The New Change Your Brain, Change Your Pain: Based on EMDR

By Mark Grant

Based on the authors 20 years of clinical experience and research using EMDR to treat pain, this book shows how to harness natural brain capacities such as attention, memory and sensory processing to change the brain activity which maintains pain. The new ‘Change Your Brain Change Your Pain’ offers a combination of insightful informa

• Language: English
• Publisher: Trauma and Pain Management Services Pty Ltd
• Release date: Sep 11, 2016
• ISBN: 9781925457261

Mark Grant

Mark Grant is an Australian psychologist/researcher with 30 years of clinical experience. He has worked extensively with survivors of all sorts of trauma and sufferers of stress-related health problems (chronic pain, fatigue, IBS etc). He has also researched the use of EMDR as a treatment for chronic pain resulting in several peer reviewed publications.Mark believes that most people know more than they think, and they just need help to recover that early-learning growth mindset that they were born with. This means strategies that are consistent with what we know about how the mind and body work - strategies which appeal to sensory-emotional aspects of brain functioning and learning. Such strategies are more intuitive, and quicker than traditional modalities that rely on insight or thinking. This can lead to surprising results - Marks Anxiety Release app, which was designed according to these principles, stimulated the first published account of an app being used to completely resolve chronic pain (in a carpal tunnel syndrome sufferer). Mark is currently co-author on two chapters regarding EMDR treatment of pain for the Oxford University Press Handbook of EMDR (2023). Mark's latest research project (2022) consists of an RCT to investigate the efficacy of a series of apps he has created to address the four main effects of PTSD; anxiety, medically unexplained pain, insomnia and damaged sense of self.

Book preview

13a

Introduction

A few years ago, shortly after publication of my Anxiety Release based on EMDR mobile app, I noticed a colleague named Judy walking in the corridor of the clinic where I work with her arm in a sling. What happened? I inquired. Carpal tunnel! she explained with a grimace. The pain is killing me – I’m probably going to need surgery if this doesn’t get better soon. I knew from my research with EMDR that bilateral stimulation (BLS) + focused attention could relieve pain and that she was a good candidate because she was generally a healthy stable person. Would you like to try something different? I asked. Sure, Judy replied, I’ll try anything if it helps. After explaining EMDR to her briefly, I instructed her to sit down and just focus on the pain while listening to alternating left-right audio tones playing through the headphones I’d given her. I waited expectantly as she listened, watching her face for those tell-tale signs of relaxation that I knew meant the BLS was working its magic. Sure enough, after about two minutes there was a discernible change in the musculature of her face. So what are you noticing now? I asked, without ceasing the BLS. It feels like it’s shrinking Judy replied a little uncertainly. Great, just keep noticing I said. The next time I checked in with her, Judy’s pain had decreased even more and after a few minutes her pain was completely gone. Judy was amazed.

I gave Judy a copy of the app and told her to use it whenever the pain bothered her and let me know how things went. Three months passed before I saw Judy again. I noticed that her arm was no longer in a sling. What happened? I asked, Did you have the surgery? No she replied, That thing you did really helped – I used the app like you suggested and after six weeks, I hardly needed any medication and the doctor said that I wouldn’t need to have surgery. Judy was obviously very happy. Judy’s experience resulted in the first published account of an app being used to overcome pain. Despite the seemingly miraculous nature of Judy’s healing, it was all based on science. She did not know that she has an ascending and a descending pain pathway, which can be stimulated to inhibit pain signals and release natural opioids. While not everyone can find relief so easily, Judy’s story demonstrates what is achievable under the right conditions.

Even though you experience pain physically, chronic pain is a mind-body problem. In addition to physical discomfort, chronic pain includes mental and emotional distress, changes in identity, altered immune functioning, and neurological changes. Overcoming pain requires a holistic approach which addresses all the elements that maintain it. While different approaches target different aspects of pain, your brain is where all these elements come together. All the physical, mental, and emotional elements that maintain your pain are represented in your brain, as altered patterns of neural firing, biochemical reactions, and even structural changes. This realization has paved the way for new strategies for overcoming pain. It is old news now that the brain is neuroplastic – capable of learning and changing throughout the lifespan. Best-sellers such as Norman Doidge’s The Brain That Changes Itself illustrate the power of neuroplasticity and the popularity of this concept. Programs such as Lumosity use neuroplasticity to improve cognitive performance, health-related applications are aimed at delaying Alzheimer’s, stimulating immune function and even reducing physical inflammation.

