Original title: Using the mind to manage body pain

The pain started when Ms Carol Ng fell and fractured her right foot at the start of the year.

Her mobility and lifestyle were affected, and the 41-year-old recruiter also could not travel for work.

“When I touched the base of my foot, the pain felt like an electric shock,” she said.

When her patience ran out, she saw an orthopaedic surgeon at Singapore General Hospital (SGH), who referred her to the hospital’s pain management centre, which sees about 6,000 patients annually. There, Ms Ng learnt that she was suffering from complex regional pain syndrome on her foot.

“If left alone, it is usually disabling and will not go away entirely,” said Dr Thor Timothy Anuntapon Chutatape, a consultant at the centre.

The pain was not just in Ms Ng’s foot, but in her mind as well. “The pain fibres and the central nervous system that processed this information became oversensitive to the painful stimulus, and it became a self-perpetuating circle of ever-increasing pain,” Dr Thor said of the syndrome.

He treated her physically and mentally.

Recalled Ms Ng: “He noticed that I was quite depressed and told me to stay positive. He told me: ‘Stop thinking that it’s painful as the brain will then give you the signal that it is painful’.”

By the time she sought help at SGH, she had left her job and was depending on her parents to take care of her. “I felt like my world had collapsed. I couldn’t move my foot and I couldn’t go out,” she said.

After the treatment, which included an injection, her pain gradually faded.

“By the third day, I could sleep better and everything just changed. I could move my right leg,” she said.

At the end of last month, Ms Ng had surgery to fix the fracture, and is now recovering.

Close to 200,000 elderly people are expected to be living with chronic pain by 2030. Conditions include back and neck pain, osteoarthritis and nerve-related pain disorders such as painful diabetic neuropathy or nerve pain associated with diabetes, the incidences of which increase with age.

Patients with these conditions typically have difficulty dealing with chronic pain and related stress such as work or family problems, said Dr Thor. Some of them may even go into depression or experience anxiety, he said.

While people may be aware of the effects pain can have on their psychological state, many are unaware that they can manage the pain psychologically, and not just through medication, said Ms Teresa Foong Li Ming.

The chief psychologist at Khoo Teck Puat Hospital’s psychological medicine department added: “Since the pain sufferer experiences pain in the body and not in the mind, the first instinct is to get rid of it by seeing a doctor.

“He or she may not understand how seeing a psychologist can be helpful in pain management, and may be initially reluctant to do so.”

Dr Thor said that research has shown that high levels of anxiety, depression and catastrophisation can increase the chances of pain becoming chronic.

“Catastrophisation is an exaggerated negative bias to a painful experience, with a tendency to ruminate on, magnify and feel helpless in the face of pain,” he said.

THE PAIN CYCLE

Pain also has the potential to affect every organ system in the body. For instance, it can increase blood pressure and heart rate, thus increasing the workload of the heart, leading to an increased risk of heart attack, said Dr Thor.

Each individual’s pain experience is shaped from birth by genetics, the beliefs and perceptions of the family and society he is a part of, previous pain experiences, as well as other physical or psychological diseases that the individual may have, he said.

“Pain, once it becomes chronic, leads to anxiety over one’s general health, about the costs of medications and treatments and their side effects, about psychosocial and psychosexual issues,” said Dr Thor.

This then leads to sleeping difficulties, fatigue, low mood and loss of energy, all of which increase the patient’s perception of pain.

There is then an avoidance of activity, resulting in physical deconditioning, increasing pain with less activity, and even more anxiety, anger and depression, he added.

For these patients, a psychologist can help by coming up with strategies to address excessive fear, anxiety, depression and catastrophisation, as well as helping them come to accept certain pain conditions.

They do this by setting goals and working closely with a multidisciplinary team whose goal is to enable patients with chronic pain to be healthy and actively involved in their own care.

“Psychological therapy for pain is about helping patients improve their quality of life and to live more fulfilling lives despite their pain,” said Ms Foong.

These therapies include teaching the patient to accept that the pain is out of his control and to commit to action that improves and enriches his life.

Said Dr Thor: “Most people know about the possible adverse effects of pain on mood but are not so aware of the reverse, whereby our state of mind and emotions can either limit or potentiate the severity of pain in our lives.”

Tackle pain by adopting the right mindset

Patients who “cannot take the pain” enter a vicious pain circle, and bear the consequences physically, psychologically and emotionally.

Their family and friends may also face some of the consequences, said Dr Thor Timothy Anuntapon Chutatape, a consultant at Singapore General Hospital’s pain medicine department.

This is because such individuals tend to be more withdrawn and less generous in dispensing love, care and affection to those around them. Hence, chronic pain sufferers should seek help early, said Dr Thor.

In order to “steel” their minds to fight the physical pain, they need to acknowledge the impact of biological, psychological, social and spiritual factors on pain.

For instance, they can exercise regularly and sleep and eat well to strengthen the “biological” part of their being, he said.

To improve their psychological resilience, they can adopt relaxation techniques to allay their anxiety; learn to focus on what is positive; and learn to forgive others and themselves, said Dr Thor.

The spiritual self can also be strengthened through praying or meditation, for instance; or simply by being grateful for what one has.

Ms Teresa Foong Li Ming, the chief psychologist at Khoo Teck Puat Hospital’s department of psychological medicine, offers two tips for pain sufferers:

• Make sense of the pain and find a positive way of looking at it. Rather than say that the pain is going to ruin your life, think about what you can still do despite the pain.
• Plan and do what you want, despite the pain. Live your life as best as you can according to your values and goals. This may have to be moderated – for instance, you may have to take more rest – but you can still move forward, rather than be stuck in the pain trap.

The pain will still be there but you may find it more tolerable because you are more engaged in things that you want to do.