Pathways to Pain Amplification and Relief
An Introduction to Central Sensitization
Today’s newsletter is the final one in a three-part series on psychosocial approaches to improving our experience of pain and other physical symptoms. In the first, I discussed mindfulness-based strategies. In the second, I wrote about the harmful pendulum swing from medical gaslighting to ignoring the biopsychosocial framework. And today’s provides a plain-language overview of how our brains modulate pain signals through a phenomenon called central sensitization.
As previously described, pain is now defined as an unpleasant sensory AND emotional experience associated with actual or potential tissue damage. Among pain scientists, there is now consensus that pain experience is not just the result of an injury or disease state, but can be shaped by neurobiological, psychological, and sociocultural factors (Raja et al., 2020).
What this means is that our brain has a powerful role in interpreting and responding to pain. While the phrase “it’s in our heads” has historically been used to dismiss and gaslight, this reality — pain experience being impacted by factors beyond the injury or condition itself — can actually highlight an incredible opportunity. How empowering it is to learn that even in the case of chronic pain or symptoms involving lifelong management (looking at you prolapse…) we have the capacity to effectively target and treat symptom experience multidimensionally, by supporting our brains in working for not against us.
**Before I dive in, I want to clearly state that although I use the word “pain” throughout, the themes and concepts also apply to other distressing physical symptoms including prolapse symptoms.
At the most basic level, pain is an alarm signal. Pain is designed to be attention-grabbing so we notice what’s off in our system and address it. But first, let’s define some terms. The term “acute pain” refers to pain with a recent onset and limited duration, that usually has an identifiable and causal relationship to injury or disease. For example, this past week I slipped off a rock on a hike and landed hard on my knee. I hobbled my way home, cleaned and bandaged a painful gash, iced my quickly-swelling bone bruise, and hoped that I would progressively feel better and better over the next two weeks versus require more intensive medical intervention. It’s still tender but improving, and I’m cautiously optimistic that there’s no major structural damage. This is an example of acute pain, and it’s in our best interest to pay attention to it/let it help guide activity choices (e.g., if I’d completely ignored it and gone to do heavy lifting or impact work at the gym the next day, I likely would have extended my recovery time and/or further injured it).
In contrast, chronic pain is long-term pain that shows up without a clear underlying cause, or persists after injury beyond the expected timeline for recovery. As an example — three years of life-impacting pelvic pain after my birth injury. It’s not that the pain didn’t have a real cause, but my pain experience didn’t track with the expected timeline for tissue recovery.
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Sometimes, our brain’s well-intentioned attempts to notice and avoid threats can worsen versus improve symptoms. There are individual-level (e.g., fear avoidance tendencies, identity disruption, etc.), societal or structural (harmful messages and misinformation, limited access to support resources, etc.), and situational (e.g., perinatal period, a time of heightened neurobiological sensitivity to threat) factors that can contribute to this, and I’ve found it’s helpful to approach this discussion with a heaping dose of compassion—for myself and others who’ve experienced this—rather than judgement. Rather than our brains betraying us, our brains are doing the best they can with a really tricky situation. Understanding how this happens can help us reset these patterns… and it’s so much easier to support change from the standpoint of empathy versus shame.
This brings us to the concept of central sensitization, a phenomenon in which our central nervous system (brain and spinal cord) becomes more sensitive and responsive to stimulation, both internal and environmental. Essentially, our “alarm system” gets reset so that the alarm sounds at a lower threshold and the volume on the pain signal gets turned up.
(This is another topic for another day, but this concept is one reason why many with chronic pain have a history of trauma, because trauma can also reset the threshold of our internal alarm system and increase vigilance to potential threat.)
Let’s imagine that I learned that ANY amount of smoke was incredibly dangerous. Then it would make sense to get a smoke alarm that would go off if it detected any smoke (not just the quantity indicative of probable fire), and we may also decide to start carrying a portable one with us throughout the day just in case. Fried eggs are no longer an option. Neither is my favorite sautéed veggie balsamic pasta. And family campfires and roasting marshmallows are tragically off the table. But that’s all a worthwhile trade for staying safe, right? Over time though, after having my portable smoke alarm go off frequently and unpredictably (person smoking across the street, popcorn in the microwave, going outside for a walk on a slightly hazy day), I’d find myself constantly on guard, scanning my environment for potential smoke… maybe start to smell phantom smoke… and ultimately may just decide to stay home with my trusty air purifiers and food that doesn’t require a heat source.
This hypothetical example, while not a perfect analogy by any means, is similar to what happens to our “pain detector” in chronic pain experiences. Pain is designed to serve a protective role, alerting us to potential or actual injury. But with central sensitization, the central nervous system remains in an ongoing state of high reactivity no matter what’s actually happening at the physiological level. The volume knob on pain detection gets turned up too high, and many types of sensory signals (no longer just those from acute pain) are interpreted as dangerous.
Despite our brain’s good intentions, over time, life becomes smaller not safer.
