To focus on pain or distract yourself?



How should you be dealing with your pain? You might be told to distract yourself and try not to think about it. You may also receive the advice to try a course of mindfulness which involves turning toward the pain experience. Navigating this journey and knowing what steps to take can be a confusing and complex experience.


Mindfulness for pain

Mindfulness-Based Stress Reduction (MBSR) was developed by Jon Kabat-Zinn and used successfully in a variety of populations, including people with chronic pain. Kabat-Zinn described Mindfulness as the process of ‘paying attention, on purpose, to the present moment, non-judgementally’. This may sound counterintuitive, why would you want to raise awareness of your pain and focus on it? Surely if you pay more attention to it, it will feel worse?


Mindfulness encourages noticing bodily sensations and turning towards them. This is a contrasting attitude to distracting yourself – the goal is not to ignore your pain and to avoid it but rather to change your relationship with it. Adopting the observer role without judgement of what you feel increases pain acceptance which involves allowing the pain rather than attempting to control it [1]. This is known to improve the physiological experience by lowering overall levels of pain and the associated psychological distress [2]. Taking a compassionate approach (i.e. not being self-critical) is a key part of mindfulness practices and helps to approach pain with less fear and more tolerance of it, therefore reducing avoidant behaviours and the impact it has on daily life [3]. A systematic review of 16 studies that looked at the effectiveness of mindfulness-based interventions (MBIs) for pain symptoms [4]. The review concludes that MBIs have a positive impact on reported pain intensity and that when compared with control groups, MBIs do result in greater reductions in pain intensity. Even better is that the effect is not time-limited as the results from follow-up reveal that reductions in pain intensity are sustained long-term.


How exactly does something like mindfulness change our experience of pain when it is such a physical experience? Modern-day brain scans have allowed us to observe how mindfulness alters brain processes and networks involved in pain. The brain responds differently to pain when approaching it from the stance of mindfulness with compassion. Research has found increased activation in areas of the brain that are associated with processing sensory experiences and decreased activity in areas of the brain related to thinking and evaluation following mindfulness [5, 6]. Essentially the brain doesn’t ‘think’ about whether the pain is good or bad but rather it processes the sensory experience through a separate neural pathway, allowing a more manageable pain experience. By focusing on your pain in a non-judgemental and compassionate manner, it stops that automatic labelling of what pain means and the consequences of it.


When does focusing on your pain become unhelpful?

Focusing on your pain can become unhelpful when it prompts relating to yourself and your pain in a way that is critical and may induce negative reactions such as catastrophising. Pain catastrophising is a set of negative beliefs and assumptions about pain that have been consistently linked to pain intensity in the literature. A critical review identified 3 mechanisms of how pain catastrophising changes cognitions and the experience of pain [7]. Catastrophising can lead to the below subsequent changes:

1. Magnification: Increases attention to pain symptoms which increases perception of pain and unpleasant bodily sensations.

2. Rumination: Repetitively focusing on the symptoms and dwelling on the possible cause and consequences of the pain. Results in being focused on the problem and feeling without taking action [8].

3. Helplessness: A perceived inability to cope with the pain which can interfere with daily life and beneficial health behaviours.


High levels of catastrophising are associated with heightened pain intensity and emotional distress [9]. Essentially this is the opposite of being non-judgemental and compassionate towards what you feel. If focusing on pain is associated with the above, this could be contributing to worsened symptoms and isn’t the most helpful approach.


Should you distract yourself instead?

Distraction is a commonly used coping mechanism for pain and is generally known to be successful to some degree. Distraction means shifting your attention elsewhere, generally to something neutral or more enjoyable so that the pain is no longer the core focus. One of the key processes of distraction is via the mechanism of attention. Attention plays a significant role in the perception of pain by increasing anxiety and hypersensitivity, thus amplifying the symptoms – hence why it feels so much worse the more you think about it. The brain is powerful and there is a strong link between what we think and our physical experience. A phenomenon known as the nocebo effect highlights that anticipation and negative expectations can trigger off physiological responses and modulate perceptions of touch, pressure, pain, and temperature [10].


