Learning to Speak the Subtle Language of Pain

Ann Bracken
11
2301

“Your mother inherited this weakness—depression—from her father.” Dad followed that offhand explanation for my mother’s deep despair with a caution and a hope, “You want to be more like my family, the Dempseys.” That model of inherited weakness from my mother’s side and strength from my father’s side marked the starting point in my journey of understanding depression. And even though I vowed to never be like my mother, Dad and my siblings’ most frequent admonishments of “You’re too sensitive” and “Grow a thicker skin” didn’t seem to bode well for my future.

Once I married my husband, Tim, he picked up where my father and siblings left off. Eventually, Tim’s taunts of “too sensitive” seemed like his way of avoiding talking about the difference in the way we each saw a situation. Over the years, I tried to work things out with Tim, but our marriage resembled a roller coaster with a long pull of heartache and disagreement to get to the top of the hill followed by a brief spell of exhilaration when we could finally manage to work things out. After many years of knowing each other and navigating challenges, I wondered why Tim couldn’t work with me instead of constantly opposing me or even worse, dismissing me.

It would take years of talking with various therapists and doctors to understand, but finally in one pithy and insightful sentence, my psychiatrist, Dr. Sherman, explained the disconnect that I felt with my husband.

“Ann, it’s not his fault that you’re a deep-sea diver and he’s a surface swimmer.” With that one sentence, all of the puzzle pieces immediately slotted into place. Dr. Sherman had provided me with a model that I could reference whenever I felt frustrated because Tim and I couldn’t connect.

But it took me a long time to learn that just because the framework of a model made perfect sense to me, I couldn’t necessarily convince someone else to agree, even using compelling evidence and straightforward logic. Never was this truer than when I tried to explain what I called “physical depressions” to my doctors. I could see it in their eyes—and almost hear them mumbling psychosomatic illness as I left the office. And while none of them ever called me a hypochondriac, I often felt as if they smiled politely and then wrote me off in the notes inside my chart.

What do I mean by physical depression? I think some people still call it hypochondria, and in some of the medical literature I’ve read, such pain is referred to as unexplained painful physical symptoms (UPPS). For example, Jaracz et al. looked at UPPS in patients with major depressive disorder (MDD) and found that “UPPS are experienced by approximately two-thirds of patients…The proportion of patients with pain, but without a documented physical explanation…has been estimated as 42.8%.”1 Additionally, the World Health Organization studied fifteen primary care centers in Asia, Africa, Europe, and the Americas and concluded that “Persistent pain was a commonly reported health problem among primary care patients and was consistently associated with psychological illness across centers.”2

I remember a particularly striking incident of UPPS that happened to my mother in the 70s. She had been struggling with horrible tooth pain and visited several dentists, hoping that one of them could find out what was wrong. I remember hearing my father explain to someone on the phone, “Yes, Helen has a mysterious toothache and she’s been to four doctors. One of them suggested pulling out all of her teeth.” Dad continued, “Finally, her psychiatrist intervened. He thinks the pain is a form of depression and suggested a new medication as well as hospitalization.”

It sounds like at least one of Mom’s doctors was aware of the research presented in 1959 by George Engel who discussed “many cases of pain disorder which resisted both diagnosis and treatment” which he called psychogenic pain. Since that time, many studies have confirmed and expanded upon Engel’s ideas, and “psychogenic explanations of undiagnosed, intractable pain have been widely supported in the literature.”3

More recent studies have confirmed that “there is a bidirectional complex relationship between pain and depression”—when doctors are presented with unexplained physical symptoms, they need to be aware that “physical symptoms may be due to MDD rather than chronic pain” and that pain can serve to increase depression indicators including depressed mood, lack of interest, and impaired concentration among others.4

And here’s where the idea of a model comes into play. Dentists heard complaints of tooth and jaw pain, so they took x-rays, proposed dental treatments, and prescribed pain meds. But Mom’s psychiatrist dealt with the invisible world of the mind. So, when he was presented with a patient who had horrific pain with no physical cause, his model of illness was entirely different from that of the dentist. Based on what I now know about the mind-body connection and how physical pain can manifest emotional pain that we can’t name, I think it’s possible that my mother’s struggle to have a voice with my father and all of her doctors may have been the cause of her pain.