Importantly, we have evidence from neuroimaging studies indicating that this process is not “just” psychological, but involves neurobiological shifts as well. For many with chronic pain, this heightened sensitivity/activation has a snowball effect, and becomes increasingly generalized beyond pain experience to anxiety and rumination, sleep difficulties, sensitivity to lights, sounds, and smells, etc.
It is worth noting that while these co-occurring challenges may share a similar underlying cause (e.g., central sensitization versus anxiety causing pain, a sentiment that often contributes to feelings of being dismissed or broken), they also reinforce and amplify each other (e.g., heightened anxiety and sleep disturbance can increase pain severity & functional impact, and vice versa).
Stated simply, anxiety may not have initially caused the pain, but inadequately managed anxiety and extreme/unbalanced pain-related thoughts do tend to make physical symptom experience worse, because of the way it fuels patterns of over-activation, increased vigilance to potential threat, and fear-based avoidance.
The good news here? We can start to pull on the threads of this tangled “everything affects everything” mess and intentionally use this interconnectedness in our favor. As a health psychologist, my goal in targeting the contributors to central sensitization is helping our brains work FOR us not inadvertently against us.
Strategies to Address Central Sensitization
“Resetting the alarm” and improving pain experience is best approached from a multidisciplinary perspective that addresses the nervous system’s heightened state and the biopsychosocial factors that maintain it. What does this look like in practice?
Pain science education, because it’s hard to change what we aren’t aware of. When we understand the physical, cognitive, behavioral, and emotional factors that contribute to chronic pain experience, we tend to have more hope that things actually can improve and feel more empowered with stronger sense of agency/confidence in our ability to play an active role in that change. Across health conditions (and life in general!), feeling a sense of control and self-efficacy versus helplessness contributes to better outcomes.
Cognitive behavioral therapy, including third-wave CBT such as acceptance and commitment therapy and mindfulness-based approaches, is an evidence-based approach that targets patterns of thoughts, emotions, and behaviors that contribute to pain experience. For example, CBT-based interventions can help us:
Identify and restructure unbalanced pain-related beliefs in order to shift our way of thinking about and interacting with pain (e.g., as a sensory experience vs. primarily indicative of threat or damage).
Improve pain-coping and distress tolerance skills so flare-ups are less derailing.
Build a repertoire of relaxation strategies such as diaphragmatic breathing and progressive muscle relaxation.
Combat fear avoidance cycles.
Increase confidence engaging in value-aligned, life-enhancing activities.
Development of return-to-activity plans (that address implementation barriers in an individualized way) often in conjunction with physical therapists or other medical providers. With chronic pain, it’s common to have some good days and bad days, and there’s often a tendency to fall into a “boom and bust” pattern. This is essentially a pendulum swing from doing too much on good days because we want to really take advantage of feeling ok… to then experiencing a pain flare-up that makes it hard to do anything at all and often results in increased mood symptoms as well. The goal of graded exposure/activity pacing is to support engagement in value-aligned activity in a progressive, systematic way that doesn’t result in a massive symptom-flare-up, and helps the nervous system gradually reset the alarm threshold. People often hear the terms graded exposure or activity pacing and think it’s all about doing more… but paradoxically, for many this means actually doing slightly less on good days to enable consistent versus maximal effort. We’re playing the long game here.
Optimize sleep. I often describe sleep as a “resilience blanket.” Inadequate sleep (quality and quantity) makes hard things harder, including pain. Poor sleep worsens central sensitization processes, and evidence-based interventions like cognitive behavioral therapy for insomnia can help!
This all sounds great… how can I get connected to skilled mental or behavioral health providers or other resources for managing pain or other physical health conditions?
After typing in your zip code, use the filters on Psychology Today’s “Find a Provider” search function to select “chronic pain” and/or “chronic illness” as the specialty area. This will bring up a list of mental health providers who have experience addressing the intersection of physical and mental health. Many providers offer brief phone calls so people can ask a few questions and evaluate fit. This is a great time to inquire about their general approach to managing pain and other physical symptoms.
There are amazing psychologists and master’s level providers who *don’t* have board certification in health psychology, but if you’re wanting a guaranteed, high standard of training & oversight, you can search the American Board of Professional Psychology directory and filter by providers who are board certified in “Clinical Health Psychology” or “Rehabilitation Psychology.”
Self-guided options: while I wish everyone managing pain or other physical symptoms had access to a multidisciplinary team of experts, I also believe in not letting the perfect be the enemy of the good. And there are some solid self-guided resources out there, such as:
Pain Reprocessing Therapy
I’ll leave you with this — while central sensitization poses significant challenges for pain recovery, understanding this phenomenon can also expand our sense of available, effective treatments. We don’t have to only rely on biomedical treatment, pharmacological therapies, etc. to shape our subjective symptom experience and enhance quality of life. Let me know in the comments — what questions do you have about central sensitization and psychosocial approaches to managing pain?
xx,
Kimberley
Disclaimer: The content provided in this newsletter is for informational and educational purposes only and is not intended as medical advice. It is not a substitute for professional therapy, diagnosis, or treatment. If you are experiencing mental health concerns or medical issues, please consult a licensed healthcare provider or mental health professional. Kimberley Johnson is not responsible for any actions taken based on the information in this newsletter.