(The Article is part of FIT's #DecodingPain series, where we pull apart the many layers of pain–the sensation, the causes, the stigma, and the treatments.)
One day in April of 2018, Shirin had a headache...and it hasn't stopped since.
"There are times when it flares up, but for the last 3 years, there hasn't been a moment where it's not been there," she says.
Multiple visits to multiple doctors and specialist have led nowhere.
MRIs? Clean. CT scans? Clean. X-ray? A-OK.
Then they turned to possible psychological triggers.
"There isn't an incident I can pinpoint to, but it was definitely a time of my life when I was going through a lot of emotional turbulence," says Shirin, thinking back.
"Infact, since July, August 2017, I had been in a bit of a downward spiral. I wasn't working at the time, so the feelings of not being productive enough, not being able to achieve anything, and feeling like a failure were constant."Shirin
It was also around this time that she lost her grandmother, whom she was very close to.
And since the headache began, she says, it flares up when she's worked up, both physically and emotionally.
This link is what her psychologist is trying to tackle along with all the other physiological treatments she's undergoing.
With modern medicine making strides in the last couple of centuries our understanding of the link between the mind and the body has come a long way.
In a previous article, FIT broke down the connection between the mind and the gut and how the health of one affects the other.
Similarly, the idea of pain being tied to mental stress, is not a new one.
A Brief History of Pain and the Brain
Let's begin with Ancient Greece. The famous philosopher Plato spoke of pain and pleasure as emotions.
Just as our interactions with the world invoked pleasure, so could it cause pain.
Ancient philosophers like Plato didn't see the distinction between the physical and the emotional, and many pain theories understood pain as an emotional response to stimuli.
We now understand that it can also be a physical response to emotional stimuli.
In the 17th Century, French philosopher and scientist, René Descartes became the first person to suggest that pain came from the brain. He also attributed pain as a product of the 'soul' that resided in the brain.
Fast-forward to the 1900s, when 'The Gate Control theory of pain', first proposed that when one faced trauma of any kind, impulses travelled up the spinal cord, through a system of nerves, to the brain.
The theory imagines that one's spinal cord has many tiny 'gates' that allow these signals to pass through to the brain where it is then processed.
Interestingly, the gate control theory also suggested that the state of mind of a person impacted how open or closed the 'gate' were.
For example, if someone is going through high levels of emotional trauma, pain impulses travel more freely up to the brain.
This theory still shapes our understanding of pain today.
How the Mental turns Physical
"All the mental processes are linked at Thalamus in the brain. The Thalamus is the seat of pain integration in the body. So mental or behavioral impulses are linked to the processing of pain impulses."Dr Praveen Gupta, Director and Head of Department, Neurology, Fortis Memorial Research Institute, Gurugram.
"Any disease, any trauma can change the sensitisation of how cells lead to secretion of transmitters. So, it is possible that changes in this cell function will lead to abnormal secretion of pain transmitters," says Dr Gupta.
"When this type of pain persists for a long period of time, it si known as chronic pain," says Dr Gupta.
And the trauma that triggers this misfiring can be both physical and mental. "Any trauma, stress, unpleasant memory can trigger and perpetuate such pain," he adds.
According to Sandeep Vohra, Neuropsychiatrist, Apollo Hospital, Delhi, "Brain handles trauma differently in different people, and psychological strain can reflect in your body differently, through different channels."
When mental stress leads to pain in the body, it is called psychosomatic pain.
"Psyche means 'mind' and soma means 'body'. And this type of pain can manifest anywhere in the body," explains Dr Vohra.
Dr Vohra further talks about how a marker of psychosomatic pain is when the pain is not resolved with regular painkillers.
Toput it simply,
When the mind is under strain, the changes in the brain transmitters will lead to changes in the peripheral neurotransmitters.
This change in the firing of neurotransmitters leads to actual symptoms of physical pain like in the case of fibromyalgia.
"Stress and anxiety is a very important accompaniment of disease like chronic fatigue syndrome or fibromyalgia. So, anxiety can perpetuate, continue and increase chronic thing."Dr Preveen Gupta, Neurologist, Fortis Memorial Research Institute
This nexus of mental and physical stress can be so entwined that it can be hard to tell where one ends and the other begins.
When Swati–a lawyer, mental health activist, and a chronic pain warrior–was handed over her diagnosis of fibromyalgia, she was barely given choices of treatment, much less a reason for it.
Now she suspects the fact that she's always struggled with anxiety and depression, and her bi-polar disorder might have something to do with it.
She speaks of her struggles with both mental health and physical pain, and how in her case, it was the physical pain that led to the diagnosis of her mental disorder.
"I had terrible migraines and the neurologist I went to suggested I see a psychologist. It took me aback at the time, but that's how I was diagnosed with depression and then eventually bi polar."Swati
An Invisible Illness With an Invisible Cause
"They are not imaginary symptom, they're physical symptoms, actual symptoms, but they are being perpetuated or caused by mental issues in the brain."Dr Praveen Gupta, Director and Head of Department, Neurology, Fortis Memorial Research Institute, Gurugram.
Invisible illnesses like chronic pain often don't come with 'injuries' which can make treating them all the more challenging.
And if the root cause is a psychological issue, it can be all the more hard to get to the bottom of.
"There has been a lot of trying to understand what could been the cause, and how it began, but it hasn't led anywhere because there was no particular incident or something that happened at that point itself."Shirin
"I have often tried to trace it back to something. If they could just tell me that it was because of this particular psychological issue even, at least I would know what to deal with." she adds.
Medical professionals too are often left grasping at straws.
"I've heard it all. One psychologist told me that given I'm in my early twenties, that my headaches were just shaadi ka stress. A conclusion he came to without even speaking to me," says Shirin.
When asked about how he goes about identifying the root case, Dr Vohra says this,
"Once we rule out all physical causes with thorough investigations, we move on to finding the psychological cause. We will typically start with asking the patient about the history of their pain, their life to find a direct temporal pain correlation with a particular event. if we don't find that we collect alot of circumstantial evidence through councelling."Dr Sandeep Vohra, Neuropsychiatrist, Apollo Hospital, Delhi
'It is Treatable'
"Chronic pain is something that people suffer from for years," says Dr Gupta.
And a major reason for this is the lack of awareness, diagnosis and guidance, even from medical professionals.
But "it can be treated," he emphasises.
Like in the case of Swati. Although she still lives with fibromyalgia and its flare ups, she reports that her migraines have stopped since she started getting treated for bi-polar disorder.
"This is why correct diagnosis and tracing the root cause is so important," says Dr Gupta.
Dr Gupta speaks of the steps in which the treatment of psychosomatic chronic pain can be approached.
First, is making the patient understand that getting to the root cause can be a long process.
To familiarise them with the physiological mechanisms of pain.
Identifying the triggers of pain, then treat or avoid those triggers.
Identifying the genesis of the pain through counselling. This step might also require some medication to ease the trauma.
Fourth is to give adequate muscle relaxants or nerve relaxants to take away the physical component of pain.
"So we treat it multimodally so that all these relevant issues are addressed," he says.
But, says Dr Vohra, the success of the treatment can also depend on how long the problem has persisted for.
"If the mental trauma happened recently or the pain has only been there for a sort duration of time, we have seen we are able to get excellent results with hundred percent recovery."Dr Sandeep Vohra, Neuropsychiatrist, Apollo Hospital, Delhi
"But if the pain has been ongoing for years, it can be difficult to resolve as completely and successfully," he adds.
(Want answers to your painful woes? Send in your questions to email@example.com, and we will get pain experts to answer them for you.)