Applying neuroplasticity to pain is an exciting new possibility for a problem that is so resistant to other treatment modalities. Changing the brain activity that maintains pain is, however, a little more challenging than say, learning to play the piano to improve cognitive performance. The neuroplastic processes that maintain pain involve substantial changes to many areas of brain functioning, structures, and mental processing. These can come from chronic pain itself or from earlier life stress. For example, according to a recent review by US psychiatrist David A. Fishbain, 10–50% of chronic pain sufferers have PTSD compared with 10% of non-chronic pain sufferers. My research suggests that, in non-veteran populations, at least as many again have levels of anxiety that are consistent with PTSD. Other research indicates that 70% of chronic pain sufferers have attachment problems, compared with 50% of people without chronic pain. We know that childhood trauma or neglect causes neuroplastic changes as well as disruption of normal sensory and mental and emotional integration. Moreover, these changes increase vulnerability to pain. For example, adult survivors of childhood adversity are more likely to be injured, more likely to develop chronic pain and less able to regulate negative affect adaptively. They are more reliant on unhealthy strategies such as workaholism or substance abuse, as opposed to social support for self-soothing. They are also less able to experience positive affect, change maladaptive behavioural responses, or learn new skills. Despite these complexities, many self-help texts treat chronic pain as though it were no more than a form of aberrant acute pain, manageable through simply adopting more adaptive patterns of thinking and behaving.

A trauma-informed approach

Although it may start with an injury, chronic often pain begins early in life as a result of experiencing adversity in the form of physical or emotional abuse and neglect. For example, upwards of 90% of women with fibromyalgia report having suffered trauma in their childhood or adulthood; 76% of chronic low back pain sufferers report at least one trauma in their past. Chronic pain sufferers are more than twice as likely to suffer from PTSD (Posttraumatic Stress Disorder) or PTSD-like symptoms. Not surprisingly, the greater the adversity, the greater the likelihood of developing pain. According to a recent review by the Institute for Chronic Pain, when compared to the general population, people with chronic pain tend to have at least double the rates of adversity.

The connection between severe stress and pain is both well known and increasingly understood. In the short term, cortisol boosts your immune system to reduce inflammation – a key process in many types of chronic pain. But prolonged stress results in fatigue, decreased cortisol levels and increased susceptibility to pain-maintaining inflammation. Prolonged severe stress also causes changes in brain structure and functioning such as increased excitability, which makes the brain more susceptible to pain-related activity. As pain expert Ronald Melzack wrote over 20 years ago, Stressors have destructive effects on muscle, skeletal and hippocampal neural tissue, which may become the immediate basis of pain, or provide a basis for the devastating effects of later minor injuries in which the severity of pain is disproportionately far greater than would be expected from the injury. Beyond its physical effects, severe stress also causes increased anxiety, tension, and altered sense of self. Chronic pain is thus best understood as a complex set of interacting physical, neurological, and psychological factors maintained by the effects of severe stress on mind and body.

Change Your Brain, Change Your Pain addresses chronic pain from a trauma-informed perspective. It looks at who you were before you developed pain and the role that unhealthy mental and emotional responses originating from earlier negative life experiences play in causing and maintaining pain. In addition to learning pain control strategies and taking better care of yourself, this also requires making peace between your mental and emotional parts. There are many names for the fragmentation that trauma causes: child/adult, EP/ANP (Emotional Personality/Apparently Normal Personality), and so on, but they all refer to the same thing – a split that occurs between mental and emotional elements of experience when things get to be too much. Many survivors of childhood adversity have done such a great job of coping that they have forgotten or dissociated the reality of their childhoods. It seems as if they developed chronic pain instead of healing normally after the injury or illness that precipitated it. But to the degree that your pain is maintained by unresolved severe stress, trauma, or neglect, you cannot overcome it without understanding what went before and how it has affected you.

About this book

So, this book begins by reviewing what we know about chronic pain at the most basic psycho-physiological level. In Chapters 1 and 2 we will review pain based on ‘first principles’, a scientific approach to problem-solving which begins by examining the very basic assumptions we have regarding a problem vs. what we really know, and then building a new theory. You will discover the very basic processes that maintain pain in terms of the relationship between your body and your brain. You will learn how your brain works, how it is affected by severe stress, and how those effects predispose you to chronic pain. You will learn how severe stress causes a separation in the normal integration of the physical, emotional and mental elements of experience, of which most people are not aware, and which is one of the key causal factors of chronic pain.

