Why "The Pain Is All In Your Head" Makes No Sense

Have you ever been told by someone that the pain you experience, that changes so much about your life, is all in your head? Or maybe the person doesn’t say it directly, but you can tell the person is kind of thinking it?

The truth is that they’re dead wrong… but also kind of right, in a misleading way.

At a basic level, the sensation of pain does get generated inside of your brain. It doesn’t matter what type of pain: whether it’s a persistent lower back pain, or pain from accidentally cutting yourself while juggling flaming swords – your brain generates the set of sensations that you experience as pain.

Then again, all sensations in your body get generated in your head. So yes, technically, the pain comes from your head; but so does the sensation of being hungry, thirsty, or needing to use the bathroom. Just because your brain generates those sensations doesn’t make them any less valid or real. So the next time someone says: “It’s all in your head”, respond by suggesting they ignore their urges to use the bathroom, because that’s also only in their head.

Beyond having a snarky response to someone’s insensitive comment, knowing more about chronic pain can actually help us manage it. When pain works as it is supposed to, it serves the critical role of alerting our brain to something going wrong in our body. An input, such as an injury to the body, causes our nerves to send signals to the brain, which result in the feeling of pain that encourages us to take action. We tend to think of this signal as a clear and direct line from the injury straight to the brain. Kind of like that scene in Cold War movies when all hell is breaking loose, and just in the nick of time the President of the US picks up the Big Red Phone and directly calls the Premier of the USSR, and, while bonding over a shared love for chocolate ice cream and action movies, they decide not to launch the nuclear weapons after all. Right?

Except that is exactly NOT how pain works. There is no direct connection between nerve endings in the body and the brain itself, and the message does not get perfectly transmitted to the brain. There’s not even one place in the brain that processes the many different aspects of pain, like the level of pain, the emotional toll, and the impact to normal activities. Instead, according to the widely-accepted Gate Control Theory of Pain, a stimulus from the body gets filtered by a chemical “gate” that determines how the signal gets sent from the body to the brain where it is interpreted as pain. That gate can amplify sensations that would otherwise be unnoticeable, or it can dampen extreme pain. It can even send faulty "pain" signals that don’t come from any bodily damage at all.

So to take our analogy of the DC-to-Moscow line of communication, it would be more like if the President needs to send a message to the Soviet Premier, but he has to do it through his Secretary of State who’s extremely moody and sometimes delivers the message perfectly and sometimes doesn’t deliver it at all, and oh actually there’s not one Soviet Premier, but more like eight different Premiers each with their own agendas, and while some of them are perfectly happy to live in peace, there’s this one permanently angry Premier who has already decided to order a preemptive strike, but instead of attacking the US, he decides to attack Greenland because he hates how misleading its name is (it’s not green!!).

The point, before the analogy ran away with itself, is that we experience pain in a very complicated and situation-dependent way. This may not be too surprising, because many of us know some people who feel very little pain when something dramatic happens, or other people who feel a great deal of pain for something seemingly minor. Even within ourselves, the same injury can cause different levels of pain depending on the circumstances. Have you ever noticed your pain increase when you’re anxious, or decrease when you’re distracted? In an extreme case, there’s a condition called phantom-limb syndrome, where amputees can feel excruciating pain in limbs that they no longer have.

Knowing about this “pain gate” doesn’t make the pain go away, unfortunately. We can’t decide one day to stop feeling pain – our brains don’t work that way. Moreover, pain is sometimes necessary: when working properly, it is our body’s way of telling our brains that something is wrong that requires action. With chronic pain, though, that process goes haywire, and no longer serves the intended purpose. But it is good news that “gates” can moderate the pain, because it gives us clues on how to better control the damage of that faulty process. Some factors have been shown to help close this pain gate, including certain medications, medical therapies, a sense of control over pain, a reasonable level of exercise, or a feeling of relaxation. Other factors can open the gate, like drug abuse, too much or too little activity, stress, or poor sleep.

Ultimately, the question of whether pain is “all in your head” is irrelevant. Instead, the important question is how to manage chronic pain, knowing that it’s caused by a complex set of interactions between our brains and our bodies. That knowledge doesn’t solve the problem, and science (so far) hasn’t given us a silver-bullet solution. But learning more about chronic pain, committing to seek out and try different strategies to manage it, and fostering a strong relationship with your primary care doctor and other health care providers, can help you better manage your chronic pain so that it doesn’t stop you from living a meaningful life.

 

Sources

Moayedi, M., & Davis, K. Theories of pain: from specificity to gate control. Journal of Neurophysiology Jan 2013, 109 (1) 5-12; DOI:10.1152/jn.00457.2012

Murphy, J.L., McKellar, J.D., Raffa, S.D., Clark, M.E., Kerns, R.D., & Karlin, B.E. Cognitive behavioral therapy for chronic pain among veterans: Therapist manual. Washington, DC: U.S. Department of Veterans Affairs.

Ramachandran, V. S., & Blakeslee, S. (n.d.). Phantoms in the brain. London: Fourth Estate.