But what does my mother’s history have to do with me? Because of what I observed with my mother’s struggles with mysterious pain and depression, I had an inkling of the mind-body connection. Although my first such experience happened quite early, it all made sense.

I’d just turned seven in June of 1959 and my baby sister Kelly was about six months old. My grandmother, still very energetic at 69, was taking care of us because my mother was… gone. No explanation. No goodbye. Not until a few years later would I learn that my mother had been a patient in a small, Catholic, psychiatric hospital in Baltimore.

But when I think back on that time, I realize that I had internalized a very powerful message about illness and attention: It’s OK to be physically ill and to need help. People give you extra care when you’re sick. People expect less of you when you don’t feel well. I didn’t know it at the time, but I would later use that information—unconsciously—many times in my life.

Like every family, we had many unspoken rules, but I guess the one that most applied to me was not to show your feelings or get upset. This rule was especially important when my mother was in the hospital. Looking back on the situation, I realize my dad must have been under terrible stress, worrying about his wife, wondering what would happen to her, and how he would take care of four small children—one of them only a few months old. Dad constantly chided us, “You kids stop fighting,” “Brothers and sisters love one another,” and “Help your grandmother with the baby.”

Several months after Mom was hospitalized, I began having stomachaches every morning when I went to school. Tummy aches were usually pushed aside, and mine was no exception. But I must have complained for several weeks and finally my dad took me to the pediatrician for a check-up. After examining me and asking Dad a few questions, he pronounced his diagnosis: “She needs to eat more breakfast.”

All these years later, I wonder what the pediatrician knew about my life? A little girl who felt as if she’d lost her mother? But in the late 50s, I don’t think there was much awareness of how emotions could affect one’s health, and certainly not in relation to children. But now I believe that at some level, I understood that it was OK to feel sick in my stomach, but it was not OK to cry a lot and act worried about my mother. And I believe at seven years of age, I had my first experience of my feelings talking to my body—but I didn’t understand the language.

“How often have we been admonished not to show feelings…ridiculed for expressing them? Ultimately, we reach a point where we forget that we were suppressing anything” 5

And in 1959, neither did my pediatrician. From what I know of that time, people had little to no awareness of the relationship between difficult life experiences in childhood and physical and mental health, especially in children. It wasn’t until 1995 that Kaiser Permanente teamed up with the Centers for Disease Control and Prevention to look at the relationship between adverse childhood experiences (ACEs) and health and social consequences across the lifespan. ACEs can include emotional, physical, and sexual abuse; emotional and physical neglect; violence towards the mother; household substance abuse and mental illness; parental separation and divorce; and parental incarceration.6 By the time I was only seven years old, I’d already experienced my mother’s mental illness and her alcohol abuse, both of which, I believe, contributed to my mysterious physical and emotional pain.

The pattern of mysterious physical pain without any discernible cause worsened once Tim and I lived together, got married, and had children. The first instance of chronic pain that I can remember from that time happened once we’d moved to Richmond. But by the third month of our living together, after we’d gotten engaged and I had started my teaching job, I began having such severe stomach pains that I stayed in bed for a couple of days every month. So, every month, I took to my bed for a couple of days until the pain subsided.

It wasn’t until we moved back to Baltimore and I got health insurance with my new job that I sought out a doctor. The gynecologist said I was fine, so he referred me to a gastroenterologist, who immediately ordered some tests. Both an upper and a lower-GI series failed to show any abnormality, so the doctor sent me on my way. As mysteriously as the stomach cramps had begun, they disappeared after about eighteen months. No one had an explanation, and I was just as stumped as everyone else. And I still didn’t understand the body-mind language, which is what I now think the discomfort was all about.

I don’t remember any more baffling instances of pain-without-a-cause until after my second child—a daughter was born in 1982. When I went in for my six-week postpartum check-up, I told the doctor I was still having after-pains—like menstrual cramps or early labor pains. They were nearly constant and sometimes pretty severe. “I don’t remember the cramping being this painful with my first baby,” I told my doctor.

