Neuroplastic psychology relieves unexplained pain

I have interviewed 7,000 people with unexplained pain or illness. Here is what I learned.

About 40% of patients in primary care have pain or illness that cannot be explained by diagnostic tests.

It is commonly assumed that the symptoms are “all in their heads,” and that little or nothing can be done. Fortunately, this isn’t true as these examples from my practice will show:

• an 87-year-old woman with recurring abdominal pain for 79 years;
• a 21-year-old man with 27 distinct body symptoms;
• a 50-year-old woman hospitalized 60 times in 15 years for attacks of dizziness and vomiting;
• a 23-year-old woman with vomiting due to a paralyzed stomach; and
• a 17-year-old diabetic boy hospitalized for more than 2 months with severe abdominal pain requiring hourly morphine.

Like thousands of others I have cared for, these patients shared three characteristics: no diagnosis, a life stress whose significance was unrecognized, and relief of their chronic pain or illness after identifying and treating the stress. My colleagues and I call these neuroplastic symptoms. That is because this form of pain or illness results from learned neural pathways in the brain (“neuro”) that are capable of change (“plastic”).

To find the underlying stress(es), I follow a three-step process. First, I want to understand the chronology of the pain or illness in relation to stressful life events. A good example is the 87-year-old patient whose pain began at age 8. This was shortly after her toddler brother died from appendicitis. She had been his main caregiver since birth and felt completely responsible for his death. She carried the guilt for 79 years. The most beneficial part of her treatment was writing a letter to ask his forgiveness.

Next, it is essential to assess for depression, anxiety or post-traumatic stress. Often these are hidden unless specific questions are asked. The 21-year-old told me he didn’t feel depressed, but he slept poorly, no longer engaged in activities that brought him joy, cried regularly, had no appetite and had lost his sense of purpose. Treatment for depression relieved all 27 of his symptoms.

The third step is to identify adverse childhood experiences (ACEs). I look for events that would cause the patient to feel sad or angry if they happened to a child the patient cares about. This framing is important. Many patients who recall ACEs underestimate or repress their severity. But when asked to imagine the same events happening to a young loved one, the emotional impact is clarified, sometimes dramatically.

Coping with ACEs can lead to problematic personality traits in adults. These include low self-esteem, perfectionism, limitations in self-care skills, excessive self-criticism, detrimental devotion to the needs of others, poor assertiveness and many more. Stress from these traits often contributes to pain or illness. Fortunately, they are amenable to treatment.

Stress also can be triggered by present day people, events or situations that have links to ACEs. This connection is easily missed if ACEs are not explored. A good example is the woman aged 50 years with dizziness and vomiting. All her attacks were associated (directly or indirectly) with encountering her abusive mother. Helping her recognize this empowered her to set boundaries and the episodes stopped.

The woman aged 23 years was a devout Christian with a single ACE that stood out. She believed she had committed a terrible sin by becoming pregnant while unmarried at age 16. She gave that baby to an adopting family, later married the baby’s father and was now pregnant for the second time. But as her pregnancy visibly progressed, she became terrified that God would punish her by harming the fetus. Reframing the past adoption as an act of sacrifice and atonement reduced her fear and the vomiting stopped.

The boy aged 17 years is an example of generational ACEs. Trauma that his mother suffered as a girl led to well-intended but suffocating control over her son’s diabetes. Helping the mother understand these connections facilitated a change in her behavior and the son’s pain steadily improved. He left the hospital after a week and the pain was gone a month later.

Several recently published clinical trials in patients with nonstructural pain confirm that this approach provides far better relief than older methods. For example, in the Boulder Back Pain study of people with pain for an average of 10 years, eight 1-hour sessions of neuroplastic psychology led to a 75% reduction in pain in 1 month. There was little change in two control groups. At UCLA, 63% of older veterans with musculoskeletal pain treated with neuroplastic psychology achieved the pain relief goal compared with only 17% who received cognitive behavioral therapy. Neuroplastic psychology has also been effective in a pilot study of patients with long COVID and in the form of a mobile app called Curable.

The techniques are not difficult to apply when medical and mental health clinicians collaborate. Self-help books and courses for patients are available, too. With these resources, the frustration associated with this condition is replaced with, as one family medicine doctor told me, “putting the joy back into my work.”

References:

• Ashar YK, et al. JAMA Psychiatry. 2022;doi:10.1001/jamapsychiatry.2021.2669.
• Donnino MW, et al. Mayo Clin Proc. 2019;doi:10.1016/j.mayocpiqo.2023.05.002.
• Thomson CJ, et al. Can J Pain. 2024;doi:10.1080/24740527.2024.2352399.
• Yarns BC, et al. JAMA Netw Open. 2024;doi:10.1001/jamanetworkopen.2024.15842.

For more information:

David Clarke, MD, can be reached at: DrDave@Symptomatic.me.