Chapter 3 introduces EMDR (Eye Movement Desensitization and Reprocessing) as a treatment for pain and describes a seven-step process for overcoming chronic pain that addresses the various physical, mental, and environmental challenges that chronic pain presents, namely:

1. Tame the pain

2. Emotional regulation

3. Trauma processing

4. Uncovering the meaning of your pain

5. Dealing with other stressors

6. Self-care

7. Reintegration

These steps are designed to help you learn to control your pain, resolve any pre-existing trauma that might be maintaining your pain, and better manage the effects of pain on your mental and emotional functioning. You will be introduced to the fact that the ascending and descending pain pathways are complemented by an ascending pain control system (Gate Control) and a descending analgesic system. Each system represents an innate pain control mechanism complete with its own pain-relieving neurotransmitters and/or endogenous (originating in the body) opioids.

In Chapters 4 and 5, you will learn how to tame your pain using ascending and descending strategies. Ascending strategies rely on sensory skin-based stimuli, whereas descending strategies rely on mental stimuli such as meditation and guided imagery. Bilateral stimulation (BLS) + focused attention, a core treatment element of EMDR, harness both. You will be assisted in applying these strategies via the audio downloads that accompany this book and/or the Overcoming Pain app (available via separate purchase).

In Chapters 6 and 7, you will learn about the role of feelings in chronic pain and how to regulate them. You will find that feelings such as anxiety and depression are actually part of an adaptive response to pain and, once understood and managed, can be helpful. Good emotional regulation and connection with your feelings are also necessary for good self-care.

Chapter 8 demonstrates the role of trauma processing with EMDR as a path to resolving chronic pain. With the help of a trained therapist, EMDR enables you to confront and move through any traumatic memories that might be maintaining your pain. Research suggests that EMDR is most effective with pain that has a significant traumatic component (e.g.; phantom limb pain), but as Judy’s story indicates, it can also help with other types of chronic pain.

In Chapters 9 and 10, you will learn how to care for yourself, physically and emotionally. Good self-care means living and interacting with the world with a moment-to-moment awareness and respect for your physical and emotional needs. Exercise, diet, adequate rest, mental stimulation, and emotional nourishment are the basic elements of self-care. They are also essential for neuroplasticity and physical and mental health. Good self-care reduces the negative emotional and behavioural patterns that are maintaining your pain and supports your mind-body system in combatting pain. Good self-care begins with developing a compassionate attitude toward yourself.

In chapter eleven we will explore the meaning of your pain, from its obvious effects on physical functioning to its deepest hidden psychological significance. What effect has pain had on how you see yourself and how you have coped with past adversity? The more conscious you are about the impact of your pain on your core self, the more you will be able to address it.

Chapter 12 addresses the stressors that arise as a result of decreased functioning caused by chronic pain. Regardless of what you have may endured in the past, chronic pain brings its own challenges. Decreased physical functioning, health uncertainty, medical treatment, changed relationships, and dealing with insurance companies are just some of the myriad added stressors that pain introduces into your life. You will learn how to change your mindset and access mental resources, such as problem-solving, to combat stress.

Chapter 13 describes what it feels like when you reach a point where you have regained some control, assimilated the losses, learned the lessons, and grown a new post-pain self. You can enjoy life again, just not as the person you used to be. You may still have pain and decreased functioning, but you are not defined by these things .

How to get the most out of this book

You can read this book from start to finish, or you can dive into different chapters according to your needs. If you want to start by learning how to tame your pain, then you might begin with Chapter 4. If you are not sure where to begin, you might find the overview in Chapter 3 helpful for assessing where you are at on your pain journey and where best to begin. Regardless of what stage or task you are working on, you will find the accompanying audio a helpful addition to the suggestions in the text. It is recommended that you listen with an open mind and find what works for you.

You will need to be patient—but by the time you complete the process outlined in this book, which could take anywhere from a month to a year or more, you should understand your pain more deeply, have a greater sense of mastery over your pain, experience less suffering, and have developed a new sense of self that can incorporate the pain into your life in an adaptive way. This book is not meant to be a substitute for professional help, but rather an adjunct to whatever medical, physical, and psychological therapies you are already receiving.