A study in healthy people assessed how verbal suggestions of pain can impact on pain experiences, clearly highlighting the nocebo effect. A group of people underwent a pain threshold assessment before being asked to rate how painful stimuli on their arm was. A portion of these people were given verbal suggestions that they would experience pain on their finger. Based on each individual’s pain threshold, tactile touch and low-intensity pain were administered. Verbal suggestion alone turned what was tactile touch into pain and low-intensity pain into high-intensity pain. A simple suggestion of pain and setting the expectation was enough to increase how painful the stimuli was. Our brain clearly has the powerful potential to change our physical experience through our thoughts. Reducing the anticipation of pain and negative thoughts around it by the mechanism of distraction is unsurprisingly an effective technique for many and modulates the perception of pain.


Distraction also reduces the mental resources your brain has available to attend to painful stimuli. In a recent study that explored the role of attention and pain, 41 people were asked to complete two memory tasks, one that required a great deal of attention and the second less attention, all whilst receiving a painful heat stimulus to their arm [11]. As expected, the high attention task resulted in less reported pain compared to the low attention task. The size of the distraction was found to be related to cognitive inhibition; shifting attention elsewhere inhibits negative thinking about pain and pain catastrophising, thus reducing the intensity of the pain. Pain catastrophising seems to be a key factor for the pain experience – distraction inhibits the thoughts whilst mindfulness reduces and alters these thoughts as opposed to ignoring them.


Summary

One of the key distinguishing factors related to whether you should focus on your pain or distract yourself is how you relate to your pain. Taking the stance of non-judgement, acceptance and compassion can improve your psychological experience by serving to reduce the negative attention paid to symptoms and the sense of helplessness that can come with it. In a similar fashion, distraction takes away the negative focus of attention from the pain and reduces the anxiety and hypervigilance which can contribute to symptoms worsening. Both appear to be effective but are contrasting approaches in practicality.


How have you approached pain in the past and how do you believe changing the way you relate to it will help?


References



[1] Kratz, A. L., Davis, M. C., & Zautra, A. J. (2007). Pain acceptance moderates the relation between pain and negative affect in female osteoarthritis and fibromyalgia patients. Annals of Behavioral Medicine, 33(3), 291-301.

[2] LaChapelle, D. L., Lavoie, S., & Boudreau, A. (2008). The meaning and process of pain acceptance. Perceptions of women living with arthritis and fibromyalgia. Pain Research and Management, 13(3), 201-210.

[3] Purdie, F., & Morley, S. (2016). Compassion and chronic pain. Pain, 157(12), 2625-2627. doi: 10.1097/j.pain.0000000000000638

[4] Reiner, K., Tibi, L., & Lipsitz, J. (2013). Do Mindfulness-Based Interventions Reduce Pain Intensity? A Critical Review of the Literature. Pain Medicine, 14(2), 230-242. doi: 10.1111/pme.12006

[5] Grant, J., Courtemanche, J., & Rainville, P. (2011). A non-elaborative mental stance and decoupling of executive and pain-related cortices predicts low pain sensitivity in Zen meditators. Pain, 152(1), 150-156. doi: 10.1016/j.pain.2010.10.006

[6] Zeidan, F., Emerson, N., Farris, S., Ray, J., Jung, Y., McHaffie, J., & Coghill, R. (2015). Mindfulness Meditation-Based Pain Relief Employs Different Neural Mechanisms Than Placebo and Sham Mindfulness Meditation-Induced Analgesia. Journal Of Neuroscience, 35(46), 15307-15325. doi: 10.1523/jneurosci.2542-15.2015

[7] Quartana, P., Campbell, C., & Edwards, R. (2009). Pain catastrophizing: a critical review. Expert Review Of Neurotherapeutics, 9(5), 745-758. doi: 10.1586/ern.09.34

[8] Nolen-Hoeksema, S., Wisco, B. E., & Lyubomirsky, S. (2008). Rethinking rumination. Perspectives on psychological science, 3(5), 400-424.[9] Petrini, L., & Arendt-Nielsen, L. (2020). Understanding Pain Catastrophizing: Putting Pieces Together. Frontiers In Psychology, 11. doi: 10.3389/fpsyg.2020.603420

[10] Colloca, L. (2017). Nocebo effects can make you feel pain. Science, 358(6359), 44-44. doi: 10.1126/science.aap8488

[11] Rischer, K., González‐Roldán, A., Montoya, P., Gigl, S., Anton, F., & Meulen, M. (2020). Distraction from pain: The role of selective attention and pain catastrophizing. European Journal Of Pain, 24(10), 1880-1891. doi: 10.1002/ejp.1634


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