms of the relationships between both types of attentional awareness and pain outcomes. A hotly contested question is whether hypervigilance is a result of pain or a predictor of it. It stands to reason that when feeling pain, a deeply threatening experience, the body would automatically try and protect against it by monitoring for further indicators of pain. The answer is something that probably lies somewhere in the middle. Although some people may have predilections for bodily focus and hypervigilance prior to onset of a persistent pain condition (perhaps due to anxiety, trauma or socialisation to the body in this way, etc), for many people hypervigilance may quickly kick in concurrent with early experiences of pain. Consequently, hypervigilant responding to pain becomes ingrained and so perpetuating a chronic pain cycle[3].


A study assessed whether hypervigilance is predictive of pain experience, by prospectively measuring hypervigilance prior to a sample of individuals having been operated on. The hypothesis was that those scoring higher on hypervigilance would likely have higher postoperative pain. This conclusion was supported, demonstrating the influence of bodily hypervigilance on pain experiences. [6] Why would this be the case? On a neurochemical level, it makes sense that the brain prioritises particular sensory information as “important” and that this results in increased sensory input from the peripheral regions of focus. Furthermore, when making the distinction between mindful awareness and hypervigilance, a key differentiator was the quality of awareness as largely informed by the emotional experience. While mindful awareness is compassionate, permissive and gentle, hypervigilance is threat-aware, fearful and urgent. Research supports the fearful nature of hypervigilance with some studies demonstrating that hypervigilance is also associated with quicker processing of emotional stimuli (these were facial expressions presented in the presence and absence of pain). This makes sense neuroscientifically as there is a big overlap in the location in the brain where pain and emotion are processed.


This is where mindfulness comes in. “Emotion regulation” is a term that refers to the effort to influence moment-to-moment emotional experiences and the behavioural and physiological expressions of them. A systematic review found that greater awareness of bodily state (a key component of mindfulness) was predictive of downregulation of negative emotions[7]. What this translates to in practice, is the importance of being able to be aware of embodied emotional experiences in order to reduce pain-related distress, which could impact the pain experience also. Mindfulness has been demonstrated to improve a variety of physical health outcomes including pain[3]. It is hypothesised that there are 2 key pathways by which is does this: 1. By increasing neural stress regulation in the prefrontal cortex and by 2. Decreasing the stress alarm system in the emotion centres of the brain.


Practically speaking it can be hard to practice mindful awareness especially directly approaching a physically painful experience but what this research shows is in these moments, mindful awareness of the emotions surrounding that experience can be just as regulating. I often advise my clients that in moments of acute pain, where nothing else can be done due to the severity, so there is no scope for distraction or usual functionality, to focus on soothing the emotional experience. What can provide comfort and a sense of safety? Activities to activate the parasympathetic nervous system can help with this. These might include:

-diaphragmatic breathing, extending the exhale

- listening to a light-hearted podcast or music

- cuddling something warm or cool

- stroking a pet

- having a drink

- using compresses


In all situations it is important to disengage from fearful thought streams as there is one thing that is for sure. Fearful thought streams do not help and only hinder.


Has this article left you with questions? Feel free to comment or write to us. Do you have your own experiences? We’d love to hear from you.



References

[1] Dittmar, O., Baum, C., Schneider, R., & Lautenbacher, S. (2015). Effects of context and individual predispositions on hypervigilance to pain-cues: an ERP study. Journal of pain research, 8, 507. [2] McCracken, L. M. (1997). “Attention” to pain in persons with chronic pain: A behavioral approach. Behavior therapy, 28(2), 271-284. [3] Creswell, J. D., Lindsay, E. K., Villalba, D. K., & Chin, B. (2019). Mindfulness training and physical health: mechanisms and outcomes. Psychosomatic medicine, 81(3), 224. [4] Keogh, E., Book, K., Thomas, J., Giddins, G., & Eccleston, C. (2010). Predicting pain and disability in patients with hand fractures: comparing pain anxiety, anxiety sensitivity and pain catastrophizing. European journal of pain, 14(4), 446-451. [5] Wong, W. S., Lam, H. M. J., Chen, P. P., Chow, Y. F., Wong, S., Lim, H. S., ... & Fielding, R. (2015). The fear-avoidance model of chronic pain: Assessing the role of neuroticism and negative affect in pain catastrophizing using structural equation modeling. International Journal of Behavioral Medicine, 22(1), 118-131. [6] Lautenbacher, S., Huber, C., Kunz, M., Parthum, A., Weber, P. G., Griessinger, N., & Sittl, R. (2009). Hypervigilance as predictor of postoperative acute pain: its predictive potency compared with experimental pain sensitivity, cortisol reactivity, and affective state. The Clinical journal of pain, 25(2), 92-100. [7] Pinna, T., & Edwards, D. J. (2020). A systematic review of associations between interoception, vagal tone, and emotional regulation: Potential applications for mental health, wellbeing, psychological flexibility, and chronic conditions. Frontiers in psychology, 11, 1792.


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