The brain illustrations in this book are designed to be accessible to the non-professional, meaning they contain just enough detail to help you understand the key brain structures and processes involved in your pain. They are not intended to be exact maps of brain structure or functioning.

The approach in this book is based on EMDR, an integrative eight-phase approach that incorporates sensory stimulation, focused attention, free association, and cognitive re-appraisal. This basically means noticing what new feelings are stimulated by bilateral stimulation (BLS) and reviewing previous thought patterns in favour of more adaptive ones. The method is thought to harness an innate information-processing capability, which transforms painful experiences into new learnings and enables us to live in the present mentally, biologically, and emotionally. Although it started out as a treatment for PTSD, research indicates EMDR can be efficacious in the treatment of emotional problems based on traumatic memories, including somatic manifestations of unresolved emotional trauma.

The ideas in this book are based on a combination of the results of my own published research, my reading of others’ research and brain science literature, and my own clinical experience. The scientific references for each chapter can be found at the end of the book.

Wishing you peace, comfort, and healing,

18a

Mark Grant, MA

Melbourne, Australia

January 2020

19a

Your Brain in Pain

You cannot solve a problem until you understand it.

Albert Einstein¹

When Albert Einstein was trying to figure out how the universe worked, he started by drilling down to the most core elements of what was known about the universe, the basic facts on which the prevailing theories were based. After many sleepless nights, he came upon a single formula that summarized the relationship between energy, mass, and light, E=mc2. Einstein applied first principles, a term Aristotle coined over two thousand years ago to describe the first basis from which a thing is known. First principles enable us to look at familiar problems more clearly, free of assumptions that can cloud our vision, and pave the way for more effective solutions. All major medical approaches (e.g., anatomy, bacteriology, and anaesthetics) resulted from someone uncovering the first principles underlying problems such as disease, infection, and pain. For example, before the Middle Ages, medical treatment of disease was based on supernatural ideas about the causes of illness. But after Vesalius, a fifteenth-century Italian physician, studied the structure of the human body, the science of anatomy was born. This led to Descartes’ revolutionary idea that pain was a disturbance that passed from the body to the brain via pain fibres (see Figure 1.1). Increased understanding of how the body works led to more effective treatments.

First principles

So what do we really know about pain? What are the core principles?

1. Normally, pain is a signal that something is wrong physically (we call this acute pain).

2. Chronic pain is caused by a combination of sensory, emotional and neurological processes.

3. Understanding how your brain maintains pain can help you overcome pain.

Despite the emphasis on the brain, pain is more than just altered patterns of brain activity. You FEEL pain in your body. You feel sad, anxious, or angry, for example, because of the pain. But understanding how your brain maintains pain is the key to overcoming it.

When you cut or burn yourself, pain receptors on your skin called nociceptors become activated and send signals up to your brain via your spinothalamic track. This understanding of pain as a signal from your body to your brain is based on Descartes’ 300-year-old idea that pain originates in the body (see Figure 1.1).

Although advanced for its time, Descartes’ understanding of pain was quite simple—he had no way of knowing how pain was relayed from the body to the brain or how the brain translates physical sensations into pain . We now know that the human nervous system has two pain pathways between the body and the brain (ascending or bottom-up) and the brain and the body (descending or top-down). Each pain pathway relies on a combination of electrical impulses (synaptic firing) and chemicals (neurotransmitters) to transmit pain. Ascending pain pathways are mainly responsible for acute pain arising from injury to the body. However, as the ascending pain pathways travel through the spinal cord and medulla, they can also be set off by neuropathic pain—damage to peripheral nerves, spinal cord, or the brain itself.

The ascending pain pathway transmits painful stimuli via two types of pain nerve: one for ‘fast’ pain (A-delta) and the other for ‘slow’ pain (C-fibres). Each type of pain fibre relies on different chemicals: glutamate and substance p, respectively. Glutamate is an excitatory neurotransmitter that amplifies the signal, if you like, whereas substance p transmits pain signals more quietly. The pain fibres travel to an area at the base of the spine called Rexed laminae 2, also known as the Substantia Gelatinosa of Rolando (SGR). This impressive-sounding term simply refers to the fact that the SGR is a large jelly-like structure, discovered by an Italian researcher named Luigi Rolando. This area is also seen as a kind of gate since this is where pain enters the nervous system. This model of pain is called the Gate Control Theory. According to this theory, anything that changes the activity of the A-delta and/or C-fibres is going to change your pain perception and ‘close the gate’—but more about that in Chapter 3.

