Last week we discussed stress and its relationship to pain. Today I continue with this topic, go a little deeper. It is a little dense, but I will make it easy to understand.
Again stress, is a difficult situation to cope with, and that creates a reaction in the body – physical, mental, emotional, and behavioral.
So, as you know, the stress response is automatic, prewired by our body, a reflex, your body's sympathetic nervous system, the fight or flight response that gets activated to save you from danger – these are the primitive prewired reactions that everyone has. Think of the primitive times when early humans were living in caves and gets spoked – the automatic nervous system, sympathetic nervous system, will automatically, without your obvious input will kick in, and will make you ready to fight, run or freeze.
So if stress is a situation that is difficult to cope with, how does your brain know which situation is stressful, thus triggering the stress response in the appropriate time, force?
We all have examples of how everyone deals with stress differently. You can see it in traffic jams, natural disasters, or, more recently, with COVID 19 pandemic.
So any situation that we encounter is appraised by our brain by way of primary and secondary appraisals.
So think of every situation, experience, circumstance, body sensation – our brain is judging it either as harmless or stressful; it is instantaneous and automatic.
Harmless experience does not activate the stress response of the nervous system.
The stressful situation will further be accessed into a threat, loss, or challenge. This is what we call a primary stress appraisal.
Then the secondary appraisal comes in, or the second question your brain automatically asks is, "Am I capable of handling this situation?".
So the brain encountered a stressful situation. It will further be accessed into a threat – the brain's perception that the danger will be above the ability to cope with, above the threshold; loss – a perception that the damage is already occurred due to this situation, and a challenge – the perception that the ability to cope with this situation, will not outweigh the potential damage of the situation.
So – threat, loss, or challenge. And it's based on the brain's perception assessment of the damage (real or potential) – assessing the coping abilities.
So the interpretation of the situation, circumstance, and thoughts will be different in different people and produce a different emotion, thus creating a different response.
So let's go over in detail the brain's stress appraisal. Once you understand that principle, you will be able to see how your brain assesses life events, circumstances, situations, and bodily sensations, including pain.
So, when the brain thinks of a stressful situation as a challenge - it is a stressful situation, can't ignore it, but there is an ability, the tools to cope with it.
For example, interviewing for a job – stressful but doable, 1st date – stressful excitement, missing a flight – not life or death situation, but unpleasant, you can't ignore it. Still, you can confront and overcome it, A condition that will require expanded physical and mental effort to manage. It can also be positive stress – the stress of school exams, for example, challenging, stressful, and actually, at times, the stress helps with focus and will result in a better grade. The stress of the race in a sporting event - the body, pushes itself mentally and physically to achieve a result, win a race; if the brain was acting as if it was walking in the park, the focus and energy would be different, right?
The challenge can be seen as negative and positive stress, but something manageable.
What is threat appraisal – stressful situation, but the ability to cope with it will be overwhelmed and potentially harmful; it is the possibility of harm or loss in the future, such as an illness or anticipation of layoffs, marriage is on the verge of a divorce. There is a strong possibility of harm, but it's not there yet. There is nothing positive about it.
Loss – if the person thinks of a stressful situation as a loss, it is already damaged by it. The stress causes irreversible damage; harm is done. The loss is the damage that already occurred – death, loss of job, divorce.
Depending on the situation and its appraisal as a threat, loss, or challenge, you will think different thoughts, feel other emotions, and behave differently.
Challenge will produce more emotions related to the potential for gain or personal growth, more motivational, energized. If the situation is appraised as loss, the thoughts of loss bring up negative emotions, such as grief, sadness, and anger if it's a threat – negative emotions – anxiety, fear.
So why we are discussing this. All experiences, situations, sensations get analyzed by the brain it decides if they are harmless or stressful. So pain is a sensation in your body that gets transmitted to the brain. The brain analyzes it, and it would only be a stressor if the brain decides that it is threatening or unmanageable if the person judges it as an experience that is beyond their ability to manage.
The brain has a significant influence on the pain system; for example, it can increase its focus on pain or actually divert the attention to something more important. So even though the pain is a trigger of alarm to the body – something is being damaged – prewired by the default to alert of potential harm or tissue damage, to ensure survival, it can be overwritten by the brain and reduce the stress level. Like a computer warning button that comes up, you can click to dismiss it.
When I was on ER rotation, I remember the trauma team who were caring for a mother and her child after a car accident. The mother had no idea her arm was broken because her focus was on her child.
So if the brain appraises the pain or potential pain as threatening, it will focus on it and be less able to shift attention to other things. If you are over focused on one thing, such as your pain, you have less attention to other stimuli or tasks, resulting in poor memory and concentration. Thus the hypervigilant focus on pain or anticipated pain will result in an inability to multitask, remember, inattention. It will also produce emotional response anxiety, worry, fear of pain, fear of potential injury. Behaviors will change by avoiding activities associated with pain or provoke pain, doing less, actually leading to deconditioning and worsening disability. Also, seeking pain relief, at times before the pain is even there, increased anxiety and fear that there will be no relief. Chronic pain is often associated with anxiety disorders.
The majority of chronic pain will be appraised as a threat.
If the brain thinks of chronic pain in terms of stress associated with a loss, it does not focus as much on the pain experience, the sensation of pain, severity of pain, but the other circumstances that are perceived as lost due to pain – loss of the previous level of activity, loss of income for example due to disability, loss of quality of life, loss of relationships due to chronic pain. So if the threat is more focused on actual pain, the stress of the loss are the consequences that result from the pain. Just like if you lost a job, which is a stressor labeled by the brain as loss, the job is gone, but the loss of income is now the stressor.
So the pain that is thought of as a loss will bring up the thoughts of loss and helplessness, reducing the actual ability to appraise the stressful situation appropriately.
I recently treated a patient who called herself "broken" "useless."
So if the stressor is a loss, the emotions will be grief, sadness, depressive feelings – often leaning to clinical depression. This leads to behaviors – reduced physical activity, increased passive activities, like sleep, inactivity, leading to loss of work, loss of income, in some cases, relationship difficulties.
Interestingly chronic pain is not often appraised as a challenge. Research shows that the majority of patients associate chronic pain with a threat, followed by loss then, challenge. So if the brain appraises pain as a challenge, the patient will tend to be more focused on overcoming fibromyalgia, a problem to be solved, rather than focusing on pain itself, worrying about it, feeling sad/depressed at a loss. The emotions are feeling of commitment and resiliency, leading to more engagement in activities, for example, more commitment to a better diet, for example, more self-management, and move more. So actually, the goal of understanding our stress responses to chronic pain is to figure out the way for your brain to appraise chronic pain as a challenge rather than a threat or loss.
So in summary, today we talked about the primary appraisal of stress – a judgement by the brain of a situation or a sensation in terms of loss, threat or a challenge.
The most common way the brain in patients with fibromyalgia and other chronic pain conditions appraisers stress or pain as a threat. There is increased focus on pain, diminishing attention, worsening memory and concentration, commonly known as fibro fog.
The loss is often associated more with consequences of chronic pain – loss of function, income, relationships. The goal, though, is to learn how to see pain as more of a challenge, something you are able to cope with that does not overwhelm the body and mind.
So next time you are faced with a stressful situation, think of your automatic response – how did you appraise it? Did you think of it in terms of a loss, a threat, or a challenge? Until then, start thinking of your life situations as well as pain.
So, the secondary stress appraisal the thoughts that the brain produces after the primary appraisal and influences the choice of coping options – it will be the next episode's topic.