Why Do Treatments Aimed at the Mind Fix Pain in the Body?

Brought to you by CHYP’s Parenting Blog

October 25th, 2021

By: Lonnie Zeltzer, MD

Families ask me: “Is my child’s pain psychological or physical?” My answer is, “Yes — both combined. Always.”

Pain is a widespread problem and it’s in your head — that is, “inside your head, in your brain.” It travels throughout your nervous system with the help of neurotransmitters.

It is hard to figure out why the cause for significant pain somewhere in the body can’t be “found,” despite numerous tests ordered by numerous specialists. Why don’t powerful pain medications work unless they make you sleep or otherwise totally knock you out?

Nathaniel Frank, a professor at Cornell University, wrote a recent article in the Washington Post:

  • “One-fifth of American adults — 50 million people — suffer from chronic pain, defined as pain experienced most days or every day during the past six months. Conditions include migraines, sciatica and gastrointestinal disorders, as well as shoulder, knee and elbow pain. Back and neck pain, too, affect up to 85 percent of adults at some point in their lives and are among the most common reasons for doctor and hospital visits. Chronic pain results in more than $500 billion each year in direct health-care and disability costs and lost productivity. Roughly half a million Americans have died over the past two decades after overdosing on opioids, commonly taken in a desperate quest for pain relief.”

Studies have shown that more than 70% of teens who have significant pain — if not addressed before adulthood — typically will have long-term chronic pain. Naturally, parents want to help their child who is suffering from pain and/or many related symptoms: fatigue, sleep problems, anxiety, depression, school absenteeism, social isolation, eating problems, and others.

They start by bringing their child to the primary care doctor, and then onward to many specialists. This, in turn, leads to numerous blood and urine tests, x-rays, MRI and CT scans, and even numerous invasive procedures and surgeries in the hope that “something will be discovered as the cause of the pain and be fixed.”

Medications are given to “fix” the problem or reduce the suffering, and, for many kids, side effects or drug interactions create new added problems and suffering. Meanwhile, your child is missing school, getting further behind, feeling more isolated as social and sports/fun activities are stopped, and the stress related to the other symptoms mounts and adds to the overall symptom load.

In frustration, when nothing is “found” as the “cause” of the pain, and no biomedical treatment is working, doctors suggest that your child see a psychiatrist and/or a psychotherapist. Your child hears, “The doctor thinks I am faking it… that I want to get out of school… or not do ballet or sports…”. Kids stop trusting doctors’ abilities to help them.

Parents don’t know where to turn as they see their child suffering, especially with significant pain. So, they often turn to practitioners who advertise magical cures online with testimonials about all of their cured patients. I am always skeptical about these online advertisers with good marketing skills who sell their magic potions or have procedures or “cures” at enormous out-of-pocket costs.

However, with newer ways of looking at the brain and neural activity and neurotransmitters, we are learning that the most powerful and effective chronic pain treatments may be through communication with your child’s brain/mind. We used to call these therapies “New Age” and non-science based.

I remember when I first brought acupuncture and hypnotherapy into my UCLA pediatric chronic pain clinic — and even just did research in these areas — my chairman at the time asked me to keep quiet about what I was doing so that his colleagues wouldn’t think he’d become too “foo-foo,” as he called it.

I then began doing scientific research into yoga and mindfulness for youth in pain. As the tools to look at brain activity developed, I and other scientists not only expanded research in mind-based pain treatments, but we were also able to see what happens in the brain that made these treatments effective.

It is difficult for many parents to see how a psychotherapist talking with their child can actually bring about neural connections and enough neural transmitter changes to alter central pain signals and reduce pain.

However, there are a variety of mind-based therapies like cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT), mindfulness, hypnotherapy, and others that have been scientifically shown to reduce or eliminate pain by changing brain signals. There are also mind-body therapies like yoga, combined with mindfulness and imagery, that have been shown to change pain signaling.

A well-designed, randomized, controlled study reported in a recent issue of JAMA Psychiatry by Asher, et al., found that changing people’s beliefs about the causes of their pain, and its threat to them, was powerful enough to reduce or eliminate pain for up to a year (the last assessment in that study).

And the reduction in pain was accompanied by changes in the brain’s pain-signaling connections as shown on functional MRI. That is, changing one’s thinking over a four-week period physically changed the brain’s pain system and got rid of, or reduced, the experience of pain. Similarly, studies have shown that a daily practice of mindfulness changes the brain’s pain signaling system, as does hypnotherapy, using the brain’s ability to imagine good or captivating experiences.

