Chronic pain both psychological, social; women more affected: Experts

NEW DELHI: Chronic pain, persisting beyond the typical healing period of three months, often has complex psychological and social dimensions, say experts who urge people, particularly women who are more susceptible, not to hesitate in seeking support from psychologists.

The experts noted that pain clinics, found in many tertiary or multi-specialty hospitals, are equipped with specialists along with psychologists to holistically treat a person, rather than just target their physical problem.

"The trend nowadays is to focus on the disease – rather than the person. We must always keep in mind that pain is a biopsychosocial phenomenon," said Dr. Mary Abraham, a Senior Consultant at Max Hospital, Panchsheel, and Max Institute of Cancer Care, Lajpat Nagar, New Delhi.

Biopsychosocial models examine how a combination of biological, psychological, and socio-environmental factors impact wide-ranging issues from human development to health and disease.

A 2023 round-up of pain research in The Lancet noted that a common biopsychosocial risk factors - poor sleep, despondency, tiredness, stress, and a body mass index (BMI) of over 30 - were the most important ones for localised pain to progress to chronic pain, independently of the underlying pain-related medical condition.

"The mind and the body cannot be separated. All these problems lead to what is known as pain behaviour," said Dr. Vandana V. Prakash, Senior Consultant Clinical Psychologist, Max Multispeciality Hospital, Vaishali, who was formerly associated with a pain clinic at Fortis Hospital, Noida.

The concept of 'total pain' was introduced in the 1960s by British palliative care physician, Dame Cicely Saunders, who defined it as the "suffering that encompasses all of a person's physical, psychological, social, spiritual, and practical struggles.” Saunders emphasised the importance of palliative (pain-related) care in modern medicine.

"Palliative care has to improve in our country. Also, even as more palliative centres have come up in the recent past, awareness regarding pain and palliative care management has to improve," said Abraham.

The doctors have observed that women tend to experience chronic pain more than men.

Dr. Lakshmi Vas, Director, of Ashirvad Institute for Pain Management and Research, Mumbai, attributed this tendency to women's cyclical hormonal activity, including pregnancy surges, along with generally high emotional responses to surroundings stemming from their innate sensitivity and empathy.

“It also doesn't help that societies around the world are largely patriarchal, forcing women's ideas and thoughts to take a second place. While some might adjust and triumph, others don't and the lifetime of inequality, discrimination and friction can create internal stresses in them," Vas told PTI.

For example, in fibromyalgia, a common chronic pain condition characterised by widespread pain and tenderness, fatigue, sleep disturbances, along with mood and cognitive changes, Prakash said there is no external injury but a person still experiences pain throughout the body and leads a miserable life.

“There is a huge psychological component which needs to be addressed here. Otherwise, patients suffer from central sensitisation in which both the brain and the spinal cord become supersensitive to pain," she explained.

"In fact, among all the fibromyalgia patients I have seen, I've not yet seen a man. Even the literature says that there is a female preponderance,” Abraham added.

An October 2023 study, published in The Open Rheumatology Journal, enrolled 121 patients with fibromyalgia at tertiary hospitals in India. It observed that most were women (93 per cent), 88 per cent married and nearly 70 per cent homemakers.

Bodyache and fatigue were found to be the most common clinical symptoms reported by the participants, along with difficulty in concentrating and gastrointestinal complaints.

The researchers of the study also noticed high prevalence of headaches, obsessive-compulsive behaviour, sleep problems - snoring, waking up at night and daytime sleepiness - and mild-to-moderate depression.

The typical profile of an Indian fibromyalgia patient is that of a middle-aged married homemaker (woman) living in a nuclear family within a middle to upper-middle-class society and with a satisfactory educational status, they said.

However, even though women are sensitive to pain, Abraham noted that they are also the more resilient ones, as they try to cope with all their varied responsibilities.

On the treatment front, Abraham and Vas have observed dry needling to be highly effective in relieving the physical aspect of pain and to some extent, the psychological aspect, owing to the calming effects accompanying the pain relief.

Dry needling involves relieving pain in muscles by inserting needles to relax the spots which become “knotted”, due to aggressive firing of the nerves.

Chronic pain, Vas said, is neuro-myopathic, involving nerves and muscles, and dry needling "hits at the root of the problem" in muscles to eliminate pain. Neural interventions targeting nerves only "hit the messenger" to suppress the pain.

However, when it comes to treating women with fibromyalgia, Vas has observed that her neuro-myopathic treatments work to an extent, but owing to the central nervous system excitation in these patients, new pains surface elsewhere in the body.

"These are young women wishing to conquer the world, yet can't even get out of the house. So, psychology comes in in a very big way in fibromyalgia," said Vas.