“Well, sometimes the after-pains are worse with the second child. Give it a few more weeks, then call me if you’re no better.” The pain continued, and I was getting alarmed, but still my doctor dismissed my discomfort.

The pelvic pain continued, and my OB wasn’t addressing my concerns very well, so I went back to my former gynecologist. After he examined me, he asked, “How are things going with the new baby?” and my eyes instantly flooded with tears.

“I don’t know what’s wrong with me,” I cried. “I’m tired all the time, and I feel totally overwhelmed by things. My daughter wakes up every four hours all day long, and I feel like I never get a break.” It felt good to finally tell someone how overwhelmed I was.

“Ann, I think you’re depressed,” he said. “Many women feel that way, especially after the second child.” He made a few notes in my file and then looked at me.

My body tensed as anger flooded my system. “I am not depressed,” I said. “I’m in pain. That’s why I’m here. What can you do to help me with my pelvic pain?” I was angry at the very notion that I could be depressed.

“Conditions like anxiety and depression greatly increase the chance of developing chronic pain…partly [as] a result of the fact that there is a considerable overlap in the areas of the brain that deal with pain and emotion” 7

The doctor looked at me and then said, “I can give you some Tylenol with codeine, but just for a few weeks. If that doesn’t eliminate the pain, then we’ll have to think about exploratory surgery.” He wrote me a prescription and pushed it across the desk. “I do hope you feel better soon. Please call me if you need to,” he said.

The pain medicine made me sick after a few weeks and exploratory surgery revealed nothing of note. I consulted a neurologist, and by that time, I was feeling desperate. So desperate, that after he examined me and found nothing physically wrong, he very gently said, “I think you’re depressed.” I was ready to listen, consulted a psychiatrist, took some meds for a few months, and then felt great. No pain, no weeping on the kitchen floor. The pelvic pain was finally gone.

Several years later, I began having intense back pain, and when doctors and chiropractors failed to help me, I sought out an acupuncturist. All I knew at the time was that someone would put needles in me and the needles could magically help get rid of the pain. Not quite, as my acupuncturist, Louise, explained to me. But in working with her on my pain issues, I began to learn more about mind-body wisdom and healing.

“Considering the complexity of the pain processes, a strategy based on [an] ‘either/ or dichotomy’ is unlikely to provide an adequate explanation of the role of psychological factors in pain” 8

Instead of seeing my back pain solely as a part of my body that hurt, I began to realize some of the metaphorical aspects of the type of pain I experienced. How was that particular pain related to my experiences as a daughter, wife, and mother; the struggles with my son related to his school achievement; and the arguments with my husband over spending more time with me or carving out time for family outings?

“More subtly, one might develop psychosomatic symptoms or stress-related symptoms because of unresolved emotional issues” 9

In talking with Louise about Qi (the life force in Chinese medicine), it gradually dawned on me that my back pain was another mask that depression wore. Instead of crying and feeling overwhelmed or giving up, my body was sending distress signals to help me realize that I was in a difficult spot.

Gradually, the back pain lessened, and I felt the weight of sadness lifting, just like it had in the past when I’d taken antidepressants. I felt like skipping down the driveway to the house. Could acupuncture really be that miraculous? I had no answers, but I knew a good cure when I felt one. And I had begun to tap into the wisdom my body held, respecting its wisdom.

My most dramatic instance of mysterious pain occurred in 1993 when I was suddenly struck with an intractable migraine that lasted for seven years. During that time, I also struggled with a severe depression. And even though my doctors and therapists all insisted that my experience of depression had its roots in a chemical imbalance, I believed that I was in the midst of a dark night of the soul where my psyche was working out something foundational. Eventually—with time, poetry, spiritual work, and therapy—the depression dissipated.

