The Social Consequences of Chronic Pain

By Ann Marie Gaudon, PNN Columnist

When someone suffers acute pain from an accident or injury, a positive consequence is that it evokes care and compassion from others. However, when that pain becomes chronic, you don’t often receive flowers, cooked meals and offers of help. Your social connections may suffer, too.

That’s not a small issue for pain patients. A 2008 study found that maintaining social activities are just as important for people in pain as many of the physical and psychological consequences of chronic pain.

Let’s take a look at a short list of five ways that chronic pain challenges the maintenance of social relationships.

1) Reduced participation in social activities  

Chronic pain physically takes people away from their social networks. Pain flares can be a disincentive to planning and engaging, and can inhibit participation in activities. Fear of judgment can also lead to social withdrawal. And a lack of invitations to social gatherings may mean others are judging or making assumptions about your capabilities.

2) Impaired interpersonal functioning

Chronic pain induces self-focused attention by latching your attention on an area that may be under threat. For example, persistent back pain may draw your attention away from others and put it on your lower back. 

When attention is taken away from others, it reduces your ability to show empathy, social interest and attentiveness. This in turn reduces pro-social behaviour and impinges on your ability to self-regulate and monitor your emotions -- skills we rely on to adapt our behaviour to different social situations and norms.

For example, we might want to laugh loudly while reading a funny book in the library, but we stop ourselves. Or we might be at a work event and notice there is no foul language, so we self-monitor and do not swear ourselves.

These types of social skills require attention.  When chronic pain is taking up attention, there will be less capacity for self-regulation and self-monitoring. The end result: pro-social behaviours suffer.

3) Chronic pain and negative mood

Although being in a bad mood is a normal but unwanted reaction to chronic pain, it is not considered socially appropriate. Pain sufferers often try to mask their mood to help others feel more comfortable.

Negative moods are contagious and can influence the mood of other people, resulting in less enjoyment for everyone. It can also induce more negative judgments and bias against others.

4) Loss of social roles and identity  

Social relationships are founded upon shared social identities and interdependent social roles. For example, as we grow and develop, we have childhood friends that we have much in common with and are close to. But as we become adults, we often go in different directions and no longer have so much in common.

Relationships erode or dissolve because of this. If a chronic pain patient can no longer work, enjoy activities or be on a team, this can erode self-identity and the commonalities that were once in place with friends.

5) Difficulty connecting with others  

Chronic pain can lead to a focus on the differences we have with others, rather than the similarities. This can fuel beliefs that you are less than, not reliable or even less competent due to your pain. As a result, you may withdraw from others rather than others removing themselves.

This is not an exhaustive list but it gives you an idea of the challenges faced in the social world by pain sufferers. It’s important for overall health to assess your social functioning as part of a biopsychosocial approach to pain management.

As a therapist, I need to understand a patient’s level of satisfaction with their social roles and identities, and the health of their interpersonal relationships with others in order to help them with strategies and coping skills to restore and maintain their social connections.

Interventions can be utilized such as group therapy, which is beneficial in the realization that you are not alone, and for strengthening relationships, reducing isolation, helping you to find your voice, and providing a safety net. Support groups offer many of these same benefits. You may learn helpful information and gain hope from the social support of others. Many support groups are free or charge a nominal fee.

Therapy can also provide social skills training. And couples training can help caregivers understand their loved one’s pain and acquire their own coping skills to avoid burnout and social isolation.

Ann Marie Gaudon is a registered social worker and psychotherapist in the Waterloo region of Ontario, Canada with a specialty in chronic pain management.  She has been a chronic pain patient for over 30 years and works part-time as her health allows. For more information about Ann Marie's counseling services, visit her website.

Health Is the Wealth We Need

By Barby Ingle, PNN Columnist

I recently came across an interesting quote on Instagram about the four types of wealth. The quote goes like this:

“There are 4 types of wealth:

1. Financial wealth (money)

2. Social wealth (status)

3. Time wealth (freedom)

4. Physical wealth (health)

Be wary of jobs that lure you in with 1 and 2, but rob you of 3 and 4.”

The quote is meant as advice for people looking for employment and the types of jobs they should seek. But I look at it from the health perspective, since that is my biggest challenge in life.  I want health wealth. Financial, social and time wealth are often dependent on our health wealth. Without health we are limited in what we can do.  

People planning to have a child wish for a healthy baby. We also wish for long and healthy lives. We don’t always get to choose our health or even learn how to achieve it. I believe one way to help this would be putting more emphasis on health education in school.

It is hard to have good social wealth when your health is poor. You can’t participate in as many social outings or events, and you may have a poorer attitude about your living situation if you have a chronic pain condition. Belonging to a social group, maintaining friendships, being actively engaged in a positive productive way, and even being married all raise your social wealth.

Maintaining financial wealth is more straightforward. You either have money or you don’t. But even when you have money, you are often working on making, getting or winning more. Most of us would love to be millionaires, but even on relatively modest incomes of $75,000, studies show that people are happier.

