Most people assume that pain and illness are caused only by injury or disease. If your back hurts, it must be damaged; abdominal pain must come only from inflammation, infection, or tumor. Most physicians learn this in medical school, as I did. But treatment based on this assumption often fails to provide relief for persistent pain, leaving millions of patients and countless well-intentioned physicians frustrated and in despair. The result is that an astounding 50 million Americans suffer from chronic pain.
The reason is that real pain anywhere in the body can be generated by the brain, even when nothing physical is wrong. Pain experts believe that emotional stress, when not fully processed, fires up the nervous system, which responds by generating pain as a danger signal.
Fortunately, a new research study shows significant relief of non-structural musculoskeletal pain can result from a new form of talk therapy called emotional awareness and expression therapy (EAET). The success of EAET, which focuses on stress, trauma, and emotions, may seem surprising but is quite logical given what new research is telling us about the role of emotions in causing physical pain. The results of the new study confirm several similar studies published in the last few years.
I am grateful to have learned about these stress-based conditions from an insightful psychiatrist at UCLA in the 1980s. In these patients, diagnostic tests either are normal or show abnormalities that are not causing the symptoms. Under the old paradigm, this is a frustrating medical mystery. But the new research helps us understand how pain can arise without physical problems, and how to treat it.
A good example is a 50-year-old patient of mine I’ll call Ellen. When we met, she told me not to waste my time with her and she had good reason for feeling hopeless. Sixty times during the previous 15 years, attacks of severe dizziness, abdominal pain, and vomiting had put her in a prestigious university hospital. But a dozen specialists, including a psychiatrist, failed to find a cause. In patients like Ellen, a major stress they do not fully comprehend drives their brain-generated symptoms. While successfully treating thousands of these patients as a board-certified internist and gastroenterologist, I developed a three-step diagnostic process.
First, I learn the chronology of the symptoms in relation to stressful life events. Ellen’s illness began for no obvious reason. However, driving through one particular town 40 minutes from her home always triggered an attack. This was an important clue that these episodes were linked to stress.
Next, it is essential to assess for depression, anxiety, and post-traumatic stress. Often these are hidden unless specific questions are asked. Ellen had none of these.
The third step is to identify adverse childhood experiences (ACEs). These would make the patient sad or angry if they happened to a child the patient loves. This framing is important. Many people underestimate or repress the severity of their ACEs. But imagining the same events happening to a child clarifies the emotional impact, sometimes dramatically.
Ellen’s mother verbally and emotionally abused her from age four until the time I saw her. Coping with ACEs can lead to stressful personality traits in adults that often contribute to pain or illness. These include low self-esteem, limited self-care skills, excessive self-criticism, perfectionism, detrimental devotion to the needs of others, poor assertiveness, and many more. Ellen and her husband recognized she had several of these characteristics. Fortunately, all of them can change with treatment.
Stress also can be triggered by people, events, or situations in the present that have links to ACEs. This connection is easily missed if ACEs are not explored. In Ellen’s case, she passed through the town that triggered her illness only on the way to visit her abusive mother. Driving the same distance (or more) for a different purpose never caused symptoms. This revelation led her husband to recall that the attacks at home followed phone calls from her mother. Recognizing these connections empowered Ellen to set strong boundaries with her mother and the illness episodes ended.
In the new talk therapy study that validates this neuroplasticity-based approach, one group of patients was treated with EAET. As with Ellen, the focus was on stress, trauma, and emotions. A remarkable 63 percent of them achieved the pain relief goal. The control group received the previously standard cognitive behavioral therapy but only 17 percent achieved the goal.
Ellen’s initial despair is shared by millions who suffer from stress-based pain or illness and have been failed by an obsolete paradigm that neglects the role of trauma and emotions. Fortunately, the new approach can be learned from textbooks and courses for professionals, at educational conferences, and from self-help resources for patients. The techniques are not difficult to apply when medical and mental health clinicians collaborate and, as one general practitioner recently told me, “They put the joy back into my work.”
David Clarke is an internal medicine physician and gastroenterologist.
