We are really pleased to welcome Clinical Psychologist, Dr Patrick Hill as our guest blog. He recently published a paper in The British Journal of Pain on how the nervous system (and brain) may play a role in how we develop chronic pain and fatigue.
Here he introduces us to a model which might help us to understand chronic pain and potential “unexplained medical symptoms”.
Neuro Science and Implications for self-management
One unfortunate consequence of the dominant reductionist medical model in health systems is that health research, like healthcare services, is often conducted in silos, with little crossover between different specialist areas. However, knowing this also creates awareness that there may be interesting and relevant things happening elsewhere, which in turn creates a drive to go and look for them.
For me personally, this awareness has grown from my experience of working with people with many different long-term conditions and realising that there is more common groundthan differences between them – especially when considering how best to support self-management.
Being mindful of this, while working with people with long-term pain, I had an inkling that the ‘fatigue’ literature might contain some interesting ideas. I was spurred on to investigate this by seeing a significant increase in the numbers of people reporting combinations of both pain and fatigue and finding that colleagues in other NHS Pain clinics were experiencing the same thing.
What I discovered in the literature was a psychological model that had been put forward in 1995 by Christina Surawy and her colleagues(Chronic Fatigue Syndrome: A cognitive approach, in Behaviour Research and Therapy 1995; 33 (5): 535-544), to explain the development of chronic fatigue. In subsequent years this model had been used successfully by other researchers to look at the development of other long-term conditions such as irritable bowel syndrome after campylobacter infection, and post concussional syndrome after mild head injury.
The model seemed applicable to long-term pain and so I wrote an article about it, which has recently been published in The British Journal of Pain. (Chronic pain: a consequence of dysregulated protective actionBritish Journal of Pain Sept 2018).
The article is focused on long term pain, but suggests that the same model could be applied to the development of so called ‘fibromyalgia’ (widespread pain and fatigue) and some functional neurological conditions, often unhelpfully referred to as ‘medically unexplained’. The article considered Surawy’s model in light of more recent neuroscience and I tried to present it in a way that was practical enough for health professionals to consider as a basis for supporting self-management.
In essence the article is based on the idea that the nervous system (which includes the brain), has evolved to warn us about potential or actual threat to the body. It does this by creating warning sensations such as pain. The suggestion is that the brain processes all the information it receives about the body and the environment and makes selective and complex decisions about different perceived ‘threats’, producing differing amounts of pain or other sensations at different times, depending on factors such as context and previous experience. The purpose of this is to protect us and sensations such as pain, fatigue or some neurological symptoms can be very effective at stopping us doing whatever the nervous system is concerned about.
Surawy’s model was based on observation of people with chronic fatigue and proposed that people who develop this condition consistently demonstrate certain behavioural tendencies, such as a propensity to push themselves too hard. My suggestion is that this tendency to constantly ‘overdrive’,ignore sensations such as pain and keep going, perhaps over rides the protective warning systems. Over time this may weaken the nervous system’s ability to make decisions and, operating on a better safe than sorry basis, its output can potentially become increasingly unregulated. One effect of this is increased sensitivity, where sensations such as pain and fatigue are constantly created, as warnings aboutthings that are not actually dangerous or exhausting, such as small increases in activity. In this confusing situation the actions of an over protective nervous system can understandably be interpreted by the individual as some form of illness.
This model can provide some helpful guidance for for self-management. It provides a theoretical basis for some things we already do, such as introducing ‘calming’ approaches like mindfulness and learning how to regulate activity through pacing and goal setting.
What this model highlights is the need to understand the underlying drivers for peoples’ behavioural propensities. This emphasises the importance of social factors which are often under emphasised in self-management support programmes. In practice one key skill that seems crucial to changing behaviour is learning how to say “No” to other people. This is much more complicated and difficult than it sounds and I will pick this up in the next blog.
About Dr Hill
Dr Patrick Hill has 30 years’ experience in applied Clinical Health Psychology, specialising in the management of long term health conditions, particularly chronic pain. He has also worked in a number of NHS national support teams, specialising in clinical governance and patient involvement in healthcare, including the UK’s ‘Expert Patient Programme’. He retired from full time NHS work in March 2015 and currently holds a part time contract with an NHS Pain Service in Bath.