I call chronic pain in teens the “smart brain pain syndrome” since most of the kids I see are smart and creative. Their brains make connections easily — that is how they learn so well.

However, for some of these kids, because they make these new neural connections so well, that pain loop in the brain can easily form and then get “stuck.” This causes ongoing pain, despite whatever origin of the pain being long gone or not even identifiable.

These kids develop ongoing pain because the brain’s “sticky neural loop” keeps the pain active.  The electrical activity in this “central pain station” in the brain then sends electrical signals down the spinal cord and autonomic nervous system (ANS) pathways to impact other parts both outside and inside the body.

Pretty soon other physical symptoms develop because of the temporarily messed up electrical signaling system causing POTS (ANS dysfunction associated with dizziness, hot/cold flashes, and other symptoms), fatigue, pain spreading to other parts of the body, intestinal problems such as constipation, diarrhea, nausea, abdominal pain, and muscle tension causing muscle spasms and headaches, among other symptoms.

Also, when physical symptoms take over, they can lead to emotional symptoms such as depression, anxiety, fear of eating (with weight loss from food restriction), difficulty sleeping, etc.

While physical symptoms can lead to psychological symptoms and vice versa — chicken and egg — the treatment is the same: Brain-aimed psychological therapies and body-up physical therapies.

If one has been sedentary for a long time because of pain, the body needs to begin moving and become active again, or muscle pain and weakness will ensue. At the same time, the brain needs to develop new neural patterns of thinking and feeling to rewire the pain loop. For some kids, medication can help the above brain-down and body-up work, as well as healthy eating and attention to facilitating good sleep patterns.

So, are pain and associated symptoms psychological or physical? The answer is both, and treatment involves brain and body together in a mind-body interconnected program.

See our new book: The Smart Brain Pain Syndrome: The Primer for Teens and Young Adults in Pain, by Weston, Zeltzer, and Zeltzer.

https://www.amazon.com/Smart-Brain-Pain-Syndrome-Primer/dp/1737438305/ref=sr_1_1?dchild=1&keywords=smart+brain+pain+syndrome&qid=1634661000&s=books&sr=1-1


Lonnie Zeltzer, M.D., is a Distinguished Research Professor of Pediatrics, Anesthesiology, Psychiatry and Biobehavioral Sciences at the David Geffen School of Medicine at UCLA and Immediate Past-Director of the UCLA Pediatric Pain and Palliative Care Program. She is a co-author on the Institute of Medicine report on Transforming Pain in America and is a member of the national steering committee assigned to provide directions for pain research at the National Institutes of Health (NIH).  She has received, among other awards, a Mayday Pain and Policy Fellowship and the 2005 Jeffrey Lawson Award for Advocacy in Children’s Pain Relief from the American Pain Society (APS).  Her UCLA integrative pediatric pain program received a 2009 Clinical Centers of Excellence in Pain Management Award from APS and a 2012 award from the Southern California Cancer Pain Initiative.  She is active in advocacy for pain care and research. She was an invited member of the Institute of Medicine National Expert Panel on pain in American and was a co-author of the IOM publication on the committee findings in 2011. She was an invited member of the Centers for Disease Control (CDC) Special Advisor on The State of Opioids in America. She is also an invited member of the FDA Committee on Analgesia, Anesthesia, and Addiction, where new pain-related drugs are given FDA approval or not, as well as an invited member of the Expert Advisory Committee on Hemoglobinopathies as a pain expert for the National Heart, Lung, and Blood Institute (NHLBI) at NIH.  She is also on an expert panel for the NIH on a national study on a mind-body intervention for teens with fibromyalgia. She is also a member of the national Autism Think Tank as a pain expert in autism. Her research includes yoga, mindfulness, hypnotherapy, and other self-help interventions, including mobile technologies, to help children and adolescents who have chronic pain, as well as understanding biopsychosocial pain mechanisms in irritable bowel syndrome, cancer, sickle cell disease, headaches, dysmenorrhea, and other conditions. She has over 350 research publications on childhood pain and complementary therapies, has written more than 80 chapters, and published her first book for parents on chronic pain in childhood (HarperCollins, 2005) and her second book for parents on chronic pain in children and young adults (Shilysca Press, 2016).