While the GCT remains popular, increased understanding regarding brain processes involved in pain has stimulated new theories such as Neuromatrix Theory (NT) and Limbically Augmented Pain theory (LAPs ). These brain-based models emphasize pain as a product of top-down processes (descending pain pathway) coming from the brain to the body. According to its author Ronald Melzack, NT posits that pain is produced by a widely distributed network in the brain rather than directly by sensory input evoked by injury, inflammation or other pathology. Rome and Rome’s LAPs posits that chronic pain is augmented by brain regions responsible for emotional processing. They distingumPFish between brain regions responsible for processing sensations (the thalamus and somatosensory cortex or lateral system) and brain regions responsible for processing the affective or emotional component of pain (the medial prefrontal cortex [ mPFC] and amygdala or medial system).

Remember the squid

Chronic pain is generally viewed as unnecessary since it lacks the warning value of acute pain. Pain therapists often describe acute and chronic pain in terms of ‘hurt vs. harm’. The idea here is that chronic pain can be ignored because even though it hurts, it does not signal harm. Since chronic pain is not thought to have any survival value, it is often suggested that it should be tolerated when trying to recover activity levels and stimulate physical reconditioning. Despite the logical appeal of viewing chronic vs. acute pain this way, until recently no one had ever bothered to research whether this was really how things worked.

In 2014 researchers from the University of Texas decided to test this popular view of acute vs. chronic pain by inducing central sensitization in squid and seeing what happened. They cut the ends off some squid, then anesthetized some of the injured squid and compared how normal (healthy, uninjured), injured no-pain (anesthetized), and injured/not anesthetized (chronic pain) squid reacted when faced with predators. The researchers found that the squid in the chronic pain condition were better at avoiding predators than both the healthy and injured no-pain squid. One of the researchers, Robyn Crook, speculated that the hyper-aware state in the injured non-anesthetized squid must serve to protect them from the increased risk of death associated with their injury. The researchers concluded that the propensity to develop chronic pain is an evolutionarily encoded feature of complex neural systems.

The research findings regarding central sensitization in squid indicate that far from lacking survival value, it helps wounded or injured organisms to protect themselves from threat. Viewed this way, chronic pain is just another manifestation of the well-known hyper-alertness that survivors of abuse and neglect develop to protect themselves. Also viewed this way, chronic pain is part of an over-developed survival response that is essentially adaptive. As you are about to learn, this makes it a kind of memory. So, if anyone tells you that chronic pain serves no purpose, remember the squid. However, as you are about to learn, having your threat-detection system on high alert all the time keeps you safe, but it comes at a cost.

Pain as a memory

Chronic pain is a psychobiological problem that is maintained by brain processes as much as nociception. For example, brain scans of chronic pain sufferers show that the areas of their brain responsible for cognition and emotion are activated, in addition to sensory-processing regions. In fact, if you look at the areas of the brain that become activated during chronic pain (see Figure 1.3), you will see that the majority of the activity takes place in areas of the brain involved in emotional rather than sensory processing. You will also notice that no one area of the brain is responsible for pain. So chronic pain hurts differently from acute pain—much more is going on in your brain than just pain perception. For example, chronic pain sufferers develop a fear of pain and fearful thoughts that non-pain sufferers do not have. Their brains become more sensitive to painful stimuli than normal. Chronic pain is thus a kind of memory in the sense that it is maintained by unconscious emotional and neurological changes.

As you will see below, memories are not just mental pictures of places you have been or things you have done; memories can also be bodily states.

Thinking of your pain this way does not mean that it is all in your head, but it is not all in your body either. It also explains why chronic pain does not make sense when viewed through the lens of acute pain. Knowing that pain is coming from your brain explains why you can hurt even though you have not moved the injured part of your body, and why pain persists instead of gradually reducing as the body heals. You will look at this in more detail later in this chapter.

Understanding your brain can help overcome pain

Knowing that chronic pain is maintained at least in part by the brain opens up new possibilities for overcoming pain. It suggests that the best way