But I wasn’t so lucky with the migraine. I worked with a nurse practitioner who specialized in migraine treatment which consisted of numerous hospitalizations where I was pumped full of steroids, treated with migraine nasal sprays and injections, and a variety of opioids. When I found no relief with using MSContin and OxyContin, my nurse put me on methadone. Eventually, all of the medications caught up with me, and I began falling asleep while I was driving. After walking away unharmed from two serious car accidents, I resolved to find a better way out of my pain and consulted an energy healer. Within four months of working with the energy healer, my migraine pain subsided, I was medication-free, and able to leave my destructive marriage.

“…chronic illness or physical pain…can also be the crisis which forces the relationship to change…And this pain or disease can, paradoxically, act as a healing agent to one or both partners and to their relationship” 10

Like straddling a rushing river, I had my feet in two paradigms—one that said depression was the result of wacky brain chemistry and one that said that my soul was working out some kind of mystery, which required patience and faith. I continued to search for answers, and I found another piece of the puzzle when I read The Paradox of Healing: Medicine, Mythology, and Transformation by Drs. Michael Greenwood and Peter Nunn.

Due to their grinding, unrelenting nature, the chronic migraines had been even harder to live with than depression, but Greenwood and Nunn’s exploration of the mind-body connection provided me with new insight. They spoke thoughtfully about a phenomenon that I knew only too well: the often-opposing perspectives held by Western medical practitioners versus holistic practitioners. The authors used a variety of stories and myths to explain the complex interweaving of our mind-body connection.

While I had previously never read the story of “The Woman with No Hands,” Greenwood and Nunn’s explanation spoke deeply to my own struggles when they said that the two things I was experiencing, migraines and depression, often appeared because “…the body is making a stab at communication, but the intellect gets a different message.” They view pain that doesn’t respond to any medication as a crisis that challenges people to integrate intellect and feelings so that healing can begin and patients can “find our personal power.” That idea both validated my experience and challenged me as I searched for answers and durable healing. I know that my journey and my mother’s may not have been so long and convoluted if, as Warraich, a fellow at Duke University Medical Center recommends, we had found doctors who understood that “pain is part of the story of the person who suffers from it, not just a separate physical phenomenon.”11

* * *

An excerpt from Ann’s unpublished memoir, Noncompliant.

Show 11 footnotes

  1. Jaracz, J., Gattner, K., Jaracz, K., & Gorna, K. (2016). Unexplained Painful Physical Symptoms in Patients with Major Depressive Disorder: Prevalence, Pathophysiology and Management. CNS Drugs. 30, 293-304. doi:10.1007/s40263-016-0328-5
  2. Gureje, O., VonKorff, M., Simon, G.E., & Gater, R. (1998). Persistent Pain and Well-being: A World Health Organization Study in Primary Care. Journal of the American Medical Association. 8 280(2), 147-151. doi:10.1001/jama.280.2.147
  3. Gamsa, A.& Vikis-Frieberg, V. (1991). Psychological events are both risk factors in, and consequences of, chronic pain. Pain, 271-277. https//doi.org/10.1016/0304-3959(91)90096- G
  4. Narasimhan, M., & Campbell, N. (2010) A tale of two co-morbidities: Understanding the neurobiology of depression and pain. Indian Journal of Psychiatry. 52(2): 127-130. doi: 10.4103/0019-5545.64586
  5. Greenwood, M. & Nunn, P. (1992) The Paradox of Healing: Medicine, Mythology, and Transformation. Victoria: BC. Paradox. p. 21
  6. American Academy of Pediatrics. (2014). Adverse Childhood Experiences and the Lifelong Consequences of Trauma.

    Wikipedia contributors. (2019, November 4). Adverse Childhood Experiences Study. In Wikipedia, The Free Encyclopedia. Retrieved 22:17, November 20, 2019, from https://en.wikipedia.org/w/index.php?title=Adverse_Childhood_Experiences_Study &oldid=924567186

  7. Warraich, Haider. (2019, 17 March). Is Pain a Sensation or an Emotion? New York Times, p. 5.
  8. Gamsa, A., & Vikis-Frieberg, V. (1991). Psychological events are both risk factors in, and consequences of, chronic pain. Pain, 271-277. https//doi.org/10.1016/0304-3959(91)90096- G
  9. Babbel, Susanne. (2010, 8 April ). The Connections Between Emotional Stress, Trauma and Physical Pain. Psychology Today. https://www.psychologytoday.com/us/blog/somatic-psychology/201004/the-connections- between-emotional-stress-trauma-and-physical-pain
  10. Greenwood, M. & Nunn, P. (1992). The Paradox of Healing: Medicine, Mythology, and Transformation. Victoria: BC. Paradox. p. 78
  11. Warraich, Haider. “Is Pain a Sensation or an Emotion?” New York Times. 17 March 2019.