Now take the average income of someone disabled by pain. Our households typically bring in less than $30,000 and many single disabled people are living on less than $15,000 a year. It is difficult to climb out of a financial rut with poor health and medical bills needing to be paid.

I know chronic pain patients who work, but due to poor health they are not able to take jobs that are high paying or sustainable long-term. Missing work due to illness, brain fog due to pain, depression, anxiety and painsomnia all affect our ability to be productive in a standard work environment. And it is often more difficult for a company hire you due to extra liability or disability costs made to accommodate you.

Even when your own health is good and you are taking care of someone who is disabled, it affects your finances through the type of jobs you take, health insurance, medical bills and supporting the rest of the family.

My husband has lost multiple jobs because my health care and insurance costs were too high for his employers. They found or invented reasons to let him go, such as missing too much work because he had to take time off to drive me to appointments. One company fired him for entering the parking lot without scanning his badge at the guard gate on the way in, a common practice in the mornings when the line to enter the lot was long.

For all of the reasons above, I believe that health wealth is the most important when it comes to living life to the fullest. It takes the most effort and action of all four types of wealth.

We strive to improve our health wealth so that we can live better lives. We don’t have the luxury of waiting for retirement to enjoy ourselves, so we must find and create moments when we can use our time and social wealth. They are the two most easily obtainable when living with chronic illness and striving for health wealth.

Barby Ingle lives with reflex sympathetic dystrophy (RSD), migralepsy and endometriosis. Barby is a chronic pain educator, patient advocate, and president of the International Pain Foundation. She is also a motivational speaker and best-selling author on pain topics.

More information about Barby can be found at her website. 

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Do Cultural Activities Reduce Risk of Chronic Pain?

By Pat Anson, Editor

Lose weight and get regular exercise are two health tips we’ve all heard before. But has anyone told you that going to a museum or concert could reduce your risk of developing chronic pain?

It’s true, according to a novel study published in the Journal of Pain.

Researchers looked at data from a 10-year study that tracked the progression of pain in over 2,600 older adults living in England. None of the participants suffered from chronic pain at the start of the study, but after ten years over 42 percent had experienced moderate to severe chronic pain.

Women (60%) were more likely to report chronic pain, along with those who lived alone, had less education, less wealth, slept poorly or were depressed. No surprise there, as many studies have found those conditions are often associated with chronic pain.

Researchers also wanted to know how often people exercised or participated in social events, such as community groups (political parties, trade unions or sports clubs) or cultural activities (visiting museums, art galleries or concerts).

Interestingly, moderate physical exercise appeared to have no effect on the incidence of chronic pain, but regular vigorous activity such as stretching and endurance training reduced the risk of developing pain, especially when it was combined with cultural activities.

“This study also found evidence that psychosocial factors may be protective against the development of chronic pain, in particular engagement in cultural activities such as going to museums, art galleries, exhibitions, concerts, the theatre or the opera,” wrote lead author Daisy Fancourt, PhD, a senior research associate at University College London. "It is notable that the odds ratios for cultural engagement were directly comparable with those of vigorous physical activity, suggesting a reduction of 25-26% in risk of chronic pain incidence."

Fancourt and her colleagues believe that going to a museum or concert provides not only gentle physical activity, but psychological benefits that come from social engagement and having positive cultural experiences.

“Notably, these positive psychological benefits have not been found consistently for community group membership, which could explain the differences in association with chronic pain found in this study. Indeed, it is notable that for participants who experienced widespread pain, only psychosocial factors, not physical factors, were found to be risk-reducing,” said Fancourt.

The study was observational in nature and does not prove that cultural experiences can prevent chronic pain. But unlike dieting and exercise, it does suggest an alternate way to lower the risk of chronic pain that most people would find enjoyable.  And maybe that's the most important lesson.

"This study is the first to explore simultaneously potential physical and psychosocial protective factors for the development of chronic pain in older adults. Our results demonstrate that both vigorous weekly activity and regular cultural engagement appear to reduce risk of incident chronic moderate-severe pain," the researchers concluded.

Obese Adults More Likely to Have Chronic Pain

Another way to reduce your risk of chronic pain is to maintain a healthy weight, according to a recent Washington State University study. Researchers there looked at data from 9 large studies conducted in different countries to calculate the odds of chronic pain among adults with an overweight body mass index (BMI).

They found that adults with a BMI of 25 or more, which is considered overweight or obese, were 14 to 71 percent more likely to suffer from chronic pain than those with a BMI below 25.

“Previous studies have shown that weight gain often precedes the development of chronic pain by many years, so I think our job as medical providers is to educate our patients early on and say, ‘You have a high BMI, your risk of one day developing a chronic pain condition, in addition to heart disease, is much higher,’” says Teresa Bigand, a doctoral student in the WSU College of Nursing.

“I think we need to do a better job of educating overweight people about their risk of potentially developing a chronic pain condition.”