11 COMMENTS

  1. Hi Ann, thank you for the article.

    The opposite was true for me and many others I have known. I have lost three people due to being told their pain was in the mind.

    Much of my pain was not something visible, and I was given antidepressants for it. I finally found a specialist that diagnosed me with myo-facial pain syndrome, and I ended up in a study to treat it.

    I think it is not fair to a patient to call something psychosomatic, just because we have outdated equipment and knowledge before it even gets thought of being invented.
    The body is complicated. I had a great neurologist many years ago that was really before his time. It was the time of MRI’s, which I was very impressed with, but he corrected my enthusiasm by saying “that new MRI is already 25 years behind”

  2. “I know that my journey and my mother’s may not have been so long and convoluted if, as Warraich, a fellow at Duke University Medical Center recommends, we had found doctors who understood that ‘pain is part of the story of the person who suffers from it, not just a separate physical phenomenon.'”

    I agree, the medical field has been so compartmentalized and specialized that none of the doctors can see the big picture. And they’re seemingly literally trained to ignore, or intentionally not bother to get to know, the whole person they are supposedly treating. Despite the known historic wisdom that, “It’s far more important to know what person the disease has than what disease the person has.”

    Best wishes in finding a publisher. I absolutely agree, the arts are a wonderful healing tool.

  3. I feel I need to revisit this article.
    My problem with this article is that sometimes people view their particular experience with their own body or mind as something that could be applied to others.

    Doctors don’t need help in the area of using “depression” in the face of physical pain.
    I have met many people who have solutions/answers to what ails me or distresses me, right down to suggesting I envision a “healing blue light”. To challenge that, I said “how is a healing blue light going to fix a broken arm?”
    Of course, that is different.
    My take on it is this. If someone tells me my experience is mental instead of physical, then I want them to prove it, and NOT within the absence of physical scientific ability.

    • I appreciate your comments on this, sam. I understand the author’s intent but I too struggled with feeling like doctors don’t need any additional ammunition to claim pain, or any other symptom, is all in our heads.

      The head of infectious diseases at the CDC referred to chronic Lyme Disease patients as “Lyme loonies” in internal documents. I am literally fighting my own government to have my illness taken seriously. The fact that Lyme Disease is now an epidemic, and that Maryland is second in new cases only behind Pennsylvania, is a direct result of suppression by the most powerful And influential health agency in the world. That they’re charged with controlling infectious diseases raises the absurdity to new and historic levels.

      So while I understand that a particular person may understand their own pain and depression in this way, I believe it’s neither scientific (e.g. cytokines and “sickness behavior”) nor helpful, to promote the idea of a psychosomatic origin of physical symptoms.

  4. Thank you, Ann. At this particular juncture in my life I more easily recognize shared touchstones in your recounting of your struggles. The world of our past and our development within it was overwrought with religious beliefs/constraints that, perhaps unknowingly, (I am so kind… or so naive) provided foundation for ignorance in the face of quickly advancing scientific inquiry and new knowledge. I have now fully embraced “faith in life” and “truth of change” as foundation for my continually emerging understanding of a whole self. Leaning evermore into a state of liberation. Opening into acceptance rather than closing inward into denial and denigration. Freedom from the inhumane, and sometimes cruel, restraints of the past and now bursting forth into the light of wisdom/fulfilment. It just takes a lifetime. 😉 Could it be achieved any other way than through the countless confounding trials of many years? Damn, I hate admitting that suffering can open the door to profound peace and joy. But it is proving to be true for me.

    I always appreciate your accompanying research into the mind-body dynamic. You work hard at justifying your position.

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