More than 69 percent of the U.S. population and 1.9 billion people worldwide are overweight. For those who are already overweight and suffering from a chronic pain, Bigand says it’s not too late to take action. Research shows people who lose the largest amount of weight have the largest drop in their pain intensity.

“Essentially, weight loss is the best thing to do, however some patients aren’t quite ready for that,” Bigand said. “Patients with the highest and most severe levels of pain intensity struggle the most to lose weight. In those cases, we have to think about how we can help patients get their other symptoms under control that might be exacerbating the pain before we can start thinking about treating their overweight or obese status.”

A recent University of Michigan study, published in The Journal of Pain, found that obese participants who lost at least 10 percent of their body weight had less overall body pain.

“It’s been known for some time that people who are obese tend to have higher levels of pain, generally speaking,” says Andrew Schrepf, PhD, a research investigator at Michigan Medicine’s Chronic Pain and Fatigue Research Center. “But the assumption has always been the pain is going to be in the knees, hips and lower back — parts of the body that are weight-bearing.”

Schrepf and his colleagues found that losing weight not only lowered pain levels in the knees and hips, but in unexpected areas such as the abdomen, arm, chest and jaw. Study participants who could reach the goal of losing 10% of their weight also reported better mental health, improved cognition and more energy. Men in particular showed improvements in their energy levels.

One Is the Loneliest Number

By Ann Marie Gaudon, PNN Columnist

Part of what makes pain "painful" is the feeling of being misunderstood and the feeling of aloneness.

"Nothing is quite so isolating, as the knowledge that when one hurts, nobody else feels the pain,” Robert Murphy wrote in his memoir, “The Body Silent: The Different World of the Disabled.”

When you combine a sufferer who sees only pain with someone who can't see it at all, a barrier often springs between the two.  Pain causes this barrier because it inverts our typical perspective. No longer able to reach out to others for work or leisure, pain patients turn inward and life becomes about self-protection. Something is wrong inside of us, so we must tend to it and ensure it doesn't get any worse. This is an evolutionary response for survival; it’s instinctive and quite normal under these circumstances.

Once patients are constrained in their daily activities, a large part of their social world and the emotional health that depends on it can quickly deteriorate. Relationships are arguably the largest part of what makes life worth living.  In contemporary Western society, our self-confidence and identity arise from social interactions.

But as chronic pain sufferers’ lives become more restricted and limited, they frequently experience an erosion of their former self-image without the simultaneous development of a new one.

For example, I have heard: “I was a nurse, a mother, a wife, a friend, a daughter, and a sister, but now all of that is gone and I am alone in a cage with my pain.”

When isolated and in pain, our mind can become our worst enemy. The collapse of one’s social world can result in feelings of anxiety, emptiness, loneliness, anger, sadness, grief, guilt and low self-worth.

All of this psychological stress (aka “dirty pain”) is a response to your physical pain (aka “clean pain”).

Stress is a complex cascade of physical and biochemical responses to strong emotional stimuli. Emotions are electrical, chemical and hormonal discharges of the human nervous system. When not processed in a healthy manner, they can generate or increase pain and illness.

People can and do help themselves. Some join groups. If possible, join a walking group for exercise. If you don’t like walking, join another. The point is not so much what the group is doing, but rather that you are in a social situation.

Online forums are another way that people connect, especially if one is mainly housebound. Online communication can help you feel not so alone with your pain.

Maybe it’s possible for you to open up your home to low-maintenance company. Host a popcorn and movie night, or it could be cards or board games. You do the choosing, including when it begins and ends. Start with a single and simple event to prevent over-exertion and see where it leads.

Remember, what’s important is that you are building and maintaining relationships. To the extent that it’s possible, stick with those who support you. This could mean family, friends or even a support group for your condition, which can be a platform to form meaningful relationships with people who understand you. By listening to each other, you both know that you are heard and that you are not alone.

Some folks make their pain more communicable and thus sharable through pictures, artwork or expressive writing. Oftentimes this helps to bring barriers down to help others understand how you are feeling. There are no rules, you choose your form of expression.

Finally, realize that it is not your fault that you live in a pained body. Adding self-blame to your list of challenges will only make things worse for yourself. Learn to ask for help when you need it. Asking for help is never a weakness but is an act of self-compassion. I work extensively with clients on self-compassion, most of whom are quite naïve about it. If beating yourself up were the way to better health, wouldn’t you be the healthiest person on the planet by now?

I also work with people to get realistic about their life and expectations. What can stay? What can go gracefully to make room for new ways of being?

People aren’t broken, they’re just stuck. It’s not always easy, but with new learning, adaptations and support, people also become unstuck.

Ann Marie Gaudon is a registered social worker and psychotherapist in the Waterloo region of Ontario, Canada with a specialty in chronic pain management.  She has been a chronic pain patient for 33 years and works part-time as her health allows. For more information about Ann Marie's counseling services, visit her website.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.